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Committee Opinion No. 668 Summary: Menstrual Manipulation for Adolescents With Physical and Developmental Disabilities

doi: 10.1097/AOG.0000000000001581
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ABSTRACT: For an adolescent with physical disabilities, intellectual disabilities, or both, and for her caregivers, menstruation can present significant challenges. If, after an evaluation, the adolescent, her family, and the obstetrician–gynecologist have decided that menstrual intervention is warranted, advantages and disadvantages of hormonal methods should be reviewed and individualized to each patient’s specific needs. Complete amenorrhea may be difficult to achieve, and realistic expectations should be addressed with the patient and her caregivers. The goal in menstrual manipulation should be optimal suppression, which means a reduction in the amount and total days of menstrual flow. Menstrual suppression before menarche and endometrial ablation are not recommended as treatments. Optimal gynecologic health care for adolescents with disabilities is comprehensive; maintains confidentiality; is an act of dignity and respect toward the patient; maximizes the patient’s autonomy; avoids harm; and assesses and addresses the patient’s knowledge of puberty, menstruation, sexuality, safety, and consent.

For a comprehensive overview of these recommendations, the full-text version of this Committee Opinion is available at http://dx.doi.org/10.1097/AOG.0000000000001585.

Committee on Adolescent Health Care: This Committee Opinion was developed by the American College of Obstetricians and Gynecologists’ Committee on Adolescent Health Care in collaboration with committee member Joanna H. Stacey, MD.

This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed.

Copyright August 2016 by the American College of Obstetricians and Gynecologists. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, posted on the Internet, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher.

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The American College of Obstetricians and Gynecologists 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920

Official Citation: Menstrual manipulation for adolescents with physical and developmental disabilities. Committee Opinion No. 668. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;128:e20–5.

Received June 20, 2016

Accepted June 20, 2016

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Recommendations

The American College of Obstetricians and Gynecologists offers the following conclusions and recommendations:

* Optimal gynecologic health care for adolescents with disabilities is comprehensive; maintains confidentiality; is an act of dignity and respect toward the patient; maximizes the patient’s autonomy; avoids harm; and assesses and addresses the patient’s knowledge of puberty, menstruation, sexuality, safety, and consent.

* Adolescents with disabilities may have other causes for menstrual irregularities, including thyroid disease in adolescents with trisomy 21, high prolactin levels due to mood-stabilizing medication, and polycystic ovary syndrome in adolescents with seizure disorders.

* In adolescents with disabilities, sexually transmitted infections (STIs) may be undiagnosed, underdiagnosed, or mistaken for urinary tract infections because the obstetrician–gynecologist may assume that the patient is not sexually active or the patient may not have the ability to feel or report symptoms.

* If, after an evaluation, the adolescent, her family, and the obstetrician–gynecologist have decided that menstrual intervention is warranted, advantages and disadvantages of hormonal methods should be reviewed and individualized to each patient’s specific needs.

* Complete amenorrhea may be difficult to achieve, and realistic expectations should be addressed with the patient and her caregivers. The goal in menstrual manipulation should be optimal suppression, which means a reduction in the amount and total days of menstrual flow.

* Antiprostaglandin drugs, in adequate dosages based on the patient’s weight, decrease ovulatory menstrual bleeding by approximately 30–40%.

* Combined oral contraceptives can be used continuously or for an extended period to attain optimal suppression.

* Oral progestins in high doses, including progestin-only birth control pills, can be used daily to attempt menstrual suppression, but efficacy in achieving amenorrhea is dependent on dose and adherence to taking the hormone as close to the same time each day as possible.

* Use of depot medroxyprogesterone acetate (DMPA) results in relatively high rates of amenorrhea by the fourth dose (approximately 90% per 90-day cycle) and has a long history of clinical use to suppress menses.

* The levonorgestrel intrauterine device (IUD) should be considered for any adolescent patient. Irregular bleeding is common initially, but amenorrhea rates increase over time and overall blood loss is decreased significantly.

* Hysterectomy for the purpose of cessation of normal menses may be considered only after other reasonable alternatives have been attempted.

* Menstrual suppression before menarche and endometrial ablation are not recommended as treatments.

© 2016 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.