Wednesday, April 20, 2011

AAPA symposium on Evolution through the Life Course: Why we shouldn't prescribe hormonal contraception to twelve year olds

When Dr. Grażyna Jasieńska invited me to give a talk on my thoughts around adolescents and hormonal contraceptives as part of an invited symposium on “Evolution through the Life Course,” I thought it was going to be an embarrassing experience, because I would not be presenting the quantitative data more common at the American Association of Physical Anthropology meetings. But I can’t say no to Grażyna, who has served as a wonderful mentor and cheerleader for almost ten years. Besides, if I can rant on a blog, surely I can let myself rant in a talk every now and then.

What follows is a bloggy version of the talk I gave Thursday the 14th, at the meetings in Minneapolis. Writing this post will, I hope, help me begin to turn this into a manuscript. Normally I wouldn’t dare write something on a blog that I would eventually want to publish. However, this is a piece that would benefit enormously from the kinds of conversations that happen in the science blogosphere. Further, I hope to publish it as an opinion piece well-studded with evidence. I think that by sharing my early thoughts now, my later thoughts will be more sophisticated.

* * *

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

From Vihko and Apter (1984).
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).
Now, 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.

From here
Despite the criticisms I’ve begun to name, 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, post-meeting thoughts

Bristol Palin. Image from here.
In this symposium, Karen Kramer delivered a beautiful paper just before mine on teen pregnancy, and I had some great conversation 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.

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.


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  1. Regarding "telling teenagers the truth;" I'd like to agree, but what's the case for this? Naively: it seems the sorts of perspectives the young adopt differ profoundly from the sorts that we find compelling. To faithfully discharge our responsibilities towards them, by guiding them towards ones that encourage positive outcomes, is truth-telling always the best approach? What else is necessary?

    Also, is the claim that "we can't expect teenagers to be rational" at least naively at tension with the goal of empowering individuals to "weigh the pros and cons as they relate to her own context?"

    Apropos, I love the way you're able to write so precisely and authoritatively about difficult issues. Do you credit this in part to your training as an anthropologist? If a nonspecialist wished to develop similar skills, how would you advise they do so?

  2. Wow, according to Vihko and Apter (1984) my 90% ovulation rate after menarche at 14 is... unusual:)

    Thank you for this! Looking forward to reading more.

  3. I wish someone had told me (or more realistically, my mother or doctor) this when I was 14 and started taking birth control pills as a hormone/cycle "regulator". After 10 years, and plenty of side effects, I finally stopped taking them and discovered I didn't need to have 20 days a month with breakthrough bleeding (I now have 0) and a I have a cycle of ~40 days instead of 28 (I also lost a full bra cup-size by stopping, but that isn't actually so terrible).

  4. Mordecai, thanks for your comment. I think you've hit on exactly the tension I felt when writing the post. There is considerable evidence to suggest that when young women are armed with correct information, they feel more confident in their decisions and empowered. I can only think this is a good thing.

    But yes, you also noticed the place where I'm uncomfortable with this! Humans don't make rational decisions, and we tend to think short-term rather than look at the big picture. Right now, my thinking is that young women need good, truthful information, but also some help with the big picture stuff. Maybe this is where getting doctors, parents and educators better access to correct information will help.

    But again, a part of me thinks that, rather than try to eradicate teen pregnancy, we need to understand that it is a consequence of an evolutionary history where having children in our teen years was not uncommon, and may have even improved our reproductive success. Maybe now it's not so good, but the question is whether we should put policies in place that isolate and shame teen moms (I kinda feel that's what we have, at least in the US), or figure out how to bring them in and help them out.

    QoB, you might have been unusual... but you also could easily have had regular-length cycles but weren't ovulating that often. I suspect you are not unusual at all... at least when it comes to this stuff ;).

    Sarah K, I'm not sure doctors think about these issues the same way anthropologists do, so it might not have occurred to them to say any of this to you. It's a real shame, and it's why I'm trying to work on improving access to this information and also reach out to doctor types to try and show them the awesomeness of anthropology :). I'm glad you are happier with the situation you're in now, either way!

  5. Even if teenagers aren't being particularly rational, there are still plenty of advantages to educating them on this and involving them in the decision-making. They may be wrong about which form of birth control they're going to be able to follow through on using, but making the decision increases their buy-in for using it.

    The discussion normalizes the process of finding an option that works and plugging away until you get there. It normalizes active responsibility for sexual decisions. It normalizes talking about sex with reliable sources of information. It normalizes "weird."

    Even with the possibility (probability?) of unwise decisions, the discussion is a win all around.

  6. Teen pregnancy could be looked at a lot of ways. It is the person's choice at times and sometimes not. I found it interesting that many people have diseases and they do not take it seriously because there isn't enough information about them going on. For example, skin cancer did not seem like a big problem to farmers mostly because they didn't know what it could do to there bodies. I feel that if teenagers learn the long term effects of teen pregnancy then they will be more careful. Of course, they should learn/know the consequences early in their lives.

  7. I remember the prime argument against teen pregnancies (both from the point of view of the teens themselves as well as from teachers/parents) in my school (in Germany) used to be the detrimental effect on the mother's education. This seems to limit how far the situation in non-industralized cultures can be transferred.

    Do you know how whether the use of hormonal contraception by teens differs significantly between Europe and the US?

  8. Stephanie - thank you for saying that so articulately. YES. That is what I was trying to get at.

    Sherry, I think you make an important connection between information and people's experiences with different physiological conditions.

    Anon, we are in agreement. The impact of teen motherhood in industrialized populations is very different than in traditional foragers. However, it's important to consider that a lot of lifestyle factors can impact a teen mother's trajectory: how old she is, her social support, what kinds of reentry programs exist for her to go to school or get a job, whether her partner is involved or invested. To me, we need to consider those issues as well.

    My understanding is that women in the US use it more than other populations, particularly for off-label use. However, I'm not sure of variation particularly in hormonal contraceptive use in adolescents. It's a good question!

  9. Thanks for your thoughtful and informative analysis. The child-rearing social structure of traditional populations to which you refer is something I really value. Mothers are the best resource to new mothers, at any age and at any point along the journey. I hope someday to raise my own children in that kind of supportive community.

  10. The pamphlets always said "long term" hormonal birth control use was 10 years, that we'd studied that in adult women. But that means a 15-year-old would be getting to the end of that time frame at 25. Is she supposed to switch to condoms then? Or accept extended-use risks that women who start at 25 don't have?

    I wish more attention was given to the use of cervical barriers. They seem like they'd be a good fit for teens: no hormonal side effects, no waiting for effectiveness to begin, you can put them in hours or a day in advance, skipping a few days or weeks won't negate or delay the effectiveness the next time you do use it, and there's still the option of using condoms with them. Yes, there's a learning curve, but since cervical barriers like the Femcap are prescription-only, that means there's an opportunity to teach and practice in the office.

  11. Being a young woman who was told for years that I should get on the pill to regulate my cycle I really appreciate this work. It was a battle for my mother and I to decide how to handle the situation. My physician made it seem that my "irregularity" was a problem and needed to be handled. While neither I nor my mother liked the idea of taking extra hormones at such a young age. We are both more of the free spirited, hippie sort and wanted to let my body "do it's thing." When my mom was put in the position that it might be detrimental for me to not be on a regulatory contraceptive it put my mom in a moral dilemma. While I like the idea of knowing and "controlling" my ovulatory cycles, I don't think that it is necessarily good for my body and I think that more research in this area is imperative for all women.

  12. Courtney Getz (249)April 26, 2011 at 12:28 AM

    I feel that we, as a society, have such a negative association with teenagers and pregnancy that we overlook the other potential harmful affects of sexual activity in adolecents, such as sexually transmitted diseases. We also seem to have a tendency to use birth control as a fix-all for anything that we see as wrong with a young women's menstraul cycle. I think we assume that girls go from menarche to regular periods and ovulation quickly, so when a girl has irregular periods for years after menarche we feel thte need to "make her regular" since we see a 28-day cycle as "normal" and anything that is not predictable as "abnormal." I think we jump to conclusions and don't stop to think about variation and what is natural for non-industrial societies, that might have a lifestyle that is closer to our environment of evolutionary adaptation. Doctors should consider these things before putting young women on contraceptives.

  13. Kimberly Anderson (249)April 26, 2011 at 1:23 PM

    As a twenty year old who has been on oral contraceptives for seven years, the first part of this article was a bit frightening. I was put on Loestrin 24 at the age of 13 after doctors were able to rule out endometriosis after an excruciating seven months. I was anemic and had an abnormally heavy menstruation for some one at such a young age. So, to replace the extreme amount of iron I lost, I took iron pills as opposed to sugar pills during my menstrual cycle. Whether or not this was the best option is a moot point by now, so I try my best not to think about it. However, when I learn that this decision could increase my risk of breast cancer, it honestly makes me a bit nauseous. On a lighter note, let me move on to teen pregnancy: I must say that I agree with you 100%. I went to high school with many girls who got pregnant. The only "successes" I saw were in mothers who had solid social support. I also agree that pushing abstinence is the absolute worst option. From a psychological standpoint, telling a teenager not to do something has one result: they are going to do it. I believe the best way to prevent unwanted pregnancy is education. Education, education, education. If teenagers are knowledgable about STD's and the hardships of pregnancy, they are more likely to take more precautions to avoid it.

  14. Jamie Sukowicz (249)April 26, 2011 at 4:13 PM

    I’m glad that you indicated how 10-15% of teenage girls can still get pregnant from not using the pill correctly and not utilizing other forms of birth control. I have been on the pill for almost 2 years now, and although I was instructed to take it at the same time daily, my schedule often does not allow me to take it at the same time every day, unless I carry it with me to work, class, group meetings, sports practice, etc. My doctor was very explicit in warning me that if I do not take it at around the same time every day, then I am not protected from pregnancy, but a lot of girls do not have that information or do not take it seriously. Those who are on it should definitely be more aware of this, though I do think that girls should be given more information before even going on the pill in the first place.
    I know that we discussed in class how research on the effects of the pill has only been conducted in adults, so we do not as clearly understand its effects on adolescents, yet at the same time, researchers cannot promote use of a potentially harmful product to teens. I was wondering if it would be possible to offer the opportunity to girls who intend to take the pill anyways and maybe offer a small monetary compensation or a free prescription for the duration of the study. I personally would have taken that opportunity when I began taking birth control at age 18, and I’d imagine that other girls would too.

  15. Elaine, I hear you. Social support seems to be the key to so many things going well in women's lives, from the early postpartum period, to parenting more generally, to the return to work.

    Anon, such good points about "long-term use," as well as other barrier methods.

    Anna, I know what you mean, and I think that's why this issue is so important. I think mothers are desperate for good information to help their daughters navigate this issue as well, and there are trade-offs to the decision to pursue hormonal contraception.

    Courtney, I agree. At this stage in my life I obviously have very different priorities than fifteen years ago, but looking back upon that age, I would think sexually transmitted diseases to be a far more serious issue than potential pregnancy. But I have the luxury of being older, of having a child and wanting more, and so that changes how I see things. I wonder how we can reach young girls where they are to help them look at all the consequences of unprotected sex, not just the potential for pregnancy.

    Kim, your risk may be increased, and it may not, and there are so many other things you are probably doing in your life that reduce your risk. At least you were put on a low dose! And I agree with you about education around sex in young girls and women, too.

    Jamie, that's a great point about what women are told about the pill. I have met many women who didn't know the importance of taking it at the same time each day. And I too hope we can do some more research -- even retrospective, so on girls who elected to go on hormonal contraception -- to understand their effects on adolescents.

  16. Jenessa Conner (249)May 1, 2011 at 2:37 PM

    I am very interested in this topic as I was put on hormonal contraceptives in junior high and breast cancer that feeds on estrogen runs in my family. Although I do not necessarily disagree with the fact my doctor put me on the pill at such as young age, it is important to be informed. I feel that young girls know little about the pill, and see it as a thing you should be put on once you hit high school. Findings like this can keep women informed and promote reproductive health.

  17. I came here, late, from the link on your SciAm blog. My soapbox about hormonal BC is the lack of information about side effects other than breakthrough bleeding. Specifically, in the late 90's and early 00's, when my high school and college friends and I were almost all on hormonal BC, no doctor or NP EVER told us that it could cause a loss of libido, or an increase in anxiety or depression. In fact, these side effects are now note on some prescriber information. I, and many of my friends, never knew to attribute the loss of libido in long-term relationships to the BC we were using. I was also using the patch and then the ring, so that I didn't have to take the pills at the same time every day.

    A friend who worked in a hormone/pseudohormone lab warned me one week to get OFF the BC patch ASAP - they had mis-calculated the estrogen dose and how quickly it was cleared from the body. If you recall, it was not pulled off the marked but ceased all advertisement and was replaced with the ring. When I was on the patch I had weight gain and especially very unusual increase in breast size and tenderness. Scary when you think about estrogen's effect on breast tissue and breast cancer...

    Overall, I wish I had known more about the side effects of hormonal BC instead of just beginning it as a matter of course once I became sexually active. Now an adult, I got an IUD. While there are side effects to the device, the resumption of my normal hormone cycling, and a near-complete resolution of the side effects from hormonal BC, have made it an excellent choice.

    Soapbox over!

  18. Now its very easy to contact with doctor .