Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Illogical and Unscientific?
- Sheldon J. Segal, New York, NY 10017 (12 May 2007)
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Author's reply
- Paula S. Derry (16 May 2007)
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Pregnancy as natural suppression
- Laura J Brindle (16 May 2007)
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What are the possibilities?
- Wendy L Martin (18 May 2007)
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Nature Versus Culture Debate Goes On
- Christine L Nuttall (18 May 2007)
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To bleed or not to bleed.
- Laura Wershler, Calgary, AB T2G 5A5 (18 May 2007)
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Who will decide?
- Gail P Grant (22 May 2007)
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Re: Who will decide?
- Sarah P Lang (25 May 2007)
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Try to avoid the word "natural"
- D Summers (26 May 2007)
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Much further than natural.
- A Minett (7 June 2007)
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Re: Nature Versus Culture Debate Goes On
- José C. Pereira (9 August 2007)
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Sheldon J. Segal, Distinguished Scientist Population Council, New York, NY 10017
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In her commentary echoing the title of our book (Is Menstruation Obsolete? Coutinho and Segal, Oxford University Press 1999), Paula Derry concludes that our book and its message are “ illogical and unscientific.” This is surprising. When we wrote Is Menstruation Obsolete? we included 338 scientific references, most of which readers could access through the U.S. National Library of Medicine.. Ms. Derry contends that why women menstruate is not understood. To the contrary, there is an abundant scientific literature on the subject. In fact our book includes a well-referenced chapter titled “Why Women Menstruate.” We explain that a unique feature of the reproductive biology of women and a few other primates is the process of endometrial decidualization. The decidualized endometrium passes the point of no return and cannot simply regress with the ebb and flow of ovarian hormones. When it loses hormonal support at the completion of an ovarian cycle of estrogen and progesterone production, the uterus undergoes contractions, enlarged blood vessels rupture and the uterine lining sloughs off in order to prepare again for the possibility of a successful implantation in the following menstrual cycle. Ms. Derry chooses to disregard the evidence that incessant menstruation has harmful health effects for many women. Instead, she dismisses menstruation suppression “as a lifestyle choice for women who dislike menstruation or find it inconvenient.” Yet, the scientific literature, as far back as the 1970s, documents the positive relationship between the number of menstrual cycles in a woman’s lifetime and the chance of developing a reproductive tract cancer; the deleterious effect of menstrual blood loss on iron deficiency anemia (which affects over a half billion women primarily in the less developed regions of the world); the causal and exacerbating effect of menstruation on endometriosis and dysmenorrhea; and the pre-menstrual triggering of catamenial diseases (i.e. epilepsy, migraine). Ms. Derry believes that long term studies on the safety of hormonal contraceptives have not been done. There are many. Apparently she is unaware of the landmark paper published in BMJ in 1999 that tracks 46,000 British women for twenty-five years. The study shows no lasting ill effects from taking hormonal contraceptives (at doses far higher than today’s products) for as long as ten years. When Kate Miller, M.P.H. wrote the forward to our book, she predicted that some would no doubt interpret its message politically. We have been pleased that, to the contrary, the discussion engendered by the book has been serious and scientific. We regret that Ms. Derry believes otherwise. Sheldon J. Segal Ph.D., M.D. (h.c.), FRCOG (a.e.) Distinguished Scientist Office of the President Population Council One Dag Hammarskjold Plaza New York, NY 10017 Competing interests: None declared |
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Paula S. Derry, health psychologist Baltimore, MD 21212 USA
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I am Dr. Derry, not Ms. Derry. Raising the question of whether a novel contraceptive medication is safe is not a mark of ignorance of the literature. While Dr. Segal’s own professional judgment is that the matter is settled, the literature is rife with controversy, for example on the safety of specific contraceptives for specific subpopulations; further, a modicum of clinical trial data demonstrating the safety of novel medications is law in the United States in order to obtain FDA approval. Long-term outcomes when extended cycle OCs are used by a large, diverse population have not been evaluated. It is not surprising that evidence can be marshalled that menstruation is correlated, directly or indirectly, with harmful health effects. Any organ system or bodily function is vulnerable to pathology in one way or another. This is not in itself evidence that the bodily function itself is harmful, it doesn’t answer the question of whether health benefits as well as costs might be found correlated with that function, and it doesn’t answer the question of whether harm may follow if that bodily function is altered. The argument that menstruation is unhealthy is linked to a conclusion that it is unnecessary and unnatural. After all, physicians don’t cut out people’s hearts even though that would cut down on the amount of heart disease, but have cut out tonsils. However, although we know something about the physiological mechanisms underlying menstruation, that is a different question from the function or evolutionary origins of menstruation in the overall human body plan. No one can know with certainty the answer to such a question, about which we lack factual knowledge. Let me be clear that I am not arguing that we know that extended cycle contraceptives are unhealthy, or that they should be avoided because they are unnatural. I believe that evidence is lacking to form a conclusion. However, in a situation in which knowledge is incomplete yet professionals must form judgments, I believe that decisions should be based on considerations directly connected with judgments of benefit and harm and informed decision-making, and not on illogical, gratuitous arguments that menstruation is unnatural. Competing interests: None declared |
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Laura J Brindle, retired (none)
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I am a healthy 68 year old woman who has had 7 normal pregnancies. I breastfed my babies a total of 39 months without any menstrual periods. I stopped menstruating at age 46, and had few side effects of menopause, without taking any medication. Perhaps a study of endometrial tissue of older women such as myself would clarify the long term effects of menstrual suppression. Competing interests: None declared |
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Wendy L Martin, behaviorist LAUSD 91402
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I'm not a doctor, rather I'm a 36 year old single woman using Depo Provera as my birth control method. I have no children but would like to in the future which of course has met with many people reminding me that my clock is ticking and that if I wait until I'm too much older I might run into complications. In the meantime, I really like the fact that since I have been using this method I stopped menstruating completely as it is very convenient. I am curious though about whether this could prolong the period of time before I would be menopausal or if this is something that is already written in our DNA. I have read that every woman is born with a set number of eggs that she will release in her lifetime. If she ceases to ovulate due to her birth control method, would this lengthen the number of years before menopause? I've always been curious about this but never had the opportunity to find out. Competing interests: None declared |
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Christine L Nuttall, clinical auditor Buckinghamshire NHS Trust, Amersham, Bucks UK HP7 0JD
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The original Portuguese title of the book written by the Brazilian obstetrician Dr. Elsimar Coutinho was "Sangue Inutil" - Useless Blood, which I think better indicates the fundamental proposals behind prescribing a drug which suppresses menstruation. Menstrual blood, as part of women's physiology, is "useless", but the menstrual cycle, which involves blood (for all women), sometimes pain, discomfort, psychological disturbances (perhaps only for some women, or those in the "West") is so much part of our "Nature" that it would seem impossible for us to let go of so much which defines us as Female beings. Elsimar Coutinho treats a large number of impoverished people in Salvador, Bahia, providing them with contraception and reproductive health advice. But his work on endometriosis is probably more well established than his research on suppressing menstruation. Any physiological processes can go wrong and require radical treatment, and endometriosis can be a very serious, debilitating, even life-threatening problem. Not menstruating may help to prevent it. A natural conclusion, then, might be that menstruation for all women is undesirable. Competing interests: None declared |
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Laura Wershler, Executive Director Sexual Health Access Alberta, Calgary, AB T2G 5A5
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I am a veteran sexual and reproductive health advocate with a particular concern over the growing medical view that synthetic hormones are a panacea for all women's contraceptive and menstrual management needs. Dr. Derry asks serious and important questions about menstrual suppression that must be addressed by all who work in the field. For Dr. Segal to suggest that these questions have been answered or that evidence has marked “case closed” on this issue is close-minded and disrespectful. Dr. Segal contends that “(Dr.) Derry chooses to disregard the evidence that incessant menstruation has harmful health effects for many women.” I contend that Dr. Segal chooses to dismiss the evidence that normal, healthy, ovulatory menstruation protects women’s health during our reproductive years and beyond. My real concern is that while making a case for how menstrual suppression can greatly help women with debilitating menstrual disorders, Dr. Segal and his colleagues keep trying to make a case for why all women should suppress menstruation. This raises the most important of unanswered questions. What health benefits accrue to women with healthy, normal, ovulatory menstruation? What health risks (besides the proven loss of bone density with Depo-Provera) do they incur if they choose to suppress healthy menstruation? Contrary to Dr. Segal’s contention, these questions have not been fully answered. Perhaps the best way to deal with menstrual disorders is with prevention strategies that minimize or eliminate symptoms and non- pharmaceutical treatments that restore menstrual health. This certainly is the approach being taken by medicine to the alarming increases in the rates of diabetes, high blood pressure and heart disease. Prevention and health promotion first, treatment with drugs as a last resort. Finally, because menstruation is a bodily function only experienced by women, I find it disconcerting that so many male physicians are leading the call for menstrual suppression. I keep coming back to the words of a motivational speaker I once heard: “Never let anyone talk you into or out of doing something if they haven’t done it themselves.” Laura Wershler, Executive Director, Sexual Health Access Alberta, Calgary, AB Competing interests: None declared |
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Gail P Grant, Teaching Fellow University of Southampton SO17 1BJ
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Paula Derry's article raises an important issue and one which, as she points out, is likely to divide 'experts'. However, she neglects to address one crucial aspect - who will decide if, and how, interventions to eliminate menstrual periods are made available to women. Will it be male doctors, male policy makers and male politicians, none of whom would have experienced menstruation? Competing interests: None declared |
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Sarah P Lang, graduate student Chicago/Evanston 60637
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Clearly, there are numerous conditions where the best current medical treatment is cessation of menstruation. I wish to emphasize current; like Laura Wershler I am concerned about prominent, near cure-all roll synthetic hormones play in the treatment for various gynecological conditions. There are numerous reasons for this (many of which have been brought up), but among them, I am concerned about how synthetic hormones are presented as a simple, harmless treatment/BC. Patients, if they have ("mild") side effects, are expected to just tough it out for three months, products such as Depro Provera have resulted in patients developing longterm panic and anxiety disorders, etc. As a teen, regardless of my reason for being in a doctor's office, the pill would come up. While I understand the importance of sexual education and knowledge, I was, even then, bothered by the regular use of a phrase like "you will never have to suffer the inconvenience of having your period on the weekend!" The fact that I would not ovulate, and hence not go though what is for many women a very sexually pleasurable experience, was not brought up. So when asked: who will decide? I think that question has largely been answered (and very much doubt it is the 14 year old in the paper- gown). Competing interests: None declared |
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D Summers, GP Ramsbottom Health Centre, Ramsbottom BB4 4PS
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Whenever I see a human action (here the suppression of menstruation) described as either natural or unnatural I want to reach for my red pen. "Natural" and "unnatural" are meaningless words. Humans, like other animals, are a part of nature. By definition, any behaviour in which we indulge is natural, as is any behaviour of a chimp, budgerigar or flatworm. If a significant number of human females can be observed to ingest substances that have an effect on their menstrual cycle then THAT IS A NATURAL BEHAVIOUR of the human animal. Human acts can, I believe, be judged as good or bad, and, separately, as helpful or unhelpful to the individual's survival and/or procreation. But they can never be judged to be "unnatural". Competing interests: None declared |
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A Minett, Biomedical Scientist Royal Bolton Hospital
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I am in complete agreement with Dr. Summers in the (mis)use of the word "natural". In fact, I would go much further than Dr. Summers and assert that there is nothing that is "un-natural" on this planet, including such things as GM crops, nuclear power stations, the jet engine, and all pharmaceuticals including contraceptives. Humans are a product of nature, just as the above items are a product of us. The argument that these items would not have come into being without our involvement, is as baseless as saying speech and language is un-natural. If you condemn the above as un-natural, then with the same breath you must also condemn clothes, almost all modern (cultivated) food sources, all forms of transport, most (if not all) of the people alive today (assisted births, palliative care etc), blood transfusions, organ transplants, etc etc. Just because our ability to manipulate our surroundings extends way over and above that of any other living creature does not make our actions un-natural. Competing interests: None declared |
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José C. Pereira, Retired 36770-210 Brazil
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The original Portuguese title of the book written by the Brazilian gynecologist Dr. Elsimar Coutinho is "Menstruação, Sangria Inútil" - Menstruation, Useless Bleeding. Competing interests: None declared |
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