Medical indications for OCP

June 1, 2012

I would appreciate your feedback on the following scenario that a local priest

presented to me the other day:

-A Catholic woman on the pill asked her priest what she should do while on the

pill for medical reasons (e.g. menorrhagia, endometriosis) given the potential

abortifacient action. To be clear, I have heard Dr. Ruppersberger's talk on

" Treating Gynecologic Issues without the Pill " several times and I certainly do

not use the pill for gyne issues, but I know that there are situations when

people have used the pill or even a hormonal IUD for medical indications as

we've discussed here before.

-A few strategies come to mind:

1) Monitor cervical mucus using your preferred method and abstain during fertile

mucus times while on the pill.

2) Use a " mid-cycle abstinence " approach by avoiding intercourse days 8-19 (e.g.

standard days) while on the pill (if regular cycles).

3) Use a hormone monitor as in the Marquette Method to monitor if there is an LH

surge. Or, use the Brown ovarian monitor to identify if there is any

progesterone rise as evidence of ovulation.

I would be interested in hearing people's thoughts on this. Has anybody used a

particular strategy to counsel women who are on the pill to avoid the

possibility of conception/abortion on the pill?

Thank you for your consideration,

Bouchard, MD

Family Medicine Resident

University of Calgary

June 2, 2012

Dear Dr. Bouchard, Given the fact that the OC’s are intended to block ovulation, option 1 will only make sense if the effect of the pill is so grossly negated by, for instance penicillin that cervical mucus build up takes place. There are degrees of interference with the ovulatory process so you’ll never be sure. Given the fact that the abortifacient action is putative, Larimore and Stanford not withstanding. The only way to avoid it 100% is to abstain.. which is above and beyond the requirements for normal marital behavior. By the same token, option 2 makes no sense. You would not know if a breakthrough ovulation occurs on your schedule. Even if there is an LH surge you do not know if ovulation ensues. And if it does, you don’t know if the sperm made it through the cervix, and if they did if conception occurred. There is no certainty. I think the priest is straining at gnats and swallowing camels. There are other meds to treat the conditions posited. Tranexamic acid for metrorrhagia, for instance, lupron for endometriosis, etc. Hanna Klaus, M.D.Natural Family Planning Center of Washington, D.C. and Teen STAR Program4400 East West Highway # 911Bethesda, MD 20814-4510301-897-9323 hannaklaus@...http://www.teenstarprogram.org From: [mailto: ] On Behalf Of BouchardSent: Friday, June 01, 2012 11:08 PM Subject: Medical indications for OCP I would appreciate your feedback on the following scenario that a local priest presented to me the other day:-A Catholic woman on the pill asked her priest what she should do while on the pill for medical reasons (e.g. menorrhagia, endometriosis) given the potential abortifacient action. To be clear, I have heard Dr. Ruppersberger's talk on " Treating Gynecologic Issues without the Pill " several times and I certainly do not use the pill for gyne issues, but I know that there are situations when people have used the pill or even a hormonal IUD for medical indications as we've discussed here before.-A few strategies come to mind:1) Monitor cervical mucus using your preferred method and abstain during fertile mucus times while on the pill.2) Use a " mid-cycle abstinence " approach by avoiding intercourse days 8-19 (e.g. standard days) while on the pill (if regular cycles).3) Use a hormone monitor as in the Marquette Method to monitor if there is an LH surge. Or, use the Brown ovarian monitor to identify if there is any progesterone rise as evidence of ovulation.I would be interested in hearing people's thoughts on this. Has anybody used a particular strategy to counsel women who are on the pill to avoid the possibility of conception/abortion on the pill?Thank you for your consideration, Bouchard, MDFamily Medicine ResidentUniversity of Calgary

June 2, 2012

Hi Dr. Klaus,Thanks for your response. Certainly there are other meds to treat these conditions, however, since I am not the patient's physician, and this may come up for priests who cannot control what treatment physicians provide, I am curious to know how you would approach it.If I understand you correctly, your view is that there is no clear NFP-based way to identify ovulation and therefore no specific recommendation can be made RE avoiding conception while on the pill. Did I understand that correctly?Thanks again for responding!

Bouchard, MDFamily Medicine ResidentUniversity of Calgary

On 2012-06-02, at 9:03 AM, Hanna Klaus wrote:

Dear Dr. Bouchard, Given the fact that the OC’s are intended to block ovulation, option 1 will only make sense if the effect of the pill is so grossly negated by, for instance penicillin that cervical mucus build up takes place. There are degrees of interference with the ovulatory process so you’ll never be sure. Given the fact that the abortifacient action is putative, Larimore and Stanford not withstanding. The only way to avoid it 100% is to abstain.. which is above and beyond the requirements for normal marital behavior. By the same token, option 2 makes no sense. You would not know if a breakthrough ovulation occurs on your schedule. Even if there is an LH surge you do not know if ovulation ensues. And if it does, you don’t know if the sperm made it through the cervix, and if they did if conception occurred. There is no certainty. I think the priest is straining at gnats and swallowing camels. There are other meds to treat the conditions posited. Tranexamic acid for metrorrhagia, for instance, lupron for endometriosis, etc. Hanna Klaus, M.D.Natural Family Planning Center of Washington, D.C. and Teen STAR Program4400 East West Highway # 911Bethesda, MD 20814-4510301-897-9323 hannaklaus@...http://www.teenstarprogram.org From: [mailto: ] On Behalf Of BouchardSent: Friday, June 01, 2012 11:08 PM Subject: Medical indications for OCP I would appreciate your feedback on the following scenario that a local priest presented to me the other day:-A Catholic woman on the pill asked her priest what she should do while on the pill for medical reasons (e.g. menorrhagia, endometriosis) given the potential abortifacient action. To be clear, I have heard Dr. Ruppersberger's talk on "Treating Gynecologic Issues without the Pill" several times and I certainly do not use the pill for gyne issues, but I know that there are situations when people have used the pill or even a hormonal IUD for medical indications as we've discussed here before.-A few strategies come to mind:1) Monitor cervical mucus using your preferred method and abstain during fertile mucus times while on the pill.2) Use a "mid-cycle abstinence" approach by avoiding intercourse days 8-19 (e.g. standard days) while on the pill (if regular cycles).3) Use a hormone monitor as in the Marquette Method to monitor if there is an LH surge. Or, use the Brown ovarian monitor to identify if there is any progesterone rise as evidence of ovulation.I would be interested in hearing people's thoughts on this. Has anybody used a particular strategy to counsel women who are on the pill to avoid the possibility of conception/abortion on the pill?Thank you for your consideration, Bouchard, MDFamily Medicine ResidentUniversity of Calgary

June 2, 2012

the issue from the moral standpoint is not decided in the Church. Therefore conscientious and virtuous responsible parenthood would seem to suggest total abstinence while on treatment since unless it were possible to be morally certain (absolute certainty isn't required) of not conceiving, one might be responsible morally for early loss. Would diligent compliance with a high estrogen formulation providing greater than 98 per cent anovulatory effectiveness suffice for moral certainty? Would the grave health risks involved in such preparations be proportionate to whatever therapeutic benefit is postulated? Could a person know (absent having perpetual access to a highly skilled ultrasonographer who could exclude any possibility of a developing or mature follicle) with moral certainty that she wouldn't conceive? And even from the purely pastoral perspective, it is generally the duty of the priest to advise the patient to consider the moral implications of any "therapy" (here in ellipses because we know much touted as therapy is not so), and consider the reasonable requirements of due proportion and strict therapeutics (first no harm; e.g.).Finally, the pill at the very best is an iatrogenic endocrine dyscrasia, as I never tire of saying. When is it really a good therapy?DominicSent from my iPhoneOn Jun 2, 2012, at 10:25 AM, Bouchard <thomasbouchard@...> wrote:

Hi Dr. Klaus,Thanks for your response. Certainly there are other meds to treat these conditions, however, since I am not the patient's physician, and this may come up for priests who cannot control what treatment physicians provide, I am curious to know how you would approach it.If I understand you correctly, your view is that there is no clear NFP-based way to identify ovulation and therefore no specific recommendation can be made RE avoiding conception while on the pill. Did I understand that correctly?Thanks again for responding!

Bouchard, MDFamily Medicine ResidentUniversity of Calgary

On 2012-06-02, at 9:03 AM, Hanna Klaus wrote:

Dear Dr. Bouchard, Given the fact that the OCâ€™s are intended to block ovulation, option 1 will only make sense if the effect of the pill is so grossly negated by, for instance penicillin that cervical mucus build up takes place. There are degrees of interference with the ovulatory process so youâ€™ll never be sure. Given the fact that the abortifacient action is putative, Larimore and Stanford not withstanding. The only way to avoid it 100% is to abstain.. which is above and beyond the requirements for normal marital behavior. By the same token, option 2 makes no sense. You would not know if a breakthrough ovulation occurs on your schedule. Even if there is an LH surge you do not know if ovulation ensues. And if it does, you donâ€™t know if the sperm made it through the cervix, and if they did if conception occurred. There is no certainty. I think the priest is straining at gnats and swallowing camels. There are other meds to treat the conditions posited. Tranexamic acid for metrorrhagia, for instance, lupron for endometriosis, etc. Hanna Klaus, M.D.Natural Family Planning Center of Washington, D.C. and Teen STAR Program4400 East West Highway # 911Bethesda, MD 20814-4510301-897-9323 hannaklaus@...http://www.teenstarprogram.org From: [mailto: ] On Behalf Of BouchardSent: Friday, June 01, 2012 11:08 PM Subject: Medical indications for OCP I would appreciate your feedback on the following scenario that a local priest presented to me the other day:-A Catholic woman on the pill asked her priest what she should do while on the pill for medical reasons (e.g. menorrhagia, endometriosis) given the potential abortifacient action. To be clear, I have heard Dr. Ruppersberger's talk on "Treating Gynecologic Issues without the Pill" several times and I certainly do not use the pill for gyne issues, but I know that there are situations when people have used the pill or even a hormonal IUD for medical indications as we've discussed here before.-A few strategies come to mind:1) Monitor cervical mucus using your preferred method and abstain during fertile mucus times while on the pill.2) Use a "mid-cycle abstinence" approach by avoiding intercourse days 8-19 (e.g. standard days) while on the pill (if regular cycles).3) Use a hormone monitor as in the Marquette Method to monitor if there is an LH surge. Or, use the Brown ovarian monitor to identify if there is any progesterone rise as evidence of ovulation.I would be interested in hearing people's thoughts on this. Has anybody used a particular strategy to counsel women who are on the pill to avoid the possibility of conception/abortion on the pill?Thank you for your consideration, Bouchard, MDFamily Medicine ResidentUniversity of Calgary

June 2, 2012

Yes, that is my view. But as the possibility of conception is drawn from mathematical models and not from documented abortions, if these meds are prescribed for pathology I do not think it’s fair to burden the couples’ conscience. If I’m asked why I do not prescribe the pill, its possible abortifacient effects have to be mentioned last, and with a lot of caveats. My choice in the cases your priest friend posits is not to get into the doctor-patient relationship. Least of all by a priest who has no medical expertise. The best he could suggest would be a second opinion. hk From: [mailto: ] On Behalf Of BouchardSent: Saturday, June 02, 2012 11:25 AM Subject: Re: Medical indications for OCP Hi Dr. Klaus,Thanks for your response. Certainly there are other meds to treat these conditions, however, since I am not the patient's physician, and this may come up for priests who cannot control what treatment physicians provide, I am curious to know how you would approach it. If I understand you correctly, your view is that there is no clear NFP-based way to identify ovulation and therefore no specific recommendation can be made RE avoiding conception while on the pill. Did I understand that correctly? Thanks again for responding! Bouchard, MDFamily Medicine ResidentUniversity of Calgary On 2012-06-02, at 9:03 AM, Hanna Klaus wrote: Dear Dr. Bouchard, Given the fact that the OC’s are intended to block ovulation, option 1 will only make sense if the effect of the pill is so grossly negated by, for instance penicillin that cervical mucus build up takes place. There are degrees of interference with the ovulatory process so you’ll never be sure. Given the fact that the abortifacient action is putative, Larimore and Stanford not withstanding. The only way to avoid it 100% is to abstain.. which is above and beyond the requirements for normal marital behavior. By the same token, option 2 makes no sense. You would not know if a breakthrough ovulation occurs on your schedule. Even if there is an LH surge you do not know if ovulation ensues. And if it does, you don’t know if the sperm made it through the cervix, and if they did if conception occurred. There is no certainty. I think the priest is straining at gnats and swallowing camels. There are other meds to treat the conditions posited. Tranexamic acid for metrorrhagia, for instance, lupron for endometriosis, etc. Hanna Klaus, M.D.Natural Family Planning Center of Washington, D.C. and Teen STAR Program4400 East West Highway # 911Bethesda, MD 20814-4510301-897-9323 hannaklaus@...http://www.teenstarprogram.org From: [mailto: ] On Behalf Of BouchardSent: Friday, June 01, 2012 11:08 PM Subject: Medical indications for OCP I would appreciate your feedback on the following scenario that a local priest presented to me the other day:-A Catholic woman on the pill asked her priest what she should do while on the pill for medical reasons (e.g. menorrhagia, endometriosis) given the potential abortifacient action. To be clear, I have heard Dr. Ruppersberger's talk on " Treating Gynecologic Issues without the Pill " several times and I certainly do not use the pill for gyne issues, but I know that there are situations when people have used the pill or even a hormonal IUD for medical indications as we've discussed here before.-A few strategies come to mind:1) Monitor cervical mucus using your preferred method and abstain during fertile mucus times while on the pill.2) Use a " mid-cycle abstinence " approach by avoiding intercourse days 8-19 (e.g. standard days) while on the pill (if regular cycles).3) Use a hormone monitor as in the Marquette Method to monitor if there is an LH surge. Or, use the Brown ovarian monitor to identify if there is any progesterone rise as evidence of ovulation.I would be interested in hearing people's thoughts on this. Has anybody used a particular strategy to counsel women who are on the pill to avoid the possibility of conception/abortion on the pill?Thank you for your consideration, Bouchard, MDFamily Medicine ResidentUniversity of Calgary

June 3, 2012

Dear et al,Agree that the first premise of her going on the pill to help with endometriosis is a flawed one. There is lupron, vaginal danocrine and nutritional studies (Darcy, do you have any studies regarding nutritional advice for patients suffering from endometriosis please?). But, if you are not her doctor, yes, a second opinion is a good idea. Secondly, we did ultrasounds in residency and in my first job for the National Health Scholarship at a Community Health Center for the migrant workers and scanned women that were on OCPs and saw plenty of follicular cysts (while they were on birth control) and decreased uterine stripe. Larrimore, Stanford & Kahlenborns papers on OCPs and Emergency Contraception reference

other articles which confirm these findings. So, we know that at least some of the time patients on current low dose formulations of the pill indeed do have breakthrough ovulation, and indeed do have decreased uterine lining, leading to increased possibility that a new life occurring from breakthrough ovulation and resulting conception will NOT have the necessary uterine lining to live. I think we should err on the side of warning women of this effect - i mean "life" depends on it, right? Also, maybe if we say it loud enough, the other side can fund research to disapprove our contention, and then we can settle the matter once and for all. Secondly, the ovulation method alone can not be used in this situation because of the effects of the exogenous daily estrogen and progesterone upon the crypts of the cervix and absent or low cervical mucus production. i don't see why you

couldn't have the woman use the Marquette monitor, and if she doesnt have highs or peak, she is not having breakthrough ovulation to the best of our ability to offer that certitude with our method at least. do you agree? Either that, or have her abstain between days 8 and 19. I think we have got to respond to the situation at hand. If a Priest is coming to you for advice, I think it is important to make him aware of all facets of this situation, but telling him to tell the patient to get a second opinion and realizing that that second opinion may be no more amenable to the "no-OCPS option" than the first, will only lead to discouragement and frustration with all parties. Blessings, Dr. Peck, MD, CCD, ABFM, Marquette NFP Instructor

Pecks Family Practice, PLC

1688 W Granada Blvd, Ste 2A

Ormond Beach, FL 32174

(386) 677-2018 fax: (386) 676-0737 cell: (386) 212-9777

"I have chosen you from the world, says the Lord, and have appointed you to go out and bear fruit, fruit that will last, alleluia" (Cf. Jn 15:16,19) From: Bouchard <thomasbouchard@...> Sent: Saturday, June 2, 2012 11:25 AM Subject: Re:

Medical indications for OCP

Hi Dr. Klaus,Thanks for your response. Certainly there are other meds to treat these conditions, however, since I am not the patient's physician, and this may come up for priests who cannot control what treatment physicians provide, I am curious to know how you would approach it.If I understand you correctly, your view is that there is no clear NFP-based way to identify ovulation and therefore no specific recommendation can be made RE avoiding conception while on the pill. Did I understand that correctly?Thanks again for responding!

Bouchard, MDFamily Medicine ResidentUniversity of Calgary

On 2012-06-02, at 9:03 AM, Hanna Klaus wrote:

Dear Dr. Bouchard, Given the fact that the OCâ€™s are intended to block ovulation, option 1 will only make sense if the effect of the pill is so grossly negated by, for instance penicillin that cervical mucus build up takes place. There are degrees of interference with the ovulatory process so youâ€™ll never be sure. Given the fact that the abortifacient action is putative, Larimore and Stanford not withstanding. The only way to avoid it 100% is to abstain.. which is

above and beyond the requirements for normal marital behavior. By the same token, option 2 makes no sense. You would not know if a breakthrough ovulation occurs on your schedule. Even if there is an LH surge you do not know if ovulation ensues. And if it does, you donâ€™t know if the sperm made it through the cervix, and if they did if conception occurred. There is no certainty. I think the priest is straining at gnats and swallowing camels. There are other meds to treat the conditions posited. Tranexamic acid for metrorrhagia, for instance, lupron for endometriosis, etc. Hanna Klaus, M.D.Natural Family Planning Center of Washington, D.C. and Teen STAR Program4400 East West Highway # 911Bethesda, MD 20814-4510301-897-9323 hannaklaus@...http://www.teenstarprogram.org From: [mailto: ] On Behalf Of BouchardSent: Friday, June 01, 2012 11:08 PM Subject: Medical indications for OCP I would appreciate your feedback on the following scenario that a local priest presented to me the other day:-A Catholic woman on the pill asked her priest what she should do while on the pill for medical reasons (e.g. menorrhagia, endometriosis) given the potential abortifacient

action. To be clear, I have heard Dr. Ruppersberger's talk on "Treating Gynecologic Issues without the Pill" several times and I certainly do not use the pill for gyne issues, but I know that there are situations when people have used the pill or even a hormonal IUD for medical indications as we've discussed here before.-A few strategies come to mind:1) Monitor cervical mucus using your preferred method and abstain during fertile mucus times while on the pill.2) Use a "mid-cycle abstinence" approach by avoiding intercourse days 8-19 (e.g. standard days) while on the pill (if regular cycles).3) Use a hormone monitor as in the Marquette Method to monitor if there is an LH surge. Or, use the Brown ovarian monitor to identify if there is any progesterone rise as evidence of ovulation.I would be interested in hearing people's thoughts on this. Has anybody used a particular strategy to counsel women who are on the pill to avoid the

possibility of conception/abortion on the pill?Thank you for your consideration, Bouchard, MDFamily Medicine ResidentUniversity of Calgary

June 3, 2012

:

I am in Utah at the moment. Attended the University " Professors " for Life Conference at BYU. I a d dinner with Joe (Dr. Stanford) and his lovely wife Kathleen. Dr. Stanford gave a presentation at the conference.

I would think you could monitor " pill " cycles for the Lh threshold or better yet a LH rise with the Clear blue Digital OPK and then apply a simple calendar formula - e.g. the earliest positive Lh test minus 6 days and the latest positive plus 3 days of the past 6 cycles. The Regular Clrarblue would not work well with the combination type pills because it will pick up the synthestc estrogen - i.e., it would only pick up the valid Lh threshold - that is why I like the idea of using the digital OPK - more sensitive and it picks up a rise. It would be nice to fo a study with women on the pill to see how often they get a significant rise in LH. I am aware of the studies that tracked developing follicles while women are on the pill - especially during the week off on placebos/sugar pills.

Bame <rbamer2@...> wrote:

Dear et al,

Agree that the first premise of her going on the pill to help with endometriosis is a flawed one. There is lupron, vaginal danocrine and nutritional studies (Darcy, do you have any studies regarding nutritional advice for patients suffering from

endometriosis please?). But, if you are not her doctor, yes, a second opinion is a good idea.

Secondly, we did ultrasounds in residency and in my first job for the National Health Scholarship at a Community Health Center for the migrant workers and scanned women that were on OCPs and saw plenty of follicular cysts (while they were on birth

control) and decreased uterine stripe. Larrimore, Stanford & Kahlenborns papers on OCPs and Emergency Contraception reference other articles which confirm these findings. So, we know that at least some of the time patients on current low dose formulations

of the pill indeed do have breakthrough ovulation, and indeed do have decreased uterine lining, leading to increased possibility that a new life occurring from breakthrough ovulation and resulting conception will NOT have the necessary uterine lining to live.

I think we should err on the side of warning women of this effect - i mean " life " depends on it, right? Also, maybe if we say it loud enough, the other side can fund research to disapprove our contention, and then we can settle the matter once and for all.

Secondly, the ovulation method alone can not be used in this situation because of the effects of the exogenous daily estrogen and progesterone upon the crypts of the cervix and absent or low cervical mucus production. i don't see why you couldn't

have the woman use the Marquette monitor, and if she doesnt have highs or peak, she is not having breakthrough ovulation to the best of our ability to offer that certitude with our method at least. do you agree? Either that, or have her abstain between

days 8 and 19.

I think we have got to respond to the situation at hand. If a Priest is coming to you for advice, I think it is important to make him aware of all facets of this situation, but telling him to tell the patient to get a second opinion and realizing

that that second opinion may be no more amenable to the " no-OCPS option " than the first, will only lead to discouragement and frustration with all parties.

Blessings,

Dr. Peck, MD, CCD, ABFM, Marquette NFP Instructor

Pecks Family Practice, PLC

1688 W Granada Blvd, Ste 2A

Ormond Beach, FL 32174

(386) 677-2018 fax: (386) 676-0737 cell: (386) 212-9777

" I have chosen you from the world, says the Lord, and have appointed you to go out and bear fruit, fruit that will last, alleluia " (Cf. Jn 15:16,19)

From: Bouchard <thomasbouchard@...>

Sent: Saturday, June 2, 2012 11:25 AM

Subject: Re: Medical indications for OCP

Hi Dr. Klaus,

Thanks for your response. Certainly there are other meds to treat these conditions, however, since I am not the patient's physician, and this may come up for priests who cannot control what treatment physicians provide, I am curious to know how you would

approach it.

If I understand you correctly, your view is that there is no clear NFP-based way to identify ovulation and therefore no specific recommendation can be made RE avoiding conception while on the pill. Did I understand that correctly?

Thanks again for responding!

Bouchard,

MD

Family Medicine Resident

University of Calgary

On 2012-06-02, at 9:03 AM, Hanna Klaus wrote:

Dear Dr. Bouchard,

Given the fact that the OC’s are intended to block ovulation, option 1 will only make sense if the effect of the pill is so grossly negated by, for instance penicillin that

cervical mucus build up takes place. There are degrees of interference with the ovulatory process so you’ll never be sure. Given the fact that the abortifacient action is putative, Larimore and Stanford not withstanding. The only way to avoid it 100%

is to abstain.. which is above and beyond the requirements for normal marital behavior. By the same token, option 2 makes no sense. You would not know if a breakthrough ovulation occurs on your schedule. Even if there is an LH surge you do not know

if ovulation ensues. And if it does, you don’t know if the sperm made it through the cervix, and if they did if conception occurred. There is no certainty. I think the priest is straining at gnats and swallowing camels. There are other meds to treat

the conditions posited. Tranexamic acid for metrorrhagia, for instance, lupron for endometriosis, etc.

Hanna Klaus, M.D.

Natural Family Planning Center of Washington, D.C. and Teen STAR Program

4400 East West Highway # 911

Bethesda, MD 20814-4510

301-897-9323

hannaklaus@...

http://www.teenstarprogram.org

From:

[mailto: ]

On Behalf Of Bouchard

Sent: Friday, June 01, 2012 11:08 PM

Subject: Medical indications for OCP

I would appreciate your feedback on the following scenario that a local priest presented to me the other day:

-A Catholic woman on the pill asked her priest what she should do while on the pill for medical reasons (e.g. menorrhagia, endometriosis) given the potential abortifacient action. To be clear, I have heard Dr. Ruppersberger's talk on " Treating Gynecologic Issues

without the Pill " several times and I certainly do not use the pill for gyne issues, but I know that there are situations when people have used the pill or even a hormonal IUD for medical indications as we've discussed here before.

-A few strategies come to mind:

1) Monitor cervical mucus using your preferred method and abstain during fertile mucus times while on the pill.

2) Use a " mid-cycle abstinence " approach by avoiding intercourse days 8-19 (e.g. standard days) while on the pill (if regular cycles).

3) Use a hormone monitor as in the Marquette Method to monitor if there is an LH surge. Or, use the Brown ovarian monitor to identify if there is any progesterone rise as evidence of ovulation.

I would be interested in hearing people's thoughts on this. Has anybody used a particular strategy to counsel women who are on the pill to avoid the possibility of conception/abortion on the pill?

Thank you for your consideration,

Bouchard, MD

Family Medicine Resident

University of Calgary

June 3, 2012

Thanks for your reply and I don't want to further disturb your meeting, and yes, of course the synthetic estrogen would interfere with the Highs (which would detect the exogenous estrogen) on the regular Clearblue monitor. It would have to be just the peaks on the monitor or better yet, the digital ClearBlue OPKs with the algorithm which you provided. And, interestingly enough (on a tangential issue), according to several of my patient's cycles/data, the Digital OPK is picking up the LH surge at least 24 hours earlier than the ClearBlue regular monitor's Peak (indicating LH surge) and in some cases, 36 to 48 hours earlier! This has tremendous potential to reduce the necessary abstinence required I would think.

Blessings to you, Dr. Peck, MD, CCD, ABFM, Marquette NFP Instructor

Pecks Family Practice, PLC

1688 W Granada Blvd, Ste 2A

Ormond Beach, FL 32174

(386) 677-2018 fax: (386) 676-0737 cell: (386) 212-9777

"I have chosen you from the world, says the Lord, and have appointed you to go out and bear fruit, fruit that will last, alleluia" (Cf. Jn 15:16,19) From: "Fehring, " <.Fehring@...> " " < > Sent: Sunday, June 3, 2012 10:45 AM Subject: Re: Medical indications for OCP

:

I am in Utah at the moment. Attended the University "Professors" for Life Conference at BYU. I a d dinner with Joe (Dr. Stanford) and his lovely wife Kathleen. Dr. Stanford gave a presentation at the conference.

I would think you could monitor "pill" cycles for the Lh threshold or better yet a LH rise with the Clear blue Digital OPK and then apply a simple calendar formula - e.g. the earliest positive Lh test minus 6 days and the latest positive plus 3 days of the past 6 cycles. The Regular Clrarblue would not work well with the combination type pills because it will pick up the synthestc estrogen - i.e., it would only pick up the valid Lh threshold - that is why I like the idea of using the digital OPK - more sensitive and it picks up a rise. It would be nice to fo a study with women on the pill to see how often they get a significant rise in LH. I am aware of the studies that tracked developing follicles while women are on the pill - especially during the week off on placebos/sugar pills.

Bame <rbamer2@...> wrote:

Dear et al,

Agree that the first premise of her going on the pill to help with endometriosis is a flawed one. There is lupron, vaginal danocrine and nutritional studies (Darcy, do you have any studies regarding nutritional advice for patients suffering from

endometriosis please?). But, if you are not her doctor, yes, a second opinion is a good idea.

Secondly, we did ultrasounds in residency and in my first job for the National Health Scholarship at a Community Health Center for the migrant workers and scanned women that were on OCPs and saw plenty of follicular cysts (while they were on birth

control) and decreased uterine stripe. Larrimore, Stanford & Kahlenborns papers on OCPs and Emergency Contraception reference other articles which confirm these findings. So, we know that at least some of the time patients on current low dose formulations

of the pill indeed do have breakthrough ovulation, and indeed do have decreased uterine lining, leading to increased possibility that a new life occurring from breakthrough ovulation and resulting conception will NOT have the necessary uterine lining to live.

I think we should err on the side of warning women of this effect - i mean "life" depends on it, right? Also, maybe if we say it loud enough, the other side can fund research to disapprove our contention, and then we can settle the matter once and for all.

Secondly, the ovulation method alone can not be used in this situation because of the effects of the exogenous daily estrogen and progesterone upon the crypts of the cervix and absent or low cervical mucus production. i don't see why you couldn't

have the woman use the Marquette monitor, and if she doesnt have highs or peak, she is not having breakthrough ovulation to the best of our ability to offer that certitude with our method at least. do you agree? Either that, or have her abstain between

days 8 and 19.

I think we have got to respond to the situation at hand. If a Priest is coming to you for advice, I think it is important to make him aware of all facets of this situation, but telling him to tell the patient to get a second opinion and realizing

that that second opinion may be no more amenable to the "no-OCPS option" than the first, will only lead to discouragement and frustration with all parties.

Blessings,

Dr. Peck, MD, CCD, ABFM, Marquette NFP Instructor

Pecks Family Practice, PLC

1688 W Granada Blvd, Ste 2A

Ormond Beach, FL 32174

(386) 677-2018 fax: (386) 676-0737 cell: (386) 212-9777

"I have chosen you from the world, says the Lord, and have appointed you to go out and bear fruit, fruit that will last, alleluia" (Cf. Jn 15:16,19)

From: Bouchard <thomasbouchard@...>

Sent: Saturday, June 2, 2012 11:25 AM

Subject: Re: Medical indications for OCP

Hi Dr. Klaus,

Thanks for your response. Certainly there are other meds to treat these conditions, however, since I am not the patient's physician, and this may come up for priests who cannot control what treatment physicians provide, I am curious to know how you would

approach it.

If I understand you correctly, your view is that there is no clear NFP-based way to identify ovulation and therefore no specific recommendation can be made RE avoiding conception while on the pill. Did I understand that correctly?

Thanks again for responding!

Bouchard,

MD

Family Medicine Resident

University of Calgary

On 2012-06-02, at 9:03 AM, Hanna Klaus wrote:

Dear Dr. Bouchard,

Given the fact that the OCâ€™s are intended to block ovulation, option 1 will only make sense if the effect of the pill is so grossly negated by, for instance penicillin that

cervical mucus build up takes place. There are degrees of interference with the ovulatory process so youâ€™ll never be sure. Given the fact that the abortifacient action is putative, Larimore and Stanford not withstanding. The only way to avoid it 100%

is to abstain.. which is above and beyond the requirements for normal marital behavior. By the same token, option 2 makes no sense. You would not know if a breakthrough ovulation occurs on your schedule. Even if there is an LH surge you do not know

if ovulation ensues. And if it does, you donâ€™t know if the sperm made it through the cervix, and if they did if conception occurred. There is no certainty. I think the priest is straining at gnats and swallowing camels. There are other meds to treat

the conditions posited. Tranexamic acid for metrorrhagia, for instance, lupron for endometriosis, etc.

Hanna Klaus, M.D.

Natural Family Planning Center of Washington, D.C. and Teen STAR Program

4400 East West Highway # 911

Bethesda, MD 20814-4510

301-897-9323

hannaklaus@...

http://www.teenstarprogram.org

From:

[mailto: ]

On Behalf Of Bouchard

Sent: Friday, June 01, 2012 11:08 PM

Subject: Medical indications for OCP

I would appreciate your feedback on the following scenario that a local priest presented to me the other day:

-A Catholic woman on the pill asked her priest what she should do while on the pill for medical reasons (e.g. menorrhagia, endometriosis) given the potential abortifacient action. To be clear, I have heard Dr. Ruppersberger's talk on "Treating Gynecologic Issues

without the Pill" several times and I certainly do not use the pill for gyne issues, but I know that there are situations when people have used the pill or even a hormonal IUD for medical indications as we've discussed here before.

-A few strategies come to mind:

1) Monitor cervical mucus using your preferred method and abstain during fertile mucus times while on the pill.

2) Use a "mid-cycle abstinence" approach by avoiding intercourse days 8-19 (e.g. standard days) while on the pill (if regular cycles).

3) Use a hormone monitor as in the Marquette Method to monitor if there is an LH surge. Or, use the Brown ovarian monitor to identify if there is any progesterone rise as evidence of ovulation.

I would be interested in hearing people's thoughts on this. Has anybody used a particular strategy to counsel women who are on the pill to avoid the possibility of conception/abortion on the pill?

Thank you for your consideration,

Bouchard, MD

Family Medicine Resident

University of Calgary

June 3, 2012

:

That is the same pattern that we are finding i-e., the digital Lh rise about one day before the threshold rise.

I drove to the airport with Cavenaugh, PhD - a moral philosophy professor at the University of San Francisco - a Jesuit Catholic University. He and I wonder if there is not srupples in worrying about a potential loss of pregnancy - e.g., did I take more of a risk of loss of life riding with Tom to the airport? He suggested reading an article by Dr. Dan Sulmasy, MD' PhD - in the Kennedy Bioethics review on the use of hormonal EC - that has relevance to this topic - re: benefits versus potential loss of life. I Need to Google and find the article.

Bame <rbamer2@...> wrote:

Thanks for your reply and I don't want to further disturb your meeting, and yes, of course the synthetic estrogen would interfere with the Highs (which would detect the exogenous estrogen) on the regular Clearblue monitor. It would have to

be just the peaks on the monitor or better yet, the digital ClearBlue OPKs with the algorithm which you provided.

And, interestingly enough (on a tangential issue), according to several of my patient's cycles/data, the Digital OPK is picking up the LH surge at least 24 hours earlier than the ClearBlue regular monitor's Peak (indicating LH surge) and in some

cases, 36 to 48 hours earlier! This has tremendous potential to reduce the necessary abstinence required I would think. Blessings to you,

Dr. Peck, MD, CCD, ABFM, Marquette NFP Instructor

Pecks Family Practice, PLC

1688 W Granada Blvd, Ste 2A

Ormond Beach, FL 32174

(386) 677-2018 fax: (386) 676-0737 cell: (386) 212-9777

" I have chosen you from the world, says the Lord, and have appointed you to go out and bear fruit, fruit that will last, alleluia " (Cf. Jn 15:16,19)

From: " Fehring, " <.Fehring@...>

" " < >

Sent: Sunday, June 3, 2012 10:45 AM