What if Menstrual Problems Arise?

Recognition and treatment of menstrual cycle symptoms is an important aspect of menstrual management in women with intellectual disability.

Menstruation is usually a simple and comfortable process for most women. There are occasions, however, when normal moods and sensations related to the cycle can be distressing.

If a woman who has an intellectual disability is to deal with these feelings in a positive fashion, it is essential for her to be able to recognise them for what they are. In some situations, staff and carers will have to recognise these feelings and to reassure the woman.

An essential part of any menstrual management program is establishing the sort of rapport where these relatively minor symptoms can be dealt with simply and efficiently.

When menstrual management is not being successfully implemented, or when other related symptoms (discussed below) are causing concern, medical advice should be sought.

If the doctor is consulted he/she will need to know:

A menstrual calendar which records strength of blood flow and the presence of associated features eg. pain, mood changes or seizure activity is very helpful in the assessment of menstrual problems (appendix 3).

The H&CS policy on Confidentiality and Privacy states that collection and exchange of all personal information should be in the best interest of the client and should only be on a "need to know" basis of that which is relevant to the particular circumstances. This is a common sense approach. For example, any records of a woman's menstrual cycle should be stored securely and not displayed on a pin board.

The doctor will need to examine the woman. The examination should include :

When deciding whether to adopt a more restrictive approach to the management of heavy periods, the effect that the periods have on the woman's quality of life is more important than the absolute volume of blood lost.

It is usually appropriate for a carer with whom the woman feels particularly comfortable to stay with her throughout the examination.

Some problems which can occur during menstruation are:

Painful Periods (Dysmenorrhoea):

Most women will feel some level of discomfort, ranging from mild cramping to severe debilitating pain, during their periods. Other symptoms may include nausea, vomiting, fainting and diarrhoea.

Techniques such as relaxation, local warmth, exercises and massage may help relieve such symptoms.

If unsuccessful, 'over the counter' period pain relief tablets may be necessary eg. Naprogesic or Ponstan. Before these can be administered carers must first check with the woman's doctor for allergies and other contra-indications. H&CS;staff must seek their supervisor's permission and document the administration and permission on the appropriate recording sheet.

Heavy Periods (Menorrhagia):

It is difficult to estimate the volume of blood lost during a menstrual cycle. There is also a wide variation in the amount of blood lost in each cycle.

Prolonged episodes of heavy menstrual bleeding can result in anaemia due to loss of iron. A diet which is high in iron or the use of iron supplements may be necessary.

A woman may control her heavy menstrual bleeding by:

Premenstrual Syndrome (PMS):

PMS is the term used to describe a range of symptoms experienced by a woman prior to her period.

The symptoms are due to hormonal fluctuations and usually go away when the period starts.

Just as there is a large variation in women's experience of PMS there are a large range of approaches to the management of PMS. These may include:

If symptoms continue to cause distress in spite of all these measures, consultation with a medical practitioner is advised.

No Period (Amenorrhoea):

If a woman who usually menstruates regularly suddenly misses a period, medical advice should be sought to exclude:

Irregular Periods (Polymenorrhoea):

If periods are irregular or variable in strength it may be necessary to :

This consultation may include:

Epilepsy:

Many women with intellectual disability have epilepsy.

In some of these women the frequency of seizures increases at the time of their periods.

A calendar showing any suspected association between periods and seizures is an excellent aid in diagnosis of this recognised medical condition (Appendix 3). Medical consultation is warranted if such an association is suspected..

Most medical treatments will result in regulation of the woman's menstrual cycle and in some situations may suppress it altogether. However, there will be some circumstances when adequate trials of these less restrictive treatments fail and menstrual suppression has to be considered in the woman's best interest.

When is menstrual suppression necessary?

Menstrual suppression should only be recommended for:

Menstrual suppression can be temporary or permanent.

The temporary suppression of menstruation can be accomplished by the use of certain medications. Medications in common use include Depo-Provera, norethisterone or combined oral contraceptives used continuously. These should only be administered after a thorough assessment of the woman's health.

Where a woman cannot give informed consent to pharmacological menstrual suppression this should be sought through :

If she has no guardian or if consensus of opinion cannot be reached, a guardian may have to be appointed through the Guardianship and Administration Board.

Permanent suppression of menstruation can be achieved by surgical intervention.

Surgical interventions which result in permanent suppression of menstruation include:

Medical conditions which require hysterectomy to be accompanied by bilateral oophorectomy (surgical removal of both ovaries), will result in a cessation of both menstruation and the hormonal fluctuations which accompany it, unless cyclical hormonal replacement therapy is instituted.

These surgical interventions result in infertility, hence are considered to be major medical procedures. Application for consent must be made to the Guardianship and Administration Board (for adults) or the Family Court of Australia (for children).

Is menstrual suppression acceptable as a behaviour management intervention?

There may be a few situations where menstrual or pre-menstrual conditions cause a woman to injure herself or others or to persistently destroy property.

Menstrual suppression for behaviour management can only be considered in these cases if less restrictive approaches are unsuccessful after an adequate trial.

Menstrual suppression by medication is considered to be a chemical restraint and can only be used in accordance with Section 44(3) of the Intellectually Disabled Person's Act 1986 which states :

"Chemical means of bodily restraint of an eligible person can only be applied if that restraint is necessary :

To prevent a person from causing injury to herself or any other person or to prevent a person from persistently destroying property"

Spreading of blood, distress at bleeding, incontinence, hygiene problems or infection control e.g. hepatitis B or C cannot by themselves justify hormonal or surgical intervention.

A Final Comment:

It is important to remember that, while there is a wide range of menstrual hygiene products and educational materials available, the success of any menstrual management program will depend largely upon adequate communication and co-operation. Ultimately, however, it will be the enthusiasm and initiative of the women, staff and corers that will determine its outcome.