What is the recommended birth control pill for a 12-year-old female with menorrhagia (heavy menstrual bleeding)?

Combined Oral Contraceptives with 30-35 μg Ethinyl Estradiol

For a 12-year-old with heavy menstrual bleeding, prescribe a monophasic combined oral contraceptive containing 30-35 μg of ethinyl estradiol with levonorgestrel or norgestimate as first-line therapy. 1

Recommended Formulations

• Monophasic pills containing 30-35 μg ethinyl estradiol plus levonorgestrel or norgestimate are the preferred initial therapy for adolescents with menorrhagia 1
• These formulations decrease menstrual blood loss and cramping by inducing regular shedding of a thinner endometrium 1
• The higher estrogen dose (30-35 μg) is specifically recommended over lower doses (20 μg) for treating heavy bleeding in this population 1

Mechanism and Efficacy

• Combined oral contraceptives improve treatment success dramatically—if only 3% of adolescents respond to placebo, COCs increase this to 12-77% 2
• COCs reduce menstrual blood loss by 20-60% through endometrial thinning and ovulation inhibition 3, 2
• The medication works by inducing regular shedding of a thinner endometrium while providing contraceptive protection 4, 1

Initiation and Timing

• Start the pill at any time if reasonably certain the patient is not pregnant 4
• If started within the first 5 days of menstrual bleeding, no backup contraception is needed 4
• If started >5 days after bleeding began, use backup contraception (condoms) for 7 consecutive days 4

Extended Regimen Considerations

For severe bleeding or anemia, consider an extended regimen where the patient takes active pills continuously for 3-4 months, followed by a 4-7 day hormone-free interval 1

Managing breakthrough bleeding with extended regimens:

• Do not allow a hormone-free interval during the first 21 days of continuous use 1
• If breakthrough bleeding occurs after 21 days, a 3-4 day hormone-free interval can be taken, but not more than once per month 1
• NSAIDs for 5-7 days can help manage persistent bleeding 4, 1

Additional Benefits Beyond Bleeding Control

• Improvement in acne 1
• Reduced risk of endometrial and ovarian cancers with long-term use 1
• Does not increase risk of infertility or breast cancer 1
• Provides effective contraception if the adolescent becomes sexually active 4, 1

Safety Profile in Adolescents

• Smoking is NOT a contraindication in patients under 35 years old 1
• Common transient side effects include irregular bleeding (especially first 3-6 months), headache, nausea, and breast pain 1
• COCs increase venous thromboembolism risk 3-4 fold, but absolute risk remains low (4 per 10,000 woman-years) 1

Critical Counseling Points

• Emphasize consistent condom use for STI protection regardless of contraceptive method, as all sexually active adolescents should use condoms 1
• Ensure confidential discussion, as adolescents are significantly less likely to use family planning services without confidentiality assurances 1
• Teach what to do if pills are missed: take the most recently missed pill immediately, and remember that 7 consecutive hormone pills are needed to prevent ovulation 1
• Use adherence strategies like cell phone alarms or family member support 1

Monitoring Requirements

• No routine follow-up visit is required 4, 1
• Advise the patient to return for side effects, concerns, or desire to change methods 4, 1
• Monitor blood pressure at follow-up visits 4, 1
• Assess satisfaction with the method and any health status changes 4

When to Evaluate Further

Before treating breakthrough bleeding, rule out:

• Pregnancy 1
• Sexually transmitted infections 1
• Thyroid disorders 1
• New pathologic uterine conditions (polyps or fibroids) 1
• Medication interactions 1

Alternative if COCs Fail or Are Not Tolerated

• Levonorgestrel-releasing IUD is more effective than COCs for reducing menstrual blood loss (71-95% reduction) but may be less acceptable in a 12-year-old 1, 2
• Depot medroxyprogesterone acetate (DMPA) can be considered as second-line, though it causes irregular bleeding initially 1