Birth control can kill you, but so can pregnancy… Or life.

I went on Facebook yesterday evening and my head exploded.

Image from uproxx.com.

And no, it was not a stroke from birth control pills.  Although, I will be the first to tell you that I am at increased risk of stroke because of them.

It was a related topic, though.  The headline cited from CBC news on at least four of my NON-MEDICAL (please note) friends was “Yaz, Yasmin birth control pills suspected in 23 deaths” along with statements from the poster that they stopped taking their pill or were putting this warning out to protect their friends.

Image from litteratursiden.dk.

I had to read the article.  As soon as I read the title, I told Patrick that this was totally because some crazy person or people decided to sue the drug company because they had a stroke or a pulmonary embolism (blood clot to the lungs).  I was right.

It is actually a sad story, a young girl died from a massive PE while working out.  I feel badly.  It could be one of my friends.  Now, her family decided to sue the drug company that produces this particular pill and are entering a class action suit with a bunch of other people and families who have had potential complications from the pill.

I am not belittling the consequences of a PE or stroke or even a DVT.  The first two can kill you and all three can lead to requiring lifelong anticoagulation, which is in and of itself a risky treatment.

This article reports that Bayer, the producer of this particular OCP that contains a novel progestin (aka a different compound that mocks progesterone in the woman’s body) that is sometimes easier to tolerate has paid out millions in lawsuits in the U.S.  It also reports the Health Canada findings of reported deaths and serious events due to these particular oral contraceptives as slightly higher than others.

Then, today, to top everything off, I see a CBC community blog reposting some of the comments and social media backlash from the report.  Most of the article reiterates a few of the horror stories of people who did have clots and a few who are glad to have changed pills or want to change pills.  Then, at the end, they acknowledge that some people pointed out that with any medication there are risks and benefits.

And this brings me to my discussion of the article.

Let’s start with some science.

Image from evolvefish.com.

I know, what does science have to do with this, our lives are at risk!?!

Seriously, science is key here.

Blood clots are normal things are bodies make all the time.  Clotting is super complicated (and fascinating) and I am not going to get into the details.  Sometimes, our bodies clot too much and that can lead to clots forming in places we don’t want them to… Like our brains or in our legs.  And those clots in our legs can break off and get stuck in other places that are dangerous, like our lungs.

Image from bbc.co.uk.

A bunch of things put us at increased risk of clotting.

I checked out a few sources that quote clot risks for your average non-pregnant, non-OCP taking female from 1 to 4 in 10,000.

Some people have genetic alterations that put them at risk.  There are certain proteins that, when present make you more at risk of forming clots at baseline.  Just a crappy genetic hand.  If you have a few relatives that have had “unprovoked clots,” then you might too.

There are other things that provoke clots… Stasis.  Aka sitting around and doing nothing.  Long distance travel, for instance.  Sitting still for flights greater than 8-10 hours, for instance is quoted as a 0.5% risk for all ages not in a high risk category.  Or following surgery or a long period of bedrest, average risk women are at anywhere from a 5-10 fold increased risk of blood clots.  Some non-hormonal medications increase that risk.  Obesity and smoking each have been quote to almost double the clot risk.

Now we move on to the hormonal stuff.  I found this fabulous post here at The Blog Who Ate Manhattan if you are a visual sort of person.

Oral contraceptive pills and other hormonal birth control contain different quantities and formulations of hormone.

I will be the first to admit that studies offer varied accounts on the rates of side effects and clots are no different for this.  Different studies have different reporting criteria and sometimes rates are grossly underestimated, although overestimation is also possible depending on the age and risk group assessed.

Image from nationalnursingreview.com.

Your traditional OCP pill (like a tricyclen or evra) have a 3-6 per 10,000 risk of clot.  OCP with the novel progesterin like Yasmin have an anywhere from 3-9 in 10,000 risk of clot. The interesting piece with the OCPs is that clot risk is highest for the first year and then does drop a bit.  The patch also has an increased clot risk of anywhere from 3-10 in 10,000.  The ring increases risk too with a 3-8 per 10,000 risk.  Progesterone-only contraceptives are some of the only ones that don’t have evidence for increasing clot risk with rates from 1-3 per 10,000.

But wait… Pregnancy is the highest risk of all hormonal risks.  It increases the risk of clots up to 5 times.  FIVE TIMES!

A lot of numbers, I know.

image from nl.123rf.com.

So, to sum it all up… Everyone is at risk for blood clots.  Our risks increase based on the combination of risks we are at.  For instance, women over 35, especially those who smoke are almost never offered combination OCP or patches because that would put them at a rather significant clot risk, especially if they decide to go on a long flight and not move.

And yes, numbers do suggest that people on OCP are at increased risk of clots.  And that women who choose Yaz or the patch or the ring are at some increased risk of clot compared to others.  But then again, pregnancy is much worse!

So, hmmm… Are there lawsuits against other hormonal contraceptive drug companies?

Heck yes.

My research for this post shows that there are class action suits in the US against what looks like most drug companies who produce whatever hormonal contraceptive, but especially the higher risk ones… The Yasmin family, the patches and the vaginal rings.

But, I question this practice.

I also wonder why women don’t start suing their male partners for making them pregnant and increasing their clot risk.  I shouldn’t.  It probably has been done.

All medications have risks.

I have heard people tell me that they don’t want to put anything foreign into their bodies.  But, even taking a supplement can be potentially toxic and even Tylenol has risk and adverse reactions.  Sure, some things have significantly more risk.  But, if you are worried about that, you weigh the risks and the benefits.  Use some common sense.

Image from jantoo.com.

When I prescribe birth control (which is rare given I am an oncology resident), I like to have a discussion to assess for other clotting risks and regarding the risks and benefits of the medication as a whole.  I was taught (and was under the impression) that physicians ask about things like smoking, high blood pressure, family history of clots and migraines with auras to work out the risks that could happen when on a hormonal contraceptive.  I will be the first to acknowledge that we in medicine could do a better job at explaining risks and benefits of drugs, but I also need to point out how many drugs there are and how tight time is.

Clotting is a KNOWN risk of hormonal contraceptives. And therefore taking it, to me, acknowledges that increased risk.  Just like you might also get nauseous, have spotting or gain weight.  Just like people who take asprin may bleed or people who take antibiotics may have an allergic reaction.  There are rare adverse events and there are common adverse events.  You always discuss the common and the life-threatening rare.   And you weigh the risks.

Clotting is also a known risk to being human.  So, really, it is sometimes difficult to attribute every complication to the pill, even if a woman is taking it.

I will be my own example.

I have no clotting risk factors.  But, I have migraines with aura.  Having a migraine with aura puts me at double the risk of stroke than my normal counterparts (stroke risk in women 15-34 is somewhere between 2 and 3 per 10,000).  Adding a combination hormonal contraceptive to the migraine pot increases that risk to anywhere from 11-23 per 10,000.  Pregnancy will increase my stroke risk to similar or greater odds.

When I learned this, I opted to take a progesterone only contraceptive.  It is a bit less effective and more use dependent, but it was worth it.  Will I still get pregnant?  Hopefully.  Risk versus benefit.  Baby>stroke risk.  OCP (that potentially worsens the migraines anyway)<stroke risk.

If I were to take a combined OCP, I could have a stroke.  I could also have a stroke without taking it.  But, who can say for sure.  It is just a probability.

The media likes to sensationalize things.  And people freak out about stuff.  And thus this makes great news.

I don’t like that the people of the media or society who freak out about crap like that is that they don’t think of the other reprecussions.  I mean, sure they are making people aware of the risk and maybe stopping a few people from taking a fine medication and thus decreasing their clot risk slightly.  But, they are also making people come off of a medication that works for them just because of heresay.  Everyone gets side effects and now many will catastrophize them because of this.  Some people will get worse side effects from a different pill.  Some people will still get a clot.  And many people could get pregnant because of their fear of the pill.

Does the cost of unwanted pregnancies that have risks of their own outweigh someone’s need for repayment, the media’s need for publicity or even a few complications (as terrible as that sounds)?

So, this whole news thing makes me crazy.  Everyone is coming out of the woodwork with their problems and their cautions.  These are KNOWN risks and KNOWN problems.  They are much less than the issues that arise with pregnancy and those that arise in people with unwanted pregnancies.

Plus, it is fostering further mistrust in the medical system.  I will be the first to acknowledge the system isn’t perfect and we make mistakes, but it is unfair to put such fear and paranoia into people.

Image from vitalia.pl.

If you want to make an informed decision read legitimate research, not news sites and private blogs (seriously, don’t take my word for it).  Talk to your doctor and your pharmacist and weigh your options and your personal risk.

Sometimes bad stuff just happens even if every other risk factor is 0.  And sometimes you can have a giant “hit me” sign on your chest and be fine.  Such is life and biology and probability.

I wish people didn’t have to hurt, but I wish they wouldn’t inflict such wrath while trying to get “justice.”

Excuses, excuses…

It was pointed out to me by several people (which blows my mind a little) that I am behind on posting.  By a whole two days.

I know… Mind blowing.

I do skip posts sometimes.  But this week was particularly crazy…

It was just me an a new senior resident this week.  That meant that we were busier overall.  I got to scrub in to a ton of surgeries, which has its pros and its cons.  I must admit, I am feeling much more comfortable with the whole thing (I have mastered the art of cutting and stapling… Kind of like kindergarten), although by Wednesday evening, I thought I might need a foot transplant (I refuse to buy proper OR shoes because I will RARELY use them in real life).

Tuesday night, chemo was running late, so I had to stay until that was over.  It was 7 by the time things wrapped up.  I had been there since before 7 that morning.  I still posted, but I was pretty pooped that night because we were out the night before too.

We had our D-group… aka small group on Wednesday night.  We ate pizza, talked about the resurrection and had a worship session complete with tambourines and other noise makers.  It ran late.  We got in at 9 and I still had to skim my research presentation for the next day and do reading for the ORs the next morning.  So, no post.

Yesterday was my department’s resident research day.  I was convinced to present by the lovely Dr. Bond.  I was terrified of looking like an idiot in front of people.  Somehow the coolness of my research combined with my love for public speaking managed to score me the award for the best rad onc resident presentation and the best overall resident presentation… It included a cash reward that will now enable Patrick and I to do something like go away on a romantic evening or something wild like that… Whoo.  After all of the research festivities, we went out for a drug company sponsored fancy supper.  They lit my desert on fire.  ON FIRE!  I got home at 9 and still had to inform my husband and parents of my exciting news. By the time that stuff was done it was past my bed time.

That leads me to tonight.  I am on call… Yet again.  It seems that happens a lot.  But, at least I have the time to post.  And catch up on some TV (possibly).  There were new shows of almost everything I watch this week… And I am weeks behind on some of them.  We are making butter chicken lasagna (I know… So weird, but it was on sale at Superstore) and chilling out for the evening (unless I get called in, which is likely given my present track record).

Instead of writing a post about something interesting, I decided to do the stereotypical make excuses about why I did not post thing.  I know, it is cliché.  But, I thought it actually does sum up the interesting stuff in my week.  Plus sometimes you need a self-satisfying “wah wah, this is how big my week was.”

I can’t make any guarantees, but things will hopefully be more interesting tomorrow.

How was your week?

Medical Mondays: Simple things can change lives… Get checked.

It is Medical Monday. If you are at all medically associated or want to read some interesting blogs about medicine-y sorts of things, be sure to click on the button below to see more.


I am doing a gynecology oncology rotation right now.

Thus, I am doing a lot of operating room time and a lot of pelvic exams.

You are probably thinking… Ew.

I am thinking you’ve seen one, you’ve seen them all… Sort of.

The thing with the pelvic exam is that sometimes you uncover things.

In many areas of medicine, the physical exam is extremely important.  But, you don’t necessarily stumble upon a finding that can change someone’s prognosis.  If someone comes in with a history of lung cancer, they are often short of breath before you hear a wheeze.  The lymphoma patient points out the lump.  And sometimes the gyne patient says there is bleeding.

But, sometimes, things seem to be going along swimmingly.  Then, you take a look.  And there, right before your eyes is a surprise no one in the room expected and no one in the room wants.  A bit of something in the vaginal vault.

Vault recurrences are one of the most common sites of recurrence in gynecologic cancer.  That is why we make all of these women have speculum exams with every visit, even though nobody likes them.  You know going in it is a possibility.  But, when you see one, it crushes you a little.

Sometimes  visit is going so well, and things are going great and then you see something red and fleshy and you know it is bad.  You have to break the news and take biopsies and all that icky stuff.  Plus, this is probably one of the worst positions to get bad news in.  At least in my opinion.  So vulnerable.

This rotation is one of the ones that remind me of the sad truth about some gyne cancers.  That many can be prevented or at least caught early.  And others are nearly impossible to catch at all until it is too late.

It is a funny dichotomy.

It often seems unfair.  The young women who could have prevented or minimized their disease and morbidity by getting a simple pap smear, the middle-aged women who, if they had maintained a healthy body weight could have avoided an endometrial cancer and if they saw the doctor about the bleeding sooner may have avoided the chemo and then there are the ladies that were perfect  and took good care of themselves until they had some bloating and constipation only to learn they have an advanced ovarian cancer that probably couldn’t have been detected any earlier.

I know you can’t catch everything and you can’t fix anything.  But, when I see young women dying in their thirties and forties of something that would have been prevented with some basic screening that takes only a few extra minutes of your day, it disturbs me.  It upsets me that physicians don’t push the issue.  It bothers me that people don’t know how much grief they can save just by going for a test that some call “embarrassing.”

It makes me crazy that we talk about healthy lifestyle and such, but it is rare that we warn women that obesity increases their risk of endometrial cancer.  Sure we do heart disease and such, but do we really discuss all the risks honestly.  Then, do we really take post-menopausal bleeding seriously?  I know so many women who were brushed off or made to wait for imaging instead of going directly for biopsy.  Time is tumor growth. Any bleeding after menopause is abnormal.  Irregular and constant bleeding before menopause should be investigated.  So many women have endometrial cancer.  It is curable.  But, we have to find it at a point where it can be cured.

Ovarian cancer is the one that is tricky.  You can’t screen for it.  It has few symptoms.  It scares me the most because it is the sneakiest.  Awareness campaigns are helping to make women know symptoms to look out for.  Unlike some other diseases, it is often not apparent until it is too late.  Other times it can be found by accident.  But the other two, they can be found early or before they happen more often than not.   I wish people would just heed that, for the sake of those who don’t have that opportunity.

When you palliate someone your own age for a cancer that could have been prevented with simple screening, you realize these things are serious.  When you find a recurrence after a seemingly excellent office visit, you realize these things are serious.  When someone you know or love has one of these diagnoses, you realize these things are serious.

Why can’t we just do the right screening when it is available?  Why can’t people report abnormal symptoms and get them tested in a timely manner?  It only seems fair, especially for those who would not be able to find things sooner.

Everyone says “if only,” but the best way to avoid the “if only” is to get checked for what you can when you should.  Cervical cancer is preventable.  Endometrial cancer is both preventable and detectable in some (though not all) cases.  If ovarian cancer could be reliably found earlier, I am sure people who have ovarian cancer would want people to get screened. At least people can be aware of possible symptoms.

So, stop saying maybe later.  We can’t prevent everything.  We can’t live in a bubble.  But, sometimes a simple test can save lives.  A lifestyle change can reduce risks you may not realize are there.  Being aware of your body can save you later.

I know screening, appropriate physician visits and self-awareness won’t prevent all illness.  But, I do know that some cancers can be avoided or their burden can be lessened.  That beats finding surprise recurrences or dying young or dealing with nasty side effects that could otherwise have been avoided.

I get that it is scary.  The mystery is scary.  Potentially finding out you have a cancer is scary.  But, knowledge is power.  And prevention/risk-reduction is everything and fortunately in the world of gynecologic cancer, it works in many cases.  If only people would take advantage of what is potentially available to them.  It could save so much grief in the long run.

So, next time you question whether you need that pap smear or wonder why things haven’t been feeling right, remember you may be saving yourself a lifetime of pain and fear that could have otherwise been prevented.  And that there are many women out there who wish they would have just done it when they had the chance.

Ducking, weaving, shivering and not looking like an idiot… The OR.

I spent the entire day in the OR today.

This makes two days this week.  And tomorrow is an OR day too.

Often, as a junior off-service resident, OR days equal me running around and taking care of patients on the floors.  When the running around is slowed down, you peer at stuff from the back of the room.

However, on this service, the floor work is much less, so I actually get to go and peer at a lot of surgeries.  This can be a good thing.  But, it can get a bit dull.

What?  Dull?  How can surgery be dull, might you ask.

Take these people, and then try to hover around to see what is happening without touching most of anything. Challenge accepted! Image via mediawiki.com.

Well, the thing is, you help get the patient positioned and then while you wait for the team to scrub, drape and start cutting into the patient, you write the orders and some of the operative note.  Then, you wander around the room hovering, standing on your toes, dodging heads and shoulders to try to get a good look at the action.  While the stretch your body into a way that enables you to see stuff is happening, you are being reminded repeatedly by the scrub nurse and the circulating nurse to not touch a million things and be careful of thing blank (these are very important warnings because contaminating a field is a very bad thing).  If you are lucky, it is a laprascopic procedure  for which you can see one of the tv screens.  Then, it is kind of like watching TV or a video game.  If you are unlucky, it is a procedure in a deep hole with a ton of arms and bodies in the way of any hope you had of seeing very much.

Eventually, the ducking, weaving and straining gets tiring.  By that time, they are finally doing something kind of interesting.  You start to space out, daydream.  That is always when the staff asks a question that you are supposed to answer.  You fumble through it.  You stare  at what is happening.  You try to not concentrate on the fact you are freezing and can no longer feel your toes.  You fidget a little.  You try to pay attention.  You try not to fall asleep standing up.

After what will feel like hours (and it often is), you realize that you enjoyed about 20 minutes of unobstructed viewing (most of which was the more senior residents closing) and maybe an hour or less of something that was cool to see… At least from that far away.  The rest consisted of chunks of view, watching people curse, watching people dig around at something you can’t see and some pimping.

You finish writing the notes.  You help move the patient to the bed and take them down to recovery.  You just start to think you might warm up and then you repeat the cycle.

Sometimes, you do get to see more.  And don’t get me wrong, the OR offers some wonderful learning experiences, even if you aren’t right in there in the action.  I have seen some really cool stuff (smelly liver abscesses, giant tumors) from the side of the room.  But, watching people do stuff you don’t fully understand for hours in dreadful. Especially when you are cold and afraid to break something.

We don’t have comfy looking viewing theatres like on Grey’s Anatomy.  I wish we did.  Maybe I could sit there instead.  And see more.  And keep warm.

It looks like much better and warmer viewing up there. Image via greysanatomy.wikia.com.

But, today, I got to mix it up.  Thanks to teaching for the other program, I got to assist in a few surgeries.  Assisting at my level is similar to assisting as a med student.  I retract.  I move the uterus around on a stick.  I suction a bit.  I cut sutures.  I clean up the patient when we are done.

Scrubbing in frightens me.  I lack hand eye coordination that is required to avoid contaminating myself or something else, so although I am fine now, I have been known to walk into undraped limbs or touch things I shouldn’t.  When I scrub, I remember those times.  Also, I am slow at suturing and such, so I am always nervous about looking stunned (even though some might argue I am supposed to be stunned because I am a first year resident).

I swear this has pretty much happened to me. Image via ddxcomics.com.

The awesome part is that you actually get to see stuff and feel stuff and although you get grilled more because you can see and feel (and they remember you are there), you also get to do something and keep a bit warmer.  It is a fabulous place to learn anatomy and about how diseases work.  A tiny piece of me likes it.

I nearly stroked out today though when I was told to assist kind of first assist style with opening the patient today.  Really, the staff was two feet away and helped me, but I did actually use the cautery (first time ever) and cut through the abdominal wall.  And helped with the procedure more than I normally would when I scrub in with an attending and a senior resident.  I was relieved when someone better at that stuff took over, but for a bit, I was kind of being surgical.  Kind of.

Being able to do that stuff is cool.  I can see the appeal.  I still don’t want to do that for the rest of my life.  Or do it very often.  But, it was cool.

Tomorrow, I am back to the freezing and hovering.  But, the first case will at least be on the screens again.  Thank goodness.  Apparently, I will be assisting more next week.  I have mixed feelings about that.  But, I am glad to be learning.  And while I am scrubbed in, I am glad we don’t have viewing theatres like on Grey’s Anatomy to see me look “special.”

“Special” Days

It is Pi Day!  Happy Pi Day to all the nerds like me out there.  Pi is my second favourite irrational number with my first favourite being Euler’s number.  I wrote about this whole number thing in this post.

Today was also first day on yet another new service day, as well as first Gyne-Onc call shift day.  I like Pi Day better.  Although, at least this service has oncology in the name.  That makes it seem a bit more relevant.

Patrick likes to inform me at random about days that are entitled ___ Day.  He just out of the blue will say, “Hey, did you know it is Women’s Day (or Talk Like a Pirate Day, etc.).”  When we were dating, he would occasionally send me festive e-cards for a particular “day.”  Once, thanks to a very big ecard error in dates, I received an ecard he had sent me on a completely different date over a year earlier on a completely unrelated day.  It was for something not quite so obscure like St. Patrick’s Day, so I just thought he was being weird.  Turned out, the internet was being weird.

I am not a festive person, but having random days for things can be kind of fun.  At least sometimes.  At other times, it is just plain annoying.

For instance, my birthday is apparently “Hug Holiday.”  What the heck?  I hate hugs (for the most part).

Today is not only Pi day, but also National Potato Chip day and Learn About Butterflies day.  Fascinating.  I feel we need to go out and pick up a bag of chips after work… I like chips better than pie and it will make call better.

The other night was my last Internal Medicine call (big win!).  I had a suspicious feeling it would be eventful for a number of reasons, including that my parents were visiting and I wanted to go out with them the next day, but also that, well, it was my last call.  Apparently, it was not a full moon, but people were all squirrely and doing things like leaping out of bed and breaking hips and all sorts of colorfulness.  I deemed it the night of delirium, though I could have also called it more interesting names like the night of the walking (er… falling) confused or last call, but really delirium was the biggest trend.  Such is medicine call.

When I was in Nuc Med, this one time, we had a bunch of renal scans, which are a bit more labour intensive than your usual bone scans and cardiac scans (at least in that it involves a different radiopharmaceutical) and we deemed it renal day.  We also once had a technologist appreciation day during which all of the students baked stuff and shared it with the techs that helped teach us… It could also have been called find an excuse to eat excessive baked goods day.

This weekend, this small theatre locally is playing old-school To Kill a Mockingbird for a discounted rate.  I really want to go see it and keep reminding Patrick about it.  I am calling it To Kill a Bird weekend… Because that is what I called the book in high school.  And I need to pretend the weekend is special somehow, even though that will really only be a two hour block of time and it kind of sounds morbid.

If I had to pick a day that is “official,” I think, at this point I would choose either July 13, “Embrace Your Geekness Day,” or July 15 “Cow Appreciation Day.”  Although, close runners up would be November 6, “Saxophone Day,” May 14, “National Dance Like a Chicken Day,” or September 29, “National Coffee Day.”  The good thing is that they all fall on separate days, so I can theoretically legitimately celebrate all of them!