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Clinical Practice Guidelines

Menstrual management in adolescents with disabilities

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    PIC Endorsed

  • See also

    Adolescent gynaecology - heavy menstrual bleeding 

    Dysmenorrhoea

    Key points

    1. Menstruation, particularly at its onset, can add a significant stress to adolescents with disabilities and their families
    2. Appropriate management can significantly improve quality of life and symptoms of other medical problems
    3. Hormonal medications for menstrual suppression may interact with other drugs, including anti-seizure medications

    Background

    • Discussions about puberty and menses should ideally occur prior to the onset of menarche
    • Menses and the hormonal changes associated with puberty can affect quality of life and cause challenges with hygiene, behaviour, mood, heavy or irregular bleeding, menstrual pain, and/or cyclical exacerbation of underlying medical conditions
    • Families are often anxious about their child's ability to cope with menstruation. There are also often unspoken concerns about sexuality, pregnancy and vulnerability to sexual abuse
    • Menstrual management can enable full participation in schooling, physical and social activities, and improve quality of life
    • Historically, surgical procedures for permanent sterilisation were common in women with disabilities. It is now unlawful to conduct permanent sterilisation in a person unable to give informed consent without court approval

    Assessment

    History

    • Menstrual history including frequency, duration, regularity, heaviness of bleeding
    • Concerns for the patient/family
      • Behaviour changes or aggression, which can be pain-related
      • Difficulties with hygiene
      • Cyclical exacerbation of medical conditions eg increase in seizure activity
    • Medication factors
      • Factors relevant to medication choice eg history of venous or arterial thromboembolism
      • Factors relevant to medication administration eg swallowing difficulties, malabsorption

    Examination

    • Height, weight, blood pressure
    • Pelvic examination is not needed prior to the initiation of treatment

    Management

    Investigations

    No specific investigations are required
    Consider blood tests if heavy menstrual bleeding

    Education and resources

    • Provide written information appropriate to age and intellectual ability (see Parent information below)
    • Menstrual underwear eg Bonds, Modibodi®, Thinx®, Eco Period Australia®

    Treatment

    • In patients with pain or behavioural changes, consider underlying constipation
    • Some medications can be crushed and given via percutaneous endoscopic gastrostomy (PEG) or buccally (see table in Additional notes)

    Non-hormonal medications

    • NSAIDs reduce menstrual pain and may reduce blood loss and associated symptoms such as nausea, vomiting or diarrhoea: ibuprofen 5-10 mg/kg (max 400 mg) TDS or mefenamic acid 500 mg TDS (12-18 years)
    • Tranexamic acid reduces blood loss and may reduce menstrual pain: 1 g TDS on days of heavy bleeding

    Menstrual suppression

    • There are many non-contraceptive benefits to hormonal menstrual suppression, including reduction in pain, bleeding, seizures and other cyclical symptoms that flare with menses
    • Can safely be used in conjunction with NSAIDs and tranexamic acid
    • Consider medication interactions, especially with anti-seizure medications
    • Oral contraceptive efficacy may be reduced in malabsorption syndromes or if medications are crushed (see table in Additional notes)
    • For more detailed information re contraceptive medications, see Contraception

    Hormonal medications

    Drug class Considerations Dose/delivery options
    Combined oral contraceptive pill

    Can be safely used continuously (ie skip non-hormone pills) for menstrual suppression

    See Contraindications

    		 Levonorgestrel 150 mcg/ethinyl estradiol 30 mcg (Levlen®) daily (active pills only)
    Oral progestogen

    Useful if oestrogen is contraindicated

    Can be used continuously for menstrual suppression

    Majority of oral progestogens are not reliable as contraception

    Norethisterone (Primolut N®) starting at 5 mg BD or medroxyprogesterone (Provera®) 20 mg daily (which can often be reduced gradually with time)

    Drospirenone (Slinda®) 4 mg daily can be used as contraception
    IM progestogen

    Effective in achieving amenorrhoea and suppression of hormonal fluctuations across the menstrual cycle

    Increased risk of

    • mood change
    • weight gain (2-3 kg per year)
    • Prolonged use associated with reduced bone density. Consider bone mineral density test at baseline (if risk factors for osteoporosis) and 2 yearly

    Medroxyprogesterone (Depo-Provera®) 150 mg IM, 12 weekly

    A 2-week trial of oral medroxyprogesterone 10 mg daily (Provera®) prior to IM medroxyprogesterone is recommended to ensure well tolerated
    Subdermal progestogen

    Can be palpated under skin, which may cause distress in some patients with sensory issues

    Adverse effects: amenorrhoea (20%), reduced menstrual bleeding (1/3), erratic, irregular or heavy bleeding (1/3)

    Requires a minor surgical procedure

    		 Etonogestrel implant (Implanon®) 3 yearly
    Progestogen-releasing intrauterine device

    97-98% reduction in blood loss at 12 months, 20% amenorrhoea

    Usually requires a general anaesthetic

    		 Levonorgestrel intrauterine device (Mirena®) 5-8 yearly

    Consider consultation with gynaecology team when

    • Complex medical conditions or drug interactions
    • Ongoing issues despite initial treatment
    • Intrauterine device insertion

    Parent information

    Websites

    Books

    • Special Girls' Business by Angelo, Anderson and Stewart. Published by Secret Girls' Business
    • Puberty and Special Girls by Anderson, Angelo and Stewart. Published by Secret Girls' Business

    Additional notes

    Medication use in children with feeding tubes

    Medications Considerations
    Ibuprofen

    Oral liquid is recommended for enteral feeding tube administration

    Film coated tablet can be crushed and mixed with water. It does not disperse easily (suitable for large bore tubes only). Do not break or crush modified release tablet or liquid-filled capsule
    Mefenamic acid Not recommended to open capsule or for enteral feeding tube administration
    Tranexamic acid

    Can be crushed and given via enteral tube

    Disperse Cyklokapron® for 2 to 5 mins in water
    Combined oral contraceptive pill Crushing may result in inaccurate doses, potentially leading to contraceptive failure. Consider crushing if desiring menstrual suppression alone
    Norethisterone Tablet is dispersible in water. Wear mask and gloves when preparing doses. Do not crush or disperse if you are pregnant

    Last updated October 2025

    Reference List

    1. Alexander M, et al. Outcomes of intrauterine device used in young women with physical and intellectual disabilities. J Paed Adolesc Gynaecol. 2016; 29(2):163-64.
    2. Fraser I, et al. A benefit-risk review of systemic haemostatic agents. Part 1: in major surgery. Drug Saf. 2008; 31:217-30.
    3. Grover S. Gynaecological issues in adolescents with disability. J Paediatr Child Health. 2011; 47(9):610-3.
    4. Grover S. Menstrual and contraceptive management in women with an intellectual disability. Med J Aust. 2002 4; 176(3):108-10.
    5. Marjoribanks J, et al. Nonsteroidal anti-inflammatory drugs for dysmenorrhoea. Cochrane Database Syst Rev. 2015(7):CD001751.
    6. Thorne JG, et al. Heavy menstrual bleeding: is tranexamic acid a safe adjunct to combined hormonal contraception? Contraception. 2018; 98(1):1-3.

  • Reference List

    1. Alexander M, Benoid J, Barth J, Breech LL, Schwarz BI. Outcomes of intrauterine device used in young women with physical and intellectual disabilities. J Paed Adolesc Gynaecol. 2016; 29(2):163-64.
    2. Fraser IS, Porte RJ, Kouides PA, and Lukes AS. A benefit-risk review of systemic haemostatic agents. Part 1: in major surgery. Drug Saf. 2008; 31:217-30.
    3. Grover SR. Gynaecological issues in adolescents with disability. J Paediatr Child Health. 2011; 47(9):610-3.
    4. Grover SR. Menstrual and contraceptive management in women with an intellectual disability. Med J Aust. 2002 4; 176(3):108-10.
    5. Marjoribanks J, Ayeleke RO, Farquhar C, Proctor M. Nonsteroidal anti-inflammatory drugs for dysmenorrhoea. Cochrane Database Syst Rev. 2015(7):CD001751.
    6. Thorne JG, James PD, Reid RL. Heavy menstrual bleeding: is tranexamic acid a safe adjunct to combined hormonal contraception? Contraception. 2018; 98(1):1-3.