Menstrual Management for Adolescents with Disabilities Elisabeth H

CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care

Menstrual Management for Adolescents With Disabilities Elisabeth H. Quint, MD, Rebecca F. O’Brien, MD, COMMITTEE ON ADOLESCENCE, The North American Society for Pediatric and Adolescent Gynecology

The onset of menses for adolescents with physical or intellectual disabilities abstract can affect their independence and add additional concerns for families at home, in schools, and in other settings. The pediatrician is the primary health care provider to explore and assist with the pubertal transition and menstrual management. Menstrual management of both normal and abnormal cycles may be requested to minimize hygiene issues, This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have premenstrual symptoms, dysmenorrhea, heavy or irregular bleeding, fi led confl ict of interest statements with the American Academy contraception, and conditions exacerbated by the menstrual cycle. Several of Pediatrics. Any confl icts have been resolved through a process approved by the Board of Directors. The American Academy of options are available for menstrual management, depending on the outcome Pediatrics has neither solicited nor accepted any commercial that is desired, ranging from cycle regulation to complete amenorrhea. The involvement in the development of the content of this publication. use of medications or the request for surgeries to help with the menstrual Clinical reports from the American Academy of Pediatrics benefi t from expertise and resources of liaisons and internal (AAP) and external cycles in teenagers with disabilities has medical, social, legal, and ethical reviewers. However, clinical reports from the American Academy of Pediatrics may not refl ect the views of the liaisons or the organizations implications. This clinical report is designed to help guide pediatricians in or government agencies that they represent. assisting adolescent females with intellectual and/or physical disabilities The guidance in this report does not indicate an exclusive course of and their families in making decisions related to successfully navigating treatment or serve as a standard of medical care. Variations, taking menarche and subsequent menstrual cycles. into account individual circumstances, may be appropriate. All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffi rmed, revised, or retired at or before that time.

DOI: 10.1542/peds.2016-0295 The physical pubertal transition is a complicated time for most adolescents and their families and may be even more challenging for teenagers with PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). disabilities. For the purpose of this report, “family” and “families” also Copyright © 2016 by the American Academy of Pediatrics refers to caregivers and guardians. Teenagers may have concerns about FINANCIAL DISCLOSURE: The authors have indicated they do body image, sexuality, and how menses will affect their lives. Parents not have a ﬁ nancial relationship relevant to this article to often worry about the impact of pubertal development on the lives and disclose. health of their daughters with disabilities.1 A large Canadian study showed FUNDING: No external funding. that parents’ concerns for their adolescent daughters with intellectual POTENTIAL CONFLICT OF INTEREST: The authors have indicated disabilities include menstrual suppression, hygiene, parental burden, they have no potential conﬂ ict of interest to disclose. and menstrual symptoms.2 The pediatrician and the medical home play a key role in anticipatory guidance with the family and teenager To cite: Quint EH, O’Brien RF, AAP THE COMMITTEE ON regarding emerging sexuality, physical changes of puberty and onset of ADOLESCENCE, AAP The North American Society for Pediatric menstruation, and the emotional and behavioral changes associated with and Adolescent Gynecology. Menstrual Management for puberty. Even before the onset of menses, the pediatrician could be asked Adolescents With Disabilities. Pediatrics. 2016;137(4): e20160295 to assist with anticipatory guidance and options for the menstrual cycle

Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 138 , number 1 , July 2016 :e 20160295 FROM THE AMERICAN ACADEMY OF PEDIATRICS because of parental fear of menstrual TABLE 1 General Principles for Approaching Menstruation in Adolescents With Disabilities periods or hormonal mood changes 1. Initiate anticipatory guidance before the start of menses as well as the complex issues of 2. Discuss concerns around sexual education and expression sexuality, vulnerability, and fertility 3. Help families with guidance on safety and abuse prevention in the context of the disability. This 4. Start menstrual management on the basis of issues related to interference with the teenager’s activities, taking into consideration patient medical needs and mobility concerns clinical report briefly addresses 5. Help families understand menstrual management options and the beneﬁ ts and limitations of the pubertal issues in female adolescents different methods with physical and/or intellectual disabilities and provides details on the options for menstruation disabilities because expectant Irregular bleeding in all teenagers management. The American Academy management allows for patients can lead patients and families to seek of Pediatrics (AAP) clinical report and families to determine whether medical intervention, but more so in titled “Sexuality of Children and they can cope, and suppressing teenagers with intellectual and physical Adolescents With Developmental menarche can result in premature disabilities, who may be dependent Disabilities” complements this report closure of the epiphyses of the long on others for their hygiene needs. and includes Internet resources on bones, preventing the patient from The impact of menses ranges from this topic.3 reaching her full height potential.2 an inability to go to school because Precocious puberty, however, should of heavy menses and inadequate be addressed in the usual manner. assistance in managing menses PUBERTY IN ADOLESCENT GIRLS WITH to severe pre- and perimenstrual behavioral changes in teenagers with DISABILITIES Menstrual management can begin developmental delay, prohibiting if cycles are creating difficulties Disabilities in children are common, normal activities and causing in the patient’s life, as determined with 2.8 million or 5.2% of US additional management challenges.12,13 children and adolescents 5 through by health care providers, patients, 17 years of age affected in 2010.4 and families. All teenagers may Approximately 3% of the general have irregular cycles initially, but INITIAL EVALUATION population has a significant by the third year after menarche, intellectual disability, and 1.2 million 60% to 80% of girls have cycles As part of the initial evaluation, the of those affected are teenagers with from 21 to 34 days long, consistent pediatrician addresses the menstrual cycle, including regularity and varying levels of cognitive abilities with those of adults.8 However, heaviness of bleeding, associated (80% have mild disability, 12% have there are some circumstances dysmenorrhea, behavioral and mood moderate disability, and 8% have that can cause teenagers with changes, and the impact on the severe intellectual disabilities).5 disabilities to have more menstrual adolescent’s life. Symptom calendars This clinical report will not include irregularities related to medical can be helpful in identifying specific discussions around teenagers comorbidities and medication noncyclical versus cyclical problems, with psychiatric illnesses. adverse effects. Medications that such as catamenial seizures. Other affect the dopaminergic system can For most adolescents with reproductive topics may include intellectual disabilities, although cause high prolactin concentrations assessment of sexual knowledge, the pattern of pubertal maturation with subsequent anovulation and interest in sexual activity, and 9 is similar to adolescents without amenorrhea. In adolescents with the need for relationship safety disabilities, the tempo and timing obesity and in teenagers with education (Table 1).3 of maturation may vary. Earlier seizure disorders and polycystic sexual development may occur ovary syndrome, anovulation is Although confidential discussions in girls with neurodevelopmental more common; independently, about sexuality and sexual activity disabilities,6 whereas some girls valproic acid can cause hormonal are recommended for all teenagers with autism spectrum disorders aberrations like those in polycystic by the AAP14 and American College may experience a slight delay in the ovary syndrome.10 Medications of Obstetricians and Gynecologists onset of menarche.7 Adolescents that can cause elevated prolactin (ACOG), 8 teenagers with any with disabilities that compromise concentrations include risperidone, disability are often incorrectly their nutrition or are associated with phenothiazines, amitriptyline, considered to be asexual or chronic inflammation may have a cimetidine, prostaglandins, uninvolved in relationships, and later onset of puberty. Premenarchal methyldopa, benzodiazepines, confidential conversations with suppression is not recommended haloperidol, cocaine, and their pediatrician may not occur. for most teenagers with intellectual metoclopramide.11 Teenagers with physical disabilities

Downloaded from www.aappublications.org/news by guest on September 28, 2021 e2 FROM THE AMERICAN ACADEMY OF PEDIATRICS TABLE 2 Methods for Menstrual Management in Teens With Disabilities There are several important issues Category Method Beneﬁ ts Cautions that need to be considered in Estrogen and COC Extended use Interaction with EI-AED menstrual management. No matter progestin Uncertain risk of VTE with limited mobility what method is used, it is difficult Ring Monthly Interaction with EI-AED to make patients completely and extended use Uncertain risk of VTE with limited mobility reliably amenorrheic. For any Dexterity/privacy with insertion teenager, having unscheduled Patch Weekly extended Interaction with EI-AED use Uncertain risk of VTE with limited mobility bleeding may be worse than having Inadvertent removal of patch scheduled controlled withdrawal Progesterone only POP Interaction with EI-AED bleeds but may be especially difficult Irregular bleeding for teenagers who rely on others for DMPA Four times per Bone density issues hygiene assistance. For teenagers in year Irregular bleeding Potential weight gain wheelchairs, even minimal weight Implant 3 y Irregular bleeding gain can be the difference between Insertion concerns the ability to transfer themselves LNG-IUD 5 y May need anesthesia for insertion and removal or having to rely on someone else, Inability to check strings thereby limiting independence. It Initial irregular bleeding Surgical Endometrial Amenorrhea rates low is important to set outcome goals ablation No long-term data (eg, no periods, scheduled bleeding Legal and ethical issues 3 times a year, no interference Hysterectomy Amenorrhea Legal and ethical issues with activities) with the adolescent Permanent sterilization and her family and periodically COC indicates combined oral contraceptive; EI-AED, enzyme-inducing anti-epileptic drugs; LNG-IUD, levonorgestrel reassess whether the goals have intrauterine device; POP, progesterone-only pills; VTE, venous thromboembolism. been reached or whether changes are indicated. In a large cohort of teenagers with developmental are just as likely to be sexually menstrual suppression does not disabilities, it took an average active as their peers and have a change the risk of abuse or sexually of 1.5 hormonal methods before higher incidence of sexual abuse.15 transmitted infections. The patient’s satisfaction was reached (range, Issues of consent and confidentiality cognitive disabilities may complicate 1–4). The most commonly selected regarding reproductive health care the decision about menstrual initial method of suppression provided by physicians to minor intervention. Similar to the use of was the extended or continuous adolescents are complex. Most states suppressive hormonal treatment oral contraceptive pill (42.3%), recognize the rights of a teenager in the nondisabled population, the followed by the patch (20%), to consent for confidential services decision to suppress menses in expectant management (14.9%), around diagnosis and treatment of teenagers with physical disabilities depot medroxyprogesterone issues such as sexually transmitted is based on whether the patient acetate (DMPA [11.6%]), and the infections, contraception, and believes this will help her better levonorgestrel intrauterine device pregnancy care; however, when the manage her life. In contrast, when (LNG-IUD [2.8%]). There was a patient is cognitively impaired, the families of adolescents with severe significant decrease in the selection issue of consent is more complicated intellectual disabilities ask for of DMPA as the initial choice for and may require discussion about menstrual suppression, the issues are menstrual suppression noted over legal guardianship or medical power more complicated if there is no clear time.2 Gonadotropin-releasing of attorney status for the families.16 medical indication, such as heavy hormone agonists are not generally bleeding or dysmenorrhea. When recommended for long-term the stated reasons for suppression menstrual suppression because of OVERVIEW OF MENSTRUAL are an inability of caregivers to adverse effects such as decreased MANAGEMENT deal with menses or fear of abuse bone density, except in cases of The decision for menstrual or pregnancy, further investigation precocious puberty.2 suppression is based on a discussion into the patient’s circumstances and with the patient and parents or safety is warranted. If the issue is The following overview focuses on guardians, clinical considerations mainly to get assistance at school, how the use of hormonal methods (eg, anemia), and social context (eg, then health care providers can help for menstrual suppression may hygiene, risk of abuse/pregnancy). families to address the student’s specifically affect teenagers with It is important to discuss that any needs with the school. intellectual and/or physical

Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 138 , number 1 , July 2016 e3 disabilities (Table 2). As placement high on the back or the lowest-dose estrogen COCs that recommended by ACOG and AAP, 17 buttocks is helpful. contain a first- or second-generation a pelvic examination is not progestin, such as norethindrone necessary before 21 years of age or Vaginal Ring and levonorgestrel for teenagers 18 to start hormonal medications. The monthly placement of a vaginal with limited mobility, because these Extensive reviews of contraception ring is another delivery form of progestins have been shown to be methods have been published combined hormones. The ring has likely associated with lower rates of 19,27, 28 and will not be addressed in this enough hormones for 35 days, and VTE. 19 report. leaving it in for 28 days at a time Progestin-Only Methods can provide continuous hormones in an off-label use.22 However, the Oral Progestins Estrogen-Containing Methods physical and privacy concerns of Oral progestins can be used cyclically Combined Oral Contraceptives having another person place the for teenagers with anovulation to Combined oral contraceptives ring intravaginally for teenagers induce menses or continuously to (COCs) are often used in a without adequate dexterity or with cause amenorrhea. Because the continuous or extended-cycle intellectual disabilities have severely lowest dose daily progestin, known fashion to limit the amount of limited its use in this population. as the “minipill,” only has a 20% rate bleeding. Because complete Bleeding profile for the ring when of amenorrhea31 and has to be taken amenorrhea is difficult20 to obtain used continuously shows a rate of at the same time every day, higher and reported in only 62% of 8% for amenorrhea and 19% for daily doses of oral progestins such as 26 individuals, scheduled withdrawal spotting. medroxyprogesterone (10–40 mg) or bleeds every 3 to 4 months may norethindrone (5–15 mg) have been be more helpful to patients with Special Considerations: Venous attempted to achieve amenorrhea Thrombotic Events and Estrogen- disabilities than unpredictable (as well as pain control in patients Containing Methods breakthrough bleeding.21,22 For with endometriosis). Amenorrhea those teenagers with difficulty The use of estrogen-containing rates are not consistently reported. swallowing, there are chewable hormones increases the risk of Although not well studied in COCs that can also be put into food venous thrombotic events (VTEs). teenagers, mood changes related to or crushed and given through a The risk of VTEs is higher for all progestins have been described.32 gastrostomy tube.23 A Cochrane formulations with increasing doses μ review examining efficacy and of estrogen (compare 20 to 35 g Depot Medroxyprogesterone Acetate safety of continuous or extended- ethinyl estradiol) and likely higher cycle versus monthly cycle use with newer generations of progestins DMPA, the intramuscular and now of combined oral contraceptives and for women using the combined subcutaneous injection, has been concludes that extended-cycle pills contraceptive patch and the vaginal used for years as both a contraceptive have similar contraceptive efficacy ring, although there are conflicting and for menstrual suppression. The and safety profiles to monthly cycle studies.27–29 rate of amenorrhea is 50% to 60% at 33 pills. Some studies suggest that 1 year and 80% at 5 years. The data on estrogen-containing menstrual symptoms of headaches, hormones and VTEs have led to There are 2 specific areas of concern genital irritation, tiredness, bloating, concerns about the risk of VTE for for use of DMPA in teenagers with and menstrual pain may be less in patients in wheelchairs; however, there disabilities. extended-cycle regimens.24 are no data to provide guidance on 1. Weight gain: the weight gain this type of immobility in teenagers. (average 13 pounds in 4 years, Combined Contraceptive Patch Immobility is not a contraindication according to package insert) The combined contraceptive patch in the medical eligibility criteria associated with the use of this may be useful in patients who have for contraception per Centers for medication is troubling for all difficulty swallowing pills. It can Disease Control and Prevention (CDC) teenagers, but for teenagers be used in an off-label continuous recommendation.30 Although the use with mobility issues, even a weekly fashion with similar of estrogen-containing contraceptives small amount of weight gain may breakthrough bleeding patterns as is not contraindicated in teenagers complicate transfers and could the continuous oral contraceptive with mobility issues, a thorough family impede independence. There pill.25 Because some patients history can decrease the likelihood of appears to be more weight gain in with developmental disabilities an inherited thrombophilia. Health obese teenagers and in teenagers may attempt to pull off the patch, care providers can consider using whose weight increases >5%

Downloaded from www.aappublications.org/news by guest on September 28, 2021 e4 FROM THE AMERICAN ACADEMY OF PEDIATRICS over baseline weight in the first 3 younger than 18 years, more that of 5 patients who had cavity months of use.34 recently have been advocated for length of less than 6 cm measured by use in teenagers for birth control by ultrasonography, 4 had a successful 2. Bone health: there have been national organizations because of insertion of the LNG-IUD.47 significant concerns around the their excellent contraceptive effect.42 effects of DMPA on bone mineral A sudden increase in vaginal bleeding The original LNG-IUD dispenses 20 density (BMD), which led to a “black may indicate LNG-IUD expulsion, and μg of levonorgestrel daily with a 50% box warning” from the US Food and families are educated to look for this dose reduction at 5 years. It is well Drug Administration (FDA) to limit potential sign. If the families notice the tolerated with a 5-year duration and its use to 2 years. It is specifically increase in bleeding and the LNG-IUD amenorrhea rates of approximately of concern to teenagers, because string cannot be checked in the office 50% at 1 year.43 It has been used in girls accrue approximately 30% because of patient intolerance of the women with disabilities and medical to 40% of their bone mass during examination, ultrasonography for conditions that exclude estrogen use. adolescence. The rate of BMD loss device location can be performed. A decreases with longer duration of newer, slightly smaller, and lower-dose Several recent studies have the DMPA use. The World Health device, 13.5-mg LNG-IUD (Skyla, Bayer addressed LNG-IUD use in teenagers Organization, 35 ACOG, 36 and HealthCare Pharmaceuticals, Wayne, with intellectual disabilities. Society for Adolescent Health and NJ) has recently become available Satisfactory outcomes by families Medicine37 have advised that health in the United States, is approved by were reported in 1 study, 44 and a care providers interpret the 2-year the FDA for patients younger than 50% amenorrhea rate in 7 of 14 duration limit individually and 18 years, and is effective for 3 years. teenagers in another.45 From a discuss with the patient and families Although the decreased size may be larger Canadian cohort, among 26 whether DMPA is the best option for helpful to address placement and adolescents with disabilities (mean them in the context of relative risks expulsion in nulliparous women, the age, 15.4 years) who chose LNG-IUD and benefits.35 In teenagers with initial bleeding profile reported on insertion, 3 patients had LNG-IUD disabilities and limited mobility, the product insert gives significantly expulsions (11.2%), and another 2 BMD may already be lower, but it lower amenorrhea rates (12% after had the LNG-IUD removed because is not clear whether this is actually 3 years)48 than the 5-year LNG–IUD, of spotting and low positioning. associated with increased fracture which may be an important factor to Amenorrhea was noted at 1 year in risk.38 The bone-density loss consider. all 21 patients who continued using appears reversible after stopping the LNG-IUD.2 As described for most the DMPA; however, for teenagers Progestin Implant patients in these series, the LNG-IUD with limited mobility, no data are can be inserted or removed under Use of the etonogestrel single-rod available.39 sedation or anesthesia, or if having implant for menstrual suppression In summary, the use of DMPA in another surgical procedure, could in teenagers with disabilities is teenagers in wheelchairs can be be inserted at the same time. The limited because of the continued considered for menstrual suppression expulsion rate of the LNG-IUD is concern regarding the unpredictable after careful counseling and slightly higher in nulliparous women bleeding patterns that are associated assessment of any contraindications (approximately 3%–4%)46 and is with the implant. Amenorrhea is to estrogen and considering whether reported at 8% in teenagers with approximately 13% after 1 year, with the potential risk of decreased BMD disabilities combining all published many days of spotting each month.49 is outweighed by the need for the studies.47 Whether ultrasonography Insertion and removal requires suppression. The AAP and ACOG before insertion of the LNG-IUD in patient cooperation, which may be do not support the use of bone- this population is helpful to predict an issue for some teenagers with density screening if long-term use successful insertion is under intellectual disabilities. of DMPA seems prudent, including discussion. A uterine length of 6 to 10 in adolescents with limited mobility, cm is recommended for 1 LNG-IUD; a Special Considerations unless fractures have occurred.36,39 newer, slightly smaller 3-year version Seizures and Hormonal Contraception Calcium and vitamin D intake may be does not have that recommendation. optimized per current guidelines.40,41 Although preinsertion For patients with epilepsy taking ultrasonographic measurements Levonorgestrel Intrauterine Device anticonvulsant medications, were recommended in 1 report, 45 interactions with hormones are LNG-IUDs have been used extensively another study on 26 LNG-IUD described. Many anticonvulsants in adult women and, although not insertions in adolescents with and some other neuropsychiatric approved by the FDA for adolescents developmental disabilities showed medications induce the hepatic

Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 138 , number 1 , July 2016 e5 cytochrome P450 system and, thus, Nonhormonal Methods outcomes, and therefore, endometrial interfere with contraceptive efficacy Nonsteroidal antiinflammatory ablation is not recommended for this 12 and cycle control reliability. As a drugs can be used to help with age group. result, COCs can cause irregular dysmenorrhea as well as with heavy bleeding, and higher doses of bleeding. Studies show a small Hysterectomy COCs may be indicated to achieve decrease in flow when nonsteroidal amenorrhea. The CDC medical antiinflammatory drugs are used Families sometimes request eligibility criteria categorize the around the clock during the hysterectomy for menstrual estrogen-containing methods and the menses.57 management in their daughter with progesterone-only pill as category 3 severe intellectual disability. When for contraception (ie, risks outweigh A new oral antifibrinolytic hysterectomy is requested, it is the benefits) for enzyme-inducing medication, tranexamic acid, was critical to delineate why the family anticonvulsant agents. In general, approved by the FDA for heavy desires this intervention. It may be hormonal contraceptives do not menses in 2009. It can be taken for considered the ideal way to achieve affect the efficacy of anticonvulsant up to 5 days of menses and results in 58 birth control and amenorrhea. This medications, with the 1 exception 40% lighter bleeding. is a complex and controversial issue of lamotrigine, which can have Surgical Requests and Options and can cause conflict between decreased efficacy when combined health care providers and families. with a COC. The lamotrigine dose may Parents may ask the pediatrician A hysterectomy (removal of the need to be adjusted, and discussion about surgical interventions, uterus and cervix) does not prevent with the prescribing physician is especially endometrial ablation or behavioral hormonal concerns. recommended when starting a COC hysterectomy, for their daughter Hysterectomy in the adolescent (CDC medical eligibility criteria, with severe intellectual disabilities, years for medical indications is category 3).50 LNG-IUDs, injectables, in the hope that it will help with extremely rare for teenagers, and implants are recommended menstrual bleeding, behavior with or without disabilities. Laws for patients on anticonvulsant changes, or perceived or expressed regarding sterilization in minors medication. For the progesterone dysmenorrhea or because of with intellectual disabilities, injectables (medroxyprogesterone concerns about the risk of pregnancy. hysterectomy, and consent issues acetate), some experts recommend Surgical interventions in these vary from state to state. There dosing on an every-10-week schedule cases have clear ethical and legal is a network of legal experts on if irregular bleeding continues.51 implications because most of patients disability with offices in every state Finally, cyclical or catamenial with intellectual disabilities cannot (http://www. ndrn. org/ about/ epilepsy and other cyclic menstrual give their own consent. paacap-network. html). In most symptoms may be a clinically jurisdictions, sterilization of women significant problem for some Endometrial Ablation with known cognitive impairments patients, and suppression of Endometrial ablation destroys has specific legal oversight hormone fluctuations can be most or all of the endometrium mandated. helpful.52 and was designed for women who have completed childbearing to Herbal Supplements Referral to a gynecologist with alleviate heavy cycles. The rates experience in this area may Because the use of complementary of amenorrhea range from 13% to be considered as well as an medicine is widespread and 83%, and complications include pain, ethics consultation and legal increasing in the population, cramping, and continued bleeding representation for the patient as pediatricians can advise families as well as the need for additional part of the review process. The that the use of these compounds procedures. Ablation leads to only ACOG has guidelines regarding can interfere with the hormonal relative infertility, and birth control permanent sterilization.59 medications.53 For example, St is still recommended, because John’s wort is known to decrease pregnancy after an ablation may the bioavailability of oral have complications. Because of this contraceptives, which might interfere relative infertility, there are legal CONCLUSIONS with contraceptive efficacy and implications for use in teenagers The pediatrician plays a pivotal may lead to spotting.54, 55 Other with disabilities (see Hysterectomy). role during the sometimes difficult herbals have been implicated in There are no studies on use of pubertal transition for patients increasing bleeding risk as well as in ablation in adolescents including with physical and intellectual hepatotoxicity.56 long-term consequences and disabilities, when concerns about

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Downloaded from www.aappublications.org/news by guest on September 28, 2021 Menstrual Management for Adolescents With Disabilities Elisabeth H. Quint, Rebecca F. O'Brien, COMMITTEE ON ADOLESCENCE and The North American Society for Pediatric and Adolescent Gynecology Pediatrics 2016;138; DOI: 10.1542/peds.2016-0295 originally published online June 20, 2016;

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