Adolescent Acne and Anxiety: The Case for FABMs Among Teens
By: Tessa Wiens
Director’s Note: This compelling interview with Elizabeth* — a woman who began taking hormonal contraception at age 12 to address the woes of puberty — details her transition to fertility awareness-based methods (FABMs) in young adulthood. Like many women, it wasn’t until she was in her 20s that Elizabeth learned “the period was not the only point of your cycle.” She now encourages young women to pursue a more comprehensive understanding of fertility as an indicator of health. In the interview, Tessa Wiens, former FACTS elective student, asked about the value of FABMs, not only as an effective form of family planning but also as an opportunity to empower women with information about their own bodies. In addition to our online elective, FACTS is delighted to offer an online CME course and our conferences for everyone! To learn more about all FACTS has to offer, join us in Providence, RI, on October 13th for our FMEC pre-conference, FACTS for You and Your Patients. Register today!
Meet Elizabeth
At 12 years old, Elizabeth* was at the “peak of puberty and anxiety” and looking for a solution to her acne. She had tried countless face washes, antibiotics, and other topicals with no success. Seeking alternatives, she went to the doctor’s office, where she was offered oral contraceptive pills (OCPs). No downsides were mentioned, and she knew plenty of friends already taking them. At age 12, she remarked, it was her mom’s choice more than her own anyway so she began taking OCPs. Although her acne improved, her anxiety worsened and she began to struggle with depression, which persisted throughout her adolescence and young adult years. She also developed a rare condition called cold urticaria, where any cold exposure triggered painful hives on her skin. Rather than search for an explanation, she was given an EpiPen and a temporary handicap parking pass. Almost 10 years later, Elizabeth feels that OCPs were an extreme solution for a common adolescent problem — one she would probably outgrow in the next few years — and may have been linked to the development of her subsequent health concerns. [1]
What is the Cycle?
After the onset of puberty, it takes up to three years for the hypothalamic-pituitary-ovarian axis to fully mature in the majority of adolescent girls, after which they typically experience regular cycles. [2] However, women are often placed on OCPs before the cycle regulates naturally. As we learned in the FACTS elective, the way the women’s body is supposed to work is an intricate balance of rising and falling estrogen levels, followed by rising and falling progesterone levels.
“After the onset of puberty, it takes up to three years for the hypothalamic-pituitary-ovarian axis to fully mature in the majority of adolescent girls, after which they typically experience regular cycles. [2] However, women are often placed on OCPs before the cycle regulates naturally.”
“The cycle gives women the opportunity to have a slightly different perspective every day of the month; it doesn’t dictate what they think or do,” explained one instructor, Dr. G. “It’s like a superpower in empathy.”
Yet few women are well-informed about their cycle, and many assume the period is the key event.
“The menses are just the bookends: out with the old and in with the new,” Dr. G explains. “The main event is actually ovulation, which occurs in the middle of the cycle, when an egg is released from the ovary. Confirmation of ovulation, along with any symptoms a woman might experience around that time, can be an excellent marker of overall health if she or her physician know what to look for.” [3] After learning this information for herself, Elizabeth remarked that she didn’t know that the period was not the only point of her cycle until she turned 22, a fact she called “ridiculous,” showing her frustration at how little women often know about their natural bodies.
The Transition to Fertility Awareness-Based Methods (FABMs)
When researching different family planning options in preparing for her upcoming marriage, Elizabeth discovered more and more of the harms of birth control, something no medical professional had ever discussed with her. She also started hearing stories from friends, including one who has had severe anxiety since beginning to take hormonal contraception. Her friend had switched pills multiple times and had still yet to find one without adverse side effects. It was even more impactful for Elizabeth to experience the sense of female empowerment that comes with FABMs and realize that there are other alternatives to hormonal contraceptives.
“It was impactful to experience the sense of female empowerment that comes with FABMs and realize that there are other alternatives to hormonal contraceptives.”
“Why do women have to suppress their own fertility and men don’t?” Elizabeth said. “We shouldn’t have to alter our bodies to be deemed socially acceptable. Birth control has the potential to cause lots of physical harm, and we do it because babies aren’t readily welcomed in society. Fertility is viewed as a bad thing to be controlled versus an inherent part of who we are.”
Convinced that hormonal contraception was neither the healthiest or most empowering way to care for her fertility and her body, Elizabeth decided to transition off OCPs. However, she still needed an effective method of family planning. She considered FABMs with some hesitancy, uncertain of its legitimacy, and stumbled upon the Sympto-Thermal Method (STM). STM uses various observable signs, combining observations of cervical mucus, cervix positioning, and basal body temperature (BBT) to track a woman’s menstrual cycle. The method has an efficacy rate of 98-99% with typical use. [4]
Given that Elizabeth had started OCPs at just 12 years old, the year she started puberty, she had never observed a true menstrual cycle. It took her body about a year to normalize. Initially, the idea of charting cervical mucus was especially difficult because she had never experienced it. It took several months for her body to begin production of mucus. As Elizabeth began charting with STM, she also struggled with the daily temperature check required by the method. By her own admission, she is not a morning person; her alarm would go off in the morning reminding her to take her temperature only for her to fall back asleep with the thermometer still in her mouth. However, she really wanted to stick with STM because she was comforted by the objective temperature data as a double check, alongside cervical mucus observations. It was then that she found Tempdrop, a wearable thermometer that monitors BBT during sleep.
“I don’t think I could’ve kept doing Sympto-Thermal otherwise,” remarked Elizabeth.
Looking Back
Charting with FABMs helped Elizabeth accept her body for the first time in her life.
“You are different from a man, and that is not a bad thing,” Elizabeth said. “You can use that information to make yourself healthier. Understanding fertility as an indicator of health gives you full insight into what’s going on in your body. It helps you pay more attention to how you feel physically and emotionally. If I’ve had a stressful month, I can tell based on how my cycle is, and I can course correct a bit.”
“Understanding fertility as an indicator of health gives you full insight into what’s going on in your body. It helps you pay more attention to how you feel physically and emotionally.”
Elizabeth reflects on the fact that many pubescent females have poor relationships with their bodies. When she experienced her first menses, she viewed her newly changing body as “gross, something that needed to be controlled, contained.” She now sees a great need for more education on female cycles starting at a young age. For Elizabeth, FABMs present a valuable opportunity to improve women’s relationships with their bodies and to empower them across all life stages.
“If you have more respect for yourself, you’re going to demand more respect from other people — which is hard to do as a teenager,” Elizabeth said. “We need an understanding that everything happening to us is normal and healthy. We need teaching skills [regarding puberty and menstruation], not to just deal with it, but to use that info to have a more full life.”
*Names have been changed to respect the privacy of the interviewee. All information is shared with permission.
References
[1] Skovlund CW, Mørch LS, Kessing LV, Lidegaard Ø. Association of Hormonal Contraception With Depression [published correction appears in JAMA Psychiatry. 2017 Jul 1;74(7):764]. JAMA Psychiatry. 2016;73(11):1154-1162. doi:10.1001/jamapsychiatry.2016.2387
[2] Committee Opinion number 651. “Menstruation in Girls and Adolescents: Using the Menstrual Cycle as a vital Sign,” American College of Obstetrics and Gynecology, December 2015, reaffirmed 2020. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2015/12/menstruation-in-girls-and-adolescents-using-the-menstrual-cycle-as-a-vital-sign
[3] Vigil, Pilar, Carolina Lyon, Betsi Flores, Hernan Rioseco, and Felipe Serrano. “Ovulation, a Sign of Health,” Linacre Quarterly, November 2017. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5730019/#:~:text=Accordingly%2C%20normal%20ovulatory%20activity%20during,adequate%20endocrine%20and%20gonadal%20function.
[4] FACTS: Fertility Appreciation Collaborative to Teach the Sciences. “Sympto-Thermal Method” https://www.factsaboutfertility.org/wp-content/uploads/2014/09/SymptoThermalPEH.pdf
ABOUT THE AUTHOR
Tessa Wiens
Tessa Wiens is a fourth-year medical student at Marian University College of Osteopathic Medicine in Indianapolis, IN. She completed her undergraduate education at South Dakota State University, studying pharmacy, Spanish, and studio arts. She plans to do her residency in obstetrics and gynecology, has a particular interest in holistic and restorative medicine, and intends to incorporate osteopathic manipulative medicine into her practice. She enrolled in the FACTS elective to gain a better understanding of fertility awareness based methods in order to be able to provide comprehensive, inclusive counseling and care to her future patients.
