A 14-year-old girl is brought to the office by her parents to discuss her menstrual periods. The patient was born at 25 weeks gestation and spent 4 months in the neonatal intensive care unit. She has cerebral palsy and her mobility is limited due to spasticity. She has no intellectual disability. The patient started menstruating 1 year ago and has monthly bleeding for 8 days with passage of clots. Her parents often need to change the patient's pads every hour during menses. She has mild intermittent asthma and migraines with aura. On examination, the patient is wheelchair-bound and has multiple contractures in the bilateral lower extremities that cause minimal active and passive range of motion. The abdomen is soft, nontender, and has no palpable masses. Pelvic examination is deferred. Which of the following is the best treatment option for this patient?

Question

A 14-year-old girl is brought to the office by her parents to discuss her menstrual periods.  The patient was born at 25 weeks gestation and spent 4 months in the neonatal intensive care unit.  She has cerebral palsy and her mobility is limited due to spasticity.  She has no intellectual disability.  The patient started menstruating 1 year ago and has monthly bleeding for 8 days with passage of clots.  Her parents often need to change the patient's pads every hour during menses.  She has mild intermittent asthma and migraines with aura.  On examination, the patient is wheelchair-bound and has multiple contractures in the bilateral lower extremities that cause minimal active and passive range of motion.  The abdomen is soft, nontender, and has no palpable masses.  Pelvic examination is deferred.  Which of the following is the best treatment option for this patient?

Quizplus · Accepted Answer

11ec25c8_d9b2_e6d4_bc81_2b95b17e396d_MD0003_00 The pubertal transition (eg, body image, sexuality) can be complicated by physical and intellectual disabilities in the adolescent population. Adolescents with disabilities may become dependent on caregivers for menstrual hygiene, limiting their independence and creating embarrassment, especially when there is heavy menstrual bleeding (eg, frequent pad changes) or severe dysmenorrhea. Menstrual management with hormonal contraception (eg, combination oral contraceptives) can be used to minimize menstrual bleeding volume and/or frequency, thereby improving the patient's quality of life and treating possible associated complications (eg, anemia). However, estrogen-containing contraception is contraindicated in patients with migraine with aura due to the increased risk of stroke (Choice A). The progestin-releasing subdermal implant is a long-acting (ie, up to 3 years), reversible contraceptive that reduces menstrual bleeding in 50% of patients and causes amenorrhea in 20% of patients. Because it can be easily placed in the upper arm, it is an ideal contraceptive option for adolescents, particularly those who have difficulty with pelvic examinations, such as this patient with lower extremity contractures. (Choice B) The copper-containing intrauterine device (IUD) is a highly effective form of nonhormonal contraception, but it is not recommended in patients with heavy menses because it can increase bleeding. In addition, an IUD may be difficult to insert in this patient with lower extremity contractures. (Choice C) Endometrial ablation cauterizes the endometrial lining, causing endometrial scarring and possible amenorrhea to treat heavy menstrual bleeding. However, it is not appropriate for patients who wish to preserve fertility (eg, adolescents) due to the increased risk of future obstetric complications (eg, placenta accreta). (Choice D) GnRH agonist therapy (eg, leuprolide) treats heavy, regular menses by acting on the pituitary to decrease pulsatile FSH and LH release, thereby producing a hypoestrogenic state and amenorrhea. However, it is not recommended for long-term use because of adverse effects (eg, decreased bone density) and is particularly avoided in patients at higher risk of bone density abnormalities (eg, adolescents, patients in wheelchairs). Educational objective: Hormonal contraception, such as the progestin-releasing subdermal implant, can be used for menstrual hygiene (eg, to decrease menstrual bleeding) in adolescents with disabilities. References: Menstrual and reproductive issues in adolescents with physical and developmental disabilities. (http://www.ncbi.nlm.nih.gov/pubmed/25004333) Adolescents with special needs: clinical challenges in reproductive health care. (http://www.ncbi.nlm.nih.gov/pubmed/26542013) Menstrual management for adolescents with disabilities. (http://www.ncbi.nlm.nih.gov/pubmed/27325636)

A 14-Year-Old Girl Is Brought to the Office by Her