No Excuse

If you haven't read about the death of this woman, you should:

Woman "Denied A Termination" Dies in Hospital

A 31-year-old woman presented to a hospital in Ireland in pain, and was diagnosed with a miscarriage in progress (what we call inevitable abortion - "abortion" being the medical term for any pregnancy that ends before viability). There was no doubt that she was going to lose the fetus. Nonetheless, the doctors were barred by law from removing the fetus or inducing labor because the fetus still had a heartbeat. The woman suffered for 2.5 days, and then died of sepsis.

Non-medical people might wonder whether this outcome might just be a rare, unexpected outcome. You might wonder whether the doctors could have known what would happen.

So, let me be clear: this outcome was entirely preventable. This woman should not have died. Her risk of sepsis was well-known, and predictable. Women who have spontaneous miscarriages are at risk of infection, and the longer the miscarriage goes on, the higher the risk. Women in second trimester (which she was, at 17 weeks) are at even higher risk, because the cervix has to dilate more, and because the reason for the miscarriage could easily be an infected pregnancy. Pregnant women are highly susceptible to infection, and less able to fight it because their immune systems are suppressed. When a woman comes in with a miscarriage that doesn't end spontaneously within 1-2 hours, we evacuate the uterus to prevent the development of complications - specifically, hemorrhage and sepsis.

Her death is not a mystery, and it is not surprising. It's hard to blame the doctors, as their hands were tied by law and they risked losing their license to practice, or going to jail, by intervening. The doctors were prevented from providing adequate medical care by the law. The people responsible for the law are the Irish lawmakers who created it.

If they had done their jobs, the lawmakers who created this law would have looked at the implications of it. They would have learned that the law would inevitably cause the deaths of women. (Who knows how many others have died that we haven't heard about?) In fact, women die every day as a result of pregnancy and of lack of access to safe abortion. Anti-choice individuals who argue that such outcomes are rare, people such as our recent nominee for vice-president, are lying, or they are speaking ignorantly. I think it's the former, because if you spend 1 minute googling maternal mortality, you can easily see that 800 women die every day in pregnancy from preventable causes.

When lawmakers dictate what physicians can and cannot do, they are presuming that they can practice medicine better than doctors can. If they want to pass laws dictating medical practice, then they should take responsibility for these patients' lives. Lawmakers who pass laws that prevent abortion even when the pregnancy is a threat to the mother's health or life are knowingly causing the deaths of pregnant women. This is murder, and should be prosecuted as such. There is no excuse for having a law like this.

Unsung Heroes

I have been helping out with disaster relief the last 5 days, and working hard. The last 3 days, I was working with Médecins Sans Frontieres (MSF), and finding myself astounded to be doing MSF work in my own city.
I have gotten a lot of moral support from everyone, and I am grateful for that. But while I think I have done some good and helped some people, I actually think that my contribution has been minimal in comparison with some of the other people out there that get less attention. I want to take a minute to highlight these ordinary people being heroic in a time of need.

1. Sanitation Workers
The city is a mess, and can't become functional until it is cleaned up. Sanitation workers are working long hours of backbreaking work to get New York back in shape. I saw sanitation workers lifting up huge pieces of furniture all over the place, and somehow getting all of it into their trucks. They were in the Rockaways today, on the streets that are covered in piles of sand and broken crap, hauling it all away.

2. Social Workers
Everyone realizes that doctors and nurses would be needed in a crisis, but few appreciate the desperate need for social workers. These amazing people can do everything from therapy to logistics to coordination. I had social workers tracking down people's insurance information to get them emergency prescription refills, comforting people with anxiety and depression that was worsened by losing their homes and being trapped in chaotic shelters, replacing broken eyeglasses for people without insurance, and basically doing everything they were asked. One of the days I was in a shelter, I was exploding with stress until a wonderful social worker arrived on the scene, and took some of the work out of my hands, handling everything with grace and perseverance.

3. Pharmacists
So many people have chronic conditions now, and many people did not expect the storm to be what it was. They brought only a few pills with them, or they didn't refill the prescription before the storm hit, and now they're stuck with no meds. Their pharmacies and doctors' offices are under water, and their insurance information is lost in the flood. Pharmacies all over the city are accommodating the need for emergency meds by urgently refilling meds, delivering to shelters, accepting partial insurance info and figuring out the rest later, waiving copays and offering 3-day emergency refills without any insurance information whatsoever. One pharmacist, when he realized how much need we had at a shelter, drove over in his car (kids in tow) to drop off not only prescriptions, but soap, lotion and other toiletries he thought people might need.

4. Nursing Home Staff
Several nursing homes and assisted living facilities were located in areas that were evacuated. These facilities had to move all of their residents, many elderly and with chronic medical and/or psychiatric conditions, into shelters. Some of the staff from these facilities worked 12-18 hour days in the shelters to stay with the patients they know, and make sure they get the meds they need in the middle of a chaotic situation. Without the staff from these facilities, caring for these patients would have been nearly impossible.

5. Home Health Aides
In the shelters I worked in, there were home health aides staying on a cot in the shelter (sharing a room with 20-100 other people) to care for their patients - changing their diapers, checking for bedsores, requesting wheelchairs, giving them medications and staying with their patients 24/7 to make sure they were well cared for.

6. Community Organizations
In many of these communities, we are outsiders; unfamiliar with the surroundings and the people. Preexisting community organizations stepped in to collect, organize and distribute donations, as well as information about where to get food, shelter and medical care. In the Rockaways, a youth organization became a hub for donations, and got so many donations (and needy people looking for donations) that they started distributing to other donation sites. These inspiring young people (in their early 20s) were the most organized and efficient group that I saw in this entire experience.

7. Good Samaritans
People came out in droves to help. Many were turned away from several sites, only to keep traveling to other ones until they found a place to help. These volunteers became essential, and many found a very specific task that they became very good at, and helped bring a chaotic situation more under control. Most were working outside their comfort zone, or even below their level of expertise. But no one balked, everyone pitched in to do whatever was necessary. Some people triaged medical patients; others climbed epic flights of stairs to knock on doors and bring water and food to trapped people; others still cared for patients in shelters too sick or old or incapacitated to fully care for themselves.

The aftermath of this storm has made me realize how much we need everyone in our city and our community to pitch in. But it also made me realize that there are people out there who do really good, hard  things every single day, who deserve our appreciation. Please take a moment to thank them.

Human Papillomavirus (HPV)

Question:
I have HPV. Is my life over?

No, your life is not over. It will be OK.
Human Papillomavirus (HPV) is an extremely common sexually transmitted infection. There are dozens of forms of HPV, but not all of them cause disease. Some forms of HPV cause cervical cancer, and some forms cause genital warts. Other forms seem to cause no disease at all.

Why is HPV important?
HPV causes almost 100% of cervical cancer. If we can prevent HPV, we can prevent cervical cancer.

How did I get diagnosed with HPV?
Most likely, the diagnosis occurred during a Pap smear.

For years, we have known that cervical cancer is almost entirely preventable. When a woman has HPV, it takes years to cause problems, and if caught before becoming actual cancer, it can be treated. That's why we do Pap smears regularly. Pap smears are a light scraping of the cervix that gently brushes off some of the cells. Those cells are examined by a pathologist to determine if they are abnormal or normal. If normal, the woman can continue her regular screening. If abnormal, they must be investigated further.

How do I know if my cervix has abnormal cells?
The abnormal readings that predict cervical cancer are called cervical dysplasia, meaning that the cells of the cervix have been altered by the presence of HPV. These readings can be either LGSIL (low-grade squamous intraepithelial lesions) or HGSIL (high-grade squamous intraepithelial lesions). The higher the grade, the more abnormal the cells, and the closer to cancer it is. However, these LGSIL and HGSIL do not mean that cancer is present, only that abnormalities are present that may lead to cancer. When a pap test shows LGSIL or HGSIL, this means that HPV is definitely present, so there is no need to do a specific HPV test. (More on abnormal Pap testing in a later blog post).

HPV --> LGSIL (low grade) --> HGSIL (high grade) --> Cancer

A third abnormal finding that may occur is called ASCUS (atypical squamous cells of undetermined significance). This means that the cells looked a little abnormal, but not quite LGSIL or HGSIL, and it was hard to tell whether their appearance indicated dysplasia or not. Until HPV testing, it was very hard to know what to do with ASCUS pap readings. Nowadays, we can test for HPV in the settings of ASCUS. If HPV is positive, then we know that there may be precancerous changes, and so we should treat that as an abnormal pap. If HPV is negative, then the woman cannot have dysplasia, and we can treat that as a normal pap.

Sometimes HPV testing can be done even when the Pap smear is negative. This is one possible method of screening available to women who are 30 years of age and older. You can talk to your doctor about what screening method is right for you.

Do I have an STD for life now?
Not necessarily. In some people, the HPV sticks around for years, and that's how it creates abnormal cells. However, many people, especially young people, acquire and eliminate HPV rapidly before it causes any damage. That's why HPV testing is not as useful in women under 30 - because they can acquire and eliminate HPV so quickly that a positive test doesn't mean much. However, in all women, including women under 30, cervical dysplasia does not disappear quickly, and does need to be followed up. That's why Pap smears are done in even young women.

Can I prevent HPV?
Yes. HPV is sexually transmitted, so the only thing that puts you at risk is having sex. The best protection is abstinence, but if you are sexually active, using condoms is the best way to prevent HPV. HPV is not usually acquired outside of sexual intercourse, so you can't get it from a toilet seat (which people often wonder).
Since men are not tested for HPV, routine STD testing will not identify whether your male partner has HPV. Therefore, it's important to always get pap smears, even if you are monogamous and/or have only had 1 partner.
There is also a vaccine against HPV. It is only partially effective, which means that you still need pap smears, but your risk of having an abnormal Pap smear is much lower, and that's great. Women aged 26 and younger are eligible for the HPV vaccine. (There's a good reason for that. I'll address it in a future post).

Red and Black

This question is from a reader. Feel free to contact me with questions!


Question:
My menstrual blood is sometimes brown instead of red. Is there something wrong with me?

Answer:
No, you're fine.

Blood is bright red when it is oxygenated. Blood has hemoglobin, which can bind oxygen molecules. In the lungs, oxygen is passed from the lungs into the blood, turning it bright red. As the blood is transported through the body, its oxygen is transferred to the organs it passes through, and the blood becomes darker (dark red, bluish). By the time it reaches the veins (which bring blood back to the heart), much of the oxygen content has reduced.

During menstruation, blood is shed by the lining of the uterus, and that is usually bright red blood. The blood does not always come out immediately. It can sit in the uterus, cervix or vagina for some time before the woman sees the blood. In that time, the blood can be oxidized (which is different from oxygenated) - it involves a transfer of electrons, rather than just binding of oxygen to hemoglobin. When blood is oxidized, it turns brownish or black.

Therefore, brownish period blood is merely blood that has been sitting around for a while. All blood, after being exposed to air, will eventually turn brown or black.

(Incidentally, this is why stool can sometimes be black - because there is gastrointestinal bleeding. If you have black stools, see your doctor)

Irregular Periods

Question: 
My periods are irregular and infrequent. Is that OK?

No, there may be a problem.

Regular menstruation usually occurs monthly. For most women, this is highly predictable, and comes every 28-30 days. Other women might have shorter or longer cycles (26 or 32 days apart, for example), or variable cycles, but they will still have a monthly period. These women all have regular menstruation.

When the period is irregular, meaning it does not come reliably every month, there is a problem. Most of the time, the problem is that the body is not ovulating, also known as anovulation.
Here is a nice video from womenshealth.gov showing the process of menstruation.

To understand why anovulation happens, it is important to understand how the female hormones work.
Estrogen and progesterone are the most commonly known female hormones. They are very important in controlling the normal function of a woman's reproductive system.

This graph shows the hormonal fluctuations that are needed to have a normal menstrual cycle:

Source: DevBio

Estrogen (blue) causes the uterine lining (the endometrium) to thicken in preparation for ovulation. Progesterone (purple) stabilizes the endometrium, preventing the blood from spilling out. Just before menstruation, both estrogen and progesterone drop quickly (see day 28), and the loss of progesterone allows the thickened uterine lining to bleed out.

Two other hormones that are less well-known also play a role. Follicle-stimulating hormone (FSH, orange) causes the ovaries to develop an egg, and lutenizing hormone (LH, red) peaks and causes the ovary to release that egg (ovulation).

When these four hormones do not fluctuate they way they're supposed to, normal ovulation and menstruation don't happen. Without the increase in LH, the body doesn't know to release the egg. And without the decrease in progesterone, the uterus doesn't shed its lining.

In many women with irregular menstruation, the periods come infrequently, and they can go several months without bleeding. When the period does come, it can be heavy because of the heavy buildup of the uterine lining, and it often lasts longer because there is no hormonal input telling the uterus to stop bleeding.

Why are the hormones abnormal?
It's not entirely clear why this happens. Many women who have anovulation also have a syndrome called polycystic ovary syndrome (PCOS). Its name comes from the fact that many women with PCOS develop multiple small cysts on their ovaries, although women can have PCOS without actually having cysts. In addition to infrequent menstruation, women with PCOS may be overweight, and may have unusual hair growth (on the chin or chest) and acne. About 5-10% of women have PCOS.

In PCOS, there is more estrogen than progesterone. In women who are overweight, the fat in the body converts some of the other body hormones to estrogen, and this leads to menstrual problems. When the women with PCOS lose weight, the PCOS sometimes gets better. However, PCOS can also exist in women who are not overweight, and in these women it is not clear why the hormones are abnormal.

There are reasons other than PCOS that a woman might not get her period. PCOS is most typical in women whose periods have always been irregular, rather than a new change. There are other causes or infrequent periods, like being underweight, thyroid disorder, high prolactin levels, kidney failure, breastfeeding, and certain medications, among others. It's important to be evaluated by a doctor to determine why your periods are irregular.

OK, my hormones don't work. But why is anovulation a problem? Isn't it lucky to not bleed every month?
When the endometrium is exposed to estrogen without the benefit of enough progesterone to match, it becomes very thick, and over many years, the cells in the endometrium can become abnormal, and eventually become cancerous.
Women who have untreated irregular periods for many years are at high risk of having endometrial (uterine) cancer. For that reason, it's important for women with irregular periods to see a gynecologist for evaluation. (There are other less common reasons why periods can be irregular, so it's important to have a full evaluation by a doctor.)

Can I get pregnant?
Women with anovulation often have infertility because they do not ovulate regularly. They may require medications like clomiphene citrate to provoke their ovaries to ovulate, and they may need to see an infertility specialist. However, it is impossible to know whether a woman is fertile before she tries to get pregnant.

What should I do about it?
In order to protect against cancer, women with anovulation or PCOS who are not actively trying to get pregnant should be on some form of hormonal birth control to balance out the estrogen and progesterone levels, and keep the uterine lining thin.
There are several forms of birth control that can protect against cancer.
The birth control pill is extremely effective. It contains estrogen and progesterone, and it replaces the body's production of those hormones. On the pill, level of hormones does not fluctuate over the month, which prevents ovulation, but the estrogen and progesterone are well matched, preventing cancer. Periods will become regular, monthly.
Ortho Evra, the contraceptive patch, and NuvaRing, the contraceptive vaginal ring, work very similarly to the pill, but are easier to use.
Depo provera, or the shot, is a large dose of progesterone that is given every 3 months. The progesterone provides a good match for the excess estrogen, and also prevents ovulation. Many women on depo provera do not menstruate, which is fine as long as the uterine lining is kept thin by the progesterone.
The Mirena IUD, which contains tiny amounts of progesterone, also provides a match for the excess estrogen in the body, and keeps the uterine lining thin. It lasts for 5 years.
The implant, which is now known as Nexplanon, is a small rod that is placed in the upper arm, and contains progesterone.
Women with anovulation or PCOS should talk to their doctor about which method is right for them.

In addition, aerobic exercise and weight loss in women with PCOS often helps improve hormonal function. Women with PCOS may also have diabetes or pre-diabetes, and may benefit from a diabetes medication called metformin. Evaluation by a doctor is the first step in determining whether infrequent periods are a sign of PCOS or another cause.

Here is more information about PCOS from womenshealth.gov

WiRED International Article

When I was working in Tororo, Uganda, a friend, Chris Spirito, generously helped me bring some e-libraries to the Tororo Hospital staff. I was interviewed for this article about it:

WiRED in East Africa

Volunteers Deliver Donated WiRED International 

Laptops and Community Health Information (CHI) 

E-Libraries to Tanzania and Uganda

Mammograms In Young Women

I'm back in the US now most of the time, and this blog has been fairly inactive. I don't have exciting stories from Uganda or South Sudan to write about (for the time being...stay tuned). So I thought I would try something new.

Many of my friends and patients have really good questions about health issues, and often turn to me because I'm just a Facebook message away, and it's hard to make a doctor's appointment just to ask a couple of questions. I'm going to start answering some of them here, because a lot of people have similar questions.

So today's question is:
I'm under 40 and I'm worried about breast cancer. Why can't I get a mammogram?

Mammograms are basically x-ray images of the breast. We use them to detect breast cancer in women who have no symptoms of cancer.

It's important to understand the difference between a screening test and a diagnostic test. A screening test is done in asymptomatic people who are at risk for a particular disease. A diagnostic test is done in someone with symptoms of a particular disease, to find out what is causing the symptom. Most mammograms are screening tests. Once a woman has already felt a mass in her breast, she no longer needs a screening mammogram; she needs a diagnostic mammogram.

For a screening test to be useful, several things have to be true:
(1) It has to be able to detect the disease reliably in people who have it
(2) It shouldn't over-detect disease in people who don't have it
(3) The disease has to be treatable
(4) The outcomes of the disease should be improved by the screening test

Therefore, mammograms are only useful if they detect cancer early, and if treating the cancer that was detected actually prevents women from dying of breast cancer.

An example of a good screening test is the pap smear. It detects early disease (cervical dysplasia) very well, before it leads to cancer, and when you catch the early disease, you can treat it and prevent it from becoming cancer.
Other tests that we use for screening include the colonoscopy, the prostate-specific antigen (PSA, controversial), HIV testing, STD testing, blood pressure and cholesterol testing. Even a physical exam can be a screening test, such as a listening to the heart rhythm, palpating the thyroid, or examining the breasts for masses.

So why don't women of all ages get mammograms? We've all heard of someone somewhere who died of breast cancer in her 30s, so wouldn't you want to prevent it?
First, mammograms aren't very effective in young women. Women under 40 have very dense breast tissue, and the mammogram imaging can't see through the tissue to detect the signs of cancer.
Second, breast cancer in women under 40 is extremely rare. Even though we've all heard of a case or two, those are the outliers. Breast cancer is largely a disease of age. Only a very small percentage of breast cancers are inherited, so the absence a family history of breast cancer is not protective.
Third, it's not clear that screening would help women who get breast cancer at a young age. Those women often have aggressive forms of cancer, which progress despite treatment. While early detection has helped some women catch their cancer early and successfully treat it, other women whose cancers were caught by mammogram early still went on to die of the cancer. This is because not all cancer is the same. Some breast cancers are slower growing, while others are fast and metastasize quickly. If the mammogram catches the cancer but the woman still dies of it despite treatment, then the mammogram didn't help.

Should anyone be screened at a young age?
Yes, some people should. People with a strong family history (for example, two first-degree relatives with breast or ovarian cancer at young ages) should talk to their doctor about being tested for genetic syndromes such as BRCA. They may be candidates for early screening because of their risk profile. However, most people with average risk do not benefit from early screening.

Is cost an issue?
Yes, it is. Cost is not the only reason not to do screening tests, but it is important to consider.  If we were to run every test available on every person all the time, we would be out of money in a heartbeat. However, the fact that something costs money isn't a reason not to do it. Cost-effectiveness studies look at how much a particular screening strategy costs - how much money is spent to detect one case, or to save one life? It can also be evaluated in terms of effectiveness - how many people need to be screened to detect one case?
However, with mammograms, cost is not really the issue preventing screening in young women. Mammograms are relatively inexpensive, but because they are largely ineffective in young women, the costs of doing them would be money wasted - money that could be better spent on other things, like researching treatments for breast cancer.

For more information here is a good fact sheet from the National Cancer Institute about mammograms.

MSF Blog: Rupture

The fifth blog post in my MSF blog, Love, Labor Loss.


When I examine the patient, I can feel the baby’s limbs so close to the skin. I look with the ultrasound, and I don’t see any uterus around the baby. I also see liquid blood around the baby. It is very indicative of uterine rupture. 
 Uterine rupture is a catastrophic complication in which the force of the contractions is too strong for the uterine muscle, and the tissue literally bursts open. It looks as if the uterus has exploded. The infant is released into the abdominal cavity, and the placenta usually is too, which means that the fetus dies within minutes. The bleeding can be so severe that the woman herself can die before reaching help, so the fact that this woman is alive at all is a positive sign.

Click here for the full post: Rupture

MSF Blog: Yin A Mat Po? (Are You Happy?)

This is the fourth essay for my MSF blog.


In South Sudan, it is unusual for a woman not to have lost at least one child. They die in childbirth, or they die later of malnutrition, malaria, infection, unexplained illness. I have seen women who have delivered 7 children, only to have 3 of them die, or delivered 4 children but having only 1 living child. When a woman arrives, the first question asked is “How many children have you had?” The second question is, “How many are alive?”

It may be a part of life here, but it would be hard to argue that these women suffer less. I truly cannot speak for them, nor know what they feel, whether they have different expectations or a more effective way of processing grief than we do. But in my opinion, grief is grief, and whether you acknowledge it or bury it, it is there and always will be. It is only how you process it that differs.

Click here for the full post: Yin A Mat Po?

MSF Blog: Sepsis

This is the third essay for my MSF blog. A segment is below.

When we arrive in the Operating Theatre (OT), the patient is under anesthesia, and the outgoing obgyn (whom I am replacing) is attempting to deliver her vaginally. She is 18 years old. It is a full term pregnancy, and the baby is already dead. She has been in labor for 4 days. Since it didn’t come out during labor, we can assume it will be difficult to get out now.

Click here for the full post: Sepsis

MSF Blog: Head Entrapment

Here is the second installment from my MSF Blog: Head Entrapment

Feel free to comment here or on the MSF blog. I have gotten some wonderful comments on the MSF site and it's really helpful to know that people are reading.

MSF Blog: Precious Blood

For the month of March, I am working with MSF in Aweil, South Sudan. I will be blogging through the MSF blog site.

Here is my MSF blog: Love, Labor Loss

My first post is called Precious Blood. I hope it inspires you to donate if you can.

Really?!

I Use Birth Control

I don't like the tone of this birth control debate. Conservatives are trying to make it sound like contraception is some fringe practice only for promiscuous people. It's ridiculous.

Contraception shouldn't even be controversial. So let's change the conversation.

I use birth control, and it's awesome.

Women, do you use birth control? Say so, loudly. Men, have you ever used a condom? Then you use birth control, too. Let's tell them. Enough with this crap already.

Ron Paul Is A Jerk

There are a lot of reasons I think Ron Paul is awful. I won't go into all of them here. However, I do want to comment on this interview with Piers Morgan, in which Morgan challenged Paul on his views on abortion, because what he said was so mind-bogglingly stupid.


Before we start, let's remind ourselves (little as I like to remember this fact) that Ron Paul is an obstetrician-gynecologist. So, in theory, he should know better.

Still Angry

While I'm glad that the Susan G. Komen foundation seems to have reversed its decision, I'm still angry.

It's time to stop demonizing abortion (and Planned Parenthood). Whatever your discomforts, convictions or beliefs about how other people should behave, it is necessary to acknowledge that life is messy, and that sometimes things have to happen that we don't like very much. You don't have to agree with abortion to be opposed to its criminalization. I would love it if no woman ever had an unwanted pregnancy, or a pregnancy complication for that matter, but that's not the world we live in.

It's time to acknowledge how easy it is to get pregnant unintentionally, whether through a momentary lapse, series of bad decisions, or unlucky contraceptive failure. It's also time to acknowledge that bearing a child and rearing a child are both significant challenges, sometimes burdens, that should not be taken lightly.

It's time to concede the grey areas. A first-trimester pregnancy is not the same as a newborn infant, and accordingly our society doesn't treat an early miscarriage the same as it does an infant death. An abortion is sad, but it is the woman's sadness, not ours, and she needs to be respected and trusted to make a decision.

The Komen foundation thought that they could quietly defund Planned Parenthood in part because we, the pro-choice community, have not been vocal enough in showing how strongly we believe in reproductive freedom. Subtly, we allow the implication that abortion is a personal failure, and is shameful. We think that it would never happen to us, until it does.

We allow politicians to yell and scream about "Medicaid funding for abortion" and we don't question them. Well, why shouldn't federal Medicaid fund abortion? It is a legal, safe procedure that affects the health of women. Taxes are not fee-for-service. I don't have a car, and I wish our country had more trains and less highways, but I don't yell and scream that my taxes shouldn't go to repairing and building roads (but maybe I should). Maybe Medicaid shouldn't fund abortions. Maybe there are good arguments to be made against funding it, even if I haven't heard any. But we should stop letting them take it for granted, and actually argue about it.

We quietly simmer while abortion access is severely curtailed through legislation and murderous intimidation. When restrictive laws are passed, we think, "How terrible. I'm glad I don't live there." Or if we do live there, then we think, "How terrible. I'm glad I don't need an abortion." What would be our response if laws restricted access to Pap smears? (After all, cervical cancer is caused by HPV, which is acquired through sex. Should Pap smears be shameful?) As this excellent Guttmacher article argues, we need to stop accepting "the apologetic approach."

Abortion is legal and most of the country is opposed to criminalization, but it is an easy target for conservatives who want to seem moral and religious. What if we yelled back, and told them that they were immoral for trying to shame women? What if we called them out for what their anti-abortion rhetoric really is, which is disrespect and hatred? The pro-choice community was angrier yesterday than I have ever seen it in my lifetime, and I think there is more anger out there. Let's start showing our anger.

Komen Foundation and Planned Parenthood

Petition against the Susan G. Komen Foundation's decision to stop funding Planned Parenthood's breast cancer screening programs.

What I wrote:

As an obstetrician-gynecologist, I have seen first-hand the devastation of women's cancer, and the importance of screening and early detection and treatment. Your actions are short-sighted, and, at best, cowardly. At worst, they are misogynistic for contributing to the forces that would deny women reproductive freedom. I will never donate another dime to your organization, and I will find other ways to support cancer research, screening, and treatment. Furthermore, I will always support and stand by Planned Parenthood.

Induced Abortion in Uganda

A research paper by the Guttmacher Institute contains interesting information about abortion in Uganda:

• Abortion is permitted only to save a woman's life
• The incidence of induced abortion is 54 per 1000 women
• One in 5 pregnancies ends in abortion
• 85, 000 women are treated every year for complications from induced abortion
• 38% of births in Uganda are unintended, and half of all pregnancies are unintended
• Ugandan women have an average of 2 more children than they want
• Only 14% of women were using an effective contraceptive method