Published in the Seattle Times Sunday, February 12, 2012

This week the FDA, after very careful consideration and exhaustive research, determined that Plan B should be available over the counter to everyone.  Right now it is available over the counter to anyone who is 17 years old or older.  Before the FDA could announce their decision, Kathleen Sebelius, the Secretary of Health and Human Services, overruled the FDA’s decision and demanded that the FDA continue their current rules.

The American Academy of Pediatrics, the American Congress of Obstetricians and Gynecologists, and the American Medical Association all agreed with the expert advisory committee that recommended approval of true over-the-counter status.  For the first time in history, Kathleen Sebelius, with no medical training, chose to go against the advice of all of the medical experts and overturn the FDA decision.  As Secretary of Health and Human Services this is well within her right.  However, it was the wrong decision.

First of all, President Obama promised that his administration would not let politics interfere with science and decisions at the FDA.  When all of the research and all of the scientific experts say Plan B should be available over the counter to all ages and the Secretary of HHS overrules them, this is letting politics interfere with science.

Secondly, medications are kept from being available over the counter because of their potential danger.  Plan B (levonorgestrel) is very safe.  It will not harm the woman taking it; it will not harm her fetus if she is already pregnant.  It is, therefore, far safer than many other over-the-counter medications.  If misused, common over-the-counter pain medications can cause severe kidney damage (ibuprofen), severe liver damage (acetaminophen), or even death (both).  But anyone, of any age can walk into the drug store or supermarket and readily buy them.

Thirdly, Sebelius is worried about a teenager buying Plan B.  The worst thing that can happen to a teen taking Plan B is that it won’t work.  (And chances are that it will.)  The alternative, which is far more dangerous, is that a young teen becomes pregnant.  An unwanted pregnancy will have a significantly negative impact on a young teen both physically and psychologically.

I am sorely disappointed in this decision.  I had truly hoped that in this administration science would trump politics in FDA decisions. Sadly, this is not the case.

Deborah Oyer, MD

The contraceptive implant, Implanon, has just been replaced by a new implant called Nexplanon.  For those of you who have Implanon, have no fear.  Your Implanon is still working and is still safe.  Two things have changed about the implant.  The changes do not effect how well the implant works or how long it lasts.

The first difference is the inserter.  The insertion procedure is still very fast, with minimal discomfort to the patient.  The new design of the applicator is to increase the ease of insertion and to decrease the chance of an incorrect insertion.

This first picture is the old Implanon:  packaging, inserter and implant.  It comes courtesy of http://persephonemagazine.com.

This picture is of the new Nexplanon, with thanks to http://nexplanon.se.

The only other difference between Implanon and Nexplanon is the addition of barium sulfate to Nexplanon.  Barium sulfate is a metal used during x-ray studies.  The reason it was added to Nexplanon is to help locate the implant if it can’t be easily felt.  The need for x-ray studies to locate Nexplanon should be rare.  Barium sulfate, however, allows location of the rod by a much simpler and cheaper test than was required to locate an Implanon that could not be easily felt.  Barium sulfate has been used for ages in medical testing and is not toxic to humans because it can’t be absorbed by them.

Virtually all patients at Aurora Medical Services will be receiving Nexplanon from now on.

Deborah Oyer, MD

Published in the Seattle Times, Thursday, October 20, 2011

Swedish-Providence merger limits women’s access to safe abortions

Guest columnist Deborah Oyer raises concerns about women’s access to abortions in light of Swedish Medical Center’s decision to merge with Providence Health Services and stop allowing abortions in its hospitals and clinics.

By Deborah Oyer

Special to The Times

Originally published Wednesday, October 19, 2011

Women have another tool in the emergency contraception (EC) toolbox, and it’s called ella (yes, it’s spelled with a lower case “e”).  Ella is a pill (ulipristal acetate) that can be taken at any time in the 5 days after unprotected intercourse.  It is equally effective whether it is taken 4 hours or 4 days after sex.  It works by preventing ovulation during those 5 days.  This does not mean you are safe for the rest of your cycle until you get your period – you still should use a barrier such as condoms until your period comes.

In clinical trials ella reduced the risk of pregnancy from an expected 5.5% without EC to 2.2%.  This makes it more effective than other oral forms of EC (the copper IUD is still the most effective form of EC).  You do need a prescription to get ella at the pharmacy.  And because it is still relatively new, not all pharmacies carry it.  They may need to order it for you.  If you are an established patient with us, we are happy to call it in for you.  Ella may be more expensive than other oral forms of EC, but if you have insurance or DSHS it may be covered.

If you are using a barrier method as your primary form of contraception, we recommend keeping EC on hand at home.  Accidents do happen.  If they happen a lot, let’s see you for a discussion about other methods.

Susannah Herrmann, ARNP

I have now done abortions for over 20 years.  Day after day the women I see are surprised to learn how common abortions are.  Over one-third of women in the United States will have at least one abortion by the time they are 45 years old!  So why does each woman think she is in this by herself?  Because no one talks about their abortion experience.  Because very few people can say the word abortion aloud.  Because, in spite of the fact that so many girls and women will have abortions, we have allowed those who are against abortion to dictate the conversation and make most women feel like it is something shameful.  I truly believe that if we all talked more openly about abortion, both personally and in the abstract, it would become less shameful, like it ought to be.

The Feminists for Choice website recently posted “How to be Pro-Choice in 8 (and a half) Simple Steps.” This article shares ways of beginning the conversation in several different situations.  Here is my Washington State edition of their list:

1. Ask your family physician, gynecologist or primary care provider if she or he performs abortions. You want your regular provider to believe that women have the same rights in which you believe.  If they don’t perform abortions, ask them why?  Even if you don’t currently have an unplanned pregnancy, you want to know how that person would respond if you came to them with one.  If they wouldn’t respond appropriately you might want to change your provider to one who would.

2. Look beyond Planned Parenthood. Many cities also are home to independent family planning clinics, like Aurora Medical Services.  If you have had a good abortion experience or family planning experience at an independent provider, please tell your friends about us, like you would if you loved your primary care physician.

3. Vote! How you vote in every election is very important.  Always “vote your conscience.”  Even people running for offices that seemingly have nothing to do with abortion rights may go on from there to higher office and have lots of control over access to abortion.  It is particularly important to vote your conscience in the Presidential elections since the President chooses Supreme Court Justices.

4. Have the conversation.  Talking with your partner before having sex with him/her about STDs is something we all know is important.  It is also important to talk to your partner about how they would respond to an unplanned pregnancy.  This is information you should want to know, whether you are the one who can get pregnant or not.  Either way, your future depends on it.  (Also know that how one feels in the abstract about how they would handle an unplanned pregnancy may not be how they feel when and if it actually happens.)

5. Know your rights. Since abortion laws vary greatly from state to state it is important to know the laws in your area.  In Washington State we have no waiting period and no parental notification laws.  In addition, abortion is legal until viability.  In Washington State this means until the fetus has a reasonable likelihood of sustained survival outside the uterus without extraordinary medical measures.

6. Know your health insurance. Your health insurance plan may cover an abortion and it may not.  At AMS we can help you sort out your insurance coverage, which is sadly not often as clear-cut as we would like or expect it to be.

7. Support local abortion funds.  Local abortion funds help women without insurance or money to pay for their needed abortion, because no one should become a mother simply because she cannot afford an abortion.  These funds always need money.  And they can usually use volunteers as well.  In Washington State, the CAIR project is our local abortion fund. http://www.cairproject.org/

8. Talk about it. Part of why abortion is so stigmatized in the United States is because no one talks about it.  Yet because it is stigmatized it is difficult to talk about.  So let’s start talking about it.  And that means being able to say the word abortion without lowering your voice or your eyes.  Try it.

8 ½. And if you’re going to talk about it … pass this list on to your friends so they can talk about it as well!

Deborah Oyer, with great thanks to Sarah at Feminists for Choice

Beginning one year from today (August 1, 2012) virtually all health insurance plans must cover all government-approved contraceptives without co-payments or other fees, according to new standards issued by the Obama administration today.  While health plans offered by certain religious groups can opt out of this requirement, almost everyone else will have to abide by it.

In addition, the government will also require full coverage for many things, including but not limited to, screening for HIV, screening for HPV, and coverage for annual preventive-care visits.

All of this is fabulous news for women.  While those who are against abortion would have you believe that most unplanned pregnancies are due to irresponsible women who don’t use contraception by choice, I know from over 20 years of talking to women with unplanned pregnancies that a great many of them find themselves pregnant because they can’t afford to pay for their contraception.  Sometimes this is because their insurance coverage ran out, sometimes because their co-pay to actually obtain their contraception was too costly for them to manage.

In the United States about half of all pregnancies are unintended.  Starting next August, free access to one’s contraceptive of choice should help decrease the number of unplanned pregnancies significantly.

The subject of HPV (human papilloma virus) comes up a lot in my work.  I have HPV discussions with my patients on a regular basis, so I thought I’d share the main points of the discussion I usually have with women.  It usually begins when a woman’s pap smear comes back abnormal because the presence of the virus has caused her cervical cells to begin to change.

HPV is a very common sexually transmitted disease (STD).  An estimated 75-80% of people will get HPV by age 50.  There are more than 120 types of HPV and more are being discovered.  HPV is responsible for warts on our hands, feet, genitals, and for cervical cancer.  Most types are harmless and invisible.  Even the kinds of HPV that cause genital warts are not associated with cancers. There are a few types that, when they travel to the cervix, are known to cause changes to the cells that can turn into cancer.  Those types are considered high risk.

If you have HPV, there is no way we can tell you who gave it to you, or how long you have had it.  We can tell you that 80% of people get rid of the virus in a year, 90% in 2 years.  So statistics are on your side.  If you are smoking, quitting can give your immune system a boost to fight off the infection.  If you have warts (low risk HPV) you can either allow your body’s defenses to fight off the infection and the warts, or you can get them treated.  There are some treatments we can prescribe for your use at home, or you can come in to have warts frozen.

If you have high risk HPV and abnormal cells on your cervix, we will refer you for something called a colposcopy. This is examination of your cervix under magnification.  The provider may take biopsies if she sees abnormal areas.  Based on the results of your colposcopy and biopsies, you will receive a recommendation on the next step.  If the cells are not very advanced in their changes, your cervix does not need any treatment and we will most likely do paps more frequently for a period of time.  If the cells are more advanced, they will need to be removed from the cervix.  Having high risk HPV does not mean that you will develop cervical cancer.  Cervical cancer is a preventable disease IF you follow all recommended steps for evaluation and/or treatment.

One of the reasons HPV is so common is that it is very easy to pass to sex partners.  All it takes to give HPV to a sex partner is skin-on-skin contact.  While condoms certainly reduce the amount of skin that touches skin, they don’t eliminate it altogether.  So the risk is always there to some degree.  We do have vaccines that can help prevent HPV before you get it.  We carry the vaccine that protects against 4 types of HPV: the 2 types that cause most warts, and the 2 types that cause most cervical cancers.  Even if you already have some form of HPV, you may still benefit from getting the vaccine.  Ask us about it.

Since HPV is an STD, people want to know what to tell their partners.  It is an important discussion to have.  Talk about ways to protect your partner from the virus as much as possible (using appropriate barriers, whether your partners are men or women), but also include the encouraging statistics that by 2 years 90% of us will have cleared the virus.  It is possible to get HPV orally and anally, and it is associated with cancers in both of those sites.  However, since men do not have a cervix, the high risk strains of HPV that may cause cervical cancer in us do not affect them in the same way.

When we talk about all the different kinds of HPV, and how common it is, a lot of people ask to get tested for it.  But there is no such test.  Depending on your age group and other factors, we may test for high risk HPV only with your pap.  But there is no test to look for every kind of HPV in every person.  Since there are so many types, and the majority of them are benign, knowing if a person has one of the harmless types does not help us in any way.  Knowing about the presence of a high risk type however, is very important to help prevent the development of harmful disease.

This is a lot of information.  If the clouds have parted and you have a whole new understanding of HPV, great!  If you have more questions than ever, also great!  I love questions, in person, by phone, or by email at susannah@auroramedicalservices.com.

Susannah Herrmann, ARNP

Since the beginning of this year a record number of anti-abortion bills have been introduced in state governments.  The laws range from banning abortion outright to putting up many barriers to abortion care that do nothing to improve the actual care that is being delivered.  Many of the bills have not passed but over the past few weeks some very destructive bills have passed in other states.

Kansas has passed a law requiring that the Kansas Department of Health and Environment write “new facility standards” for abortion clinics.  These standards were finalized by the Department of Health and Environment on June 17^th.  This was the date on which they told the clinics in Kansas that they must be able to meet all of the requirements by July 1^st.  The new standards regulate the temperature of the clinic, the temperature of the recovery room, the amount of time a woman must spend in the recovery room after her procedure, the size of the operating room, the size of the janitor’s closet, the features of the staff dressing room, the features of the patient dressing rooms, the number of bathrooms, etc.  While claiming that these rules are to improve the health and safety of the women having abortions, as one who has been doing abortions for 20 years, I can tell you that these rules will not make an already very safe procedure any safer.  If that were really the goal, the Department of Health and Environment would have given a reasonable amount of time for the clinics to meet a more reasonable set of regulations.  What also makes it clear that this 36-page set of regulations is just to stop abortions is that there are 241 ambulatory surgical centers in the state but only the three clinics that do abortions are subject to the new regulations.

Luckily, last Friday a judge blocked enforcement of the new rules until they can be fully challenged in court.  So for now a Kansas woman’s access to abortion remains the same.

In Ohio last week the House of Representatives passed a bill outlawing abortion after the embryo has a heartbeat.  A very rudimentary heart begins to beat, and can be seen on ultrasound, somewhere between 5 and 6 weeks after a woman’s last menstrual period.  This correlates with about 1½ weeks after a woman misses her period.  This is also often before a woman has any symptoms of pregnancy.  A law, which again, makes abortion virtually impossible for a woman to attain.  Especially if one takes into account that in Ohio there is a law requiring a 24-hour waiting period.  The woman must go into the clinic and have her counseling/informed consent session with the doctor at least 24 hours before she actually has her abortion.  When the state is giving you only 7 to 10 days after a missed period to realize that you are pregnant, make a decision about the outcome of that pregnancy, find the money to pay for the abortion (because Ohio does not have public funding for abortion, or allow abortion coverage in the new state insurance exchange), perhaps arrange a ride to the clinic each day, arrange for childcare or coverage at work, taking away one of those valuable days for a 24-hour waiting period makes it all an even tighter timeline.

And these are just the most recent assaults on a woman’s ability to have a legal medical procedure.  According the NARAL Pro-Choice America, there have been three times as many anti-choice state bills this year as there were last year.  And this year the states have actually enacted 44% more bills this year than they did during the entire year of 2010.

And this is why I feel very lucky to live in Washington State.  At this point we have no laws such as these being passed in other states.  We don’t have extreme informed consent laws which require women to hear government-mandated lies about the risks of abortion (other states make the doctor tell the patient that this abortion will increase her risk of breast cancer or psychological problems in the future; both of which have been proven to be false by good scientific research), we don’t have a required waiting period between counseling and the abortion (we know that women have been thinking hard about their decision from the time they learn they are pregnant until they walk in our doors and they don’t need the state to tell them when they are ready to make a decision), we don’t have parental consent laws requiring a minor to involve one or both of her parents in her decision (we know that most minors do involve their parents and that laws forcing children to involve their parents lead to delays in care and to children sometimes taking matters into their own hands changing a very safe procedure into a dangerous situation).  In addition we in Washington State have public funding for abortion because we know that just because a woman can’t afford to have an abortion shouldn’t mean she has to have a baby.

But, we all know all of this could change with the next election.  That is why it is so important to know that even while the right to have an abortion has felt so secure for so many years keeping Washington State’s laws as women-friendly as they are is imperative.  Or we might end up like Kansas or Ohio, where we have the right to an abortion but don’t have the means to access one.

Deborah Oyer, MD

With virtually each patient encounter I, not surprisingly, find myself talking about contraception in quite a bit of detail. There is one conversation that comes up on a fairly regular basis.  It is one which I have had several times this week alone.  And that is whether a particular type of birth control is “natural” or not.  Which then of course raises the question, “Is something bad if it is not natural?”

The only truly “natural” methods of birth control are barrier methods (condoms, diaphragms, cervical caps), withdrawal and fertility awareness method.  Barrier methods need to be used with spermicides, which aren’t natural.  Which leaves condoms (many of which come with spermicide in/on them), withdrawal and fertility awareness method (FAM).  Withdrawal and FAM are completely natural.  Withdrawal, however, is quite unreliable and completely dependent on the male partner’s control.  FAM involves monitoring one’s body temperature each day, keeping track of when one’s period begins each month, monitoring the consistency of one’s cervical fluid, among other things.  It is labor intensive and requires one to be very dedicated to the process, and then to not have sexual intercourse, or to use a condom on the days that one is likely to be most fertile each month.  (Taking Charge of Your Fertility, by Toni Weschler, is a wonderful book that can guide you through FAM in great detail.)

The less labor intensive and more reliable options all involve hormones or chemicals that allow women to not have to spend as much time and energy each day thinking about their contraception.  They are more effective at preventing pregnancy.  None of them, however, is “natural.”  Birth control pills, the patch, the vaginal ring, the shot, the implant and one of the IUDs all contain hormones that are released into the woman’s blood stream and impact her menstrual cycle in several different ways.  (The hormones in these birth control methods are synthetic versions of the hormones made by all women.)  The other IUD includes copper which is also slowly released by the device.

With some of these methods, a woman continues to have regular, monthly periods.  With some she does not.  Some of these methods allow a woman to decide if she wants to get a period, and how often.  Since these periods are brought on by manipulating hormones, these periods also are not “natural.”

I would contend, however, that there is nothing bad about any of these types of birth control.  In fact, all of these medicated methods have some very real and positive effects on women’s health – some methods decrease the risk of certain kinds of cancer, some decrease menstrual cramps and bleeding, some decrease acne, to name only a few.  In addition, they give women, and couples, the security of knowing that the chance of getting pregnancy is very small.  Most of these methods have a failure rate of less than 2% with perfect use.  Even with the occasional mistake in taking one’s pill late, forgetting to change the patch on time, the failure rate is still considerably less than 10%.  Most barrier methods and withdrawal have typical use failure rates closer to 20 or 30%.

The longer-acting methods, the IUDs and the implant, have failure rates well less than 1% because once they are placed by your health care provider you can forget about them.  You don’t have to remember to use them each day or week or month.  They are there for years at a time.

So I don’t believe that birth control has to be natural.  I believe it needs to be safe, effective and have few side effects.  There is no birth control method that is perfect for everyone.  Since each woman is different, the only way to know if a particular method will work for you is to try it.  We are happy to help you find the right method for you.