Durango Herald Medical Population Public Health

Pick Mirena

If you were designing a perfect family planning method, what characteristics should it have? Certainly, the method would be highly effective and safe. Probably it should be designed for women, since they are usually more interested than men in controlling fertility. It would be nice if the method also had some beneficial side effects such as making periods lighter and less painful. Fortunately such a method is now available!
I have known about Mirena® for several years. Doctors in other countries, who have many years’ experience with it, have raved about it. The FDA finally approved it for use in the United States in 2000. It is wonderful to have another option for American women. As effective as tubal ligation, it is temporary and can be removed easily if a woman wishes to conceive.
Mirena® is made out of soft plastic in the shape of a “T”. The stem is filled with levonorgestrel, a potent form of progesterone—the hormone of pregnancy. A tiny amount of the hormone passes continually through the plastic into the uterus. It contains enough to last five years. Fortunately, although the levonorgestrel has a direct effect on the uterine lining, very little gets into the woman’s blood stream. Most women have no generalized symptoms from the hormone.
But isn’t this an Intrauterine Device (IUD)? Aren’t IUDs dangerous? Well, one IUD—the Dalkon Shield—was a disaster. Many years ago it was rushed to market before they had sufficient time to test it well. It made women vulnerable to serious infections, and some became infertile from the Dalkon Shield.
Two IUDs are now available in the United States, and both are amazingly safe. A woman who is in a mutually monogamous relationship is the best candidate for an IUD. Furthermore, IUDs work best for women who have given birth, since pregnancy stretches the uterus a bit. A potential user should be well informed about IUDs, and she should learn how to check that it is in the proper position. The device must be inserted skillfully by a qualified doctor or nurse.
How does Mirena® function? The levonorgestrel makes it more effective than other IUDs. Because the hormone causes the uterine muscle to relax, it also decreases cramps. The hormone prevents pregnancy in at least two ways. The principal way that it works is that it makes cervical mucus thick and sticky so that sperm cannot pass through. It also thins out the lining of the uterus. If a sperm got past the inhospitable cervical mucus and an egg did get fertilized, it would be unlikely to implant. This thinning effect also makes bleeding lighter or stops it completely.
One way of looking at Mirena® is that it is a means of getting the hormone where it can work most effectively. Because the hormone is released inside the target organ, only a tiny amount is needed, and side effects are minimized. One advantage of any IUD is that the user is constantly protected against pregnancy without having to do anything on a regular basis.
Levonorgestrel can cause a few annoying side effects. Certain women complain of increased acne or headaches, and rarely they will have breast tenderness or nausea. Some women stop having periods entirely, which is normal for a Mirena® user, as long as the device is in place. Fortunately, it does not cause weight gain.
Mirena® is small and flexible, which makes it well tolerated even by women who haven’t had a baby. The other popular IUD, Paragard®, is a bit larger and stiffer. Although Paragard® lasts longer than Mirena®—ten years versus five—women do not tolerate it as well if they haven’t started their family yet. In fact, young, childless women have requested many of the Mirenas® that I have placed so far.
Mirena® is called an IntraUterine System (IUS). I think that this is a marketing ploy to distinguish it from other IUDs. It is also possible that the manufacturer is preparing to market it for other indications. In many countries it has been used to help women who suffer from excessive bleeding or bad menstrual cramps. In addition, it prevents abnormalities of the lining of the uterus (including cancer), especially in menopausal women on estrogen. Although the FDA hasn’t approved Mirena® by for noncontraceptive uses, women welcome it for help with these problems.
At last we have an IUD that has a very low failure rate, few side effects and many benefits. Mirena® has great potential to help women control their fertility and deal with other problems.
© Richard Grossman MD, 2005

Family Planning Global Climate Change Population

Cool Off the Planet

“The ultimate test of a moral society is the kind of world that it leaves to its children.”
Pastor Dietrich Bonhoeffer

Writing last month’s article depressed me. The article predicted run-away global warming within this century.
This series on global warming is long overdue. The vast subject is crucial because climate change will affect our progeny so severely. The ultimate cause of global warming is our outsized population and extravagant use of fossil fuels.
The first article defined positive feedback loops—which have very negative effects. The second was about the problem itself, and this one offers suggestions to slow greenhouse gas emissions—the problem’s cause.
Certain common gases in the atmosphere (especially carbon dioxide and methane) hold in the sun’s heat. Global warming is caused by unprecedented rises in the concentrations of these gases.
This article is easier to write because of a book that contains much more information than I could put in 750 words. You Can Prevent Global Warming (and Save Money): 51 Easy Ways is brief and to the point. Not all 51 ways will apply to every reader, of course, but this $11 investment will pay for itself many times over. The authors claim one can save over $2000 the first year by just following the easy tips!
You can buy a copy from Maria’s Bookshop, 960 Main, Durango. The Durango, Bayfield and Ignacio public libraries also have copies.
Unfortunately, the book has two shortcomings. I’ll criticize them at this article’s end.
The book starts with my favorite way to save electricity (and thus decrease CO2 emissions). Compact fluorescent bulbs use only a quarter of the energy of the more common incandescent bulbs, and last many times longer. That also saves money, of course. Since CO2 is released when most electricity is generated, CFs prevent huge quantities of the greenhouse gas CO2 from being added to the atmosphere. These bulbs are smaller and cheaper than just three years ago when the book was written. There is almost no reason not to use them to replace the old-fashioned energy hogs.
It also soundly trounces my pet peeve—oversized, inefficient vehicles needed to bolster an undersized ego, rather than required for utility. To accentuate the positive, however, this book includes the advantages of high-mileage vehicles, public transportation, biking (including information about electric bikes) and walking.
In addition to the 51 tips, the book includes basic information about greenhouse gases and global climate change. There are also Internet references for those who want more information.
The two shortcomings of You Can Prevent Global Warming are major. The book includes 51 ways to decrease emissions of CO2 and methane. However, it does not compare the end result (even if you followed all the tips) with the goal—actually stopping global warming. It does state that the aim of the Kyoto Accord would be reached if just a third of all people in the USA followed the 51 tips.
The other obvious failing of this book is that it never looks at the effects of human numbers. We could live our accustomed profligate lives with much less effect on the environment, and little risk of changing the climate, if the population of the USA were just 100 million rather than 300 million. Choosing to have a small family, or no children at all, is still the most important step we can take to slow climate change.
If you haven’t seen “An Inconvenient Truth”, you must. It is an amazingly persuasive and accurate film, seeking to convince unbelieving U.S. citizens that global warming is a titanic problem. Stay to the end, because the closing lists some of the steps that an individual can take to slow greenhouse emissions. It also refers you to its website
We are in for a hell of a future if global warming is as bad as scientists forecast. The planet will be hotter, drier and less productive. For every degree Celsius the temperature increases, grain output on the planet will decrease 10%, leading to massive famines. Moreover, the fossil fuels that have been our virtual slaves for the past two centuries will become scarce. Their byproducts (carbon dioxide, mercury and others) will linger for centuries, thus changing the world that we leave our grandchildren.
Watch Al Gore’s movie and read You Can Prevent Global Warming to learn actions you can take to minimize the problem—and save money. Next month’s article will focus on ways some communities are already using to combat global warming.

© Richard Grossman MD, 2006