Healthcare for Women with Disabilities: Challenges and Breakthroughs

You're listening to ReachMD XM160, The Channel for Medical Professionals.  You're listening to ReachMD, The Channel for Medical Professionals.  Welcome to Advances in Women's Health, I'm Dr. Lisa Mazzullo, your host and with me today is Dr. Cassing Hammond, Director of the section, a Family Planning and Contraception at Northwestern University, Medical Hospital.  He is also the director of OB-GYN Services at the Rehab Institute of Chicago.

DR. LISA MAZZULLO:

Welcome, Dr. Hammond.

DR. CASSING HAMMOND:

Thank you.  It is nice to be here.

DR. LISA MAZZULLO:

It is a pleasure to have you.  Today, we are going to be discussing some of the challenges and the needs that need to be met a women with disability that you're specifically very close to as part of the director of OB-GYN Services at RIC.  Tell us a little bit about your practice there?

DR. CASSING HAMMOND:

Well.  We have a Center for women with disabilities at the Rehab Institute.  It's multidisciplinary clinic that really serves women with about every kind of physical as well cognitive disability that you can name.  I see patients along with another gynecologist and nurse practitioner and also in conjunction with the team of physiatrist and patients on any given day could have multiple sclerosis, spinal cord injury, traumatic brain injury, transverse myelitis, and cerebral palsy, really almost any physical or cognitive disability, comes into our clinic to receive comprehensive women's health care.

DR. LISA MAZZULLO:

Why do you think, there was aneed for separate reproductive health clinic for women with disabilities.  Isn't the idea of the Americans with disability act that every one should be able to seen in the same clinic setting?

DR. CASSING HAMMOND:

That's actually,one of the most difficult issues that we can frank, as you get it or heard what disability really is and whether a clinic such as thisdoes need to exist and if you really accept that as the Americans with disabilities act does, the whole contextual or social model of disability.  Disability is not just regroup, it is not something that a person belongs, or it doesn't belong to, it's really something all of us have it periods throughout our life and often involved, they were coming social on other artificial barriers that impose that on the individual.  So, with that kind of a framework yet, all of these patients that we see at our RIC in the Women Center really should be able to be seen in private offices because there should be no barriers to them.  Now what's interesting is if you accept the exact opposite model of disability, which is the medical model, which assumes that disability arises in the individual and is something to overcome a lot of tiny Tim in a Christmas carol or even the approach that Christopher Reeves did take.

DR. LISA MAZZULLO:

Well, then you still last with this issue of why is that we segregate women's reproductive health care when you've got clinic that are providing comprehensive care based on the disability already at RIC?

DR. CASSING HAMMOND:

So, I think, the fact that I work in this clinic means, yes, I do recognize or some patient who it's justify of having this clinic, but we are constantly asking ourselves what is that unites our patients?  What is it that our mission is at this Treasury Care Center for Women with disabilities rather than simply sending these patients to routine GYN offices?  I think the place where we come down is first of all our patients internally are seen by both in RIC physiatrist and us.  There are lot of patients whom we say, I think should be seen in the community.  Our patients are a little bit different because they all have a physiatrist also at RIC and are getting multidisciplinary care, but the other things that makes them unique are that they all lack physically accessible reproductive and gynecologic care.  These are patients who often can't be accommodated and in lot of offices just because the officers are unable to see patients of this later this degree of disability.  Most of our patients tend to be viewed as a sexual, so a lot of times if these patients do seek care in private offices.  Gynecologist and other health care providers forget to ask about contraception, to ask about sexually transmitted screen because the immediate assumption is when this person is disabled they couldn't possibly be having sex.

DR. LISA MAZZULLO:

I think that's a remarkably important issue because it's not just aquestion of that.  So, many younger people may have been injured and had started to have a sexuality that they were really enriched with and then are suffering this physical ailment often that is impacting upon them in so many ways that who denied that that exists ever again.  I think it is only adding to the mental instinct and physical concerns these people have.

DR. CASSING HAMMOND:

If I think, you are right and frankly, a lot of these patients who already suffer from low self-esteem may be even more likely on that basis to be taking sexual risk that we don't know about and health care providers are often quite likely to try to just wait of some these patient from getting pregnant because of certain concerns about the risk of pregnancy that may be or may be not be well founded.  At that same time and this is ironic, they often are also just waiting these patients from obtaining effective contraception either because of unjustified fears of contraception or because of this whole myth of asexuality they don't perceive that they wouldn't be likely to having sex regardless.

DR. LISA MAZZULLO:

Interesting, I would like to talk on about more about that because obviously there are other reasons for contraceptive to be used besides contraception, you know for control of menorrhagia or the period for a women who is very difficult to deal with the hygiene of the situation and so do you think that oral contraceptives can be used in patients who have a significant physical disability?

DR. CASSING HAMMOND:

A lot of what we do at the Rehab Institute is not truly evidence-based and I would like to see that as a preface to this discussion and it's probably going to be hard to get good evidence with respect to disability because it is very uncommon that we deal with pure disability.  Often times, our patients, for example, have spinal cord injuries and some degree of traumatic brain injury and so, it is hard to get uniform groups to give good evidence.  So, what of all we rely on appeals to physiology and also knowing what we're doing at RIC and what of these other specialty clinics are doing to kind of create standard of care?  With respect to birth control pills you're exactly right, combination oral contraceptive have a lot of good both contraceptive and non-contraceptive benefits in this population because not only do a lot of these patient need birth control, but a lot of them if they have menorrhagia or have severe hygienic issues, trying to deal with menstrual blood, trying to deal with anemia, trying to deal with menstrual blood that they already had decubitus ulcers and so forth and to the ability to regulate cycle is greatly beneficial to these patients.  They also have, they suffered some kind of cognitive deficit.  Often caregivers will report some acting out around time of menses or behavioral disorders.  So, if we can use combination oral contraceptive, for example to make patients amenorrheic, and will often also improve well being for people who have cognitive defects.  Now the problem is everyone's worry is venous thromboembolism because we're often dealing with patients who are chronically immobilized, but the chance that we take in many other centers for women with disabilities have taken is that our patients are not the same as people who are chronically immobilized because of postoperative situations.  Our patients even some have spinal cord injured are often doing transfers and squeezing capacitance vessels that they're not truly immobilized in the sense of other patients.  We have people who are out their in wheelchair, playing basketball and doing track events.  Frankly, the joke I often point out with the nurses, which is far from the truth, lot of these patients are much more physically active than I am without a physical disability and yet we allow to give them what may well be one of the safest options in order to prevent pregnancy and also to control hygiene issues for them.  So, we use them we are just try to minimize the estrogen dose in these patients and often we will try at least it for first 20 micrograms pills instead of 30 to 35 mcg to see we can regulate them with us.

DR. LISA MAZZULLO:

If you're just tuning in, you're listening to Advances in Women's Health.  I am Dr. Lisa Mazzullo, your host and we are being joined today by Dr. Cassing Hammond, a Director and physician at Northwestern University Medical Center in the section of Family Planning and Contraception and the Director of OB-GYN Services at the Rehab Institute of Chicago.

In discussing patient particularly women with disability even contraception issues.  We were just saying that combined oral contraceptive can be used in low doses or then we will try if someone doesn't tolerate or chooses not to use that particular type of contraception.

DR. CASSING HAMMOND:

Sure, but again they all kind of have their own advantages and disadvantages.  We are using alternatives to oral contraceptives in people who let's say can't swallow the pill or they still use something that has estrogen.  So, we do have a number of patients here, for example, using NuvaRing, which gives them great cycle control.  The only problem is lot of people who have denervation atrophy of the pelvic floor may have some trouble holding the NuvaRing in place or if they don't have use of their hands they may not be able to check for it's presence or the places so, they need to have a caregiver, who can do so for them, but we have a number of patients with spinal cord injury who are successfully using NuvaRing and also using it continuously to make them feels amenorrheic.  Depo-Provera is also quite commonly used among our patients, but there are certain side effects with Depo that we are particularly concerned about in this population.  Weight gain is an issue because a lot of our people who are spinal cord injured already who had risk for becoming heavier and heavier and so giving them yet another agent that may compound this problem, can be a problem.  Depression is often an issue with Depo and depressive illness is more common among a lot of women with disability, so we are particularly tuned to  I see and then there is the issue of osteopenia and when I wear my other hat as director of Family Planning Program, I am very guarded about bringing this up because I think that the issue of osteopenia in non-disabled adolescence has been incredibly overplayed, it is probably not a significant problem in most teenagers and others who are on Depo and I usually encourage people to use this but at RIC, where we have people who are truly chronically immobilized and often already osteoporotic, we are a little bit cautious with this use on a long term basis, because it may make a bad situation already worse.

DR. LISA MAZZULLO:

What do you think about IUDs with these patients?

DR. CASSING HAMMOND:

Well, IUDs are interesting, because we're starting to use them more and more and it's interesting to me because we got a call a few years ago from a darkened Argentina and I would say that by the way we get calls and appreciate calls and e-mails all the time, because people often will get one of these patients and the wonder what are people who actually deal with this recurrently doing and so, we don't mind telling them what we and some of the other sides are doing.  But this reticular doc had gone through the Center for Research on Women with disability web site or crowd and found a summary of Margaret  very importantdataregarding disability and there is something buried in that site is that IUDs are contraindicated and women with spinal cord injury and we looked at ourselves and said haa!, where is this coming from ? because there is no published data and we actually like IUDs in this population.  The fear I think, people have had especially in some women with spinal injury has been, if you have somebody with a high spinal cord lesion, usually above T6.  If you're using a copper-bearing IUD, which can increase the amount of menstrual flow, could you potentially exacerbate autonomic dysreflexia at least during the time of these people's menstrual periods?  And there has also been the concern is if somebody puts in an IUD, and does develop a pelvic infection can they sense signs of infection or would they potentially be at risk for having a more severe infection before it's caught given their inability to have sensation and then finally, they can't often feel to tell if it is expelled or check for the string.  Yet, we don't feel these are significant issues, because IUDs are overall is a safe and we frankly think now with a Mirena, which can potentially decrease the amount of menstrual flow that the converse of most of these things may be true that the Mirena IUD may by regulating their cycle give them the hygienic issues we spoke about earlier and for those people with high spinal injuries actually protect against dysreflexia during the menstrual periods.

DR. LISA MAZZULLO:

Women with disabilities make up a diverse population of often underserved women.  We believe a climate of respect, clinical expertise, and special consideration, can you prove their care and improve clinical success for women with disability.

Thanks to Dr. Cassing Hammond,who has been our guest and we have been discussing the challenges of carefor women with disabilities in gynecology.

I'm Dr. Lisa Mazzullo.  You have been listening to the Advances in Women's Health, from ReachMD, The channel for Medical Professional.

Please visit our web site (www.reachmd.com) which features our entire library through on demand podcasts, for call toll free with your comments and suggestion at 888-639-6157.

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