Discontent with Arguments against Birth Control

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

"Birth control is a crutch."

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

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

"Birth control is bandaid therapy."

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

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

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

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

"The pill kills."

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

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

Elevator Speeches

Here are my quickie explanations for some of my countercultural choices. If someone really wants to know what I think, I tell them without holding back, in a way I think they'll understand.

Not prescribing contraceptives

Credit: euthman

I counsel about everything, but there is enough cell biology to make me think human organisms form at sperm-egg fusion that I don't like the post-fertilization effects of hormonal contraceptives. Barriers are harder to find a problem with, to be honest, but sex at its best is a total gift of one person to another, and barriers block some of that gift. I know it's not a perfect world, but (not to be crass) I want everyone to have sex at its best and I think not having that has bigger ripple effects than we think.

Opposing abortion
There are a lot of people personally affected by abortion, and I don't know where you stand. I can't pretend I understand any particular person's story but I can at least speak to the science that I tried to delve into. There is enough cell biology to make me think human organisms form at sperm-egg fusion, but that's the easy part. If we think there's an organism with human DNA formed at fertilization, the hard question is, when do we protect it like we protect the mom? When we're potentially talking about--ending of millions of protectable human life--I say we should be cautious. 

Offering NFP

I really think women should learn about all their options, and the quality of the evidence that supports each of them. There are fabulous numbers attached to several fertility awareness-based methods, but we need to acknowledge that these studies haven't passed through the rigors of statistical significance, peer review, and FDA approval.

Being a Christian

I believe there is a truth, something objective that exists and that is right and wrong. If you think that, you realize that truth has staying power, which is why fads and memes slip away so fast. One of the things with the greatest staying power is a two thousand year old story of a man who reportedly rose from the dead to save sinners. I'm a sinner, and I thought that staying power was something worth looking into. The rest can't fit into an elevator speech.

Being a Catholic

History leads to Catholicism. You can tell that men writing in the early decades and centuries A.D. were very identifiably Catholic. The reason why I'm Catholic isn't because I love the customs, the people in the hierarchy, or the feelings I get. It's because I love Christ and I see that this is the Church He founded.

Being a consecrated virgin
The Jewish idea of the people of God as the bride of God really flowered within the Catholic faith, and in the early centuries there were women married permanently to God. That rite is used today, and it's a beautiful life.


This post was a draft for a long time, because it takes me a lot of introspection and lived experience to encapsulate things that are this controversial and this important to me. Hope this is helpful!

A Licit Device to Prevent Pregnancy?

Credit: eglisetraditionaliste.org

Every few years the story about the "nuns in the Congo" that a pope (usually it's Bl. Pope Paul VI) said could take birth control resurfaces. Inevitably there are debunkers and rebunkers. It's very hard to find original documentation on this question, even in the age of the internet, because it was apparently all internal memos from theologians.

The story causes lots of confusion, but probably shouldn't because A) there was more estrogen in pills back then, so they probably were all truly anti-ovulant, B) it wasn't known that pills could even be contra-gestive or abortifacient, and C) emergency contraception (i.e. anti-ovulation or anti-fertilization in nonconsensual intercourse) is even now viewed as legitimate in Church teaching.

Nevertheless, every time the story arises, I think to myself: what sort of intervention could be licit in such a situation?

The problem is this: I need effective pregnancy prevention without post-fertilization effects. An ideal intervention would be anything that prevented fertilization only, such as something that inhibited cervical fructose production, capacitation, or the acrosome reaction. Of questionable permissibility would be something to inhibit the zona reaction (preventing the thick rind of chemicals around the egg from hardening), which would allow polyspermy and lead to a nonviable embryo. If life begins at sperm-egg fusion (which I find compelling) then allowing polyspermy would allow some viable embryos to become nonviable due to increased chromosome content.

But none of that technology exists. Just considering existing technologies, the most effective preventative devices are hormonal, but the only licit ones are barriers, and those mostly rely on male cooperation (or don't prevent STDs, like the diaphram). Hormonal strategies are illicit because they have post-fertilization effects. Going back to the doses of estrogen that pills contained in the time of Pope John XXIII is unsafe for women.

What I'm about to say does not come from an ethicist, a Church official, or even someone with a real degree in theology. 

A diaphragm. Just for clarity: the Catholic Churchis very clear that barrier contraceptives like
diaphragms are gravely sinful in marriage.

So, I guessed, maybe I need a barrier with hormonal-but-not post-fertilization effects. Maybe (this sounds really uncomfortable but hang on) a diaphgram plus or minus a cervical extension designed to go to (but not past) the endocervical os. The device could have a very, very low concentration of  levonorgestrel in it, so low that it had only autocrine effects on the cervical crypts only, and not on endometrial tissue or ovaries. Perhaps levonorgestrel would have too long a half life, and we'd have to synthesize a shorter-acting progesterone or one that had a long half life in an inactive form, then a short half life in an active form.

The result would probably be a ton of mechanical cervicitis. But (maybe) no postfertilization effects and effective pregnancy prevention. You could decrease the rate of cervicitis by using it only during your fertile window. (And maybe the diaphragm part of it could include a BBT thermometer component so that the device itself could tell you when to take it out, or an app connected to the device.)

But is this a good thing? Is it a crutch that would just act like another LARC, or would it help women (especially those who learned to chart so that they could use it only 5-10 days a month)? Would it drive us even deeper into the culture of death by helping people in absurd states (e.g. these women and this woman), or would it help lift us out, until we're more ready for the ideal of everyone-married-and-using-NFP?

And where do I go now? The patent office, or the confessional?

An Epiphany

This post is not about magi. It's about a revelation that is changing or might change my career.

Last time I posted asking whether you knew what Catholic teaching said about contraception. You may have been surprised to discover (or rediscover) that the Church has only said contraception is illicit within marriage. Although there have been many occasions to broaden this proscription, the Church has not done it.

I learned this at a local CMA guild event. Myself, a few other residents and a few attendings of various stripes (pediatrics, psychiatry, OB) gathered at the convent of the Religious Sisters of Mercy (who included pharmacists, a med student, two nurses, and one of the attendings). The topic, ostensibly, was birth control in the mentally ill. I went because I had patients like that on a PAG rotation in med school, and I have patients like that today.

But the conversation broadened to what Catholic teaching is on contraception outside of marriage. The facilitator pointed out that it has never been defined, although he stressed the issue of prudence in preventing promiscuity.

We were all terrified, because none of us had ever realized this. One of the pediatric attendings thought that we should never discuss this--her "Catholic" hospital was already handing out condoms...how terrible would it be if they started handing out hormonal birth control! She was afraid that one of the nation's largest "Catholic" pediatric hospitals would suddenly start handing out birth control if they were better educated on Catholic teaching. How sad!

At the same time as I felt sad and afraid, I was also tempted to shrug. Why would a marginally Catholic institution that already doesn't care about God's will suddenly care about God's will when given new ground? A "Catholic" hospital that doesn't want to follow in God's footsteps will not care about "prudence" that would want to protect pediatric patients from promiscuity (or STDs, pregnancy, statutory rape, etc).

Still, argued the pediatrician, if we can keep the real boundaries of the teaching quiet, we can keep hormonal birth control from harming a few lives (in spite of the Catholic hospital).

I asked myself whether I should talk about this with others at all. Would I only create situations where people would be imprudent?

I decided to post about it because if we don't articulate what the teaching really is, we get pharisaical about it. We draw large margins of safety around established rules, which are burdensome and nonsensical. I found a few unfortunate examples of people who believed that all use of contraception is mortally sinful. (Although I have heard recent challenges to the Peoria protocol from the Linacre, so stay tuned.)

I feel like this is a big shift in my understanding of what makes up the culture of death. Contraception is not in the category of objective evil all the time, at least we don't know that it is. It's not per se like abortion*, against which I must fling my whole self because I understand it to be the taking of a human life. Granted, it still is contributing to the horrible idea that sex and procreation are totally different things, and that sexual life is for the self-satisfaction of two consenting individuals. It's still chemicals women don't always need. It's still a bandaid most of the time. But it's now a crutch without which some of us could be thrown into worse chaos.

If only I had a big glowing orb in the sky to tell me where to go.



*By this I mean that the act of using a contraceptive is not known to be objectively evil. Post-fertilization effects are akin to abortion.

Quiz: What's Catholic Teaching on Family Planning? (Shocker)

Catholic doctrine on contraception (including hormonal and non-hormonal, long- and short-acting) is:

1. Use of contraceptives by sexually active persons breaks up the unitive and procreative aspects of sex, and is grave matter that may constitute mortal sin.
2. Contraceptives are a band-aid for women's health issues and should not be used for medical purposes in women who are not sexually active.
3. Contraceptive use is technically occasionally licit (i.e. not objectively wrong), but is always imprudent.
4. A and B
5. A and C
6. None of the above

The answer, shockingly, is F. Humana Vitae (HV) explained why contraception is objectively sinful because it destroys the good in licit sexual acts. The only licit sexual acts occur within sacramental marriages, and HV only touched on contraception in marriage. When sex occurs outside marriage, there is already an objective evil. It is not clear (i.e. it is not yet part of Catholic teaching) whether contraception augments the evil in these actions (like fornication, adultery, and extramarital sexual abuse) or can mitigate it. Theologians who wish to think with the mind of the Church have gone both ways on this issue. Many, like Germaine Grisez and Janet Smith, have opined that contraception is always wrong. Others, like Fr. Robert Landry, maintain that it is not always objectively illicit, but is usually or often imprudent. For more, here's Jimmy Akin.

True or false: It is good that children not come of non-marital sexual unions.

True. It's occasionally uncomfortable to admit it, but it's actually good when children are not conceived outside of marriage. Children have a right to grow up in a family, raised by a father and a mother, and many or most children born today are born with this right infringed. You're not a eugenicist if you think it's good that children's rights are preserved. Don't believe me? Try the next question.

True or false: It is good that children not be born of non-marital sexual unions.

Careful here. It's good when children aren't conceived. But once conceived, their rights must be protected as much as possible, including their right to life. Post-fertilization effects and abortion rob a child of something even more basic than the right to be raised by mother and father.

Catholic doctrine on primary sterilization (mutilating of a human body by removal or altering of otherwise-healthy organs for the sole purpose of destroying fertility) is:

1. Sterilization is mutilation of the human body, which is dignified not only by creation in the image of God, but also by the Incarnation.
2. Temporary sterilization is occasionally appropriate even if the principle of double effect does not apply.
3. The Catechism only specifies that sterilizations on innocent persons are against the moral law.
4. A and B
5. A and C
6. None of the above.

The answer is A. No temporary sterilization, no sterilization ever unless there is a medical reason for removal of a "diseased organ." C is interesting. The second half of a sentence in CCC 2297 states "directly intended amputations, mutilations, and sterilizations performed on innocent persons are against the moral law." But to take this and run off sterilizing prisoners would ignore the first half of the sentence: "Except when performed for strictly therapeutic medical reasons...." With all this information, let's go see a patient.

Case Study: A 32-year-old African-American G5P2113 (pregnant five times, with two children born at term and one born preterm, with one abortion or miscarriage, we don't know which; currently pregnant) at 26 weeks presents to obstetrical triage at Hospital A with abdominal pain. This is her third visit this pregnancy. She consistently maintains that she receives care at the resident clinic at Hospital B, but has likely never established prenatal care. She is unmarried and does not have custody of her living children. She has multiple psychiatric admissions for bipolar disorder, she is not currently on medications, she is currently homeless, and the resident seeing her suspects she just came from selling herself. She has been kicked out of several maternity homes for disruptive behavior. During today's interview in triage, she appears disheveled and emotionally labile. It is clear from her responses to questions about her medical and social history that she is either intellectually disabled or out of touch with reality. She insists that she is full term and that it's time to induce her labor, although her triage workup reveals no evidence of labor, or other obstetric or gynecologic pathology. Upon the patient's discharge from triage from Hospital A, the attending supervising the resident states, "she needs a strong postpartum plan," meaning that she should receive a LARC or be sterilized so that she won't get pregnant again. Hospital A and Hospital B are Catholic. What is an acceptable postpartum family planning option for this patient?

1. Natural family planning/fertility awareness
2. Mirena
3. Paragard
4. Nexplanon
5. Essure
6. Postpartum filshie clip tubal ligation
7. Parkland method tubal ligation
8. Depot haldol and social work consult for another group home placement

A: Wrong. There is so much beauty to NFP, but for a woman who doesn't have money for bus ticket and who isn't medicated and out of touch with reality, it is not enough.

B: Wrong. Mirenas can be placed immediately postpartum but rate of expulsion is relatively high. Plus, mirena is a progestin-containing system and has post-fertilization effects.

C: Wrong. Paragard can also be expelled when placed in the postpartum period, and also has post-fertilization effects.

D: Wrong. Can be placed postpartum, but has post-fertilization effects.

E: Wrong. Cannot be placed postpartum, and is a permanent, primary sterilization.

F: Wrong. Even if it can safely be done postpartum and is as close as you can get to a temporary sterilization (you can pop off the clips and re-anastomose the tubes), it's still a primary sterilization and HV condemns even termporary sterilizations.

G: Wrong. That's a permanent primary sterilization.

H: Really? That's the best we can do for her? I am totally dissatisfied with our options. 

This woman is unmarried and her ability to truly consent to sex is in question. Children have a right to be born to a family, raised by a mother and father, and it is better for her not to have children right now. I can't render her sterile because that is objectively wrong. It may not be objectively wrong for me to render her infertile (although it might be imprudent), but all my options for rendering her infertile (aside from condoms, which she can't control) have postfertilization effects.

Conclusion: I want to think with the mind of the Church. I know Catholic teaching, like every appropriate body of law, does not include dicta for every particular situation. But I know Catholic teaching grasps the truth whenever it speaks on issues of faith and morals. And it works, because it's the truth. 

But right now, there is nothing that works for patients like my case study (and I have seen her for three of those four triage visits). Where is the truth here? Do I need to develop something new?

"Absurd States," Gradualism, and NFP

I'm going to tie two patients together to illustrate a point about the difficulties I'm facing in a post-pill culture. The phrase "absurd state" in the title comes from the phrase used to describe cryopreserved embryos, who need to be maintained in cryopreservation to avoid likely death. It's a state that would never had existed had we not used technology outside of the truth.

I saw a  patient at one in the morning on call a few weekends ago. My diagnosis was round ligament pain, but we spent most of the visit talking about how she was trapped in a cycle of heroin and cocaine use, and she wanted to get clean. She had overdosed twice in the past week, she told me, and she didn't want that for her future. She told me about her plans to get into a suboxone clinic and a maternity home. She impressed me and I told her so.

Exactly twenty-three hours later (I looked at the clock) she was back after being found unresponsive, having overdosed again. She was brought back with narcan and the emergency department sent her to triage to rule out obstetric concerns. In the words of my second-year who was in triage at the time, she was "high as a kite." I was angry at drugs and angry at her for ruining a life that had such potential to turn around. I'd been told that if drug addicts' lips are moving, they're lying. I grew used to that as a fact during my time on the substance abuse service as a third year med student, but it stung to be reminded.

Three overdoses in a week. "She's going to kill herself," I observed softly to my second-year. One of these times, someone's not going to find her, or she's going to make sure she's not findable.

"That poor baby," added my second-year. Both baby and mother were in an absurd state, brought about by drug developments and the breakdown of marriage, families, and mores.

I saw a different patient in clinic a few days later. This one had been addicted to narcotics and benzodiazepines, but had weaned off her narcs by the time I saw her. She complained that she had missed so many prenatal care visits because she'd lost her job and was now living with her two alcoholic parents. I was less impressed with this person from the start, but I sympathized and tried to connect her with social help to get her better situated. Narcotics and benzodiazepines, more than some other drugs, seem to make people childish.

Not a week later, she happened to present to triage in labor, and I saw her with her mother, who looked exactly like mine. I know people can hide alcoholism more than they can hide, say, meth addiction, but I was even less trustful of this patient than before. She was moving her lips when she called her parents alcoholics; was she lying? I saw her postpartum. She was not handling new motherhood well, and I was again unimpressed. I know the postpartum state is uncomfortable (especially when we aren't giving you your xanax), but I felt frustrated by this patient, and I spoke with a little more sternness than I usually do.

"Do you want to be pregnant again?"

"No," she answered. "Unless I meet Mr. Amazing."

I ignored the comment and dug back to the issue. "What are you planning to use to prevent pregnancy?"

"Abstinence," she answered readily.

I had to recover from an instant of shock, because she was completely serious. "Is that what you used before this pregnancy?" I asked, unimpressed in the extreme.

"Yeah," she said, still serious. "It worked really well until one day I just said '**** it.'"

I was pressing my lips together in frustration at this point. "This time," I said, "I want you to think about another way to avoid pregnancy."

"I don't want my tubes tied."

"I don't think you should have your tubes tied," I rejoined. She was under thirty and there was still hope that she'd stop the benzos and go back to a normal life. "But abstinence didn't work last time, so you can't use it again." I gave her a run-down of the available methods of family planning, including NFP. And then came the time in my life I never wanted to come: I advised that someone not use NFP.

"But fertility awareness takes discipline," I said at the end, "and I don't think that's the best choice for you right now." The words were like a knife in my soul, but I went on: "You either need to make big changes in your life so that you can develop that discipline, or you need to use something that will chemically change you so that you can't get pregnant."

Our culture has become dependent on birth control. There are failings in the culture that seem to now need the crutch of birth control to avoid great evils. There are whole swaths of souls in absurd states. Following in the (unfortunately infamous) footsteps of Benedict XVI, I applied the principle of gradualism during that conversation. Was I wrong? I went to confession and the priest was vague; he told me it was grave matter (which I knew), but did not tell me whether I had sinned or not.

It's in these cases where I begin to feel very culture-of-deathish sentiments creeping up in me. Sentiments like "she shouldn't be able to be pregnant any more," or "it would have been better for that child not to have been conceived." But those are lies. A life can be made right and she should keep her fertility. And that life is precious, and should be cared for (by another person, perhaps).

But does gradualism allow us to avoid the objective evil and choose a lesser evil in situations like this? Not because it's good, but as a bridge to what is good? Can I suggest mirena (not as my peers do, as a panacea for all female woes, but) as a rescue until a person's life can grasp the good?

This post doesn't come to a clear conclusion and I'd appreciate comments and suggestions.
 

How to Counsel on Family Planning

Ask whether they want to be pregnant (in a clinic or postpartum setting) in the next few years. Based on the respose, talk about the three types of family planning methods: long-acting, short-acting, and natural. Long-acting includes nexplanon (3 years), mirena (5 years), pargard (10 years), and depo (3 months). Short-acting includes the pill, the patch, and the nuvaring.

You have to explain natural a little more, because Sex Ed and Bedsider haven't already. I explain FABMs like this: "There are fertility awareness methods that researchers have found to be effective. Our bodies are smart: we can only get pregnant a few days a month, and our bodies give us signs about which days these are. You can learn to pick up on these signs and know every day whether you can get pregnant that day, or whether you can't. And based on that, you use that day for intercourse or not. Some women find it really empowering."

If they express interest in FABMs, I always add: "It's neat because you'll be able to use it all your life. But to get that confident with your own feritlity, you do meet with a teacher. Maybe decades ago women knew this, but our mothers haven't taught us! Do you have the time and transportation to meet with a teacher? Usually it's every two weeks, then every month, and it takes about six or eight months to feel really confident." (Some are online if the answer is no.)

Method	Effectiveness		The Good	The Bad	Lasts	Cautions/ Contraindications	Cost (cash)
	Method	Typical
OCPs	0.1%	3-5%	Some with Fe, folic acid	Effectiveness based on pt (applies to all short acting and FABMs)	24+ h	Lactation, estrogen warnings (never in daily smoker > 35 yo, h/o DVT/PE/CVA/MI, SLE with APA, migraine w aura + FNDs)	$10-62/ mo
POPs (progestin-only pills)	0.5%	3-5%	Safe in lactation (applies to all progestin-only)	Intermenstrual bleeding, spotting	24 h		$10-50/ mo
Ortho evra (patch)	1.07%	9%	Simpler than pills	Doesn’t work well >90kg, double risk VTE compared w/ OCPs	7 d	Lactation, estrogen warnings	$82/mo
Nuvaring	1.28%	9%	Simpler than pills	Vaginal discharge	7 d	Lactation, estrogen warnings	$83/mo
Depo provera	0.3%	6%	Amenorrhea in 55% at 1 yr, 68% by 2. Decreases crises in SCD	Irregular bleeding, wt gain 3lb/yr, reversible bone loss	3 mo	possible pregnancy, local cellulitis	$50-95/ shot
Nexplanon	0.05%		No GU tract procedure. Palpable by patient	Unpredictable bleeding that doesn’t Δ w/ time. 10% rule for 1) irreg bleeding, 2) wt gain, and 3) acne	3 yr	possible pregnancy, local cellulitis	$500-750
Mirena/ Skyla	0.2% for yr 1 0.7% by yr 5		Amenorrhea in 20% and oligo in 60% at 1 yr	Irregular bleeding first 3-6 months	5 yr/ 3yr	IUD contraindications (<6wks postpartum, uterus sounds >8cm, possible pregnancy, untreated GU infxn incl PID in past 3 mo) plus brca, anticoagulant use, liver dz/tumor	$400-900
Paragard	0.6-0.8%		No hormones	Increased bleeding with natural cycle	10 yr	IUD contraindications plus Wilson’s	$500-900
Creighton	0.14-0.5%		Translates into GYN managmt, distance teaching	Very involved charting and follow-up	∞	Language barrier, h/o noncompliance
Billings	1.1-3.2%	10.5-22%	Simple	Needs follow-up	∞	Language barrier, h/o noncompliance
Marquette	2.1%	14.2%	Objective, online teaching available	Monitor $200 Strips $35/30 (need 10+/mo)	∞	Language barrier, h/o noncompliance, not good with devices
CCL	0.4-0.6%	1.43-2.2%	Thermom $10 Couples only	Most difficult rules	∞	Language barrier, h/o noncompliance

I always put something in her hand if she wants to try a natural method. That's the way the prescriptions and devices work: there's always a pill pack, a crisp, robust brochure, or a prescription at the end of conversations for contraceptives. When I refer a patient to an NFP teacher, I hand her a nifty little packet (I made a bunch of these) with the person's business card and a page detailing her new method of family planning and singing its praises.

Prices for FABMS vary by location and teacher. I called around to get prices for each of the teachers I refer to (MM, CrMS, and BOM in my new metroplex) so that I can tell the patient what to expect.

---

Sources: the chart is reprinted from FACTS with the author's permission. Her sources:
Cost estimates: 1 and 2.

Mirena data: PI.

Depo data: PI.

Nexplanon data: PI. (No pregnancy rate, so I used the norplant datum from the paragard PI, which matched the CDC data linked below.)

Nuvaring data: PI.

Patch data: PI. 

Paraguard PI is here, but there aren't any numbers on increased bleeding.

Effectiveness: CDC (6% for depo)

The big chart you might see everywhere is from Trussell J. Contraceptive efficacy. In: Hatcher RA, Trussell J, Stewart F, Cates W, Stewart GK, Kowel D, Guest F. Contraceptive Technology: Seventeenth Revised Edition. New York, NY: Irvington Publishers; 1998.

FABM review here.

List of NFP-Friendly OB/GYN Programs

This list is a composite of a list created in 2008 and updated in 2015. It reflects word of mouth from applicants and interviewees and does not represent program directors' opinions or desires. Not all programs on this list are equally enthusiastic, and not all programs listed here may have been honest with the applicants who passed on the word about them. Disclaimer: this list doesn't exempt you from talking to people and using good judgement at interviews!

In no particular order:

• MedStar/Washington Hospital Center (Washington, D.C.; has absorbed previously recommended Georgetown)
• Exempla St. Joseph (Denver, Colorado)
• Phoenix Integrated Residency (Phoenix, Arizona)
• St. Louis University (St. Louis, Missouri)
• Mercy Hospital (St. Louis, Missouri)
• Presence St. Joseph (Chicago, Illinois)
• Presence St. Francis (Evanton, Illinois)
• University of Illinois College of Medicine (Peoria, Illinois)
• Grand Rapids Medical Education Partners (Grand Rapids, Michigan)
• St. Joseph's Mercy (Ann Arbor, Michigan)
• Loma Linda University (Loma Linda, California)
• Baylor University Medical Center (Dallas, Texas)
• Methodist (Dallas, Texas)
• Methodist (Houston, Texas; has absorbed previously recommended St. Joseph's)
• Baylor College of Medicine (Houston, Texas)
• Memorial Hermann (Houston, Texas)
• Texas A&M University/Scott and White (Temple, Texas)
• University of Texas Southwestern (Austin, Texas)
• SUNY, Sisters of Charity (Buffalo, New York)
• Florida State University (Pensacola, Florida)
• Louisiana State University (Baton Rouge, Louisiana)
• St. Francis Care (Hartford, Connecticut)
• Creighton University School of Medicine (Omaha, Nebraska)
• Tulane School of Medicine (New Orleans, Louisiana)
• Wright State College of Medicine (Dayton, Ohio)
• University of Minnesota (Minneapolis, Minnesota)
• University of Utah (Salt Lake City, Utah)
• University of Cincinnati (Cincinnati, Ohio)

Do you use NFP? Be Pro-Environment...

I am at Billings teacher-in-training and I'm also being trained as a medical consultant for the Creighton model FertilityCare system. At both BOMA and CrMS trainings, I was told something terrifying: the charts are getting harder to read. They're getting weirder and more difficult to interpret. Dr. Hilgers himself said this multiple times, when speaking exclusively to the medical consultants-in-training.

Why is this? Apparently, it has to do with where women live. A FertilityCare Educator (teacher of teachers) explained that she was once supervising two new practitioners (Creighton teachers). One practitioner had clients with perfect charts. Every single chart looked like the textbook cycle! (The Educator almost didn't believe her.)

At the same time, the other practitioner had messy, long, confusing, patchy cycles that needed loads of help, management, and doctor help to understand. The clients of both practitioners were all around the same age and demographic (the typical NFP user). The only difference: the clean charts were from rural North Dakota, and the nasty charts were from New York City. The Educator attributed the difference to pollution.

This scared me.

There are certainly other factors at work in this anecdote. Even so, this needs more research, because this could mean the beginning of the end of mucus based fertility awareness methods. If people can't make valid observations and be confident in their own interpretations, how can they use their fertility to plan their family naturally? I feel like I'm putting on an aluminum foil hat, but it's the truth: if we can't rely on observations and sensations, we can't use methods like BOMA or CrMS.

Even if the health of our environment is only one factor in the health of women, I would feel more motivated to care for it to help families use NFP. Meanwhile, more research is needed to discover how much pollution contributes to cycle irregularity. (I've put it on my list of research projects to do.)

If you're a couple using NFP, you know it's not easy! If you think NFP is a good thing (and that it's already hard enough, thanks), you may want to be more earnest about good environmental stewardship.

Eight weeks of Freedom!

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

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

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

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

Residencies' Reactions to My Choices

I interviewed for twelve categorical (four-year) OB/GYN positions at programs all over the country. Overall, most of them received my choices (not to prescribe, sterilize primarily, or abort) well. This surprised me. In retrospect, I think this largely had to do with careful selection of the programs and the fact that I was a very, very good applicant. (I scored in the 96th percentile on STEP 1 and the 80th percentile on STEP 2 CK, and most OB/GYn applicants in last year's match floated just under the 50th.)

Some programs challenged me, though. I was told at one program that my counseling on contraceptives would have to be observed and checked off (not usually a skill that needs to be observed and checked off), so that the program director could be sure I was being unbiased and using evidence to talk about NFP. I was told at another that I couldn't teach NFP in the clinic because it would be (to paraphrase) a disservice to the women of a certain demographic (poor women with less education). A third program said that my choices would not be compatible with what they saw as mandatory for the education of an OB/GYN (I won't be ranking them).

Everyone was polite. But it was clear in those three settings that what I am choosing to do is not an
equivalent alternative to mainstream gynecology.


There were other programs that were off-putting because of their liberal cultures. The program where "every" resident had "their" IUD and carried little Mirena samples on their ID badges to show to patients. The program where the endearing favorite professor was dear because he was the "gay friend" to all the residents, and heroically did sex-change surgeries. And finally, the Catholic hospital that repeatedly reassured us that the ERDs "do not get in the way of providing what your patients need."

But I'm happy to say that I have a strong top six programs, at any of which I would be happy. Truth be told, I'd be happy to be an OB/GYN at any of the programs I'm ranking, so I'm very grateful to God that he made all this possible!

The Truth Turned Someone Away from an IUD

Because of my conversation with a patient, she chose not to have a hormonal IUD implanted, a form of long-acting contraception that can end a zygote's life. All I had to do was tell her how it worked.

I was on an audition rotation in a pretty pro-birth control clinic. A young patient with extremely severe menorrhagia was failing oral management (i.e. NSAIDs and high-dose birth control pills weren't helping). Her compliance with daily pills was in question and at the last visit my attending, Dr. L, had discussed mirena with her. I would have been comfortable giving her a mirena, except that she was sexually active. And I know that the mirena can cause damage to a zygote ("fertilized egg" to some, but a person nonetheless). So I told her that the attending would be speaking with her about that prescription, but that there were nonhormonal options, too (lysteda or amicar). I counseled her about the nonhormonal options and about mirena and nexplanon. She couldn't decide what she wanted to do.

"What would you do?" she asked. My heart sang.

"HA! She ASKED," I thought victoriously. "I told myself that I wouldn't make my own recommendations in opposition to the attending unless explicitly asked. AND SHE ASKED!"

"Actually," I said aloud to the patient, "I don't recommend mirena." I explained how it affects the endometrium and can cause loss of the cells that forms after sperm and egg fuse. "And when that embryo is lost, that's an early miscarriage. And I don't want that--"

"I don't want that either," broke in the patient.

"--so I won't in conscience recommend mirena to my patients. But Dr. L does prescribe it, so..."

"No," the patient said. "I guess I'll try the other things."

I left the room promising to bring back a pamphlets on those meds. I returned to the charting room and faced the pamphlet rack. As I pulled out a lysteda brochure, Dr. L said, "Tell me about your lady."

I presented her. "This is your 14-year-old African American patient with a two year history of disabling dysmenorrhea. She hasn't had relief with ibuprofen, orthocyclen, or ogestrel; we talked about mirena and nexplanon but she's interested in something non-hormonal. I counseled on lysteda and she wants more information. Physical exam is benign, she's had guardasil, and HEADS survey is unchanged since last visit; same male partner, 100% condom use. No tobacco, alcohol, or drugs."

My attending was pleased with my presentation, but not pleased that the patient didn't want a mirena. Dr. L joined me at the pamphlet rack and began to pull out brochures for nuvaring, nexplanon, and skyla. She stuffed the sheaf into my hands and sent me back into the patient's room.

(Skyla, btw, has the a disturbingly and tragically accurate advertising campaign, featuring sexually-active women explicitly prioritizing activities over children. How can people ignore the identical mindset behind contraception and abortion?)

I showed the patient the whole stack, but emphasized that everything that has hormones works like mirena. I gave her the pamphlet she wanted, and went back to my attending. "She's still going with lysteda," I said.

Then my attending went in with me. I was a little afraid that she might dissuade the patient from her decision. But this attending actually walks the walk when she supports "patient autonomy," so my patient was allowed a limited trial of lysteda. I have no idea what happened after that, but at least for now, that patient is aware of what hormonal contraceptives can do.

Fund a Battleship

I'm going to the Pope Paul VI Institute (PPVI) medical consultant program in November! This is a six-month thing with two on-site weeks in Nebraska at PPVI. It's going to cost about $5,000, so I'm fundraising. Tell EVERYONE you know! Even if you don't donate: go to the page, comment with Facebook, tell more people to do the same. Let's make it the most popular gofundme ever!!

My Plans for the Future

For a long time, I've thought about where the best use of my God-given skills and education lies. How can I provide the best care to women, the best example to my peers, and the best remedy to our culture?

I want to be a doctor to the whole person and that includes maintaining education in primary care areas as well as in OB and gynecology. I also think having an in-house NFP teacher, in-house dietician, and in-house psychologist (IPS, anyone?) would be excellent. A multispecialty group practice appeals to me, so that whatever practice I have can be a patient-centered medical home.

Of course, part of the future is offering women's healthcare in accord with Catholic teaching, which is to say to offer the best women's healthcare. Perhaps I would imitate Mystical Rose or Caritas Complete Women's Care or the Vitae Clinic with my own private practice. Maybe I would imitate Tepeyac Family Center/Divine Mercy Care and become an ACO.

St. Guiseppe Moscati, doctor to the poor
(well, the very romanticized movie version)

Also, I see many groups of women who are frequently forgotten: the uninsured, the illegal immigrants and refugees, religious, the abused, former prostitutes and drug addicts, the incarcerated, and the difficult. I want to find and care for these women, even though I might have trouble keeping the lights on!

Becoming a subspecialist in a maternal-fetal-medicine (MFM) also appeals to me. As an MFM, I could operates on the unborn, work with infertile couples, and take care of very high-risk pregnancies, also appeals to me. I have this dream of showing people how human the unborn are, how like us and how worthy of attention they are. What if we could re-implant babies who implanted in the wrong place? What if we could treat things like Potter's syndrome? (What if we could pull out all the "medical reasons" for abortion?) There are other advantages to this idea, too: my refusal to prescribe contraceptives and refer for abortions might irk fewer colleages if I was in MFM and had fewer occasions to do these things.

♪  MFM  ♪

But as much as I like the MFM dream, a subspecialty (long fellowships, expensive services) take me a little away from the poor. So I always thought I would have to choose: to serve the poor in those impoverished or those unborn. But what if these didn't conflict?

If I started a women's healthcare center and used midlevel professionals (NPs and PAs) and allied health (nurses, MAs, psychologists, social work, and dieticians) to establish a large group of primary care and OB/GYN providers for women, we could serve the poor and offer cutting-edge infertility and prenatal service with excellent gynecology. That's the future I'm working for now. (Now, if you'll excuse me, I need to go study for a shelf exam so that people don't laugh in my face when I say I want to do a surgical subspecialty.)