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

Load more