Teens and medicines that cause birth defects: Do doctors drop the ball?

My 14-year-old daughter recently started taking isotretinoin, a medication that can help severe acne — and that can cause severe birth defects. I knew that there was a process in place for preventing pregnancy in girls taking it, but I was caught off guard by just how many hoops we had to jump through to get her prescription.

There were two pregnancy tests a month apart at the beginning, continued monthly pregnancy tests as well as monthly online questions about contraception and her understanding of the effects of the medicine, and a special ID card that has to be brought to the pharmacy within a very short window after the monthly blood tests. I’d never seen anything like it, and I’m a doctor. It got me thinking: Why don’t we do this kind of thing for all the medications that cause birth defects? Are we dropping the ball?

The answer, says a recent study published in the journal Pediatrics, is yes.

For the study, researchers looked at 4,172 visits to a large Midwestern academic pediatric center. They found that 1,694 girls ages 14 to 25 got 4,506 prescriptions for Category D or X medications. Category D medications can cause birth defects, but in some cases the benefits outweigh the risks for a pregnant woman; for Category X medications, it’s felt that the risks outweigh the benefits.

There were all sorts of Category D and X medications prescribed, mostly by neurologists, dermatologists, and hematologist-oncologists. The five most common were topiramate, methotrexate, diazepam, isotretinoin, and enalapril. And here’s the scary part:

• Less than a third of the girls got a prescription or referral for birth control, or even counseling about birth control.
• Less than a quarter were asked questions about sexual activity.
• Less than a sixth were asked questions about their period (like when they last got it).

What was particularly interesting was that when girls were in programs like the one my daughter is in, they got asked about sex and periods even less. That certainly is true for us: the dermatologist has yet to ask those questions of my daughter — or even to ask to meet with her alone, which is usually the best way to have a confidential conversation with a teen. I suppose she thinks that the monthly pregnancy test and online quiz is enough — but everybody knows how to lie on an online test, and the idea is to prevent the monthly pregnancy test from becoming positive, not just check to see if it is.

Nobody likes to think about their teen daughter having sex. In general, both parents and doctors do a not-so-great job of talking to girls about sexuality and contraception, despite the fact that by their senior year in high school, roughly two-thirds of U.S. teens have had sex. But what worries me is that many of the girls taking these medications might not fully understand the risks — or might have misconceptions about sex or birth control — and unwittingly cause harm to a baby.

Clearly, we doctors have got to get our act together. We need to be more conscientious, ask the awkward questions, offer the education and birth control. But parents can make a difference, too. Here’s what they can do:

• Always ask about all the side effects of any medication your child is prescribed — including whether it causes birth defects.
• Make sure your daughter has the facts when it comes to sex and birth control. Yes, it’s important to pass on your values — but be sure she has the information she needs. Whether she needs it at age 15 or 30, she still needs it. Do it on the early side. Better safe than sorry.
• Encourage your daughter to meet alone, confidentially, with her health care providers. The most important thing isn’t that you know everything; the most important thing is that your daughter be safe and well.