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Safety of oral contraceptives for teenagers
JOURNAL OF ADOLESCENT HEALTi-i 1992;13:333-336
fe AMERICAN
ra COLLEGE OF OBSTETRICIANS
Teenage pregnancy rates in the United States are higher than in nearly all other industrialized nations of the world (1). About 1 million teenagers conceive each year in the United States, and in 1985, there were over 800 legal abortions performed for every 1,000 live births to women aged 15-19 years (2). Improved use of contraceptives is an important part of a strategy to prevent adolescent pregnancy. However, adolescents often do not begin using the most effective methods of contraception until almost 1 year after initiating intercourse (3). In addition, compliance with the most effective method, oral contraceptives, remains a problem (4). Adult women in the United States are grossly misinformed about the health effects of oral contraceptives, and teenagers share in this confusion (5). Fear of complications or side effects is a major deterrent to use of oral contraception. Commonly cited fears include blood clots, cancer, impaired fertility, weight gain, nausea, acne, vaginal discharge, breakthrough bleeding, and absence of withdrawal bleeding (5-8).
Thromboembolism Most epidemiologic studies have shown an association between oral contraceptive use and an increased risk of venous thrombosis and embolism (9,lO). For teenagers using the low-dose pills available today, the risk of death from thromboembolism is not known but is very small. In 1987, only 4 out of 9,047,OOOwomen aged 15-P years in the United States were reported to have died from thromboembolic disease, and whether any of these women had used oral contraceptives is unknown (11,12).
AND GYNECOLOGISTS
Cardiovascular Disease Although data are scant, evidence suggests that use of low-dose oral contraceptives actually reduces, not increases, a woman’s risk of cardiovascular disease (12). Studies suggest that the estrogen component of oral contraceptives has a protective effect on the coronary arteries independent of lipid changes. Since atherosclerosis starts early in life, use of oral contraceptives by teenagers may even confer important protection against heart disease (13). Preexisting hypertension is considered by some, but not all, to be a contraindication to oral contraceptive use (14,15). The prevalence of hypertension in the United States is strong1.y related to age, with the lowest rates in young persons (16). Most studies suggest that l-5% of normotensive pill users develop elevated blood pressure while taking oral contraceptives, although this has not been confirmed by all investigators (14,17). When use of oral contraceptives is stopped, blood pressure returns to normal in nearly all women. Rarely, malignant hypertension emerges during oral contraceptive use. The risk for development of hypertensive problems is remote for teenagers (18).
Cancer Cancer persists as an important concern of women about oral contraceptive use. However, there is compelling epidemiologic evidence that use of oral contraceptives provides significant protection against endometrial and ovarian cancer (19,20). The potential association between oral contraceptives and cervical neoplasia is as yet unsettled. Recent studies continue to raise concerns about an association between breast cancer and the use of oral contraceptives, particularly for those who have
Copyright 0 February 1991 Reprinted with permission from ACOG Committee Opinion Number -.. 90_ . Published by Elsevier Science Publishing Co., Inc., 655 Avenue ot tne Amensas, New York, NY 10010
333 1054-139x/921$5.00
334
ACOG
taken the pill for many years and/or started to take it before age 25 or before their first full-term pregnancy(21-23). However, the majority of studies concur that use of oral contraceptives, even for long intervals before first giving birth, has no impact on the risk of breast cancer. While additional research is called for on this issue, current knowledge does not warrant changing prescribing practices regarding the use of oral contraceptives in adolescents.
Amenorrhea and Delayed Fertility The risk of amenorrhea after pill discontinuation is less than l%, and this appears to be more common in women who had irregular menses prior to using oral contraceptives. Thus, rather than causing oligomenorrhea or amenorrhea, oral contraceptives may merely mask it by inducing cyclic withdrawal bleeding (14). Oral contraceptives may delay the return of fertility upon discontinuation of use, but this effect is transient (24). In fact, misunderstanding about the resumption of ovulation has led to many unplanned pregnancies among teenagers, who may believe that they had reliable protection against pregnancy lasting up to 8 months after discontinuation (7).
Menstrual Irregularities Breakthrough bleeding and failure to experience withdrawal bleeding can be frightening to teenagers and may prompt discontinuation of oral contracep tives. These two side effects usually occur in the first few months of use (25). Because these two side effects are relatively frequent with low-dose oral contraceptives, teenagers should be counseled that they may occur but are innocuous and tend to resolve within a few cycles of use. Additionally, irregular bleeding in teenagers using oral contraceptives can be due to incorrect use of the pill, missed pills, and/ or cervicitis or endometritis.
Effect on Height and Weight Medical providers and parents may fear that oral contraceptive use will stunt physical growth. Oral contraceptives in currently available low dosages do not cause premature closure of the epiphyses or inhibit skeletal growth. By the time menarche occurs, endogenous estrogen production has already initiated epiphyseal closure, and this process cannot be altered by small doses of exogenous steroids (6,26). Teenagers are exquisitely sensitive about their appearance~ and weight gain-whether real or per-
JOURNAL OF ADOLESCENT HEALTH Vol. 13, No. 4
ceived-is a major worry. Existing evidence suggests that women are as likely to lose weight as to gain weight while taking oral contraceptives (27). Other complaints, such as nausea, aggravation of acne, or leukorrhea are infrequent with the low-dose oral contraceptives available today. Should these side effects occur, they can be managed by an alternative choice of pills based on symptoms.
Sexually Transmitted Diseases Oral contraceptives cannot protect against sexually transmitted diseases. Although 70% of adolescents report that they are aware of the possibilities of acquiring sexually transmitted diseases and over 50% report knowledge regarding their need for medical treatment, sexually transmitted diseases (excluding human immune deficiency virus [HIV] infection) remain a problem affecting 2.5 million adolescents (28). The common adolescent behavior of “serial monogamy” exposes each partner indirectly to the previous partners and underscores the need for education (including information about HIV infection), as well as for dispensing condoms and demonstrating condom use in addition to oral contraceptives.
Benefits of Oral Contraceptives In addition to preventing pregnancy, the health benefits of oral contraceptives for teenagers outweigh the small risks. Oral contraceptive use confers protection against five life-threatening conditions: ovarian and endometrial cancers, pelvic inflammatory disease (PID), ectopic pregnancy, and toxic shock syndrome. Endometrial and ovarian cancers are rare among teenagers, but, if oral contraceptives are taken for more than 1 year, the protection against these cancers may last for at least 15 years after discontinuation of use (19,20). Teenagers have the highest rate of hospitalization for PID in the United States. By altering the cervical mucus and endometrial lining, oral contraceptives confer protection against PID by preventing the disease agent from ascending to the upper genital tract. Use of oral contraceptives reduces the risk of being hospitalized for PID by about 50% (29). The risk of ectopic pregnancy is reduced hy about 90% in oral contraceptive users (30). Teenagers are at lower risk for ectopic pregnancy than are older -women but are just as likely as older women to die if they develop an ectopic gestation. Epidemiologic
June 1992
studies (though not specific to teenagers) also indicate that the risk of toxic shock syndrome is reduced by about 50% in oral contraceptive users (31). Oral contraceptives also confer protection against five conditions that can affect a teenager’s quality of life: primary dysmenorrhea, benign breast disease, functional ovarian cysts, iron deficiency anemia, and possibly, leiomyomata uteri. Dysmenorrhea is one of the most frequent and debilitating ailments of teenagers. Most women have moderate to complete relief of dysmenorrhea within a few months of starting oral contraceptives (32). A large number of studies have documented a significant reduction in the risk of benign breast disease among oral contraceptive users (33). Similarly, numerous studies have documented a significant reduction in the frequency of functional ovarian cysts requiring surgery (34). Many teenagers have marginal iron stores, and the resultant iron deficiency anemia is a common problem among adolescents. Since menstrual blood loss is decreased by nearly 50% with the use of oral contraceptives, the risk of anemia is significantly decreased (35). Finally, contrary to gynecologic tenets, use of oral contraceptives may protect against, rather than contribute to, the development of leiomyomata. These growths, however, are rare in adolescents (36).
Summary By age 18,5l% of adolescent women will be sexually active. Oral contraceptives are a safe method to avoid the potentially disastrous outcome of an unwanted pregnancy. The overall risks of taking oral contraceptives are much less than the risks of pregnancy (20). Specifically, the risks associated with the use of oral>ontrace$ives by teenagers are negligible. Lowdose oral contraceptives have not been linked with either heart attack or stroke in contemporary U.S. studies. While the risk of thromboembolism in oral contraceptive users as a whole may be increased over that of the general population, the risk to teenagers, especially those who do not smoke, is minimal. The risk of death from oral contraceptive use for teenagers is virtually nil (12). As with all medical choices, the benefits of a treatment must be weighed against any potential risks. For adolescents, the benefits associated with the use of oral contraceptives outweigh the risks, particularly those of pregnancy. However, teenagers at risk for sexually transmitted diseases should be advised
SAFETYOF ORAL CONTRACEPTIVES FOR TEENAGERS
to use a barrier method ceptives.
335
a!ong &th oral contm
References 1. Jones EF, Forrest JD, Goldman N, Henshaw SK, Lincoln SR, Rosoff JI, et al. Teenagepregnancy in developed countries: determinants and policy implications. Fam P1ann perspect 1985;17:53-63 2. Henshaw SK, Kenney AM, Somberg D, Van Vort J, eds. Teenage pregnancyin the United States-the scope of the problem and state responses. New York: The Alan Guttmacher Institute, 1989 3. Hayes CD, ed. Risking the future, adolescent sexuality, preg nancy, and childbearing. Vol 1. Washington, DC: National Academy Press, 1987 4. Jay MS, DuRant RI-I,Litt IF. Female adolescents’ compliance with contraceptive regimens. Pediatr Clin, North Am 1989; 36:731-7% 5. Herold ES, Goodwin MS. Perceived side effects of oral contraceptives among adolescent girls. Can Med Assoc J 1980; 123:1022-1026 6. Bolton GC. Adolescent contraception. Clin Obstet Gynecol 1981;24:977-986 7. Kisker EE. Teenagers talk about sex, pregnancy, and contraception. Fam Plann Perspect 1985;17:83-90 8. Emans SJ, Grace E, Woods ER, Smith DE, Klein K, Merola J. Adolescents’ compliance with the use of oral centraceptives. JAMA 1987;25733773381 9. Realini JP, Goldzieher JW. Oral contraceptives and cardiovascular disease: a critique of the epidemiologic studies. Am J Obstet Gynecol1985;152:729-798 10. Hehmich SP, Rosenberg L, Kaufman DW, Strom B, Shapiro S. Venous thromboembolism in relation to oral contraceptive use. Obstet Gynecol 1987;69:91-95 11. National Center for Health Statistics. Vital statistics of the United States, 1987. II. Mortality, part A. Department of Health and Human Services publication no. (PHS) 90-1101. Washington, DC: U.S. Government Printing Office, 1990:276 12. Porter JB, Jick H, Walker AM. Mortality among oral contraceptive users. Obstet Gynecol1987;70:29-32 13. Newman WP III, Freedman DS, Voors AW, Gard PD, Srinivasan SR, Cresanta JL, et al. Relation of serum lipoprotein levels and systolic blood pressure to early atherosclerosis. The Bogalusa Heart Study. N Engl J Med 1986;314:138-144 14. Andrews WC. Principles of oral contraception. In: Carson SL, Derman RJ,Tyrer LB, eds. Fertilitycontrol. Boston:Little, Brown, 1985157-169 Gmydanus DE. Alternatives to adolescent pregnancy: a dis15. cussion of the contraceptive literature from I!?60 to 1980. SemIn PerInatoI1981;5:53-98 16. Drizd T, Dannenberg AL, Engel A. Blood pressure in persons 18-74 years of age in 1976-80 and trends in blood pressure from 1960 to 1980 in the United States. Vital Health Stat 1986C(234):1-68 17. Blumenstein BA, Douglas MB, Hall WD. Blood pressure changes and oral contraceptive use: a study of 2676 black women in the southeastern United States. Am J Epidemiol 1980;112:539-552 18. P+ti DB, Klatsky AL. Malignant hypertension in women aged 15 to 44 years and its relation to cigarette smoking and oral contraceptives. Am J Cardiol1983;52297-298
336
JOURNAL OF ADOLESCENTHEALTH Vol. 13, No. 4
ACOG
19. Combination oral contraceptive use and risk of endometrial cancer. The Cancer and Steroid Hormone Study of the Centers for Disease Control and the National Institute of Child Health and Human Development. JAMA 1987;257:796-800 20. The reduction in risk of ovarian cancer associated with oral contraceptive use. The Cancer and Steroid Hormone Study of the Centers for Disease Control and the National Institute of Child Health and Human Development. N Engl J Med 1%!?;316:650-655 21. Schlessebnan JJ,Stadel BV, Murray P, Lai S. Breastcancer in I relation to early use of oral contraceptives-no evidence of latent effect. JAMA 1988;259~182~1833 22. Kay CR, Hannaford PC. Breastcancer and the pill-a further report from the Royal College of General Practitioners’Oral Contraception Study. Br J Cancer 1988;58:675-680 23. Oral contraceptive use and the risk of breast cancer. The Cancerand Steroid Hormone Study of the Centers for Disease Control and the National Institute of Child Health and Human Development. N Engl J Med 1986;315:405-411 24. Vcssey MP, Wright NH, McPherson K, Wiggins P. Fertility after stopping different methods of contraception, Br Med J 1978;1:265-267 25. Jay MS, DuRant RH, Shofttt T, Linder CW, Litt IF. Effect of peer counselors on adolescent compliance in use of oral contraceptives. Pediatrics 1984;73zl26-131 26. MisheB DR Jr, Brenner P, Chcz PA, Chris&~ CD, Ccnncl: EB, Queenan JT, et al. Oral contraception and the teenager. J Reprod Med 1982;27:275-295 27. TyrerLB. Oral contraceptive practice. In: Corson SL, Derman
28. 29.
30.
31. 32.
33.
34.
35.
36.
RJ, Tyrer LB, eds. Fertility control. Boston: Little, Brown X&%171-185 Centers for Disease Control. Results from the National Adolescent Student Health Survey. MMWR 1989;38:147-150 Rubin GL, Ory HW, Layde PM. Oral contraceptives and pelvic inflammatory disease. Am J Obstet Gynecol1982;144630635 Ory HW. &topic pregnancy and intrauterine contraceptive devices: new perspectives. Women’s Health Study. Obstet Gyneco: 1981;57:137-144 Gray RH. Toxic shock syndrome and oral contraception. Am J Obstet Gyneco11987;156:1038 Chan WY, Dawood MY. Prostaglandin levels in menstrual fluid of nondysmenorrheic and of dysmenorrheic subjects with and without oral contraceptive or ibuprofen therapy. Adv Prostaglandin Thromboxane Res 1980;8:1443-1447 Ory H, Cole P, MacMahon B, Hoover R. Oral contraceptives and reduced risk of benign breast diseases. N Engl J Med 1976;294:419-422 Vessey M, Metcalfe A, Wells C, McPherson K, Westhoff C, Yeates D. Ovarian neoplasms, functional ovarian cysts, and oral contraceptives. Br Med J 1987;294:1518-1520 Royal College of General Practitioners. Oral contraceptives and health: an interim report from the oral contraception study. New York: Pitman Publishing, 1974 Ross RK, Pike MC, Vessey MP, Bull D, Yeates D, Casagrande JT. Risk factors for uterine fibroids: reduced risk associated with oral contraceptives. Br Med J 1986;293:359-362
fe AMERICAN
ra COLLEGE OF OBSTETRICIANS
Teenage pregnancy rates in the United States are higher than in nearly all other industrialized nations of the world (1). About 1 million teenagers conceive each year in the United States, and in 1985, there were over 800 legal abortions performed for every 1,000 live births to women aged 15-19 years (2). Improved use of contraceptives is an important part of a strategy to prevent adolescent pregnancy. However, adolescents often do not begin using the most effective methods of contraception until almost 1 year after initiating intercourse (3). In addition, compliance with the most effective method, oral contraceptives, remains a problem (4). Adult women in the United States are grossly misinformed about the health effects of oral contraceptives, and teenagers share in this confusion (5). Fear of complications or side effects is a major deterrent to use of oral contraception. Commonly cited fears include blood clots, cancer, impaired fertility, weight gain, nausea, acne, vaginal discharge, breakthrough bleeding, and absence of withdrawal bleeding (5-8).
Thromboembolism Most epidemiologic studies have shown an association between oral contraceptive use and an increased risk of venous thrombosis and embolism (9,lO). For teenagers using the low-dose pills available today, the risk of death from thromboembolism is not known but is very small. In 1987, only 4 out of 9,047,OOOwomen aged 15-P years in the United States were reported to have died from thromboembolic disease, and whether any of these women had used oral contraceptives is unknown (11,12).
AND GYNECOLOGISTS
Cardiovascular Disease Although data are scant, evidence suggests that use of low-dose oral contraceptives actually reduces, not increases, a woman’s risk of cardiovascular disease (12). Studies suggest that the estrogen component of oral contraceptives has a protective effect on the coronary arteries independent of lipid changes. Since atherosclerosis starts early in life, use of oral contraceptives by teenagers may even confer important protection against heart disease (13). Preexisting hypertension is considered by some, but not all, to be a contraindication to oral contraceptive use (14,15). The prevalence of hypertension in the United States is strong1.y related to age, with the lowest rates in young persons (16). Most studies suggest that l-5% of normotensive pill users develop elevated blood pressure while taking oral contraceptives, although this has not been confirmed by all investigators (14,17). When use of oral contraceptives is stopped, blood pressure returns to normal in nearly all women. Rarely, malignant hypertension emerges during oral contraceptive use. The risk for development of hypertensive problems is remote for teenagers (18).
Cancer Cancer persists as an important concern of women about oral contraceptive use. However, there is compelling epidemiologic evidence that use of oral contraceptives provides significant protection against endometrial and ovarian cancer (19,20). The potential association between oral contraceptives and cervical neoplasia is as yet unsettled. Recent studies continue to raise concerns about an association between breast cancer and the use of oral contraceptives, particularly for those who have
Copyright 0 February 1991 Reprinted with permission from ACOG Committee Opinion Number -.. 90_ . Published by Elsevier Science Publishing Co., Inc., 655 Avenue ot tne Amensas, New York, NY 10010
333 1054-139x/921$5.00
334
ACOG
taken the pill for many years and/or started to take it before age 25 or before their first full-term pregnancy(21-23). However, the majority of studies concur that use of oral contraceptives, even for long intervals before first giving birth, has no impact on the risk of breast cancer. While additional research is called for on this issue, current knowledge does not warrant changing prescribing practices regarding the use of oral contraceptives in adolescents.
Amenorrhea and Delayed Fertility The risk of amenorrhea after pill discontinuation is less than l%, and this appears to be more common in women who had irregular menses prior to using oral contraceptives. Thus, rather than causing oligomenorrhea or amenorrhea, oral contraceptives may merely mask it by inducing cyclic withdrawal bleeding (14). Oral contraceptives may delay the return of fertility upon discontinuation of use, but this effect is transient (24). In fact, misunderstanding about the resumption of ovulation has led to many unplanned pregnancies among teenagers, who may believe that they had reliable protection against pregnancy lasting up to 8 months after discontinuation (7).
Menstrual Irregularities Breakthrough bleeding and failure to experience withdrawal bleeding can be frightening to teenagers and may prompt discontinuation of oral contracep tives. These two side effects usually occur in the first few months of use (25). Because these two side effects are relatively frequent with low-dose oral contraceptives, teenagers should be counseled that they may occur but are innocuous and tend to resolve within a few cycles of use. Additionally, irregular bleeding in teenagers using oral contraceptives can be due to incorrect use of the pill, missed pills, and/ or cervicitis or endometritis.
Effect on Height and Weight Medical providers and parents may fear that oral contraceptive use will stunt physical growth. Oral contraceptives in currently available low dosages do not cause premature closure of the epiphyses or inhibit skeletal growth. By the time menarche occurs, endogenous estrogen production has already initiated epiphyseal closure, and this process cannot be altered by small doses of exogenous steroids (6,26). Teenagers are exquisitely sensitive about their appearance~ and weight gain-whether real or per-
JOURNAL OF ADOLESCENT HEALTH Vol. 13, No. 4
ceived-is a major worry. Existing evidence suggests that women are as likely to lose weight as to gain weight while taking oral contraceptives (27). Other complaints, such as nausea, aggravation of acne, or leukorrhea are infrequent with the low-dose oral contraceptives available today. Should these side effects occur, they can be managed by an alternative choice of pills based on symptoms.
Sexually Transmitted Diseases Oral contraceptives cannot protect against sexually transmitted diseases. Although 70% of adolescents report that they are aware of the possibilities of acquiring sexually transmitted diseases and over 50% report knowledge regarding their need for medical treatment, sexually transmitted diseases (excluding human immune deficiency virus [HIV] infection) remain a problem affecting 2.5 million adolescents (28). The common adolescent behavior of “serial monogamy” exposes each partner indirectly to the previous partners and underscores the need for education (including information about HIV infection), as well as for dispensing condoms and demonstrating condom use in addition to oral contraceptives.
Benefits of Oral Contraceptives In addition to preventing pregnancy, the health benefits of oral contraceptives for teenagers outweigh the small risks. Oral contraceptive use confers protection against five life-threatening conditions: ovarian and endometrial cancers, pelvic inflammatory disease (PID), ectopic pregnancy, and toxic shock syndrome. Endometrial and ovarian cancers are rare among teenagers, but, if oral contraceptives are taken for more than 1 year, the protection against these cancers may last for at least 15 years after discontinuation of use (19,20). Teenagers have the highest rate of hospitalization for PID in the United States. By altering the cervical mucus and endometrial lining, oral contraceptives confer protection against PID by preventing the disease agent from ascending to the upper genital tract. Use of oral contraceptives reduces the risk of being hospitalized for PID by about 50% (29). The risk of ectopic pregnancy is reduced hy about 90% in oral contraceptive users (30). Teenagers are at lower risk for ectopic pregnancy than are older -women but are just as likely as older women to die if they develop an ectopic gestation. Epidemiologic
June 1992
studies (though not specific to teenagers) also indicate that the risk of toxic shock syndrome is reduced by about 50% in oral contraceptive users (31). Oral contraceptives also confer protection against five conditions that can affect a teenager’s quality of life: primary dysmenorrhea, benign breast disease, functional ovarian cysts, iron deficiency anemia, and possibly, leiomyomata uteri. Dysmenorrhea is one of the most frequent and debilitating ailments of teenagers. Most women have moderate to complete relief of dysmenorrhea within a few months of starting oral contraceptives (32). A large number of studies have documented a significant reduction in the risk of benign breast disease among oral contraceptive users (33). Similarly, numerous studies have documented a significant reduction in the frequency of functional ovarian cysts requiring surgery (34). Many teenagers have marginal iron stores, and the resultant iron deficiency anemia is a common problem among adolescents. Since menstrual blood loss is decreased by nearly 50% with the use of oral contraceptives, the risk of anemia is significantly decreased (35). Finally, contrary to gynecologic tenets, use of oral contraceptives may protect against, rather than contribute to, the development of leiomyomata. These growths, however, are rare in adolescents (36).
Summary By age 18,5l% of adolescent women will be sexually active. Oral contraceptives are a safe method to avoid the potentially disastrous outcome of an unwanted pregnancy. The overall risks of taking oral contraceptives are much less than the risks of pregnancy (20). Specifically, the risks associated with the use of oral>ontrace$ives by teenagers are negligible. Lowdose oral contraceptives have not been linked with either heart attack or stroke in contemporary U.S. studies. While the risk of thromboembolism in oral contraceptive users as a whole may be increased over that of the general population, the risk to teenagers, especially those who do not smoke, is minimal. The risk of death from oral contraceptive use for teenagers is virtually nil (12). As with all medical choices, the benefits of a treatment must be weighed against any potential risks. For adolescents, the benefits associated with the use of oral contraceptives outweigh the risks, particularly those of pregnancy. However, teenagers at risk for sexually transmitted diseases should be advised
SAFETYOF ORAL CONTRACEPTIVES FOR TEENAGERS
to use a barrier method ceptives.
335
a!ong &th oral contm
References 1. Jones EF, Forrest JD, Goldman N, Henshaw SK, Lincoln SR, Rosoff JI, et al. Teenagepregnancy in developed countries: determinants and policy implications. Fam P1ann perspect 1985;17:53-63 2. Henshaw SK, Kenney AM, Somberg D, Van Vort J, eds. Teenage pregnancyin the United States-the scope of the problem and state responses. New York: The Alan Guttmacher Institute, 1989 3. Hayes CD, ed. Risking the future, adolescent sexuality, preg nancy, and childbearing. Vol 1. Washington, DC: National Academy Press, 1987 4. Jay MS, DuRant RI-I,Litt IF. Female adolescents’ compliance with contraceptive regimens. Pediatr Clin, North Am 1989; 36:731-7% 5. Herold ES, Goodwin MS. Perceived side effects of oral contraceptives among adolescent girls. Can Med Assoc J 1980; 123:1022-1026 6. Bolton GC. Adolescent contraception. Clin Obstet Gynecol 1981;24:977-986 7. Kisker EE. Teenagers talk about sex, pregnancy, and contraception. Fam Plann Perspect 1985;17:83-90 8. Emans SJ, Grace E, Woods ER, Smith DE, Klein K, Merola J. Adolescents’ compliance with the use of oral centraceptives. JAMA 1987;25733773381 9. Realini JP, Goldzieher JW. Oral contraceptives and cardiovascular disease: a critique of the epidemiologic studies. Am J Obstet Gynecol1985;152:729-798 10. Hehmich SP, Rosenberg L, Kaufman DW, Strom B, Shapiro S. Venous thromboembolism in relation to oral contraceptive use. Obstet Gynecol 1987;69:91-95 11. National Center for Health Statistics. Vital statistics of the United States, 1987. II. Mortality, part A. Department of Health and Human Services publication no. (PHS) 90-1101. Washington, DC: U.S. Government Printing Office, 1990:276 12. Porter JB, Jick H, Walker AM. Mortality among oral contraceptive users. Obstet Gynecol1987;70:29-32 13. Newman WP III, Freedman DS, Voors AW, Gard PD, Srinivasan SR, Cresanta JL, et al. Relation of serum lipoprotein levels and systolic blood pressure to early atherosclerosis. The Bogalusa Heart Study. N Engl J Med 1986;314:138-144 14. Andrews WC. Principles of oral contraception. In: Carson SL, Derman RJ,Tyrer LB, eds. Fertilitycontrol. Boston:Little, Brown, 1985157-169 Gmydanus DE. Alternatives to adolescent pregnancy: a dis15. cussion of the contraceptive literature from I!?60 to 1980. SemIn PerInatoI1981;5:53-98 16. Drizd T, Dannenberg AL, Engel A. Blood pressure in persons 18-74 years of age in 1976-80 and trends in blood pressure from 1960 to 1980 in the United States. Vital Health Stat 1986C(234):1-68 17. Blumenstein BA, Douglas MB, Hall WD. Blood pressure changes and oral contraceptive use: a study of 2676 black women in the southeastern United States. Am J Epidemiol 1980;112:539-552 18. P+ti DB, Klatsky AL. Malignant hypertension in women aged 15 to 44 years and its relation to cigarette smoking and oral contraceptives. Am J Cardiol1983;52297-298
336
JOURNAL OF ADOLESCENTHEALTH Vol. 13, No. 4
ACOG
19. Combination oral contraceptive use and risk of endometrial cancer. The Cancer and Steroid Hormone Study of the Centers for Disease Control and the National Institute of Child Health and Human Development. JAMA 1987;257:796-800 20. The reduction in risk of ovarian cancer associated with oral contraceptive use. The Cancer and Steroid Hormone Study of the Centers for Disease Control and the National Institute of Child Health and Human Development. N Engl J Med 1%!?;316:650-655 21. Schlessebnan JJ,Stadel BV, Murray P, Lai S. Breastcancer in I relation to early use of oral contraceptives-no evidence of latent effect. JAMA 1988;259~182~1833 22. Kay CR, Hannaford PC. Breastcancer and the pill-a further report from the Royal College of General Practitioners’Oral Contraception Study. Br J Cancer 1988;58:675-680 23. Oral contraceptive use and the risk of breast cancer. The Cancerand Steroid Hormone Study of the Centers for Disease Control and the National Institute of Child Health and Human Development. N Engl J Med 1986;315:405-411 24. Vcssey MP, Wright NH, McPherson K, Wiggins P. Fertility after stopping different methods of contraception, Br Med J 1978;1:265-267 25. Jay MS, DuRant RH, Shofttt T, Linder CW, Litt IF. Effect of peer counselors on adolescent compliance in use of oral contraceptives. Pediatrics 1984;73zl26-131 26. MisheB DR Jr, Brenner P, Chcz PA, Chris&~ CD, Ccnncl: EB, Queenan JT, et al. Oral contraception and the teenager. J Reprod Med 1982;27:275-295 27. TyrerLB. Oral contraceptive practice. In: Corson SL, Derman
28. 29.
30.
31. 32.
33.
34.
35.
36.
RJ, Tyrer LB, eds. Fertility control. Boston: Little, Brown X&%171-185 Centers for Disease Control. Results from the National Adolescent Student Health Survey. MMWR 1989;38:147-150 Rubin GL, Ory HW, Layde PM. Oral contraceptives and pelvic inflammatory disease. Am J Obstet Gynecol1982;144630635 Ory HW. &topic pregnancy and intrauterine contraceptive devices: new perspectives. Women’s Health Study. Obstet Gyneco: 1981;57:137-144 Gray RH. Toxic shock syndrome and oral contraception. Am J Obstet Gyneco11987;156:1038 Chan WY, Dawood MY. Prostaglandin levels in menstrual fluid of nondysmenorrheic and of dysmenorrheic subjects with and without oral contraceptive or ibuprofen therapy. Adv Prostaglandin Thromboxane Res 1980;8:1443-1447 Ory H, Cole P, MacMahon B, Hoover R. Oral contraceptives and reduced risk of benign breast diseases. N Engl J Med 1976;294:419-422 Vessey M, Metcalfe A, Wells C, McPherson K, Westhoff C, Yeates D. Ovarian neoplasms, functional ovarian cysts, and oral contraceptives. Br Med J 1987;294:1518-1520 Royal College of General Practitioners. Oral contraceptives and health: an interim report from the oral contraception study. New York: Pitman Publishing, 1974 Ross RK, Pike MC, Vessey MP, Bull D, Yeates D, Casagrande JT. Risk factors for uterine fibroids: reduced risk associated with oral contraceptives. Br Med J 1986;293:359-362