Sense and Sensibility

Dr. Charles points us to a very interesting article:

The Partial-Birth Abortion Ban Act of 2003, which is the only federal law ever to include the phrases "gruesome and inhumane" and "removing the baby's brains," was signed last November by George W. Bush and has just been declared unconstitutional by three separate U.S. District Court judges. Its next stop is the U.S. Circuit Courts of Appeal. ... This story is about that mission, and about how one abortion doctor and one right-to-life cartoonist helped set off the most sustained and rhetorically high-pitched battle in the forty-year history of this country's abortion wars.

The Partial-Birth Abortion Ban does not prohibit what most people think it prohibits. It is not a late-abortion law. Apart from a single quoted remark in its "findings" section, which is a kind of declaratory preface, the ban contains no mention at all of third-trimester abortion, or of any gestational point in pregnancy. It criminalizes only by method, outlawing some actions during a pregnancy termination but not others, meaning that as practical legislation-isolated from its mission, that is, and considered solely as a directive on what physicians may and may not do in a procedure room-it makes clear ethical sense only to people who don't spend much time thinking about abortion. Defending the Partial-Birth Abortion Ban in court, as teams of Justice Department lawyers were dispatched this spring and summer to do, requires arguing to judges that pulling a fetus from a woman's body in dismembered pieces is legal, medically acceptable, and safe; but that pulling a fetus out intact, so that if the woman wishes the fetus can be wrapped in a blanket and handed to her, is appropriately punishable by a fine, or up to two years' imprisonment, or both.

Two comments (emphasis and quote order mine):

On August 26, Richard Casey overturned the Partial-Birth Abortion Ban. His ruling described D&X as "gruesome, brutal, barbaric, and uncivilized,"...

Granted, it's difficult for me to look at a surgical procedure through the eyes of a lay person; I have a completely different perspective. But let's make one thing clear. A D&X is not gruesome, brutal, barbaric, and uncivilized. It is an appropriate surgical procedure. Nothing more, nothing less.

[I had a bunch of drawings and pictures to show you, but Blogger ate my post. I'll try to find them again, and I'll update.]

And:

What the ambivalent and unconvinced need, from the perspective of the indefatigable right-to-life tactician, is visuals-literal visuals, to shock people from complacency; and verbal descriptions that force people to keep picturing what actually takes place in an abortion-procedure room. This has been the primary mission of the Partial-Birth Abortion Ban. There is long-term legal strategy at work, too, and practical thinking about ways to discourage abortion doctors from going about their business, but the ban-like its offshoot, the Unborn Child Pain Awareness Act, introduced late this spring in both the House and the Senate-is fundamentally an image-manipulation campaign.

...

Was any method safe, if up-close visual acceptability were to become the basis for some new legal standard?

Needles to say, I think the standard of care for a surgical procedure should be medical, not image-manipulation campaign[s], or visual acceptability. Women who have an abortion already *have* to pass the "moral struggle" test--if they don't become dejected about having to undergo the procedure, they're at best suspect, at worst defective. Now, it appears women will have to pass a new, surreal "procedural gross-out acceptability" test.

Bodily functions and fluids, blood and guts, burning flesh, and decomposing tissue--both maternal and fetal--are not aesthetically pleasing, and, often time, the smell is quite bad. There's nothing civilized about any type of surgery. It's a brutal, traumatic undertaking. If the new standard of care for women's health is to become not offending strangers' sensibilities, allow me to sound a note of alarm. This is an unattainable standard, totally divorced from reality.

Mauve Fingers

One country looks to the future.



Another country, not so much.

Legislating Delivery, Kansas Style

Just as we were decompressing from our last, shall we say, spirited post about politicians and reproductive health, a reader points us to a bill pending in the Kansas legislature, House Bill 2088 (.pdf)--AN ACT concerning crimes and punishment; relating to giving birth without medical assistance.

Before we go on, I can't help but notice that between legislating pregnancy, giving birth (HB 2088), miscarriages, abortions, and birth control, pretty much the full spectrum of a woman's reproductive life has been, or is in the process of being, regulated by strangers. I'm considering coining a new term for this, "cervical gazing", and strongly urging politicians to refrain from engaging in it. If the urge to reprolegislate strikes, female politicians can gaze at their own cervix, and male politicians can gaze at a plastic model. But I digress.

Back to HB 2088. I'm a bit pressed for time, but I will try to hit the main points.

The bill could be summed up as: an old theme (see Virginia's HB 1677) with a couple of twists.

The old: unattended births, including stillbirths [24 weeks and up], are to be considered a criminal act; duty to call and report births to law enforcement; violation is a felony.

The twists: 1) HB 2088 only covers hospital births [I don't think this was the legislators' intent, but that's what the text says.]; and 2) the bill makes anybody who has mere knowledge of an unattended birth, and who fails to call law enforcement or EMS, a criminal.

HB 2088 defines giving birth without medical assistance as (emphasis mine):

Unlawfully giving birth without medical assistance is giving birth to a fetus and intentionally refusing medical assistance or refusing to seek medical assistance from a health care provider immediately after such birth if the fetus does not survive for 12 hours.

Right off the bat, there's a big problem with this definition [other than criminalizing unattended births]. As defined, the only deliveries that would be criminalized are those occurring in hospitals.

Under HB 2088 an unattended delivery is giving birth to a fetus and intentionally refusing medical assistance. However, as a rule, a home birth (and by that I mean a birth anywhere outside a health care facility) excludes offers of medical assistance. Either there's nobody around, or there isn't anybody qualified to offer a medical assist. No offers of medical assistance, no intentionally refusing it, no coverage by HB 2088 of home deliveries.

In contrast, if you give birth in a hospital (and by that I mean any place equipped to deal with medical situations) you're guaranteed an offer of medical assistance. This satisfies the bill's main requirement for a designation of unassisted delivery--an offer of assistance has to be made. If you intentionally [as opposed to what, inadvertently? Oops, I hadn't realized I was in an ambulance; I thought I was on the crosstown bus with a frisky bus driver.] refuse the assistance, you've just become a felon, according to HB 2088.

But what about the second part of the definition, the or refusing to seek medical assistance from a health care provider immediately after such birth ...? Doesn't this somehow cover home births? No, it doesn't because of the use of "such birth".

"Such birth", as defined in the first part of the paragraph, is giving birth to a fetus and intentionally refusing medical assistance. Without an offer of assistance and, thus, an opportunity to refuse [home births] a birth doesn't fall under the "such birth" definition. As such, there's no obligation to seek medical assistance immediately after giving birth. Once more, home births are not covered by HB 2088.

The other twist introduced by HB 2088, and one of the bill's main problems, is the criminalization of strangers (and by strangers I mean anybody other than the woman giving birth) who might know about the delivery, but fail to report it to the authorities:

Knowing that a person has given birth to a fetus and intentionally refused medical assistance or refused to seek medical assistance from a health care provider immediately after such birth if the fetus does not survive for 12 hours; and

(2) failing to immediately contact a law enforcement agency or emergency medical services.
(c) It shall not be a defense to charges arising under this section that the defendant believed that the fetus was dead at birth or died before the defendant sought medical assistance.

This is as misguided as criminalizing women for the mere act of giving birth.

Without spending too much time on this section, consider just one issue: How intrusive are these people--relatives, friends, neighbors, taxi drivers--permitted to be to make sure they comply with HB 2088? In order to determine the EGA (estimated gestational age), are strangers allowed to demand access to the woman's confidential medical records, or can they just go ahead and do a bimanual pelvic exam on her?

The main problem with HB 2088 is:

Criminalizing unattended deliveries.

Why is it unlawful to give birth (livebirth or stillbirth) without medical assistance?

Why is a woman having an unattended delivery presumed guilty and incompetent? HB 2088 mandates you report the woman to law enforcement, so the delivery must be a crime. Moreover, the woman (or those around her) *has* to secure the supervision and testimony of medical or law enforcement personnel. Just her account of events isn't acceptable.

In effect what HB 2088 allows the state of Kansas to do is to: first, collect evidence from you, just because you happen to be a woman giving birth; then, ponder and decide if a crime has been committed; and, finally, accuse you of an actual crime.

Other problems with the bill:

Creating an obligation to seek medical assistance.

Why is a woman delivering obligated to get medical assistance? As a rule, it's never mandatory for a person, even a pregnant or diseased one, to seek medical help.

Infringement on patient (?personal) autonomy.

Why isn't a woman giving birth allowed to refuse medical assistance? Even in a hospital setting, a competent person is allowed to sign AMA and leave before any treatment is started [and even after that].

Requirement to predict the future, and act on that prediction.

... refusing to seek medical assistance from a health care provider immediately after such birth if the fetus does not survive for 12 hours.

How is a woman [how is anyone?] to determine how long the newborn will survive for, immediately after giving birth?

Confusing "delivered fetus" with "term fetus".

"Fetus" means a 24 week or more term fetus delivered and no longer in the womb.

Why is this key definition incorrect? A 24 week [to 36 weeks 6 days] fetus can not be "term". "Term" means: born anytime after 37 completed weeks of gestation, up until 42 completed weeks. In other words, the act of delivery doesn't make a fetus "term", the length of time spent in utero does.

Requirement to diagnose fetal age.

How is a woman [not to mention a stranger] expected to estimate fetal age? Oh the fun (irregular menstrual periods, small for gestational age fetus, etc.) we could all have if we lived in Kansas!

When it comes to strategies aimed at decreasing the number of discarded infants, according to the Department of Health and Human Services:

At present, public education about resources available to pregnant women and alternatives to discarding an infant remains the primary method for addressing this issue.

When it comes to HB 2088, there's no evidence that either its aim, or its impact is to reduce the number of discarded infants. So the question remains: What is the point of HB 2088?

If you'd like to contact the bill's sponsor:

Peggy Mast
Kansas House Republican
District 76
First Term: 1997
765 Road 110
Emporia, KS 66801
Phone: (620) 343-2465
Email: mast@house.state.ks.us

For more information on the topic of abandoned infants:

-- Fact sheet on Boarder Babies, Abandoned Infants, and Discarded Infants (from the National Abandoned Infants Assistance Resource Center)

Discarded infants are newborns who have been abandoned in public places, other than hospitals, without care or supervision.

-- Statistics (from the U.S. Dept. of Health and Human Services)

Nationwide, in 1998 there were 105 discarded infants.

-- Review of national "safe heaven" laws (from the National Conference of State Legislatures)

After 13 infants were abandoned in the Houston, Texas, area within a 10-month period in 1999, state lawmakers acted to encourage desperate parents to leave their children in a safe location rather than simply abandoning them. Since the Texas law was adopted, 34 more states have enacted so-called "safe haven" laws. All the statutes generally promise that women who relinquish unharmed infants in designated safe places will not be prosecuted or provide that abandonment in compliance with the law constitutes an affirmative defense to prosecution.

So far, the effects of the new laws appear to be limited. Although some newborns have been left at hospitals or police and fire stations, others continue to be found in unsafe places. Serious concerns remain regarding the general lack of research on abandoned babies and their mothers, the implications of these laws on states' adoption and child welfare practices, the rights of the infant's father and the relatively small number of infants involved. Some child welfare experts have expressed concern that the laws do not include an examination of existing statewide child abuse prevention strategies and services for women at risk.

This report examines what is known about infant abandonment, provides an overview of key aspects of the legislation, describes state experience with the new laws and discusses some policy implications for lawmakers.

-- Review article (from AGI)

Despite these various concerns, legislators and advocates representing a wide array of interests are publicly lining up in favor of infant abandonment laws. For many, it seems, a flawed approach is better than no approach, if the alternative is to appear "soft" on the issue.

Still, some within the advocacy world are struggling to define their position, and this may be particularly true within the reproductive rights community.

...

Indeed, a key point of agreement within the reproductive rights community is the need to focus society's attention on preventing such events from occurring in the first place. Katherine Kneer, chief executive officer of Planned Parenthood Affiliates of California, says this involves "investing in comprehensive sexuality education and family planning programs, as well as providing access to abortion services, so that sexually active teenagers-and all women-are better able to protect themselves against unintended pregnancy." Kneer says it also means working within communities to encourage parents to communicate with their children, so that pregnant teenagers do not feel so socially isolated that they hide their pregnancies from their families.

-- List of state "safe heaven" laws (private site)

-- Infant abandonment resources (private site)

Unsafe Sex Study

From this report:

The public health burden related to unsafe sexual activity is three times higher in the U.S. than in other developed nations, according to researchers at the Centers for Disease Control and Prevention (news - web sites).

Nearly all the premature deaths and adverse health consequences are preventable, the investigators maintain.

I wasn't able to look at the original study, but a few things in the report caught my eye:

The study showed that sexual behavior accounted for nearly 30,000 deaths and around 20 million adverse health consequences in 1998, such as infertility, abortions, and sexually transmitted infections.

and,

Cervical cancer was the leading cause of sex-related mortality among women, followed by HIV.

Something's not right with this study. Abortion isn't an adverse health consequence of sexual behavior, pregnancy is. In other words, the comparison is between not pregnant and pregnant, and/or pregnancy and abortion.

Also, the 2003 estimates for cervical cancer in the U.S. are: more than 13,000 new cases, resulting in 4,100 deaths.

During the same year, an estimated 11,498 women had a diagnosis of AIDS, and 4,736 women with AIDS died.

An aside, but an important one. You should be aware of these numbers (emphasis mine):

The rate of AIDS diagnoses for African American women (50.2/100,000 women) was approximately 25 times the rate for white women (2.0/100,000) and 4 times the rate for Hispanic women (12.4/100,000)

Update: Here's another report on the study.

Tangled Bank

To learn new and interesting things, please don't miss this week's Tangled Bank.

A Government Guide to Reducing Abortion

[If you are easily offended by language, ideas, or reality, please skip this post.]

The Washington Times sets the stage for us:

That strategy [to continue chipping away at the legality of abortion] was reflected in his [the president's] annual phone call yesterday to the March for Life in Washington, which was led by pro-life activist Nellie Gray.
[What follows is my rendition of the quote, not an actual quote.]
"The America of our dreams, where every woman is abused ... in life and oppressed in law, may still be some ways away," he acknowledged from Camp David. "But even from the far side of the river, Nellie, we can see its glimmerings."

[The actual quote:

"The America of our dreams, where every child is welcomed ... in life and protected in law, may still be some ways away," he acknowledged from Camp David. "But even from the far side of the river, Nellie, we can see its glimmerings."]

Until the glimmerings of that blessed day are upon us, let us see what else has been going on the Mall:

The president made it clear that despite the polarizing nature of the abortion debate, he places a premium on politeness.

But of course, pas être, paraître. Who cares if the debate is about stripping women of the ability to have a say in medical decisions that will significantly impact their risk of death? As long as we all mind our manners, magically, women's health won't be affected. The premium should always be [and apparently, as far as Mr. Bush is concerned, it already is] placed on appearance, not reality.

"I want to thank you, especially, for the civil way that you have engaged one of America's most contentious issues," he told the pro-lifers in remarks broadcast on the Mall. "A true culture of life cannot be sustained solely by changing laws. We need, most of all, to change hearts."

Look here, it's not enough to subject women to laws that strip them of the ability to make medical decisions for themselves, increase their risk of death, and treat them like incompetent buffoons. We need, most of all, to insure they accept this subjugation with an open and willing heart, a smile on their face, a twinkle in their eye, and a spring in their step. Also, a heartfelt "thank you!" wouldn't kill them. [The laws might, but come on, when's the last time anyone died from being polite and cheerful?]

That statement was widely interpreted as a reluctance to challenge Roe v. Wade directly, a posture the president first articulated in a 2003 press conference.
"I don't think the culture has changed to the extent that the American people or the Congress would totally ban abortions," he told reporters in the Rose Garden then.

However, it appears that just killing physicians, violence and harassment at abortion clinics, and enacting a federal refusal to treat women law is not enough. Neither is conferring privileged legal status, when it comes to violence, to one group of citizens--pregnant women [well, if you can really consider women citizens; I say let's stick with calling them little darlings, so as not to muddle the demarcation between, you know, actual people and women]--over ordinary, nonpregnant little darlings. [At least we still have them lowliest of creatures, infertile and hysterectomized women, to be attacked and killed at will, since they're clearly worth even less than then normal, nonpregnant ones.] Nor is it enough to forbid pregnant women to obtain a divorce. Some anti-abortion activists yearn for even more control over women:

But pro-life activist Stephen Peroutka, who participated in yesterday's march, said, "That's a tough thing to say to the 4,000 babies who will be aborted tomorrow - that this is not the right time to outlaw abortion.

Indeed, since only embryos and/or fetuses are aborted, finding, not to mention communicating, with imaginary babies could prove to be a tough thing. And, although Mr. Peroutka doesn't consider this matter serious enough to use facts [nor does the reporter bother to check], I say we limit ourselves to making up babies, but draw the line at making up numbers. The actual number of daily abortions is not 4,000, but rather ~2,338.

"When is the right time - when public opinion polls say it's the right time?" he [Peroutka] asked. "Shouldn't he be a leader and make it the right time? Let's stop leading by public-opinion polls."
Mr. Peroutka credited the president with reigniting the debate over abortion, even if he hasn't gone far enough in banning the practice. He called for Mr. Bush to adopt a take-no-prisoners approach to abortion in his second term.

Shades of totalitarianism anyone? Note to Mr. Peroutka: be careful what you wish for, it may come true. Today a Dear Leader's diktat might only oppress insignificant women. However, tomorrow He might decide to ban practices that would affect men.

But White House press secretary Scott McClellan suggested that the president will continue to take a nonconfrontational approach to the abortion issue.
"I think that he's made it very clear that whether we agree or disagree on the issue of abortion, that we can all work together to take practical steps to reduce the number of abortions," the spokesman said yesterday.

So, the President of the United States has made it clear that we are to work together to take practical steps to reduce the number of abortions. I don't know about you, but I for one am trembling with abject gratitude for the government's interest and guidance. [Hey, it's never to early to start ingratiating yourself to people who'll soon have the power of life and death over you. If you're smart and want to survive, may I suggest you follow suit, and start kissing some government popo.]

My opposition to politicians having a say in individuals' medical decisions notwithstanding, let's see how the government proposes to reduce the number of abortions:

According to the White House, those steps include passage of the Child Custody Protection Act and the Unborn Child Pain Awareness Act.
The first measure would make it illegal for an adult to transport a minor across state lines to avoid a parental-notification law in the girl's home state.
The second measure would require abortion doctors to inform mothers how painful an abortion will be to an unborn child at least 20 weeks old and to offer anesthesia for the fetus.

So, according to our most benevolent leaders the way to reduce abortion is to: 1) enact some more laws that don't work; and 2) lie to women, and offer to increase their intraop risks. [If some of the anesthesiologists out there could blog a little about the difference between administering anesthesia to a pregnant patient vs. a nonpregnant one, the inherent difficulties and risks, drug delivery to the fetus, and what anesthetizing a fetus during an abortion procedure would entail, that would be most instructive.]

To reduce the number of abortions, instead of misguided politics and dreamy religion, how about some science? Emergency contraception (estimated to prevent 800,000 abortions per year). Education [one based on facts, not wishful (.pdf) thinking]. Increasing the availability of existing birth control methods to American women. Encouraging R&D of new methods.

[Let me make it clear that I do not expect the government to develop new birth control methods. That's the job of the private sector. But, at a minimum, I do expect the government not to obstruct, misrepresent, delay, and interfere with the availability of existing methods, and the development of future ones.]

Finally, just in case the (R) designation next to a politician's name lulls you into a false sense of security, allow me to bring you back to reality:

Mrs. Clinton, in a speech to about 1,000 abortion rights supporters at the state Capitol, firmly restated her support for the Supreme Court ruling that legalized abortion nationwide, Roe v. Wade. But then she quickly shifted gears, offering warm words to opponents of abortion - particularly members of religious groups - asserting that there was "common ground" to be found after three decades of emotional and political warfare over abortion.

...

In addition to her description of abortion as a "tragic choice" for many," Mrs. Clinton said that faith and organized religion were the "primary" reasons that teenagers abstain from sexual relations, and reminded the audience that during the 1990's, she promoted "teen celibacy" as a way to reduce the number of unwanted pregnancies.

Politicians, no matter what their party affiliation, should not decide what's medically appropriate for you. You are as capable as any politician [if not more] to make decisions about your health. And only you, as opposed to a stranger, not matter how divinely inspired, or politically skilled he/she might be, will always know best what is in your interest when it comes to your health.

(via Drudge)

Grand Rounds

Make sure not to miss this week's Grand Rounds.

Does Size Matter?

My contribution to the "Technique vs. Size" discussion: the shape of the vagina in-situ.

Go here first. Scroll to the 3rd drawing and orient yourself. In particular: the urinary bladder (4)...sitting on top of the uterus (7)...and the vagina (2), to the right [ignore the speculum].

Now, go [WARNING, graphic; pathology specimen] here. This is an abnormal (diseased) specimen, but ignore that. Look at the relationship between the organs; just like in the drawing--the urinary bladder...sitting on top of the uterus...and the vagina, to the right. Notice how the vaginal walls (the top and bottom one) are collapsed; they touch each other. This is what is meant by a "potential space". In the body, the vagina is not tube-shaped. Looking directly at the vulvar end of the vagina, the shape is not a circle (because the vagina is not a tube), but rather ~ H (because the top and the bottom walls are in contact).

[edited for clarity]

HIV Drugs for Rape Victims

Apparently, the CDC is now recommending post-exposure prophylaxis for anyone exposed to HIV from rapes, accidents or isolated episodes of drug use or unsafe sex:

Health professionals applauded the government's new recommendation that rape victims and occasional intravenous drug users get emergency drug treatment to prevent the AIDS (news - web sites) virus, describing it as "progressive" and "a safety net."

...

People accidentally or incidentally exposed to the AIDS virus are usually given a three-drug combination that includes AZT and 3TC. Treatment should start no more than 72 hours after the exposure to the virus, and the drugs should be used for 28 days, according to the CDC.

The CDC said it hesitated to recommend wider use of AIDS drugs for curbing the spread of HIV because it did not have enough information on their effectiveness in reducing infection rates. But the agency said recent animal and lab studies and data from state and city programs that offer HIV drugs to rape victims and others provided a foundation for revising the guidelines.

"The severity of the HIV epidemic dictates we use all available tools to reduce infection," said Dr. Ronald Valdiserri of the CDC.

He stressed that emergency drug treatment is a "safety net," not a substitute for abstinence, monogamy, and the use of condoms and sterile needles.

"It is clearly not a 'morning-after pill,'" he said.

In tests on primates, drug cocktails prevented infection with the monkey version of HIV 100 percent of the time if given within 24 hours of exposure to the virus, and 52 percent of the time if administered within 72 hours, said Dr. Charles Gonzalez, assistant professor of medicine at New York University School of Medicine and a member of the New York State AIDS Institute medical guidelines board.

But no data exists on how effective the drugs are in stemming HIV infection in people.

...

The CDC said the regimen is not recommended for habitual drug users who share needles or for people who frequently engage in risky sex. Those people would have to take medication practically nonstop, which the health agency does not endorse.

I'm not too keen to admit this publicly, but here it goes. I didn't know post-exposure prophylaxis for rape victims wasn't the standard of care in all emergency departments. [In my defense, I don't get out much--school, residency, and work all in one state.] In any case, the important point to remember is that a rape patient should not leave the ER without the standard HIV prophylaxis meds (usually, a 1-week supply).

Posting this has made me think back to my first exposure experience. [Since I don't feel comfortable talking about cases involving patients or colleagues, you're stuck with stories about me.]

I truly remember it like it was yesterday. I had just started my internship and had managed to gain permission to scrub in on a cesarean section as the 3rd hand--the assistant to the surgeon's assistant. [Don't even ask what levels of servitude I had to sink to make that happen. Suffice it to say the senior resident owned me.] My lowly station notwithstanding, I was elated to be in the OR with one of the best attendings we had. I even got to do some suturing--how cool was that! But I digress.

What happened was that, halfway through the operation, the brilliant surgeon stuck me with a needle. And no all you smarty-pants, it wasn't my fault. The surgeon actually apologized to me! [For all you nonmedical readers, surgeons do not, ever, ever, apologize to an intern, unless they do something monumentally wrong, and even then it's not a given. If something is the intern's fault, what usually happens is this: the surgeon yells and swears at you, slaps your hand, calls you a moron and throws you out of the OR.]

The interesting part was not what happened, but how everybody reacted. The surgeon asked if I was feeling OK [scary], and if I wanted to scrub out (I didn't). The senior resident told me I could go home [unheard of] if I wanted (I didn't). And the nurses were especially attentive to me, and voluntarily acknowledged I was in the room [eerie]. For the rest of the surgery there was a strange silence in the OR, and everybody treated me like I was made of porcelain.

When the needle went into my finger I registered the event, but I didn't really react to it. I just went through the motions--gloves off, betadine, gloves back on--and continued assisting. I was more unnerved by everybody's concern and focus on me, than the actual needle stick.

The second the surgery was over however, that's when the autopilot switched off. While I was pouring every disinfectant I could find on my hand, it hit me. My first thought was: This. Is. It. I'm going to die now. My second thought was, shall we say, of a naughtier nature; something along the lines of "could there be a lamer way to acquire HIV?". Before you judge my reaction, keep in mind I was actually hyperventilating at this point. I was hanging on to the scrub sink for dear life. Everything was in slow motion as I was confronting my mortality for the first time.

And then I had a moment of clarity. There were only two options, and I had to make a decision. Either I walk out of the OR and out of the hospital, and never come back, or I return to the OR, help them move the patient, and accept the risk of death as part of taking care of my patients, and never think about it. I went back to the OR.

And that was it. I never gave it a second thought. I've been stuck a few more times since then, but I never had that odd reaction again. Of course, I've also been fortunate enough to have patients I could follow up on, and who were nice enough to consent to being tested, so I've never actually had to take the prophylaxis meds. But I know people who have, and it's not an easy thing to do. And, despite my own experience, I can't even begin to imagine what it must be like for a rape victim to consider the implications of HIV exposure.

A History Lesson

Update: I need to add a Warning about the graphic nature (description of cases) of this post. [I didn't even realize it, sorry about that, and thank you to Prof. Myers for pointing it out.]

Two reproductive health icons, Drs. Elizabeth Connell and Louise Tyrer, recall what it was like to be an Ob/Gyn before Roe v. Wade, and express fear and rage about the current state of reproductive rights and family planning in this country and what the future may hold.

Dr. Elizabeth Connell:

"It's hard to conceptualize what it was like before Roe v. Wade unless you were actually there," Connell says, barely containing her anger. "In the large hospitals, ward after ward was filled with women suffering and dying from botched abortions. In some hospitals, it was the job of the first-year resident to sleep all day, because he would be up all night scraping out the remains of illegal abortions, giving blood to the women who were bleeding, trying desperately to keep them out of shock and treating their infections. This was the norm until we got Roe v. Wade and the New York law that preceded it. I'm very much afraid that the way things are going now, we could go right back to that again."

...

One woman made a particular impression.

"She was not able to get a sterilization procedure done by anyone," Connell remembers. "She never wanted to have children, and she'd had several abortions. There wasn't a doctor in New York City she could find who would do a tubal ligation, which is what she wanted, because she was young and had no children. She happened to be a lab technician, so she took cultures home, looked in a mirror and found her cervix and squirted these cultures of live organisms up through her cervix trying to block off her uterus and tubes with scar tissue. This just goes to show how desperate women were during those times. They resorted to very desperate means to control their fertility. She nearly died. She finally pulled through but not without some very hair-raising moments."

Dr. Louise Tyrer:

"These women came in dying from botched abortions and infections. It was just such a waste of human life," says Tyrer.

The first deaths "sear the soul," says Tyrer, and they remain fresh memories for her, as do images of women lined up on gurneys outside the operating room 18 hours a day, "waiting for doctors to take them in and scrape out the remnants of what was causing the hemorrhaging and infection."

"One woman came in already in shock, she was hemorrhaging so much. The first thing we did was to give her blood to rebuild her strength so she could go through the surgical procedure to remove leftover tissue from the partial abortion. Despite getting a transfusion, she continued to bleed," says Tyrer, who then discovered that the abortionist had torn the cervix and the uterine artery. Tyrer had to cut through the abdomen and tie off the uterine artery to stop the bleeding.

The woman survived the botched abortion, but two days later she came down with gangrene, "obviously through the use of unclean instruments during the abortion. We couldn't give her penicillin, because it had all gone to war. We gave her a sulfa drug, but it didn't work. We put her in the private room reserved for women who were dying." An autopsy revealed she had gangrene extensively throughout her body.

Tyrer tells another story that underscores the importance of women having the right to reproductive options. A gypsy woman, pregnant for the 13th time, had been in labor for three days. Tyrer discovered that the fetus was already dead and lying cross-wise in the woman's worn-out uterus. At 3 am, Tyrer telephoned her female supervisor at home - most of the male doctors had gone to war - who advised Tyrer to give the woman ether until she stopped breathing to relax the uterus, so that Tyrer could manually turn and extract the fetus. However, the turn ruptured the uterus and the uterine artery, and the woman started hemorrhaging. In a second call, the doctor suggested a hysterectomy to control the bleeding, but it was too late, and the woman died.

Plan B OTC?

OTC Plan B? It was not to be. [Sorry, couldn't resist.]

Today was the day the government was to issue its pronouncement about Plan B: would discriminatory, age-restricted OTC sales of Barr's emergency contraceptive be allowed? Despite Barr's obligatory optimism, not any time soon according to this report:

WASHINGTON - The government has delayed a decision about whether to allow women to buy the morning-after birth control pill over the counter but hopes to act soon, the manufacturer said Friday.

...

Under federal guidelines, the FDA had aimed to have a decision by Friday. But Barr Pharmaceuticals said in a statement Friday that the FDA told the company it was unable to complete its review by then.

"The company remains optimistic that the agency will approve Plan B for OTC sale," Barr said.

The statement said the FDA indicated that "it is committed to completing its review of the application in the near future."

Nancy Keenan, president of NARAL Pro-Choice America, said, "I certainly hope FDA's decision isn't motivated by political considerations three days before President Bush (news - web sites)'s supporters stage their annual anti-choice protest in Washington."

Take a moment to reflect how much the situation has deteriorated when the possibility that the timing of political and religious events is a plausible (and, may I add, likely) explanation for the FDA's decision to delay OTC sales of Plan B.

Not a Parody

Sam Heldman, a lawyer, comments on a judge's decision in Alabama about a minor's request to bypass the state's parental-notification law in order to have an abortion:

So what did the judge do? He denied the petition. In large part he made up reasons that (as the appellate opinions explain) were entirely unsupported by the evidence, or ignored the relevant law. But he went beyond that. He said that the minor was not mature, in that it is (he said) "not an act of maturity on her part to put the burden of the death of this child upon the conscience of the Court." The trial judge went on, dripping in sarcasm and moral condemnation:

The legislature, in its infinite wisdom, has determined that an unborn child who never has had even the ability to do any wrong, could be put to death so that his mother can play [sports]. ...
"Ah, but this young woman has more ambition than to play [sports]. Her possible ... scholarship is but the means to the end of her becoming a [health--care provider]. But what is the duty of a [health--care provider]? To save lives. Should her child die so that, possibly, she might later save other lives?
"There may be physical complications to an abortion. There may be psychological complications or consequences. She said that she does not believe that abortion is wrong, so, apparently, in spite of her church attendance, there won't be spiritual consequences, at least for the present."
He went on to say, "This is a capital case. It involves the question whether [the minor's] unborn child should live or die."

That just wasn't "law" in any sense. The judge's personal beliefs were driving the decision.

I was going to end my post here--the judge's insolent attempt to question the religious beliefs of a perfect stranger, and his condescending treatment of a young person are appallingly evident. However, his abject ignorance of medical facts might not be. In the context of "Should her child die so that, possibly, she might later save other lives?", the "There may be physical complications to an abortion." is just too much. There is no child*. There is a first trimester conceptus/embryo [possibly a fetus, if the pregnancy was past the 7th week]. Moreover, having a first trimester abortion significantly decreases a woman's risk of death** from 1 in 10,000 [from continuing the pregnancy] to 1 in 263,000.

Once again, I am stunned by the caliber of the men who have the power of life and death over the lives of tens of millions of women.


*Williams 21ed p 86

** -"- p 1518

(via Instapundit)

News Roundup and Roe V. Wade

Some positive reproductive health news, from Virginia (via Ms. X):

RICHMOND - A bill to require parental notification when a minor receives birth control or other health services from a public agency failed to advance in a House committee Tuesday.

HB1662, proposed by Del. L. Scott Lingamfelter, R-Prince William, was tabled on a 15-7 vote. There was no indication the committee plans any further action on it.

The bill would have required any state or local government employee who provides services to a minor "relating to sexually transmitted diseases, the provision of emergency contraception, pregnancy, illegal drug use, and the contemplation of suicide" to notify a parent within two days.

and Spain:

MADRID, Spain - In a substantial shift from traditional policy, the spokesman for the Catholic Church in Spain has said it supports the use of condoms to prevent the spread of AIDS (news - web sites).

"Condoms have a place in the global prevention of AIDS," Juan Antonio Martinez Camino, spokesman for the Spanish Bishops Conference, told reporters after a meeting Tuesday with Health Minister Elena Salgado to discuss ways of fighting the disease.

The Catholic Church has repeatedly rebuffed campaigns for it to endorse the use of condoms in the fight against AIDS. The Vatican (news - web sites) states that condoms, because they are a form of artificial birth control, cannot be used to help prevent the spread of HIV (news - web sites), the virus that causes AIDS.

Martinez Camino said the church's stance was backed by the scientific world. He cited a recent study by experts in the medical magazine Lancet that supported the so-called "ABC" approach of abstinence, being faithful to partners and using condoms.

"The Church is very worried and interested by this problem," he said.

There was no comment from the Vatican to the Spanish statement.

Update: MADRID (AFP) - The Roman Catholic Church in Spain moved to quench any notion of a sea-change in its attitude to the use of contraceptives, saying remarks by one of its top people had been misunderstood and that doctrine remained as before.

Also, some troubling news from Lagos:

LAGOS (AFP) - Two million Nigerian children have been orphaned by HIV/AIDS and 900 people are dying needlessly from the virus every day, the international medical aid agency Medecins Sans Frontieres (MSF - Doctors Without Borders) said.

"Instead of being the future of this country, these children grow up as orphans lacking parents who could take care of their education or even teach them the most basic skills in their lives," said MSF spokesman Tobias Luppe.

And some deeply disturbing [but not for the obvious reason] news from the U.S. (emphasis mine):

WASHINGTON - The woman once known as "Jane Roe" has asked the Supreme Court to overturn its landmark Supreme Court decision that legalized abortion 32 years ago.

Norma McCorvey, whose protest of Texas' abortion ban led to the 1973 ruling, contends in a petition received at the court Tuesday that the case should be heard again in light of evidence that the procedure may harm women.

...

Two lower courts last year threw out McCorvey's request to have the ruling reconsidered.

But in a strongly worded concurrence, 5th U.S. Circuit Court of Appeals (news - web sites) judge Edith H. Jones criticized the abortion ruling and said new medical evidence may well show undue harm to a mother and her fetus.

This is what I find disturbing: The Supreme Court is asked to act based on what Ms. McCorvey calls evidence that the procedure may harm women [I assume she means *new* evidence? I ask because this "evidence" is nowhere to be found in the specialty's reference textbooks, the American College of Ob/Gyns' practice guidelines, standard of care protocols, etc.], and on judge Jones' divining that, maybe, perhaps at some time in the near, or possibly distant future, and/or never, new medical evidence may well show undue harm to a mother and her fetus.

I hesitate to use this important development to be snarky [oh, who am I kidding, I simply must], but: baseless* lawsuits can't be kept away from taxing the highest court's time and resources, and still the garden variety torterts insist the system isn't broken.

*[Update: Disregard this paragraph] Please take into account the fact that I haven't actually seen what's in the papers filed with the Supreme Court (I tried to do a search on the site, but wasn't able to locate the documents); this is just my informed opinion [I'm not aware of any revisions to the existing risks of medical or surgical terminations.]

Oh, why do I do these things! I just had to take a look at some of this "evidence", and what I found is even more disturbing than what I had initially thought. [Note to self: sometimes, ignorance is bliss.]

Here is, what I believe to be, the 5th U.S. Circuit Court of Appeals' opinion (.pdf) mentioned in the article. The Court dismisses Ms. McCorvey's lawsuit, Judge Jones concurs with the dismissal, and then goes on to say [and this is where we see Ms. McCorvey's "evidence" outlined] (emphasis mine):

Even more ironic is that although mootness dictates that Ms. McCorvey has no "live" legal controversy [mootness, a legal thing, was the basis for the case dismissal], the serious and substantial evidence she offered could have generated an important debate over factual premises that underlay Roe.

So, what is this serious and substantial evidence that abortion may harm women offered by Ms. McCorvey? (emphasis mine)

McCorvey presented evidence that goes to the heart of the balance Roe struck between the choice of a mother and the life of her unborn child. First, there are about a thousand affidavits of women who have had abortions and claim to have suffered long-term emotional damage and impaired relationships from their decision. Studies by scientists, offered by McCorvey, suggest that women may be affected emotionally and physically for years afterward and may be more prone to engage in high-risk, self-destructive conduct as a result of having had abortions. Second, Roe's assumption that the decision to abort a baby will be made in close consultation with a woman's private physician is called into question by affidavits from workers at abortion clinics, where most abortions are now performed. According to the affidavits, women are often herded through their procedures with little or no medical or emotional counseling. Third, McCorvey contends that the sociological landscape surrounding unwed motherhood has changed dramatically since Roe was decided. No longer does the unwed mother face social ostracism, and government programs offer medical care, social services, and even, through "Baby Moses" laws in over three-quarters of the states, the option of leaving a newborn directly in the care of the state until it can be adopted. Finally, neonatal and medical science, summarized by McCorvey, now graphically portrays, as science was unable to do 31 years ago, how a baby develops sensitivity to external stimuli and to pain much earlier than was then believed. In sum, if courts were to delve into the facts underlying Roe's balancing scheme with present-day knowledge, they might conclude that the woman's "choice" is far more risky and less beneficial, and the child's sentience far more advanced, than the Roe Court knew.

To summarize, Ms. McCorvey's new medical "evidence" [yes, I'm using scare quotes deliberately] is:

1) Abortion linked to emotional, physical, and psychological problems: [A]bout a thousand affidavits of women who have had abortions and claim to have suffered long-term emotional damage and impaired relationships from their decision.

[In the legal paper, the [s]tudies by scientists, ... [that] suggest that women may be affected emotionally and physically for years afterward and may be more prone to engage in high-risk, self-destructive conduct as a result of having had abortions. are sourced to an affidavit of David Reardon, Ph.D. (reporting on clinical and scientific findings demonstrating that abortion is linked to emotional, physical, and psychological problems in women and criticizing the studies relied on by the Roe Court). The Elliot Institute, and David Reardon, Ph. D notwithstanding (valid methodology and all that), a link between abx and emotional/physical?/psych problems hasn't been demonstrated.]

So, about 1001 affidavits of women who have had abortions and claim to have experienced beneficial long-term emotional gains and enhanced relationships from their decision will disprove Ms. McCorvey's "evidence".

2) Consultation with attending physician: [A]ffidavits from workers at abortion clinics ... call[ing] into question ... Roe's assumption that the decision to abort a baby will be made in close consultation with a woman's private physician.

Again, affidavits + 1 from workers at abortion clinics supporting Roe's assumption that the decision to abort a baby will be made in close consultation with a woman's private doctor will disprove Ms. McCorvey's "evidence".

3) Changes in the unwed motherhood sociological landscape: [Ms.] McCorvey conten[ion] that the sociological landscape surrounding unwed motherhood has changed dramatically since Roe was decided.

Two women's contradictory contentions will suffice to disprove Ms. . McCorvey's "evidence".

4) Fetal pain: [N]eonatal and medical science now graphically portrays, as science was unable to do 31 years ago, how a baby develops sensitivity to external stimuli and to pain much earlier than was then believed.

We've already discussed fetal pain, a fetus' sentience, and the misinformation surrounding this topic. [Also, advances in medical science detection methods does not = "new medical evidence against Roe".]

After reading Ms. McCorvey's "evidence" I stand by my earlier conclusion: the Supreme Court petition to rehear Roe v. Wade does not contain any new medical evidence.

I Told You So

From the department of "I told you so!", forcing teens to get their parents' permission before getting contraception will do nothing to scare youngsters off having sex and may in fact increase rates of teen pregnancy. Trying to frighten teenagers about the risks of pregnancy also doesn't work (emphasis mine):

[U.S.] researchers said their findings support the argument that teens need to get good information about contraceptives, including condoms, and argue against current federal policies pushing abstinence-only education.

"The research published today shows abstinence-only does significant disservice to American youth by increasing the risk of pregnancy and disease," Cynthia Dailard, an analyst at the nonprofit Alan Guttmacher Institute, a reproductive health think tank, told reporters in a telephone briefing.

Several newly elected senators have pledged to press for a federal notification law and such laws are also in the works in several states. A study of 1,500 girls under the age of 18 who used family planning clinics, which provide contraceptive and pregnancy services, showed the parents of 60 percent of them knew the young women were using the clinics, said the Institute's Rachel Jones.

But close to 20 percent of the girls said if they had to get permission to use contraceptives from their parents, they would do without, Jones and colleagues report in this week's issue of the Journal of the American Medical Association (news - web sites).

"Only 1 percent said their response would be to stop having sex," Jones told the briefing.

"We need to recognize that mandated parental notification laws would not stop teens from having sex but ultimately would increase rates of sexually transmitted diseases and pregnancy," Jones said.

In the second study, Peter Bearman, who directs the Columbia University Institute for Social and Economic Research and Policy, found that fear of pregnancy did little to keep a girl from having sex, and those with positive attitudes about contraception were much less likely to become pregnant.

"Policymakers often have concerns that talking positively about contraception encourages young people to have sex," Bearman said in the journal Perspectives on Sexual and Reproductive Health.

"There's a lot of research to show that's just not true. Even those adolescents who most actively believe they are not going to have sex before marriage, for instance those who take virginity pledges, 80 percent of them will eventually have sex before marriage."

I am one of the people who think adolescents, in particular young adolescents, should not have sex, because at that age the risks of sexual activity outweigh the benefits. I also think being straightforward, and providing teenagers with complete and accurate information is the best way to go about it.

Grand Rounds

The great Waking Up Costs hosts this week's Grand Rounds. The theme is medical errors; please make sure to stop by.

Skip Period Regimens

Skip a period, or skipping your period on Yasmin, tricyclics, and NuvaRing are among the most common terms used by the people who find my site via search engines. So, to help these visitors, as well as my regular readers, I've decided to do a post on the regimens used to skip a menstrual period. This way, you'll have all the information in one place.

Before we start, note:

I. What follows is just an outline of the "skipping your period" (extended) regimens.

II. If you use the Pill, it's best to use a monophasic brand.

TIP: To find out if the brand you're using is monophasic, look at the pack. For a 28-day pack, if 21 pills are the same color and contain the same amount of estrogen and progestin, and 7 pills are a different color and are inactive (placebo), it's a monophasic brand.

Note: The 28-day pack, shortened placebo interval (24/4), brands Loestrin 24 Fe and YAZ are monophasics. As are the 84-day pack brand Lybrel and the 91-day pack brand Seasonale. The other 91-day pack brand, Seasonique, is a biphasic.

III. Your menstrual period and withdrawal bleeding are not one and the same thing.

When you use a combination birth control method, like the Pill, you are not skipping a menstrual period. That's because, for as long as you use such a method, you don't have a menstrual period. What you are doing is shifting the frequency of the withdrawal bleeding episode from once a month to once every few months.

The monthly menstrual period and the monthly withdrawal bleed are distinct, unrelated events.

The monthly period is the body-directed shedding of a thickened uterine lining, under the influence of fluctuating endogenous hormone levels, at set intervals (~21 days). The monthly withdrawal bleed is the user-directed artificial destabilization of a thin uterine lining, as a result of deliberately manipulating the dosage of exogenous hormones in the Pill, at arbitrarily set intervals (21 days, 49 days, 84 days, 168 days, or 336 days).

A monthly menstrual period has a [single] biological purpose: to prepare the uterine lining for pregnancy. A monthly withdrawal bleed has no physiological or biological purpose. It's a designer trick, intended mostly to appease politicians and Popes. It's a historical artifact, not a biological requirement.

IV. The most common side effect with an extended regimen is breakthrough bleeding/spotting (BTB).

V. If you plan to skip your period for a special event, it's best to plan ahead.

Extended regimens work best (less/no BTB) if you plan ahead and give your body at least three months to get used to the new regimen. This applies to both these scenarios: a) you're already using one of the methods on a regular regimen and plan to switch to an extended regimen, or b) you're not using any method and plan to start using an extended regimen.

Of course, it's not always possible to plan ahead. So, if you need to skip your period sooner rather than later, ask your doctor about the high dose, progestin-only regimen (e.g., 5 mg norethindrone acetate, 1-3 times daily). This regimen can be started anywhere from 3 weeks (preferably), to 1 week before the event.

VI. Extended regimens offer the same pregnancy protection as regular regimens.

VII. The .pdf links used in the post are to a method's prescribing information.

VIII. Most of the regimens are based on clinical experience.

IX. Finally, your doctor gives you medical advice, your blogger gives you educational information.

Here are the methods and the regimens.

MONOPHASIC PILL (Yasmin)

Yasmin (.pdf) is a combination, monophasic--estrogen (0.03 mg ethinyl estradiol) + progestin (3 mg drospirenone)--birth control pill. All active pills (21 yellow pills) contain the same amount of hormones. The placebo pills, or "sugar" pills (7 white pills) are inert.

Regular regimen: To bleed once a month

Take one active pill [yellow pill for Yasmin] per day for 21 days, followed by one placebo pill [white pill for Yasmin] for 7 days (bleeding). After the last placebo pill start a new pack.

Extended regimen: To bleed once every three months

Take one active pill [yellow pill for Yasmin] per day for 84 days, followed by one placebo pill [white pill for Yasim] for 7 days (bleeding). After the last placebo pill start another 84-day, active pill, cycle. [You'll need four pill packs per cycle for this regimen.]

TIP: To vary the bleeding interval, vary the number of packs you use. For example, to bleed every month and a half you'll need two pill packs. Take one active pill per day for 42 days, followed by one placebo pill per day for 7 days (bleeding). Or, you can start with three pill packs, and take one active pill per day for 63 days, followed by one placebo pill for 7 days (bleeding).

TRIPHASIC PILL (Ortho Tri-Cyclen Lo)

Ortho Tri-Cyclen Lo (.pdf) is a combination, triphasic--estrogen (0.025 mg ethinyl estradiol) + progestin (0.180 mg/0.215 mg/0.250 mg norgestimate)--birth control pill. All 21 active pills (7 white, 7 light blue, and 7 blue) contain the same amount of estrogen. The amount of progestin varies: the 7 white pills have 0.180 mg; the 7 light blue pills have 0.215mg; and the 7 blue pills have 0.250 mg. The placebo pills, or "sugar" pills (7 green pills) are inert.

Regular regimen: To bleed once a month

Take one active pill [7 white + 7 light blue + 7 blue pills for Orto Tri-Cyclen] per day for 21 days, followed by one placebo pill [green pill for Ortho Tri-Cyclen] for 7 days (bleeding). After the last placebo pill start a new pack.

Extended regimen:

To skip one "period" (or delay the bleeding by one week)

A) Take one active pill [7 white + 7 light blue + 7 blue pills for Orto Tri-Cyclen Lo/Ortho Tri-Cyclen] per day for 21 days. When you get to the 7 placebo pills [green pill for Ortho Tri-Cyclen Lo/Ortho Tri-Cyclen] throw them out and instead take the third week of active pills from a new pack [7 blue pills for Ortho Tri-Cyclen Lo/Ortho Tri-Cyclen].

Once you're done, either start a new pack right away (skip bleeding) or wait one week and then start a new pack (delays bleeding by one week).

[Pack #1] 7 white pills + 7 light blue pills + 7 blue pills + [Pack #2] 7 blue pills.
Start a new pack right away/Wait one week, then start a new pack.

B) Take one active pill [7 white + 7 light blue + 7 blue pills for Orto Tri-Cyclen Lo/Ortho Tri-Cyclen] per day for 21 days, followed by one placebo pill [green pill for Ortho Tri-Cyclen Lo/Ortho Tri-Cyclen] for 7 days (bleeding). After the last placebo pill wait for one week*; don't take any pills. Then start a new pack and take the 21 active pills, followed by the 7 placebo pills. [This regimen shifts the bleeding episode by one week during the second month.]

*VERY IMPORTANT: You are not protected against pregnancy during the week you delay taking the next pack. You must use an alternate birth control method (condom, diaphragm, sponge, etc.).

7 white pills + 7 light blue pills + 7 blue pills + 7 green pills.
Wait one week (no pills). [No Pregnancy Protection!]
Start a new pack.

To bleed once every three months

1. Take one active pill [7 white + 7 light blue + 7 blue pills for Orto Tri-Cyclen Lo/Ortho Tri-Cyclen] per day for 21 days. When you get to the 7 placebo pills [green pill for Ortho Tri-Cyclen Lo/Ortho Tri-Cyclen] throw them out and instead start a new pack. Repeat the regimen with the new pack; use 4 packs total. Stop for one week [either don't take any pills, or take the 7 green pills] (bleeding) then restart.

7 white pills + 7 light blue pills + 7 blue pills.
Start a new pack (take active pills only). Repeat [4 packs total].
Wait one week, then start a new pack.

TIP: To vary the bleeding interval, vary the number of packs you use.

Note: This is the regimen most likely to trigger BTB.

2. Take one active pill [7 white + 7 light blue + 7 blue pills for Orto Tri-Cyclen Lo/Ortho Tri-Cyclen] per day for 21 days. When you get to the 7 placebo pills [green pill for Ortho Tri-Cyclen Lo/Ortho Tri-Cyclen] throw them out. Start a new pack backwards, after first discarding the 7 placebo pills from this new pack [7 blue + 7 light blue + 7 white pills for Orto Tri-Cyclen Lo/Ortho Tri-Cyclen]. Repeat the regimen with the next two packs; use 4 packs total. Stop for one week [either don't take any pills, or take the 7 green pills] (bleeding) then restart.

[Pack #1] 7 white pills + 7 light blue pills + 7 blue pills + [Pack #2] 7 blue pills + 7 light blue pills + 7 white pills + [Pack #3] 7 white pills + 7 light blue pills + 7 blue pills + [Pack #4] 7 blue pills + 7 light blue pills + 7 white pills.
Start a new pack backwards (take active pills only). Repeat [4 packs total].
Wait one week, then start a new pack.

3. Start with three new packs (or two). Take the first 7 active pills [white pills for Ortho Tri-Cyclen Lo/Ortho Tri-Cyclen] from each of the three packs, for a total of 21 pills. Then take the next 7 active pills [light blue for Ortho Tri-Cyclen Lo/Ortho Tri-Cyclen] from each of the three packs, or 21 pills total. Finally, take the last set of 7 active pills [blue pills for Ortho Tri-Cyclen Lo/Ortho Tri-Cyclen] from the three packs, or 21 pills total. Stop for one week [either don't take any pills, or take the 7 green pills] (bleeding) then restart.

[Pack #1] 7 white pills + [Pack #2] 7 white pills + [Pack #3] 7 white pills + [Pack #1] 7 light blue pills + [Pack #2] 7 light blue pills + [Pack #3] 7 light blue pills + [Pack #1] 7 blue pills + [Pack #2] 7 blue pills + [Pack #3] 7 blue pills.
Stop for one week, then restart.

SKIN PATCH (Ortho Evra)

Ortho Evra (.pdf) is a combination--estrogen (0.75 mg ethinyl estradiol) + progestin (6.00 mg norelgestromin)--birth control skin patch. It releases 0.020 mg of estrogen and 0.150 mg of progestin per day.

Regular regimen: To bleed once a month

Apply one patch and leave it on for 1 week. At the end of the week, remove the patch, discard it and replace it with a new patch. Do this for 3 weeks in a row. At the end of the third week, remove and discard the last patch and wait for one week; that's the patch-free week (bleeding). Once the week is over, restart the regular [3 weeks:3 patches on/1 week off] patch regimen.

Extended regimen: To bleed every few months

Apply one patch and leave it on for 1 week. At the end of the week, remove the patch, discard it and replace it with a new patch. Do this for 8 weeks (or 12 weeks) in a row. At the end of the eighth week (or twelfth week), remove and discard the last patch and wait for one week; that's the patch-free week (bleeding). Once the week is over, restart the the extended-use [8 weeks:8 patches (or 12 weeks:12 patches) on/1 week off] patch regimen.

Note: Use of the regular patch regimen [3 weeks:3 patches on/1 week off] entails a 60% higher exposure to estrogen than use of a typical combination Pill brand containing 35 μg of estrogen on a regular regimen [21 days on/7 days off]. Although the clinical relevance of this finding is unknown, you should be aware of it before starting an extended patch regimen.

VAGINAL RING (NuvaRing)

NuvaRing (.pdf) is a combination--estrogen (2.7 mg ethinyl estradiol) + progestin (11.7 mg etonogestrel)--birth control vaginal ring. It releases 0.015 mg of estrogen and 0.120 mg of progestin per day.

Regular regimen: To bleed once a month

Insert one ring and leave it in place for 3 weeks in a row. At the end of the third week, remove the ring, discard it and wait for one week; that's the ring-free week (bleeding). Once the week is over, restart the regular [3 weeks on/1 week off] ring regimen.

Extended regimen: To bleed every few months

Insert one ring and leave it in place for 3 weeks in a row. At the end of the third week, remove the ring, discard it and replace it with a new ring right away. Keep the new ring in for 3 weeks in a row. [That's 6 weeks total.] At the end of the third week, remove the ring, discard it and either:

a) wait for one week; that's the ring-free week (bleeding). Once the week is over, restart the extended-use [6 weeks on/1 week off] ring regimen.

b) replace it with a new ring right away. Leave the new ring in place for 3 weeks in a row. At the end of the third week, remove the ring, discard it and replace it with a new ring right away. Keep the new ring in for 3 weeks in a row. [That's 12 weeks total.] At the end of the third week, remove the ring, discard it and wait for one week; that's the ring-free week (bleeding). Once the week is over, restart the extended-use [12 weeks on/1 week off] ring regimen.

TIP: You can also insert one ring and leave it in for 4 weeks in a row, instead of 3 weeks.

[At the end of the fourth week, remove the ring, discard it and replace it with a new ring right away. The rest of the extended regimen is the same as above, except you leave the ring in for 4 weeks, instead of 3 weeks, in a row.]

Note: Use of the regular ring regimen [3 weeks on/1 week off] entails a 50% lower exposure to estrogen than use of a typical combined Pill brand containing 30 μg of estrogen on a regular regimen [21 days on/7 days off]. Although the clinical relevance of this finding is unknown, you should be aware of it before starting an extended ring regimen.


UPDATE: Right after I finished posting I noticed someone found this by using the search term "secrets to delaying menstrual period". Heh, there are no secrets. Just information.

ETA: I've updated the post.

Tag Test

Just read about Technorati's new tags and, of course, I had to try it out.

Health

FDA's EC Decision

According to this report, the FDA could decide as early as this week if age-restricted OTC sale of emergency contraception (EC) will be allowed.

The good news: this will insure access to proper medical care for some women.

The bad news: millions will be barred from getting OTC EC for no other reason than their age. Hmm, isn't this age discrimination?

There's another aspect of this I hadn't even considered (emphasis mine):

The decision to reject Barr's first application led critics to say that the FDA was bending to conservative politics.

"A treatment for any other condition, from hangnail to headache to heart disease, with a similar record of safety and efficacy would be approved quickly," three physicians on the FDA advisory committee wrote in an editorial published by the New England Journal of Medicine (news - web sites) last April.

They said that requiring customers to prove their age or putting the drug behind the counter are steps "designed to intimidate women." The authors noted that the advisory committee rejected such moves.

"In this case, there is no medical dispute," the wrote. "Rather, the delay results from the concern of some groups ... that the availability of the drug may have a corrupting influence on sexual behavior. If easy access to the drug could have such an influence, it would seem that the battle had already been lost."

HB 1807 Update

No wonder HB 1807 didn't make sense; it has nothing to do with rape/statutory rape. The intent is to prohibit sexually active minors access to birth control. [Must learn to think like a politician.] A similar law has already been enacted in Texas. Respectful of Otters has the full discussion. If you live in Virginia, may I suggest you read very carefully, and learn.

The Tongue Ring

This is what can happen when you're pregnant and you swallow your tongue ring:


[both the ring and the fetal spine are on the left side of the pic, and the head is midline, towards the bottom of the pic]

Who's Who?

Who's the political nut case and who's the blogger?

Cosgrove says he filed the bill at the request of the Chesapeake Police Department, which over the past few years has had to respond to instances of full-term newborns abandoned in trash cans or snowbanks.

On the other hand, the Virginia Association of Chiefs of Police wrote Cosgrove to say that, while it supports notifying a doctor or public health facility, requiring a woman to report a miscarriage to police "seems particularly cruel."

Cosgrove is upset that his bill has been misinterpreted.

"I don't care about bloggers and political nut cases," he says, "but I do care about women who had miscarriages, and they were truly upset. That's why I responded to every single one."

You decide.

Who? What? Where? When? Why?

Update: To understand the real reason for HB 1807 read this discussion.

Virginia: the state that keeps on giving ... me a headache.

Meet Delegate Robert G. Marshall and his whimsical HB 1807:

§ 18.2-63.2. Providing birth control to minor in certain circumstances; penalty.

If any person knows or has reason to believe that a minor is engaging in sexual relations with a person three years or more older than the minor and such person provides the minor with a contraceptive or contraceptive device, he shall be guilty of a Class 6 felony.

I don't even know where to begin with this bill. It doesn't make sense. The effect of withholding proper medical care from sexually active minors is an increase in the number of minors who become pregnant, suffer life-long health problems, or die as a result of a pregnancy, and/or contract a sexually transmitted infection. Surely this can't be the bill's intent.

Since statutory rape is illegal in Virginia, for medical personnel there is a duty to report. This duty to report is independent of providing contraception. I don't know what the reporting requirements for non-medical people are, but I'd offer an educated guess that parents providing birth control to their minor children also report statutory rape. In this context, what does providing contraception have to do with anything? I'm missing something here. So, let's investigate a bit.

HB 1807 will apply to both minors having sex with other minors, as well as adults having sex with minors [a minor ... engaging in sexual relations with a person three years or more older than the minor]. So we need to know what are the current laws (pdf) about sex with minors?

Currently, providing another with a contraceptive or contraceptive device is not illegal in Virginia, regardless of the individual's age.

It is ... a Class 6 felony in Virginia to have intercourse with a consenting victim age 13 or 14 when the accused is a minor is three years or older than the victim (§ 18.2-63).

Aha, so we learn that minors having sex with minors is already illegal in Virginia.

An aside: The punishment for a Class 6 felony is imprisonment for one to five years or jail for up to 12 months and a fine of up to $2,500, either or both.

You might be interested to know that another offense considered a Class 6 felony in Virginia is an attempt to commit aggravated sexual battery. Also, so are dousing someone in acid, or setting them on fire (as long as it isn't done maliciously), and physically defiling a dead human body. And, if HB 1807 passes, so will providing birth control to some sexually active minors.

At least you'll be relieved to know that it's not just health care professionals, parents, store clerks, and a minor's friends who are to be made felons in Virginia. Unmarried adults who have sex, aka fornicators, are also to be punished: Any person, not being married, who voluntarily shall have sexual intercourse with any other person, shall be guilty of fornication, punishable as a Class 4 misdemeanor. [You know, there are ways to neutralize a person's libido. Virginia legislators, call me!]

Back to current laws. We also learn that during 2002 and 2003:

[T]here were 46 offenders (minors at least three years older than the
victim) who were convicted under § 18.2-63. The largest portion of these offenders (44%) were sentenced to local-responsible (jail) time, but over one-third (39%) were sentenced to state responsible (prison) time. The offenders who were sentenced to prison received a median sentence of two years incarceration.

[C]arnal knowledge of a consenting 13 or 14 year old is raised to a Class 4 felony when to accused is an adult. Under § 18.2-371(ii), consensual intercourse with a minor age 15 or older is a Class 1 misdemeanor when the accused is not the parent.

As we'd expect, statutory rape is also already illegal in Virginia. [I don't have time to research the parent thing, but I'd really like to believe that if the adult is the parent, there will still be a punishment.] As for the number of cases, during 2003 and 2004:

...33 offenders held pre- or post-trial in jail were convicted under this statute during the two-year period. All 33 offenders received local responsible (jail) time, with a median sentence just under three months.

Another aside: The median sentence for the minor offenders is two years incarceration, while that for the adult offenders is just under three months. Why?

So, Virginia already has laws dealing with sexual intercourse with a minor. Also, the yearly number of cases (~23 minor offenders, and ~11 adults)* does not appear to be overwhelming the system. How would not providing adequate medical care to sexually active minors (HB 1807) fit in here and augment the existing laws?

*Not the actual number because I didn't have the raw data.

(via Democracy for Virginia)

Update: Virginia's fornication law has been struck down.(via Instapundit)

A Blog Flog for Del. Cosgrove

Since I didn't focus too much on the role the Internet played in the withdrawal of HB 1677, here's an editorial from the Virginian-Pilot (reg. required) to make up for that:

A blog flog for Del. Cosgrove
The Virginian-Pilot
© January 13, 2005
Last updated: 7:10 PM

What happens in Vegas, a popular TV ad goes, stays in Vegas.

Not so Virginia. Just ask John Cosgrove.

The Chesapeake delegate found this out the hard way last weekend after he received more than 500 irate e-mails from across the country. Cosgrove had introduced a misguided bill that would have required police to be informed within 12 hours when a fetal death occurs without medical attendance.

Cosgrove says it was an attempt to penalize mothers who abandoned babies, even though that’s already a serious crime for which at least one mother was jailed here in 2003.

But that’s not how the bill was interpreted. Most people saw it as a heartless law obliging a distraught woman who miscarries to make an incident report to the police and answer inappropriate questions. (Aren’t conservatives, like Cosgrove, supposed to believe in limiting government intrusion into people’s lives?) Regardless, it was a tough introduction for the Republican to the brave new world of Internet “blogs.” Short for “Web logs,” blogs are personal Web sites and discussion boards.

And in short order, a slew of them mercilessly pounded him. One Web site, the Virginia-based democracyforvirginia.typepad.com, that posted information about Cosgrove’s legislation, received nearly 70,000 hits in 24 hours. More than 100 others picked up and posted the information, including Web sites for women who’ve endured miscarriages.

After spending the weekend responding to angry screeds from Texas and California, Cosgrove decided on Monday to retreat, and pulled the bill.

There is a lesson here about the lightning speed with which information, rumors and angry epistles can travel in the computer age. Introduce dubious legislation in Virginia and, with the click of a mouse, someone in North Dakota can know — and sound off about — its every detail.

Thanks to the power of the Internet, what happens in Richmond no longer stays there.

But Cosgrove’s actions also raise pertinent questions. If the intent of his bill was, as he claims, to penalize mothers who dump babies, why didn’t he simply copy language from a similar measure he introduced two years ago? Unless Cosgrove intended to broaden its scope, why make such a bill so intentionally vague?

There are already laws on the books against child abandonment and neglect in the commonwealth. The real shame is that it took an avalanche of outrage from Texas and California, not Virginia, to change Cosgrove’s mind.

[I added the links to the original article.]

(via Ms. X)

HB 1677 Is Very Much Needed

Just as I was getting ready to move on, Maura at Democracy for Virginia pulls me right back in. Mind you, it wasn't her finally coming clean about who's funding her posts on Del. Cosgrove (disclaimer: joke) that prompted me to write this. Although, I must say, you have to admire those Nigerians; their tentacles are far reaching. (disclaimer: joke) Oh, and in case you're wondering, my posts on this topic are still for sale. (disclaimer: joke ... unless you're the rich widow of a recently deposed Nigerian dictator, in which case, let's talk) [Disclaimers courtesy of Del. Cosgrove who kindly illuminated for us the pervasive problem of online readers not being able to read and form an independent thought at the same time, not to mention the *real*, palpable, well-documented problem of the Internet misinformation fueling the confusion on HR 1677.]

What merits our continued attention is the Delegate's planned withdrawal speech (emphasis mine):

"The motion to strike will include an explanation that the reason that it is being stricken is in large part because of the misinformation that has been propagated on the Internet about what the intent was here," said Cosgrove....

"The misinformation has fueled the confusion on what should be a fairly straightforward piece of legislation that is still something that I think is very much needed," Cosgrove said.

Unfortunately, my suspicion that the Delegate still thinks this is a good bill has been confirmed.

I think it would be very counterproductive to allow the Delegate to get away with blaming the bill's withdrawal on unsupported allegations of the misinformation that has been propagated on the Internet. I can't speak for other bloggers, but as far as I'm concerned this is not about the reliability of the Internet. It might be a side story, but it's one quite low on the priority scale.

Let's keep the focus on what's important here: HB 1677 and its effects on the people of Virginia. Actually, Maura brings up an interesting point. She says:

I'm not taking Cosgrove's defense personally. He's a politician, and he's got to sa[v]e face.

His desire/need to save face is irrelevant, and shouldn't be allowed to serve as a justification for the Delegate blowing off his constituents and leading them on a wild Internet chase. Politics shouldn't be about the politicians; it should be about the product of their work.

All the Delegate has to do is serve the people of Virginia and address the issues of HR 1677:

Why does a bill aimed at reducing liveborn mortality exclusively apply to women who experience a fetal death?

What is the legal basis for presuming pregnant women [even those who deliver a stillborn/baby that is dead] guilty of a crime for having an unattended delivery?

Where is the Chesapeake Police Department legislative package containing a request for this bill? [If such a request does not exist, why did the delegate make it up?]

Is the existing program (programs?) aimed at preventing the death of liveborn neonates as a result of abandonment working? If it isn't, why not, and what modifications are needed to make it work? Are those modifications incorporated in HB 1677?

Why is Del. Cosgrove, an elected public official, in the employment of the people of Virginia, and accountable to them, withdrawing a bill he thinks is beneficial for his constituents, and very much needed because of the Internet? Isn't this dereliction of duty on his part?

I don't know the procedure involved in withdrawing a bill, but I was wondering if other Delegates are allowed to ask questions, and demand an explanation from Del. Cosgrove? Also, is it possible to get a transcript of Del. Cosgrove's actual withdrawal speech? Contrary to the Delegate's unsupported assertions, we Internet propagators of misinformation (disclaimer: sarcasm) do so love fact-checking a primary source.