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    ACOG Guidelines: Menstrual manipulation for adolescents with physical and developmental disabilities


    Treatment options

    Nonsteroidal anti-inflammatory drugs

    Nonsteroidal anti-inflammatory drugs (NSAIDS) may be used to reduce ovulatory menstrual bleeding and reduce dysmenorrhea by reducing prostaglandin production. The principal action of NSAIDS is inhibition of cyclo-oxygenase. NSAIDS will not achieve amenorrhea but they are helpful for reducing menstrual flow and pain.

    Estrogen-containing methods

    Estrogen-progestin pills, patch, or ring are options for patients with disabilities, barring any medical contraindications to estrogen. These methods can be used in a continuous or extended-cycle fashion. Complete amenorrhea may not be achieved, but unscheduled light bleeding typically is tolerated by patients, as long as they have been counseled that this may occur. All estrogen-progestin methods require active management by a patient or her caregiver. Some concern exists about estrogen-containing methods and immobility in regard to overall venous thromboembolism (VTE) risk. Providers, patients, and families must weigh the risk of heavy menstrual bleeding, severe dysmenorrhea, or pregnancy against the risk of a VTE.

    Progestin-only methods

    Oral progestins are useful to reduce menstrual blood flow, and in some doses will achieve amenorrhea. Patients must consistently take the pill at the same time to reduce the likelihood of unscheduled bleeding.

    Depot medroxyprogesterone acetate (DMPA) is useful for reducing bleeding and pain, and in some cases, will achieve amenorrhea. DMPA is given intramuscularly every 12 weeks. In patients using enzyme-inducing antiepileptic drugs, the dosing interval may need to be reduced to every 10 weeks. Unscheduled bleeding is common initially, but typically improves with continued use. Adolescents using DMPA may see a decrease in bone mineral density (BMD), but studies indicate that BMD recovery occurs after discontinuation. BMD testing is not recommended in adolescents.11 One area of concern is weight gain with DMPA use. Patients with limited mobility may depend on their own strength or the assistance of others for transfers and weight gain may make those maneuvers more difficult. Progestins do increase the seizure threshold and are helpful for patients with seizure disorders.12

    The levonorgestrel intrauterine device (LNG-IUD) is a safe method and should be considered for adolescents with disabilities. Very few contraindications to IUD use exist, making the method ideal for patients with multiple comorbidities.

    Progestin subdermal contraceptive implants may be used in this population, but the high incidence of unscheduled bleeding makes them somewhat less desirable. They do, however, reduce dysmenorrhea and provide highly effective contraception. Patient cooperation is required to ensure safe and proper subdermal placement.

    Surgical intervention

    Families may request hysterectomy as a means of definitive amenorrhea. However, it is not recommended unless other less-invasive options have been exhausted. Hysterectomy is irreversible and is major surgery with attendant morbidity/mortality risks. It will not protect the patient from sexual abuse or STIs.1 Disabled adolescents have the same rights as any women, and the benefits of surgical intervention must outweigh the risks.

    Next: Should birth control be OTC?

    While not the focus of this committee opinion, caregivers may sometimes request hysterectomy to accomplish permanent sterilization of a patient. ACOG Committee Opinion No. 371, “Sterilization of women, including those with mental disabilities,”13 provides guidance on ethical considerations surrounding sterilization. All sterilization requests should be evaluated on an individual basis and follow the principles of respect for autonomy, beneficence, and justice.

    Not recommended

    Endometrial ablation is not recommended for adolescents for 2 reasons: the rate of failure is higher in younger patients and it is not a sterilization procedure.


    1. Menstrual manipulation for adolescents with physical and developmental disabilities. ACOG Committee Opinion No. 668. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2016;128:e20-25.

    2. Quint EH. Menstrual and reproductive issues in adolescents with physical and developmental disabilities. Obstet Gynecol. 2014;124:367-375.

    3. Erickson W, Lee C, von Schrader S: 2012 Disability Status Report: United States. Ithaca, NY, Cornell University Employment and Disability Institute (EDI), 2014.

    4. Hamilton A, Marshal MP, Sucatos GS, et al: Rett syndrome and menstruation. J Pediatr Adolesc Gynecol. 2012: 25:122.

    5. Hamilton A, Marshal MP, Murray PJ: Autism spectrum disorders and menstruation. J Adolesc Health. 2011: 49:433.

    6. American College of Obstetricians and Gynecologists: Guidelines for Adolescent Health Care, 2nd edition. 2012. http://www.acog.org/Resources-And-Publications/Guidelines-for-Adolescent....

    7. American Academy of Pediatrics. Bright Futures. Available: brightfutures.aap.org

    8. Quint EH. Adolescents with special needs: clinical challenges in reproductive health care. J Pediatr Adolesc Gynecol. 2016;29:2-6.

    9. Menstruation in girls and adolescents: using the menstrual cycle as a vital sign. Committee Opinion No. 651. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2015;126:e143-146.

    10. Curtis KM et al. U.S. Medical eligibility criteria for contraceptive use, 2016. MMWR Recomm Rep. 2016 Jul 29;65(3):1-103.

    11. Depot medroxyprogesterone acetate and bone effects. Committee Opinion No. 602. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2014;123:1398-1402.

    12. Foldvary-Schaefer N et al. Hormones and seizures. Cleve Clin J Med. 2004;71(suppl2):S11-18.

    13. Sterilization of women, including those with mental disabilities. ACOG Committee Opinion No. 371. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2007;110:217-220.


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