24 Gynecology O B .GYN. NEWS • February 15, 2005 Monophasic OCs Said to Ease Menstrual Migraines

BY NANCY A. MELVILLE tients,” she said. “Invariably, you will have a patient track diating hyperalgesia, and prostaglandin is known to in- Contributing Writer her calendar and over a month’s period of time she will crease during migraine attacks. report that within a day or two of switching to a new dose A key approach to treatment is having patients main- S COTTSDALE, ARIZ. — Because fluctuating hor- of pill, the woman will experience a migraine attack.” tain a diary in which they track their menses and mones are believed to be the key culprit behind menstrual Migraine patients generally fare much better when us- days, Dr. Lay said. The journal can help guide treatment migraines, low-dose monophasic oral contraceptives are ing monophasic low-dose (20-mcg) birth control pills, options and determine the role of oral contraceptive use. generally the best alternative to help such patients, Chris- which offer a more uniform hormone level, Dr. Lay said, Since menstrual migraines can occur in young, other- tine Lay, M.D., said at a symposium sponsored by the adding that the patch is another effective way wise healthy women, Dr. Lay strongly recommended us- American Headache Society. of providing a more steady level of estrogen. Newer non- ing caution in approaching contraceptive issues. Ob.gyns. often turn to biphasic contraception instead cycling methods such as Seasonale (ethinyl and “This is a critical time to discuss with patients preg- of monophasic pills in the belief that varying the hor- ) are also good alternatives for migraineurs, nancy planning and medication contraindications in preg- mone dosage will help alleviate menstrual migraines, but she said in an interview nancy because, invariably, some of these patients could the dosage schedule can make the problem worse, said Estrogen use in patients who suffered from migraines wind up getting pregnant” unintentionally. “We recom- Dr. Lay, a neurologist with the Headache Institute at Roo- was frowned upon for many years, but the International mend taking a patient off the pill when efforts to prevent sevelt Hospital, New York. Headache Society Task Force on Combined Oral Con- migraines are unsuccessful,” Dr. Lay added. Dr. Lay gave the example of Mircette, which contains traceptives and HRT determined more recently that it was “Physicians may have the patient go off the pill in or- 21 days of 0.15-mg desogestrel/0.02-mg ethinyl estradi- safe for migraineurs, provided that there are no other risk der to observe the migraine pattern over time. Howev- ol, followed by 2 days of placebo pills and 5 days of 0.01- factors for coronary heart disease or vascular disease. er, the migraine pattern may not improve for at least 3- mg ethinyl estradiol. “I have numerous ob.gyns. who put In addition, the migraine should be without aura and pa- 6 months. In such cases, it’s essential to talk about patients on Mircette because they think it might help tients should be given the lowest effective hormone dose. pregnancy issues if the patient is on the pill for contra- menstrually-related migraines,” she said. In the ebb and flow of hormone levels, it is the with- ceptive purposes.” Instead, the method introduces another level of fluctu- drawal of estrogen, specifically, that experts believe con- Short-term prophylaxis approaches recommended to ation of estrogen, and it is that fluctuation that is believed tributes to menstrual migraines. The withdrawal is believed prevent the onset of menstrual migraines range from to trigger the migraines in the first place, said Dr. Lay not only to affect trigeminal pain pathways and have vas- NSAIDs to triptans, and for a more long-term preven- Even worse for menstrual migraines are triphasic pills, culature effects, but it may modulate neurotransmitters tion, Dr. Lay suggested considering standard preventive which cause greater fluctuation in hormone levels and of- and magnesium, Dr. Lay said at the meeting. medications, including tricyclic antidepressant, ten are high-dose pills, said Dr. Lay. The release of prostaglandin also plays a role in mi- antiepileptic drugs, β-blockers, and selective serotonin “The triphasic pills are the worst for migraine pa- graines, sensitizing peripheral nociceptors to pain and me- reuptake inhibitors. ■ Study: Parental Notification Laws Consider Discontinuation of May Lead to More Teen Pregnancies Hormonal Contraceptives to Reverse Sexual Dysfunction BY MARY ELLEN SCHNEIDER taining sexual health services at the clinic. About Senior Writer 4% said they were unsure if their parents knew. BY KATE JOHNSON taking oral contraceptives, but Reasons respondents gave for not informing Montreal Bureau one had been using a contracep- aws that require parental notification for teens their parents include: tive patch and one had been us- Lto receive prescription contraception at fami- Ǡ Not wanting parents to know of the teen’s sex- P HILADELPHIA — Discon- ing a contraceptive . ly planning clinics could increase the risk of teen ual activity. tinuation of hormonal contra- The serum levels were as- pregnancy, according to a study by Rachel Jones, Ǡ Not wanting parents to be disappointed by the ceptives should be the first-line sessed again 4 months after the Ph.D., and her colleagues. teen’s sexual activity. approach in addressing sexual women discontinued using con- “Family planning clinics need to be supported in Ǡ Not feeling comfortable with discussing sex dysfunction in women using traception. Patients also com- the work that they are doing with teens,” said Dr. with their parents. these agents. Susan Sarajari, pleted questionnaires at base- Jones, senior research associate at the Alan Ǡ Not wanting parents to know the reason for the M.D., outlined her study of 20 line and at the end of the study, Guttmacher Institute (JAMA 2005;293:340-8). teen’s clinic visit. women who experienced im- which assessed sexual function, The study found that if a law required clinics to Ǡ Wanting to take responsibility for their own proved sexual function after dis- related distress, and sexual desire inform parents in writing when their teenagers got health. continuing hormonal contra- and energy. prescription birth control, 18% of teens would have Concerned Women for America (CWA), a group ception. Mean total and free testos- sex using no contraceptive method or would rely that supports abstinence-only education, dis- “This is the first trial that cor- terone levels increased, while on rhythm or withdrawal. counted the study. CWA said the study is biased be- relates serum androgen changes SHBG rose significantly after About 1% of teens surveyed said their only re- cause its authors are researchers associated with the with specific domains of sexual contraceptive discontinuation. action to such a law would be to stop having sex, Alan Guttmacher Institute, which is affiliated with function,” she said at the annu- These changes coincided with the study said. Planned Parenthood. CWA claims that Planned al meeting of the American So- an increase in sexual energy, de- Most teens said they would continue to use the Parenthood is concerned that greater parental in- ciety for Reproductive Medicine. crease in sexual distress, and an services at the clinic even if parental notification was volvement will mean less business for them. About 15% of hormonal con- improvement in global sexual required or would use over-the-counter contracep- “Policymakers need to stop treating parents as traceptive users report sexual function scores. tives, such as condoms. a suspect class, presumed not to have their own dysfunction in the form of low “There was significant im- The implications are that mandated parental no- kids’ best interests at heart,” Wendy Wright, libido, vaginal dryness, impaired provement in arousal, lubrica- tification laws would discourage few teens from CWA’s senior policy director, said in a statement. orgasm, and decreased arousal. tion, orgasm, and satisfaction,” having sex and likely would increase rates of ado- “Adolescents benefit when their parents are in- “This may be the result of she said, noting that the “an- lescent pregnancy and sexually transmitted dis- volved in their lives, and policymakers shouldn’t changes in serum androgens,” tiandrogenic” profiles of hor- eases, the study authors concluded. forbid their involvement in their daughters’ and said Dr. Sarajari, a fellow in re- monal contraceptives that are The study was based on a nationwide survey of sons’ most important decisions.” productive endocrinology and promoted by drug companies 1,526 adolescent females under age 18 years who Texas and Utah currently require parental con- infertility at the University of are not entirely beneficial. were seeking sexual health services, excluding sent for teenage use of state-funded family plan- California, Los Angeles, Med- But she says the fact that sex- abortion and prenatal and postnatal care, at pub- ning services, and a similar restriction exists in one ical Center. ual dysfunction can be reversed licly funded family planning clinics in 33 states. county in Illinois. Last year, lawmakers in Ken- Her study measured baseline with discontinuation of hor- About 60% of respondents said their parents tucky, Minnesota, and Virginia introduced bills to total , free testos- monal contraceptives is encour- were aware that they were using a clinic for sexual impose parental consent requirements on teens terone, and sex hormone–bind- aging. health services. In most cases, the teens had either seeking contraception. ing globulin (SHBG) in pre- “We don’t recommend testos- voluntarily told their parents or they had come to On the federal level, lawmakers have introduced menopausal women (mean age terone supplementation ad lib, the clinic at the suggestion of a parent. plans in recent years to require parental involve- 34) who had been using hor- or at all, until the cause of some- About one-third of teens surveyed said their par- ment in teens seeking contraceptives at federally monal contraceptives for at least one’s sexual dysfunction is inves- ent or guardian was unaware that they were ob- funded clinics; none has become law. ■ 6 months. Most women had been tigated, Dr. Sarajari said. ■