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Menstrual management in adolescents with disabilities

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  • See also

    Heavy Menstrual Bleeding in Adolescents

    Key Points

    1. Menstruation, particularly onset of menstruation, can add a significant stress to adolescents with disabilities and their families
    2. Appropriate menstrual management can significantly improve quality of life and symptoms of other medical problems

    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 exacerbate underlying medical or behavioural issues
    • Challenges include: hygiene, behaviour, mood, heavy or irregular bleeding, menstrual pain, and/or cyclical exacerbation of underlying medical conditions
    • Menstrual management can enable full participation in schooling, physical and social activities, and to improve quality of life
    • Families are often anxious about their daughter’s ability to cope, but there are also often unspoken concerns about sexuality, pregnancy and vulnerability to sexual abuse
    • Historically, surgical procedures for permanent sterilization were common in women with disabilities. It is now unlawful to conduct permanent sterilization in a person unable to give informed consent without court approval

    Assessment

    History

    • Time since onset of secondary sexual characteristics (if pre-menarchal)
    • Onset of menarche - frequency, duration, regularity, heaviness of bleeding, associated physical or emotional symptoms
    • Specific issues can include:
      • Behavioural changes or aggression; this can be a manifestation of pain
      • Difficulties managing hygiene
      • Exacerbation of medical conditions, such as an increase in seizure activity
      • Personal and family history of venous and arterial thromboembolism
      • Medical complexity such as swallowing difficulty, malabsorption, medication interactions and obesity

    Examination

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

    Management

    Investigations

    No specific investigations are required
    FBE, ferritin and coagulation screen if heavy menstrual bleeding

    Treatment

    Education and Resources
    Many adolescents with intellectual disabilities can cope with menses given the right tools:

    • Written information appropriate to age and intellectual ability
    • Menstrual underwear (e.g. Modibodi®, Thinx®)

    Pain and Behavioural Changes

    • Consider underlying pain, particularly in non-verbal adolescents. A trial of Non-steroidal anti-inflammatories (NSAIDs) should be considered on days of heavy bleeding/dysmenorrhoea
    • Consider underlying constipation, particularly the week prior to menstruation, and manage as appropriate

    Heavy Menstrual Bleeding
    Heavy menstrual bleeding can cause distress.  
    Tranexamic Acid is safe to use in combination with NSAIDs and with both combined and Progestogen-only hormonal methods

    Menstrual Suppression

    Hormonal
    There are many non-contraceptive benefits to hormonal suppression, including a reduction in seizures and other cyclical symptoms that flare with menses

    Consider:  

    • Medication interactions, especially with anti-epileptics, and contraindications (thromboembolism)
    • Route of delivery: some medications can be crushed and given via percutaneous endoscopic gastrostomy (PEG) or buccally, but seek pharmacist advice
    • Frequency of administration

    Oral Contraceptive Pill (OCP)

    • Monophasic combined oestrogen and Progestogen OCP can be safely used continuously (i.e. “skip” non-hormone pills) for menstrual suppression

    Progestogen-only

    • Norethisterone (Primolut N®) can be used continuously for menstrual suppression - it is not a reliable contraceptive for adolescents
    • Medroxyprogesterone (Depo-Provera®) IM. Prolonged use is associated with reduced bone-density, consider bone mineral density test at baseline and every 2 years.
      • A 2 week trial of oral medroxyprogesterone 10mg daily (Provera®) prior to IM medroxyproesterone is recommended to ensure well tolerated.
    • Levonorgestrel-containing intrauterine device (Mirena®), commonly inserted under general anaesthetic in adolescents

    Medications

    Drug Class

    Considerations

    Contraception

    Dose

    NSAIDs

    Reduces menstrual pain, up to 30% reduction in blood loss, may reduce nausea, vomiting, diarrhoea

    No

    Ibuprofen 400mg tds
    or
    Mefenamic acid 500mg tds

    Tranexamic acid

    45-60% reduction in blood loss, can reduce pain

    No

    Tranexamic acid 1g tds on days of heavy bleeding

    Continuous OCP

    Marked reduction in menstrual pain and blood loss, may eliminate cyclic seizures and other symptoms

    Yes

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

    Oral Progestogen

    Reduction in menstrual blood loss and pain, may eliminate cyclic symptoms

    No

    Norethisterone  (Primolut N®) starting at 5mg BD, continuously

    IM Progestogen

    Markedly reduces menstrual pain and blood loss, may eliminate cyclic seizures and other symptoms

    Yes

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

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

    Subdermal Progestogen

    Highly effective contraceptive but erratic pattern of bleeding is common. Minor surgical procedure

    Yes

    Etonogestrel implant (Implanon®), 3 yearly

    Progestogen-releasing intrauterine device

    97-98% reduction in blood loss at 12 months, reduces menstrual pain. Highly effective contraceptive. Requires general anaesthetic

    Yes

    Levonorgestrel intrauterine device (Mirena®), 5 yearly

    Consider consultation with local gynaecology team when:

    • Complex medical conditions or drug-interactions
    • Failed initial treatment
    • Intrauterine device insertion

    Parent resources

    Websites

    Books

    Last updated April 2020

  • 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.