Hello, SOGC

Hello.  It’s Me.  I am ranting once again about HPV

Well, not about HPV, just the vaccines.  Actually, not just the vaccines: pretty much everything I heard at a day-long SOGC workshop with the long-winded title, “Women and their Reproductive Health Across the Continuum: Setting Priorities for Women’s Reproductive Health Research”.  Attending were both health professionals and interested individuals.  And me: women’s health advocate and HPV vaccine skeptic.

Regarding the latter, I waited till the very end of the day to finally screw up my courage.

“I am about to state a very unfavorable opinion.  There are reputable health professionals who are opposed to mass HPV vaccination; in part, because some of the research has been tainted by conflict of interest; and also because of the way public messaging has stigmatized parents who have decided not to vaccinate their children.”

I added that equating infection prevention and cancer prevention is what has made public health and Big Pharma messaging so compelling to the general public.

There was absolutely no response.

The Sunnybrook Hospital meeting space was set up like a dinner party, with long lines of tables, labelled with discussion topics for the afternoon.  Speakers’ topics were preceded by the title, “State of the Evidence”: Human Papillomavirus, Fertility, Contraception, Menopause and The Environment.  Three out of five talks set my teeth on edge.

First up, Dr. Nancy Durand.

After giving some basics about HPV types and statistics (10 – 30% of adults are infected at any given time – good one) and the risks for persistence (being over age 30, smoking, having multiple sub-types and immunosuppression) she launched into straight into HPV vaccines as public health strategy.

Dr. Durand assumed, correctly, that she had the room in terms of the evidence she presented on the three available HPV vaccines regarding efficacy and safety.  She said that doctors should treat these vaccines like flu shots and encouraged doctors to say, “Have you had your HPV shot yet?”  She suggested it could be administered to babies with their childhood vaccines.  She quoted research that indicated there should be no upper limit in vaccinating; and that even if one had already been infected, vaccination was still effective (first time I’d heard that).  And yet…

Hello from the other side

My electronic files are full of evidence of conflict of interest (COI) between researchers and pharmaceutical companies and the attempts to expose them.

Moreover, the accepted medical evidence also insists that the only adverse side effects are irritation at the site of injection and increased fainting.

Japan has changed direction on HPV vaccination.  France, Spain  and Denmark have also reconsidered their position.

Fertility

Dr. Heather Shapiro did not mention potential environmental causes of infertility.  When I asked her about this, she said that was a whole other talk.  She leapt into Assisted Reproductive Technologies starting at IVF without passing through less invasive techniques like IUI.  I did find out that 90% of IVF babies are healthy; and the rates of success decline with age; and that there are now fewer multiple births.  Her talk was less about fertility and infertility that assisted reproductive technologies.  One presumes the research is directed towards treatment rather than prevention.  No mention of Pelvic Inflammatory Disease.

Contraception

I was glad to hear Dr. Dustin Costescu discuss unintended births in the context of the social determinants of health.  He said they occurred more often in younger, racialized, poor and Indigenous women; and that the greatest risk was due to systemic factors.  Among the contributors to non-use were being a sexual or gender minority, funding, and failure to initiate contraception.  He also blamed health care providers who sometimes recommended a “washout”; i.e., stopping a method to see if side effects subsided without offering a replacement method.

He pointed out changing trends.  With women having their first child around age 30, they require about 11 years of contraceptive use.

I was glad to hear him say that researchers needed to understand women’s experience through qualitative research regarding access, counselling, decision making and understanding side effects.  In our discussion session in the afternoon, he acknowledged that front-line workers have a lot to contribute to research.  Here are some of my contributions in WordPress:

 

Menopause

Any of the women attending who had not already gone through menopause and were listening to Dr. Jennifer Blake were probably bug-eyed looking at the list of what sounded like inevitable symptoms.  Early on in her talk, she said that perimenopause, the 2 – 3 years preceding the cessation of menses, was the “best time to get help”.  Now if that isn’t a clear medicalization of menopause, I don’t know what is.

Dr. Blake was quite definitive.  The “pleats” that make women’s vaginas stretch more easily smooth out.  You’re going to shrink, was the message.  Not to mention the loss of bone mineral density, the release of lead stored in the bones, changes in blood vessels, changes in abdominal fat metabolism, decreased carbohydrate tolerance, loss of lean muscle mass, vasomotor symptoms (hot flashes that could last up to 20 years), mood changes, reduced stress tolerance and memory changes (or as comedian Sandra Shamas tells us, loss of nouns.

And, oh, yes, loss of libido.  I’ve had a few thoughts on that one as well.

Dr. Blake gave a nod to the importance of exercise and good nutrition before moving ahead with hormone therapy (HT), “the single most effective treatment”.  She spent a good deal of time discussing the history of research on the effects of estrogen, in particular, how the Nurses’ Health Study was written and interpreted.  One telling statement at the end of her remarks on HT: “there is a higher risk of breast cancer with later pregnancy than with hormone therapy”.  In other words, you don’t need to worry about using HT.

Not all women experience menopause the same way – and that also applies to women around the world, their diets and lifestyles.  Women who suffer greatly from menopausal symptoms who consider HT are well advised to limit the duration of its use.

Environment

I’ve saved the best for the last. Dr. Eric Crighton laid it all out.  There are currently 80,000 registered chemicals currently in use.  7,000 new industrial chemicals are introduced annually.  Pregnant women have 43 different chemicals in their bodies.

He pointed out that some people are at higher risk than others, most notably those Indigenous people who are living with contaminated water and mercury poisoning.  Of course, we are all exposed to environmental toxins.  According to Health Canada’s 2010 statistics, they caused 13% of disease burden, an increased risk of prenatal and early childhood effects.  He talked about pesticide exposure and its effects on the brain development of four year olds…in short, he scared the *&*^% out of his audience.  I was sadly familiar with some of these issues, in particular through the Canadian Women’s Health Network.

There is good work being done by CPCHE which has published a number of useful brochures, but he pointed out that individual actions are not enough.  Moreover, he said when someone is struggling, for example, to feed their family, environmental toxins are low down on their list.  If you can barely afford formula, the plastic in the bottle becomes a non-issue.

I spoke with him afterwards, thanking him for mentioning the struggle of nail salon workers to limit their exposure to workplace toxins.  He was aware of the work of the Toronto Healthy Nail Salon Network.

Hello from the outside.  At least I can say that I’ve tried

I’m not sorry I went.  I did learn a few things and have checked out a dozen links to the studies quoted.  But there was little opportunity to challenge the experts or change the tone of the discourse.  It does make me wonder why the SOGC invited us in the first place.

Birth control – what you need to know

My friend’s Huff Post blog on cervical mucus has garnered 26,000 likes and 3,049 shares. Women have written from all over the world to thank her for this information.  Despite our best efforts as sex educators, although we have been teaching specifics about female fertility for decades, it still seems to remains a mystery – not only to those who want to plan a pregnancy – but also to those who are trying to use their knowledge of fertility as a method of contraception.  With the operative word being “trying”.

Yet, clearly Canadians are using some form of birth control, because the age of first pregnancy is continually rising.  According to a report by Statistics Canada “the switch happened in 2010 and widened in 2011, when there were 52.3 babies born per 1,000 women ages 35 to 39 and 45.7 per 1,000 women ages 20 to 24… birth rates for women in their early 40s now are nearly as high as for teens.”

Young adults are trying to figure out how to succeed at work and somehow “work in” a family to their lives.  The most popular methods used by young people today are male condoms, oral contraceptives and withdrawal.

But what is the best method?

There is no “one size fits all”; but there are some serious considerations – especially for women – before making a choice.

  • age
  • number of partners
  • current health and medical history
  • how effective the method needs to be

The last point may seem odd, but a woman needs to ask herself how she would feel about being pregnant if her birth control method didn’t work.  Some women would accept the pregnancy; others would not.  She needs to examine her feelings about abortion as well as its availability.

What works?

Methods that are 98% –99%+ effective:

  • sterilization
  • intra uterine system (Mirena IUS)
  • combined oral contraceptives (the Pill), the Patch or the vaginal ring
  • Depo Provera (depot medroxyprogesterone acetate)
  • IUD (copper intrauterine device)

Effectiveness is measured in two ways: perfect use and typical use.  For example,

“male condoms are an effective method.  However, a man must use a condom correctly from start to finish.  With perfect use, 2 women out of 100 would get pregnant (98%); but with typical use, 15 would get pregnant (85%)”. 

Withdrawal, the third most common method used by young people must also be used carefully.  An inexperienced man may find that its effectiveness drops as his desire to stay inside increases.

What my friend has written about fertile mucus comes in very handy when using withdrawal or condoms.  If a man does not pull out in time and his partner is at the most fertile time in her cycle, she needs to consider using emergency contraception.  The same advice holds true for a condom that breaks.

What influences the method you choose?

“Ask a woman if she is using birth control and she will likely tell you whether or not she is taking “the pill.” For most women, they are synonymous. Often, she’ll ask her doctor to ‘put’ her on the birth control pill, which conjures the image of a five-minute consultation, prescription pad at the ready. Do the words “informed consent” have any real meaning when it comes to birth control?”

Sadly, pharmaceutical companies skip through the loophole in Canadian laws prohibiting direct to consumer advertising in order to sell hormonal contraceptives, especially the pill.  But safety is an issue.  There is a difference between side effects and risks.  As I point out, some hormonal methods and formulations are riskier than others.

This leaves some people wondering about alternatives.

Unfortunately, there isn’t much that’s new on the contraceptive scene.  A few methods are in clinical trials, but nothing that really changes the birth control landscape.

As for men, how about a remote controlled implant or a “vasectomy switch”, the Bimek SLV?  Unfortunately, there doesn’t seem to be anything on the scene that seems workable.

But perhaps youngish women should not practise contraception too long if they want to have a baby “some day” given the decline in fertility after 35.  As a young friend said to me recently, “Just assume that all my friends who are rapidly approaching 40 are trying.”

 

 

Reducing pregnancies for teens and poor women = reduction in poverty: reductio ad absurdum?

This New York Times article http://www.nytimes.com/2015/07/06/science/colorados-push-against-teenage-pregnancies-is-a-startling-success.html?partner=rss&emc=rss&_r=2  asks the following question: “If teenagers and poor women were offered free intrauterine devices and implants that prevent pregnancy for years… would those women choose them?” The answer?  A “resounding yes”, which they deem a “startling success”.

Pregnancies to teenagers and “unmarried women who had not finished high school” plunged, especially in the poorest areas of the state, allowing them time, according to the article, to “gain a foothold in an increasingly competitive job market”.  It was seen as a poverty reduction strategy.

I wish I had been a fly on the wall during the counselling sessions that led these young and poor Colorado women to choose long-acting contraceptives.  Were they fully briefed on the side effects and potential risks?  Did they discuss Sexually Transmitted Infection (STI) prevention?  What was the overall vision of poverty reduction in Colorado?

During my sexual health clinic days, there were women who chose – and continued to use – Depo Provera, a contraceptive injection that lasts for three months.  They did so after I had fully informed them of potential side effects and risks of the progesterone-only method.  Some adolescents who came to the clinic were good candidates for the copper IUD and it worked very well for them.  After a clinic counselling session, when young teens or disadvantaged women opted for a method of birth control that worked for them; or they chose to end a pregnancy realizing that their circumstances would not allow them to raise a child at that time, they were making informed choices.  I recognized then as I do now, that reproductive control and poverty, while linked, are not the only elements in the equation.  After reading the article, I wondered about other measures proposed to reduce poverty in Colorado; and what will happen when the private grant to fund this experiment runs out.

Teenage pregnancy and pregnancy for low income women are complex issues.  Factors that result in unplanned pregnancies to teenagers include lower economic status, sexism, racism, prior sexual abuse and ongoing abusive relationships.  The absence of the social determinants of health can result in risk-taking behaviours, like smoking and unprotected sexual activity.  With regard to sexual abuse, for example, without the benefit of comprehensive counselling, young women run the risk of future sexual assault and abusive, controlling partners.  Some exploitative male partners will refuse to “allow” them to use contraception; or they may refuse to use condoms.  When one has little control in one’s life, reproductive control is not even on the table.

For younger and poor women, while it may not be prudent financially, emotionally or even physically to continue a pregnancy, if poverty itself were eradicated, part of the burden to the state would be eliminated, while still allowing funding to provide parenting support.

I imagine some ideological detractors of the Colorado experiment might accuse them of eugenics, deliberately limiting births to racialized and poor women.  I do not subscribe to this point of view.  However, one must acknowledge the history of eugenics practices in North America and abroad that will inevitably make some people skeptical of the motivation behind this poverty reduction experiment.

And yet, research is conflicting on the relationship between teen pregnancy and poverty.  According to Statistics Canada, “women from disadvantaged backgrounds are more likely to end up disadvantaged even if they delay childbearing. And while teenage childbearing continues to be a significant indicator of lower socioeconomic outcomes, the effect is smaller than originally believed” (http://www.statcan.gc.ca/pub/75-001-x/2008105/article/10577-eng.htm).

While I agree that delaying pregnancy is a tool towards poverty reduction, let’s be frank: only the redistribution of wealth will eradicate poverty.

The second issue in terms of the counselling process is STI prevention and treatment.  Like women who use oral contraceptives, women who use IUDs, injections (and implants in the US) may not see the need for condom use.  I would like to know if they discussed and offered testing and treatment for STIs like chlamydia, the rate of which is especially high in older adolescents and young women.  Because there are no symptoms of chlamydia in the majority of cases, without testing, women may contract Pelvic Inflammatory Disease which, if undetected over time, may lead to infertility – not a recommended form of birth control.

A Public Health map of Toronto that plots adolescent pregnancies follows the same geographical trajectory as STIs in the city, which, in turn, follows the curve representing its poorest neighbourhoods.

And who is at higher risk for poverty in Toronto?  Recent immigrants, Aboriginal people, those who are disabled, elderly and alone, racialized or children (http://www1.toronto.ca/City%20Of%20Toronto/Social%20Development,%20Finance%20&%20Administration/Strategies/Poverty%20Reduction%20Strategy/PDF/povertyinTO.pdf).

Poverty reduction, like unplanned pregnancy to young and poor women, is also complex.  There are no magic wands, but there are proven tools.  If we take the lead from developed countries where there is more economic equity, we see that a higher minimum wage and/or guaranteed income, a fair tax system where the wealthy and corporations paid their fair share and increased services, results in a profound reduction in poverty.

In the meantime, contraception and birth control, including post-coital options and abortion, should be freely available to all as a public health service.

Additional reading

The hidden epidemic: A Report on child and Family poverty in Toronto, November 2014

http://www.torontocas.ca/app/Uploads/documents/cast-report2014-final-web71.pdf

Poverty causes Teen Parenting, Not the other way around

http://rhrealitycheck.org/article/2013/04/29/poverty-causes-teen-parenting-not-the-other-way-around

Good Practices in Anti-poverty Family-focused Policies and Programmes in Developed Countries

http://www.un.org/esa/socdev/family/docs/egm12/PAPER-RICHARDSON.pdf

Birth control – whose choice? June 3, 2013 –

Ask a woman if she is using birth control and she will likely tell you whether or not she is taking “the pill.” For most women, they are synonymous. Often, she’ll ask her doctor to “put” her on the birth control pill, which conjures the image of a five-minute consultation, prescription pad at the ready. Do the words “informed consent” have any real meaning when it comes to birth control?

Women who need birth control are likely to change methods several times during their reproductive years depending on their age, health status, income, partner(s) and number of children. Knowing those circumstances is key to assisting a woman in finding the method that suits her at that particular time in her life. While health-care providers may have prejudices and biases regarding certain methods, the operative word should always be “choice”: hers.

Oral contraceptives (the pill) are clearly the method of choice for most health practitioners because of the effectiveness when used as prescribed. The copper IUD (intrauterine device) is nearly as effective; but it is only recently that health-care providers changed their prescribing practices due to its updated safety record, resulting in increased use, including for women who have never been pregnant. The cheaper, non hormonal IUD is often overlooked by health-care providers in favour of the Mirena Intra Uterine System (IUS), an IUD that releases a progestin. It was originally designed to help women with very heavy bleeding, but it soon became commonly prescribed, possibly due to aggressive marketing. A woman on social assistance in some provinces, like Ontario, is more likely to use Mirena than the copper IUD, even if she prefers a non-hormonal method, because she has to pay for the copper IUD whereas Mirena is covered by the government. This is illogical and wasteful, as the Mirena actually costs about four times more than the IUD (when obtained in publicly funded clinics); it is usually more expensive when inserted by a family doctor.

A woman who wants to use a combined hormonal method, but does not want to take a daily pill may opt for the patch or vaginal ring. The patch has a higher dose of hormones; the vaginal ring uses a “third generation” progestin (see below). Her remaining hormonal option is Depo Provera, a method that should include comprehensive counselling about potential side effects.

Otherwise, she can use condoms (male or female), withdrawal, Natural Family Planning or a combination. She is unlikely to find a clinic that still carries the diaphragm or the gel that accompanies it.

Teaching a woman the basics of her menstrual cycle—in particular, recognizing fertile mucus with a view to charting her fertile days—is a fundamental strategy in educating women about their bodies. There’s even an app for that. If she wants to use this knowledge to prevent pregnancy, she can use the Standard Days Method.

Understanding fertility can also increase the effectiveness of a method like withdrawal, which has a “perfect use” effectiveness rate of 96 per cent. Granted, with typical use, it drops to 73 per cent. If there’s a slip-up, she can take emergency contraceptive pills (or use a post-coital IUD). Although Plan B does not have a consistently high effectiveness rate, its availability over the counter has increased access.

With regard to hormonal methods, there are safety issues which may not be raised by health-care providers.

Women who were already taking pills often wanted to buy them more cheaply from the sexual health clinic where I worked. Some had been prescribed Diane-35 by their doctor. This medication, which is  only approved for short-term use to treat serious acne and hirsutism, also has contraceptive properties. Pharmaceutical companies highlighted the latter application to doctors. So, although it has never been approved as a contraceptive, it is prescribed “off-label” as birth control. When women asked me about Diane-35, I directed them to the Health Canada website and warning because women using Diane-35 as birth control are likely not aware that its use as a contraceptive is off-label. Diane-35 is no longer prescribed in France because of four thrombosis related deaths, and Health Canada recently reminded prescribers ”that Diane-35 should not be used as an oral contraceptive.”

Third and fourth generation birth control pills contain progestins that are associated with a higher risk of blood clots. The brand name drugs Yasmin and Yaz are currently named in lawsuits because of safety issues with the progestin, drospirenone. The vaginal ring uses a third generation progestin, desogesterel. Is there any discussion of that fact before a woman receives her prescription? Mea culpa: I never mentioned it.

Continuous oral contraceptives were first marketed to women by asking them if they wanted to have fewer periods, presumably with the intention of “liberating” them from this bodily function. Many women did switch to continuous oral contraceptives; however, I am unaware of any research into potential long-term consequences (for example to their breast health) of an increase in estrogen over the long term.

Health-care providers are charged with giving patients clear and up-to-date information so that they can make informed choices. Patients must demand nothing less.

The case against hormonal contraception – January 22, 2014

I’m no big fan of hormonal contraception. That said, it has its place in the limited birth control options available to women. As I have written here before, the principle—as always—is informed choice and individual circumstance. “Informed” is the operative word and the provenance of the information is critical. Nevertheless, with the recent demonization of hormonal methods, I feel like weighing in once again and trying to seek some kind of balance.


For a related article, see also the Network book review of Sweetening the Pill

A friend posted an article on Facebook from The New American about Depo Provera and how the Gates Foundation was “killing African women.” I started to read the article on which the post was based and got as far as the statement that Depo causes STIs and cervical cancer.

The Rebecca Project For Human Rights’ Kwame Fosu quoted the reverend Dr. Randy Short,: “The used [sic] of Depo Provera contributes to and in several cases causes life threatening diseases and medical problems: cervical cancer, breast cancer, diabetes, osteoporosis, stroke, heart attack, sterility, miscarriages, HIV/AIDS, Chlamydia, and other STIs/STDs.”

In 1986, women’s health advocates (including me and Anne Rochon Ford representing the Toronto Women’s Health Network) made deputations to the Regional Meetings on Fertility Control. We were opposing the approval of Depo as a method of birth control primarily because not all the facts were in about its potential connection to breast cancer. At that time, we also argued that it had been used off-label to the detriment of women who did not give their informed consent—women with disabilities, poor and Indigenous women.

At that time, I was already working for a public health unit, a job that included counselling people in a sexual health clinic. When Depo was approved, although we did not consider it to be a “first-line” method, we counselled and prescribed its use. Counselling included giving women the facts as we knew them.

Aside from anecdotal information, there is no scientific evidence for most of the claims made by Reverend Short about Depo. Yes, it can cause what are considered to be reversible effects on bone mineral density; and, of course, if condoms are not used, people are likely to get STIs including HPV from infected partners. But Depo is not linked to the rest of Randy Short’s list. At the clinic, there were women who used it and liked it; there were women who used it and quit. Some women who quitcontinued to experience side-effects for many months after their last injection. All had been forewarned about the side-effects and risks, including Depo’s potential long-lasting effects.

We taught women at clinic who were about to start a combined contraceptive method about its potential side-effects and risks, including a lesson in the warning signs for a blood clot or stroke.

In the past few years, oral contraceptives have taken a public beating. Cavalier prescription of third and fourth generation hormones (e.g., Orthocept, Yasmin), which carry a higher risk to women than earlier formulations, have resulted in lawsuits, disability and death. Diane-35’s off-label use is simply a travesty. It would appear from a recent CBC program (The Current Oct. 28, 2013) that bad press as well as dissatisfaction have resulted in the increased use of withdrawal and fertility awareness as alternative methods.

In the program, the participants Ann Friedman, Holly Grigg-Spall and Kate Carraway, argued that women who were generally users of “natural products” were concerned about the side-effects and risks of hormonal contraception. For that reason, they were avoiding synthetic hormones in favour of withdrawal and/or the fertility awareness methods of birth control. They suggested that the women using withdrawal were in committed relationships and might accept an unplanned pregnancy.

It turns out that it was the younger women (25 to 26) interviewed by Friedman who were more concerned about pregnancy; older couples who were on the fence about having kids felt it would not be the end of the world if there were a pregnancy.

This is the crux of the problem. Ideally, we plan according to our personal lives and current needs. However, in real life, around 40% of pregnancies are unplanned.

The program raised the issue of STIs—and rightly so. They said women using withdrawal were making the choice to have unprotected sex with partners they trusted. They added that young people’s attitudes to STIs had changed and that condoms were seen as less important than they once were  during the worst of the AIDS epidemic. But younger women (15 to 24) are statistically at higher risk for STIs like Chlamydia which, if untreated, could lead (ironically) to infertility.

The point was made that, not surprisingly, withdrawal as a birth control method continues to have some stigma attached to it. It is very effective with perfect use (96%). But the current “pull-out generation” is indeed taking a risk if they are unaware of the factors that increase the effectiveness of the method including the ability to track their own fertility. Grigg-Spall, who favours Fertility Awareness Methods (FAM), has done women a favour by shining a light on this information. She sees FAM as the feminist way of dealing with birth control.

I acknowledge that withdrawal and FAM are both underrated methods. What irks me is what comes across as cheerleading for some methods, and the vilification of others.

Hormonal contraception is far from benign. There is ongoing research into its effects on the endocrine system, its risks and even its effectiveness. For example, there is ongoing controversy over the pill’s effectiveness for women who are obese. Shockingly, BMI was recently indicated as a significant factor in the reduction of the effectiveness of emergency contraceptive pills (ECP). [See also CWHN FAQ on ECP]. And there is, of course, the horrendous loss of life for women who are not well monitored on the pill (the Patch or NuvaRing); or whose symptoms are incorrectly diagnosed when they suffer a circulatory event like a clot or a stroke.

An individual or couple should have the all of the tools at their disposal to make a deliberate, informed decision when it comes to preventing pregnancy. Health advocates with their eyes wide open are understandably cynical about who sponsors the research and how the results are then transmitted to the public. Birth control is, after all, big business. So let’s make it our business to be as informed as we possibly can.