It is important to put this change in perspective.

The initial wording of the bill did not mention vaginal ultrasound, it specified an ultrasound  most “appropriate” for determining gestational age. For many women that would have meant a vaginal probe, as a vaginal ultrasound is often the most accurate way to determine gestational age in the 1rst trimester. While some women will avoid a vaginal probe because of these changes, many women getting a 1rst trimester will get a vaginal ultrasound as part of their routine pre-abortion care. So, it is hard to know how many vaginal ultrasounds will actually be avoided by the changes.  

In my opinion, changing the bill to expressly exclude transvaginal ultrasound doesn’t improve it much and all the focus on the potential increase in vaginal ultrasounds detracted from other egregious aspects:     

• Politicians are still stipulating how a medical procedure should be performed (the ultrasound requirement). That’s wrong. Medical care should be between a patient and her provider. 
• The added cost that a potentially unnecessary ultrasound imparts. Studies tells us that many 1rst trimester ultrasounds could actually be avoided. 
• The 24 hour delay between getting the ultrasound and having the abortion. Unless of course you live 100 miles a way, then a 2 hour window between ultrasound and procedure is acceptable. The cost and inconvenience of taking an extra day off of work or arranging another day of childcare, never mind the cost of gas for women living 30 or more miles from their provider is obscene. Most counties (88%) have no abortion provider and 97% of non-metropolitan areas are without an abortion provider. This bill unfairly disadvantages women based on geography. 

The medical evidence indicates that cost and geographic location do not affect choice with regards to abortion, they only delay the procedure until funds and transportation can be secured. Therefore, this bill can serve no other purpose other than one or all of the following:

• Punishment of women who choose abortion
• Imposing the religious beliefs of one group on another
• Political posturing in an election year  
• Legislation (and rather poor legislation at that) of the practice of medicine 

There is one silver lining. People made a lot of noise and it clearly had some impact. Not enough, but some.

And the people who made that noise vote.   

No school and no sitter to be had. No play date to scrounge up. So, despite howls of objection, the plan was 24 Hour Fitness and the Kid’s Club. For some reason it requires negotiations only previously experienced when engaging North Korea to get my kids to sit in front of a video for 45 minutes at 24 Hour Fitness. Interestingly, they beg to do the same activity at home.

The treaty signed, we headed to the gym only to find the Kid’s Club full. Curses.

This will happen I told myself, but deep down I felt a slight surge of panic. Exercise is now a crucial part of my life. I need it. It makes me feel strong, keeps me healthy, and is helping me maintain my 50 lbs weight loss (5 months and counting!). It also sets a good example for my kids, no matter how much they complain about the childcare arrangements.

I never once saw either of my parents do any physical activity. Exercise was an experience of no value in my household, although late-night binge eating was an olympic level sport. Neither exercise nor binge-eating were ever discussed, but I saw one and not the other. Guess which behavior I modeled?

So home I dragged them for an hour of cleaning. I called back to the gym. The Kid’s Club had an opening. Yes! Back into the car seats and back to 24 Hour Fitness we went.

Checked in, I whisked the boys to the TV Room of Doom and just as I signed them in the perky child care worker announced, “We close at noon.”

The clock on the wall said 11:31.

Nooooooooooooo.

I was in a foul mood as I scrambled to the treadmill. I need to do 3 miles. I have to do 3 miles. I’ll never get in 3 miles. Never.

I started at a 9:31 pace (6.3 mph).

I’ll never do it, I’m lucky to run 30 minutes at 9:31.

And then it hit me. What kind of fucking attitude is that?

I thought about something I never believed I would have had the ability to do.

I thought about having the guts to leave an abusive relationship. I thought about sitting in my car day after day at work, crying. About how scared I was, but somehow one day I found the strength to say, “Fuck this shit,” and leave.

I increased my speed.

I thought about my son dying at birth. How I couldn’t imagine living with my soul cut in half. But somehow I picked myself up. I thought about how I am not only just living, but I actually have joy.

I increased my speed again.

I thought about the months my boys spent in the intensive care unit. How day after day I stumbled through my existence, but somehow I found a spark and reignited my fire.

I pushed myself harder.

I thought about Victor, my poor sweet Victor, born with tight and twisted muscles. How the doctors and therapists tried to soften the blow about his cerebral palsy. About what he wouldn’t be able to do. I thought about how I poured my fire into him and worked his gnarled limbs day after day until I sparked enough of a flame that he took over. I thought how his teachers say they have never seen a student squeeze every last drop out of himself.

I ran even faster.

I thought about my little bug, Oliver, whose tiny hands collapse on his pencil. How beads of sweat form as he tries to hold it the right way. When, in frustration, he wants to throw his pencil against the wall I ask, “What’s our motto?” “We never give up,” he chirps in his staccato, and then we hug and work on his grip again. Every day he digs so deep just to hold that Goddamn pencil. Once, very recently, he did it all on his own. Once with 5 years of trying. “If I can do it once, I can do it again,” I hear him telling himself and it makes me proud because I know where he got that attitude.

I stepped it up again.

I thought about having the courage to get divorced. A second time. How I mined depths I didn’t know I had to tell my kids. God, that was hard. But I did it and we are so much better for it.

I increased my pace again.

I thought about the dedication that it took to lose 50 lbs. How that was all me. Day after day after day.

I looked down. I was at a 8:37 pace (7 mph) and I finished out the 26 minutes feeling great.

I didn’t make it to 3 miles, but then again I’d never have believed I could run 2.8 miles in 26 minutes. But I did.

And the next time I need to dig deep, I’ll add that to the list.

Despite his complete lack of medical education, Mr. Santorum is now qualified to tell us that amniocentesis should not be a covered benefit because he believes an amnio leads to abortion.

For the record, my amniocentesis saved the lives of my two surviving children. This is because there are genetic amniocentesis and there are amniocentesis for other reasons. For example, my amnio diagnosed a serious infection at 26 weeks and so my OB/GYN recommended an immediate delivery. An amniocentesis may also be performed to check for lung maturity if a premature delivery is considered for health reasons in the later part of the 3rd trimester.

But I’m sure Santorum is referring to genetic amniocentesis (maybe I shouldn’t assume he knows there is a difference?). Genetic amniocentesis is part of prenatal testing and is used to confirm or exclude the presence of a genetic problem. While more women who have a genetic amnio and are subsequently diagnosed with a genetic birth defect have an abortion, it is a flawed argument to say the amnio leads to the abortion. You can only know about the genetic problem with 100% accuracy with an amnio or chorionic villus sampling and more women who would consider abortion chose an amnio in the 1rst place.

But it’s not just amniocentesis that Mr. Santorum is after. He wants to do away with insurance coverage for genetic testing altogether. Because obviously genetic testing is the fast-track to abortion. This is where the whole medical school thing comes into play…there are many reasons to consider genetic testing even if you would never have an abortion.

This is how I explained genetic testing when I practiced obstetrics:

“Genetic testing is a tool to help identify serious conditions that can affect a baby. Some conditions are not compatible with life, such as anencephaly. Others are associated with varying degrees of disability, such as Down’s syndrome and spina bifida. Many parents want to know about these conditions, some because they might choose an abortion. Even if abortion would never be an option that you would consider, genetic testing can still be very helpful. For example, if we diagnose spina bifida or certain bowel conditions we may recommend a c-section. Some spina bifida defects can even be repaired during pregnancy and if that were the case then you would be referred to a medical center that is best able to provide that kind of highly specialized care. If we find that your baby has a heart defect we may recommend that you deliver in a hospital with a pediatric heart specialist. Finally, if you find out that your baby has a serious medical condition knowing in advance can help you prepare. It can help you figure out work arrangements and child care. It can help you prepare your family members and friends. It also will give you time to research the condition and speak with other parents, because knowing more will only help you provide the best possible care for your child.”

That is the difference between being a real-live OB/GYN and just playing one on TV.

Genetic testing provides a pregnant woman and her partner with knowledge. Knowledge is empowering.

And that is why politicians should not be involved in the practice of medicine. Because power without knowledge is truly a frightening thing.

• raise the cost of the procedure to reduce the number of women who can afford an abortion
• require/offer/describe a view of the fetus to dissuade/shame pregnant women into not having the procedure

It’s interesting to me that on both sides there has been very little discussion of the medical evidence. So that’s what I’m going to do.

Issue #1: Cost

Second-trimester abortion

Let’s just take that off the table. Every second trimester abortion needs an ultrasound and often gets more than one. Second-trimester abortions are more often done for birth defects, typically diagnosed or confirmed by ultrasound (sometimes a few ultrasounds are done). In addition, these procedures require more skill the further along, so it is essential the practitioner knows the gestational age with as much accuracy as possible. Ultrasound laws will not change any procedure costs for 2nd trimester ultrasounds, but they may affect the viewing requirements (whether the woman sees/hears a description of the ultrasound). I’ll get to that in just a bit.

First-trimester abortion

Many providers already do a 1rst trimester ultrasound, especially with medical abortion. This is because a medical abortion can only be done up to 63 days (9 weeks). However, there is a growing body of literature suggesting medical abortion can safety be accomplished without an ultrasound for 98% of women. So these laws will prevent practitioners from doing away with an ultrasound (i.e. prevent them from practicing evidence based medicine) which will halt efforts to expand medical abortion into low resource settings. Ultrasound requirements will also affect many women getting a surgical procedure as and ultrasound is typically not required if the size of the uterus agrees with the dating of the pregnancy (although some providers do ultrasounds anyway, generally for medico-legal reasons).

So regarding cost, ultrasound requirements may affect a lot of women seeking a 1rst trimester abortion.

Does this accomplish anything? (Which you might want to know if you are going to spend tax payer money enacting a law). No. In fact, studies tell us that both cost and local availability of a provider has no effect on the decision to get an abortion, it simply delays the procedure while the woman figures out her resources. It is insulting to insinuate that a woman has an abortion out of convenience or cost. In Canada, where abortion is free and unencumbered by ill-informed politicians, the rate of abortion is lower than in the United States. It is sex education and widespread access to medical care and contraception that reduces abortion, not laws.

Issue #2: Viewing the image to dissuade a woman from having an abortion

A 2009 study looked at whether viewing an ultrasound image pre-abortion was something women wanted and whether it had an impact on her choice to have the procedure or her emotional experience(1). When given the option, almost 73% of women chose to view their ultrasound image and of those who did, 85% felt it was a positive experience. Not one woman changed her mind about having the abortion after viewing the image. Ten women were selected for an in-depth interview on the subject and all felt that women should be given the choice about viewing their image.

So in fact, states that require a provider to offer a view of the image to the patient are following evidence-based recommendations. Requiring a patient view the image, such as in Texas, is another matter.

We know that cost and laws do not affect the abortion rate. We also know that long acting reversible contraception lowers the abortion rate. There are some excellent studies that tell us that when women get depo-provera or an IUD post-abortion they are far less likely to have a subsequent unplanned pregnancy. But interestingly, many in the anti-choice movement also discourage birth control. If they were really pro-life (i.e. wanting to prevent every abortion possible) they would be handing out contraceptives instead of picketing clinics and clamoring for laws that restrict tobacco, as cigarettes are responsible for the deaths of 5-7% of all premature babies and cause 23-31% of SIDS).

Laws that increase barriers to abortion create hardships for the women seeking the procedure but they do nothing to lower the abortion rate. To focus on abortion restrictions and not contraception is the height of hypocrisy and a waste of taxpayer dollars, because the laws will inevitably get challenged and held up in court, as we have seen in South Carolina and Oklahoma.

Sigh. (See my recent piece, What if all the money spent fighting about abortion…).

There is no medical evidence to support ultrasound laws. They are a waste of taxpayer dollars and do nothing to accomplish the goal of reducing abortion. They also create a dangerous precedent of allowing hypocritical politicians to set unacceptably low standards of medical care based on political goals, religion, and misogyny.

Smaller government indeed.

1) Kulier R, Kapp N. Comprehensive analysis of the use of pre-procedure ultrasound for first- and second-trimester abortion. Contraception 2011;83:30-33.

It has a four year cycle that parallels the elections. It is most quiescent in the winter after a Presidential election, with a moderate spike in the lead up to midterm elections. There is a respite the following winter and then a full blown attack starts a year before Election Day. Symptoms crescendo until the President is elected and then the cycle starts again. The cure for uncontrolled vagina and uterus syndrome is Traditional American Values. A known byproduct of this illness is shaking money out of the pockets of the Religious Right.  

Evidence that we are now in a the midst of a full-blown epidemic of uncontrolled vagina and uterus syndrome:

The GOP doesn’t think employers, or even health plans, should cover contraception. Reason being it’s cheap (to a millionaire yes, yes it is) and it’s going to put us all on a fast track to Hell’s nightclub, Sodom and Gomorrah. To quote the learned Mr. Santorum, contraception is “a license to do things in a sexual realm that is counter to how things are supposed to be.” That is assuming, of course, that the television shows “Virgin brides” and “19 kids and counting” are part of your manifesto for a fulfilled life.

Take home message: sex is only for procreation inside of marriage.

The House Oversight Committee Chairman Rep. Darrell Issa (R-CA) is running a hearing on the Obama administration’s new birth control rule with an all male panel. Not one of whom is even a gynecologist.

Take home message: contraception, it’s a man’s issue.

And of course, there is the eloquent Foster Friess, a chief financial backer of Rick Santorum, who suggested women use, “Bayer aspirin” for birth control. You know, putting it between their legs.
Take home message: women are all sluts and if we just learned to keep our legs together and not tempt men everything would be just fine.

Well ladies, I say let’s give the voting public a copy of the Handmaid’s Tale a taste of the GOP vision!

I hereby proclaim February 22^nd as National No Non-Procreative Sex Day (or NNNPSD for short). And no cheating with oral sex y’all, because oral sex is sex (and it’s certainly not for procreation!). If you’re trying to have a baby you’re good to go, but anyone having sex for fun, well, don’t.

I chose February 22^nd because that’s the date of the next GOP debate and nothing is a bigger libido killer than watching four old men argue about how to govern the vagina and uterus.

So ladies, tune into the debate on February 22^nd and get turned off. And in the wee hours of February 23^rd as we all fitfully toss and turn before arguing with our partners over who gets the cold shower first  we can all feel what it’s really like to be a champion of traditional American values.

Condyloma (wart) in the mouth

Human papilloma virus (HPV) is the virus that causes most cervical, vaginal, and anal cancers. It also causes cancer of the vulva, and penis. More recently, HPV has been identified as an increasing cause of head and neck cancers, especially for men. From 1984 to 2004 the percentage of head and neck cancers related to HPV jumped from 16% to 70%.

While there are more than a 100 types of HPV, there are several strains (HPV 16 and HPV 18 in particular) that are particularly cancer causing both above or below the belt.

HPV is ubiquitous in the genital tract. If you are a woman and you are sexually active there is a 70% chance you will have been infected by the age of 22. The good news is most people clear their HPV infection. It’s the infections that the immune system can’t clear that are at risk of progressing to disease (either cancer or genital warts, the other manifestation of genital HPV infection). Regardless, while your body is working to get the infection under control you can spread the virus through sexual contact.

So what about the mouth?

We know oral sex is a risk factor for HPV-related head and neck cancers. If you have had oral sex with 6 or more partners your risk of head and neck cancer increases 8-fold.

A study just published in JAMA (Gillison et al, January 26, 2012) evaluated more than 5,000 people for oral HPV. They collected a lot of demographic data to try to determine risk factors.

The results:

• 6.9% of people ages 14-69 have an active HPV in their mouth
• The peak prevalence of oral HPV infection is ages 30-34 and 60-64
• Men are more likely to have oral HPV than women (10.1% vs. 3.6%)
• Sexual contact is a risk factor for oral HPV: 0.9% of people who have never had sexual contact had HPV versus 7.5% who had ever been sexually active.
• The number of oral sex partners has a big effect on oral HPV. The prevalence is basically the same for 0 or 1 oral sex partner (3.5% and 3.3% respectively), but by the time you hit 21 or more sexual partners the prevalence of oral HPV jumps to 21.5%

HPV Prevalence by # lifetime oral sex partners

So what about kissing? (Sometimes when I pull these studies I think, gosh, I’d just rather not know…).

To me, the data in the JAMA study suggests oral sex is not the only method of transmission because 0.7% of those had never been sexually active at all and 3.5% of those who said they had never had oral sex were HPV positive. I suppose it’s possible that participants weren’t completely honest about whether they had engaged in sex or oral sex, but the study used NHANES participants and the data is generally high quality. So if oral sex wasn’t involved in transmission for the non sexually active/non oral sexually active participants, well, what was?

The studies are sparse. One small study looking at men only, published in 2009 (Journal of Infectious Diseases), tells us that for men “open mouth kissing” with 10 or more partners is associated with an increased prevalence of oral HPV. It’s not a huge study and it has limitations, but, well, there you have it. By no means am I saying that open mouth kissing is a major route for oral HPV transmission, but it definitely suggests we need more studies.

Whether the HPV vaccine will help with prevention of oral HPV remains to be seen; however, the editorial that accompanied the JAMA article pointed out that in an animal study a HPV vaccine was able to prevent oral infections. In addition, fewer genital infections (due to vaccination) should translate into fewer oral infections given the known oral sex connection.

Why are we seeing more HPV-related head and neck cancers? I have a hard time accepting it’s all oral sex, since I’m pretty sure oral sex wasn’t invented in the last 20-30 years. Although, studies suggest there is more oral sex happening earlier (20% of kids in grade 9 have tried oral sex!), so perhaps adolescence is a more vulnerable time for oral HPV exposure. Smoking was also major cause of head and neck cancer and there are fewer smoking related cancers, so percentage wise HPV is now a bigger player. It is also possible other environmental co-factors are involved. Again, more studies are needed.

What we know for sure:

The more oral sex partners you have, the more likely you are to get HPV in the mouth. Like genital infections, most oral HPV will clear, but persistent infections increase your risk of head and neck cancer. Seventy percent of head and neck cancers in men are now HPV related.

Where STDs are concerned, fewer partners is safer. If you are going to have multiple oral sex partners, use a barrier method. Studies are conflicting about their effectiveness, but some protection is better than no protection.

The HPV vaccine reduces your chance of having cervical and anal cancers.

And while oral sex might not get you pregnant, it should be considered sex because it certainly has all the same infection related risks.

Related posts:

How many sex partners do people really have?

Can I get gonorrhea from oral sex?

The oral sex-oral cancer connection

I suppose it’s not a surprise, after all poets and song writers have described the euphoria and obsession of love for centuries. Throw can’t sleep, can’t eat, can’t think straight into the mix and I could be describing someone in love or someone addicted to narcotics. In fact, new love is so like an opiate that it reduces moderate pain in an experimental setting by 44%. By 7 months other parts of the brain make more contributions to the love experience. Reward centers are still involved, but it’s less druggy. I guess one could say one regains a little more control of one’s faculties.

Knowing that early love is like a drug helps to explain a lot of early relationship mistakes. Everything is Awesome! Wonderful! Amazing! It’s easy to do something that seems like a good idea, say move in or start to make long term plans, when life seems so grand. Shit, everything seems so great, even volunteering for a study where they put really hot things on your skin to see how effective love is at reducing thermal pain (one of the investigators told me it was the easiest study he ever recruited for!). The point is, if the bloom comes off the rose and you’ve made commitments, you could easily end up waking up next to someone at 5 months and wonder, ‘What the fuck have I done?”

I’m the first to admit this valuable piece of information could have served me well. If I’d have known I could be high for up to 7 months, I would never have agreed to move in with my now ex-husband before that critical juncture. Unfortunately, once the sofa was arranged and my dopamine depleted (i.e. things started to not seem so lovely), I assumed the relationship could be fixed because it had been “so good,” when really I should have said, “Well, that was fun and it’s a bitch we moved in, but I wasn’t in my right mind.”

How do researchers find people in love? I mean, lots of people say they’re in love, but their actions say otherwise. Well, there is a validated scale that I am pleased to announce I discovered during my late night skulking on PubMed: the Passionate Love Scale (PLS).

At first blush I admit it sounds a tad Dr. Phil-ish or like a quiz one might find in the back of Teen Cosmo. The 15-question short version of the PLS (yes, there is a 30-question long version) was first reported by Hatfield & Sprecher in 1986 in, ahem, the Journal of Adolescence. Although the PLS is not just a puppy love scale, as it has also been validated in adult populations. It is also the scale used in these neurophysiology of love studies.

The PLS can be used for shorter-term love (less than 7 months) and is also valid for people who say they are still in love after a few years (confirmed by MRI, of course). The score drops a little over time, but not that much. Something to think about before you haul a couch up 3 flights of stairs.

Here’s Hatfield & Sprecher’s Passion Love Scale in case you are interested. Answer the questions thinking about your partner and score yourself for each question on a scale of 1-9 (9 being the most and 1 being the least), add them up and then check your passion.

And if you care to log your results in my handy quiz master, it would be most appreciated. Don’t worry, it’s completely anonymous. I’m just genuinely curious.

What do you think? Does the Passion Love Scale seem valid to you?

For those who asked, this case happened post Roe v. Wade. And yes, the patient lived.

I am all for making abortion an un-needed procedure. The best way to accomplish that is to prevent unplanned pregnancies. If every pregnancy in the world were planned, wouldn’t that be an amazing thing?

Imagine if all the money spent on fighting about abortion, on both sides, were directed towards preventing unplanned pregnancies? If we expanded sex education, access to contraception, worked on reducing poverty, and eliminated intimate partner violence (or at least made it far easier to leave).

Imagine what we could accomplish.

And as an aside, when faced with the prospect of an abortion, I didn’t have one. Pregnant with triplets a selective reduction was recommended and it just wasn’t for me. I wanted all three of my boys. Desperately. But things didn’t work out the way I’d planned it. One of my boys died at birth.

There are a lot of intelligent, media-savvy people on both sides. Why can’t we just look at the abortion issue differently and focus on our common ground? Why can’t we take all the money spent on lobbying, and laws, and advertising, and fighting and spend it on evidence-based ways to reduce unplanned pregnancies?

Finding common ground is hard. I look at Rick Santorum and I think, “You and I have nothing in common.” But you know I’m wrong. We’re both parents. We both love our children very much. And we have both lost a child. And I suspect if each one of use looked at someone who holds a different view about abortion, we could find something in common. Some way to start working together instead of screaming at each other. Could we put aside our dogma and everything that we think we know and just focus on the issue? Unplanned pregnancies?

Wouldn’t that truly improve the human condition and isn’t that our common goal?

As I sprinted down the stairs, I ran through the possible scenarios. I wasn’t on call, so the day to day gynecologic emergencies weren’t my purview. I hadn’t operated on anyone in the past few weeks, so unlikely to be one of my own patients with a complication.

Logically there was only one conclusion.

A nurse was holding the staff entrance to the ER open. From the look on her face I surmised this was to save the minute or two it would take to punch in the numbers on the lock and inquire at the desk for patient’s whereabouts.

“Down there,” she pointed.

On the gurney lay a young woman the color of white marble. The red pool between her legs, ominously free of clots, offered a silent explanation.

“She arrived a few minutes ago. Not even a note.” My resident was breathless with anger, adrenaline, and panic.

I had an idea who she went to. The same one the others did. The same one many more would visit. A doctor, but considering what I had seen he could’t have any formal gynecology training. The only thing he offered that the well-trained provers didn’t was a cut-rate price. If you don’t know to ask, well, a doctor is a doctor. That’s assuming you are empowered enough to have such a discussion. I was also pretty sure his office didn’t offer interpreters.

I needed equipment not available in an emergency room. I looked at the emergency room attending. “Call the OR and tell them we need a room. Now.” And then I turned to my resident. I was going to tell him to physically make sure a room, any room, was ready when we arrived, but he had already sprinted towards the stairs. He knew.

We didn’t wait for an orderly. A terrified medical student and I raced down the hallway with the gurney. The amorphous red pool dripped onto the floor as we rounded the corner to the elevators.

The double doors that led to the operating rooms swung open. “The urology room. They’re between cases,” my resident shouted.

I saw an anesthesiologist out of the corner of my eye. “You. Now!” Most emergencies can wait a few minutes to check in at the front desk and for the anesthesiologist and nursing staff to take stock of the situation. This was not one of them.

The urologist, whose room I appropriated, blustered and sputtered in behind me. “What the fuck are you doing barging in, I’ve got another case…” but as we moved my patient over to the operating table and he saw the blood, he stopped. He grabbed a tray of instruments and opened. “I’ll be your scrub.”

The anesthesiologist was pissed. Not really mad, more riled up than anything. No one likes to be blind sided, no matter how well intentioned. And he probably thought I was over reacting. That is until he put in another intravenous.

“Fuck.” What looked like blood tinged water flashed back.

And now they all understood what I knew the second I laid eyes on this patient. Abortions that go horribly wrong bleed out. Quickly.

The room filled with surgeons, nurses, and students eager to help. To do something. Anything.

I opened the vagina and by feel clamped through the holes on either side of the uterus where I knew from experience I would find the uterine arteries, the likely site of the puncture. I didn’t know which side, and at that point it didn’t matter. I just needed to stop the blood flow. It took less than a minute. She would have bled to death if I had opened her belly.

As the bleeding had stopped, it was up to the anesthesiologist to fix the hematologic tempest. A vascular system so traumatized by sheer blood loss that it had run haywire and lost the ability to clot. Disseminated intravascular coagulation. This is how many young women die when an abortion goes wrong.

My hands started to shake. Everything from leaving my clinic to this point had been one crescendoing adrenaline-fueled reflex. Now that there was nothing physically for me to do the energy had to go somewhere.

I looked around. A forest of IV poles, laden with blood instead of fruit. Everyone not directly helping was running back and forth to the pharmacy or blood bank. A nurse and another surgeon started to clean the floor. We were all bonded by this nameless woman whose life we were desperately trying to save. And we were bearing witness, because we knew if she died it was unlikely anyone would read about her in the paper. It was unlikely her family would protest. A myriad of potential reasons. Shame of the abortion. Distrust of government. Fear of immigration officials.

The urologist, a grizzled older man with whom I had nothing in common except a medical degree and this patient, rested his hand on my shoulder. It was a kind, fatherly gesture. The weight was comforting.

“You done good.” He said. And then he added, “Those bastards.”

I knew he was referring not just to the physician who did this procedure, but to everyone in society who had contributed to a disadvantaged woman finding herself in such a desperate situation.

The only problem? The low oxalate diet doesn’t work.

How this diet became almost main stream is a testimony to lack of evidence, desperation of patients, inadequate evidence-based therapies, and snake oil. A perfect storm.

Calcium oxalate crystals in the urine

The whole idea that oxalate could potentially have a role in vulvodynia stemmed from a single case report published in 1991 in which a woman with refractory vulvodynia was found to have periodic hyperoxaluria. For this one patient, the addition of calcium citrate alleviated symptoms. Calcium citrate binds oxalate, therefore preventing it from irritating the skin/nerves during urination – the mechanism of cause and effect proposed in the case report.

A single case report and somehow it gets recommended. Initially by word of mouth, by both patients and providers and then later on web sites and chat rooms. Someone writes a cookbook about the diet and someone offers 24-hour urinary oxalate testing. You know, for a price.

However, we know that dietary oxalate consumption appears to be the same among women with vulvodynia as compared with controls and a prospective study of urinary oxalate levels in 130 women with vulvar pain and 23 controls found a similar distribution of oxalate levels between the two groups. In studies looking at a low-oxalate diet, improvement in pain ranges from 2.5% to 24%, which is equivalent or worse than the placebo response rate in other vulvodynia studies. In addition, women with kidney stones (and have high levels of oxalate in the urine) do not have appear to have a higher incidence of vulvodynia.

I would guess at least 50% of my patients with vulvodynia have tried the calcium oxalate diet and perhaps 5-10% felt it helped. A far worse outcome than placebo effect. Many of my patients spent money on the cookbook and others spent even more money sending 24-hour urine samples to “a special lab in Colorado for oxalate testing.”

Well, you might think. What’s the harm in trying the diet without wasting money on the testing? After all, if it works, it works, right?

The low oxalate diet is very restrictive and many patients get stressed about it (stress is bad for pain). Others feel inadequate because they just can’t do it (also not good for pain, most people with chronic pain don’t need an additional reason to feel bad). It is also better to focus energies and resources on proven therapies, not on a diet where there is a mountain of evidence to disprove both the theory of causation and the effectiveness of the intervention.

Are there any diets that can help women with vulvar pain? None that have been specifically studied. However, women with vulvodynia who have either painful bladder syndrome or irritable bowel syndrome may find relief of bladder or bowel symptoms with specific dietary measures aimed at eliminating bladder or gastrointestinal triggers. Pain in one area of the body makes pain elsewhere worse. So, getting bladder or bowel symptoms under control may help reduce vulvar pain.

But the low oxalate diet and vulvodynia is a cautionary tale about jumping on the results of a single case report. Not much different from Andrew Wakefield’s now retracted and debunked case series on the MMR vaccine and autism. Two things may co-exist, that’s all a case report or a case series tells us. We need prospective studies to guide treatment recommendations.