Abortion Gang

Lots of great new contraceptive options are coming your way soon if you’re in the United States.  You may have already heard about Skyla, but do you know about Twirla and Cyclofem?  Read on and learn.

Skyla

Skyla (or the levonorgestrel 14 mcg IUD, or LNG-14) recently was approved by the FDA and has received a fair amount of attention.  It is now available from some providers and may be an excellent choice for some women.  The LNG-14 has three claims to fame: its smaller size (and, as a result, smaller inserter), its lower dose of progesterone, and its official approval for use by women who have never been pregnant.

First off, the smaller size: in the grand scheme of things, we’re talking about only a very tiny difference (the IUD itself is 1.1 by 1.2 inches, compared with Mirena’s 1.3 by 1.3 inches, while the inserter is 0.04 inches smaller than Mirena’s; see this great article for more details).  However, that very small difference may in fact make insertion of the device less painful for some women, particularly women who have never been pregnant and may be more likely to have a tighter cervix.  Since the data have yet to be published, I can’t tell you for sure if insertion is indeed less uncomfortable than insertion of other IUDs; however, preliminary presentations of the data (such as here) have indicated that, for women who have never been pregnant, those who underwent insertion of Skyla had less discomfort than those who were assigned to Mirena. 

Skyla releases less progesterone than the Mirena (without losing any of its contraceptive efficacy) which for some women is a good thing, but for others might not be.  One of the features of Mirena that is most appreciated by some users is that almost everyone experiences lighter periods over time, and many women no longer have periods at all.  For some women, that’s fabulous, while others would rather keep seeing their period.  Women using Skyla will mostly have lighter periods, but fewer of them will have no period (though some will, and there is no way to know ahead of time what any individual’s reaction will be).  Although Mirena exposes users to a very low systemic dose of progesterone (a dose low enough that most don’t notice it), for women who are extremely sensitive to artificial hormones it can still be too much.  If you’re in this category but there are reasons why a progesterone-releasing IUD is a good option for you (such as heavy periods), Skyla may be an excellent option.

Finally, on Skyla’s approval for women who have never been pregnant.  This is great news, but really, it’s not news; women who have never been pregnant can safely use any IUD, regardless of what is on the packaging.  We’ve known this for years, and doctors use products and medicines off-label all the time.  There’s nothing wrong with off-label use as long as there is good evidence to show that your practice is safe.  Fortunately, we have decades of data that prove that women who have never been pregnant can safely use any kind of IUD they want.  So the labeling for women who’ve never been pregnant may be generating a lot of buzz, but it’s nothing new.  However, if there are pesky insurance companies out there that won’t pay for IUDs for women who’ve never been pregnant because the label says it’s not OK, this might help push them along, so it can’t be bad.

There’s a lot to love about Skyla.  The smaller size might make it easier and more comfortable to insert for some women, and the lower hormone dose might be beneficial in some cases.  Unfortunately, Skyla only lasts for 3 years (as opposed to 5 for Mirena and 12 or more for the copper-IUD).  For some women who don’t like the idea of something lasting a long time this may a good thing, but for many having to get a new one placed after 3 years could be a drag, as it means another doctor’s visit and potentially more costs.

Twirla

Twirla (also known as AG 200-15) is a new contraceptive patch that uses a combination of progesterone and estrogen, similar to Ortho-Evra.  This method is not yet FDA approved but will likely be approved in the next year.  Twirla has a few claims to fame: its lower estrogen dose and its novel adhesive.  As for the lower estrogen dose, as only a few papers have been published on Twirla thus far, I don’t know for sure if the lower estrogen dose in this patch compared with Ortho-Evra leads to fewer side effects, but it is quite likely it does, and we know that this patch is just as effective as Ortho-Evra.  

So if you’re very sensitive to hormones and want to use a patch, Twirla may turn out to be a great option, especially if the side effects you experience on birth control are related to estrogen (such as nausea, bloating, or headaches) and you have reasons to want to continue using an estrogen-containing method, such as maintaining regular periods or to improve acne.  The novel adhesive may be good news for loyal patch fans who are annoyed by the little bits of adhesive residue that sometimes seep out next to where the patch is applied, or for women who want to use the patch but are among the minority of women for whom it just won’t stay on for the whole week.

Cyclofem

Cyclofem (also known as depot medroxyprogesterone acetate 15 mg/estradiol cypionate 5 mg) is not actually a new contraceptive; rather, it’s a method that’s been around for a while and has never really taken off, either in the US or abroad.  Cyclofem is an injectable contraceptive that was briefly marketed in the US as Lunelle about a decade ago, but has not been available recently.  It is used in some other countries around the world.  It has a lower dose of the progesterone that is used in Depo-Provera, the three-monthly injectable, and unlike Depo-provera also has estrogen.  Cyclofem’s claims to fame: the only combined hormonal injectable method available; convenience of once-monthly dosing.

Although Depo-Provera, or DMPA, is not one of the most popular methods in the U.S., it has loyal followers.  Some of the pros of DMPA are that injections are required only every three months, with a very forgiving window period allowing you to get your shot a few weeks early (in case you’re heading off for vacation) or a few weeks late (up to 15 weeks since the prior injection – considering the busy lives many of us lead, the more likely scenario), and that most women stop having periods within 6 to 12 months of starting the method.  DMPA only includes progesterone; for women who want an injectable that also has an estrogen, Cyclofem could be useful.  Women using Cyclofem generally continue to have regular periods, but the big drawback is that injections have to occur every month.  There are some situations where Cyclofem could be extremely useful; for instance, someone who wants to use a combined hormonal method but can’t swallow pills or someone who requires absolute privacy regarding her use of contraceptives.

Unlike the other new methods I’ve described, it’s hard for me to believe this method will take off in the US context outside of some specialized settings, as the majority of women who can’t take pills will probably be well-served with either a contraceptive patch or ring, and women who need to use an “invisible” method will in most cases do very well with an IUD or a contraceptive implant.  Monthly visits to the doctor for injections are just not practical for most women in a US context.  Despite my pessimism, I do hope that Cyclofem finds its niche; more choices are always better, and there will always be women who find that a given method works very well for them.

What about plans for the next five and ten years?  There are lots of great products in the works, from a much lower-cost generic version of the Mirena IUD being developed by Medicines360 (this could really be a game changer for women in many low-income countries; not only is the levonorgestrel IUD a great contraceptive method, but it also is a first-line treatment for many other gynecological conditions that are currently treated with surgery in settings where it is unavailable) to a contraceptive vaginal ring that can be used for a whole year.  A new female condom that may be easier to use and more comfortable is also in the works.

Acknowledgments: This post was inspired by a great webinar from the Association of Reproductive Health Professionals.

When the NY Times says there is a drug which may be as revolutionary for women as the introduction of the Pill back in the 60s, I read it.  I also assume there is more to the story than a Viagra rebranding to propagate the myth of the frigid woman and make some money for pharmaceuticals.  However, after conferring with my fellow Gangsters I believe this may in fact be exactly what we’re dealing with.

The frigid woman, if you are unfamiliar, is a concept that stems from our societal myth of women coming in two varieties hypersexual and non-sexual.  The photos in the article do a really good job of demonstrating this dichotomy, there is the grumpy, sad woman and the woman in ecstasy, with nothing in between. The frigid woman has no passion, is clearly in denial of her need for intercourse, and will probably die alone.   Many of the women depicted in this article seem to be embodying this myth.  They are broken because they no longer desire their partners the way they once did, and feel obligated to “fix” themselves for their partners.

Desire is a very tricky thing. To the journalist’s credit, he does write- off evolutionary psychology as nonsense, and admits that we don’t really know how physical attraction and lust change over time, because no one has studied it longitudinally.  What we do know is that women’s desire generally peaks around 30, about a decade after men’s.  We also know that desire often dissipates over shorter periods of time, but again this too is understudied.  The problem is, that’s not how the article framed it. It was framed as women’s diminishing desire specifically, what about men’s?

Men are completely missing from the conversation here.  Men too potentially have waning desire stemming from considerations outside their partner like jobs, and kids, and whatever else.  Why don’t they need a pill to fix their lust?  Viagra used by men, as it is discussed here, simply creates a physical response in the penis. It doesn’t affect desire.  The sweet, sweet irony being that what they are marketing as a new innovative drug for fostering women’s lust is essentially Viagra, with a mint coating.

So why sell drugs to women by convincing them their desire needs to be fixed?  Because women are clearly all crazy and recognize themselves to be.  Duh.  I mean, the man behind the drug cites his inspiration as being dumped in his 20s and wanting to spend the rest of his life studying the depths of the (crazy how could anyone ever dump me) female mind.  A man scorn hath no fury…or logic.

Perhaps, and heaven forbid I bring this up and try to be credible, not all people are happy being monogamous.  Maybe some people just get bored, male, female, or otherwise.  Maybe there are some people who can be really happy and monogamous for decades while there are other who cannot be for six months.  Sound like anybody you know?  The fact of the matter is the evidence to support any of these suppositions is just not there.  We don’t know.  Maybe in fact we are just like trumpeter swans and there is a reason people keep coming back to the idea of “happily ever after,” or perhaps it is a very cruel trick.  We just don’t know.  And how could we?  People barely have the space to choose their partners and create the relationships they want, with equality and trust.  But maybe there’s a pill for that?

While some people celebrate May 5th with tequila and nachos, the International Coalition of Midwives wants to remind us that midwives save lives by designating it the International Day of the Midwife. Although what they can do varies significantly by country, midwives provide comprehensive sexual and reproductive health care, including contraception, preventive care like pap smears, prenatal care, and normal deliveries, and also know when their patients require care from a physician. In North America and Western Europe, midwives are preferred over physicians by many women for their traditionally more holistic approach to pregnancy and childbirth. In low- and middle-income countries with severe health worker shortages, midwives are literally saving lives by providing maternal and newborn care, contraceptives, and safe abortion care.

When properly trained and supported, midwives can deliver babies, administer treatment for potentially deadly complications of pregnancy such as pre-eclampsia and post-partum hemorrhage, and provide newborn care. Although physicians will always be needed, much of their work can be shared with midwives. Most low- and middle-income countries need to double, triple, or quadruple their midwife workforce to fully meet their needs. Fortunately, midwives can be trained more rapidly than physicians and may be more likely to stay in rural and underserved areas than doctors. As countries develop, inequality between the rich and poor, and between urban and rural populations increases; training more midwives is a key strategy to ensure that women who are poor or live in rural areas are not left behind.

Countries that have focused on increasing the number of midwives and strengthening the quality of care they provide have seen dramatic decreases in maternal mortality. On this International Day of the Midwife, let’s not forget that reducing maternal mortality is not only about having a skilled birth attendant present at the time of birth; equally important are access to contraception for those who do not wish to be pregnant, and access to safe abortion care for those who are already pregnant and do not want to be. Midwives can insert IUDs and contraceptive implants and perform first trimester medical and surgical abortions as well as physicians and should be empowered to do so. Despite evidence that midwives can safely provide abortions, they are allowed to do so only in a minority of states in the US and countries worldwide. These restrictions are due to ideological objections in some cases, and due to lobbying from physicians in others. Neither objection is based in evidence.

Take a moment to thank your favorite midwife today, and as you advocate for increased access to reproductive health services, don’t forget how much midwives already contribute, and how much more they could contribute if politics weren’t in the way!

I assume when I go into my doctor’s office that my primary care physician has the skills and knowledge to be able to help me make basic health care decisions, including information about birth control and what my options are. I deserve to make my own, informed decisions about my reproductive health based on what works best for me. If my doctor can’t give me accurate information or counsel me about my options, where would I go for help?

It seems ridiculous to think that in 2013 doctors could not be trained to provide birth control or abortion, but that could be a reality. The Accreditation Council on Graduate Medical Education (ACGME), the group that sets the standards for medical education and curricula in the US, has removed contraception and options counseling from the requirements, meaning that a family doctor could graduate a program with a medical degree and not know anything about birth control.

The requirements also don’t include IUD insertion, implant insertions, or abortion, services that people need and may have to travel long distances to obtain if their family doctor is unable or unwilling to provide them. As restrictive laws continue to make reproductive health care less and less available at the local and state level, it is more critical than ever that we press for comprehensive care, including abortion, to be included in primary care settings.

Lisa Maldonado, Executive Director at the Reproductive Health Access Project (RHAP), an organization working to expand comprehensive reproductive health services in primary care settings, says:

“Family physicians are more likely than any other clinical specialty to work in rural areas and with underserved populations. Ensuring that family physicians get proper training in contraception, prenatal, miscarriage and abortion care will expand access for everyone. But, if residency programs aren’t required to provide training, then they probably won’t, especially religiously affiliated programs. And, if no one is trained, no one can provide and no one has access, even if its legal and covered by insurance. Too many women already have to travel long distances, cross picket lines and deal with unnecessary restrictions to get basic women’s health care as it is. Family physicians need to have the best possible training in family planning and women’s health.”

No person deserves to be denied information or basic health care because their doctor attended a religiously-affiliated medical school, and we can’t let that happen. I want to get reproductive health care from my doctor, the person who I feel comfortable with and who knows me. I deserve that, and you do too.

We have until April 25 to let the ACGME know what we think and to voice support for reproductive health and family planning counseling in primary care settings. I hope you will join me and stand up for your rights by signing the RHAP petition here.

Egg donation number two was FAR less fun than egg donation number one, if “fun” is even an appropriate word to use here. My body responded a bajillion times better to the hormones (though my mind did not, and I’ll get there), and I developed eggs much faster that were larger (more inconsistent in size), but nearly all were considered large enough for use.

This meant that my largest egg in my right ovary was .3mm, sharing space with 12 other eggs, all hovering around or above .2mm. My left ovary was more reasonable in size, though not in number. There were 15 eggs and they ranged in size from .14mm-.21mm. A total of 28 eggs were produced between the two, taking up nearly 5mm of ovary space… considering that the normal ovulation cycle produces 1 ovum to ovulate at an average of .2mm… it sucked. Like more than I could have ever anticipated. I was bloated to the point of looking pregnant (5 months pregnant, according to my formerly pregnant – now mothers – friends), and I could not do normal activities. Even walking was just terrible. And, this was right before Christmas, so much celebrating and being around people was inevitable.

Boy, was I miserable to be around. Just ask my boyfriend. He thought I was going to break up with him, and to be frank, so did I. Everything he did was annoying to me, not just because I was in pain (and I was in pain nearly constantly for the last week of shots), but because it seemed that my patience had been reduced to nothing for whatever reason. Poor kid. I still feel bad about how I treated him during that time.

Anyway, how does this relate to advocating for myself? So, like the 5th day of shots, I asked the doctor if it was normal to begin feeling my ovaries inside my body, because it had taken at least 2 days longer for me to notice them the first time. They assured me that this was fine. But like 3 days later, they had begun to hurt enough to interfere with my life. I SHOULD have asked for more frequent ultrasounds, and I should have advocated for having my surgery a day earlier than I had it. I literally felt like my ovary was going to burst, which is not a cool feeling. I should have told them I wanted an ultrasound every day after that 5th day… but I didn’t, and I paid the price. My recovery was much longer this time (10 days as opposed to 7), and overall it was just a miserable experience.

IF I choose to donate again (a big “if” at the moment), I will not allow my doctors to ignore unusual and more dramatic pain. I will not allow them to keep me to a schedule that puts me at greater risk with an enlarged organ. And I will ask more questions than ever before.

We don’t just consume media every minute of every day, we are force-fed media. Media is unavoidable. It’s on the computer, where many of us do a lot of work. It’s on the TV, where we sometimes go to relax. Here in NYC, it’s on every single street. You can’t leave your apartment without being assaulted by socializing images and ideas. So until I was 23 and my best friend had a baby, almost everything I knew about pregnancy came from media – television shows, movies, and magazines. I could hardly remember my mother’s two pregnancies after my birth, so I didn’t have much, as it were, up-close-and-personal experience.

But even if I did, it wouldn’t have mattered, because here’s the thing about pregnancy: everyone lies about it.

Lies! So many lies. And so much lying by omission; so much just not-telling about the truth of pregnancy. Media has a nicely packaged version of pregnancy that is meant to make it look difficult, but funny, and ultimately completely worthwhile. This is understandable, since most media is run by people who can never, ever actually get pregnant. I have a theory about the lying and lying-by-omission done by people who have understand pregnancy on more intimate terms, too. I think that people who know the truth about pregnancy lie about it because if we knew the truth about pregnancy, almost no one would ever consent to being pregnant.

I always thought there was a secret mommy-club I wasn’t part of, where women (in the time and place where I grew up, pregnancy, parenting, and everything else were highly gendered) sat around in little sewing-type circles, drinking tea and lightly sharing what I viewed as some of the most mysterious secrets of the universe. And I was right. There is a secret mommy club. When my first close friend got pregnant, I was inducted as an honorary member and given a special pass, which I still keep on a lanyard for when I need it. The mommy club pulled back the curtain for me, and what I saw behind it scared the ever-loving shit out of me.

I have been exposed to more images of fake baby-bumps that I have been exposed to actual people’s real, pregnant bodies. As a result, I thought pregnant bodies had sort of big, round, firm bellies, like a safe case for the baby – like a guitar in a guitar case. THIS IS NOT TRUE. A pregnant belly is a lot more like a sac that an alien is growing in, and it’s freaky. Babies move in-utero and sit on your spine, on your vital organs – one friend, while in-utero, sent her mother to bed for several months because she just loved to lie on a major artery and she CUT OFF HER MOTHER’S BLOOD SUPPLY. Once, my friend’s baby reached it’s little hand out, from the womb, to high-five me. I could see a hand trying to reach through my friend’s stomach, from the inside. Guys, pregnancy is horror-movie-level WEIRD, and that is no joke.

Morning sickness? That ain’t some cute shit you see in the movies where you throw up once or twice and then the truth slowly dawns all over your face and then you run to the drug store, pick up a test, and flash-cut to you sitting on a toilet holding a stick with a plus sign and then it fades away so you can hurry up to the setting-up-the-crib montage. Morning sickness often doesn’t fade away. Morning sickness is crippling. For some pregnant people, morning sickness is code for “7 months of constantly having the flu, running a slight fever, vomiting several times a day.” You should read the whole post I just linked to. It’s by a young woman who’s pregnant and it mostly details sitting on or near the toilet literally all day, every day.

My friend is breastfeeding. Her hair is falling out. Her dentist told her she’s losing so much calcium to the adorable, beloved parasite (this is the cutest parasite in history, you have no idea) that she may need dental surgery.

Mood swings? Hollywood loves to make mood swings the funny center of a relationship up-and-down that starts with yelling and ends with The Woman sitting on the couch, crying, admitting that she feels fat and powerless, and The Man sitting down, the weight of everything she’s doing for him suddenly settling upon him, vowing to do better, Exeunt Stage Right, Consumed By Bliss. Except that mood swings for several of my friends more closely resembled crippling depression. They were unable to get out of bed. They felt powerless because pregnancy had actually rendered them powerless; they couldn’t go to work, or go to the grocery store, or do really fucking basic things for themselves, and it felt awful. And their partners felt despair, because they too were powerless, because they could go to the grocery store and pick up flowers and say nice things but they couldn’t make it better.

There came a time in my life where people started being honest about pregnancy and I started listening, but many people I know got pregnant before anyone had explained to them seriously what being pregnant might mean. When I describe immobility, helplessness, depression, severe physical discomfort, daily vomiting, and hair loss, I am not describing pregnancy worst-case-scenarios: I am describing common side effects of pregnancy.

And that’s just pregnancy. That’s not even getting in to childbirth itself. Do you know what a vaginal tear is? If you think you may ever give birth, it’s a fairly common phenomenon you may want to familiarize yourself with.

I may get pregnant someday; I may decide to have kids someday. But in the meantime, I interrogate pregnant friends and family members, in their most vulnerable, defenseless, pregnant state, like it’s my job. If I am ever going to do this thing, I want to know, as much as I possibly ever can, exactly what I have gone and gotten myself into. And I want my partner to know as well. I want both of us to be aware of what carrying a child will mean for my body, and what those changes, and frankly, that damage, will mean for our life together. I want a shared honesty about what could essentially be termed a temporary insanity brought on pregnancy and what that would mean for our home.

I see The Truth About Pregnancy being shared more and more, but still mostly in female-dominated spaces, like “mommy blogs” and Pinterest. I’d love to see young people move towards a complete honesty of what this experience means to them, or meant for them, and what elements of that experience seem unique or commonly shared.

In other words, “Sit down, honey. We need to talk about vaginal tears.”

Yesterday, I attended a luncheon held by the New York Times on Women in Leadership. It was a great opportunity to sit down with women who are leaders in their fields, and who have great stories to tell, and to learn from them. One presenter, in particular, spoke extensively about her research on the lives of women who were pioneers in their field; what were their lives like as children, how did their families interact, when they went to college, who encouraged them to pursue their dreams?

When I speak with friends and family members who are new to the idea of egg donation, they all say the same thing: “You’re going to have a child running around somewhere! Doesn’t it bug you?” And, first of all, not my kid. I just don’t have the same connection to my DNA that other people do. But second, even if I had that connection to my genes, it wouldn’t bug me. I’m happy to have given this gift to another family. We’ve spoken extensively on the blog about adoption, and I think this is similar. I’m happy to help others have a family.

But that doesn’t mean that I don’t want good things for my eggs. Of course I’m curious about the type of family that they’re going to. The screening process is entirely unfair in that I don’t get to see THEIR family profile. They know almost everything about me; my height, weight, eye color, but more than that, they know my hobbies and my skills and my passions. But I know nothing about where my little eggies are going.

But I can hope. And I hope that they go to families that will support them in whatever they want to do. I want a family that will challenge them, argue with them, and make them critically think about why they do what they do. I want them to be loved, of course, but I don’t want it to be a love that limits them by overprotecting them. I want them to have the freedom to make their own choices, and parents who are responsible enough to make them own the consequences, good or bad, and who will help them learn and grow. I want purposeful parents who encourage creativity and who find joy in their successes, but who can find the silver lining in their child’s failures. I want a father who invests in his children, especially his daughters, and who allows them their voice. And I want a strong mother who encourages her babies to find balance and joy.

I’d love atheist parents, but if my eggs aren’t raised that way, I want a family that is ok with the idea that religion doesn’t define life, but it can complement it. I want parents who will teach and encourage compassion and kindness and humanity.

Basically, I want parents who are like me. But I’m so grateful that it’s not me having and raising these eggs. They’re not my children, despite our DNA connection, but that doesn’t mean that I can’t and don’t hope for wonderful things for them.

A guest post by an anonymous independent abortion clinic staff member. 

For those of you do not work in women’s’ health, hand holder is exactly what it sounds like. I literally hold the hand of women during their abortion. Granted, there are other responsibilities involved; generally assuming responsibility for all bodily functions above a woman’s waist. I monitor her vital signs, including pulse, blood pressure, and oxygen saturation. I count her respirations, how many full breaths she takes in one minute. But all of these medical functions are secondary to my primary task; keeping her comfortable and distracted.

Hand holding can be physically challenging. I have come home with scratches on my hands from fingernails, or swollen fingers that were gripped too tightly for too long. These occurrences are rare, but happen.

The more challenging part is finding fresh but neutral points of conversation. I want to keep her distracted and entertained but dodge any potentially emotionally triggering topics. During the holidays, conversation is easy. “Any plans for the upcoming holiday? Will you be spending it with your family? What’s your favorite dish to cook? Have you started on your holiday shopping?” Then January lends itself to all of the follow up questions after these events. Summer is a great time to talk about family trips, vacation, school breaks. Mid October can be challenging, I have to search a little harder.

Asking women about their jobs and careers can be interesting. I have been a hand holder for wine distributors, concierge to celebrities, cheese mongers, and musicians. I have asked an array of questions to women I would never have met outside of the clinic like toll both attendants or public transit operators. I have learned so much from women firefighters, policewomen, and women in active military service.

Sometimes, though it is more cautious territory, women will discuss their partners; Husbands, boyfriends, babydaddies, or lovers. Sometimes they will brag about their men, or vent small frustrations about domestic cohabitation. I’ll confess: if they share an interesting detail, I sometimes peek into the waiting room to see what their prince charming looks like.

Hand holding can be emotionally draining. On days where this is my role, I usually will go home, eat junk food, and watch either an Tina fey or Amy Poehler sitcom to return me to a reasonable level of my emotional equilibrium. I want to watch something funny and silly, but still with a feminist undertone. I understand that self care is critical, and have found what works for me.

If you have the opportunity to hand hold at your clinic, I recommend attempting it at least once. It is not for everyone, but I have definitely learned more in that position than in my entire career of reproductive justice. Handholding is like a good Barbara Walters segment, it’s a soft interview and sometimes, the guest cries.

Access to abortion services is becoming more and more difficult around the country, and remains problematic worldwide. One potential way to improve access for the majority of women who need abortion services in the first 9 weeks of pregnancy would be to make the medications that induce abortion available over-the-counter at pharmacies nationwide.

Medical abortion (see below for a detailed definition, but for our purposes, an abortion that is completed at home, with just pills rather than a procedure in a clinic) is an extremely safe and effective way to end unintended pregnancies. The most effective regimen, a combination of misoprostol and mifepristone, works up to 98% of the time. In other words, 98% of women who take these two drugs correctly to induce an abortion at up to 9 weeks after their last menstrual period will expel their pregnancy completely, with no medical intervention whatsoever. So why not take the providers out of the equation?  It would certainly make abortion far more accessible and affordable for many women.

Additionally, such an approach might present a missed opportunity for providing contraceptive care. If women aren’t seeing a medical provider for their abortion, they may lose out on the opportunity to start a contraceptive method immediately after their abortion. In fact, offering contraceptive counseling and providing a method if desired is a key component of quality abortion care. It’s true that in a perfect world, women would be able to start their chosen contraceptive method immediately after their abortion in all cases (and in fact it would be much easier for many women to do so if more contraceptive methods were available over-the-counter as well!). However, it is never appropriate to make availability of one health service contingent on provision or acceptance of another. (Unfortunately, this is common practice; many medical providers still require patients to come in for their preventive care visits before they will renew prescriptions for contraceptives. Just because it’s common doesn’t make it right).

Finally, some may worry that women who are past the recommended 9 weeks since their last period will use the method even though the instructions say not to. First of all, as I mentioned above, many people do not follow the directions for the use of over-the-counter products. It doesn’t mean those products should not be available. Second, although misuse of over-the-counter products such as acetaminophen (Tylenol) are frequent causes of death and disability in the United States, there are no restrictions on their sale. Third, these medications are still safe to use after 9 weeks of pregnancy; however, their efficacy decreases. In other words, women who use the medications in these doses after 9 weeks of pregnancy are less likely to have a complete abortion, although much of the time the regimen will still work correctly. The worst case scenarios, therefore, are an incomplete abortion or an ongoing pregnancy if women do not use the product as recommended. Such situations would require medical attention, but if a good referral service is available women would be able to access appropriate follow-up care.

What would my dream over-the-counter abortion kit include?

1) Clear, easy-to-understand instructions and a 24-hour phone number to call with questions.  Information is key.  The instructions should help women determine if a medical abortion is the right choice for them, based on their gestational age and medical history, as well as provide information on where she can go if a medical abortion at home isn’t the best option for her.  Additionally, women need to have someone they can call at any time if they have questions before, during, or after the process.  The instructions should also point
women to websites and hotlines they can call for information and referrals for contraception after their abortion.

2) Mifepristone and misoprostol.  The mifepristone-misoprostol regimen is the most effective for inducing abortion.  If the method is going to be used by women on their own, it needs to be a method that is extremely reliable.

3)  Several doses of ibuprofen.  The most difficult part of a medical abortion for some women is the cramping; pain control is a key component of abortion care.

4) A low-sensitivity urine pregnancy test.  Women could take this test themselves at home 2 weeks after their abortion.  Although medical abortion is extremely effective, and most women are able to determine from their symptoms alone that their abortion is complete, this test will catch the very rare cases of continuing pregnancy.

Although this may seem to be a radical proposition, the fact is that we have the evidence to support that it would be safe and effective. I would like to see research that it is, additionally, acceptable to women, but it’s hard to believe women wouldn’t be happy about having more choices and more control.  What do you think?

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Medical abortion: Medical methods of abortion, or medical abortion, is defined by the World Health Organization as follows: The “use of pharmacological drugs to terminate pregnancy. Sometimes the terms “non-surgical abortion” or “medication abortion” are also used.” Medical abortion in the United States is most commonly performed using a combination of mifepristone and misoprostol (this is the recommended protocol as it is the most effective), although sometimes methotrexate is used in combination with misoprostol. In countries where mifepristone and/or methotrexate are not available, misoprostol alone can be used, although it is less effective, that is, less likely to end in a complete abortion.

Low sensitivity urine pregnancy tests: Similar to regular urine pregnancy tests, except they only are positive at higher pregnancy hormone levels. Although it can take several weeks for pregnancy hormone (ß-HCG) levels to become completely undetectable after an abortion, these tests will only turn positive if hormone levels are still high.

A new study came out this week saying that 2 in 5 women don’t use birth control. The two most common reasons listed for not using birth control were not being sexual active, and believing they were unable to become pregnant. The study also mentioned that many women underestimate their ability to become pregnant. I believe our current lack of comprehensive sexual education is partially responsible for this situation. I also believe that sex education is not the only change needed. We need to stop being afraid of young adults having sex, and we need to stop thinking of it as a horrible tragedy when young adults have sex. We need to stop believing that it’s wrong to talk about sex with anyone, at any age. We need to start seeing our body’s sexual organs, cycles and activities as part of us.

Young adults, yes,  teenagers, are having sex. Our culture’s refusal to acknowledge that has led to the situation we’re in now. Any sort of talk about teenage sex is deemed as “encouraging” or “promoting” teenage sex, and thus seen as a horrible thing. While parents and teachers and administrators and policy makers squawk back and forth at each other over how they shouldn’t talk about sex because we don’t want teens having sex, teens are having sex. They are having sex and not paying attention to the discussion others are having about whether their sexual activities are right or wrong. And it’s not just teenagers who are in this situation, but also unmarried adults. Even married adults sometimes falter when trying to talk about sexual activities- after being taught for so long that sex is bad, it’s hard to make a 180 turn and say sex is okay.

Our refusal to educate the public about sexual activity has put them at risk, and it’s time for us to stop worrying about whether we are encouraging sex or not, and start teaching teens (and everyone!) about how our bodies and reproduction work.

One result from the above study should be easily resolved with education. As previously stated, one of the most common reasons for not using birth control was a woman believing that she couldn’t get pregnant. This is surely due in part to our fear mongering over pregnancy. Many people believe they have an equal chance of getting pregnant every time they have sex. In reality, one’s chances of becoming pregnant are higher and lower at different parts of the ovulation cycle. If a person has sex when they are not near ovulation, and thus does not become pregnant, this can lead to a false belief that they are unable to become pregnant. While I do not support NFP for teenagers as a way to prevent pregnancy, I highly suggest we begin educating teenagers (male and female) about the ovulation cycle, and encourage young women to track their cycles. Tracking your cycle as a young adult can lead to better understanding of your body, and help you figure out when to have your chances of becoming pregnant when trying to avoid pregnancy or when trying to create a pregnancy. Tracking your cycle can also help you notice something out of the ordinary that requires a doctor’s attention.

The other man reason for not using birth control was a lack of sexual activity. While I see nothing wrong with this, I do believe that even people who are sexually inactive should be educated on condoms and hormonal contraceptives. Anyone who is currently sexually inactive could change their mind and become sexually active, and they should be prepared for that if/when it happens. Hormonal contraception is not easy to get quickly- one usually needs a doctor’s appointment, then to actually purchase the birth control at a pharmacy, and then wait for it to take effect. While we hope sexual activity is well thought out and planned for, often it actually happens in the heat of the moment. No one should have to be risk pregnancy or STIs because they weren’t educated on effective contraception since they weren’t yet sexually active. Education should always come before activity.

A person facing an unplanned pregnancy should not be judged for their situation or lack of education. We should not be asking the individual, “why didn’t you know better?” or “why didn’t you use birth control?” We should be asking the establishment, “why didn’t you provide proper education?” and “why did you limit access to contraceptives for this individual?” Our cultural fear and shame around sex has led to a situation where people rely on rumors whispered among friends, websites that aren’t always accurate, and even lies taught in schools practicing abstinence-only education. We need to stop hiding sexuality under the rug, and start talking about it openly and honestly.