Alain Joffe, MD, MPH, FAAP reviewing Quint EH et al. Pediatrics 2016 Jun 20.

A variety of contraceptive options are available to reduce menstrual-associated symptoms and reduce or eliminate menses.

Onset of menses can present unique challenges for adolescents with intellectual or physical disabilities. The Committee on Adolescence of the American Academy of Pediatrics has issued a clinical report to help pediatricians address these concerns. Key points include:

• Menstrual suppression should only be initiated after a through discussion with the adolescent (unless precluded by severe intellectual disability) and her family, taking into account clinical factors and social context (e.g., hygiene issues, school placement). Goals for treatment should be clearly defined.
• Achieving complete amenorrhea is difficult; scheduled withdrawal bleeds may be easier to manage than unscheduled breakthrough bleeding.
• Combined oral contraceptive (COC) pills and the patch can be used to achieve menstrual suppression. Girls with mobility limitations should be screened for inherited thrombophilias; lower-dose COCs with first- or second-generation progestins may be preferred. Seizure medications and herbal supplements can affect the efficacy of COCs.
• Depot medroxyprogesterone acetate (DMPA) injections achieve amenorrhea rates up to 80% at 5 years. However, weight gain associated with DMPA use can further limit mobility in girls with physical disabilities. While bone density loss associated with DMPA use appears to be reversible for most girls, it is unclear whether this is also true for girls with limited mobility.
• Levonorgestrel intrauterine devices can also be used for menstrual suppression; progestin implants have limited utility because irregular bleeding is the norm.
• Some families may request a hysterectomy for a daughter with severe intellectual disabilities. An ethics consult and legal representation for the patient should be considered.

CITATION(S):

Quint EH et al. Menstrual management for adolescents with disabilities. Pediatrics 2016 Jun 20; [e-pub]. 

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