The management of teenage pregnancy
BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g5887 (Published 15 October 2014) Cite this as: BMJ 2014;349:g5887
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This article has highlighted the issues of Teenage pregnancy very well. One of the most important points through the article was that up to 40% of pregnant teenagers feel stigmatized by their pregnancy. A possible explanation for the amount of stigma felt by these individuals could boil down to the financial benefits they receive or at least are perceived to receive by the general public.
There have been countless journalists reporting of 15 year olds getting pregnant in order to obtain hundreds of pounds a week in benefits, and a rent-free roof over their head, which has undoubtedly contributed to the stigma. Furthermore characters such as Vicky Pollard in the BBC’s old show ‘Little Britain’ added further fuel to the fire.
Though some of the individuals may consider the above as true, we could look at abortion rates to consider the amount of individuals who have become pregnant and decided against having a baby - therefore meaning there had no financial gain. The graph 'Figure 2 in Abortion Statistics, England and Wales: 2013' which shows Abortion rates from 2013, 2012, and 2003 in England and Wales shows that in the teenage years the rate of abortion increases exponentially. It does however peak at the age of 23, following which there is a decline.
Analysing the graph in terms of stigma would suggest that the teenagers, who have the highest rate of abortion, would not be having a baby simply for the financial and housing benefits. The real problem that this divulges is that as the article suggests, prevention is the best method, whether this is through education or contraceptive measures.
The method of prevention could also be aided by helping the general public understand that should the above methods of education and contraception measures fail, that their support and not their judgement will help these teenage mothers get back into college and along career paths they wish to choose and become valued members of society.
Competing interests: No competing interests
I agree with David Paintin that young teenagers can become pregnant due to sexual abuse from older men and an induced abortion is needed.1 However, must progestogen steroid abuse be added to sexual abuse? Any study of induced abortion with either breast cancer or depression is confounded by age of first use of progestogen-based hormonal contraceptives.
There is no doubt that breast cancer risks increase with longer use of oral contraceptives (OCs). Longer use relates to age of first pregnancy and first hormone use. The data from the UK National Case-control Study of breast cancer before age 36.2 Of women with young age breast cancer cases 80% had used OCs for more than 4 years if they started use before age 19 while only 30% of cases were longer users if they started after age 24. Figure1 In the USA breast cancer with distant metastatic involvement has increased by 78% in women aged 25 to 39 and their 5 year survival rate was 31%.3 Increases in breast cancer have matched increases in hormone use since 1962. Figure 2
Progesterone or progestins can cause depression by increasing monoamine oxidase levels in the late secretory phase of a normal cycle or during medication with a progestin.4 Monoamine oxidase inhibitor drugs are antidepressants.
A levonorgestrel containing Intra Uterine System is classified as a “newer” hormonal contraceptive but levonorgestrel is the active half of norgestrel. The highest doses of norgestrel tested in the 1960s caused depression and loss of libido when given with 50 micrograms of ethinyl oestradiol and also raised monoamine oxidase levels for most of the treated cycles.
In a Swedish study of nearly a million women progestin-only takers had significant increased risks of antidepressant use with most risk for 16-19 year olds including for those using combined hormonal contraceptives.5
High dose long acting progestogen contraception encourages longer use, more risk of breast cancer and depression due to suppression of warning symptoms.
1 Paintin DB. Re Management of teenage pregnancy. BMJ 19 October 2014 http://www.bmj.com/content/349/bmj.g5887/rapid-responses
2 UK National case-control study. Oral contraceptive use and breast cancer risk in young women. Lancet 1989;i:973-82.
3 Johnson RH, Chien FL Bleyer A. Incidence of Breast Cancer With Distant Involvement Among Women in the United States, 1976 to 2009. JAMA 2013;309(8):800-805.
4 Grant ECG, Pryce Davies J. Effect of oral contraceptives on depressive mood changes and on endometrial monoamine oxidase and phosphatases. BMJ 1968;3:777-80.
5 Lindberg M, Foldemo A, Josefsson A, Wirehn AB. Differences in prescription rates and odds ratios of antidepressant drugs in relation to individual hormonal contraceptives: a nationwide population-based study with age-specific analyses. The European journal of contraception & reproductive health care : the official journal of the European Society of Contraception. 2012;17(2):106-18.
Competing interests: No competing interests
In ‘The management of teenage pregnancy’ I read much good advice to fight this problem. Teenage pregnancy, together with the abortion rate, is an indicator of the state of civilization in a population.
Accessibility to contraception as well as availability of contraceptives and last but not least acceptability of contraception are the three pivotal factors that may limit teenage pregnancy and abortion rate. How can we explain the difference in teenage pregnancy and abortion rate between the UK and the Netherlands, while accessibility to and availability of contraceptives in both countries are well organized and high standard? Can we identify a difference in the third factor, acceptability of contraception, between the two countries? Acceptability of contraceptives and our attitude towards sex are associated. Some years ago, I, as a Dutch gynaecologist, was requested by the English teacher of our son to discuss the subject ‘genetics’ in his international class with students of 9 years old. After consultation with the teacher, she admitted that the essence of the lesson was sex education.
Competing interests: No competing interests
This article is not a comprehensive account of teenage pregnancy and is relevant only for the 51 per cent of women in England and Wale aged 18 or less who chose to continue their pregnancies (in 2012[1]). It is not sufficient for McCarthy et al to write that “All options about continuing the pregnancy should be discussed and should include termination of pregnancy ....” when this choice is made by almost half of the girls — much more information about their management is needed. These young women had decided that this pregnancy would have a harmful effect on their lives — that this was the wrong time to have a baby — a decision that is within the law in Britain and that most British gynaecologists would support. Also, the authors do not mention the possibility of sexual abuse, and the action that must be taken, when the teenager is willing to release only scanty information about the male partner, particularly if she is less than 15.
Contrary to the response from Dr Breen, there is sound evidence that induced abortion does not predispose to long term mental illness or increase the risk of breast cancer([2] — he appears to be referring to studies selected by those who oppose induced abortion on religious grounds.
1. ONS. Conception Statistics, England and Wales, 2012: conceptionstatisticstables2012finalsdcrev2pubcopy_tcm77-354097
2. The Care of Women Requesting Induced Abortion: Evidence-based Clinical Guideline Number 7, 2011; RCOG Press: London.
Competing interests: I have been an supporter of legal abortion since the 1960s (and of evidence-based practice).I directed an NHS District Pregnancy Advisory Service for Paddington and North Kensington from 1968 to 1991.
Fergus McCarthy and colleagues detail many adverse effects of teenage pregnancy on mother and child. A knee-jerk reaction is to recommend long acting contraception.1 This ignores the fact that progestogen use increases the risk of bleeding, cancers, vascular and mental illnesses, weight gain and infections.2
Progestogens up and down regulate thousands of genes and switch immunity from cellular to humoral which increases viral, bacterial and fungal infections in users. The world’s largest oral contraceptive cohort study reported significant increases in conjunctivitis, colds, catarrh, sinusitis, bronchitis, pleurisy, gastric flu, gastroenteritis, cholecystitis, chicken pox, herpes simplex, rubella, pyelitis, cystitis, monilia, vaginitis, trichomonas, and cervicitis.3
It is concerning that long acting contraceptive progestogens are being promoted at a time when there is world-wide alarm about the spread the Ebola virus. Annwyne Houldsworth notes that a humoral response may be less favourable for resolution of the virus than a cytotoxic response.4,5
It is safer for teenagers to delay sexual intercourse for as long as possible and ignore the promotion of so called “no cost” contraception in the form of long acting progestogens,
1 McCarthy FP, O’Brien U, Kenny LC. The management of teenage pregnancy. BMJ 2014;349:g5887.
2 Grant ECG. Re: Newer non-oral hormonal contraception http://www.bmj.com/content/346/bmj.f341/rapid-responses
3 Royal College of General Practitioners. Oral Contraceptives and Health. 1974 Pitman Medical, London
4 Houldsworth A. Re: Ebola: an opportunity for a clinical trial? Sophie Arie. 349:doi10.1136/bmj.g4997 17 October 2014
5 McElroy AK, Erickson BR, Flietstra TD, Rollin PE, Nichol ST, Towner JS, Spiropoulou CF. Ebola Hemorrhagic Fever: Novel Biomarker Correlates of Clinical Outcome, J Infect Dis. 2014; 210 (4): 558-566.
Competing interests: No competing interests
This article would seem to have an Irish address....Cork and Drogheda. Many if not most people in Ireland would disagree with the advice given. In particular the advice about abortion. We are in the eye of an abortion storm with the recent legislation called "The protection of life during pregnancy bill" which is a misnomer, because it actually is the destruction of life during pregnancy bill. It went full tilt a few weeks ago when a young women was delivered at 25 weeks by C section because she wanted an abortion for psychiatric reasons. Meantime this bill ignored the professional psychiatric advice endorsed at special government hearings, prior to the bill, which clearly stated that there is no evidence to show that abortion is a treatment for suicidality. In fact the evidence shows that it is not good for mental health and leads to depression and suicidality.
Instead of subjecting young girls to abortion and contraception (with breast cancer risks greatly increased as a result) should public health not invest in education? After all this article references several sources showing the success of education in lowering teen pregnancy up to 40%?
Competing interests: No competing interests
Re: The management of teenage pregnancy
A recent comprehensive article on abortion and breast cancer shows that religion has nothing to do with it as suggested by David Paintin. 1. Abortion has an evidence based association with increased breast cancer, as have female hormones be they taken as HRT or the oral contraceptive pill, or as injections.2.
1.A E Lanfranchi et al. Breast cancer and induced abortion. Law and Medicine. V29. N 1;3-133. Spring 2014.
2. E G Breen. The Screech Owls of Breast Cancer. Author House. 2013.
Competing interests: No competing interests