Case of a Girl with Special Needs Seeking Menstrual Management



Disabilities are common in children and adolescents with >5% of children and adolescents affected by a physical or intellectual disability. The onset and progression through puberty may be challenging for girls with mental and physical disabilities and their families and caregivers. Gynecologic care may be underutilized in adolescents with disabilities, but pediatricians and pediatric and adolescent gynecologists should use a nonjudgmental approach, incorporating anticipatory guidance regarding pubertal changes and options for menstrual regulation, confidential care with the adolescent, and attention to parental concerns. Menstrual regulation can be useful to reduce symptoms of dysmenorrhea, reduce irregular menstrual bleeding, and decrease the frequency or amount of menstrual breeding. Options for menstrual regulation include combined hormonal contraceptives (available in pill, patch, and vaginal rings), progesterone-only contraceptives (including pills, injectables, implants, and IUDs), NSAIDs, and, as a last resort, surgical intervention. The ability to give consent for consensual sexual activity should be assessed in patients with disabilities. Adolescents with disabilities are at higher risk for sexual abuse and should receive sexual abuse prevention education at an appropriate level for their intellectual abilities.


Intellectual disability Puberty Adolescent development Sexual maturation Menstrual cycle Menstruation Contraception 


  1. 1.
    US Census Bureau. Disability characteristics of school age children: 2010 – Children – Newsroom - U.S. Census Bureau. Available at: Accessed 1 Sept 2016.
  2. 2.
    Committee Opinion No. 668: Menstrual manipulation for adolescents with physical and developmental disabilities. Obstet Gynecol. 2016;128:e20–25.Google Scholar
  3. 3.
    Prasher VP. Down syndrome and thyroid disorders: a review. Downs Syndr Res Pract. 1999;6:25–42.CrossRefPubMedGoogle Scholar
  4. 4.
    Hamed SA. The effect of epilepsy and antiepileptic drugs on sexual, reproductive and gonadal health of adults with epilepsy. Expert Rev. Clin. Pharmacol. 2016;9:807–19.CrossRefPubMedGoogle Scholar
  5. 5.
    Herzog AG, Schachter SC. Valproate and the polycystic ovarian syndrome: final thoughts. Epilepsia. 2001;42:311–5.CrossRefPubMedGoogle Scholar
  6. 6.
    Reynolds MF, Sisk EC, Rasgon NL. Valproate and neuroendocrine changes in relation to women treated for epilepsy and bipolar disorder: a review. Curr Med Chem. 2007;14:2799–812.CrossRefPubMedGoogle Scholar
  7. 7.
    Hu X, et al. A meta-analysis of polycystic ovary syndrome in women taking valproate for epilepsy. Epilepsy Res. 2011;97:73–82.CrossRefPubMedGoogle Scholar
  8. 8.
    Lambert TL, Farmer KC, Brahm NC. Evaluation of serum prolactin levels in intellectually disabled patients using antipsychotic medications. Int J Endocrinol Metab. 2013;11:57–61.PubMedGoogle Scholar
  9. 9.
    Quint EH, O’Brien RF, COMMITTEE ON ADOLESCENCE & North American Society for Pediatric and Adolescent Gynecology. Menstrual management for adolescents with disabilities. Pediatrics. 2016;138. pii: e20160295.Google Scholar
  10. 10.
    Kirkham YA, et al. Trends in menstrual concerns and suppression in adolescents with developmental disabilities. J Adolesc Health. 2013;53:407–12.CrossRefPubMedGoogle Scholar
  11. 11.
    Quint EH. Menstrual and reproductive issues in adolescents with physical and developmental disabilities. Obstet Gynecol. 2014;124:367–75.CrossRefPubMedGoogle Scholar
  12. 12.
    Quint EH. Adolescents with special needs: clinical challenges in reproductive health care. J Pediatr Adolesc Gynecol. 2016;29:2–6.CrossRefPubMedGoogle Scholar
  13. 13.
    Hamilton A, Marshal MP, Sucato GS, Murray PJ. Rett syndrome and menstruation. J Pediatr Adolesc Gynecol. 2012;25:122–6.CrossRefPubMedGoogle Scholar
  14. 14.
    ACOG Committee Opinion No. 651: menstruation in girls and adolescents: using the menstrual cycle as a vital sign. Obstet Gynecol. 2015;126:e143–6.Google Scholar
  15. 15.
    Moyer VA, U.S. Preventive Services Task Force. Screening for cervical cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;156:880–891. , W312.CrossRefPubMedGoogle Scholar
  16. 16.
    Practice Bulletin No. 157: Cervical cancer screening and prevention. Obstet Gynecol. 2016;127:e1–20.Google Scholar
  17. 17.
    Lethaby A, Augood C, Duckitt K. Nonsteroidal anti-inflammatory drugs for heavy menstrual bleeding. Cochrane Database Syst. Rev. 2000;(2):CD000400. doi:10.1002/14651858.CD000400.Google Scholar
  18. 18.
    Matteson KA, et al. Nonsurgical management of heavy menstrual bleeding: a systematic review. Obstet Gynecol. 2013;121:632–43.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Abdel-Tawab M, Zettl H, Schubert-Zsilavecz M. Nonsteroidal anti-inflammatory drugs: a critical review on current concepts applied to reduce gastrointestinal toxicity. Curr Med Chem. 2009;16:2042–63.CrossRefPubMedGoogle Scholar
  20. 20.
    Reimers A, Brodtkorb E, Sabers A. Interactions between hormonal contraception and antiepileptic drugs: clinical and mechanistic considerations. Seizure. 2015;28:66–70.CrossRefPubMedGoogle Scholar
  21. 21.
    First chewable oral contraceptive. FDA Consum. 2004;38:4.Google Scholar
  22. 22.
    Benagiano G, Carrara S, Filippi V. Safety, efficacy and patient satisfaction with continuous daily administration of levonorgestrel/ethinylestradiol oral contraceptives. Patient Prefer Adherence. 2009;3:131–43.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    van Hylckama Vlieg A, Helmerhorst FM, Vandenbroucke JP, Doggen CJM, Rosendaal FR. The venous thrombotic risk of oral contraceptives, effects of oestrogen dose and progestogen type: results of the MEGA case-control study. BMJ. 2009;339:b2921.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Sulak PJ, et al. Frequency and management of breakthrough bleeding with continuous use of the transvaginal contraceptive ring: a randomized controlled trial. Obstet Gynecol. 2008;112:563–71.CrossRefPubMedGoogle Scholar
  25. 25.
    Stewart FH, et al. Extended use of transdermal norelgestromin/ethinyl estradiol: a randomized trial. Obstet Gynecol. 2005;105:1389–96.CrossRefPubMedGoogle Scholar
  26. 26.
    Emans, Laufer, Goldstein’s pediatric & adolescent gynecology. Wolters Kluwer Health/Lippincott Williams & Wilkins Health; 2011.Google Scholar
  27. 27.
    Speroff L, Darney PD. A clinical guide for contraception. Phladelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2011.Google Scholar
  28. 28.
    Altshuler AL, Hillard PJA. Menstrual suppression for adolescents. Curr Opin Obstet Gynecol. 2014;26:323–31.CrossRefPubMedGoogle Scholar
  29. 29.
    Arias RD, Jain JK, Brucker C, Ross D, Ray A. Changes in bleeding patterns with depot medroxyprogesterone acetate subcutaneous injection 104 mg. Contraception. 2006;74:234–8.CrossRefPubMedGoogle Scholar
  30. 30.
    Lopez LM, et al. Progestin-only contraceptives: effects on weight. Cochrane Database Syst Rev. 2016;(8):CD008815.Google Scholar
  31. 31.
    Lopez LM, Chen M, Mullins Long S, Curtis KM, Helmerhorst FM. Steroidal contraceptives and bone fractures in women: evidence from observational studies. Cochrane Database Syst Rev. 2015;(7):CD009849. doi:10.1002/14651858.CD009849.pub3.Google Scholar
  32. 32.
    Hubacher D, Lopez L, Steiner MJ, Dorflinger L. Menstrual pattern changes from levonorgestrel subdermal implants and DMPA: systematic review and evidence-based comparisons. Contraception. 2009;80:113–8.CrossRefPubMedGoogle Scholar
  33. 33.
    Hidalgo M, et al. Bleeding patterns and clinical performance of the levonorgestrel-releasing intrauterine system (Mirena) up to two years. Contraception. 2002;65:129–32.CrossRefPubMedGoogle Scholar
  34. 34.
    Pillai M, O’Brien K, Hill E. The levonorgestrel intrauterine system (Mirena) for the treatment of menstrual problems in adolescents with medical disorders, or physical or learning disabilities. BJOG Int J Obstet Gynaecol. 2010;117:216–21.CrossRefGoogle Scholar
  35. 35.
    Hillard PJA. Menstrual suppression with the levonorgestrel intrauterine system in girls with developmental delay. J Pediatr Adolesc Gynecol. 2012;25:308–13.CrossRefPubMedGoogle Scholar
  36. 36.
    Alton TM, et al. Retrospective review of intrauterine device in adolescent and young women. J Pediatr Adolesc Gynecol. 2012;25:195–200.CrossRefPubMedGoogle Scholar
  37. 37.
    Hare AA, Olah KS. Pregnancy following endometrial ablation: a review article. J Obstet Gynaecol. 2005;25:108–14.CrossRefPubMedGoogle Scholar
  38. 38.
    Arpaia G, et al. Risk of deep venous thrombosis (DVT) in bedridden or wheelchair-bound multiple sclerosis patients: a prospective study. Thromb Res. 2010;125:315–7.CrossRefPubMedGoogle Scholar
  39. 39.
    Rousseau MC, Guillotel B. Risk factors for deep venous thrombosis in tetraparesic mentally retarded patients. Brain Inj. 2001;15:1041–4.CrossRefPubMedGoogle Scholar
  40. 40.
    Lohiya G-S, Tan-Figueroa L, Silverman S, Le HV. The wheelchair thrombosis syndrome. J Natl Med Assoc. 2006;98:1188–92.PubMedPubMedCentralGoogle Scholar
  41. 41.
    American Academy of Pediatrics: Committee on Child Abuse and Neglect and Committee on Children with Disabilities. Assessment of maltreatment of children with disabilities. Pediatrics. 2001;108:508–12.Google Scholar
  42. 42.
    Murphy GH. Capacity to consent to sexual relationships in adults with learning disabilities. J Fam Plann Reprod Health Care. 2003;29:148–9.CrossRefPubMedGoogle Scholar
  43. 43.
    Schopp LH, Sanford TC, Hagglund KJ, Gay JW, Coatney MA. Removing service barriers for women with physical disabilities: promoting accessibility in the gynecologic care setting. J. Midwifery Womens Health. 2002;47:74–9.CrossRefPubMedGoogle Scholar
  44. 44.
    Sweeney L. Human sexuality education for students with special needs. Electron J Hum Sex. 2007;10:1–1.Google Scholar

Suggested Educational Reading, References, and Policies

  1. Altshuler AL, Hillard PJA. Menstrual suppression for adolescents. Curr Opin Obstet Gynecol. 2014;26:323–31.CrossRefPubMedGoogle Scholar
  2. Committee Opinion No. 668: Menstrual manipulation for adolescents with physical and developmental disabilities. Obstet Gynecol. 2016;128:e20–25.Google Scholar
  3. Quint EH, O’Brien RF, COMMITTEE ON ADOLESCENCE & North American Society for Pediatric and Adolescent Gynecology. Menstrual management for adolescents with disabilities. Pediatrics. 2016;138. pii: e20160295.Google Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  1. 1.Cleveland Clinic Lerner College of Medicine at CaseClevelandUSA
  2. 2.Center for Adolescent MedicineCleveland Clinic Children’s HospitalClevelandUSA

Personalised recommendations