December 15, 2016
by Alison Contreras, PhD, FCP
As a fertility educator, I have a particular interest in teaching young women about their bodies. I know that at 22 when I first learned that observable signs of a women’s body were cyclical and could be charted to interpret fertility, I was amazed. That amazement changed to frustration when I realized that I had been having periods for nearly a decade, but still didn’t understand the basics of how my body worked.
I think there is a prevailing thought that young women can’t learn to chart, are not interested, or are too irresponsible. I have not found this to be universally true. A few months ago I was giving a talk at a local high school about using fertility awareness based methods (FABMs) to educate young women about their bodies. When it came time to talk about charting the cycle, two girls announced that they knew when their period was coming because they were using an app to track their cycle. Another girl came up to me afterwards and privately shared “I’ve just seen this discharge you’re talking about! I had no idea what it was before today, but now that I know its normal, that’s such a relief! I’m not defective!” Her words resonated with me, as I remember having similar thoughts years earlier.
Who knows how many other girls that day became empowered by just a little more education about their body?
Teens at increased risk for depression
Last month we covered a study indicating increased risk of depression when taking hormonal contraception. We basically called for fully informing patients of their birth control risks. So how do young women come into play? As reported, young women and teens were affected the most, with an 80% increase in depression when taking a combined pill and 120% increase when taking a progestin-only pill . The new research about the effect of birth control on adolescents is particularly concerning given recent trends in depression among teens in the United States. Young women are more likely to experience depression than young men, and that number is on the rise. “Doctors should perhaps be more careful when they prescribe hormonal contraception to young women and get a history of previous depression first,” Lidegaard, the lead researcher of the Danish study, said .
Then, last month a separate cross-sectional national survey published in Pediatrics revealed that across demographic categories in the US, the number of major depressive episodes of adolescent females has increased from 13% in 2005 to 17% in 2014, whereas the increase from boys was present but much lower at 4% in 2005 to 6% in 2014 . While many cultural or environmental reasons could be contributing to the increase, it seems wise to further explore the connection between birth control use and depression among teens as well, especially considering the prevalence of depression found in females vs. males.
…and other side effects
Increased rate of depression is just one of the side effects teens are at a higher risk of experiencing with hormonal contraception. Younger women face more obstacles to consistent use and are more likely to abandon a method and try another if they experience side effects.  Teens discontinue hormonal birth control for a variety of other reasons, the most common for Norplant and Depo-Provera being irregular menstrual bleeding (64%), weight gain (41%), and increased headaches (30%), even after longer term use . There is research indicating that early use of hormonal birth control also leaves young women at a higher risk of contracting sexually transmitted diseases, as it changed the way the cervix matures. . Other research indicates that breast cancer rates may also increase the longer a woman uses hormonal birth control before her first full term pregnancy. Long-term oral contraceptive use among young women or use beginning near menarche may be associated with a small excess breast cancer risk, possibly due to susceptibility to genetic damage in breast epithelial cells at ages of high breast cell proliferative activity. [7, 8]
As we understand the side effects of hormonal birth control more and more, physicians should naturally be concerned with how to incorporate this information into their practice. Why are teens affected so differently? Should teen health be treated the same way as a mature female adult? A great place to start is to consider what are the needs of the patient. What are teens looking for by going on hormonal birth control in the first place?
What are teen reproductive health needs?
While many teens do go on the pill to avoid pregnancy, up to 82% of teenagers go on the birth control pill either partly or solely for non-contraceptive reasons, hoping to alleviate other symptoms they are experiencing, including painful periods, acne, and irregular cycles . This means that by offering the pill or other device that provides a birth control solution, the root problem is often never addressed. Creating side effects can then compound those problems.
In an interview with NPR about the recent study linking depression and contraception, Catherine Monk, an associate professor of psychiatry and director of research at the Women’s Program at Columbia University Medical Center, had this to say.
“Understanding women’s health has been neglected, and there’s not enough research into understanding our hormones,” Monk says. “This is partially a story about women’s health research and how we need more of it.” 
One way to start this conversation is to encourage even young women to start charting their cycles and look into ways to partner with their physician about their health. One group doing this is FEMM, Fertility Education and Medical Management, in NYC. FEMM focuses on educating young women about signs of their reproductive health. “The FEMM app is designed to help women understand their bodies and health, in order to achieve their health and fertility goals. Symptoms such as acne, migraines, fatigue, PMS and infertility all point to hormonal imbalances, and the FEMM app helps women to understand and identify these imbalances from symptoms and observations in their cycle. The app then links women with health educators and doctors to help them get the support and medical care they need” said Anna Halpine, co-founder of FEMM.
Charting for teens
What if instead of offering a chemical solution to these issues that come with a whole host of side effects, physicians offered young women a way to understand their bodies better while simultaneously trying to dig down to the root of the reason why they are experiencing discomfort? Taking a fertility awareness course benefits teenagers with information about their reproductive health. Charting their cycle can not only lead to pursuing treatment that fixes the underlying issues causing these symptoms, but improved knowledge of their cycle can also help them to make effective and informed family planning decisions.
 Skovlund, et al. Association of Hormonal Contraception with Depression. JAMA Psychiatry. 2016;73(11):1154-1162.[link]
 Mojtabai et al. National Trends in the Prevalence and Treatment of Depression in Adolescents and Young Adults. Pediatrics.Volume 138, Number 6, December 2016. [pdf]
 Gupta et al. Hormonal Contraception for the Adolescent. Pediatrics in Review. November 2008, VOLUME 29 / ISSUE 11 [link]
 Harel et al. Adolescents’ reasons for and experience after discontinuation of the long-acting contraceptives Depo-Provera and Norplant. J Adolesc Health. Aug;19(2):118-23. 1996 [link]
 White E, Malone KE, Weiss NS, Daling JR. Breast Cancer Among Young U.S. Women In Relation To Oral Contraceptive Use. J Natl Cancer Inst 1994.[link]
 Brinton LA, Daling JR, Liff JM, Schoenberg JB, Malone KE, Stanford JL, et al. Oral Contraceptives And Breast Cancer Risk Among Younger Women. J Natl Cancer Inst 1995;87:827-35. [link]
 Abma JC, Martinez GM ,CopenCE. Teenagers in the United States: Sexual activity, contraceptive use, and childbearing, National Survey of Family Growth 2006–2008. National Center for Health Statistics. Vital Health Stat 23(30). 2010. [pdf]