Skip Period With Ortho Evra

Good news for birth control skin patch (Ortho Evra) users who want to use the patch to skip the monthly fake period:

A contraceptive patch that has been effective for the standard 21-day cyclic regimen appears to translate seamlessly into an extended regimen, results of a 112-day pilot study suggest.

...

The 123 women who completed the extended regimen applied a new patch weekly for 12 consecutive weeks, and then skipped a week to allow for bleeding. The 68 women who completed the study in the cyclic group applied a new patch weekly for 3 consecutive weeks, and then skipped a week to allow for bleeding.

Period-Free

I keep forgetting to post this. Wyeth is working on a dedicated continuous use combination pill (ethinyl estradiol/levonorgestrel), Librel (scroll half-way down the page):

LIBREL is anticipated to be the first approved continuous use oral contraceptive regime. This continuous suppression of ovulation leads to the inhibition of menses allowing women to become period-free. The elimination of menses is also expected to inhibit the development of cycle-related symptoms such as dysmenorrhea, premenstrual dysphoric disorder (PMDD) and premenstrual symptoms (PMS).

Initially, I though this announcement was from a business site, so I was going to go easy on them, but I noticed it's actually from the manufacturer--for shame! And this is why:

LIBREL is anticipated to be the first approved continuous use oral contraceptive regime. This continuous suppression of ovulation leads to the inhibition of menses allowing women to become period-free.

The continuous use in the first sentence refers to the regimen of use, the way you take the pills--one active (hormone-containing) pill every day, continuously. This regimen is unique to this new brand, Librel and it allows you to became fake period-free (not the same as period-free, as we shall see in a moment).

The continuous suppression in the following sentence refers to the mechanism of action, the way the pills work--the Pill hormones continuously suppress the body's hormones, and thus, menstruation. This mechanism of action is universal; it's the same for all combination Pill brands. In other words, it doesn't matter if you take Pill brand X on a 3 weeks on/1 week off regimen, or Pill brand Seasonale, on a 12 weeks on/1 week off regimen, or even Pill brand Librel, on a continuous regimen--all these brands continuously suppress your ovulation and your menstrual period, and allow you to become period-free.

Bottom line: Menstrual suppression and shifting the frequency of the fake period are not one and the same thing. All Pill brands suppress your menstrual period and allow you to become period-free. All Pill brands used on a continuous regimen allow you to become fake-period free. Only Librel will be packaged with an insert actually telling you how the continuous regimen works. [OK, I'm being a bit flippant here. Librel will also be a brand backed by specific continuous use studies.]

Are You Immune?

Since I talked about the flu vaccine and pregnant women in my healthcast [yes, I've expanded into audio, and no, you may not make fun of my DJing abilities], I thought I should elaborate here, and review immunizations in pregnant women.

Immunizations, which are usually given as injections (shots), protect you from disease and reduce the chance that an epidemic can develop. A vaccine prompts your immune system to form antibodies to fight a particular disease in the future. Most vaccines are killed viruses, meaning it's impossible for you to get the disease from the vaccination. Even when the vaccine is live, it's weakened so much that a person with a normal immune system almost never gets sick from it. Of course, pregnancy is a special case.

For all pregnant women, the best time to be immunized is before becoming pregnant!

Some of the common vaccines related to pregnancy are:

[inactivated] Influenza (flu) vaccine: killed virus--Acceptable in pregnancy

Tetanus vaccine: toxoid--Yes

Hepatitis B vaccine: recombinant surface antigen--Yes

[inactivated] Poliovirus vaccine: killed virus--Yes

Measles/Mumps/Rubella (MMR) vaccine: live attenuated virus--No

Varicella-zoster vaccine (VZV): live attenuated virus--No

Who should receive these vaccines?

Influenza vaccine
All pregnant women who will be in their second or third trimester (beyond 14 weeks) during flu season (~October to January) and all women at high risk regardless of trimester.

Tetanus vaccine
All women who have not had a primary series or who have not had a booster within 10 years.

Hepatitis B vaccine
Pregnant women completing an immunization series begun prior to becoming pregnant and nonimmunized women at high risk for hepatitis B.

Poliovirus vaccine
Pregnant women who will be traveling to areas where polio is endemic. (The oral polio vaccine is no longer given because there's a risk the vaccine may cause paralytic poliomyelitis.)

MMR
This vaccine is not administered to pregnant women. If you are found to be rubella nonimmune during pregnancy, make sure you receive MMR within the first 48 hours after delivery (postpartum). In other words, ask for the vaccine, and don't leave the hospital before receiving it.

VZV
This vaccine is not administered during pregnancy. Because maternal infection around the time of delivery is dangerous for the neonate, if you develop chicken pox in the period 5 days before to 2 days after delivery, make sure the baby receives varicella-zoster immune globulin (VZIG).

The CDC has additional immunization information.

*Primack BA, Zimmerman RK. Influenza and Other Vaccinations Important for Women. Female Patient. Oct 2004;29(10):34-40.

Mais Non!

Are the French really going to give up smoking? There are some efforts underway, at least in Paris:

The reputation of Paris's cafes as charming but smokey establishments where customers light up cigarettes with a laissez faire disregard for others could come in for a change under a new initiative launched by the city.

The municipality, in tandem with France's main hospitality union, announced cafes, restaurants and hotels may from mid-November be issued with a label declaring "This is a 100 percent smoke-free place".

Hmm, I'd be surprised if the non-smoking trend catches on. After all, let's not forget that France gave us this:

Lupus, Syphilis, and Breast Milk

A few articles you might find interesting:

Lupus and the Pill

Using birth control pills is safe for the majority of women suffering from systemic lupus erythematosus (SLE) A new clinical trial finds that oral contraceptives do not increase flares in SLE patients.

Oral Sex and Syphilis

You should be aware that syphilis is readily transmitted via unprotected oral sex (and so are other sexually transmitted infections). Mouth (oral) lesions may carry high concentrations of Treponema pallidum [the syphilis organism] and are thus highly infectious.

Breast Milk Storage

Human breast milk should be stored at refrigerator temperatures for no longer than two days, according to the results of a small trial.... Storage for longer periods or at colder temperatures causes the milk to lose antioxidant activity.

Grand Rounds

Frozen apologies are drafted, and Shriners hear voices at lunch. Don't miss this week's edition of Grand Rounds.

Menstrual Cups, Instead, Keeper, Moon, DivaCup, and Gynotex

Menstrual cups like Instead, the Keeper, Moon and DivaCup are alternatives to menstrual tampons. Barnard has a Menstruation Alternatives event planned for Nov. 3 which will cover the topic of menstrual cups (as well as menstrual suppression, and yoga for PMS).

If you just can't wait until Nov. 3 to find out about tampon alternatives, here's a quick primer.

Menstrual cups are not birth control methods.

These tampon alternatives are not birth control methods, and should not be used as such. Their design tends to resemble that of some of the barrier methods and it is possible to have sexual intercourse while using one of these menstrual products. However, they do not offer any pregnancy protection.

There are several menstrual cup brands available.

Instead Menstrual Cup



Instead is a disposable menstrual cup, shaped somewhat like a diaphragm. It consists of a thick, flexible ring at the top, connected to a thin, flexible pouch. The plastic pouch collects the menstrual blood. You insert the cup into the vagina, and you place it over the cervix. Instead can be left in place during your period for up to 12 hours, on light flow days. Because this cup is inserted high in the vagina, sexual intercourse is possible with the cup in place.

Keeper Menstrual Cup



The Keeper is a reusable menstrual cup that looks a little like a cervical cap (or a small plunger). The cup has a flexible rod connected to its base to aid in its removal. It is made of natural gum rubber, and the cup collects the menstrual blood. You place the cup inside the vagina, fairly close to the vaginal opening. The Keeper can be left in place during your period for 6 to 12 hours, and it can be reused for up to ten years. Because this menstrual cup is placed low in the vagina, sexual intercourse is impractical with it in place.

The Moon Cup, the soft silicone version of the Keeper, is aimed at women who are allergic to latex rubber.

DivaCup Menstrual Cup



The DivaCup, made of soft silicone, is similar to the Moon Cup but has a shorter stem and, according to the manufacturer, a more secure fit. The cup should be removed before intercourse.

Gynotex Menstrual Tampon



The Gynotex menstrual tampon is a disposable device that resembles the birth control sponge. It is made of a soft foam material which absorbs the menstrual blood. You insert it into the vagina, and you place it over the cervix. Gynotex can be worn for up to 8 hours, but it is recommended you change the tampon after 4 to 6 hours. Because it is inserted high in the vagina, sexual intercourse is possible with the tampon in place.

Remember: While some of these menstrual products allow for unencumbered sexual intercourse during the menstrual period, they do not offer any pregnancy protection and should not be relied on as birth control methods.

ETA: Here's a pic of the Sea Sponge Tampon:



Sea sponge tampons tend to come in different sizes:



UPDATE: I checked with Barnard; unfortunately, the event is only for students.

Pill Cuts Cancer, Coronary Risk

The same huge federal study that led millions of women to abandon use of hormones after menopause now provides reassurance that another hormone concoction - the birth control pill - is safe.

In fact, women on the pill had surprisingly lower risks of heart disease and stroke and no increased risk of breast cancer, contrary to what many previous studies have found.

The study in question is the Women's Health Initiative (WHI), and the American Society for Reproductive Medicine's press release is here.

The article mentions one possible explanation for how Pill use lowers the risk of heart disease:

Studies in animals suggest that estrogen may reduce inflammation in the bloodstream and help prevent deposits from forming and blocking vessels, [Dr.] Victory said.

Another possible mechanism is the Pill's effect on hemoglobin levels.

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 turns out to be a major independent predictor of outcome," [Dr.] Pepine said.

Women who use the Pill have higher hemoglobin levels (less blood loss) than nonusers.

The article also touches on the difference between women being exposed to the Pill's hormones, and the hormones used in combination hormone therapy (CHT, old name HRT):

"Those women went for a prolonged period of time without estrogen and then were re-exposed to estrogen" when they took so-called hormone replacement therapy after menopause, [Dr.] Victory said.

This is a crucial difference, and one of the main reasons you can't extrapolate hormone use findings from one population (reproductive-age women) to another (postmenopausal women).

Reproductive-age women continuously produce estrogen (E) (and progesterone). In women who use the Pill, the body's E is replaced by the Pill's E; there's a net hormone substitution (no hormone addition or deficiency). In contrast, postmenopausal women no longer produce E. In women who use HRT, the HRT's E is added to the body; there's a net hormone addition.

If you'd like more information about the HRT studies, I have a list of links on my book site (please pardon the appearance, it's still under construction).

Tangled Bank

Tangled Bank #14, your science COV is up. Please go read about the anthropic principle, a message to people who hate humanity (you must take a look at the pictures; they are brilliant!), and Wigglesworthia.

Grand Rounds

The flu vaccine, implantable chips and black boxes, a cautionary tale about urinary tract infections (UTIs) in women, and a surprise nudity attack coupled with lubricant gel--it's Grand Rounds time!

NuvaRing News

Good news for NuvaRing users. A small study found that ring use is well tolerated and may have a beneficial effect on vaginal health:

The ring was well tolerated; the few genital symptoms reported were generally scored as mild and their incidence was similar to that reported with OC [oral contraceptive] use, with the exception of vaginal wetness.

Increased vaginal wetness was reported with 2.74-fold incidence...in ring users compared with those using OCs (ring, 63% vs OCs, 43%). "Women who reported more vaginal wetness did not differ on laboratory findings from women who did not report this symptom," the authors note.

Laboratory findings showed that the concentration of Lactobacillus colony-forming units positive for hydrogen peroxide (H2O2) also significantly increased during ring use....

The researcher's conclusion:

"This study provides some reassurance that an increase in vaginal wetness reported by a woman using the combination vaginal ring most likely does not represent pathology," the authors write, adding that increased H2O2-producing Lactobacillus concentrations may even indicate a favorable effect on vaginal health by preventing viral and bacterial infections.

A 1992 study also found that using a vaginal ring continuously (up to two months) didn't cause unfavorable changes in the vagina.

This is important information for women who use the ring for menstrual management. Why? Because when you use the ring to skip the fake period, you use a continuous regimen--the ring remains in place for months at a time. In other words, you insert the ring into the vagina and leave it in for either 3 or 4 weeks (twenty-eight days). After that, you remove it and throw it out. Then you replace the old ring, immediately, with a new one. There is no ring-free week between the old and the new ring. You continue to do this for 2-3 months. At the end of that interval you stop using the ring for 7 days (you'll have the fake period during these 7 ring-free days).

In an ongoing extended-wear study, women have been using the vaginal ring (replacing it every 3 weeks) continuously for six weeks, twelve weeks, and twelve months. Preliminary results should be available by the end of the year.*

*Aarts JM, Miller L. Design of an open-label, randomized, multicenter trial of continuous regimens with NuvaRing. Obstet Gynecol. 2003;101(45):145.

Express Yourself

In the New Products section (not online yet) of the latest issue of Contemporary Ob/Gyn:

"Expressions" is the first consumer-designed birth control carrying case in Ortho-McNeils's Personal Pack line of discreet OC [oral contraceptive] compacts. A panel led by fashion designer Nicole Miller chose the new design from entries in a company-sponsored contest for women last fall.

You can view all the designs here.

Links

I need help with a link problem: my blogroll links extend all the way out to the left, well beyond the link text. I've tried to contain them to just the text, but nothing I do seems to work. Any suggestions? (thank you)

Menstruation Leave?

Parallel Universe alerts us to a proposed Senate Bill that would affect working [as in outside the home only] Filipino women:

Sen. Miriam Defensor-Santiago Wednesday proposed a bill that would allow women workers to take a one-day leave during their monthly menstruation period.


Proposed Senate Bill 1687 or the Menstrual Leave Act provides that women workers can avail of 50 percent of the day's pay during their period.

Interestingly, women in South Korea, Japan, Indonesia, and Taiwan already enjoy this "benefit".

The rationale for the Bill is that women should be allowed to rest during their menstrual period, when most women experience abdominal cramps, among other menstrual symptoms. In other words, women should be sent home to suffer in the privacy of their own rooms.

This doesn't make a lot of sense. There's no reason why menstruating women should be in pain; many treatments are available. And even if, for whatever reason, a woman doesn't avail herself of the treatments, she should be able to take sick days off because she doesn't feel well, not because she's menstruating. Pain is pain, and so is nausea, vomiting, a migraine, etc.

Why do women have to put up with monthly period-related problems, and why do they have to justify the etiology of their medical problems?

(via Medlogs)

You Are [Not] Your Uterine Lining

Recently, Rachel's Well, Inc., a non-profit aim[ing] to improve access to preventative health services for uninsured women and develop a model of healthcare delivery for all Americans, and the Society for Menstrual Cycle Research, a nonprofit whose mission is to be the source of guidance, expertise, and ethical considerations for researchers, practitioners, policy makers and funding resources interested in the menstrual cycle, co-sponsored a discussion, The Menstrual Cycle is a Vital Sign, designed to raise awareness about the role of menstruation as a unique indicator of a woman's overall physical health. Proctor & Gamble supported the meeting via an unrestricted educational grant. Here is the press release, and you can listen to the webcast here (free registration required).

I wasn't able to listen to the webcast, but I did read the press release and I have a few comments.

First, what is a vital sign? A vital sign is a physical sign that indicates an individual is alive. Respiratory rate, temperature, and pulse are vital signs (often, blood pressure is also included). The menstrual period is not a vital sign.

Moreover, the period isn't even a very specific indicator of your overall health. In other words, if you no longer have a pulse you're dead. In contrast, if you no longer have a period you could be healthy (just a shift in cycle, or you're pregnant, or maybe breastfeeding, or using hormonal drugs), or there might be a problem, ranging from stress, to a brain tumor. [Actually, the most common cause of missed periods in reproductive age women is a pregnancy. This is why, before you worry about this or that disease, it's important to always rule it out first.] For a different opinion about the importance of the period as a health sign [the loss of period regularity as the first sign of everything from pregnancy, to autoimmune adrenal insufficiency, to drug abuse, and then some more], please go here. (Just based on the name, I think the author is the founder of Rachel's Well Inc., but I'm not sure.)

Interestingly, one poll found that more than two-thirds of the women surveyed did not rely on their period as a "health" sign. [scroll down to question #3]

Practical tip: If you do rely on your period to let you know if you are/aren't healthy and you are considering using hormonal birth control, like the Pill, for birth control, remember that you will no longer have a menstrual period for as long as you use the Pill. So, while there's nothing unhealthy about deliberately suppressing your period, you should consider that whatever "health" signs you might have drawn from the period will no longer be present. A barrier method, like the sponge, or the Oves cap, might be a better alternative for you.

Returning to the press release:

Doctors and scientists also discussed the long- and short-term effects of irregular or interrupted periods (amenorrhea) brought on by over-training of female athletes and excessive dieting and exercise, as well as oral contraceptives designed to suppress the monthly cycle. The experts called for more research to determine the impact of menstrual suppression and its potential side effects on future fertility and long-range health.

Let's look at this passage one step at a time:

Interrupted periods brought on by over-training and excessive dieting and exercise (functional amenorrhea)

What happens during an interrupted period brought on by over-training or excessive dieting and exercise? Briefly, the menstrual cycle is shut down and with it, so is the body's production of estrogen and progesterone.

What is the net effect of this type of period interruption? You become hormonally deficient (in particular, estrogen).

How does this type of period interruption affect fertility and long-range health (for example, bone density)? There's an overall negative impact. If whatever problem causing the period interruption isn't treated, fertility will be impaired. Also, the lack of hormones (estrogen, in particular) causes brittle bones.

Interesting aside: Women who suffer from interrupted periods brought on by over-training or excessive dieting and exercise experience bone loss. Taking the Pill helps these women improve bone strength.*

Bottom line: This is an abnormal state. There is an absence of menstruation when menstruation should occur. There's also a hormonal deficiency (low estrogen, or hypoestrogenism). Overall, the impact is negative.

Interrupted periods brought on by oral contraceptives designed to suppress the monthly cycle (elective menstrual suppression)

What happens during an interrupted period brought on by oral contraceptives? Again, briefly, the menstrual cycle is paused and with it, so is the body's production of estrogen and progesterone. At the same time the oral contraceptive's estrogen and progesterone are introduced into the body; the body "thinks" the hormones are "home made" and uses them as it would its own.

What is the net effect of this type of period interruption? The hormones produced by the body are replaced by the hormones in the oral contraceptive. No hormonal deficiency.

How does this type of period interruption affect fertility and long-range health (for example, bone density)? There's an overall positive impact. Over 30 years of studies have determined that the Pill doesn't have a negative impact on your fertility (it takes on average 1 month for fertility to retun). Actually, it appears quite the contrary is true: using the Pill enhances your fertility. A recent study of over 8,000 women found that women who had used the Pill had an increased ability to become pregnant (compared to nonusers). As for bone density, it's been determined that Pill use does not have a negative effect on bone density. Moreover, it appears the Pill has a positive effect on bone mass--estrogen helps with strengthening the bone (mineralization). For example, long-term use of the Pill, and taking calcium in later reproductive years, is a highly effective way to strengthen the bones and halt midlife bone loss.*

Bottom line: This is a normal state. There is an absence of menstruation when menstruation should not occur. There's no hormonal deficiency, and the overall impact is positive.

Also in the press release:

"The most important thing to emphasize about menstrual suppression is that the long-term effects are simply unknown," said Jerilynn Prior, M.D., professor of endocrinology and metabolism at the University of British Columbia in Vancouver, and board member for the Society for Menstrual Cycle Research.

Actually, the long-term effects of abnormal period interruption (functional amenorrhea) are not only known, they are well established (e.g., brittle bones). Similarly, the long-term effects of the elective, normal menstrual suppression achieved by using the Pill are known from over 30 years of studies and clinical experience. According to the FDA: over the years, more studies have been done on the pill to look for serious side effects than have been done on any other medicine in history.

Continuing with the release:

"Whether a woman is electing to do so [suppress the period] with new birth control products, or it results from excessive dieting or exercise, we as a society are allowing the one vital sign unique to women to go unmonitored, which could ultimately lead to an enormous uncontrolled experiment with a woman's health."

Mentioning elective menstrual suppression and exercise- or diet-induced amenorrhea in the same sentence does not magically make these two unrelated processes one and the same thing. Unfortunately, all it does is create confusion. Again, menstrual suppression--normal, and no hormone deficiency; amenorrhea resulting from excessive dieting or exercise--abnormal, and accompanied by hormone deficiency.

Moreover:

the one vital sign unique to women

Infusing the menstrual period with all sorts of meanings does not serve a useful purpose. The menstrual period is not a vital sign; just like in men, women's vital status is determined by assessing respiratory rate, temperature, and pulse, not some special, feminine indicator.

we as a society are allowing the one vital sign unique to women to go unmonitored

It's possible that this is just a rhetorical flourish, but just in case it's not: Women don't need society to monitor their menstrual periods. It doesn't take a village to figure out menstrual happenings. How about we allow society to monitor, say the state of the roads or the equipment of military troops, and we entrust women with monitoring their own bodily functions.

an enormous uncontrolled experiment with a woman's health

Last, but not least, conspiracy theories--what are they good for? A more useful approach would be to either state the facts, if you have any, or refrain from conspiratorial insinuations.

The release concludes:

The clear message of today's forum was the importance of the relationship between women and their menstrual cycles.

It is important for women to have complete and correct information about their menstrual cycle. It is detrimental and presumptuous to define women by their menstrual cycle; there's more to a woman than the state of her uterine lining. And it is unfortunate to have a discussion about the menstrual period that confuses and misleads.

The menstrual period is not something to be ignored, nor is it of outmost importance; it's just a body function.

*Speroff L. Bone Mineral Density and Hormonal Contraception. In: Dialogues in Contraception. 2002;7(5):1-3,8. [sorry, not online]

Good Health Reporting

I often bring to your attention sub-par reporting on topics of concern to reproductive-age women. The latest was this report about the birth control skin patch (Ortho Evra). So it behooves me to also let you know when I come across good health reporting. I talked to a reporter a couple of months ago when she was doing research for an Elle feature on menstrual management. I didn't think it was appropriate to mention anything before the article came out but now the November issue is available on newsstands. The period control feature is short, but to the point.

This was one reporter who knew her subject--not in the I'm-just-looking-for-a-headline-to-shock-and-confuse-readers way, but rather in the I'm-familiar-with-the-pros-and-cons-of-period control-and-I'm-able-to-ask-questions-that-will-actually-educate-my-readers way. Here are a couple of full length articles by this reporter, one on predicting a woman's reproductive lifespan, and one about the "perfect" pregnancy. Both are good examples of what a health article should do--give you correct information, and illuminate and educate you.

Bendectin and Bogus Science

Turns out that Bendectin, a drug used by pregnant women to combat morning sickness, was also very good at combating bad science. Too bad it succumbed to torters.

(via Psych Central)

Business Book Club

It's true that menstrual management can improve productivity. For example, Texas Instruments noted a 25% reduction in the productivity of its female workers during their periods. Also, the costs of period-related disorders to the U.S. industry are an estimated 8% of the total wage bill and can even impact industrial output.

Still, I was [pleasantly] surprised to see my book selected by the Forbes.com Book Club. Business people: always looking for ways to improve job performance.

Of course, I couldn't help notice two other selections, Tantric Secrets: 7 Steps to the Best Sex of Your Life and Tantric Sex: Making Love Last. Striving for all around improvements, indeed.

Grand Rounds

For medical news and commentary, don't forget to visit the last installment of Grand Rounds.

Condom Use and STIs

I found a very good summary of the 2001 report evaluating the published evidence on condom use and Sexually Transmitted Infection (STI, old term STD) prevention.

Some STIs facts from the article (U.S. data):

Chlamydia

830,000 infections in 2002 (estimated ~3 million per year)

highest rates among 15- to 19-year-olds (2,620 per 100,000 population per year) and 20 to 24 years (2,570 per 100,000 per year)

Gonorrhea

~352,000 cases in 2002 (estimated 650,000 per year)

in women, highest rate among 15- to 19-year-olds (676 per 100,000 population per year)

Genital Herpes (HSV)

45 million people infected (with herpes simplex virus type 2)

~1 million new infections per year

prevalence is estimated to be 19% among 14- to 49-year-olds

Human Papillomavirus (HPV)

an estimated 75% of the reproductive-age population has been infected

at any one time, 20 million people have a transmittable genital HPV infection

5.5 million new cases per year

Trichomoniasis

~5 million cases per year

HIV/AIDS

~850,000 to 950,000 HIV infection (one-quarter of these individuals are unaware)

~385,000 people living with acquired immune deficiency syndrome (AIDS)

~40,000 new HIV infections per year

half of the newly infected people are younger than 25 years of age

in women, the proportion of adult/adolescent AIDS cases increased from 7% to 26% (from 1985 to 2002)

Bottom line:

Consistent condom use is highly effective in preventing transmission of HIV

Available evidence supports the effectiveness of condoms in preventing other STDs

Condom use is associated with lower rates of diseases associated with HPV, including cervical cancer

One more crucial fact you should note: The report didn't say that condoms do not work. Rather it concluded that, when it comes to condom use and certain STIs, the data are inadequate to draw a conclusion.

Resources

From the Association of Reproductive Health Professionals, two clinical proceedings you might find useful:

Extended and Continuous Use of Contraceptives to
Reduce Menstruation

New Developments in Intrauterine Contraception

Pain relief not a human right, blogger says

In case you didn't know, we now have a Global Day Against Pain or GDAP:

Treatment to alleviate pain is a human right, whether people are suffering from cancer, AIDS or any other distressing condition, a leading medical authority said, marking the first-ever Global Day Against Pain.

Let's make this short and simple: Pain relief is not a right, it's appropriate medical treatment (with the notable exception of TV sitcoms featuring women delivering). I thought American politicians were the only ones harboring secret "let's play doctor" fantasies. I stand corrected:

The occasion [GDAP] was being marked here by a conference of WHO and pain treatment specialists. It coincides with new recommendations by the Council of Europe in Strasbourg on pain relief.

Why is the Council of Europe issuing medical recommendations? More importantly, what is it with this push to infuse assorted body functions, like the menstrual period and pain, with all sorts of social/moral/religious/political meaning? I mean, it's one thing for a [barely] human in a cave to employ magical thinking to explain the period. It's quite another for the WHO to co-sponsor a campaign designed to explain pain relief as a societal construct. I sense a trend and it's a dubious one.

In any case, just to be on the safe side I have already started preparations for the first-ever Global Day Against Operating With Dirty Hands.

[via a certain Ph.D....she gets a new RSS feed on her blog...I feel compelled to get one too...and end up discovering MyYahoo, reading the pain story, and spending way too much time customizing My Yahoo]

Update: A commenter points out my post might be a bit confusing:

I know, call me "Stupid" but I find your comments a little confusing. Since I'am a cancer survivor I like to think pain control is my right. Why is that even something you want to take issue with? Are you saying cancer (and the like) patients are only living a some what pain free life because we are at the mercy of your goodness? That it is "your" right as to rather we receive pain relief or not? Thats a scary thing, if you were to be that consumed with self-importance.

My point is that a patient experiencing pain shouldn't be at anyone's mercy. Pain relief is not a human right (a societal construct) to be conferred upon you, the patient, by a benevolent government, righteous religious people, or even self important doctors. You should expect pain relief because that's the standard of care, a medical fact dependent only on anatomy and physiology.

Rights are granted and can be revoked. Medical facts exist independently. You, in consultation with your physician should decide your medical care, not the government.

Test

Instructions: After reviewing the country list*, answer the two test questions:

Albania

Argentina

Australia

Belgium

Benin

Cameroon

China

Côte d'Ivoire

Denmark

Finland

France

Gabon

Guinea

Israel

Jamaica

Kenya

Lithuania

Madagascar

Malaysia

Mali

Mauritius

Morocco

Namibia

New Zealand

Norway

Portugal

Republic of Congo

Senegal

South Africa

Sri Lanka

Sweden

Switzerland

Thailand

Togo

Tunisia

United Kingdom

Vietnam

Question 1: Why do the governments of these countries think their women are smarter/more responsible/trustworthy/literate/moral than American women?

Question 2: Why is it acceptable for any country's government to decide what medical care is appropriate for reproductive-age women? [Strongly consider "long-standing, secret fantasy to lead the life of an Ob/Gyn" as one of your answers.]

*Hint: Countries where emergency contraception (EC) is available over-the counter.

Tangled Bank

In anticipation of Halloween, please go visit Tangled Bank #13, the science COV. Featured topics include a puma encounter, earthquakes, caterpillar legs, math and physics.

Analyze This

It's very interesting that Edwards named "big insurance companies, big drug companies and big H.M.O.'s" as those entities that he fought against despite the fact that all the lawsuits that he filed and got rich off of were against physicians and hospitals.

Dr. Rangel comments on the tort reform and medical malpractice lawsuits questions from last night's debate.

Pill Use and Healthy Babies

More potential good news for women who use the combination birth control pill (the Pill). According to a new study, using the Pill before you become pregnant appears to increase fetal birthweight and placental [afterbirth] weight.

The increase in fetal and placental weight seen in women who used the Pill before they became pregnant was 207.3-gram (7.312 ounce) and 64.9-gram (2.289 ounce), respectively. Although it's not yet clear why the Pill exerts this beneficial effect:

"Because fetal growth is conducive to the health of the newborn, these findings suggest that pregravid [before pregnancy] oral contraceptive [Pill] use may have similar effects," the authors note.

Grand Rounds

[I]f a drug company is liable for putting a dangerous drug on the market, is the FDA liable for lives lost by holding up live saving drugs?

The answer to this question, and lots more medical posts at this week's Grand Rounds, hosted by Galen's Log. Wash hands before reading and enjoy.

Womanhood and Menses

From Amanda, at Mouse Words:

Manhood, regardless of whether you define it as machismo or maturity, you are still defining proper manhood as a function of will. Manhood is about choices, intelligence, even the soul.

Womanhood is a biological function that women have no control over.

Amanda is spot on. There is a tendency to infuse the menstrual period with all sorts of societal meanings of almost mythical proportions (e.g., the essence of womanhood, woman power, etc.). This is detrimental, especially when it comes to women making informed period-related health decisions. Why? Because, by definition, myths aren't to be explained; they're to be believed. This is a dangerous proposition when it comes to your health.

An often encountered myth about the period is that having periods "protects" a woman from becoming more like a man. Obviously, if you've been told ever since before you had your first period (menarche) that menstruating "makes you a woman", you might feel apprehensive about using hormonal birth control or menstrual management and no longer having a monthly period. This reluctance to use a potentially beneficial tool might negatively impact your lifestyle (for women who don't like having a monthly period), or your health (for women who suffer from period-related health problems). To make an informed decision you need facts, not beliefs. So, apropos of what makes a woman a woman, let's look at some facts.

A major difference between the sexes is their chromosomes. A chromosome is a unit of genetic material made up of DNA (deoxyribonucleic acid); chromosomes define who we are as a species.



Humans have 46 chromosomes--22 identical pairs, and a pair of sex chromosomes (XX for women, XY for men).



Having or not having a monthly period has no effect on your genetic makeup. It doesn't change one of your Xs into a Y.

Another difference between women and men is their levels of "female" and "male" hormones--estrogen and testosterone. Both women and men produce estrogen and testosterone. However, reproductive-age women have more estrogen, while men have more testosterone, hence the "female"/"male" designation. Both these hormones contribute to the development and maintenance of secondary sexual characteristics: muscle mass and fat deposition, hair distribution, breast development, etc. Using period control to skip the monthly period has no effect on the balance of these two hormones. In other words, when you use menstrual management your testosterone level doesn't shoot up to equal a man's. (Actually, quite the opposite. If you use the Pill, it tends to lower your testosterone level.) Nor does your estrogen level plummet. Quite the opposite. Instead of the periodic low levels experienced by women with monthly periods, women using period control maintain a relatively constant estrogen level.

Finally, we can differentiate between women and men based on their reproductive organs. Women have ovaries, uteri, and vaginas. Men have testicles, prostates, and penises. At the risk of stating the obvious, having or not having a period doesn't cause your uterus to vanish, nor do your ovaries mutate into new organs.

On a related note, if you use menstrual management you don't become your grandmother (i.e., menopausal). When you use hormonal birth control you are not postmenopausal. While it's true that neither group of women have a period, postmenopausal women stop menstruating because their ovaries stop working and they have no more eggs. Women who use period control still have viable eggs and their ovaries function perfectly well; the eggs and the ovaries are simply on stand-by. Once the woman stops using hormonal birth control, the monthly cycles restart, as does the ability to have children. Here's an easy way to think about this:

It's relatively easy to restart the monthly bleeding in women after menopause. This is why postmenopausal women can, and have carried pregnancies and have given birth. (The oldest woman on record to give birth is a 63-year old Californian.) What's not possible (yet) is for these women to be fertile, to create a baby from their own eggs--they no longer* have any and have to use donor eggs.

Contrast the fertility situation in postmenopausal women with that in reproductive-age women who no longer have a period because they use hormonal birth control. Once these women stop using period control, they are fertile because they have functioning eggs. Not only that, but it appears that using the Pill actually improves fertility. A study of more than 8,000 women found that women who had used the Pill had an increased ability to become pregnant. Moreover, the longer the women used the Pill, the better their chances of conceiving within the first 6 months after stopping the Pill.

On another related note, pausing your monthly cycle--like when you use period control or when you're pregnant--does not hasten the onset of menopause.

Bottom line: The period is nothing more and nothing less than an ordinary body function. Having a menstrual period does not make women inferior, nor does it empower them to rule the world. And, at least biologically speaking, the menstrual period most certainly does not a woman make: managing your period won't make you become more like a man.

*Recently, researchers have found that, in mice, the ovary appears to produce eggs throughout the female's life. [If this finding is accurate, and if it holds true for humans, this would absolutely revolutionize the way we view human fertility and reproduction.]

(via Alas, a Blog)

Menstrual Migraines and Period Control

Not all headaches are created equal: migraine headaches affect more than twice as many women as men. Interestingly, in 60-70% of women, the headaches are related to the menstrual cycle. Period-related headaches that occur from one week to 3 days before the start of your period are called premenstrual migraines. The ones that occur from 3 days before the start of your period to 2 days afterward are called true menstrual migraines.

Menstrual headaches are a classic example of a problem thought to be caused by cyclic hormone changes. Researchers suspect falling and/or low estrogen levels trigger these types of headaches. Either the estrogen made by your body or the synthetic estrogen found in birth control can be the culprit. This means menstruating women, as well as women who use a hormonal birth control method like the Pill on the regular 3 weeks on/1 week off are prone to period-related headaches. Why?

During the menstrual cycle, your body's hormones (both the local ones like estrogen and progesterone, and the control ones like FSH and LH) go up and down. For example, at the end of your period, your estrogen levels start going up, hit a peak about midcycle, and then decline sharply right before the start of your next period. Similarly, when you're taking the Pill, your fake period is triggered by withdrawing the synthetic hormones for one week. In particular, the level of synthetic estrogen goes down suddenly (it takes the body about 24 hours to clear the Pill hormones out of the body), before your own body has a chance to rev up to produce enough estrogen to replace it.



In either case--a dip in natural or synthetic estrogen levels--the result can be a menstrual headache. Can period control help with menstrual migraines? Let's look at some studies.

1. One study measured the timing, frequency, and severity of hormone-related symptoms, including period-related headaches, in 262 Pill users. (The breakdown was 193 current users, and 69 new users). Specifically, the aim was to compare the pattern of headaches during the active-pill (the three weeks with hormone-containing pills) and the placebo pill (the one week hormone-free) interval.

Current users had more headaches during the placebo week than during the three active-pill weeks (70% vs. 53%). Similar headache patterns were seen in new users after the first cycle of use.

CONCLUSION: Headaches were significantly worse during the placebo week interval than during the three active-pill weeks. In other words, although using the Pill on the regular 3 weeks on/1 week off regimen helps with period-related headaches, women on this regimen still experience more headaches during the 1 week off.

2. Another study looked at 50 Pill users who were experiencing period-related problems, like menstrual migraines, during the placebo week. Migraine was the second most frequently occurring problem cited by the women (the most frequent was dysmenorrhea, or a painful period)--78% for dysmenorrhea and 76% for migraine. Also, migraine was most often ranked as the most severe problem (48%). To control their period-related problems, the women were given the option to use an extended, menstrual management regimen.

Women chose a 12-week (84 days on/7 days off) regimen, a 9-week (63 days on/7 days off) regimen, or a 6-week (42 days on/7 days off) regimen. All the women who used an extended regimen reported a delay in onset and a decrease in the severity of period-related problems. Interestingly, one woman reported many days of breakthrough spotting but continued to use the extended Pill regimen because of the relief she experienced from the migraines she used to have during the placebo interval.

CONCLUSION: Using an extended, menstrual management regimen (delaying the fake period by extending the number of consecutive days of active, hormone-containing pills) is well tolerated and efficacious. In other words, using an extended regimen, and shifting the frequency of the fake period from monthly to once every 12 weeks (or 9, or 6 weeks) reduces the placebo-related headaches experienced by women who use the Pill.

3. Finally, a study measured the acceptance and use of extending the number of active-pill days beyond three weeks and/or shortening the placebo interval. All 292 Pill users reported experiencing problems, like headaches, pelvic pain, etc., during the placebo week. The women who chose to use the extended regimen typically used a regimen of 12 weeks on/6 days off. The most common reason given for choosing the extended regimen was headache (35%), followed by dysmenorrhea (21%), heavy periods, or hypermenorrhea (19%), and premenstrual symptoms (13%). Other reasons were: convenience and endometriosis.

In terms of symptom improvement, 86% of the women on the extended regimen reported that their symptoms improved (compared to 41% of women on the regular 21/7 regimen). In terms of quality of life improvement, 94% of the women on the extended regimen reported quality of life improvements (compared to 43% of women on the regular 21/7 regimen).

CONCLUSION: The majority of patients with hormone withdrawal symptoms on OCs [Oral Contraceptives] will initiate a regimen of extending active pills, often with a shortened hormone-free interval to reduce frequency and severity of associated symptoms. In other words, the majority of Pill users who experience symptoms during the placebo week prefer to use an extended, menstrual management regimen to reduce the frequency of the fake period (from monthly to once every 12 weeks), and to lessen the severity of the placebo week symptoms.

Bottom line: For women who experience menstrual migraines and are considering period control, a good first step is using the Pill on the regular 3 weeks on/1 week off regimen. This accomplishes the following:

the period is suppressed for the entire month (actually, it's suppressed for the entire time you use the Pill--months, years)

the body hormones no longer fluctuate

the Pill hormones only fluctuate one week per month

a monthly fake period pattern is established

If the regular 3 weeks on/1 week off regimen doesn't help, the next step is using an extended Pill regimen. This can be a 6-week (42 days on/7 days off), a 9-week (63 days on/7 days off), a 12-week (84 days on/7 days off) regimen, or any other regimen that fits your unique needs. This accomplishes the following:

the period is suppressed for the entire month (again, it's suppressed for the entire time you use the Pill)

the body hormones no longer fluctuate

the Pill* hormones only fluctuate once every 6, 9, 12, etc. weeks

a shift in the fake period pattern, from monthly to once every 6, 9, 12, etc. weeks

Other menstrual migraine treatments include: non-steroidal anti-inflammatory agents (NSAIDs like ibuprofen), 5-HT-1 agonists (sumatriptan), daily prophylactics (beta blockers, calcium channel antagonists, tricyclics), and other hormonal regimens (danazol).

Menstrual migraines are common and they can be very disruptive. Although we don't yet fully understand what causes these headaches, treatments are available. So, if you experience period-related headaches, there's no need to suffer in silence. Ask for treatment, and expect relief.

*monophasic Pill brands