Women's Health Exam 2
battle over birth control: the oral contraceptive pill
contraception: not a new concept
egypt 1850 BCE
arcadia leaves and honey
animal dung
greece 4th century
spermicides: olive and cedar oil
17th century, condoms
pre-industrial
douches
elixir to miscarry
changes in modern contraceptives
1839: Goodyear improves condom manufacturing through the vulcanization of rubber
early 1870s: contraceptives available by mail, vendors, pharmacies
condoms, douching materials, vaginal sponges, cervical caps, “womb veils”
anti-contraceptive laws
1873: created the New York Society for the Suppression of Vice
sale and distribution of obscene materials since the 19th century
Comstock Law
illegal to send an “obscene, lewd, and/or lascivious” materials through the mail, including contraceptive devices and information
defined contraceptives as obscene
comstock laws
24 states enact their own comstock laws
massachusetts
anyone disseminating contraceptives, or information about contraceptives faced a fine and imprisonment
connecticut
the act of using birth control is prohibited
married couples could face one year in prison
looked away in many cases, but laws on the books
challenges
1916: Margaret Sanger arrested for opening the first birth control clinic in the US
1918: women could use birth control for therapeutic purposes
1936: amendment, physicians could send now contraceptives across state lines. paved the way for more relaxing of birth control laws
margaret sanger
grew up in poverty
mother had 18 pregnancies, 7 miscarriages. died at 49 of TB and cervical cancer
1916 founded the first birth control clinic in Brooklyn
coined the term “birth control”
Women Rebel 1914
dream of creating “the pill”
enter the pill
why do we need the pill?
gender inequalities
higher efficacy
empowerment for women
sexual revolution
enter the workforce
control over motherhood
sexual freedom
gregory pincus
sanger meets gregory pincus
harvard scientist
1934, in-vitro fertilization of rabbits
Brave New World recently published
pincus labeled “Dr. Frakenstein” by new york times
denied tenure
john rock
medical doctor
devout catholic
seen as skeptical at first by sanger
later, critical advocate
believed the pill should be accepted by the church
took great risk to his career
witnesses problems in his practice
taught birth control to med students in the 1940s
katherine McCormick
graduated from MIT with a degree in biology
married stanley mccormick, heir to international harvester fortune
suffrage movement
committed to birth control with sanger
financed the pill research
initial studies
pincus conducts animal trials with progesterone. ovulation inhibited
population needed for a trial
GD Searle already had progesterone medications developed
large scale study conducted in Puerto Rico
no comstock laws
dense population
science seen as a good thing
catholic church rejects pill
rock argues hormones same as in the woman naturally
increasing “safe period”
Rock authors The Time Has Come: A Catholic Doctor’s Proposals to End the Battle Over Birth Control
church released Of Human Life
the pill
pill receives FDA approval in 1960
within 2 years, 500,000 prescribed
by 1965- 6 million on the pill
key component of the sexual revolution
by 1970, two-thirds of all catholic women and three-quarters of those under 30 were using the pill and other birth control methods banned by the church
pill decent
by the late 1960s, thousands of women were complaining of side effects
power and doctors at the time
1969 expose by barbara seaman
1970 hearings. no women to represent women
Alice wolfson
“why are 10 million women being used as guinea pigs?”
philip ball
“they used a sledge hammer to drive small nail.”
contraceptives as a social issue
social determinants of health
education access and quality
healthcare and quality
neighborhood and built environment
social and community context
economic stability
benefits (guttmacher, 2013)
a large and growing body of literature explores the health benefits related to services received at family planning clinics
research indicates that family planning, including planning, delaying and spacing pregnancies, is linked to improved birth outcomes for babies, either directly or through healthy maternal behaviors during pregnancy
contraceptive methods have a range of benefits other than their primary purpose of pregnancy prevention
contraception reduces pregnancy-related morbidity and mortality, reduces the risk of developing certain reproductive cancers
used to treat many menstrual-related symptoms and disorders
in addition to contraception, a range of other beneficial health services are available to clients at family planning clinics. services to prevent, screen for and treat diseases and conditions such as chlamydia, gonorrhea, HIV, HPV, and cervical cancer, as well as to address intimate partner violence, benefit both female and male clients who visit these clinics
because not all women have equal access to the many benefits of contraception and other health services, there is more work to be done in implementing programs and policies that advance contraceptive access and improve health outcomes for all women
contraceptive use in the US
nearly half of pregnancies in the US are unintended
intended, 51%
unintended: occur earlier than desired, 29%
unintended: occur after women have reached their desired family size, 20%
contraceptive need (guttmacher, 2018)
there are 61 million US women of reproductive age (15-44). about 43 million of them (70%) are at risk of unintended pregnancy- that is, they are sexually active and do not want to become pregnant, but could become pregnant if they and their partners fail to use a contraceptive method correctly and consistently
couple who do not use any method of contraception have approx. an 85% chance of experiencing a pregnancy over the course of a year
in the US, the average desired family size is two children. to achieve this family size, a woman must use contraceptives for roughly three decades
contraceptive use (guttmacher, 2018)
more than 99% of women aged 15-44 who have ever had sexual intercourse have used at least one contraceptive method
some 60% of all women of reproductive age are currently using a contraceptive method
10% of women at risk of unintended pregnancy are not currently using any contraceptive method
the proportion of women at risk of unintended pregnancy who are not using a method is highest among those aged 15-19 (18%) and lowest among those aged 40-44 (9%)
intersectionality
unintended pregnancy rates are highest among low-income women (i.e., women with incomes less than 200% of the federal poverty level), women aged 18-24, cohabiting women and women of color
rates tend to be lowest among higher-income women (at or above 200% of poverty), white women, college graduates and married women
the rate of unintended pregnancy among women with incomes less than 100% of the poverty was 112 per 1,000 in 2011, more than 5 times the rate among women with incomes of at least 200% of poverty (20 per 1,000 women)
when used correctly, modern contraceptives are very effective at preventing pregnancy
among U.S. women at risk of unintended pregnancy, the 68% who use contraceptives consistently and correctly throughout the course of any given year account for only 5% of all unintended pregnancies
in contrast, the 18% who use contraceptives inconsistently account for 41% of unintended pregnancies, and the 14% who do not use contraceptives at all or have a gap in use of at least one month account for 54% of unintended pregnancies
in 2008, the 2/3 of us women at risk of pregnancy who used contraceptives consistently accounted for only 5% of unintended pregnancies
women report a variety of reasons for contraceptive nonuse
40%- problems accessing or using methods
19%- infrequent sex
18%- do not care if pregnancy occurs
7%- underestimate pregnancy risk
16%- other
dr. butler’s study
dr. butler conducted a study among 2,800 college students, 1584 had used a condom in the last year
variables
condom and safe sex product use
embarrassment
attitudes towards condom distribution programs
errors and problems
condom acquisition
most students were sexually active in the last year, 73% had vaginal sex, 76% oral sex, and 17%
58% had used a male condom in the last year, less than 1% female condoms, and 1% latex dams
errors and problems
57% wanted to have sex but did not have a condom available
56% does not typically squeeze the air out of condom
51% did not check the condom for visible damage
50% added condom after sex had begun
47% started sex with condom, removed condom, and continued having sex
43% problems with how condoms feel
30% condom slipped off during sex
30% condom broke during sex
26% initially applied condom the wrong side up and flipped it over
20% does not typically leave a space at the tip
20% problems with how condom fit
11% used a sharp object when opening condom package
8% used an oil-based lubricant
condom embarrassment
45% were embarrassed to ask a pharmacist about condoms, 27% embarrassed to purchase condoms at a drug store near campus, 21% to acquire them at the student health center, and 17% embarrassed to acquire them at the local health department
the condom as dual protection
some 5.5 million women rely on the male condom. condom use is most common (i.e., at least 25% greater than the national average of 15%) among 15-19 year olds, those who report their religious affiliation as “other,” those born outside of the U.S., college graduates, those who are uninsured and those who are nulliparous or are expecting at least one (more) child
ever-use of the male condom increased from 52%in 1982 to 93% in 2006-2010
dual method use offers protection against both pregnancy and STIs. some 8% of women of reproductive age simultaneously use multiple contraceptive methods (most often the condom combined with another method)
emergency contraceptives
1 in 9 sexually experienced women of reproductive age have used emergency contraception, as of 2010. the majority of these women used emergency contraception only once (59%)
use is highest among 20-24 year olds and never-married women, of whom 23% and 19%, respectively, report having ever used emergency contraception
ACHA, 2023
college students who reported having vaginal intercourse (penis in vagina) within the last 12 months were asked if they or their partner used emergency contraception (“morning after pill” or “plan b”) in the last 12 months:
17% cis men, 21.5% cis women, 21.3% trans/gender non-conforming
college students who reported having vaginal intercourse within the last 12 months were asked if they experienced an unintentional pregnancy or someone got pregnant within the last 12 months
0.9% cis men, 1% cis women, 1.9% trans/gender non-conforming
title x
health policy started by richard nixon in 1970
specifically designed to subsidize family planning and health services
grants provided to 4,500 health centers serving 5 million people
designed to help low income families, including those not eligible for medicaid
FY2016, congress appropriated around $327 million for the title x family planning program
funds cannot be used for abortions
nearly 90% also received preventive gyno attention, and over 50% were treated for STIs or reproductive tract infections or related conditions
in 2006, publicly funded family planning services (Medicaid, title x, and state funds) helped women avoid 1.94 million unintended pregnancies, thus preventing about 860,000 unintended births and 810,00 abortions
without publicly funded family planning services, the number of unintended pregnancies and abortions in the U.S. would be nearly two-thirds higher among women overall and among teens; the number of unintended pregnancies among poor women would nearly double
impact of public funding
altogether, the services provided at publicly funded family planning visits in 2010 resulted in a net savings to the federal and state governments of $13.6 billion. the services provided at title x-supported centers accounted for $7 billion of that total
in 2010, every $1.00 invested in publicly funded family planning services saved $7.09 in medicaid expenditures that would otherwise have been needed to pay the medical costs of pregnancy, delivery and early childhood care
scabies
what is scabies?
scabies is a mite which causes a skin rash, very itchy
the mite burrows its way into the skin
considered contagious, spreads easy among partners, families, schools, nursing homes, prisons, etc.
typically, you treat everyone who may have been exposed
key point
scabies is easily treated. medicated skin creams or pills kill the mites that cause scabies and their eggs
but itching may not stop for many weeks after treatment
typical locations on infections (adults)
between the fingers and toes
in the armpits
around the waist
along the insides of the wrists
on the inner elbows
on the soles of the feet
on the chest
around the nipples
around the belly button
around the genitals
in the groin area
on the buttocks
typical locations of infection (children)
fingers
face, scalp, and neck
palms of the hands
soles of the feet
causes (mayo clinic)
scabies is caused by a tiny, eight-legged mite. the female mite burrows just under the skin and makes a tunnel where it lays eggs
the eggs hatch, and the mite larvae travel to the surface of the skin, where they mature. these mites can then spread to other areas of the skin or to the skin of other people. itching is caused by the body’s allergic reaction to the mites, their eggs and their waste
close skin-to-skin contact and, less often, sharing clothing or bedding with a person who has scabies can spread the mites
pets don’t spread scabies to humans. the scabies mites that affect animals don’t survive or reproduce in people
however, coming in contact with an animal that has scabies may cause a brief itching if the mite gets under the skin. but within a few days, the mite will die, so treatment isn’t needed
complications
scratching too much can break your skin and cause an infection, such as impetigo
impetigo is an infection on the skin’s surface that’s caused most often by staph bacteria (staphylococci) or sometimes by strep bacteria (streptococci)
crusted scabies
a more severe type of scabies, called crusted scabies, may affect certain people including:
young children
people with developmental disabilities
people with weakened immune systems, such as those with HIV or lymphoma, or people who have had organ transplants
people who are very sick, such as people in hospitals or nursing facilities
older people in nursing homes
crusted scabies makes the skin crusty and scaly, and affects large areas of the body. it’s very contagious and can be hard to treat. quick treatment with both a prescription pill and a skin cream is needed
typically, someone with scabies has about 10 to 15 mites. but someone with crusted scabies may have millions of mites. yet itching may not occur or may be mild
prevention
to prevent scabies from coming back and to keep the mites from spreading to other people, take these steps:
wash all clothes and linen. heat kills the mites and their eggs. use hot, soapy water to wash all clothing, towels, and bedding used in the last three days before beginning treatment. dry with high heat. dry-clean items you can’t wash at home
starve the mites. place items you can’t wash in sealed plastic bags and leave them in an out-of-the-way place, such as your garage, for a week. mites die after a few days without food
clean and vacuum. it’s a good idea to clean your home to prevent scabies from spreading. this is especially true for people with crusted scabies. vacuum furniture, carpets and floors to remove scales and crusts that may have scabies mites
women’s health epidemiology: cervical cancer and the HPV vaccine
types of cervical cancer
the type of cervical cancer that you have helps determine your prognosis and treatment. the main types of cervical cancer are:
squamous cell carcinoma- this type of cervical cancer begins in the thin, flat cells (squamous cells) lining the outer part of the cervix, which projects into the vagina. most cervical cancers are squamous cell carcinomas
adenocarcinoma- this type of cervical cancer begins in the column-shaped glandular cells that line the cervical canal.
sometimes, both types of cells are involved in cervical cancer. very rarely, cancer occurs in other cells in the cervix
pre-cervical cancer conditions are extremely common
the american cancer society estimates for cervical cancer in the u.s. for 2020 are: about 13,800 new cases of invasive cervical cancer will be diagnosed
about 4,290 women will die from cervical cancer
survival rates
SEER stage → 5-year survival rate
localized- 92%
regional- 56%
distant- 17%
all SEER stages combined- 66%
causes of cervical cancer
healthy cells grow and multiply at a set rate, eventually dying at a set time. the mutations tell the cells to grow and multiply out of control, and they don’t die. the accumulating abnormal cells form a mass (tumor)
cancer cells invade nearby tissues and can break off from a tumor to spread (metastasize) elsewhere in the body
the role of human papillomavirus (HPV)
the common sexually transmitted infection
“normal” to be infected
incidence- 17 million
prevalence- 79 million
not always linked to cancers, it’s very confusing
signs and symptoms
early-stage cervical caner generally produces no signs or symptoms
signs and symptoms of more-advanced cervical cancer include
vaginal bleeding after intercourse, between periods or after menopause
watery, bloody vaginal discharge that may be heavy and have a foul odor
pelvic pain or pain during intercourse
risk factors
many sexual partners- the greater your number of sexual partners- and the great your partner’s number of sexual partners- the greater your chance of acquiring HPV
early sexual activity- having sex at an early age increases your risk of HPV
other STIs- having other STIs- such as chlamydia, gonorrhea, syphilis and HIV/AIDS- increases your risk of HPV
a weakened immune system- you may be more likely to develop cervical cancer if your immune system is weakened by another health condition and you have HPV
smoking- smoking is associated with squamous cell cervical cancer
exposure to miscarriage prevention drug- if your mother took a drug called diethystilbestrol (DES) while pregnant in the 1950s, you may have an increased risk of a certain type of cervical cancer called clear cell adenocarcinoma
long term use of oral contraceptives
age and cervical cancer
cervical cancer is most frequently diagnosed in women between the ages of 35 and 44 with the average age at diagnosis being 50
it rarely develops in women younger than 20
pre-cancer
cells in the transformation zone do not suddenly change into cancer. instead, the normal cells of the cervix first gradually develop abnormal changes that are called pre-cancerous
doctors use several terms to describe these pre-cancerous changes, including cervical intraepithelial neoplasia (CIN), squamous intraepithelial lesion (SIL), and dysplasia
when the pre-cancers are checked in the lab, they are graded on a scale of 1 to 3 based on how much of the cervical tissue looks abnormal
in CIN1 (also called mild dysplasia or low grade SIL), not much of the tissue looks abnormal, and it is considered the least serious cervical pre-cancer
in CIN2 or CIN3U (also called moderate/severe dysplasia or high-grade SIL) more of the tissue looks abnormal; high-grade SIL is the most serious pre-cancer
treatment (pre-cancer)
cryosurgery to freeze off the abnormal cervical tissue
LEEP (loop electrosurgical excision procedure) to burn off the abnormal cells with an electrical looped wire
surgery to remove the abnormal cells with a laser, scalpel, or both
treatment (cancer)
depending on the type and stage of the cancer, need more than one type of treatment may be needed
for the earliest stages of cervical cancer, either surgery or radiation combined with chemo may be used. for later stages, radiation combined with chemo is usually the main treatment. chemo (by itself) is often used to treat advanced cervical cancer
the HPV vaccine 527 emory and gc students
a study by gc alum for her masters thesis at emory
more than half (55.8%) of students reported they had initiated the HPV vaccine series (received at least one dose), and 80% of initiators completed the three dose series. among students who did not receive the HPV vaccine (non-initiators), only 4.5% reported they were planning to get it within the next year, while 50% reported they don’t plan to get it, and 45.5% were undecided
factors that would influence whether they got the vaccine
if a doctor encouraged you to
if a parent/guardian encouraged you
if the CDC guidelines recommended it
if there was an HPV vaccine awareness program on campus
if you talked to someone who had a good experience with it
our recent study
we assessed condom use among 2,809 students from 6 colleges and universities. we also measured other sexual health outcomes
47% of students have had a gynecological/testicular exam in the last year
54% of women vs 32% of men (p<.001)
70% have been vaccinated for HPV
73% of women vs 63% of men (p<.001)
37% have been tested for STIs in the last year
42% of women vs 26% of men (p<.001)
HPV vaccine
there were originally two different vaccinations (bivalent and quadrivalent)
currently there is a 9 valent vaccine (which is the one you want)
protection against cervical, vaginal, and vulvar cancers in females, anal cancer, certain head and neck cancers, such as throat and back of mouth cancers and genital warts
HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58 (18 and 18 account for 70% of the cancers)
Abortion: Social Issues and Considerations
Abortion Issues
Abortion in the US
at 2014 abortion rates, about one in four (24%) women will have an abortion by age 45
in 2017, there were 862,000 abortions in the US
more than half of all US abortion patients in 2014 were in their 20s: patients aged 20-24 obtained 34% of all abortions, and patients aged 25-29 obtained 27%
some 75% of abortion patients in 2014 were poor (having an income below the federal poverty level of $15,730 for a family of two in 2014) or low-income (having an income of 100-199%) of the federal poverty level)
when abortions occur
in 2016, two-thirds of abortions occurred at eight weeks of pregnancy or earlier, and 88% occurred in the first 12 weeks
abortion rates are at historic lows
the US abortion rate reached a historic low in 2017 (13.5)
closures in clinics
between 2011 and 2017, closures of clinics offering abortion were concentrated in the south and midwest, regions also enacted a slew of new abortion restrictions
roe v wade is overturned
dobbs v. jackson women’s health organization, in a 6-3 decision, the SCOTUS decides abortion is not a guaranteed right by the US constitution
before dobbs, georgia abortion law
in georgia, the following restrictions on abortion were in effect as of september 1, 2019:
a patient must receive state-directed counseling that includes information designed to discourage the patient from having an abortion, and then wait 24 hours before the procedure is provided
health plans offered in the state’s health exchange under the affordable care act can only cover abortion in cases of life endangerment or severely compromised physical health
abortion is covered in insurance policies for public employees only in cases of life endangerment
the parent of a minor must be notified before an abortion is provided
public funding is available for abortion only in cases of life endangerment, rape or incest
an abortion may be performed at 20 or more weeks postfertilization (22 weeks after the last menstrual period) only cases of life endangerment, severely compromised physical health or lethal fetal anomaly
battle over birth control: the oral contraceptive pill
contraception: not a new concept
egypt 1850 BCE
arcadia leaves and honey
animal dung
greece 4th century
spermicides: olive and cedar oil
17th century, condoms
pre-industrial
douches
elixir to miscarry
changes in modern contraceptives
1839: Goodyear improves condom manufacturing through the vulcanization of rubber
early 1870s: contraceptives available by mail, vendors, pharmacies
condoms, douching materials, vaginal sponges, cervical caps, “womb veils”
anti-contraceptive laws
1873: created the New York Society for the Suppression of Vice
sale and distribution of obscene materials since the 19th century
Comstock Law
illegal to send an “obscene, lewd, and/or lascivious” materials through the mail, including contraceptive devices and information
defined contraceptives as obscene
comstock laws
24 states enact their own comstock laws
massachusetts
anyone disseminating contraceptives, or information about contraceptives faced a fine and imprisonment
connecticut
the act of using birth control is prohibited
married couples could face one year in prison
looked away in many cases, but laws on the books
challenges
1916: Margaret Sanger arrested for opening the first birth control clinic in the US
1918: women could use birth control for therapeutic purposes
1936: amendment, physicians could send now contraceptives across state lines. paved the way for more relaxing of birth control laws
margaret sanger
grew up in poverty
mother had 18 pregnancies, 7 miscarriages. died at 49 of TB and cervical cancer
1916 founded the first birth control clinic in Brooklyn
coined the term “birth control”
Women Rebel 1914
dream of creating “the pill”
enter the pill
why do we need the pill?
gender inequalities
higher efficacy
empowerment for women
sexual revolution
enter the workforce
control over motherhood
sexual freedom
gregory pincus
sanger meets gregory pincus
harvard scientist
1934, in-vitro fertilization of rabbits
Brave New World recently published
pincus labeled “Dr. Frakenstein” by new york times
denied tenure
john rock
medical doctor
devout catholic
seen as skeptical at first by sanger
later, critical advocate
believed the pill should be accepted by the church
took great risk to his career
witnesses problems in his practice
taught birth control to med students in the 1940s
katherine McCormick
graduated from MIT with a degree in biology
married stanley mccormick, heir to international harvester fortune
suffrage movement
committed to birth control with sanger
financed the pill research
initial studies
pincus conducts animal trials with progesterone. ovulation inhibited
population needed for a trial
GD Searle already had progesterone medications developed
large scale study conducted in Puerto Rico
no comstock laws
dense population
science seen as a good thing
catholic church rejects pill
rock argues hormones same as in the woman naturally
increasing “safe period”
Rock authors The Time Has Come: A Catholic Doctor’s Proposals to End the Battle Over Birth Control
church released Of Human Life
the pill
pill receives FDA approval in 1960
within 2 years, 500,000 prescribed
by 1965- 6 million on the pill
key component of the sexual revolution
by 1970, two-thirds of all catholic women and three-quarters of those under 30 were using the pill and other birth control methods banned by the church
pill decent
by the late 1960s, thousands of women were complaining of side effects
power and doctors at the time
1969 expose by barbara seaman
1970 hearings. no women to represent women
Alice wolfson
“why are 10 million women being used as guinea pigs?”
philip ball
“they used a sledge hammer to drive small nail.”
contraceptives as a social issue
social determinants of health
education access and quality
healthcare and quality
neighborhood and built environment
social and community context
economic stability
benefits (guttmacher, 2013)
a large and growing body of literature explores the health benefits related to services received at family planning clinics
research indicates that family planning, including planning, delaying and spacing pregnancies, is linked to improved birth outcomes for babies, either directly or through healthy maternal behaviors during pregnancy
contraceptive methods have a range of benefits other than their primary purpose of pregnancy prevention
contraception reduces pregnancy-related morbidity and mortality, reduces the risk of developing certain reproductive cancers
used to treat many menstrual-related symptoms and disorders
in addition to contraception, a range of other beneficial health services are available to clients at family planning clinics. services to prevent, screen for and treat diseases and conditions such as chlamydia, gonorrhea, HIV, HPV, and cervical cancer, as well as to address intimate partner violence, benefit both female and male clients who visit these clinics
because not all women have equal access to the many benefits of contraception and other health services, there is more work to be done in implementing programs and policies that advance contraceptive access and improve health outcomes for all women
contraceptive use in the US
nearly half of pregnancies in the US are unintended
intended, 51%
unintended: occur earlier than desired, 29%
unintended: occur after women have reached their desired family size, 20%
contraceptive need (guttmacher, 2018)
there are 61 million US women of reproductive age (15-44). about 43 million of them (70%) are at risk of unintended pregnancy- that is, they are sexually active and do not want to become pregnant, but could become pregnant if they and their partners fail to use a contraceptive method correctly and consistently
couple who do not use any method of contraception have approx. an 85% chance of experiencing a pregnancy over the course of a year
in the US, the average desired family size is two children. to achieve this family size, a woman must use contraceptives for roughly three decades
contraceptive use (guttmacher, 2018)
more than 99% of women aged 15-44 who have ever had sexual intercourse have used at least one contraceptive method
some 60% of all women of reproductive age are currently using a contraceptive method
10% of women at risk of unintended pregnancy are not currently using any contraceptive method
the proportion of women at risk of unintended pregnancy who are not using a method is highest among those aged 15-19 (18%) and lowest among those aged 40-44 (9%)
intersectionality
unintended pregnancy rates are highest among low-income women (i.e., women with incomes less than 200% of the federal poverty level), women aged 18-24, cohabiting women and women of color
rates tend to be lowest among higher-income women (at or above 200% of poverty), white women, college graduates and married women
the rate of unintended pregnancy among women with incomes less than 100% of the poverty was 112 per 1,000 in 2011, more than 5 times the rate among women with incomes of at least 200% of poverty (20 per 1,000 women)
when used correctly, modern contraceptives are very effective at preventing pregnancy
among U.S. women at risk of unintended pregnancy, the 68% who use contraceptives consistently and correctly throughout the course of any given year account for only 5% of all unintended pregnancies
in contrast, the 18% who use contraceptives inconsistently account for 41% of unintended pregnancies, and the 14% who do not use contraceptives at all or have a gap in use of at least one month account for 54% of unintended pregnancies
in 2008, the 2/3 of us women at risk of pregnancy who used contraceptives consistently accounted for only 5% of unintended pregnancies
women report a variety of reasons for contraceptive nonuse
40%- problems accessing or using methods
19%- infrequent sex
18%- do not care if pregnancy occurs
7%- underestimate pregnancy risk
16%- other
dr. butler’s study
dr. butler conducted a study among 2,800 college students, 1584 had used a condom in the last year
variables
condom and safe sex product use
embarrassment
attitudes towards condom distribution programs
errors and problems
condom acquisition
most students were sexually active in the last year, 73% had vaginal sex, 76% oral sex, and 17%
58% had used a male condom in the last year, less than 1% female condoms, and 1% latex dams
errors and problems
57% wanted to have sex but did not have a condom available
56% does not typically squeeze the air out of condom
51% did not check the condom for visible damage
50% added condom after sex had begun
47% started sex with condom, removed condom, and continued having sex
43% problems with how condoms feel
30% condom slipped off during sex
30% condom broke during sex
26% initially applied condom the wrong side up and flipped it over
20% does not typically leave a space at the tip
20% problems with how condom fit
11% used a sharp object when opening condom package
8% used an oil-based lubricant
condom embarrassment
45% were embarrassed to ask a pharmacist about condoms, 27% embarrassed to purchase condoms at a drug store near campus, 21% to acquire them at the student health center, and 17% embarrassed to acquire them at the local health department
the condom as dual protection
some 5.5 million women rely on the male condom. condom use is most common (i.e., at least 25% greater than the national average of 15%) among 15-19 year olds, those who report their religious affiliation as “other,” those born outside of the U.S., college graduates, those who are uninsured and those who are nulliparous or are expecting at least one (more) child
ever-use of the male condom increased from 52%in 1982 to 93% in 2006-2010
dual method use offers protection against both pregnancy and STIs. some 8% of women of reproductive age simultaneously use multiple contraceptive methods (most often the condom combined with another method)
emergency contraceptives
1 in 9 sexually experienced women of reproductive age have used emergency contraception, as of 2010. the majority of these women used emergency contraception only once (59%)
use is highest among 20-24 year olds and never-married women, of whom 23% and 19%, respectively, report having ever used emergency contraception
ACHA, 2023
college students who reported having vaginal intercourse (penis in vagina) within the last 12 months were asked if they or their partner used emergency contraception (“morning after pill” or “plan b”) in the last 12 months:
17% cis men, 21.5% cis women, 21.3% trans/gender non-conforming
college students who reported having vaginal intercourse within the last 12 months were asked if they experienced an unintentional pregnancy or someone got pregnant within the last 12 months
0.9% cis men, 1% cis women, 1.9% trans/gender non-conforming
title x
health policy started by richard nixon in 1970
specifically designed to subsidize family planning and health services
grants provided to 4,500 health centers serving 5 million people
designed to help low income families, including those not eligible for medicaid
FY2016, congress appropriated around $327 million for the title x family planning program
funds cannot be used for abortions
nearly 90% also received preventive gyno attention, and over 50% were treated for STIs or reproductive tract infections or related conditions
in 2006, publicly funded family planning services (Medicaid, title x, and state funds) helped women avoid 1.94 million unintended pregnancies, thus preventing about 860,000 unintended births and 810,00 abortions
without publicly funded family planning services, the number of unintended pregnancies and abortions in the U.S. would be nearly two-thirds higher among women overall and among teens; the number of unintended pregnancies among poor women would nearly double
impact of public funding
altogether, the services provided at publicly funded family planning visits in 2010 resulted in a net savings to the federal and state governments of $13.6 billion. the services provided at title x-supported centers accounted for $7 billion of that total
in 2010, every $1.00 invested in publicly funded family planning services saved $7.09 in medicaid expenditures that would otherwise have been needed to pay the medical costs of pregnancy, delivery and early childhood care
scabies
what is scabies?
scabies is a mite which causes a skin rash, very itchy
the mite burrows its way into the skin
considered contagious, spreads easy among partners, families, schools, nursing homes, prisons, etc.
typically, you treat everyone who may have been exposed
key point
scabies is easily treated. medicated skin creams or pills kill the mites that cause scabies and their eggs
but itching may not stop for many weeks after treatment
typical locations on infections (adults)
between the fingers and toes
in the armpits
around the waist
along the insides of the wrists
on the inner elbows
on the soles of the feet
on the chest
around the nipples
around the belly button
around the genitals
in the groin area
on the buttocks
typical locations of infection (children)
fingers
face, scalp, and neck
palms of the hands
soles of the feet
causes (mayo clinic)
scabies is caused by a tiny, eight-legged mite. the female mite burrows just under the skin and makes a tunnel where it lays eggs
the eggs hatch, and the mite larvae travel to the surface of the skin, where they mature. these mites can then spread to other areas of the skin or to the skin of other people. itching is caused by the body’s allergic reaction to the mites, their eggs and their waste
close skin-to-skin contact and, less often, sharing clothing or bedding with a person who has scabies can spread the mites
pets don’t spread scabies to humans. the scabies mites that affect animals don’t survive or reproduce in people
however, coming in contact with an animal that has scabies may cause a brief itching if the mite gets under the skin. but within a few days, the mite will die, so treatment isn’t needed
complications
scratching too much can break your skin and cause an infection, such as impetigo
impetigo is an infection on the skin’s surface that’s caused most often by staph bacteria (staphylococci) or sometimes by strep bacteria (streptococci)
crusted scabies
a more severe type of scabies, called crusted scabies, may affect certain people including:
young children
people with developmental disabilities
people with weakened immune systems, such as those with HIV or lymphoma, or people who have had organ transplants
people who are very sick, such as people in hospitals or nursing facilities
older people in nursing homes
crusted scabies makes the skin crusty and scaly, and affects large areas of the body. it’s very contagious and can be hard to treat. quick treatment with both a prescription pill and a skin cream is needed
typically, someone with scabies has about 10 to 15 mites. but someone with crusted scabies may have millions of mites. yet itching may not occur or may be mild
prevention
to prevent scabies from coming back and to keep the mites from spreading to other people, take these steps:
wash all clothes and linen. heat kills the mites and their eggs. use hot, soapy water to wash all clothing, towels, and bedding used in the last three days before beginning treatment. dry with high heat. dry-clean items you can’t wash at home
starve the mites. place items you can’t wash in sealed plastic bags and leave them in an out-of-the-way place, such as your garage, for a week. mites die after a few days without food
clean and vacuum. it’s a good idea to clean your home to prevent scabies from spreading. this is especially true for people with crusted scabies. vacuum furniture, carpets and floors to remove scales and crusts that may have scabies mites
women’s health epidemiology: cervical cancer and the HPV vaccine
types of cervical cancer
the type of cervical cancer that you have helps determine your prognosis and treatment. the main types of cervical cancer are:
squamous cell carcinoma- this type of cervical cancer begins in the thin, flat cells (squamous cells) lining the outer part of the cervix, which projects into the vagina. most cervical cancers are squamous cell carcinomas
adenocarcinoma- this type of cervical cancer begins in the column-shaped glandular cells that line the cervical canal.
sometimes, both types of cells are involved in cervical cancer. very rarely, cancer occurs in other cells in the cervix
pre-cervical cancer conditions are extremely common
the american cancer society estimates for cervical cancer in the u.s. for 2020 are: about 13,800 new cases of invasive cervical cancer will be diagnosed
about 4,290 women will die from cervical cancer
survival rates
SEER stage → 5-year survival rate
localized- 92%
regional- 56%
distant- 17%
all SEER stages combined- 66%
causes of cervical cancer
healthy cells grow and multiply at a set rate, eventually dying at a set time. the mutations tell the cells to grow and multiply out of control, and they don’t die. the accumulating abnormal cells form a mass (tumor)
cancer cells invade nearby tissues and can break off from a tumor to spread (metastasize) elsewhere in the body
the role of human papillomavirus (HPV)
the common sexually transmitted infection
“normal” to be infected
incidence- 17 million
prevalence- 79 million
not always linked to cancers, it’s very confusing
signs and symptoms
early-stage cervical caner generally produces no signs or symptoms
signs and symptoms of more-advanced cervical cancer include
vaginal bleeding after intercourse, between periods or after menopause
watery, bloody vaginal discharge that may be heavy and have a foul odor
pelvic pain or pain during intercourse
risk factors
many sexual partners- the greater your number of sexual partners- and the great your partner’s number of sexual partners- the greater your chance of acquiring HPV
early sexual activity- having sex at an early age increases your risk of HPV
other STIs- having other STIs- such as chlamydia, gonorrhea, syphilis and HIV/AIDS- increases your risk of HPV
a weakened immune system- you may be more likely to develop cervical cancer if your immune system is weakened by another health condition and you have HPV
smoking- smoking is associated with squamous cell cervical cancer
exposure to miscarriage prevention drug- if your mother took a drug called diethystilbestrol (DES) while pregnant in the 1950s, you may have an increased risk of a certain type of cervical cancer called clear cell adenocarcinoma
long term use of oral contraceptives
age and cervical cancer
cervical cancer is most frequently diagnosed in women between the ages of 35 and 44 with the average age at diagnosis being 50
it rarely develops in women younger than 20
pre-cancer
cells in the transformation zone do not suddenly change into cancer. instead, the normal cells of the cervix first gradually develop abnormal changes that are called pre-cancerous
doctors use several terms to describe these pre-cancerous changes, including cervical intraepithelial neoplasia (CIN), squamous intraepithelial lesion (SIL), and dysplasia
when the pre-cancers are checked in the lab, they are graded on a scale of 1 to 3 based on how much of the cervical tissue looks abnormal
in CIN1 (also called mild dysplasia or low grade SIL), not much of the tissue looks abnormal, and it is considered the least serious cervical pre-cancer
in CIN2 or CIN3U (also called moderate/severe dysplasia or high-grade SIL) more of the tissue looks abnormal; high-grade SIL is the most serious pre-cancer
treatment (pre-cancer)
cryosurgery to freeze off the abnormal cervical tissue
LEEP (loop electrosurgical excision procedure) to burn off the abnormal cells with an electrical looped wire
surgery to remove the abnormal cells with a laser, scalpel, or both
treatment (cancer)
depending on the type and stage of the cancer, need more than one type of treatment may be needed
for the earliest stages of cervical cancer, either surgery or radiation combined with chemo may be used. for later stages, radiation combined with chemo is usually the main treatment. chemo (by itself) is often used to treat advanced cervical cancer
the HPV vaccine 527 emory and gc students
a study by gc alum for her masters thesis at emory
more than half (55.8%) of students reported they had initiated the HPV vaccine series (received at least one dose), and 80% of initiators completed the three dose series. among students who did not receive the HPV vaccine (non-initiators), only 4.5% reported they were planning to get it within the next year, while 50% reported they don’t plan to get it, and 45.5% were undecided
factors that would influence whether they got the vaccine
if a doctor encouraged you to
if a parent/guardian encouraged you
if the CDC guidelines recommended it
if there was an HPV vaccine awareness program on campus
if you talked to someone who had a good experience with it
our recent study
we assessed condom use among 2,809 students from 6 colleges and universities. we also measured other sexual health outcomes
47% of students have had a gynecological/testicular exam in the last year
54% of women vs 32% of men (p<.001)
70% have been vaccinated for HPV
73% of women vs 63% of men (p<.001)
37% have been tested for STIs in the last year
42% of women vs 26% of men (p<.001)
HPV vaccine
there were originally two different vaccinations (bivalent and quadrivalent)
currently there is a 9 valent vaccine (which is the one you want)
protection against cervical, vaginal, and vulvar cancers in females, anal cancer, certain head and neck cancers, such as throat and back of mouth cancers and genital warts
HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58 (18 and 18 account for 70% of the cancers)
Abortion: Social Issues and Considerations
Abortion Issues
Abortion in the US
at 2014 abortion rates, about one in four (24%) women will have an abortion by age 45
in 2017, there were 862,000 abortions in the US
more than half of all US abortion patients in 2014 were in their 20s: patients aged 20-24 obtained 34% of all abortions, and patients aged 25-29 obtained 27%
some 75% of abortion patients in 2014 were poor (having an income below the federal poverty level of $15,730 for a family of two in 2014) or low-income (having an income of 100-199%) of the federal poverty level)
when abortions occur
in 2016, two-thirds of abortions occurred at eight weeks of pregnancy or earlier, and 88% occurred in the first 12 weeks
abortion rates are at historic lows
the US abortion rate reached a historic low in 2017 (13.5)
closures in clinics
between 2011 and 2017, closures of clinics offering abortion were concentrated in the south and midwest, regions also enacted a slew of new abortion restrictions
roe v wade is overturned
dobbs v. jackson women’s health organization, in a 6-3 decision, the SCOTUS decides abortion is not a guaranteed right by the US constitution
before dobbs, georgia abortion law
in georgia, the following restrictions on abortion were in effect as of september 1, 2019:
a patient must receive state-directed counseling that includes information designed to discourage the patient from having an abortion, and then wait 24 hours before the procedure is provided
health plans offered in the state’s health exchange under the affordable care act can only cover abortion in cases of life endangerment or severely compromised physical health
abortion is covered in insurance policies for public employees only in cases of life endangerment
the parent of a minor must be notified before an abortion is provided
public funding is available for abortion only in cases of life endangerment, rape or incest
an abortion may be performed at 20 or more weeks postfertilization (22 weeks after the last menstrual period) only cases of life endangerment, severely compromised physical health or lethal fetal anomaly