In 1973 I was a senior in high school.  On January 22^nd the Supreme Court handed down their decision, in Roe v. Wade, making abortion legal in the United States.  Prior to this date girls who got pregnant in my high school disappeared for many months.  Some eventually returned to school.  Some did not.  Since that date girls and women of reproductive age have had the ability to decide if and when to have children.  It has made a world of difference.

Sadly, since 1973 there have been many restrictive abortion laws passed at both the federal and state level.  The last two years have seen record numbers of such laws.  It is clear, however, that abortion is part of normal health care for many women.  About one-third of women in the United States will have at least one abortion in her lifetime.

As a physician my goal is that my patients not only be healthy themselves, but that they be in healthy relationships and have healthy families.  Choosing when to have a pregnancy or whether to carry a given pregnancy to term gives a woman a much greater chance of having a healthy pregnancy and a healthy life.  And each and every woman deserves that chance.  As a result I will happily help her keep from getting pregnant, until she wants to, by providing her with her chosen method of contraception.  I will also happily help her end a pregnancy that isn’t one she wants to carry, whatever her reason may be.  A woman only has control over her pregnancy decisions if abortion is available to her.  My goal is not only to provide accessibility to abortion, but to make sure each woman feels well cared for, does not feel judged and gets great patient-centered, evidence-based medical care.

Deborah Oyer, MD

In this year’s May 24th issue of the New England Journal of Medicine is a study confirming what we at Aurora Medical Services have known for years — women and girls have fewer unplanned pregnancies if they use longer-acting methods of contraception.

The study looked at unintended pregnancy rates in 14- to 45-year-olds.  What they found was a contraceptive failure rate of women using the pill, patch or ring that was 20 times higher than the failure rate of women who used IUDs, implants or injections.  The data also said that the risk of unintended pregnancy of pill, patch or ring users who were less than 21 years of age was significantly higher than for pill, patch and ring users 21 years of age and older.

Part of the increased effectiveness of the longer-acting methods of contraception is due to the fact that more women continue to use them for a longer period of time.  12 months after starting the pill, patch or ring only 49 – 57% of women are still using them.  This is compared to women who chose IUDs and implants.  12 months later over 80% of women are still using IUDs and implants.  So more women still using their chosen method, along with the inability to “mess up” their method (missing a pill, for example), leads to the significantly fewer unplanned pregnancies.

Please feel free to call with questions about the longer-acting methods of contraception.  Or better yet, come in for an appointment and get one.

http://www.nejm.org/doi/pdf/10.1056/NEJMoa1110855

Deborah Oyer, MD

Patients are often confused about what is happening when they see a health care provider for a pelvic exam.  Some people think that a pelvic exam and a pap smear are the same thing.  They are not.  One cannot do a pap smear without doing at least part of a pelvic exam.  But a pelvic exam does not necessarily involve a pap smear.  In addition, having had a pelvic exam does not mean that you have had STD testing.

A pelvic exam is an inspection of the woman’s genital area – both by looking and by feeling. A pelvic exam is done for several reasons.  It is usually done each year as part of an annual health maintenance exam to make certain that everything looks and feels normal.  A pelvic exam is also done when a woman is having symptoms such as abdominal pain, pelvic pain, abnormal vaginal bleeding, or abnormal vaginal discharge.

In general the first part of a pelvic exam involves a visual inspection.  The provider doing the exam first looks at, and likely feels, the external genitalia (the vulva or outside area of the genitals).  Then a speculum (see pictures below) is placed in order to be able to see inside (the vagina and the cervix).  During the inspection of both the outside and the inside the examiner is looking for several things:  changes in color of the skin or tissue lining the vagina, lesions (bumps or sores), abnormal gland swelling, abnormal vaginal discharge, to name a few.

It is while the speculum is in that other tests are done.  Swabs can be used to test for sexually transmitted diseases and vaginal infections.  Some of those swabs need to be sent to an outside laboratory for testing.  For those swabs it takes several days to get the results.  Some tests can actually be done in the office lab so you will have the results of those before you leave that day.

This is also the time that a pap smear would be done.  Like many things in medicine the pap smear is named for the doctor who invented it:  Dr. Papanicolaou.  The pap smear is a screening test used to look for pre-cancerous or cancerous cells of the cervix. (The cervix is the part of your uterus that opens into your vagina.)  A small, soft plastic brush is used to collect cells from the cervix.  The cells are then placed in a small jar which is sent to the outside lab to be examined there.  It takes several days to a week to get the results back.   The results can range from normal to cancer.  The vast majority of pap smear results are normal or pre-cancerous.  It is very, very rare to get back a result of cancer.  How often you need a pap smear depends upon your age and on the results of not only your most recent pap smear, but of your previous smears as well.  The current recommendation is to begin having pap smears at age 21.

After the health care provider has looked at your vagina and cervix, and taken any swabs necessary for testing, the speculum is removed from your vagina.  Then the second part of the pelvic exam is done.  This is called the bimanual exam.  The provider uses two hands to feel the pelvic organs (uterus, fallopian tubes, ovaries).  S/he will put two fingers into your vagina while the other hand is on your lower belly.  By gently pushing with both hands the provider can feel your organs.  What we are feeling for is whether anything feels enlarged, whether the exam causes pain (the exam will cause you to feel pressure and some discomfort, but you shouldn’t feel true pain), whether we feel anything abnormal.

A pelvic exam isn’t comfortable, but as stated above, it shouldn’t hurt either.  It will be more comfortable if you have emptied your bladder beforehand.  It is also much more comfortable if you can relax during it (easier said than done, I know).  If something hurts it is very important for you to speak up and say so.  This is true both for the speculum exam and the bimanual exam.

In summary, a pelvic exam is a visual and manual inspection of the pelvis.  Any given pelvic exam may or may not include testing for STDs, vaginal infections and cervical cancer (a pap smear).  Ask your provider what is going to be done before they begin.  It is important that you be a partner in your own health care.

Deborah Oyer, MD

http://www.theintellectualdevotional.com/blog/2010/02/09/the-cervix-gatekeeper-of-the-uterus/

Speculum

http://www.quickmedical.com/sklar-pederson-vaginal-speculum.html

http://women.webmd.com/pelvic-examination-with-speculum

Today, due to the Affordable Care Act, women with health insurance now have some great changes to their plans.  This poster from UltraViolet highlights the changes.

http://act.weareultraviolet.org/signup/healthbenefits_c/?source=uv_website#

One example of the change this makes happened in our office today.  We called the health insurance company of a patient who is scheduled to have an IUD inserted here tomorrow in order to check on her insurance benefits.  Her insurance company told us that they will pay fully for both the insertion and the IUD itself.  The woman herself will pay nothing.  If her appointment was yesterday she would have paid $547 out of her own pocket!

What a difference a day makes!

Deborah Oyer, MD

Finally frustrated enough with legislative intrusion into the doctor-patient relationship I wrote the following letter that was published in the New England Journal of Medicine last month.

http://www.nejm.org/doi/full/10.1056/NEJMc1205009

N Engl J Med 2012; 366:2326-2327.  June 14, 2012

To the Editor:

Since becoming an abortion provider in 1991, I have watched as barriers to abortion have been erected by legislatures around the country. Many laws have undermined the doctor–patient relationship — mandating that doctors say things to patients that are blatantly untrue, requiring that specific tests be performed whether the doctor thinks they are necessary or not, and requiring waiting periods regardless of whether the woman and her doctor think she is confident in her decision.1 Arizona Senate Bill 1359, however, threatens to undercut the doctor–patient relationship most of all.

This bill gives a doctor the right to withhold information about the health of a fetus. The doctor cannot be sued for malpractice if he or she thinks that revealing these findings might influence a woman to have an abortion. In addition, once the child is born, no lawsuits can be filed regarding the child’s disability.

This law gives doctors the right to lie to their patients. Over the past 20 years, as each new antiabortion law has seemed more outrageous than the last and encroached further on the doctor–patient relationship, I have wondered, “Where is the outrage in the medical community?” Until recently, doctors who do not work in family planning have not come forward to question such legislation. In the past few months, a handful of physicians have spoken up about bills requiring ultrasonographic examinations before abortions.2 And I appreciate that they have spoken up so eloquently.

But, quite frankly, I wonder why so few have come forward and what has taken them so long. Arizona passed a bill that legitimizes lying to one’s patients. Where were the medical associations testifying against this law? Why did they not pull out their full lobbying power to put a stop to this intrusion into the doctor–patient relationship?

How does a doctor’s ability to stop an abortion supersede a woman’s right to full knowledge of her medical condition? Doctors in the antiabortion movement continue to declare themselves more virtuous than me. But I ask which one of us tells only the truth to our patients, and which of us is willing to lie to get what we want. I will not lie to my patients, no matter how difficult it may be to deliver the news. I trust them to ask good questions and make educated decisions, with my help if they ask for it. I had hoped that the rest of the medical community shared my beliefs about being honest with patients. I am greatly saddened to learn otherwise.

1. Gold RB, Nash E. Troubling trend: more states hostile to abortion rights as middle ground shrinks. Guttmacher Policy Review, Winter 2012 (http://www.guttmacher.org/pubs/gpr/15/1/gpr150114.html).
2. Abston P. Pediatrician speaks out against forced ultrasound/abortion legislation written by Senator Clay Scofield in Alabama (http://www.youtube.com/watch?v=G2KEkvFQ3g4).

A Letter to the Editor in the New York Times this week responds to my last blog post.  I have been wondering why doctors have not been actively speaking up about the laws that have been debated and enacted in the Congress and the state legislatures.  There has now been a slow trickle of doctors responding.  This letter comes from the president of the American Congress of Obstetricians and Gynecologists.  I continue to wonder where are all the other doctors in all of the many medical fields.  While the current laws are effecting reproductive health, the precedent this sets for government involvement in health care is concerning and could expand easily to other areas of medicine.

Deborah Oyer, MD

To the Editor:

Re “The Campaign Against Women” (editorial, May 20):

The onslaught of laws focusing on denying reproductive health care rights is a concerted campaign against women. These laws are not grounded in science or evidence-based medicine.

The American Congress of Obstetricians and Gynecologists believes that access to family-planning counseling and to the full array of contraceptives is a basic and essential component of preventive health care for women.

Efforts to defund Planned Parenthood, which provides cervical cancer and mammography screening, contraception and other preventive care to millions of women, are egregious and disproportionately hurt poor women.

As physicians for women’s health care, ob-gyns see firsthand the havoc that punitive ideology-based laws have on the health of women and their families. These ill-conceived laws are based on the pretext of protecting health, but they do anything but that.

Mandating that women be legally forced to undergo transvaginal ultrasound or any other medical procedure against their will and against their physician’s judgment is an outrageous violation of patient autonomy and the confidential doctor-patient relationship. Decreasing access to family planning and contraception will only increase unintended pregnancies and negatively affect family and societal health.

Politicians were not elected to, nor should they, legislate the practice of medicine or dictate the parameters of the doctor-patient relationship. Our message to politicians is unequivocal: Get out of our exam rooms.

JAMES T. BREEDEN
President, American Congress
of Obstetricians and Gynecologists
Washington, May 22, 2012

The New York Times, last week, ran an editorial outlining the current assault on women’s rights. Some of the laws being discussed have passed, some not. These laws are being discussed and passed in state legislatures, as well as in our federal government. While we in Washington State are currently not dealing with any such legislation, if this year’s elections don’t go the right way, we could be dealing with efforts to curtail women’s rights here in Washington very soon. Please read this and remember women’s rights when you vote this year, and every year.

Deborah Oyer, MD

Editorial,

Published: May 19, 2012

The Campaign Against Women

Despite the persistent gender gap in opinion polls and mounting criticism of their hostility to women’s rights, Republicans are not backing off their assault on women’s equality and well-being. New laws in some states could mean a death sentence for a pregnant woman who suffers a life-threatening condition. But the attack goes well beyond abortion, into birth control, access to health care, equal pay and domestic violence.

Republicans seem immune to criticism. In an angry speech last month, John Boehner, the House speaker, said claims that his party was damaging the welfare of women were “entirely created” by Democrats. Earlier, the Republican National Committee chairman, Reince Priebus, sneered that any suggestion of a G.O.P. “war on women” was as big a fiction as a “war on caterpillars.”

But just last Wednesday, Mr. Boehner refuted his own argument by ramming through the House a bill that seriously weakens the Violence Against Women Act. That followed the Republican push in Virginia and elsewhere to require medically unnecessary and physically invasive sonograms before an abortion, and Senate Republicans’ persistent blocking of a measure to better address the entrenched problem of sex-based wage discrimination.

On Capitol Hill and in state legislatures, Republicans are attacking women’s rights in four broad areas.

ABORTION On Thursday, a House subcommittee denied the District of Columbia’s Democratic delegate, Eleanor Holmes Norton, a chance to testify at a hearing called to promote a proposed federal ban on nearly all abortions in the District 20 weeks after fertilization. The bill flouts the Roe v. Wade standard of fetal viability.

Seven states have enacted similar measures. In Arizona, Gov. Jan Brewer signed a law that bans most abortions two weeks earlier. Each measure will create real hardships for women who will have to decide whether to terminate a pregnancy before learning of major fetal abnormalities or risks to their own health.

These laws go a cruel step further than the familiar Republican attacks on Roe v. Wade. They omit reasonable exceptions for a woman’s health or cases of rape, incest or grievous fetal impairment. These laws would require a woman seeking an abortion to be near death, a standard that could easily delay medical treatment until it is too late.

All contain intimidating criminal penalties, fines and reporting requirements designed to scare doctors away. Last year, the House passed a measure that would have allowed hospitals receiving federal money to refuse to perform an emergency abortion even when a woman’s life was at stake. The Senate has not taken up that bill, fortunately.

ACCESS TO HEALTH CARE Governor Brewer also recently signed a bill eliminating public funding for Planned Parenthood. Arizona law already barred spending public money on abortions, which are in any case a small part of the services that Planned Parenthood provides. The new bill denies the organization public money for nonabortion services, like cancer screening and family planning, often the only services of that kind available to poor women.

Gov. Rick Perry of Texas and the state’s Republican-dominated Legislature tried a similar thing in 2011, and were sued in federal court by a group of clinics. The state argues that it is trying to deny money to organizations that “promote” abortions. That is nonsense. Texas already did not give taxpayer money for abortions, and the clinics that sued do not perform abortions.

Last year, the newly installed House Republican majority rushed to pass bills (stopped by the Democratic-led Senate) to eliminate funding for Planned Parenthood and Title X. That federal program provides millions of women with birth control, lifesaving screening for breast and cervical cancer, and other preventive care. It is a highly effective way of preventing the unintended pregnancies and abortions that Republicans claim to be so worried about.

EQUAL PAY Gov. Scott Walker of Wisconsin, the epicenter of all kinds of punitive and regressive legislation, signed the repeal of a 2009 law that allowed women and others to bring lawsuits in state courts against pay discrimination, instead of requiring them to be heard as slower and more costly federal cases. It also stiffened penalties for employers found guilty of discrimination.

He defended that bad decision by saying he did not want those suits to “clog up the legal system.” He turned that power over to his government, which has a record of hostility toward workers’ rights.

President Obama has been trying for three years to update and bolster the 1963 Equal Pay Act to enhance remedies for victims of gender-based wage discrimination, shield employees from retaliation for sharing salary information with co-workers, and mandate that employers show that wage differences are job-related, not sex-based, and driven by business necessity.

DOMESTIC VIOLENCE Last month, the Senate approved a reauthorization of the Violence Against Women Act, designed to protect victims of domestic and sexual abuse and bring their abusers to justice. The disappointing House bill omits new protections for gay, Indian, student and immigrant abuse victims that are contained in the bipartisan Senate bill. It also rolls back protections for immigrant women whose status is dependent on a spouse, making it more likely that they will stay with their abusers, at real personal risk, and ends existing protections for undocumented immigrants who report abuse and cooperate with law enforcement to pursue the abuser.

Whether this pattern of disturbing developments constitutes a war on women is a political argument. That women’s rights and health are casualties of Republican policy is indisputable.

From today’s The Daily of the University of Washington, by reporter Kaitlynn Miller:

The UW chapter of Medical Students for Choice and Revolution Books are co-sponsoring an event to discuss safe abortion care, access to contraceptives and medical care, and age-appropriate sexuality education.

“[The abortion controversy] has become and remained such a fault line for decades because it really gets to the heart of what you see in women,” said Sunsara Taylor, writer for Revolution Newspaper and supporter of the Revolutionary Communist Party.

Medical Students for Choice is trying to teach doctors how to practice safe and compassionate abortion procedures, educate UW students about abortion, and help people to understand the role the anti-abortion movement has played in the lives of women and doctors.

Marcy Bloom, U.S. capacity development officer for GIRE, said the anti-choice movement has tried to scare women.

“Women are able to make the best decisions about their lives, bodies, and pregnancies, and we as a society can trust women,” Bloom said.

Strong advocates of educating students about safe abortion and the right to contraceptives also believe the anti-abortion movement views clinic staff, women, and abortion providers as bad people.

“It has become more and more difficult for women to have access to safe abortion care in this country,” Bloom said.

Supporters of abortion think it’s a good opportunity to talk to college students about what has been happening in the fight for women’s rights and freedom in 2011 and 2012. Bloom said there has been a 30 percent increase in the number of “anti-choice” bills passed in the United States.

Dr. Deborah Oyer, a physician at Aurora Medical Services in Seattle, said the age of most college students (18 to 25 years old) is when most women have abortions.

“Having people talk about it can be a very positive thing because it brings it out of the closet and normalizes it,” Oyer said.

Bloom said it is critical to view abortion not as a stand-alone issue, but as an entire fabric of a woman’s life, her reproductive rights, and her future. Fifty million women in the United States have made the choice of abortion since the 1970s.

“It is a much, much needed medical procedure that is difficult to obtain, and it is all about women and women’s place in society,” Bloom said.

Taylor said women should be able to move forward and expand their rights, and there is no moving forward without having the right to abortion and without apology. Over one-third of women will have an abortion.

The event organized by Medical Students for Choice wants to give deeper understanding of the reality that society is losing the war on women.

“We don’t have to lose this war if we change how we’re acting,” Taylor said. “We need to fight for the lives of women.”

The panel will be tonight at 6 p.m. in the Health Sciences Building, room T-435.

Reach reporter Kaitlynn Miller at news@dailyuw.com.

http://dailyuw.com/news/2012/mar/27/student-group-aims-change-abortion-conversation/

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