Two hundred and fifty-four teenagers, aged 14-20 years (17.6 ± 1.6) participated in the study. About half (54.3%) of the subjects were either past or present COCP users (n = 138). COCP duration of use ranged from one month to 4 years. The mean age of COCP users was 18 ± 1.4 years and 17.1 ± 1.6 years for non-users (P < 0.0001). Overall, the average of incorrect beliefs was high in the whole study group (MS 4.1), and similar in both COCP non-users and current or past users (MS 4.1 versus 4.2, respectively) ( Table 2 ). The distribution of MS among teenagers shows that the majority of interviewees had 2-6 out of 10 misconceptions (Figure 1). The prevalence of every misconception was similar between COCP non-users and past/current users, apart from future fertility which was believed to be impaired by the pill by significantly more COCP users than non-users ( Table 3 ).
The misconception score is the average of incorrect beliefs, and uncertainty score is the average of 'do not know' replies
Age did not serve as a confounding factor for all misconceptions. In relation to future fertility a logistic regression model analysis, including age and COCP use as covariates and the interaction between them, was performed. COCP use only was found to be significant (odds ratio = 1.7, 95% confidence interval 1.02-3.13). The prevalence of doubts regarding COCP (subjects who answered 'do not know') ranged from 13.8-27.8%. Overall, the average US was 2.1 in the whole study group, and similar in both COCP non-users and current or past users (US 2.1 versus 1.97, respectively) ( Table 2 ). The association between COCP use and acne/hirsutism was significantly clearer to subjects who had experience of using the COCP ( Table 4 ) (Figure 2). Analysis of the subset of subjects with known duration of COCP use (n = 153) showed that duration of COCP use was not associated with declining prevalence of COCP misconceptions for body image (P = 0.18), future health risks (P = 0.56), method of use (Figure 2, P = 0.46) and side effects (P = 0.18).
The duration of COCP use was not associated with declining prevalence of COCP misconceptions.
Among the physicians interviewed the MS was 2.2, about half of that of the whole group of adolescents'. No differences in the prevalence of misconceptions were documented regarding the physician's age, gender, subspecialty, seniority and affiliation with an academic center. COCP-prescribing physiecians were significantly more knowledgeable about the pill than COCP users; however, they still held several disbeliefs much like their patients, e.g. COCP increases appetite and breast cancer risk and is dangerous to health ( Table 3 ).
Nine out of 10 sexually active teenagers use a contraceptive method, although not always consistently or correctly (Piccinino and Mosher, 1998). The COCP is the method most frequently chosen by adolescent girls (Polaneczky, 1998). However, this population holds many common misconceptions about the pill.
We investigated the doubts and the perception of knowledge about the pill by the prevalence of uncertainties and misconceptions in the teenage community. There is a major difference between the two in relation to risk behavior, as mistaken knowledge (misconception) can result in risk behavior while perceived lack of knowledge (uncertainty) may not. The MS in this study represents erroneous perceived knowledge about hormonal contraceptives, regarding various side effects, future health hazards and method of use. Thus, incorrect knowledge about the accurate use of COCP, its side effects and future health hazards may enhance COCP discontinuation and an unintended pregnancy.
We sought to study the misconception profile during adolescence because adolescents score higher than adults on personality measures associated with risk taking. They are more vulnerable to peer pressure and typically conform to a particular way of acting or thinking (Brown et al., 1986). Although peer pressure is a key aspect of normal adolescent development, it has been found to be a strong predictor of risk behaviors and potential psychosocial difficulties (Darcy et al., 2000). Peer influence has also been found to be an important factor in sexual attitudes and contraceptive behavior (Mirande, 1968; Shah and Zelnick 1986). At this age, peers influence adolescent contraceptive use in various ways: by modeling pill use; by shaping norms, attitudes and values; and by providing a discussion and support group for COCP users. The debut of sexual intercourse is frequently associated with negative feelings such as anxiety, shame, discomfort, inadequacy and isolation that may be instrumental in motivating young individuals to conform (Lashbrook, 2000).
To our knowledge, the misconception profile of this unique study group has rarely been fully characterized. The subjects in our study have come to the clinic intentionally for contraception counseling and to acquire information about birth control, thus they were highly motivated to use COCP. Engagement in information acquisition activities should have increased their perceived knowledge about the pill. These subjects were high school-educated, sexually active young women who were expected to have higher levels of knowledge about the pill, originating from school sexuality education, medical counseling and peer communication. Nevertheless, exceedingly high levels of misconceptions of COCP were found in this highly selective study group. Moreover, knowledge of the pill was not enhanced with the COCP duration of use. On the contrary, concerns about future fertility were even more prevalent among COCP users than non-users, and doubts regarding the impact of the pill on acne and hirsutism have settled in COCP users probably on the basis of personal experience. COCP in Israel can be used by a teenager (a minor) without notification of her parents or guardians; this adds another alarming aspect to adolescent ignorance.
Of all potential sources of information about the pill, we chose to investigate the COCP-prescribing physicians. Previous studies showed that 51-65% of the patients' information about birth control and its side effects came from medical sources (Goldfield and Neinstein, 1985; Oddens et al., 1994). A lower prevalence of misconceptions was unveiled within the group of physicians compared with COCP users, showing some specific lack of knowledge of the pill in the physicians' community as well as insufficient communication between the caring physician and the patient.
In agreement with former reports (Greydanus et al., 2001; Ekstrand et al., 2005) discrepancies were evident between adolescent perceptions of weight gain, acne, hirsutism, depression, breast cancer and future infertility risk with use of the COCP and the available scientific evidence.
Misconceptions of Body Image
Body image is a major concern during adolescence (Feingold and Mazzella, 1998). In a Canadian survey studying concerns of the teenage population, overweight and acne were reported as most worrying to teenagers (Feldman et al., 1986). In girls, overweight is associated with negative self-esteem, negative mood and anxiety. Moreover, girls appear to be immersed in a subculture where the importance of being slender is emphasized, and where there are frequent discussions about weight loss behaviors (Moreno and Thelen, 1995; Mukai, 1996; Paxton, 1996). Peer teasing has been found to be related to body dissatisfaction among girls (Levine et al., 1994; Wertheim et al., 1997). Likewise, acne vulgaris can cause psychosocial health problems including depression, suicidal ideation, anxiety and psychosomatic symptoms, such as pain and discomfort, embarrassment and social inhibition (Tan, 2004).
Our study corroborates others who cited weight gain as a major problem with COCP use (Gupta, 2000). We found exceedingly high prevalence (60%) of teenagers who believed that COCP causes weight gain by increasing appetite, as cited by half of both patients and clinicians. Yet, studies of the low-dose preparations fail to demonstrate a significant weight gain with COCP, with no differences among the various products. As an obvious misconception, weight gain was similar in COCP-treated and placebo groups (Tan, 2004). Slight fluid retention due to the stimulation of renin-angiotensin mechanism by the COCP may account for up to 1-2 kg in about 30% of COCP users. Teenagers gain some weight as they grow, whether they take COCP or not (Speroff and Fritz, 2005).
One-third of adolescent girls and 14% of physicians believed that COCP actually causes acne and/or hirsutism. In fact, low-dose COCP improves acne regardless of which product is used. The current progestin doses (including the most androgenic levonorgestrel formulations) are usually insufficient to stimulate an androgenic response and provide effective treatment for acne and hirsutism (Speroff and Fritz, 2005).
Hum Reprod. 2007;22(12):3078-3083. © 2007 Oxford University Press
Cite this: Misconceptions About Oral Contraception Pills Among Adolescents and Physicians - Medscape - Dec 01, 2007.