Curbside Consultation

Menstrual Concerns in an Adolescent with Disabilities

 


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Am Fam Physician. 2015 Nov 1;92(9):823-831.

Case Scenario

A mother brought her 12-year-old daughter to my clinic for gynecologic concerns. The daughter has a congenitally acquired intellectual disability. Recently, the girl began to menstruate, which appeared to cause her distress. While at school, she repeatedly removed her sanitary pad. The mother asked about a procedure to stop her daughter's menstrual periods. She was unable to say which procedure she meant, only that a friend had arranged one for her daughter. We discussed long-acting contraception and recommendations to wait and see whether her daughter might become accustomed to her menses. Is it ethical to initiate a long-acting contraceptive in this adolescent to suppress menses? If the mother was requesting something more permanent than implantable or intrauterine long-acting contraception, what is the best way to proceed?

Commentary

Clinicians who care for female adolescents with cognitive and physical disabilities are often consulted on the management of menstrual bleeding for purposes of hygiene, dysmenorrhea, and treatment of premenstrual symptoms.13 Contraception is also commonly discussed to mitigate pregnancy risk from consensual intercourse and situations of abuse.13  During these visits, discussions regarding menstrual suppression are common. Effective interventions may improve patient quality of life and caregiver fatigue (Table 115). The following principles can be applied in such cases.

View/Print Table

Table 1.

Select Considerations for Menstrual Manipulation and Symptom Control in Adolescents with Disabilities

TreatmentIndicationsAdvantagesDisadvantagesComments

Preferred options for menstrual suppression

Combined contraceptive patch

Menstrual hygiene, premenstrual syndrome, contraception, dysmenorrhea, menstrual suppression

Extended or continuous use; predictable duration of menses

Breakthrough bleeding; may be less effective at contraception in persons weighing > 198 lb (90 kg); patient may prematurely remove patch

Additional risk of thromboembolic events in patients who are immobile is unknown; estrogen exposure may be higher than with use of other estrogen-containing methods; effectiveness may decrease with use of specific antiepileptic drugs (e.g., topiramate [Topamax])

Combined contraceptive ring

Menstrual hygiene, premenstrual syndrome, contraception, dysmenorrhea, menstrual suppression

Extended or continuous use; predictable duration of menses

Breakthrough bleeding; assistance often needed for placement (privacy issues)

Additional risk of thromboembolic events in patients who are immobile is unknown; effectiveness may decrease with use of specific antiepileptic drugs (e.g., topiramate)

Combined oral contraceptives

Menstrual hygiene, premenstrual syndrome, contraception, dysmenorrhea, menstrual suppression

Extended or continuous use; predictable and adjustable duration of menses; certain formulations may be chewed or administered per gastronomy tube

Breakthrough bleeding; may require surveillance for daily use

Additional risk of thromboembolic events in patients who are immobile is unknown; daily regimen may be advantageous in situations where other daily medications are regularly given; effectiveness may decrease with use of specific antiepileptic drugs (e.g., topiramate)

Depot medroxyprogesterone (Depo-Provera)

Menstrual hygiene, premenstrual syndrome, dysmenorrhea, contraception, menstrual suppression

Four injections per year; high rates of amenorrhea

May decrease bone mineral density, especially in patients who are immobile; weight gain in adolescents who are overweight or obese; irregular bleeding (tends to improve over time)

Weight gain may affect independence and mobility (e.g., patient transfers)

Levonorgestrel-containing intrauterine system (Mirena)

Menstrual hygiene, contraception, dysmenorrhea, menstrual suppression

May help reduce heavy bleeding; effective for three or five years (depending on model) without need for patient action

Irregular bleeding (tends to improve over time); potential need for sedation; patients may be unable to voice pain or discomfort associated with procedure or complications

Five-year model likely preferred because the three-year model has limited data on menstrual control and requires more frequent replacements

Other options for menstrual suppression

Hysterectomy

Contraception, menstrual hygiene, menstrual suppression

Permanent

Surgical complications

Legal and ethical considerations of sterilization apply; generally not a first-line treatment

Progestin-only pills*

Menstrual hygiene, contraception, dysmenorrhea

May be used temporarily to assess effect of progestin on behavior and mood before longer-acting progestin-only method is established

Irregular bleeding; may require surveillance for daily use

Daily regimen may be advantageous in situations where other daily medications are regularly given; effectiveness may decrease with use of specific antiepileptic drugs (e.g., topiramate)

Adjunctive treatments

Emergency contraceptive pills

Contraception

Greatly decrease rate of

Author disclosure: No relevant financial affiliations.

Address correspondence to David A. Klein, MD, MPH, at david.a.klein26.mil@mail.mil. Reprints are not available from the authors.

REFERENCES

show all references

1. Kirkham YA, Allen L, Kives S, Caccia N, Spitzer RF, Ornstein MP. Trends in menstrual concerns and suppression in adolescents with developmental disabilities. J Adolesc Health. 2013;53(3):407–412....

2. Quint EH. Menstrual and reproductive issues in adolescents with physical and developmental disabilities. Obstet Gynecol. 2014;124(2 pt 1):367–375.

3. American College of Obstetricians and Gynecologists. Reproductive health care for adolescents with disabilities (supplement to guidelines for adolescent health care, 2nd edition). 2012. http://www.acog.org/Resources_And_Publications/Guidelines_for_Ado-lescent_Health_Care/Reproductive_Health_Care_for_Adolescents_With_Disabilities (login required). Accessed March 30, 2015.

4. American College of Obstetricians and Gynecologists Committee on Adolescent Health Care. ACOG committee opinion no. 448: Menstrual manipulation for adolescents with disabilities. Obstet Gynecol. 2009;114(6):1428–1431.

5. Paransky OI, Zurawin RK. Management of menstrual problems and contraception in adolescents with mental retardation: a medical, legal, and ethical review with new suggested guidelines. J Pediatr Adolesc Gynecol. 2003;16(4):223–235.

6. Committee on Practice Bulletins—Gynecology. Practice bulletin no. 136: Management of abnormal uterine bleeding associated with ovulatory dysfunction. Obstet Gynecol. 2013;122(1):176–185.

7. Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC). U.S. selected practice recommendations for contraceptive use, 2013: adapted from the World Health Organization selected practice recommendations for contraceptive use, 2nd edition. MMWR Recomm Rep. 2013;62(RR-05):1–60.

8. Klein DA, Arnold JJ, Reese ES. Provision of contraception: key recommendations from the CDC. Am Fam Physician. 2015;91(9):625–633.

9. Centers for Disease Control and Prevention (CDC). U.S. medical eligibility criteria for contraceptive use, 2010. MMWR Recomm Rep. 2010;59(RR-4):1–86.

10. Darney P, Patel A, Rosen K, Shapiro LS, Kaunitz AM. Safety and efficacy of a single-rod etonogestrel implant (Implanon): results from 11 international clinical trials. Fertil Steril. 2009;91(5):1646–1653.

11. Lopez LM, Edelman A, Chen M, Otterness C, Trussell J, Helmerhorst FM. Progestin-only contraceptives: effects on weight. Cochrane Database Syst Rev. 2013;(7):CD008815.

Case scenarios are written to express typical situations that family physicians may encounter; authors remain anonymous.

This series is coordinated by Caroline Wellbery, MD, Associate Deputy Editor.

A collection of Curbside Consultation published in AFP is available at http://www.aafp.org/afp/curbside.

Please send scenarios to Caroline Wellbery, MD, at afpjournal@aafp.org. Materials are edited to retain confidentiality.



 

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