Quick Takes

We're still in pandemic times, so here are some quick but fiery opinions.

#1

Whatever you think of external fetal monitoring, the fetal heart rate strips remind me a little of Adoration. The fetuses have be watched constantly, and the culture of OB/GYN labor and delivery teams is to want someone to watch them. If we're going down to get snacks, we think about who is watching while some of us go. If we get distracted by something, we look up and make sure what we just missed looked okay. If the system breaks down and we can't see the strips the way we usually do, we find a way around this to watch the strips. In Adoration, you can't leave the Blessed Sacrament alone. He is vulnerable. You may not be able to see him as usual sometimes, or you may have to leave, but you're solicitous about Him never being alone. When you get distracted from Him, you check right back in.

#2

I recently heard an argument that it is more merciful to do a KCl termination followed by an induction of a dead fetus, rather than to deliver a live fetus and have it painfully gasping for air. "I couldn't bear watching my baby gasp for air," the argument goes. While I empathize with that emotional response, a KCL termination is different in the objective nature of the act--it directly takes the life of the unborn, and we don't know if it's painful or not. A gentle induction which doesn't take that life directly can be followed by perinatal palliative care. Just like for an actively dying adult patient, morphine can be given for air hunger. Even so, it is not clear if extremely preterm babies feel this, but they can feel pain and much of their skin is not keratinized. (The air hunger question is particularly important because that's the emotional hinge of the argument, but fetuses under OB/GYNs' management are constantly experiencing difficulties with acid-base balance and we don't consider this painful.)

#3

Dear Editor,
NaPro technology is a little bit primitive and behind the evidence-based-medicine times. And it sort of likes that. But it's not really ready for prime time in medicine right now, so let's stop pretending that it is. Instead, why don't we work on getting it there?
Sincerely, a Catholic OB/GYN

#4

I took care of a lesbian patient who was overjoyed to tell me about her coming out. I told her I was glad for every step she took closer to real love. This story happened before the blog issues related to LGBT posts. I'm still angry about this misjudgment of me sometimes. (But forgiveness sometimes doesn't take away all the emotions connected to an experience. So I suppose that's okay.)

Discontent with Arguments against Birth Control

Get ready for some ideas that have been stewing in me for some time, but are coming out now as a rather unedited blog post because we're in the middle of a pandemic. As a board eligible obstetrician and gynecologist, I don't like some of the arguments and language used to explain why contraception is wrong. Comments are open, content is subject to the Church's teaching.

"Birth control is a crutch."

I don’t like the arguments made by certain bioethicists that hormonal birth control is a "crutch," and therefore it’s wrong. This is certainly not the only argument they have against birth control. But let’s think about crutches: they’re actually a really useful medical treatment to take a load off of a healing joint. If this is an apt analogy, then birth control is a really useful medical treatment for...something? What do these bioethicists claim we are bridging towards with birth control? I think their position is actually that birth control is intrinsically problematic and it is being used lazily and problematically. But “crutch” is absolutely the wrong word for that. When making analogies about medical things to medical people, at least make your analogies accurate.

The real scenario is actually more like the analogy and less like the intended meaning. In its best form, birth control is a bridge to something better according to gradualism.

"Birth control is bandaid therapy."

Furthermore, I also don’t like the word “bandaid” in these analogies. Birth control as “bandaid” therapy is an oft-used phrase in Catholic gynecology. Rather than solve the PCOS or dysmenorrhea or whatever (so goes the argument), physicians prescribe birth control to “cover it up.” Can we talk about how this is not a good summary of what birth control is doing here? The best example is PCOS. Certainly, we are not solving PCOS at its root cause, but that is because we don’t know its root cause. And NaPro, regardless of how much more natural it is, also doesn’t address the root cause. A sign of this is that medical NaPro has to keep treating and treating and treating its patients with cooperative E and P. (Ovarian wedge resection is the closest thing we have to addressing the root cause, which is part of surgical NaPro.)

But OCPs being used for PCOS do more than just "cover up the problem." They don’t simply hijack, replace, or cover up a woman’s natural cycle. They interrupt the failed cycling that a PCOS patient has, which is much closer to stopping the problem at its source than the "bandaid" argument makes it sound. PCOS is possibly best conceptualized as a failure to move through the menstrual cycle, instead getting stuck somewhere close to the LH surge, which produces the effects of hyperestrogenism and hyperandrogenism due to aromatase (including abnormal hair growth, endometrial hyperplasia, glucose intolerance, and abnormal blood lipid concentrations).

Birth control (unlike cooperative E and P) puts a stop to this arrested cycle at its origin, the hypothalamus, by suppressing secretion of GnRH. It upregulates sex hormone binding globulin (SHBG) which sops up extra estrogen in the blood and eases the effects of hyperestrogenism and hyperandrogenism. It hits a reset button on the CPU of a woman’s cycle: not natural, but sometimes needed for normal operations. It’s not a bandaid, it’s actually a pretty sophisticated cocktail of shelf-stable hormones that work by a clever mechanism of action to stop dangerous effects that PCOS can have on a woman's body.

I will happily admit that birth control as a "bandaid" is a much more apt analogies for conditions like dysmenorrhea, where it may actually mask conditions like endometriosis. But even here, there is a legitimate role for nonspecific medical therapy before surgical treatment in many common conditions, such as anemia of unknown cause or back pain. Why should we belabor gynecologists for wanting to do something that will most likely be helpful, as long as it's not illicit?

"The pill kills."

We really need to stop saying “the pill kills” as an argument against contraception. This holds no intellectual weight with any kind of opposition. All medications have side effects, and many medications have caused death. Many very important medications cause more death than the pill. The doses of estrogen are lower than the doses in the original pills which could be classified as carcinogens.

True, women don’t need these medications the same way they need warfarin or vancomycin or even Tylenol. And true that even small doses of estrogen can, over long periods, affect multiple body systems and we continue to see effects of hormone therapy in women of all ages. But “the pill kills” as a soundbyte-turned-argument is not serving us well. Admit that the pill is actually a pretty clever and pretty safe medication, and then debate whether its small panel of side effects should be taken on for fertility (a good)—you then have a more robust argument without so many holes, and an argument that better resembles the true problem with hormonal birth control.