According to the Centers for Disease Control and Prevention (CDC), there are over 12 million children and adolescents aged 3 to 17 years with a diagnosed developmental disability.

This number is growing, with the CDC reporting an increased incidence of developmental disabilities in children and adolescents from 16.2% between 2009 and 2011 to 17.8% between 2015 and 2017.

 Although adolescents with disabilities make up a significant portion of obstetricians and gynecologists’ patient panels, specific training on the best care for this population is often lacking.

The reproductive health care of adolescents with disabilities has been fraught with a painful history—including forced sterilization, which has lasting impacts on patients to this day. A recent study found that 15- to 40-year-old females with physical or sensory disabilities are at an increased risk of sterilization (odds ratio, 1.36; CI, 1.03-1.79) after adjusting for age, race, ethnicity, marital status, insurance, parity, and self-reported health.

 Additionally, the disproportionate incidence of sexual violence against children with disabilities is staggering.

 Recent research suggests that children with disabilities are 3 times as likely to experience sexual violence as those without disabilities, with the highest rates of violence occurring between aged 12 and 15 years.

Furthermore, adolescents with disabilities receive inadequate sexual education and counseling regarding contraception and experience higher rates of sexually transmitted infection and unplanned pregnancy.

 Finally, even in the past 2 decades, it has been well documented that patients with disabilities are less likely than their peers to receive appropriate breast and cervical cancer screening.

 provides a comprehensive description of the sexual and reproductive health disparities that affect adolescents with disabilities. It is imperative that providers better understand how to care for this patient population so that all patients are treated with the dignity, respect, and compassion they deserve.

General approach to patients with disabilities

According to the American College of Obstetricians and Gynecologists (ACOG), “excellent gynecologic health care for women and adolescents with disabilities is comprehensive; maintains confidentiality; is an act of dignity and respecttoward the patient; maximizes the patient’s autonomy; avoids harm; and assesses and addresses the patient’s knowledge of puberty, menstruation, sexuality, safety, and consent.”9As demonstrated in 

, adolescent women with disabilities face several interrelated barriers to this excellent gynecologic health care.

Many of the most critical aspects of providing quality care to adolescents with disabilities are not groundbreaking techniques but rather, common-sense practices that empower patients to be active participants in their own health care. It is imperative that the provider assess the patient’s competence and ability to communicate without making assumptions that caregivers should speak on behalf of the patient. This can sometimes be met with discomfort from well-intentioned families who are accustomed to having a large amount of control over an adolescent’s life. However, it is essential to provide health care in a way that gives maximal autonomy to the patient based on age and level of competence—not the comfort of family members.

Speaking directly with patients in an adult tone and working to establish familiarity and rapport can also improve care in patients with disabilities. Furthermore, it is beneficial to ask adolescents how they communicate best and be willing to engage with assistive devices. It is crucial to provide an environment that minimizes sensory strain for patients with intellectual disabilities to promote engagement. It is also necessary to assess the physical disability of adolescents and pursue creative options to ensure that they have equitable access to gynecologic exams and procedures if they are indicated.

The physical, mental, and emotional changes that adolescents with disabilities experience during puberty will be largely similar to those of their nondisabled peers. It is important to normalize and anticipate these changes with patients and their families in addition to understanding the special considerations discussed below.

Special considerations in this population

For most adolescents with disabilities, the process and pattern of menstruation vary little from those of their peers. No matter the timing of puberty, ideal sexual health care of adolescents with disabilities involves anticipatory guidance that begins before menarche, when breast development begins.

Specific disabilities that can be anticipated to affect the tempo and timing of puberty include Prader-Willi syndrome and spina bifida. Patients with Prader-Willi syndrome often experience delayed or incomplete puberty with sustained irregular menstruation.

 Patients with spina bifida, especially those with myelomeningocele, may experience central precocious puberty and require prompt referral to a pediatric endocrinologist to minimize unwanted side effects.

 There is conflicting evidence on the timing of puberty in adolescents with autism spectrum disorder (ASD), with a recent study suggesting that there is no statistically significant difference in pubertal timing for adolescents with ASD compared with the rest of the population.

During puberty, patients may have an increased sense of separation from their peers, which can result in challenges with friendships and social isolation.

 Normal mood changes during puberty may be especially challenging for patients with disabilities, who may already be struggling with emotional regulation, communication, and age-appropriate behavior.

Physical interventions required for monthly menstruation, such as pads or tampons, might be difficult or impossible for adolescents with certain disabilities to use. Menstrual suppression is therefore one of the most common reasons patients with disabilities seek gynecologic care. In a retrospective study of 300 adolescents with developmental disabilities ranging in age from 7 to 19 years, the main reason patients sought care was menstrual suppression, followed by hygiene and caregiver burden14 

.Patients with cognitive or physical impairments who make appointments for pubertal anticipatory guidance typically present 13.5 months prior to menarche,

 with more than half of families describing potential behavior changes as their main concern.

It is important to note that menstrual suppression is not recommended prior to menarche, according to ACOG’s Committee on Adolescent Healthcare.9 As with all patients, menstrual suppression plans should be individualized following discussion of all options (pill, patch, ring, shot, implant, intrauterine device [IUD]) and elucidation of adolescent preference. Families will sometimes ask about surgical options for menstrual suppression (hysterectomy) but these should be reserved only for medically indicated reasons such as cancer or when all other treatment options have been exhausted. According to ACOG, endometrial ablation is never recommended for menstrual suppression in adolescents. 

Setting expectations with families is a crucial component of menstrual management for adolescents with disabilities. Families may be unaware that surgical treatment to permanently end menses will not affect the mood changes that occur with menses. Additionally, it is important to emphasize that complete amenorrhea may be difficult to achieve with medical management. All menses management methods have benefits and drawbacks; see 

 for an overview of factors to consider when deciding on the best method to use.

Previously, the most popular contraceptive method for adolescents with disabilities was depot medroxyprogesterone acetate (DMPA) because of its injection form and possible resultant amenorrhea with long-term use.

However, because DMPA is associated with loss of bone mineral density, other forms of contraception without this side effect are often considered first line today. Oral contraceptive pills (OCPs), hormonal transdermal patches, and levonorgestrel IUDs are safe and common agents for menstrual suppression in adolescents with disabilities.

 Amenorrhea is often achieved via continuous hormone therapy (with OCPs or transdermal patches) or levonorgestrel IUD placement. In a 2021 study, of 30 patients with disability who desired hormonal management of menses, 30% had an IUD placed, 30% chose OCPs, and 20% chose oral progestin. Ninety-six percent were satisfied with their final bleeding pattern and 50% achieved amenorrhea.

 The remaining 20% of patients who chose not to begin hormonal management of menses demonstrate that providing education and resources prior to menarche can equip patients and their families to manage menses without medication.

It is important to mention the small but well-supported increased risk of venous thromboembolism (VTE) with estrogen-containing contraceptive methods. The population of adolescents with disabilities includes many with limited mobility, wheelchair dependence, or other baseline risk factors for VTEs. Data from 2019 suggest that patients with cerebral palsy are at an increased risk of VTE whether they are ambulatory or not.

 Although VTE is incredibly rare in adolescents (estimated 0.07/10,000 children < aged 18 years),

 we recommend weighing each patient’s specific risk factors and opting for progestin-only options for menses management in patients with multiple risk factors.

According to ACOG’s practice bulletin on noncontraceptive uses of hormonal contraceptives, data show that levonorgestrel IUD placement and endometrial ablation have similar reductions in menstrual blood loss up to 24 months, supporting the effectiveness of IUDs in menses suppression.

 IUD insertion can prove more challenging in adolescents with disabilities, however, sometimes requiring intravenous (IV) sedation or general anesthesia in the operating room (OR) for placement. A recent study looking at 159 females under 22 years who had disabilities found that of 189 IUDs placed in this population over 10 years, 96% of insertions were done in the OR. Continuation rates were high, with 95% of patients keeping their IUD at 1 year and 73% at 5 years.15 It is also not uncommon to combine IUD insertion with other medical procedures requiring IV sedation or the OR. Cervical cancer screening (Papanicolaou test) at the time of insertion is recommended
if appropriate.


Sexual health education can be challenging and uncomfortable for all adolescents, and this is no different for patients with disabilities. For centuries, incorrect beliefs about adolescents with disabilities, including a presumed lack of sexual desire/activity, and lifelong infantilization led to neglect of sexual health in this population. Sexuality education is still often overlooked in this population, and adolescents with disabilities receive far less of it than their peers despite being at an increased risk of poor sexual health.

Discussions with patients can help providers assess patient understanding, knowledge, and attitude toward sex and sexual development. Providers should educate adolescents on a wide variety of topics, including the anatomic and physiologic changes of puberty, sex and sexual development, gender identity, healthy relationships, safe online practices, consent, and sexual abuse 

Although these topics can be time-consuming to discuss, they can have a profound positive impact on adolescents whose sexuality is often ignored. Help from other providers (nurse practitioners, social workers, sexual health educators) can ensure that patients get adequate age- and development-appropriate teaching. It is imperative to assess an adolescent’s level of cognition, and have at least some discussions of sexual health privately, without the presence of family, if deemed appropriate. In today’s era of virtual visits, it can be challenging to ensure this level of true privacy. Office visits, where both patients and providers can be confident in the privacy of the exam room, may be superior for visits regarding sexual health education.

Teens with disabilities can be vulnerable to abuse and exploitation because of social isolation and restrictions on their reproductive rights. If apt, it is important to discuss with patients what types of touching are inappropriate and to develop a plan they can carry out if they do experience inappropriate touching. In the era of constant online connectedness, both patients and families must be involved in discussing ways to ensure online communication is consensual, safe, and appropriate.

As health care providers, we are uniquely positioned to be involved with and improve the reproductive health care and education of patients with disabilities. It is imperative that we treat all patients equally, offering all sexual and reproductive services regardless of whether a patient has a disability. 

1.Disability and health information for women with disabilities. Centers for Disease Control and Prevention. September 16, 2020. Accessed May 12, 2022. https://www.cdc.gov/ncbddd/disabilityandhealth/women.html

2.Increase in developmental disabilities among children in the United States. Centers for Disease Control and Prevention. May 16, 2022. Accessed May 16, 2022. https://www.cdc.gov/ncbddd/developmentaldisabilities/features/increase-in-developmental-disabilities.html

3.Smeltzer SC, Mitra M, Long-Bellil L, Iezzoni LI, Smith LD. Obstetric clinicians' experiences and educational preparation for caring for pregnant women with physical disabilities: a qualitative study. 

. 2018;11(1):8-13. doi:10.1016/j.dhjo.2017.07.004

4.Wu JP, McKee MM, McKee KS, Meade MA, Plegue M, Sen A. Female sterilization is more common among women with physical and/or sensory disabilities than women without disabilities in the United States. 

2017;10(3):400-405. doi:10.1016/j.dhjo.2016.12.020

5.Legano LA, Desch LW, Messner SA, et al. Maltreatment of children with disabilities. 

. 2021;147(5):e2021050920. doi:10.1542/peds.2021-050920

6. Iezzoni LI, Mitra M. Transcending the counter-normative: sexual and reproductive health and persons with disability.

. 2017;10(3):369-370. doi:10.1016/j.dhjo.2017.04.001

7. Ballan MS, Freyer MB. The sexuality of young women with intellectual and developmental disabilities: a neglected focus in the American foster care system. 

. 2017;10(3):371-375. doi:10.1016/j.dhjo.2017.02.005

8Wisdom JP, McGee MG, Horner-Johnson W, Michael YL, Adams E, Berlin M. Health disparities between women with and without disabilities: a review of the research. 

. 2010;25(3):368-386. doi:10.1080/19371910903240969

9.American College of Obstetricians and Gynecologists’ Committee on Adolescent Health Care. Committee Opinion No. 668: Menstrual manipulation for adolescents with physical and developmental disabilities. 

. 2016;128(2):e20-e25. doi:10.1097/AOG.0000000000001585

10.Crinò A, Schiaffini R, Ciampalini P, et al. Hypogonadism and pubertal development in Prader-Willi syndrome. 

. 2003;162(5):327-333. doi:10.1007/s00431-002-1132-4

11. Almutlaq N, O'Neil J, Fuqua JS. Central precocious puberty in spina bifida children: Guidelines for the care of people with spina bifida. J Pediatr Rehabil Med. 2020;13(4):557-563. doi:10.3233/PRM-200728

12.May T, Pang KC, O'Connell MA, Williams K. Typical pubertal timing in an Australian population of girls and boys with autism spectrum disorder. 

. 2017;47(12):3983-3993. doi:10.1007/s10803-017-3281-3

13.Patel DR, Greydanus DE, Calles JL Jr, Pratt HD. Developmental disabilities across the lifespan. 

. 2010;56(6):304-397. doi:10.1016/j.disamonth.2010.02.001

14.Kirkham YA, Allen L, Kives S, Caccia N, Spitzer RF, Ornstein MP. Trends in menstrual concerns and suppression in adolescents with developmental disabilities. 

. 2013;53(3):407-412. doi:10.1016/j.jadohealth.2013.04.014

15Fei YF, Ernst SD, Dendrinos ML, Quint EH. Preparing for puberty in girls with special needs: a cohort study of caregiver concerns and patient outcomes.

. 2021;34(4):471-476. doi:10.1016/j.jpag.2021.03.008

16.Daunov M, Rondinelli J, Ahuja SP, Stehouwer NR. Prevalence of venous thromboembolism in ambulatory and non-ambulatory patients with cerebral palsy. 

. 2019;134(suppl 1):2428. doi:10.1182/blood-2019-130622

17Spentzouris G, Scriven RJ, Lee TK, Labropoulos N. Pediatric venous thromboembolism in relation to adults. 

. 2012;55(6):1785-1793. doi:10.1016/j.jvs.2011.07.047

18ACOG Practice Bulletin No. 110: noncontraceptive uses of hormonal contraceptives. 

. 2010;115(1):206-218. doi:10.1097/AOG.0b013e3181cb50b5

19Michielsen K, Brockschmidt L. Barriers to sexuality education for children and young people with disabilities in the WHO European region: a scoping review. 

. 2021;21(6):674-692. doi:10.1080/14681811.2020.1851181

Articles

Despite a painful history, equitable care is imperative

Reproductive health care for adolescents with disabilities requires special consideration

The plaintiff was experiencing ongoing pelvic pain and presented to a nonparty physician on February 2, 2011, for laparoscopic lysis of adhesions, laparoscopic left salpingectomy, and laparoscopic ovarian cystectomy. The nonparty physician could not remove the cyst and concluded the surgery instead of converting to an open procedure.

The plaintiff then presented to her primary care physician, who felt a suspected a mass on her left side. An ultrasound was performed, suggesting a large complex cystic mass. Based on the concern for cancer, the primary care physician referred the plaintiff to the defendant, a gynecologic oncologist (Defendant Gyn-Oncologist).

On December 21, 2011, the plaintiff presented to Defendant Gyn-Oncologist’s office for a history of a complex 7-cm mass in the left pelvis. Defendant Gyn-Oncologist explained to the plaintiff that the risks of surgery included risk of injury to adjacent organs and bleeding. Ultimately, the plaintiff agreed to proceed laparoscopically with possible conversion to open.

On January 8, 2012, the plaintiff presented to the Defendant Hospital for a left salpingo-oophorectomy via laparoscopic approach to address a left ovary encased in cyst and scar tissue. Prior to the surgery, Defendant Gyn-Oncologist reiterated the various risks of surgery and the plaintiff filled out consent forms. Defendant Gyn-Oncologist was assisted during surgery by Defendant Fellow and Defendant Chief Resident, as well as Defendant Anesthesiologist.

As per the operative note authored by Defendant Gyn-Oncologist, the surgery was difficult due to excessive scar tissue, and the left ovary was adhered to the left pelvic side wall and encased in scar tissue. Defendant Gyn-Oncologist used the Hasson technique, making a small incision before introducing her instrumentation. She also used a LigaSure device for cutting and lysis of adhesions. The LigaSure was inserted via a port and the port incisions were made in the lower quadrant. During the surgery, Defendant Gyn-Oncologist needed to manipulate the infundibulopelvic (IP) ligament, medial to the left external iliac artery, to gain access to the left ovary. Because of the extensive scar tissue, dissection was required in the area of the left external iliac artery, IP ligament, and left ovary, as they were all adherent to the left pelvic side wall. Good hemostasis was achieved with no evidence of active bleeding at the site of the interrupted IP ligament or the left pelvic side wall following dissection to free up the left ovary. The plaintiff had an uneventful postoperative recovery in the postanesthesia care unit, aside from expected postoperative pain. She was discharged home on the same date.

The plaintiff called the hospital the following day and complained of “numbness and tingling in her left leg.” Defendant Gyn-Oncologist and Defendant Anesthesiologist were informed, and a nurse called the plaintiff back and the plaintiff indicated she had spoken with Defendant Gyn-Oncologist. Defendant Gyn-Oncologist spoke with the plaintiff on January 10, 2012, and told her that she could be experiencing paresthesia as a result of being placed in the dorsal lithotomy position during surgery and to call if the condition worsened. The next day the plaintiff called and complained of coldness and pain in her foot and was directed to return to Defendant Hospital or the nearest hospital. Defendant Gyn-Oncologist’s office referred her to the vascular lab, where ankle-brachial index and pulse volume recording studies were performed. These studies revealed diminished flow to the lower portion of the plaintiff’s left leg. As a result, she was admitted to Nonparty Vascular Surgeon’s service, and surgery was performed.

On January 12, 2012, Nonparty Vascular Surgeon performed a repair of the left external iliac artery and venous injuries. During this surgery, Nonparty Vascular Surgeon injured the venous structure while attempting to get access to the artery, given that all the vessels and surrounding tissues were amalgamated along the left pelvic side wall, secondary to scar tissue. The injury was noticed and repaired intraoperatively without incident. Nonparty Vascular Surgeon also found a “focal injury” (a “kink” in the artery per Defendant Gyn-Oncologist, who was present to observe the surgery) to the left external iliac artery, which was repaired with good return of blood flow.

The plaintiff was discharged home on January 15, 2012. She followed up with Nonparty Vascular Surgeon on January 23, 2012. At this visit, the plaintiff had no complaints and was walking around without difficulty. On February 2, 2012, the plaintiff saw Defendant Gyn-Oncologist for a postoperative checkup. Defendant Gyn-Oncologist’s note on this date described the procedure performed in extensive detail. She indicated that the injury to the artery could have been thermal, or traction related.

Six months later, the plaintiff had another follow-up visit with Nonparty Vascular Surgeon. She was noted to be doing well with no complaints and had no difficulty walking around. The plaintiff’s last visit with Nonparty Vascular Surgeon was on June 10, 2013. At this appointment, she was walking without difficulty. Examination revealed a weak palpable right pedal pulse and Nonparty Vascular Surgeon could not appreciate the left pedal pulse. He recommended a noninvasive arterial study and encouraged her to refrain from smoking and to stay active. It did not appear that the plaintiff underwent this study as recommended or followed up with any vascular doctors. The record also makes note of an apparent “bug bite” that was not healing.

In her deposition, Defendant Gyn-Oncologist noted that although the primary concern for the referral was a palpable mass in the presence of history of metastatic colon cancer, the plaintiff was also dealing with chronic pelvic pain.

Plaintiff alleged that the injury was a “severed” left external iliac artery. In the Amended Bill of Particulars, plaintiff claimed the defendants caused a retraction injury, failing to visualize the left iliac vessels, failing to check the lower extremity pulses prior to closure of the surgical site, and failing to tell the plaintiff to return to the hospital immediately.

The plaintiff alleged she sustained a “severed” left iliac artery requiring repair, extensive scarring, 3 large holes in the abdominal area, left leg nerve and motor damage, lack of feeling in the left thigh, pain when bending the left leg, increased pain when ambulating, inability to self-ambulate, need for physical therapy, pain and suffering, and loss of enjoyment of life. She also claimed she was experiencing ongoing extremity numbness and weakness.

The patient testified she had wanted an open procedure but agreed to have the surgery performed laparoscopically. On the day of the surgery, she woke up and was told the mass had been removed; she was given discharge instructions and went home. She first started experiencing pain in her abdomen and leg in the car on the way home. When she went into her bedroom, her legs buckled and she fell asleep. When she got up to go to the bathroom in the middle of the night, her leg felt numb. That morning she had pain, and her leg felt as though it were falling asleep.

She called the hospital and an anesthesiologist called her back and said the stirrups could impact her nerves but it would resolve. When Defendant Gyn-Oncologist called her, her toes were turning blue and she was told to return to the hospital. Following surgery she went to the intensive care unit. She testified that while in the intensive care unit, she asked Defendant Gyn-Oncologist what had happened, who replied that the “cyst” was caught in scar tissue, which was why it looked so large, and that she had removed all the scar tissue and had “nipped” her and “did not see it.”

The patient also testified that the vascular surgeon told her that hers was “the most complicated case” he had done, but that he was not going to let her lose her leg. She returned to work 2 weeks later but testified that she continues to have numbness in her inner left thigh and groin pain.

In her deposition, Defendant Gyn-Oncologist noted that although the primary concern for the referral was a palpable mass in the presence of history of metastatic colon cancer, the plaintiff was also dealing with chronic pelvic pain. Defendant Gyn-Oncologist discussed the standard risks of surgery, including the risk to adjacent organs, which would be secondary to expected findings of scar tissue, which can alter normal anatomy. The “usual” organs injured in a case such as this are the small bowel and ureters, which lie in close proximity to the mass.

The defendant’s expert believed the cause of the injury was likely manipulation during surgery in the face of extensive adhesive tissue, which was clearly necessary under the circumstances.

Defendant Gyn-Oncologist later testified that there was an amalgamation of vessels and organs plastered to the left pelvic side wall secondary to extensive scar tissue. Ultimately, the patient agreed to proceed laparoscopically, with possible conversion to open. As to the surgery, it was difficult, secondary to excessive scar tissue in the pelvis, especially the left pelvis. The left ovary was adhered to the left pelvic side wall and encased in scar tissue. Defendant Gyn-Oncologist stated that “generally” these types of surgeries are performed in a “2-hour time frame,” and that this surgery was slightly longer than that.

Notably, Defendant Gyn-Oncologist did not recall whether she had specifically visualized the left external iliac artery, although she insisted that she made certain when she cuts that no organs or vessels are in the way. In this case, because of the extensive scar tissue, dissection was required in the area of the left external iliac artery, IP ligament, and left ovary, as they were all adherent to the left pelvic sidewall. She testified that the rationale for performing retraction and/or dissection and/or lysis of adhesions would have existed whether the procedure had been done via an open technique or laparoscopically. Defendant Gyn-Oncologist stated that although there was no “active” bleeding, there was a fair amount of oozing from the surgical site.

Defendant Gyn-Oncologist was not involved in the discharge but recalled speaking with the patient on the first postoperative day after being advised of her paresthesia of the left foot. Defendant Gyn-Oncologist recalled being made aware on the second postoperative day that the patient was now complaining of coldness and pain in her foot and directed her to immediately return to the hospital. She recalled there being a “kink” in the iliac artery that was repaired without incident and that the vein was injured–and repaired–during the vascular surgery. She opined that the etiology of the injury was either retraction or heat transference during cautery, thereby causing injury to the intima and allowing platelet propagation and development of thrombus.

The defendant’s expert felt the only way to perform this surgery was laparoscopically, as the plaintiff had an extensive surgical history and likely many adhesions. Additionally, use of the LigaSure device was appropriate, as it controls heat transference beyond the surgical site. Ideally, a surgeon would dissect all the way down to the vasculature. In this case, given the extensive scar tissue, once the mass was extricated there was no longer a reason to dissect further, as that would have exposed the patient to potential injury.

The patient’s expert opined that the vasculature and pulses should have been examined before closure and discharge, but the defendant’s expert opined that this was not the standard of care for a gynecologic surgery. Other than ordinary observation prior to closure, nothing else was required. There was also no indication for pulse checks prior to discharge; the patient herself testified that her problems began to manifest after she was discharged.

The defendant’s expert believed the cause of the injury was likely manipulation during surgery in the face of extensive adhesive tissue, which was clearly necessary under the circumstances. He also opined that because of the anatomy in this presentation (the artery sitting below the encased ovary in the presence of extensive adhesive tissue), the risk of a retraction injury to the vasculature existed regardless of surgical technique used. As to the plaintiff’s complaints of lack of sensation to the left thigh, there are sensory nerves that sit atop the ovaries. During an oophorectomy a patient may have an injury to these sensory nerves, but most regenerate and heal within
6 months. Nonetheless, these nerves do not have an effect on motor function or deep sensation.

The patient’s expert opined it was a departure from standard procedure that none of the physicians checked the patient’s pulses before closing or in the postanesthesia care unit prior to discharge. He also opined that failure to visualize the left iliac vessels was a departure from good surgical practice. Moreover, he opined that the hospital staff should have insisted the plaintiff return to the hospital immediately after the first phone call.

Dismissals were obtained as to the residents involved. The patient’s current records and surveillance belied her claimed permanent motor injuries. After negotiation, the case was settled for a moderate amount prior to trial.

While, the injury was a known risk of the surgery and essentially unavoidable, there was strategic concern that the vascular surgeon would testify at trial that neither of the injuries occurred at his hand, thus implicating Defendant Gyn-Oncologist in 2 vascular injuries during the same procedure. Given the significant diminution in the plaintiff’s demands to resolve the matter prior to trial, the decision was made by all concerned to settle the case fairly nominally rather than subject the physicians to trial.

Was this vascular injury the result of negligence? 

Plaintiff alleges surgeons caused “severed” iliac artery injuries

Nearly half (45%) of all pregnancies in the United States from 2015 to 2019 were unintended.

 The majority of such pregnancies occur in patients who are not using contraception or are inconsistently using contraception. Emergency contraception is treatment to prevent pregnancy after unprotected vaginal intercourse or when there has been a contraceptive failure, and has an important role in reducing unintended pregnancy.

Unfortunately, patients are likely to receive inaccurate information about emergency contraceptive pills from retail pharmacies.

Additionally, significant gaps exist in training and knowledge of emergency contraception among obstetrics-gynecology and family medicine residents.

For these reasons, as well as the concerns stemming from anticipated changes in the legal options for reproductive health care across the United States, clinicians must remain vigilant about their knowledge being up-to-date to dispel misinformation and help patients make informed decisions 

Two FDA-approved emergency contraceptive pills (ECPs) are available in the United States: oral levonorgestrel 1.5 mg as a single dose (Plan B One-Step or generic equivalents) and oral ulipristal acetate 30 mg as a single dose (Ella).

 The 2-dose levonorgestrel regimen is no longer manufactured. ECPs are not indicated in the setting of known pregnancy, but do not harm or disrupt an existing pregnancy if inadvertently taken. A urine pregnancy test is not required prior to administration of ECPs and there are no absolute contraindications. Specifically, ECPs are acceptable in patients with medical comorbidities such as cardiovascular disease, a history of venous thromboembolism, or a history of ectopic pregnancy. Women who are lactating may also safely take oral levonorgestrel. ECPs may be less effective in patients with obesity (> 75 kg) or a history of malabsorptive bariatric surgery, but there are no safety concerns regarding these populations.

Both ulipristal and levonorgestrel can cause nausea; if vomiting occurs within 3 hours of taking an ECP, another dose should be administered.

Single-dose oral levonorgestrel may be taken within 72 hours
(3 days) of unprotected intercourse or contraceptive failure. It is available over the counter to individuals of any age or gender without a prescription or an ID being required.

 The primary mechanism of action is prevention of ovulation. The drug may also alter the endometrium to inhibit implantation but isnot effective once implantation has occurred. Single-dose levonorgestrel prevents up to 84% of expected pregnancies and is more effective the sooner it is taken after unprotected intercourse or contraceptive failure. It will not affect long-term fertility and patients may resume or start hormonal contraception without delay. Levonorgestrel is typically well tolerated, but adverse effects include menstrual changes, nausea, vomiting, lower abdominal pain, fatigue, headache, dizziness, and breast tenderness.

Single-dose oral ulipristal acetate is available by prescription only and may be taken up to 120 hours (5 days) after unprotected intercourse or contraceptive failure. Ulipristal acetate is a progesterone agonist/antagonist that postpones ovulation. In clinical trials, the expected pregnancy rate of 5.6% without emergency contraception was reduced to 1.9% with ulipristal acetate.

 When compared with levonorgestrel, the pregnancy rate was lower with ulipristal acetate (1.4% vs 2.2%).

After taking ulipristal acetate, patients should delay initiating or resuming hormonal contraception for at least 5 days because exogenous progesterone may reduce ulipristal acetate’s ability to delay ovulation. Patients should use barrier methods until their next menses.

Lactating patients should be counseled to express and discard breastmilk for 24 hours after taking ulipristal acetate as its excretion in breastmilk is highest in the first 24 hours.

As with levonorgestrel, common adverse effects of ulipristal acetate include headache, abdominal pain, nausea, dysmenorrhea, fatigue, and dizziness.

Methods without FDA labeling for emergency contraception

The Paragard intrauterine copper contraceptive (CuT380A) and high-dose combination estrogen and progesterone regimen (Yuzpe method) have been used for many years for emergency contraception.

 More recently, there is evidence that the 52-mg levonorgestrel-releasing intrauterine system (Mirena) is effective for emergency contraception as well.

 Neither method has FDA labeling for emergency contraception.

The Yuzpe method comprises a dose of 100 µg of ethinyl estradiol and
0.5 mg of levonorgestrel taken together, followed by a second dose of both hormones in 12 hours. This regimen is not sold as an emergency contraceptive product but consists of a variety of typical combination hormonal contraceptive pills. Patients using the Yuzpe method are significantly more likely to have nausea and vomiting than those taking single-dose ECPs. This regimen prevents 56% to 89% of unexpected pregnancies.

The CuT380A intrauterine device (IUD) has been used for emergency contraception for over 20 years. It can be inserted up to 120 hours after unprotected intercourse or, if the timing of ovulation is known, more than 5 days after unprotected intercourse if insertion occurs no later than 5 days after ovulation

 Its primary mechanism is preventing fertilization by impairing sperm viability and function and it may also prevent implantation if fertilization has already occurred. It is the most effective form of emergency contraception, with pregnancy rates of 0% to 0.5%.10 Prior to inserting CuT380A, the health care provider must be reasonably certain that the patient is not already pregnant. Other contraindications to insertion are acute pelvic inflammatory disease, uterine abnormality resulting in distortion of the uterine cavity, endometritis in the past 3 months, and known uterine or cervical malignancy. A significant benefit of this IUD is that it can remain in place for 10 years as a long-term contraceptive method.

 However, use of the device for emergency contraception is limited by patients having to undertake an office visit for insertion within 5 days of unprotected intercourse, as well as by cost and insurance coverage; additionally, patients frequently prefer the levonorgestrel IUD over the copper IUD.

The levonorgestrel IUD is the most common IUD selected for long-acting contraception in the United States. A recent noninferiority trial randomly assigned patients to the levonorgestrel 52-mg IUD or CuT380A for emergency contraception within 120 hours of unprotected intercourse. The levonorgestrel IUD was noninferior to the CuT380A , with pregnancy rates of 0.3% and 0%, respectively. Similarly, retrospective data suggest the levonorgestrel IUD functions as emergency contraception.

To date, the American College of Obstetricians and Gynecologists, Society of Family Planning, and the Centers for Disease Control and Prevention have not made recommendations regarding the use of the levonorgestrel 52-mg IUD for emergency contraception; in contrast, Planned Parenthood’s patient education materials include it as an option.

 It is unclear whether use of the levonorgestrel IUD for emergency contraception will become
widely accepted.

Several options are available for patients who are at risk for unintended pregnancy due to unprotected intercourse or contraceptive failure. Emergency contraception is safe and has very few contraindications. It does not cause abortion and does not reduce future fertility. Discussing emergency contraception should be part of all well woman preventive health care encounters, but particularly with patients who are at risk for unintended pregnancy including those who are not using contraception, those using a less reliable form of contraception, or those who may lose access to their contraception options. Although the copper IUD remains the most effective option for emergency contraception and can be inserted up to 5 days after unprotected intercourse, single-dose oral levonorgestrel 1.5 mg is safe, has no contraindications, and is available for patients to purchase without any restrictions due to age, gender, or insurance status. 

1. Unintended pregnancy and abortion in Northern America. Guttmacher Institute. March 2022. Accessed August 9, 2022. www.guttmacher.org/fact-sheet/unintended-pregnancy-and-abortion-northern-america

2. Haeger KO, Lamme J, Cleland K. State of emergency contraception in the US, 2018. 

3. Ritter AH, Isaacs CR, Lee SM, Lee AJ. Single-dose levonorgestrel emergency contraception and silent barriers to its access: is it really just one step

 2018;27(5):646-650. doi:10.1089/jwh.2017.6345

4. Rapkin RB, Griner SB, Godcharles CL, et al. Obstetrics and gynecology and family medicine residents’ training and knowledge on emergency contraception. 

. 2019;28(6):794-801. doi:10.1089/jwh.2018.7297

5. Plan B One-Step. Prescribing information. Duramed Pharmaceuticals, Inc; 2009. Accessed May 20, 2022. www.accessdata.fda.gov/drugsatfda_docs/label/2009/021998lbl.pdf

6. Ella. Prescribing information. HRA Pharma America Inc; 2021. Accessed May 20, 2022. https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/022474s011lbl.pdf

7. Curtis KM, Tepper NK, Jatlaoui TC, et al. US medical eligibility criteria for contraceptive use, 2016. 

. 2016;65(3):1-103. doi:10.15585/mmwr.rr6503a1

8. Kapp N, Abitbol JL, Mathé H, et al. Effect of body weight and BMI on the efficacy of levonorgestrel emergency contraception. 

. 2015;91(2):97-104. doi:10.1016/j.contraception.2014.11.001

9. Plan B One-Step. Fact sheet. PlanBOneStep.com. Accessed June 1, 2022. https://www.planbonestep.com/assets/downloads/plan-b-one-step-fact-sheet.pdf

10. Practice Bulletin No. 152: emergency contraception. 

.2015;126(3):e1-e11. doi:10.1097/AOG.0000000000001047

11. Turok DK, Gero A, Simmons RG, et al. Levonorgestrel vs copper intrauterine devices for emergency contraception. 

. 2021;384(4):335-344. doi:10.1056/NEJMoa2022141

12. Paragard. Prescribing information. CooperSurgical, Inc; 2019. Accessed May 20, 2022. www.accessdata.fda.gov/drugsatfda_docs/label/2019/018680s069s070lbl.pdf

13. How do IUDs work as emergency contraception? Planned Parenthood. Accessed May 20, 2022. 

www.plannedparenthood.org/learn/morning-after-pill-emergency-contraception/how-do-iuds-work-emergency-contraception

Updates on emergency contraception

Contraceptive care is an essential health service; however, inequities will persist until care provision is designed to address the needs of groups who have been marginalized. Patients who come from groups who have been marginalized, or pushed to the periphery of society, are likely to experience racism, discrimination, and overall poor health outcomes.

Research has uncovered disparities in contraceptive use in the United States.

 Individuals who identify with groups that have been marginalized are less likely to use contraception in general, and those who do use contraception are less likely to use highly effective methods (implant, intrauterine devices, or sterilization).

 Traditionally, contraceptive care has focused on the need to prevent pregnancy and unintended pregnancy, rather than considering contraception as a tool that can improve overall health. However, it is important to expand the scope of conversations around hormonal contraception, which can be used as an instrument that both prevents pregnancy and treats a range of reproductive health conditions.

Contraceptive use may be influenced by a number of factors, such as patient education and knowledge, insurance status, access to reproductive health services, health system factors (counseling, trust, satisfaction with provider, and access to same-day devices), and structural factors (systemic racism, laws, policies, and economic inequality). Here, we focus on approaches to contraceptive care that can promote equity.

Obstetrician-gynecologists (ob-gyns) providing contraceptive care must understand the history of coercive reproductive health care among populations that have been marginalized and how this affects communities today. In the 20th century, thousands of individuals were coerced into sterilization based on their racial, gender, or socioeconomic identities and/or ability status.

 Even today, individuals from marginalized groups report bias in contraceptive care. According to findings from a study about contraception use in young individuals, participants felt pressured to use long-acting contraception and perceived provider bias regarding their contraceptive choices.

 Black women reported bias and coercion in data from another study about contraception in the postpartum period.

 It is not surprising, therefore, that patients and their families or communities may hold feelings of mistrust regarding reproductive health care. We must, then, incorporate this knowledge into our contraceptive care and use approaches to care that mitigate bias and discrimination.

Given this historical context, ob-gyns who approach contraceptive care with attitudes aligned with reproductive justice and patient-centered approaches will be well poised to care for patients who have been marginalized. Reproductive justice supports the ability to parent or not parent and to raise children in sustainable environments.

 Health care providers who practice with reproductive justice values are knowledgeable about historical oppression, have skills in leveling power differentials, and work to combat barriers to reproductive autonomy. The American College of Obstetricians and Gynecologists (ACOG) supports adopting a reproductive justice approach to contraceptive care.

 To do this, health care providers must understand their own biases, which they can initiate by completing an assessment such as the Implicit Association Test and by attending unconscious bias workshops or training.

Next, providers should commit to a lifelong approach of mitigating bias that embraces self-reflection, normalizing and destigmatizing bias, and exploring the lived experiences of patients while breaking down power structures.

 This often involves understanding one’s own identity and the identities in the communities they serve, which are often multidimensional. A reproductive justice approach includes using cultural safety skills—those that acknowledge diverse beliefs by engaging patients in humble and inquisitive conversation about their needs.

Finally, focusing on the patient by eliciting their goals and preferences and providing balanced information can reduce bias, establish trust, and promote reproductive justice in contraceptive care 

Ob-gyns who apply the concept of intersectionality to contraceptive care may improve care for marginalized communities. Intersectionality allows a provider to consider how the inequalities that patients of various identities face can be compounded to create poor health outcomes.

 In contraceptive care, intersectionality can help health care providers understand or support contraceptive decision-making. For example, a provider may consider injectable contraception to be the best method for a patient based on the patient’s preferences and medical history. However, by inquiring about their geographic location and socioeconomic and parenting status, for example, as well as their identity-based experiences, the provider may realize that the patient may not have adequate transportation to the clinic or affordable childcare, which would make it difficult for them to return for regular injections. Additionally, the patient may say that their experiences with racism contribute to their wish to avoid multiple visits to the health center. Therefore, this broader understanding of the patient and their experiences may lead the provider to make a different recommendation regarding contraceptive methods. With the understanding that patients come from unique cultures, backgrounds, and communities, health care providers can use an intersectionality lens to provide comprehensive contraceptive care.

Providers who engage in conversations with community members and leaders are well placed to understand barriers and facilitators to reproductive health care and create an open dialogue for advocating for change. Several advocacy initiatives have been successful at improving access to reversible contraceptive methods for marginalized communities; these have focused on improving barriers to contraception such as lack of patient knowledge, cost, lack of provider training in provision of long-acting reversible contraception (LARC), and inability to provide same-day contraception. Contraceptive programs, such as the Contraceptive CHOICE Project, have focused on improving access to reversible contraception among communities that have been marginalized, with a goal of increasing the uptake of LARC.16 This approach has some concerns; for example, the focus on LARC may impair the patient’s ability to exercise reproductive autonomy and result in further marginalization.

 Additionally, these programs have not considered how to approach access to LARC removal to ensure that all aspects of contraception are considered with an equity lens.

In Puerto Rico, however, the Zika outbreak resulted in the initiation of the Zika Contraception Access Network (Z-CAN) program, which advocated for increased provider training of LARC management, secured contraceptive product donations, and negotiated nominal pricing from pharmaceutical manufacturers.

 Innovative partnerships between health care workers, community leaders, and social media influencers were also used to increase knowledge regarding availability of reversible contraceptive methods. This led to an increase in information-seeking behaviors related to contraception use.

 Patients everywhere are increasingly turning to social media platforms such as TikTok, Instagram, and Twitter for information—including regarding their health.

 As we consider how epidemics affect contraceptive care, it will be important to use social media and engagement to improve education and access.

The Zika crisis in Puerto Rico further exemplified the gains in contraceptive access that can be made when advocacy extends beyond the individual patient-provider interaction. The Z-CAN program was able to provide contraceptive care to over 21,000 women, with over 20,000 receiving same-day provision of their contraception of choice.

 Expansion of contraceptive coverage through the Affordable Care Act (ACA) was associated with improvements in contraceptive refills and a decrease in births among commercially insured women,

 but did not improve access for women without commercial insurance. In recent years, contraceptive coverage under the ACA has been under attack through policy changes such as the Supreme Court upholding the religious exemptions from the contraceptive mandate.

Ob-gyns are uniquely positioned to advocate on a national level and affect policy decisions that disproportionately affect marginalized populations. Presently, ACOG supports continued access to both FDA-approved contraceptive options without cost sharing and OTC access to oral contraceptives without a prescription from a physician or pharmacist.

The COVID-19 pandemic accelerated innovations in telehealth and virtual care that can be used to increase access to contraception.

 Though the expansion of telehealth services is a viable option to increase access to contraceptive services, it may not address issues related to cultural concerns for privacy or lack of telecommunication connectivity. Telehealth—whether conducted in real time, through interactive audiovideo communication, or asynchronously—allows patients to forgo a physical exam and reduce traveling distance and travel-related costs. This is particularly important in areas of the country that lack readily available access to contraceptive providers or where wait times for receiving care may be prohibitive. Telehealth services provide an opportunity to access a provider remotely and fill prescriptions closer to home through a local pharmacy or mail delivery service.

 Research findings have uncovered concerns about low use of telehealth for contraceptive visits among patients identifying as Black or multiracial compared with all other racial identities.

 This is consistent with health service data showing lower telehealth usage for preventive care among individuals living in marginalized areas.

 There are several concerns about the use of telehealth, such as inequities in accessing the necessary devices or high-speed internet required for 2-way audiovisual communication, discrepancies in reimbursement for telehealth visits,

 and lack of formal telehealth training for providers. Prior to the pandemic, reimbursements for telehealth visits by the Centers for Medicare & Medicaid Services were limited to 2-way audiovisual communication. Since the pandemic, restrictions for reimbursement of some telephone-only encounters have been waived, allowing health care providers to be compensated for visits completed via telephone.

 Formal training can equip providers with tools to establish rapport in the virtual setting and education on common pitfalls encountered with telehealth.

Improving contraceptive access for marginalized populations is a complex and multifaceted challenge that calls for innovative approaches. It requires that ob-gyns first examine their own biases alongside the historical context of the development of contraception in the United States, which often involved coercion of marginalized individuals. Using a patient-centered framework and cultural safety approach is the first step in increasing access to contraceptive services. The role of the ob-gyn is constantly evolving and requires that we serve as advocates for our patients in the exam room and at the national level through policy changes that directly impact them. 

1.Hall JM, Stevens PE, Meleis AI. Marginalization: a guiding concept for valuing diversity in nursing knowledge development. 

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2.Dehlendorf C, Rodriguez MI, Levy K, Borrero S, Steinauer J. Disparities in family planning. 

. 2010;202(3):214-220. doi:10.1016/j.ajog.2009.08.022

3.Sundstrom B, DeMaria AL, Ferrara M, Meier S, Billings D. "The closer, the better:" The role of telehealth in increasing contraceptive access among women in rural South Carolina. 

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4.Stern AM. Sterilized in the name of public health: race, immigration, and reproductive control in modern California. 

. 2005;95(7):1128-1138. doi:10.2105/AJPH.2004.041608

5.Committee Opinion No. 695: Sterilization of Women: Ethical Issues and Considerations. 

. 2017;129(4):e109-e116. doi:10.1097/AOG.0000000000002023

Consider the needs of marginalized patients to promote equity

Vol 67 No 09

Reproductive health care for adolescents with disabilities requires special consideration

Plaintiff alleges surgeons caused “severed” iliac artery injuries

Updates on emergency contraception

Improving contraceptive care for marginalized populations

Inclusion is not erasure

‘Tis the season for vaccination