How News Travels About Periods

What have I done??

Honestly, I never expected this would happen. All I did was write a short comment on a post about the new birth control pill that stops menstruation, and I released a firestorm. If I had known my comment would be picked apart with a microscope, I might have elaborated my position more, clarified some sentences, etc. But now it's generally lost in the conflagration.

One post here, a comment there, causes another post somewhere else, and more comments

This is what happened, and I think it's incredibly interesting as a example of how the blogosphere undulates--if I can use that word--when something is added.

First, Apoorva Mandavilli wrote about the new pill, Lybrel, at Spoonful of Medicine.

This got me thinking about the issue, and I read the articles the post linked to. I thought that was the end of it.

Second, Ann Althouse heard the news and posted a short question on her blog.

Is there some deep psychological/sociological/feminist angle to this story or is it obvious that everyone should obviously want to avoid something that's so inconvenient and annoying and that the only serious question is whether the pill is safe?

Well, maybe it didn't start with me, it started with her assertion that "the only serious question is whether the pill is safe?" (emphasis added). One commenter disagreed with the absolute nature of her question, and replied,

menstruation, like childbirth, is just part of being a woman. If another woman would want to escape it, then sure, she should go for it. But, not being punny, it just wouldn't feel right to sidestep it.

This got Eugene posting on The Volokh Conspiracy. He said,

Again, concerns about long-term health effects are quite sensible. But I don't see any justification for the feeling that it's not "right to sidestep" something that's "part of being a woman." I suppose it could be some esthetic judgment that argument won't much drive; but setting aside esthetics, why on earth should we want to accept natural but painful or unpleasant things?

At this point I jumped in. The Volokh Conspiracy gets so many comments, that I didn't think much about mine--subconsciously figured it would be lost in the proverbial sea, so to speak. I said,

This is an example of how much medicine is an ART and a science. Ultimately, pills treat symptoms and change chemicals that produce a different state of being--but the ideal state of being differs from person to person.

It's been amazing seeing my wife and other women deal with her first pregnancy. Immediately upon announcing to the world she's pregnant, my wife was part of the "in crowd." Every mother--whether she knew my wife well or not--could smile and talk about morning sickness, or finding out the baby's gender, or feeling bloated, etc.

So, it is not aesthetic. Humanity derives meaning from shared experiences, and deleting one of the most universal and central of all female experiences can subtract perceived meaning from people's lives. In that regard it is very important.

As a soon-to-be-doctor, I would never recommend such birth control without bringing up and discussing the social and emotional ramifications in addition to the physiological ones.

Apoorva Mandavilli over at Nature's Spoonful of Medicine posted a little on it about two weeks ago.

The blog post links to Mandavilli's good article on pros and cons in Women's Health. Check it out too.

The other reason I felt this comment wouldn't be noticed, is because I didn't feel I said anything too inflammatory. It turns out I was wrong on two counts.

I figured people were being too literal and misunderstanding my point when a commenter, UVAgirl, wrote,

From the doctor, I get a condescending lecture that I'm missing out on the experience of being a woman if I choose to take this pill.

Then, Eugene Volokh posted a response post, quoting my analogy to pregnancy and saying,

Humanity does derive meaning from some shared experiences — but not all. Shared experience that you bond over: pregnancy. Shared experiences that you don't bond over: hangnails, nearsightedness, tooth decay.

...But let's hear from some people who actually menstruate, and have been pregnant. When you menstruate, do you feel that you're part of the "in crowd"? If you chose to stop -- not because of menopause, which is a marker of age and of lost fertility, but voluntarily and reversibly -- would you feel "out"? Do you smile and talk to your friends about the cramps, the mood swings, and the like? Do you feel you derive meaning from the fact that you share menstruation as an experience with other women? Would you feel meaning subtracted if you stopped menstruating, because menstruation is so "central" a "female experience[]"? Do you find menstruation to be similar to pregnancy in any emotionally positive way?

Eugene posted a comment later where he defended his second post by saying,

When someone says "menstruation and pregnancy are analogous, and pregnancy is A, B, and C," it seems sensible to explore the analogy by asking whether menstruation is A, B, and C, too.

Is it that people didn't connect that my questions were just quotes from Triet's comment, aimed at showing that Triet's analogy was unsound?

Well, obviously no analogy is perfect. And yes, you can sit and look at why the analogy might not work, but that's only half the issue--you should also look at why the analogy might work too. Some of the comments on the first post had basically agreed with me, but things changed. Taking just this quote, people became very polarized about whether or not you can derive meaning from a period. Now I sit here and wonder if the rapidity and severity of the response doesn't prove my point.

Có tật giật mình.

But that's not the end. Ann Bartow from Feminist Law Professors remarked on her blog that he needed to be educated. Someone defended him at Is That Legal? by saying,

Some guy said something kinda stupid, and Volokh replied: "Oh, really? Lets ask actual women about menstruation. So, women, how about it? Is it a life affirming shared cultural experience?"

That's an entirely reasonable response.

So now, I've said "stupid" things, according to someone I'll never know. But that's not all people said. In the comment section to the second post, many women agreed with me, like the first one that said

Is it a bonding experience? Sure; it can be. Especially if you live with the women in question, because then you all get cramps together.

and of course other's disagreed

A bonding experience? Puhleeze. Look men, would you want to spend five or six days every month with blood leaking from your body, sometimes coming on with little warning, and potentially putting a very embarrassing stain on your business suit?

All I did was write a short comment ...but now it's ... lost in the conflagration

Unfortunately, as often happens in comment threads (see Xanghe's post on Breeder's of Hate), the discourse tends towards the extremes instead of answering the question in a logical and amicable way. I noticed that people had now totally missed the point of Lybrel--to offer a way for women to take birth control without monthly periods, but that it still comes with it's own issues (one of which is random bleeding). Everyone is pontificating on how many periods are normal, etc. Another commenter, Falafalafocus, summed it up greatly, saying,

I must say, this topic is like an incredibly large automobile collision. I can do nothing to help it along and there are parts that make me want to run and hide, but I find myself strangly [sic] fascinated by the discussion nonetheless.

Since it was my comment that caused the "automobile collision," I felt obligated to respond and clarify. On the subject of bonding, I said,

I believe it does derive meaning from all shared experiences, good or bad. Some may play a larger and more central role in a person's life, and the composite of experiences that people share changes from relationship to relationship, but we bond over the bad and the good, the trivial and the important.

Haven't we all complained off the cuff about stubbing our toe or having a hang-nail and someone else said "yeah, that sucks." Such a small and arguably insignificant thing has demonstrated another level of understanding between the two people involved.

And shared bonds that we may not want to endure still provide meaning to our lives. When my lung collapsed spontaneously as a high school student, I was introduced serendipitously to a girl in Minnesota who had the same thing. We became pen-pals and friends, bonding on many levels including the pain we suffered dealing with a collapsed lung. In addition to the bonding, I also gained a little more "meaning" to my life by realizing that I would be dead if not for some modern machines.

And on my last sentence which caused such consternation, I said,

This is not because women should be persuaded out of this pill--no, not at all!--but that all women should be advised of the physiological changes and risks taking the pill entails, as well as the lifestyle changes (including possible absence of monthly menstruation), so that they can decide with their doctor if taking the pill is in their best interest for their health, lifestyle, and vision of who they are.

Another commenter, JM Hanes, totally misunderstood how humanity might derive meaning from common experiences and yet people can derive individually different meanings from experiences. Well, I'm going to use another analogy--which we all know are never perfect--that I think can illustrate the premise.

When you learn about bacteria, there are many kinds. One for example, is Escherichia coli. E. coli is familiar to us because we get sick from it, typically if we eat an undercooked hamburger. But not all E. coli's are the same. In fact, there are broad categories of E. coli--ones that cause watery diarrhea, ones that cause bloody diarrhea, etc. And when you look even closer at one type (say, Enterohemorrhagic E. Coli, or EHEC, that causes bloody diarrhea) you will see numerous variations in its genetic code that gives attributes, such as increased susceptibility or protection from antibiotics.

So also is humanity. We may gain meaning from shared experiences, but yet have differences. On a microscopic scale we may seem incredibly different from each other, espeically if just one issue, like menstruation, is looked at. But when we step back and look at the aggregate of our experiences, we start to have more and more in common.

JM Hanes also said this about my last assertion to talk with the patient about all the consequences of a pill:

I'll chalk up the unwitting condescension here to youth, and suggest that you pay your future patients the courtesy of keeping your ruminations on the subtractive nature and social raminfications of the decision at issue to yourself! There is simply no way you can inject questions about the symbolic, psychological, and social affects of womanliness without adding gratuitous, if not specious, judgmental freight to a decision which, per this discussion, women are perfectly capable of sorting out as they, themselves, see fit.

to which I responded,

And I'm sorry you groaned over my last comment, but you must have missed the point. How could I bring up any birth control pill without discussing the social and emotional ramifications with a patient? I have been taught repeatedly to do that in medical school and I believe it is a correct principle. If a woman came in wanting birth control, I am going to talk to her about ramifications such as:

1. Social -- do you know this birth control causes random spotting and bleeding? If your job or lifestyle puts you in situations where this might be inconvenient, then I might recommend a different pill.
2. Emotional -- do you feel a period is a part of being a woman you don't want to give up? If yes, then obviously I'm going to suggest a typical estrogen+progesterone pill. If no, then the new one might be right for her.
3. Physiological -- as with all progesterone+estrogen pills, this one carries with it an increased risk of blood clots, heart attacks and strokes. Typically estrogen+progesterone pills do not carry the increased risk of cancer that progesterone only pills carry.

Such a discourse in no way dictates condescendingly to a woman what pill she should take, but gives her the full knowledge so she can make an informed decision about what is best for her life.

Oh, but that's not the end. For the furvor caused not only my first post on menstruation, and this second post, but a third post on The Volokh Conspiracy, those posts on Feminist Law Professors and Is That Legal?, and a post on Conglomerate by Christine Hurt. It is refreshing for a couple reasons.

1. It is a real thoughtful response to his second post's questions, which the other commenters didn't do, and
2. It agrees with me, which is very nice since my first comment got picked apart.

She says, in part,

1. Yes, pregnancy and childbirth make women part of a very large club whose members have something very important in common. Consider it like sports for men, or Dungeons and Dragons. Female culture doesn't have a common theme that most girls' youth revolves around that joins generations of women together other than fertility and childbirth. I remember finally having something in common with my grandma when I got pregnant. Menstruation is similar. When girls begin to menstruate, they do join sort of a club, but it's much more underground. Once girls begin to menstruate at school, their other friends want to also. No one wants to be left out of this growing up thing, obviously.

2. Menstruation might be more of a bonding thing in this country if the culture were different. In the U.S., our culture is one of sanitizing and deodorizing must bodily functions. We shave a lot, bathe a lot, shampoo a lot, powder and perfume a lot, etc. Menstruation runs against that. So to some extent, especially among young girls, menstruation is embarrassing. The onset of menses also comes when girls are the most self-conscious they will ever be, adding to the secrecy and embarrassment. I'm not sure it has to be that way, though.

It is a great post, so please click on the link and read the whole thing.

Ultimately, I take you through this journey partly because I'm very interested in how YOU feel about the new pill and menstruation, but more because I'm fascinated by how discussion travels in waves around the blogosphere. One post here, a comment there, causes another post somewhere else, and more comments. Eventually people like me are reading blogs I would never have before (like Feminist Law Professors or Conglomerate) and different types of people are mingling. I'm sure some sociologists far smarter than I will or have already dissected this phenomenon and shed some light on it.

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A Woman's Life Without Periods?

A new contraceptive pill cleared by the FDA that drops the monthly menstruation some common in women's lives has garnered a lot of publicity and talk from a variety of corners.

Ultimately, any decision on birth control should not be made on the fly

I first heard of the pill from a new blog I'm following: Nature's Spoonful of Medicine.

At the time, I thought it a curious concept, but nothing too serious. After all, the pill women take now in effect does away with true menstruation anyway, since there is no ovulation. As Spoonful says,

This fake period was designed into the pill when it was first introduced in 1960 so as not to freak women out too much.

Later, Eugene Volokh posted his take on it at his blog, The Volokh Conspiracy. He felt it was

perfectly sensible to be concerned about the pill's safety, ... But [he didn't] see any justification for the feeling that it's not "right to sidestep" something that's "part of being a woman."

It was the second assertion where I disagreed with him. I left a comment, and that was that.

Today I noticed that he posted about it again, but this time QUOTED ME. I must say, I was quite flattered, even if he agreed with me in part. I respect his opinions and intelligence greatly (part of why I read his blog). So I have commented again.

I feel that this discussion lends itself easily to tangents that confuse and distract. From a medical standpoint we must not forget that no contraceptive pill is perfect. Pills come in two general classes: estrogen + progesterone pills and progesterone-only pills.

The standard menstrual cycle is roughly 28 days. The follicular phase lasts 12-14 days, ovulation is 1 day, and the luteal phase is 12-14 days. Normally, a woman's anterior pituitary in your brain secretes two hormones, FSH and LH, into her bloodstream. The amount of these hormones in the blood cycles throughout the day. At ovulation, a surge in Estradiol (an estrogen) sparks a surge in FSH and LH and a release of an egg from the ovary. Progesterone functions to maintain pregnancy by decreasing fluid secretion and motility of the uterus. Without fertilization, progesterone levels drop, and the body sloughs off the bloody lining of the uterus with the unfertilized egg during menses.

Estrogen + progesterone pills block ovulation by "tricking" the woman's body into believing it doesn't need to secrete an egg. Then, a placebo week drops progesterone levels and the woman's uterus sheds the blood-filled lining.

They have two types: monophasic and multiphasic. Monophasic pills have a fixed dose of hormones that the woman receives daily. Multiphasic pills have varying dosage of hormones throughout the month and lower total steroid levels.

Today I noticed that he posted about it again, but this time QUOTED ME

Progesterone only pills have an increased risk of endometrial breakthrough (i.e. cancer), but are a good option for nursing mothers because estrogen messes with lactation. They also have a higher failure rate because technically progesterone doesn't prevent ovulation, it just makes it near impossible to be fertilized and implanted in the uterus.

Lybrel, the new pill that eliminates periods, is an estrogen + progesterone pill, and therefore blocks ovulation. However, it's not the magical bullet people think it is. The FDA says,

Women who use Lybrel would not have a scheduled menstrual period, but will most likely have unplanned, breakthrough, unscheduled bleeding or spotting.

...The risks of using Lybrel are similar to the risks of other conventional oral contraceptives and include an increased risk of blood clots, heart attacks, and strokes.

Seasonale, a pill that came out in 2003 and limits menstruation to four times a year also has spotting.

"It was really inconvenient, which kind of defeats the purpose," grumbles Pierrette Lo, 27, of Houston, who tried Seasonale last year but gave up after a few months.

For those women who don't have horrible cramping during their periods, they might be better off with the regular pills, because at least then a woman knows when she will bleed. Lybrel's real benefit comes not in giving every woman who doesn't want a period an out, but in helping those women who really have bad cramps and other symptoms. Those women can opt to give up the five days of torture for unscheduled bleeding and spotting.

Ultimately, any decision on birth control should not be made on the fly. All options should be discussed with a doctor, so a woman can best decide what type of pill will do the job effectively without causing undue physiological changes/problems. She will also be able to decide if the lifestyle changes that taking the pill entails is truly what she wants. For a patient's emotional well-being should be just as important to the modern physician as her physical well-being.

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Snapshot of Bus 87

Yesterday morning I hopped on the 87 bus and headed up to the medical center. Route 87 is the main conduit for students and workers to the two medical schools in the medical center--Baylor and UT-Houston. In addition to the 87, routes 297 and 298 carry professionals to the medical center from the 'burbs, and the light rail carries professionals and students from the southwest. But nothing says student bus like the 87.

I got on about 9:00am and the bus was packed--standing room only--as usual. So I, being the bored, odd person I am, counted everyone who got off the bus. I can do this because UT-Houston is the "last" stop--it's the last place people need to go in the morning, so I'm always the last person off the bus. Then the 87 starts the return part of it's loop.

Now, the 87 is an incredibly interesting loop, because it runs from Sunnyside through the southside of the medical center and ends at the medical center proper. Then it backtracks. Sunnyside is predominantly African-American and very poor. South medical center is racially heterogeneous and predominantly students or middle class professionals who work at the medical center. Hence it has two incredibly different population bases that it services. Also interestingly, they don't overlap. Those who use the bus in Sunnyside rarely go to the medical center, and those who live south of the medical center rarely travel to Sunnyside.

My impromptu count represents a snapshot of the populace that lives south of the medical center--not Sunnyside. The results?

Total people: 45
Caucasian: 5
African-American: 7
Indian: 12
Chinese: 21

Thoughts?

Finals

I've reached the other side...

At 3:00pm Friday I walked out of the NBME Microbiology test, heaved a sigh of relief, and laughed. For the first time in a month, I did not have a test to study for. For the first time in nine months, I did not have anything school-related to do.

I was free.

Oh, how beautiful is freedom. Our founding fathers got it right. How could they have foresaw the exquisite joy of having no pressing responsibilities weighing down on your shoulders as you watch tv in the evening? They were men of genius.

The exam schedule was rough--nine exams spaced over two and a half weeks. Studying for the exams starts about a week and a half before the first exam, so in reality a full month is spent on these things. I study and go to class from 8 am until 2 am for a week and a half, then have three exams in a row--Wednesday, Thursday, Friday--just to finish the fourth block. Two weeks, six exams, and no sleep later, I'm done.

Thank you to everyone who's helped me--or laughed at me--especially my wife, who lived without a husband for a month. It's no fun going to bed before your spouse, so you only see him for ten minutes as you drive him to school each morning, but that's what she did for four straight weeks.

Now it's on to summer--the last "summer" of my life. I start a preceptorship at Ben Taub hospital on Tuesday and hopefully I'll do research to keep me busy once the preceptorship is finished.

But for now, it's nice to watch tv....

The Month from ...

This is a disclaimer. I will be blogging only SPARSELY -- and by that I mean only if something really tugs at me -- because starting tomorrow (May 2) and running through May 18 (three weeks) I have exams.

Yes, you read that right. Three weeks of exams.

This week are my Block IV exams, and the next two weeks are finals. Do I think it's stupid to have three whole weeks of exams like this? Yes, yes I do. But it could be worse (such as dropping on the class the day before the exam the news that the exam is cumulative over the semester and not just over this block's materials...like my Physiology prof did today).

So, pray for me, that I will make it out alive, with my sanity, and passing.

As I used to tell "dying" missionaries back in California, "I'll see you on the other side."