Frederick R. Jelovsek MD, MS
"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.
| 
