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March 03, 2006

Is the NIH posting misleading EC info?

Emma, an OB-GYN blogging at The Well Timed Period, spotted a very suspicious claim in the Medline Plus entry on ectopic pregnacy:

The "morning after pill" is associated with a 10-fold increase in risk of this condition [ectopic pregnancy] when its use fails to prevent pregnancy.

MedlinePlus is a online health encycolpedia for consumers published by the National Institutes of Health.

Emma writes:

Well, knock me over with a feather and call me Fifi; a 10-fold increase you say?

The way I see it, there are 3 possible explanations for this statement:
1) It's a typo.
2) The information is accurate.
3) The government is deliberately making stuff up.

I haven't yet contacted the site operator, so the typo explanation remains a possibility.

It's also possible that, while I slept last night, the medical consensus has changed and ECP use is, indeed, associated with a 10-fold increase in risk of ectopic pregnancy. This one is easily verifiable; all we need to do is to look at the relevant literature.

Emma goes on to review the literature.

Synopsis: If failed ECP increases the risk of ectopic pregancy, nobody told science. There is no evidence that failed ECP increases the risk of ectopic pregancy vs. normal pregnancy. Besides which, ECP is just plain effective at preventing pregnancy--which means that it reduces a woman's risk of both the ectopic and non-ectopic varietes.

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Comments

Ah, but it's such an excellent (Rovian) lie. If you take this pill, not only will you get pregnant, you will explode and die. Extra brilliant because it requires one to imagine that there are enough pregnancies using the morning after pill to create a statistically-meaningful sample. You have to stipulate the "pill doesn't work" part in order to debate the "will maim/kill" part.

The site states:

The "morning after pill" is associated with a 10-fold increase in risk of this condition [ectopic pregnancy] when its use fails to prevent pregnancy. (Bold added)

You respond:

Au contraire, ECP is so effective at preventing pregnancy that it reduces a woman's risk of both ectopic and regular pregnancy.

This isn't strictly responsive, is it? The original site is disaggregating the failed uses of ECP from the successful uses, while you are not. It's not claiming that it increases the likelihood, but that for the small set of women for which it doesn't work, the likelihood is higher than it would have been if the drug had not been taken. I have no idea if that's true or not, of course, but your response is not inconsistent with the original statement.

" It's not claiming that it increases the likelihood, but that for the small set of women for which it doesn't work, the likelihood is higher than it would have been if the drug had not been taken."

While that might be true, it is not a rational argument against using the drug. You might as well say that pregnant women who took the drug were hundreds of times more likely than other women to develop ectopic pregnancies. Considering that most of the other women were not pregnant, it would be an accurate but worse than useless statement.

Eli, you're right, that's potentially unclear. Emma is making a two-part claim, both aspects of which she backs up with the relevant literature.

First, there's no evidence that failed ECP increases the risk of ectopic pregnancy. Second, there's ample evidence that using ECP decreases a woman's risk of both ectopic and non-ectopic pregnancy.

Ah. I read the article. It is not a screed against the use of the drug, as I had thought. There is actually a useful purpose in the statistic, if it is true. If a woman uses the emergency contraception, and it fails, she might want more vigilant medical scrutiny.

Taken as a guide for medical practice after the fact, the statistic has relevance. As a guide for the drugs use, it has none.

Emma has made a classic modern mistake by attempting to look soley at the accepted scientific research. Clearly, she failed to take into account the important factual opinions of the religious and political community.

She probably needs to hire a recent college graduate who has worked in political campaigns to review her statements.

I was blathering based on the assumption that the most generous reading of the stat would be right. From the looks of it though, even that is just not so.

Before this administration there was a reasonable authenticity to anything that NIH and the CDC had to say. Might not be right, might be subject to bias or even bribery. But there was an acceptance that the investigatory work was on a par with or better than most other sources.

Now, it is impossible to believe anything that comes out of our government. All is immediately and seriously suspect. To react in any other way, is to regress to believing in the tooth fairy.

There are numerous case reports wherein Levonorgestrel has been associated with ectopic pregancies when it fails to prevent conception, but it still seems to be a rare occurance. I don't know where the "10-fold" number comes from, and it would be nice to have the reference, but it actually seems plausible.

Lindsay Beyerstein is right. You'll see the same kind of statements regarding IUDs, dating from before the Bush administration.

I thought it would be helpful to know what the margin of error is, but... The go2planb website (operated by Barr Laboratories -- I think we can safely assume that this is a non-planb-hostile environment) has the following:

Ectopic pregnancies account for approximately 2% of reported pregnancies (19.7 per 1000 reported pregnancies). Up to 10% of pregnancies reported in clinical studies of routine use of progestin-only contraceptives are ectopic. [...] Health providers, however, should be alert to the possibility of an ectopic pregnancy in women who become pregnant or complain of lower abdominal pain after taking Plan B.

Hm. So "up to" a five-fold increase. However, the Feminist Women's Health Center also says this:

EC does not harm an established pregnancy. It acts on the uterus and cannot prevent an ectopic pregnancy.

Aha! So it's not that there's an increase in risk, it's that an ectopic pregnancy is more likely to proceed despite use of EC than a non-ectopic pregnancy. Which actually makes sense. So much sense that the ratio of ectopic to non-ectopic pregnancies among the pregnancies actually experienced by users of Plan B might even be as high as 20%. Or it might just as easily be somebody extrapolating wildly from insufficient data.

In any event it doesn't "increase the risk" ten fold. That part is just plain crap.

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