Arguably, the introduction of the birth control pill has transformed female health more than any other drug in modern medicine. Although many of us practicing now do not know life without it, its history is not that long.
“The Pill” – as it is often referred to – was introduced in May of 1950.1 At that time, prevention of pregnancy was not listed as an indication, and promoting birth control was politically, socially, and legally unacceptable. In fact, the Comstock Law prohibited public discussion and research about contraception.1 Therefore, when the birth control pill was introduced, it was for cycle control and for married women only. It was not indicated for use as contraception in the United States until 1960.
Since that time, the birth control pill has evolved dramatically, not only in its formulation but in its indications as well. As pediatricians, we do not always find it easy to discuss with parents hormonal regulation and starting a patient on the birth control pill, particularly when it will not be used for contraception. There are many fears about using hormonal control, but there are many useful indications that improve the health and well-being of the pediatric patient.
Menorrhagia and dysmenorrhea are likely the most common reasons that hormonal therapy is started in adolescence. Beginning with the lowest estrogen dose to reduce side effects is prudent, adjusting accordingly if side effects should occur. Breakthrough bleeding is a common side effect that usually improves over time. Patients should continue treatment for at least 3 months before deciding if treatment is effective or not. If breakthrough bleeding continues, increasing the estrogen component or changing to a triphasic pill might reduce bleeding.
Primary or secondary amenorrhea – no menarche by the age of 15 years or the cessation of menses for greater than 3 months – is common in adolescence for a variety of reasons. Excessive sports, poor diet, and stress tend to contribute to the onset of primary or secondary amenorrhea; polycystic ovary syndrome is another possible cause. Serum studies including HCG, FSH, prolactin, and TSH help rule out other causes that may need to be addressed. Administering norethindrone acetate 5-10 mg for 5-10 days will usually lead to bleeding.
For a child with mental or significant physical disabilities, suppression of ovulation to prevent a menstrual cycle is very useful. Extended regimens can help to completely suppress ovulation, thereby avoiding withdrawal bleeding. There is anxiety about extended regimens, but there is no greater risk with using hormonal therapy continuously vs. intermittently.2 In fact, using it continuously reduces many of the unwanted side effects associated with the use of oral contraceptive pills (OCPs), for example, heavy bleeding, headaches, and nausea. Complete suppression is difficult, but the odds are better with continuous treatment. Using monophasic OCPs for 42-63 days on and 4-7 days off can be tried. The benefit of using monophasic pills is if a dose is missed, it is easy to make it up by just taking an extra pill. Companies have come out with extended-regimen packs, for example, Seasonale, Seasonique, Quartette, and Lybrel. There now is a chewable pill known as Femcon Fe, which would be useful in those patients who are not able to swallow pills.
Progestin-only regimens can be given as a pill (norethindrone acetate) or by injection (Depo-Provera [medroxyprogesterone]). Some important considerations for the disabled patient is that these are associated with more weight gain, which could be problematic for the patient who requires assistance. Another consideration is that progestin-only pills must be taken at the same time every day, and can be associated with increased acne. Breakthrough bleeding is also more common with progestin-only regimens, but adjusting the Depo-Provera regimen to a 10-week schedule reduces the breakthrough bleeding after 4-6 months.3
Another indication for OCPs in the adolescent patient is acne. Although the exact mechanism is not completely understood, estrogen does decrease sebum by reducing the size of the gland4, and, therefore, all OCPs can reduce acne. Norgestimate combinations have the highest androgen to progesterone binding ratio, so they are more effective than OCPs that do not. A newer progestin, drospirenone, is a 17 alpha-spironolactone derivative that produces antiandrogenic activity.5 When used in a combination OCP, acne control appears to be even greater. Hormonal therapy should be considered whenever there has been limited improvement with topical treatment or if acne breakouts are associated with the onset of menses.
Another consideration is to add spironolactone 100 mg by mouth daily to the regimen. Studies have shown it can be safely used in women to reduce acne.6 Patients should be monitored frequently for hyperkalemia, and it should not be used in patients who are already pregnant.4 Lab work should be done to rule out other causes of hyperandrogenism; lab tests would include serum testosterone, androstenedione, dehydroepiandrosterone, sex hormone–binding globulin, and prolactin.4
Premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD) – which is the onset of depression, irritability, or anxiety in the second half of the menstrual cycle and remits with the onset of the menstrual cycle – also can be treated with hormonal therapy. This can be particularly helpful in teens with depression, as well as in those who are on treatment without significant resolution. PMS/PMDD appears to be best regulated with OCPs containing drospirenone,7 and using either a shortened course of the placebo phase or a continuous regimen appears to be the most beneficial.
Regardless of the indication for hormonal therapy, the initiation and management are essentially the same. Initiation can be on the first day of the menstrual cycle, on the Sunday after, or at the time of the visit. Initiation midcycle may result in breakthrough bleeding, but that will likely resolve over the next 3 months. No lab tests are required to start hormonal therapy, except for an HCG to rule out pregnancy. Weight and blood pressure should be documented so they can be monitored on follow-up visits. A detailed verbal explanation along with a handout should be provided on proper administration and side effects. Contraindications for the use of OCPs can be found on the Centers for Disease Control and Prevention’s website under medical criteria for the use of contraceptives .
Educating families and patients on their options for hormonal therapy can be life changing. Detailed questions about the menstrual cycle should be asked at every visit, and understanding the wide variety of indications for hormonal therapy can maximize treatment for a better outcome.
Dr. Pearce is a pediatrician in Frankfort, Ill. She said she had no relevant financial disclosures.