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Why We Shouldn’t Prescribe Hormonal Contraception to 12 Year Olds

The views expressed are those of the author and are not necessarily those of Scientific American.

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This is a re-post, with slight editing, of a piece I wrote on the old blog after last year’s AAPA meetings. I would like to keep thinking on this topic so thought I would share this before I write anything new for the Sci Am space.

Variation in adolescent menstrual cycles, doctor-patient relationships, and why we shouldn’t prescribe hormonal contraceptives to twelve year olds

The United States has the highest rate of unintended teen pregnancy among industrialized nations. So I can understand why there are so many papers, and such a great effort, to get young girls on hormonal contraception (Clark et al. 2004; Clark 2001; Gerschultz et al. 2007; Gupta et al. 2008; Krishnamoorthy et al. 2008; Ott et al. 2002; Roye 1998; Roye and Seals 2001; Sayegh et al. 2006; Zibners et al. 1999).

But I’ve noticed two things: first, that hormonal contraception is used imperfectly in this population, with some estimates that 10-15% of adolescents on hormonal contraception still get pregnant (Gupta et al. 2008). Second, discontinuation rates for hormonal contraception in young girls are high, with many girls complaining about side effects, particularly breakthrough bleeding (Clark et al. 2004; Gupta et al. 2008; Zibners et al. 1999). I have to admit some concern over the fact that many of the papers I read that mentioned these discontinuation rates and side effects were almost condescending in their tone. The implication was that the side effects weren’t a big deal.

One of the ways clinicians and sexual health educators are trying to improve hormonal contraceptive use in adolescents is to emphasize their off-label use as a “regulator” – that is, the pill can regulate your cycle, regulate your mood, regulate your skin. The idea is to emphasize the positive effects of hormonal contraception to combat the side effects young girls both worry about, and actually experience. This also tends to produce campaigns and commercials with images of idealized young women that young girls would want to model themselves after – skinny, confident, and of course very feminine.

This is not my favorite idea. The pill should not regulate the cycles of adolescent girls who experience moderate variation in their cycles, which, as it turns out, is what characterizes the normal adolescent menstrual cycle. (This is independent from debilitating, pathological experiences of the menstrual cycle or menstrual bleeding, which occur in a very small percentage of women.)

Allow me to explain.

From Vihko and Apter (1984)

From Vihko and Apter (1984). These are from old site so you can click to embiggen.

Vihko and Apter (1984) showed that there is variation in age at menarche, and that that variation tells us something about how long it should take an adolescent to start to achieve regular ovulatory cycles. The later your age at menarche, the longer you will experience irregular cycles. However, even in girls with ages at menarche twelve and under, it still took on average five years to achieve regular cycles. This indicates that, in adolescents, irregularity is in fact regular.

Lipson and Ellison (1992) have also looked at age-related variation in progesterone concentrations. Progesterone is the sex steroid hormone secreted by the ovary after ovulation, which is in the luteal phase. Luteal phase function is the one that seems to be the most variable within and between populations, and so progesterone is a great way to understand how female bodies vary. They found that those with the lowest hormone concentrations were on the extreme ends of their sample – 18-19 year olds, and 40-44 year olds and, as you might expect, hormone concentrations were higher as you moved towards the middle of that age range. So both younger and older women have low hormone concentrations relative to women in their reproductive prime, which is 25-35 years of age. But of course, this means that low hormone concentrations when you are in those early or late age ranges means that you are normal for your age.

From Lipson and Ellison (1992)

From Lipson and Ellison (1992). These are from old site so you can click to embiggen.

Despite these issues, there are substantial benefits to hormonal contraception in adult women. When women take hormonal contraception in adulthood, particularly in the 25-35 year range, they are very effective contraception. The pill also may reduce risk of reproductive cancers, though results are mixed (Collaborative Group 1996; Collaborative Group 2008; Kahlenborn et al. 2006; Marchbanks et al. 2002; Modan et al. 2001; Narod et al. 1998; Smith et al. 2003). And of course, off-label use to treat painful periods or premenstrual syndrome can be beneficial for many (Fraser and Kovacs 2003).

However, the benefits of hormonal contraception in adults seems to be limited to more industrialized populations. Bentley (1994; 1996) first raised these concerns. She discussed the possible genetic, ethnic and developmental differences between women that could produce variation in pharmacokinetics, which could in turn vastly change the experience and efficacy of hormonal contraception in a global context. Virginia Vitzthum and others have also shown that there are high discontinuation rates and complaints of breakthrough bleeding in rural Bolivian women on hormonal contraception (Vitzthum and Ringheim 2005; Vitzthum et al. 2001). Other studies have shown similar discontinuation rates and side effects in other non-industrial populations (de Oliveira D’Antona et al. 2009; Gubhaju 2009).

You might notice that the issues in non-industrial populations mirror what has been seen in industrial adolescent girls. This isn’t surprising, given that they also have in common fewer ovulatory cycles and lower hormone concentrations.

So, I worry about whether the clear benefits of hormonal contraception in adulthood can be applied to adolescent girls, some as young as eleven or twelve years old. With the imperfect administration and high discontinuation rates, they aren’t that great as contraception. But there are additional, physiological concerns. What are the effects of giving doses of hormones to young girls with newly developing hypothalamic-pituitary-ovarian axes? The variation I mentioned before, where irregularity is regular in adolescence, is because the feedback loop between the brain and the gonads is priming and developing in this period, and this takes time. The sensitivity of the feedback loop is being set. If we flood this feedback loop with extra hormone, does this alter its sensitivity? It is a question worth testing.

Further, if we flood this immature system that normally has irregular cycles and low hormones, are we increasing lifetime estrogen exposure? High lifetime estrogen exposure is a risk factor for breast cancer and other reproductive cancers. Is it possible that hormonal contraception in adolescence could have the opposite effect of hormonal contraception in adulthood? Again, we need to test this hypothesis.

Future work on this topic includes asking whether adolescent menstrual cycle variation is any different today than twenty to thirty years ago. The only data we have (at least that I know of) are from the aforementioned 1984 and 1992 papers, and maybe some derivative papers using the same datasets. But we all know there have been massive changes in body composition, diet and health in the last few decades that deserve consideration. So, this work needs to be re-done on a current population.

We also need to ask how adolescent reproductive functioning varies within and between populations. While this has been studied extensively in adult women, we don’t have a sense of adolescent population variation. This will give us a sense of what ecological variables produce variation not only in age at menarche, but in how long cycle irregularity persists and reproductive hormone concentrations.

Some additional, provocative thoughts
In this symposium where I gave this talk, Karen Kramer delivered a beautiful paper just before mine on teen pregnancy, and I had some great conversations with session participants and attendees, that has further evolved my own thinking on this issue. I want to say something just a little provocative:

While I think teen pregnancy should be avoided, culturally we overstate its dangers and consequences because we have a real problem with young people reproducing. This can lead young girls to overlook potentially more serious issues like sexually transmitted infections, HIV, and cervical cancer, all of which girls and women are at risk for if they use only hormonal contraception and have otherwise unprotected sex.

Let me explain two important points here. First, in most industrialized nations we are not set up well to support young mothers because of the way families are isolated, yet social support is a strong predictor of birth weight, postpartum depression, and labor progression (Collins et al. 1993; Feldman et al. 2000; Turner et al. 1990). So there are very strong and obvious reasons why teen pregnancy and motherhood can be incredibly challenging in industrialized environments. I wonder sometimes if that lack of cultural support is related to a fear that more young girls will get pregnant if they feel they have permission to procreate. This is similar to the argument in favor of abstinence-only sex ed: if they don’t know their options, or are shamed into believing this option is the worst possible one, then of course they won’t make them. But adults aren’t rational. I’m unsure why we expect adolescents to be.

Painted rock that reads "Ellen congrats on beating teen pregnancy! Happy 20th birthday LSC 2010"

Birthday gift for a Northwestern student. Image by vxla on Flickr, Creative Commons license.

We also need to consider population variation in adolescence and pregnancy. Variation in age at first birth in traditional populations is quite wide, from sixteen to almost twenty six years of age (Walker et al. 2006). In more traditional populations you see a lot of allomothering and grandmothering to support first time mothers, who are often teenagers (Hawkes 2003; Hrdy 2009; Kramer 2005; Kramer 2008). So, support systems are built in, and it does not alter the trajectory of your life in the same way teen pregnancy does in an industrialized population.

This range of variation in age at first birth, and the fact that most of those young mothers do just fine, perhaps even end up with higher reproductive success, leads me to my second point: the physiological evidence against teen pregnancy might be overstated. In her talk, Karen discussed a paper of hers in the American Journal of Physical Anthropology that described the negative health outcomes of teen pregnancy (Kramer 2008). In it, she reviewed literature that suggests that when you control for lack of prenatal care, first pregnancy, and low socioeconomic status, the common assumption that pregnancy is harmful to teens is significantly weakened.

Further, in her own work with Pumé foragers in Venezuela, mothers under the age of fourteen were the only group to have greater infant mortality than the referent group of late reproducers (Kramer 2008). Yet when we teach young girls about their bodies, we tell them that their bodies are not equipped to have babies in their teens and that there are extreme consequences (in fact, I have said exactly this in the past). The reality is that those consequences are worst for very young teens, and may not be as significant in older teens.

Am I advocating teenagers get pregnant? Absolutely and unequivocally no. But I think they need access to correct information, not skewed information. This means telling them the truth about our uncertainties about the health implications for hormonal contraception in adolescence, it means educating them about the importance of barrier methods, and it means making sure they understand the health risks associated with unprotected sex.

This is a nuanced issue that requires nuanced thinking. Despite my concerns about adolescent hormone contraceptive use, there are problems with barrier methods as well, particularly when there may be a cultural bias against their use, or in situations when women cannot safely use contraception in an obvious way with their partner (Gupta et al. 2008). Again, what is important here is conveying correct information, so that each individual can weigh the pros and cons as they relate to her own context. This means it could be an excellent idea for some twelve year olds to be on hormonal contraception, and a terrible one for other girls through the age of twenty. It is going to have to be up to them.

I hope this post generates some thinking and some conversation, and I welcome people who might push me in a different direction than where I’m currently thinking. I am sharing this now, before putting it together as a manuscript, to provoke thoughts and comments.

References (watch out! Ref list almost as long as post!)

Bentley GR (1994). Ranging hormones: do hormonal contraceptives ignore human biological variation and evolution? Annals of the New York Academy of Sciences, 709, 201-3 PMID: 8154705

Bentley GR. 1996. Evidence for interpopulation variation in normal ovarian function and consequences for hormonal contraception. In: Rosetta LaM-T, C.G.N., editor. Variability in human fertility. Cambridge, UK: Cambridge University Press. p 46-65.

Clark, L. (2004). Menstrual irregularity from hormonal contraception triggers significant reproductive health fears in adolescent girls Journal of Adolescent Health, 34 (2), 123-124 DOI: 10.1016/j.jadohealth.2003.11.091

Clark, L. (2001). Will the Pill Make Me Sterile? Addressing Reproductive Health Concerns and Strategies to Improve Adherence to Hormonal Contraceptive Regimens in Adolescent Girls Journal of Pediatric and Adolescent Gynecology, 14 (4), 153-162 DOI: 10.1016/S1083-3188(01)00123-1

Collaborative group (1996). Breast cancer and hormonal contraceptives: collaborative reanalysis of individual data on 53 297 women with breast cancer and 100 239 women without breast cancer from 54 epidemiological studies The Lancet, 347 (9017), 1713-1727 DOI: 10.1016/S0140-6736(96)90806-5

Collaborative Group on Epidemiological Studies of Ovarian Cancer, Beral V, Doll R, Hermon C, Peto R, & Reeves G (2008). Ovarian cancer and oral contraceptives: collaborative reanalysis of data from 45 epidemiological studies including 23,257 women with ovarian cancer and 87,303 controls. Lancet, 371 (9609), 303-14 PMID: 18294997

Collins, N., Dunkel-Schetter, C., Lobel, M., & Scrimshaw, S. (1993). Social support in pregnancy: Psychosocial correlates of birth outcomes and postpartum depression. Journal of Personality and Social Psychology, 65 (6), 1243-1258 DOI: 10.1037//0022-3514.65.6.1243

D’Antona Ade O, Chelekis JA, D’Antona MF, & Siqueira AD (2009). Contraceptive discontinuation and non-use in Santarém, Brazilian Amazon. Cadernos de saude publica / Ministerio da Saude, Fundacao Oswaldo Cruz, Escola Nacional de Saude Publica, 25 (9), 2021-32 PMID: 19750389

Feldman PJ, Dunkel-Schetter C, Sandman CA, & Wadhwa PD (2000). Maternal social support predicts birth weight and fetal growth in human pregnancy. Psychosomatic medicine, 62 (5), 715-25 PMID: 11020102

Fraser IS, & Kovacs GT (2003). The efficacy of non-contraceptive uses for hormonal contraceptives. The Medical journal of Australia, 178 (12), 621-3 PMID: 12797849

Gerschultz KL, Sucato GS, Hennon TR, Murray PJ, & Gold MA (2007). Extended cycling of combined hormonal contraceptives in adolescents: physician views and prescribing practices. The Journal of adolescent health : official publication of the Society for Adolescent Medicine, 40 (2), 151-7 PMID: 17259055

Gubhaju, B. (2009). Barriers to Sustained Use of Contraception in Nepal: Quality of Care, Socioeconomic Status, and Method-Related Factors Biodemography and Social Biology, 55 (1), 52-70 DOI: 10.1080/19485560903054671

Gupta, N., Corrado, S., & Goldstein, M. (2008). Hormonal Contraception for the Adolescent Pediatrics in Review, 29 (11), 386-397 DOI: 10.1542/pir.29-11-386

Hawkes, K. (2003). Grandmothers and the evolution of human longevity American Journal of Human Biology, 15 (3), 380-400 DOI: 10.1002/ajhb.10156

Hrdy SB. 2009. Mothers and others: the evolutionary origins of mutual understanding: Belknap Press.

Kahlenborn, C., Modugno, F., Potter, D., & Severs, W. (2006). Oral Contraceptive Use as a Risk Factor for Premenopausal Breast Cancer: A Meta-analysis Mayo Clinic Proceedings, 81 (10), 1290-1302 DOI: 10.4065/81.10.1290

Kramer, K. (2005). Children’s Help and the Pace of Reproduction: Cooperative Breeding in Humans Evolutionary Anthropology: Issues, News, and Reviews, 14 (6), 224-237 DOI: 10.1002/evan.20082

Kramer KL (2008). Early sexual maturity among Pumé foragers of Venezuela: fitness implications of teen motherhood. American journal of physical anthropology, 136 (3), 338-50 PMID: 18386795

KRISHNAMOORTHY, N., SIMPSON, C., TOWNEND, J., HELMS, P., & MCLAY, J. (2008). Adolescent Females and Hormonal Contraception: A Retrospective Study in Primary Care Journal of Adolescent Health, 42 (1), 97-101 DOI: 10.1016/j.jadohealth.2007.06.016

Lipson, S., & Ellison, P. (2008). Normative study of age variation in salivary progesterone profiles Journal of Biosocial Science, 24 (02) DOI: 10.1017/S0021932000019751

Marchbanks, P., McDonald, J., Wilson, H., Folger, S., Mandel, M., Daling, J., Bernstein, L., Malone, K., Ursin, G., Strom, B., Norman, S., Wingo, P., Burkman, R., Berlin, J., Simon, M., Spirtas, R., & Weiss, L. (2002). Oral Contraceptives and the Risk of Breast Cancer New England Journal of Medicine, 346 (26), 2025-2032 DOI: 10.1056/NEJMoa013202

Modan B, Hartge P, Hirsh-Yechezkel G, Chetrit A, Lubin F, Beller U, Ben-Baruch G, Fishman A, Menczer J, Struewing JP, Tucker MA, Wacholder S, & National Israel Ovarian Cancer Study Group (2001). Parity, oral contraceptives, and the risk of ovarian cancer among carriers and noncarriers of a BRCA1 or BRCA2 mutation. The New England journal of medicine, 345 (4), 235-40 PMID: 11474660

Narod, S., Risch, H., Moslehi, R., Dørum, A., Neuhausen, S., Olsson, H., Provencher, D., Radice, P., Evans, G., Bishop, S., Brunet, J., Ponder, B., & Klijn, J. (1998). Oral Contraceptives and the Risk of Hereditary Ovarian Cancer New England Journal of Medicine, 339 (7), 424-428 DOI: 10.1056/NEJM199808133390702

Ott, M., Adler, N., Millstein, S., Tschann, J., & Ellen, J. (2002). The Trade-Off between Hormonal Contraceptives and Condoms among Adolescents Perspectives on Sexual and Reproductive Health, 34 (1) DOI: 10.2307/3030227

ROYE, C. (1998). Condom use by hispanic and african-american adolescent girls who use hormonal contraception Journal of Adolescent Health, 23 (4), 205-211 DOI: 10.1016/S1054-139X(97)00264-4

Roye CF, & Seals B (2001). A qualitative assessment of condom use decisions by female adolescents who use hormonal contraception. The Journal of the Association of Nurses in AIDS Care : JANAC, 12 (6), 78-87 PMID: 11723916

SAYEGH, M., FORTENBERRY, J., SHEW, M., & ORR, D. (2005). The developmental association of relationship quality, hormonal contraceptive choice and condom non-use among adolescent women Journal of Adolescent Health, 36 (2), 97-97 DOI: 10.1016/j.jadohealth.2004.11.009

SMITH, J., GREEN, J., DEGONZALEZ, A., APPLEBY, P., PETO, J., PLUMMER, M., FRANCESCHI, S., & BERAL, V. (2003). Cervical cancer and use of hormonal contraceptives: a systematic review The Lancet, 361 (9364), 1159-1167 DOI: 10.1016/S0140-6736(03)12949-2

Turner, R., Grindstaff, C., & Phillips, N. (1990). Social Support and Outcome in Teenage Pregnancy Journal of Health and Social Behavior, 31 (1) DOI: 10.2307/2137044

Vihko R, & Apter D (1984). Endocrine characteristics of adolescent menstrual cycles: impact of early menarche. Journal of steroid biochemistry, 20 (1), 231-6 PMID: 6231419

Vitzthum, V., & Ringheim, K. (2005). Hormonal Contraception and Physiology: A Research-based Theory of Discontinuation Due to Side Effects Studies in Family Planning, 36 (1), 13-32 DOI: 10.1111/j.1728-4465.2005.00038.x

Vitzthum, V. (2001). Vaginal bleeding patterns among rural highland Bolivian women: relationship to fecundity and fetal loss Contraception, 64 (5), 319-325 DOI: 10.1016/S0010-7824(01)00260-8

Walker, R., Gurven, M., Hill, K., Migliano, A., Chagnon, N., De Souza, R., Djurovic, G., Hames, R., Hurtado, A., Kaplan, H., Kramer, K., Oliver, W., Valeggia, C., & Yamauchi, T. (2006). Growth rates and life histories in twenty-two small-scale societies American Journal of Human Biology, 18 (3), 295-311 DOI: 10.1002/ajhb.20510

ZIBNERS, A., CROMER, B., & HAYES, J. (1999). Comparison of continuation rates for hormonal contraception among adolescents Journal of Pediatric and Adolescent Gynecology, 12 (2), 90-94 DOI: 10.1016/S1083-3188(00)86633-4

Kate Clancy About the Author: Dr. Kate Clancy is an Assistant Professor of Anthropology at the University of Illinois. She studies the evolutionary medicine of women’s reproductive physiology, and blogs about her field, the evolution of human behavior and issues for women in science. Find her comment policy here. Follow on Twitter @KateClancy.

The views expressed are those of the author and are not necessarily those of Scientific American.

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  1. 1. rusalka 3:15 pm 04/27/2012

    Wonderful as always. The “additional, provocative thoughts” are excellent, and a perspective I’ve never seen before.

    One question that came immediately to mind when you said, “The United States has the highest rate of unintended teen pregnancy among industrialized nations. So I can understand why there are so many papers, and such a great effort, to get young girls on hormonal contraception.”: what are the other industrialized nations doing differently? My immediate assumption is that it’s probably not that they’re putting more 12-year-olds on hormonal birth control than we are, but do you have information on this? I’d guess it’s probably a complex combination of factors (better sex ed? easier access to contraceptives or abortion? greater income equality?), not all of which we have the power to change in the U.S., but hormonal contraceptives seem like a bit of a weak stopgap.

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  2. 2. doridoidae 4:48 pm 04/27/2012

    Perhaps it’s better that they hold an aspirin between their knees?

    Look, while I agree that this isn’t ideal, that 12 year olds are probably not responsible enough to take a pill every day (which they would need to for other medical conditions) and that 12 year olds probably shouldn’t be having sex at all, I have to point out how quickly you glossed over the rest of what’s in your sub title, including things like “irregular periods”.

    Perhaps you might want to include that there are always exceptions.

    (and here comes the purely anecdotal evidence…)

    My 11 year old daughter (well, 7 years ago 11 year old daughter) had what a quick reading might brush off as “irregular periods” the irregularity is that she was bleeding… heavily… and becoming physically ill with it about 20 days out of 30. Her life was hell until she went on “the pill”. She was on it for about a year and a half, until she matured physically more and her body started regulating more normally.

    and yes, I know that my daughter’s experience is not a large enough sample size to draw a reasonable conclusions from, but you also noted in your article that a lot of work needs to be done on studying onset of menses in young girls. Maybe that work needs to be done before we can start drawing conclusions about the usefulness of hormonal contraceptives. With girls getting their periods at younger and younger ages, I wonder how many other young girls are having similar problems, and require some sort of medical intervention.

    In any case, I think while we have to acknowledge that any medicine, no matter what the use, should be used with caution and awareness in ANY population, we shouldn’t start making blanket value judgements on one form of medication, especially where no good alternative exists.

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  3. 3. Kate Clancy in reply to Kate Clancy 4:59 pm 04/27/2012

    Hi doridoidae, perhaps you missed this in my post:

    “The pill should not regulate the cycles of adolescent girls who experience moderate variation in their cycles, which, as it turns out, is what characterizes the normal adolescent menstrual cycle. (This is independent from debilitating, pathological experiences of the menstrual cycle or menstrual bleeding, which occur in a very small percentage of women.)”

    We all read through the lens of our own experience, and I appreciate that you and your daughter probably had a rough time of things. I’m glad the pill provided relief for her. But as you yourself point out, your daughter is an n = 1. The many articles I cited here offer an alternative interpretation for the majority of young girls, and do not represent a blanket value judgment but one informed by many years of education and my own academic research.

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  4. 4. Kate Clancy in reply to Kate Clancy 5:01 pm 04/27/2012

    Hi rusalka, what a great question. I honestly don’t know why teen pregnancy isn’t as high in other countries. I have read a fair bit about differences in outcomes between kids who get comprehensive versus abstinence sex ed, so that might be one place to look first, as you yourself suggest. It would be interesting to look at cultural differences, and differences in age at sexual self-concept, in first sexual experiences, and first sexual intercourse. I wonder if they’re having as much sex but protecting themselves better, or if they’re waiting longer.

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  5. 5. Dulcinea 7:18 pm 04/27/2012

    What an interesting post and, apparently, very provocative for some! Just my two cents but I wonder if the low prevalence of teen pregnancy in other countries is related to better access to healthcare and fewer obstacles to teens in search of information/medical care relating to sexuality. I strongly suspect teen pregnancy is the US is associated with indicators of SES (highest incidence likely to be for poorest individuals/counties??). It would be interesting to see if teen pregnancy was related to median national incomes or, perhaps more specifically to measures of the difference between top and bottom national incomes (something measured by the GINI coefficient).


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  6. 6. em_allways_right 11:04 pm 04/27/2012

    Regarding teen pregnancy: you talk about the teen body being able to handle pregnancy, yet you ignore the psychological and financial hartship for both the mother and the baby.

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  7. 7. Ordover 11:56 pm 04/27/2012

    It has long been my thought that the so-called problem with teen pregnancy is that as our industrialized society is currently set up, teens are not economically viable. So this is a problem of economics, not biology.

    Also, there exist a variety of hormonal implants that could be given to teens routinely that would not require teens to reliably take a pill daily – it seems to me that would lead to much higher compliance rates.

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  8. 8. jtdwyer 12:31 am 04/28/2012

    Of the undeveloped countries of the world, is teen pregnancy also very high? If teens in the U.S. can’t reliably use contraceptives, how can those in underdeveloped regions be relied upon to do so?

    I find that overall population growth rates for African and the Middle East exceed 50% for the past couple of decades. What method of birth control might be effective in reducing unsupportable childbirths in overpopulated regions?

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  9. 9. Jjo95117 1:29 am 04/28/2012

    An excellent article. Superbly written.

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  10. 10. Kate Clancy in reply to Kate Clancy 9:13 am 04/28/2012

    Hi em_allways_right, I wonder if you saw this part of the post?

    “First, in most industrialized nations we are not set up well to support young mothers because of the way families are isolated, yet social support is a strong predictor of birth weight, postpartum depression, and labor progression (Collins et al. 1993; Feldman et al. 2000; Turner et al. 1990). So there are very strong and obvious reasons why teen pregnancy and motherhood can be incredibly challenging in industrialized environments.”

    I don’t think saying I ignore these things is accurate. Further, the focus of the post is on the physiological impact of hormonal contraception on the adolescent, which happens to be negative in normal girls (though, again, possibly quite positive in girls with some pathologies).

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  11. 11. Kate Clancy in reply to Kate Clancy 9:15 am 04/28/2012

    Hi Ordover, I agree that in girls where contraception is necessary (again, as opposed to “regulating” a cycle that doesn’t need regulation) that there are implants and injections available that would probably be more reliable than a daily pill. Many young women have good experiences with Depo-Provera, for instance. My main concern in this piece is the number of girls who are being prescribed any kind of hormonal contraception — pills, rings, implants, injections — who don’t need them, but are also increasing their risk of certain diseases later in life, and possibly permanently altering their own sensitivity to their natural hormones.

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  12. 12. Kate Clancy in reply to Kate Clancy 9:22 am 04/28/2012

    Hi jtdwyer, thanks for writing. Teen pregnancy is likely high in those populations, but it is not identified as a cultural or health problem, most likely. They likely have an age at later menarche but earlier age at first birth, and little to no access to contraception. Energetic constraint, and maybe also pathogen load, is going to reduce their cycle to cycle fecundity in the more extreme environments, but there is still definitely a need for contraception in some of those populations, for women who want it. There is a huge need to reduce total number of pregnancies and reduce maternal and infant mortality among many developing populations.

    As for your statement about population growth, I’ll have to admit ignorance. But in terms of birth control in these populations, they face the same challenges as we do for industrialized adolescents: birth control was never designed for them, so the concentrations are probably too high. Women in developing countries report lots of negative side effects with hormonal contraception and their discontinuation rates are high. So there need to be better, lower hormone options that are explicitly tested in adolescents and those in developing populations if we want a viable solution.

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  13. 13. Kate Clancy in reply to Kate Clancy 9:23 am 04/28/2012

    Thank you, Jjo95117!

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  14. 14. penglish2 3:27 pm 04/30/2012

    Hormonal contraceptives’ primary function is to prevent pregnancy.

    Pregnancy is pretty dangerous.

    Hormonal contraceptives may not be perfect – and certainly aren’t tailored to adolescent bodies – but the dangers of pregnancy are vastly greater than the dangers of hormonal contraceptives. Pretty well any adverse reaction associated with contraceptives is much more (often orders of magnitude more) likely with pregnancy than with hormonal contraceptives.

    It’s true that oral contraceptives may not be taken reliably. That’s one reason why implants are so popular for this age group. They can also use lower doses than tablets – most of the drug when taken by mouth is metabolised in the liver (causing some of the adverse reactions in the process) – blood from the guts goes first to the liver, then to the rest of the body; whereas when it gets straight into the blood stream, bypassing the liver, lower doses can be used.

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  15. 15. Kate Clancy in reply to Kate Clancy 3:43 pm 04/30/2012

    Thanks for writing, penglish2. I think you might be missing two of the primary points of this post:

    1) Many young girls are on hormonal contraceptives for non-contraceptive purposes.

    2) Pregnancy in teenagers is not as dangerous as we once thought.

    These kinds of insights require us to try and be nuanced about the best way to move forward. I am not sure I agree with an open and shut perspective, that simply says “pregnancy is worse than hormonal contraception.” I’m pretty sure breast cancer is worse than pregnancy, and hormonal contraception in adolescence increases the risk of breast cancer.

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  16. 16. Diesel67 5:46 pm 04/30/2012

    The most effective form of birth control is what it always has been – self control.

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  17. 17. ssellers 2:29 am 05/4/2012

    Kate–great post as usual. Not to get too much off-topic, but how much is known about variation in menarche ages in non-industrial populations and how this affects the regularity of cycles in teenage years? You seem to have established rather well that cycles for these populations are generally less frequent and less regular than for women in the industrialized world (although I’m sure this will change as less industrialized populations start to act more like we do in the west). But within non-industrialized populations, do we see greater irregularity in cycle duration for teenage-aged girls than for older women in their communities, as is seen in the west? Do we know if this irregularity in non-industrialized teenagers is greater or lesser than that of girls in the west?

    On another point, I’m not so sure I am sold by your call to bring nuance to these issues. Not because I think you’re wrong about your interpretation or by your desire to look at them in a nuanced fashion. Academics more acutely than most recognize the complexity of the world around them and the issues they study, and I think nuance is an accurate way of looking at these issues. But accurate interpretations do not necessarily lend themselves to effective messages, particularly when it comes to helping populations with still-developing brains make health care decisions.

    If nuance is brought about by experience and by a detailed look at the world around us, then I would suggest that teenagers generally lack the life experience or the perspective to appreciate the nuance and complexity behind the science you’re discussing. So when communicating to teens about birth control and other reproductive health-related topics, to simplify the conversation and to “just say no” will work about as well as it did with drugs, which is to say terribly. But to go to the other extreme, and deliver a message that is too muddied, that suggests there is still too much uncertainty to really have any grounding to make effective choices about your body might be equally dangerous. I worry that a message layered with too much nuance or uncertainty might lead people to make poor decisions or to simply be indecisive when making good decisions is critical. So while I don’t think that’s where you’re leading, I would just caution against advocating for using the same messaging/tone that you use in an academically-oriented blog post such as this when crafting health education messages for teenagers. Now let me add the disclaimer that I’m not an expert in the developmental psych literature (I’m still trying to get a grasp on Public Finance), so I don’t want to suggest that I’m making these claims based on an extensive literature review (which I haven’t the time, nor the background to conduct at the moment). But I would just caution against the overuse of nuance as a barrier to getting teenagers to make good decisions. Call me paternalistic if you want, but that’s my concern.

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  18. 18. Kate Clancy in reply to Kate Clancy 9:42 am 05/4/2012

    Hi ssellers, thanks for your comment. As far as I know, no one has looked at adolescent menstrual variation in non-industrialized populations (but hush! I want to, and soon! ;) ). I think this is a crucial piece of the puzzle and you’ve identified the questions that make it important.

    And I appreciate your point about nuance. On the one hand, I do think that teens lack some kinds of emotional maturity, but I also think we tend to see them as second class citizens without the intellect to understand advanced concepts. I think it’s worth having open conversations with young people to see what THEY think, not just what WE think they they, or what we WANT them to think. And from there, we can figure out how much nuance to build in. I take a lot of my perspective about what teens can handle from the website Scarleteen.

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  19. 19. ssellers 8:45 pm 05/5/2012

    I think that’s a fair response. Teaching, like all professions, is a craft, and is intended to serve the needs of others. But teaching is somewhat unique in that your “clients” don’t always understand their needs–developing that understanding is part of a teacher’s job. That doesn’t mean teaching can’t be a two-way street–teachers need to listen to all their students and incorporate feedback appropriately.

    Does this mean teachers should treat students as second-class citizens? No, and I think making assumptions about what students know or what we think they should know is generally a dangerous thing. But a good teacher does not need to assume. A good teacher learns, much as students do. The more time a teacher spends with a group of students, he or she has a better feel for what degree of nuance students can handle. While nuance and complexity are characteristics of accurate interpretations of reality, people tend to make decisions and judgments based on simplifications of reality to various degrees (because most of us don’t have time to read the biological anthropology literature). Nuance should not be lionized in the classroom to the degree that it precludes effective decision-making by young people making important health care choices.

    On another note, and please don’t take this the wrong way, I think communicating with my professors in college might have felt less stressful had they used more emoticons. :)

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