Empowering Women’s Health after Spinal Cord Injuries

Women encompass about 20% of all the traumatic spinal cord injury (SCI) population and there is increased incidence and prevalence of women with SCIs. The most recent data estimate that approximately 40,000-45,000 women with SCI are living in the United States, increasing from previous years, with the most common cause still being motor vehicle collisions. Throughout their lifespan, women with SCI present with unique healthcare needs compare to the male population. Therefore we present a comprehensive summary to empower and equip all providers with awareness of these needs and recommendations of care.

Key points

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Women with spinal cord injuries (SCIs) do experience temporary amenorrhea in the acute phase of their injury but are often able to bear children in the long term.
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Women with SCI require precautionary lumbar epidural injections before labor due to the propensity for autonomic dysreflexia during delivery.
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Women with SCI during the antenatal period are at a high risk of experiencing worsening symptoms of neurogenic bladder/bowel, pressure injuries, and venous thrombosis.-Gynecological and preventative care in women with SCI.
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Gynecological and preventative care in women with SCI should follow same guidelines and urgency as in able body population.
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Providers should address all aspects of sexual health in women with SCI, since it has a significant factor in their quality of life.

Epidemiology

Women encompass about 20% of the traumatic spinal cord injury (SCI) population, and there is an increased incidence and prevalence of women with SCI. The most recent data estimate that approximately 40,000 to 45,000 women with SCI are living in the United States and that 19% of all new SCIs are diagnosed in women, an increase compared to prior years. The most common causes of SCI in women are motor vehicle collisions, followed by falls and injuries sustained via sports. There has been a shift in recent years with a decrease in the number of SCIs secondary to violence and an increase in the mean age of injury in women. Several studies have found that the severity of the inciting injury, as well as socioeconomic status, medical comorbidities, and pressure injury, are associated with overall mortality and life expectancy in patients with SCI.

Sexual function

Women with SCI report changes in all aspects of sexual health, and all dimensions should be assessed: biological, psychological, cultural, and relational. ^,

Sexual function is a part of the biological dimension and can include changes in sensation, physical arousal, achieving orgasm, incontinence, reduced mobility, limiting positioning, spasticity, and pain. ^, Impaired sensation was found to be a significant factor leading to decreased sexual activity in women with SCI. When surveyed, roughly 50% of women reported the ability to achieve orgasm after SCI, and for those able to, the time it took to achieve orgasm was increased compared to preinjury. Women with upper motor neuron lesions are more likely to be able to achieve orgasm than women with lower motor neuron lesions. As many men with SCI rely on psychogenic and/or reflexogenic stimulation to increase arousal and likelihood of achieving orgasm, women also benefit from doing the same.

The psychological aspect should not be overlooked because women have reported profound changes in this dimension postinjury. Many women report that after SCI, the psychosocial connection often becomes more important than physical sexual needs. After injury, women report struggling more with communicating their sexual needs, viewing their bodies in a positive light, and feeling emotionally close to others. In addition, women with SCI should also be screened for mood disorders such as depression that also affect sexual function.

In regards to relationships postinjury, women report struggling with emotional closeness. Of these women surveyed, they rated having an open dialog with their partner as the most beneficial component, where women could discuss what they find enjoyable and how they can work around physiologic impairments together.

A barrier to improving sexual function in women post-SCI is education. Many women report receiving little-to-no education regarding sexual function and sexual activity postinjury while in acute inpatient rehab. This is often problematic as many women report that after inpatient rehabilitation, they never receive further education on this topic. We recommend sex education as early as during the acute inpatient rehabilitation stay with both the patient and partner. Clinical psychologists become key team players in introducing this topic and communicating with the physiatrist about potential areas of education, with education continued over subsequent outpatient visits. Physical and occupational therapists can assist/train patients in positioning and prevention of complications, as well as introduce the need for adaptive equipment to facilitate sexual activity.

Sexually Transmitted Diseases

Previously reported rates of sexual activity among women with disabilities have ranged from 50% to 83%, ^, with one study revealing that 40% of women in study sample resumed sexual activity within 6 months of injury. ^, Women with SCI must be asked if they are sexually active and should be screened for STDs like that in the able-bodied population. Sensory impairments can lead to absence of characteristic symptoms, such as pelvic pain, or lead to unspecific symptoms, such as general malaise and increased spasticity, limiting early detection. Early education on diagnosis and treatment, as well as access to information and contraceptive resources, are essential to ensure favorable outcomes in women with disabilities. The consistent and correct use of barrier contraceptives such as condoms and dental dams is critical for prevention, and the ability to independently use these versus partner-assisted should be considered when providing education and counseling. When detected, these infections should be treated the same way as in the general population.

Candida

Studies have shown that women with SCI have alterations in their vaginal microbiota, with a higher concentration of candida species and fewer lactobacillus species, which predominates in women without SCI. It was also found that women with SCI have higher rates of candiduria, and this increase is seen in part due to antibiotic use and indwelling catheters.

Fertility and Contraception in Women with Spinal Chord Injury

Fertility in patients with SCI is due to dysfunction of the hypothalamic–pituitary axis rather than primary ovarian failure. Women with SCI experience temporary amenorrhea due to stress-induced prolactin secretion. In approximately 25% of women of childbearing age with SCI, the elevations in prolactin have been found to correlate to an increased incidence of developing temporary amenorrhea. The increased prolactin provides negative feedback to inhibit ovulation. Upon resolution of amenorrhea and resumption of menses, the physiologic capability to conceive returns to baseline in women with SCI. Despite fertility being unaffected, many women with SCI have a drastically lower rate of pregnancy, and those with complete neurologic injuries are among the least likely to become pregnant than those with incomplete neurologic injuries.

Resumption of menses, typically 6 to 12 months after injury, is thought to be the first step in women with SCI regaining their sexuality and fertility. There is no correlation between the mechanism of injury or neurologic classification of SCI and the duration of amenorrhea. Some studies have shown patients with regular menstruation before the injury continue to have the same afterward, and in some women, dysmenorrhea is relieved due to lighter menstruation. There are some cases in which women with SCI experience dysreflexic episodes and autonomic disturbances during menstruation. It is essential that modalities women learn at the onset of menstruation are implemented, such as maintaining skin integrity at the vulva with frequent cleanings and changing tampons and pads frequently. Symptom management using analgesics such as acetaminophen and non-steroidal antiinflammatories is recommended to reduce the risk, frequency, or severity of autonomic dysreflexia (AD) episodes.

Women with SCI should be educated on the need for contraception when menstruation and sexual activity resume if they wish to prevent pregnancy. The options for contraception in patients with SCI are identical to those without SCI; however, consideration regarding the patient’s function, mobility, risk factors, and ability to adhere to the treatment is required. Barrier methods can be utilized, but assistance from the partner may be needed in women with restricted hand dexterity. Combined estrogen–progesterone contraceptive pills and progestin implants are used with caution in this population of patients due to the already high risk of venous thromboembolism. Intrauterine device insertion can be performed in women with SCI but is considered high risk due to impaired pelvic sensation and the risk of overlooked pelvic inflammatory disease. In these cases, there is a justification for more frequent medical supervision to ensure proper placement of the intrauterine device. There are no clear recommendations in this area, and more research is needed.

Pregnancy in women with SCI

Approximately 90% of women with SCI become pregnant more than 1 year after their initial injury, but there has been no increased risk of adverse outcomes in those who conceive earlier. Currently, there are no stringent guidelines regarding medical management from an obstetric standpoint in female individuals with SCI. However, there must be a concerted effort between the SCI physiatrist and the obstetrician who will be caring for these patients, as they have the potential to become high-risk pregnancies. In this section, pregnancy in SCI will be discussed in 4 stages of care: prenatal, antenatal care, intrapartum, and postpartum.

Prenatal Care

Education regarding obstetric medical care, including the potential complications of pregnancy as well as the expectations of labor and delivery, should be extensively discussed with this population of patients before conception.

Certain medications pertain specifically to SCI, which should be reviewed during the prenatal period. Commonly used drugs include antispasmodics, analgesics, and anticholinergics. Medications such as baclofen, tizanidine, and valium for spasticity are not recommended during pregnancy. Oral baclofen has been associated with short-term withdrawal symptoms in neonates, but when given intrathecally at a reduced dose, it is thought to be safe due to less exposure to the fetus. There have been no data that show baclofen exposure during pregnancy increases the risk of the fetus developing birth defects above the regular background risk of 3% to 5%, which exists for all pregnancies. Therefore, the guidelines regarding continuing baclofen are predicated upon assessing the risks and benefits for each patient. Quick weaning off these medications as early as possible during the first trimester is recommended. Women should not take opioids during pregnancy to reduce the risk of neonatal abstinence syndrome. Oxybutynin for neurogenic bladder spasms can still be utilized; however, it may suppress lactation.

Additional optimization of maternal health involves education on proper folate supplementation to prevent neural tube defects and vitamin D supplementation to improve bone density and minimize the risk of developing pre-eclampsia.

Antenatal Care

During gestation, patients must be frequently monitored for medical complications that can occur. These medical complications and suggested management are listed in Table 1 .

Table 1

Antenatal care

Genitourinary	Neurogenic Bowel	Dermatologic	Hypercoagulable	Respiratory Drive
• UTIs and pyelonephritis are the two most common causes for antenatal hospitalization in pregnant SCI patients. • Women with SCI are at a high risk of genitourinary tract infections due to neurogenic bladder. • The uterus enlarges during pregnancy, causing compression of ureters and urinary retention. • There is no benefit in regular urinalysis screening or prophylactic antibiotics (asymptomatic bacteriuria is common in SCI). • Treat when women become symptomatic or dysreflexic. • Consider indwelling catheters to promote adequate bladder drainage.	• Uterus enlarges during pregnancy, causing constipation. • Limitation in physical maneuvers for bowel evacuation and decreased peristalsis due to hormonal changes. • Gastrocolic and rectocolic reflexes are used through bowel programs, which consist of timed meals, digital stimulation, and laxatives/stool softeners. • Dose adjustments or addition of laxatives/enemas should be utilized. • Fecal impactions may cause dysreflexic episodes.	• Incontinence perianal dermatitis, anemia, and weight gain/difficulty with pressure relieving mechanisms can cause deep tissue pressure injuries. • There is a high risk of skin breakdown in the sacral, coccygeal, ischial, and the greater trochanteric areas. • Pressure relief requirements are unchanged during the first trimester of pregnancy. The second and third trimesters must be performed every 2 hours with a mattress and wheelchair cushion surfaces for pressure redistribution.	• There is an increased risk of developing DVT in the first 6 months after an acute SCI. • After the acute period, the risk is equivalent to that of the general population due to physiologic remodeling of vasculature below the lesion level. • The enlarging uterus compresses pelvic veins, causing venous stasis and increasing the risk of DVT. • Passive movements, elevation of the lower extremities, and lateral decubitus position decrease the risk of DVT. • Indication to start pharmacologic prophylaxis is based upon risk factors such as age, weight, smoking history, parity, and comorbid hypercoagulable state such as cancer or lupus.	• SCI results in restrictive ventilatory changes with reduced vital capacity and functional residual capacity and worsening with enlargement of the uterus. • Women with cervical or high thoracic (above T5) lesions should obtain baseline pulmonary function test (PFT) during the prenatal period, followed by serial PFTs throughout their pregnancy. • Chest rehabilitation is recommended if dyspnea, insufficient cough, or atelectasis is found, as this can result in pneumonia. • In severe cases, mechanical ventilation is indicated to avoid respiratory compromise.