Depo-Provera

NEW YORK -- Although contraceptive injection is widely used in mentally and physically disabled women, many of these patients are candidates for a much wider variety of contraceptive methods, according to Dr. Maida Taylor.

"There is a ton of Depo-Provera [medroxyprogesterone acetate] used in women with disabilities, because it requires one injection every 12 weeks and is highly effective in preventing pregnancy. However, it has a host of side effects such as headache and bloating, weight gain, and irritability and is not for everyone. Clinicians should remember that the disabled are not a monolithic group and are capable of using a variety of contraceptives," Dr. Taylor said at a gynecology symposium sponsored by Symposia Medicus.

Dr. Taylor, of the University of California, San Francisco, reviewed several disabilities and diseases and commented on what contraceptives were suitable for affected women:

* Visual impairment and blindness. "If the underlying cause is thrombotic, estrogen-containing methods may be contraindicated," she said, "but there is no evidence that hormonal contraception accelerates microvascular disease in diabetics. Since pregnancy has a high probability of accelerating retinal disease, effective contraception is essential for susceptible insulin-requiring diabetics."

* Stroke, cerebrovascular accident, and head injury. "Barriers and IUDs are okay. If the underlying disorder is thrombotic, then no estrogen-containing contraceptives should be used. Even if the underlying cause was trauma, be cautious with OCs. While the risk of a future [cerebrovascular accident] attributable to OCs is small, any further damage would be devastating in such cases. Contraceptive implant and progestin injectable might be considered with consultation," Dr. Taylor said.

* Cerebral palsy, polio, and muscular dystrophy. "Use oral contraceptives and other estrogen-containing methods as dictated by how active the individual is. Immobility increases risks of venous thrombotic events. If there is impaired bladder function in the patient, a diaphragm may increase the risk of urinary retention and UTI," she said.

* Mental retardation. "Barrier methods are not suitable for the severely retarded. However, if supervised, oral contraceptives are very useful in this group. Of course, contraceptive injection and implant are widely used with these women. With any and all contraception in this population, consent issues with parents, conservators, or courts may be raised. And there is a need to work with patients so they can comprehend, as much as possible, pregnancy, sexuality, and childbearing."

* Upper-extremity amputation. "Barrier methods are good if there is a partner willing to assist," she said.

* Lower-extremity paresis, paralysis, or amputation. "If confined to a chair or bed, the patient should be treated the same as [are] women suffering from paralytic disorders; namely, do not use the estrogen-containing contraceptive methods," Dr. Taylor said. She also presented a couple of case studies to illustrate the complexities that some patients may present to gynecologists:

* Case 1. A pair of sisters, aged 33 and 35, both have progressive demyelinating inherited disorder. Both were normal until age 19, when they became increasingly impaired intellectually and developed unstable gaits, though both can still walk. Their mother placed them in a skilled nursing facility (SNF) and wants them to have contraception in case of rape. "The staff in the SNF had placed both women on oral contraceptives. Considering that both sisters were becoming increasingly debilitated and immobilized, we advised switching to Depo-Provera," she said.

* Case 2. An 18-year-old had congenital heart disease and, as a result of a cardiac arrest, is partially deaf and completely blind. At age 1, she had a heart transplant and has since been on cyclosporine for immunosuppression. She is fully ambulatory, and is using condoms. "Great care needs to be taken in monitoring cyclosporine levels, since estrogen competes with cyclosporine for metabolism by CYP3A4 isoenzymes, thus posing a risk of increased levels of the immunosuppressant, Dr. Taylor said.

COPYRIGHT 2003 International Medical News Group
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