Adolescent Menstrual Variation and Oral Contraceptives
By: Theresa Emmerling, Ashley Higgins and Kathryn Clancy
Many informational videos and documentaries have been produced to inform young women on the changes that they will experience during puberty and upon first menstruation, also called menarche. Unfortunately, these explanations are quite often generalizations that can lead to misrepresentations of what is normal. The information available to young women today stresses normative values for menstrual cycle length rather than the wide degree of variation characteristic of their cycles and may have an impact on adolescents’ future choices concerning oral contraceptives.
|Figure 1 from Vihko and Apter 1984|
|Figure 2 from Vihko and Apter 1984|
Given that it is more common, even normal, for adolescents to have very long menstrual cycles, we are concerned with what looks like stronger criteria for amenorrhea in exactly the population where it is expected (though the AAP paper discusses the low frequency of very long cycles, it also fails to mention the frequency of the pathology they worry is hidden in these long cycles). Further, more stringent criteria that misrepresents normal variation in this group of women serves only to frighten a population already concerned about normality and fitting in. For many, the teenage years are a time when standing out is to be avoided, and anything that makes one seem abnormal – an early or late age at menarche, long or short menstrual cycles – can be a stigma and cause stress. Educating young women on the reality, that this variation is what is normal, and that if anything the 28-day cycle is abnormal at this life stage, may prevent some of the considerable misunderstandings they have about their health. Understanding one's own body is an important step in making educated, healthy choices in the future. If most young women do not actually experience what they are taught is the average menstrual cycle, despite the fact that the reality is that wide variation in menstrual cycle length is the primary characteristic of post-menarcheal cycling, we are providing information that could lead them to feel abnormal and want to treat what is likely healthy variation.
A source of serious concern stems from what’s happening in the doctor’s office. Doctors, particularly in the United States, prescribe oral contraceptives at the slightest mention of deviation from the norm or evidence of a “menstrual disturbance.” In 79% of cases, health care providers will prescribe OCs at the patient’s request (Andrista et al, 2004). Less than 5% of doctors offer alternative forms of contraception to their patients in the US (Gerschultz, 2007), despite the fact that intrauterine devices, or IUDs, are more widely prescribed globally, and are both safe and effective. Future research questions should address whether doctors believe OCs are the best choice for women or that they the easiest method to prescribe; further, it is important to understand the decisions involved in prescribing these hormone treatments to adolescents. We have found evidence of doctors prescribing oral contraceptives to girls as young as twelve years of age (Cromer et al., 2008). Additionally, doctors prescribe OCs for adolescents who do not “live a lifestyle conducive to menstruation” (Sucato, 2002). We worry that ingesting cocktails of exogenous hormones have become a tool of convenience without regard to the possible trade-offs in their consumption. There is a large gap in the literature concerning adolescents and the long-term effects of OCs, yet doctors’ primary concern is that adolescents will accidentally skip a couple pills every pack (Omar et al, 2005).
Natural variation in adolescent hormone levels is a largely unexplored realm of science, with the same handful of decades-old articles cited repeatedly. Further research will yield not only a better understanding of this "time of change" but also less pathologizing of natural variation. However, until that research is published and generally accepted in the scientific and medical communities, the prescription of OCs for adolescents should weighted against the possible long-term impacts of priming an immature HPO axis with hormones.
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Apter, D, Viinikka, L, Vihko, R. (1978). Hormonal pattern of adolescent menstrual cycles. J of Clin Endocrinol Metab 47: 944-954.
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