Female Contraceptive and Reproductive Issues
The sexual and reproductive health needs of women with physical disabilities and chronic health conditions are similar to those of all women; accurate information, accessible health services, supportive and knowledgeable health care providers. However, women with disabilities often encounter a number of obstacles that prevent or limit their access to such services. Issues such as poverty, lack of transportation, reliance on others for personal care, communication difficulties, limited barrier-free facilities, and stereotypes that perpetuate the image of the disabled as being asexual challenge the sexual and reproductive rights of women with disabilities. Since accurate information provides the foundation for effective health care delivery, the following section provides current and concise contraceptive information for a number of specific disabilities and chronic health conditions. The information in each section highlights proven contraindications as well as ongoing research into possible contraindications. Other factors that could influence the choice of contraceptive methods, such as manual dexterity, mobility, and personal hygiene issues are also discussed when appropriate. Following the entries for individual disabilities/conditions is a bibliography of the most recent research literature. It is hoped that the provision of such information with begin to address some of the healthcare inequities that women with disabilities experience.
No contraindications exist for the pill, IUD, condoms. The use of Depo-Provera is not recommended since it increases a woman’s risk of osteoporosis, a condition women with cystic fibrosis are at increased risk of developing. Males with cystic fibrosis are usually infertile, however the use of condoms is still crucial for the prevention of STDs.
There is no conclusive research that documents the affect that estrogen has on the symptoms or progression of the disease. Some evidence exists that symptoms improve during pregnancy only to return in the postpartum period. In addition, some postmenopausal women who take HRT have reported a stabilizing of MS symptoms. However, researchers have not proven that estrogen in the birth control pill will either improve MS symptoms or slow the progression of the condition. In general, the pill is an accepted method of contraception for women with MS who do not have severe mobility impairment. Any use of estrogen based contraceptives is not recommended for immobilized women at risk of thrombosis. The progesterone only pill can be a possible alternative for such women.
Birth control pills that contain a high dose of ethinyl estradiol are not recommended for lupus patients. Some studies have linked high doses of synthetic estrogen with the exacerbation of lupus symptoms. Progesterone only pills, or combination low-dose estrogen pills are preferred alternatives for women without major organ involvement (i.e. active lupus nephritis). Barrier methods of contraception, and the IUD are options for women with lupus.
Research has indicated a relationship between hormonal fluctuations of the menstrual cycle and various types of seizures. Not all seizures are sensitive to estrogen and progesterone ratios, however the possibility that some are must influence the choice of hormonal contraceptives. Anticonvulsive medication can interact with estrogen based contraceptives and the result can be a lowered rate of efficacy. A higher dosage estrogen pill might be appropriate for women using epilepsy drugs that affect the rate at which the liver metabolizes estrogen. The dosage for emergency contraception (morning after pill) will also depend on the type of anticonvulsive medication a woman takes. The use of barrier methods is appropriate for women with epilepsy. Insertion of the IUD can cause a reflex seizure (a seizure that is in response to a specific event) in a small minority of epileptic women.
Contraception for women with diabetes must be evaluated for its potential to affect carbohydrate metabolism and glucose tolerance. The higher dose birth control pills used in the past did have some impact on blood glucose levels and were not always recommended for women with diabetes. However, research indicates that most users of the current low dose pills do not experience significant blood glucose fluctuations. Some physicians recommend progestin only pills since subtle changes in glucose tolerance tend to be more common among users of combination pills. The blood glucose levels of all pill users should be monitored to ensure that fluctuations do not occur, and to determine if diabetes medication needs to be adjusted. There is no extensive research on injectable and implant forms of hormonal contraception. Presently, these forms of birth control are considered appropriate for women with diabetes with the proviso that blood glucose levels be monitored for possible fluctuations. There are no major concerns with the use of other forms of birth control, such as barrier methods and the IUD. However, since women with diabetes are susceptible to vaginal yeast infections, the diaphragm might increase the risk of these infections for some users.
Spinal Cord Injury
Women with spinal cord injuries are at an increased risk for developing deep vein thrombosis due to limited or nonexistent mobility. The use of estrogen containing OCs is contraindicated for this reason. Other hormonal contraceptives are possible alternatives (i.e. progestin only pill, implants, and injectables). The progestin only pill can cause unpredictable bleeding, which may pose a concern for women who have difficulties managing personal hygiene. There is some evidence that injectable contraceptives can predispose women to develop osteoporosis, and this fact could influence the use of such contraceptives by women with severe mobility impairment. The use of the diaphragm is possible for women who have the manual dexterity to manage insertion or for those with a partner who can assist with insertion. However, if the bladder is emptied by pressing on the abdomen the diaphragm could be dislodged. There are some concerns associated with the use of the IUD by spinal cord injured women. Loss of sensation in the pelvic region would prevent a woman from noticing any discomfort or pain that could indicate a perforation, PID or ectopic pregnancy. Women lacking manual dexterity would be unable to periodically check for the strings of the IUD. As well, increased menstrual flow associated with IUD use could present personal hygiene challenges for some women.
The use of oral contraceptives by women with rheumatoid arthritis has been linked to an improvement in symptoms. Some studies indicate a slight reduction in joint damage in women with multiple pregnancies and long term use of OCs. However, research has failed to prove that OC use results in significant long-term improvement of the disease process. The use of OCs is contraindicated for women with severe mobility impairment.
Research has yet to explain the effect that hormones have on the incidence and severity of interstitial cystitis symptoms. Some patients report an increase in symptoms with the use of OCs that contain high levels of estrogen while others find that progesterone containing OCs exacerbate their symptoms. The use of a diaphragm can cause irritation in some women due to pressure exerted on the bladder. Many women with interstitial cystitis are hypersensitive to chemicals found in spermicides and some have allergic reactions to non-latex condoms. The choice of an appropriate contraceptive is dictated by an individual’s tolerance for the method since there are no demonstrated medical contraindications for any specific hormonal or barrier method.
Inflammatory Bowel Disease
Some studies have suggested an association between the use of OCs and the occurrence and relapse of Crohn’s disease, with a slightly higher risk for relapse identified among previous rather than current users. However, since research has not established a statistically significant connection between OC use and the disease course of Crohn’s the use of OCs is generally not contraindicated.