Management of menstrual problems and contraception in adolescents with mental retardation: a medical, legal, and ethical review with new suggested guidelines

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.

Role of family caregivers regarding sexual and reproductive health for women and girls with intellectual disability: A scoping review

BACKGROUND

While people with intellectual disability (ID) face disparities relating to sexual and reproductive health (SRH) services, little is known about the role of family caregivers who assist women and girls with ID access SRH services. This scoping review examined the findings of studies to elucidate the role of family caregivers with regard to SRH for women and girls with ID.

METHOD

We used Arksey and O'Malley's six-stage scoping framework, with Levac, Colquhoun and O'Brien's revisions, to evaluate identified sources. We searched three electronic databases, six ID journals and reference lists in full-text articles. Inclusion criteria included (1) primary and secondary source research studies in peer-reviewed journals; (2) published in English; (3) all research methodologies (i.e. qualitative, quantitative, mixed methods and systematic reviews or commentaries); (4) published between 2000 and 2016; and (5) studies from any country.

RESULTS

The search yielded 2062 studies; 57 articles met inclusion criteria. Most studies employed purposive, convenience or criterion sampling. Participants included people with ID, family caregivers, paid caregivers and health-care professionals. Findings were summarised thematically: (1) menstruation and menopause; (2) vaccinations and preventive screenings; (3) supporting sexuality and healthy relationships; (4) coordinating with health-care providers and (5) contraception and sterilisation.

CONCLUSIONS

Findings from this scoping review underscore the need for more and better-quality research, including how family caregivers assist women and girls with ID access perinatal and preventive SRH services and sexual abuse education. Family caregivers, women and girls with ID and health-care providers need increased access to information about SRH.

Contraceptive Practices and Reproductive Health Considerations for Adolescent and Adult Women with Intellectual and Developmental Disabilities: A Review of the Literature

Whereas progress has been made on increasing access to comprehensive healthcare for individuals with intellectual and developmental disabilities (I/DD), disparities continue in health outcomes, including those related to the reproductive health of adolescent and adult women with I/DD. This review summarizes reproductive care considerations for adolescent and adult women with I/DD and current practices regarding the delivery of contraceptive services to these women. Forty-seven (47) articles based on research conducted in the US between 1999 and 2019 were selected for inclusion in the review. Primary themes discussed include (1) common reproductive health concerns for adolescent and adult women with I/DD, other than pregnancy prevention; (2) contraceptive methods and disability-related concerns; (3) informed consent and reproductive decision-making; and (4) provider knowledge and education. The management of menses and hormonal dysregulation were identified as concerns that providers encounter among patients with I/DD and their families. Disability-related concerns with regard to use of contraception in general and considerations regarding certain methods in particular include challenges with prescription adherence, physical effects of hormonal therapies, drug interactions for individuals with additional health conditions, and legal and ethical concerns involved with decision-making and consent. The results of this review also suggest that focused efforts in partnership with health care providers may be needed to address barriers that adolescent and adult women with I/DD face when trying to obtain quality reproductive health services and contraceptive guidance.

Ethical dilemmas and legal aspects in contraceptive counselling for women with intellectual disability-Focus group interviews among midwives in Sweden

BACKGROUND

Few studies have explored ethical and legal issues in contraceptive counselling among women with intellectual disability (ID). This study aimed to gain a deeper understanding of these issues during midwifery contraceptive counselling.

METHOD

The present authors interviewed 19 midwives in five focus groups in Sweden 2016 - 2017 and analysed data with content analysis.

RESULTS

The participants expressed that women with intellectual disability have equal right to relationships and sexual expressions, but feared exposure to sexual exploitation/abuse. They experienced ethical dilemmas related to principles of fairness and autonomy, but strived to provide assistance in spite of the women's cognitive impairment, presence of supporting persons and uncertainty of optimal counselling. Organizational support was insufficient.

CONCLUSIONS

The midwives experienced ambivalence, uncertainty and ethical dilemmas in their counselling. They were, however, aware of legal aspects and strived for the women's best interest, right to self-determination and autonomous choices. The participants wanted better professional teamwork and support.

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.

Primary care provider adherence to reproductive healthcare guidelines in adolescents and young adults with disabilities: A retrospective matched cohort study1

PURPOSE

Assessing provider adherence to preventative sexual and reproductive healthcare guidelines in adolescents and young adults (AYA) patients with physical and intellectual disabilities (PWD).

METHODS

Records of PWD (N= 42) age 12-26 receiving health maintenance between 01/01/11-12/31/16 were reviewed for: (1) initiation and completion of human papilloma virus (HPV) vaccination series, (2) initiation and completion of meningococcal vaccination, (3) screening for human immunodeficiency virus (HIV), and documentation of (4) sexual, (5) menstrual, and (6) pregnancy histories. Unaffected age and gender-matched patients provided comparison data (Comparison Cohort, CC).

RESULTS

The mean age of both groups was 17.3 years ± 3.8 and 40.5% were female. There was no significant difference between groups regarding the completion of HPV or meningococcal vaccine series. Among those 15+ years of age, 7.1% of PWD and 28.6% of CC were screened for HIV (p= 0.04). Sexual history was documented in 19.0% of PWD versus 73.8% of CC (p< 0.001). Among females, menstrual regularity was recorded in 11.8% of PWD versus 47.1% of CC (p= 0.02) and pregnancy history in 0.0% of PWD versus 29.4% of CC (p= 0.04).

CONCLUSIONS

Adherence to sexual health guidelines was suboptimal, and lower among PWD. Vaccination rates did not differ between the two groups.

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.

Disparities in receipt of family planning services by disability status: New estimates from the National Survey of Family Growth

BACKGROUND

A substantial and increasing population of US women of childbearing age live with disability. Disability-based disparities in access to family planning services have been previously documented, but few studies have used population-based data sources or evidence-based measures of disability.

OBJECTIVE

To determine population-based estimates of use of family planning services among women 15-44 years of age in the United States, and to examine differences by disability status.

METHODS

This is a secondary analysis of a cross-sectional survey, the 2011-2015 National Survey of Family Growth. These analyses include 11,300 female respondents between the ages of 15 and 44 who completed in-person interviews in respondents' homes.

RESULTS

Approximately 17.8% of respondents reported at least one disability in at least one domain. Women with disabilities were less likely than those without disabilities to receive services; the largest differences by disability status were seen among women with low education, low income, and those who were not working. Logistic regression analysis suggests that women with physical disabilities and those with poorer general health are less likely to receive services.

CONCLUSIONS

Women living with disabilities reported lower receipt of family planning services compared to women without disabilities, but the differences were small in some subgroups and larger among disadvantaged women. Physical disabilities and poor health may be among the factors underlying these patterns. Further research is needed on other factors that affect the ability of women with disabilities to obtain the services they need to prevent unintended pregnancy.

Concerns for Individuals with Intellectual Disability in India

Intellectual disability (intellectual developmental disorder) is characterized by deficits in general mental abilities, such as reasoning, problem solving, planning, abstract thinking judgment, academic learning, and learning from experience (DSM V). This neuro developmental disorder is one of the conditions with onset in the developmental period. This condition has been classified into four categories on the basis of the individual's IQ (Intelligence quotient). The objective of the present paper is to highlight some of the areas that are related to the concerns for the people with intellectual disability. The paper focuses on the following topics: 1) Legal services, 2) Challenges faced by parents, 3) Health issues, 4) Sexual knowledge, 5) Marriage, 6) Quality of life, 7) Old age, 8) Attitude of society towards the individual with intellectual disability, 9) Implications, management and prevention for future improvement for individuals with intellectual disability.

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).

Sterilization as last resort in women with intellectual disabilities: protection or disservice?

The legacy of the eugenics movement in the United States, including the involuntary sterilization of those deemed unfit to reproduce, has created a profound backlash against sterilization among certain populations. Particularly in treating women with intellectual disabilities, the field of obstetrics and gynecology has widely adopted an antisterilization stance. When treating women with intellectual disabilities, sterilization is generally considered a last resort. This essay revisits the issue of sterilization in women with intellectual disabilities, asking whether the field's stance of sterilization as a last resort is best viewed as a protection of this vulnerable population or one that actually does significant harm. We use a hypothetical but realistic patient case to examine the potential risks and benefits of sterilization. After reviewing the arguments against sterilization as a first-line treatment, we defend the controversial position that, in some cases, sterilization should be presented as an equally legitimate choice to reversible contraceptives.

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.

Sexual and reproductive health care for women with intellectual disabilities: a primary care perspective

Adults with intellectual disabilities (ID) face multiple health disparities and challenges to accessing health care. Little is known about sexual health care of this population and about how to optimize women's reproductive health care for women with intellectual disabilities. Women with ID face important barriers to care, including lack of provider training and experience, hesitancy to broach the topic of sexual health, a lack of sexual knowledge and limited opportunities for sex education, disability-related barriers, higher prevalence of sexual abuse and assault, often underreported, lack of dialogue around this population's human right to consensual sexual expression, undertreatment of menstrual disorders, and legal and systemic barriers. We conducted a limited literature review related to six aspects of sexual health care of women with ID, including barriers to sexual health care, sex education, sexual abuse and consensual sexuality, contraception, screening for sexually transmitted infections and cervical cancer, and pregnancy and parenting. After providing background information about each topic, we suggest practice recommendations for primary care clinicians, using a rights-based framework.

Concepts of contraception for adolescent and young adult women with chronic illness and disability

Sexual behavior is common in adolescents and young adults with or without chronic illness or disability, resulting in high levels of unplanned pregnancy and STDs. Individuals with chronic illness or disability should not receive suboptimal preventive health care. These individuals have a need for counseling regarding issues of sexuality and contraception. Sexually active adolescent and young adult women can be offered safe and effective contraception if they wish to avoid pregnancy. Women with chronic illnesses and disabilities who are sexually active should also be offered contraception based on their specific medical issues. Condoms are also recommended to reduce STD risks. Table 36 summarizes basic principles of contraception application for specific illnesses, which have been identified since the release of the combined OC in 1960. Clinicians should also consider the noncontraceptive benefits of this remarkable and life-changing technology that allows all reproductive age women to improve their lives, including those with chronic illnesses and disabilities.

The use of contraception by women with intellectual disabilities

BACKGROUND

Worldwide, contraception is frequently used by women for the prevention of conception, to regulate or postpone menstrual bleeding. The study aims to determine the use (number and method) of contraception by women with intellectual disabilities (ID), the indications, sources of referrals and relations with level of ID and age of the women concerned.

METHODS

The study group consisted of 234 women aged between 15 and 59 years and residing at a Dutch service provider for persons with ID. Data were obtained via the pharmacy database, attending physicians and individual medical files.

RESULTS

Nearly one half (48%, n = 112) of the 234 residential women used some method of contraception: 87 (78%) took pharmacological contraceptive methods, 23 (20%) underwent surgical contraception and 2 (2%) both. Main reasons for contraception were problems with menstruation, behaviour and/or prevention of pregnancy. Requests for contraception were initiated mainly by physicians and parents. Differences between users of different contraceptives with regard to age and level of ID were not statistically significant.

CONCLUSIONS

Further studies should focus on the development and implementation of adequate health promotion materials on this subject.

Mental retardation in children ages 6 to 16

Mental retardation (MR) is a life long condition that affects 6 million American and 560,000 Canadian children under the age of 14. This review discusses the definition of MR, an approach to investigation, common comorbidities, and a general approach to management.

Kontrazeption bei geistig und körperlich behinderten und chronisch kranken Jugendlichen

The contraceptive management of the handicapped adolescent does not differ much from what is recommended for the non-disabled and healthy adolescent. However, one of the major differences is that education about sexual issues does not necessarily lead to self-regulation, especially in the mentally handicapped. The decision for a particular contraceptive should take into account the individual situation and the mental and physical capabilities of the adolescent. The ability of a disabled adolescent to give free and informed consent to different methods of contraception always has to be determined before a choice is made.

Gynecological care for adolescents with disability: physician comfort, perceived barriers, and potential solutions

OBJECTIVE

The goal of this study was to assess the barriers to gynecologic care for adolescents with disability in this state.

DESIGN

Providers of gynecologic care in Utah were surveyed to assess existing conditions, attitudes, and comfort levels regarding this population.

RESULTS

The survey was completed by 136 gynecologic clinicians (50% return rate). The comfort level among surveyed clinicians in providing gynecological care to disabled adolescents was relatively low, even for routine screening. Respondents identified the following as barriers to providing this care: time, reimbursement, inadequate knowledge, and disability-related issues (office access and preference to not serve this population). Suggested solutions included: continuing education programs, consultation to practices on serving both youth and individuals with disability, and better billing mechanisms.

CONCLUSION

While many of the surveyed clinicians are comfortable providing care to adolescents with disability, a substantial number are not. Respondents perceive many barriers to providing care to this population, though the barriers appear modifiable. Potential interventions were identified which should be tested for their effectiveness in improving access to quality care for this underserved population.