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GYNECOLOGICAL CONSIDERATIONS IN
TREATING WOMEN WITH PHYSICAL
DISABILITIES
Developed by the Center for Research On Women
with Disabilities, Baylor College of Medicine
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OBJECTIVES

• Identify effects of physical disabilities on
  masking symptoms and creating special concerns in
  reproductive health.
• Describe factors that interfere with diagnosing
  STDs in women with physical disabilities.
• Select special techniques for conducting pelvic
  examinations.
• List the requirements of the Americans with
  Disabilities Act (ADA) for medical facilities.
• Recognize the symptoms of physical and sexual
  abuse, and refer women appropriately.

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Percentage of Women
22
with Disabilities
Compared to
Overall
Population
U.S. Census, 1994.
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FINDINGS
National Study of Women with
Physical Disabilities
94 sexually active Equal rates of STDs 31
denied services Significantly less likely to
receive exams Barriers significantly
discouraging 62 abused
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CASE STUDY
Day 1
HISTORY 24-year-old Complete T2 SCI
Intermittent catheterization
Previous UTIs Yeast infections
EXAM Discharge Frequent leg spasms.
TREATMENT OTC miconazole
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CASE STUDY
Day 11
COMPLAINTS Fever Headache Sweating
EXAM 160/95 70 bpm Bruises Firm,
tender abdomen Elevated WBC
Few bacteria
DIAGNOSIS Urinary Tract Infection
TREATMENT Oral cotrimoxazole
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CASE STUDY
Day 15-ICU
COMPLAINTS Fever Headache Sweating
Nausea Flushing Cold feet
EXAM 210/105 Bowel sounds absent
Firm abdomen WBC 21K w/97
segs Staphylococcus epi, E. Coli
Klebsiella BP elevates w/bimanual
exam (EXAM STOPPED)
DIAGNOSIS Urosepsis
TREATMENT
Nitroprusside drip ceftazidime
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CASE STUDY
Day 16-18
TREATMENT Ampicillin Clindamycin
Exploratory laparotomy drainage
DIAGNOSIS Acute salpingitis and tubo-
ovarian abscess Cultures grow
chlamydia
NOTE Day 18 fever resolves, BP returns
to 100/70 mmHg
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STDs in women w/SCI
Factors Interfering with Diagnosis
Common symptoms absent or undetected
Findings attributed to more common causes
Nonspecific signs and symptoms unrecognized
Delay in seeking medical attention
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AUTONOMIC DYSREFLEXIA
Lesion
Stimulus
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AUTONOMIC DYSREFLEXIA
Symptoms
Severe hypertension Pallor
Piloerection Sweating
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AUTONOMIC DYSREFLEXIA
Management
Education / Prevention Gentle use of
speculum Local anesthetic
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AUTONOMIC DYSREFLEXIA
Treatment
Remove stimulus Gentle use of speculum
Local anesthetic Stop exam Reposition
patient Loosen clothing Check bladder /
rectum Administer short acting
antihypertensive
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THE GYNECOLOGICAL EXAM

• Historymenstrual and sexual
• Examination
• Breastinspection and palpation
• Pelvicspeculum, bimanual
• Rectal
• Screening tests as appropriate
• Mammogram
• Pap Test
• Vaginitis STDs
• Fecal occult blood
• Bone density
• Contraceptive counseling

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PATIENT TRANSFERS
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EXAM POSITIONS
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EXAM POSITIONS
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CONTRACEPTION

• General
• Data scarce
• Effects of hormones on disabilities
• Oral contraceptives
• Thrombotic predisposition
• Effect on coagulation markers
• Benefits

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CONTRACEPTION

• Depo-provera and norplant
• Irregular bleeding
• Decreased bone mass
• Barrier methods
• Inconvenient
• UTI
• IUDs
• Pelvic inflammatory disease

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MENSTRUAL MANAGEMENT
Manual dexterity Transfer techniques
Pharmaceutical intervention
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DISABILITY MENOPAUSE
Premature osteoporosis
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OTHER ISSUES
Decreased tissue turgot strength Loss of
skin elasticity Reduced blood supply to skin
soft tissue Vasomotor instability
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ABUSE
High prevalence among women with
disabilities Longer periods of time More
difficulty resolving abusive situations More
likely abuse in medical settings Excuses for
signs of abuse
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ABUSE

Clues from Medical History

• Inconsistent description
• Time delay
• Accident-prone history
• Suicide attempts or depression
• Repeated psychosomatic complaints
• (Adapted from Salber PR, Taliaferro, E, 1995)

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ABUSE
Clues from Medical History (cont.)
Alcoholism and/or drug abuse Injuries during
pregnancy Poor nutrition Other
pregnancy-related problems Post-traumatic
stress syndrome Disability-related abuse
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HOW TO HELP
What To Do For Abused Patient

Talk about abuse

Assess degree of danger

Help develop safety plan

Document the incident

Plan for follow-up

Provide resource information
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ADA - Examples of Disabilities
Orthopedic, visual, speech and hearing
impairments Cerebral palsy Epilepsy
Muscular dystrophy Multiple sclerosis
Cancer Heart disease
Diabetes Mental retardation Psychiatric
disability Specific learning disabilities
Tuberculosis Past history of drug
addiction and/or alcoholism
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ADA REQUIREMENTS
Guaranteed services Equal services
Integrated setting Facility evaluation
Accessibility modifications Administrative or
eligibility criteria Practices, policies, and
procedures Providers costs
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IDEAL PHYSICIANS OFFICE

• Hallways and exam room able to accommodate
  wheelchair
• Adjustable-height, extra-wide padded exam table
• Platform scale
• Staff trained to assist with dressing and to be
  sensitive to disability issues

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GOOD EXAMPLES
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EXAM TABLE
ADJUSTABLE
HEIGHT
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PLATFORM SCALE
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HOPES DREAMS
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This CME Presentation was developed by the
Center for Research on Women with
Disabilities Margaret A. Nosek, PhD, Executive
Director Department of Physical Medicine and
Rehabilitation Baylor College of
Medicine Houston, Texas www.bcm.tmc.edu/crowd/
With funding from the
Paralyzed Veterans Association, Education and
Training Foundation and the National Institute on
Disability and Rehabilitation Research