Menstrual and contraceptive issues among young women with developmental delay: a retrospective review of cases at the Hospital for Sick Children, Toronto

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.

"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.

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.

“It Gives Me, as her Caregiver, a Sense of Security.” Young People with Intellectual Disability and Their Experiences with Sexuality, Menstruation, Gynecological Treatment and Contraception: A Follow-up Analysis of Parents’ and Caregivers’ Perspectives

Background

Research shows that caregivers support but also impede people with intellectual disabilities from developing intimate relationships. People with intellectual disability experience coital sex later and less often compared to adolescents without disabilities. Caregivers often request hormonal contraception from gynecologists on their behalf. Their main motives are pregnancy avoidance (either as a result of consensual sex or sexual abuse) and menstrual suppression.

Method

The sample included 42 primary caregivers of young people with intellectual disability aged 14 to 25. Interviews were evaluated with qualitative content analysis.

Results

Nine of the main caregivers assumed that sexual intercourse had taken place. Half of the carers evaluated the importance of sexuality for the young people with intellectual disability as high. The main reason for seeing a gynecologist was the prescription of hormonal contraceptives; the outcome of which was arbitrary and dependent on the individual gynecologist. The majority of young women took general hormonal contraceptives as a preventive measure or due to heavy bleeding, regardless of sexual activity. One-fifth took hormone depots as a form of long-term contraception.

Discussion

A trusting relationship with the gynecologist favored the compliance and well-being of the young women. The administration of hormonal contraceptives seems to be controlled by third parties. Caregivers used hormonal contraceptives to simplify the regulation of menstruation and felt relieved by it. Carers view the sexual activities of the young women more critically because they fear a pregnancy and the responsibility for a potential grandchild. The use of hormonal contraceptives made carers clearly more tolerant of sexual activity.

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.

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.

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.

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.

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.

Hysterectomy for the Management of Menstrual Hygiene in Women With Intellectual Disability. A Systematic Review Focusing on Standards and Ethical Considerations for Developing Countries

Background: Menstruation poses particular challenges for women with intellectual disability (ID). In low-and middle-income countries, where these women do not have access to facilities and resources for adequate menstrual care, hysterectomy could be considered as an ethically acceptable procedure. We conducted the first systematic review to identify what constitutes best practice for menstrual hygiene in women with ID and explored the perspectives of actors involved in the hysterectomy decision.

Methods: Theory-informed mixed-method thematic systematic review with theory development.

Results: Eleven ethical guidelines and 17 studies were included. Respect for autonomy and the patient's best interest were the criteria to determine what constitutes best practice. The actors' values and attitudes expressed some dimensions of existing inequities. In low-and middle-income countries, the main concern of parents was the difficulty to train their daughters about menstrual hygiene. Parents (mothers in particular) also expressed the feeling of being excessively burdened, and complained about the limitations of their support networks. Doctors perceived hysterectomy as a safe procedure and a solution for women with ID, whose menstrual hygiene is problematic. In general, the more severe or profound the level of ID, the more likely the interested parties advocated for a hysterectomy. The women with ID perceived their menstruation as a negative experience. Hence, the three parties supported hysterectomy for menstrual hygiene. Parents and doctors considered informed consent or assent (from the women with ID) as necessary and achievable.

Conclusion: The international ethical guidelines suggest that non-therapeutic hysterectomy in women with ID should not and ought not to be recommended as routine and appropriate method to cope with menstrual hygiene even if it is technically safe. Although hysterectomy to cope with menstrual hygiene is still a live issue in high-, middle-, and low-income countries, in high income countries it is performed with authorization from the Court; whilst in low-and middle-income countries there is not an active involvement of the State, or financial or training support for women with ID and their carers. Hence, in low-and middle-income countries there is an urgent need to develop and enact policies and statutes in this area of public health and clinical practice.

Management of Menstrual Disorder in Adolescent Girls with Intellectual Disabilities: A Blessing or a Curse?

Objective

This study aims to describe the menstrual pattern and menstrual care of girls with intellectual disabilities and to evaluate the impact of menstruation and awareness of parents/guardians on girls with intellectual disabilities.

Methodology

Parents/guardians of girls aged 9–17 years with known intellectual disabilities who attended a scheduled public forum and Paediatrics and Adolescent Gynaecology Clinic (PAC) were recruited in a questionnaire-based study.

Results

A total of 123 parents/guardians with a mean age of 41.83 ± 5.45 years completed the questionnaire. The mean age of girls with intellectual disabilities was 12.28 ± 2.78 years, and the mean menarcheal age was 11.12 ± 1.76 years. Only 53 (43.1%) parents/guardians were aware of availability of menstrual suppression. Parents/guardians with lower family income (OR = 0.00; 95% CI = 0.00–0.20), unable to manage menses (OR = 0.03; 95% CI = 0.00–0.61), and moderate severity of menses (OR = 0.01; 95% CI = 0.00–1.21), were associated with seeking medical help on menstrual suppression. The factors associated with parents/guardians requesting for sterilization were lower family income (OR = 0.02; 95% CI = 0.00–0.36) and concern about sexual abuse (OR = 0.25; 95% CI = 0.06–0.39).

Conclusion

Menstrual pattern in girls with intellectual disabilities is similar to those without disabilities. Parents/guardians' knowledge and awareness on menstrual suppression were still lacking.

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.

Maternal attitude towards delaying puberty in girls with and without a disability: a questionnaire-based study from the United Arab Emirates

BACKGROUND

Parental anxiety about the impact of puberty/menses, particularly in girls with severe disability leads to seeking therapeutic pubertal suppression. We aim to explore maternal attitudes and reasons for seeking pubertal suppression.

METHODS

Mothers of girls receiving gonadotropin -releasing hormone analogue therapy in Mafraq hospital, Abu Dhabi were enrolled in the study. A semistructured interview was conducted to ascertain possible reasons for delaying puberty. The study group was divided into girls with a disability with central precocious puberty (CPP) or normal puberty and girls without a disability presenting with CPP.

RESULTS

42 mother-daughter pairs were enrolled and divided into two groups; group A: 15 girls with CPP with no disability; group B: 27 girls with disability (10 had CPP (group B1) and 17 had normal pubertal timing (group B2)). Mothers in group A aimed to delay puberty, while in group B, 13 (48%) mothers desired to halt puberty and 7 (26%) requested permanent surgical intervention. Fear of short stature (15, 100%), inability to cope psychologically (10, 67%) and fear of peer rejection (9, 60%) were the main concerns in group A. In group B, mothers were concerned about menstrual hygiene management (25, 92.5%), fear of child abuse or unwanted pregnancy (15, 55%) and fear of inability to express pain/discomfort with menstruation (8, 30%).

CONCLUSION

Mothers of girls with a disability commonly seek medical help to delay/halt puberty due to concerns about menstrual hygiene. Short final height was the main concern for girls without a disability. Culture and religion play an important role in puberty management in girls with a disability.

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.

Teaching menstrual care skills to intellectually disabled female students

AIMS AND OBJECTIVES

The aim of this study was to teach pad replacement skills to intellectually disabled adolescent female students during their menstruation periods by demonstrating on a dummy.

BACKGROUND

It may be difficult to make intellectually disabled adolescents achieve self-care during menstruation. In addition, there are difficulties experienced in explaining menstruation, such as physical changes and the practice of cleaning during this period.

DESIGN

The study used a 'One group pretest and post-test model'.

METHOD

The study was performed in a special educational institution. The population consisted of 77 female students in the high school section. Calculation of a sample size was not attempted, and 54 students with no attendance issues agreed to take part in the study and were included.

RESULTS

In this work, we found that pad replacement training significantly changed the scores of mentally disabled adolescents before and after training. Our training yielded positive results, and the population improved their skills at all stages of skill building.

CONCLUSION

Training adolescents with mental disabilities helped them gain hygiene habits. Performance of these trainings occurs at the beginning of menstrual hygiene education.

RELEVANCE TO CLINICAL PRACTICE

To achieve improved success in life, it is important that adolescents assume the responsibility of self-care and manage sustained care activity on their own.

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).

Contraception for adolescents

A working knowledge of contraception will assist the pediatrician in both sexual health promotion as well as treatment of common adolescent gynecologic problems. Best practices in adolescent anticipatory guidance and screening include a sexual health history, screening for pregnancy and sexually transmitted infections, counseling, and if indicated, providing access to contraceptives. Pediatricians' long-term relationships with adolescents and families allow them to help promote healthy sexual decision-making, including abstinence and contraceptive use. Additionally, medical indications for contraception, such as acne, dysmenorrhea, and heavy menstrual bleeding, are frequently uncovered during adolescent visits. This technical report provides an evidence base for the accompanying policy statement and addresses key aspects of adolescent contraceptive use, including the following: (1) sexual history taking, confidentiality, and counseling; (2) adolescent data on the use and side effects of newer contraceptive methods; (3) new data on older contraceptive methods; and (4) evidence supporting the use of contraceptives in adolescent patients with complex medical conditions.

Complication rates associated with levonorgestrel intrauterine system use in adolescents with developmental disabilities

STUDY OBJECTIVE

To assess the complication rates with the use of the levonorgestrel intrauterine system (LNG IUS) in adolescents with developmental disabilities.

DESIGN

Retrospective chart review of all adolescents with developmental disabilities taken to the operating room for LNG IUS insertion between January 2000 and July 2009 at the Royal Children's Hospital, Melbourne, Australia. Cases identified from the surgical database, and medical records reviewed.

MAIN OUTCOME MEASURES

Complication rates with LNG IUS use in adolescents with development disabilities: non-insertion, uterine perforation, infection, and expulsion.

RESULTS

Fifty-six adolescents with developmental disabilities had an attempted LNG IUS insertion. The average age at insertion was 15.6 years (range 10.5-21.5 y). The LNG IUS was used as first line therapy in 14 cases (25%). Pre-insertion ultrasonography was ordered in 48% of cases, out of which 5 cases had uterine lengths <6 cm. Despite this, 4 of these cases had successful insertions. Two insertion attempts were abandoned intra-operatively (3.6%); one due to inadequate uterine length of 4 cm, and the other due to anatomic distortion. One spontaneous expulsion occurred at approximately 5 months (1.9%). Four IUDs were removed prematurely (7.4% withdrawal rate); 1 for persistent abdominal pain, 1 for irregular bleeding, and 2 for suspected malpositions. There were no documented cases of infection, perforation, or pregnancy.

CONCLUSION

Our experience in this population has been very positive and confirms that complication rates are comparable to that in adults.

Trends in menstrual concerns and suppression in adolescents with developmental disabilities

PURPOSE

Demonstrate changes in methods of menstrual suppression in adolescents with developmental disabilities in a recent 5-year cohort compared with an historical cohort at the same hospital.

METHODS

Retrospective cohort study of patients with physical and cognitive challenges presenting for menstrual concerns at an Adolescent Gynecology Clinic between 2006 and 2011 compared with a previous published cohort (1998 to 2003).

RESULTS

Three hundred patients with developmental disabilities aged 7.3 to 18.5 years (mean 12.1 ± 1.6) were analyzed. Caregiver concerns included menstrual suppression, hygiene, caregiver burden, and menstrual symptoms. Ninety-five percent of patients had cognitive disabilities, 4.4% had only physical impairments. Thirty-two (31.7) percent of patients presented premenarchally. The most commonly selected initial method of suppression was extended or continuous oral contraceptive pill (OCP) (42.3%) followed by patch (20%), expectant management (14.9%), depot medroxyprogesterone acetate (DMPA) (11.6%), and levonorgestrel intrauterine system (LNG-IUS) (2.8%). Published data from 1998 to 2003 indicated a preference for DMPA in 59% and OCP in 17% of patients. The average number of methods to reach caregiver satisfaction was 1.5. Sixty-five percent of initial methods were continued. The most common reasons for discontinuation were breakthrough bleeding, decreased bone mineral density, or difficulties with patch adherence. Second-choice selections included OCP (42.5%), LNG-IUS inserted under general anesthesia (19.2%), DMPA (17.8%), and patch (13.7%).

CONCLUSIONS

Since identification of decreased bone mineral density with DMPA and emergence of new contraceptive options, use of extended OCP or patch has surpassed DMPA for menstrual suppression in our patient population. LNG-IUS is an accepted, successful second-line option in adolescents with developmental disabilities.

Menstrual suppression in the adolescent

Menstrual suppression, the use of contraceptive methods to eliminate or decrease the frequency of menses, is often prescribed for adolescents to treat menstrual disorders or to accommodate patient preference. For young women using hormonal contraceptives, there is no medical indication for menstruation to occur monthly, and various hormonal contraceptives can be used to decrease the frequency of menstruation with different side effect profiles and rates of amenorrhea. This article reviews the different modalities for menstrual suppression, common conditions in adolescents which may improve with menstrual suppression, and strategies for managing common side effects.

Menstrual suppression with the levonorgestrel intrauterine system in girls with developmental delay

STUDY OBJECTIVE

To describe the experiences of 21 girls with developmental delay accompanied by multiple other medical problems, seen over a 3-year interval, who underwent insertion of the levonorgestrel intrauterine system (LNG-IUS) for menstrual suppression.

STUDY DESIGN

Retrospective chart review.

SETTING

A referral pediatric and adolescent gynecology clinic within a tertiary care medical center with referrals from community pediatricians, pediatric subspecialists including developmental and behavioral pediatricians, community gynecologists, and adolescent medicine specialists.

PARTICIPANTS

Adolescents and young women with developmental delay and multiple comorbid conditions who were seen for consultation with their families requesting menstrual suppression.

INTERVENTIONS

Participants were offered hormonal options, for menstrual suppression including the LNG-IUS.

MAIN OUTCOME MEASURES

Satisfaction with menstrual suppression among families electing the LNG-IUS.

RESULTS

Adolescents and young women seen at CCHMC with developmental delay and multiple comorbid conditions with requests for menstrual suppression were offered hormonal options, including the LNG-IUS. Twenty-one families chose this option. Fifteen of 21 girls had previously used hormonal menstrual suppression. General anesthesia was required for 20 of 21 insertions, and 9 of 20 of these insertions were combined with other surgical procedures. There were no unsuccessful insertions or major complications. Mean duration of follow-up was 11 months, and families were satisfied with this option for menstrual suppression. There was 1 request for removal.

CONCLUSIONS

LNG-IUS for menstrual suppression, in girls with developmental delay and multiple comorbid medical conditions for which amenorrhea is desirable and therapeutic, appears promising.

Rett syndrome and menstruation

OBJECTIVE

Describe the experience that girls with Rett syndrome have with menstruation including menstrual hygiene, dysmenorrhea, premenstrual syndrome (PMS), and attempts at treatment.

DESIGN

Anonymous web-based survey.

SETTING

Convenience sample recruited from Rett syndrome LISTSERV in July of 2009.

PARTICIPANTS

Mothers of girls with Rett syndrome between the ages of 10-25 who have had at least one menses.

MAIN OUTCOME MEASURES

Prevalence, frequency, and severity of dysmenorrhea and PMS; hygiene concerns; and treatments attempts and perceived effectiveness.

RESULTS

Dysmenorrhea and PMS are common problems among young women with Rett syndrome. Despite their frequency and severity they do not routinely limit activities. Multiple treatment attempts are common. Hormonal contraception is used mostly for menstrual cycle control with oral contraceptive pills the most commonly used method.

CONCLUSIONS

Young women with Rett syndrome have standard symptoms of dysmenorrhea and PMS as well as autism spectrum specific PMS symptoms. Hormonal contraception is commonly used for menstrual management.

Caring for a daughter with intellectual disabilities in managing menstruation: a mother's perspective

BACKGROUND

The concerns of mothers and their experiences while providing help to their daughters with intellectual disability (ID) and considerable support needs during menstruation have rarely been addressed. This qualitative study explored mothers' experiences and perceptions of managing their daughters' menstruation.

METHOD

Twelve Taiwanese mothers of 13 daughters with ID (1 mother had twins) were interviewed to explore their experiences of providing help to their daughters with high support needs during menstruation.

RESULTS

Support networks were limited and mothers developed their own strategies for managing their daughter's menstruation. Surgical hysterectomy or use of medication to cease or postpone menstrual bleeding was never considered by the mothers. The financial cost of menstrual pads and nappies was significant.

CONCLUSIONS

Both an appropriate allowance for families involved in the menstrual care of women with ID and access to appropriate support are needed. More information and educational programs need to be provided to relevant professionals and carers.

Gynecologic issues of adolescents with Down syndrome, autism, and cerebral palsy

STUDY OBJECTIVE

The gynecologic issues of adolescents with disabilities are understudied. The purpose of this study was to identify and compare the presenting complaints, treatments, and follow-up of adolescent girls with Down syndrome (DS), autism, and cerebral palsy (CP) presenting to a specialized gynecologic clinic for women with developmental disabilities.

SETTING

Outpatient gynecology clinic.

PARTICIPANTS

Forty four adolescents (<21 y); 13 with DS, 14 with autism, and 17 with CP who presented to the clinic from 1999 to 2006.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

A retrospective review of the electronic medical records to collect data on age at presentation to clinic, ethnicity, menstrual history, chief complaint, treatment, and follow-up.

RESULTS

Mean age at presentation to clinic was 15+/-3.5 years, and age of menarche was 12.5+/-2 years; age at menarche did not significantly differ between groups. The most frequent complaints were irregular bleeding (n=10) and mood/behavioral changes (n=6). Girls with autism were significantly (chi(2)=8.89, P=.012) more likely to present with behavioral issues than the other 2 groups. Initial management for the behavior issues in the autism group included nonsteroidal anti-inflammatory drugs (NSAID), oral contraceptives, and education.

CONCLUSION

The most common gynecologic complaints of adolescent girls with DS, autism, and CP centered on menstruation and mood disorders. Patients with autism were more likely to present with behavioral issues related to the onset of periods.

Menstrual suppression for adolescents with developmental disabilities

The approach to menstrual suppression for adolescents with developmental disabilities has evolved considerably over the years due to changing philosophies and evolving treatment options. We review the medical management options available for menstrual suppression with a focus on the needs and treatment of adolescents with developmental disabilities.

Prevalence and severity of menstrual symptoms among institutionalised women with an intellectual disability

BACKGROUND

Perimenstrual syndrome (PMS) among women with an intellectual disability (ID) has not been investigated in Taiwan. This study explores the prevalence/severity of PMS experienced by women with ID who are institutionalised.

METHOD

Ninety two female residents aged 15 to 54 at six public institutions completed a structured interview between June and November 2006, together with the Moos Menstrual Distress Questionnaire (MMDQ).

RESULTS

Strong significant differences were detected between the participants' physical, emotional, behavioural, and psychological changes during the perimenstrual and remainder phases in all domains other than Arousal. Cramps, hot flushes, affection, orderliness, excitement, and bursts of energy/activity were most prevalent during the perimenstruum (>50%). The participants' unique characteristics and cultural context were associated with the various domains of the PMS.

CONCLUSIONS

Special attention should be paid in future to ascertain whether these experiences and perceptions of PMS are common among all women with ID.

Suppression of menstruation in adolescents with severe learning disabilities

As girls with severe cognitive developmental delay progress into puberty and become young women with learning disabilities, concerns about menstruation are common amongst carers and health care professionals are often consulted for advice. Very little, however, has been published on this area to guide the practitioner and studies are almost exclusively confined to the gynaecological literature. We aim to give an account of the various therapeutic options available and current practice within the paediatric endocrinology unit at our institution.

Decidual cast in a girl receiving depot medroxyprogesterone acetate--a case report

BACKGROUND

The passage of tissue per vaginam in a young girl raises several diagnostic considerations that include aborted pregnancy, benign polyp, rhabdomyosarcoma, and rarely decidual cast.

CASE

A 9-yr-old girl who was receiving depot medroxy-progesterone acetate to suppress menstruation passed tissue per vaginam. Pathological examination of the tissue showed a decidual cast with no chorionic villi, while a serum hCG test was also negative.

CONCLUSIONS

Decidual cast formation is a rare side effect of progestogen use and should be considered in the differential diagnosis of passage of tissue per vaginam.

A qualitative study of menopause among women with disabilities

Few studies have examined the way women with disabilities understand and make decisions regarding menopause. This report is a qualitative descriptive study detailing how women with varying mobility impairments view the menopausal transition. Nineteen women aged 42 to 64 years were interviewed regarding their menopausal experiences. Results described their experiences as minority groups of women with disabilities using a women's ways of knowing framework. Overall, most women described menopause as a back burner issue, but maintained the need for accurate information from which to make informed decisions that might impact future health and functional outcomes.

Associations between fracture incidence and use of depot medroxyprogesterone acetate and anti-epileptic drugs in women with developmental disabilities

PURPOSE

We sought to evaluate any association between incidence of osteoporotic fractures and use of depot medroxyprogesterone acetate (DMPA) and/or anti-epileptic drugs (AEDs) among women and girls with developmental disabilities.

METHODS

Cross-sectional population-based observational study of all noninstitutionalized females with developmental disabilities age >/=13 who received fee-for-service Medicaid in Washington State during 2002 (n = 6,773), using administrative data.

MAIN FINDINGS

In a sample of 6,773 females, 140 women (2%) had an osteoporotic fracture during 2002. Among 340 users of DMPA, 13 (3.8%) had an osteoporotic fracture with an odds ratio of 2.4 (95% confidence interval [CI], 1.3-4.4) for fracture compared to nonusers. Among 1,909 users of AEDs, 60 (3.1%) had an osteoporotic fracture with an odds ratio of 1.9 (95% CI, 1.3-2.6) for fracture compared to nonusers. We controlled for use of drugs (DMPA or AEDs), age and race (as white or other racial and ethnic groups).

CONCLUSIONS

Use of either AEDs or DMPA by women with developmental disabilities is associated with significantly increased incidence of fracture. Women and girls who have developmental disabilities may be poor candidates for DMPA use owing to increased risk of fractures. Further research is indicated to 1) determine the specific risks profile of DMPA for this population, 2) explore alternative means of managing significant menstrual problems and contraceptive needs in this population, and 3) screen current and previous users of DMPA and chronic users of AEDs for osteoporosis risk, regardless of age.