"My daughter just turned 17. About 1 1/2
years ago we put her on the pill to help the incredible
pain she goes through every month with her period.
It helped for about 4 months and that's all. We have
continually asked her Gyn if there is anything stronger
than Vicodin (already prescribed) and Naproxen (doesn't
work either)....all they say is that they can put
her on the pill continuously without the break, so
she just won't get her period. This CANNOT be healthy!
What about all the OTHER side effects of the pill?
It doesn't seem they are taking those into consideration!"
J.G.
Your doctor is treating your daughter under the diagnosis
of primary dysmenorrhea or "painful menses".
Intrauterine pressure generated with some menstrual
cramps have been measured as high as 300 mm Hg. A
uterine contraction during labor only gets as high
as about 80 mm Hg so you can see that a bad menstrual
cramp can easily be 4 times as painful as laboring
with a baby.
Before we go on to address treatment, however, endometriosis
is often reported in adolescents and if the pain just
seems to persist too strong too long, you may need
to ask your doctor about diagnostic laparoscopy to
see if any endometriosis is present and also to dilate
the cervix at the same time. While continuous oral
contraceptive pill regimens can treat endometriosis,
there are other therapies that might be used if there
was a certain knowledge (not just guessing) that endometriosis
was present.
As far as pain medicines for dysmenorrhea, the non
steroidal anti inflammatory drugs (NSAIDs) are the
best because they block the formation of prostaglandin
which causes the severe uterine contractions. They
have to be taken on a regular basis during menses,
however, not just when your daughter can't stand the
pain. See our discussion in this newsletter about
NSAIDs.
A common problem with medications that doctors see
is that an adolescent (or even an adult) looking for
instant relief, waits until the pain builds up and
then decides a pain medicine is needed. When she then
takes an NSAID like Aleve(R) (she should take 2 or
3 at once, not just one like the bottle says) the
onset of blocking the cause of the pain does not take
place for several hours. So by that time she has concluded
the pain medicine does not work. Instead, she should
take two tablets regularly twice a day as soon as
she senses that the cramps are going to start. The
expectations should not be for total pain relief,
but merely to lower the magnitude to the point where
she can cope with the cramps until the period is over.
Vicodin (R) and other narcotic pain medicines are
not very effective at all for menstrual cramps.
Oral contraceptive pills (OCPs) can be quite useful
in treating menstrual cramps because they decrease
the amount of menstrual tissue formed and lower the
pain level (amplitude) of the uterine contractions
probably due to their progestin effect. When given
in a continuous fashion, i.e., no week of placebo
pills to allow an artificial menstrual period, they
can further reduce the level of pain because most
of the time menstrual periods are blocked completely.
There still may be some irregular spotting with cramps
but generally they are of much lower severity and
less interruptive of everyday activities.
You have concerns about long term side effects or
complications of continuous birth control pills. It
would be helpful to know which concerns you have in
mind because the television and newsprint media often
exaggerate reported studies or experts comments out
of proportion; otherwise they would have "ho-hum"
news. You may need a personal medical educational
consult to answer a specific concern.
In general, physicians do not have evidence of significant
long term problems from either normal withdrawal oral
contraceptive regimens or continuous oral contraceptives
as used for endometriosis or severe menstrual cramps.
OCPs are associated with a much lower incidence of
ovarian cancer and endometrial cancer. In fact they
are one of the very few medicines known to actually
prevent any cancers. Cervical cancer is slightly higher
on the pills and breast cancer is essentially unchanged.
As far as cervical cancer goes, the pills are not
thought to have a chemical effect on it but rather
they allow the behavior, intercourse with multiple
partners, that has been also associated with increased
cervical cancer. Long term use of OCPs are not known
to affect future fertility one way or the other so
this treatment now should not affect her ability to
have a pregnancy in the future.
The main deleterious effect of OCPs is the formation
of blood clots in the veins and arterial thrombosis.
The increased incidence is real but very small, on
the level of two times increased over not taking the
pills - 3 per 10,000 women. The risk can go higher
in women who are over 35 years of age and smoke or
who have hypertension but it is highly unlikely your
17 year old will have a problem with this. The small
increase in risk does have to be weighed against the
possible benefits, however.
All in all, I would be comfortable prescribing the
continuous pill regimen for this purpose. If she does
not have significantly less days of severe pain after
a 3 month course of continuous pills, then I would
strongly consider a diagnostic laparoscopy to look
for endometriosis. Endometriosis is the one thing
that if not diagnosed early, can cause impaired fertility
in the long run.
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