Where We Hear From the NY Post And We Are Left Wondering What It "All" Means...Er, "Means"

After noticing several factual inaccuracies about Plan B in a NY Post op-ed, I emailed the columnist:

Ms. Wisse Schachter,

I'm contacting you to alert you to a number of factual mistakes in your op-ed. Briefly:

--Plan B is the "emergency contraception pill[s]", or the "postcoital pill[s]", not the "morning-after pill". [That's an incorrect and misleading term.]

--Plan B is not a pill, it's two pills. Two 0.75 mg levonorgestrel pills, to be exact. [Essential information in view of the new dosage recommendations.]

--Plan B is not basically a double dose of the regular birth-control pill. [Even without defining "regular birth-control pill", Plan B is neither a double dose of the regular progestin-only pill, nor of the EC regimen combination one.]

--Plan B is not associated with "cardiovascular disease, high blood pressure, blood clots, heart attack and strokes." (For that matter, neither are the COC EC regimens.) [In fact, Plan B is the preferred EC method for patients with a history of blood clots or stroke.]

(Full post here.)

Thank you for your time.

ema

Today, Ms. Schachter emails back:

Dear Ema,

Thank you for your message and for taking the time to read and respond to my op-ed.

The side effects listed in my piece are those commonly associated with taking birth control, as I make perfectly clear.

It would have been nice had taken as much time reading the column as you did "rebutting" it.

Regards,
Abby Schachter

First, I appreciate the response.

Second, allow me to address this:

It would have been nice had taken as much time reading the column as you did "rebutting" it.

People, as a rule, when emailing me, assume I'm dense and just say what you mean. Not having to divine intent saves me a lot of time.

I'm not sure, but here's what I think Ms. Schachter's admonition means--"I write a piece focused on the political and social implications of OTC availability of Plan B, and you 1) don't address those issues at all, and/or 2) refute them [not] by pointing out, and correcting, the factual mistakes about Plan B." Correct and incorrect at the same time.

Correct, because all I did was address the factual mistakes about Plan B--what it is, it's side effects, etc. My position (and concern) is that, unless we know the basics about a drug, we cannot have an informed discussion about the politics surrounding it.

Incorrect, because, by pointing out the mistakes about Plan B, I was not rebutting anything; I wasn't presenting any opposing evidence to Ms. Schachter's opinions. The facts about Plan B, like its progestin-only content, are not up for debate. It's not a "she said", "she said" situation. We don't each get a few minutes to make our case. Plan B's composition, or side effects for that matter, are a given, independent of anyone's argument/counterargument [you know, the "science" part].

Last, but not least, we have this:

The side effects listed in my piece are those commonly associated with taking birth control, as I make perfectly clear.

Here's the thing [yes, I know, I'm watching way too much Monk]: 1) the side effects listed in the piece are not those commonly associated with taking birth control, and 2) there's nothing even remotely clear [not to mention correct] about Plan B's side effects in the piece.

There are seven groups of birth control, and over eighty individual methods:

1. Hormonal Group

-Combination Pill

-Progestin-only Pill

-Skin Patch

-Vaginal Ring

-Implants

-Shots

-[Hormone-releasing IUDs]

2. Nonsteroidal Pill Group

-Centchroman

3. Intrauterine Device Group

-Older IUDs

-Frame IUDs

-Frameless IUDs

-[Hormone-releasing IUDs]

4. Barrier and Spermicide Group

-Condom (male, female, and unisex)

-Diaphragm

-Cervical Cap

-Ovès Cap

-FemCap

-Lea contraceptive

[Good pics here.]

-Sponges

-Spermicides

5. Natural Family Planning Group

-Continuous Abstinence

-Outercourse

-Sexual techniques

-Breastfeeding

-Fertility Awareness

6. Sterilization Group

-Male

-Female

7. Emergency Contraception Group

-Combination Pill

-Progestin-only Pill

-Antiprogesterone Pill

-Progesterone production blocker Pill

-IUD

These are the side effects listed in the op-ed:

...mild, such as dizziness, weight gain and irregular periods. ... more serious, if rare - cardiovascular disease, high blood pressure, blood clots, heart attack and strokes.

Ms. Schachter says these are the side effects (emphasis mine) commonly associated with taking birth control. Since we're talking about common side effects, everything after rare (cardiovascular dz, HTN, blood clots, heart attack and strokes) is out.

So we're left with dizziness, weight gain and irregular periods. According to Ms. Schachter, these are the side effects commonly associated with taking birth control. Really? When's the last time your partner's condom use caused you to gain weight?

Okay, I'm being facetious, but you get the point. There's no such thing as side effects ... commonly associated with taking birth control. That's because a method's side effects depend on group, mode of action, dosage, route of administration, risk factors, etc..

Even if Ms. Schachter was only referring to the Hormonal Group when listing the side effects, it's still essential to be accurate.

Cardiovascular disease, high blood pressure, blood clots, heart attack and strokes are not common side effects of methods in the hormonal birth control group. They are rare effects of some of the methods--the combination (estrogen + progestin) ones--in this group. [To give you an idea ...even deaths due to rare events, such as accidents or homicides, are much more common than deaths due to OC-related adverse events.*]

Moreover, the Hormonal Group and the EC Group are not one and the same. The side effects associated with combination methods in the Hormonal Group differ from those associated with combination methods in the EC Group. Cardiovascular disease, high blood pressure, blood clots, heart attack and strokes are not side effects--rare or otherwise--associated with combination (estrogen + progestin) EC regimens. [From my previous post: No deaths or serious complications have been causally linked to emergency contraception.]

Last, but not least, Plan B is a PROGESTIN-ONLY method. Its side effects differ from the combination (estrogen + progestin) methods in the EC Group.

Which brings us to Ms. Schachter's assertion that she made it perfectly clear in her piece that the side effects she lists are commonly associated with (?hormonal/?estrogen-progestin) birth control, in general, not Plan B. I disagree, and here's why.

In a piece

...titled 'PLAN B': What Science Can't Tell Us...

...containing the statement But it plainly is all about Plan B...

...focused on issues surrounding the approval of OTC sales of Plan B...

...stating that OTC approval of Plan B is troubling because women could get it without the benefit of a doctor's warning about side effects...

Well, approval raises a host of troubling questions. For one: Since it's only a double dose of regular birth control, women over 18 (or girls with fake IDs) could get "the pill" without a prescription - or a doctor's warnings about side effects.

...personalizing the issue of lack of physician counseling about side effects, if Plan B becomes available OTC, by quoting an Ob/Gyn's concerns about losing the opportunity to present medical issues associated with OTC sales of Plan B...

Medical professionals have doubts. Dr. Vivian Roston, an OB-GYN at St. Luke's Roosevelt Hospital, worries that over-the-counter access to emergency contraception [that would be Plan B] means she won't have the chance to educate her patients. "I wouldn't want someone not to have access [to emergency contraception]," she told me. "But then again, you lose the opportunity to present all the medical issues associated with taking a high-dose hormonal drug" [again, Plan B] if a woman doesn't have to see a doctor to get it.

(emphasis mine)

...where the above paragraph--about Dr. Roston's worries that OTC sales of Plan B would rob her of the opportunity to discuss with women medical issues associated with taking Plan B--is immediately followed by an enumeration of side effects...

Of course, some of the risks are mild, such as dizziness, weight gain and irregular periods. But others are more serious, if rare - cardiovascular disease, high blood pressure, blood clots, heart attack and strokes.

it is not at all perfectly clear that the listed side effects are not those associated with Plan B, but rather those associated with some mythical "birth control".

Bottom line: This is not about Ms. Schachter's opinions on OTC sales of Plan B, or my reading comprehension and/or debating prowess. It's about the duty of a publication like the NY Post to present factually accurate medical information to its readers. Or not; in which case the NY Post should have no objection to publishing my article entitled "Plan B Causes Cooties."


*Dialogues In Contraception. Winter 2002;7(7):4

Skipping Your Period With a Triphasic Pill, Part I

I've been getting a lot of questions about using a triphasic birth control pill brand and skipping a period. Before we discuss what regimen you use to skip your period with a triphasic Pill brand, let's make sure we're all clear on the differences between the various pill brands.

We'll discuss extended triphasic regimens in a subsequent post.

There are two groups of birth control pills:

A. Nonsteroidal (centchroman)

B. Steroidal (estrogen/progestin)

A. Nonsteroidal Birth Control Pill

This type of birth control pill contains a substance called centchroman.

The pill is taken once-a-week (twice-a-week for the first 3 months of use), the brand names are Centron or Saheli, and its main advantage is that users don't experience the side effects associated with the steroid (estrogen/progestin) pill. Its main side effect is delayed menses (in less than 10% of cycles). Of course, if the reason you're using a birth control pill is to skip your period, this is a feature not a drawback.

In any case, since this pill isn't available in the U.S., let's move on to the other Pill group, the steroidal one.

B. Steroidal Birth Control Pill

Pills in this group contain estrogen and/or progestin. The pill is taken once-a-day, and there are many brand names. More importantly, pills in this group can be further subdivided, based on what type of hormone (estrogen/progestin) they contain.

There are two main types of birth control pills in this group:

B.1. Progestin-only Pill (progestin)

B.2. Combination Pill (estrogen and progestin)

B.1. Progestin-only Pill

As the name implies, these pills have only one hormone, a progestin. A progestin is either a natural or man-made (synthetic) hormone with properties similar to the natural hormone progesterone.

Progestin-only pill brands are divided into "mini" pill brands, and full-dose brands (not available in the U.S.). As a rule, "mini" pill brands come in 28-day packs, and full-dose ones come in 20-day packs.

Progestin-only brands are not your first choice when it comes to skipping your period.

B.2. Combination Pill

These pills have two hormones, a combination of estrogen and progestin.

Combination Pill brands are further subdivided into mono-, bi-, and triphasic; some come in a 21-day pack, others in a 28-day one, and the newer ones, Seasonale and Seasonique, comes in a 91-day pack. Finally, based on the amount of estrogen, brands are classified as very low-dose (15 mcg or 20 mcg), low dose (35 mcg), and high dose (50 mcg).

All the pills in a 21-day pack are active. An active pill is a pill which has hormones. The 28- and 91-day packs have 7 days of inactive or placebo ("sugar") pills. These pills don't have hormones.

The mono-, bi-, and triphasic designation refers to the amount of hormones in the pill pack.

Monophasic

Brevicon

Each active pill in the pack has the same amount of estrogen and progestin. Also, all the active pills are the same color. This color is a different color than that of the 7 placebo pills found in the 28- and 91-day packs.

Biphasic

Mircette

For most brands, all the active pills in the pack have the same amount of estrogen, but two strengths of progestin.

A 21-day biphasic pack has pills of one strength and color taken for seven or 10 days, then a second pill with a different strength and color for the remainder of the cycle.

A 28-day biphasic pack has an extra seven placebo pills of a third color.

For a 28-day brand like Mircette, a pack has 21 pills of one strength [20 mcg ethinyl estradiol (EE)/0.15 mg desogestrel] and color, 2 placebo pills of a different color, and 5 pills with only estrogen, of a different strength [10 mcg (EE)] and color.

Of note, Mircette is one of the few available sequential brands with a shortened placebo interval: 2 days vs. 7 days. The shortened placebo interval has to do with withdrawal bleeding (fake period) which is different from menses (real period). [More on birth control pill brands with no or shortened placebo interval.]

Triphasic

Ortho Tri-Cyclen Lo

The active pills have either the same or varying amounts of estrogen, and varying amounts of progestin.

A 21-day pack has pills with three different colors and strengths. First, pills of one strength and color are taken for five to seven days. Then pills of a different strength and color are taken for the next five to seven days. Finally, a third strength and color pill is taken for the reminder of the cycle.

A 28-day pack (look under triphasics) has an extra seven placebo pills of a fourth color.

So, there you have it. Lots of birth control pill types, and brands. The important thing to remember is this:

To skip a period a monophasic brand is best.

A monophasic combination Pill brand is best because all active pills contain the same amount of hormones. Less hormonal fluctuation, due to the steady hormone levels, means you're less likely to experience nuisance side effects like irregular bleeding (breakthrough bleeding/spotting).

TIP: Regardless of which type of brand you use--monophasic or triphasic--starting an extended regimen at least three months in advance of the time you plan to skip your period allows your body to get used to the new regimen, and minimizes irregular bleeding.

If you use a monophasic Pill brand, to skip a period you take the 21 active pills, discard the 7 placebo pills, and start a new pack right away.

If you use a triphasic Pill brand you have several regimen options. One of them is to use the same regimen used for the monophasic brands--take the 21 active pills, discard the 7 placebo pills, and start a new pack right away. [Note: this regimen is mostly likely to be associated with irregular bleeding.]