Can a 13-year-old with irregular menses be started on Birth Control Pills (BCPs)?

Starting Birth Control Pills in a 13-Year-Old with Irregular Menses

Yes, you can start a 13-year-old on birth control pills even with irregular menses—combined oral contraceptives can be initiated at any time if it is reasonably certain she is not pregnant, and irregular cycles are not a contraindication. 1, 2

Key Principles for Initiation

Timing of initiation does not require regular menses. The CDC explicitly states that combined hormonal contraceptives can be started at any time during amenorrhea (absence of periods) if pregnancy can be reasonably excluded. 1 This is particularly relevant for adolescents, as irregular menses are common in the first 1-3 years after menarche due to anovulatory cycles.

Pregnancy Exclusion in Adolescents

Before starting BCPs in a 13-year-old with irregular menses:

• Obtain a pregnancy test if she is sexually active or there is any possibility of sexual activity 1
• If uncertain about pregnancy status, the benefits of starting hormonal contraception likely exceed any risks 2
• Consider a follow-up pregnancy test in 2-4 weeks if uncertainty exists 2

Backup Contraception Requirements

When starting BCPs in the setting of amenorrhea or irregular menses:

• She needs to abstain from sexual intercourse or use additional contraceptive protection (condoms) for the next 7 days 1, 2
• If started within the first 5 days of menstrual bleeding (when it occurs), no backup contraception is needed 2
• If started after day 5 of a menstrual cycle, backup contraception is required for 7 days 2

Safety Profile in Adolescents

Birth control pills are extremely safe for teenagers. The American College of Obstetricians and Gynecologists confirms that the risks associated with oral contraceptive use by teenagers are negligible, and the overall risks are much less than the risks of pregnancy. 3 Specifically:

• The risk of death from oral contraceptive use for teenagers is virtually nil 3
• Low-dose oral contraceptives have not been linked with heart attack or stroke in contemporary U.S. studies 3
• The risk of thromboembolism in teenagers who do not smoke is minimal 3

Medical Eligibility

No gynecologic examination is required to determine eligibility for COC use in adolescents. 1 Combined oral contraceptives can be used by women of all ages and are reversible with no negative effect on long-term fertility. 1

Practical Prescribing Approach

Recommended Formulation

Start with a monophasic low-dose pill containing 30-35 μg of ethinyl estradiol and a progestin such as levonorgestrel or norgestimate. 1 This approach allows for:

• Monthly bleeding patterns initially, with option to extend cycles later based on patient preference or medical indications 1
• Lowest copay options on insurance formularies when multiple equivalent formulations exist 1

Same-Day "Quick Start" Method

Initiate BCPs on the same day as the visit in healthy, nonpregnant adolescents. 1, 2 This approach:

• Improves initial continuation rates 2
• Eliminates delays that might result in pregnancy or loss to follow-up
• Requires counseling about 7-day backup contraception requirement 1

Prescribing Duration

Prescribe up to 1 year of COCs at a time to reduce barriers to continuation. 1 Schedule a routine follow-up visit 1-3 months after initiation to address adverse effects or adherence issues. 1

Noncontraceptive Benefits for Irregular Menses

BCPs provide therapeutic benefits beyond contraception that are particularly relevant for adolescents with irregular menses:

• Decreased menstrual cramping and blood loss 1
• Improvement in acne 1
• Regulation of menstrual cycles
• Extended or continuous cycles may be particularly appropriate for adolescents with severe dysmenorrhea, abnormal uterine bleeding, or bleeding diatheses 1

Managing Expected Side Effects

Irregular Bleeding

Counsel the patient and family that irregular bleeding is common in the first 3 months of OCP use. 4 During this initial period:

• Counseling and reassurance are adequate 4
• If bleeding persists beyond 3 months, consider supplemental estrogen and/or an NSAID 4
• Alternative option is to change to an OCP with higher estrogen content or different progestin formulation 4

Other Common Transient Effects

Inform patients about common transient adverse effects including irregular bleeding, headache, and nausea. 1 These typically improve with continued use.

Critical Counseling Points

Emphasize that consistent timing is essential for effectiveness:

• Take pills at approximately the same time each day 2
• Use backup contraception (condoms) for STI protection if sexually active 1, 3
• Provide clear instructions on what to do if pills are missed 1

Contraindications to Screen For

BCPs should not be prescribed if the adolescent has: 1

• Severe uncontrolled hypertension (≥160/100 mm Hg)
• Migraines with aura or focal neurologic symptoms
• History of thromboembolism or known thrombophilia
• Active or chronic liver disease
• Complicated valvular heart disease

Smoking is NOT a contraindication to COC use in teenagers and adults younger than 35 years old. 1

Common Pitfall to Avoid

Do not delay initiation waiting for "regular cycles" to establish. Irregular menses in early adolescence are physiologic, and waiting for cycle regularity is unnecessary and may result in unintended pregnancy if the patient becomes sexually active. 1, 2