lnt J Gynaeco l Obstet 16 : 564- 567, 1979
Teenagers and Contraception Henri Rozenbaum H opital A ntoine Biclere, Clamart, France
ABSTRACT Rozenbaum H (Hopital Antoine Biclere, Clamart, France). Teenagers and contraception. lntj Gynaecol Obstet 16: 564-567, 1979 Early sexual activity in young women has created new problems in contraception and gynecologic pathology for physicians. None of the existing birth control methods seems ideally adapted to the y oung: oral contraceptives, the only infallible method, may present adverse effects. Intrauterine devices may result in expulsion or infection. Diaphragms or spermicides are less effective and not always well accepted by young girls. The physician, however, must bear in mind that whatever inconvenience may result, birth control is always preferable to an unwanted pregnancy or to abortion. Given the seemingly growing incidence of venereal disease and of abnormalities of cervical cytology, physicians must exercise the utmost care and consider a birth control consultation by a young girl as a full m~dical act.
INTRODUCTION According to recent statistics (13), 30%-40% of teenagers experience sexual intercourse. This fact is by no means the sole privilege of Western nations, for it is es timated that 40% of the female African population marries between the ages of 15 to 19 years, as well as almost 30 % in Asia versus 15% in the U nited States and 7% in Europe. If there is a difference, it lies mainly in the ratio of sexual intercourse outside marriage versus conjugal intercourse. The fact that puberty starts at an earlier age (by approximately three years earlier than 100 years ago) is certainly a determinant factor accounting for the precocious sexual life of teenagers. Early sexual activity presents the medical profession with a number of problems: (a) contraception, (b) the spreading of venereal diseases, (c) modifications of classic epidemiologic data concerning cancer of the cervix and (d) some modifications of disorders occurring in pregnancy or related to interruptions of pregnancy. Teenage girls are increasingly asking for some contraceptive method. Or, more precisely, very
lntj Gynaecol Obstet 16
young girls are now having sexual intercc:>urse with or without a contraceptive method. This situation creates a number of problems: 1. On the ethical level, the role of the medical profession is not to moralize but to help these young girls in the best possible way. This help should not be merely technical, limited only to prescription and application of a contraceptive method, but of a much broader nature. Incomplete information on sexual matters still exists too often among teenage girls. It should be the task of the doctor to fill in the gaps left uncovered by family and school. Often , a teenage girl's visit to a doctor which began as a discussion of oral contraception ends as a psychological session. 2. On the medical level, the choice of a contraceptive method is not a simple matter; however, the primary concern should be that these young girls need above all an efficacious protection. Most oral contraceptives work by suppressing ovulation ; currently, it is unknown whether or not it is dangerous to suppress ovulation in the young girl at the postpuberty period because of the effects it may have on her fertile years in the future. We know that there is often a postpuberty luteal insufficiency, the origin of which we ignore. To make a comparison with the trials of Barraclough and Gorski (1) would certainly be risky. These authors showed that injecting sexual steroids intramuscularly in the female rat five days after birth definitively disrupted the subsequent rhythm of the hypothalamus, resulting in ovarian lesions in the adult female rat which were close to ovarian micropolycystic dystrophy. These trials also proved that the hypothalamus-hypophysis maturity is not present in the newborn female rat. This is far different from the human species, although postpuberty luteal insufficiency is sometimes ascribed to the " immaturity" of the ovarian hypothalamus-hypophysis system. Will postpill amenorrhea be more frequent among young girls? There are almost no studies on this subject. Only one work (3) (of no significant value because of the small number involved) tends to indicate that the frequency of postpili amenorrhea, or at least of time required for ovulation to reappear after interrupting oral contraception, is
Teenagers and contraception
inversely proportional to the age at which the pill was first prescribed. The research done in France on this same subject has shown different resu lts. In September 1976, we sent to all (29 380) French general practitioners and gynecologists a questionnaire asking them to list the number of amenorrhea cases that they had diagnosed in 1975- 1976, including sudden amenorrhea as well as amenorrhea still present three months after interrupting the oral contraceptive regime. This resu lted in a compilation of 1592 cases of amenorrhea, of which 291 occurred postpi ll. No correlation has been estab lished between the users' age and the frequency of amenorrhea; maximum frequency has been observed among the age bracket of 25-30 years, which is a lso the average age of oral contraceptive users in France (Fig. 1). Should we wait for cycles to become regu lar again before prescribing an oral contraceptive? As a rule, certainly (7) th is attitude appears to be more or less rational. The pill should be prescribed only after six to 12 months of regu lar menstrual cycles. This rule, however, is not always applicable in practice for the fo llowing reasons : (a) some of these very young girls will never have a regu lar cycle and (b) others requ ire very early the use of some contraceptive method ,
Percent 100
90
80
Amenorrhea as a function of age
70
60 50
Use of oral
40 30 20 10
.
~~.. ...
0
.
\
40-54 20-39 Age (i n years) Fig . 1. Comparison between ame norrhea as a function of age of the patie nt a nd the use of oral contraceptives as a function of age . 15-19
565
and some of these other methods are not always applicable. All of this indicates the usefulness of obtaining, if possible, the fo llowing kind of information before prescribing an oral contraceptive: (a) The thermic curve over one or two cycles should be ascertained. Thus, the finding of a thermal difference wi ll determine if there has probably been a spontaneous ovulation even when menstrual cycles are irregu lar. This kind of procedure a llows the young girl to become familiar with her menstrual cycle, namely, to get a better understanding of the time of ovulation . (b) A hormone evaluation should be made if the spontaneous cycles seem to be too irregular. (c) A rad iograph of the pituitary fossa should be done, if episodes of spontaneous amenorrhea have already been observed. Possibly, this last condition is not in itself a contraindication for the prescription of a n ovulation inhibitor. Most authors agree that there seems to be a higher rate of postpill amenorrhea in women who previously had irregular cycles. We found in our questionnaire study 50.2 % episodes of irregular cycles versus 17 % in the general popu lation. In any event, the presence of a hypophysial adenoma is a definite contraindication to the use of an oral contraceptive (2, 8, 11) and, of course, the usual criteria of clinical and biologic follow-up which must precede and accompany any prescription for an oral contraceptive shou ld be observed . On the other hand, it seems important, if oral contraception is the chosen method, to prescribe a combined estrogen-progestogen low-dose compound . Th is type of compound exerts less inhibitory effect on the hypothalamus-hypophysis system (6). A decrease in the incidence of postpi ll amenorrhea may possibly occur with the use of this compound. However, because the biologic tolerance of this type of compound is vastly superior to th at of classic oral contraceptives, it appears wise to prescribe usc of the low-dose products for young girls who will likely use them on a long-term b asis. Until other contraceptive methods evolve, th e low-dose compound seems best for the younger teenager who chooses oral contraception . Another practical problem exists in determining whether or not a young girl must periodically interrupt the intake of an oral contraceptive regime . There is no scientific evidence justifying this attitude. There is no proof whatsoever that the " interruption period" reduces the incidence of postpill amenorrhea. Personally, I presently advise, perhaps more for psychological reasons rather than for scientific ones, to stop taking the pill during one cycle once every two or three years. During the " break" period, the
lntj Gynaecol Obstel 16
566
Rozenbaum
teenage girl should establish her thermic curve, which only leaves her unprotected for 15 days. It should be explained to her that she is protected from the third day of the ther:nal plateau. This will reasssure the patient and the prescribing doctor, as a thermal difference assures that the return of ovulation has normally taken place. The pill can then be taken again at the following cycle. On the contrary, if the temperature curve remains flat, the patient is instructed not to take the pill and to visit her doctor. We must remember that if the oral contraceptive treatment is interrupted too frequently or for too long, it may result all too often in an interrupted pregnancy. Finally, while some might object to oral contraceptives having to be taken 21 days per cycle, while sexual intercourse might take place only occasionally, the fact remains that there is not yet a "morning-after pill" which can be safely used. Another problem arising from the use of estrogenprogestogen compounds is the effect sexual steroids have on the epiphysial cartilage. Because some young girls begin experiencing sexual intercourse while they are still teenagers, some doctors may prefer to ask for a radiologic assessment of the osseous age before prescribing an oral contraceptive. For, although it is generally accepted that the pill will not affect growth in the last year of development, this is not so when oral contraception is taken at an earlier stage. The intrauterine devices (IUDs) should not, on principle, be inserted in young nulliparas because of association with a higher incidence of infections. Many authors believe such a risk, no matter how minimal, should not be incurred by a nulliparous patient. Some modifications may be advisable here, however. For nulliparas who have already had an abortion, certainly an IUD has less risks than another abortion, if no other method is applicable. Further, when oral contraceptives are contraindicated and the use of an IUD is the only acceptable method, an IUD may be prescribed for a young teenager. It is interesting to note the experience obtained in a study conducted with the help of midwives from an institution for young single mothers who were 13- 18 years old. These young girls came generally from low-income families and were often quite incapable of taking oral contraceptives. We inserted 59 IUDs (Gravigard or Copper-T), 14 before the resumption of menses, 30 within the days following the resumption of menses and 14 two to three months later. Over exposed cycles, there Wt!re no pregnancies or perforations. Two IUDs inserted immediately after the resumption of menses and one IUD inserted two months later were expelled. The
lntj Gynaecol Obstet /6
insertion of an IUD during the postpartum period is perfectly feasible and is, in most cases, a very useful and efficient contraceptive method. This is also the opinion of Hagbard et al (5), who based their experience on 242 subjects. The diaphragm should prove to be one of the best methods for this age group: it is safe and can be used intermittently. However, many young girls refuse to use it. On the other hand, the size of the diaphragm can only be determined if the young girl has already had intercourse and only then can she be taught how to use it . Foams, gels and spermicidal ovules can also be used as intermittent contraceptive methods, although their efficacy is debatable. The temperature method is too restrictive as a permanent solution for the young patient , but can be used when sex ual intercourse takes place occasionally. Even on a provisional basis, its use has the advantage of helping the young girl to become more familiar with the physiology of her menstrual cycle. Postcoital contraception is a limited option. The teenage girl, more than any other woman, is often exposed unprotected to unplanned intercourse. Therefore, the doctor must always keep in mind the possibility of prescribing high doses of estrogen: 50 mg/day of diethylstilbestrol or 5 mg of ethinyl estradiol for three or five days. It should be remembered that, theoretically, there is a span of five to six days following a possible fertile intercourse during which the high dose of estrogen is effective; in fact, the method is totally efficient only if started within 48 hours of intercourse. Obviously, the high doses required for this method restrict its use to very special circumstances. In short, we lack an appropriate method of contraception for the teenage girl which would be 100% efficient, could be used on an intermittent but nonrestrictive basis and is entirely safe. A "morningafter" pill complying with these requirements would be the ideal solution. Unfortunately, products presently under study for this purpose (some of the progestogen hormones, for example) have proved to be relatively disappointing. Finally, it should always be noted that, in considering teenage contraception, anything is better than nothing. In the absence of a contraceptive method which could be used intermittently and which would be 100% efficient, the doctor has to choose among methods presently in use. He must above all remember that, in the field of teenage contraception, the worst possible course of action is to do nothing. The results of the negative attitude are abortion and pregnancy. There is little need to point out here the severe consequences-psychological as well as physical-
Teenagers and contraception
which abortion can have on the life of a young girl. Such an act could have a repercussion on her fertile years to come or increase her risk of endometriosis, synechia, infection and incompetent cervix, to mention a few . Teenage pregnancies may be threatened by a high risk of fetal abnormality and the gestation and delivery may be more difficult than for the older woman . On the socioeconomic level, the consequences of motherhood between the ages of 14 and 18 years are often disastrous.
Gynecologic pathology and contraception in the young girl Does an early start of sexual intercourse carry higher pathologic risks? This question mainly applies to venereal diseases. The recrudescence of venereal diseases noted in recent years does not spare the teenage girl. During a systematic study which included swabs and serologic tests, Roddick (10) noted 2.8% of positive results in reference to gonococcal infection. Zalcker et al ( 12) also observed that the incidence of gonorrhea was slightly higher in the younger patients. The precocity of sexual intercourse and often the polymorphism of partners can only favor such a tendency. In general practice, the physician must remain aware of the significance of symptoms such as urethritis in the male and leukorrhea with urinary complications in the young girl.
Epidemiology of cancer of the cervix The following factors contribute to the risk of cancer of the cervix: (a) low socioeconomic level , (b) precocity of sexual intercourse and diversity of partners and (c) herpes virus type 2. The results of some recent studi es on cervical cytology in the young girl are particularly disturbing. In a population of 33 541 girls under 19 years of age, Fields et al (4) found 1. 7% cytologic abnormalities (Papanicolaou smears of type III, IV or V). In a group of 1594 young women, half of them under 21 years of age, Roddick ( 10) found a 4.8 % incidence of cervical abnormalities. Rauramo (9) found that the incidence of cervical dysplasia (20%) in girls under 19 years has multiplied five times since 1971. In addition to the opportunity for finding cytologic abnormalities, the young girl's visit to her doctor for a contraceptive method is an excellent time to detect some organic conditions sometimes observed in her age bracket, such as ovarian cyst and endometriosis. These two conditions should be considered as a possible cause when amenorrhea is significantly present, especially when it persists after oral contraceptives are taken.
567
CONCLUSION Contraception in th e young girl presents multiple problems. Both the precocity of puberty and that of an active sexual life plunge the young girl into the world of the adult woman regarding contraception , pregnancy, abortion and gynecologic pathology. Contraceptive problems are difficult to solve because no ideal method of intermittent contraception exists. A pregnancy or an abortion , however, represents a much greater disaster with heavier consequences than the theoretical wrong derived from the use of any contraceptive method . Before any contraceptive method is prescribed, of course, prudent medical practice demands that the gynecologic examination and Papanicolaou smear be done regardless of the age of the patient, as gynecologic pathology is not exceptional a mong young girls.
REFERENCES I. Barraclough CA, Gorski RA : Evidence tha t the hypotha lamus is responsible for a ndrogen-induced sterilit y in the fema le ra t. Endocrinology 68:68, 196 1. 2. BenderS : The pill a nd the pituit a ry. Br MedJ 1:567, 19 72. 3. Evrard JR , Buxton B, Erickson D : Amenorrhea following ora l contraception . Am J Obstet Gynecol I 24:88 , 19 76. 4. Fields C , R estivo RM , Brown M: Experience in mass Papa nicola ou screening and cytologic observations of teenage girls. Am J Obstet G ynecol 124:730 , 1976. 5. Hagba rd L, Ingema nson CA, Sorbe B: Ea rl y postpa rtum insertion of Copper IUD. Contraception I 7:355, 1978. 6. M ezzana F, Netter A, Levy C, Rozenba um H : Effets d 'une nouvelle associa tion estroprogesta ti ve fa ibl ement dosee sur les tau x de FSH et de LH plasma tiques. Contracepti on 3:7, 1975. 7. Pa piernik E, Roze nbaum H : Contraception et fertilite ulterieure. J Gynecol Obstet Bioi Reprod 4:636, 1975. 8. Poel WE : Pituit ary tumors in mice a ft er prolonged feedin g on synthetic progest. Science I 54:402, 1966. 9. Ra ura mo L : Comment. Am J Obstet Gynecol 126:888, 1976. 10. Roddick JW: Gynecologic disease in young, sexua lly acti ve women . Am J Obstet Gynecol I 26:880 , 1976. II. Self LW: Pituitary cytology of rats receiving eth ynodiol diaceta te a nd mestra nol for 2 yea rs. M etabolism [Suppl] 14:3 11 , 1965. 12. Za lcker J, Orback H , Brolnitshy D, Brown MC : A mass screening program for the detection of gonorrhea. Am J Obstet Gynecol I 12:77 2, 1972. 13. Zelnick M , Kantner JF: The resolution of teenage first pregna ncies. Fa m Pl ann Perspect 6:74 , 1974.
Address for reprints: Henri Rozenbaum 15 Rue Daru 75008 Paris France
lnt} Cy naecol Obstel / 6
Teenagers and Contraception Henri Rozenbaum H opital A ntoine Biclere, Clamart, France
ABSTRACT Rozenbaum H (Hopital Antoine Biclere, Clamart, France). Teenagers and contraception. lntj Gynaecol Obstet 16: 564-567, 1979 Early sexual activity in young women has created new problems in contraception and gynecologic pathology for physicians. None of the existing birth control methods seems ideally adapted to the y oung: oral contraceptives, the only infallible method, may present adverse effects. Intrauterine devices may result in expulsion or infection. Diaphragms or spermicides are less effective and not always well accepted by young girls. The physician, however, must bear in mind that whatever inconvenience may result, birth control is always preferable to an unwanted pregnancy or to abortion. Given the seemingly growing incidence of venereal disease and of abnormalities of cervical cytology, physicians must exercise the utmost care and consider a birth control consultation by a young girl as a full m~dical act.
INTRODUCTION According to recent statistics (13), 30%-40% of teenagers experience sexual intercourse. This fact is by no means the sole privilege of Western nations, for it is es timated that 40% of the female African population marries between the ages of 15 to 19 years, as well as almost 30 % in Asia versus 15% in the U nited States and 7% in Europe. If there is a difference, it lies mainly in the ratio of sexual intercourse outside marriage versus conjugal intercourse. The fact that puberty starts at an earlier age (by approximately three years earlier than 100 years ago) is certainly a determinant factor accounting for the precocious sexual life of teenagers. Early sexual activity presents the medical profession with a number of problems: (a) contraception, (b) the spreading of venereal diseases, (c) modifications of classic epidemiologic data concerning cancer of the cervix and (d) some modifications of disorders occurring in pregnancy or related to interruptions of pregnancy. Teenage girls are increasingly asking for some contraceptive method. Or, more precisely, very
lntj Gynaecol Obstet 16
young girls are now having sexual intercc:>urse with or without a contraceptive method. This situation creates a number of problems: 1. On the ethical level, the role of the medical profession is not to moralize but to help these young girls in the best possible way. This help should not be merely technical, limited only to prescription and application of a contraceptive method, but of a much broader nature. Incomplete information on sexual matters still exists too often among teenage girls. It should be the task of the doctor to fill in the gaps left uncovered by family and school. Often , a teenage girl's visit to a doctor which began as a discussion of oral contraception ends as a psychological session. 2. On the medical level, the choice of a contraceptive method is not a simple matter; however, the primary concern should be that these young girls need above all an efficacious protection. Most oral contraceptives work by suppressing ovulation ; currently, it is unknown whether or not it is dangerous to suppress ovulation in the young girl at the postpuberty period because of the effects it may have on her fertile years in the future. We know that there is often a postpuberty luteal insufficiency, the origin of which we ignore. To make a comparison with the trials of Barraclough and Gorski (1) would certainly be risky. These authors showed that injecting sexual steroids intramuscularly in the female rat five days after birth definitively disrupted the subsequent rhythm of the hypothalamus, resulting in ovarian lesions in the adult female rat which were close to ovarian micropolycystic dystrophy. These trials also proved that the hypothalamus-hypophysis maturity is not present in the newborn female rat. This is far different from the human species, although postpuberty luteal insufficiency is sometimes ascribed to the " immaturity" of the ovarian hypothalamus-hypophysis system. Will postpill amenorrhea be more frequent among young girls? There are almost no studies on this subject. Only one work (3) (of no significant value because of the small number involved) tends to indicate that the frequency of postpili amenorrhea, or at least of time required for ovulation to reappear after interrupting oral contraception, is
Teenagers and contraception
inversely proportional to the age at which the pill was first prescribed. The research done in France on this same subject has shown different resu lts. In September 1976, we sent to all (29 380) French general practitioners and gynecologists a questionnaire asking them to list the number of amenorrhea cases that they had diagnosed in 1975- 1976, including sudden amenorrhea as well as amenorrhea still present three months after interrupting the oral contraceptive regime. This resu lted in a compilation of 1592 cases of amenorrhea, of which 291 occurred postpi ll. No correlation has been estab lished between the users' age and the frequency of amenorrhea; maximum frequency has been observed among the age bracket of 25-30 years, which is a lso the average age of oral contraceptive users in France (Fig. 1). Should we wait for cycles to become regu lar again before prescribing an oral contraceptive? As a rule, certainly (7) th is attitude appears to be more or less rational. The pill should be prescribed only after six to 12 months of regu lar menstrual cycles. This rule, however, is not always applicable in practice for the fo llowing reasons : (a) some of these very young girls will never have a regu lar cycle and (b) others requ ire very early the use of some contraceptive method ,
Percent 100
90
80
Amenorrhea as a function of age
70
60 50
Use of oral
40 30 20 10
.
~~.. ...
0
.
\
40-54 20-39 Age (i n years) Fig . 1. Comparison between ame norrhea as a function of age of the patie nt a nd the use of oral contraceptives as a function of age . 15-19
565
and some of these other methods are not always applicable. All of this indicates the usefulness of obtaining, if possible, the fo llowing kind of information before prescribing an oral contraceptive: (a) The thermic curve over one or two cycles should be ascertained. Thus, the finding of a thermal difference wi ll determine if there has probably been a spontaneous ovulation even when menstrual cycles are irregu lar. This kind of procedure a llows the young girl to become familiar with her menstrual cycle, namely, to get a better understanding of the time of ovulation . (b) A hormone evaluation should be made if the spontaneous cycles seem to be too irregular. (c) A rad iograph of the pituitary fossa should be done, if episodes of spontaneous amenorrhea have already been observed. Possibly, this last condition is not in itself a contraindication for the prescription of a n ovulation inhibitor. Most authors agree that there seems to be a higher rate of postpill amenorrhea in women who previously had irregular cycles. We found in our questionnaire study 50.2 % episodes of irregular cycles versus 17 % in the general popu lation. In any event, the presence of a hypophysial adenoma is a definite contraindication to the use of an oral contraceptive (2, 8, 11) and, of course, the usual criteria of clinical and biologic follow-up which must precede and accompany any prescription for an oral contraceptive shou ld be observed . On the other hand, it seems important, if oral contraception is the chosen method, to prescribe a combined estrogen-progestogen low-dose compound . Th is type of compound exerts less inhibitory effect on the hypothalamus-hypophysis system (6). A decrease in the incidence of postpi ll amenorrhea may possibly occur with the use of this compound. However, because the biologic tolerance of this type of compound is vastly superior to th at of classic oral contraceptives, it appears wise to prescribe usc of the low-dose products for young girls who will likely use them on a long-term b asis. Until other contraceptive methods evolve, th e low-dose compound seems best for the younger teenager who chooses oral contraception . Another practical problem exists in determining whether or not a young girl must periodically interrupt the intake of an oral contraceptive regime . There is no scientific evidence justifying this attitude. There is no proof whatsoever that the " interruption period" reduces the incidence of postpill amenorrhea. Personally, I presently advise, perhaps more for psychological reasons rather than for scientific ones, to stop taking the pill during one cycle once every two or three years. During the " break" period, the
lntj Gynaecol Obstel 16
566
Rozenbaum
teenage girl should establish her thermic curve, which only leaves her unprotected for 15 days. It should be explained to her that she is protected from the third day of the ther:nal plateau. This will reasssure the patient and the prescribing doctor, as a thermal difference assures that the return of ovulation has normally taken place. The pill can then be taken again at the following cycle. On the contrary, if the temperature curve remains flat, the patient is instructed not to take the pill and to visit her doctor. We must remember that if the oral contraceptive treatment is interrupted too frequently or for too long, it may result all too often in an interrupted pregnancy. Finally, while some might object to oral contraceptives having to be taken 21 days per cycle, while sexual intercourse might take place only occasionally, the fact remains that there is not yet a "morning-after pill" which can be safely used. Another problem arising from the use of estrogenprogestogen compounds is the effect sexual steroids have on the epiphysial cartilage. Because some young girls begin experiencing sexual intercourse while they are still teenagers, some doctors may prefer to ask for a radiologic assessment of the osseous age before prescribing an oral contraceptive. For, although it is generally accepted that the pill will not affect growth in the last year of development, this is not so when oral contraception is taken at an earlier stage. The intrauterine devices (IUDs) should not, on principle, be inserted in young nulliparas because of association with a higher incidence of infections. Many authors believe such a risk, no matter how minimal, should not be incurred by a nulliparous patient. Some modifications may be advisable here, however. For nulliparas who have already had an abortion, certainly an IUD has less risks than another abortion, if no other method is applicable. Further, when oral contraceptives are contraindicated and the use of an IUD is the only acceptable method, an IUD may be prescribed for a young teenager. It is interesting to note the experience obtained in a study conducted with the help of midwives from an institution for young single mothers who were 13- 18 years old. These young girls came generally from low-income families and were often quite incapable of taking oral contraceptives. We inserted 59 IUDs (Gravigard or Copper-T), 14 before the resumption of menses, 30 within the days following the resumption of menses and 14 two to three months later. Over exposed cycles, there Wt!re no pregnancies or perforations. Two IUDs inserted immediately after the resumption of menses and one IUD inserted two months later were expelled. The
lntj Gynaecol Obstet /6
insertion of an IUD during the postpartum period is perfectly feasible and is, in most cases, a very useful and efficient contraceptive method. This is also the opinion of Hagbard et al (5), who based their experience on 242 subjects. The diaphragm should prove to be one of the best methods for this age group: it is safe and can be used intermittently. However, many young girls refuse to use it. On the other hand, the size of the diaphragm can only be determined if the young girl has already had intercourse and only then can she be taught how to use it . Foams, gels and spermicidal ovules can also be used as intermittent contraceptive methods, although their efficacy is debatable. The temperature method is too restrictive as a permanent solution for the young patient , but can be used when sex ual intercourse takes place occasionally. Even on a provisional basis, its use has the advantage of helping the young girl to become more familiar with the physiology of her menstrual cycle. Postcoital contraception is a limited option. The teenage girl, more than any other woman, is often exposed unprotected to unplanned intercourse. Therefore, the doctor must always keep in mind the possibility of prescribing high doses of estrogen: 50 mg/day of diethylstilbestrol or 5 mg of ethinyl estradiol for three or five days. It should be remembered that, theoretically, there is a span of five to six days following a possible fertile intercourse during which the high dose of estrogen is effective; in fact, the method is totally efficient only if started within 48 hours of intercourse. Obviously, the high doses required for this method restrict its use to very special circumstances. In short, we lack an appropriate method of contraception for the teenage girl which would be 100% efficient, could be used on an intermittent but nonrestrictive basis and is entirely safe. A "morningafter" pill complying with these requirements would be the ideal solution. Unfortunately, products presently under study for this purpose (some of the progestogen hormones, for example) have proved to be relatively disappointing. Finally, it should always be noted that, in considering teenage contraception, anything is better than nothing. In the absence of a contraceptive method which could be used intermittently and which would be 100% efficient, the doctor has to choose among methods presently in use. He must above all remember that, in the field of teenage contraception, the worst possible course of action is to do nothing. The results of the negative attitude are abortion and pregnancy. There is little need to point out here the severe consequences-psychological as well as physical-
Teenagers and contraception
which abortion can have on the life of a young girl. Such an act could have a repercussion on her fertile years to come or increase her risk of endometriosis, synechia, infection and incompetent cervix, to mention a few . Teenage pregnancies may be threatened by a high risk of fetal abnormality and the gestation and delivery may be more difficult than for the older woman . On the socioeconomic level, the consequences of motherhood between the ages of 14 and 18 years are often disastrous.
Gynecologic pathology and contraception in the young girl Does an early start of sexual intercourse carry higher pathologic risks? This question mainly applies to venereal diseases. The recrudescence of venereal diseases noted in recent years does not spare the teenage girl. During a systematic study which included swabs and serologic tests, Roddick (10) noted 2.8% of positive results in reference to gonococcal infection. Zalcker et al ( 12) also observed that the incidence of gonorrhea was slightly higher in the younger patients. The precocity of sexual intercourse and often the polymorphism of partners can only favor such a tendency. In general practice, the physician must remain aware of the significance of symptoms such as urethritis in the male and leukorrhea with urinary complications in the young girl.
Epidemiology of cancer of the cervix The following factors contribute to the risk of cancer of the cervix: (a) low socioeconomic level , (b) precocity of sexual intercourse and diversity of partners and (c) herpes virus type 2. The results of some recent studi es on cervical cytology in the young girl are particularly disturbing. In a population of 33 541 girls under 19 years of age, Fields et al (4) found 1. 7% cytologic abnormalities (Papanicolaou smears of type III, IV or V). In a group of 1594 young women, half of them under 21 years of age, Roddick ( 10) found a 4.8 % incidence of cervical abnormalities. Rauramo (9) found that the incidence of cervical dysplasia (20%) in girls under 19 years has multiplied five times since 1971. In addition to the opportunity for finding cytologic abnormalities, the young girl's visit to her doctor for a contraceptive method is an excellent time to detect some organic conditions sometimes observed in her age bracket, such as ovarian cyst and endometriosis. These two conditions should be considered as a possible cause when amenorrhea is significantly present, especially when it persists after oral contraceptives are taken.
567
CONCLUSION Contraception in th e young girl presents multiple problems. Both the precocity of puberty and that of an active sexual life plunge the young girl into the world of the adult woman regarding contraception , pregnancy, abortion and gynecologic pathology. Contraceptive problems are difficult to solve because no ideal method of intermittent contraception exists. A pregnancy or an abortion , however, represents a much greater disaster with heavier consequences than the theoretical wrong derived from the use of any contraceptive method . Before any contraceptive method is prescribed, of course, prudent medical practice demands that the gynecologic examination and Papanicolaou smear be done regardless of the age of the patient, as gynecologic pathology is not exceptional a mong young girls.
REFERENCES I. Barraclough CA, Gorski RA : Evidence tha t the hypotha lamus is responsible for a ndrogen-induced sterilit y in the fema le ra t. Endocrinology 68:68, 196 1. 2. BenderS : The pill a nd the pituit a ry. Br MedJ 1:567, 19 72. 3. Evrard JR , Buxton B, Erickson D : Amenorrhea following ora l contraception . Am J Obstet Gynecol I 24:88 , 19 76. 4. Fields C , R estivo RM , Brown M: Experience in mass Papa nicola ou screening and cytologic observations of teenage girls. Am J Obstet G ynecol 124:730 , 1976. 5. Hagba rd L, Ingema nson CA, Sorbe B: Ea rl y postpa rtum insertion of Copper IUD. Contraception I 7:355, 1978. 6. M ezzana F, Netter A, Levy C, Rozenba um H : Effets d 'une nouvelle associa tion estroprogesta ti ve fa ibl ement dosee sur les tau x de FSH et de LH plasma tiques. Contracepti on 3:7, 1975. 7. Pa piernik E, Roze nbaum H : Contraception et fertilite ulterieure. J Gynecol Obstet Bioi Reprod 4:636, 1975. 8. Poel WE : Pituit ary tumors in mice a ft er prolonged feedin g on synthetic progest. Science I 54:402, 1966. 9. Ra ura mo L : Comment. Am J Obstet Gynecol 126:888, 1976. 10. Roddick JW: Gynecologic disease in young, sexua lly acti ve women . Am J Obstet Gynecol I 26:880 , 1976. II. Self LW: Pituitary cytology of rats receiving eth ynodiol diaceta te a nd mestra nol for 2 yea rs. M etabolism [Suppl] 14:3 11 , 1965. 12. Za lcker J, Orback H , Brolnitshy D, Brown MC : A mass screening program for the detection of gonorrhea. Am J Obstet Gynecol I 12:77 2, 1972. 13. Zelnick M , Kantner JF: The resolution of teenage first pregna ncies. Fa m Pl ann Perspect 6:74 , 1974.
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