Oral Contraceptives Reduced Pica Behavior in a Female with Autism Spectrum Disorder

To the Editor:

Here we describe the successful use of an oral contraceptive pill (OCP) in reducing pica in a female with autism spectrum disorder (ASD).

A 17-year-old female with an autism diagnostic observation schedule-confirmed diagnosis of ASD (Social Responsiveness Scale T-score: 91) was referred for evaluation of pica. Full-Scale Intelligence Quotient was 91. At 6 months, ingestion of sand and rocks began. Pencil ferrules, clothing, and electrical insulation followed. Behavioral approaches failed, and watchful monitoring was implemented after ingestions. A one-to-one school aid was assigned. Basic laboratory, heavy metals, and thyroid testing were unremarkable. Behavioral drivers of pica, including physical discomfort, were not identified. Sertraline was prescribed at age 11 years targeting transitional anxiety. An initial dose of 12.5 mg was increased by 12.5 mg quarterly to 100 mg by age 13 years. Response was appreciated at 50 mg with further benefit up to 100 mg, which the patient continues currently. The family and patient did not pursue higher doses. Despite improvement in transitional anxiety, pica remained persistent and unchanged throughout the sertraline treatment.

Menarche was at age 13 years. Though subjectively “heavy,” neither anemia nor dysmenorrhea occurred. Anxiety, mood, and repetitive behaviors were stable during the menstrual cycle. However, the frequency of pica incidents increased ∼3 days before menstruation, returning to baseline frequency upon resolution of menses. At age 16 years, a combined OCP (0.03 mg ethinylestradiol/0.3 mg norgestrel) was started, with remission of the premenstrual pica frequency spike and a reduction in pica incidence to levels below her premenarche baseline across all menstrual phases. However, breakthrough pica symptoms occurred within 24–48 hours upon administration of placebo week pills. At age 17 years, the frequency of the placebo week was reduced from monthly to quarterly, with near remission of pica behavior. The school-based aid was discontinued.

With respect to mechanisms, OCPs may have reduced menstrual discomfort. Pica can worsen with psychological and physical stress (Stiegler 2005), and women with ASD may be susceptible to behavioral manifestations of menstrual stress given sensory vulnerabilities and challenges communicating distress (Cummins et al. 2018). However, this would not account for the observed reduction of pica in other menstrual phases. Alternatively, pica may share phenotypic features with obsessive-compulsive disorder, which can worsen during the premenstrual period (Karpinski et al. 2017). Although controlled trials are lacking in pica, selective serotonin reuptake inhibitors are the most commonly prescribed medication (Stiegler 2005). Estrogens exert serotonergic effects in the central nervous system by increasing serotonin synthesis, monoamine oxidase A inhibition, and increasing receptor assembly (Karpinski et al. 2017).

Regardless of mechanism, OCPs may be a consideration for pica, especially when associated with menstruation. Studies exploring associations of hormone levels with pica may be especially informative. Randomized clinical trials would determine the utility of OCPs in treatment of pica in females.