By Sandra Welner, M.D.
(Updated March 2011)
For several reasons, women with disabilities often cannot find access to good gynecological care. Their doctors don’t believe they could be sexually active, they don’t understand disability concerns, or their exam rooms are not accessible. Here is some hard-to-come-by information.
Vaginal infections such as yeast, Gardnerella and trichomonas are common in all women, but can be more difficult to treat in wheelchair users. Yeast, the most prevalent of three, grows quickly in dark, moist areas that are not well-ventilated — typical of the vaginal area of wheelchair users. Bladder leakage may contribute more moisture.
Preventive measures include keeping the area clean and dry by using absorbent underclothing – cotton instead of nylon – and a pad that can be changed during the day.
If a yeast infection is diagnosed, it should be treated with intravaginal creams or suppositories. Women who have difficulty inserting medication vaginally may be able to use the equally effective oral Diflucan tablet. (Overuse, however, may result in resistant yeast infections that are very hard to treat.) Nontraditional remedies – available over the counter – include intravaginal caproic acid or boric acid capsules, oral and intravaginal acidophilus capsules, and yogurt with live acidophilus cultures.
It has been long presumed that persistent irritation, redness and tenderness in the vaginal area is just a yeast infection that has not been detected. But sometimes, even multiple anti-yeast treatments are not successful. These cases could represent a condition called vulvar vestibulitis. The cause of this disorder is unclear but is thought to have a neurologic component, and thus has been termed neuropathic pain. Antidepressant medications in doses far lower than those used to treat depression sometimes help alleviate this condition.
Urinary tract infections are a common complaint, but prevention depends on the individual situation. If the UTI is caused by bladder muscle dysfunction and inadequate bladder emptying, a simple adjustment in medication may minimize recurrence. Many women, however, find that their bladders require continual vigilance.
Catheterization and sexual activity often introduce bacteria directly into the urethra, and spermicides can decrease resistance to UTIs. Voiding or self-cathing in combination with a one-time dose of an antibiotic such as Macrodantin immediately after sexual activity can help minimize this risk. It has not been substantially proven that cranberry juice prevents recurrence of UTIs, but drinking copious amounts right after intercourse or catheterization has been effective for some women.
UTIs are treated with antibiotics, but when women have had so many infections that they no longer respond to these drugs, surgical reconfiguration of the bladder may be recommended (see Bladder Matters, December 2008).
Birth control options depend on personal circumstance. A woman with rheumatoid arthritis may improve with oral contraceptives, whereas a woman with lupus may get worse and develop blood clots. Women with paralysis are at increased risk for developing blood clots in their legs when using oral contraceptives that include estrogen. For them, contraceptives containing only progesterone may be safer, but the FDA still recommends the same exclusion criteria for these contraceptives as their estrogen counterparts. These types of treatments include progesterone only pills (“mini-pill”); Depo-Provera (a progesterone injection given every three months); and Norplant (progesterone capsules implanted under the skin of the upper arm).
All of these methods have side effects. The mini-pill is slightly less effective than other pills and sometimes causes irregular spotting, Depo-Provera can also cause irregular bleeding, but usually after six to 12 months, periods stop altogether due to a significant drop in estrogen levels. Decreased estrogen could lead to thinning of the bones, which may already be a problem for women who are not mobile. Although calcium supplements help prevent osteoporosis when estrogen levels are adequate, they don’t work well when estrogen is very low. These concerns should be discussed with a doctor.
Irregular bleeding or cessation of menses is also sometimes seen with Norplant, but estrogen levels remain unaffected, so osteoporosis is a less likely consequence. The major problem with Norplant is difficulty inserting or removing the rods, so women with contractures or spasticity probably should not use this method. Also, some seizure medications may lessen the effectiveness of Norplant.
Intrauterine devices provide very effective contraception, but come with a slightly increased risk of pelvic inflammatory disease. IUDs are useful for women with dexterity problems or who can’t take the pill because of a history of blood clots, but are less suitable for women with reduced sensation in the pelvic area. Without sensation, a woman may not be able to detect the warning pains of a pelvic infection, and if left untreated, these can be dangerous or, in very rare cases, even fatal.
Sexually transmitted diseases can occur in any woman who is sexually active or a victim of abuse. Although signs and symptoms may differ according to the woman’s physical disability, most untreated infections can enter the bloodstream and cause serious health consequences. STDs fall into two main groups: nonviral infections that can be treated and cured, and viral infections that can be treated to improve symptoms but can never be cured.
Common nonviral STDs include gonorrhea, chlamydia and syphilis. Women with impaired pelvic sensation may experience chlamydia or gonorrhea as increased spasticity or other vague symptoms. There may also be vaginal discharge.
Syphilis is different. At first, it causes only a variable sized ulcer that may not be painful, even to women who have intact sensation. (If you are sexually active and cannot do self-inspections, make sure your attendant alerts you to any skin changes.) This syphilis sore will stick around for three to 12 weeks and will go away by itself without any treatment. The condition, however, is still in the body. The next stage results in flu-like symptoms and skin rash, which may be difficult to identify because some women with chronic disabilities already experience nonspecific aches and pains, and others take medications that cause skin rashes. If a syphilis infection is not treated at this stage, it will again become invisible and can remain so for months or years. But if it’s not treated, the consequences can be quite serious, including damage to the nervous system, blood vessels and brain.
Common viral infections include herpes, hepatitis, human papilloma and HIV.
Herpes ulcers may be experienced by women with spinal cord injury as muscle spasms, sweating, headache and blood pressure changes (dysreflexia). There is no cure for herpes, but treatment can help the blisters heal faster and make them less painful and less likely to cause dysreflexia. Many women have recurrent herpes outbreaks that are preceded by a prodrome, a premonitory symptom in the location of the previous outbreak. At this point, women with sensation would take medication to prevent the recurrence, but women with sensory impairment need to develop other ways to indentify a prodrome.
Some women with disabilities who were in accidents many years ago may have been infected with the hepatitis virus by blood transfusions without realizing it. Women who contracted hepatitis from transfusions, sexual contact or IV drug use should ask a physician to monitor their liver function. There is no treatment for hepatitis, but restricting toxins such as alcohol may be necessary to avoid its worst effects.
Human papillomavirus (HPV) is common, and women should be screened for it regularly because it predisposes them to cervical cancer. Unfortunately, women with physical limitations often do not have regular pap smears because of access issues. Two FDA-approved vaccines, Gardasil and Cervarix, do exist and can help in preventing the types HPV that cause most cervical cancers. The vaccine is only recommended for women up to age 26. For the greatest benefit, all three doses should be administered before beginning sexual activity.
Symptoms of HIV can be extremely variable, from vague unwell feelings early on to the development of frequent and hard-to-treat infections as the immune system becomes further damaged. But again, many chronic diseases and disability states involve vague feelings of unwellness and fatigue, so women who notice these symptoms may not recognize them as related to HIV. A persistent, unusually nasty yeast infection may signal an immune system problem. Sexually active women should take an annual HIV test if they’ve had more than one partner since their last test or have been involved in any other activities that may transmit HIV.