I'll Be Back Soon...

Well, it's been a long year. Really it hasn't - it has flown by - but it's been an incredibly tough year. I never thought I'd survive. I suppose that technically speaking, I still may not survive, but the end is so close I can smell it! Yesterday was my last day of class, and Thursday is my final exam in Neurobiology. That marks the end of my first year of medical school, and almost more importantly, the end of NEUROBIOLOGY! I'll be 25% doctor. And more importantly, I'll be half-way through this horrendous basic-science-lecture-laden first two years before clinical rotations! HALF-WAY THERE! That's progress.

I'm really just writing to apologize for the blogging hiatus, and to reassure you that I'll be back at it again as soon as I get through this last exam. My next post will be a continuation of the Pill series, so stay tuned. In the meantime, I'll be in my study bubble, study cave, whatever you wanna call it. Just means I'll be on my couch in my pajamas staring at my laptop for two days straight. Faaaaaaabulous. Catch ya on the flip side!

A Tough Pill to Swallow: Vascular Complications

The decision to use or discontinue combined oral contraceptives (COCs) is a very personal one, as we’ve discussed already. Particularly for women who do not have any ethical or religious conflicts with contraception, an emphasis must be placed on weighing the benefits against the risks for a given set of circumstances. The purpose of this mini-series is to provide scientifically grounded information to women seeking to better understand the health risks associated with oral contraceptive use in order to make informed personal health decisions – it’s not about making judgments or defining right and wrong. Only you can determine the best course of action for you, given your particular circumstances and future reproductive intentions.

Left Hemisphere Stroke, via Google Images 
http://www.theuniversityhospital.com/stroke/inhospital.htm

The Pill & Vascular Health

The risk of “blood clots” seems to be the most widely recognized of the many COC-related health risks, so we’ll start there (though you’re probably already inferring from my use of quotation marks that there’s a lot more to the story). Blood clots (also known as thromboses) are serious business, as they can break free (or embolize) and travel to any number of vital organs, blocking blood flow and causing ischemia (inadequate blood supply resulting in prolonged oxygen shortage and tissue death). When this happens in the brain, we call it a stroke. When it happens in the heart, we call it a heart attack. We all know that stroke and heart attack are life-threatening and life-altering events. But ischemic events can cause damage to the liver, lungs, eyes, kidneys… any organ that receives blood flow (and if you have a pulse, that should include ALL of them!).


Deep vein thromboses (DVT), or blood clots of the deep veins (usually in the legs) can also form in the extremities and cause pain and swelling, and are often the culprit underlying pulmonary embolism (PE). Blood from the lower extremities returns directly to the right side of the heart and is immediately pumped out to the lungs to pick up fresh oxygen, at which point the oxygenated blood returns to the left side of the heart to be pumped out to the rest of the body. The arrangement of this circuit provides a convenient, direct pathway through which an existing DVT can send a chunk of clot up to the lungs where it lodges and forms a PE. The presence of a PE prevents blood from reaching certain areas of the lung by blocking blood vessels, creating “dead space” in the lung where no blood is arriving to pick up the fresh oxygen, which means that less oxygen is transferred from the lung to the blood with each breath. This oxygenation difficulty can quickly lead to labored breathing, rapid heart rate, cardiac arrhythmia and sudden death.

The causal relationship between COCs and these vascular health risks is complex. Oral contraceptives essentially mimic pregnancy by providing the balance of hormones that a pregnant woman’s body would produce, which leads to cessation of the normal cyclical hormone fluctuations that cause ovulation and menstruation. (The “menstruation” that women experience on the Pill really isn’t true menstruation, but rather “withdrawal bleeding” that is triggered by the withdrawal of progesterone during the “sugar pill” [or very low-dose] week of the Pill pack.) This particular balance of hormones is known to produce elevated levels of various clotting factors in the blood and to increase platelet aggregation both in the pregnant state and (to a slightly lesser degree) during COC use⁴. There are also studies that have implicated COC use in the genesis of hypertension^1,2 (known more commonly as chronic high blood pressure), and still others that have demonstrated elevated serum cholesterol levels in COC users relative to non-users² – factors that have yet to be causally linked to COC-related thrombosis and heart attack, but that certainly may play a role.

And now for the nuts and bolts^3,5:

•  The risk of venous thrombosis increases 3 to 6-fold in oral contraceptive users relative to non-users.
•   That risk is doubled again for the “third generation” (read: newest) combined oral contraceptives containing desogestrel or gestodene.
• Stroke and heart attack risk is elevated 2 to 5-fold relative to non-users.
• Risk does increase with age, as well as risk factors such as high cholesterol, high blood pressure, diabetes and smoking.
• What about “low-dose” pills? Are they safer? Unfortunately, most studies say no – these risk statistics hold for the newer low-dose pills as well (though there are a few studies that report a modest decrease in heart attack risk).
• What if I only used the Pill for a year or two? These risks are independent of the duration of use, so whether you used the Pill for a few months or a decade, your risk is the same.

Most young women on the Pill stand a good chance of never experiencing any of these health issues, especially if they don’t smoke and live out an overall healthy lifestyle. What is disturbing is that rather than put this information out there so that women can make their own informed decisions, many practitioners choose to disregard the information altogether. They have decided on their own that the benefits outweigh the risks, and so the decision has been made for the patient, and without the patient’s knowledge. Many women don’t even realize that there are serious potential consequences to be weighed. I hope that this knowledge will empower you to take a second look at your reproductive health and make an informed, conscious decision.

Stay tuned for further exploration of the health risks associated with oral contraceptive use. I plan to tackle cancer, bone loss, infertility, and permanent loss of libido among many other intriguing topics in women’s health.

***UPDATE: Catch the next post in this series, Contraindications to COC Use


References
1. Basile, J. and M. Bloch. Identifying and managing factors that interfere with or worsen blood pressure     control. Postgraduate Medicine. 2010 Mar; 122(2):35-48.

2. Bressler, R. and J. Durand. Oral contraceptive risks: a realistic appraisal. Drug Therapy. 1979 Oct; 9(10):81-95.

3. Martinez, F. and A. Avecilla. Combined hormonal contraception and venous thromboembolism. European Journal of Contraception & Reproductive Health Care. 2007 Jun; 12(2):97-106.

4. Poller, L. Relation between oral contraceptive hormones and blood clotting. Journal of Clinical Pathology. 1969; 3: 67–74.

5. Tanis, B. and F. Rosendaal. Venous and arterial thrombosis during oral contraceptive use: risks and risk factors. Seminars in Vascular Medicine. 2003 Feb; 3(1):69-84.

A Tough Pill to Swallow: An Introduction to the Health Risks Associated with Oral Contraceptive Use

Have you ever wished that someone would just sift through the mountain of scientific data out there regarding the risks and benefits of oral contraceptive use and just give you the bottom line? HA! Yeah, me too. While I have yet to find the time to pull off that monumental task, I am attempting to use my knowledge base and resources to do some digging and bring you the highlights (or lowlights, as it were).

The story is a complex one, full of controversy and heated debate. As is true of nearly any heavily researched topic in the sciences, you will find a variety of studies that often yield wildly different conclusions. It’s no wonder that young women are confused. It’s no wonder that, faced with a towering heap of conflicting data, most women take the word of their healthcare providers at face value and assume that the benefits outweigh the risks.

As a physician-in-training, I have become aware of an entirely new perspective on healthcare – that of the medical “establishment”. As valiantly as healthcare providers may struggle to keep the best interest of each individual patient in mind, we cannot know each of our patients as well as we’d like to, particularly when it comes to making highly personal decisions concerning such issues as reproductive health. This disparity often leads providers to make general recommendations from a broader public health standpoint, and that is an important point for the patient to understand.

When evaluating the evidence for contraceptive-associated health risks, the “establishment” weighs the relatively small risks to women’s health against the broader socio-economic impact of unwanted pregnancy. The economic burden on society grows with every free abortion and every pregnant teen loaded onto the public assistance payroll. The outcomes for teen pregnancies are just dismal, for both the young woman and her child. In third world countries where it is not uncommon for women to die in childbirth, the public health impact of oral contraceptives is of tremendous consequence. These are the kinds of issues that play into the perspective of healthcare providers when it comes to contraceptives. The percentage of women experiencing adverse side effects would have to be quite substantial to trump these benefits from a public health standpoint. Given this perspective, and the decades over which it has become engrained, it is easy to see how the risks have become a finely printed footnote in the pages of real-world medical practice.

You, on the other hand, know yourself intimately. You know your individual circumstances and reproductive intentions. None of these public health considerations are of any consequence to you when considering risks to your own health, but without receiving any explicit warnings from your physician you may never find cause to question the safety of any medication you’ve been prescribed. Hopefully your doctor will (at the very least) screen you for risk factors prior to writing a prescription, but after a blood pressure check and a brief family health history questionnaire most physicians are eager to hand out contraceptives, particularly to young women. Unfortunately, ladies, we bear the burden of digging up the information necessary to make our own personal health decisions.  And when it comes to contraceptives, the decision is certainly a very personal one.

With regard to contraception, the burden has always fallen on women (despite the fact that men are fertile every day of the year, while women have only a few fertile days per month to control). Along with that burden comes a choice – a choice to follow the crowd, allowing artificial hormones to sterilize that which makes us life-giving creations of God, or to seek out other means of “protection”. Being the self-sacrificing lot that we are, women often choose the route of least resistance and opt to pop a little pill once a day and forget all about our fertility. We are told time and again that it’s no big deal – that we don’t need that part of ourselves until we’re ready to have children anyway. But what if that very Pill made it impossible for a woman to conceive when that long-awaited time came? What if, after leaving the Pill behind and conceiving several beautiful children, that very Pill still had the potential to ravage a woman’s body (and that beautiful family that she has built) through a devastating battle with cancer?

It is easy to put off the consequences of contraception because we don’t feel them today. Ironically, we won’t experience those consequences until it comes time to take back what we so willingly gave away in the first place – our fertility, our ability to create life, our desire for children and family.

For me, those things are a rather HUGE deal. I’d bet a paycheck that most women feel similarly. Perhaps the until-recently-highly-male-dominated medical establishment didn’t quite “get” the profound gravity of a woman’s fertility. Perhaps women have been kept in the dark for selfish reasons (the mainstream alternatives to the Pill being abstinence or condoms, neither of which are particularly pleasant). In any case, it is time to close the gap between the information (or lack thereof) disseminated in birth control clinics and GYN offices and the reality of oral contraceptive use. Not only because women deserve to know, but because they may need a kick in the pants to acknowledge the significance of their own future health and fertility.

Stay tuned… the information you’ve been missing is on its way. I haven’t quite decided how to present it – perhaps in “mini-series” form to keep the posts at a manageable length. In any case, I hope that at the very least you’ll find it eye-opening… and maybe even life-changing.


*UPDATE*: Catch the next post in this series here! Topic: The Pill and Vascular Health

The National Day of Prayer: What are The Non-Theists Really Afraid of?

Warnings:

1. This post is quite long. Pee first, maybe get something to eat.

2. This post is an opinion piece, and may ebb a little more progressive than you're used to (because I'm just not your typical Conservative Christian) but I hope you'll hang with me 'til the end before formulating a scathing new opinion of me and my kooky politics ;]

US District Court Judge Barbara Crabb recently handed down a ruling stating that government sponsored prayer, ie. The National Day of Prayer, violates the Constitution. On the surface, I am as appalled as anyone, mainly because that’s simply not true. But I believe that this entire upheaval speaks to a deeper issue in this country that is worth addressing.

For now, let’s start with the basics. Why should anyone be upset about a government-endorsed National Day of Prayer? There’s no good reason, really.

First of all, acknowledging a National Day of Prayer does not endorse any one particular religion. We’re all welcome to pray to whomever we choose – it’s the not the “National Day of Prayer to the God of the Judeo-Christian Tradition”. Perhaps they’re abstractly promoting “spirituality” or “faith” in a general sense by encouraging prayer, but it’s quite a stretch to call that a Constitutional violation, and it certainly is not discriminatory against non-theists.

Second of all, the government’s endorsement of a holiday does not mandate any individual’s participation in said holiday. Every citizen maintains his or her freedom to completely disregard ANY holiday they choose, on any given day of the year. We are all free to choose NOT to pray at all on the National Day of Prayer! The government endorses a lot of holidays, and a lot of people for whom those holidays don’t mean much SIMPLY IGNORE THEM. If Presidents’ Day means nothing to you, you don’t even have to acknowledge it except to enjoy your paid day off of work if you’re on a government holiday schedule. Simple as that. If it irritates you, pretend it didn’t even happen. The bottom line is, no one is grabbing your hand and thrusting you into a prayer circle – just go about your business, people!

You know, I’ve never met a Jewish person who was personally offended at the government’s recognition of Christmas as a holiday. Perhaps you have met such an individual, but have you ever seen a coalition of Jewish people file a lawsuit and spark a media frenzy over it? NO! Do you know why? Because they just choose not to celebrate Christmas. And I’d venture to say that that Christmas is a much larger inconvenience to Jews than the National Day of Prayer is to non-theists, what with the mall traffic, school closings, and all that Christmas music playing everywhere you go for three months. Of course I don’t mean to be cheeky about Christmas itself, but practically speaking, am I right or am I right?

The main point of contention for the non-theists, as best I can tell, is based in the apparent “evolution” of our country toward a far more secular state of affairs than ever before in its history. Given this secularization, they apparently perceive such “official” acknowledgements of prayer and spirituality along a continuum from simply antiquated to outright discriminatory. It seems that they would prefer it if our government failed to recognize or address religion at all in any official capacity, as if we should just let the religious roots of our history slowly fall by the wayside until they’ve been long forgotten. Somehow “progress” should be gradually pushing religion “out of vogue”.

I disagree with them for two reasons; (1) religion is and always will be a majority sentiment – it’s not going anywhere anytime soon; and (2) Our history is important and it has already been written – it is what it is – and simply recognizing the religious component of that history should never be considered “unconstitutional”. That’s just baloney.

That said, I think that there’s more to this story and that there is a valid broader message to be gleaned from this upheaval amongst non-theists. This is the part where I start losing friends along the other end of the political spectrum and am left with… well, no friends. But I hope you’ll hear me out. While I certainly believe that the government’s promotion of “spirituality” and recognition of the Christian roots of our country’s founding are entirely defensible, there is a larger movement out there that seeks to broaden the influence of those “Christian roots” in government. And that, my friends, is where the non-theists have a point.

I believe that it is our Constitutional freedoms that set America apart and make us who we are as a nation, and that includes Freedom of Religion.  I will never refer to America as a “Christian Nation” because I believe that that statement undermines those very freedoms that give me such pride in my country. The fact that our founding fathers were of Judeo-Christian faith themselves does not make us an intrinsically “Christian Nation”, in my humble opinion. In fact, I’ll even venture to say that the founding fathers just might agree with me, given the literal blood, sweat and tears that they poured into securing that very Freedom (of Religion) that we enjoy today. The American Revolution wasn’t about establishing a “Christian Nation”, it was about establishing a nation in which any religion (or lack thereof) could be practiced freely without threat of imprisonment or worse – where all citizens would be afforded “certain unalienable rights” without discrimination.

I certainly won’t deny that the God of the Constitution was intended as the Judeo-Christian God, but I simply don’t accept the idea that this fact somehow trumps the clear intent of the founding fathers to ensure equality of all religions under the law. I believe that this is where Conservative politics have steered our country wrong.  The non-theists do not necessarily feel threatened by the National Day of Prayer itself, but rather the larger “Christianization” of our nation that it represents to them. Their response to this specific issue is a backlash against the larger Conservative agenda. The National Day of Prayer has never been a problem (on this scale) in the past. It has become a problem because non-Christians in our country are beginning to feel that their way of life is being threatened.

Let’s be a little more concrete about this. I am all for the criminalization of abortion, for example, but I am not “for” any law that is based purely on Biblical teachings. Yes, I’m serious. I am a Christian (and so I choose to live my life by Biblical teachings) but I live in a country that does not legislate based purely on religious principles, because our forefathers fought and died to ensure that our freedom to practice any religion that we choose would be upheld. Sure, many laws happen to coincide with a variety of religious teachings which is just fine and dandy, but legislation based purely on the teachings of any religion is unconstitutional in my book. I am for the legal criminalization of abortion because I believe that abortion constitutes infanticide, which is already a crime in this country. I believe that, scientifically, the definition of “life” (and in turn the spectrum of what constitutes murder) as beginning at any point other than conception is a bogus and arbitrary definition, and I believe that any legislation concerning abortion should be based in that reality – not on Biblical teachings, dear as those may be to my own heart.

But it’s not about what’s dear to my heart – that’s not how America works. The beauty of how America does work, so long as the Constitution is upheld, is that no matter what the religious majority may become in the future, the rest of us will never be forced to live our lives by its teachings. Just as we Christians would be appalled if Muslims became the majority and forced us to stop and pray toward Mecca on a daily basis, Muslim Americans (or Hindu Americans, or Buddhist Americans, or Non-theist Americans) should be appalled at the prospect of any purely “Christian” teaching being forced upon them as law. An American citizen is an American citizen, like it or not, and being a Judeo-Christian Anglo-Saxon white person doesn’t afford me any extra right to legislate my personal religious beliefs – I don’t get to claim any more “ownership” of this country than anyone else, because we are a country of immigrants. That’s just our reality (again, like it or not).

The point that I’m trying to make is this: Just as many Conservatives are in a state of backlash and upheaval over what they perceive as a new set of ideals being forced upon them by a new administration of which they do not approve, non-theists feel similarly toward the Conservative Christian movement. They feel that their Constitutional right to live their lives outside the scope of religious influence (as far as the law is concerned) is being threatened, not by the National Day of Prayer itself, but by the larger movement that it represents.

In my opinion, they have a point. I see our country headed in that direction if the Conservatives regain power, and while the ensuing course of events might appease my personal Christian values in many ways, it saddens my heart as an American. Of course my Christian values come first in my own life, but those values should NOT be imposed on any non-Christian American. Selfishly invoking our majority status to impose our beliefs is not the way to win others for Christ, it’s just a way to get what we want, and what we think is best. Given the Constitutional provision against religious influence of that nature, that simply is not the Constitutional way to govern. 

See Jane Bake ...quite possibly the cutest cookies you'll ever eat

So, remember how I said that my friend Laura is multi-talented? Remember when I said "you name it, she's mastered the art"? Well, that was even before she unveiled this little treat...

It's SEE JANE BAKE 
...and it's Laura's newest venture. You can enjoy these delectable little creations in the comfort of your own home... if you can bring yourself to eat them, that is. You can visit on Facebook or Etsy! 

How adorable are these?!?! Baby showers... bridal showers... birthday parties... the possibilities are endless. I just can't get over it!

Oh Laura. You just blow my mind, girl.

Laura's Brilliant New Series, "A Life Apart"

For those of you who don't know my friend Laura, she is a gifted writer - a woman of many talents, in fact. Decorator, re-finisher, baker, adorable-little-girl-dress-maker... you name it, Laura's perfected the art. She also happens to be a tirelessly devoted wife and mother (to two of the most adorable little red heads you've ever seen!), and a faithful Catholic. She has recently begun a new blog series entitled "A Life Apart", and I think it's gonna knock your socks off. What is "A Life Apart", you ask?

"What is A Life Apart? It's freedom from the Culture of Death, and the decline of marriage and the family. It's a call to rise above the mainstream ideals of sex, love and the human condition. A Life Apart is the belief that anyone can reclaim their faith, find spectacular love and live an authentic life. Through a series of guest posts, crazy ideas and fabulous resources, we'll introduce you to a way of living that'll leave you thinking harder and making changes."


You're intrigued. Go ahead, read on. You'll be glad you did. The link will take you to an introduction to the series. You'll also find a side-bar listing of any series-related posts she has published to date, including a guest post from yours truly, chronicling my whirlwind journey from the Pill to Natural Family Planning. This series is bound to bless you in ways you never thought possible - I highly recommend it. 

"The Pill as an Abortifacient": Appendix A, on IUDs

It has come to my attention that my previous post on the Pill as an abortifacient may have been a little narrow. Certainly the Pill is the most common of the chemical contraceptives, but I would be remiss if I didn't include a section on hormonal IUDs (or Intra-Uterine Devices, like Mirena), another commonly misunderstood form of chemical contraception.


Many women are under the impression that an IUD is simply an implantable, more permanent version of the Pill. Well, semi-permanent anyway - they can usually be implanted and left for up to 5 years. The misconception there is that the chemical composition of an IUD is distinct from that of the common Pill, in that IUDs release only progestins while most common oral contraceptives contain both estrogen and a progestin (there are "progestin-only oral contraceptives", but these are usually prescribed for specific medical reasons related to gynecological health and are not the same as the estrogen-progestin oral contraceptives commonly referred to as "the Pill"). The role of progestins in contraceptive devices is two-fold as you may remember from the main post:

1. They thicken the cervical fluid to help prevent the entrance of sperm into the cervix and shorten its lifespan within the female reproductive tract, and
2. They dramatically thin the lining of the uterine wall that normally builds up and sheds cyclically in preparation for physical implantation and nutritional support of a fertilized embryo, making it very difficult for a fertilized embryo to implant successfully - it is instead "washed out" with the monthly menstrual flow. 

Unrelated to the hormonal effects of progestin, the IUD also attempts to physically interfere with entry of the sperm into the fallopian tube by its placement location (though the IUD can and will shift over time, and we're talking about microscopic sperm and eggs that would have to squeeze by... take that for what it's worth).

You may also recall from the main post on this issue that it is the estrogen component of oral contraceptives that prevents follicle maturation and ovulation from occurring monthly. Directly from the Mirena (a popular brand name IUD) website, this means that an IUD "may stop the release of your egg from your ovary, but this is not the way it works in most cases" (emphasis mine). 

What does it all mean, in practical terms, for IUD users? It means that you can assume that during most months, you will ovulate. Given the disruption of the normal cyclical patterns of progesterone circulation induced by the IUD, your normal fertility signs will also be disrupted (such as patterns in basal body temperature and cervical fluid consistency, which could normally be used to determine when ovulation is occurring). Bottom line: you have little hope of being able to determine when or if you've ovulated. At this point, all that's standing between your egg and fertilization is the thickened cervical fluid and the rather weak "physical barrier" of the IUD itself to sperm travel. 

Here in lies the main difference between the Pill and IUDs, as far as abortifacient properties are concerned: the IUD does comparatively little to prevent fertilization (relative to the Pill, which is designed to prevent ovulation altogether, however imperfectly that may work). Once a successful fertilization has occurred, you (as an IUD user) are now relying on the IUD to ensure that your body rejects that conception (as a result of the thinned uterine lining). If you happen to be a woman who is pro-life and defines life as beginning at conception, you have put yourself in a terrible position. You are using a birth control method that allows for ovulation to occur, and loosely attempts to prevent fertilization, but primarily functions to create an inhospitable uterine environment that will reject a fertilized egg. 

I won't venture to call one chemical contraception method "worse" than the other, because that really isn't the point here - that would be splitting hairs. I make this point because many IUD users may not fully understand the mechanism behind their chosen form of birth control (I've mentioned how I feel about the tragic dearth of patient education going on in OB/GYN offices these days) - they may believe, as most women on the Pill do, that they are not ovulating. Pro-life IUD users really need this information, so that they may carefully consider the facts: that they most likely are ovulating, and are therefore risking a lot of fertilization. It is precisely this risk of fertilization that lends chemical contraceptives their classification as "abortifacients".