Intrauterine Device Use in Adolescents with Disabilities Beth I

Intrauterine Device Use in Adolescents With Disabilities Beth I. Schwartz, MD, Morgan Alexander, MD, Lesley L. Breech, MD BACKGROUND AND OBJECTIVES: Intrauterine devices (IUDs) are increasingly being used in adolescents abstract and nulliparous women for contraception. Levonorgestrel IUDs also have beneficial effects on bleeding and pain. Although they are recommended for menstrual suppression in adolescents with disabilities, there are limited data on their use in this population. Our objective is to describe the characteristics and experiences of levonorgestrel IUD use in nulliparous children, adolescents, and young adults with physical, intellectual, and developmental disabilities. METHODS: A retrospective chart review was conducted for all nulliparous patients ages #22 with physical, intellectual, or developmental disabilities who had levonorgestrel IUDs placed between July 1, 2004, and June 30, 2014, at a tertiary-care children’s hospital. Descriptive statistical analysis and survival analysis were performed. RESULTS: In total, 185 levonorgestrel IUDs were placed in 159 patients with disabilities. The mean age was 16.3 (3.3; range of 9–22) years. Only 4% had ever been sexually active; 96% of IUDs were inserted in the operating room. IUD continuation rate at 1 year was 95% (95% confidence interval: 93%–100%) and at 5 years was 73% (95% confidence interval: 66%–83%). The amenorrhea rate was ∼60% throughout the duration of IUD use among those with available follow-up data. Side effects and complications were #3%. CONCLUSIONS: In this study, we provide evidence for the therapeutic benefit and safety of levonorgestrel IUD use in adolescents and young adults with physical, intellectual, and developmental disabilities. It should be considered as a menstrual management and contraceptive option for this population. Division of Pediatric and Adolescent Gynecology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio WHAT’S KNOWN ON THIS SUBJECT: Intrauterine devices (IUDs) reduce unintended pregnancies and Dr Schwartz conceptualized and designed the study, performed and interpreted data analysis, improve bleeding, pain, and quality of life for women drafted the initial manuscript, and reviewed and revised the manuscript; Dr Alexander contributed with heavy menstrual bleeding and dysmenorrhea. to the design of the study, performed all data collection, performed and interpreted data analysis, There are minimal data on IUD use for menstrual assisted in preparation of the initial manuscript, and critically reviewed and revised the manuscript; Dr Breech contributed to the conceptualization and design of the study and critically management and contraception in young women with reviewed and revised the manuscript; and all authors approved the final manuscript as submitted disabilities. and agree to be accountable for all aspects of the work. WHAT THIS STUDY ADDS: This is the largest study of Dr Schwartz’s current affiliation is Department of Obstetrics and Gynecology, Sidney Kimmel IUD use in young women with physical, intellectual, Medical College, Thomas Jefferson University, Philadelphia, PA. and developmental disabilities. With these data, we DOI: https://doi.org/10.1542/peds.2020-0016 provide evidence that IUDs are effective, well-tolerated, Accepted for publication May 8, 2020 safe menstrual management and contraceptive options for this population. Address correspondence to Beth I. Schwartz, MD, Department of Obstetrics and Gynecology, Thomas Jefferson University, 833 Chestnut St, 1st Floor, Philadelphia, PA 19107. E-mail: beth.schwartz@ jefferson.edu To cite: Schwartz BI, Alexander M, Breech LL. Intrauterine PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Device Use in Adolescents With Disabilities. Pediatrics. 2020;146(2):e20200016 Copyright © 2020 by the American Academy of Pediatrics Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 146, number 2, August 2020:e20200016 ARTICLE There are increasing data on medications.12,13 A disadvantage of cavity distortion.15 Because of intrauterine device (IUD) use in IUD use in this population is that it reliance on coding and billing adolescents and nulliparous women, often requires anesthesia because of databases for subject identification, but these are usually limited to the inability to tolerate or be we were unable to include contraceptive use. The 5-year 52-mg adequately positioned for office unsuccessful IUD placements, levonorgestrel IUD has also been placement. This can sometimes which are typically due to patient shown to have beneficial effects be coordinated with other inability to tolerate an office on heavy menstrual bleeding1–3 examinations or procedures under pelvic examination or procedure, and dysmenorrhea4,5 in adults. anesthesia. provider inability to sound the There are minimal data on the uterus or pass the inserter, or the fi use of levonorgestrel IUDs for Because of the many bene ts, the uterus sounding too small to fit other indications, especially in American College of Obstetricians and an IUD. adolescents. Gynecologists lists off-label use of the 52-mg levonorgestrel IUD as an Data abstraction was performed by Desire for menstrual management or option for menstrual management in a single reviewer for consistency. The 14 suppression is common in young adolescents with disabilities. data collected included demographics women with special needs, including However, there is a paucity of data on (age, race, BMI, insurance, and complex medical conditions and levonorgestrel IUD use in this parity), indications for IUD use, physical, intellectual, and population. In this study, our insertion location, sexual activity, developmental disabilities.6 Patients objective is to describe the comorbidities, and previous request hormonal management for characteristics, experiences, and contraceptive or menstrual abnormal bleeding, hygiene, mood outcomes of levonorgestrel IUD use in management methods. Baseline issues, exacerbation of other medical nulliparous children, adolescents, and bleeding and pain were abstracted. conditions, and prevention of young adults with physical, Continuation and amenorrhea rates pregnancy. Many young women with intellectual, and developmental were recorded at each year. disabilities require methods without disabilities. Amenorrhea was defined as the estrogen because of medical complete absence of bleeding for 3 comorbidities, medication months, as defined by the World METHODS interactions, or decreased mobility Health Organization and used in that may increase the risk for We conducted a retrospective chart many contraception trials, including thrombosis.7 Levonorgestrel IUDs review of successful levonorgestrel a recent systematic review and meta- have great potential for use in this IUD placements at Cincinnati analysis of amenorrhea with population for multiple reasons. They Children’s Hospital Medical Center levonorgestrel IUD use.16,17 We are convenient and long lasting, with between July 1, 2004, and June 30, considered a patient amenorrheic if a 5-year duration of use for the 52-mg 2014. Patients were identified by they reported no current bleeding or levonorgestrel IUD (Mirena), although querying hospital electronic medical spotting and no bleeding in the a newer 52-mg levonorgestrel IUD records and billing databases. All 3 months preceding the visit. If they (Liletta) is approved for 6 years, and identified charts were manually were amenorrheic for the majority of there are data that support efficacy reviewed. The inclusion criteria were the year but had some current or for up to 7 years.8,9 They result in nulliparity, age #22, and either recent bleeding, they were not significantly decreased bleeding, with a physical disability that limited considered amenorrheic. Change in an amenorrhea rate of up to 50% at mobility (including conditions such as bleeding was abstracted from the 1 year in adults, depending on the cerebral palsy, spina bifida, and chart by comparison of reported definition of amenorrhea.10,11 Unlike caudal regression syndrome), an bleeding frequency, duration, and other hormonal methods, their intellectual disability, or global or flow to that described at the time of actions are localized with minimal specific developmental delays. If insertion. Bleeding was determined to systemic absorption, side effects, or a patient had $1 IUD insertion during be increased if explicitly documented interactions with other medications this time period, each insertion was or if bleeding was more frequent, or medical problems. This may be included separately. Patients with prolonged, or heavier in flow. particularly beneficial in this a history of pregnancy beyond 20 Bleeding was recorded as decreased population given the high rates of weeks’ gestation were excluded, as if explicitly documented or if bleeding medical comorbidities and use of were those with known uterine was less frequent, of shorter duration, other medications, including anomalies, because of the or lighter in flow. Bleeding was antiepileptic drugs that can have contraindication to IUD use in considered unchanged if explicitly interactions with hormonal patients with significant uterine documented or the described Downloaded from www.aappublications.org/news by guest on September 26, 2021 2 SCHWARTZ et al bleeding was similar to before the IUD insertion. Change in pain was similarly abstracted by comparison to baseline data. All reported side effects beyond the 6-week initial follow-up appointment were recorded, given the

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