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Oral Contraceptive Use by Teenage Women Does Not Affect Body Composition

From the Departments of Health Evaluation Sciences and Obstetrics and Gynecology, Penn State College of Medicine, The Milton S. Hershey Medical Center, Hershey, Pennsylvania.

Address reprint requests to: Tom Lloyd, PhD, Penn State College of Medicine, The Milton S. Hershey Medical Center, Department of Health Evaluation Sciences, Mail Code H173, Hershey, PA 17033; E-mail: tal3{at}psu.edu.

	ABSTRACT

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OBJECTIVE: To assess the effect of oral contraceptive (OC) use during adolescence on body composition parameters and cardiovascular disease risk factors.

METHODS: We used 9 years of longitudinal data from 66 non-Hispanic white females who were 12 years old at study entry in 1990, and who were subsequently classified either as OC users or nonusers. The OC users (n = 39) used OCs for a minimum of 6 months, were still using at age 21, and had used OCs, on average, for 28 months. The nonusers (n = 27) never used OCs. Individuals who started and then stopped using OCs before age 21 or used OCs for less than 6 months were excluded from these analyses. Cardiolipoprotein profiles were obtained from fasting blood samples (from age 16 to 21), and body composition measurements were made by dual energy x-ray absorptiometry (from age 12.5 to 21). Longitudinal models were used to examine changes in body composition patterns and in cardiolipoprotein patterns.

RESULTS: Between ages 12.5 and 21, gains by OC users and nonusers in height, weight, body mass index (BMI), and percent body fat were not significantly different. However, between ages 16 and 21, the OC users had significantly greater increases in total serum cholesterol, serum low-density cholesterol, and serum triglycerides than did the nonusers.

CONCLUSION: The use of OCs in young women is associated with less favorable blood lipid patterns, but is not associated with weight gain or increased body fat. The long-term effects of the alteration in the lipid profiles are unknown.

The percentage of sexually active female adolescents in the United States has grown dramatically in the past two decades; and in 1990, two-thirds of females were sexually active before completion of the 12th grade.¹ Among this population, approximately 46% use oral contraceptives (OCs).² The mechanisms by which OCs prevent pregnancy in teenage girls is identical to that in older women, yet much less is known about the effects of OCs on other physiologic processes in teenagers as the major studies of the effects of OCs have been performed with women over age 20. Because physiologic systems undergo substantial maturation during adolescence, it is important to understand whether OC use during these developmental years has different metabolic and physiologic effects.

Formulations of recent generations of OCs have been made with progressively lower amounts of estrogens and progestins, and these low-dose preparations have substantially fewer adverse effects in adult users than their predecessors.^3–9 A meta-analysis performed by Lobo and coworkers to determine the effect of low-dose OCs containing 150 µg desogestrel and 30 µg ethinyl estradiol on plasma lipid concentrations in healthy adult women led to the conclusion that use of these OCs results in significant increases in high-density lipoprotein cholesterol (HDL-C) and triglycerides (TG) and significant decreases in low-density lipoprotein cholesterol (LDL-C).¹⁰ Thus, although contemporary formulations of OCs appear to be less atherogenic than earlier generations, the effects of OCs on lipid metabolism, thromboembolic risk, and body composition in adult women continue to be actively studied.

Perceived weight gain is the most common single reason American women give for discontinuing OCs—surpassing complaints of nausea, headache, and menstrual abnormalities.¹¹ In a sample of European young women, fear of weight gain was the most frequent reason for not using OCs.¹² We examined data from our ongoing longitudinal study to evaluate the effects of recent formulations of OCs on body composition patterns and on cardiovascular disease (CVD) risk factors among teenage girls in an effort to provide clinically useful information for those who provide health care to teenage girls.

	MATERIALS AND METHODS

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The Penn State Young Women’s Health Study is a prospective epidemiologic study that began in 1990 with the enrollment of 112 healthy, premenarchal females, aged 11.9 ± 0.5 years. The study population is representative of white female adolescents attending public school in central Pennsylvania. Details of the recruitment, baseline anthropometric, endocrine, and bone measurements, and the effects of a calcium supplementation trial on bone gain have been previously reported.¹³ The study was approved by the Pennsylvania State University College of Medicine institutional review board, and the parents of participants provided written informed consent when participants were minors. Thereafter, participants provided written informed consent.

During the first 4 years of the investigation, study visits occurred every 6 months, then annually. The average relative difference between actual and target clinic visit dates was 5 days. Oral contraceptive users (n = 39) were those individuals who had used OCs continuously for at least 6 months and were still using at age 21. Several low-dose preparations were used by the OC group. Nonusers (n = 27) had never used OCs. Individuals who had started and stopped using OCs or who had used OCs less than 6 months (n = 8) were excluded from analyses. Three individuals who used depot medroxyprogesterone and the one individual with an incomplete OC use history were also excluded from analysis. OC use was self-reported. As this cohort has performed well in a longitudinal study involving 4 years of pill counting and 3-day prospective diet records every year, their OC use reports are believed to be accurate.

Mean (± standard deviation) age of menarche for the OC group was 13.4 (± 0.9) years; and for the nonusers, it was 13.4 (±1.2) years. All study subjects had uneventful reproductive maturation. The mean number of menstrual periods per year for the OC users at age 17 was 9.9 ± 2.1; and for the nonuser group, it was 10.2 ± 1.6. There were nine smokers among the OC users, and two smokers among the nonusers.

Cardiolipoprotein profiles were obtained from fasting blood samples, from age 16 to 21. Total cholesterol, HDL-C, LDL-C, and triglycerides were measured by established clinical chemistry methods.¹⁴ Sitting systolic and diastolic blood pressure measurements were made by the research nurses in our General Clinical Research Center.

Percent body fat and percent lean body mass measurements were made by dual energy x-ray absorptiometry (DXA) using Hologic equipment (QDR 1000W and QDR-2000W; Hologic Corp., Bedford, MA) and standard procedures. Each participant underwent a total body scan using pencil-beam mode at each visit, and the manufacturer’s tissue phantom was used from age 12.5 on. As has been reported by others,¹⁵ our observed coefficient of variation was less than 0.7% for the day-today quality control scans using the manufacturer’s spine phantom. All body composition scans were obtained using the pencil-beam mode in the presence of the Hologic three-step acrylic/acrylic-aluminum wedge standard that simulates lean and soft tissue.¹⁶ Body composition analysis was performed using Hologic software, 5.71A.

Physical activity between ages 12 and 18 was assessed with a sports exercise questionnaire that was based on existing instruments.^17,18 In brief, the questionnaire listed 28 activities including 1) school-based activities (eg, soccer, cross-country, marching band), 2) outside-of-school organized activities (eg, swimming, dance, aerobic classes), and 3) individual activities (eg, walking, running, tennis). The following scale was used to record frequency of each sport/activity: 0 = less than once per month; 1 = once per month; 2 = once per week; 3 = 2 or 3 times per week; and 4 = 4 or more times per week. Participants recorded frequency of participation in each sport or activity for grades 6 through 12 (ie, ages 12–18) and at age 21. The cumulative sports exercise score was the arithmetic sum, in arbitrary units, for the 8 years covered by the questionnaires.

Statistical procedures were accomplished using a range of procedures in SAS (SAS Institute, Cary, NC). Descriptive statistics (percentages, means, and standard deviations) were used to characterize the sample. The random effects growth models were used to compare the yearly trends of body composition and cardiovascular disease risk factors between the OC users and the non-users during ages 16–21. The random effects growth model is appropriate for longitudinal data analyses because it assumes an underlying fixed effect for the overall trend for each group but that the deviations of individual slope and intercept from the overall trend are random.¹⁹ Group and slope interaction was included in the model to test whether the yearly trends are similar between the OC users and the nonusers. All analyses were adjusted for body mass index (BMI) at age 12.5 and for the sports exercise scores.

	RESULTS

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Among the 39 OC users, the mean cumulative duration of OC use was 27.8 months (±16.9 months); 7 subjects had used OCs for 6–12 months; 16 subjects had used OCs for 13–24 months, and 16 subjects had used OCs longer than 24 months. The youngest subject in the OC group was 16 years old when she began using OCs. The natural history of subjects who ever used OCs for at least 6 months is presented in Figure 1. Descriptive statistics of body composition parameters and of adolescent sports exercise scores of the OC users and nonusers at age 21 are presented in Table 1. Other than the OC users having a lower mean BMI value, the two groups were not different. Tracking of body weight and percent body fat of the two groups is presented in Figure 2. The values at all time points for the OC user group include all those individuals who would eventually be OC users, regardless of when they started. The two groups were not significantly different from one another with respect to body weight or percent body fat over ages 12.5 to 21 years.

View larger version (11K): [in this window] [in a new window]   Figure 1. The natural history of oral contraceptive (OC) use from age 12 to 20. The number of study participants seen in each year of the study is as follows: age 12 = 112; age 13 = 99; age 14 = 91; age 15 = 90; age 16 = 88; age 17 = 86; age 18 = 81; age 19 = 79; age 20 = 77; and age 21 = 78. Lloyd. OC Use by Teen Women. Obstet Gynecol 2002.

View larger version (16K): [in this window] [in a new window]   Figure 2. Body weight and percent body fat tracking of the oral contraceptive (OC) users and nonusers. The number of nonusers was 27. The values at all time points for the OC users group (n = 36) include all those individuals who would eventually become OC users (n = 39), regardless of when they started. Lloyd. OC Use by Teen Women. Obstet Gynecol 2002

	DISCUSSION

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This study provides additional information for two clinical issues related to the use of OCs by teenage girls: 1) the effect of OCs on cardiovascular disease risk factors and 2) the effect of OCs on body composition patterns. With regard to the effect of OCs on cardiovascular disease risk factors, we observed that the OC users had significantly different cardiolipoprotein patterns from the nonusers, which is in contrast to what has been observed in adult women. In adult women, the use of low-dose OCs is associated with modest increases in triglycerides and HDL-C, modest decreases in LDL-C and inconsistent effects on total cholesterol.¹⁰ Thus, OC use by adult women is not considered atherogenic. The present study shows that OC use by teenage girls results in significant increases in total cholesterol, LDL-C, and triglycerides. Although the rates of change of total cholesterol, LDL-C, and triglycerides of the OC user group are statistically different from the nonuser groups, the blood lipid profiles of the OC users remain within normal ranges.

Our results on total cholesterol, LDL-C, and triglycerides are similar to those reported in cross-sectional analyses in The Bogalusa Heart Study comparing young OC users and nonusers.²⁰ In their first cross-sectional analysis, Greenlund et al reported that among young women aged 18–27 years, white OC users had significantly higher total cholesterol and LDL-C, and lower HDL than nonusers. Three to 5 years later, white OC users again had higher total cholesterol, LDL-C, and triglycerides versus their nonuser counterparts, yet HDL-C was unaffected. Raitakari et al studied 1398 young women, aged 15–24 years, in The Cardiovascular Risk in Young Finns Study and reported that OC use was associated with higher triglycerides and systolic blood pressure.²¹ Taken together, these previous studies and the present one show that the latest generations of OCs have more influence on blood lipid profiles of women under 25 years than on women over 25. Whether the changes have clinical significance remains to be determined. A limitation of the present study is the fact that our data do not include the specific brands of OCs used.

The OC user and nonuser groups in this study were well matched at baseline (age 12.5), and we have provided the first longitudinal information on the natural history of OC use by this group (Figure 1). The two groups were indistinguishable with respect to BMI, percent body fat, and lean body mass 9 years later. We conclude that OC use by teenage girls does not result in an increase in weight gain or an increase in percent body fat over those increases seen by nonusers. Although perceived weight gain is also a common complaint among adult women using oral contraceptives, careful prospective and retrospective studies do not support this perception.^22–25 The present study provides evidence that OC use by teenage girls also does not affect body composition, and we suggest that potential users be counseled accordingly.

	Footnotes

 
This work was supported by Public Health Service R01 HD25973 (TL), K08 HD0118(RSL), and a General Clinical Research Center grant M01 RR 10732 to the Pennsylvania State University.

PII S0029-7844(02)02056-2

Received October 15, 2001. Received in revised form March 5, 2002. Accepted March 14, 2002.

	REFERENCES

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20. Greenlund KJ, Webber LS, Srinivasan S, Wattigney W, Johnson C, Berenson GS. Associations of oral contraceptive use with serum lipids and lipoproteins in young women: The Bogalusa Heart Study. Ann Epidemiol 1997; 561–7.

21. Raitakari OT, Porkka KV, Rasanen L, Viikari JS. Relations of life-style with lipids, blood pressure, and insulin in adolescents and young adults. The Cardiovascular Risk in Young Finns Study. Atherosclerosis 1994;111:236–47.

22. Weindling H, Henry JB. Laboratory test results altered by "the pill."JAMA 1974;229:1762–8.[Medline]

23. Musa BU, Seal US, Doe RP. Elevation of certain plasma proteins in man following estrogen administration. A dose response relationship. J Clin Endocrinol Metab 1965;25: 1163–6.[Medline]

24. Wittert GA, Livesey JH, Espinert EA, Donald RA. Adaptation of the hypothalamopituitary adrenal axis to chronic exercise stress in humans. Med Sci Sports Exerc 1996;28: 1015–9.[Medline]

25. Aron DC, Tyrell JB. Glucocorticoids and adrenal androgens. In: Greenspan FS, Baxter JD, eds. Basic & clinical endocrinology. Norwalk, CT: Appleton & Lange, 1994: 314–46.

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