- Good evening, this is Janet Sanders, Assistant Dean of Women at KU, and I'd like to welcome you to A Feminist Perspective. This weekly radio broadcast is sponsored by the Women's Resource and Career Planning Center a program and information service of the Dean of Women's office. 220 Strong Hall. A Feminist Perspective provides a forum for women themselves to speak publicly on issues of concern to them and helps inform other women and men of the movement which is remaking the shape and substance of women's and men's lives. The Women's Resource and Career Planning Center contains large amounts of information, newspaper clippings, government documents magazine articles, research studies, and books pertaining to the many aspects of the women's movement. We would like to invite you to come in and browse around or take advantage of the materials which can be borrowed. That's in 220 Strong Hall at the University of Kansas. Tonight's program is part of a series on choice and sexuality. Our tentative topic is choice and contraception. And our guest tonight is Dr. Dale Clinton. Dr. Clinton is a graduate of KU and of the University of Kansas medical school. He is in private practice in Lawrence and Kansas City and he specializes in reproductive medicine. Dr. Clinton, how would you define reproductive medicine? That's a new specialty for me. - I was afraid you'd ask that and I'm not sure I know how to define it either. But I deal largely in such things as family planning, office gynecology. I do male sterilizations. I don't do female sterilization. So those are referred, but in the general area of the illnesses related to reproduction and sexuality. - Well, Dr. Clinton, I consider to be quite an expert in the area I wanted to consider tonight. And originally I had named it contraception which in some ways I believe is technically incorrect as to what I want to discuss. I guess what I'm talking about is a family limitation, determining how many children you want, when you want them. Let's start out in the area of contraception and discuss some of the choices that are available to women and to men who are planning on being sexually active and don't want children. I guess one place to start out. I read some figures that indicate if a couple is having an active and regular sexual relationship, within the first year of that relationship, they have a 50% chance of conceiving. And if it goes on for two years an 80% chance that there will be a pregnancy. - Yes I heard those figures. And I think there, I think there's another figure that one can depend upon fairly accurately, I think. And that is the people who are having regular active sexual contact so that the woman was statistically speaking will be pregnant within five months. I mean, this is another way I think of saying somewhat the same thing here. - So this, it seems like biologically a woman's choices are limited. If she is sexually active she is going to have a pregnancy unless she chooses. - Pregnancy right. Unless she does something effective about it or unless, they do something about it. One or the other on board. - All right so let's assume that a person has made the initial choice that they do not want children at this present time. Now then let's consider the wide spectrum of options available to people. I would start with the non-prescription methods. What do you consider to be the most effective other than abstinence? The most effective non-prescription? - Well, even abstinence is not very effective. Because there are ways to be abstinent and get pregnant too almost. Well none of the non-prescription items and you're saying other than the birth control pill and the IUD. The diaphragm is also a prescription item. Although actually it's just for the fitting. Okay, well then let's start with the diaphragm and work down from there. Statistically you can locate in many different sets of figures but the diaphragm with jelly or the foam without a diaphragm and the rubber all fall in the 70% effective range for one reason or another. In other words, with any of these four methods you get about a 30% failure rate. And this is for most people unacceptable. If you combine say foam and rubber then you theoretically cut the failure rate down to about 10%, which is also pretty high. - Yes. - And it depends upon how you look at this 10%. You mean one out of every 10 times you get pregnant you see, then that's unacceptable. But anyhow, these are the choices that are available in the non-prescription area. And I think it's interesting. It's interesting to me. And for this reason I don't fit diaphragms in fact. And that is that foam properly used is statistically just as effective as diaphragm and jelly. And many people don't know this. Many people will contest this statement too however. But the the diaphragm actually, the only purpose of the diaphragm is to keep the jelly in place literally. And the foam stays in place about that well if it's used properly. So for women who insist upon using this sort of method I tell them that they're just as well off to use the foam. And if they want double the protection and they can use it with a rubber also - I think that you brought up an interesting point. If it's used properly I've read several things which indicate that these non-prescription methods have such a high rate of failure because people do not use them properly. Women insert the foam too early. - Or too late. - Or else they douche immediately after using it. A man does not know how to properly use a condom. What kind of suggestions can you give people for increasing the effectiveness of these cases - Use them properly? Well, I don't know what you mean. You want to go into specifics about this? - Well I'm just wondering, I have a sample kit of contraceptives which I use in my counseling, and I've noticed that the packages of condoms have no instructions. - No instructions right okay. Now the foam does, and this is something I started to say. If one will read the instructions on the foam package and follow the instructions and that's about the best you can do. It tells you when to use it and how to use it. True prophylactics, to my knowledge, I don't know of any that have instructions, but there probably are some. But the important thing is not that they break very often. They do sometimes, but this isn't the big factor. The big factor is that they come off and that they leak. And so around the edges, that is. And so of course it's a mistake to use a rubber say and then fall asleep. You see, I mean that's a guarantee. So one has to be rather careful about the method, and careful about what ones do. You don't have absolute freedom in other words. There are certain routines you have to follow if it's going to work. - All right. You've left out one of the non-prescription methods. - I left out two. - Oh I was thinking of rhythm. And I thought that was conspicuously absent. - All right in my opinion. And as we're getting more experienced with menstrual extractions the rhythm system as I have stated before I consider it to be a mythological method of birth control because it simply does not work. And women although they usually ovulate somewhere around the mid cycle, the ones that get caught can testify to the fact that that is not when they ovulated. You know, the ones that get pregnant and know that the only time they had intercourse was at the end of their period or the middle of their period. And they got pregnant anyhow, you see. Well, this is not a reliable method. It has a very high failure rate. And so I call it exactly that it's mythological, not just in terms of religious myths, but I think it's one of the medical myths that we have perpetuated over the years. And that is that women ovulate at a certain time, that's not true. - I've been reading some research that people have been trying to do to ensure the rhythm method. For example, one of the things was kind of a litmus test. And if you put a piece of treated tape in the woman's mouth every morning for a month and when she ovulates the saliva, the chemical composition changes and you can tell a-ha this is the fertile time. Some of these research things go back five years - I'm sure that lends to great sex. - And still we don't seem to have any reliable predictor on the market. - No. - And I was wondering if, if there was such a thing as this as spontaneous ovulation, sometimes in the literature you read that intercourse itself might bring on ovulation. - Well, we know how it does in other animals. And I presume that occasionally occurs in a human. But in other words that sexual excitement initiates ovulation. I don't think this is documented as a thing that occurs very often in the human female, however. - But nevertheless ovulation can occur at any time during the cycle. - Yes it does, it does. - And so the rhythm method. - It does. The usual grouping is around the center but you can't depend upon it. - All right what was the other non-prescription? - Withdrawal, statistically about 25% effective - Better than nothing but not too much. - Better than nothing but not much more, not much better than nothing. - Now, sometimes when I am visiting the residence halls and discussing contraception, I come across some myths and I wondered if you would care to comment on them. And one of them is about the famous Coca-Cola douche. And it was explained to me very seriously that the way this works is that the sugar in the Coca-Cola explodes the head of the sperm and kills it. And that this is widely practiced among teenagers as a form of birth control. - I hadn't heard that theory. I mean, Coca-Cola and 7UP and anything else under pressure of course can be used expertly as douche. I mean wow you get a lot of liquid there under considerable pressure, you know, and you can do a douche but the point is is that the douche is not an effective method of contraception. And even if it does explode the head of the sperm, the one you're worried about is long gone. You see, I mean he's not available for explosion, he's already inside the cervix. - Yes. - So I would say that it's definitely a myth. It's not effective. - I think that we've effectively exploded that myth in particular. Let's move on into the prescription methods. Now I noticed that you counted the diaphragm as nonprescription after they do the first prescription of it. And then after that, then the woman can continue what for a year, perhaps longer? - With the diaphragm? - Yes before she needs to be refitted. - Yeah rubber deteriorates and probably the safe time is about a year and then it should be replaced And it really should be refitted then too because things change. Actually the woman's weight, if she gains weight her measurements are likely to change too. So she should be remeasured, but if she's going to use it. But I don't like the diaphragm at all. I think it's I think it's really kind of an archaic sort of method to use. - All right, let's move on to the IUD. - Okay the IUD then, and this this is the next best method, the pill being the best. - Why don't you explain a little bit about what the IUD is and how it works. - The IUD is for the most part, most IUD's are plastic devices which are inserted into the uterus. And they provide contraception by a method or methods not too clearly understood. But apparently some modification of a foreign body reaction that is the lining of the uterus, the endometrium does react to this as though it were a foreign body and produces certain cells which render the endometrium incapable of implantation of the fertilized egg. - So conception can occur. - Conception apparently does occur. - The egg can be fertilized. - Well now this is debated. Because the IUD does have some other effects which have been demonstrated at least in the monkeys. And that is that it speeds up the rate of ovum transport. Once the egg leaves the ovary the foreign body in the uterus apparently causes contractions that speed up the transport of the egg so that it arrives in a state, which is unfertilizable. And so certainly in monkeys the unfertilized eggs have been recovered with some regularity. Whether this occurs in the human we don't really know. But apparently the general consensus of opinion is that its main function is that it does something to the endometrium, which makes implantation impossible. - All right and a doctor needs to insert the IUD, is this correct? - Yes this is considered a surgical procedure and indeed it is. It doesn't involve a cutting procedure but it does involve an invasion of a body cavity in a sense that's little bit different than brushing your teeth. I would say for instance you know. And in fact usually it involves a dilatation of the cervix. There are forms that can be put in without dilatation. The most popular brands now will go in without dilatation but it's a little bit risky because it's a hard push and you might just put it right on through the uterine wall you see. So I think most physicians prefer to dilate first and then they know exactly where they're putting it in. In fact, placement is important for effectiveness too. - All right well, how effective is the IUD? - The manufacturers say 2% failure rate. And in fact they say two pregnancies per hundred woman per year. And this is not exactly translatable into 2% failure rate. - So that is if we have 100 women, each of them using the IUD for an entire year. - Over a year's time the manufacturer says we will see two pregnancies. I think they're lot higher than that. I don't know how high, because I really haven't. I've put in, well I've put in about a thousand, I would say, give or take 50. And this was not a big enough series to know, it really isn't. And so for the people that are the studies where they put in 10 or 12,000 of these things, they report that they think that the rate is about 2% also. But in everyday practice, I see so many women with IUDs who are pregnant, that I question the figures. But then of course, I'm seeing a skewed sample here. - I've had the question several times. What is the effect on the development of the fetus? If a woman has an IUD and becomes pregnant. - None, nothing. If the woman becomes pregnant, the IUD is not, it's external to the membranes which enclose the fetus. And I don't believe there's been any case on record for the IUD caused any adverse effect. Now it does have an effect upon spontaneous abortions however. And we used to think that if you took the IUD out the chances of her aborting were increased but now it appears that it's the other way around. If you leave it in her chances of spontaneous abortion are apparently increased a little bit, not a great deal, however. But as far as deforming the fetus, no. - There's no effect, all right. What about the rejection syndrome? - Rejection rate? - I've heard some women talk about that. - This apparently is improving. That is, whereas the rejection rate with some of the older models was as high as 15%, with some of the newer devices it's lower than that I think. But I have seen every model on the market pushed out, rejected. - Which particular shapes do you use? - Well, at the moment I use the Lippes loop and I use the the Julia Smith safety coil, and I use the Dalkon Shield. Those are the three that I keep in stock now. The Shield, I think is probably the least often rejected that is expelled, spontaneously. I'm not impressed with the pregnancy rate being any lower than the others however other than that. - Some of the research materials I've been reading is talking about the copper T, an IUD which is covered with a thin coating of copper. And it's assumed that the copper itself has a contraceptive properties. - That's right. Just the other day, I took out one from a woman who was pregnant. And so that shattered my hopes in the copper T. - Yes I think that it would be, that's truly empirical evidence. - It's a comfortable device to wear apparently. Apparently it inserts easily. And but certainly women do get pregnant with it which I can document. - All right you were saying that the number one contraceptive as far as effectiveness is the oral contraceptive, the pill. - Right. - Just briefly and in simple terms, if possible, how does the pill work? What does it do in a women's body? - Again the pill does several things and we think that it works primarily by inhibition of ovulation. And we also know that it creates some recognizable changes in the endometrium, which means that if the woman does ovulate and occasionally apparently some women do that it arrives in the uterus and meets an environment which is not suitable for implantation. So it works by two methods, one it inhibits ovulation two, it creates an endometrium which is not suitable for implantation. - All right and it does this because it is primarily hormones, active hormones. - Right, that's right. Apparently the endometrium has to be prepared in a rather delicate way to receive that egg. And again, the hormones have to be just right for the egg to be released to begin with. - And so what would would you assume the effectiveness rate to be? - Well, the effectiveness rate is stated to be so close to a hundred percent, that it's difficult to calculate. There are a few women who do get pregnant but they're extremely rare. - And would you say that many of those pregnancies could be attributed to forgetting a pill? - Oh yes yes yes. I'm talking about genuine failure. I'm talking about genuine pill failure. Oh yes there are lots of women get pregnant by taking the pill improperly but that's hard to do too. Now, for instance, while we were talking about myths let's lay another one. And that is that if you miss a pill or two, you're going to get pregnant. It is not that critical. And again, I don't want to get people to think that they can just be real sloppy with the pill but actually you would have to miss at least enough pills to start a period before you would ovulate. In other words, the woman would get a clear signal that she had forgotten her pills long before she ovulated. - All right, I understand that some of the older pills had higher levels of estrogen, hormone estrogen than the newer pills. And would you say that there is a greater risk with the lower dosage of if you forget a pill for a day or two? - Yes I would say that there are, I think and again I haven't had this much experience with some of the very latest. And there are Parke-Davis for instance has two new products called Lo Estrone which is simply a variation on their norlestrone lower dose. And I don't know what the pregnancy rate is. But I do caution these people to be very careful about taking their pills and not forgetting any and making them up if they do. We know that the old sequentials produced some pregnancies. - All right I think that a lot of the push for developing the low estrogen pill was on the basis of side effects, both the minor side effects and also people who assume that major medical disabilities such as blood clots and cancer could result. What's your impression about these side effects? - Well, my impression is that by far the great majority of women can take one of the birth control pills. If the first one or two are not satisfactory if she'll just stick around a little bit until she gets a formula that is satisfactory for her that she can take them and be comfortable and effective, and they'll be effective. But the usual, the woman who comes in and says I have tried everything and I can't take any of the pills has not tried everything. And probably she can take the pill. - All right what about the new mini pill that won't have any estrogen in it at all? I have a research report from 1971 and they said within a matter of weeks, we will have this this new pill and have you heard about that? - Well, yes, this now the mini pill, I don't know whether it's safer or not, because to me there isn't any obvious danger to the other pills either. But the mini pill has two disadvantages. One, it has a known and documented pregnancy rate pretty close to that of the IUD. It also causes unpredictable bleeding episodes which most women do not like. Now this is also true for the injectable contraceptive, which is available in which is approved and which is good for about three months. And it works about as well as the pill apparently but the bleeding episodes are unpredictable and most women don't like that apparently. - Dr. Clinton there is so much that we could discuss about the pill. I think what I would like to do is recommend that women in the listening audience would consult with their physicians or perhaps they could call you or are they could call the information center and be referred to a counselor if they have questions about the pill. Wouldn't you agree that it is very important for a woman to understand what kind of medication she's taking? - Yes and I think that the biggest problem with this pill business is that there is about as much misinformation available as there is information. And I'm afraid that this is true of the government publications, including the little warning insert that goes inside the package now, which most women have gotten hold of one time or another, and it is nothing but frightening. It tells the woman nothing useful, but it is frightening. And in fact, some of the statements made in that little warning gadget are on very very tenuous ground. And this thrombophlebitis bit is far from settled and most authorities don't think thrombophlebitis has anything to do with birth control pills at all. So this was a misleading, frightening thing. And I think it is a bad thing. And again, as I say the problem is that there the woman had better have up-to-date information and information from a person who knows and who is not speculating. - All right, we just have a brief amount of time left and I would like to go on to one further type of choice that women have that they might not be aware that they have either as a form of family limitation or a last resort in case of contraceptive failure. And that's the new procedure of menstrual extraction. Would you describe when a woman is a candidate for menstrual extraction and what is involved in it? - Well, the term menstrual extraction is a difficult thing to define. But generally speaking when a woman has missed her period and has reason to think that she could be pregnant that is she's had intercourse since her last period and is not taking birth control pills. And if she is within two weeks of the overdue period then she is generally speaking a candidate for menstrual extraction. Which simply means a vacuum curettage of the uterus. It simply means emptying the uterus of whatever is in there. - Is this a surgical procedure? - I would definitely consider a surgical procedure. - But minor surgery. - Minor surgery, office surgery yes. - No incision. - No incision. - Oh, how does a menstrual extraction take place? - How is it done? - Uh uh could you describe? - Well, the woman actually, this involves slight dilatation of the cervix. Sometimes it can be done without dilatation but one should expect to be dilated a little bit. A plastic device is put into the uterus and the endometrium is vacuumed out under suction. - And this, how long would that take? It's very brief I understand. - Well, the procedure itself, that is the actual curettage takes perhaps two minutes. But preparation and instruction and that sort of thing as well, 20, 30 minute procedure altogether. - But still very brief, and how about being effective? - Very effective, properly done, very effective. By properly done I mean using adequate instruments and using dilatation ahead of time, primarily because the physician has much better feel that way. He knows whether or not the job is complete. - You mentioned that when a woman's period is late she's a candidate for this, how late, what's the ideal time. And what's the maximum time limit beyond which this procedure is impossible. - Well my criteria would include the fact that if the woman is as much as five days late she should immediately contact her physician so that some attempt can be made to start her period without doing an extraction. And if that fails, then she is a candidate. So I would say she should begin to worry at day five. - Day five. And then what is the last possible time that it could be done? - Well, this was difficult to say and I determine by the examination. - But let let's say that 12 to 14 days. - Okay it depends upon whether you call it an extraction but the technique is really quite feasible, technically feasible for at least six weeks for the menstrual extraction technique, Beyond that time other things have to be done really. - All right, if you have further questions about menstrual extraction you can call Dr. Clinton or please call the University Information Center. I'd like to thank you very much Dr. Clinton for being with us this evening. - It has been a pleasure. - And invite all of you to tune in in next week to KNNU and A Feminist Perspective.