The gynecological risks of contraception for young girls depend on the method used. Risks are almost nonexistent for oral contraceptives (OCs) and are significant only for IUDs. OCs are the only completely effective method. Users should be informed about the possibility of slight bleeding irregularities, which are usually transitory. A more serious problem, postpill amenorrhea, is apparently not a function of the age of the user but of the dose and the possible existence of cycle problems such as episodes of spontaneous amenorrhea before OC use. Low- dose combined pills disturb hypothalamopituitary function less profoundly than do higher dosed formulations and are preferable for that reason. Periodic interruption of OC use to verify cycle return has been a longstanding practice but has not been demonstrated to be effective in reducing the incidence of postpill amenorrhea. It does increase the possibility of undesired pregnancy and should be avoided in adolescents. Early fears that use of sexual steroids would limit the bone growth of young girls have not been confirmed. The major growth spurts precede puberty. A recent fear is more serious: that the later risk of breast cancer is increased by use of an OC before the 1st normal pregnancy. The methodology of the retrospective study that suggested increased risk has been criticized. It is possible that early pregnancy protects against breast cancer rather than OC use before pregnancy increasing risk. Fears that the pregnancy risk of forgetting 1 or more low-dosed pills are too great do not seem realistic enough to justify avoiding their use in adolescents. It should be sufficient to recommend that the 1st pill be taken on the 1st cycle day and that supplemental precautions be taken in case pills are forgotten on 2 consecutive days. Fears that low-dose combined OCs do not inhibit ovarian folliculogenesis sufficiently do not seem to warrant avoiding low-dosed formulations. Triphasics are associated with slightly higher serum estradiol levels at the beginning of treatment, but levels are comparable to those of other formulations by the 3rd week of use. Low-dose synthetic progestin-only formulations do not seem appropriate for adolescents because of their higher failure rate, bleeding problems, and other side effects. IUDs should be avoided because of the significant risk of infection. They should be considered a last resort if no other method is possible. Diaphragms and condoms can be used on an as needed basis and offer protection against sexually transmitted diseases. Their higher failure rate and interruption of coitus are major disadvantages.
Although information on contraception is readily available and a 1974 French law allows adolescents to receive contraceptives in family planning centers at no cost and without parental consent, over 1/2 of French adolescents have their 1st sexual intercourse with contraceptive protection and 13,000 adolescents under 17 become pregnant each year. Factors in the imperfect access of adolescents to contraception include conflicts with adult sources of contraception information, faulty perception of the risk of pregnancy, and presentation of contraceptive information in rational and technical terms to the exclusion of affective and relational aspects. Practical difficulties in finding a physician and paying for the consultation and fear of the examination itself are obstacles for some adolescents. The ambivalence of family planning providers faced with very young clients can be a significant barrier to access. At the 1st consultation, the adolescent should be seen alone. A complete medical consultation should be carried out including discussion of the adolescent's activities, habits, and affective life. Information on sexually transmitted diseases should be provided in a straightforward way, with possible symptoms included. The consultation usually ends in prescription of a combined oral contraceptive (OC), but for undecided adolescents or those with episodic sex lives several prescriptions may be given to provide a choice between OCs, condoms and spermicides, or the morning-after pill. Follow-up usually entails evaluation of weight and blood pressure, a gynecological examination with annual Pap smear, and management of secondary effects. A breast examination is necessary because of the sensitivity of breasts to estrogen at this age. OCs with a progestin dominance should be chosen for adolescents. In case of menstrual headaches the OC should be modified or terminated. Minor side effects such as acne are often the cause of termination and should not be ignored. Follow-up should be frequent and regular in the 1st year. Very young adolescents should be given standard-dose OCs. In case of absolute contraindications to combined OCs, a low-dose progestin pill may be selected. A low-dose pill and dietary counselling may be provided in case of weight gain, and an estrogen-dominant pill may help in case of moderate acne. OCs should be stopped in the event of hepatitis or expected surgery. Combined OCs are usually without medical contraindications and well tolerated by adolescents.
Epidemiological studies clearly indicate that combined oral contraceptives (OCs) increase risks of vascular thromboses. The risk of myocardial infarct is increased by 3 for combined OC users aged 30-39 and by 5 for those aged 40-44. Risks of deep phlebitis and cerebral thromboses are also 5 times greater in OC users. The effects of OCs on serum lipid levels depend on the dose and type of estrogens and progestin. Ethinyl estradiol causes an increase in triglycerides and HDL cholesterol, while progestins tend to increase total cholesterol and decrease HDL cholesterol. Low-dose combined OCs have slight or no effect on cholesterol, HDL cholesterol or triglycerides. Moderately dosed combined OCs elevate triglycerides but their effects on total cholesterol and HDL are moderate. High dose combined OCs increase triglyceride and cholesterol levels. The combined effects of the estrogen and progestin in high dose pills usually increase HDL cholesterol, but there is some doubt as to whether the increase is beneficial. Although all combined OCs have deleterious effects on serum lipids, only persons predisposed to hyperlipidemia are truly at risk. Young women using OCs require systematic control, of serum lipid and lipoprotein levels. Low-dose formulations are generally preferable. Standard or high dosed OCs can cause disturbances of glucose metabolism in predisposed women, but risks of patent diabetes are small. Glucose intolerance developed during pill use is not always reversible. The risk appears more serious with pills containing estranes or norgestrel than with those containing pregnanes. Low-dose pills entail less deterioration than higher dosed pills. Low-dose progestin-only pills also have deleterious effects. OCs interfere with glucose metabolism in part by creating an effect of peripheral insulin resistance and in part by diminishing the insulin-secreting capacities of the islets of Langerhans. All OCs are contraindicated in women with histories of gestational diabetes or glucose intolerance. Insulin-dependent diabetes in adolescents is a relative contraindication. Regular surveillance is required of weight and blood sugar for normal women using OCs. Estrogens have been the major factor identified in variations of coagulation factors and fibrinolysis in OC users. Platelet aggregation has been less well studied. OCs should be avoided in case of hypercoagulative states of platelet hyperaggregation.
Contraception for adolescents has become a topic of concern for parents, educators, and physicians in recent years because of the trend toward more widespread and early sexual activity among young people and because of the devastating consequences of unprotected sexual activity at early ages. Reasons for high adolescent pregnancy rates include lack of knowledge of contraceptives or of risks of pregnancy, the unanticipated and unprepared nature of many sexual encounters, lack of access to contraceptives, and fear of their possible side effects. There is no ideal contraceptive method for adolescents. Successful use of contraception by this age group requires careful and complete explanations of the use of the method. Abstinence is a satisfactory method only for adolescents who are not yet sexually active. Periodic abstinence may in theory be a way of learning about the physiology of reproduction and of preparing for mature sexual life, but the requirements of periodic abstinence conflict with the unpredictability of a sporadic sex life and the menstrual irregularity of many adolescents. Withdrawal should be presented as a less effective method, but 1 is better than no method at all and that is available at all times. Condoms and spermicides are considered unsatisfactory by many adolescents because they are less sure, they may tear, and they decrease sensation. But they may be acquired without prescription and have been widely publicized for their protective effects against sexually transmitted diseases and AIDS. They have no side effects and are suited to the sporadic sexual encounters of many adolescents. Diaphragms require a considerable investment of time in order to be effective. IUDs increase the risk of infection in adolescents with potentially serious effects on later fertility. They should be used only in exceptional cases. Oral contraceptives seem to offer advantages for adolescents in that they reduce excessive menstrual bleeding, prevent functional uterine bleeding, almost completely control dysmenorrhea, and reduce the risk of upper genital tract infections. Their great effectiveness and remoteness from the sexual act are also positive features. But some longterm effects of OCs such as their possible effects on hepatobiliary functioning are largely unknown. Adolescents are at great risk of discontinuing the method because of annoying though minor side effects. It is extremely important to explain the workings of OCs and their possible side effects in detail, to be accessible in case of concerns, and to encourage conscientious follow-up. Any combined OC can be used by adolescents, but those with low estrogen doses seem to cause fewer annoying side effects. Less androgenic progestins are preferred. Low-dose progestin-only formulations should be avoided if possible. Postcoital contraception should be reserved for exceptional cases.
