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Letter to the Editor
The article on managing menstrual problems for women and girls with intellectual disability1 was a very thorough review of the various medical, social and ethical dilemmas faced by clinicians. However, I would like to draw attention to the use of long-acting reversible contraception in these patients.
Insertion of the levonorgestrel-releasing intrauterine device (Mirena) into a uterine cavity less than 6 cm (by ultrasound) may increase the incidence of expulsion, bleeding, pain, perforation, and possibly pregnancy. Its use may therefore be limited in younger patients with intellectual disability.
The use of the medroxyprogesterone injection (Depo-Provera or Depo-Ralovera) appears to be associated with weight gain, particularly in those under 18 years who may already be overweight or obese.2 Also, its use in women under 20 years has been associated with lower bone density.3
The etonorgestrel implant (Implanon) provides reliable contraception and results in amenorrhoea in up to 22% of women. If bleeding patterns are unacceptable, the implant can be used with a low-dose combined oral contraceptive pill or progestogen-only pill if amenorrhoea and long-acting reversible contraception is required and other methods are not preferred.4,5
The article discussed the potential for sexual abuse and consent. The perpetrators of sexual abuse may include family members, support workers or co-residents. People with an intellectual disability may not be assertive enough to report the abuse or have the verbal skills to articulate it.6 Using the etonorgestrel implant which is palpable on the arm may further increase the risk of abuse as the perpetrator is aware of its presence.
I hope other readers will derive benefit and certainly offer better care to their patients with intellectual disability.
Village Family Practice
Samford Village Warner Family Medical Practice
- Tracy J, Grover S, Macgibbon S. Menstrual issues for women with intellectual disability. Aust Prescr 2016;39:54-7. [cited 2016 Jul 1]
- Faculty of Sexual and Reproductive Healthcare clinical guidance. Progestogen-only injectable contraception. London: Faculty of Sexual and Reproductive Healthcare; 2014.
- Walsh JS, Eastell R, Peel NFA. Effects of depot medroxyprogesterone acetate on bone density and bone metabolism before and after peak bone mass: a case-control study. J Clin Endocrinol Metab 2008;93:1317-23.
- Mansour D, Korver T, Marintcheva-Petrova M, Fraser IS. The effects of Implanon on menstrual bleeding patterns. Eur J Contracept Reprod Health Care 2008;13 Suppl 1:13-28.
- Brache V. Treatment of vaginal bleeding irregularities induced by progestin-only contraceptives: RHL commentary. Geneva: The WHO Reproductive Health Library; 2007. [cited 2016 Jul 1]
- Eastgate G, Scheermeyer E, van Driel ML, Lennox NG. Intellectual disability, sexuality and sexual abuse prevention: a study of family members and support workers. Aust Fam Physician 2012;41:135-9.