How Many Women Need to Take Birth Control for Medical Reasons?

I frequently hear that many women (1.5 million in 2011, according to Guttmacher) use birth control pills exclusively for medical reasons, and that 58% of pill users use the pill for contraceptive and medical purposes. This distribution is similar for other types of hormonal contraceptives, especially the progestin IUD. This leads me and most to ask whether birth control in these settings is acceptable. Tl;dr? Read bold.

Some don't know that section 15 of Humana Vitae reads:

On the other hand, the Church does not consider at all illicit the use of those therapeutic means necessary to cure bodily diseases, even if a foreseeable impediment to procreation should result there from—provided such impediment is not directly intended for any motive whatsoever.

And some don't realize that this doesn't answer the question.

Pope Paul VI wrote HV before the post-fertilization effects of the pill were well known, before the controversy over its side-effects, before four decades of gynecological advancement, and before lower-dose pills (in early trials, pills contained the estrogen of three high-dose pills on todays market, and the progestin of ten Plan B One-steps). We can still apply his intention, but we need to ask the question again: should we use the pills currently available as we currently do?

First of all, let's cover some basics.

• What is a "medical purpose?"
• What is "treatment?" What is "cure?"
• What medical purposes are usually included in this discussion?

"Medical purpose" is a vague phrase. Merriam-Webster defines medical as "relating to the treatment of diseases and injuries," and purpose as the intention (the reason and hoped-for end point) of an action. Taking an action for a "medical purpose" must have treatment of disease as its intention.

What is treatment? In an editorial of precisely that title, a pediatrician named John Knowles wrote the American Academy of Pediatrics, just around the time that Pope Paul VI was writing HV. The piece is pithy and relevant:

[A]n increasing number of physicians are equating good treatment practices solely with specific drug therapy. This is recognizable most often in the use of the word treatment as synonymous with antibiotic. "No, I'm not 'treating' him" too often means "No, I'm not giving him any antibiotic." ...[The] personal bias of the physician [impacts] his philosophy and policies in respect to the treatment of his patients [but] let us not confuse the patient or ourselves by equation of a specific modality of therapy in which we happen to have transient faith with the total treatment rendered by careful analysis and responsible advice. [Physicians] have both a privileged advantage and a responsibility in developing a realistic appreciation of "what medical care is" in their patients....

Treatment, says Dr. Knowles, begins with our first contact of the patient, continues in our listening, exam, workup, and dialogue, and culminates in executing a plan for the patient's care. Knowles tells the story of a resident who develops a detailed plan for a young patient with a viral infection, and confesses at the end of the conversation to the patient's mother that "I don't think I will treat her at this time," meaning that he would not give an antibiotic. Knowles condemns this attitude, stating that the resident had treated the patient completely, and describing use of antibiotics as "treatment" was a mistake.

To "cure" is a relatively familiar concept, thanks to lots of oncology marketing. It means "to make someone healthy again."

Hormonal contraceptives are often regarded as treatment (or "standard of care") for gynecological problems like fibroids (235 million women worldwide), abnormal uterine bleeding (53 per 1000 women in the U.S.), dysmenorrhea (25% of women), polycystic ovarian syndrome (116 million women worldwide), and endometriosis (6-50% of women, depending on the population). (Not ovarian cancer.) Many Catholic ethicists and activists will repeat that hormonal contraceptives remove the symptoms of these disorders without changing the underlying cause. This is mostly true.

The gynecological disorders just mentioned are problematic because of cyclic hormones--her own hormonal factories are over- or under-firing, to her body's detriment. Hormonal contraceptives supply an artificial set of hormones, suppressing the patient's hormones and stopping the cyclic problem. (This is an over-simplified explanation for the multi-system, multifactorial PCOS, but is a decent explanation of the others.) This means hormonal contraceptives do address the cause of the disease: they silence the woman's production of hormones. But they don't cure: they don't repair the woman's organs so that she can cycle naturally and healthily on her own. The goal for women on hormonal contraceptives is either indefinite prescriptions, or to stop at some point (usually when fertility is desired) and hope for resolution of symptoms.

Hormonal contraceptives are also prescribed while women are taking teratogenic medications prescribed for other conditions (e.g. methotrexate for lupus, rheumatoid arthritis, or cancer; accutane for acne). Here, they do not treat the medical condition, but are used to prevent conception while the woman is taking something that would lead to birth defects or spontaneous abortion. (The irony of using something with post-fertilization effects to prevent spontaneous abortion should be obvious.)

Now let's answer the questions.

• Are contraceptives the only option for gynecological abnormalities?
• What about contraceptives for medically-indicated teratogens?

We're not in 1968 any more, and there's something better than hormonal contraceptives. As a reminder, hormonal contraceptives replace a woman's own cycle with pregnant-like levels of modified steroid hormones. In doing so (even for good purposes!) they adversely affect fertility and can lead to early pregnancy loss.

But that's not the only option. Gynecologists who want to can target specific times in a woman's cycle, if she's aware of the signs and symptoms of her own fertility. With those times identified, the physician can identify (by blood test) hormonal deficiencies, then supplement (by oral, vaginal, or intramuscular injection) individual cycles on time. Because this approach respects the timing of the woman's cycle, it does not affect her fertility. (In fact, especially in the case of PCOS, it may give it back.) The goal for women who are treated like this is slow weaning off of hormonal support, so that they can cycle normally on their own. 

What about women taking contraceptives because they are also taking a medication that can cause severe birth defects? Women who need isotretinoin for disfiguring acne (which pulls some out of depression and bad social situations) or who need methotrexate for disabling autoimmune conditions like rheumatoid arthritis and lupus are often told they must be on two forms of birth control. 300,000 women used isotretinoin in 2000, almost all of whom were of reproductive age (more recent data are not available). I couldn't find good statistics on methotrexate use, but I hazard a guess that approximately 2 million women of reproductive age used it last year for cancer and autoimmune conditions.

Accutane leads to a syndrome of malformations of the face, heart, and nervous system; methotrexate, to one of craniofacial and extremity malformations (both are also abortifacient, causing miscarriages). In cases of pregnancy during either therapy, physicians are taught to offer elective abortion (termination) to their patients.

This standard of care is noticeably contradictory in its approach to the value of an embryo. Embryos are valuable and do not deserve to be exposed to harmful chemicals, so do not become pregnant. Embryos are not valuable, so use a contraceptive which can cause their early demise. Embryos are valuable, so March of Dimes is indignant that miscarriages occur with accutane. Embryos are not valuable, so abortion is an option. 

That can of worms discussion is beyond the scope of this post; it's enough to say that fertility awareness based methods of avoiding pregnancy are 93-99.5% effective when used correctly, and don't carry all the ethical baggage of hormonal contraceptives. Not only that, but they offer hope of cure, without replacing a woman's own cycle, without post-fertilization effects, and (for the Catholics) without separating spousal love and fertility. 

So the answer? I can't be sure; if naprotechnology was the standard of care, maybe zero.

Reflection on the years of medical school

People say that M1 is the worst year, and it keeps getting better. I think that's simplistic.

M1 was the easiest year. M2 was the most fun. M3 was the most enlightening. M4 has been the most important.

Src: Horse Report

M1 was easy. I knew how to study effectively (thanks, TAC), I didn't party much, and I took out enough loan money to live a simple and comfortable life. I'd already seen all of this material in high school or summer college classes, so I really relaxed that year--lots of time for prayer and (as you can see from the blog history) cooking, blogging, and biking.

M2 was fun. I knew my way around the medical school, I was an even more efficient student, and the material was finally all new and medical. It wasn't much more of a courseload than M1, and I got to present a poster at a CMA conference.

This dressage horse's lip has been cut 
by her bit. Src: Writing of Riding

M3 was...enlightening. It started better than M1 and M2 (since I started on psychiatry, family med, and peds), and it was a real rush to see patients and be in clinical settings. But things changed as I rotated through OB/GYN, medicine, and surgery (the three rotations with residents and hard schedules). I began to learn how workplace drama, gossip, and unresolved personality issues can spoil happiness in a residency. I learned more about my traits and vices that tear down a peaceful life: perfectionism, vanity (about how I appear to others intellectually and morally), lying (about what I know) and envy. All of these survived M1 and M2 because I had enough time and privacy; now they were exposed and wreaking havoc. These all lead to anxiety, which kills love. On top of clerkship angst, I was also very concerned with the approaching future and what God desired for my career. I got a wake-up call about how much stress I was under when I was diagnosed with UC. At the end of M3, I felt broken.

Src: Dressage Academy

But M4 has been the most important. During M4 I've solidified and processed the lessons of M3. During a hurricane, there is no time to think about flood damange and conservation of angular momentum; afterwards, you can clean up the wreakage and improve your meteorology. Glutted with the worry of M3, I finally realized how disgusting it was. I now refuse to live that way. Therefore, M4 has been pride/perfectionism rehab, and the planning phase to prevent residency from becoming another M3.

I've also learned as an M4 what my particular calling is within medicine. This came in large part from the formative process of interviewing, which was a batting box for my refusal to prescribe/abort/sterilize, as well as a time for me to see what really fit. I've also started to do some of the things I really love: research, teach, and study NFP and women's health.

What will residency be like? I know I'll be working around 80 hours a week. I know I'll move services (go from gynecology to obstetrics to oncology to nights...) every month. In those two ways, it will be like M3. But I categorically refuse to rise to the level of anxiety I allowed during M3. I'd prefer to be the lowest resident in the class than to do that again. Since my faculty know me and have four years (instead of six weeks) to assess me, I hope that I can relax and be unafraid of mistakes and ignorance. I hope I can make enough time for prayer and recreation, friends and family, and take care of my health. To my surprise, medical school has prepared me in more than one way to be a doctor: I'm intellectually ready, and I've been morally broken and built up to learn how to live a demanding life with joy.

(Sorry to the horse people for mixing dressage and jumping in my metaphor.)

Eight weeks of Freedom!

I am currently on my last of eight weeks of no clinical duties. Free as a bird! What did I do with my time off? Well, I'm an unusual bird....

This was supposed to coincide with interview seasons so that I wouldn't be interviewing while working at the hospital, but I actually only had two interviews at the beginning of this "Christmas break," so I've basically had the time off.

Half of this eight-week break was actually a stay-at-home elective with teaching duties for the second-years preparing for their STEP 1. The other four weeks were pure vacation. Interestingly (ahem), I have done almost none of the teaching duties (I guess I'll do that during those apparently free afternoons during anesthesiology and radiology). Instead, I've been doing other things I'm really interested in:

• Taking courses in four main methods of NFP: Coupe to Couple League, Marquette, Creighton, and Billings
  
• Giving presentations to medical students about NFP (one on Marquette, one on Creighton, and one on all the methods)
  
• Starting a research project! (Late in my med school career but early in my reseraching career.)
  
• Finishing up a required "Quality Improvement" study...basically a shell project for a required fluff course
  
• Continuing to work on the two inventions I'm helping with. Gah, these things move so slowly!
  
• Preparing a talk with FACTS to give to OB/GYNs and to eventually (hopefully) integrate in OB/GYN clerkships and residencies. I'm going to help give this presentation at the AAPLOG conference in February.
  
• Working with a medical illustrator to create the BEST fertility cycle chart EVER
  
• Playtesting a gamebook I wrote and vacillating about publishing it (email me if you want to help playtest, which means reading it and discovering all the mistakes I made)
  
• Planning for residency. I used to think I could float through life without much planning, but third year showed me that you can't float through 70+ hour work weeks without meal planning and aggressive prayer planning. Therefore I am planning a year of meals and a year of Scripture meditations. So much fun/work/screen-staring....