Talk:Emergency contraception/Archive 3

"No direct evidence"

"There is no evidence that direct access to ECPs without a prescription results in fewer unintended pregnancies than controlled access via prescription." Why not move this sentence to the section on efficacy or societal impact? It seems out of place in its current location (under "Legal/Ethical Controversies") as a summary of the political issues in the approval process. If the controversy is that the drug was approved in spite of an absence of efficacy data, that should probably get its own bullet point (i.e. separate from the political controversy) as well as a citation to someone raising that concern. MastCell 23:38, 7 November 2006 (UTC)

...I think it belongs there because it was one of the arguments made against OTC approval, in the actual controversy. The account of the controversy should probably reflect both sides of the argument/more of the con side, so that the cite I have included does not falsely appear to be the only against-argument. I have waded through some of the FDA dockets submitted pro/con, and there was a NEJM article giving both sides of the issue. The "other side" makes some compelling arguments against self-medicating--in the "actual use" study conducted at PP, 28% of women "didn't understand the directions" and some used EC even though it was contraindicated for them. (That same study has been claimed for both sides, with one side saying "most women self-administered correctly, therefore it should be available OTC" and the other saying "28% did not, therefore it shouldn't be available OTC") Also point about ectopic pregnancy, and danger of women not under medical supervision not noticing or seeking help or able to self-diagnose ectopic/danger of not self-diagnosing or seeking help in time, when time is critical. (More on ectopic from the product insert and the updated physician's warning re Levonelle shoudd be in article elswhere...)Anyway, I think at least a few points made by the anti-OTC side should be included for balance. Aside from any opinions you or I may have of the merits of the arguments on the opposing side in real-world debate, it should be a report of the actual real world debate, right? The opposing arguments are largely made by pro-lifers/the sources to cite are pro-life. But, pro-lifers are a huge "POV with adherents," and the OTC debate did have more than one side to it. For a neutral account, their POV should be included/they should be cited as sources-- even by us pro-choicers. Cindery 00:56, 8 November 2006 (UTC)

Sure... If you have some of the relevant cites, go for it. Otherwise I'll get around to digging through my old NEJM's. It might make sense to split the political controversy and the medical issues into 2 separate bullet points. MastCell 06:12, 8 November 2006 (UTC)

Perhaps simple solution is to say, right after --"FDA advisory committee..." --"Arguments submitted to the FDA against were blahblahblah. Arguments in favor were blahblahblah." (Main arguments TBD.) Then maybe Susan Woods' resignation over "abortion politics" could be mentioned--that clarifies what the big deal was about--and then the news story re the Raine study--both extremely briefly. They were both big-news events which occurred after initial pro-con arguments were made, actually. This would remove Raine study from appearing to be the "conclusion."

Not a directly related point, and minor, but: I think there should be a slight tweak to the reason given by the FDA--"experimental data" could be confusing for a reader who is not highly familiar with the subject--could it say something more like "insufficient evidence to conclude that EC could be used safely by adolescents without medical supervision"? (I think that is the actual FDA quote...) I think also "ostensibly" is overly leading/not encyclopedic style/not necessary--you cast enough doubt on the truthfulness of FDA's claims with sworn testimony, etc. "FDA stated" or "The stated reason given by the FDA" is probably better? First give their stated reason, then raise doubts/cast valid aspersions on it. (point-counterpoint instead of counterpoint-counterpoint. set 'em up and knock 'em down. Can't really knock 'em down if you don't set 'em up first, right? :-) I think "ostensibly" takes the drama out of the refutation provided by sworn testimony...(plus it's not really neutral to interpret the validity of their statement while giving it, rather than quote them.)

Also: I think "risky sex" shouldn't be jumbled into "related studies and statistics"--it should have its own little section that goes something like "Data on the relationship between increased sexual risk taking behavior and EC access either by prescription or OTC is inconsistent and inconclsuive. Some studies show a correlation, some do not. In Sweden and the UK, blahblah. In the US, the issue has been hotly debated viz OTC access for teens (insert idiotic orgy hype made up by Woodcock here), but a US study has shown that teens are not any more likely to engage in risky sex with OTC access than older people are." (Hence the studies will be organized so they make more sense to the reader, and it is another place where an aspect of the US controversy can be explained/put into context.) Cindery 22:49, 8 November 2006 (UTC)

Plan B and race in prescribing info

"No formal studies have evaluated the effect of race. However, clinical trials demonstrated a higher pregnancy rate in the Chinese population with both Plan B and the Yuzpe regimen (another form of emergency contraception consisting of two doses of ethinyl estradiol 0.1 mg + levonorgestrel 0.5 mg). The reason for this apparent increase in the pregnancy rate of emergency contraceptives in Chinese women is unknown."

I'm confused--is this/the reason for stating this in the prescribing info explained more anywhere else? A search of Cochrane database only reports that most of the efficacy trials took place in China, not a difference between progestin pharmokinetics in Asian/Chinese women and other women. (Most recent research on DMPA pharmokinetics and Asian women is that there is no difference between Asian/Caucasian...) But, I am not a progestin-pharmokinetics-by-race expert... Cindery 01:57, 9 November 2006 (UTC)

Preven prescribing info

This is the pdf: [1]--I don't know how to format it as ref, but it should probably go after "Until 1998, the Yuzpe regimen was believed to prevent at least 75% of expected pregnancies." Cindery 02:28, 9 November 2006 (UTC)

Markup is along lines of:

<ref name="Preven">{{cite web | author=Gynetics Inc | title=Preven Emergency Contraceptive Kit | url=http://www.fda.gov/cder/foi/label/1998/20946lbl.pdf | format=PDF| work=Product labels | date=9 Jan 1998 | publisher= FDA | accessdate=2006-11-09}}</ref>

Gynetics Inc (9 Jan 1998). "Preven Emergency Contraceptive Kit" (PDF). Product labels. FDA. Retrieved 2006-11-09.

:-) Yours David Ruben ^Talk 15:15, 9 November 2006 (UTC)

I don't think Yuzpe was ever widely believed to prevent 75% of expected pregnancies. When I was doing the PubMed searches to write the history section, there were lots of articles about "New pill could cut unintended pregnancies by half" and such - implying a 50% effectiveness, not 75%. Lyrl ^Talk _Contribs 23:35, 9 November 2006 (UTC)

the history of yuzpe effectiveness and "belief" goes like this:

• first efficacy rate, asserted by yuzpe himself, was 100%
• this was slightly adjusted to 95-100%, based on the 100 women=100 pregnanices "theory" of fertlitiy...
• the silvestre meta-analysis was published in 1991, showing failure rate of 44-100%, causing big controversy about how the previous 95-100% efficacy was calculated
• trussell subsequently accounted for the 8% and published rate of 75% (see ref 18)
• fda approved preven based on 75% efficacy (see ref 11--I haven't looked at PC4 prescribing info, etc)
• subsequent studies reported efficacy to be more like 57%, yuzpe dedicated products pulled from world markets, etc.

Cindery 23:55, 9 November 2006 (UTC)

differences among studies in abortion rates section

...epidemiological comparisons between EC use + abortion rate different from randomized controlled trial of individual users. Cindery 03:17, 10 November 2006 (UTC)

Sure, but they both support the point Glasier was making. In general, it's most useful to have primary study data first, then an expert/editorialist summarizing "what it means". This improves readability for the general reader. MastCell 19:52, 10 November 2006 (UTC)

...No, I don't think the different kinds of studies are clear to the general reader unless they are separated. Randomized controlled trial should go last because it is medically accepted standard of greater evidentiary value/and it offers explanation of why the abortion rates are not lower. (this explanation is given by Glasier, who states that the studies may show not just that abortion rates aren't lower, but that they may not be lower because EC efficacy may be a lot lower etc, as efficacy is "based on a lot of assumptions that are impossible to validate.")

Wash times

This section references many nonsci sources, and rightfully so--it's not strictly about the medical aspects of EC. "Pop sources should be avoided" not "never used"--the important thing is to evaluate them/when and where they used. In this case, the source situates/contextualizes the significance of the study socially-what did people say about it? at what time did it occur in the history of events being discussed? what did the study researchers say about it? It's an extremely useful source for the reader in this context. Cindery 20:09, 10 November 2006 (UTC)

The text writes "A study showed...", then a link to the study. Fine. Then there's also a link to the Wsh Times. There's nothing in the text about interpretations of the study (and the WA Times is hardly a non-partisan source). It's fine to include WA Times as a source, but it needs to be clear we're citing the WA Times, and not the study in question. The text doesn't make that clear, and the WA Times article added little to what was already there. Ideally, regardless of what's done elsewhere, we should "avoid citing the popular press" per WP:RS; since the WA Times article doesn't add to what's stated in the article text, it's a perfect time to avoid citing it. MastCell 20:20, 10 November 2006 (UTC)

There's nothing in the text about interpretations of the study--there doesn't need to be--what the text says is "In 2005...", indicating that the year has some significance, and the study is included at a specific point in a narrative context. The Wash Times evenhandedly quotes both sides, and Raine (including giveing Raine the last word). This whole section gives newspaper sources--it's about the social/political context of a medical issue. Cindery 20:35, 10 November 2006 (UTC)

I'm not arguing that the Wa Times article is misleading; I'm saying that it adds nothing in terms of verifiability to the sentence in question, and pushes the limits of WP:RS. If we approach this article with the goal of getting it to featured-article quality (which I think is a worthy goal for any article one works on), then the sources need to be tightened up to accord with WP:RS; that will be one of the first issues in the process. I have no problem citing newspapers on sociopolitical issues, or if there's no alternative when describing a study. However, if the sentence is a straight description of a study, and we've already referenced the study in question, then a popular-press source is both superfluous and discouraged by WP policy. MastCell 22:16, 10 November 2006 (UTC)

I don't think you really grasp WP:RS--most of the sources cited in the "US legal controversies section" are news sources.

The edit summary for the addition of Wash Times article was link-study-to-controversy: the one sentence and the placement in context both have a source, in other words. Wash Times explains how the study pertains to the controversy/is a source indicating placement-in-context. Not every reader will understand from reading the study that it had something to do with the controversy/occurred at a specific point in the controversy. (That article is an extremely informative/useful source, and was cited by NARAL...) Cindery 22:31, 10 November 2006 (UTC)

Yes, but the other news sources are used for current events. The sentence in question is the only one in which a news source is quoted as the citation for a medical study. Leaving aside my comprehension of WP:RS, and some significant issues on this page with WP:OWN, the problem is simple: the paragraph discusses the political controversy (i.e. the role of a pro-life constituency on the approval process, testimony that the decision to reject was made before the scientific analysis was even performed). The sentence in question, about the Raine study, is out of place. There could well be another paragraph about scientific controversy related to OTC approval, where said study would fit right in. I agree readers won't understand why the study is mentioned there; we should either improve the prose of the article to make that clearer, or (my preference) move it to a new section (on scientific controversy over OTC status) where it would be more at home. MastCell 01:22, 11 November 2006 (UTC)

Yes, but the other news sources are used for current events--no, all of the news sources are cited for "recent" events, beginning in 2003 and extending to 2006, including the 2005 news source re the Raine study. It's a simple concept: the medical study was a medical study and a news story. Hence two citations. The two political sides are quoted/addressed in the news story, locating the study in the political controversy. Cindery 01:40, 11 November 2006 (UTC)

What's lacking is any indication, in the article paragraph, of how the study in question bears on the political approval controversy. MastCell 01:44, 11 November 2006 (UTC)

It's possible you may think that because you define the controversy more narrowly than it existed in the real world. Cindery 02:34, 11 November 2006 (UTC)

barret and marshall

...that's where i remember the 24% from: 24% is the per-month/per-cycle pregnancy rate for random acts of intercourse, per Barret and Marshall in 1969. (Still, as Lyrl pointed out, the comparison between EC use once with unknown number of acts of intercourse is difficult comparison to make to intercourse-all-month with unknown number of acts. But, if you have random unprotected sex all month, there's a 24% risk of pregnancy. If you have random unprotected sex all month and used EC after every time, the risk would be greater than 24%. If you had unprotected sex all month and only used EC once at midcycle, the risk is 25%.

The user directions/fertility calculations still need to be included /addressed somewhere, I'm just not sure where. I did find American Assn of Pediatricians article which gives what I am guessing is the argument Lyrl was referring to--it says, more or less, midcycle fertility should be calculated into decision to take EC, but if date of LMP is unknown --and because date of ovulation can vary from person to person and cycle to cycle--there can be a risk of pregnancy any day. (But there's a big diff between "take after unprotected intercourse" and that...) Cindery 20:38, 10 November 2006 (UTC)

too much information

"Dr. John Jenkins, head of the FDA's Office of New Drugs, testified under oath than FDA Commissioner Mark McClellan had decided to reject the OTC application before the scientific analysis had been completed."

• we already have one example that makes the point that the center for reproductive rights/pro-choice side believes the FDA was influenced; one is enough

• there's mcclellan's rebuttal, which would make this way too long, but must be included (and inclusion would weaken/drown in wordiness a clear point about woodcock)--mclellan's rebuttal is a) that he did consider the scientific evidence b) that he left before the decision was made.

• this clutters the paragraph with names that aren't familiar to a lot of people, and it isn't a cross section of the most important names that could be mentioned (makes no sense to mention mclellan but not galson or eschenbach...)

• all depositions are sworn under oath--that's what a depostion is, and there's a wikilink to depostition already.

Cindery 01:57, 11 November 2006 (UTC)

I've shortened it, removed names, etc. There are two separate but related issues: decisions made before the scientific review, and the basis for that decision being a specific political agenda, so I've tried to condense it. MastCell 02:14, 11 November 2006 (UTC)

...except that the way have shortened it is false, POV, and possibly defamatory to living people:

"The Center for Reproductive Rights then filed a lawsuit regarding the approval process. In the depositions, senior FDA officials testified under oath that the decision to reject the OTC application was made even before the scientific analysis was complete, and that they were told the application had to be rejected "to appease the administration's constituents", but that it could be approved later"

• you have to include the rebuttals for NPOV and per rules on living people--both Woodcock and Mclellan say that didn't do or say those things, in their own sworn testimony. Mclellan's argument is pretty good/including him makes a weak case here--he left/didn't make any decisions. Since the decision came after the analysis, it will always be a mere allegation, anyway--there is no way to prove that, becasue they didn't issue decision before analysis, temporally.

• the way you have written it here falsely implicates all the FDA officials, and has a "they" which is undefined; gives false implications. Stick to giving one example, Woodcock--the link I provided to the CRR site that has all the other depositions, if readers want to learn more. Or summarize the CRR conclusion w/o giving examples.

Cindery 02:29, 11 November 2006 (UTC)

Ownership

I'm not sure how to put this in a way so as not to offend, given our history, but I think there are significant ownership issues with this page, and it would be worthwhile to review WP:OWN. Specifically, characteristics of ownership include the following:

• Minor edits concerning layout, image use, and wording are disputed on a daily basis by one editor
• The owner may patronize other editors, claiming that their ideas are interesting but that they lack the deep understanding of the article necessary to edit it

The article will only benefit by being open to other editors besides myself and Cindery. Although we probably both have a vision for how the page "should" look, it would probably be helpful to encourage more input from other editors, and to be a little less defensive and more open to ways in which the article can be altered/improved. This will be a necessity if the article is ever to reach featured-article quality. MastCell 02:12, 11 November 2006 (UTC)

...I also do not mean to offend, but, I invite you to ponder pov--and how you may not be optimally objective regarding the OTC controversy. It's possible you may be excessively argumentative out of frustration that the section is being npov'd; you seem to be very resistant to changes which give any other side of the controversy. It's not very much fun for me to give Janet Woodcock's statememt in her own defense, for example, but it has to be done for NPOV. The claims against her are allegations, and she's a living person...and it's not neutral to only give one side. Cindery 02:50, 11 November 2006 (UTC)

I have no problem with putting in Janet Woodcock's response, nor have I ever removed it or any other content that states Janet Woodcock's side. I agree it improves and balances the section, and I thank you for adding it. As far as being "excessively argumentative", I've made a few relatively minor changes to the article recently (reorder Glasier quote, re-added info on approval controversy with an updated source, removed non-RS citation), all of which have been immediately reverted by you. I think this article needs more editors; articles edited as a back-and-forth between only two editors are suboptimal (and run the risk of becoming argumentative). Articles owned entirely by one editor, in which all other editors have been essentially driven off, are often even worse. That's all I'm getting at. MastCell 03:05, 11 November 2006 (UTC)

No, you removed Woodcock's statement, and it is not currently in article. And you need to clarify who is saying what, rather than making blanket accusations in article against the whole FDA, from a partisan lawsuit which hasn't been resolved/is in progress.

"Rewording Glasier" is not a "minor" point--there were probably 40 pages of discussion.

Articles owned entirely by one editor, in which all other editors have been essentially driven off, are often even worse. That's all I'm getting at--that's uncivil at best, and is preciesly the sort of comment that makes other editors want to stay away. Cindery 03:24, 11 November 2006 (UTC)

I know Cindery doesn't want to hear this from me, but it is way too hard for me to keep track of all the changes with the history page blown up with dozens and dozens of minor and major changes mixed together over the past few days. I would suggest maybe using an external word processor to work up a new version, and makeonly a few edits at a time, not roughly 150 edits over the course of 10 days between basically 2 editors. My two cents on this issue generally. I haven't really been able to keep up with the specific conflicts because of this. Maybe that is my fault, but I know I am not alone in being a wikipedian-against-countless-edits-in-a-row.--Andrew c 03:30, 11 November 2006 (UTC)

I'm waiting for Cindery to wind down on the edits. I intend to continue to contribute to this article, but am not in a state of mind to maintain the level of energy necessary to co-edit with Cindery when she is on a mission. I haven't even looked at the article in about a week (though I read this Talk page); I don't want to get myself wound up over any changes I might disagree with. I kindof agree with MastCell on the ownership thing, and definitely with Andrew on how difficult it would be to try to follow the edits as they occur. But from past experience with Cindery I believe this is a temporary phenomenon, and that over the next few weeks this article will become more welcoming to other editors. In the end, the article will be better off because of this intense editing episode. See also eventualism. Lyrl ^Talk _Contribs 03:39, 11 November 2006 (UTC)

..yes, that is how i have edited when doing a major overhaul, to this and to mifepristone--short intense bursts, with major research. I prefer small edits over a large one, like Lyrl's Sept 30 edit, because I think large edits all at once are harder to decipher, and because I think points should be brought up one by one in advance on talkpage first/kept separate for clarity. In order to keep up, you would not just need to keep up with my edits, but in doing/following the research/refs behind them, which will take time--that's why smaller edits are easier to follow I think--because they are easier to trace later: if you look at the archaeology of the edit history, each edit summary describes what was done; it's not hard to find what you're looking for, what was changed by whom and why etc. I expect that it will take time for other editors to catch up in this article, so a clear trail is left. (No one checked the references re the Swedish study deleted by the anon for a month, for example...until I checked them. So checking refs/duplicating general and specific research on a major overhaul will take longer, I suppose. This article doesn't have many regular editors, esp. since Plan B was approved in Aug/interest waned, and not much collective effort has been made here in a while to research/go over/follow up on anyone's edits, major or minor...) Cindery 07:47, 11 November 2006 (UTC)

Re the Glasier edit, I didn't add or delete a word, just switched the order of two parts... i.e. a "minor edit concerning layout", which was immediately reverted. I've repeatedly said I feel this article could use more input from others besides me & Cindery; I'm not sure how this equates to "making other editors want to stay away". There are clearly other interested editors (Lyrl, Andrew c, David Ruben for instance). About the FDA stuff, I'm not citing a "partisan lawsuit". I'm citing sworn testimony, as reported by Reuters. It doesn't get much more reliable than that, given the threat of perjury. About Woodcock's statement, you first said the paragraph was too long and mentioned too many names. So I boiled it down to remove names and shorten it, and now am being accused of pushing a POV. I'm happy to try to reinsert McClellan's/Woodcock's testimony, but casting its removal as me trying to push an anti-FDA POV is inaccurate. MastCell 17:10, 11 November 2006 (UTC)

• David is on vacation

• the order of the parts on Glasier was the subject of 40pp of discussion

• you are misrepresenting the facts re the CRR lawsuit. I get the impresssion that you don't actually know that much about it, you're just copying from a single news article. It should be clear to readers that this is 1) ongoing litigation, which has not been resolved in favor of any side 2) the two cherrypicked cases--Mclellean and Woodcock--represent very few of the depositions., i.e., it is inaccurate and possibly slanderous to say "officials" in general and imply the whole FDA.

Woodcock would be a good single example, if you want to say, "CRR filed a lawsuit, and deposed FDA officials. In one deposition, a senior FDA scientist said. blah. In her own deposition, Woodcock said blah." Mclellan is a bad example, because the counterargument in his favor is lengthy--not just that he denies it, but that he was not FDA commsissioner when the decision was made. You're looking at the subject as "how to summarize the points i want to make from the news report of the depositions," not how to summarize them within the lawsuit. "The FDA made the decision without considering the scientific evidence" is an accusation the pro-choice side wants to make--but it isn't really supported by evidence, and would be impossible to prove. Mcclellan is not "the smoking gun" you seen to think he is--out of context, it seems that way. Now that I have looked up the lawsuit, it's obviously an extremely weak point.

re repetition, you should have omitted "sworn under oath," not deposition. "Sworn under oath" can mean in court or in a deposition, and is hence misleading to the reader. "Deposition" is the word you are looking for. Cindery 17:32, 11 November 2006 (UTC)

perhaps to clarfiy: the NPR headline, for example, was "Plan B depositions allege FDA politically motivated." and then tells us there were 2, in the opening sentence. It needs to be very clear that these are a tiny number of depositons, in which allegations are made in ongoing litigation which has not found for either side--they way you have presented it implies that there is "proof." Allegations, particularly ones made in ongoing litigation, are not proof of anything. A summary without names could be "The depostitons of two FDA officials allege that the FDA decision on Plan B was politically motivated. Depositions taken from other FDA officials do not indicate White House involvement." Cindery 18:14, 11 November 2006 (UTC)

Sigh. Instead of addressing the accusations of slander, and the assertion that I don't know what I'm talking about (I'm used to that one by now), I'll just say that I think your version looks fine and I'm happy with it. MastCell 20:17, 11 November 2006 (UTC)

I'm glad you like it. The conflation of the Houn and Jenkins quotes with the whole FDA was potentially libelous--to the FDA and to Jenkins and Houn, who made specific quotes about specific people. Omitting the testimony of Woodcock/McClellan falls under false light and POV, not really libel.

I'm not citing a "partisan lawsuit". I'm citing sworn testimony, as reported by Reuters. It doesn't get much more reliable than that, given the threat of perjury

• you excluded any mention of the sworn testimony of the other side/other living people, also reported in reuters
• you omitted the fact--reported in reuters--that the testimony comes from an in-progress lawsuit (brought by a partisan org) that has no disposition
• Perjury is contradicting one's sworn testimony. Perhaps you meant libelous. Libelous would be printing false/unsubstantied negative assertions. (That everyone in the FDA said what Houn says Woodcock said, or that anyone said so for example). "False light" and POV would be repeating allegations made by one side and not giving the other, and/or publishing allegations and not specifying they are allegations. I.e., it's not libel for Houn or Jenkins to say those things in a deposition, as court testimony is exempt from libel and slander. If anything Houn or Jenkins says is repeated in print, it is not similarly exempt and must be qualified as alleged, not distorted in any way etc.

News reports on aspects of ongoing legal cases generally overemphasize whatever is considered newsworthy at the moment (but, for legal reasons, they are always careful to include both sides to avoid casting one in a "false light," and not to assert allegations as fact). Things which may not be emphasized in news articles are more important to include in a general summary which is repeated in print than they may appear to be. If you have biases and you only look at one source, it's possible you may come to the conclusion that "I'm citing sworn testimony from Reuter's," when actually you are citing sworn testimony of only one side, and the source is a lawsuit, not "Reuter's." You might exclude the other side's sworn testimony because it wasn't as emphasized-- but if you reproduce only what seems to be emphasized in a single news source about a lawsuit, and exclude things from the same source which appear to be less emphasized, you run the risk of excluding crucially important info viz libel/false light and POV in a published summary. Cindery 00:58, 12 November 2006 (UTC)

Sigh. Instead of addressing the repeated accusations of slander, libel, POV violations, "false light", etc, your condescending tone, or the assertion that I don't know what I'm talking about (I'm used to that one by now), I'll just say that I think your version looks fine and I'm happy with it. MastCell 01:14, 12 November 2006 (UTC)

..you don't appear to know what you're talking about/understand what defamation is. (you don't even seem to know the difference between perjury and defamation...) I thought it kind to explain it to you, for future reference, instead of just telling you what you presented/how you presented it was defamatory, after I looked up the lawsuit/checked the refs. Newspapers are sued for repeating "sworn testimony" if they don't meet the standards of the "fair report" exemption under defamation tort--giving both sides, not giving any misleading information. Wikipedia could be sued; that information should have been removed a lot less lackadaisically by me/other people. Cindery 02:12, 12 November 2006 (UTC)

Since we agree on the content of the section in question, and you've reinforced the ownership issues I mentioned, I was going to let you take your last condescending shot at me and move on, but since you've seen fit to raise the specter of legal action, let me say this: I wrote here that "In the depositions, senior FDA officials testified under oath that the decision to reject the OTC application was made even before the scientific analysis was complete, and that they were told the application had to be rejected "to appease the administration's constituents", but that it could be approved later." This is a true statement. I'm not a lawyer, but I'm not aware of any jurisdiction in the U.S. where a true statement can be grounds for defamation. Truth is generally an absolute defence against libel, "fair report" notwithstanding. Again, I'm not a lawyer, but I think you should really be more careful about slinging legal accusations against people you're having a conflict with. MastCell 18:27, 12 November 2006 (UTC)

falsehoods in your above statement that I am obligated to correct:

• you made the accusation that it is "reinforcing ownership issues" to point/out explain that your edits were not NPOV and could be defamatory to living people--but your edits weren't NPOV and were in fact defamatory to living people.
• it is not "slinging legal accusations" to point out Wikipedia's policy regarding libel and living people.
• your above rewrite which leaves out names uses recognizable quotes which are attributable to two people about two other people; they are not statements made in general by "FDA officials" about the FDA. (The ref attached id's the quotes) What you wrote is a distortion which could be considered libelous.
• I very thoughtfully tried to explain it to you, but you didn't/don't seem to get it: if Houn and Jenkins make defamatory accusations in court documents, they are exempted from libel. Anyone who repeats the defamatory accusations in print is not similarly exempted. There is a "fair report/neutral report" exemption for reporters which allows them to republish defamatory accusations made in public proceeding/public controversy, as long as the report is "unbiased and accurate"--that means both sides are given, nothing is added or distorted, etc. States have a patchwork of statutes/cases are still argued all the time. (The laws of the state of Florida are in effect for Wikipedia.) The simpler kind of libel/defense to libel of "truth"--is it true they said those things?--does not apply to publishing or republishing defamatory accusations made in a public proceeding/controvery. For example, if you wrote a report of your local city council meeting, and you included quotes from one side of a controversy and not the other, the excluded side could sue for defamation, and you would not have a "neutral report" defense. And if a court found in favor of the CRR in CRR v FDA, the outcome could be reported all by itself, but during ongoing litigation, reporting only accusations made by one side is not neutral reporting (and is definitely not NPOV). The "neutral report privilege" is an example of the NPOV principle when it is in effect legally. (I got the impression from the way you worded your account the first time that the Houn/Jenkins testimony was from the GOA inquiry, which was settled. When I checked the ref and researched a litle/realized it was ongoing litigation, I realized there was a problem.)

Cindery 20:49, 12 November 2006 (UTC)

fair/neutral report privilege

Perhaps what is/was confusing for you is that you don't understand/I haven't adequately explained that Reuters' defense to publishing accusations made in depositions is not "truth"--they do not investigate the truth or falsehood of accusations; the exemption to the truth defense required for libel defense newspapers claim is the fair/neutral report exemption. So if you reproduce deposition accusations from a newspaper source, in order to piggyback on their neutral report exemption, you have to adopt it/reproduce that as well. The fair/neutral report exemption can exempt sources from liability for the truth or falsehood of accusations, which allows them to report that accusations were made without liability for whether or not the accusations are true, as long as the reports are unbiased, complete, do nothing to assert the accusations as true, but merely report on them, etc. If the report is not "fair and balanced," the exemption can be challenged/denied and the source then becomes liable for proving that the accusations are true/the source can be liable for defamation. In ongoing litigation, it would be impossible for Reuter's to prove that any accusations were true, as the courts have not ruled on the case yet, so reports can only be made under the fair/neutral report exemption/there is no possible "truth" exemption to be made. In short, the fair/neutral report exemption is specifically an exemption to the truth requirement viz libel defense. As long as reports are neutral/balanced, unproven accusations can be repeated and the source is not likely to be sued. If the report does not meet the standards of fair/neutral, it is no longer exempted from the requirement that it must be be true in order not to be libelous. Below are layman's descriptions of the requirements a report must meet in order to claim the truth exemption (not a libel exemption--the order would go, truth is a defense to libel, and fair report is an exemption to truth). (Note that "accurate" does not equal "true"--accurate would apply to attribution of a quote to a speaker and no other party, etc. Attributed to the "official record" means in the text of a deposition or the recorded minutes of a meeting, etc.)

Fair report or reporter’s privilege

Fair report or reporter’s privilege protects reports of official government proceedings & records if the reports are:

         1. accurate

         2. fair or balanced

         3. substantially complete

         4. not motivated by malice

Courts in some states have said the report must be attributed to the official record or meeting for privilege to apply.

First Amendment protection for neutral reportage of controversial charges

The charges must be:

   1. newsworthy and related to a public controversy,

   2. made by a responsible person or organization,

   3. made against a public official or public figure,

   4. accurately reported with opposing views, AND

   5. reported impartially. 

Cindery 03:17, 13 November 2006 (UTC)

Use of DES

"Use of DES as EC gradually decreased, but only long after its carcinogenic effects were known--the last US manufacturer of DES, Eli Lilly, did not cease production until 1997." This is a little misleading and unbalanced. It makes it sound like DES was still being handed out as EC through 1997, which is not backed up by the cited source and, I think, not the case. DES did remain on the market through 1997, and is still available (and used) through compounding pharmacies, for conditions such as prostate cancer. Even the cited source's statement reads, "Gradually use for other therapeutic purposes [i.e., not as EC] decreased and in the spring of 1997 Eli Lilly, the last, and predominant, manufacturer of DES in the United States ceased production." Certainly the use of DES as EC should have been stopped sooner, but the statement as written suggests it was negligently given through 1997 as EC. I can't find anything to suggest that this is the case, and the cited reference doesn't seem to support it, so I've changed the statement to read, "Use of DES as EC gradually decreased after its carcinogenic effects were known." MastCell 01:52, 14 November 2006 (UTC)

The cited source lists the "other theurapetic processes," (meaning other to "preventing miscarriage") and lists EC as primary among them. It also states that DES was used as EC after it was known to be transplacentally carcinogenic, and noted that since it was not 100% effective in preventing pregnancy, that was highly problemmatic. This source states "It (DES) was commonly used as a morning after pill on college campuses well into the 80s," but it is a subscription only source, and not as good a source as the one I provided in article from EEA. [2] If you can find a source that says there's no way DES was used as EC as late as 1997, please supply. Otherwise the implication that since Eli Lilly didn't cease production of DES for its "other therapeutic uses" and that also means EC isn't an inaccurate implication, since its other therapeutic uses included EC. I get the impression from another source that the use was off-label after a certain year, and for rape victims/college students, but can't locate the year. Glasier mentions DES as currently used in EC in 1991 (?) And the Silvestre meta-analysis reconfigured the efficacy for DES in 1991--meaning it was currently in use, as well as Yuzpe. Again, if you can find exact dates, please supply. Otherwise that source is the best available; cited content should not be deleted unless you have better citation which contradicts it, not because "I think it is not the case."

Cindery 02:41, 14 November 2006 (UTC)

This is the source [3] which seems to indicate, if I am reading correctly, that DES was appoved "once and only" in 1973 as EC (indicating that use occurred afterward indicated by other sources was off-label). (It also gives interesting parallels to later debates re EC. But, it's a student paper and gives out-of-date 1999 info re hormones and menopause). Glasier's paper on postovulatory contraception says stilbestrol no longer in US as of 1990, but doesn't indicate if that means not in use per labelling but in use off-label; and that does indicate labelled for use elsewhere--Europe dates would be helpful, also). Cindery 03:03, 14 November 2006 (UTC)

"Use of DES as EC gradually decreased after its carcinogenic effects were known."--I am going to leave years of use vague until more research is done,but I am going to correct this statement because it is flatly incorrect--per the source, DES was approved for use as EC after its carcinogenic effects were known. Cindery 03:06, 14 November 2006 (UTC)

This ref states that Eli Lilly put disclaimer on package in 1978 saying DES should not be used as postcoital contraception, but FDA did not withdraw approval. Also indicates it is in use anyway, as of 1992: PMID 12287765 Cindery 04:12, 14 November 2006 (UTC)

The freshman paper you mention is essentially unreliable; there are a number of parts that simply don't make any sense (the whole part about Evista, for example... "In addition to Evista, many other drugs used to treat osteoporosis contain 0.625mg of estrogen (in the form of DES)"???) I think you're correct that the Glasier paper (PMID 2225600) is a good reference, indicating that, at least as of 1990, DES was "no longer used in the U.S." as EC - pretty unequivocal. As far as cited content... having a reliable citation is necessary, but not sufficient, for inclusion in Wikipedia. I don't edit cited content lightly, but just because something has a ref after it doesn't mean it's off-limits for editing, improvement, or removal. MastCell 05:11, 14 November 2006 (UTC)

yes, i clearly stated that the student paper was a student paper/did not cite it as source in article or recommend that it be cited as a reliable source--all I mentioned it for re dates was that it seemed to support that use sometime after 1973 was/became off-label. The problem with citing Glasier as saying stilbestrol no longer in use in US as of 1990 is that it doesn't indicate if it is still being used off-label/not-as-labelled, and 1990 is contradicted by the 1992 source. Per the Lilly/1978 source, it doesn't seem that the FDA ever withdrew approval--what happened is Eli put a disclaimer on the package in 1978, but it was still used anyway, "well into the 80s," "until 1990" "as late as 1992" or "until Eli Lilly withdrew it in 1997," which would make some sense since that's about when Preven was approved. Again, any help/work you would like to do to supply dates for US, Europe, and the rest of the world would be appreciated. I don't edit cited content lightly--actually, you have a demonstrated habit of very hastily deleting cited content on flimsy pretexts that don't hold up or objecting to it without looking at it very carefully. But I don't mean to discourage you from doing research/finding citations--that would be extremely helpful, especially for finding all the exact international dates for DES as EC. Cindery 05:32, 14 November 2006 (UTC)

"DES may be currently prescribed as a "morning after" birth control pill to terminate an early pregnancy. If you are in an emergency situation, and are advised to use a "morning after" pill, you may wish to ask your doctor if he or she can prescribe a drug compound which does not contain DES."--this is dated 2006, from the Office of the Attorney General, State of California. (Although they also win the award for the most idiotic description of EC I have ever read: "does not prevent contraception" etc. Probably research into whether the FDA has ever withdrawn approval for DES as EC is necessary. Cindery 05:51, 14 November 2006 (UTC)

...and there's this: PMID 2309736 ---certainly if postcoital contraception for rape victims is defined as DES in US in 1990, it was in use. (I don't know where to put that ref, if at all--EC and sexual assault?--there's already a ref saying DES was "liberally" used as postcoital treatment for rape victims. Pharmacist contraversy?) Cindery 08:28, 14 November 2006 (UTC)

The Glasier paper says DES is "no longer used in the U.S" as EC as of 1990. That's fairly unequivocal. We can speculate about off-label use, but unless there's some clear and reliable evidence that Glasier is wrong, that speculation should probably stay out of the article. The California Attorney General's website should not be construed as trumping a peer-reviewed paper by an expert in the field (see WP:RS). The 1992 paper you are citing does not claim, nor imply, that DES remained in use as EC as of its publication in 1992; it merely says the FDA had not withdrawn approval. The FDA has never withdrawn approval for chloramphenicol, for instance, but nobody uses it anymore.

We're unlikely to find a reliable source saying "DES as EC was stopped on X date" (I have been looking), which is why I suggested the wording of use declining and apparently ceasing (per Glasier) by 1990 at the latest. Other sources (e.g. The Guttmacher Institute) say that "In the early 1970s, the high-dose estrogen regimens [e.g. DES] gave way to a combined estrogen-progestin standard [e.g. Yuzpe]." This type of wording might be more relevant if our point is to describe the progressive development of EC methods, as opposed to slagging the FDA and/or the medical community for their supposed ongoing use of DES into the 1990's. I realize you're unable to comment here without sniping at my editing style. Rather than responding to your accusations, I'll just say that on a less ad-hominem level the fact remains that citation is a necessary but not sufficient criterion for inclusion in Wikipedia. MastCell 20:10, 14 November 2006 (UTC)

• as I said in the edit summary, leaving out a date or date range when some idea of dates is known is weasel-wording.
• The California AG is a more reliable source on US practice than a European study (as you pointed out, compunds of banned drugs are still used--DES still used for prostate cancer, and controversially so/with mixed results it seems...) It's possible that Glasier, never having conducted a US study, relied on the 1975 DES ban date.
• the clearest source so far on use/frequency of use is the legal case in which the rape victim sued in 1990 for not being given access to DES at a catholic hospital in US. that means, not only was it in use, it was the standard medical practice per a US source. (And the source which states it was handed out on college campuses "well into the 80s")

The picture I am getting is that it was found to be carcinogenic to offspring around 1971, approved for use as EC in 1973, withdrawn by the FDA in 1975...after which it was no longer used to "prevent miscarriages," but was still used as standard EC until 80s/90s. Lilly stopped making it in 1997, and then compounds of it were used. It seems likely based on sources that frequency of use as standard EC in US declined between 1991-97, and that EC was used primarily on college campuses and for rape victims/was a med targeted to those populations, not the general public. But I agree more study is needed, especially on Europe/rest of world, and why it was used after it was withdrawn by FDA in 1975--why did Lilly continue to make it until 1997 if it was banned in 1975? Why was it given "liberally" to rape victims in 1976? Why would a rape victim sue because they weren't offered DES in 1990? One thing to keep in mind is the efficacy stats--until 1991, high-dose estrogen was believed to be more effective than yuzpe. (When progestins were first studied, they were believed to be far less effective than DES or yuzpe.) Only after the Silvestre meta-analysis in 1991 was any doubt raised that DES was 99% effective as postcoital contraception. It seems that the reasoning was that it was ok to use it for short time as EC, as it was so highly effective. (One US study claimed that the positive emotional effects of not worrying about pregnancy outweighed the health risks of DES...) In 1978, Lilly became aware that DES could be carcinogenic in short term high-dose as well as long term low-dose, and they put a disclaimer on the package, but it was still used.

I am, in case you hadn't noticed, genuinely curious about almost everything and like to do to research/methodically go through each section and improve it. Cindery 21:20, 14 November 2006 (UTC)

"the clearest source so far on use/frequency of use is the legal case in which the rape victim sued in 1990 for not being given access to DES at a catholic hospital in US." I don't agree. The paper in question cites a legal judgement (Brownfield v. Daniel Freeman Marina Hospital) made by an appeals court in 1989. Assuming that it takes some amount of time for a case to work its way through the legal system to the California Court of Appeals, the patient in question was treated (or not treated) significantly prior to 1989. Unfortunately, I can't locate the original decision, only the appellate one from 1989, so it's not clear exactly at what point the patient in question was refused DES - just that it was before 1989, and before Glasier's paper. MastCell 23:20, 14 November 2006 (UTC)

Also, the California Attorney General's website is not a more reliable source on standard medical practice than a peer-reviewed paper from an expert in the field. You've already pointed out some inaccuracies on the site in question. Glasier specifically states DES "is no longer used in the U.S." - it's not like there's some ambiguity about which country she's referring to. "It's possible that Glasier, never having conducted a US study, relied on the 1975 DES ban date." Sure... lots of things are possible, and we can speculate all we want about what might have been going on in Glasier's head. But the most likely scenario is that Glasier, as a respected expert in the field making an unequivocal statement in a peer-reviewed journal, was accurately stating a fact, and this is what the article should reflect. MastCell 23:27, 14 November 2006 (UTC)

I think the misunderstanding you may have re the rape victim case is that the reference to EC as DES is a reference made by the article author, not the case--current for 1990.

This is from the popline database/Johns Hopkins, which is often more complete than pubmed:

Title: Postcoital contraception. Author: Fischer RG Source: PEDIATRIC NURSING. 1985 Oct-Sept;11(5):384. Abstract: This column reviews options available for postcoital contraception estrogens, progestins, estrogen-progestin combinations, and the IUD. High dose estrogen therapy, with diethylstilbestrol (DES), conjugated estrogens, and ethinyl estradiol, has been the most widely used such method. However, since DES therapy is followed by extreme nausea and vomiting in 31-55% of patients, the medication may not be retained. This problem is often minimized if patients take each dose (25 mg twice/day for 5 days) with food. Conjugated estrogens 30 mg/day and ethinyl estradiol 5 mg/day for 5 days are also effective postcoital contraceptives, with pregnancy rates of 1.6/100 and 0.7/100, respectively. The progestational agent Norgestrel, which has a failure rate of 2.2-2.8/100, is an option when estrogens are contraindicated. Combined estrogen-progestogen therapy is the method of choice in many medical centers and is recommended by the IPPF. A commonly used regimen involves 200 mcg of ethinyl estradiol and 2 mg of norgestrel in divided doses. This regimen has a success rate of 98.6%, but nausea and vomiting occur in about 50% of patients. All these drugs should be administered only in emergency cases and no later than 72 hours after exposure to unprotected intercourse. Patients should be advised to refrain from unprotected intercourse for the rest of the menstrual cycle in case ovulation occurs. IUDs can interfere with implantation of the fertilized ovum if inserted 5-7 days after unprotected intercourse and should be considered for patients who have delayed seeking medical attention or in those unable to tolerate estrogens.

An exhaustive lexis news search reveals that the Yuzpe regimen--not as dedicated product, but the use of regular OC pills as EC--was not endorsed by the FDA until 1997. See USA Today, Feb 25 1997, and "Makers of the Pill Hide Behind Fears of Liability, Protests, Pro and Con," NYT July 4, 1996. (I think that's interesting/should be in article re history of Yuzpe in US.) But, the issue with DES seems to be two issues--when was it no longer used in US if it is no longer used, and when did it stop being widely used? It also seems possible that sometime between 1985-1997, Ovral overtook or equalled DES as most often prescribed EC. It seems highly unlikely, per the sources, that DES was no longer used in 1990, if a US author refers to EC as DES in 1990, and if in 1985 it is widely used, and other methods are advised only if high dose "estrogens are contraindicated"--What is presumed to have changed between 1985 and 1990? I think what changed is the efficacy belief after Silvestre, and that the change happened gradually after 1991... Cindery 23:57, 14 November 2006 (UTC)

I've reworded the paragraph a little, to emphasize the fact that it's not clear exactly when DES stopped being used. However, the source that most directly addresses this question is Glasier, which happens to also be a peer-reviewed journal article by an expert in the field. Therefore this source deserves primacy. I think to overturn it, we need an equally direct and reliable source contradicting it, rather than speculation pieced together from a variety of indirect sources culled together to make a point. Again, I respect the research you've done, and you may well be right about the reasons for various things happening, but for Wikipedia purposes your ideas or speculation, however well-informed, can't trump a reliable source directly addressing the question at hand. MastCell 05:04, 15 November 2006 (UTC)

DES and rape

In the US, it seems clear that EC was used primarily for rape victims, and that EC equalled DES.

This tell us that a physician advisory was sent in late 70s, informing physicians that "Use of DES as postcoital contraception should be limited to situations where the fully informed patient or her physician deems that there is no alternative." PMID 37020 Meaning, it was in use as EC after it was banned in 1975.

This tell us that "DES is still approved for post-coital contraception in rape" as of 1985. PMID 3985466 Meaning, in spite of the known existence of Yuzpe, DES was the standard treatment. Likely because it was believed to be more effective than Yuzpe. (Although inflated Yuzpe stats were believed then also, though DES was still believed more effective--it still doesn't completely make sense...unless "no alternative" was judged to mean "no slighly less effective alternative.")

This German study tells us that mid-80s, DES was believed to have failure rate of .07, consistent with the pre-Silvestre stats/belief PMID 6489843 Cindery 22:02, 14 November 2006 (UTC)

mysteries of compounding

...and the obvious answer to why would Lilly continue to manufacture it until 1997 if it was banned in 1975? --is that Clinton passed resolution regarding pharmacy-compounding of banned drugs in 1997: [4] That would mean use of DES as EC after 1975 wasn't off-label, as the drug wasn't approved for any use and couldn't therefore be used off-label for another. Pharmacy compunding was the loophole. If a smaller manufacturer(s) is still making it, that would explain why it might still be available (but is still not approved for use, or even for pharmacy-compound use). Cindery 22:18, 14 November 2006 (UTC)

factual errors

I have corrected the erroneous assertion that DES was only used in cases of rape or incest--we already have a source which says it was used on college campuses, and the Pediatrics source which does not specify rape/incest only.

Also: DES was not withdrawn in 1971--1971 is when it became well-known that it was carcinogenic. It was not removed from the market until 1975 (source--FDA--is included above--the 1997 docket lists DES, and the year it was withdrawn: 1975).

More research should be done to get exact dates/frequency of use, but it is clear per the 1985 pediatrics source that it was a first line treatment, believed to be more effective than combined hormones, and that should be indicated in article. The rape victim source is RS, and American. (As I mentioned, the source names the morning after pill as DES, not the case.) Further research needs to be done on this, and re Europe and the rest of the world for dates/use as first line treatment...

I'm not sure what POV issues you see here--I didn't know much about DES as EC except that it was the first, in 1973. You seem to have a POV issue in that you believed it was not used after it was known to be carcinogenic (and clearly it was). The original statement "DES use gradually decreased long after it was known to be carcinogenic"--per the source I cited--is in fact the case: use as first-line treatment in 1985 is 14 years after it was known to be carcinogenic...that Lilly stopped making it in 1997--same year that Yuzpe was endorsed by the FDA, and banned drugs like DES were prohibited from pharmacy compounds-- appears to be not at all a misleading cap year for gradual use decline. Cindery 07:14, 15 November 2006 (UTC)

Actually, what I wrote was that DES was withdrawn for use in pregnant women by the FDA in 1971, which is correct. Use as EC was considered separately - clearly a mistake in hindsight. I see the FDA source you're referring to ("NDA withdrawn 1975"), but I'm not clear at all that the FDA actually withdrew the drug. If that had happened, it would no longer be available at all (except through compounding pharmacies), whereas it seems it was still widely used after 1975 and produced by a major pharmaceutical firm -- these things would not be the case if the drug was actually withdrawn from market by the FDA. I'm not clear on what the implications of rescinding the NDA are, but it seems clear that DES was still on the market after 1975 - and the DeMarco article (PMID 12287765), from 1992, clearly states that "The FDA had not withdrawn its approval of DES for this purpose [EC]." MastCell 20:57, 15 November 2006 (UTC)

Also, it might be worth double-checking the references you've added - some of them appear broken (probably just a minor typo). I fix them myself when I can, but given how quickly this page changes it's probably best that you do it. MastCell 21:01, 15 November 2006 (UTC)

another factual error

No, DES was approved for EC after it was known to be carcinogenic in humans. The rodent studies were in the 30s--DES was approved for use in humans in 1949, when it was known to be carcinogenic in rodents. In 1971, the Boston doctors discovered the cluster of cancer cases in DES daughters and made the connection--a generation later. Cancer in humans=1971. DES approved as EC=1973. Here is a reader-friendly timeline, from ITVS, which is part of PBS: [5] Part of ongoing confusion is that it is not well known that DES was used as EC at all, and it was used by far fewer women for Ec than it was used by women to "prevent miscarriage" for 20+ years. When it was discovered to be completely ineffective for preventing miscarriages--a separate discovery from the fact that it is carcinogenic--it was promoted as EC.) The FDA remains the ultimate reliable source on when it withdrew DES: 1975. It just says, all doses of 25mg. Unless you can show that the FDA withdrew it for one purpose only, it was withdrawn by FDA in 1975. An advisorywas sent re cancer in 1971, but it wasn't withdrawn. I'm saying: yes, it appears pharmacy compounding was the loophole; Lilly dumped it when that loophole was closed. I think it merits more research, and probably contacting NIH/NCI, which received fed funding in 1992 to study/follow up on DES (a fact we can thank Ted Kennedy for; it was his legislation :-), and the two main DES action centers--one in Toronto, one in CA, as they may know where to find more sources. Cindery 21:10, 15 November 2006 (UTC)

This is not so much a "factual error"; as a misunderstanding. You wrote, "DES was approved in spite of its known carcinogenic effects". I took this to mean approved by the FDA in general, while you meant approved specifically as EC. Easy enough to clarify. I'll look into the NDA issue more; it doesn't compute that on one hand, we're saying the drug was "withdrawn by the FDA" in 1975, while it was also "widely used" into the 1980's. MastCell 22:19, 15 November 2006 (UTC)

Um, the section is about EC, not DES in general. You added "in rodents," which is factually incorrect. Perhaps you would have fewer misunderstandings and the page would be changed less frequently if you read sources more carefully/brought up issues on talkpage instead of making hasty edits? I have explained several times now that it appears DES use after 1975 was possible through the pharmacy loophole. That is also mentioned in the article. I have also repeatedly explained that it was believed to be more than 99% effective--the most effective hormonal EC, until 1991, which explains why anyone would want to "widely" use it/use it as first line treatment. That is clearly spelled out in the pediatrics source, which I reproduced in full, so you wouldn't even have to look it up... Cindery 22:34, 15 November 2006 (UTC)

OK. I'm not sure if your incivility is an attempt to provoke a reaction, or simply a personality trait, but please... I read the source carefully and I'm familiar with the use of DES in pregnancy vs. as EC. I explained where this misunderstanding came from, and how it could potentially be addressed, in what I presumed was a reasonably civil manner. You apparently refuse to see this as a misunderstanding and insist on accusing me of willful ignorance, failure to read sources, failure to understand something you've "repeatedly explained" to me, and "hasty editing". Hasty edits? I make a few edits/day, at most, to this page, and my edits have the lifespan of a sickly mayfly before they're reverted. I'm all for discussing controversial issues here, but I'm also not required to get the Cindery stamp of approval on the talk page prior to each edit. Such a presumption is a further indication of the significant ownership issues that affect this page. MastCell 23:05, 15 November 2006 (UTC)

...you made three factually inaccurate edits in the last 24hrs, (and then complained that the page changes a lot). All of the "misunderstandings" could have been prevented not just if you did research before editing, but if you had merely read the sources already provided on talkpage. So yes, for the second time I have pointed out that you have a demonstrated habit of making hasty ill-considered edits. Perhaps instead of reacting with hostility, you should take it as constructive criticism (especially if you complain that your edits are reverted, etc). The reason your edits are often reverted is that you often make hasty and incorrect edits. It's perfectly reasonable to point out to someone who does that that it's irritating, especially when they complain that their edits are reverted... Cindery 23:41, 15 November 2006 (UTC)

Suggesting that I run around adding "factually incorrect" edits is not only incorrect but uncivil. What you're calling "factually incorrect" has to do with our different interpretations of sources, a misunderstanding based on the text (explained above), and a misreading on your part ("withdrawn for use in pregnant women", see above). These things all happen when people edit; the problem here is that they're being cast as willful ignorance on my part. If you consider your comments to exemplify "constructive criticism", we must have very different understandings of the concept. I've learned a lot from the sources you've cited, and this article is immeasurably better as a result of your edits. However, it's exhausting to try to edit with someone while constantly fending off accusations of inserting factually incorrect material every time we disagree about content. I won't even get into the issue of your massive expansion of the DES section, only to have my half-sentence sourced addition reverted as violating "summary style". I think this article needs more editors, but it's hard to make that happen when every content issue blows up into this kind of thing. MastCell 23:57, 15 November 2006 (UTC)

You inserted into the article that 1) DES was only used in cases of rape or incest 2)DES was withdrawn in 1971 3)DES was used as EC after it was known to be carcinogenic "in rodents." That's three factual errors, which is what I said. Also, you didn't even need to do research to know those were errors, all you had to do was read the sources on the talkpage. Three in 24hrs is good enough reason to point out that it would be better for you to take more time to consider your edits, instead of complaining that they are reverted. Cindery 01:19, 16 November 2006 (UTC)

OK. First of all, I wrote that DES was withdrawn for use in pregnant women (not as EC) in 1971, which is factually 100% correct; the fact that you misread this doesn't mean I made a factual error. Second, you wrote DES "was approved in spite of its known carcinogenicity". I explained at length that I took this to mean approved by the FDA, whereas you meant approved as EC - this is a misunderstanding, not a factual error. Finally, some sources say DES was to be used only in cases of rape or incest, others suggest it was "widely used"... again, a bit of a gray area. I say this not to score points, but because you persistently jump to the conclusion that I'm making "factual errors" left and right, and that I'm sloppy and ignorant. We're trying to edit this article together, and misinterpreting these kind of things as "factual errors" and attacking me for them is totally unproductive. If you find yourself busy cataloging what you believe to be "factual errors", and unable to assume good faith and discuss these differences without resorting to incivility and condescension, then perhaps it's time to disengage for awhile. MastCell 18:07, 16 November 2006 (UTC)

When one corrects another's edits--especially if the editor in question continually complains that their edits are reverted--the thing to do is explain on the talkpage why the edits were reverted. After I explained why I reverted your edits, you wanted to argue about whether or not the edits were "misunderstandings" or "errors" (which is completely irrelevant/beside the point, and I adopted your term of "misunderstanding." The point is that the information had to be removed because it was factually incorrect, so I removed it and explained why to you.)

I wrote that DES was withdrawn for use in pregnant women (not as EC) in 1971, which is factually 100% correct --that statement is 100% factually incorrect--an FDA advisory was sent; the drug was not withdrawn until 1975.

DES was approved in spite of its known carcinogenicity in rodents--you added "in rodents," which is not correct for EC, as EC was approved in 1973 and the cancers in humans were discovered in 1971. (Whether this is a "misunderstanding" or "an error" doesn't matter--it is still factually incorrect and had to be removed from article; and I gave you an explanation.)

some sources say DES was to be used only in cases of rape or incest, others suggest it was "widely used".--exactly; which is why, per the sources, it is not correct to say it was "only used in cases of rape ot incest." (it was also used on college campuses, per a source I provided.)

I did in fact assume good faith--that you didn't purposely put incorrect info in, but didn't understand that you did that because you didn't read the sources--and took care to further explain things to you that were already in sources provided, pointed you to a "reader-friendly timeline," etc. The problem here seems to be that instead of accepting that your edits were reverted and good reasons given, and accepting the criticism that maybe you should read sources more carefully or bring up issues you may be confused about before editing if your only edits are errors and you complain that your edits are reverted, you are stuck on whether you were "right" or "wrong," and you are flailing about making accusations--you have repeatedly wrongfully accused an editor who corrected your factually incorrect edits of "incivility," claimed that your three factually incorrect edits had "the lifespan of a sickly mayfly," as if you were some kind of a victim, and now you are claiming that you were called "sloppy and ignorant," and that you were "attacked"--which is flatly untrue. This is not dissimilar from when you insisted on putting libelous information in the article, and insisted that you were right while insulting me, accusing me "owning" the article, and that I was talking to you like you didn't know what you were talking about, when in fact you were completely wrong and had no idea what you were talking about. (But I assumed good faith that you just didn't understand, weren't doing it on purpose, and explained libel to you in spite of your insults. I could have just said "it's libel" and reverted you as much as necessary--3RR doesn't apply to libel--and reported it to an admin. When you started edit warring, I decided to err on side of being nice, because I really believed you didn't understand/I was assuming good faith.) The pattern here is that when you put something in the article which shouldn't be there because it is libelous, factually incorrect--no matter how careful or comprehensive the explanation given, or how much good faith is assumed--you attack with insults. Perhaps an admin should be involoved if you find you are incapable of discussing changes in the article--which is what the talkpage is for--instead of using it as a forum to vent/attack when your edits have to be reverted. Cindery 21:48, 16 November 2006 (UTC)

I agree that this talk page isn't really the place for this discussion. I initially responded to your "Factually incorrect" heading in the interest of explaining that it was a misunderstanding, so that you didn't think I was trying to be difficult. I then raised the other issue (miscasting my edits as based on sloppiness/ignorance, and then repeating this bad-faith interpretation to justify your actions) because it contributes to the difficulty in getting more editors involved on this page. I'm not sure exactly what you mean by "involving an admin", but outside scrutiny/input would probably help break the cycle we're in here. I'll be the first to admit that this isn't my finest hour, but then I think both of our records on Wikipedia speak for themselves. MastCell 23:06, 16 November 2006 (UTC)

What you need to do is stop making personal insults and accusations like the ones that make up most of the post below. As I have already told you not to address me on my talkpage because I believe you were harassing me (and you posted several times after I asked you to stop), I think it's possible you are using this talkpage as a forum to harass me/vent personal animus. By admin involvement, I mean making a complaint against you for harassment/personal attacks. "Your incivility" is a "personality trait" is a clear personal attack. No editors who read this talkpage need to be bored or annoyed by posts such as the one below; they are not appropriate for the talkpage of an article. Nor are they appropriate anywhere on Wikipedia. You should just stop. Cindery 04:17, 17 November 2006 (UTC)

:OK. I'm not sure if your incivility is an attempt to provoke a reaction, or simply a personality trait, but please... I read the source carefully and I'm familiar with the use of DES in pregnancy vs. as EC. I explained where this misunderstanding came from, and how it could potentially be addressed, in what I presumed was a reasonably civil manner. You apparently refuse to see this as a misunderstanding and insist on accusing me of willful ignorance, failure to read sources, failure to understand something you've "repeatedly explained" to me, and "hasty editing". Hasty edits? I make a few edits/day, at most, to this page, and my edits have the lifespan of a sickly mayfly before they're reverted. I'm all for discussing controversial issues here, but I'm also not required to get the Cindery stamp of approval on the talk page prior to each edit. Such a presumption is a further indication of the significant ownership issues that affect this page. MastCell 23:05, 15 November 2006 (UTC)

You're right, it's time to let this non-productive thread die. As far as what you consider my "harrassing" comments on your talk page, personal attacks, etc, as I said, I think both of our records on Wikipedia speak for themselves. MastCell 18:15, 17 November 2006 (UTC)

"stilbestrol"

I put in the exact wording, because that is the exact wording used in abstract. Abstract doesn't specifically say, "stilbestrol no longer used as EC in US," it says "stilbestrol no longer in use in US." The whole article is mostly reliable only as a relic of erroneous beliefs held about EC in 1990--that DES was more than 99% effective, that Yuzpe was 98% effective, that Danazol was effective at all...and since it is full of what we now know to be errors, and until more exact dates can be located, the two sources, one American and one European, should reflect what they actually say. (Personally, I think saying anything other than it was first line treatment as of 1985 in US, and use gradually declined after that; efficacy was recalculated for Yuzpe and Yuzpe was approved in 1997, when Lilly also dumped DES, is probably a bad idea--it is not necessarily true that the date is not known, it is only true that we don't know it. What we have is two sources, one full of errors, the other referring to "the morning after pill" as DES in a 1990 article--neither is conclusive evidence, which may exist. Also, both are pubmed abstracts, not necessarily the wording used by original authors. If both are wrong, it would not be the first time a pubmed abstract didn't use wording used/peer-reviewed by authors. (The pubmed summary of the Silvestre meta-analysis is particlarly misleading--one must read the whole study to "get it," and the pubmed "conclusion" is so misleading as to be completely wrong; give the opposite conclusion of the study.) Your impatience to contradict the source which implies it was in use to some degree in US until 1997 may not really be serving the article; and it may have been in last legs of it use after 1997 (though it seems unlikely, since Lilly stopped making it in 1997; Yuzpe was approved in 1997.) Cindery 21:49, 15 November 2006 (UTC)

Poor Glasier. Saying her paper is "full of errors" is misleading; in reality, it accurately represented the state of knowledge in 1990. We now know more, and the paper's stats on efficacy have been superceded by more up-to-date and robust information; that's how science works. However, simply because the scientific conclusions of the study, while reasonable in 1990, are now out of date, does not logically imply that a statement such as "DES is no longer used in the U.S." is inaccurate. That's not something that will change with more research. Implying that everything in the paper is de facto suspect simply because the state of knowledge has advanced since 1990 is a legalistic fallacy. In fact, her paper remains the only source to definitively address the issue of when DES stopped being used. Attempts to undermine its credibility in that respect, based on the fact that newer studies have superceded Glasier's efficacy calculations, don't seem relevant. If your argument is that the PubMed citation for Glasier is factually incorrect, please provide more details... but in the absence of such details, PubMed's citation is a reliable source. MastCell 22:53, 15 November 2006 (UTC)

I believe the primary point I made is that both sources are pubmed abstracts, not articles, and since they are being used to make a point we aren't sure of, it's probably a better idea to do more research instead. I am already uncomfortable with saying "it is not known" because there's no source for that--we don't know; that doesn't mean it's not known. (And we can't even discuss "Glasier's paper" because we don't know if that is the wording she used; we aren't citing the paper, but the abstract--do you have access to the paper? Citing an article full of out-of-date info because the wording of the abstract is believed to determine another point is kinda weird and questionable.) Because the abstract is so full of errors, it's not a great idea to cite it except in a place in the article where the errors are explained--if someone happens upon the page and reads "US availibilty" but not "controversy in calculating efficiacy" and the "history" section wherein Danazol efficacy is addressed, they could come to inaccurate conclusions...But, again, upon considering, I really don't think either source for 1990 is RS for its purpose--we are relying solely on the wording of abstracts to establish a fact. The article should reflect what we do know for sure: 1)it was first line treatment as of 1985. 2)it was beleievd to be 99% effective until 1991 3)Lilly stopped making it in 1997. Until there are stats/sources on when it was no longer used/when it was no longer used as first-line EC treatment, we shouldn't speculate that those things are not known just because we don't know them, or provide questionable sources for a speculative date. If it is determined that what we have is the best information, then perhaps both sources should remain. Cindery 00:04, 16 November 2006 (UTC)

I'm sorry... why is "stilbestrol" in quotes? What point are we trying to make? It's a Briticism for DES. Putting in quotes serves only to confuse the meaning of the sentence. MastCell 00:00, 16 November 2006 (UTC)

It's in quotes because it's a quote. There are a hundred names for DES, "stilbestrol" the most recognizable, so it is hardly confusing. (That it is not a term that was ever widely used in US could be a point unto itself, I suppose.) Cindery 00:08, 16 November 2006 (UTC)

Yes, but we summarize the content of articles all the time. Putting quotes around the term implies there's something different about it, and it simply confuses any reader who's not intimately familiar with the naming system of DES. We don't use pick-and-choose terms elsewhere when quoting studies. It's a matter of clarity, and I'm not clear why this study is any different, although I realize you disagree with its conclusions about time period of DES use. MastCell 00:11, 16 November 2006 (UTC)

I've never heard of an unequivocal statement ("DES... no longer used in the U.S.") in a peer-reviewed journal, as cited on PubMed, being declared an "unreliable" source for Wikipedia purposes out of hand. If you really believe that the paper doesn't meet WP:RS criteria, I think we should get a 3rd opinion. I'm happy to pull the actual paper next time I make it to the library, but it might be a while. Until then, I don't see how a blanket impeachment of the PubMed indexing system, or the fact that the state of medical knowledge has evolved since 1990, can override what is a very explicit Wikipedia policy. MastCell 00:44, 16 November 2006 (UTC)

What I said was, we are relying on pubmed abstracts, not papers, to establish a fact--which is probably not a great idea per RS. It's not just the Glasier abstract, it's the other abstract too, and what we are using them for: we're relying solely on them to establish a specific year, and neither abstract is specifically about DES history, and the two sources contradict each other. Also, it is not known if "stilbestrol no longer used in US" refers to EC or not, as EC isn't included in the quote--there's an element of doubt regarding whether the study authors or the abstract writer are referring to the 1975 ban date on DES. The element of doubt introduced by the contradictory sources is reflected in a statement that is probably OR: "the year is not known, but..." Also there is the problem regarding all the out-of-date info in the Glasier abstract/how to explain in that location that if the 1990 date is accurate, all the rest of the info is not. So yes, I think this could be a case for Third Opinion. The problem with third opinion is that it just a nonbinding third opinion/it's not a policy board. This might be a case for NOR/RS, if you feel you can't agree that what is needed is more research--reading the actual texts of the papers, determining if there is more and better info available re DES/years used in the US. It is possible that it will look quite stupid to consider the use of abstracts a big deal without reading the papers, and I think both abstracts as used for purpose of establishing a year should be removed to talk along with the statement "it is not known..." until more research is done. Cindery 01:41, 16 November 2006 (UTC) Cindery 01:41, 16 November 2006 (UTC)

I agree more research is needed, and I will pull the paper next time I'm at the university library (my current locale doesn't carry the journal in question). I'm also fine with removing the entire speculation until we get the actual article text. As far as paternalistically "protecting" the reader from the out-of-date info in Glasier's paper, I don't think that's a reasonable justification for excluding it as a source. If a reader manages to slog through the article and is browsing the footnotes, they'll have had ample information about the state of knowledge on EC effectiveness, and how it has evolved. Of course a 3rd opinion is non-binding, but since it's just the 2 of us going back and forth on a policy point (WP:RS), the perspective might be helpful. We can table that until we retrieve Glasier's actual article text, though. MastCell 19:54, 16 November 2006 (UTC)

...you do not appear to have noticed the source which cites the AMA re 1990, which backs up the other American source re 1990. (But putting in a source which is full of out-of-date info which is not explained is still a bad idea per RS--a source like that should only be used as a citation to show what was wrongfully believed in 1990.) Cindery 22:01, 16 November 2006 (UTC)

Cancer

I am going to begin a comparative cancer section, beginning with what is known (and not known) about levonorgestrel and breast cancer. All info positive/negative about levo, and combined synthetic hormones used in EC should go in section, I think; as well as belief that because use of EC is such limited exposure, exposure not considered as risky as long-term exposure (or, presumably, as beneficial). This is also where fact of no studies of long term impact of high doses or repeat high doses should go...? Cindery 21:50, 15 November 2006 (UTC)

Don't you think that information should go in the articles about the individual drugs? Remember we had the huge list of side effects over at hormonal contraception because that term is an umbrella term? I believe the same reasoning should apply here. This article is not about a specific drug, but a number of drugs used for a similar end result.--Andrew c 22:02, 15 November 2006 (UTC)

I think a brief section noting certain facts belongs in article: 1) no long-term studies done of repeat high doses of levo 2) levo allowed for use without those studies because short exposure not considered high risk

levo particularly important, because it is sole ingredient of EC used most worldwide in Postinor-2, Plan B, Levonelle, etc. Practically no study on levo and breast cancer done (not much study on progestins and breast cancer done). The only study I am aware of which addressed levo in particular, the large Norwegian cohort, states "The relative risk of breast cancer increased significantly with increasing cumulative dose of levonorgestrel."

The most up-to-date (Sept/Oct 2006) in vitro research on levo is that it increases the vascular endothelial growth factor in T47-D breast cancer cells, in a study which concluded that differential effects of progestins on VEGF and T47-D cells "may be related to breast cancer growth."

Those studies should be noted in article, but qualified by facts mentioned above + any other mitigating effects. Yes, I think that info should go in levo article as well. But breast cancer risk and other levo OC is mentioned in individual articles. Also, it is part of Plan B labelling: "no long term studies done"--we should mention that and explain what it means; why no studies done; what risks may exist in spite of no long term studies. Cindery 22:22, 15 November 2006 (UTC)

We've covered a similar conflict like this in the past. I think it is original research to dig through journals and publish "what risks may exist in spite of..." If this information isn't mentioned on the product label, and hasn't raised flags from the FDA or any other regulatory group, I do not believe it is our place to suggest that these possible, hypothetical, and otherwise unknown (to the FDA and drug companies) risks still exist. But maybe I am assuming things about exactly what you want in the article (if that is the case, I apologize). I agree that a bit of the information you suggested could be included. I just think it is also important to make it concise and to the point, and allow the more detailed information to exist in the specific drug articles.--Andrew c 22:39, 15 November 2006 (UTC)

...I think we have addressed this problem in this article: is the article required to be a faithful reproduction of the product insert? No. Is information from the product insert worth mentioning? Yes. And we have dealt with this very recently re NOR--the article is about EC, levonorgestrel EC is the most widely used EC throughout the world, hence info about levo is relevant. Anything about levo (esp in contraceptive pills) and breast cancer is relevant. It is mitigating that the FDA deemed any risks to be slight because exposure is short, and should be mentioned. Cindery 23:00, 15 November 2006 (UTC)

...the American Academy of Family Physicians does not advise use of EC for women who have breast cancer [6](as of 2006, meaning yes, they have heard of Plan B. Even estrogen-dependent breast tumors can be sensitive to/fed by progestins, as progestins can affect cell receptor mediation in ER cells, mediate ER cells etc. Also, levo is androgenic and estrogenic as well as progestogenic.) AAFP also mentions that is does not advise use of IUD in case of STD or rape (presumably because of possible STD risk), which should be mentioned somewhere. Cindery 23:24, 15 November 2006 (UTC)

"Summary Style"

I think it's worth stating that significant cautions were attached to DES use as EC from the start (e.g. recommended abortion if pregnancy ensued after DES use). Otherwise, the paragaph leaves one with the impression that the risks were entirely disregarded when DES was approved as EC (when in fact, they were only partially disregarded). It's a matter of balance. Bringing up "summary style" as a justification seems a bit arbitrary, since we seem to have decided to balloon the "U.S. Availability" section into a rehash of the lifecycle of DES - adding an additional half-sentence for balance isn't the issue. I'd be happier with the whole DES thing in the "History" section; the "Availability" section could then focus on what's actually available right now. I won't bother bringing up the issue of "removing cited content". MastCell 23:43, 15 November 2006 (UTC)

I think this is a POV issue for you--I don't read "abortion was advised" as anything other than evidence DES was made available in spite of known teratogenicity; therefore it's a good citation for the statement it precedes. No cited content was removed, the citation was left to support an assertion already made, that didn't need to be repeated: hence it was summarized. "Abortion was advised" doesn't tell us anything about availability, other than what we already know: DES was available even though it caused cancer. The info currently given in the US availability section "rehashes" facts pertinent to availability--when was it available, why was it available.

I think perhaps there could be a separate DES section, if it can't be dealt with per availability in each country where it was the first EC. "History" is not really appropriate, because use of DES isn't ancient history in any country where it was used; Yuzpe and DES both started in early 70s, and DES would take up the whole history section if that's the only place info about it is given. And the history section tells us about all the forms of EC, even though we get more info about them in other sections as well...

Cindery 00:21, 16 November 2006 (UTC)

The history of DES use is appropriate for the "History" section. There's room for the DES stuff and the other forms of EC; the section is quite brief at present. DES is no longer available, so the comment in the "U.S. Availability" section should be brief. MastCell 00:36, 16 November 2006 (UTC)

I also support moving the DES discussion to the History section. The section is not titled "World History" - just "History", which is inclusive of the United States. Just because that would make it obvious that the rest of the history section needs expansion is not a reason against the move. Rather, it is a reason to expand the rest of the history section. Wikipedia articles are often out of balance while they are growing, and there is nothing inherently wrong with that. But a long discussion of a substance that is currently unavailable as EC is inappropriate in a section titled "Availability". Lyrl ^Talk _Contribs 00:43, 16 November 2006 (UTC)

I think a general description--DES was used as of late 60s in world, found to be carcinogenic in 1971, still used, etc could go in history section. Specific info about regulatory bodies of specific countries should go in "availability," for clarity, as there are big differences, and it would be a lot of tedious info that could get confusing. It's not true that DES is no longer used--so far, as I mention below, there's St. Croix. Cindery 00:51, 16 November 2006 (UTC)

...it's also not a long discussion of a substance--it sticks to US availability. I think mention of DES should be expanded in other places of article/history section expanded, more mentioned in efficacy/history of efficacy. What's "out of balance" is the availability section--usu only Plan B is mentioned, not other methods/years they were introduced or withdrawn. Also, sad lack of other countries...where, for example, is Germany? Any Asian or South American country? Australia?.... Cindery 00:57, 16 November 2006 (UTC)

Plan B is the main form of EC currently available in the U.S. It's not "out of balance" to feature it in the U.S. Availability section, therefore. Other methods, which have since been withdrawn, are appropriate for the "History" section, as they are no longer "Available". See below; I agree with Lyrl that the History section is ripe for expansion and discussion of history of EC in other countries. That doesn't mean we shouldn't put the DES stuff in the appropriate location, though. MastCell 01:08, 16 November 2006 (UTC)

There's too much country-specific information about the availability of each form of EC--without generalization, the history section would be a confusing laundry list. It's because the "availabilty" section is still really underdeveloped that this is not obvious. China is the country in which EC is used most, and they use mifepristone. Some drug starting with a Q was used a lot in South America, where DES was pretty much never used as EC. "Anodivin" (sp) was used in China before mifepristone...the history section should give a general overview, and the availability section can give per-country info, as it varies widely. The "DES stuff," --like the FDA and the NIH info--only applies to the US. I am actually in favor of DES having its own section/having it higher up in article like where history is, but it clearly makes sense to list which drugs were available, became unavailable, and are now available in the availability section. The section was originally contructed as a list-of-four-Western-countries-where-Plan B-is-available, which is "recentist." There's no good reason for availability not to address the availability of other EC drugs, including when which drugs became available, if they are available now, etc. Cindery 01:58, 16 November 2006 (UTC)

"Too much information" is not a reason to not write a section. Wikipedia is not paper - there's plenty of room on the MetaWiki servers. "Confusing laundry list" can be avoided - or fixed, after the fact - by good writing style. Having a team of editors to do the research and the copyediting means people with different talents can all contribute in different ways (research, copyediting relevant to this discussion) to end up with an improved article. Availability should be confined to what is currently or in the very recent past - one or maybe two years - available. Everything else is history, and belongs in the history section, regardless of which country it applies to. Lyrl ^Talk _Contribs 03:50, 16 November 2006 (UTC)

I think for readers who have a specific question--when was Postinor-2 made OTC in Australia? Was DES ever available in Brazil? What year was a Yuzpe dedicated product made available by prescription in the UK? There should be an organized place where that info is kept. Generalizations about history should be in the history section; specific information should be in the per-country availability sections. "Too much information" isn't the reason not to write a section--I have never said the history section shouldn't be there, and have said it should be expanded--"too much information" is a reason to keep info specific to specific countries organized in availability. Why not help do some of the research about what became available where and when? As there is no "deadline," perhaps it will become more obvious as more research is done on each country--or even the major continents--that availability information might belong in availability. Cindery 04:46, 16 November 2006 (UTC)

systemic bias

Now might be a good time for you to read up on the Wiki guidelines regarding systemic bias. One of the biggest systemic biases is US-centricity. The history of the availability of DES in the US is not the same as the history of DES in the world/history in general. The FDA and the NIH do not apply to any other country. (As I mentioned before, more research needs to be done re Europe and the rest of the world re DES. My research so far indicates that DES is still being used as EC in St. Croix, and that it was used less in parts of Europe in the mid-80s than it was in US, because Denmark, for example. approved PC4 in mid-80s, along with UK...) Long before an article can be considered for "featured" status, a simple "request for feedback" will address basic errors like systemic bias/US-centricity... Cindery 00:45, 16 November 2006 (UTC)

Those are all valid points. However, as Lyrl pointed out, moving the DES stuff to the history section doesn't mean the section is complete. It's a start; at least it will be in the appropriate section. The History section can be expanded and sub-categorized as we accumulate more info about other countries. The question isn't so much whether the DES paragraph, as currently written, is the final word on "History". It's a question of where this type of information belongs, and I agree with Lyrl that the "History" section seems most appropriate. MastCell 01:05, 16 November 2006 (UTC)

Information that only applies to a specific country about the history of the availability of the drug in that country should go in availability; a general overview of the history of drugs used for EC should go in history... Cindery 02:03, 16 November 2006 (UTC)

There is nothing preventing us from putting country specific subsections in the history section. I have never before heard the argument that something titled "history" is mistitled if it goes into depth on the subject it covers. I thought history was anything - specific or broad - that happened in the past? If so, history of ECP availability is a perfectly appropriate either as a subtopic or integrated into ECP development history. I still believe it is misleading to talk about drugs that are not actually available in the "availability" section, and oppose that use of the section. Lyrl ^Talk _Contribs 22:57, 16 November 2006 (UTC)

There is nothing preventing us from putting country specific subsections in the history section--nobody said there was; I said there's so much country-specific info that it could be more clearly organized in availability per-country/with world generalizations in "history."

I have never before heard the argument that something titled "history" is mistitled if it goes into depth on the subject it covers.--nobody made the argument that history is mistitled, or even suggested that it was mistitled.

I still believe it is misleading to talk about drugs that are not actually available in the "availability" section, and oppose that use of the section--I don't; I think availability can include history of availability as well as current availability. The section is not "current availability." Again, there's no deadline, and a great deal of work needs to be done researching countries--the availability section is still in really sad shape/doesn't even mention Mexico or South America or Eastern Europe... Is there some reason you think it is an urgent issue, and would you like to post a request on Third Opinion? Cindery 04:53, 17 November 2006 (UTC)

AMA/1990

According to Thompson/Micromedex, the AMA recommended DES "only for emergencies such as rape or incest" in 1990, which is certainly some indication taht it was still used in US in 1990. [7] Cindery 02:27, 16 November 2006 (UTC)

Levo and breast cancer

This section is a bit misleading. It cites the Norwegian cohort study (PMID 12767072) in a context that applies it to EC by association. However, the increased risk with levo was specifically found with combined estrogen-progesterone contraceptives. Progestins require estrogen to affect the target tissue, and the authors specifically write:

To be active progesterone needs estrogen action on target tissue. Only estrogens are able to determine synthesis and increase in progesterone receptors. Progesterone has an effect on an estrogen primed breast tissue, and in synergy produce an alveo-acini proliferation. Moreover, maximum mitotic activity in the breast occurs during the luteal phase of the menstrual cycle. That suggests combined OCs like combined hormonal replacement therapy would exert a greater influence on risk of breast cancer than estrogen alone (e.g., estrogen replacement therapy) or progestagen alone (e.g., progestagen-only pills).

They also conclude that "Our data suggest estrogen is the component of OCs most strongly related to breast cancer risk" and that "Our findings suggest that the increased risk of breast cancer related with total duration of OC use is due mostly to estrogen component." They found no increase in breast cancer risk in patients who took progestin-only ("mini-pill") contraceptives, which would seem to be a more appropriate comparison group for users of progestin-only EC. Extrapolating their data to imply that the increased risk is relevant to users of levo-only EC is unsupportable - the increased risk with levo was seen only in the context of concurrent estrogen exposure, and the authors clearly state that the estrogen exposure is belived to be the primary driver of the increased risk. MastCell 18:21, 16 November 2006 (UTC)

...their conclusion is that the increased risk they found could be due mostly to the estrogen component. That they isolated levo and found a statistically increased risk is significant, esp. as practically no study has been done on levo and breast cancer. You also seem unfamiliar with the fact that levo is estrogenic as well as progestogenic, so it can never be used without an estrogen component. The accepted risk with levo--it is advised for all progestin-only BC--is that women with breast cancer shouldn't use it, because it can feed tumors. Whether it can spark carcinogenesis is unknown.

Cindery 22:08, 16 November 2006 (UTC)

The conclusions of the study are clear, as is the fact that they found no increased risk with progestin-only pills. The authors clearly believe that the increased risk is largely due to the estrogen component, which makes sense since progestin-only pills did not show a similar risk increase. They didn't "isolate" levo in the sense you mean; the increased risk was seen in combination estrogen/levonorgestrel pills. You're misrepresenting the study, and I'm sure you understand very clearly the difference between any mild estrogenic activity that progestins may have, and the doses of estrogen used in OC's (the authors also spell out the mechanisms by which additional estrogen is generally required in the excerpt I quoted above). All hormonal therapies are generally avoided in women with known breast cancer, as a matter of precaution; again, you're misrepresenting this to apply to women without breast cancer. Overall, when dealing with a very serious topic like breast cancer risk, we need to be very careful not to overreach the data to support our own biases. MastCell 22:34, 16 November 2006 (UTC)

They didn't even study progestin-only pills. No study has been done on progestin-only pills and breast cancer, that I know of--if you know of one, please point it out to me. They isolated the components of various hormonal OCs, and they found an increased risk for levo. Because they didn't find an increased risk for all the other progestins, they surmised that the increased breast cancer risk with OCs is the estrogenic component. Since this isn't an article about breast cancer and OCs, only what is relevant to levo is relevant. (And in light of new findings of testosterone + estrogen HRT having higher risk than estrogen + progestin, the high androgenicity of levo is likely more risky than the estrogenicity--but it is not correct to say that levo is "only" progestogenic.) The point is --is it worthy of inclusion in the article that a study found an increased risk for levo? Yes. What could be added, which I mentioned, is that no long term studies of high doses and levo/Plan B have been done, and that the short exposure was not deemed high risk to warrant the studies. I'm not "misrepresenting" the study--I included a direct quote--the only one which refers directly to levo. Cindery 22:47, 16 November 2006 (UTC)

They say It was difficult to conclude for the other groups due to lack of power. In other words, they isolated levonorgestrel not because it is particularly associated with breast cancer, but rather because it is the most common progestagen. Their use of the other progestagens in statistical analysis (cumulative dose for all progestagen groups were non-significant) implies that they believe all the progestagens are involved in breast cancers associated with EC. And their conclusion - the part of their research they believed was most significant - was that estrogen exposure was the most likely primary cause of these cancers. Leaving the levonorgestrel-breast cancer statement out of context as it currently stands in the article misrepresents the study. Lyrl ^Talk _Contribs 23:08, 16 November 2006 (UTC)

I can understand the first sentence, the one that about the WHO saying high dose progestin-only contraception is contraindicated with breast cancer. Isn't that enough? We don't go on to cite 3 studies on why pregnancy is contraindicated. And shouldn't we mention the bleeding contraindication? I don't think we need subheaders for such small section. I think we should write one paragraph about all of the contraindications and leave it like that. Short and sweet. We aren't writing a research paper on why the contraindication exist, right? This is an encyclopedia. I'd propose something along the lines of the following:

The WHO advises that current breast cancer, pregnancy, unexplainend bleeding, and hypersensitivity to any component of the product are absolute contraindications to high-dose progestin-only contraception. Because they contain estrogen, combined estrogen-progestin emergency contraception (Yuzpe regimen) pills should not be used by women with a history of heart attack, stroke, blood clots, breast cancer, or patients with severe liver disease or the very rare condition of porphyria.

What more do we really need? --Andrew c 23:20, 16 November 2006 (UTC)

Regarding Cindery's comment: the Norwegian study did in fact include progestin-only pills. Perhaps Cindery is reading only the abstract. If you read the article itself, go to Table V. Their cohort included about 56,000 woman-years of exposure to the "mini-pill" (i.e. progestin-only). The relative risk of breast cancer in progestin-only users was 0.85 (95% CI 0.62-1.17) for <3 years of mini-pill use, and 1.14 (0.77-1.70) for >3 years of use. The p-value was 0.99, indicating no statistically significant increased risk of breast cancer with progestin-only pills. Cindery, if you'll accept a suggestion from me, in spite of your belief that I don't bother to read sources carefully, read the article itself - it does, in fact, comment on "progestin-only pills and breast cancer". Again, saying that the study "found an increased risk for levo" is misleading - it found an increased risk for levo combined with estrogen, and the authors explain why the estrogen is felt to be critically important in the increased risk. It also found no increased risk with progestin-only pills, which is the most relevant comparison to Plan B, although not conclusive by any means (as Lyrl points out, the study wasn't powered very highly in this regard). MastCell 23:31, 16 November 2006 (UTC)

...yes, you are correct that they separated out a tiny number of progestin-only pill users--but they studied the progestins per type of progestin, including progestins used in progestin-only, not progestin-only use when they determined that levo was the only progestin correlated with increased risk. Yes, it is clearly possible that they reason they only found a correlation between levo and breast cancer among the porgestins is that there was insufficient data regarding the other progestins--the progestins have been sadly little studies with regard to breast cancer--that doesn't mean the finding re levo is therefor irrelevant, it means it is more relevant--that there is any increased risk with progestins is something oft dismissed with the claim that they have been insifficiently studied, therefore there is no risk. Increased risk with levo=increased risk with levo (whereas perhaps when adequate study is done, we will know there is increased rsik for all the progestins, to greater and lesser degrees.)

No, actually this is incorrect. Go back to Tables VI and VII in the article, which is where they note the increased risk with levo. Both table headings specifically say, "Progestagen-only users excluded". In other words, the increased risk they noted with levo was, in fact, in patients who used combined estrogen-levo OC, not in levo-only users. Therefore, "increased risk with levo (+ estrogen)" does not equal "increased risk with levo (alone)." MastCell 18:27, 17 November 2006 (UTC)

You are omitting what I mentioned before about the "estrogen + progestin" hypothesis re HRT--it is now believed following the HRT studies that progestin + estrogen is worse because of how progestin interacts with estrogen, but this is agreed to be poorly understood because of how progestins are mediated by ER receptors, and because testosterone + estrogen was recently discovered to be worse than estrogen + progestin. (also the in vitro studies about how progestins are metabolized/used by the body through gene transcription--a progestin is never "just" a progestin--it's always in complex interplay with estrogen.)

"The estrogen augmented by progestagen hypothesis has been put forward. It assumes that estrogen and progestagen in combination would produce a higher mitotic rate in the breast epithelium than estrogen alone. The effects of the different progestagens on human breast tissue are not clear and no proper classification is available."

"The hormonal effect of OCs on the breast is complex. On the one hand, they often cause protective anovulation; on the other hand, the mixture of estrogen and progesterone may stimulate mitotic activity in breast tissue. Experimental data strongly suggest that estrogens have a role in the development and growth of breast cancer. Estrogens promote the development of mammary cancer in rodents and exert both direct and indirect proliferative effects on cultured breast-cancer cells from humans. Taken together, the body of data supports the hypothesis that estrogen and its metabolites are related to both the initiation and the promotion of breast cancer, but that these associations are complex."

DISCUSSION Our study seems to indicate a positive association between total dose of estrogen and risk of breast cancer. Such an association could be viewed as a chance association due to bias or confounding factors, or as a plausible causal association.

"Grouping the various types of combined oral contraceptives by estrogen dose ignores the pharmacological effects of the accompanying progestagen, a problem that is difficult to overcome by statistical adjustment. We classified progestagens according to their molecular structure and metabolic pathway. Pills containing levonorgestrel group of progestagen are the most used by women." CONCLUSION Our findings suggest that the increased risk of breast cancer related with total duration of OC use is due mostly to estrogen component. The relationship between progestagen containing in OCs and breast cancer requires further investigation.

...everything that they say supports that the finding that levonorgestrel was correlated with higher breast cancer risk is significant and relevant. (Levo is estrogenic and androgenic; and the complex interaction of levo in vivo never takes place without ER receptors/estrogen.)

Extrapolating their data to imply that the increased risk is relevant to users of levo-only EC is unsupportable--I didn't say it was relevant only to users of levo, I said it was relevant to users of levo. Cindery 00:57, 17 November 2006 (UTC)

...i think clarity re why there is a contraindication is good for each contraindication. For pregnancy, for example, it is contraindicated because it doesn't work after implantation. "Unexplained bleeding" is general progestin-only contraception contraindication, and like current breast cancer, is not included on current US labelling (but does appear to be inlcuded on current UK packaging, and is contraqindicated by WHO). So, "contraindicated in pregnancy because it won't work after implantation"; contraindicated for unexplained bleeding because that is general contraindication for progestin-only contraception; contraindicated for breast cancer because that is a general contraindication for progestin-only contraception. That the specific progestin in levonorgestrel EC--levonorgestrel--is little-studied but has shown increased risk is also relevant. Two mitigating factors could be included: 1) though IARC classifies OCs as carcinogenic; there is only slight increased risk/little study has been done on progestins, and none on high dose progestins 2) study of high dose progestins was not required because short exposure was deemed to be slight risk. But there is no good reason to exclude what is known (and not known, i.e., inadequate studies done) about levo and breast cancer. Cindery 23:45, 16 November 2006 (UTC)

Again, based on the citation, levo has shown an increased risk only in combination with estrogen - and the estrogen is felt to be the driving factor. The part of the study focusing on progestin-only contraception found no increased risk. I feel like a broken record, but using the Norwegian study to imply that progestin-only EC may increase the risk of breast cancer is a misuse of the study. I actually agree with Andrew c here... a section on detailing the contraindications is sufficient, and it avoids getting into an area where we're trying to stretch the evidence beyond what it actually says. If there was actual evidence about the risk of breast cancer with progestin-only EC, then we could include it, but I haven't seen such evidence - the Norwegian study on progestin-only pills suggests they don't increase breast-cancer risk. MastCell 23:55, 16 November 2006 (UTC)

I like the idea of giving a reason for each contraindication. However, I think having one reason is fine. We don't need to play armchair scholar and cite 3 different obscure journals that results in all this debate on the talk page. We can all agree that breast cancer is a contraindication, and the reason is because hormones can augment cancer cell growth. I think if one editor cites a primary source, and it's interpretation leads to much debate, I think that is a sign that we are being TOO meticulous for an encyclopedia entry. This way we can avoid wrong interpreations or even worse, original research, while keeping the article concise and encyclopedic. We aren't writing a book about every mention of EC in the scholarly literature (which is funny, because these studies aren't even about EC, are they?)--Andrew c 00:16, 17 November 2006 (UTC)

Right--it shouldn't have to be that big of a deal. Re levo and breast cancer it should say a few things, briefly 1) contraindicated by WHO because progestins could feed tumors 2) what little available research there is does indicate levo correlated with higher risk 3) no adequate studies done, because short term use not deemed high risk.

(Also worth mentioning re ongoing discussion of interplay of hormones in OC in breast cancer risk and what implications that has for the "estrogen + progestin hypothesis" which is currently in doubt per standard medical belief, is that levonorgestrel is not derived from progesterone, but from testosterone--it is broken down by aromatase, which means its androgenic component is broken down into estrogen-- it's highly androgenic of the progestins, which explains why it may be more correlated with breast cancer than other progestins, in addition to fact that it was the most used and therefore most studied in the norwegian cohort. lack of relative estrogenicity in DMPA, for example goes a long way toward explaining why it has a much more negative effect on bone density than other progestins--the androgenic/estrogenic degrees of the progestins are likely to matter a lot once they have been adequately studied.) Cindery 01:24, 17 November 2006 (UTC)

The most recent expansion of this section (diff) goes into way more detail about estrogen and theories relating long-term use to breast cancer than is warranted in an article about short-term use of (increasingly) a progestogen-only formulation. I would modify Cindery's proposed list to 1)contraindicated by WHO in women with breast cancer because progestins could feed tumors 2)levonorgestrel combined with estrogen correlated with higher risk 3)short term use not deemed risky.

I'm also in favor of Andrew's suggestion of combining several of these sections. Having so many small sections (everything between "effectiveness controversy" and "risky sex" inclusive) makes the article difficult to read, and I believe a number of them could be coherently combined. This should result in something easier to read without a loss of information. Lyrl ^Talk _Contribs 01:55, 17 November 2006 (UTC)

...Andrew made a suggestion regarding combining all the contraindications, nothing else. I strongly disagree viz readability and combining everything between "efficacy" and risky sex"--it makes that info much more easily digsetible to have it clearly demarcated than to glump it into one section. ("risky sex" in particular was made to organize a bunch of stuff from "related studies and statistics" into something coherent, and seemed to be a particularly good solution to the problem of how to phrase the raine study to make the point regis A wanted it to make without putting it in total contradiction to/pitting it against the Swedish studies.) Cindery 02:07, 17 November 2006 (UTC)

I don't at all suggest to combine all of them in one section. Just into fewer sections than they are currently in. For example, I have previously objected to splitting the effects of EC on society (sexual behavior, abortion, and STDs) into multiple sections and maintain that objection. Lyrl ^Talk _Contribs 02:32, 17 November 2006 (UTC)

I'm confused about what your objection is--abortion follows efficacy, STDs+risky sex are combined elsewhere. That's two sections. (Although I would agree with you that "risky sex" is not the best title--edit summary says "better title?". Do you think it should be called "STDs and Sexual Risk Taking Behavior" or something?) Abortion, per extensive discussion, was agreed to follow efficacy--do you think STDs/risky sex should immediately follow that? (There would be strong disagreement from me re moving abortion into "social impact" because it's clearly a separate subject from STDs/risky sex, there's no data in the abortion studies about STDs and risky sex.) Cindery 02:45, 17 November 2006 (UTC)

long version of breast cancer study

Actually, maybe it shouldn't be abbreviated--it does a good job of explaining the current estrogen-progestin hypothesis, and why 1) futher study is needed--there's not much data on progestins 2)e-p viz breast cancer is a speculative hypothesis and what that means/hormonal interplay complex 3) it provides info that applies to levo and yuzpe. It should probably be modified to reflect more than one source, though. Cindery 02:00, 17 November 2006 (UTC)

I still think the Emergency contraception article is not the place for the debate to take up space. Go to the individual drug articles, or at the very least the parent article, hormonal contraception. --Andrew c 02:12, 17 November 2006 (UTC)

...there's no "debate," there's "what is currently known." Breast cancer is mentioned in all the hormonal bc articles (and has a section in "progestin-only pill"). EC (except for IUD which is not hormonal IUD) is hormonal; breast cancer is most common gynecological cancer (2nd most common cancer after lung). Clearly it's relevant if the WHO says it's an absolute contraindication, etc. (I think it's especially useful for readers who have no clue--like whomever put all the Plan B stuff in the levonorgestrel article, and then complained that estrogenic, androgenic, and progestogenic needed an explanation other than wikilinks because those terms aren't clear unless one is a doctor. I wanted to say, um, if you have no idea what the diff between estrogens, progestins and androgens are, maybe you should find out before you're strongly in favor of consuming them for political reasons :-) Cindery 02:24, 17 November 2006 (UTC)

There is not reason to even suspect EC as a leading cause of breast cancer. Or other hormonal contraceptives, for that matter, despite the known risk increse caused by ongoing combined hormonal contraception. Lifestyle choices play a huge role - having a first child after the age of 30 increases breast cancer risk 431% over having a first child before the age of 20 (PMID 10658528). Other chemicals also are leading suspects: phthalates are a much more pervasive and (in large part because of that pervasiveness) more damaging class of chemicals than EC or even ongoing hormonal contraceptives. Because of the extremely minor role EC might - or might not - play in breast cancer, it is unwarranted to have such a large section discussing theories of breast cancer. Especially since they are only tangentially related to EC. Lyrl ^Talk _Contribs 02:40, 17 November 2006 (UTC)

Nowhere is it asserted in the article that EC is a leading cause of breast cancer. Synthetic hormones are believed to be a significant risk factor for breast cancer (and I don't think most people understand why.) If you want to explain what "significant correlation between increasing cumulative dose of levonorgestrel" means, it is probably is a good idea to give info about current status of "progestin-estrogen hypothesis" viz synthetic hormone use and breast cancer. Stating that estrogen was believed to be the only bad actor prior to the HRT studies and the in vitro levo studies doesn't explain the levo finding/put it in context. Cindery 02:54, 17 November 2006 (UTC)

I think the issues here are relatively straightforward. I agree with Lyrl and Andrew c. This article is not the place to debate basic-science hypotheses about androgenic or estrogenic crossover of levonorgestrel. These are hypotheses, and their clinical relevance in this context is unknown. Placing them in a section entitled "Levonorgestrel and breast cancer", which goes on to imply that levo-only EC increases the risk of breast cancer (not supported by the citation), raises fears that are not supported by the literature. Not to mention that we're blurring the lines between levo being contraindicated in women with known breast cancer to imply that levo raises the risk of developing breast cancer - again, not supported by our citations. It's important that medical/health-related articles are presented evenly and informatively, without minimizing known risks, but also without engaging in scare tactics or making implications that aren't supported by the available data. Not only is it OR (joining A and B to advance position C, which is not argued by the authors), Lyrl is right that it also gives undue weight (per WP:NPOV) to an association that has not been shown to exist. MastCell 17:57, 17 November 2006 (UTC)

Also, Cindery wrote above that the increased risk with levo was seen in a combined group of levo/estrogen plus levo-only users. That's not the case - in fact, Tables VI and VII of the Norwegian article (those in which the authors note the increased risk with levo) both say specifically, in the Table headers, "Progestagen-only Users Excluded". In other words, another reason why this study does not say anything about an increased risk of breast cancer with levo-only EC; it just says that they didn't find an increased risk with progestin-only contraception - if anything, evidence (albeit somewhat weak) that levo-only EC would not increase the risk of breast cancer. MastCell 18:33, 17 November 2006 (UTC)

Levo/breast cancer

In keeping with the above thread, I'd propose the following section in the interest of keeping things brief, summarized, relevant to the topic at hand, and in line with the relevant published data:

---

Breast cancer, levonorgestrel, and estrogen

The WHO advises that current breast cancer is an absolute contraindication to high-dose progestin-only contraception. In a large cohort study, users of combined estrogen-levonorgestrel contraceptive pills had an increased risk of breast cancer which paralleled the increasing dose of levonorgestrel. However, the exposure to estrogen was felt to be the most important factor in this increased risk. In women who used progestin-only contraception, there was no increase in the risk of breast cancer.

---

I've left the remainder of the previous section in the article and just commented it out with tags, so it's not gone for good. Input on the above? MastCell 18:40, 17 November 2006 (UTC)

And I've added the following sentence: "The study authors encouraged further research on the effect of progestin-only contraception on breast cancer risk." ... to point out that more research would be useful. MastCell 18:44, 17 November 2006 (UTC)

...it seems you completely missed the point that titling it "levonorgestrel, estogen, and breast cancer" addresses "yuzpe and levo," which I mentioned above.

Also, Cindery wrote above that the increased risk with levo was seen in a combined group of levo/estrogen plus levo-only users. No--I used a direct quote from the study, that someone else qualified with the study "conclusion," to which I added more from the study and its conclusion to explain what it meant/make it more accurate--estrogen/progestin hypothesis, etc, more study needed on progestins.

scare tactics--I have clearly and repeatedly stated that any and all mitigating factors should be mentioned, and repeatedly stated that no studies were required re EC and breast cancer because the short exposure was deemed low risk, and that that should be mentioned. Let's not err on the side of falsely implying inadequate study/one study means there is for sure no risk, or minimizing what is known. (It is not as though there is a study anywhere which says, "the impact of really high single and/or repeat doses of levonorgestrel--the equivalent of taking 40 minipills at once-- has been studied long term, and it has been determined that it is impossible that such a hormonal disruption could spark mutagenisis which could result 30 years later in a breast tumor, as was the case with really high doses of diethylstilbestrol, which we have only learned less than five years ago sparked breast cancer in pregnant women who took it to prevent miscarriages.")

The question is, how to summarize study findings/what is known/relevant about breast cancer risk and estrogen/levo for both yuzpe and levo as succinctly as possible without leaving out so much information it doesn't make sense to a lay reader? (I have found that, in POV-unbalanced articles, sometimes when something which is relevant to the article but may be construed as negative is discussed, that bickering about what it "means" becomes the issue for those who would like to keep the information out. In that case, verbatim wording is best. Then, when the "conclusion" is nitpicked because the wording is verbatim and can't be nitpicked, it's good to leave in a long quote and let it sit for a while/let someone who was not originally involved summarize it, or just wait until cooler heads prevail.

(Clearly, the summary of the Norwegian study includes --and the summary of what is known about levo and progestins in general includes--that they haven't been adequately studied; that the interplay of estrogens and progesterone/progestins is very complex and poorly understood; that estrogen used to be considered the greater risk factor but that has changed since the WHI study. The finding about levo in the Norwegian cohort can't be dismissed by falsely summarizing the study; the study itself notes that estrogen hypothesis is speculation and that progestins require more study...and the estrogen hypothesis viz breast cancer is acutely relevant to yuzpe, which is still in use. Moreover, I didn't say "the androgenicity and estrogenicity of levo should be explained in article," I pointed out that estrogen + progestin=greater breast cancer risk is not an argument to exclude a finding about levo when it was isolated in estrogen-progestin study, because levo is not strictly a progestin.

I think a "conclusion" or additonal info could be added to the verbatim quote from the study, but it should be accurate, and that some explanation of the contraindication of yuzpe + breast cancer should be included (meaning additonal source(s), as the Norwegian study is not the definitive study on breast cancer and synthetic hormones.) What is unique about the study is that it studied levo, and so very little is known about levo and breast cancer risk. (A recent French study notes that only one study has been done on levo-IUD and breast cancer, and that it is "C level" quality.) Cindery 20:30, 17 November 2006 (UTC)

I think your current edit of the breast cancer/levo paragraph looks good. I'd still favor removing the in-vitro stuff and focusing on the clinical studies, for clarity and relevance, and obviously the paragraph can be expanded to address Yuzpe, but I think the summary of the two levo-related clinical studies (as it exists in the above edit that you made) looks reasonable. MastCell 21:58, 17 November 2006 (UTC)

DES/abortion

The point you are trying to make--that doctors informed patients of the carcnogenic/teratogenic effects and/or there was follow-up for treatment failures--is not reflected in the literature. The Detroit hospital case clearly illustrated terrible follow-up, and the pediatrics source says nothing about warnings or informed consent. You could say, FDA warned that therapeutic abortion should be seriously considered, but literature doesn't show evidence that patients were warned, advised, or follow-ed up with to determine if they were pregnant. There isn't good evidence that informed consent was followed at all or even advised--"patient or her doctor deems that there is no alternative"--and "no alternative" turned out to be "no slightly less effective or more expensive alternative." Keep in mind that PPIs didn't even exist until late/mid-70s for the birth control pill, after the National Women's Health Network staged the first protest at the FDA, specifically regarding the dangers of high dose estrogens. The concept/practice of informed consent has evolved a great deal (and was still not considered adequate in 1996)--what doctors were warned about wasn't necessarily passed on to patients--the opposite was the case. It's an interesting discussion/matter to explain in article, but it isn't particularly relevant to availability. (What the Med Lett source reiterates is already in the JAMA article used in "history.") Cindery 23:08, 20 November 2006 (UTC)

The source (Med Lett) says "Early therapeutic abortion is recommended when this use of DES fails." I agree it says nothing about issues of informed consent, whether women were actually advised to abort, etc - only that the recommendation in the medical literature was to consider abortion in such cases. (I'm not sure it was the FDA themselves who made the recommendation, or I'd attribute it to them as you suggested). I'm not trying to make the point that doctors were informing pts of the effects; I agree that the informed consent process has come a long way since the 1970s and is still a work in progress. I'm adding it because it seems relevant that the risk was seen as high enough that abortion was (theoretically) encouraged if DES failed. MastCell 23:51, 20 November 2006 (UTC)

..it's not relevant to availability; it's misleading without more context about who said that and what it meant to whom, and it's stated twice in cited sources which readers can go to for more information--most of the info re DES is in sources, not summarized in article. To make the point that is was known to be carcinogenic, we don't need to do anything other than provide citations. Cindery 00:23, 21 November 2006 (UTC)

I think the fact that the most widely available/used form of EC was dangerous enough that abortion was recommended is relevant, or at least as relevant as the rest of the DES stuff in the paragraph; it adds to the first half of the sentence, which describes DES' effects on the fetus. I'm happy to work on making the sentence less "misleading", although as it currently stands it seems fairly straightforward. MastCell 00:35, 21 November 2006 (UTC)

DES/2000

This tells us that DES was still used as EC in 2000, but not where--Europe? Turkey? Should probably go in general history. [8] Cindery 01:51, 21 November 2006 (UTC)

latest US usage

Re Lyrl edit summary--1985 is not the latest year--1990, per the AMA, (source above in "AMA 1990") is the latest date so far that it was used in US. Cindery 02:02, 21 November 2006 (UTC)

The AMA link is now broken (it has timed out on every one of several attempts to view it), so I have no way to verify that statment. Lyrl ^Talk _Contribs 00:35, 22 November 2006 (UTC)

...it is not downloading for me either, but it is available through cache. It's an excellent source for DES in general--it must be available at another location, perhaps another Thomspon/Micromedex site. For some reason, the host is "overlake hospital" or something. Put AMA + 1990+ rape or incest + Thompson Micromedex into google, or I can copy the cache link for you.

For some reason, DES is still listed in pharmacology textbooks as EC. Here is an example from Tulane: [9] Cindery 02:30, 22 November 2006 (UTC)

Thank you, that search worked for me. I'm beginning to wonder if many of the post-80s mentions of DES as EC are just copies of earlier versions of literature, made by people who have not done research to realize DES is no longer actually used. If in doubt, don't delete information - seems to be an average person's reaction to things they are not familiar with. Lyrl ^Talk _Contribs 02:56, 22 November 2006 (UTC)

... I would call up Tulane and demand an explanation, but we couldn't use it --would be OR:-) Since EC in any form wasn't widely used before the ICEC initiatives, it's hard to find info on use stats etc., but I am still planning to contact DES action/CDC. My guess based on latest research (mostly legal) would be that it wasn't just the efficacy controversy started by Silvestre et al, but the chilling effect of the lawsuits piling up--big settlements were paid out in late 80s/early 90s, and fed funding for the CDC/NCI to study/follow DES-esposed women long term came through in 1992. It seems unlikely that it was used as first-line after that, because it was in the news so much then. The masses do not read NEJM, but 4.5 million dollar lawsuits/acts of Congress make the evening news everyone sees. But because it was so dirt cheap, I'm sure that as long as it was available it was used in some places by/for the poor. Cindery 03:12, 22 November 2006 (UTC)

Textbooks do tend to lag behind the literature/current practice a little... they're revised every few years, but how up-to-date they are depends on how aggressive the chapter author is, and out-of-date information can persist in textbooks for quite some time in some cases. MastCell 19:25, 22 November 2006 (UTC)

I had looked through the University of Ankara's website trying to find the email address of the authors of the paper that says DES still used as EC in Eastern Europe. Couldn't find them. It didn't help that I can't read Turkish, but I couldn't even find something promising enough to put through a web translator.

Even though we could not directly use such information because of WP:OR, it could be used to inform which sources we choose to site in the article, as our current list is somewhat ambiguous. Lyrl ^Talk _Contribs 02:03, 23 November 2006 (UTC)

ICEC

Regarding the section on the ICEC: does it belong under "Controversy"? As currently written, the section makes no mention of any controversy. Also, in the interest of summary style, it could probably be shortened dramatically; most of the section is a verbatim quote from the website source. Why not shorten the quote to just say that the ICEC focuses on "Manufacturing an EC Product, Facilitating Product Registration, and Negotiating a Public-Sector Price", perhaps with a (very) brief expansion of each point? MastCell 23:19, 21 November 2006 (UTC)

I didn't even notice that it was under controversy; I thought I put it just before International Availability. It should probably be part of or after history--it's an extremely significant historical development, and explains why suddenly EC is on everyone's radar/was ever considered as a "public health measure." The very difference in what the term "emergency" means has changed viz postcoital contraception since ICEC/1995-98. I envisioned it as raw material needing to be summarized (and info re marketing and "social marketing" needs to be added; so it's incomplete). The fact that Postinor-2 is the most commonly used brand of EC--not Plan B--should be emphasized somewhere, and it should be emphasized in ICEC summary that ICEC was conceived of/functions as a means to bring Postinor-2 to developing countries with first world money. (Emergency contraception!--brought to you by the World Bank...and Frank Carlucci. Ok, not "you," but the third world by way of "you," because USAID isn't allowed to put money into contraceptives that aren't approved in US anymore...since that's my take on it, it's probably better if someone else summarizes it first--but the implication that they helped create a market where none existed shouldn't be 86'ed entirely--they admit as much. And the fact that the consortium exists to bring Postinor-2 to the 3rd world, and that Postinor-2 is used in more countries than any other brand should be given due weight.

Cindery 23:41, 21 November 2006 (UTC)

It's always hard/impossible to separate the profit motive from more altruistic concerns in the pharmaceutical industry, but to keep things from veering into "Constant Gardener" territory, we should probably also state or summarize the ICEC's purpose in its own words (as the section currently does) - after all, many people think that expanding the range and availability of contraceptive options in the developing world is a laudable goal, and one of the Consortium's stated aims is to improve the affordability of EC. MastCell 19:18, 22 November 2006 (UTC)

Mmm, it's not just the pharma profit issue--that's really secondary to the population control agenda. Many have criticized the handful of population orgs included in ICEC--most funded primarily by the US Gov-- for trying to keep population down in 3rd world by any means necessary to protect western economic interests, not because they have any altruistic interest whatsoever in providing choice for women in developing countries. The use of the Concept Foundation as a shell company for the WHO's ownership of Cyclofem and to promote Postinor-2 is an especially unsavory association. Cindery 03:14, 23 November 2006 (UTC)

I see what you're saying; however, I think expanding contraceptive options/access in the 3rd world doesn't solely benefit Western economic interests - reproductive freedom/access to contraception could conceivably be helpful to the interests of those developing nations and their citizens as well, and some would go so far as to consider these items to be human rights. I don't know about "any means necessary"; the ICEC and friends are talking about expanding access and availability, not forcing anyone to do anything against their will. And I don't know about contraception serving "Western economic interests"; one could argue the opposite, that having a large supply of desperate, overcrowded people ensures these interests easy access to cheap and pliable labor in the era of outsourcing. Sure, economic interests undoubtedly play a role in what the ICEC does, and I wish that wasn't the case. But it doesn't seem like the worst thing in the world to expand access to contraception in developing countries either. MastCell 04:34, 23 November 2006 (UTC)

No, it's not what I'm saying--remember, we report on debates, we don't carry them out. That these orgs have been criticized for what I stated is well-known, verifiable, etc. Maybe if it's something you're interested in learning more about, you should do that--start with Barbara Ehrenreich's essay on the Depo page, and read the verbatim quote from Ravenholt re western interests and 3rd world contraception. Read recent accounts of what Indian women say about the contraception provided to them and what they think about "choice." There is a lot of well-known crit debunking the "overpopulation" propaganda fed western highschool/college students; essays regarding whether there are too many Africans and who says so, whether economic justice/equitable distribution of wealth would better serve African poverty than the millions spent on contraception--which has been provided coercively (i.e, other aid like food/medicine provided conditionally on the basis of contraceptive "acceptors.")--it's a very big subject, and there are a lot of reliable sources. A great example of US "altruism" is La Operacion--the sterilization of 1/3 of Puerto Rican women, after Puerto Rico's manufacturing industry was decimated by US, leaving an "unemployment" and hence "overpopulation" problem that the US decided should be solved through sterilization...first the US created the poverty, then they labelled it overcrowding, then they "solved" it with an expensive "altruistic" contraceptive campaign. That's sort of what the World Bank does on a global scale. If you're unaware of any of this/how big this subject is/how much has been written, there's not much I can do except mention what a big subject it is. Some of the ICEC orgs are worse than others; some have engaged in "greenwashing" to repair their images; some like PATH actually do some good with Gates money. Concept Foundation and PSI...not so good. When I have more time, I will look for any appropriate refs which reference ICEC in specific/population control issues. But, this is re how to summarize ICEC info (which has all come only from their site; is totally noncontroversial)--I'm not going to carry on a long off-topic conversation with you to explain that the pop-org-critical POV exists, or argue the POV--I don't have to; this isn't a discussion forum, it would be impossible to explain such a huge subject if you don't know anything about it, etc. And we're already aware that the pop orgs say "we're altruistically expanding choice in the third world"--that's what their press releases say, too. Whether it's even necessary to include pro/con/debate/or any other info about ICEC hasn't been established--I think it's unlikely. Different people will read the summary of their press release description of themselves differently, and come to different conclusions, based on what they know. That's probably enough. Cindery 06:18, 23 November 2006 (UTC)

I'm sorry, when I wrote that "I see what you're saying", I was talking about the arguments you chose to highlight on the talk page. I agree the talk page isn't the place to debate this issue. I do think it's worth considering that I've thought and read on the topic beyond the "propaganda" I was presumably fed in high school/college, but have come to a different conclusion than you have, as reasonable and educated people sometimes do on complex issues - this isn't always a mark of deficient knowledge on one party's side. I do agree with you that it's unnecessary to include a lengthy pro/con debate about ICEC on this page, and that people can reach their own conclusions. MastCell 17:18, 23 November 2006 (UTC)

Exactly: if someone brings up, in a discussion of a subject, that reliable sources address a POV critical to the subject, perhaps mention the existence of any other POVs/reliable sources (but don't argue your opinion vs. the critical POV mentioned. It personalizes issues which are not personal, and can take the discussion productively off-topic--especially, I think, using your opinions to state why you personally believe in the status quo. Better to bring up an alternate POV with adherents which exists in the world and hasn't been mentioned.)

I don't know about contraception serving "Western economic interests"--if you've never heard that argument, or the US Gov admission from Ravenholt regarding the purpose of USAID provisison of contraception is to protect US economic interests, it's reasonable to assume you don't know who Ravenholt is/one of the primary criticisms made against populations orgs--I was trying to make it clear that these are not my opinions, after you reacted by arguing your opinions. But please forgive me if I read your "I don't know..." statement incorrectly to mean that you didn't know about what Ravenholt said/criticisms of pop orgs to that effect.

I think a productive discussion could go: I'm aware of x, but y exists also, according to z, and should be incorporated into article as well if article covers debate or criticism of subject, because <blank>." An unproductive discussion begins, I see what you're saying, but I think...and the appropriate response to that is to refer back to sources, point out that x exists. If debate or criticism about a subject is included in articles, it can be structured in a number of ways, depending on the article, the subject, how many prominent POVs must be represented, etc. But it is not structured to favor a POV, or to approximate unnatural balance, only to give due weight--so, for example, it wouldn't go status quo about the subject--criticism--reinforcement of status quo from the POV of the subject. In a long complicated article, like abortion debate or stem cell research, complicated arguments, counterarguments etc can be delineated/described. In an extreme summary of a subject which includes most notable criticism, rarely would "y," --wherein y is a restatement of what the subject says about itself-- require sufficient due weight in comparison to the criticism to function as a rebuttal--that's more how people think/argue, not how debates are summarized.

...nor would a "y" argument really function as an adequate rebuttal if it were included in this context. If we said, for example, "The World Bank is one of the primary funders of ICEC orgs. Critics of population orgs funded by the World Bank have accused that financially focusing available aid dollars almost exclusively on contraception is an unwise use of resources designed to reduce the population of already underpopulated countries, rather than increase the ratio of resources per person. The Bank has also been criticized for implementing 'free market' trade agreements which have bankrupted the cocoa farming industry in Africa, resulting in child slavery, more extreme poverty than existed just a decade ago, and no possibility for cocoa farmers to recoup their costs, let alone support themselves. However, populations orgs receiving money from the Bank to distribute emergency contraception in Africa claim that the Bank's interest in providing contraception is humanatarian, and supports their longstanding belief that reproductive rights are a fundamental human right." Or, "Nigerian doctor <blank>, concerned that foreign aid to Africa is overly focused on contraception--for which there is not a great demand due to high infant mortality and fear of side effects in the impoversished and only marginally healthy--says, 'patients come to me, sick, and I don't even have penicillin or bangages...just cupboards and cupboards of contraception.' However, the World Bank, which funds most contraceptive initiatives in Africa, continues to provide millions of dollars worth of contraception per year to Africa because "reproductive freedom is a fundamental human right." Cindery 22:30, 23 November 2006 (UTC)

OK. I don't have the energy right now to respond to another 4 paragraphs, but as you seem to believe I single-handedly drew this thread off-topic into a non-productive realm of arguing personal beliefs, it might be worth re-reading it from the top. Fortunately, I think we agree that arguing the pros/cons of the ICEC and World Bank's societal impacts is outside the scope of this article. MastCell 04:51, 24 November 2006 (UTC)

...It's not really a decision between us; any editor at any time in the history of the article could decide to include criticism/more context of ICEC. (I'm still somewhat undecided.)

And...I was trying to persuade you not to personalize/argue your opinions, but to argue sources, and to think of how to structure available pro/con arguments from the known range of available sources in an impersonal way, as if both were your problem. (Think like a lawyer! :-) It helps with detachment, and you can make much better arguments for either side when you can argue both.) Maybe a more direct approach will work better: one could argue the opposite, that having a large supply of desperate, overcrowded people ensures these interests easy access to cheap and pliable labor in the era of outsourcing.--do you have a source for this? Cindery 09:45, 24 November 2006 (UTC)

Sure - Margaret Sanger made such an argument as long ago as 1920, and it's a (probably over-)simplistic application of the principles of supply/demand to the labor market. But before we get into eugenics and the evils of Planned Parenthood, it does seem like, for now at least, this thread can be closed - after all, Lyrl was kind enough to address the initial issue by moving the ICEC paragraphs, and I need to get back to consuming my disproportionate First-World share of the world's turkey and stuffing resources. MastCell 20:25, 24 November 2006 (UTC)

Regarding your source, it isn't a source for the argument you made--it dosen't offer "large supply of desperate overcrowded people" in developing countries in the "age of outsourcing" as an argument in favor of focusing first world aid to developing countries on contraception. "One could argue the opposite..." is your opinion; doesn't come from a source. (None of Africa is overcrowded, by the way--there's a really low ratio of people to land. Not much "outsourcing," either.)

Let's go back and simplify: we have population control orgs, we have criticism of population orgs...and we have what else, according to sources? and what would be the argument for including it? Cindery 04:58, 25 November 2006 (UTC)

I'm not making an argument for including anything, at the moment. That's why I felt this thread could die off for now. Sanger's argument was that huge families provide a ready source of labor, and the increased availability of labor drives down wages, hence the economic interest of "capital" is not necessarily population control. Also, overcrowding is not a simple matter of population divided by continental land area. "None of Africa is overcrowded"... Really? Lagos? MastCell 19:20, 25 November 2006 (UTC)

...Sanger was not a demographer, and neither are you. :-) And you've got it backwards--"overpopulation" is not a simple matter of numbers of people or population density: per even UNFPA, population and resources, i.e., development are inextricably linked, hence ICPD--the International Conference on Population and Development. Africa has very low population density; it's not overcrowded, nor do demographers argue that it is or was. "Overpopulation" is a concept which is never numbers alone, but resources in relation to numbers. Cindery 01:27, 26 November 2006 (UTC)

Criticism of population organizations should go in the article of that specific organization, or in an article dedicated to the subject such as population control. Such information is not appropriate for the EC article. Lyrl ^Talk _Contribs 22:25, 25 November 2006 (UTC)

I agree. <restored deleted comment> MastCell 19:55, 26 November 2006 (UTC)

The more I think about it, the more I think many general readers will have no idea what kinds of orgs make up ICEC, where their funding comes from, why they would focus on the developing world. It's pretty signifigant given that "virtually no dedicated EC product existed before ICEC" --world awareness of EC, the use of EC dedicated products, the world market for EC, and the very use of EC as a public health measure are all recent developments tied to ICEC. It might make sense to describe the orgs in a sentence, and to refer to their funding sources, such as World Bank and US Gov in a sentence. Perhpas since The Concept Foundation did all the actual distribution of Postinor-2, it would make sense to note that, and explain the World Bank connection Concept has. The World Bank article does a good job of explaining criticism of the Bank, and should be linked. In terms of the "development" component of "population and development," it is very clear that the policies of the World Bank have grossly impoverished countries in Africa, worsening the ratio of resources per person. There are many, remember, who believe that human rights also include rights to food, housing, medical care, and a living wage. Orgs funded by the Bank tout contraception as a "human right" which could exist in isolation from other human rights which the Bank actively denies, or solve the problem of "overpopulation," which is a direct factor of resources per person, resources which the Bank is actively reducing in Africa (and other developing countries). Cindery 01:27, 26 November 2006 (UTC)

You said "no part of Africa is overcrowded", and I said that Lagos (for example) is overcrowded whether one looks at population density, resource availability, development, or any other rational measure. Maybe ICEC deserves its own page, I dunno... but I strongly agree with Lyrl that criticism of population organziations, the evils of the World Bank, etc etc, should not be in this particular article. Sure, I believe in those other human rights you listed as well, but this is the emergency contraception page... let's stay focused. MastCell 19:59, 26 November 2006 (UTC)

..you're making a very weak semantic argument to avoid admitting you were wrong: Africa is not overcrowded. (Bangladesh has a similar population density as some developed countries.) The stereotype of developing countries as "overcrowded" is precisely one of the uncritically examined stereotypes promulgated by US highschool social studies textbooks. Margaret Sanger did not address globalization, or in any way make the argument you made (and her argument for US immigrants on the Lower East Side in the 1920s was not a credible demographic theory viz labor and resources at the time)--you just made untenable OR arguments, explaining biases you hold which inspire you to defend the status quo in the face of criticism.

I think the uncritical bias "the ICEC orgs are humanitarian" is what in particular needs to be addressed-- a quote from the Concept Foundation that its work is "humanitarian" should be used, and counterbalanced with a quote regarding the decidedly unhumanitarian work of its main funders. Cindery 07:45, 27 November 2006 (UTC)

I'm still not sure why we're arguing. There's no content issue at stake, and I've suggested we close this thread a few times now. Yet you seem to be twisting my very simple statement about an overcrowded part of Africa, and then claiming I'm the one who can't admit to being wrong. I also have no interest in defending what you describe as the "status quo", nor do I uncritically accept that the ICEC and friends have only the developing world's best interests at heart. It's just that you went off-topic on the World Bank, "no part" of Africa being overcrowded, etc and I (perhaps foolishly) took the bait, thus encouraging you to paint me as a naive dupe of my high-school social studies textbook. I do feel I should ask, on behalf of the country's social studies teachers, for a source for your now thrice-repeated statements that high-school social studies indoctrinates students into a false view of "population control". I don't remember learning anything about population control in social studies, and we read a standard textbook as well as Howard Zinn. If you need the last word, go ahead, and then let's close this thread unless there's a concrete content issue to be discussed. MastCell 19:22, 27 November 2006 (UTC)

• you just don't seem to get it that it's not up to you to "close" any threads anywhere on Wikipedia; you've made the erroneous presumption that this is just a "conversation" between you and I (an erroneous presumption which you began with the statement, "I see what you're saying, but I think...") You keep responding as if it were a conversation; that doesn't make it so--ICEC is a topic with relevance to the article, what is being left out or put in etc. for other editors to add to and future editors to consult. The "content" issue is ICEC--and, as I mentioned, because ICEC radically altered EC into a public health measure which is part of mainstream reproductive health care programs wordwide, ICEC is enormously significant to the EC article.

• The Concept Foundation is the distribution arm of ICEC. That means the mechanism by which EC is distributed to the largest number of countries in the world is the Concept Foundation. The Concept Foundation is funded by the World Bank. Hence the World Bank is acutely relevant to EC.

• Africa is not overcrowded. "Overcrowded" is a word you introduced in an off-topic OR argument about your opinions, in response to the criticism that ICEC funders, such as the World Bank, serve Western interests: And I don't know about contraception serving "Western economic interests"; one could argue the opposite, that having a large supply of desperate, overcrowded people ensures these interests easy access to cheap and pliable labor in the era of outsourcing. (Actually, the opposite argument has been made-- women are easier to exploit as cheap sweatshop labor if they have fewer children or none--childcare interferes with punching the clock.) "Overcrowded" is a stereotype, a mental picture of Bangladesh. "Overpopulation" is not overcrowding; too many people. Population and development problems involve poverty--too few resources per person, not too many people. The World Bank actively reduces the ratio of resources per person in impoverished countries. Hence it is not difficult to criticize or question the Bank's humanitarian commitment to population and development problems, i.e., reducing poverty.

• My big off-topic aside: Contraception may be a human right to reproductive rights advocates, however, the World Bank is not a reproductive rights advocate. The politics of population control orgs and the politics of reproductive freedom intersect strangely, and with great ethical problemmatics; not dissimilarly from how feminism and the Catholic Church are strange bedfellows when they both criticize population control orgs--same criticism, different reasons. You may support "expanded contraceptive access" and reproductive rights when you support EC, that doesn't mean that's what the World Bank is supporting. And when the Bank gets PSI to spend millions of dollars on social marketing and PR, they spend some of the money on issue framing: casting products as virtues-in-themselves which pro-lifers oppose, which must be good because pro-lifers oppose them. Whether there are better solutions can be ignored in the heat stirred up by opposition to pro-lifers; public debate artificially limited by diversion.

• The site for the Committee on Women, Population, and the Environment has a number of essays, listed below, on the biases perpetuated in highschool textbooks on "overpopulation." Betsy Hartmann, director of the Hampshire College program on Population and Development, made a whole alternate highschool curriculum in response to the problem, which is available at the program's site.

Proposing Alternatives to Secondary School Curricula on Population

Currently much of the material in mainstream US textbooks presents a simplistic view of 'overpopulation' as the cause of poverty and environmental degradation, reinforcing cultural and racial stereotypes of poor people in the Third World. It also accepts the use of coercion in population control programs in countries such as India and China, ignoring important ethical issues of reproductive choice. In order to encourage the introduction of more complex, gendered, and culturally sensitive analyses of population and the environment into secondary school social studies curricula in the United States, CWPE has undertaken this project in collaboration with the Population and Development Program at Hampshire College to survey currently available mainstream and alternative curricular materials, and to assess the need for further curriculum development.

• U.S. High School Textbooks: Perpetuating the Idea of Overpopulation by Anne Hendrixson

• Demography or Teaching Fear: The Population Problem in U.S. and U.K. Social Studies Textbooks by Anne Hendrixson

• The Industrious Europeans and the Hungry Third World Masses: The Story of Population Told by U.S. High School Social Studies Textbooks by Anne Hendrixson (based on research by Laura Agustín)

• Are People a Good Thing? How British Social Studies Textbooks Present Population Issues by Susan Bullock Leather

• The Problem of Population in U.S. High School Biology Textbooks by Syd Lindsley

Cindery 20:45, 27 November 2006 (UTC)

I can't distinguish between Cindery's purely conversational writings vs. her suggestions for changing the ICEC section. Would a sample paragraph be too much to ask? It would sure help me decide whether I agreed with the proposed changes or not. Lyrl ^Talk _Contribs 00:47, 28 November 2006 (UTC)

The fact that this thread had become a two-way conversation about off-topic issues was the very reason I've repeatedly suggested we close it - I think we agree that nobody has the authority to unilaterally close threads. That said, I'm with Lyrl again, as I mentioned in my last few posts - can we have a concrete content issue to discuss, so the soapboxing can cease? MastCell 04:47, 28 November 2006 (UTC)

The Concept Foundation is the distribution arm of ICEC. That means the mechanism by which EC is distributed to the largest number of countries in the world is the Concept Foundation. The Concept Foundation is funded by the World Bank. Hence the World Bank is acutely relevant to EC.--I'll just go ahead and add something about it, now that we've established that developing countries are not "overcrowded," and that And I don't know about contraception serving "Western economic interests"; one could argue the opposite, that having a large supply of desperate, overcrowded people ensures these interests easy access to cheap and pliable labor in the era of outsourcing. is a meritless, unsourced OR argument that neither can be included nor is a justitifcation for exluding facts or critical info regarding ICEC, developing countries, and the World Bank. Cindery 11:19, 28 November 2006 (UTC)

You may want to re-read the IPPPH source on the Concept Foundation that's cited in the article. Sure, the World Bank is one of the funders of the Concept Foundation, but its contribution is dwarfed by that of the Rockefeller Foundation (and that of the UNFPA) - by that rationale, the Rockefeller Foundation is even more "relevant" to EC. More significantly, the source also states that "The grant from the World Bank and UNFPA facilitated the licensee selections process and technology transfer of Cyclofem. While the grant from Rockefeller and Packard Foundations, assisted in the clinical development of emergency contraception (EC) with various dedicated EC pills." Poor grammar aside, it seems explicitly clear that the World Bank funded Cyclofem, while the Concept Foundation's EC activities were funded primarily by the Rockefeller Foundation. We all have axes to grind, but making the case that the World Bank is "acutely relevant" to the topic of EC seems a stretch. The Rock Foundation is way more financially involved in the distribution of EC, but even so, it has its own article and shouldn't merit more than a passing mention and Wikilink here. MastCell 17:53, 28 November 2006 (UTC)

...What I put in article is that the CF is funded "by the World Bank and the other organizations, which also operate with the World Bank." I am planning to add more about how inextricably intertwined the orgs are. PSI, for example, gets more than half its funding from the US Gov. The Population council is just an arm of Rock, founded by Rock, and gets non-Rock money from USAID--US Gov. If you read the source already provided, you would know that UNDP/UNFPA/WHO/WB function as one entity: HRP, which funds IPPF and is what funded CF with Rock (which means also PC)--the appearance of 7 orgs is illusory once you look at their funding. It's corporate sockpuppetry, and all roads lead to the WB, and the western interests it protects, such as, say, oil money (i.e., Rock). It's obvious to me now that that's one of the primary issues which needs clarity for a general reader.

Meanwhile, as far as "axes to grind." I have said this over and over to you, and tried to explain by example ("do you have a source for this?" etc) but it just doesn't seem to sink in for you that this isn't a discussion between you and I--it's possible for it to be a content issue disussion. You need to think in a detached way about what information lay readers might need to understand ICEC. (I can look at it, for exmaple, and I recognise those orgs and I know things about them. It's harder for me to tell what a general reader does or doesn't know, or might want or need to know--that's what the editorial discussion should be about. As long as you're overly fixated on me/having a personal discussion with me in which you argue your opinions, you're not making useful observations or contributions to the article, or to content discussions about the article. I almost wrote something after you wrote "I think it's worth considering that I've thought..." which went: No, no one needs to consider what you've thought; nothing is about you or being addressed to you, you're personalizing things which are not personal/being inappropriately self-absorbed. I decided to try to get you to see you were inappropriately personalizing by asking you for a source instead, but I'm saying it now. I've contributed 58 citations to the article--more than half the research. Not once did I give you a second thought: I'm concerned with the article, not you. That's the way it should be. You, on the other hand, have contributed 60+ posts to the talkpage, all addressed to me: it would appear you're fixated on me. You need to detach. Cindery 18:38, 28 November 2006 (UTC)

Given your level of involvement with the page, it's impossible to edit without interacting with you. I thought I was commenting on a content issue - namely, I don't think the Rockefeller Foundation's "protection" of oil interests is relevant enough to include on the EC page, whereas you feel that it's one of the "primary issues that need clarity" here. That's a content issue. It seems that the Rockefeller Foundation, rather than the World Bank, financed the development of the Concept Foundation's EC product - that has implications for the content as well. Obviously, I don't speak for the other editors, and I'd like to know what they think as well. About my previous comments: Wikipedia functions by consensus. It's hard to build consensus when you assume that differing opinions are based on youthful ignorance, obstinacy, or malice, rather than thoughtful consideration of a complex issue. My comments were a request that you respect views that differ from your own as possibly being equally well-founded, even if you disagree with them. MastCell 00:26, 29 November 2006 (UTC)

ICEC pt2

Given your level of involvement with the page, it's impossible to edit without interacting with you.

Absolutely nothing is preventing you from contributing research to the article-- there are many ways to edit which do not involve me. If you were contributing any research to the article, you could still engage in or begin talkpage discussions regarding content without fixating on me--your excessive, automatic, reactionary personal argumentativeness has become a problem, and is not "editing."

I thought I was commenting on a content issue - namely, I don't think the Rockefeller Foundation's "protection" of oil interests is relevant enough to include on the EC page, whereas you feel that it's one of the "primary issues that need clarity" here.

? Neither Rock nor oil is mentioned.

That's a content issue. It seems that the Rockefeller Foundation, rather than the World Bank, financed the development of the Concept Foundation's EC product - that has implications for the content as well.

The orgs which funded EC--ICEC--are all listed. The funding relationships between the orgs are barely delineated yet. Perhaps you still have not read the source/do not have personal knowledge of HRP, so you don't understand that WHO/UNPFA etc are the WB--not my problem if you don't read sources.

Obviously, I don't speak for the other editors, and I'd like to know what they think as well. About my previous comments: Wikipedia functions by consensus. It's hard to build consensus when you assume that differing opinions are based on youthful ignorance, obstinacy, or malice, rather than thoughtful consideration of a complex issue. My comments were a request that you respect views that differ from your own as possibly being equally well-founded, even if you disagree with them. MastCell 00:26, 29 November 2006 (UTC)

Wikipedia functions by consensus is counterbalanced by "Wikipedia is not a democracy"--this helps in POV-unbalanced articles. Facts are facts--if consensus on the Bigfoot article is that Bigfoot exists, it won't hold up, etc.

You haven't presented "views that differ"--you've presented unsourced OR arguments that were of-topic and not of merit for inclusion, by your own assessment. None of these words were used to describe you: ignorance, obstinacy, or malice Your continued focus on yourself is tiresome and completely inappropriate for the talkpage. Again: disengage. If you can't focus on the article, perhaps we need an admin. Cindery 01:06, 29 November 2006 (UTC)

Cindery, when your involvement in the page is so complete I feel the need to ask your permission to change the format of one sentence (see entire section below), I would say it's impossible to edit without interacting with you. (Or, would you have let the edit I proposed stand if I had just made it?)

Lyrl, the clearly logical response to your suggestion is below--since when do topic sentences not summarize topics? As you had no response to that, I assumed it was a non-issue. If you felt you had to ask my permission, that's your problem; I do not control your feelings. Nor did I notice that you addressed your talkpage suggestion to me--it did not begin with my name, etc. I generally propose all changes on talk first--and the suggestions I propose are not addressed to anyone in particular (as I have repeatedly tries to explain to MC...)

Your excessive, automatic, reactionary personal argumentativeness has long made it a difficult task to co-edit articles with you.

We have only "co-edited" one other article--last summer. I will take your inappropriate comments with a grain of salt, in light of talkpage discussions with you over the last two days, and our unpleasant diaagreements regarding your views that 1) overpopulation exists as a consequence of your extreme minority belief in a coming food shortage 2)Africa should have been transitioned off food aid 3) the Dalkon Shield saved lives in the third world...

It's impossible to tell if you deliberately misunderstand Mastcell's comments in order to make long complex replies, or if it is an actual miscommunication.

Diplomacy generally takes longer than bluntness, and I have continually tried to be diplomatic with him here after his "wikistalking-harassment" episode elsewhere. His behavior is probably something that should go to Arbcom, as it has been so persistent.

Facts can be presented in wildly differing ways, and conversation to build consensus is vital to productive co-editing. No, none of us are in danger of being "outvoted" on editing, because Wikipedia is not a democracy. However, contributors to this article are in severe danger of my continuing to talk to them :)

Endless personally motivated bickering on talkpages, however, is disruptive.

From WP:TPG, There is reasonable allowance for speculation, suggestion and personal knowledge with a view to prompting further investigation, but it is a serious misuse of a talk page to continue to argue any point that has not met policy requirements. Speculation, suggestion, and personal knowledge - unsourced - are all explicitly allowed on Talk pages. Even encouraged: Giving an opinion helps in convincing others and reaching consensus. Only if a consensus develops that specific suggestions are unsupportable even with further research, and an editor continues to argue the point without sources, would the guidelines be violated. As I agree with Mastcell, and the three of us are currently the only ones conversing, I don't think we're in any danger of developing such a consensus.

Reasonable allowance is not be confused with misusing the talkpage usenet-style--hence the template "this page is for discussing changes to the article, not the topic in general." Bringing up sourced information and discussing if and how it should be included is helpful, arguing personal opinions is WP:NOT. "There's another POV and sources for it" is appropriate; "I think it's worth considering that I've thought..." is not:

• Stay objective: Talk pages are not a forum for editors to argue their own different points of view about controversial issues. They are a forum to discuss how the different points of view obtained from secondary sources should be included in the article, so that the end result is neutral and objective (which may mean including conflicting viewpoints). The best way to present a case is to find properly referenced material. (For an alternative forum for personal opinions, see the m:Wikibate proposal.)

I do not see any special relevance to EC of the funding of the ICEC member organizations. As currently presented, the funding topic is equally relevant to almost every other form of contraception. General issues such as funding of these organizations should be addressed in the individual organization articles, and possibly in one central-topic article. As it currently stands (i.e. no special relevance to EC vs. most other forms of contraception), I oppose including funding information in the ICEC section. Lyrl ^Talk _Contribs 02:43, 29 November 2006 (UTC)

Not enough information about ICEC and how instrumental it is the history and conception of EC has been included yet--again, the whole current conception of it has changed since ICEC, and was changed by ICEC--who and what ICEC is, who funds it is incredibly relevant--let's take it to Third Opinion for neutral outside view. Cindery 03:51, 29 November 2006 (UTC)

Cindery, when you repeat an unfounded charge of Wikistalking/harrassment, and then threaten me with ArbCom or "an admin", it starts to feel like you're trying to bully me. I've already addressed your charges of Wikistalking here and here, and explained what should have been obvious with a basic assumption of good faith. You deleted both explanations, while leaving behind your accusations - that's your right, it's your talk page, but continuing to sling the accusations/smears after they've been shown to be unfounded is disheartening. That said... the ICEC's existence and role in expansion of EC availability is relevant and notable; I don't think anyone has disputed that. I'd also be OK with one sentence to the effect that the ICEC is funded by the World Bank, WHO, Rockefeller Foundation, etc - and letting readers draw their own conclusions if they regard those institutions negatively. I agree with Lyrl that the argument that "all roads lead to the World Bank, and the western interests it protects such as, say, oil money (i.e., Rock)" is outside the scope of this article. I'm a strong advocate of getting outside opinions - it may be worth asking Andrew c or David Ruben, assuming we haven't scared them off. Failing that, a formal Third Opinion request makes sense. Either way, it would help to have something concrete to discuss, as we may be more in agreement than we think. As Cindery seems to be the one who feels this information is relevant for inclusion, perhaps she could propose wording. MastCell 05:17, 29 November 2006 (UTC)

If you engage in a continued course of conduct which disrupts Wikipedia in order to harass one person (who has made an article NPOV to your chagrin, because you are not capable of being objective about your POV), it cumulutively becomes undeniably obvious, and is a problem not just for the person, but for the community.

Telling other people to assume good faith has also been considered a failure to assume good faith. It is also not necessary to assume good faith if you have reason to believe otherwise--i.e., AGF is not a magic pass which removes bad faith actions from scrutiny.

They were not shown to be unfounded--when you asked for feedback at Depo Provera, you were clearly told that you were indeed "being more argumentative" than you should. After you were told that Wikipedia is a content over community site, and that you do not have the right to demand that other people interact with you, and to disengage, you persisted in posting messages which were deleted on sight to discourage you/enforce boundaries. You then resticted your edits to this page--most of your edits to Wikipedia--to only reacting to me in an excessively argumentative and disruptive way--you have been warned repeatedly not to engage in personal attacks, etc. The talkpage of this article is now full of tendentious and petty argumentativenes in response to one editor, who has told you not to talk to her outside of article pages, because you were unable to do so appropriately. There is a clear injunction in policy to disengage if you find you cannot get along with someone--that means, do not post 70 tendentiously argumentative edits full of incivilty and personal attacks/borderline personal attacks to the talkpage of one article in reposnse to one editor, while doing no research/contributing in no other way--it becomes painfully obvious that you are abusing the process, and no one need assume good faith. It has gone past being merely annoying to me, and is now a problem for the community--your argumentativeness takes up an entire talkpage archive, which is a good threshold for a complaint.

That statement isn't in the article, nor has Lyrl said anything pertaining to that statement for you to agree with.

You should take a break, and return to the article constructively--do some research, think before you post on talkpage about how and if your posts will help the article, or if they are tendentiously argumentative and disruptive. The talkpage is not a forum for you to harass people who refuse to talk to you outside of the talkpage--it's a boring waste of everyone's time. If you cannot do that, I am going to make a complaint, because that is the best thing for the article/Wikipedia. For the last time: disengage. Cindery 13:00, 29 November 2006 (UTC)

I think disengagement is a good idea, but it's a two-way street. You've just leveled several pages of insinuation and unfounded accusations at me, and then told me that I need to disengage. It doesn't work like that. That's not disengagement; it's a need to have the last word. It's tempting to waste more space addressing your mischaracterizations of my record one-by-one (e.g., you cite my comment that "I'm probably getting more argumentative than I should", which was made in the spirit of defusing conflict, as "proof" that I'm a Wikistalker/harrasser), but since both of our records/edit histories are public, if anyone cares they can look for themselves.

Again, on content issues: I think a one-sentence rundown of funding sources for ICEC is appropriate; I'd oppose going into more detail (specifically trying to link ICEC to the World Bank's putative agenda) on grounds of relevance to EC, and the fact that the EC funding appears to have come from the Rockefeller Foundation rather than the World Bank. I don't want to put words in Lyrl's mouth, but my sense was that she agreed in general that detailed funding information for the ICEC was outside the scope of this article. It would be helpful to have a sample paragraph/sentences, as that might move the discussion from the abstract to something more concrete where there may be substantial agreement. MastCell 18:32, 29 November 2006 (UTC)

Cindery and I obviously disagree on interpretation of WP:TPG, having each quoted sections of it that support our position. All three of us in this discussion have demonstrated firmly formed opinions; I do not see any resolution coming of further debate over guideline interpretations. The talkpage of this article is now full of tendentious and petty argumentativeness - it takes at least two to argue.

Not enough information about ICEC and how instrumental it is the history and conception of EC has been included yet--again, the whole current conception of it has changed since ICEC, and was changed by ICEC--who and what ICEC is all this I agree with. Mastcell has also stated agreement - the ICEC's existence and role in expansion of EC availability is relevant and notable. But funding of the ICEC member organizations has not been presented in such a way that it is specifically relevant to EC (vs. most other forms of contraception), and that sentence in the current article should be removed. Lyrl ^Talk _Contribs 01:46, 30 November 2006 (UTC)

...I won't have time to write much until next week, but I will address two things: 1) There's not a difference of opinion regarding WP:TPG; Lyrl just misunderstands the guideline--opinions regarding secondary sources etc. are helpful, not opinions in general regarding any controversial subject. Post on village pump and get some clarity on that. 2) There's a great deal of info in oral contraceptive about funding for development. USAID's interest in Norplant is there, Population Council's interest in Mirena is there--you're just wrong re "vs most other forms of contraception." (If that info weren't in other articles, it still wouldn't be a sufficient argument to exclude any relevant info from this article; it would be an argument in favor of adding that info to other articles.) Cindery 15:44, 30 November 2006 (UTC)

Fair enough - while some might consider a request to follow the talk page guidelines to be "petty" or "harassment", I'm not one of them. So, in the interest of focusing on content/sources and having a concrete edit to discuss, I've made a couple of changes. First, added more references (not new sources, just matching claims to their source) in the ICEC paragraph. Second, changed the Concept Foundation description to accord with the source, which clearly states that funding for EC activities came from Rockefeller and Packard, and not from the World Bank. As this is the EC page, not the Concept Foundation or World Bank page, the focus on EC seems appropriate. I still tend to agree with Lyrl that the funding of ICEC members is of borderline relevance, but so long as it's in the article we can at least reflect what the source says re: funding for the Concept Foundation's EC projects. MastCell 23:11, 30 November 2006 (UTC)

I appreciate the tightening up the sentence from "funding of organizations that funded EC activities (but also many other things)" - to "funds earmarked for the development of EC", thus tying the funding issue specifically to the EC article. Lyrl ^Talk _Contribs 00:32, 1 December 2006 (UTC)

You're confused about the funding, I added clarity; you're both confused about the importance of ICEC/postinor-2, etc--still more research needs to be done, esp.on non-Western countries, more info added for due weight regarding non-Western usage/historical significance of ICEC itself made more clear. Still US-centricity/recentist bias. That's part of the problem of endless reactive bickering/not doing any research--nitpicking about subjects-in-progess without making attempt to take responsibility for the article as whole, look objectively at what needs to be expanded, how further research can or will change whatever it is that's being nitpicked is just a waste of time. Let's prematurely make a huge issue out of 1990 on lame sources without doing any research! Let's fill up ten pages insisting on using a lame source instead of doing any research! etc--you should both do at least a little research yourselves instead of consistently focusing so narrowly and reactively only my preliminary research efforts, as if whatever research I provide was the only information available. One thing so far from my recent research is that it seems ICEC spreads a lot of PR hooey about how many units they're moving in the third world, or at least creating the impression that usage is high--it's spread out, but usage is low. EC hasn't caught on at all it seems. "used in over 100 countries" or whatever is misleading. "Used by hardly anybody in over 100 countries" is more like it. Cindery 16:30, 1 December 2006 (UTC)

The ICEC's statement trumpets the availability of EC in >80 (or >100) countries - after all, their stated mission is to increase availability, rather than to move as many "units" as possible. I think I speak for most editors of this page when I say that we appreciate the work you put into researching sources for the page. Adding sources is an important (but not the only important) task here - we're also trying to resolve issues of relevance, topicality, POV, phrasing, etc. What you perceive as "nitpicking" your contributions is part of this editing process. On that topic, I think both Lyrl and I have concerns about relevance/summary style when it comes to elaborating at length on the alphabet soup of funding agencies for ICEC. The paragraph on the member orgs of ICEC is reasonable, but the following paragraph gets into six-degrees-of-separation (ICEC -> Concept Foundation -> HRP -> World Bank), which severely dilutes the focus of the section and seems outside the scope of the article. MastCell 22:51, 1 December 2006 (UTC)

I think Cindery has put in more hours of work on this page than other currently active editors, and has added significant valuble information to it. It is an unfortunate feature of Talk pages that disputes take up almost all of the page, while community approval is often only implied (through the inaction of added content being left in place).

Even work involving fewer total hours than research, however - such as our discussions over the past several days - still contributes to Wikipedia. Also, there is no deadline on Wikipedia: articles are always a work in progress. It's OK to focus on a small portion of the article and let the rest of it slide until later. Or even to figure someone else will work on it - because, eventually, someone else will.

I think we all agree that copying the entire contents of, for example, the Concept Foundation article into this one would be inappropriate. Equally, I believe we all agree that some of the information is appropriate to include here - the debate is just over where to draw the line. Personally, I would draw it at information directly and specifically related to EC. Where would other editors see this line? Lyrl ^Talk _Contribs 04:02, 2 December 2006 (UTC)

Effectiveness of ECPs

The effectiveness of emergency contraception is calculated based on projected probabilities of conception, and expressed as a percentage reduction in probable pregnancy rate for a single use of EC.

The first sentence in the "Effectiveness of ECPs" section (above) is almost 30 words long, on the point of being difficult to understand just because it is so wordy. While such length is sometimes justified, I believe in this case that removing the phrase calculated based on projected probabilities of conception, would greatly increase the readability of the sentence while not reducing the quality of information imparted. The calculation method for ECPs is addressed later in the section; it does not need to be in the opening sentence. It also might be confusing for some readers to introduce the relatively complex subject of how ECP effectiveness is calculated in the same breath as explaining what the effectiveness numbers mean. Lyrl ^Talk _Contribs 03:09, 27 November 2006 (UTC)

a third of the "words" are prepositons or definite/indefinite articles. I think it's as simple as it gets for something so complex--remember, we don't dumb down Wikipedia. Subtracting "conception probablilites" doesn't shed light more simply on conception probabilities, it just subtracts a key concept. I thought Wikilinking to "conception probabilities" would be a good idea, and merited an article. (There are, again, three main methods: Dixon, Trussell and Tietze. Trussell, an economist and Professor of Population Studies at Princeton, is not a doctor or fertility expert of any kind. He's an EC advocate who invented his own method after Silvestre, in order to publish new efficacy rates in 1996.) The centrality of conception probabilites to EC efficacy calculations may well need more verbiage--I still don't think it's clear, for example, that conception probabilities differ, and are utterly hypothetical: EC has never been proven to prevent a single pregnancy. The efficacy rate based on different methods of conception probability determination are and can be different. Plan B is not "75% effective"--it's hypothetically 75% effective based on the calendar method of probability conception. (And 75% effective is the same as doing nothing, according to Barret and Marshall; 75% effective is only an improvement in comparison to Trussel's own differing "do nothing" annual rate of 85%.)

Cindery 07:29, 27 November 2006 (UTC)

Why does the first sentence have to include conception probabilities when they are addressed later in the paragraph? Lyrl ^Talk _Contribs 00:53, 28 November 2006 (UTC)

Generally, a topic sentence includes what is going to be addressed in more depth in the paragraph because it is going to be explained in more depth. Did you have some new rationale for topic sentences, whereby they no longer summarize topics? Cindery 11:42, 28 November 2006 (UTC)

Are you saying that 25% of EC users become pregnant after each use? I ask that because you are comparing it to an effectiveness rate - "75% effectiveness of doing nothing" (per month?) - that means a 25% pregnancy rate. Lyrl ^Talk _Contribs 00:53, 28 November 2006 (UTC)

See "Barret and Marshall," above. Cindery 11:42, 28 November 2006 (UTC)

Inserting a lot of verbiage about various conception-probability methods muddies the waters unnecessarily. Efficacy stats exist; they are all, perforce, estimates; let's give the ranges and sources and leave it there. This isn't the forum for a novel re-assessment of the effectiveness of EC. MastCell 18:05, 28 November 2006 (UTC)

Actually, I think a better definiton of conception probablities--in the absence of a Wiki article about them--is essential. Readers have every right to know that the conception probability method used to determine EC efficacy is not the only conception probablitiy method, and what that means. Barret and Marshall is 1969--hardly "novel." Trussel's 1996 invention is novel. The history of Ec efficacy is fraught with controversy/unstable. Cindery 18:59, 28 November 2006 (UTC)

In medicine, a concept that's updated every 30 years is hardly "unstable". The ad-hominem stuff about Trussell seems a little off-base - the guy is a Professor of Population Studies; surely that gives him some professional standing on questions of conception probabilities. Again, this is really not the forum to reassess the ways in which a drug's efficacy is calculated. MastCell 00:30, 29 November 2006 (UTC)

• EC was updated by someone with a COI in the last ten years, after a big controversy
• it's not ad hom to point out Trussel's qualifications--perhaps you should look uo ad hom in the dictionary
• explaining a key concept that lay readers might not understand--in the absence of a Wiki page to link to--is advised, not a reassessment of anything.

Cindery 01:06, 29 November 2006 (UTC)

Complex paragraphs can have more than one summarizing sentence. ([10] Sometimes topic sentences are actually two or even three sentences long.) Writing guides (one example) recommend total sentence length - including prepositions and indefinite/definite articles - be limited to 15 to 20 words. More shorter sentences are easier for readers to comprehend than fewer longer sentences. It's possible the section will evolve to have one paragraph on effectiveness stats, and a second paragraph on calculation methods - which would, again, result in shorter introductory sentences.

Your suggestion was not two opening sentences, it was to remove conception probabilities from the opening sentence. Good sentences average 15-20 words, but can be up to 50 words or less than 5 words. Sentences that do not vary in length adversely affect readability--an article full of sentences precisely 15-20 words long would be less readable than article with variety. Sentence length is not the only element of readability--word syllable complexity are also very important, as are construction of sentences (parallelism etc.) Do you have a two-sentence topic sentence suggestion? (It seems to me that the comma offers a better parallel construction explaining the two main aspects of EC effectiveness calculation than a period + repetition of half the first sentence would.)

I'm still confused about what Cindery is saying about EC effectiveness. Comparing expected pregnancy rates from one act of intercourse after which EC was used (75% reduction * 8% no-EC pregnancy = 2% EC-failure-pregnancy?) to pregnancy rates after one month of unprotected intercourse, no EC (25% pregnancy - 75% "effectiveness") to pregnancy rates after one year of unprotected intercourse, no EC (85% pregnancy - 15% "effectiveness") is currently looking, to me, like comparing apples to oranges to bananas. I'm obviously missing something here, and am requesting help in understanding.

That's why I think a better explanation of conception probabilites is necessary. But again, see Barret and Marshall, above, for comparison of EC to monthly conception probability. Cindery 13:19, 29 November 2006 (UTC)

This confusion about single-use EC efficacy vs. monthly and yearly unprotected pregnancy rates, which I share, is one of the indications to me of the dangers of trying to recalculate EC efficacy when there is already published data available. MastCell 18:48, 29 November 2006 (UTC)

"Barret and Marshall, above" (if you have random unprotected sex all month, there's a 24% risk of pregnancy. If you have random unprotected sex all month and used EC after every time, the risk would be greater than 24%. If you had unprotected sex all month and only used EC once at midcycle, the risk is 25%.), again, makes no sense to me. How it reads to me: using EC increases the risk of pregnancy - using EC once at a specified cycle day results in exactly a 1% increase in the risk of pregnancy. No sources or further reading suggestions were given. This is not helping me. Lyrl ^Talk _Contribs 00:42, 30 November 2006 (UTC)

The estimates are calculated based on an 8% pregnancy rate mid-cycle after one act of intercourse. - moved from the third sentence to the second - could easily be a topic sentence. Or, left in place, it could also further explain the topic of effectiveness introduced by the opening sentence - exact definition of everything covered in the paragraph is not required for topic sentences. The types of studies used in researching EC effectiveness, for example, is not covered in the current topic sentence, yet fits in very well in the paragraph, currently as the second sentence.

Reviewing the current third sentence has made me realize it's uncited. In contrast to its claim of 8% pregnancy rate mid-cycle after one act of intercourse, one study cites a 56%-67% per-intercourse pregnancy rate when it occurs in a four-day fertile window (PMID 8401097). Multiple acts of intercourse focused on the fertile period can increase pregnancy rates in one cycle to over 70% (PMID 1479570). 8% pregnancy per intercourse seems rather low for what is implied to be the most fertile period ("mid-cycle"). I would be curious to read the source for that number. Lyrl ^Talk _Contribs 00:42, 30 November 2006 (UTC)

I remembered the source for that 8% number: [11]. It specifically says "middle two weeks of their menstrual cycles" - which explains the unexpectedly low pregnancy rate. They're averaging the number out over two weeks (while the pregnancy rates I cited above are for just a few days). I'll think about how to work in the "middle two weeks" clarification of the 8% number, and I'll add the reference for that statement. Lyrl ^Talk _Contribs 00:46, 1 December 2006 (UTC)

grammar

Did some minor cleanup of grammar, fixed a few awkward phrases. I tried to maintain the original sense and content and left anything that made me semantically nervous strictly alone. If I have changed any meaning unintentionally please let me know on my talk page, I would appreciate any feedback if I've messed up. Resonanteye 16:48, 27 November 2006 (UTC)