Trends in menstrual concerns and suppression in adolescents with developmental disabilities

Menstrual education programs for girls and young women with intellectual and developmental disabilities: A systematic review

BACKGROUND

Providing menstrual education and guidance for menstrual management for girls and young women with intellectual disabilities is recommended to ensure smooth pubertal transitions and to support menstrual self-agency.

METHOD

The purpose of this systematic review is to explore menstrual education interventions for girls and young women with intellectual disabilities.

RESULTS

Nine studies were included. Interventions were provided in small groups (n = 4) and individually (n = 5). Most studies used dolls (n = 7) and task analysis (n = 7) to teach pad-replacement skills. All reported significant improvements in participant skills and/or knowledge following the intervention. Only one study addressed self-agency and self-esteem as an outcome of the intervention. Menstrual education for girls and young women with intellectual disabilities is largely focused on pad-replacement skills.

CONCLUSION

Further research is needed to understand the impact of menstrual health and hygiene education on variables apart from skill improvement such as self-agency and long-term health outcomes related to menstrual health.

Reproductive healthcare in adolescents with autism and other developmental disabilities

BACKGROUND

Adults with developmental disabilities often have less access to reproductive health services than adults without these disabilities. However, little is known about how adolescents with developmental disabilities, including autism, access reproductive healthcare.

OBJECTIVE

We aimed to characterize the use of reproductive healthcare services among adolescents with autism and those with other developmental disabilities in comparison with adolescents with typical development.

STUDY DESIGN

We conducted a cohort study of a sample of adolescents who were continuously enrolled members of Kaiser Permanente Northern California, an integrated healthcare system, from ages 14 to 18 years. The final analytical sample included 700 adolescents with autism, 836 adolescents with other developmental disabilities, and 2187 typically developing adolescents who sought care between 2000 and 2017. Using the electronic health record, we obtained information on menstrual conditions, the use of obstetrical-gynecologic care, and prescriptions of hormonal contraception. We compared healthcare use between the groups using chi-square tests and covariate-adjusted risk ratios estimated using modified Poisson regression.

RESULTS

Adolescents with autism and those with other developmental disabilities were significantly more likely to have diagnoses of menstrual disorders, polycystic ovary syndrome, and premenstrual syndrome than typically developing adolescents. These 2 groups also were less likely than typically developing peers to visit the obstetrician-gynecologist or to use any form of hormonal contraception, including oral contraception, hormonal implants, and intrauterine devices. Adolescents in all 3 groups accessed hormonal contraception most frequently through their primary care provider, followed by an obstetrician-gynecologist.

CONCLUSION

Adolescents with autism and those with other developmental disabilities are less likely than their typically developing peers to visit the obstetrician-gynecologist and to use hormonal contraception, suggesting possible care disparities that may persist into adulthood. Efforts to improve access to reproductive healthcare in these populations should target care delivered in both the pediatric and obstetrics-gynecology settings.

An integrated qualitative and quantitative study on sexual and reproductive health problems faced by women with disabilities in Chandigarh, India

OBJECTIVES

To estimate the prevalence of sexual and reproductive health (SRH) problems among women with disabilities (WWD) in Chandigarh, India, and to ascertain the difficulties experienced by WWD in accessing hospital services.

METHODS

This cross-sectional study was conducted during 2014 to 2017 in Chandigarh, India. The study participants were women 15 years and older with at least 40% disability. A pretested questionnaire and in-depth interview were used to determine sociodemographic profile, medical history, sexual and reproductive morbidity, treatment-seeking behavior, and the type, extent, and course of the disability. Verbatim responses of the participants were noted. Data were manually coded and collated into possible themes.

RESULTS

Postpolio residual paralysis (80; 30.7%) was the main reported disability, followed by severe sight impairment (52; 19.9%). A majority (170; 65%) of participants were unmarried. Of them, 66 (39%) were not willing to get married. The prevalence of SRH problems was high (151; 57.9%) among WWD, and only 82 (54%) took treatment. Dysmenorrhea (47; 31.1%), irregular periods (36; 23.8%), and vaginal discharge (17; 11.3%) were the main problems reported. The WWD in this study were likely to hide their SRH problems from others out of shame or fear.

CONCLUSION

Among WWD, the prevalence of SRH problems is high and obtaining relief is difficult.

"They had the lunch lady coming up to assist": The experiences of menarche and menstrual management for adolescents with physical disabilities

BACKGROUND

Menarche is a pivotal time in an adolescent's life but can be experienced differently by those with physical disabilities. Parents typically serve as the primary educators and support for their daughters during this time. Little is known about the parent's perspective of their daughter's experience preparing for menarche and learning to manage menses.

OBJECTIVE

We sought to understand the parent's perspective of the experience of their daughter with a physical disability around menarche and their preferences for health care provider support.

METHODS

Individual semi-structured interviews were conducted with 21 parents of a daughter with a physical disability ages 7-26. Interviews were coded by 2 reviewers using Grounded Theory, with disagreements resolved by consensus.

RESULTS

Six themes emerged regarding the parent's perception of the experiences, including 1) variation in emotional responses to menarche, 2) parent's perception of their daughter's experience with menses and menstrual symptoms, 3) cross-section of disability and menstrual management, 4) menstrual management at school, 5) parental knowledge correlating to daughter's preparation for menarche, and 6) desires for health care provider support.

CONCLUSIONS

All parents reported that their daughters faced challenges during menarche, ranging from emotional distress to dealing with the inaccessibility of hygiene products. Managing periods at schools was particularly burdensome. Parents who were better educated about what to expect were better able to prepare their daughters, but had difficulties finding informed, supportive providers. Health care providers should provide both anticipatory guidance and holistic, respectful, and equitable options for the management of menstrual symptoms.

Caregiver goals and satisfaction for menstrual suppression in adolescent females with developmental disabilities: A prospective cohort study

BACKGROUND

Adolescents with developmental disabilities and their caregivers often seek menstrual management. Caregivers frequently serve as medical decision-makers, and little is known about caregiver goals for menstrual management and satisfaction over time.

OBJECTIVE

Assess caregiver reasons for initiating menstrual management in adolescents with disabilities and satisfaction over 12 months.

METHODS

Prospective cohort study of caregivers of adolescents with developmental disabilities seeking menstrual management at a pediatric and adolescent gynecology clinic. Data derive from caregiver surveys and adolescents' electronic medical records.

RESULTS

Ninety-two caregiver-adolescent pairs enrolled. The mean age of adolescents was 14.4 (±2.6). The most common method started was levonorgestrel intrauterine device (LNG-IUD; 52, 56.5%), followed by oral norethindrone acetate (21, 22.8%). Caregivers cited hygiene concerns (84.8%), behavioral problems (52.2%), and heavy/excessive bleeding (48.9%) as reasons for initiating menstrual suppression. Caregivers who identified hygiene or heavy/excessive bleeding as the most important reason for management were more likely to select LNG-IUD (p = 0.009). Caregivers who cited behavioral/mood or seizure concerns as the most important reason were more likely to choose other methods (p < 0.05). At 12 months, caregiver satisfaction with all methods was high (66.2-86.9 on a 100-point scale). For every additional day of bleeding, satisfaction decreased by 3.7 points (95% CI: 2.3-5.0).

CONCLUSIONS

Caregiver satisfaction with all methods is high; however, it negatively correlates with days of bleeding. Caregiver reasons for menstrual suppression influence the method chosen. Management may reflect both patient and caregiver priorities; research is needed to better understand shared decision-making models that promote reproductive autonomy in adolescents with a developmental disability.

Norethindrone dosing for adequate menstrual suppression in adolescents

OBJECTIVES

We sought to study factors predictive of achieving menstrual suppression with norethindrone vs. norethindrone acetate in adolescents, as optimal dosing is unknown. Secondary outcomes included analyzing prescriber practices and patient satisfaction.

METHODS

We performed a retrospective chart review of adolescents ages <18 years presenting to an academic medical center from 2010 to 2022. Data collected included demographics, menstrual history, and norethindrone and norethindrone acetate use. Follow-up was measured at one, three, and 12 months. Main outcome measures were starting norethindrone 0.35 mg, continuing norethindrone 0.35 mg, achieving menstrual suppression, and patient satisfaction. Analysis included Chi-square and multivariate logistic regression.

RESULTS

Of 262 adolescents initiating norethindrone or norethindrone acetate, 219 completed ≥1 follow-up. Providers less often started norethindrone 0.35 mg for patients with body mass index ≥25 kg/m2, prolonged bleeding, or younger age at menarche, but more often for patients who were younger, had migraines with aura, or were at risk of venous thromboembolism. Those with prolonged bleeding or older age at menarche were less likely to continue norethindrone 0.35 mg. Obesity, heavy menstrual bleeding, and younger age were negatively associated with achieving menstrual suppression. Patients with disabilities reported greater satisfaction.

CONCLUSIONS

While younger patients more often received norethindrone 0.35 mg vs. norethindrone acetate, they were less likely to achieve menstrual suppression. Patients with obesity or heavy menstrual bleeding may achieve suppression with higher doses of norethindrone acetate. These results reveal opportunities to improve norethindrone and norethindrone acetate prescribing practices for adolescent menstrual suppression.

Assessing the menstrual cycle and related problems in adolescents with a Genetic Syndrome associated with Intellectual Disability

STUDY OBJECTIVE

This study aimed to assess the experience and quality of life related to menstruation in adolescents with a genetic syndrome accompanying intellectual disability (ID).

METHODS

This prospective cross-sectional study was conducted on 49 adolescents with a genetic syndrome accompanied by ID, which was defined by the Wescher Intelligence scale for children-Revised and 50 unaffected controls. In a survey created by the authors, demographic information, menstrual history, and information regarding menstrual difficulties, school abstinence, dysmenorrhea, and premenstrual changes were collected. The Childhood health assessment questionnaire was utilized to evaluate physical impairment, whereas the QoL scale was utilized to evaluate QoL in general and during menstruation. Data was collected from caregivers and additionally from the participants with mild ID, whereas in the control group, data was collected from the participants.

RESULTS

Menstrual history were similar between the two groups. Menstruation related school absenteeism was higher among the ID group (8%vs.40.5%, p<0.001). Mothers reported that 73% of their daughters need help with menstruation care. Social, school, psychosocial functioning, and total QoL scores during menstruation were significantly lower in the ID group when compared with the controls. A significant decrease in physical, emotional, social, psychosocial functioning and total QoL score occurred during menstruation in the ID group. None of the mothers requested menstrual suppression.

CONCLUSION

Although menstrual patterns in two groups were similar, QoL decreased significantly while menstruating in the ID group. Despite a decrease in QoL, an increase in school absenteeism and a high percentage of needing assistance while menstruating none of the mothers requested menstrual suppression.

General Approaches to Medical Management of Menstrual Suppression: ACOG Clinical Consensus No. 3

SUMMARY

The purpose of this document is to review currently available management options, general principles, and counseling approaches for reproductive-aged patients requesting menstrual suppression. It includes considerations for unique populations, including adolescents, patients with physical or cognitive disabilities or both, and those with limited access to health care. Gynecologists should be familiar with the use of hormonal therapy for menstrual suppression (including combined oral contraceptive pills, combined hormonal patches, vaginal rings, progestin-only pills, depot medroxyprogesterone acetate, the levonorgestrel-releasing intrauterine device, and the etonogestrel implant). Approaches to counseling should be individualized based on patient preferences and goals, average treatment effectiveness, and contraindications or risk factors for adverse events. Counseling regarding the choice of hormonal medication for menstrual suppression should be approached with the utmost respect for patient autonomy and be free of coercion. Complete amenorrhea may be difficult to achieve; thus, obstetrician-gynecologists and other clinicians should counsel patients and caregivers, if applicable, about realistic expectations.

Menstrual and reproductive health in female adolescents with developmental disabilities

Youth with intellectual and developmental disabilities (I/DD) are impacted by pubertal changes and the onset of menses disproportionately. Despite the fact that for most youth with I/DD, the progression of puberty, menarche, and irregular cycles due to axis immaturity appear to be consistent with the general population, cyclic behavioral changes and premenstrual symptoms may be more common. Furthermore, for some disabled youth there are endocrine or medication effects that may impact menses disproportionately. Education and access to care is essential for this group to address many aspects of treatment, from prepubertal anticipatory guidance to menstrual management, with special attention required for addressing issues concerning hygiene, cyclic pain, behavior changes, sexuality, potential for abuse, and pregnancy prevention.^1-4 This article will provide an overview of the policies and guidance available for management of the menstrual issues encountered in adolescents with intellectual and developmental disabilities and complex medical disorders. Included will be a review of studies that evaluate the different types of methods that are utilized for menstrual management and the different conditions that are encountered.

Pediatric Neurologists' Perspectives on Sexual and Reproductive Health Care for Adolescent and Young Adult Women With Epilepsy and Intellectual Disability

OBJECTIVE

To explore perspectives of pediatric neurologists regarding sexual and reproductive health care for adolescent women with epilepsy (WWE) and intellectual disability.

METHODS

We interviewed pediatric neurologists regarding sexual and reproductive health for WWE with intellectual disability. We audio-recorded and transcribed interviews and conducted qualitative analysis.

RESULTS

16 pediatric neurologists participated. Themes included the following: (1) Pediatric neurologists have differing perspectives about how intellectual disability affects WWE's sexual and reproductive health needs, (2) pediatric neurologists provide sexual and reproductive health counseling variable in content and frequency to this population, (3) pediatric neurologists tend to recommend longer-term methods of contraception for this population, and (4) pediatric neurologists are asked to be involved in decision-making around sterilization, yet express ethico-legal reservations.

CONCLUSION

Our findings suggest pediatric neurologists provide variable, often suboptimal, sexual and reproductive health care for WWE and intellectual disability. Themes reveal ethical concerns among neurologists about sexual and reproductive health practices including sterilization. More tailored clinical guidelines and provider training on sexual and reproductive health for this population may be beneficial.

Satisfaction With Hormonal Treatment for Menstrual Suppression in Adolescents and Young Women With Disabilities

PURPOSE

To characterize the population of adolescents and young women with special needs presenting for gynecologic care, describe usage patterns of hormonal suppression methods, and evaluate outcomes of menstrual management.

METHODS

This retrospective cohort study included females with special needs up to age 26 years presenting for menstrual management from 2009 to 2018. Demographic, social, and medical histories were collected to investigate effects on bleeding pattern and satisfaction with menstrual management.

RESULTS

Of 262 patients who presented for menstrual complaints, final methods of treatment included combined hormonal contraceptives (30.9%), oral progestins (19.8%), depot medroxyprogesterone acetate (8.0%), etonogestrel implant (1.9%), and levonorgestrel intrauterine device (16.8%). Eighty-five percent of patients were satisfied with their final bleeding pattern. Patients with amenorrhea or light regular periods were more likely to be satisfied than patients with heavy or irregular bleeding (p < .001). Satisfied patients tried an average of 1.4 methods, compared to 1.8 methods tried by the unsatisfied group (p = .042). By the end of the study, 26.0% were amenorrheic and 12.8% had only light spotting. Satisfaction rates were similar with each method, including 88.4% with use of combined hormonal contraceptives, 82.5% with oral progestins, 93.3% with depot medroxyprogesterone acetate, 100% with etonogestrel implant, and 83.9% with levonorgestrel intrauterine device.

CONCLUSIONS

Amenorrhea or light regular bleeding led to satisfaction in most patients. No hormonal method was superior. When counseling families and patients who present for menstrual suppression, emphasis should be placed on goals of treatment and expectations for outcomes, as light regular periods may be as acceptable as amenorrhea.

Preparing for Puberty in Girls With Special Needs: A Cohort Study of Caregiver Concerns and Patient Outcomes

STUDY OBJECTIVE

To characterize the patient population with cognitive or physical impairments that presents for anticipatory guidance of puberty, evaluate caregiver concerns with respect to puberty, and describe chosen management strategies and outcomes following menarche.

DESIGN

Retrospective cohort study SETTING: Academic tertiary care women and children's hospital PARTICIPANTS: Eligible female patients with special needs up to age 26 years presenting for anticipatory guidance from 2009 to 2018 MAIN OUTCOME MEASURES: Primary outcomes included characterization of patients presenting for anticipatory guidance and their reasons for menstrual management. Secondary outcomes were satisfaction with menstrual management and bleeding patterns.

RESULTS

A total of 61 patients presented for anticipatory guidance of puberty, on average 13.5 months prior to menarche. Compared to the overall adolescent population with special needs who presented for gynecologic care, patients who had autism spectrum disorder (ASD), were nonverbal, or had attention-deficit/hyperactivity disorder (ADD/ADHD) were more likely to present for a pre-menarchal visit to discuss anticipated pubertal development (P < .001, P = .009, and P = .04, respectively). More than half of families described potential behavioral changes as their main concern. The majority of post-menarchal patients (80%) desired hormonal management of menses, including 30% of patients who had placement of a levonorgestrel intrauterine device. In all, 96% of patients were satisfied with their final menstrual bleeding pattern; 50% achieved amenorrhea or light spotting.

CONCLUSIONS

This study describes the important role of pre-menarchal reproductive counseling for girls with disabilities. Anticipation of puberty causes great anxiety in families and patients, especially those with ASD, ADD/ADHD, and non-verbal status. Providers should consider initiating these conversations early in pubertal development.

Are Nepal's water, sanitation and hygiene and menstrual hygiene policies and supporting documents inclusive of disability? A policy analysis

PURPOSE

This study assesses the inclusion of disability in Nepal's policy and guidance relevant to water, sanitation and hygiene (WASH), and menstrual hygiene management (MHM) in comparison to gender. We investigated both policy formulation and implementation, using the Kavrepalanchok district as a case study.

MATERIALS AND METHODS

We used the EquiFrame framework, adapted for disability and gender, and focusing on WASH and MHM. Ten Nepali policies and guidance documents were reviewed and scored for quality against the framework, which included 21 core concepts of human rights. We also interviewed key informants to consider the inclusion of disability in the implementation of MHM interventions. We applied stratified purpose sampling to 12 government officials and service providers working in Kathmandu and the Kavrepalanchock district; conducted in-depth interviews and analysed data thematically using Nvivo 11.

RESULTS

Disability was inadequately covered within the policy documents, and MHM policy commitments for disability were almost non-existent. Participation of people with disabilities in policy development was limited; within Kavrepalanchok, policy commitments were not implemented as intended and disability service providers were unable to allocate government resources. Inadequate data on disability and MHM resulted in limited professional understanding of the issues, as service providers had no training. A narrow WASH infrastructure approach to improving MHM for people with disabilities was prioritised. MHM interventions were delivered in schools; these failed to reach children with disabilities who are often out of school. Finally, there were indications that some caregivers seek sterilisation for people with disabilities who are unable to manage menstruation independently.

CONCLUSION

Though the Constitution of Nepal enshrines gender equality and disability inclusion, there are consistent gaps in attention to disability and MHM in policies and practice. These omit and exclude people with disabilities from MHM interventions. Investment is required to generate evidence on the MHM barriers faced by people with disabilities, which would then be drawn on to develop training on these issues for professionals to improve understanding. Subsequently, policy makers could include more concepts of human rights against disability in relevant policies and service providers could implement policy commitments as intended.

Qualitative study exploring the barriers to menstrual hygiene management faced by adolescents and young people with a disability, and their carers in the Kavrepalanchok district, Nepal

BACKGROUND

Menstrual hygiene management (MHM) is a recognised public health, social and educational issue, which must be achieved to allow the realisation of human rights. People with disabilities are likely to experience layers of discrimination when they are menstruating, but little evidence exists.

METHODS

The study aims to investigate barriers to MHM that people with disabilities and their carers face in the Kavrepalanchok, Nepal, using qualitative methods. Twenty people with disabilities, aged 15-24, who menstruate and experience 'a lot of difficulty' or more across one or more of the Washington Group functional domains were included, as well as 13 carers who provide menstrual support to these individuals. Purposeful sampling was applied to select participants. Different approaches were used to investigating barriers to MHM and triangulate data: in-depth interviews, observation, PhotoVoice and ranking. We analysed data thematically, using Nvivo 11.

RESULTS

Barriers to MHM experienced by people with disabilities differ according to the impairment. Inaccessible WASH facilities were a major challenge for people with mobility, self-care and visual impairments. People with intellectual impairments had difficulty accessing MHM information and their carers despaired when they showed their menstrual blood to others, which could result in abuse. No support mechanisms existed for carers for MHM, and they felt overwhelmed and isolated. Menstrual discomfort was a major challenge; these were managed with home remedies, or not at all. Most participants followed menstrual restrictions, which were widespread and expected; many feared they would be cursed if they did not. As disability is often viewed as a curse, this demonstrates the layers of discrimination faced.

CONCLUSION

Issues related to MHM for people with disabilities is more complex than for others in the population due to the additional disability discrimination and impairment experienced. Research exploring these issues must be conducted in different settings, and MHM interventions, tailored for impairment type and carers requirements,should be developed. Attention to, and resourcing for disability inclusive MHM must be prioritised to ensure 'no one is left behind'.

Gynecological Care and Contraception Considerations in Women with Cerebral Palsy

The purpose of this literature review was to further explore gynecological care and contraceptive use in women with cerebral palsy. We address barriers to pelvic examinations for cervical cancer screenings and current contraceptive methods in severely debilitated patients with cerebral palsy.

Gynecologic Care in Women With Down Syndrome: Findings From a National Registry

OBJECTIVE

To estimate receipt of recommended gynecologic care, including cancer screening and menstrual care, among women with Down syndrome in the United States.

METHODS

We conducted a retrospective cohort study of women participating in DS-Connect, the National Institute of Health's registry of women with Down syndrome. Using 2013-2019 survey data, we estimated the proportion of women receiving recommended age-appropriate well-woman care (Pap tests, mammogram, breast examination, pelvic examination) and compared receipt of gynecologic care to receipt of other preventive health care. We also estimated proportion receiving care for menstrual regulation.

RESULTS

Of 70 participants with Down syndrome, 23% (95% CI 13-33) of women received all recommended gynecologic components of a well-woman examination. Forty-four percent (95% CI 32-56) of women aged 18 years and older reported ever having a gynecologic examination, and 26% (95% CI 15-37) reported ever having a Pap test. Of women aged 40 years or older, 50% (95% CI 22-78) had had a mammogram. Fifty-two percent (95% CI 41-65) had tried medication for menstrual regulation, and 89% (95% CI 81-96) received all recommended components of nongynecologic routine health care.

CONCLUSION

Women with Down syndrome received gynecologic care, including cancer screening, at lower-than-recommended rates and at substantially lower rates than other forms of health care. Efforts to improve gynecologic care in this vulnerable population are needed.

Long-Acting Reversible Contraception: Specific Issues for Adolescents

Long-acting reversible contraceptives are the most effective methods to prevent pregnancy and also offer noncontraceptive benefits such as reducing menstrual blood flow and dysmenorrhea. The safety and efficacy of long-acting reversible contraception are well established for adolescents, but the rate of use remains low for this population. The pediatrician can play a key role in increasing access to long-acting reversible contraception for adolescents by providing accurate patient-centered contraception counseling and by understanding and addressing the barriers to use.

Intrauterine Device Use in Adolescents With Disabilities

BACKGROUND AND OBJECTIVES

Intrauterine devices (IUDs) are increasingly being used in adolescents and nulliparous women for contraception. Levonorgestrel IUDs also have beneficial effects on bleeding and pain. Although they are recommended for menstrual suppression in adolescents with disabilities, there are limited data on their use in this population. Our objective is to describe the characteristics and experiences of levonorgestrel IUD use in nulliparous children, adolescents, and young adults with physical, intellectual, and developmental disabilities.

METHODS

A retrospective chart review was conducted for all nulliparous patients ages ≤22 with physical, intellectual, or developmental disabilities who had levonorgestrel IUDs placed between July 1, 2004, and June 30, 2014, at a tertiary-care children's hospital. Descriptive statistical analysis and survival analysis were performed.

RESULTS

In total, 185 levonorgestrel IUDs were placed in 159 patients with disabilities. The mean age was 16.3 (3.3; range of 9-22) years. Only 4% had ever been sexually active; 96% of IUDs were inserted in the operating room. IUD continuation rate at 1 year was 95% (95% confidence interval: 93%-100%) and at 5 years was 73% (95% confidence interval: 66%-83%). The amenorrhea rate was ∼60% throughout the duration of IUD use among those with available follow-up data. Side effects and complications were ≤3%.

CONCLUSIONS

In this study, we provide evidence for the therapeutic benefit and safety of levonorgestrel IUD use in adolescents and young adults with physical, intellectual, and developmental disabilities. It should be considered as a menstrual management and contraceptive option for this population.

Menstrual suppression in girls with disabilities

BACKGROUND

Girls with disabilities and their caregivers are challenged during pubertal transitions, particularly with menses onset. More than 50% of caregivers report concern and anxiety related to menarche, and they have sought health care providers to discuss options. Menstrual suppression planning and education from nurse practitioners (NP) is key to ensure quality of life for these girls and their caregivers.

OBJECTIVE

The purpose of this systematic review is to examine and evaluate the state of the science surrounding the use of medical modalities for menstrual suppression in adolescent girls with disabilities.

DATA SOURCES

Articles were identified through systematic electronic search of the following databases: CINAHL, Medline, Health Sources: Nursing/Academic Edition, Psychology and Behavioral Sciences Collection, PsycINFO, Cochrane Register of Controlled Trials, and Academic Search Complete.

CONCLUSIONS

Results indicate that the most common medical modality used for menstrual suppression in girls with disabilities is the combined oral contraceptive pill, but depot medroxyprogesterone acetate and levonorgestrel-releasing intrauterine system have been recommended. Concerns related to menstrual suppression include expressed wishes of the girl and her caregivers, existing comorbid conditions, and risks associated with medical modalities used for suppression.

IMPLICATIONS FOR PRACTICE

Meaningful conversations about concerns and expectations related to pubertal transitions are essential to ensure smooth transitions. NPs should provide counseling and discuss the variety of interventions available for menstrual suppression, being mindful of the need for comprehensive gynecological care. Additional studies using robust methods, including longitudinal and prospective strategies, are needed to better inform NPs of the goals and desirable outcomes for these girls and their caregivers.

Menstrual hygiene management among visually impaired women

This descriptive study aimed to determine the menstrual hygiene management among visually impaired women. The study sample included 187 visually impaired women. Data were evaluated using descriptive statistics. Of the visually impaired women, 61.5% had knowledge of menstrual hygiene management. They obtained this information mostly from their mothers (49.5%). Of them, 95.7% used sanitary pads, 52.4% changed their sanitary pads less than four times a day. Only 52.9% of the women managed their menstrual hygiene dependently. Most of the women determined the start date of their menstrual cycle noticing the smell of blood and determined the end date monitoring the duration of their normal cycle. In conclusion, visually impaired women had difficulty in managing their menstrual periods independently, their menstrual hygiene practices were not at a desired level, almost half of them received support in menstrual hygiene management, most of them used some indicators to determine the start/end of their menstrual period.

Management of Menstrual and Gynecologic Concerns in Girls with Special Needs

For girls with physical and developmental disabilities and their families/caregivers, puberty and menstruation can present significant problems such as vulnerability, abuse risk, unintended pregnancies, difficulties with managing menstrual hygiene, abnormal uterine bleeding, dysmenorrhea, behavioral difficulties/mood concerns or changes in seizure pattern. Healthcare providers may have an important and positive impact for both the adolescents and their families/caregivers during this stage of life. Whether menstrual manipulation is indicated should be decided after a detailed history is taken from both the patient and the caregivers to determine the impact of current problems on quality of life. It should be explained that complete amenorrhea is difficult to achieve and realistic expectations should be addressed. The goals for the management of menstrual concerns should be a reduction in the amount and total days of menstrual flow, reduction of menstrual pain and suppression of ovulatory or cyclic symptoms, depending on each individual patient’s needs. Advantages and disadvantages of available treatment methods should also be discussed.

Menstrual Suppression in Pediatric and Adolescent Patients with Disabilities Ranging from Developmental to Acquired Conditions: A Population Study in an Australian Quaternary Pediatric and Adolescent Gynecology Service from January 2005 to December 2015

STUDY OBJECTIVE

The aim of this study was to review the efficacy of different medical modalities for menstrual suppression in the cohort of patients with disabilities who presented to the Queensland Paediatric and Adolescent Gynaecology (PAG) Service between January 2005 and December 2015. Menstrual suppression in adolescents with disabilities is an important aspect of care to support the patient and their carers in managing the complexities of menstrual hygiene, pain, and other discomfort associated with menses. It is important for general practitioners, pediatricians, and gynecologists to establish the right modality of suppression for each individual adolescent. DESIGN, SETTINGS, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: The study was a retrospective case notes review of 68 adolescents who presented to the Queensland PAG Service, Brisbane, Australia with a request for menstrual suppression. The medical interventions included treatment with either combined oral hormonal contraceptive, oral medroxyprogesterone, depot medroxyprogesterone, or the levonorgestrel intrauterine system (Mirena, Bayer). The primary outcome measure was success of menstrual suppression from commencement of medical intervention to achievement of complete amenorrhea or very light bleeding described as spotting, for each medical modality. Secondary outcomes were length of time from first treatment to first observed menstrual suppression, and the number of outpatient appointments taken to achieve menstrual suppression.

RESULTS

Of the 68 adolescents, 59/68 (86.8%) successfully achieved menstrual suppression, with 9/68 (13.2%) having ongoing treatment or loss to follow-up at the time of conclusion of the study; 39/68 (57.4%) were menstrually suppressed with their chosen medical modality after their initial appointment.

CONCLUSION

Medical modalities are highly effective in achieving menstrual suppression and no young women at this institution required a hysterectomy. Depot medroxyprogesterone was the most successful modality used to achieve menstrual suppression followed by the levonorgestrel intrauterine system. The combined oral hormonal contraceptive was the least successful medical treatment in achieving menstrual suppression.

Hormonal Contraceptive Prescription in Young Women With Cerebral Palsy

PURPOSE

The purpose of the study was to describe the prevalence and patterns of prescription of hormonal contraceptive medications to young women with cerebral palsy (CP) and determine if CP topography or ambulatory status was associated with the type of contraceptive prescribed.

METHODS

Data were extracted by manual chart review for women with CP between the ages of 15 and 25 years who were seen at a tertiary pediatric hospital and a rehabilitation hospital between the years of 2011 and 2013. CP topography was defined as the number and pattern of limbs affected (hemiplegia, diplegia, triplegia, or quadriplegia), and ambulatory status was defined as whether a wheelchair was used for community mobility. Logistic regression analysis was used to assess associations between patient age, CP topography, ambulatory status, and contraceptive prescription.

RESULTS

Data were collected for 483 women with CP with an average age of 19 years (standard deviation: 3 years). One hundred thirty-one patients (27%) were prescribed hormonal contraceptives. Estrogen-progestin combined oral contraceptives were most frequently prescribed (73%). Prescription of hormonal contraceptives was not associated with CP topography (p = .95) or ambulatory status (p = .44); however, older subjects were more likely to be prescribed hormonal contraceptives (p = .01). There was no association detected between CP topography and contraceptive composition (p = .09) or between ambulatory status and contraceptive composition (p = .06). There was also no association detected between CP topography (p = .18) or ambulatory status (p = .09) and depot medroxyprogesterone acetate prescription.

CONCLUSION

Ambulatory status and CP topography were not associated with the types of hormonal contraceptives prescribed in this cohort.

Case Report of the Successful Use of Mirena Levonorgestrel Intrauterine System in a Patient with Didelphys Uterus and Obstructed Hemivagina

BACKGROUND

The Mirena levonorgestrel intrauterine system (IUS; Bayer HealthCare Pharmaceuticals) is frequently used for menstrual suppression in adolescents with special needs. However, the presence of a uterine anomaly is generally considered a contraindication to IUS insertion, thereby excluding a potentially highly effective option for this patient population.

CASE

A Mirena IUS was used in a medically and surgically complex special needs 14-year-old adolescent with a didelphys uterus and obstructed hemivagina. With the IUS inserted into the unobstructed uterus, she achieved amenorrhea and significant reduction in pain, with interval reduction in hematometra in the contralateral obstructed uterus.

SUMMARY AND CONCLUSION

We report the successful use of the Mirena IUS in a patient with a Müllerian anomaly, supporting the use of this device in carefully selected patients.

Systematic review of menstrual hygiene management requirements, its barriers and strategies for disabled people

BACKGROUND

One quarter of the global population is of menstruating age, yet menstruation is shrouded in discrimination and taboos. Disability also carries stigma, so disabled people may face layers of discrimination when they are menstruating. The objective of the review is to assess the menstrual hygiene requirements of disabled people, the barriers they face, and the available interventions to help them manage their menstruation hygienically and with dignity.

METHODS

Eligible studies, gathered across all countries, were identified by conducting searches across four databases (MEDLINE, PubMed, EMBASE, Global Health) in May 2017, with alerts set on each database to highlight new titles added until April 2018. Eligible studies incorporated analyses relevant to menstruating disabled people and/or how their carers provide support during their menstrual cycle.

RESULTS

The 22 studies included were published since 1976; the majority after 2010 (n = 12; 55%). One study was a quasi-experiment; all others were observational. Most studies (n = 15; 68%) were from high income countries and most (n = 17; 77%) focused on people with intellectual impairments, so the review findings focus on this group and their carers. Outcomes investigated include choice and preference of menstrual product, ability to manage menstrual hygiene and coping strategies applied. Barriers faced included a lack of standardised guidance for professional carers; a lack of menstruation training, information and support provided to people with intellectual impairments and their carers; a lack of understanding of severity of symptoms experienced by people with intellectual impairments, the high cost of menstrual products and lack of appropriate options for people with physical impairments. Few interventions were found, and strategies for menstrual hygiene management applied by carers of persons with intellectual impairments include limiting the disabled person's movements when menstruating and suppressing their menstruation.

CONCLUSIONS

Little evidence was identified on the requirements of disabled people and their carers in managing their menstruation, and only one intervention, but a range of barriers were identified. This gap in evidence is important, as the consequences of failing to meet menstrual hygiene needs of disabled people includes shame, social isolation, and even sterilisation.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018095497.

Management of contraceptives and menstrual complaints in patients with Down syndrome

Enhanced health care for patients with Down syndrome (DS) results in improved overall quality of life and longer life expectancy. The main gynecologic complaints of patients with DS and their caregivers relate to menstrual cycles, hygiene and reproductive issues. Certain aspects, such as age of menarche, menstrual cycles, internal genitalia, and hormone profile are similar to those observed in the general population. However, individuals with DS may have a higher incidence of other disorders related to menstruation, such as hypothyroidism, epilepsy and use of anticonvulsants. Contraceptive measures for individuals with DS can be used for both contraception and control of menstrual symptoms. The physician must be to make an individualized recommendation aimed at offering the most efficient and least invasive method with the fewest side effects. Among medical options are oral contraceptives, quarterly injectable medroxyprogesterone acetate, oral progesterone, a levonorgestrel-releasing intrauterine system, transdermal patch and vaginal rings. Surgical methods, including hysterectomy, endometrial ablation, or tubal ligation, are rarely considered because they raise ethical and legal questions. This article reviews the literature and basic guidelines to assist physicians who attend adolescent girls and women with DS to provide guidance on the appropriate management of the main gynecologic complaints of this population.

Recognition and treatment of mood dysregulation in adults with intellectual disability

Mood dysregulation is a common feature in the psychopathology of people with intellectual disability (ID) and co-occurring behavioral/psychiatric disorders. It can present with a host of dangerous behaviors, including aggression, self-injury, and property damage. There are special techniques that are used to assess these behaviors in people with ID, that can eventually inform an appropriate approach to pharmacologic and nonpharmacologic treatment. Two case studies are presented that illustrate the elements in the assessment and treatment of mood dysregulation in ID.

Contraceptive Provision to Postpartum Women With Intellectual and Developmental Disabilities: A Population-Based Cohort Study

CONTEXT

Women with intellectual and developmental disabilities who experience pregnancy, like all women, require postpartum care that supports their contraceptive knowledge and decision making. Yet, little is known about the postpartum contraceptive care these women receive, or how it compares with care given to other women.

METHODS

A population-based study using linked health and social services administrative data examined provision of postpartum contraceptive care to women who had a live birth in Ontario, Canada, in 2002-2014 and were beneficiaries of Ontario's publicly funded drug plan. Modified Poisson regression was used to compare care between 1,181 women with and 36,259 women without intellectual and developmental disabilities. Outcomes were provision of any nonbarrier contraceptive in the year following the birth and type of method provided.

RESULTS

In the first year postpartum, women with intellectual and developmental disabilities were provided with contraceptives at a higher rate than were other women (relative risk 1.3); the difference was significant for both nonsurgical and surgical methods (1.2 and 1.8, respectively). The higher rate of nonsurgical contraceptive provision was explained by provision of injectables (1.9); there were no differences for pills or IUDs.

CONCLUSION

Nonbarrier contraceptives may be the most appropriate methods for some women with intellectual and developmental disabilities. However, future research should investigate why women with such disabilities are more likely than others to receive injectable contraceptives, which have possible negative side effects, and surgical contraception, which is irreversible. Research also should investigate how these women perceive their participation in contraceptive decision making.

Review of gynecologic and reproductive care for women with developmental disabilities

PURPOSE OF REVIEW

Care for women with developmental disabilities requires special consideration for unique needs related to their cognitive and physical abilities. These women and their caregivers require more support and guidance during reproductive health care. We review the literature and provide expert opinion surrounding gynecological issues for women with developmental disabilities to support healthcare providers better understand and care for this population.

RECENT FINDINGS

Women with developmental disabilities are more vulnerable to abuse and experience poorer gynecological healthcare outcomes. Many women with developmental disabilities are fertile and participate in sexual activity without adequate knowledge. They are at higher risk of pregnancy and birth complications. They are less likely to receive appropriate preventive screening.

SUMMARY

The review highlights important issues and practice suggestions related to the reproductive health care of women with developmental disabilities. Topics include clinic visits, menstruation, sexuality, sexual abuse, sexual health education, contraception, sexually transmitted infections, pregnancy, labor and delivery, and cancer screening/prevention. We emphasize the need for an individualized, comprehensive approach for these patients and review perceived and actual barriers to care. More education is needed on the aforementioned topics for women with developmental disabilities, their caregivers, and their providers.

Sexuality and Disability in Adolescents

Healthy sexual development is important for adolescents with and without disabilities, yet the topic of sexuality is often ignored in the disabled population. Adolescents with mild or moderate degrees of disability have rates of sexual activity and reproductive health needs comparable to their typically developing peers. Their need for support, risk reduction, and education in sexual health may exceed that of their peers. The medical provider may support healthy sexual development through education, anticipatory guidance, menstrual and contraceptive management, and by expanding the notion of sexuality to include a broader conceptualization of sexual behavior and expression.

Uterine Length in Adolescents with Developmental Disability: Are Ultrasound Examinations Necessary before Insertion of the Levonorgestrel Intrauterine System?

STUDY OBJECTIVE

(1) To determine if there are any differences in uterine length between adolescents with developmental disability (DD) compared with their normally developing (ND) peers that might necessitate ultrasonography before insertion of levonorgestrel intrauterine system (LNG-IUS) in patients with DD; and (2) to characterize the LNG-IUS insertion procedure in adolescents with disabilities.

DESIGN, SETTING, PARTICIPANTS, AND INTERVENTIONS

This was a retrospective cohort study of 223 female adolescents with or without DDs. Seventy-five adolescents had DD; 33 underwent intrauterine system insertion in the operating room and 42 did not. A comparative cohort of 148 ND adolescents who had pelvic ultrasound examinations for abnormal uterine bleeding were included. The study period was between January 2006 and July 2013 at the Hospital for Sick Children, Toronto, Canada. Cases were identified from surgical databases and medical records.

MAIN OUTCOME MEASURES

Mean uterine length on pelvic ultrasound, demographic characteristics (age, age at menarche, time from menarche to ultrasound, weight), and descriptive statistics on intrauterine system insertion.

RESULTS

There was a statistically significant difference (P = .03) in uterine length between adolescents with and without DD (6.7 vs 7.1 cm). However, this was not a clinically significant difference because insertion of the LNG-IUS in patients with DD was successful in patients with uteri more than 5 cm long. There was no difference (P = .97) in uterine length of adolescents with DD whether they had LNG-IUS insertion or not (6.7 cm). Adolescents with DD were younger than adolescents without DD at time of ultrasound examination (P = .01). However, among patients with DD, those who underwent intrauterine system insertion were older (P = .001). Incidence of uterine anomaly in patients with DD is low (2.7%) and was the same as in ND adolescents. Rates of complications and expulsions were low and there were no failures of LNG-IUS insertion in adolescents with DD.

CONCLUSION

Routine pelvic ultrasound examinations are not necessary before insertion of the LNG-IUS for menstrual suppression in adolescents with DD. Renal abnormalities, obstructive symptoms, and very small stature might necessitate imaging. Insertion using anesthesia is often straightforward and successful with minimal complications.

The Effect of Menstrual Issues on Young Women with Angelman Syndrome

STUDY OBJECTIVE

To characterize menstrual health issues and their effect in young women with Angelman syndrome (AS). Our secondary objective was to compare them with young women with autism spectrum disorders (ASDs).

DESIGN

Cross-sectional convenience sample survey.

SETTING

An institutional review board-approved Web-based survey of young female members of the Angelman Syndrome Foundation.

PARTICIPANTS

Caregivers of young women with AS, aged 12-25 years.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Symptom characterization and effect of menses on young women with AS.

RESULTS

Menstrual and premenstrual symptoms were common among young women with AS, but infrequently caused problems at home or school. Less than half of the subjects used hormones to control their flow. Of those who used hormones, 75% used them continuously. Caregivers were satisfied with their method to control periods. Girls with seizures were more likely to use hormonal methods to control menses than those without seizures. Menstrual-associated morbidity in young women with ASD and AS was fairly similar, but with greater morbidity in the ASD group than in the AS group. However, girls with AS had more problems with menstrual hygiene with almost all of them requiring full assistance for managing hygiene.

CONCLUSION

In this group of young women with AS, who have moderate to severe neurodevelopmental disabilities and cannot manage their own hygiene, menstruation is not associated with significant problems. Menstrual management by hormones is used by less than half. When hormonal therapy is used, it is most commonly used continuously to suppress menses.

Menstrual Management for Adolescents With Disabilities

The onset of menses for adolescents with physical or intellectual disabilities can affect their independence and add additional concerns for families at home, in schools, and in other settings. The pediatrician is the primary health care provider to explore and assist with the pubertal transition and menstrual management. Menstrual management of both normal and abnormal cycles may be requested to minimize hygiene issues, premenstrual symptoms, dysmenorrhea, heavy or irregular bleeding, contraception, and conditions exacerbated by the menstrual cycle. Several options are available for menstrual management, depending on the outcome that is desired, ranging from cycle regulation to complete amenorrhea. The use of medications or the request for surgeries to help with the menstrual cycles in teenagers with disabilities has medical, social, legal, and ethical implications. This clinical report is designed to help guide pediatricians in assisting adolescent females with intellectual and/or physical disabilities and their families in making decisions related to successfully navigating menarche and subsequent menstrual cycles.

Adolescents with Special Needs: Clinical Challenges in Reproductive Health Care

Adolescents with special needs have unique reproductive health care needs related to their physical and cognitive issues. This review discusses some of the most common concerns that are encountered in clinical practice, as the clinician will partner with the adolescent and her family to guide her through the pubertal transition and to help navigate the risks and rights of reproduction. Families often seek anticipatory guidance before menarche on menstrual hygiene, abuse risk and sexuality and can be reassured that most teens with special needs do very well with menstruation. The clinician needs to evaluate the teenager's reproductive knowledge as well her risk for abuse and coercion and her ability to consent to sexual activity, if she requests contraception. Menstrual management is mostly based on the impact of the menstrual cycles on the teenager's life and activities. The adolescents may have a decreased ability to tolerate menses or pain, or experience changes in seizure pattern or altered mood. Hormonal treatment is often used to assist with menstrual hygiene, cyclical mood changes or dysmenorrhea. The goal of treatment can be complete amenorrhea, alleviate pain or regulate and decrease menstrual flow. The unique risks and benefits of hormonal treatment for this special population are highlighted.

Menstrual suppression in special circumstances

OBJECTIVE

To provide a Canadian consensus document for health care providers with recommendations for menstrual suppression in patients with physical and/or cognitive challenges or those who are undergoing cancer treatment in whom menstruation may have a deleterious effect on their health.

OPTIONS

This document reviews the options available for menstrual suppression, its specific indications, contraindications, and side effects, both immediate and long-term, and the investigations and monitoring necessary throughout suppression.

OUTCOMES

Clinicians will be better informed about the options and indications for menstrual suppression in patients with cognitive and/or physical disabilities and patients undergoing chemotherapy, radiation, or other treatments for cancer.

EVIDENCE

Published literature was retrieved through searches of Medline, EMBASE, OVID, and the Cochrane Library using appropriate controlled vocabulary and key words (heavy menstrual bleeding, menstrual suppression, chemotherapy/radiation, cognitive disability, physical disability, learning disability). Results were restricted to systematic reviews, randomized controlled trials, observation studies, and pilot studies. There were no language or date restrictions. Searches were updated on a regular basis and new material was incorporated into the guideline until September 2013. Grey (unpublished) literature was identified through searching websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).

BENEFITS, HARMS, AND COSTS

There is a need for specific guidelines on menstrual suppression in at-risk populations for health care providers. Recommendations 1. Menstrual suppression and therapeutic amenorrhea should be considered safe and viable options for women who need or want to have fewer or no menses. (II-2A) 2. Menstrual suppression should not be initiated in young women with developmental disabilities until after the onset of menses. (II-2B) 3. Combined hormonal or progesterone-only products can be used in an extended or continuous manner to obtain menstrual suppression. (I-A) 4. Gynaecologic consultation should be considered prior to the initiation of treatment in all premenopausal women at risk for abnormal uterine bleeding from chemotherapy. (II-1A) 5. Leuprolide acetate or combined hormonal contraception should be considered highly effective in preventing abnormal uterine bleeding when initiated prior to cancer treatment in premenopausal women at risk for thrombocytopenia. (II-2A).

Menstrual and reproductive issues in adolescents with physical and developmental disabilities

Most obstetrician-gynecologists will encounter adolescents with disabilities in their practice, because developmental and physical disabilities are common in young patients (8.4%). Reproductive health issues such as puberty, sexuality, and menstruation can be more complicated for teenagers with disabilities and their families as a result of concerns surrounding menstrual hygiene, abuse risk, vulnerability, changes in seizure pattern, and altered mood. Teenagers with disabilities have gynecologic health care needs similar to those of their peers as well as unique needs related to their physical and cognitive issues. The gynecologic health visit for a teenager with disabilities should include an evaluation of the teenager's reproductive knowledge as well as an assessment of her abuse and coercion risk and her ability to consent to sexual activity. The menstrual history is focused on the effects of menstrual cycles on her daily life. Diagnostic testing is not different from other adolescents. Hormonal treatment is often requested by the patient and her family to alleviate abnormal bleeding, cyclic mood changes, dysmenorrhea, or a combination of these, to assist with menstrual hygiene, and to provide contraception. Menstrual manipulation can be used to induce complete amenorrhea, regulate cycles, or decrease regular menstrual flow. However, treatment risks and side effects may have a different effect on the lives of these adolescents. The comfort level of health care providers to respond to the special concerns of adolescents with disabilities is low, and several barriers exist. This review addresses the complex issues of puberty, menstruation, sexuality, abuse, and safety highlighting the distinctive needs of this population. The options and decisions around menstrual manipulation are highlighted in detail.

Menstrual suppression: current perspectives

Menstrual suppression to provide relief of menstrual-related symptoms or to manage medical conditions associated with menstrual morbidity or menstrual exacerbation has been used clinically since the development of steroid hormonal therapies. Options range from the extended or continuous use of combined hormonal oral contraceptives, to the use of combined hormonal patches and rings, progestins given in a variety of formulations from intramuscular injection to oral therapies to intrauterine devices, and other agents such as gonadotropin-releasing hormone (GnRH) antagonists. The agents used for menstrual suppression have variable rates of success in inducing amenorrhea, but typically have increasing rates of amenorrhea over time. Therapy may be limited by side effects, most commonly irregular, unscheduled bleeding. These therapies can benefit women’s quality of life, and by stabilizing the hormonal milieu, potentially improve the course of underlying medical conditions such as diabetes or a seizure disorder. This review addresses situations in which menstrual suppression may be of benefit, and lists options which have been successful in inducing medical amenorrhea.