Menstrual problems in adolescents with disability - TOG article

Question 1

What are the common reasons parents or caregivers access PAG services?

Answer 1

1. Anxiety around menstrual hygiene exacerbated in girls with physical disability and incontinence
2. Cyclical behavioural chages

Question 2

PMS ocurs in how many women with disabilities vs the general population?

Answer 2

18% vs 5%

>3x more common

Question 3

PMS occurs in how many women with autism compared to matched controls?

Answer 3

92% vs 11%

Question 4

What is the name given to an increase in seizures at certain stages of the menstrual cycle?

Answer 4

Catamenial seizure exacerbation

Question 5

Which other reproductive disorders are higher in women with epilepsy/disability than the general population?

Answer 5

PCOS - also linked with sodium valproate
Hyperprolactinaemia
Irregular bleeding in t21 2dry to thyroid disease

Question 6

What are the considerations in using COCP in girls with disability?

Answer 6

• If immobile - risk of DVT
• Inability to swallow (can use NG)
• Compliane with OD dosing
• Enzyme inducing drugs reducing efficacy (e.g. phenytoin and phenobartbitone)
• Enzyme inhibiting drugs - need less oestrogen (e.g. valproate, clonazepam)
• Change in plasma levels of e.g. lamotrigine

Question 7

What are the benefits of combined transdermal patch in girls with disability?

Answer 7

Unable to swallow/malabsorption/need to bypass hepatic metabolism
Can divide dose (low BMI, enz-inhibiting drugs)

Question 8

Which is the most suitable POP in girls with disability and what is its amenorrhea/regular/erratic period rate?

Answer 8

Cerazette - better side effect profile, less breakthrough bleeding

20% will be amenorrhoeic
40% regular periods
40% erratic bleeding

Question 9

How many women achieve complete cessation of menstruation after 1 year using DMPA?

Answer 9

50%

Breakthrough bleeding can be a problem

Question 10

What are the concerns re: DMPA and what is advised in girls with disability?

Answer 10

• Risk of reduced bone mineral density - esp if low BMI
• Weight gain 4.6kg/yr
• Generally limit 2 years in adolescence - but need to weigh up e.g. life expectancy
• DXA scan annually and 2 years after discontinuation
• 1300mg calcium and 400IU vitamin D + daily exercise
• Oestrogen supplement if no contraindication if risk of osteopenia

Question 11

What are the amenorrhoea/irregular bleeding rates with Nexplanon and what are the concerns in girls with disability?

Answer 11

20% amenorrhoea
50% irregular bleeding

Concern re: mood swings - more prone to PMS
May pick at site causing infection

Question 12

What are the concerns using GnRH analogues in girls with disability?

Answer 12

Bone mineral density reduction during treatment (recovers after)
Menopausal symptoms - manage with oestrogen supplements
No data re: effect of control

Question 13

What are the concerns using LNG-IUS in girls with disability?

Answer 13

• Insert under GA
• Minimul cavity of 5cm
• USS may be difficult if catheterised/incontinent
• Difficulty communicating cramps/pain
• Breakthrough bleeding, cyst formation, weight gain

Question 14

What are the concerns for endometrial ablation in girls with disability?

Answer 14

• Young - more likely to need further ablation
• Unknown risks in adolescence
• Need for contraception
• Rollerball or transcervical resection may be better option - but hydrothermal better if small cavity and can be repeated
• Can be used with LNG-IUS

Question 15

When is surgery considered in girls with disability that are unable to give consent?

Answer 15

Last resort when mestruation severe, medical management has failed and not for the benefit of the caregiver. Need approval from high court judge.