FREE

a book about birth control free

1st edition, fall 1979

Written by Donna Cherniak

Edited by Shirley Gardiner
Published by the Montreal Health Press, Inc./Les Presses de la Sante de Mont-
real, Inc. (1973), an independent, non-profit corporation under Quebec law.
Production by the workers of Journal Offset, Inc., Montreal, Quebec, local
Confederation des syndicats nationaux (CSN).
Illustrations by Michel Hebert
Front cover photo by Pierre Brault
Back cover photo by Allan Manus

Administration and distribution by Catherine Deppisch and Janet Torge ,

Members of the Montreal Health Press collective: Donna Cherniak, Shirley

Gardiner, Marilyn Bicher, Janet Torge, Catherine Deppisch, Ghyslaine Fortin.

Copyright 1979 by Montreal Health Press Inc.

Reproduction of a book about birth control in whole or in part, or any systema-
..c mutilation or addition to, copies before distribution, constitutes copy-
of,
right violation unless the express consent of the publishers has been granted.
The photographs a book about birth control were taken of models (by consent)
in
or in public places. They are not meant as comments on any individual's life-
style or politics.

a book about birth control is sold to organizations at cost price and is meant
for free, mass distribution. Resale of the books is strictly forbidden.

The Montreal Health Press is interested in your comments about its publications. We
would also like to know how they are used in your community and how they are received.
Let us hear from you.

Special thanks to all those people who supported us when we were down, who proof-
read at a moment's notice, and who will still be around for the next book.

Printed in Canada

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3. All orders must be accompanied by cheque, money Other publications:
order, or official purchase order, made payable to
The Montreal Health Press. a book about sexual assault
4. Postal orders (50-300 copies) are sent by insured VD Handbook
parcel post in multiples of 50 copies per book. Le petit manuel de la contraception
5. Large orders (500 copies or more): All orders are Les maladies transmises sexuellement
sent FOB Montreal. Shipping fees are payable Poster kit no 1 Female and Male Reproduction
:

directly to the transport company. For U.S. orders Poster kit no 2: Birth Control Methods
 ginal penetration without pregnancy. Whereas men
introduction once accepted the threat of pregnancy as a legitimate
reason for a woman's refusal, now men who see sex-
ual submission as a wife's duty expect to be "ser-
viced" regardless of the woman's desires. Where-
A book about guide to the use of
birth control is a as women once avoided pregnancy by encouraging
existing methods of contraception. It provides basic other forms sexual
of gratification (remember the
information about human sexuality and reproduction. thrill of adolescent petting), now there is no reason
It discusses the factors which influence both the not to "go all the way", even if the experience is
choice of and the successful use of a birth control less exciting.
method. Sexual liberation requires the recognition of sexual
The Montreal Health Press has been distributing potential in both women and men, the valorization of
information about birth control for almost 10 years. many forms of gratification, and mutual responsibi-
The Birth Control Handbook first appeared in 1968 lity for contraception. Birth control is merely an ad-
when the legality of distributing such information was junct to liberation, not its cause.
still in question. Its unexpected and continued success
Reproduction
bears witness to the need for this information and the potential for reproduc-
Birth control creates the
importance of an inexpensive mass distribution net- tive self determination. Women can determine if,
work. The Handbook was last revised in 1974; since
when and how often they will bear a child. But re-
then the technology of birth control has only changed
productive determination is only realizeable
self
in detail. But the social and political impact of con-
when social conditions are favorable to parenting.
traception has continued to evolve. The Montreal
The decision not to parent because of economic or
Health Press is taking a fresh look at contraception
social constraints despite a desire to parent is op-
with the creation of a new publication. A book about
pressive.
birth control replaces the Birth Control Handbook
which we will no longer distribute.
which threatens a woman's future fer-
Birth control
tility, her ability to conceive or
either by reducing

Contraceptive research by harming the fetus is unacceptable. As are other

It is not surprising in a society which values effi-
ciency over safety that the thrust of contraceptive
research has been toward methods of very high ef-
fectiveness. But the price has been high: side effects
which endanger the comfort and health of the user.
We believe that control over fertility is possible
without endangering the health of women. A woman
is fertile only a few days each cycle. Instead of
eradicating the natural female cycle the technology
should be used for precise prediction of the days of
fertility. At that time, a woman could merely abstain
from vaginal penetration or use a safe but effective
mechanical method; the rest of the cycle she would be
free from the burden of contraception.
Modern technology offers earlier pregnancy de-
tection and methods of early pregnancy termination
with few health risks. For many women the morality
of interfering with the reproductive process soon
after fertilization or implantation is no more trouble-
some than interfering prior to conception. A safe,
self administered method df early abortion must be
a priority in birth control research.
Sexuality
Contraception challenges the idea that sexual acti-
vity without reproductive intent is sinful.
is merely the means to reproduce the species and not
punishment for sexual activity. A woman's pleasure
in sexual experience has only recently been given pub-
lic recognition, and many women are exploring their
sexuality with greater expectations.Removing the link
between pregnancy and sexuality can open up the
possibility of sexual behaviour which carries no risk
of pregnancy oral-genital sex, masturbation,
mutual masturbation, sex with a partner of the
sex, etc...
But unless men participate in this enlargement of
the sexual experience, birth control can backfire for
women. Birth control permits a woman
hazards to fertility air pollution, mercury in fish,
drugs in meat, additives in processed foods, etc...
Reproductive self determination includes the right to
have healthy children.
Birth control does not change the status of women
in society. It merely permits women to assume so-
cialroles that are not maternal. When a woman is
blocked from advancement, when employment re-
presents drudgery not unlike that at home (with low
wages and less freedom), limiting one's family size
is hardly liberating.
Population control
Overpopulation is a concept used by people with
much wealth to control the masses of people with
little wealth. Instead of attacking corrupt govern-
ments and profit hungry multi-national corporations,
overpopulation theories blame poor people for their
poverty.
The rape
of the Third World and the overconsump-
tion in thewest have been sufficiently documented
elsewhere. Western funds for family planning in the
Third World have skyrocketed while other forms of
aid have diminished. In 1975-76 over 2/3 of all U.S.
foreign assistance health allocations were ear-
marked for population planning. High maternal and
Pregnancy infant mortality rates are used as an excuse for the
use of contraceptives considered too dangerous for
use in North America. Social and political possi-
bilities range from tax on children to putting con-
traceptives in the water supply.
This planet does need a policy on population size.
But this policy must be based on an equal distribution
of the planet's resources. No individual or group
has the right to greater material freedom or repro-
same ductive freedom than another. No nation has the right
to impose its notion of progress or civilization on an-
other. Respect for human rights is basic to such a
policy; neither forced maternity nor arbitrary re-
to have va- striction of maternity is acceptable.
PAGE 4

anatomy
A knowledge of sexualand reproductive anatomy
is important to understand sexual behaviour, con-
ception and contraception.
Men and women often worry if their genitals are
normal. Genitals probably vary as much as noses do.
Noses are sufficiently similar to fulfill their func-
tion of breathing but sufficiently different to give in-
dividual character to a person's face. It is the same
for genitals. True genital abnormalities are usually
discovered in early childhood; abnormalities of re-
productive organs may not be discovered until pu-
berty.
In both men and women, sexual and reproductive
Structures are symmetrical. Single structures such
as the clitoris or penis are in the midline. Most
structures are double, one on the left and one on the
right.

Male anatomy
Scrotum: This sac of thin skin is covered by pubic
hair and hangs between and slightly in front of the
thighs, behind the penis. The scrotum contains the
testicles. It is sensitive to sexual stimulation and to
called seminiferous tubules. These tubules join to-
gether to form fewer but larger tubes which in turn
join to form the epididymis.
Epididymis (2) This coiled tube on the back of
:

temperature change. each testicle provides the path for sperm out of the
Testicle (2) One testicle hangs in each side of the
:
testicle and into the vas deferens. Cells lining the

scrotum. Usually one testicle hangs lower than the epididymis secrete a substance important for sperm
other. Each testicle is composed of cells which pro- development.
duce either sperm or hormones. At puberty the tes- Vas deferens (2) Each vas deferens is about 45 cm
:

ticles begin to produce male hormones called andro- (18 in.) long. This tube goes from the epididymis,
gens which cause body changes such as the growth enters the pelvis at the groin, and lies above and to
of pubic and facial hair. Androgens also stimulate the side of the bladder. Behind the bladder each vas
the production of sperm in cells lining tiny tubes widens into the ampulla where sperm are stored.

Male sexual and

reproductive organs

seminal vesicle

ejaculatory duct

scro urethral opening

-
 PAGE 5

Seminal vesicle (2) : This gland lies on the outer Female anatomy
side ofeach ampulla. produces secretions impor-
It
Female reproductive organs are located within the
tant for the survival of sperm. The duct of the sem-
pelvisand supported by the pelvic muscles. The sex-
inal vesicle joins the duct of the ampulla to form the
ual organs are situated outside these muscles. The
ejaculatory duct. Gland secretions and sperm are
reproductive structures are protected inside the
mixed together here just before ejaculation. body, and the sexual structures are accessible for
stimulation at the body surface.
Prostate: This chestnut shaped gland is located
beneath the bladder. The urethra from the bladder
A woman can see her own genitals more easily if
she holds a mirror between her legs. These outer
runs through it. The prostate produces substances
structures together are called the vulva.
important for sperm survival. These substances en-
Mons veneris: This cushion of fat at the base of
ter the urethra through many tiny ducts and mix with
the belly covers the pubic bones. At puberty the mons
sperm only seconds before orgasm.
becomes covered with pubic hair.
Urethra: This tube leaves the bladder, goes through Labia majora (2) These outer lips begin at the
:

the prostate, through the pelvic muscles, into the
bulb of the penis, through the length of the penis to
open at the glans. In men the urethra has two func-
mons and join in front of the anus. They are made of
fatty tissue and are covered with pubic hair.
Labia minora (2) The inner lips are delicate folds
:

tions: urine from the bladder is passed out through of pink skin between the outer labia. In front they

the urethra. When a man ejaculates, seminal fluid join to form a hood over the clitoris. They separate

(mixture of sperm and gland secretions) is forced
out the urethra. A sphincter closes the opening from
the bladder so that urine cannot mix with semen.
Penis: The penis is made up of three bodies of
spongy erectile tissue. Two parts lie side by side
forming the upper part of the shaft of the penis. They
curve and separate, and anchor the penis to the pubic
bones. The middle spongy part forms the lower part
of the shaft: at the tip it widens to form the glans;
and at the inner end beneath the pubic joint, it widens
to form the bulb of the penis. The urethra enters the
bulb and opens at the glans. The penis is covered
with loose skin which is attached to the circumfer-
ence of the glans. A fold of this skin called the fore-
skin loosely covers the glans.
During sexual arousal the spongy bodies of the
penis become engorged with blood causing the penis
to become hard and erect. The glans of the penis is
particulary sensitive to sexual stimulation.
In many cultures, the foreskin is removed by an
operation called circumcision. Jews circumcise boys
on either side of the vaginal opening and join again.
The inner lips are moist and without hair. They are
sexually sensitive; when a woman is excited they be-
come engorged with blood which makes them slightly
erect. The inner labia vary in size and form from
one woman to another.
Clitoris: Only the glans of this small sensitive or-
gan can be seen between the inner labia. The shaft
can be felt under its hood. The shaft bends and di-
vides into two parts which attach to the pubic bones.
When stimulated the clitoris enlarges and retracts
beneath the hood.
Urethral opening: The urethra from the bladder
runs between the pubic bone and the vagina. Its open-
ing is between the clitoris and the vaginal opening.
Vulva: female genitals
mons veneris

at birth; in other cultures circumcision is done at

puberty. Health advantages and disadvantages of cir-
cumcision are widely debated. Uncircumcised men
must pull the foreskin back to clean the glans ade-
quately.
M
Examination of the male
clito
There is no equivalent of the annual gynecological
check-up for men. Male contraception does not re- urethral open
minora
quire supervision. There are no screening tests for
cancer.
A man's external genitals are in full view. The labia majora* vaginal opening
man can examine himself occasionally for sores,
masses or discharge.
Although gonorrhea usually causes symptoms in
the male, the frequency of male gonorrhea without
symptoms is increasing. Men who have several sex- anus

ual partners should have a test for gonorrhea once

or twice a year.
After age 30, both men and women should have an
annual rectal examination to rule out cancer of the
rectum. This examination is usually not painful but
can be uncomfortable. In men, the prostate can be
felt with the finger through the rectal wall.
PAGE 6

Vaginal opening: The outer third of the vagina is

sensitive to sexual stimulation. In young girls, the

opening partially covered by an elastic membrane
is

called the hymen. The hymen is open enough to let

menstrual blood pass out and to permit use of a tam-
pon. The first time a girl's vaginal opening is pene-
trated during sexual intercourse, the hymen is
stretched further and sometimes bleeds. This can be
uncomfortable and should be done gently.
On either side of the vaginal walls are two bulbs
of erectile tissue. During sexual excitement they be-
come engorged with blood. Thin muscles around
them contract rhythmically during orgasm.
Pelvic "muscles surround the vaginal opening as
well as the urethral opening. They can be contracted
voluntarily, *for example to prevent urination. They
contract and relax rhythmically during orgasm. These
muscles also prevent a tampon from falling out.
Vagina: The inner two thirds of the vagina has few
nerve endings and is not very sensitive. The vaginal
walls normally touch each other but stretch to ac-
comodate a penetrating object. They also stretch
when a woman is sexually excited. The walls are
lined with a moist mucous membrane much like the
inside of the mouth. During sexual stimulation lu-
bricating fluids come out of this membrane.
fluidsare not necessary for conception.
The vagina lies at about a 45 degree angle, in about
the same plane as the urethra and rectum which are
in and behind it respectively. The vagina ends
front
in pockets around the cervix. Though there are var-
iations, the cervix usually enters the vagina at an
angle from the front.
Uterus: In a woman who has never been pregnant,
the uterus is about 8 cm long and 5 cm wide. After
each pregnancy it remains slightly larger. The uter-
us is made up of several layers of strong muscle
fibers. The inner walls of the uterus form a small
cavity lined with a spongy tissue called the endo-
metrium.
The uterus is shaped like a pear. Normally the
These top triangular portion is bent forward (anteflexion)
and the cervix enters the vagina from the front at an
angle of about 90 degree (anteversion). In about 15%
of women, the uterus is positioned differently; it

Female sexual and reproductive organs

8opian tube

canal

clitoris

urethral opening

anus
 PAGE 7

may be bent backwards (retroflexion) or enter the hormones. They produce the female hormone, estro-
vagina from an angle toward the back (retroversion). gen which affects the body in many ways. Estrogen
The position usually does not affect a woman's sex- is important for the development of the egg-contain-

ual or reproductive experience but it can affect the ing follicles. Estrogen is necessary for ovulation,
use of some birth control methods. the release of the egg from the follicle. It also causes
The cervix the long part of the uterus which
is the endometrium to develop and thicken.
projects into the upper vagina. It is a thick muscular The follicles (blister-like sacs) on the ovaries are
tube with a narrow canal. This canal provides the sensitive to estrogen. Several follicles grow and
only entrance from the vagina into the uterus. one begins to stick out. This follicle ruptures re-
Fallopian tubes (2) One Fallopian tube is attached
:
leasing its egg or ovule; this is called ovulation.
to either side of the uterus. Each narrow tube is Some women feel their ovulation as a sharp or dull

about 10 cm long. Its loose end widens near the ova-
ry. The tube is lined with tiny hairs and the walls
have a layer of muscle.
Ovary (2) One ovary lies on each side of the uter-
:
us to which it is attached by a ligament. Each ovary
is almond shaped. At birth the ovary contains im-
mature egg cells which develop after puberty. Other
cells produce female hormones.
the menstrual cycle
For half of her life, each woman's body goes
through a monthly cycle of changes to prepare for
pregnancy. It is called the menstrual cycle from
the latin word "menses" meaning month. The most
obvious event in the cycle is menstrual bleeding, the
shedding of the endometrium.
abdominal pain.
After ovulation the ruptured follicle on the ovary
becomes the corpus luteum. This tissue produces the
hormone, progesterone, which is important for the
continued development of the uterine lining. Proges-
terone also causes the body temperature to rise a
small but appreciable amount.
Uterus: The endometrium, the inner lining of the
uterus, is sensitive to ovarian hormones. Estrogen
causes it to thicken and tiny arteries to grow in it.
Progesterone causes glands to develop in the endo-
metrium and the little arteries to become coiled.
When the hormones decrease, the endometrium dis-
integrates and the little arteries bleed. Chemicals
in the endometrium prevent the blood in the uterus
from clotting. This blood and bits of endometrium
flow through the cervix and out the vagina. This is
the woman's menstrual period. Not all of the lining
is discarded. A thin layer remains which starts to

Girls usually begin to menstruate between the ages develop again when it is stimulated by estrogen.
of 10 and 16. At about the same time pubic hair When there is a lot of estrogen, the glands of the
becomes obvious, thicker and darker, and breasts cervix produce lots of thin mucus which is easily
develop. Women stop having menstrual bleeding bet- penetrated by sperm. Some women
notice a wet
ween the ages of 45 and 50 after which pregnancy feeling at the vulva at the time of ovulation. When
is no longer possible. there is less estrogen the glands produce a thicker
This chapter describes a normal menstrual cycle. mucus which is harder for sperm to get through.
Menstrual bleeding is considered the beginning of Other parts of the body also respond to female
the cycle. The chart (following page) shows the events
hormones. Some women find that their breasts en-
of a 30 day cycle. The text follows the chart, first
large and become tender just before or during their
describing the role of each organ, and then placing period.

each event in its proper time sequence. Body temperature is increased slightly by pro-
gesterone. The temperature rises around the time
Reproductive organs of ovulation and remains high until menstruation when
it drops again.
Pituitary: This small gland in the brain releases
Estrogen and progesterone have many other effects
many hormones, each which affects a particular
of
on the body which are not usually noticeable. During
body function. The pituitary releases two hormones
pregnancy or when hormones are taken for birth
which affect the menstrual cycle: Follicle Stimulat-
control or other treatment, these effects can be-
ing Hormone (FSH) and Luteinizing Hormone (LH).
FSH causes several egg-containing follicles on the come important.
ovary to develop. It also stimulates the ovary to An average menstrual cycle
produce a hormone called estrogen. LH is neces- Women are told the "normal" menstrual
that
sary for the follicles to burst open and release its cycle is always precisely regular and is 28 days
egg. LH causes the ruptured follicle to turn into the long. This is a myth. Although some women do have
corpus luteum which produces the hormone proges- 28 day cycles, the normal range of cycle length is
terone. about 20 to 40 days. One woman may have menstrual
The pituitary acts like a thermostat. When there is bleeding every 22 days and her sister every 38 days;
a lot of estrogen in the blood, the pituitary stops both women are regular.
releasing FSH. After ovulation and when the corpus Few women are perfectly regular; their cycles are
luteum is making progesterone, the pituitary stops not exactly the same length each time. A woman
releasing LH. whose cycle is about 28 days may have cycles of
The pituitary can be affected by other parts of the 26, 29,and 28 days; this woman has a regular
brain. This explains why a woman's menstrual cycle cycle. An irregular cycle would be one of 28 days,
changes under conditions such as physical or emo- the next of 20 days, and the third of 36 days; this
tional stress. woman is unable to predict when she will have her
Ovaries: The ovaries are sensitive to pituitary period.
PAGE 8

The Menstrual Cycle

s M T W T F S
7 17
2 3 * 5
1

6 7 8 9 10 11 12
13 14 15 16 17 18 19
20 21 22 23 24 25 26
27 28 29 30

pituitary

ovary

uterus

wet
stringy dry
cervical mucus menstruation dry transparent scant
abundant opaque

<m
basal body
temperature

T 1

M T W T F S

1 2 3 4 5
6 9 10 11 12
7 8
13 14 ,15 16 17 18 19
20|21 22 23 24 25 26
2728 29 30
 .
The length of the menstrual cycle is determined
by the time between the beginning of menstruation
to ovulation. This time prior to ovulation can vary
from about 6 to 20 days. The time from ovulation
until the beginning of the next period is much more
constant at about 14 days.
The names given to each phase of the cycle are
based on the endometrium. The menstrual cycle is
continuous; it has no real beginning or end. How-
ever since bleeding is something the woman can
observe, the first day of bleeding is called day 1
Days 1 to 5; menstruation: Hormones are low at
the beginning of the cycle. The pituitary begins pro-
ducing Follicle Stimulating Hormone (FSH). The
ovaries produce little estrogen and the follicles are
not yet developing. The endometrium is breaking down
and bleeding. Mild contractions of the uterine mus-
cles push this tissue through the cervix. Bleeding
may be abundant for several days and tapers off.
The glands of the cervix produce very little mucus.
Body temperature is low.
Days 6 to 16; proliferatory phase: The pituitary
produces more FSH and begins to release Luteiniz-
ing Hormone (LH). The ovaries respond by secreting
estrogen. Several follicles on the ovaries get bigger.
One gets very big and sticks out. The endometrium
which had been stripped to its thin layer is becom-
ing thick again; its cells are proliferating. The
cervical glands begin to produce more mucus. Body
temperature remains low.
Day 17; ovulation: Both pituitary hormones have
spurted suddenly, especially LH. The ovaries also
release a spurt of estrogen. The follicle which was
sticking out bursts open and the egg is released
near the opening of the Fallopian tube. The glands
of the cervix produce lots of very thin stringy mucus
which is easily penetrated by sperm.
Days 18 to 26; secretory phase: FSH and LH
decrease rapidly. The ovaries release less estro-
gen. The ruptured follicle turns into the corpus lu-
teum which produces progesterone. The egg is moved
down the Fallopian tube toward the uterus. The
glands of the endometrium develop and secrete
substances important for the early nourishment of
an embryo. The cervical glands produce less mucus.
Progesterone causes the body temperature to rise
slightly.
Days 27 to 30; premenstrual: Pituitary hormones
are low. conception did not occur, the corpus lute-
If
urn starts to break down so less progesterone is re-
leased. The arteries of the endometrium begin to go
into spasm.
When the endometrium starts to break down on
the 31st day, the woman's period starts. This day
becomes day 1 of her next cycle.
Menstrual bleeding
The bloody discharge a woman knows as her
period contains cells of the degenerating endome-
trium, many white blood cells, and actual blood.
Chemicals either prevent the blood from clotting
or break up clots. Clotting only occurs when bleed-
ing is so heavy that the chemical is used up. Con-
tractions of uterine muscles help the flow along.
PAGE 9
Women lose approximately 20 to 80 cc (1 to 3
ounces) of blood during each period. Bleeding lasts
between 2 and 8 days.
A woman can have sexual activity of any kind dur-
ing her period. Orgasm causes the muscles of the
uterus to relax and contract. Some women find this
relieves menstrual cramps. Most women find that
the flow is heavier for several hours after orgasm.
In all cultures women have had ways to absorb the
menstrual flow. They have used natural products
such as moss, reuseable products such as cloth,
and disposable products such as sanitary napkins
and tampons.
Sanitary napkins are held at the vulva either by a
belt or by fastening them to underpants with pins or
tape. The flow is absorbed externally. Pads come
in various sizes for or heavy bleeding.
light
Tampons are used internally. They are often sold
with an applicator which helps to position the tampon
beyond the muscles at the vaginal opening. A properly
positioned tampon cannot be felt and will not fall out.
The opening in the hymen is large enough to permit
women who have never had intercourse to use tam-
pons. Tampons also come in various sizes for light
and heavy bleeding, and two tampons can be used at
once for very heavy bleeding. A forgotten tampon can
be responsible for foul smelling discharge.
Problems with the menstrual cycle
Women frequently consult doctors because of pro-
blems with the menstrual cycle. Often their com-
plaints are not taken seriously so they are not pro-
perly examined nor adequately treated.
Menstrual problems can be indicative of serious,
even life-threatening disease. More often, they are
simply uncomfortable, inconvenient and a source of
worry. Women have the right to adequate investiga-
tion and to thorough explanation of any menstrual
problem.
Irregular cycles: When the length of a woman's
menstrual cycles varies by more than about 8 days,
she has irregular cycles. She is probably not ovulat-
ing, or is ovulating some cycles and not others.
Lack of ovulation is common in teenagers, in pre-
menopausal women, and in some women who have
just stoppedthe birth control pill. Women with
irregular cycles cannot use birth control methods
which depend on the prediction of ovulation. Some-
times these women need regular pregnancy tests to
ensure that they are not unknowingly pregnant. A
woman who has bleeding between her periods or
bleeding after intercourse must have a medical
check-up.
Abundant periods: A woman has abundant periods
if she is constantly staining her underwear or bed-
sheets despite frequently changing her tampon. A
woman who has always had abundant periods may
have no health problems; she adapts to her situa-
tion by wearing two tampons, by keeping tampons
by the bed, etc... She must eat enough iron-contain-
ing foods and be checked intermittently for anemia.
A woman whose period suddenly becomes very heavy
should see a doctor both to limit the blood loss and
to rule out any disease.
 .

PAGE 10

Cramps: Many women have a tolerable amount because they menstruate; they are certainly not re-
of discomfort during their periods. Women have warded because they ovulate. Furthermore, men,
ways of reducing this discomfort: keeping in good who neither menstruate nor ovulate commit far more
shape, doing yoga, using a heating pad, having violent acts thanwomen.
someone rub their belly, having an orgasm, drinking A woman's mind is affected bythe menstrual cy-
scotch. No one remedy works for all women. Women cle. The cycle controlled by the pituitary
itself is

who miss work or social events because of severe and hypothalamus, both parts of the brain. But there
cramps should seek medical attention. is no reason to conclude that this makes women in-
Some women have discomfort and a heavy bloated feriorpeople. This implies that a man's body and
feeling for several days before their period which mind are the norm for human beings; in so far as
is often dramatically relieved when the flow starts. women deviate from that norm, they are inferior.
Mood changes: Much has been said about women's The norm must be expanded to include both female
emotional vulnerability just before and/or during and male models.
menstruation. It is difficult to separate myth and We are not against interference with the menstrual
prejudice from fact. Some women do feel more cycle. The Pill has been beneficial to many women.
depressed or hostile at this time. Others feel Hysterectomy can be a life-saving operation. But
more sexual. Many notice no particular change. Ma- women must be confident that those who do interfere
ny women find ways to cope with these feelings - with their cycle have a basic respect for the inte-
laughing at themselves, warning those close to them, grity of the female body.
etc... Occasionally women feel the need for either
hormonal or psychological treatment to help them
through these days.

Politics of the menstrual cycle. sexuality

Even though menstrual bleeding is a normal event,
it is often treated as abnormal, dirty and shameful.
Historically and even today in some cultures, mens- Birth control is more effectively and satisfactorily

truating women are set apart and their activities used when the user comfortable with his or her
is

sexuality. Many birth control resources, whether

restricted. Some may have benefited
of these rituals
women, relieving them from responsibilities of child
care and food preparation. In western cultures such
benefits seem lost; what remains are attitudes which
describe menstruating women as weak (you'll get
sick if you wash your hair during your period), or
dirty and contaminating (don't have intercourse,
don't go swimming), or irresponsible (don't hire
women; they take too many sick days)
Except in intimate circles, a menstruating woman
is expected to pretend that nothing is happening. If
she restricts her activities she finds an excuse to
explain her absence. If she has cramps, she bears
them in silence or pretends to be ill. Some women
are embarassed to buy tampons; some men refuse to
buy them. It is a social disaster to find a blood stain
on one's clothes in public.
If menstruation were considered normal, such
behaviour would seem ridiculous. Imagine being em-
barassed to buy toilet paper. Imagine accusing a
they are clinics, school courses, films or pamphlets,
avoid the sensitive subject of sexuality. These oc-
casions provide valuable opportunities to encourage
responsible attitudes toward sexuality.
Sexuality and reproduction
Certain sexual activity carries greater risk of
pregnancy than others. Coitus (penetration of the
vagina with an erect penis) between a man and a
woman is the usual way a woman gets pregnant. The
man ejaculates, releasing sperm into the woman's
vagina.
Other sexual behaviour carries no risk of preg-
nancy. Anything that a person does alone or with a
partner of the same sex will not lead to pregnancy.
Kissing, hugging, fondling and touching do not result
in pregnancy. Cunnilingus, licking and sucking a
woman's genitals cannot make her pregnant. Fel-
latio, oral stimulation of a man's penis, cannot lead

person who is constipated of rejecting his identity, to pregnancy even if the man ejaculates into the
as a woman who complains of menstrual cramps is woman's mouth.
accused of rejecting her femininity. These are all healthy forms of sexual behaviour
Many factors perpetuate these ideas - attitudes which can be satisfying for both men and women.
about sexuality, about the role of women, and about Many couples derive pleasure from them as their
body functions. A woman's reproductive organs are principal sexual activity, or as preparation for
not seen as integral parts of her body. Doctors tam- coitus. When penetration is unacceptable because of
per with them with what seems to be little concern. the risk of pregnancy, vaginal infection or discom-
Hysterectomy, the removal of the uterus, is often fort, non-coital stimulation can be an agreeable
done for questionable reasons. A woman whose birth substitute.
control method stops her periods is told she has
been relieved of a nuisance. Sexuality and birth control
The menstrual cycle is often used to discredit a Birth control has been hailed as the great lib-

woman's intellectual and emotional abilities. Studies
that cite that most violent acts committed by women
occur just before or during her period fail to say
that women commit fewer criminal acts just before
or during ovulation. Women are refused opportunities
erator of female sexuality, and it has been denounced
as the cause of female promiscuity. The assumption
in both cases is that by eliminating the risk of
pregnancy, birth control has vastly expanded a wom-
an's sexual potential.
 PAGE 11

The only sexual act which birth control affects is lution. There is no real break as a person passes

coitus. To say that a woman's sexual potential is from one phase to the other. The pattern of response
vastly expanded by birth control is to assume that is similar whether a person is masturbating or
her sexual potential is through vaginal
realized making love with someone.
penetration. Other sexual behaviour is relegated to Excitement phase: Sources of sexual excitement

"foreplay", mere preparation for the "real" sex
act. Virginity is still defined by not "going all the
way", that is, not permitting penetration.
It is not true that a woman's sexual potential
comes from her vagina. Women have probably been
telling their lovers this in the privacy of their
bedrooms for generations. Now the sex researchers
are supporting them with scientific information about
the human sexual response.
Another belief about birth control is that it makes
sexuality more spontaneous. Episodic contraception,
particularly the condom is often rejected because it
interferes with spontaneity. Spontaneity is not al-
ways essential for sex to be good; this is a romantic
idea which avoids the practical aspects of life (chil-
dren, telephone etc.). What spontaneity often implies
is unplanned sexual intercourse or even the denial of
intent to have sexual intercourse.
Continuous birth control such as the Pill or
IUD does permit greater immediate spontaneity.
But it also permits a couple to totally avoid dis-
cussing contraception and sexuality. In silence, the
woman foresees her need for contraception: going
to the doctor, filling her prescription, remembering
to take her pill. She is caught in a double bind: she
must prepare herself contraceptively or risk preg-
nancy, but if she is too assertive sexually she may
jeopardize her reputation.
Birth control has been important in the changing
attitudes toward female sexuality. The recognition
of a woman's sexual pleasure during coitus was an
important step toward similar recognition of her
pleasure in non-coital sex.
are as varied as the human imagination. Pictures,
sounds, colour, music, smells and thoughts can all
cause sexual arousal. Both sexes enjoy fantasizing.
Direct stimulation of the breasts, nipples, thighs
and genitals can be exciting both for the person doing
the touching and the one being touched.
If the person is receptive, the body responds in
many ways. Both the heart rate and breathing rate
increase. The skin may flush. The breasts enlarge
and the nipples become erect. In women, the clitoris
becomes erect, the inner labia swell and deepen
in colour. The lining of the vagina releases a lu-
bricating fluid. The deeper part of the vaginal walls
separates and the uterus moves up in the pelvis,
increasing the vaginal diameter. In men, the penis
enlarges, becomes hard and erect.
Plateau phase: If sexual stimulation continues, the
body continues to respond. The heart rate and
breathing become even faster. Muscle contraction
and congestion in the pelvic area increase. The
clitoris becomes exquisitely and retracts
sensitive
under the hood above it. Stimulation of the inner
labia causes stimulation of the clitoris by moving
the hood back and forth over it. Swelling of the
vaginal opening decreases the diameter of the
opening itself; during coitus this provides a gripping
sensation on the penis.
Tom Levitt

Sexual physiology
Men and women have similar although not iden-
tical responses to sexual stimulation. The erogenous
zones include areas whose prime function is not
sexual such as earlobes and tongues. In both, the
areas near the genitals such as the lower abdomen
and inner thighs can be highly sensitive.
The most sensitive sexual organs in both men
and women are made up of erectile tissue. In re-
sponse to sexual stimulation, the small arteries in
erectile tissue dilate causing engorgement. This
blocks the outflow of blood from the veins which in
turn causes further engorgement. When engorged,
erectile tissue turns darker in colour, increases in
size and stiffens. In men, the penis, particularly the
glans, is the most sensitive. In women, the clitoris,

the inner labia and the vaginal opening are the most
sensitive. Tension in the pelvic muscles also adds
to the feeling of sexual arousal.
Clinical research to explain the human sexual
response was pioneered by William Masters and
Virginia Johnson in the 1960's. Based on their re-
search, they have developed theories of sexual
therapy. Other researchers and therapists are now
increasing our technical knowledge of sexuality.
Masters and Johnson divide sexual response into 4
main phases: excitement, plateau, orgasm and reso-

PAGE 12
the male, the glans of the penis becomes slight-
ly
In
more engorged and darkens in colour.
If sexual stimulation stops during excitment, the
body returns to the unaroused state quickly and com-
fortably. If sexual arousal stops during the plateau
phase, the changes take longer to resolve.
Orgasm: The sudden release of congestion and
muscle tension is called the orgasm or climax. It
is often likened to a sneeze. In women, the muscles
at the vaginal opening contract and relax rhythmical-
ly. In men, rhythmic contractions of the pelvic
muscles cause ejaculation, the forced release of
seminal fluid.
Male orgasm is usually sudden and brief. There
seems to be greater variation in the orgasmic ex-
perience of women sometimes sudden and brief,
but sometimes long and slow, or rippling waves of
sensation. Both men and women can experience or-
gasm as intensely pleasurable, as a moment
ful abandon.
Resolution: In both women and men, the blood
flow is released and the erect tissues lose their
rigidity. If there is no further stimulation, the con-
gestion disappears and the body returns to its
normal state. This is often a time of closeness and
cuddling, of giggling and of tears. There is a sense
of well being, often so relaxing that the lovers drift
asleep.
If sexual stimulation continues, a woman can
respond immediately and have another orgasm short-
ly after. She can go through the phases of sexual
response repeatedly until she feels satiated. A man
cannot have another orgasm immediately. A variable
amount of time called the refractory period must
pass before he can have another orgasm. This time
becomes longer with age.
Sexual politics
Human sexuality is more than a series of physio-
logical responses. Sexual behaviour is learned. As
individuals and as members of a society, we learn
to conform to beliefs about acceptable sexual behav-
iour. The teaching may not be as obvious as learning
to use a fork and knife, but it is nonetheless direct
and powerful.
Sex between two people of the opposite
strongly influenced by
the cultural roles of each
sex. In many cultures, masculinity is associated
with assertiveness, dominance and power; in con-
trast, femininity is viewed as weak and passive.
Men are expected to initiate sex, and many sexual
contacts enhance their image. A woman is expected
to be innocent of sexuality and faithful to one man.
Sexual experience brands her as promiscuous. This
double standard allows men to be lauded for beha-
viour which would condemn a woman.
We do not have good models of sexual behaviour
and sexual relationships. When we try to behave re-
sponsibly in our sexuality, we are breaking new
ground and should expect occasional setbacks. We
can make these fewer and not so painful if we share
our experience with each other. Our expectations of
each other must be reasonable; sexual patterns are
not altered overnight. We must show patience and
understand impatience. We must be trusting and face
distrust. But the reward of honest, open and respon-
sible sexuality is high. ,
.
well woman care
Many control methods require a doctor's
birth
As a result, young healthy women go to
prescription.
doctors more often than they otherwise would, cer-
tainly more often than do men of the same age.
Women often consider their appointment for birth
control as their annual check-up.
Where a woman goes for birth control will influ-
ence the quality of care she receives. Each place
has advantages and disadvantages.
A family doctor who knows the woman's physical
and social history might consider her more general
health needs, rather than focusing on just one part
of her being. Not all family doctors are well inform-
ed about birth control, and some are prone to moral
judgments.
It is unnecessary to see a gynecologist (specialist)
of joy-
for birth control. Specialists treat people with spe-
cial problems; they are usually too preoccupied to
give thorough preventive care to healthy women.
Birth control clinics and community clinics are
often democratically organized and education is em-
phasized. Nurses and para-medics play an important
role. The woman may not see the same doctor or
birth control counsellor at each visit; however conti-
nuity of care is assured by adequate charts, and per-
haps more importantly by a common attitude toward
birth control.
Hospital clinics with few exceptions are imper-
sonal, almost assembly line style. Medical students
either accompany the doctor or see the woman alone,
often with inadequate supervision. The woman is not
always informed when a hospital is doing research.
These clinics are sometimes less expensive than
private services; sometimes they are the only ser-
vices available to low paid and unemployed women.
A woman should have an annual birth control
check-up. She should have more frequent check-ups
if she has any abnormality or complication, if she
decides to change birth control methods and/or if
the risk of sexually transmitted disease is high.
The first birth control check-up should take 30 to
45 minutes or be divided into two visits. Follow-up
sex is examinations should be long enough to deal with any
changes since the last visit and to answer any fur-
ther questions. In Quebec doctors are paid $28 for
a "major complete examination" (45 min.), $14.50
for a "complete examination" (30 min.), and $7.50
for a minor examination (15 min.)
The following description of a birth control con-
sultation is intended not only to prepare a woman for
her first experience but, also to set a standard by
which a woman can judge the quality of the service
she is offered. We hope to encourage women to ap-
proach their own health and specifically the control of
their fertility witha sense of responsibility and self
determination. Use of birth control can be an affir-
mation of a woman's sexual lifestyle. It is a cons-
cious act by which she postpones or rejects ma-
ternity, affirming a social role in addition to or other
than motherhood. The "rituals" surrounding birth
control how it is taught, where it is obtained,
from whom, how it is used should reflect and sup-
port this positive image of woman as an active sexual
social being.

A birth control consultation
Screening a method of distinguishing between
is
the majority of healthy people and the few who have
problems which need investigation and possible
treatment. Screening may be a series of questions
about working conditions, a physical examination such
as the breast examination for breast cancer, or a
laboratory test such as the Pap test for cervical
cancer. Screening in birth control counselling looks
for problems which might be related to the birth
control method of choice. Anemia, high blood pres-
sure, liver problems and sexual dissatisfaction are
examples of problems which influence a woman's
choice of contraception. Screening also includes
tests for diseases which often cause no symptoms
such as sexually transmitted diseases. Finally,
screening looks for health hazards in a person's
environment or behaviour cigarette smoking,
dangers on the job etc...
Education is the transfer of information which
permits a person to take responsibility for herself
to the full limit of her abilities. Education may be
quite informal; when the blood pressure is taken, a
simple explanation can be given of what blood pres-
sure is. All screening tests should be explained; it
is unreasonable to expect people especially those
who don't feel sick to accept tests simply on the
basis of faith in the profession.
A woman should have the opportunity to learn about
all birth control methods available to her. More de-
tailed information must be given about the method
the woman has chosen. When a woman leaves the
clinic she should know: what method she will use,
where to get it, how to use it, how much it costs,
why and when to stop it, what problems she can anti-
cipate and how to cope with them, and what to do if
the method fails. Basic sexual education is impor-
tant not only to promote sexual satisfaction but also
to ensure successful birth control use.
Evaluation is the most individualized aspect of birth
control counselling. The woman and the counsellor
look at what she has been using for birth control and
assess the need for change. The woman comes to a
decision based on her personal history, both medical
and sexual, an assessment of her present needs and
an adequate physical examination. An interested coun-
sellor offers both experience with the technology of
medicine and contraception as well as experience
with people's attitudes and behaviour related to health,
birth control and sexuality.
is the counsellor's responsibility to create an
It
atmosphere of confidence, respect and confidentiality.
Many women get inadequate birth control services be-
cause they are hesitant to describe experiences or
feelings for which they feel they may be judged. The
medical profession has been predominantly male,
wealthy, and conservative. It has provided birth con-
trol services to the women of its own class for
generations; but until birth control became profitable
business, the profession remained silent and even
blocked attempts to make available safe and compre-
hensive birth control services to those who could not
pay. To truly help a woman choose and use birth con-
trol to her own satisfaction, a counsellor must be
sensitive to the enormous price women have paid in
the face of the repressive forces of the church, the
PAGE 13
state, and the medical profession regarding sexuality
and reproduction. A good counsellor can accept a
woman's distrust as realistic and understandable,
rather than as a personal affront.
Personal history
The woman describes her past health: major ill-
nesses, hospitalizations, and operations. If a woman
is unclear about the diagnosis or treatment of any ill-
ness, she may request the hospital to send a sum-
mary of her chart to the clinic.
The woman describes her present health, includ-
ing chronic illness and the medications she takes for
it. She discusses any new symptoms such as fatigue,
or diarrhea. Any regular habits such as cigarettes,
alcohol, or special diets should be noted. A brief ac-
count of her responsibilities job, family, school,
recreation and her feelings toward them may be
helpful.
The state of health of other members of the wo-
man's family should be noted.
The woman describes her reproductive history.
At what age did she begin having menstrual pe-
riods? How
long are her cycles? Do they vary in
length? How
long does the bleeding last? Is it light or
heavy? Does she have cramps or feel bloated during
her period? Does she have any bleeding between pe-
riods or immediately after intercourse? Does she
have flushes or other symptoms of menopause? The
date of her most recent period is recorded in the
chart.
The woman describes her pregnancies and their
outcome miscarriage, induced abortion, or deliv-
ery. She describes any interventions that occurred
during her pregnancies, and any complications. She
may discuss her plans for a future pregnancy.
The woman may discuss her sexual experience, in
particular her present experience(s). Is she satis-
fied with her sex life? If not, what does she see as
the problem? Does she usually have sex at home or
elsewhere? How often? Does she have one partner or
several? Has she had any particularly traumatizing
sexual experiences sexual assault or incest?
The woman describes her contraceptive experience,
if possible in chronological order, from the time she
started using birth control to the present. What me-
thod did she use and for how long? Why did she stop
each method? Did she have any particular problems
with each method? What is she using now? For how
long? Is she having any problems with it? Are there
any reasons why she should change methods? Does
she know as much as she would like to about other
methods?
Kenisls
PAGE 14
Physical examination
Most people are nervous about a physical examin-
ation. Most women seeking birth control are not sick
when they are examined. Nonetheless they must ex-
pose their bodies to the sight and touch of a stranger,
often male, something which is usually done only in an
atmosphere of far greater intimacy and where the
other person is equally vulnerable. The gynecological
examination ("pelvic") in particular may cause a
woman much anxiety, especially if she is unprepared
or if she has been examined roughly previously. The
more a woman relaxes, the more useful and the less
uncomfortable this examination is. It is the examin-
er's responsibility to help a woman relax if she is
anxious.
A bath or shower, or simply washing the genitals
with soap and warm water is adequate preparation.
Douches, creams and powders hide signs of infec-
tion and should not be used for at least 24 hours prior
to a pelvic examination. The examination will be more
comfortable if the woman empties her bladder be-
forehand.
The woman undresses for the physical examination.
To be properly examined, a woman must completely
expose certain parts of her body at different mo-
ments; there is no reason for her to be left nude for
extended periods. A woman may use a robe, sheet,
or her own clothes to cover herself to her own satis-
faction and still be properly examined.
w^
Gynecological examination - A metal or plastic speculum
the cervix are examined. Inset: direct view of the cervix.
The woman weighs herself, and her height and
blood pressure are recorded. A brief examination
is made of the woman's skin, neck, heart, lungs,
abdomen, back, groin and legs. The examiner is
looking for lumps, swellings, painful spots or other
signs of disease. Any problem area is examined
more thoroughly. The woman's breasts are examined.
Ifshe does not know how to examine her own breasts,
she should be shown how.
For a pelvic examination, the woman lies on her
back with her buttocks at the edge of the table, her
feet in supports and her legs spread apart. The outer
genitals are examined for sores or signs of irritation.
To look at the cervix and the inside of the vagina,
the examiner uses a metal or plastic instrument cal-
led a vaginal speculum. A metal speculum should be
warmed first and both kinds should be lubricated
with water or jelly. The speculum is inserted into
the vagina with its blades closed, and the blades are
gently opened. The speculum is moved until the cer-
vix can be clearly seen. The vaginal walls and the
cervix are examined for inflammation.
The examiner may do several tests. These tests
can be slightly uncomfortable but rarely painful. The
Pap test or cytology for cervical cancer should be
done once a year, and more often in women who have
had a previous abnormal test. A flat stick is used to
wipe the surface of the cervix; cells which are re-
moved are examined in a laboratory for signs of
t . if.
is inserted in the vagina. The walls of the vagina and
 PAGE 15

cancer. Women who have more than one sexual part- collected urine sample is examined in the laboratory
ner or whose regular partner may have other lovers for bacteria.
should have a test done for gonorrhea. In a woman Blood may be taken for several tests. A test for
who has an abundant or foul discharge or whose vulva anemia (low blood count) should be done in women
is itchy, vaginal secretions can be examined imme- who have very heavy menstrual periods. A test for
diately under the microscope to determine the cause syphilis should be done in women who have several
of infection. When the tests are done, the examiner sexual partners. A test for antibodies against ru-
closes the blades of the speculum and removes it. bella (german measles) should be done to determine
To examine the woman's internal organs (uterus, the need for the rubella vaccine in women who want
ovaries, and Fallopian tubes), the examiner puts two to have children.
fingers of a gloved hand into the vagina and puts the
other hand on the lower abdomen. The internal or- Decision making
gans can be felt between the two hands; their size, "The woman chooses the method of contraception
shape and position are determined. If the woman is she feels will suit her needs. She understands why
relaxed this examination should not be painful; pain she has made this choice. She has some idea of what
is caused either by tension, rough handling or dis- changes in her life might make her want to change
ease. Sometimes the uterus is felt better with one methods. She arranges any necessary follow-up
finger in the rectum instead of the vagina. A rectal visits to the clinic.
examination should be done in women over 30 to If any problems were found, the counsellor ex-
detect early signs of rectal cancer. plains them to the woman. Any further tests are
arranged, and the woman is referred to a specialist
Laboratory tests if needed.
Unless a problem is found, few tests are neces- The counsellor may take this opportunity to dis-
sary. Women should ask why a test is ordered. She cuss health prevention and hygiene. The advantages
may have had a similar test done recently or she of cotton underpants rather than synthetic ones may
may feel it is not worth the money, either from her be mentioned. The harmful effects of "feminine hy-
own pocket or through taxes. giene" products should be stressed.
A simple urine test for kidney function and for Finally, there should be time for the woman to be
diabetes is done at the clinic. If the urine is cloudy sure that her questions have been answered adequate-
or if the woman has trouble urinating, a specially ly.

Bimanual examination With one hand on the abdomen and two fingers in the vagina, the examiner feels the
its size, shape and position. Inset: examiner feels each ovary and tube.
uterus, noting
PAGE 16

nancy and how the pregnancy would affect the dis-

reproduction
Deciding to have a child
Pregnancy was once an almost inevitable conse-
quence of an active sex life. Birth control often suc-
ceeded in delaying but not in preventing pregnancy.
Families adapted well or poorly to each pregnancy,
but they adapted after the fact. With the development
of highly effective contraception and the increasing
women can control with much
availability of abortion,
greater accuracy the timing of their pregnancies.
There is no ideal time to have a child. Each situa-
tion is unique with advantages and disadvantages. No
situation is eternal or entirely predictable; some
circumstances are beyond our control. Economic and
political conditions alter the circumstances in which
families live. More intimately, changes in health and
marital situations can totally change our life plans.
Flexibility and adaptability, important qualities for
parenting, are also useful in making the decision to
parent.
Why do people have children? How important is
biological instinct in human reproduction? What are
the psychological implications of parenting? How
does one culture vary from another? How is this
changing in modern times?
Practical matters also influence both the decision
to have a and the timing of pregnancy. These
child
issues may be
considered, although in a more urgent
fashion, by a woman who becomes pregnant unex-
ease. Women who have their first child in their 30's
have more complications than younger women. As a
woman's age increases, the possibility of having an
abnormal child also increases.
Raising a child also requires energy and health.
Potential parents must think about how they will cope
with the demands of a newborn and the needs of a
growing child.
Relationship of parents: The family is no longer
the stable unit it once was. Women are choosing to
have children on their own or within a non-marital
relationship. Couples who have children within mar-
riage must think about what would happen to the
children in case of separation or divorce.
Sharing the experiences which are part of parent-
ing can certainly enrich a relationship; nonetheless,
the presence of a child can so alter the daily expe-
rience of a couple that they may forget what their
relationship was based on beforehand. Time alone
together becomes less frequent and less spontaneous.
Lifestyle: A child inevitably reduces the freedom
of its parents to fulfill themselves in other aspects
of life, whether it be for a career, sport or hobby.
The decision to have additional
Existing children:
children taken in the context of an existing family
is

pectedly and who is debating between parenthood and unit. How close in age children should be mus.t take

abortion. There will be moments both during preg- into consideration the needs of the parents and the

nancy and after the child is born when a parent will impact on the children.
doubt the wisdom of the decision. Sharing these feel-
ings with close friends, some of whom may also be The right of individuals to decide whether or not
parents can be helpful. Thorough discussion of the and when to have children is not a universally rec-
factors which influence this decision is beyond the ognized right. The important role of the Church in
scope of this book, but several are worth mentioning: the politics of reproduction may be decreasing, but
the state is place with great enthusiasm.
taking its
Economic: Raising a can be expensive. A
child
A community should have a collective approach to-
child is not merely another mouth to feed and body
ward reproduction and population size. These poli-
to clothe and shelter. A child requires supervision
cies should be made at the local level by people who
in its early years. For a certain period of time, one
have in mind and heart the well-being of both the in-
parent may be unable to work outside the home. Day- dividual and the community.
care is still rare and costly. Maternity leave is far
from universal, and paternity leave is non-existent.
A community must back its reproductive policies
Health: Pregnancy a stress on a woman's body.
is with services: contraception and abortion, pre-natal
A woman who has a chronic disease should consult a care, midwives, daycare, maternity leave, paternity
doctor about how her disease would affect the preg- leave, part time employment, etc.
Robert Marquis

Preparing for pregnancy
Stopping contraception
Most methods of birth control are immediately
reversible; that is, a woman is able to get pregnant
almost immediately upon stopping the method. A
woman who uses intermittent methods such as the
condom or diaphragm merely stops using them. A
woman who calculates her fertile period to avoid
pregnancy can use the same calculations to enhance
her chance of conceiving. An IUD should be remov-
ed during a woman's period. If it is removed mid-
cycle, she should use another method such as the
condom until her next period. When a woman stops
the Pill to get pregnant, she should use another
method of birth control for at least 3 cycles before
'trying to conceive. If after 3 months she does not
have a period and a pregnancy test is negative, she
should seek medical attention.
Health hazards
The fetus is vulnerable to outside influences es-
pecially in early pregnancy. A woman who is pre-
paring for pregnancy cannot cut herself off from her
environment but she should be aware of its possible
dangers. The most common hazards to pregnant
women include the following:
X-ray (or any form of irradiation) should be avoid-
ed, especially in the early months because of possi-
ble malformations. If an X-ray is necessary, a wom-
an can be given a special shield to put over her ab-
domen to block irradiation.
Drugs should be avoided whenever possible, in-
cluding prescription drugs, over the counter drugs,
and illicit drugs. Some drugs are known to be dan-
gerous; most are considered potentially dangerous.
A woman who takes continuous medication should
consult her doctor about its use during pregnancy.
Cigarette smoking decreases the birth weight of
the baby and is a possible cause of premature deliv-
ery. The effect is related to the amount smoked.
Women who are unable to quit smoking should not be
made to feel as though they are already inadequate
mothers. There will be many other moments when
for whatever reason a parent is unable to do what
would be best for the child.
Certain viral infections can harm the fetus caus-
ing malformations and retardation. The two most
known are rubella (german measles) and toxoplas-
mosis. A woman who has had german measles or the
vaccine will have immunity from the disease. This
means that she has antibodies in the blood which
protect her from the disease. After puberty, all girls
who have not had the disease should have the vaccine
or a blood test to see if she has rubella antibodies. If
she does not, she should have the vaccine. She must
wait 3 months after the vaccine before trying to con-
ceive in case the vaccine itself harms the fetus. If
she is already pregnant and has no antibodies she
must not have the vaccine. Instead she must be care-
ful about exposing herself to infection especially dur-
ing the first 3 months of pregnancy.
A toxoplasmosis may also be
test for antibodies to
done but there no vaccine for it. Toxoplasmosis is
is
transmitted primarily from cat feces. A pregnant
woman who does not have antibodies should not keep
cats. Toxoplasmosis may harm the fetus at any time
during pregnancy.
PAGE 17
Sexually transmitted diseases may also harm the
fetus. Syphiliscauses malformations. Gonorrhea in-
fects the baby's eyes during delivery. A woman
should be tested for both of these diseases before
and during pregnancy. A woman who has more than
one lover should consider altering her sexual habits
during pregnancy to avoid possible infection. She
might ask her partner to do the same.
Mercury poisoning from contaminated fish can
cause malformations and stillbirths. Commercial
fish are regularly tested for mercury but fish caught
in local lakes should not be eaten unless mercury
testing has been done. Mercury poisoning is a seri-
ous problem for native peoples of North America
and elsewhere for whom fish is not only a staple of
the diet but a source of income.
The work place may also contain dangers for the
woman or the fetus.
Nutrition
Development of the fetus depends on the nutrition
of the mother. A woman can look at what she eats
and evaluate its adequacy for pregnancy. A pregnant
woman must eat enough protein, vitamins (especial-
ly those found in green vegetables) and iron. Women
who are vegetarians or have other special diets
should think about how to adapt their diet in pregnan-
cy.
Genetic screening
Parents who know that genetic illness exists in
their familiesshould enquire about genetic counsell-
ing. Certain racial groups carry certain genetic dis-
orders which can be screened: for example, sickle
cell anemia among North American Blacks, and Tay
Sachs disease among Jews of European origin.
Physiology of conception
Conception is the union of an egg cell (ovum) from
a female with a sperm cell from a male. The ovum
and sperm unite to form a zygote. This union is call-
ed fertilization. It is basic to all animal reproduc-
tion.
The male contribution
From puberty on, men produce sperm cells con-
tinuously. Sperm look like microscopic tadpoles with
a large head and a long thin tail. The head contains
23 chromosomes which are made up of many genes.
The tail is capable of whip-like motion which moves
the sperm toward the egg.
Millions of sperm are produced in the testicles.
They are collected in the epididymis and moved along
the vas deferens to a place where the vas widens just
before the prostate. Just before a man ejaculates,
the sperm are mixed with substances from the pros-
tate and other glands to make up the seminal fluid.
During ejaculation this fluid is pushed out the ure-
thra. One ejaculation contains about 350 million
sperm.
When the sperm are deposited in the vagina, their
tails lash back and forth, causing them to move very
quickly. Most of the sperm will not reach an egg.
Some are killed in the vagina because of its acidity.
Some get caught in the folds of the vaginal walls.
Some do not get through the mucus of the cervix.
Once in the uterus, some sperm go into each Fal-
lopian tube, only one of which may contain an egg.
Sperm can survive about 48 hours in the Fallopian
tubes.
PAGE 18
The female contribution
A woman releases only one egg (ovulates) each
cycle. Ovulation occurs about 14 days before her next
period would be expected. The egg also contains 23
chromosomes, the genetic inheritance from the
mother. It is surrounded by a protective coating of
small cells. The egg can survive for approximately
24 hours after ovulation.
The egg cannot move on its own. It is picked up by
the end of a Fallopian tube by a suction-like action.
Tiny hairs lining the tube move the egg toward the
uterus.
Since the woman's body will house the growing
fetus, a "nesting place" is prepared for the fertiliz-
ed egg. The lining of the uterus thickens and its
glands produce substances important for the early
nourishment of the embryo.
Fertilization
One sperm encounters a ripe egg in the Fallopian
tube and penetrates the egg's cell membrane. A re-
action occurs which prevents other sperm from en-
tering. The fertilized egg or zygote is moved down
the Fallopian tube toward the uterus. As it moves,
the chromosomes combine; the zygote now has 46
chromosomes containing the genetic material which
determines many of the child's characteristics.
One set of chromosomes determines the sex of
the fetus. The egg contains an X chromosome. The
sperm contains either an X or Y chromosome. If the
sperm with an X chromosome fertilizes the egg, the
zygote will have two X's and the fetus will be female.
If a sperm with a Y chromosome fertilizes the egg,
the zygote will have one X and one Y chromosome
and the fetus will be male.
Multiple births (twins, triplets) happen for several
reasons. The ovary may produce two or more eggs,
If these eggs are fertilized, two or more fetuses will
develop. These are fraternal twins; their chromo-
somes are not alike. Identical twins happen when fer-
tilization occurs normally but the zygote divides to
form two or more zygotes. These twins have very
similar genetic inheritance and are of the same sex.
Implantation
The zygote divides into a cluster of cells which
reaches the uterus about 3 days after fertilization.
It floats in the uterus for several days before bury-
ing itself in the lining of the uterus. This is called
Mike Kropveld
implantation or nidation. The endometrium does not
break down and the woman misses her period.
Substances in the endometrium nourish the cluster
of cells which continue to divide. Some cells form
the tiny embryo which grows into the fetus. Others
become the placenta which supplies the fetus with
nutrients and produces hormones. These hormones
prevent the woman from releasing another egg while
she is pregnant.
Confirmation of pregnancy
Women suspect pregnancy when they miss a
first
period. A woman evaluates what the likelihood of
pregnancy is: did she miss any pills, did she not use
a condom, is her IUD still in place? Shortly after the
missed period, a woman may have other signs of
pregnancy such as nausea and breast enlargement.
The sooner a woman finds out that srfe is pregnant
the better. If she wants to be pregnant, she can begin
pre-natal care early. If she wants an abortion, the
sooner it is done, the safer the procedure is.
A woman who has irregular periods or who has
just stopped the Pill may be less suspicious about a
late period. Sometimes a woman has some very light
spotting at about the time her period was due. In
these cases if there is a possibility of pregnancy, it
must be confirmed or ruled out by a pregnancy test
and pelvic examination.
Any woman who suspects she might be pregnant
and does not want to be, should continue using birth
control until the pregnancy is confirmed. There are
other reasons why a woman might miss a period.
Many women have become pregnant because they
stopped contraception when they thought they were
already pregnant.
The age of the pregnancy is calculated from the
date of the woman's last menstrual period, and not
from the time of ovulation. If a woman is 3 weeks
late and if she has regular periods every 4 weeks,
she is 7 weeks pregnant.
Pregnancy tests
Most pregnancy tests measure the presence of
Human Chorionic Gonadotrophin (HCG) in the urine.
This hormone is produced by the placenta. It is not
present in the urine in sufficient quantities to be de-
tected until 6 weeks
after the last menstrual period.
Research to make
these tests more sensitive will
lead to the development of tests which are positive
earlier in pregnancy.

100% accurate. They may be
These tests are not
positive when the woman is not pregnant; such a
"false positive" is common in women approaching
the menopause. The test may be negative when the
woman is pregnant; this is a false negative. Any
woman who has a negative pregnancy test at 6 weeks
after her last period should repeat the test a week
morning urine gives most accurate
later. A
first
results. The bottle should be clean with all the soap
removed.
The newer pregnancy tests cost about 50<fc to
perform but pharmacists often take advantage of a
woman's anxiety and charge from $3 to $10. In Que-
bec, pregnancy tests are free at many community
clinics and hospitals.
Recently a blood test has been developed which de-
tects pregnancy within days after fertilization. It is
still too expensive for general use and is available
only in research centers.
Physical Examination
A positive pregnancy should be followed by a
test
physical examination. This also necessary for a
is
woman who has missed two periods even if the preg-
nancy test is still negative.
The doctor should ask the woman
the following
questions: When did her last period begin? Was it a
normal period? What has she been using for birth
control? Has she used it regularly? Has she had
sexual intercourse since her last period? How does
she feel about a pregnancy? Has she had any signs
of pregnancy? Has she had any liquid coming from
her breasts? Has she had any other recent changes
in her health?
The doctor examines the woman (see page 14) look-
ing for signs of pregnancy. In pregnant women the
genitals often take on a bluish colouring. A bimanual
examination is performed with one hand in the vagina
and the other on the lower abdomen. In pregnancy
the cervix feels slightly softer than usual. The uterus
is enlarged. The doctor estimates the age of the
pregnancy by its size.
If the doctor finds no signs of pregnancy, the test
is negative and there is no obvious reason for a
woman to miss her period, she should investigate
the woman more thoroughly both through question-
ing and examining her to discover the reason for the
absence of periods. Often there is an obvious reason:
climate change, stress, rapid gain or loss of weight.
The persistent absence of periods may be the sign
of serious disease. If no obvious reason is found,
the woman should be referred to a gynecologist.
It was once common practice to provoke a missed
period by giving a woman progesterone pills for 3
days. If she was not pregnant, her period would usual-
ly start several days after the last pill. Progesterone
pills do not cause an abortion. They should not be
taken as a test of pregnancy as there is a very slight
risk of causing malformations in the fetus.
Infertility
the inability to conceive or carry a
Infertility is
pregnancy long enough so that the baby survives at
birth.
Most couples have no reason to suspect a fertility
problem. It is only when they decide to have a child
PAGE 19
and, if after many months of trying, the woman is
not pregnant, that the idea of infertility becomes
still
a reality. Infertility can make a woman feel inade-
quate as a woman and a man inadequate as a male.
Many people feel so discouraged by the discovery of
a fertility problem that they do not seek help.
There are many causes of infertility. Some are
easily treated, others are presently untreatable, and
most are at least possibly treatable. If a woman has
not conceived after 6 months of a regular sex life
without contraception, the couple should seek medical
advice.
Investigation of infertility includes tests to deter-
mine the cause and to estimate the chance of suc-
cessful treatment. can be a long process, taking
It
from 6 months to more than a
year. The early exam-
inations and tests are simple: more complicated
tests may be suggested later. It is important that the
couple discuss their feelings at each step as one or
the other may be discouraged or resentful of the
time, money and inconvenience of the investigations.
The man and woman have the right to clear explana-
tions of each test and a realistic estimate of their
chance for a successful pregnancy.
The couple should also discuss adoption. If this
alternative is acceptable to both, they should begin
the procedures for adoption, especially if the couple
wants only a baby or young child.
General causes
Misinformation: Many couples lack information
about sexual and reproductive functions. All couples
seeking treatment for infertility should receive clear
explanations about how conception occurs including:
when a woman is most fertile, positions during and
after intercourse which enhance the movement of
sperm through the cervical canal, etc.
Disease: Many illnesses affect fertility. When dis-
eases are prevented or adequately treated, infertility
may be reversed. Malnutrition, obesity and severe
diabetes are some examples. A medical history and
physical examination of both the man and the woman
must be done to exclude illness as the cause of in-
fertility.
Environment: Researchers suggest that pollutants
cause Stress or other psychological fac-
infertility.
tors also be important. It is unknown how these
may
factors affect fertility and if the effects can be pre-
vented or reversed.
Causes of male infertility
Infertility in the male accounts for 30% to 40% of
infertility.
Sperm quality: A man may produce no
quantity and
sperm sperm. The sperm may be unable
or too few
to move adequately (non-motile). The cause of insuf-
ficient or non-motile sperm may be reversible. For
example, heat has a negative effect on sperm pro-
duction; a man may be wearing too tight an athletic
support too often. An irreversible cause would be
absence of the testicles either from birth or from
surgery. Undescended testicles, either unrepaired
or repaired at a late age, inflammation of the tes-
ticle after an illness, drugs, and alcohol are other
causes of male infertility.
The test for sperm is a simple one. A man ejacu-
lates into a clean bottle and the fresh semen is ex-
amined under a microscope.
PAGE 20
Robert Marquis
Blocked passage: The complex passage from the
may be blocked. The block may
testicle to the penis
be caused by scar tissue after an infection such as
gonorrhea, or by surgery. If only one side is block-
ed, the man is still fertile. Certain diseases or sur-
gicalprocedures can cause retrograde ejaculation
where the semen goes into the bladder instead of out
the penis.
Male can be treated in certain cases by
infertility
insemination. The sperm can be concentrat-
artificial
ed and placed in the woman's cervical canal or uter-
us. In unsuccessful cases, sperm from a donor can
be used. The pregnancy rate using donor sperm is
about 70%.
Causes of female infertility
Problems in the female account for about 60%
all infertility.
Lack of ovulation: A woman may be ovulating in-
frequently or not at all. Her hormonal system may
be disrupted. This is nomal just after puberty,
before menopause and during breastfeeding. It may
develop for the first time after a successful preg-
nancy or after using the Pill. Some woman have ab-
normal ovaries either from birth or as the result of
disease. A woman who is not ovulating usually has
irregular and painless periods. To test for ovula-
tion, a woman takes her basal body temperature
(see page 24) and records it on a graph daily for
several cycles. If she is ovulating a rise in tem-
perature will occur after ovulation and be sustained
until her period.
Depending on the cause of the lack of ovulation, a
woman can be treated with drugs to stimulate ovula-
tion. Pregnancy rate after stimulation is about 50%
with a slightly higher than usual rate of multiple
births. Miscarriage in these pregnancies is just
slightly higher than average. Birth defects are not
increased.
Blocked passage: Sperm may be blocked at any
point in the female reproductive tract. The path of
the egg may also be blocked. This block may be phy-
sical or chemical. At the cervix, the mucus may be
too thick or too acid for sperm to pass. A woman
may have an easily treatable cervical infection. Any
of the reproductive organs may be absent or mal-
formed from birth. The most common problem is
blockage of one or both Fallopian tubes following in-
fection or surgery. Tuberculosis of the tubes is now
less common in North America; gonorrhea and IUD
now the biggest causes of tubal
related infections are
blockage.
Examination of cervical secretions shortly after
intercourse can be done to see if the sperm are still
alive and moving. Tests using air or dye injected
into the uterus will show any malformations or
blockages. Surgical techniques to reconstruct the
reproductive organs are improving but the present
success rate is still low.
Spontaneous abortion: Between 15% and 20% of
pregnancies abort spontaneously. In most cases, the
woman carries another pregnancy to term without
difficulty. Some women repeatedly miscarry. This is
a particularly difficult form of infertility because
one's hopes are repeatedly raised. These women
have high risk pregnancies and have the right to
specialized supervision during pregnancy.
Early miscarriage may be caused by chromosomal
abnormalities in the fetus, by inadequate hormonal
support of the pregnancy, and perhaps by external
factors such as drugs. Research on hormone treat-
ment is moderately successful but is complicated by
concerns for the effects on the fetus.
Later miscarriage may be caused by an "incom-
petent cervix" which dilates causing the fetus to be
expelled. Stitching the cervix closed until just before
the expected delivery date has often been successful.
choosing a method
of
The ideal method of birth control has been des-
cribed as one which is 100% effective, does not in-
terfere with a couple's sex life, has no harmful
effects, is inexpensive, easy to obtain, and easy to
use. No such method exists. It seems unlikely that
one method will satisfy the contraceptive needs of all
men and women. There will probably always be a
need for many birth control methods.
The choice of a birth method must be a
control
free choice. Pressure to use one method rather than
another may be direct or subtle. A woman may be
"forced" to use the Pill because her man does not
like condoms. An adolescent may be "forced" to use
no method because of parental or peer disapproval.
When government funds are withheld for abortions,
women are forced to use the most effective methods
of contraception available regardless of the conse-
quences to their health.
That the choice be a free one is not simply a ques-
tion of individual human rights. A contraceptive
method chosen under duress is one which is used
poorly, forgotten, and easily discarded.
It is important that the woman choose a method
which is adapted to her own needs. To do this, she
must understand what her needs are. She must be
able to recognize why and when her needs might
change so that she can change methods when neces-
sary.
 PAGE 21

What is a man's role in choosing contraception? one's present sexual activity. In choosing a method
Women, not men, become pregnant. Most birth control to suit herself, a woman should examine her own

methods are inconvenient or potentially dangerous for
women and not for men. Many women feel that men do
not appreciate the effort - physical, emotional and
social - which is required for women to have adequate
birth control.
There are several ways a man who is genuinely
concerned about his partner can be supportive. He
attitudes and her present sexual life. A woman who
is reasonably satisfied with her sexual life - the
partner(s), the frequency, the quality - tries to choose
a method which she feels will enhance it.
Adolescents who are just beginning to express
themselves sexually with another person often look
for a method such as the Pill which least interferes

can express his feelings about sexuality, birth control with their sexual explorations. On the other hand,
and parenthood. He can try momentarily to put him- the method most easily available to them is the con-
self in the woman's shoes - to understand why she has dom.
chosen a particular method and what support she A woman who has been in one relationship for many
years and suddenly finds herself with another man
may need to persevere with it. This is as important
in a brief sexual encounter as in a long standing
may feel very much as the adolescent does. She
relationship. Merely asking what a woman is using
may not want to use a method that might interfere
with sexual spontaneity.
is important. Accepting or suggesting condoms is
helpful. A man can show a willingness to experiment
A woman who has intercourse infrequently may
sexually to avoid penetration, if pregnancy would be
resent taking a pill every day. At the same time, she
an unwanted possibility. If he has some objection to may feel pressure to be contraceptively "ready"
her method, he should be willing to work out a solu- should the occasion arise.
tion with her. A woman with several sexual partners may like
the continuous protection of the IUD or the Pill;
Effectiveness
others feel that the condom offers some protection
The effectiveness of a birth control method is
against sexually transmitted diseases.
described by its failure rate: if 100 sexually active
women use a certain method for one year, how many Health
will get pregnant? For example, if 100 women use
In choosing a birth control method, a woman de-
no birth control for one year, 80 of them will get
cides which risks she is willing to take. For a
pregnant.
healthy woman, especially a young woman, this seems
Failure rates are described as either theoretical
very abstract; she may be more upset by minor
or actual failure rates.The theoretical failure rate
side effects such as heavier menstrual bleeding.
measures the pregnancies due to a failure of the
method alone, assuming that it is used correctly
Women with health problems or older women are
and 100% of the time. The actual failure rate also
justifiably more concerned about the dangerous com-
plications.
includes those pregnancies caused by human error:
when the doctor prescribes the wrong size diaphragm, Robert Marquis

when a man doesn't bother using a condom, or when

a woman forgets her pill.

Research studies show different effectiveness

statistics. These reflect the quality of the research,
the particular group studied, the quality of the birth
control counsellors, and other factors.

A woman should consider what she would do if the

method failed and she became pregnant. If she is
planning to have a child the near future she may
in

feel that several months difference

in the timing of
the birth is unimportant; therefore she may be com-
fortable with a less effective method. A woman who
wants no (or no further) children might choose the
most effective birth control method available, though
she might equally use a less effective method with
abortion as a back-up.
The availability of abortion influences a woman's
attitudetoward contraceptive effectiveness. Abortion
may be legal or illegal, easy or difficult to obtain,
costly or paid by the state, depending on where a
woman lives. Abortion may or may not be socially
or morally acceptable to herself, her family and her
friends. The option of safe, legal abortion is a ne-
cessary part of any birth control programme.

Sexual lifestyle

Feelings and attitudes toward sexuality affect a

person's choice of birth control. So do a person's
past sexual experiences and the circumstances of
PAGE 22
To make the decision about contraception a woman
must have a reasonable idea of her own state of
health. She must also have information about the
possible side effects of each method. She should
know what measures, if any, she can take to avoid
side effects, or to make their consequence less
severe should they occur.
Some healthy women who have no medical reasons
preventing the use of any method are nonetheless
uncomfortable with the idea of using something which
alters the body's natural state. Such women are
prepared to tolerate the inconvenience of methods
used only during intercourse such as condoms rather
than to alter their bodies with continuous contracep-
tion.
Pregnancy itself has certain risks. In developing
countries, illness and death associated with pregnancy
and childbirth are common. Population control pro-
ponents use this to justify contraceptive methods
which have risk levels unacceptable in western
countries. Contraception is no substitute for decent
nutrition and adequate pre-natal care.
Judy Crawley
Social context
Many aspects of a woman's personal and social
environment can affect her choice of birth control.
Attitudes toward sexuality, parenthood, technology,
sex roles, relationships and other factors combine
and create pressure on an individual to behave in
certain ways. A woman is in a better position to
defend her behaviour and her choices if she has at
least given these attitudes some thought.
A woman may be getting along well or poorly with
her sexual partner. The ups and downs of a relation-
ship are often felt in the bedroom. A man who disap-
proves of his wife working may see a pregnancy
as a solution to his problem.
Adolescents are faced with the problem of parental
approval or disapproval of their sexual activity.
Adolescents often rely on confrontation politics;
"getting caught" because a girl is pregnant is more
dramatic than if her mother discovers her pills.
Peer pressure is often strong. Having condoms
in a wallet may bolster a boy's ego but being on
the Pill may label a girl promiscuous. In other cir-
cles a woman who chooses anything but the Pill or
IUD may be labelled old fashioned or even irrespon-
sible.
A woman may feel pressure by popular attitudes
about the "right" number of children to have. Child-
less people and those with many children are often
criticized.
Method inconveniences
A woman should choose a method which she is
willing to use. She must be honest with herself about
her own lifestyle and about her feelings towards the
method's inconveniences.
Each method has inconveniences which require
effort to do or tolerate. Often women stop using a
method because they have not been informed about
the possible inconveniences which accompany the
method.
Women who are afraid of injections or who don't
like taking pills might avoid hormonal methods.
Women who don't want to interrupt their sexual ac-
tivity might avoid the condom. A
diaphragm or
woman who works alternating shift work might find
it difficult to remember to take her Pill. A woman
who drinks a lot or uses drugs might find methods
which depend on her memory difficult. In each case
the woman might decide that the method has enough
advantages to be worth the effort of accommodating
these inconveniences.
Some methods cause body changes which are rarely
dangerous but can be disagreeable. The Pill can cause
breast enlargement and acne. The IUD can cause
menstrual cramps. Women who are not prepared for
these changes may be frightened by them and stop
using what otherwise seemed an acceptable method
to them.
Ability to use a method
A woman should choose a method which she can
use. Mostmethods require some intellectual or tech-
nical skills. Some women do have trouble inserting
the diaphragm. Some women do misunderstand the
instructions for taking the Pill. Additional counselling
is usually adequate to correct these problems or to
find a more appropriate method. Birth control me-
thods can be adapted to the needs of the handicapped.
Most methods require social skills. A woman has
to seek out and use appropriate medical services.
She must show some insight into herself and her
lifestyle. She often has to initiate discussion about
contraception with her sexual partner. This is not
always easy even in a stable couple; in a casual
encounter where the social and sexual dynamics have
not been established it can be that much more diffi-'
cult.
book, the available methods are
In the rest of this
described: how
they work, their effectiveness, their
effect on the menstrual cycle, sexuality, health and
fertility, and how they are used. They are placed in
order depending on how they interfere with the re-
productive process: altered sexual behaviour (biolo-
gical methods), mechanical or chemical barriers to
sperm transport (condom), continuous hiethods un-
related to the sex act (IUD), methods used after inter-
course or after conception (abortion), and finally,
permanent methods.
 PAGE 23

Proponents these methods claim high use ef-

of
biological methods fectiveness temperature, cervical mucus and
for
combined methods. Critics claim that many couples
Biological birth control includes any method which do not sustain the effort required for full effective-
depends on abstinence from coitus (penetration of ness.
the vagina) when a woman is fertile. A woman In practice, this means that if a woman is disci-

observes her body for signs of fertility to determine plined about her observation, accurate in interpreta-

when she should avoid penetration. tion, and abstains according she can
to her results,

Biological methods are the only means of birth effectively avoid pregnancy. If she becomes lax in
control permitted by the Catholic Church. Yet the her observations or "cheats" by having coitus during
Church itself is responsible for their bad reputa- the unsafe period, she is risking pregnancy.
If a second method (ex. condom) is used during
tion: that they are not effective, and that they re-
quire great sacrifice of sexual expression. When the infertile period, the total effectiveness is in-

instruction is adequate, biological methods can be creased and depends on both methods. If a second
quite effective.And the restriction on penetration method is used during the fertile period (to permit
during the woman's fertile period does not preclude coitus), the woman is relying on the biological

other forms of sexual intimacy. method only during the infertile time and on the
second method only during the fertile period.
Breastfeeding delays ovulation after birth but the
Action
return of fertility cannot be predicted. The contra-
Biological methods depend on the sequence of ceptive effectiveness of breastfeeding is moderately
events of the menstrual cycle (page 7). To predict
high only if the mother is providing all of the baby's
the fertile period, the following factors must be
feeds. Once formula or supplements are begun, the
considered: return of fertility is likely, even before the first
The time from menstruation until ovulation is menstruation.
highly variable, from 6 to 20 days.
Ovulation always occurs about 14 days before the
Effect on sexuality
next menstrual period.
Progesterone released by the corpus luteum after Biological methods spontaneity by forbidding
limit
vaginal penetration during the fertile period. Im-
ovulation causes a measureable increase in basal
body temperature (BBT) which remains raised until posed abstinence for any reason may be used to
avoid existing sexual or conjugal problems. Factors
the next period.
The egg can live for 24 hours after ovulation. other than desire influence a couple's sexual rhythm:
fatigue, lack of privacy, schedules. Biological me-
Sperm can live for at least 48 hours.
Cervical mucus is scant, thick and opaque when a thods require abstinence from penetration but not
woman is infertile; it becomes abundant, thin and from hugging, kissing, mutual masturbation, oral-
transparent when she is fertile.
genital sex, or orgasm.
Because ovulation cannot yet be predicted with Material describing biological methods is directed
precision, a margin of safety is added to the begin- at stable couples. These methods require considera-
ning and end of the estimated fertile or "unsafe" ble sexual maturity for a single woman with spora-
dic heterosexual activity.
period.
There are 4 methods of calculating the fertile
period. In the calendar method a woman uses the Effect on fertility
length of previous cycles to predict the probable When a woman wants to conceive, she can use the
fertile period. In the temperature method a woman same calculations to have sex when she is most
records her temperature daily to detect the sustain- fertile. She can confirm pregnancy by a continued
ed rise after ovulation. In the cervical mucus me- elevated temperature.
thod (Billings) a woman examines her cervical mu-
cus to detect signs of fertility. In the combined me-
thod (sympto-thermic) a woman uses the increase
in temperature and the changes in cervical mucus to
determine the limits of her fertile period.
No matter how the calculation is made, the woman
must abstain from vaginal penetration during the
fertile period.

Effectiveness
The theoretical effectiveness is a measure of how
precisely the fertile period can be calculated. The
calendar method which measures past rather than
present cycles is the least effective. The cervical
mucus method has not yet been tested thoroughly
but it appears quite effective after adequate training.
The temperature method is theoretically highly ef-
fective in predicting the end of the fertile period.
The combined method is theoretically the most ef-
fective of these methods.
PAGE 24

irregular cycles, following aoortion or delivery, or

while breastfeeding.
The calendar method
Basal body temperature (BBT): The woman uses
Length of shortest First unsafe day Length of longest Last unsafe day a specially marked thermometer to take her tem-
cycle cycle
perature each morning immediately upon waking,
10th day
before any other activity (getting up, smoking, eat-
21 days 3rd day 21 days
22 days 4th day 22 days 11th day ing). She takes it for 4 minutes, either orally or
23 days 5th day 23 days 12th day rectally. She records her temperature on a graph.
24 days 6th day 24 days 13th day She notes the days of menstruation, of sexual
25 days 7th day 25 days 14th day
activity, and of any factors influencing her tempera-
26 days 8th day 26 days 15th day
27 days 9th day 27 days 1 6th day ture. This method does not predict when ovulation
28 days 10th day 28 days 1 7th day will occur; it detects the temperature rise which
29 days 11th day 29 days 18th day proves that ovulation has occurred. The unsafe time
30 days 12th day 30 days 19th day
prior to ovulation is arbitrarily taken as day 3 of
31 days 13th day 31 days 20th day
32 days . 14th day 32 days 21th day the cycle or as calculated by the calendar method.
33 days 15th day 33 days 22th day When the woman ovulates the temperature rises
34 days 16th day 34 days 23th day and remains elevated. She draws a line on the graph
35 days 17th day 35 days 24th day
one tenth of a degree higher than the highest
36 days 18th day 36 days 25th day
37 days 19th day 37 days 26th day temperature recorded prior to the rise. When the
38 days 20th day 38 days 27th day temperature remains above the line 3 times, the
fertile period is over.
The temperature method can be used by a woman
Use with irregular cycles but not immediately followirig
Users of biological methods require training to an abortion or delivery.
recognize the signs of fertility. Some doctors and Cervical mucus: A woman uses her fingers to
clinics offer instruction. In Canada, SERENA gives examine the cervical mucus present at the vaginal
courses where couples who use these methods train opening. It is not necessary to touch the cervix.
new couples. Similar groups exist in the U.S.A. A woman should abstain from coitus during the first
Many of these groups have religious affiliations; cycle of observation so she can examine only cer-
they are usually against abortion. vical mucus without confusion from semen or con-
Calendar method: Before using this method, a traceptives. Each morning the woman notes: 1. the
woman notes the length of her cycle for at least 6 sensation at the vulva - dry, moist or wet; 2. colour
months. She uses a non-hormonal contraceptive, of the secretions - yellow, white, opaque or transpa-
such as the condom, during this time. The length of rent; and 3. their consistency - thick, thin, or
a cycle is calculated as follows: the first day of stringy.
bleeding is day 1; the last day of the cycle is counted A fertile cycle looks Ike this: several days of
as the day before the next period starts. menstrual bleeding, a few dry days (except in short
The woman subtracts 18 from her shortest cycle cycles), moist to wet days, followed by dry days
to get the first fertile (unsafe) day. She subtracts untilthe next period.
11 from her longest cycle to get the last fertile day. The
first sign of moistness indicates the first
She avoids vaginal penetration from the first unsafe unsafe day. Because this change may occur quickly,
day to the last unsafe day inclusive. penetration is permitted only every 2nd day during
She continues recording her period on the calen- menstruation and pre-ovulation dry days.
dar. She uses the shortest and longest cycles of the Ovulation is indicated by the last wet day called
6 most recent cycles to calculate the unsafe period the peak. The last unsafe day is the 3rd consecutive
of the present cycle. dry day after the peak. Intercourse may resume the
This method should not be used by women with following day until the next period,
Temperature method

Sexual Relations 1/ \f / /
Menstruation X" XX XX xxxx
Day of cycle
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 t9 20 21 22 23 24 25 26 27 28 29 30 1 2 3 4 5 6 7

18 20 22 24 26 28 30 1 3 5 7 9 11 13 15 17 19 21 23
Date: March

1
37.2 I

37.0 L 7\ il 7S L

-jzSnNr s Smmh
i

-
36 8 _l ,...._ J Jfc-
- 3^ 4 Zr- Se-
36.6 nZ_ZS_^
zsz \3z
I
sz s th
S^
36.4
'

V - -4- S I

36.2
II Oliabl* I meal call
K f '

36.0 I
I
 PAGE 25

Effect on sexuality
coitus interruptus Coitus interruptus exactly what the name says
is

Coitus interruptus, also known as withdrawal or

an interruption of intercourse. This can be un-
"being careful" is a widely used although question- pleasant for both partners. The man cannot relax
ably effective method. It is often the method used because he must be prepared withdraw his penis
to

during a girl's first sexual experience and in certain in time. a woman has doubts about her partner's
If

casual encounters. Before the introduction of modern ability or his intention to withdraw in time, she will

contraception, coitus interruptus was probably fre- be understandably tense.

quently used by many couples. Couples with much sexual maturity could
theoretically adapt their sexual behaviour around this
method to their own satisfaction, depending on non-
Action
coital means of gratification. Unfortunately it is often
The man withdraws his penis from the woman's young people with little sexual experience who try
vagina before he ejaculates. If no sperm are re-
to use withdrawal when nothing else seems available.
leased in or near the vagina, the woman cannot get
pregnant.
Use
Effectiveness The man must be aware of his level of sexual
Withdrawal is not a very effective contraceptive excitement. When he feels himself approaching a level
method but it is better than nothing. Sometimes men which could lead to orgasm, he withdraws his penis
are not conscientious about withdrawing in time. from the woman's vagina. He makes sure to ejaculate
Younger boys in particular have difficulty controll- away from the woman's genitals.
ing the timing of ejaculation. If either partner is not yet satiated, they can
A well intentioned man cannot
necessarily control satisfy themselves or each other through mutual
the release of semen. Sperm are often found in the masturbation or oral-genital sex.
lubrifying liquid which is secreted before ejacula- If penetration is desired after the man ejaculates,

tion. If this liquid leaks out before the man with- he must wipe his penis carefully first, particularly
draws, the woman can become pregnant. the tip.

condom slightest penetration of the

tions
woman's vagina. Secre-
released from the urethra during sexual ex-
citement can contain sufficient sperm to cause preg-
nancy. The condom must be used each time the
The condom (prophylactic, safe, rubber) is a
couple has sex.
sheath worn on the penis during sexual intercourse
to prevent pregnancy in the female partner. It is the
only widely used reversible male contraceptive. Effect on sexuality
Early condoms were made from animal intestines. The condom must be put on the man's penis during
Skin condoms are still available but are more ex- sexual activity. Some men and women resent this
pensive and offer no advantages. Rubber condoms interruption. Others find erotic ways to integrate
were developed in the early 1800's and soon mass its use withtheir sexual behaviour. Either partner
produced. can the application of the condom, indicating
initiate
The condom is recovering from a "bad reputa- a desire for penetration.
tion". Its use for the prevention of sexually trans- Many people wonder about the right time to suggest
mitted disease and its association with questionable condoms. Often the hesitancy to discuss contracep-
sexual conduct made it less acceptable within tion represents an unwillingness to admit frankly
marriage. Difficulties in the early manufacturing that sexual intercourse is going to occur. The ini-
process resulted in many faulty condoms. With tiative in suggesting both sexual activity and con-
improvements both in production and in testing, traception is often appreciated by either partner.
modern condoms are highly reliable.
The condom is especially suitable for couples
Allan Manus
having sporadic sex, in the months preceeding a plan-
ned conception, during transition from one method
to another, and following treatment of genital infec-
tions.

Action
The condom is worn on the erect penis during

penetration. provides a physical barrier prevent-

It

ing sperm from entering the vagina.

Effectiveness
Theoretically the condom is highly effective. Its
actual use effectiveness varies from high to low.
A condom must be worn whenever there is even the
PAGE 26
111

There is little difference between

brands. All
condoms are approximately the same size (19cm.
x 2.5 cm.). They are either dry or lubricated. Con-
doms keep in their packages for at least 3 years, as
long as they are not exposed to heat. Condoms
carried in a pocket close to the body are destroyed
^fc by body heat.
condoms are pre-rolled. Otherwise they
Most
should be rolled up just before use. When the con-
dom is unrolled on the erect penis, a half inch
space must be left loose at the tip to collect the
semen. Air should be expelled from the tip before
the condom is rolled on. The condom is unrolled to
the base of the penis. A stronger ring of latex keeps
the condom from slipping off. Be careful not to
catch rings or fingernails on the condom.
The condom must be put on before any penetra-
tion of the vagina. Following ejaculation the man
must withdraw his penis from the vagina before
totally losing his erection. He holds the top of the
condom against the base of his penis to prevent any
leaking of semen. Another condom must be used for
any further vaginal penetration.
If a condom breaks or if semen spills out the top,
the woman should insert spermicidal foam imme-
diately. Otherwise she can use the morning after
pill.

Rolling condonf on erect penis

_j
vaginal spermicides
Effects on health
Rarely one partner a coumpound in
is allergic to A spermicide
is a chemical which kills or im-

the condom or the lubricant. The couple can try mobilizes sperm. Historically in many cultures,
changing brands. many substances such as lemon juice and honey
Modern condoms are thin and transmit heat well. were put in the vagina to prevent pregnancy. These
Recently, condom producers have developed coloured home-made contraceptives were easily available to
and ribbed condoms. Whether these condoms im- all women and reasonably effective.
prove sexual sensation for either partner is dif- Most spermicides were marketed before govern-
ficult to prove. Many young men
with difficulty de- ment agencies required extensive evidence of their
laying ejaculation the condom permits
find that effectiveness and safety. Presently the American
them to enjoy a slower sexual rhythm. Men with Food and Drug Administration is reviewing all va-
ginal spermicides.
difficulty maintaining an erection are less enthu-
siastic.
A vaginal spermicide is recommended in combina-
tion with other methods, in times of transition from
Some couples find the condom dry. They can use
saliva, contraceptive foam or lubricated condoms.
one method to another, and in the months preceeding
Do not use vaseline as a lubricant because vaseline a planned conception.
destroys rubber.
Action
The condom offers protection from sexually trans-
Spermicides interfere with the metabolism of
mitted diseases, especially gonorrhea, trichomo-
sperm, immobilizing or killing them. The active
nas, and Candida. It is less useful for diseases which
chemical in common spermicides is nonylphenoxy
are carried on parts of the genitals other than the
polyethoxy ethanol. The spermicide is contained in
penis or the vagina, for example, syphilis, venereal
a base which determines whether the contraceptive
warts and herpes.
is a jelly, cream, foam or suppository. The base
distributes the spermicide in the vagina.
Effect on fertility

If a woman becomes pregnant after using a con-

Effectiveness
dom, the baby will be unaffected. When a woman
Spermicides are tested in a test tube to measure
desires pregnancy, her partner stops using the
their ability to kill sperm. During coitus, the ability
condom.
of the base to evenly distribute the spermicide is an
important factor in effectiveness. Foam contracep-
Use tives are better distributed than jellies, creams and
Men and women can buy condoms in drugstores suppositories. We recommend that when a vaginal
without a prescription. Birth control clinics also spermicide is the only method of birth control, only
sell condoms in bulk at less cost. foams be used.
 PAGE 27

Actual use effectiveness of foam varies from

high to low. Factors which influence effectiveness
are: having the foam available, shaking the container
thoroughly, using enough foam, and using it for each
act of coitus.
-*.

Effect on sexuality
A vaginal spermicide must be inserted very soon
before intercourse. If a woman is concentrating on
interrupting her partner in order to insert the
spermicide before penetration, she is less able to
relax and enjoy herself. Some spermicide remains
on the vulva or leaks out the vagina. It gives a chem-
ical taste during oral sex. Some couples use a
spermicide as lubrification; others find it too wet.
A stable couple has time to work out solutions to
these inconveniences. During a casual encounter a
woman must inform her partner of her birth control
method and integrate it into the sexual experience
with or without his support.

Effect on health
Vaginal spermicides cause no serious side effects.
Occasionally one partner is allergic to the spermi-
Foam insertion
cide. A genital irritation, rash or itchiness develops.
Changing the brand usually solves the problem.
Spermicides may act on bacteria as well as Foam is inserted as close to the time of penetra-

sperm, possibly preventing certain vaginal infec- tion as possible. Load the applicator just before use.
tions. Researchers are working on a spermicide Shake the bottle of foam very well and press the ap-
which would also prevent sexually transmitted plicator on the nozzle. Foam will enter the applica-
diseases. tor pushing the plunger up. (Some brands load
differently.) Insert the applicator into the vagina as
Allan Manus
far as possible or until it reaches the cervix. With-
draw the applicator half an inch and push in the
plunger to release the foam. Remove the applicator,
and if possible, drop it into a glass of water. If the
applicator holds less than 10 cc of foam, a second
application is necessary.
If more than half an hour passes between inser-

foam and vaginal penetration, more foam

tion of the
should be inserted. An additional application of
foam is necessary for each act of coitus. Douching
must be delayed for at least six hours after the
last act of intercourse.
The applicator should be washed in soapy water
before the next use. If foam has dried on the appli-
cator, let it soak first. The applicator should not be
boiled.

Effect on fertility
If a woman becomes pregnant while using foam,

the baby will not be affected. When a woman wants diaphragm and jelly
to become pregnant she stops using the spermicide.

Use The diaphragm is a rubber dome worn inside the

A woman or man can buy foam at drugstores or vagina during sexual intercourse. It is used with a
birth control clinics. Buy two containers since it is cream or which kills sperm. The diaphragm
jelly
difficult to tell the bottle is empty. Foam is
when requires a medical prescription.
sold with or without an applicator. The same appli- Records of early civilizations show evidence of
cator can be used many times. Have a second one similar vaginal contraceptives such as sponges used
in case the first breaks or gets lost. Pre-loaded with honey, oils or herbs. The modern diaphragm
applicators are expensive for regular use but was developed in the late 1800's and was widely
convenient for week-end holidays. used by the European upper classes. Recently some
There is little difference between brands. Some clinics have repopularized the diaphragm, stressing
brands of foam sold in North America are: Because, its safety and exploring ways to make it more
Dalkon, Delfen, Emko, Koromex and Pre-Fil. acceptable and more effective.
PAGE 28

If the diaphragm is too large, it may press on

the urethra, causing discomfort and even urinary
retention.
If a diaphragmis forgotten in the vagina, the
woman notice a foul smelling profuse discharge,
will
low back pain, and general pelvic discomfort. Remov-
ing the diaphragm provides great relief. The woman
can douche if she wishes afterwards. She should
soak the diaphragm in alcohol.
It is not known if the diaphragm protects the
woman from inflammation or infection of the cervix.

Effect on fertility
If a woman becomes pregnant while using the
diaphragm, the fetus is unaffected. When a woman
wants to become pregnant, she stops using the dia-
Action phragm.
The diaphragm covers the cervix and holds the
spermicidal jelly in place at the cervical opening Diaphragm fitting
both during and after intercourse. Sperm are killed
A woman must be fitted for a diaphragm. Many
or immobilized before they can enter the uterus.
doctors have neither the experience nor the minimal
equipment necessary to fit a diaphragm. To avoid
Effectiveness wasting one's time, or risking an improper fit, call
The diaphragm has a high theoretical effectiveness. and ask if the doctor fits diaphragms.
Actual use effectiveness rates vary from high to A birth control counsellor explains the diaphragm
low. The diaphragm must be properly fit. It must method. The woman is asked about any problems
be big enough to allow for expansion of the vagina such as uterine prolapse which might interfere
during sexual excitement. The diaphragm must be with a diaphragm fitting. These should be noted and
properly placed each time. It must be used each time confirmed by vaginal examination before deciding
a woman has intercourse. The diaphragm must that a woman cannot use the diaphragm.
always be used with a spermicidal jelly. Additional A gynecological examination permits an evaluation
spermicide must be added for repeated acts of coi- of a woman's pelvic anatomy: the position of the
tus. uterus and cervix, the depth of the angle behind the
pubic bone, and the vaginal muscle tone. The coun-
Effect on the menstrual cycle sellor asks the woman to examine herself and ex-
plains these findings to her. She must be confident
The diaphragm can be used during menstruation
that she recognizes her cervix which feels like the
either for its contraceptive benefit or to prevent blood
tip of one's nose.
staining during intercourse.
Any severe change in pelvic anatomy is a contra-
indication to the diaphragm. If the abnormality is
Effect on sexuality
moderate, and the woman is highly motivated, it is
The diaphragm must be inserted before vaginal worth trying to get a good fit.
penetration. Its use must become an integral part
The counsellor estimates the length of the vagina
of a woman's sexual behaviour. She must think by putting two fingers into the woman's vagina as
ahead whether or not she will need it. She must be deeply as possible and marking where the pubic
sufficiently assertive to interrupt unexpected sexual bone hits the examining fingers. The counsellor
play in order to insert the diaphragm. She may be measures this distance with a ruler or compares it
disappointed if she has inserted the diaphragm and directly with fitting rings. These rubber rings come
does not have sex. in diameters of 55mm and increase by 5 mm to the
Some women teach their lover to insert the dia- largest of about 100 mm.
phragm for them, and/or to verify that it is properly The counsellor tries the fitting ring which cor-
in place. Some women buy condoms and alternate
responds to the measurement taken. The ring is
methods. compressed and inserted into the vagina. The coun-
The spermicidal jelly does not taste good. During sellor checks that the front rim is snug behind
insertion some jelly remains on the vaginal lips. the pubic bone and the back rim goes beyond the
Some women insert the diaphragm in the bathroom cervix. The ring is removed and the next largest
where they can wash afterwards. A damp cloth by size inserted.The fit is checked again. The woman
the bed serves the same purpose. is asked to cough and to bear down. The largest
Displacement of the diaphragm may be more com- size which is comfortable and does not slip out is
mon in coital positions with the woman on top, or chosen.
when the penis is withdrawn and reinserted repeti- The woman examines herself with the ring in
tively. place. She removes the ring by hooking her finger
around the front rim and pulling down and out. She
Effect on health reinserts the ring herself; she compresses the ring
A few people are allergic to rubber. Others are with one hand, separates her vaginal lips with the
allergic to some brands of spermicide. other and slides the ring into the vagina. She checks

to see if it is in place by feeling for her cervix.. The
counsellor examines her to check that it is in the
proper position.
The woman may find it easier to insert the dia-
phragm while squatting or standing with one foot
raised on a chair. She removes the ring and rein-
serts several times until she is confident that she
it
can do it accurately.
If a woman has trouble inserting the diaphragm
she can try a plastic inserter which looks like a
crochet hook with several notches. The diaphragm
stretches onto the inserter. The woman puts the
inserter into the vagina with the diaphragm toward
the cervix. The diaphragm is released by twisting
the inserter which is then removed.
During a fitting the woman and the counsellor have
their hands in and out of the woman's vagina many
times. If a woman is relaxed the fit will be more
accurate. The woman should leave the ring in for
10 minutes and then be re-examined when she
more relaxed.
Once the size determined the counsellor sug-
is
gests which kind of diaphragm would be best for
the woman. There are 3 types of diaphragms. Not
all kinds are available at one pharmacy. There has
been little research comparing the different types.
The coil spring diaphragm is prescribed to women
with strong vaginal tone and no anatomical abnorma-
lity. The flat spring diaphragm is prescribed to
women with a shallow pubic arch, with moderate
descent of bladder or rectum, or with an anteverted
uterus. The arcing spring diaphragm is prescribed
to women with weak vaginal tone, moderate descent
of the pelvic organs, or extreme positions of the
uterus (anteversion or retroversion).
The woman is given a prescription for the diaph-
ragm. She buys it, practices with it, but does not
depend on it She comes back a week
for birth control.
later with the diaphragm in place; its fit and posi-
tion are checked again.
Some clinics sell diaphragms. The woman tries
the diaphragm immediately. She* learns how to apply
the jelly, putting about a tablespoon of jelly on the
inside and on the rim. She verifies that her cervix
is covered by the diaphragm. If she is confident
about the insertion she begins using the diaphragm
as a contraceptive. She is also sold an applicator
Diaphragm insertion
PAGE 29
for the jelly or foam repeated intercourse.
for
A small tube spermicidal jelly is supplied
of
with the diaphragm. Afterwards the woman buys
only the jelly.
Actual use
The diaphragm is always used with spermicidal
cream or jelly. A tablespoon is smeared on the
inside cup-like part of the diaphragm and on the
rim. These spermicides work for about 6 to 8 hours.
The diaphragm should not be inserted many hours
before intercourse is expected. If more than 2
hours pass, the diaphragm should be removed and
more jelly added.
The woman inserts the diaphragm as she did the
fitting ring in the position most comfortable for her.
Squeezing the diaphragm in one hand, she spreads
her vaginal lips with the other and slides the
is diaphragm into the vagina. She puts a finger into
the vagina to check that the cervix is covered.
The diaphragm must be left in place for 6 hours
after intercourse in order for the jelly to kill all the
sperm. If the woman has sex again within this 6
hours she must leave the diaphragm in place and
add an applicator of spermicide. The diaphragm is
removed no sooner than 6 hours after the last act
of coitus. The woman must not douche during this
time.
If the diaphragm is properly placed, neither
partner should be disturbed by its presence during
intercourse.
A diaphragm does not restrict a woman's activity.
If she has a bowel movement, she should check that
the diaphragm has not been displaced.
When the diaphragm is removed, it should be
washed with mild soap and water, patted dry, pow-
dered with cornstarch and kept in its container.
Talcum powder must not be used because it destroys
rubber. Before re-using, the diaphragm should be
checked for cracks or holes by holding it up to the
light or filling it with water.
A woman should be refitted for a diaphragm after
a delivery, major abdominal or pelvic sur-
after
gery, and after a gain or loss of more than 10 to 15
pounds. The fit can be verified at an annual check-
up.
Diaphragm in place
PAGE 30
intra-uterine device
An an object placed in the
intra-uterine device is
uterus to prevent pregnancy. Historically, nomads
put stones into the uteri of camels to prevent preg-
nancy during desert journeys. Records of use in
humans date to Hippocrates, but modern research
began only in the 1900's. The first lUDs were made
of materials ranging from silkworm gut to silver
wire. Plastic devices were marketed in the late 50's.
Copper was added to several lUDs in the late 60's,
and the 70's brought lUDs which release progeste-
rone. \ The size of an IUD determines its effectiveness:
The IUD from other reversible methods in
differs
that the woman has little control over its use. She
needs medical services to obtain an IUD and to
have it removed.
The IUD is widely distributed in Third World
countries. The international agencies responsible
for this distribution are more concerned with con-
trolling population size than with the cultural, eco-
nomic and health needs of people. In cultures where
menstruating woman are outcast, long and irregular
periods associated with the IUD can have major
consequences. Bribery of a day's wages if the woman
accepts an IUD has led many poor women to remove
the IUD themselves and return to a different clinic
for another paid insertion. This is hardly voluntary
birth control; women must be wary of methods
which they themselves do not control.
/
-
Y menstrual flow, often just
*1 - S.-.S
| persistant, and accompanied by cramps, it is pos-
1
i Pain during menstruation is often increased with
IUD in uterus
Action
It is not known how the IUD prevents pregnancy.
The IUD causes an inflammation of the endome-
trium (uterine lining)
possibly preventing implanta-
tion ofa fertilized egg. The inflammation may cause
white blood cells to attack sperm or the fertilized
egg. The IUD speeds up the movement of the egg in
the Fallopian tube so that it may not be mature
enough for fertilization.
Finally, the IUD affects
chemicals the endometrium which are necessary
in
for implantation.
The IUD does not prevent ovulation. Nor does it
always prevent conception.
the larger it is, the more effective it is. However
the larger it is, the more likely it is to cause com-
plications. The ideal IUD must be large enough to
be effective but small enough to be tolerated.
It is unknown how copper prevents pregnancy.
The contraceptive action of copper permits a smaller
IUD to be used without decreasing effectiveness.
Progesterone alters the mucus at the cervix,
preventing sperm from entering the uterus. How-
ever, the main benefit of progesterone lUDs is the
reduction of bleeding.
Effectiveness
Theoretically lUDs are greater than 95% ef-
all
fective, with difference between brands. Actual
little
use effectiveness is slightly lower since it includes
women who have the device removed because of
complications but who do not adopt another method.
The IUD is more effective in older women and in
women who have been pregnant. The competence of
the technician who inserts the IUD also influences
effectiveness.
Once inserted, the IUD is effective immediately.
Most IUD failures occur during the first 3 to 6
months after insertion, including pregnancies with
the IUD in place and those following expulsion of the
IUD.
Effecton the menstrual cycle
The IUD can cause a longer and more abundant
in cycles follow-
the first
ing insertion. If bleeding is extremely abundant,
sible that the IUD is too big or is not in the right
position. It should be removed; another IUD can be
inserted immediately or during the next period. If
bleeding has been very heavy, the woman should
have a blood test for anemia.
an IUD, especially in the first cycles. A heating pad
or mild painkiller usually provides relief. If the
pain is intolerable or occurs between periods, the
device should be removed. Another can be inserted
immediately if there is no sign of infection.
The IUD can cause bleeding between periods. This
spotting is more a nuisance than a danger. If it
persists, especially in an older woman, the IUD
should be removed. Serious causes of spotting such
as uterine cancer must be ruled out before another
IUD is inserted.
 PAGE 31

Effect on sexuality Effect on fertility

Some women experience a change in the feeling Method failure: If a woman becomes pregnant with
of the rhythmic contractions of the uterus during an IUD, she should be examined to rule out ectopic
orgasm. pregnancy. Whether or not the woman wants to
If the IUD is causing infection, the woman may continue the pregnancy, the IUD should be removed
experience pain during deep penetration of the vagi- to prevent infection. The chance of miscarriage is
na. She should seek medical attention. Rarely, the slightly less if the IUD is removed. An IUD does not
pain persists after removal of the IUD and treat- cause fetal malformations.
ment of the infection. Stopping the method: When a woman wants to be-
A woman using an IUD who has infrequent sexual come pregnant, she has the IUD removed, preferably
may
relations resent any discomfort she experiences during her period. There is no reason to delay
when she is not profiting from its contraceptive conception. Previous use of an IUD will not affect
action. the fetus.
the IUD is
If properly placed it should not be Past IUD users should be alert to the possibility
felt by the male partner during intercourse. If the of ectopic pregnancy. If pregnancy does not occur
IUD strings are cut too short so that they stick within 6 to 12 months, the woman should be invest-
straight out of the cervix, the man may feel them. igated for infertility due to blocked tubes.

Effect on health Use

Perforation: The uterus may be perforated during
an IUD insertion. If the uterine sound perforates,
the woman may or may not feel pain. The doctor
notices that the sound goes in too far. The IUD in-
sertion delayed until the next period.
is
Although most perforations with the
during insertion, the IUD can perforate the uterus
later on. An IUD which perforates into the abdo-
men usually causes no trouble and can be left
there. It no longer prevents pregnancy. Copper
lUDs must be removed because the copper reacts
with internal organs. The IUD can be removed by
laparoscopy (page 48) or abdominal surgery.
Pelvic Inflammatory Disease (PID): Infection is
the most serious side effect of the IUD. The uterus
and Fallopian tubes can become infected (called
Prior to insertion: When a woman considers using
an IUD she should have a pre-insertion check-up.
She describes her past health experience to find
any reason why she should not use the IUD. Women
should not use an IUD if they have had: a previous
IUD occur ectopic pregnancy, a uterine abnormality such as a
double uterus, a severe case of pelvic inflammatory
disease, or undiagnosed abnormal uterine bleeding.
Other conditions where a woman should strongly
consider another method are: severe cramps or very
heavy bleeding during menstruation, untreated ane-
mia, or mild pelvic inflammatory disease within
the past 6 months. A very young women who has,
never been pregnant should consider another method.
A woman with valvular heart disease should be given
antibiotics prior to insertion and removal. each
In

endometritis and salpingitis respectively). The case, she should be alert to possible problems and
woman's symptoms may be vague: abdominal or low be seen more frequently for check-ups.
back pain, irregular bleeding, low fever, vaginal The woman has a gynecological examination to
discharge, or a general feeling of ill health. Treat- ensure that her reproductive organs are normal
ment with antibiotics can be slow and incomplete. and that she has no infections. A test for gonorrhea
Severe cases require hospitalization and even is done.
removal of one or both tubes. Rarely, hysterectomy The woman discusses which IUD is best for her.
is necessary. Death from infection has occurred in The doctor must have some experience with the IUD
1 out of 100,000 IUD users. PID occurs more often she chooses; otherwise she should choose either
in young women and in women who have never been a different IUD or a different doctor.
pregnant. Thereare 3 kinds of IUDS: inert, copper-re-
leasing, and hormone-releasing. Inert lUDs such as
Infection in pregnancy: Infection is also possible
the Lippes Loop and Saf-T-Coil are made of plas-
if the IUD is left in the uterus during pregnancy. tic. They come in different sizes and can be left in
Several women died from such an infection when Allan Manus
using the Dalkon shield. This IUD is no longer dis-
tributed in North America; any woman who still
has one should have it removed.
Ectopic pregnancy: An ectopic pregnancy develops
outside the uterus, for example, inside a Fallopian
tube where there is little room for the embryo to
grow. The woman may experience abdominal pain
similar to that of appendicitis. Rupture of an ectopic
pregnancy can be life threatening; surgery to re-
move it is always necessary.
Researchers disagree whether or not the IUD causes
ectopic pregnancy. The IUD can cause infection of
the tubes. Scarring after infection may partially
block a tube increasing the risk of ectopic pregnancy
which could occur even after the IUD has been Types of lUD'S: inert (saf T Coil), hormone (Progesta-
removed. sert), and copper (Cu-7).
PAGE 32

cervix. The IUD is released into the uterus with a

Brands of lUDs plunger mechanism. The inserter is removed leav-
Name Size Inserter size Strings ing the IUD in place with the attached strings com-
Copper 7 medium smallest 1 black ing out the cervical opening. The strings are trim-
medium large 2 pale blue
Copper T med to about 2 inches long.
Saf T Coil small small 2 green
If the woman faints the procedure is stopped until
medium small 2 green
large small 2 green she is fully conscious. If the woman feels faint, she
Lippes loop A small medium 1 or 2 blue should cough. Some doctors use atropine before in-
Lippes loop B medium medium 1 or 2 black
sertion to prevent fainting.
Lippes loop C medium medium 1 or 2 yellow
medium
The speculum is removed and the woman is given
Lippes loop D large 1 or 2 white
Progestasert large large 2 clear a sanitary pad. She relaxes on the table until she
feels ready to get up.

the uterus for at least 5 years. Copper lUDs are

also made of plastic; a fine copper wire is wound
around them. The copper is released very slowly
into the uterus. Originally copper devices were
changed every 2 years; now they are left in for 3
to 4 years without a decrease in effectiveness. The
Progestasert must be changed each year. All lUDs
are visible on X-ray.
The size of both the device and its inserter
influences the choice. A woman with several child-
ren should use a large IUD. A woman who has never
been pregnant should use a small device with a
narrow inserter.
The IUD should be inserted during menstruation,
ensuring that the woman is not pregnant. Cramps
or bleeding following insertion will occur at the
same time as her period.
An IUD can be inserted immediately after an
abortion by aspiration or at the next period.
An IUD can be inserted 8 weeks after delivery
whether or not the woman has her period. If the
woman had an episiotomy during delivery she may
still be too tender for an IUD insertion. After
delivery by ceserean, the woman should wait 3
months. Post insertion instructions: The woman should
IUD insertion: Some women have greater dis- not use tampons for the rest of this menstrual
comfort during and after an IUD insertion than period. To avoid infection, she should avoid penetra-
others. It is sensible to minimize one's obligations tion until this period is finished. She should expect
that day, and to have someone else drive home. some cramps which will diminish. If she has severe
The woman undresses and positions herself on pain and/or fever she should contact the clinic.
the examining table. She has a gynecological exam- Her periods may be heavier and longer with the
ination tothe position of the uterus. A
confirm IUD. To replace the iron lost she should ensure
speculum is put in the vagina exposing the cervix that she has an adequate amount of iron and vitamin
which is washed with an antiseptic solution. .
C in her diet. Once a week she should put her
Local anesthesia (freezing) can be used. Freezing finger into the vagina to check for the IUD strings.
prolongs the procedure and increases its risks (ex: If she feels something hard, the IUD is no longer in

possible allergy to anesthetic). However if the cer-
vix is tight, local anesthetic is useful. Anesthetic
is injected into the cervix and takes effect in
several minutes. Freezing does little to relieve the
cramps once the IUD is in place. The pain of an
IUD insertion is increased by fear and tension.
Local anesthetic is no substitute for reassurance and
patience.
The cervix is grasped with a clamp to hold it
steady. A long thin uterine sound is passed through
the cervix to the top of the uterus. This often causes
cramping. The sound measures the distance from
the top of the uterus to the cervical opening. The
sound is removed.
place and should be removed. If she can't find the
strings she should also return to the clinic.
The IUD is effective immediately; however most
failures occur in the first 3 cycles. Some women
use an additional method (ex: foam) during this
time. If the woman is already on the Pill she can
continue it for several cycles both for its contra-
ceptive effect and to counteract the heavy periods
of the IUD.
She should have a follow-up examination in 3
months.
Follow-up: The woman recounts her experience
since the IUD insertion. She mentions any change
in her periods, any pain on intercourse, and if she

necessary, the IUD is loaded into its inserter.

If can find the IUD strings. A gynecological examina-
A stop is positioned on the inserter at the distance tion confirms whether or not the IUD is still within
measured with the sound. The loaded inserter is the uterus. If there is no problem, the woman need
passed into the uterus until the stop reaches the not return for one year.
 PAGE 33

If a woman who has regular menstrual cycles
misses her period while using an IUD, she should
wait two weeks and have a pregnancy test. She
should not have the IUD removed until the pregnancy
is confirmed. If she is pregnant, the IUD must be
removed. If the test is negative she should repeat
it in 2 weeks. If she misses 2 periods she should
consult the clinic.
If the woman cannot finds the strings on self
examination, she should consult the clinic. An X-
ray or ultrasound test will confirm where the IUD
is. If the IUD is still in the uterus it can usually be
reached through the cervix. Another IUD may be
inserted immediately or at the next period.
Pelvic infection usually accompanied by abdo-
is
minal or low back pain, vaginal discharge, irregular
bleeding and slight fever. A woman with these
symptoms should see a doctor quickly. It is not easy
to distinguish between a badly placed IUD, a mild
infectionand a serious infection. The IUD should be
removed and the infection treated with antibiotics.
Regular visits are necessary to confirm the diagno-
sis and evaluate the treatment. In severe cases the
women may be hospitalized.
Removal: An IUD may be removed at any time,
but preferably during one's period. The cervix is
slightly more open, making removal easier. If an
IUD is removed at mid-cycle, pregnancy from a
very recent coitus could still occur.
IUD removal is quicker and less painful than
insertion. The doctor uses a clamp to pull on the
strings along the axis of the cervical canal. Rarely
the doctor must probe into the uterus to find the
IUD itself. If the IUD is still the method of choice,
another IUD can be inserted immediately.
Cost
Doctors pay about $8 for each inert and copper
jUD. Doctors have charged women from $10 to $60
just for the IUD. This profit is often cash "under
the table, not declared on income tax. Many birth;
control clinics supply lUDs free or at cost price.
In Quebec doctors are paid about $30 for insert-
ing an IUD and the regular cost of a visit for an
IUD removal.

Action
oral contraception In the menstrual cycle, fluctuations of hormones
control ovulation. Estrogen and progesterone affect
The represents a turning point in the evolu-
Pill a feedback mechanism in the pituitary gland, which
tion of modern contraception. It is the first method in turn controls the amount of hormones in the blood
which is 100% effective, one of the important criteria (see page 7).
of the ideal birth control method. The control pill is made up of synthetic
birth
It was
not until the turn of the century that scient- estrogen and progesterone. Instead of cyclical fluc-
ists began to understand the role of hormones in tuations, the Pill provides a constant level of these
human reproduction. In the 1940's progesterone hormones the blood. The feedback mechanism of
in
was discovered the wild mexican yam, making
in the pituitary is blocked which in turn blocks the
large scale production possible. Human studies be- ovaries from producing estrogen in the usual pat-
gan in Puerto Rico in 1956 and Enovid 10, the first tern. Without the estrogen peak, ovulation cannot
Pill, was marketed in the U.S. in 1960. Enovid 10 occur. Without ovulation, pregnancy cannot occur.
was over 20 times stronger than brands of the Pill Estrogen alone is sufficient to block ovulation.
used today. Since the mid 1970's over 50 million wo- Progesterone alters the mucus of the cervix, mak-
men in the world use the birth control Pill. ing it impassable by sperm. Progesterone slows
The advent of the Pill coincided in North America the transport of the egg in the Fallopian tube and
with major social changes. Women began to make interferes with implantation.
advances their educational, economic and politi-
in Effectiveness
cal status,and to break out from restrictive sexual Theoretically, containing 30 meg or more of
pills
standards. To do so without the burden of maternity estrogen have an effectiveness approaching 100%;
was liberating. however there have been pregnancies in women who
Disillusionment with the Pill began as women ex- have taken the pill exactly as directed. Pills contain-
perienced its side effects. No other medication has ing less than 30 meg of estrogen such as Minestrin
been so thoroughly investigated; debates on the re- 1/20 (Loestrin 1/20) or Zorane 1/20 are less ef-
lative safety of the Pill still rage. It has become fective and should not be used.
clear that female reproduction is intimately linked The effectiveness affected by other
of the Pill is

with other vital body functions. The Pill's interfe- drugs. Rifampicin, used tuberculosis, and
to treat
rence with the natural cycle inevitably affects the dilantin, used to treat epilepsy, decrease the ef-
entire organism. Many women are no longer willing fectiveness of the Pill. Ampicillin, phenobarbital,
to pay such a high price for contraceptive effective- certain anti-histamines and certain tranquillizers
ness. may also decrease its effectiveness.
Third World women have been particularly at the Extended use effectiveness of the Pill ranges
mercy drug companies. These women have been
of from highly effective to moderately effective. Preg-
the guinea pigs of research for products to be nancies occur when: the Pill is not taken at appro-
marketed in the west. When drugs are considered ximately the same time each day, the Pill is for-
too dangerous for North American use, they are gotten, or if the Pill is stopped because of side
returned to Third World countries as a tax deduc- effects and another method is not adopted.
tible donation. This "pharmaceutical dumping" is
responsible for the present distribution of high dose
Effect on the menstrual cycle
The replaces the hormonal fluctuations of the
Pill
pills in the developing world.
cycle with a steady level of both estrogen and pro-
PAGE 34

gesterone. Ovulation does not occur.
The Pill is taken in a "3 weeks on, 1 week off"
pattern. When no pills are taken the hormone levels
drop causing menstrual-like bleeding. Bleeding on
the Pill is usually lighter, shorter and less painful
than a woman's usual period.
The Pill gives a woman a very regular menstrual
cycle. A woman who takes the Pill consistently at
the same time each day can accurately predict when
her period will start. To change the day of her
period she either omits one or more days of the
Pill at the end of the cycle, or adds one or more
days. She should not delay starting a new package
for more than 7 days following the previous one.
If a woman makes major changes in her cycle, her
body may not respond as she would like and her
cycle may become irregular.
Some pills have male-like effects. If a woman has
irregular but heavy periods, oily skin, acne and a
slightly masculine distribution of hair, she should
use a Pill with little androgenic (male) effect.
Women who have very irregular and very light
cult toseparate the effect of the Pill from the cir-
cumstances in a woman's life. Some women may
experience a very gradual decrease in desire while
on the Pill. A woman who suspects that the Pill is
decreasing her desire should try a weaker brand or
change to another method to see if she notices any
improvement.
Effect on health
The issue of the safety of the Pill has provoked
intense controversy. Extreme positions range from
recommendations to distribute the Pill in coin ma-
chines to taking it off the market. The Pill can cause
serious illness and death. The Pill also causes in-
conveniences and discomfort. Many women are
willing to take these risks for very high contraceptive
protection.
The most serious complications of the Pill occur
while the woman is using it. Length of time on the
Pill affects some complications but not all. With
several exceptions, the risk of complications does
not continue once the woman stops the Pill.

periods are more likely to have difficulty re- The description which follows is a
of side effects
establishing regular cycles after the Pill. They reference guide to the difficulties a woman can ex-
probably should not use the Pill. perience on the Pill. Millions of women have used
Spotting: Sometimes a woman has spotting or the Pill without any trouble. Minor discomforts are
breakthrough bleeding between periods. Spotting in often resolved by changing brands. The serious
the first half of the cycle is due to insufficient estro- complications are often prevented by better screen-
gen whereas spotting in the second half of the cycle ing of women who take the Pill.
is due to insufficient progesterone. When spotting Blood vessel and blood clotting disorders: These
occurs during the first three cycles on the Pill it diseases which normally are not common in women
represents no danger. If spotting continues beyond of reproductive age represent the greatest risk of
3 months, the woman should change brands. Most the Pill. They include:
1. superficial or deep vein
spotting problems can be resolved with a pill strong- thrombosis
the formation of a thrombus (blood
er in progesterone. If spotting occurs when a woman clot) partially or completely blocking a vein in the
has been on the Pill for an extended time, she should leg or pelvis. Deep vein thrombosis can cause swel-
see a doctor to make sure that the spotting is not ling and pain, or there may be no symptoms. 2.
caused by a disease rather than the Pill. Pulmonary embolism part of the blood clot can
Premenstrual tension: Women who experience pre- break off and float to the arteries of the lungs where
menstrual tension (irritability, and depression often it can block the blood flow to the lungs. Chest pain
accompanied by bloating just before or during and shortness of breath can happen very suddenly;
menstruation) often have these feelings relieved if not treated pulmonary embolism can be fatal. 3.
by the Pill. Blocking of an artery or bleeding from an artery
Amenorrhea: Some women get no periods while the damage caused depends on which artery. Two
on the Pill. If a woman misses more than one period examples are heart attacks and strokes. The dangers
she should have a pregnancy test. If she continues of heart attack are well known; a stroke (blocked or
to miss periods after 3 months on the Pill she bleeding artery in the brain) can cause mild to severe
should change to a brand with greater progesterone paralysis, loss of speech, and death.
strength. Large studies have shown an increase in these
Some women do not get any periods after stopping diseases in Pill users. Risk factors which drama-
the Pill. A woman should have a pregnancy test
done if she misses more than one period. She should
Rates of Mortality (per 100,000 Woman-years)
use contraception if she does not want to become
from Circulatory System Diseases
pregnant. She can record her basal body tempera-
ture (page 24) detect the first ovulation. If a
to Pill Users Controls Absolute
Age Difference
woman is still without periods after 6 months, she 15-24 7.5 7.5
should see a doctor to rule out any other cause. 25-34 8.8 4.4 4.4
35-44 42.6 33.0
9.6
45-49
Effect on sexuality 140.9 140.9
Smoking
The permits a woman to have sexual inter-
Pill
Habit
course at any time in the cycle without fear of Nonsmokers 13.8 3.0 10.8
pregnancy. Some women who take the Pill when their Smokers 39.5 8.9 30.7
sex life is slow resent the risks they are taking for Duration of
so little benefit. Use
Pill in
Months
1-59 17.5 5.2 12.3
It controversial whether or not the
is Pill alters 60 + 50.5 45.3
5.2
a woman's sexual desire and experience. It is diffi-

tically increase the risk of the Pill are increasing
age and smoking. Women at risk are those who are
over 35, who smoke and who have used the Pill
for more than 5 years. Other risk factors for cir-
culatory disease are: hypertension, obesity, dia-
betes, and an aggressive impatient personality.
The more risk factors a person has, the greater
the possibility of circulatory disease.
The following women should probably not use the
Pill: women with any form of circulatory disease;
women over 40, women over 35 who smoke, women
who have any diseases associated with an increased
risk of circulatory disease: hypertension, diabetes,
high blood cholesterol, heart valve disease, sickle
cell anemia, or obesity.
If a woman with strong contra-indications to the
Pill still chooses the Pill, she should be re-evaluat-
ed regularly to detect early signs of complications.
A woman who has a strong family history of cir-
culatory disease may use the Pill but requires re-
gular evaluation.
Migraines: Migraine headaches are one-sided
rapidly intensifying headaches caused by spasms
of blood vessels. A woman who has migraines can
use the Pill. If the migraines become more severe
or more frequent, she should probably change
methods.
Hypertension (high blood pressure): Blood pres-
sure is very slightly increased in all women on the
Pill. It returns to its original level when the Pill is
stopped. Both estrogen and progesterone are impli-
cated in the effect on blood pressure. Rarely, the
Pill increases a woman's blood pressure dramatical-
ly and she must stop the Pill immediately. In some
women the blood pressure increases moderately;
these women should change to a weaker pill. If
after 3 cycles, the blood pressure is not satis-
factorily lowered, the woman should stop the Pill.
Cancer: To date the information is encouraging
that the Pill does not cause cancer even in the long
term.
Some tumours are increased by female hormones.
Anyone with a known or suspected cancer should not
take the Pill.
There no evidence that the Pill either reduces
is
or increases the incidence of breast cancer. Breast
cancer is more common in women who have had
no or few children, and possibly in those who have
not breastfed.
The risk of cervical cancer increases when the
first sexual experience occurs at an early age and
when there are many sexual partners. These facts
make it difficult to sort oat the role of the Pill. The
Pill may increase the growth of pre-cancerous
cervical tissue. Any woman with an important ab-
normality on her Pap test such as carcinoma in
situ should stop the Pill.
The Pill may decrease the incidence of cancer of
the ovaries.
Benign breast disease: Increase of normal breast
tissue is due to both estrogen and progesterone.
Women who already have cystic or nodular breast
disease sometimes find that their breasts are more
tender or that the cysts increase when taking the
Pill. Other women find their symptoms improve on
the Pill.
PAGE 35
Lactation: The Pill decreases the quality and
quantity of breast milk. Women who are breastfeed-
ing should not use the Pill. Some doctors recom-
mend starting the Pill when the baby is being
weaned, when breast milk is no longer the baby's
main source of nourishment.
Liver and gall bladder disease: The Pill does
cause a slight increase in a rare tumour of the
liver. This tumour is not cancerous but it can rup-
ture and cause severe hemorrhage. Women who have
abdominal pain while taking the Pill should consult
a doctor.
Women who have had serious liver disease should
not take thePill. Women who have had mild or
moderate liver disease should wait at least 6 months
after their liver tests become normal before start-
ing the Pill.
Women on the Pill have an increased risk of gall
bladder disease. A woman who becomes jaundiced
(yellow) or has other symptoms of gall bladder
disease should stop the Pill and see a doctor. If
surgery is recommended she should get a second
opinion.
Diabetes: The Pill does not cause diabetes.
Because of the association between both the Pill and
diabetes with circulatory disease, diabetic women
should probably not use the Pill. Use of the Pill may
change the insulin dose necessary to control the
blood sugar.
The Pill does change the results of a glucose
tolerance test which measures the amount of sugar*
in the blood after a meal containing a controlled
amount of sugar. These tests return to normal when
the Pill is stopped. If a woman has had abnormal
glucose tolerance during pregnancy, or if she has a
family history of diabetes, she should have a glucose
tolerance test before taking the Pill and at 6 to 12
month intervals. If there is a marked change in
glucose tolerance, she should stop the Pill.
Depression: The Pill can cause depression,
and fatigue in some women. These symp-
irritability
toms may be related to fluid retention or to a reduc-
tion of vitamin B6. Treatment with vitamins has
been questionably successful. Sometimes changing
to a Pill containing less progesterone, relieves the
depression. Depression appears to come on gradually
during Pill usage so that it is only after stopping
the Pill that a woman associates the depression
with the Pill.
Puberty: Estrogen plays a role in the end of the
adolescent growth spurt. If a girl has had menstrual
periods for 6 months, there is no danger of affect-
ing her growth with the Pill.
Nutrition: The Pill alters the absorption of cer-
tain nutrients. Diet supplements are not necessary
but a lack in the diet may become apparent sooner.
Vitamin C and folic acid are decreased. Vitamin A,
iron and copper are increased.
Interaction with Drugs: The Pill alters the clot-
ting factors in the blood. Insulin dosage may be al-
tered by oral contraceptives. The Pill decreases the
sensitivity of skin tests for tuberculosis. The Pill
affects the urinary elimination of certain drugs such
as Promazine (Sparine) and Meperidine (Demerol).
Lab tests: Many laboratory tests used in the dia-
gnosis of disease are altered by the Pill. A woman
should tell her doctor that she is on the Pill. The
PAGE 36
Gloria F. Mallaroni
doctor may recommend that she stop the Pill be-
fore any tests are done.
Water retention: Water retention can cause any
of the following symptoms: nausea, leg cramps,
bloatedness, headaches, changes in vision, changes
in the fit of contact lenses, irritability and breast
tenderness. If these symptoms occur early in the
cycle, the water retention is probably due to excess
estrogen. If they occur during the week when no pills
are taken, the Pill is proably too strong in proges-
terone. If these symptoms do not decrease to an
acceptable level after 3 cycles, the woman should
change brands of the Pill.
Skin changes: Darkening of the skin around the
eyes and mouth is due to estrogen. Women who
experienced such changes during pregnancy are also
likely to do so on the Pill. The woman should change
to a Pill with less estrogen or stop the Pill as these
changes are not always reversible.
Acne, oily skin and hair, and increased hairiness
are due to the androgen effect of some of the pro-
gesterones. If these occur, the woman should change
to a Pill with less androgen effect. Loss of hair may
be due to excess progesterone.
Weight gain: Bloatedness at the same time each
cycle is due to water retention. Increased appetite
and weight gain which are stable occur in a few
women and are due to the androgen effect of the Pill.
Changes of vagina and cervix: An excess of estro-
gen increases the normal vaginal discharge. A lack
of estrogen can cause drying of the vaginal lining.
An excess of estrogen alters the growth of cells
lining the cervical canal. An excess of progesterone
is associated with an inflammation of the cervix.
Repeated yeast infection of the vagina may be
caused by excess progesterone.
Effect on fertility
Method failure: If a woman becomes pregnant
while taking the Pill, there is an extremely small
risk of serious fetal malformation. If a woman
thinks she is pregnant, she should stop the Pill.
Stopping the Pill: It is controversial whether or
not the risk of fetal malformation or of early mis-
carriage continues after the Pill is stopped. To re-
duce whatever risk exists, a woman should stop the
Pill and use another method for at least 3 cycles
before trying to become pregnant.
The oversuppression syndrome: Many women do
not ovulate for several cycles after the Pill. They
either have no periods or very irregular periods.
The function of the hypothalamus and the pituitary
is still blocked, preventing ovulation. After 6 months
less than 3% of Pill users have not established re-
gular cycles. Some of these women also have some
secretions from one or both breasts. These women
must be examined to rule out any other disease.
The woman should continue using birth control
as it is impossible to know exactly when fertility
will return. She should have a pregnancy test every
4 to 6 weeks if she is concerned about an unwanted
pregnancy.
If after 6 months the woman has no periods
still
and wants to become pregnant, she can consider
treatment with one of several drugs which stimulate
the pituitary and cause ovulation.
Use
When a woman decides she wants to use the Pill,
she must see a health professional to evaluate
whether or not there is any reason why she should
not use it. The Pill requires a doctor's prescrip-
tion in North America.
The woman should have a complete check-up (see
page 12). The doctor should ask specific questions
to rule out factors which may make the Pill unsafe
for her. Any health factors which require more fre-
quent supervision should be noted in the chart.
The physical examination includes: weight, blood
pressure, breast examination, listening to the heart
and lungs, feeling the abdomen for any lumps or
tenderness, and a gynecological examination. A sam-
ple of urine is tested for sugar. In black women, a
blood test for sickle cell anemia should be done.
The medical history might indicate the need for ad-
ditional tests such as a glucose tolerance test, liver
function tests, and cholesterol.
Choosing a Pill: There are over 20 brands of the
Pill on the market. Doctors rarely discuss their
differences with women who are using them. Pres-
criptions are changed in a hit and miss fashion de-
pending more on the selling techniques of the drug
salesman than on medical science. It has not been
easy even for the doctors to get facts about the dif-
ferences between the brands.
The confusion stems from the different hormones
used in each brand. Each birth control pill contains
one of two synthetic estrogens: mestranol or ethinyl
estradiol. Mestranol is weaker than ethinyl estra-
diol. Compagnies using the stronger drug boasted
when they reduced the quantity of hormone in their
pill from 50 meg to 30 meg. But 30 meg of ethinyl
estradiol is as strong if not stronger than 50 meg
of mestranol. Companies using mestranol worried
that doctors would prescribe on the basis of num-
bers rather than strength. They marketed a 35 meg
pill, except that they changed to ethinyl estradiol.
What is marketed as their low dose pill is in fact as
strong or stronger than the same company's more
commonly known pill.
The story gets even more confusing with proges-
terone. There are four different progesterones
used in commonly prescribed brands. Each one
varies in its strength as a progesterone. But pro-
gesterone also has estrogen-like effects and an-
drogen (male) effects.
 PAGE 37

Because estrogens and progesterones interact with use a second method of birth control until the end of
each other, each brand of the Pill must be compared that cycle.
as a whole and not by its separate hormones. The If a woman is nauseated with the Pill she should
strength of each hormone is based on its effect on take it with a meal or just before going to bed.
the endometrium which may or may not be a good If a woman has repeated vomiting or diarrhea
measure of its ability to cause side effects. for more than one day, she should continue the Pill
In choosing a brand, remember that estrogen is but use a second method of birth control for the rest
responsible for most of the dangerous complications of the cycle.
and many of the minor discomforts; the less estrogen Signs of serious complications: A woman should
the better. Progesterone is responsible for a few of be alert to the signs of serious complications, and
the dangerous complications and some of the dis- should seek immediate medical attention if they
comforts. Progesterone can be changed to relieve occur: severe pain in the leg, severe abdominal
minor side effects with less danger of serious com- pain, severe chest pain, shortness of breath, severe
plications. headaches, or changes in vision.
Follow-up: All women who begin the Pill for the
Relative hormone strength of
first time should return to the same doctor or clinic
oral contraceptive brands
within 3 to 6 months to review their experience with
LOW Estrogen strength Progesterone strength Androgen strength the Pill. The physical examination should include
Logest 1 5/30 Brevicon Anoryol
(Zorane) Modacon Brevicon weight and blood pressure, as well as any other
Loestrin 1.5/30 Anoryol Modacon examination suggested by the woman's symptoms.
Norlestrin Ovcon 35 Demulen
Ovcon 35 If everything is normal, she need not return for 6
Demulen MinOvral (LoOvral) to 12 months when a complete examination should be
MinOvral Ortho Novum Norinyl 1 or 1/80
(LoOvral) 1/50 or 1/80' Ortho Novum repeated.
If the woman is at risk for any of the complica-
Norinyl 1 Norinyl 1 or 1/80 1/50 or 1/80
Ortho Novum 1/50 Ovcon 50 Ovcon 50
Norlestrin 1
tions associated with the Pill, she should return to
Norlestrin 1
Logest 1/50 the clinic at more frequent intervals. The examina-
Logest 1 50
(Zorane) tion should be directed at detecting any change in
Brevicon MinOvral
these risk factors.
Modacon Norlestrin 1

(Modicon) Ovral Logest 1/50 There is no need to stop the Pill for a "rest".
Ovcon 35 Demulen But there are valid reasons other than the desire
Ovral Logest 1 5/30
for pregnancy to discontinue the Pill: a less active
Loestrin 1.5/30 Ortho Novum 2
Ovcon 50 Norinyl 2 sex life, desire to try another method, desire to
Ortho Novum Loestrinl 5/30
1/80 or 2
evaluate any subtle effects of the Pill. A break of
Ortho Novum 2 Logest 1 5/30
J f Norinyl 1 '80 or 2 Norinyl 2 Ovral several cycles does not decrease the risk of serious
HIGH Anoryol Norlestrin 2 5 Norlestrin 2.5
side effects.
A woman who knows she will have surgery, should
Starting the Pill: The woman waits for her period stop the Pill at least one month before the opera-
before starting the Pill. She counts the first day of tion to avoid the increased risk of circulatory com-
her period as day 1. She counts each day and takes plications.
the first pill on day 5. She takes one pill each day for
21 days. For 7 days she does not take a pill. On the
8th day she starts a new package. From then on
mini-pill
she continues the same pattern of 21 days "on" and
The mini-pill containing only progesterone was
7 days "off", She will start a new package on the marketed in 1973 in an attempt to avoid the serious
same day of the week each time.
side effects of estrogen. Injectable progesterone
Some brands are marketed packages which
in
known as Depro Provera is unavailable in the USA
have 21 identical pills containing hormones and 7
but widely distributed in the Third World.
pills ofa different colour containing only sugar
(placebos). The woman takes the 21 pills followed
by the 7 pills. When she finishes one package of 28 Action
pills she begins a new package the next day.
Progesterone in small doses can block ovulation,
The woman gets her oeriod several days after the but its main contraceptive effect is to change the
last hormone pill. She starts the new package one mucus at the cervix. The thickened mucus prevents
week after finishing the last whether or not she has sperm from entering the uterus. Progesterone also
her period. slows the transport of an egg through the Fallo-
The pill must be taken at approximately the same pian tube.
time each day to maintain a constant amount of
hormone in the blood. A woman is less likely to for- Effectiveness
get the Pill if she associates it with some other daily The mini-pill is theoretically slightly less ef-
activity such as teeth brushing. fective than the estrogen/progesterone but it is
Pill

If a woman forgets one pill, she takes it as soon still highly effective. The extended use effectiveness
as she remembers, even if that means taking two is considerably lower. Missing one mini-pill in-
pills one day. The chance of pregnancy is still
in creases the risk of pregnancy much more than
very small. The risk of pregnancy increases if a missing the combined pill. For unknown reasons
woman forgets more than one pill in a cycle. She the pregnancy rate is higher in the first 6 months.
should take the pills as soon as she remembers If a woman has regular menstrual cycles on the

them, taking not more than two a day. She should mini-pill she is probably still ovulating. She should
PAGE 38

consider using a second method such as the condom bleeding.

at mid-cycle. If a woman forgets a pill she should take it as
Depro Provera injections provide contraceptive soon as she remembers. She should use a second
protection for approximately 3 months. The effective- method of contraception for the rest of the cycle.
ness is about the same as the mini-pill but the return Breakthrough bleeding is not dangerous but a
of fertility is less predictable. nuisance. If it becomes too bothersome, considej
Effect on the menstrual cycle changing birth control methods. If spotting occurs
In many women, progesterone causes spotting and for the time after many cycles of the mini-
first

actual menstrual-like bleeding at any time during the pill, see a doctor to rule out disease.

cycle. The inconvenience of this irregular bleeding If a woman using the mini-pill goes more than
is the reason many women stop using the mini-pill. 45 days without a menstrual period, she should have
Other women have no periods. Unfortunately a a pregnancy test.
woman cannot know if she is missing a period be- A woman should return to the clinic for a follow-
cause of the drug or because she has accidentally up examination after 3 cycles of the mini-pill. If
become pregnant. there are no problems she can be given a prescrip-
tion for the rest of the year. If there are no further
Effect on sexuality
It is unknown whether the mini-pill has an effect problems she need only return for an annual check-
on sexual experience. Women or their
desire or up.

partners who recoil from sex during a woman's

period may find the spotting a deterrent to their
usual sexual pattern.
postcoital methods
Effect on health Birth control used after sexual intercourse is not
Less progesterone is used in the mini-pill than well known. Postcoital methods are promoted as
in the combined Pill. Theoretically the mini-pill emergency measures when a condom breaks, or
should eliminate the estrogen side effects and di- for rape victims. A postcoital method is also a
minish the progesterone ones. However the pro- suitable contraceptive for women with infrequent
gesterone effects may be greater in the mini-pill heterosexual intercourse.
since it is not balanced by estrogen. methods available are: the morning
Postcoital
The reasons for not taking the combined Pill also after containing female hormones, and insertion
pill
apply to the mini-pill but with somewhat greater of an intra-uterine device. The critical factor is the
flexibility. A woman with risk factors for diseases time between unprotected intercourse and the subse-
associated with the Pill should be re-evaluated fre- quent use of the method. For example, the morning
quently if she uses the mini-pill. after pill must be taken within 72 hours after inter-
If a woman has inter-menstrual bleeding for which
course. It will not abort a pregnancy from an earlier
the cause is unknown, she must delay use of the mi- sexual experience nor will it prevent pregnancy
ni-pill a diagnosis has been made. Otherwise
until later on in the cycle.
the diagnosis of serious disease such as uterine
cancer could be missed. Action
Postcoital methods act in two ways. They influence
Effect on fertility the speed at which the egg travels in the Fallopian
Method failure: Ectopic pregnancy (pregnancy out- tube so that fertilization does not occur. They also
side the uterus) occurs more frequently in women
affect the endometrium so that even if fertilization
who become pregnant while using the mini-pill, pro- occurs, implantation is unlikely. If the morning after
bably due to the slow transport of the egg. An ecto-
pill is given just before the estrogen peak, ovula-
pic pregnancy is potentially fatal and surgery must
tion may be prevented.
be performed to remove it.
Both estrogens and progesterones have been test-
The risk of fetal malformation is probably similar
ed for postcoital use. Recently they have been tested
to that with the combined Pill.
together in the form of the combined Pill, Ovral.
Stopping the method: A woman should use another
The lUDs tested for postcoital use are the Copper
method for 3 cycles after stopping the mini-pill. In
7 and the Saf-T Coil.
most cases, she will have re-established normal
cycles by then. Progesterone given by injection is Effectiveness
associated with a longer and more variable time In large enough doses, hormones tested
all of the

of infertility after the injections are stopped. are greater than 95% effective. However when post-
coital contraception is used repeatedly in one cycle,
Use the effectiveness is decreased.
When a woman
decides to use the mini-pill she
Postcoital IUD insertion is also highly effective. In
must see a doctor for an evaluation and prescrip-
addition, continuous contraception is assured for the
tion. A woman should have a complete check-up be-
following cycles.
fore starting the mini-pill. Particular attention
should be paid to the menstrual history and the Effect on the menstrual cycle
gynecological examination. The morning after pill can advance or delay the
Counting the first day of menstrual bleeding as date of the next period. The following cycle should
day 1, take the first pill on day 5. Each package be of normal length.
contains 28 identical pills. Take one each day at Effect on sexuality
about the same time of day. When the package is Postcoital contraception permits a to en- woman
finished, begin the new package the next day re- gage in an unexpected sexual encounter without risk-
gardless of whether or not there is menstrual ing pregnancy.

Effect on health
Many brands ofthe morning after pill cause mild
to severe nausea and repeated vomiting. The corn-
Dined estrogen/progesterone Pill causes the least
nausea.
No serious illness or death has occurred in studies
Df postcoital contraception. Cautious doctors often
jse the same criteria as is used for the regular
Pill (page 34) in deciding for whom this method
might be unsafe. The morning after pill contains
more hormone than the regular combined Pill but it
s taken only once, not continuously. A woman who
night not be a good candidate for the Pill, might
still take the morning after pill.
When an IUD is inserted postcoitally it is intended
to remain in the uterus for continuous contraception
(see page 31 for IUD side effects). Because of the
risk of existing infection, a woman with several sex
aartners should not have an IUD inserted postcoi-
tally. To avoid further discomfort, an IUD should
not be used postcoitally in rape victims.
Effect on fertility
Method failure: The morning after pill carries
a slight risk of fetal malformation. Diethylstilbes-
trol (DES) given slightly later in pregnancy causes
a rare cancer of the vagina in female offspring. No
woman should use the morning after pill unless she
would consider an abortion in case of pregnancy.
A woman who becomes pregnant with an IUD in
place should have it removed.
Desired fertility: After the morning after pill a
woman should wait until she has had a regular
period before trying to conceive. An IUD should be
removed during the menstrual period.
Use
When a woman has intercourse without contracep-
tion or if she discovers that her method is ineffective
(broken condom, IUD expelled, etc), she must decide
whether to use postcoital contraception or to await
her period. There is no need to run to the emergency
department at 3 am but within reason the sooner she
starts treatment the better.
A woman who has not had routine well woman care
should see a doctor to determine whether or not
this is a safe method for her. More thorough examina-
tion can be delayed until another visit. A woman who
is known to the doctor or clinic can sometimes get
a prescription by phone. A woman who has inter-
course very infrequently may get a prescription
filled in advance, and use this method at her own
discretion.
The combined estrogen/progesterone pill is the
first choice of the morning after pills. The dosage
is 0.1 mg ethinyl estradiol and 1.0 mg of dl norges-
trel (2 Ovral tablets) taken immediately, and re-
peated 12 hours later.
Many centers still use diethylstilbestrol or con-
jugated estrogens for 5 days. Anti-vomiting pills
must be prescribed. If the woman vomits after
taking the estrogen, she must take another estrogen
pill.
The woman must use another method such as the
condom until she gets her period.
A woman who wants an IUD inserted postcoitally
must see a doctor for the insertion within 48 to
PAGE 39
hours after unprotected intercourse. See page 32 for
a description of its insertion.
If a woman does not get her period within 3 weeks,
she should have a pregnancy test and begin whatever
procedures are necessary to obtain an abortion. If
she gets her period she need only make an appoint-
ment for well woman care or to choose a birth con-
trol method. If an IUD was inserted, she should
have a check-up within 6 to 8 weeks.
menstrual extraction
Menstrual extraction is the withdrawal of the ute-
rine lining by suction at the time of the expected
menstrual period or shortly afterwards.
Menstrual extraction was developed by a group of
feminists in the early 70's as a simple method
which women could do for each other. Menstrual
extraction is both a method of birth control and a
method of reducing menstruation time to a few mi-
nutes.
The medical profession also developed a similar
technique of very early abortion for use by para-
medics, especially in the Third World and where
anti-abortion laws exist. When aspiration is done
prior to a possible confirmation of pregnancy,
charges of illegal abortion can be avoided.
The medical profession still views abortion as
something to keep to a minimum. Women are chal-
lenging this attitude by comparing the dangers of
birth control with the relative safety of early abor-
tion. An interference with the reproductive process
very shortly after implantation does not necessarily
pose a greater moral dilemna than methods which
interfere prior to fertilization or before implanta-
tion.
Action
Menstrual extraction is an aspiration of the uterus
at the time of the expected period or within two
weeks, without a confirmation of pregnancy. A hollow
tube is inserted through the cervical canal into the
uterus. Suction draws the upper layers of the endo-
metrium into the tube. The woman experiences mi-
nimal spotting rather than a regular menstrual flow.
If an early embryo is present, it is withdrawn and
the woman is no longer pregnant.
Effectiveness
There is a small possibility that the embryo is
not removed during menstrual extraction. A preg-
nancy test two weeks later is recommended to detect
continuing pregnancy.
Menstrual extraction does not remove a tubal
pregnancy. At this early stage, diagnosis of tubal
pregnancy is not obvious during a gynecological
examination.
Effect on the menstrual cycle
In the non-pregnant woman, menstrual extraction
does not alter the balance of hormones which con-
trols the events of the menstrual qycle; therefore
the date of her next period should not change. If the
woman was pregnant, her next period should occur
72 within 3 to 6 weeks.
PAGE 40
It is unknown if repeated menstrual extractions,
especially in the non-pregnant woman, have an effect
on the cyclical development of the endometrium.
Missing a period can occur for reasons other than
pregnancy. No periods for an extended time or gross
irregularity can be a sign of certain diseases. Re-
peated menstrual extractions might prevent a woman
from discovering a medical problem.
Effect on health
The chapter on abortion discusses in detail the
complications of any aspiration procedure. Any of
these complications (perforation, hemorrhage, in-
fection and damage to the cervix) is possible follow-
ing menstrual extraction but the frequency and
severity are much less. The long term consequences
of repeated menstrual extraction are unknown.
With earlier detection of pregnancy, fewer aspira-
tion procedures would be done in non-pregnant
women. Until more is known, sexually active women
should not be encouraged to use menstrual extrac-
tion as birth control. It is an excellent method for
a woman with a very sporadic sex life or with con-
firmed low fertility.
Effect on fertility
The occasional menstrual extraction probably has
no effect on a woman's fertility. It is unknown
whether repeated extractions cause fertility pro-
blems.
Use
Once a brief chart is recording the
filled out
woman's medical history, the woman prepares her-
self for the extraction. She empties her bladder. She
undresses and positions herself on the table with
her legs in stirrups. A gynecological examination is
done to determine the size and position of the uterus.
A speculum is inserted into the vagina exposing the
cervix which is washed with antiseptic solution.
Relief from discomfort and pain can be accom-
plished by mild sedation, laughing gas, earphones
with music, local anesthetic or self relaxation.
The cervix grasped with a clamp which the
is
woman might feel as a sharp pinch. If local anesthe-
tic is used, it is injected into the cervix now. A ste-
rile plastic tube about 6 mm in diameter is pushed
through the cervical canal. Sometimes dilators must
be used before the tube passes easily. The end of
the tube is attached to a source of suction such as a
50 cc syringe with a control to prevent air return-
ing into the uterus. The tube
rotated so that the
is
open tip faces each part of the uterus. The material
is collected in the syringe. The woman usually ex-
periences some cramping. When the procedure is
finished, the instruments are removed.
The woman need not restrict her activities fol-
lowing an extraction. Otherwise the instructions
following extraction are similar to those following
early abortion.
If examination of the tissue does not confirm that
an embryo was removed, a pregnancy test should
be repeated in two weeks. The woman should be
followed for the possibility of tubal pregnancy.
An injection of immunoglobulins given to Rh nega-
tive women after abortion is probably unnecessary
after menstrual extraction.
abortion
Abortion is the termination of pregnancy. Spon-
taneous abortion or miscarriage is an act of nature
which occurs in approximately 15% of all pregnan-
cies. Induced abortion is the intentional termination
of pregnancy. Therapeutic abortion implies only
that the abortion is legally sanctioned; all other
abortions are called criminal abortions. Septic
abortion refers to the many complications such as
infection and bleeding following an incompetently
induced abortion.
In all cultures throughout history induced abor-
tion has been part of women's experience. In the
world today there is about 1 induced abortion for
every 3 live The social and legal status of
births.
abortion depends on several factors: the definition
of the beginning of life, the perception of ideal
population size, and the influence of the medical
profession.
Aristotle defined the beginning of life as 40 days
after conception for a male fetus and 90 days after
conception for a female. St. Thomas Aquinas felt
that the fetus acquired a soul only when the mother
could feel the fetus move (about 4-5 months). Abor-
tion was permitted before this time. It was only in
the late 1800's that Pope Leo XIII declared that life
begins at conception, and hence abortion came to be
defined as murder. In Canada today, a fetus is con-
sidered viable if it weighs more than 500 gm (2 /2 1
pounds) or the pregnancy is greater than 20 weeks.
Many circumstances influence the perception of
Nomadic peoples have always
ideal population size.
limited theirpopulation size effectively with con-
traception, abortion and infanticide. In agricultural
societies children are an economic asset and large
families are the rule. With industrialization, family
size diminishes. Infanticide and abandonment of new-
borns were common practices in the late 1800's.
Abortion often becomes illegal in times of political
expansion and war. Today the Population Council and
other western organizations are the strongest forces
lobbying for change in the abortion laws of Third
World countries while in the USA federal funds are
withheld for payment for abortions.
As the medical profession gradually usurped
matters of reproduction away from midwives, folk
methods of abortion became less available. But the
abortion methods of the medical profession were
so dangerous that laws restricting abortion were
created to protect women from infection and death
at the hands of doctors. Many doctors still think
abortion is very dangerous, although research
clearly demonstrates the safety of modern techni-
ques.
 PAGE 41

of restrictive abortion laws

Who are the opponents? The predominantly male
Consequences
medical profession does not want to lose control
When
safe abortion is not over who can have an abortion. The clergy, espe-
Illness and death:
cially Catholic, not only male but celibate, impose
available, women resort to abortion at the hands of
their authority over the most intimate behaviour of
unskilled people or at their own hands. Some sur-
their congregations. Pro-life groups financed by the
vive the experience with only psychological scars;
Catholic church deem themselves protectors of the
others are found maimed and dying on the steps of
sanctity of human life. Governments maintain the
hospitals all over the world.
birth rate to provide workers or soldiers, or are
Whenabortion is not available women are forced
unwilling to confront a controversial issue before
to use the most effective but also the most dange-
elections.
rous methods of birth control. Until women can be
sure that abortion is available, they must take
In Canada, abortion is included in the federal
criminal law which was liberalized in 1969 such that
unnecessary health risks to prevent pregnancy.
With each week of pregnancy, abortion becomes threat to the life or health of a woman became
increasingly dangerous, especially after 12 weeks. ground for abortion. A committee of 3 doctors
Red tape delaying an abortion also forces women decides on each case, and the abortion is performed
in hospital. The law does not insist that all hospitals
totake greater health risks.
Increased maternal and infant deaths: When establish such a committee nor does it recommend

women are forced to continue a pregnancy they
are exposed to the risks of pregnancy and delivery.
Those women especially at risk include: the very
young, the ill, those with many children, those with
a previously difficult delivery, the pre-menopausal
women. Although doctors credit themselves for the
declining maternal and infant mortality rate, greater
credit is due to the declining birth rate.
Hysterectomies have been necessary
Infertility:
to save a woman's life after a butcher abortion; in
less severe cases, scarring prevents a future
pregnancy. Controlling fertility at one moment has
prevented many women from bearing children at
another.
Class differences: Even when a country has a
how a "threat to health" should be interpreted. In
1977 the Badgley report demonstrated that the law
is applied differently in each province and in each
hospital; consequently there is unequal access to
abortion. The law doesn't work.
In 1973, Dr Henry Morgentaler was arrested for
performing vacuum aspiration abortions in his of-
fice. He was acquitted in court but in an unprece-
dented legal move, a government appeal reversed
the jury decision and sent him to jail. In a retrial in
1976, Dr Morgentaler was again acquitted by jury.
He used the defense of necessity which protects a
doctor when performing an act whose omission
would have great negative consequence to the patient.
In 1977, the newly elected Parti Quebecois dropped

restrictive abortion law, a few doctors will perform
abortions for a price. Women with money and con-
nections have less trouble getting a safe abortion
either at home or in a foreign country. Within one
country or even one province great differences in
availability of abortion exist. Abortion is far more
accessible to women in large cities than those in
smaller ones. In 1976 over 4000 abortions were
the remaining charges against him and stopped
harrassing competent doctors practicing abortions.
Where does this leave the abortion struggle in
Quebec and Canada? In Montreal private doctors
perform abortions lucratively and with impunity
while government community clinics which could offer
free services have been blocked from doing so.
The Quebec government launching several hospital
is

performed in one Montreal hospital; only 1 hospital abortion clinics; there is no guarantee that these
abortion was performed in Quebec city. clinics will make their services accessible or that
Compulsory parenthood: When unemployment is modern techniques will be used. In the rest of Canada
high, daycare rare and expensive, and the cost of
living high, a child is an additional strain on any
household. When both parents must work full time,
little time is left for parent and child to enjoy each

other. The slogan "every child a wanted child" is

a statement of concern both for the rights of women
to control their fertility and for a child's right to
reasonable material and spiritual care.
Lack of research: When few abortions are per-
formed, there is no support for research to improve
abortion techniques. Even existing improvements
are not adopted.

The struggle for abortion

The wave of feminism in the 1960's made control
of reproduction a major issue. Women's groups
fought for the right of all women to decide if and
when to have children, including the right to safe
abortion regardless of ability to pay. The struggle
for abortion is one part of a global movement re-
garding the status of women and their relation to
reproduction and production: daycare, maternity
leave, educational opportunities, equal pay, etc...
PAGE 42
disparities still exist. Women must travel great
distances for an abortion, and many go south of the
border.
In the United States abortion is governed by state
laws rather than federal. In the 1960's the laws
varied widely from state to state. In 1970, the state
of New York passed a law making abortion a decision
between a woman and her doctor. Overnight, New
York became the abortion capital of the country.
Hospitals, community clinics and private doctors set
up abortion services of varying quality and cost.
From July 1970 to June 1972, 402,000 abortions were
done in New York City.
In 1973 the Supreme Court declared that the Ame-
rican constitution guarantees the right of privacy
including the right of *a woman to an abortion. It
lifted all restrictions on abortion in the first 3
months pregnancy. Between 4 and 6 months, the
of
state has the right to determinewhere and by whom
abortions can be performed.
Where does the abortion struggle stand in the
United States? Without universal health insurance,
cost still determines who gets a safe abortion. Anti-
abortion groups have promoted and passed laws pre-
venting the use of public funds to pay for abortions.
The are presently pushing laws giving full human
rights to the fertilized egg.
Media portrayal of the struggle for safe abortion
has often made militant women seem insensitive to
the experience of abortion. In fact feminist groups
in North America established the first abortion coun-
selling services where women counselled other
women, helping them make their final decision about
abortion, preparing them for the abortion itself
providing information about birth control. These in-
novative services became the model for professional
abortion counselling in the 70's.
In the context of Quebec, the Montreal Health
Press supports the following demands:
1. removal of abortion from the criminal code;
2. abolishment of therapeutic abortion committees;
3. establishment of abortion services up to 12 weeks
gestation in community clinics;
4. training of all medical students to do abortions;
5. research to develop a safe, self-administered,
non-prescription abortion technique for early
abortions.
Action
Up 12 weeks: Uterine aspiration is the safest
to
method The opening of the cervix
of early abortion.
is gradually dilated to permit passage of a hollow
tube into the uterus. The tube is attached to a suction
which draws out the fetus and placenta.
Dilatation and curettage (D. & C.) was the method
of early abortion before aspiration techniques were
invented. A sharp spoon-like instrument is used to
scrape out the fetus and placenta.
12 to 16 weeks: Dilatation and evacuation is a
modified form of the above methods. Forceps are
used to remove pieces of the fetus which are too
large to pass through the tube. The abortion is com-
pleted with aspiration and/or curettage.
Over 16 weeks: Several different hormones or
chemicals are used to induce premature labour and
delivery.
New techniques: Laminaria tents made from
weed were developed in Japan. They are used to
dilate the cervix very gradually which makes the
uterus contract. When the uterus is well contracted,
the complications of evacuation procedures are re-
duced.
A vaginal suppository which slowly releases a
hormone called prostaglandins will cause an abor-
tion in early pregnancy. Once perfected such a sup-
pository could be widely distributed and self-ad-
ministered. A non-surgical method of abortion
makes control of abortion by women themselves a
possible reality and no longer a dream.
Effectiveness
Theoretically uterine aspiration and curettage
are 100% effective. In practice, the occasional failure
occurs. Reasons for failure include: inadequate
vacuum pressure, physician inexperience, abnormal-
ly shaped uterus. Failures occur more often in very
early pregnancy. Some centers suggest a repeat
pregnancy test when the abortion is performed be-
fore 8 weeks.
If the pregnancy
is in the tube rather than in the
uterus, aspiration will not terminate the pregnancy.
The tube must be removed by surgery.
Effect on the menstrual cycle
Abortion has no lasting effect on the menstrual
cycle. After an abortion a woman's next period usually
begins within 4 to 8 weeks. A woman can ovulate and
become pregnant before having a period.
Effect on sexuality
and Abstinence from vaginal penetration is recom-
mended for one week following early abortion and
until there is no further discharge following a pre-
mature delivery.
Usually an abortion has no effect on sexual desire
or experience unless the circumstances surrounding
the abortion were particularly unpleasant.
Effect on health
All abortion techniques carry certain risks. Late
abortions carry far greater risks than early abor-
tions. In the United States between 1972-74 there
were 0.4 deaths per 100,000 abortions done under 8
weeks, 3.6 deaths per 100,000 performed at 11-12
weeks, and 19.8 per 100,000 when done between 16
and 20 weeks. By comparison, tonsillectomy carries
an estimated risk of 3 deaths per 100,000 cases and
appendectomy of 352 per 100,000 cases. The rela-
tive safety of early abortions proves that obstacles
which delay abortions are dangerous.
Perforation: Any of the instruments used in early
abortion can be accidentally passed through the mus-
cle of the uterus. If the woman is awake, she usually
experiences a sharp pain; the doctor is aware of a
perforation when the instrument goes too far without
resistance. Usually "the instrument is withdrawn and
the uterus heals. Rarely internal damage is caused
by the perforation and an abdominal operation must
be done to repare this damage.
Blood loss: Normal bleeding during a vacuum
aspiration is minimal (approximately 100 ml); it is
a curettage. In late abortions
slightly greater during
blood loss approaches that after a delivery. Hemor-
sea- rhage during abortion is not common; it occurs

more in late than early abortions. The woman should
be given ergot to make the uterus contract if there
is any doubt about the tone of the uterine muscles.
Excessive bleeding occurring in the two weeks
following the abortion is usually caused by incom-
plete removal of the placenta. If bleeding is not se-
vere and the woman has no signs of infection, she is
treated with antibiotics and ergot. Occasionally a
curettage must be repeated.
A woman who has bled abnormally following an
abortion should be tested for anemia.
Infection: There are two causes of infection:
improper sterile technique during the abortion, and,
more commonly, bits of placenta retained in the
uterus. The woman may experience chills, vague
abdominal discomfort, and foul discharge. Most in-
fections can be treated with antibiotics; occasionally
a curettage is necessary. Infection occurs least fol-
lowing aspiration, slightly more after curettage and
more commonly following late abortion. Some
centers give antibiotics automatically for several
days after the abortion.
Damage to the cervix: Occasionally the clamp
holding the cervix slips off, tearing the cervix. The
tear should be repaired with sutures and usually
heals without problem.
There is some debate whether or not the rapid
dilatation of the cervix damages the cervix so that
it cannot support a pregnancy in the future. There
is no proof that women who have had abortions have
a greater incidence of miscarriage or of premature
delivery. However, the earlier the abortion and
therefore the less the dilation, the better.
Psychological: Most women are relieved after an
abortion, and resume their lives without interrup-
tion.
Effect on fertility
There no indication that an abortion interferes
is
with a woman'sability to conceive and carry another
pregnancy (see above). Women should always include
their experience of abortion when they recount their
obstetrical history.
When a woman is pregnant, a blood test is done to
determine her Rh factor. If she is Rh negative, she
is given an injection of immunoglobulins. These
proteins prevent her own system from making anti-
bodies against Rh positive blood. Otherwise these
antibodies could harm the fetus of her next pregnancy.
All women having abortions should have a test to
determine their Rh factor. Within 72 hours after an
abortion all Rh negative women should have an in-
jection of immunoglobulins. This may not be neces-
sary in very early pregnancy. Since this injection is
essentially safe, it should not be withheld from
women who still intend to have children.
Use
When a woman who has regular periods misses
one, she should suspect pregnancy. She should con-
tinue using birth control until pregnancy has been
confirmed (see page 18).
Even if a woman is unsure whether or not she
wants an abortion she should make an appointment
for one. It is easier to cancel an appointment than
to try to find one as the weeks advance. To get an
appointment a woman asks her doctor to refer her
PAGE 43
or she can call a local women's group. Most femi-
nist groups do abortion referral. Sometime it is
necessary to call a group in another city.
Early are usually done in a clinic or
abortions
private office. When a woman calls for the appoint-
ment she should ask about which method is used,
what anesthetic is used, what is the price, what
does the price include, and what health insurance is
accepted. An early abortion should be performed
in hospital only if the woman has some other medical
problem such as heart trouble which requires greater
supervision. In Canada, many women are admitted
to hospital and given a general anesthetic because
these are the only legal abortions covered by health
insurance.
Late abortions should be done in hospital. However
if a clinic is equipped to handle emergencies it is
preferable to have an abortion by evacuation at the
clinic than to wait for an induction of labour at the
hospital.
Vacuum aspiration
The woman
should try to relax and get a good
night's sleep. She should have a bath or shower or
merely wash well; some clinics suggest a douche.
Shaving of pubic hair is not necessary. The woman
should have a snack if her appointment is early, or a
regular breakfast if the appointment is late. If pos-
sible she should go accompanied and limit her
obligations for the rest of the day.
The woman is registered and seen by a nurse or
paramedic. Questions about her past health and pre-
sent pregnancy will be asked. A minimal physical
examination is done. Sometimes blood and urine
tests are done. If the woman does not know her blood
group, a blood test is done to determine her Rh
The abortion procedure is explained.
factor.
The woman undresses and puts on a gown or drape.
She empties her bladder before lying on the table
with her feet in stirrups. When a woman is tense,
her buttocks lift off the table making it harder for
the doctor to do the abortion and possibly increasing
the pain of the abortion. Usually the nurse will re-
mind the woman to relax and suggest that she take
long deep breaths.
A gynecological examination is performed to
estimate the size of the uterus and its position in
the pelvis. The doctor and nurse may wear masks,
the instruments are sterile and handled only with
sterile gloves.
A speculum is inserted into the vagina. The cer-
vix and vaginal walls are washed with antiseptic
solution which may feel cool.
A clamp placed on the cervix. The woman often
is
feels a sharp pinch which goes away quickly. Local
anesthetic (xylocaine) is injected into the cervix
and the nerves around it. Some women find the in-
jection painful and others are hardly aware of it.
The anesthetic takes effect very quickly. Local
anesthetic takes away any direct pain caused by the
instruments but does not eliminate the discomfort
caused by contractions of the uterus.
A uterine sound is passed through the cervical
canal as far as it will go into the uterus. The sound
measures the length the uterus and shows the
of
direction of the cervical canal. The woman ex-
periences cramps when the sound is inserted.
PAGE 44
>*
^^imP
'<
Abortion: a. dilating the cervix
The cervix is A
series of metal rods each
dilated.
1 mm
in diameter larger than the next is passed
through the cervical canal. Dilation is often the
most uncomfortable part of the abortion, causing
cramping.
A vacurette is a plastic or metal hollow tube
with one or more holes near the tip. The length of
the pregnancy determines the size of the vacurette.
The vacurette is passed into the uterus and the suc-
tion is turned on. The vacurette is moved back and
forth in the uterus; it is turned so that the hole at
the tip faces each part of the uterus. The suction
apparatus makes a vibrating- noise lasting for ap-
proximately one minute. The doctor determines when
to stop by the feel of the vacurette in the uterus and
by the look of the material which comes out. The
pressure is stopped and the vacurette removed.
In some cases, the doctor checks with a curette
to make sure the uterus is empty. A curette is a
spoon-like instrument with sharp edges used to
scrape the inner walls of the uterus.
When the procedure is complete, all of the instru-
ments are removed from the vagina. The woman is
given a sanitary napkin and stretches out on the table
where she remains until she feels ready to sit up.
She changes positions slowly to avoid fainting. When
she is ready she walks to the recovery room.
The woman can have something light to eat. She
takes an aspirin or other mild analgesic if she is
bothered by cramps. The sanitary pad is checked to
see if she is bleeding. She can go home when she
feels ready, usually in about half an hour. She is
given the following instructions:
Menstrual-like bleeding can continue tor about a
week after an abortion, becoming heavier around the
third day when the hormones of pregnancy decrease.
If heavy bleeding continues longer than 1 week or if
it becomes extremely heavy, or if it is accompanied
by severe pain or fever, call the clinic.
Cramping for several days is normal. A heating
pad or mild pain-killer usually decreases the dis-
comfort.
b. suction removes pregnancy
To avoid infection do not put anything into the
vagina for one week after the abortion or until bleed-
ing stops. This includes a tampon, finger, penis or
douche.
Take your temperature twice a day for 2 days.
Continue taking it if you have increased cramping or
feel feverish. If your temperature is above 38 C
twice in a row, call the clinic.
The next menstrual period usually occurs 3 to 6
weeks after the abortion. You can become pregnant
again before the next period. The Pill can be started
5 days after the abortion. An IUD can be inserted
immediately after the abortion or at the next mens-
trual period. The condom, foam or diaphragm can
be used after one week. Biological methods are less
dependable until after the next period. Tubal ligation
can be done any time afterwards.
The woman should make an appointment for a
check-up 2 to 4 weeks after the abortion.
Dilatation and evacuation
This method is similar to methods of earlier
abortion but the procedure takes longer and the risk
of complications is greater. It should be done in
hospital or in a clinic with emergency facilities.
Preparation for the abortion is similar to that
for early abortion. The woman should not eat as
medications which sometimes cause vomiting may
be used.
Moderate sedation, anesthetic or light
local
general anesthesia is used during the abortion. An
intraveinous drip is attached in the vein of one
arm. Oxytocin, a hormone which causes uterine'
contractions is put in the intraveinous fluid.
The cervix is dilated to about 12 mm. Forceps
are used to remove the fetus. Either an aspirator
or a curette is used to ensure that the uterus is
emptied.
Immediate recovery is slightly longer. The woman
should be kept for several hours for observation, and
overnight if there are any problems. Some doctors
prescribe antibiotics during and after the abortion.
 PAGE 45

Instructions after the abortion are the same as many cannot be used for abor-
states, federal funds

those for an earlier abortion. Because the risk of tions. The lowest cost abortions are available in
complications is greater, the woman should be clinics sponsored by either feminist groups or by

signs of trouble. She needs to rest zero population groups. The earlier an abortion is
more alert to
and preferably should not stay alone. done, the less it costs. A saline abortion can cost
as much as $500.

Premature induction of labour

Several substances when injected into the uterus
will cause labour to begin. Strong salt solutions sterilization
and the hormone prostaglandin are the most com- Permanent birth control is called sterilization.
monly used. Prostaglandin will also cause labour Vasectomy, cutting or blocking the vas deferens,
when given intraveinously or in a vaginal supposi- is the method of male sterilization. Tubal ligation,
tory. These procedures should be done only in cutting or blocking the Fallopian tubes is the method
hospital. of female sterilization.
Local anesthetic is injected into the skin on the Much the experience with sterilization comes
of
woman's lower abdomen. A long needle is passed from the Third World where sterilization is pro-
through the abdominal muscles into the uterus. moted as a solution to poverty and starvation. Large
Some of the amniotic fluid is removed with a sy- families are blamed for the decaying social condi-
ringe and replaced with salt solution or hormone. tions created by dictatorial governments and greedy
Usually the woman will abort within 12 hours. industries. Funds for massive programmes to pro-
Often oxytocin is given intraveinously to stimulate mote sterilization are more often than not of west-
contractions. Contractions do not become painful ern origin, both public and private. 1978 the U.S.
In
until about 2 hours before the fetus is aborted. Agency for International Development allocated $25
The woman can be given sedatives and painkillers million for sterilization services.
as necessary. India is the classic example of such policies. In
When the cervix is sufficiently dilated, the fetus the early 70's in one state alone over 200,000 vasec-
passes out the vagina. In very rare cases the fetus tomies were performed in a 2 month period. In 1976
is still alive; the hospital staff are obliged by law India almost passed laws requiring compulsory
to treat it as they would a premature baby. sterilization for couples with 3 children. Demon-
Recovery after this type of abortion is similar strators objecting to sterilization policies (bribery,
to recovery from a complicated delivery. Usually village vasectomy quotas, etc.) were shot upon by the
the woman stays under supervision in hospital at military.
least until the next day and longer if she has com- Women other parts of the world have difficulty
in
plications. She is often given a prescription for anti- getting sterilization. Many countries particularly in
biotics and for ergot. Latin America have restrictive sterilization laws
The woman's breasts can be tender and produce which require that a woman be over 40 and have
milk. An adequate bra, ice and mild painkillers are many children.
usually sufficient treatment. InNorth America abortion services have been
Vaginal discharge will gradually change from denied to welfare women who will not consent to
bloody to pink to white. If it becomes bloody again, sterilization. On the other hand, women requesting
foul smelling, or is accompanied by fever, the woman sterilization, especially single women without chil-
should seek treatment. dren are refused it.
The next period begins approximately 6 to 8 weeks In 1977 over 80 million couples used sterilization
after the abortion. The woman can become pregnant as contraception. The decision to end one's repro-
before the next period. The woman should not resu- ductive potential is a personal one. Anything less
me vaginal intercourse until her discharge is no than a totally voluntary decision is an infringement
longer bloody. She can start the Pill 14 days after on human rights. The denial of safe sterilization for
the abortion. She should wait until her period to have religious or political reasons is equally unaccept-
an IUD inserted. The diaphragm fit should be ve- able.
rified before using it.
If there was much bleeding during the abortion,
she should have a blood test for anemia.
She should make a follow-up appointment within
6 weeks.
Because of its similarity to a full term delivery,
a late abortion can be a stressful experience. Some
depression afterwards might be expected.

Cost
In Quebeca doctor is paid $65 by the government
health insurance for performing an abortion. Hos-
pital costs are also paid. Doctors working in private
clinics are also paid $65 by the health plan, but
"clinic costs" are charged to the client and range
from $150 to $350.
In the USA the cost of abortion varies greatly. In
PAGE 46
Male sterilization: vasectomy
Action
In a vasectomy, the vas deferens which normally
carries sperm from each testicle is cut. Sperm
continue to be produced but are no longer carried
along the vas to become part of the seminal fluid.
If there are no sperm in the semen, the man's
partner cannot get pregnant.
Effectiveness
A vasectomy is not immediately effective.
take several months (or about 15 ejaculations) for
the sperm transport system to be completely cleared
of sperm. A man must have his semen examined
surgery. He or his
weeks
for sperm at 8 after
partner continues to use birth control until two tests
show no sperm in the semen.
Vasectomy is not 100% effective. Occasionally the
cut ends rejoin and sperm are carried into the
semen again. Researchers are using
to block the vas in an attempt to make vasectomy
reversible. These experimental
have greater failure rates than traditional methods.
Effect on sexuality
A vasectomy has no direct effect on a man's se-
xuality. Sperm make up only 10% of seminal fluid;
when a man ejaculates the amount of liquid and the
sensation are not appreciably changed. Hormone
levels do not change after vasectomy.
Effect on health
Immediately after surgery, a man can expect some
uncomfortable swelling of the scrotum. Bleeding and
infection can occur. Signs of infection are increased
swelling and discomfort, possibly accompanied by
fever. Treatment with drainage and/or antibiotics
is effective.
Fewlong term complications are known. Sperm
production continues; the sperm dissolve and are
reabsorbed. There has been much publicity about the
formation of sperm antibodies. The body produces
antibodies in its defence against disease but less
often against its own tissue. To date no danger has
been found. However these antibodies may affect the
quality of sperm, reducing the possibilities of suc-
cessful reversal of a vasectomy.
Effect on future fertility
a man impregnates a woman because he has not
If
waited long enough following the vasectomy, or if
the ends of the vas rejoin, the baby will not be af-
fected.
If man who has had a vasectomy wishes to
a
father a child, he may undergo surgery to try to
join up the vas again. Surgeons vary in their rate
of success at vasectomy reversal. There is some
question whether the man will still be producing
It can sufficient sperm of quality to become fertile.
Use
Vasectomies are performed in private offices,
clinics, and outpatient departments of hospitals. Ask
to be referred to someone who performs many
vasectomies.
Arrange to take 2 days off from work. Ask some-
one to be available to drive you home. The doctor
new techniques should give instructions for the day of surgery re-
garding bathing, and trimming or shaving the pubic
techniques can hair.
During the operation, the man lies on his back.
The genitals are washed with antiseptic solution,
and sterile drapes cover the thighs and abdomen
leaving only the genitals exposed.
The doctor injects local anesthetic into the wair
of the scrotum just over the vas on one side. The
man may feel a stinging sensation but the anesthetic
takes effect almost immediately. The doctor makes
an incision in the scrotum, exposing the vas. The
vas is cut and the ends are tied, clipped, burned
or plugged. The incision is closed with absorbable
sutures. The procedure is repeated on the other
side.
The man rests a few moments on the table. When
he feels ready he can go home. He should be given
the following post-operative instructions:
Expect some discomfort from swelling and bruis-
ing of the scrotum. Use an icepack and aspirin for
the first two days. Wear a scrotal support for as
long as it gives relief. After 48 hours, a warm bath
several times a day is comforting. Do not bathe
or shower for two days. Sexual activity can be re-
sumed in 2 to 3 days or when comfortable. No
strenuous exercise or lifting for at least a week.
Be alert for signs of infection or bleeding: increas-
ed increased pain, fever, chills. Call the
swelling,
doctor if you are concerned. Continue using con-
traception until you have had two negative sperm
counts.
At the follow-up appointment one week later, the
doctor examines the scrotum to make sure all is
healing well. An appointment for a sperm count is
made at 8 weeks following surgery. The man eja-
culates into a clean container. The semen is examin-
ed under the microscope for sperm. When there are
no sperm in the semen on two consecutive examina-
tions, the man can depend on the vasectomy for
permanent contraception.
Cost
In Quebec, a doctor is paid $45 for performing a
vasectomy. Usually all costs are covered by public
health insurance; private clinics still charge a fee
for use of the clinic.
 PAGE 47

Female sterilization

Action
All methods of female sterilisation are based on
the same principle: if the Fallopian tubes are block-
ed, sperm cannot reach an egg to fertilize it.
j
Cutting and tying the tubes is the basis of female
sterilization; with modern techniques the tubes may
also be burned, clipped or amputated. The different
types of female sterilization depend on how the tubes
are reached: mini-laparotomy - through an incision
smaller than 3 cm in the abdominal wall; lapa-
roscopy - passing a telescope-like, instrument
through a very small incision in the abdomen; cul-
potomy - through an incision in the lower wall of the
vagina; and hysteroscopy - passing a telescope-
like instrument through the cervix into the uterus.
Hysterectomy, the removal of the uterus, also
makes a woman sterile. Hysterectomy is major
surgery and has a long recovery period. Unless
there are serious medical reasons for removing the
uterus, sterilization should be accomplished by
some other means.
Many sterilizations are performed during cese-
rean delivery or within a few days after a vaginal '

ju r;4i .^. <X

delivery. Often the gynecologist suggests steriliza-

tion to the woman for the first time while she is in
Tubal ligation
labour. This is not the time to make such a perma-
nent decision. Unless the woman has made her deci-
sion in advance, we recommend postponing steriliz- Infection is a greater problem when sterilization
ation for several months after delivery. is done through the vagina.
Bleeding can be a problem in any operation.

Effectiveness Infection of the bladder occurs occasionally fol-

A woman should continue contraception until the lowing any procedure in which the bladder is cathe-
time of surgery. A pregnancy test should be done to terized.
guarantee that the woman is not pregnant at the time All the above complications occur during or
of

of surgery. Some
doctors do a curettage at the same soon is less clear whether or not
after surgery.
It

time as sterilization; if the woman has used contra- sterilization causes any long term health problems.
ception this is unnecessary and may increase com- The medical profession, so pleased with the reduc-
plications. tion in the surgical complications of sterilization,
Female sterilization is immediately effective. seems reluctant to investigate the possibility of
When the woman resumes sexual activity she can later complications.
depend on her sterilization to provide permanent
birth control. Effect on fertility
Sterilization is not 100% effective. The cut ends of If a woman becomes pregnant because of a failure

the tube can rejoin permitting fertiliza-

Fallopian of tubal ligation, the baby is not affected.
tion.The only way a woman can know this is if she Many doctors will try to reconnect the ends of
becomes pregnant. If a woman who has been steriliz- the Fallopian tubes in women who desire fertility
ed misses more than one period she should have a after sterilization. The success rate is low.
pregnancy test.
Use
Effect on health When a woman wants a sterilization, she should
Each method of sterilization carries a certain risk have a complete examination to determine how she
of complications. The surgeon's experience with the will react to general anesthesia, and to detect any
method influences the complication rate. factors which might influence which method is better
Sterilization is usually performed under general for her. A woman who has had any previous
anesthesia which itself carries a small risk of abdominal surgery or gynecological problem which
death, especially for women who have heart or lung would cause scarring in the pelvis is not a good
disease. candidate for sterilization through the laparoscope
Some complications are common to all methods nor through the vagina.
and some are more common for a particular me- If a woman has a strong preference for a certain

thod. Injury to organs other than the Fallopian
tubes occurs more often with the laparoscope; it is
sometimes necessary to open the abdomen to repair
the damage. The gas used in laparoscopy can cause
discomfort after the operation. Rarely it is accident-
ally injected into a blood vessel which can be fatal.
method, she should find a doctor who has experience
with that method. If the woman has confidence in a
particular doctor, she should respect the doctor's
choice of method. The doctor's experience with the
method is an important factor in reducing side
effects.
PAGE 48
The woman should arrange to take a few days to
a week off work and to have some help around the
house.
Prior to surgery, the woman wiii be sent for tests:
chest cardiogram, and blood tests. If the
X-ray,
woman is admitted to hospital, these are usually
done the day before surgery. Although many centers
keep the woman overnight, some centers do lapa-
roscopic sterilizations on an outpatient basis. The
woman should make sure she knows the procedure
of the hospital. If she is to come in only the morning
of surgery, she should be given instructions regard-
ing any pre-operative preparations.
Prior to surgery, the woman is usually given a
sedative to help her relax. In the operating room,
the anesthetist will put her to sleep usually by an
injection in the intraveinous solution. The anesthe-
tist puts a tube down her throat and attaches a ma-
chine which will control her breathing and keep her
asleep.
Sterile technique is used in all sterilization me-
thods. In a mini-iaparotomy an incision of less than
3 cm is made in the abdomen. A rod placed in the
uterus from the vagina permits movement of the
uterus so that the tubes are brought in front of the
incision. Each tube in turn is cut, tied, burned or
clipped. The incision is closed with sutures.
In a laparoscopy, a smal! incision is made just
beneath the belly button. A tube is inserted into the
abdomen and carbon dioxide or an equivalent gas is
pumped into the abdomen. The gas expands the abdo-
men and improves the visibility. The tube is remov-
ed and replaced with a telescope-like instrument
called a laparoscope. Surgical instruments can be
passed with the laparoscope or through another
incision. Each tube is brought into view and burned,
cut or clipped. The instruments are removed and
the gas allowed to escape. The small incisions re-
quire a few sutures
In culpotomy, the woman positioned with her
is
legs in stirrups. A large speculum is placed in the
vagina. An incision is made deep in the vagina.
Each tube is brought into view, cut and tied. The
incision is repaired with absorbable sutures.
In hysteroscopy a telescope-like instrument is
passed through the cervical canal into the uterus.
When the opening to the tube is located, it is blocked
by one of several methods. Hysteroscopy is still
experimental; at present its failure rate is high.
The woman wakes up in a recovery room. Her
throat may be sore from the breathing tube. She
may have some abdominal pain. If she had a lapa-
roscopy, she may have some shoulder pain caused
by the gas.
Instructions after surgery vary depending on the
method: Rest at home for at least 2 or 3 days.
Women vary in the time necessary to recover from
a general anesthetic. Avoid strenuous work for at
least a week. Resume sexual activity within about a
week or as desired. Penetration is postponed
longer following vaginal sterilization. Shower
bathe as desired. Use a mild analgesic such as a
pirin tor abdominal discomfort. The stitches
dissolve by themselves. If you have increasing pain,
fever, bleeding from the incision, fainting spells,
or pain on urinating, call the doctor. Otherwise have
a follow-up examination in a month.
Cost
In Quebec a gynecologist is paid $85 for per-
forming female sterilization.