Girls Given Drugs That Cause Birth Defects Don't Get Contraception Counseling

Most teenage girls who are prescribed drugs known to cause birth defects don’t receive adequate counseling about contraception, putting them at risk for negative pregnancy outcomes, according to a study published Wednesday in the journal Pediatrics.

The medications are given to treat a wide range of conditions, including acne and anxiety.

More than 70 percent of female patients in the study who were prescribed such medications did not receive counseling about preventing pregnancy or given prescriptions for contraceptives or referral for such care.

“There is room for great improvement,” said lead author Stephani Stancil, a nurse practitioner in the division of adolescent medicine and clinical pharmacology at Children’s Mercy Hospital in Kansas City, Missouri. “We hope the study is a good first step to increase education to prescribers and patients and families to make healthier reproductive choices.”

The study examined electronic medical records from female patients between 14 and 25 years old who received the drug prescriptions during office visits between 2008 and 2012 at a major Midwestern academic pediatric medical center.

Nearly 1,700 girls and women received 4,506 prescriptions for so-called teratogenic medications -- meaning those that can cause birth defects -- during 4,100 office visits.

The study found some disparities. White patients were more likely to receive contraception counseling than minority patients, the study said. The study did not suggest reasons for that, but doctors not involved in the research say it could be due to general health care disparities and a cultural or language gap between doctors and patients.

Older patients, those ages 16 to 25, in the study were more likely to receive counseling about contraception than the 14- and 15-year-olds, perhaps driven by doctors’ expectation that older teens were more likely to be sexually active, researchers wrote.

But statistics show this assumption about teenage sexual behavior may be off-base. The Centers for Disease Control and Prevention's 2013 Youth Risk Behavior Surveillance System showed that 35 percent of adolescent females in grades 9 to 12, ages 14 to18, were classified as currently sexually active, having had sex in the previous three months, researchers said.

Young patients take drugs that can cause birth defects to treat all sorts of conditions, including common ones.

In the study, the most commonly prescribed were:

• isotretinoin -- used to treat severe acne
• diazepam -- used to treat treat anxiety disorders or seizures
• methotrexate -- used to treat certain cancers, arthritis and inflammatory bowel disease
• topiramate -- used to treat seizures
• enalapril -- used to treat high blood pressure and heart conditions.

The pediatricians who most frequently prescribe the drugs are from the neurology, hematology-oncology and dermatology specialties, the study said, but others use them to treat teens for other conditions as well.

Dr. Elizabeth Gleghorn, a pediatric gastroenterologist and division chief at UCSF Benioff Children’s Hospital Oakland who was not involved in the study, said she counsels patients about the risk of birth defects when prescribing methotrexate to help treat inflammatory bowel disease.

“We are very aware of our drugs that are known or thought to cause birth defects," she said. “We talk about it to patients.”

But with adolescent patients, it can be a tricky situation to navigate with the whole family involved, she said.

“At what point do you unceremoniously kick the family out and find out if the patient is sexually active, counsel her, and bring her family back in?”

She said some parents feel they are the only ones who should be discussing sex with their children.

So Gleghorn will sometimes start out discussing the topic in a general way by saying, “In the case of women who are pregnant, this drug could be dangerous.”

She says the subject can be met with strong reactions from patients and families. She recalled that the mother of a teenage girl patient became hysterical when Gleghorn raised the issue of methotrexate causing birth defects.

“It raised fears of her daughter’s reproductive future, and went to the basis of her anxiety that her daughter wouldn’t have a normal life living with a chronic illness,” Gleghorn said.

But Gleghorn says she counsels patients that when a woman decides to become pregnant, she would go off methotrexate and perhaps use a different medication that poses less risk to a fetus.

One adolescent girl insisted she was never going to have sex and never going to have kids, so the risk of birth defects wasn’t a problem, Gleghorn said.

“So I told her, ‘It may not be an issue for you right now, but I am telling you so you know for the future.’ ”