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Letter to the Editor
OB/GYN September 2003
Is Death a Sign of Failure?
To the Editor:
Lady, ya should have quit while ya was ahead!
The 89-year-old patient has already lived 10 years longer than
the average life expectancy for women in the United States [Novielli
KD. Evidence-based medicine or magical thinking. The Female
Patient. 2003;28(June Suppl):3]. She is likely to have "a
vascular event that [will] lead to significant suffering
and [an expected] death" simply because of her age.
The idea that hormones were a "fountain of youth" was discredited
by the time I reached residency in 1979, partly because of overwhelming
evidence to the contrary, and partly due to the feminists
raging against a society focused on youth. We also couldn't blame
postmenstrual syndrome on "hormones," that is, until it became
a defense in the United Kingdom
for murder.
I was skeptical of the claims that estrogen would protect women
from heart disease when the subject first arose about 10 or so
years ago. It seems to me that all this commotion is a futile attempt
to cheat the reaper. Our collective life expectancy has increased
30 years in the past 100 years. We are all going to die at some
point, but physicians seem loath to accept that, more so than most
patients.
Death is nature's way of telling you to slow down. It isn't a
sign of failure.
David A Rivera, MD, FACOG
Lombard, Ill
There appears to be no shortage of magical thinking [Novielli
KD. Evidence-based medicine or magical thinking. The Female
Patient. 2003;28(June Suppl):3]. I am assured by Wyeth and
the US Food and Drug Administration that problems associated with
conjugated equine estrogens/medroxy-progesterone acetate, as reported
by the Women's Health Initiative (WHI), should be assumed to be
relevant to all varieties of estrogen therapy. I am assured that
the WHI means that every epidemiologic study on estrogen ever performed
may be discarded as inadequate. In short, the WHI seems to represent
a monumental spiritual event, a new religion, a new way of looking
at the universe analogous to Galileo's heliocentric revolution.
What silliness! There are hundreds of studies reported in peer-reviewed
journals suggesting estrogen produces positive health benefits
to women. At a conference I attended on thyroid disease last fall,
one thoughtful speaker wryly reminded the audience that there has
never been a randomized controlled trial (RCT) demonstrating the
superiority of the data obtained from RCTs. You may choose to genuflect
before the sacred edifice of the WHI, but I regard it as merely
another piece of evidence in a very big, very complex picture that
is scarcely visible, let alone understood.
Yes, magical thinking is alive and well in the 21st century, and
the zealots of the WHI are some of its most active practitioners
when they insist that their study trumps everything we've heard
about estrogen.
Richard L. Kirby, MD
Salisbury, Md
VBAC Litigation Paranoia
To the Editor:
I read the article “New Challenges in Cesarean Delivery” [Bennett
T, Gibbs C, Greenspan PB, et al. New challenges in cesarean delivery. The
Female Patient. 2003;28(7):14-21.] hoping to see some rational
discussion of vaginal birth after cesarean delivery (VBAC). Unfortunately,
the article does not question the merits of the American College
of Obstetricians and Gynecologists (ACOG) Committee Opinion of
2001 requiring anesthesia and surgical staff “immediate” availability
for VBAC labors. Unfortunately, this standard has been established
primarily for litigation concerns, not based on established significant medical
risk.
The paranoia over litigation from the complication of uterine
scar rupture has made even the consideration of doing VBAC untenable
for many physicians and hospitals. The insurance carrier for our
rural hospital has dictated that they will not insure the hospital
for VBAC deliveries if the immediate availability cannot be adhered
to, and would charge an increased premium even if this were achieved.
Consequently, we are not allowing VBACs anymore. This is in direct
contradiction to the ACOG Technical Bulletin in 1999 delineating
offering the option of VBAC for most candidates. We are going to
see another skyrocketing of cesarean delivery rates due to the
demise of VBAC. The federal government's goal of a 15% cesarean
delivery rate will never be achieved if we eliminate VBAC from
all but major medical centers. Instead, the cesarean delivery rate
will continue to climb with more and more repeated cesarean deliveries.
The risk of uterine rupture with VBAC has not changed in the past
10 to 15 years. The article quotes a risk of 0.5%. The risk that
has increased is the risk of lawsuit. We frequently take similar
risks in medicine. Laparoscopy has a risk of major vascular injury.
Do we have a standard dictating that a vascular surgeon needs to
be immediately available for any elective laparoscopy? What do
we tell the woman who has had a prior successful VBAC or several
successful VBACS? Her risk of rupture is not lower. Does she now
have to submit to a repeat c-section due to our paranoia about
litigation?
There needs to be reform in the legal system so that physicians
and hospitals won't be held liable for low-incidence bad outcomes
(not bad medicine), the risk of which an informed patient is willing
to take. Perhaps what is needed is a VBAC Uterine Rupture fund,
a no-fault type of insurance, to pay for the rare bad outcomes
from uterine rupture.
The bottom line is that we don't need to return to the “once
a cesarean, always a cesarean” because of the ongoing medical
liability crisis. Let's be advocates for our patients.
Steven Thompson, MD, FACOG
Truckee, Calif
Billings Method Explained
To the Editor:
There were some inaccuracies in the explanation of the Billings
Ovulation Method in the June 2003 issue of The Female Patient.
[Nelson AL; Zieman M. Just say no every now and then. The Female
Patient. 2003;28(6):45-47.]
Because of the work of Swedish physician Erik Odeblad, MD, PhD,
we teach women to pay attention to the sensation of the vulva.
Dr Odeblad has determined that it takes only 5 mg of mucus for
a woman to sense that mucus is present while walking around, but
it takes 40 mg to actually see the mucus. For that reason, the
emphasis is on sensation and not the visual aspects of cervical
mucus. We do not want the women to stretch the mucus between their
fingers as the article states. It is not scientific and it is simply
not necessary.
To postpone/avoid pregnancy, there are three rules to follow before
ovulation and one rule after ovulation.
Women who have what is termed a Basic Infertile Pattern (infertility
prior to the fertile phase beginning) are able to have intercourse
on alternate evenings (not days as written in the article). The
Basic Infertile Pattern is either a time of dryness (nothing felt/nothing
seen) or it is a time of unchanging discharge. The Basic Infertile
Pattern is caused by a plug of G- mucus that prevents sperm and
bacteria from entering the cervix. Women with short cycles typically
do not have a Basic Infertile Pattern because there isn't enough
time for the plug to be formed.
Please consider visiting www. woomb.org for more information on
the science of the Billings Ovulation Method and www.boma-usa.org
for resources/teachers in the United States.
In more than 120 countries around the world, the Billings Ovulation
Method is getting 99%-plus effectiveness rates in postponing pregnancy.
In addition, couples frequently have success in achieving pregnancy
because the window of fertility is so easily recognized.
I do appreciate your efforts to include natural methods such as
the Billings Ovulation Method when describing family planning options.
Sue Elk
Executive Director
Billings Ovulation
Method Association – USA
Saint Paul, Minn
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