INKLINGS Contraception—when did something so right go so wrong? As a reproductive endocrinologist, I spend much of my day helping patients choose when and how to build families—or not to have a family at all. Accordingly, the latest debate about the contraceptive mandate within the U.S. Affordable Care Act (ACA) and the recommendations in the listing of recommended basic benefits by the Institute of Medicine (IOM) have struck me as quite odd. Let us start by talking about the contraceptive benefits, then discuss the important noncontraceptive aspects that often are ignored in the debate. Fifty percent of pregnancies are unplanned. This does not mean the resultant children are not loved and do not go on to lead productive lives and enrich their families and society. However, the ability to determine the timing of and perhaps more importantly how many times for conception is a critical issue for many women. Internationally, the subjugation of women—in terms of decisions on when and who to marry, when to have children, and how many children to have— has a profound impact on societies. In countries where women are not educated and do not have free will regarding reproductive issues, there is more poverty, more political instability, and a perpetuation of the lack of education (for women and men) as the population grows. The ability to harness the power of all the world's citizens (men, women, and children) requires the ability to have planned pregnancies and to limit family size. The goals should be healthy pregnancies—pregnancies that are conceived in a healthy environment (with interpregnancy spacing, maternal nutrition, and no toxic exposures)—and children born into a society with the resources to educate them and to ensure they have adequate health care and vaccinations. This is not just a problem in underdeveloped countries. The United States has long lagged behind other developed countries with respect to family planning and contraceptive access and usage. This is not a religious issue—it is a health issue. Look, for example, to Catholic-majority countries of Europe such as France and Italy: sex education is more widespread, contraceptive (and even abortion) services are widely available, birth rates are down, and teenage sex and pregnancy out of wedlock are less common. Our values represent our internal guiding principles, which are developed over time through interactions with our parents and our communities. These values should not be driven by withholding education or access to any kind of contraception (condoms or hormonal contraception). It has been well proven that ‘‘abstinence plus’’ programs (where counseling about abstinence is included as well as information regarding sexually transmitted infections and contraception) are more successful at preventing early sex and unplanned pregnancies than ‘‘abstinence only’’ programs. Further, for some women, pregnancy presents significant health consequences such that effective contraception is a medical necessity. Beyond their contraception benefit, hormonal contraceptives are enormously powerful agents for the treatment of many conditions in reproductive-aged women. Oral contraceptive pills are the most commonly recommended treatment for women with polycystic ovary 32
syndrome. The estrogenic component increases sex hormone-binding globulin, which lowers free androgen and thus improves hyperandrogenic symptoms (hair growth and acne), and the progestogenic component protects the endometrium from the unopposed estrogen and the risk of endometrial cancer. Even for women without polycystic ovary syndrome, oral contraceptive pills are frequently used to control acne. In addition, it is mandated that young people take oral contraceptive pills when receiving some highly teratogenic medicines for acne or other indications. For many women, dysmenorrhea can be very effectively managed with oral contraceptive pills, as can endometriosis. Hormonal contraceptives are used to control abnormal uterine bleeding of a functional nature and to treat many women during the menopausal transition (which is, by the way, the second highest age group for unplanned pregnancy behind teenagers). Many women with primary ovarian insufficiency (premature ovarian failure) or hypoestrogenism from hypothalamic dysfunction, hyperprolactinemia, or other causes take combined hormonal contraception to prevent symptoms and protect the bones. The Mirena intrauterine device may be used to protect the endometrium during treatment with tamoxifen for breast cancer or as an adjunct to protect the endometrium during menopausal hormone therapy. It can be used for local suppression of central pain from endometriosis. In fact, no other pharmaceuticals available in the armamentarium of the gynecologist are as widely and successfully used in noncontraceptive cases. The separation of church and state—now in a perverse way being manipulated to support the restriction of access to contraception—protects my rights over my body. You may choose not to use contraception yourself, but you are not allowed to restrict my access (or that of my patients). As for who should pay for such treatment, a number of things that presently are covered for the ‘‘greater good’’ in our society do not personally benefit me or my family. This is part of the grand bargain we make to live in a society. For example, members of some religions choose not to drive on Saturday; however, they cannot deny transportation support on Saturdays to prohibit everyone else from driving. That is, even though you, as an individual, may choose not to drive, society requires that you continue to support public transportation, traffic control, and the lights and electricity that control the system. Likewise, in the health field, the same could be said for childhood vaccinations— the greater good supports coverage for vaccinations of all children, even though you may choose not to vaccinate your child. The political right believes in individual freedoms and fights against the intrusion of government in personal rights—until it comes to reproductive rights, the most personal aspect of humanity. In this area, the few (and it really is a vocal minority) are choosing to impose their views on society, to manipulate the argument regarding separation of church and state to promote their personal agenda at the societal level. Surveys suggest more than 99% of women between the ages of 15 and 44 years who have ever had sexual
VOL. 102 NO. 1 / JULY 2014
Fertility and Sterility® intercourse have used contraception at some time in their life (1). Given the importance of hormonal contraception for non-medical indications, and the significant role that pregnancy timing plays in the health of individuals and societies, the IOM and ACA recommendations for coverage should be incontestable. Marcelle I. Cedars, M.D. Department of Obstetrics, Gynecology and Reproductive Sciences, University of California-San Francisco, San Francisco, California http://dx.doi.org/10.1016/j.fertnstert.2014.04.052 You can discuss this article with its authors and with other ASRM members at
VOL. 102 NO. 1 / JULY 2014
http://fertstertforum.com/cedarsm-contraception-rightwrong/ Use your smartphone to scan this QR code and connect to the discussion forum for this article now.* * Download a free QR code scanner by searching for “QR scanner” in your smartphone’s app store or app marketplace.
REFERENCE 1.
Daniels K, Mosher WD, Jones J. Contraceptive methods women have ever used: United States, 1982–2010, National Health Statistics Reports, no. 62. Hyattsville, MD: National Center for Health Statistics; 2013. Available at: http:// www.cdc.gov/nchs/data/nhsr/nhsr062.pdf. Last accessed May 30, 2014.
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syndrome. The estrogenic component increases sex hormone-binding globulin, which lowers free androgen and thus improves hyperandrogenic symptoms (hair growth and acne), and the progestogenic component protects the endometrium from the unopposed estrogen and the risk of endometrial cancer. Even for women without polycystic ovary syndrome, oral contraceptive pills are frequently used to control acne. In addition, it is mandated that young people take oral contraceptive pills when receiving some highly teratogenic medicines for acne or other indications. For many women, dysmenorrhea can be very effectively managed with oral contraceptive pills, as can endometriosis. Hormonal contraceptives are used to control abnormal uterine bleeding of a functional nature and to treat many women during the menopausal transition (which is, by the way, the second highest age group for unplanned pregnancy behind teenagers). Many women with primary ovarian insufficiency (premature ovarian failure) or hypoestrogenism from hypothalamic dysfunction, hyperprolactinemia, or other causes take combined hormonal contraception to prevent symptoms and protect the bones. The Mirena intrauterine device may be used to protect the endometrium during treatment with tamoxifen for breast cancer or as an adjunct to protect the endometrium during menopausal hormone therapy. It can be used for local suppression of central pain from endometriosis. In fact, no other pharmaceuticals available in the armamentarium of the gynecologist are as widely and successfully used in noncontraceptive cases. The separation of church and state—now in a perverse way being manipulated to support the restriction of access to contraception—protects my rights over my body. You may choose not to use contraception yourself, but you are not allowed to restrict my access (or that of my patients). As for who should pay for such treatment, a number of things that presently are covered for the ‘‘greater good’’ in our society do not personally benefit me or my family. This is part of the grand bargain we make to live in a society. For example, members of some religions choose not to drive on Saturday; however, they cannot deny transportation support on Saturdays to prohibit everyone else from driving. That is, even though you, as an individual, may choose not to drive, society requires that you continue to support public transportation, traffic control, and the lights and electricity that control the system. Likewise, in the health field, the same could be said for childhood vaccinations— the greater good supports coverage for vaccinations of all children, even though you may choose not to vaccinate your child. The political right believes in individual freedoms and fights against the intrusion of government in personal rights—until it comes to reproductive rights, the most personal aspect of humanity. In this area, the few (and it really is a vocal minority) are choosing to impose their views on society, to manipulate the argument regarding separation of church and state to promote their personal agenda at the societal level. Surveys suggest more than 99% of women between the ages of 15 and 44 years who have ever had sexual
VOL. 102 NO. 1 / JULY 2014
Fertility and Sterility® intercourse have used contraception at some time in their life (1). Given the importance of hormonal contraception for non-medical indications, and the significant role that pregnancy timing plays in the health of individuals and societies, the IOM and ACA recommendations for coverage should be incontestable. Marcelle I. Cedars, M.D. Department of Obstetrics, Gynecology and Reproductive Sciences, University of California-San Francisco, San Francisco, California http://dx.doi.org/10.1016/j.fertnstert.2014.04.052 You can discuss this article with its authors and with other ASRM members at
VOL. 102 NO. 1 / JULY 2014
http://fertstertforum.com/cedarsm-contraception-rightwrong/ Use your smartphone to scan this QR code and connect to the discussion forum for this article now.* * Download a free QR code scanner by searching for “QR scanner” in your smartphone’s app store or app marketplace.
REFERENCE 1.
Daniels K, Mosher WD, Jones J. Contraceptive methods women have ever used: United States, 1982–2010, National Health Statistics Reports, no. 62. Hyattsville, MD: National Center for Health Statistics; 2013. Available at: http:// www.cdc.gov/nchs/data/nhsr/nhsr062.pdf. Last accessed May 30, 2014.
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