Gimme That Old Time Religion Neuron

Imagine you’re at the wheel of a trolley and the brakes have failed. You’re approaching a fork in the track at top speed. On the left side, five rail workers are fixing the track. On the right side, there is a single worker. If you do nothing, the trolley will bear left and kills the five workers. The only way to save five lives is to take responsibility of changing the trolley’s path by hitting the switch. Then you will kill one worker.

Now imagine that you are watching the runaway trolley from a footbridge. This time there is no fork in the track. Instead, five workers are on it, facing certain death. But you happen to be standing next to a big man. If you sneak up on him, and push him off the footbridge, he will fall to his death. Because he is so big, he will stop the trolley. Do you willfully kill one man, or do you let reality play out and allow five people to die?

Which alternative would you choose, and, more importantly, why?

Period Math

The length of the monthly cycle varies. Usually, during the first 5 to 7 years after your first menstrual period, the cycles are more irregular and the interval between them is longer than for cycles later in life. Typically, during your twenties and thirties, the cycles become increasingly shorter and more regular. When a woman enters her forties, the cycles begin to lengthen again.

So, how do you know if you're cycle is normal? An average cycle length is 28 days, but if your cycle lasts anywhere between ~24 to 35 days, it's considered normal. A normal period flow lasts anywhere from 4 to 6 days, causes an average blood loss of 25-60 ml, and can be light, moderate, or heavy. Flow lasting longer than one week and blood loss of more than 80 ml are considered abnormal. Also, passing the occasional blood clot is normal.

By convention, the 28-day cycle is considered the ideal cycle. (Only 10-15% of cycles last exactly 28 days.) This doesn't mean that if your cycle isn't exactly 28 days there's something wrong with you; 28 days is just an average. [Not to mention that it makes the math simple--in a 28-day cycle, ovulation happens at the halfway mark, on the 14th day.] Also, by convention, the first day of bleeding is considered the start of the cycle, and is denoted as Day 1; the period lasts for 5 days (in an ideal cycle), or from Day 1 to Day 5; and the cycle ends on Day 28. Of course, real life doesn't always conform to conventions: if you're cycle isn't 28 days, how do you number the days of your cycle? Let's use an example to illustrate.

Say your period starts on the tenth of the month, your bleeding lasts for 4 days, and your cycle length is 30 days.

The day the bleeding starts, the tenth of the month, is Day 1 of your cycle. The blood flow days are Day 1 through Day 4, or the tenth through the thirteenth of the month. Your cycle ends on Day 30, or the ninth of next month.

One more useful calculation: your ovulation day. (Ovulation = the release of the egg from the ovary.) In an ideal, 28-day cycle, ovulation happens on day 14. Obviously, if you're cycle isn't 28 days, that doesn't help you. Fortunately, ovulation day is remarkably constant from woman to woman, and you can calculate your probable ovulation date based on the length of your monthly cycle. Here's one helpful way to think of the monthly cycle: a cycle divided into two intervals. The first interval (preovulatory) lasts from the end of your period to ovulation. The second interval (postovulatory) lasts from ovulation to the start of your next period. The preovulatory interval can vary widely; it may last for four days, or nine days, depending on the length of your cycle. In contrast, the postovulatory interval tends to be fairly constant at 14 days, regardless of how many days your cycle lasts. Crystal clear, right? You can now calculate your ovulation day, even in your sleep if you have to. [Huh? - ed. Now you know how I feel when someone tries to explain tech-related stuff to me.] Let's go through this step-by-step:

First, you need to track your cycle. Mark the day your period starts; this is Day 1 of your cycle. Then count the number of days until your next period; this is your cycle length. Do this for about three cycles in a row (more than three is fine, less, not so much). [The reason you need a minimum of three months is because cycle length might not always be the same each month. After three consecutive months you should be able to see a cycle length pattern.] Once your fourth period starts, count forward from Day 1 the number of days in your cycle length and mark that date. Then, from that day, count backwards fourteen days. This is your presumptive ovulation day. [You never count forwards, from the start of your period, because the preovulatory interval varies in length. You count backwards, because the postovulatory interval is fairly consistent at 14 days.]

For example, let's say your cycle lasts 24 days and your best friend's last 31 days. Both of you will most likely ovulate 14 days before the start of the next period. For you, this means ovulation is on Day 10 of your cycle (24 - 14 = 10), while for your friend, ovulation happens on Day 17 of her cycle (31 - 14 = 17).

Keeping track of your monthly cycle isn't useful just for planning a pregnancy. It's also beneficial if you plan to manage your period. In particular, it's useful if you plan to use period control occasionally, like for a scheduled event. If you know you have an upcoming event (vacation, exams, business trip) and you don't want to have a menstrual period around that date, the best time to suppress your real or fake period is about three months in advance. The advantage: it lowers the likelihood of nuisance side effects, like breakthrough bleeding/spotting.

Love, No Choice Style

I wish I had some clever commentary to offer about this article, but the only thing that comes to mind is So Much Human Potential to Destroy, So Little Time:

Petr and Fatima arrive as a wedding is about to begin. Women are busy making traditional Kyrgyz bread for the occasion, and men sit in chairs outside, talking and sipping tea. The groom confesses he has had some difficulty finding a bride, but he is hopeful that "this one will stay."

When the bride does arrive, she is dragged into the groom's house, struggling and crying. Her name is Norkuz, and it turns out she has been kidnapped from her home about a mile away.

Fatima had prepared Petr for this scene, telling him that the custom of bride kidnapping is shocking, but he is still stunned by what he is seeing.

(via Gweilo Diaries)

Penguin Group Sex

Via ms. musings, we are alerted to the fact that:

A wave of confessionals and self-help guides written by current or former stars of pornographic films is flooding bookstores this year, accompanied by erotic novels, racy sexual-instruction guides, histories of sexual particulars and photographic treatments of the world of pornography.

One of the books mentioned in the article is How to Make Love Like a Porn Star: A Cautionary Tale (HTMLLAPS), by Jenna Jameson:

Ms. Regan's [the publisher] most recent offering is "How to Make Love Like a Porn Star: A Cautionary Tale," a memoir by Jenna Jameson, probably the most successful woman ever in the adult-film business, written with Neil Strauss, a former reporter and music critic for The New York Times.

The book, which is already climbing the best-seller lists, is long (579 pages), graphic (with clinical descriptions of a smorgasbord of sex acts) and bulging with color photos of a mostly nude Ms. Jameson (which led some stores, including Wal-Mart, to refuse to stock it).

Since I have something very much in common with Ms. Jameson--the first-time author predicament, if you must ask, you naughty, naughty people--my curiosity was peaked. [Actually, there's another reason--serendipity; I'll come back to that in a moment.] In particular, the part about Ms. Jameson's book climbing the best-seller list (it's currently #7 at Amazon) interests me. Why? Because the one goal I have for my book is to expose as many women as possible to the correct and complete information about menstrual management. This means I can always stand to learn a valuable lesson from a book that's reaching a wide audience. So, let's see how my book compares to Ms. Jameson's book:

--579 pages

My book has 272. Drat, I told the editors not to cut those extra 100+ pages, but they didn't listen to me. Advantage: HTMLLAPS.

--graphic (with clinical descriptions of a smorgasbord of sex acts)

Ha, my book has graphic descriptions, too (granted, they're the anatomically correct kind, but still, a description of the hymen is a description of the hymen). As far as the sex acts go, with your indulgence I might be able to make a claim--a clinical description of the genital tract, both upper and lower...both involved in orgasm...orgasm being the result of sexual intercourse...ergo [more or less] my book also has descriptions of sex acts. Advantage: neither book. Let's call it a draw.

--bulging with color photos of a mostly nude Ms. Jameson

Oh, this really makes me mad! I had gorgeous color photos of all the birth control methods mentioned in the book, but the editor didn't think they were necessary. [I'm so holding my breath and my typing fingers right now, so as to render myself incapable of expressing my opinion vis-a-vis this decision.] Advantage: HTMLLAPS.

--led some stores, including Wal-Mart, to refuse to stock it

My book is stocked by Wal-Mart. Advantage: my book.

Obviously, the above comparison is meant as a funny diversion. The two books belong to different categories: HTMLLAPS (Biographies & Memoirs), my book (Women's Health). Also, since I haven't read Ms. Jameson's book, I'm not qualified to compare/review it. Yet, serendipity has allowed me to offer you (and myself, for that matter) a behind-the-scene look at the making of a best-seller book.

A couple of nights ago, as I was flipping through the channels, I notice a VH1 documentary about a porn start. What caught my attention, as a first-time author: porn star has just written a book (HTMLLAPS), book's publisher (Judith Regan) appears in the documentary as a "character witness" interviewee, and one of the documentary's producers is...wait for it...the publisher (Regan Media). I must say, this is one brilliant book Infomercial.

Of course, I'd feel more comfortable if content alone determined a book's ranking. [Should you even mention content, seeing how your book is not even ranked at Amazon? -- Ed. Please, don't interrupt with such mundane observations; I'm trying to make a point here.] However, being the quick study that I am, I now know what I must do: get my publisher to produce a documentary about the menstrual period, get the editor-in-chief to give a menstrual management testimonial, and have it broadcast on MTV. Oh, and maybe throw in some shapely, scantly-clad gentlemen in the background. Who says learning useful things about your health has to be boring?

Update: Old Hag offers an interpretive guide to the sex+porno+books article:

"What we're seeing now in novels is that they're sexy, but they're very sophisticated," Mr. Wietrak said.
Translation: "Do I make you horny, baby? Do I?"

Malaysian Period

She's a Chinese female. And she menstruates.

Menstrual Suppression vs. Continuous Use

Good review article on new-ish birth control methods, emergency contraception, and the IUD. Since continuous contraception is mentioned, let's use this opportunity to look at the difference between menstrual suppression (deals with the real menstrual period) and continuous use (deals with the fake period).

Menses (Real period)

Each month, under the influence of hormones, cyclical changes take place in the ovary and the uterus. This is the monthly cycle. For the purpose of our discussion, we can artificially divide this monthly cycle into an ovarian cycle and an uterine one. Since we're talking about the menstrual period, we're only concerned with the uterine cycle; namely the monthly changes undergone by the lining of the uterine cavity (endometrium).


(Functional layer sheds; basal layer doesn't)

In the beginning of the uterine cycle, the lining is thin. It builds-up gradually during the month, reaches a maximal thickness and then, if there's no pregnancy, most of this thickness is shed, in the form of menstrual bleeding. Then the cycle starts anew.

As you can see, the menstrual period (menses, the real period) is just a small part of the uterine cycle. And, contrary to what you might've been told, the period is not so much a sign of the past (your body failed to become pregnant), as it is a sign of the future (your body is ready and able to sustain a pregnancy). How come?

Briefly, on a cellular level, a fertilized egg (egg + sperm) has a couple of unique characteristics: it has foreign genetical material (the sperm's DNA from the male), and, when it implants, it uses techniques similar to those used by tumor cells. [Implantation is the burrowing of the fertilized egg into the lining of the uterus.]


Inside<--invading fertilized egg<--uterine cavity
the
uterine
wall

So, the uterus has to be able to provide a growing, nourishing environment to something it views as a foreign invader. This poses a problem: normally, the body has mechanisms that fight both foreign bodies (think organ transplant rejection), and tumor cells (the body tries to limit the growth of cancer cells). The solution? In anticipation of implantation, the cells in the lining of the uterus start to undergo specialized changes, (decidualization). Decidualization allows the fertilized egg to implant, and at the same time, limits the egg's invasive ability.

As an aside, occasionally this process breaks down, there's no limiting influence on the fertilized egg, and the results can be [WARNING graphic picture/pathological specimen] disastrous; the woman can die (the tissue keeps growing and growing, it invades through the uterus, into the lungs, the brain).

Returning to decidualization, this process solves one set of problems: it allows the uterine tissue to be ready to accommodate the unique needs of the fertilized egg. At the same time, it creates a new problem for the body--it starts an irreversible clock.

Decidualization happens independent of a fertilized egg. In other words, each month the body jumps the gun if you will. It doesn't actually wait to see if there's a fertilized egg or not. [It doesn't even care if there's any sperm around.] The body gets ready for a pregnancy, period [no pun intended]. However, once decidualization happens, if a fertilized egg isn't there to implant within a certain window of time, the opportunity for pregnancy is lost. Any new fertilized eggs, formed at a later date (e.g., during the next monthly cycle), won't be able to implant. Fortunately, during the menstrual period, the decidualized cells are shed, and brand new cells take their place. These replacements are then able to undergo their own changes, and allow a new fertilized egg to implant.

Returning to the macro level and the uterine cycle, two very important concepts:

a) Fluctuations in hormone levels cause the changes in the uterine lining.

If your hormone levels don't fluctuate, the uterine lining will not thicken, and it will not shed (there's no need to shed it since it's not thick). No shedding means no menstrual period.

b) The only biological reason for these changes in the lining is to prepare the uterus for a possible pregnancy.

Unless you're planning a pregnancy, there's no reason to have any cyclical changes in your uterine lining. Of course, you may still wish to undergo these monthly changes, but you don't have to.

Withdrawal bleeding (Fake period)

When you use a hormonal method of birth control, like the Pill, you no longer have an uterine cycle/a menstrual period. This is normal; it's the way the Pill works and it lasts the entire time you use the Pill. If you use the Pill for 7 years, you don't have uterine cycles/menstrual periods for 7 years. How is that possible?

Briefly, while you take the Pill, your body hormone levels stay low and, most importantly, they don't fluctuate. The levels of Pill hormones are also pretty steady. So, since there are no longer any hormone fluctuations, the lining of the uterus stays thin.

This is very important: the uterine lining stays thin ALL THE TIME, for the entire time you use the Pill (not only throughout the month, but throughout the 7 years in our example above).

No build-up of the lining means no periodic shedding. No shedding means no menstrual period. This is how the Pill suppresses the menstrual period (menstrual suppression). [Keep this term, menstrual suppression, in mind; it's an essential term and we'll come back to it in a moment.]

What you do have when you use the Pill is a monthly withdrawal bleeding episode, or a fake period. This withdrawal bleeding and the menstrual period are not one and the same thing. Briefly, by manipulating the dose of hormones in the Pill, you can destabilize the thin uterine lining enough to cause some bleeding.

But, if the fake and the real period are not one and the same, then why do we have a fake period on the same schedule as the real period, namely, monthly? Again, briefly, because of a Puritanical politician, a Catholic Pope, doctors who didn't wash their hands, and many dead rabbits. In other words, the reason for the monthly schedule of the fake period is a "designer" one, not a biological or medical one. There's no biological or medical reason to destabilize the thin uterine lining monthly.

When the Pill first came out, the concept that any woman can control her fertility was revolutionary enough. Mind you, what was revolutionary was not the desire to control fertility. Throughout history women had been using various methods of birth control (gold shields, plants, potions). With the advent of vulcanized rubber (diaphragms, cervical caps) and the Pill, the groundbreaking event was that safe and effective birth control was finally widely available. Heaping the concept that women could also control their menstrual period on top of their fertility was considered just too much for the political, religious, and societal sensibilities of the 1950s. Enter the fake period. By building-in this monthly bleeding episode into Pill use, the scientists hoped to ease the "shock". [Remember, what we're talking about here is a female health issue, something that, apparently by definition and divine law, requires final approval from politicians, religious leaders, and as many self-appointed "protectors of women" as we can find. In the 1950s, unfortunately just like today, giving women all this control over their bodies and their health was inconceivable; decisions about female health issues couldn't possibly be left to the women and their health care professionals.]

Returning to the fake period, what happens when you use a regular Pill brand and you want to skip "your period", or when you use Seasonale (continuous or extended use)? Let's first see what doesn't happen. The frequency of your menstrual period is not affected. Why? Because when you're using any Pill brand, you no longer have a menstrual period; the menstrual period is suppressed. What does happen is that you're shifting the frequency of your fake period. For example, if you use Seasonale, you're shifting from a monthly fake period, to a trimonthly one. Of course, if you want, you could shift to a bimonthly fake period, or a biannual one. Or you could shift the fake period only once every three years, when you attend a wedding (yours, and your best friend's, of course).

Bottom line:

1. The real and the fake period are not one and the same

2. Suppressing your menstrual period by using the Pill on a regular schedule (menstrual suppression) and shifting the frequency of your fake period by using the Pill on an extended schedule (continuous use) are not one and the same, either.

The difference between menstrual suppression (real period) and continuous use (fake period) is important. For example, if you're already using the Pill and you're considering the safety of shifting your fake period, your focus should be on the benefits/drawbacks of continuous use, not menstrual suppression. Unfortunately, almost every single lay article on Seasonale and/or continuous use I read misinforms you about this crucial topic. So, in future posts, we'll go over this in more detail.

Female Domys

It's staggering how many health dogmas and myths (domys) women have to put up with, just because they're women. [Domys? Did you just make up a word, and pluralized it? Ed. Yes, yes I did.] Three of the most entrenched ones are:

- Painful and inconvenient menstrual periods are an integral part of being a woman.

- Women must feel excruciating pain during childbirth!

- Pregnancy and nausea and vomiting go hand-in-hand.

No, no, and no! None of these harmful domys are true, and it's high time we get rid of them. My book informs women about the first domy. Thankfully, most physicians are doing their part in combating the second one, by being aware of, and informing women about pain management options during delivery. [Unlike the majority of TV executives who find it perfectly acceptable, not to mention amusing, to depict a woman squirming in pain while giving birth!] So, let's spend a little time today deconstructing the nausea and vomiting of pregnancy (NVP) domy.

The prevalence of NVP is 70% to 85% (about 50% of women have both nausea and vomiting; 25% have nausea only). About 35% of pregnant women have NVP severe enough to disrupt their daily routine. As many as 50% of these women are not offered treatment for their condition. The most severe form of NVP, hyperemesis gravidarum, requires hospitalization. This condition is seen in 3 to 20 of every 1,000 pregnancies. NVP usually present before the 10th week; about 30% of pregnant women can expect it to go away before 10 weeks, in about 30% of women it will resolve between 10-12 weeks, and in another 30% of women by 12-16 weeks.

The physical discomfort experienced by pregnant women with NVP (even at milder levels of severity) is similar in intensity and character to the nausea and vomiting induced by cancer chemotherapy.

What helps with NVP? Although not well supported by studies, lifestyle changes might help--avoiding foods and activities that worsen the NVP; small, frequent meals; protein liquid meals. Also, there are alternative remedies, like ginger (250 mg by mouth 3-4 times a day), and acupuncture. Moving on to drugs, studies found that multivitamins can help reduce the severity of NVP. If none of these work, or if you don't want to try them, you have very good alternatives available: vitamin B6 (pyridoxine) and Bendectin (only if you live outside the U.S., otherwise you have to improvise). [And while we're on the subject of availability: Avoid thinking of the multi-millionaire lawyers who file frivolous lawsuits while you're vomiting; it may aggravate your condition.]

Vitamin B6 (10 to 25 mg every eight hours) should significantly reduce the vomiting. If this doesn't work, the next step is Diclectin (available only outside the U.S.). In the U.S., the equivalent drug Bendectin was voluntarily withdrawn from the market in 1982 because of greedy lawyers. [For the full story, in the article I linked to, look under Bendectin: The sad saga of a useful drug, or click here (pdf file).]

One tablet of Bendectin had 10 mg each of vitamin B6 and doxylamine. Approximately the same amount of doxylamine (12.5 mg) can be found in half a tablet of the OTC drug Unisom. So, if vitamin B6 alone doesn't help, half a Unisom tablet can be added; that is half a tablet every eight hours. (Only Unisom in tablet from works; the gel caps have a different active ingredient.)

Other drugs used, for more severe cases and hospitalized patients, are: Phenergan, Dramamine, Reglan, Tigan, Zofran, and Medrol.

Bottom line: feeling nauseous and vomiting during your pregnancy is not a "must-have" experience. Treatment is available; ask for it! And, as always, verify everything you read here with your own health care professional.

Creative bonus, since I'm in a slogan-y kind of mood: Know More, Live Better. Just Say No to Domys!

Skipping Your Period and Google

I don't know if this is a common blogosphere occurrence, but I must say I receive the most interesting questions. A reader wanted to find out more information about skipping her period, or menstrual management (MM) so off to Google she went. And this is what happened:

90% of the results are about menstrual management for developmentally or intellectually disabled women! In fact, in the first three pages of Google hits, the only non-disability-related results are related to you; they all point to this blog or sites about your book.

I realize the menstrual management idea is relatively new and all, but is handling disabled women really the only context in which it's been discussed until now? Nothing about non-disabled women who just don't want their periods? I'm just blown away.

Actually, I had the same reaction when I discovered the dearth of MM information available to women; hence, my decision to write the book. While we wait for it to come out, let's try to fill this informational gap a little bit by, briefly, going over who can benefit from using MM, and then by looking at why you (and, apparently, Google) don't have enough MM information.

Before we start, I must nip this meme in the bud: the MM idea is relatively new. No, it's not! The only thing that's new is women *finally* getting some information about it.

First, the Pill was initially FDA-approved as a MM drug (in 1957), not a birth control one. That came later, in 1960. Second, using hormonal birth control to treat period-related problems (e.g., endometriosis) has been the standard of care for decades. Third, studies of women using the Pill to suppress the monthly [fake] period have been published as far back as the 1970s. [If you think the concept of Seasonale/a trimonthly bleeding episode is new, think again. The women in a 1977 British study used a similar, trimonthly regimen. Interestingly, 82% of those women welcomed the reduction in the number of periods.] And last, but not least, everybody from honeymooning brides to students, and farmers--women with no period-related problems--have been using MM for lifestyle reasons, also for decades (provided their physician was familiar with it). Apropos of physicians: a 2003 Gallup poll commissioned by ACOG (the American College of Ob/Gyns) found that female ob/gyns are nearly unanimous (99%) in the view that menstrual suppression--the daily use of the Pill to stop monthly periods--is safe for their patients. More than half of women ob/gyns have tried menstrual suppression themselves.

Bottom line: MM is not a new idea. It's been in use for decades.

1) Who can benefit from using MM?

A. Women who don't want to have monthly periods

(because they simply don't like to or because they live in societies that consider menstruating women "untouchable")

B. Women who lead an active lifestyle

(women in the military, women who enjoy active sports, women with physically demanding jobs--stay-at-home mothers taking care of small children, shift factory workers, residents and nurses, mail carriers, etc.)

C. Women with period-related health problems

(cramps, heavy periods, endometriosis, seizures, etc., as well as women with various disabilities)

D. Nonmenstruating women

(women using hormonal birth control no longer have menstrual periods, yet they still experience fake period-related health problems--cramps, migraines,etc.)

One important note: there's no connection between sexual activity and using MM. In other words, MM can be equally beneficial to nuns and mothers of five children. (So, if you had any naughty ideas, nice try, but no.)

Bottom line: although disabled women are one group who can benefit from using MM, they're just one of many. In fact, non-disabled MM users are the clear majority. So then, where's the MM information for non-disabled women? Apparently not on Google.

One thing just occurred to me: most physicians who know about MM aren't probably even aware that this information isn't widely available. I certainly wasn't until something happened--I looked for a good lay MM book to recommend--that made me joltingly aware. [In my colleagues' and my defense: I think we live in a bubble. The lay people we come into contact with, our patients, know about MM because we tell them. All the rest, co-workers and friends, also already know since the majority are medical professionals.] As to the health care professionals who don't know about MM, as well as women in general--how can they be expected to be aware of an information shortage when they're not aware the information exists to begin with?

2) Why isn't MM information widely available?

A. Health-care professionals

(too little time spent with patients, some don't know about MM, etc.)

In a survey of nurses and physicians, 43% said they don't prescribe MM drugs because patients don't ask for them and 4% don't prescribe them because of the extra counseling time involved.

B. The government and pharmaceutical companies

(bureaucracy, no interest in changing drug designation from off-label to "on-label", etc.)

A quick primer on the impact of an off-label designation. First, what do "off-label" and "on-label" mean? Here's an example: the antidepressant Zoloft is FDA-approved for treating depression. This is an "on-label" use. [Once a drug is FDA-approved, for whatever indication, physicians can prescribe it for another indication.] While using Zoloft, physicians notice that it's also very effective at treating premature ejaculation and start using it for that as well. This is an "off-label" use. Most drugs are used off-label, and the off-label use is often considered the standard of care. Only drugs that are FDA-approved can be used off-label.

How does the off-label designation impact you? In a major way. It keeps you out of the loop by law. Pharmas are not allowed to distribute information about off-label use directly to consumers. Most often, they don't even volunteer the information to physicians (they can, but usually, only if the physician initiates the inquiry). Unfortunately, since the drug is already FDA-approved and the physicians are already using it, legally, off-label, the drug manufacturer has little incentive to invest in changing the drug designation to "on-label". In other words, there's little incentive to keep you informed.

For example, before Seasonale was FDA-approved in September of last year, MM use of the Pill, although the standard of care, was off-label. In practical terms, this meant that, unless your health-care professional new about MM and elected to share the information with you, it would've been very hard for you to educate yourself about MM. Now that Seasonale is "on-label", you can get some MM information. As in, you can get information about Seasonale and nothing else. Not the over 10 other monophasic Pill brands* with the exact same composition as Seasonale, not about using a triphasic brand for MM (despite the fact that, according to the manufacturer, a triphasic brand is the one most used by American women), and most certainly not a peep about using NuvaRing, the vaginal ring, or other hormonal methods for MM. Remember, only Seasonale is "on-label"; the rest, although identical in the case of the other monophasics, are off-label. And you're not allowed to know anything about them, under threat of great physical harm. [I'm joking, of course. Or am I? After all, it's quite possible your pretty little heads will explode now as a result of exposing you to all this information.]**

C. The media and society

(the message that the menstrual period is more disgusting than any other known and widely advertised body function--acid reflux, gas, impotence, etc.; acceptable to discuss anal sex, vibrators, decomposing bodies, while mentioning the period, not so much)

*Monophasic Pill brands equivalent to Seasonale (same hormone content, different packaging):

Seasonale estrogen 0.03 mg + levonorgestrel 0.15 mg
Femigoa
Femranette
Levlen
Levora 0.15/30
Microgynon 30
Minidril
Monofeme 28
Nordette
Ologyn micro
Ovranette
Stediril 30

*Just so you know, in the book all you get is the actual data. The purpose of the book is to give you complete and correct information about MM, to allow you to know more and live better. It's not to expose you to my personal comments and opinions. Despite their brilliance, they're irrelevant to your health decisions. [That's why I have a blog, in case you were wondering. Wouldn't want to deprive the world of my opinions. And that's also the reason I blog more-or-less anonymously. I'm quite uncomfortable with physicians expressing their personal views right alongside medical information.]

Tangled Bank

From dinosaurs to high blood pressure, the 9th edition of the Tangled Bank(the science COV) has something for everybody. (If you'd like to submit a post for future editions, click here.)

Sex Ed

Reuters reports that the new sex-education textbooks in Texas are likely to ignore birth control:

Texas educators are debating what will be taught in new sexual education textbooks for its high school students. The 15-member Texas Board of Education is considering and will likely approve four books, all of which extol the virtues of abstinence. Three make no mention of contraceptives at all while one makes passing reference to condoms.

Pardone moi? What exactly is there to debate? There's only one way the human body works. Or, to paraphrase a line from My Cousin Vinny: are we to believe that the laws of biology are suspended in Texas?

...

National surveys indicate that a wide majority of parents support a strong abstinence message to teens in sexual education.

Hmm, maybe this is the problem. I should think a sexual education class is supposed to teach facts, not dispense moral/societal messages. There's a difference between abstinence, the facts, and abstinence, the message. The facts are that abstinence is but one of over 80 methods of birth control, one that's not very effective (because it's user-dependent). These facts apply equally to all the students in a class (their number, sex, family situation, or religion are irrelevant). In contrast, the abstinence message is different for every student in a class; it depends on the student's particular circumstances--what societal or religious background he/she comes from, what message the parents wish to transmit to their child, etc.

...

Local school districts are not required to use one of the new books but they receive state funding to buy them if they do.

This use of state funds is eerily similar to the Alabama EC one. And, again, I have to ask: why is the government involved at all? Shouldn't the educators and the parents decide what the curriculum should be?

...

The education board has been at the center of many political and religious battles over the years including a recent proposal by evangelical Christian groups to have the state's textbooks include items debunking evolution.

This doesn't make sense. Just like gravity, human anatomy and physiology exist independent of political system or religious denomination. Moreover, we still have separation of State and Church. So why are religious groups making state school curriculum proposals? I'm not absolutely certain, but I think members of a religion can have their own private, religious schools.

Texas standards require sexual education books to "analyze the effectiveness of barrier protection and other contraceptive methods, including the prevention of sexually transmitted diseases, keeping in mind the effectiveness of remaining abstinent until marriage."

As discussed in an earlier post, very few abstinence-only-until-marriage programs have been rigorously evaluated and, thus, there is no compelling evidence to date that they actually change sexual behavior. If teaching students STD prevention is the goal, I do hope they spend time on microbicidal spermicides. I'll have a more detail post on these methods, but, briefly: a spermicidal kills sperm; a microbicidal kills microbes (like the ones causing STDs); a microbicidal spermicide prevents both pregnancy and STDs.

State Education Agency officials said mention of condoms and contraceptives in the teacher's editions or in supplements to the books enable them to meet Texas curriculum standards.

Richard Blake, a spokesman for Holt, Rinehart and Winston said his company offers a supplement for students that goes into comprehensive detail about forms of contraceptives.

The supplement for students is free with the purchase of the textbooks. It is excluded from the main text in order to offer flexibility and meet the needs of school boards across the United States that have differing views on how to treat a subject many see as highly sensitive.

Let me see if I understand this correctly: we take out the actual information from the textbook and we put it in a supplement. Then we give the students the textbook containing...what? If you take out the information abut birth control from the "Birth Control Methods" chapter, you're not offering the students flexibility; you're giving them blank pages. And, unless only philosophers and artists--people who can look at a blank page and have many different views of it--are allowed on school boards, there's only way to treat the subject of science: give students the information.

Update: Another view, from Austin, TX.

Period Control and Heart Disease

Good WaPo article, highlighting the differences in heart disease between women and men:

"The whole disease is poorly understood in women, from the expression of the symptoms all the way down to some of the basic mechanisms," said Carl J. Pepine, a cardiologist at University of Florida's College of Medicine in Gainesville. "The disease has a very broad spectrum, and more men are at one side and more women are at the other side."

Instead of one main blockage, arteries in many women go into spasm or have smaller, easily missed buildups along their entire lengths, which can be just as dangerous as one big one. And often the problems lie not in the major arteries that nourish the heart muscle but in the frequently overlooked smaller branches.

These differences, frequently found in younger women, could help explain why the symptoms are often so different than in men, why women are often misdiagnosed -- or never diagnosed -- why they commonly are not treated until much later, and why women are more likely to die from their heart disease even when they are treated. The standard tests, drugs and procedures simply may not work as well for many women.

For reproductive-age women, in addition to the well-known risk factors (high blood pressure and cholesterol, obesity, smoking), there's one additional, period-related risk factor:

Some researchers suspect that the crucial oxygen-carrying protein in blood, hemoglobin, may also be important. Women tend to have less hemoglobin than men because of their monthly menstrual cycles, and low hemoglobin may further starve the heart muscle. Hemoglobin deficits may also reduce nitric oxide levels.

"Hemoglobin turns out to be a major independent predictor of outcome," Pepine said.

One way for women to increase their hemoglobin is to limit unnecessary monthly blood loss (e.g., the fake period in women who use hormonal birth control, like the Pill). Bottom line: period control could prove to be an important preventive tool in the fight against heart disease.

Extremes

CREEPY: "Perfect boyfriend" [quarter] dolls


Kameo's Boyfriend Arm Pillow (via feministing)

CUTE: Giant microbes dolls


Common Cold Virus (via Pharyngula)

One for the Boys

When it comes to male birth control, a method has to be able to prevent insemination. Insemination is the deposition of sperm in or near the vagina. There are two ways to disrupt insemination: mechanical or hormonal. The first one is relatively easy to accomplish: you cut the vasa, you use a condom. The hormonal route is more challenging. Why? Let's quickly compare the maturing of egg and sperm to give you an idea.

Each monthly cycle about 20 ovarian follicles are recruited to develop and mature. [Think of the follicle as a little individual egg nest inside the ovary.] By the end of the cycle--Day 14 in a 28-day cycle--only one follicle fully matures and one egg is expelled from the ovary. There are exceptions to this rule, but for the purpose of our discussion one ovary = once-a-month = one mature egg. The ovaries alternate in this function: one month the egg is released from the right ovary, the next from the left one. [So, even if one ovary is removed, fertility is retained.]


[Maturation starts top left, and progresses, clockwise, from top left (Follicules ovariques primaires = Primary ovarian follicle) to bottom middle (Ovocyte expulse = Ovulation); the yellow body (Corps jaune) is what's left of the follicle after the egg is released; the white body (corpus albicans) is what's left of the yellow body if no pregnancy occurs.]

Bottom line in a woman: from one primary/immature germ cell-->one egg; takes one month to mature; between two successive egg maturations the woman is not fertile (most of the month).

In contrast, a man produces and matures sperm, in the testicle, continuously. It takes about 64 days for sperm to mature. So, on any given day of the month a man has some immature, some developing, and some mature sperm. In other words, one testicle = continuously = millions of mature sperm. [To give you an idea of the numbers involved: an adult testicle produces approximately 1,000 sperms per second. So a single ejaculate may contain from 200 to 600 million sperm.]

Sperm development

Bottom line in a man: from one primary/immature germ cell-->four sperm; takes 64 days to mature; cells are in different stages of maturation, so man is fertile throughout the month.

In both women and men, hormones control the production of eggs/sperm. There are local hormones involved--estrogen, progesterone, and, in men, testosterone--and control hormones, called gonadotropins. All these hormones work in concert, and influence each other via feedback loops (e.g., high levels of one shut down production of another).

Finally, and briefly, hormonal birth control methods, like the Pill, work at the level of these hormones: they inhibit the gonadotropins. In women, all you have to do is prevent a once-a-month event, ovulation. You're not so much concerned with the development and maturation of the egg (which take place inside the ovary) as you are with blocking the release of a mature egg from the ovary. In contrast, in men your focus is on blocking the production/release of sperm, a continuous process.

So, now that we have the theory out of the way, let's look at the male birth control methods. Currently, the 3 widely-used methods are:

Coital techniques

Condom

Sterilization (Vasectomy)

Vasectomy is a surgical procedure in which the vasa deferentia (tubes involved in sperm transport) are cut and the passage of sperm is blocked. Because no sperm is present in the ejaculate, insemination is prevented.

The two techniques used are conventional, and no-scalpel (NSV); the procedure is a minor operation (when compared to female sterilization) lasting approximately 10-20 minutes. Usually only a local anesthetic is needed. A man is not sterile immediately after a vasectomy. It usually takes about 3 months (or 20 ejaculations) for all the mature sperm, stored in the vas beyond the blockage point, to be eliminated. An alternate method of birth control must be used during this period until sterility is verified. The 1st year failure rate is 0.15% with typical use, and 0.10% with perfect use. Vasectomy is the most effective method of male birth control currently available.

Reversal surgery (vasovasotomy or epididymovasostomy) is possible, but it involves more complex surgery than the initial procedure. The success rate of the reversal is low. Although it's possible to obtain a vas patency rate of 50% to 80%, the pregnancy rate is only about 30%.

The male methods under development can be divided into 7 groups:

Heat
Birth control pills
Injectables
Implants
Vaccines
Vasectomy
Plant compounds

Heat

Sperm can not form and mature at normal core body temperature. This is why the testicles are located outside the body, in the scrotal sac, where the temperature is several degrees cooler vs. the core body temperature.

Heat methods warm the testicles in order to inhibit sperm formation. The heat source can be either natural body heat (a special undergarment is used to elevate/keep the testicles very close to the body) or an external heat source (ultrasound waves, etc.). Further research is needed to establish the long-term effects of this method.

Birth control pills

a) Synthetic hormones
b) Nifedipine
c) Sugar pill

a) Synthetic hormones

If a man takes the hormone progestin, his body's secretion of gonadotropins is suppressed. This, in turn, inhibits sperm and testosterone (T) production in the testis; sperm counts are reduced to levels that are unlikely to cause pregnancy. Because the natural T production is suppressed, synthetic T needs to be added in order to maintain sexual drive. Birth control pills for men, containing a combination of a progestin and a synthetic T or just a progestin, have been studied.

A combination Pill (progestin and T), taken twice a day for 16 weeks, lowers the sperm counts to very low levels and appears to have few side effects. This pill has been tested in a small study.

Another progestin-only pill has been studied; the synthetic T is added usually in the form of an injection or patch. One drawback: it may take weeks to months to reach full effectiveness.

b) Nifedipine

Nifedipine is a widely used antihypertensive drug (a drug used to lower high blood pressure). A side effect of this medication is that it prevents the binding of the sperm to the egg. This could be useful for its future development as a male birth control pill.

c) Sugar pill

This method uses a sugar-based compound, administered in the form of a pill. The compound attaches to a sperm enzyme essential for egg recognition and penetration. Because this enzyme is blocked, sperm can not properly bind to the egg and fertilization is prevented.

Injectables (Shots)

a) Testosterones
b) Combination
c) GnRH Antagonists

a) Testosterones

If a man takes synthetic testosterone (T), his body's T production is inhibited. This, in turn, causes a dramatically suppressed sperm count. Because the synthetic T in the blood can not cross into the testicles, peripheral T levels remain high enough to preserve the man's libido. This represents an advantage, when compared to the progestin-only pill which suppress peripheral T levels. Three different types of synthetic T shots have been studied. [Interestingly, hormonal methods work better in Asian men than in Caucasian men; it's not yet clear why.]

b) Combination

A combination of a progestin and a synthetic testosterone (T) appears to be more effective in suppressing sperm formation than synthetic T alone. Also, by adding the progestin the dose of synthetic T can be lowered, thus reducing its potential side effects. Studies of a monthly progestin/T shot are currently underway.

c) GnRH Antagonists

A GnRH antagonist is a compound that blocks the production of gonadotropin-releasing hormone (GnRH). The lack of GnRH, in turn, causes the testicle to stop sperm and testosterone (T) production; the man's fertility is inhibited. Because the body's natural T synthesis is blocked, a synthetic T needs to be added. GnRH antagonists are administered as a subcutaneous injection (under the skin) and they've showed good effectiveness in small trials. The disadvantages of using this method: GnRH antagonists are difficult to produce, and maintaining their action with only one synthetic T has had mixed success.

Implants

One type of male hormonal implant consists of 2 rods: one rod has gonadotropin-releasing hormone (GnRH), and the other has the hormone nortestosterone (MENT). The hormones block the formation of new sperm, so the man is temporarily infertile.

Another type of male implant under study contains biodegradable testosterone pellets.

Vaccines

The methods in this group aim to use the body's own immune system to act as a contraceptive (via a birth control vaccine that could potentially "immunize" a man against being fertile). The vaccine could stimulate the body's immune system to create antibodies against something that is essential for the man's reproductive process. Potential targets that have been studied: sperm, epididymal proteins, and the gonadotropin follicle-stimulating hormone (FSH).

Anti-sperm vaccines contain one of two types of sperm antibodies (Abs): Abs against sperm metabolism, and Abs against sperm and egg interaction. Studies with sperm vaccines are underway.

In animal studies, immunization against FSH has resulted in significant decreases in sperm counts but inconsistent effects on fertility. The research on these vaccines is at the laboratory stage.

Vasectomy

a) Battery-powered capsules
b) Chemical injections
c) Silicone plugs
d) Reversible vasectomy

a) Battery-powered capsules

Small, battery-powered capsules can be implanted into each vas deferens, where they emit a low-level electrical current which immobilize passing sperm.

b) Chemical injections

Various chemical substances can be injected into each vas deferens, where they can produce enough scaring of the vas wall to block the passage of sperm. Obviously, the chemical must be able to scar the walls, and must also be nontoxic. This is a non-reversible method.

c) Silicone plugs

A plug device, consisting of very small silicone cylinders, can be inserted into each vas deferens and anchored with a tiny suture to the wall of the vas. The cylinder physically blocks the passage of sperm, and it has the advantage that it can be inserted and removed without using a scalpel. This device is also known as "the shug".

Another type of plug, consisting of a liquid form of polyurethane or silicone (MPU and MSR), can be injected into each vas deferens. Once injected, the material hardens (in about 20 minutes), and forms a plug that stops the passage of sperm. In addition, the plug also causes the vas to rupture which leads to scar tissue formation, further blocking sperm passage. These plugs are removed in an outpatient surgical procedure, usually requiring only one suture. A 98% sterility rate was noted in one study, and another study found the same rate after three years.

d) Reversible vasectomy

A substance called Styrene Maleic Anhydride (SMA) can be injected into the vas deferens, where it raises the acidity inside the vas. Because sperm can not live in an acidic environment, sperm passing through the vas are killed. This method is reversible because SAM can be flushed out of the vasa with an injected solvent. This procedure is also known as Reversible Inhibition of Sperm Under Guidance (RISUG).

Plant compounds

a) Tripterygium
b) Gossypol

a) Tripterygium

Tripterygium wilfordii is a plant used in traditional Chinese medicine. Daily doses of Tripterygium extract affect sperm motility and reduce sperm counts.

b) Gossypol

Gossypol, a plant compound derived from cotton-seed oil, has been tested as a birth control pill for men. It works by suppressing sperm production, but it also produces undesirable side effects: irreversible infertility in over 10% of men, and a low potassium level (hypokalemia). Gossypol has been studied since the 1970s and currently, due to its side-effects, some researchers do not support further studies; others are conducting ongoing studies in several countries.

As you can see from my limited review (I haven't even mentioned GnRh agonists and inhibin, or sulfasalazine, imidazoles, and pyrimethamine), researchers are working on a number of potential male birth control methods. Unfortunately, any wide-spread commercial use is years (probably decades) away. If you'd like to keep up-to-date with developments, malecontraceptives.org might be of use. [It appears to be a private site; good info, but I didn't have time to evaluate in-depth.]

Update: I replaced a picture (it was doing funny things to my blogroll) with a link.

Gay Marriage and Abortion

Responding to this WaPo article, Virginia Postrel makes the case that gay marriage is not the "new abortion". I'm surprised that such a comparison would even be entertained. Spontaneous abortions (miscarriages) are body processes; induced abortions are medical procedures. Marriages--gay, straight, or in-between--are societal constructs. Congress, the courts, state legislatures, and referendums are supposed to have a say in, and regulate these societal matters. They're not supposed to, and shouldn't play an equal [or, ideally, any] role in medical decisions. [Although, it'll be interesting, in a Kafkaesque sort of way, to see how Congress regulates spontaneous ab's.]

This surprised me: People support abortion rights out of fear. Fear of what? In any case, this sounds akin to, and I'm paraphrasing: Providing EC to low-income women is the right thing to do because other women already have access to it. Subjective criteria like fear, and noble intentions shouldn't play any role in influencing medical care. Proper care should be the only determining factor. And the more social, moral, religious, and political [oops, almost said mystical] meanings we keep attaching to body functions and medical procedures like abortion, the greater the disservice to our health.

And just because I'm that type of person [one who believes the more you know the better off you are], here's a quick lesson for you:

Abortion* = the termination of pregnancy by any means before the fetus is sufficiently developed to survive.

Spontaneous Abortion (Miscarriage) = an abortion that occurs without medical or mechanical means to empty the uterus; the four types of spontaneous abortion are: threatened, inevitable, incomplete, and missed.

Induced Abortion = the medical or surgical termination of pregnancy before the time of fetal viability; therapeutic and elective abortions fall into this category.

Marriage = the legal union of a man and woman as husband and wife/the state of being married; wedlock/a common-law marriage/a union between two persons having the customary but usually not the legal force of marriage: a same-sex marriage.

*all medical definitions are from Williams Obstetrics 21st ed.

What Never Fails?

A great passage, indeed (via A Voyage to Arcturus):

"The best thing for being sad," replied Merlyn, beginning to puff and blow, "is to learn something. That is the only thing that never fails. You may grow old and trembling in your anatomies, you may lie awake at night listening to the disorder of your veins, you may miss your only love, you may see the world about you devastated by evil lunatics, or know your honour trampled in the sewers of baser minds. There is only one thing for it then -- to learn. Learn why the world wags and what wags it. That is the only thing which the mind can never exhaust, never alienate, never be tortured by, never fear or distrust, and never dream of regretting. Learning is the thing for you. Look at what a lot of things there are to learn -- pure science, the only purity there is. You can learn astronomy in a lifetime, natural history in three, literature in six. And then, after you have exhausted a milliard lifetimes in biology and medicine and theocriticism and geography and history and economics -- why, you can start to make a cartwheel out of the appropriate wood, or spend fifty years learning to begin to learn to beat your adversary at fencing. After that you can start again on mathematics, until it is time to learn to plough."

T.H. White, The Once And Future King

Family Planning ~ Abstinence-Only!

Did you know that the proposed 2005 budget funding for family planning programs almost equals that for abstinence-only programs? I didn't. (The original article* is subscription-only, so I'll quote extensively.)

With record deficits, it may seem counter-intuitive to suggest that it makes sense now, more than ever, to establish full funding for family planning in the United States and internationally. There is good evidence, however, that family planning programs are not just cost-effective, but cost-saving: these programs save money in both the short- and long-term and thus remain a key priority, even in times of budget deficit.

...

Unfortunately, the $2.4 trillion budget proposed for the U.S. for the next fiscal year goes almost exactly against this evidence, leaving family planning funding to stagnate while doubling money for abstinence-only programs.

...

Consider the example of family planning. Every dollar invested in family planning saves $4 or more in public costs—including at least $3 in Medicaid expenditures, with savings starting in the very first year. A recent study of family planning care provided through Medicaid waivers found that every state studied saved money, even while increasing access to care. Yet, despite the great dividends—economic and otherwise—generated by family planning, the 2005 budget request for Title X, the U.S. family planning program for low-income men and women, is the same as the total for last year. At the proposed funding level of $278 million, the program's funding is not keeping up with inflation, and currently provides care for only about half of the low-income women and men who need family planning services.

...

While family planning and reproductive health programs are being subjected to “fiscal abstinence,” “abstinence-only” programs are receiving unprecedented levels of funding. Abstinence-only-until-marriage programs teach that sex within marriage is the only acceptable context for sexual activity, without giving accurate information about contraceptives and safe sex. Very few abstinence-only-until-marriage programs have been rigorously evaluated and, thus, there is no compelling evidence to date that they actually change sexual behavior. In the new U.S. budget, the funding level proposed for abstinence-only-until-marriage programs is doubled from last year, from $140 million in 2004 to more than $270 million in 2005. Money for “marriage promotion” is also increasing, as part of the President's proposed $1.5 billion marriage initiative.

From the Ministry of Silly Walks and Stating the Obvious: we'd be much better off if we could only give science a chance.

*original article: Stewart FH, Shields WC, Hwang AC, et al. The 2005 United States budget: Wasteful expenditures, foregone opportunities. Contraception. 2004 Aug;70(2):87-8.

How's Your Sex Drive?

I mentioned before that sex drive (libido) in reproductive-age women is a complex issue. Many factors play a role: current health, physical and social environment, past sexual experiences, hormone levels, cultural and educational background, and relationship with partner. In particular, the role of testosterone is not well-defined. [Women produce a number of male-type hormones (androgens), like testosterone, both in their ovaries, as well as their adrenal glands. (The adrenals are two small glands that sit atop the kidneys.)]

We know that in men (and some postmenopausal women) low levels of androgens create a deficient state called hypoandrogenism, we know the problems associated with this state (e.g., low sex drive), and we know how to treat it (testosterone supplementation). However, in women it's not clear that such a low androgen state even exists. So, before you apply that testosterone patch [I'm joking, please don't do that!] I found a very good article for you to read. In it, two experts discuss the evidence for the pro and con positions, and conclude:

YES:

As research continues in this area, especially in the area of assays that accurately measure free T [Testosterone] at low levels, our understanding of androgen insufficiency in woman will broaden.

NO:

In summary, FAI [Female Androgen Insensitivity syndrome] is poorly defined and characterized. There are no clear diagnostic criteria. Therapy with androgen has yet to be proved safe and effective.

In addition to the substance of the article, pay particular attention to its form. Why? It will help you learn how to evaluate medical information. This is very important to remember: in order for you to make a truly informed health decision you have to 1) have complete and correct information, and 2) be able to evaluate that information. I plan a more detail post on this topic, but for now look at the article and notice that:

--there are no sensational titles

--there's no inflammatory language

--there are no personal/moral/social pronouncements

--the article is well-referenced

Update: Here's a case study of a woman with low sex drive. Although of limited practical use--patient is 51 years old and perimenopausal--the discussion does offer an interesting insight:

Anne, age 51, presents with complaints of depressed mood and low libido. She says she has become irritable and snaps easily at her 2 children and her husband. She has no interest in sex, no urge to masturbate, and has had no sexual intercourse for 6 months.

Anne also complains of fatigue, dry hair and skin, warm flushes, and painful joints.

She has no personal or family history of depression. She is not suicidal but she "really doesn't want to live anymore if this is it."

Anne says her husband is angry about the lack of sexual intercourse, and she feels the stress in their marriage. She also is worrying about her children leaving for college and about her mother's ill health.

She scores 20 on the Beck Depression Inventory, which indicates that she has mild to moderate depression. Her menstrual periods remain regular, but her cycle has shortened from 29 to 24 days. She reports that some hot flashes wake her at night, and says she hasn't had a good night's sleep in months.

Kaiser Update

In my last post I mentioned I was going to contact the Kaiser Family Foundation and ask for the reference for this passage I found in several of their reports (emphasis mine):

Although EC -- which can prevent pregnancy if taken within 72 hours after sexual intercourse -- works by preventing ovulation, preventing fertilization of an egg or inhibiting a fertilized egg from implanting in the uterus, medical and legal texts do not all agree on whether pregnancy begins at conception or when an embryo implants in the uterus....

I called (1-202-266-5952) this morning and the "mystery" has been solved. What the passage means to say is that, although all medical texts agree on when a pregnancy starts, not all legal texts do. In other words, this has nothing to do with science, or medicine; it's a legal issue. I'm glad this has been clarified. (Perhaps if they'd change the phrasing a bit, the medical/legal distinction would be obvious.)

One more legal clarification. I mentioned that I didn't understand the connection between federal funding and medical decisions made by state health clinics. Matt kindly provides an explanation:

Federal funds are one method the Federal Government uses to legislate laws that are actually the domain of the states. For example.

There is no federal law setting 21 as the legal drinking age. But any state with a drinking age lower than 21 will receive no Federal highway funds for new roads. So Congress in effect set the national drinking age to 21 without directly legislating it.

So I would assume that the same thing has happened here. Congress is requiring all public health departments to provide EC, even though congress does not have the legal power to make a law to that effect.

In other words, by controlling the disbursement of federal funds, Congress dictates medical care. Just brilliant! Although, to be fair, based on Secretary Thompson's letter, it appears the government is just "suggesting" what the medical treatment should be: Alabama state clinics are expected to "offer" EC, they're not "required" to provide it. Either way, I find this government practice very troubling.