Talk:IntraUterine System/Archive 1

message: Let's all work on reaching a consensus for a new infobox to be placed on each individual birth control method's article.  I've created one to start with on the Wikipedia Proposed Infoboxes page, so go check it out and get involved in the process. MamaGeek (Talk/Contrib) 12:23, 14 June 2006 (UTC)
thread_title:  Proposed Infobox for individual birth control method articles 

message: Hundreds of women have reported severe side effects not reported by the manufacturer of this product.
    * CHRONIC fatigue
    * CONSTANT bleeding (up to 9 months)
    * Heavy bleeding and clotting
    * SEVERE Lower abdominal pain (cramps)
    * SEVERE joint and pelvic pain
    * SEVERE Acne or other skin problems
    * DEBILITATING Back pain
    * SEVERE bloating
    * SEVERE weight gain
    * SEVERE Headache
    * SEVERE Mood changes and wood swings
    * Constant Nausea
    * Loss of hair
    * Vaginal Dryness
    * SEVERE depression and feeling of hopelessness
    * Decreased Libido
    * Increased body hair
    * Dry skin
    * Incontinence and constipation
    * Many many more
www.mirenaclassaction.com
—The preceding unsigned comment was added by Cindery (talk • contribs) 21:48, 25 July 2006  (UTC)
Quite aside from what opinion one might have as to manufacture's altruism in reporting side effects - the listed side effects are those required by the regulatory authorities (FDA in US, was MCA in UK but now renamed). Side effects will be included if similar products have exhibited them (hence a slow-release tablet will generally "inherit" the list from a previous short-acting tablet). Post-marketing adverse events reporting ("Yellow card" scheme in UK) are run by the regulators and they will & do insist upon modifications to the data sheets if evidence emerges. All this as it may, to list side effects from claimants in a class action against a drug, does not "prove" the claims - for that one needs cite scientific/epidemiological evidence presented in WP:Reliable sources. 
I am still not clear from the talk-page entry above what the precise reason was for tagging the article with neutrality disputed tags (given they were applied to specific sections, I've modified them from article-disputed to section-disputed):
* Neutrality - Is it that the sections are not written in a WP:NPOV style ? Remember even if one group make claims that some information is being missed from the data sheets, one must find a reliable source to cite in order to verify adding in to an encylopedia "additional facts". 
* Disputed - Wikipedia is not a soapbox, and so is not the place to discuss whether differing opinions are correct or not. However the fact that there is a dispute may in itself need including under NPOV. (i.e. it is the issue of there being a real-world 'disputing' that is notable and worthy of memtion, rather than whether the actual details of the claim can be verified and cited for)
Hence an article on MMR vaccine needs mention the Wakefield/media issue of claimed links to autism - the controversy undeniably exists and vaccine uptake fell as a result (references can be found for these aspecs), yet MMR-autism has not be proven and thus there is no reference one can provide to justify altering the wikipedia articles to state the one being the cause of the other. 
If proof can be found that the group's action is notable (i.e. widespread media coverage and commentary, or similar in medical press) then perhaps a "Controversy" section should be included. But if this remains just claims for a litigation group, then I suspect the neutrality-disputed tags should be emoved from the encyclopedia article. David Ruben  Talk  01:58, 26 July 2006 (UTC)
thread_title: Other possible side effects

message: The neutrality of this article is disputed because it appears to be an advertorial for Mirena, rather than an impartial encyclopedia entry.  It excluded factual information such as 1) Progeseterone, the active ingredient of Mirena, is a carcinogen according to the State of California (Prop 65), the National Toxicology Report, and studies cited by the Breast Cancer Fund.  2)There is a class action suit pending against the manufacturer of Mirena, which lists a large number of side effects not included in Mirena's advertising/marketing campaign.  Because the money spent by Big Pharma makes it difficult for the FDA to prevent the approval of dangerous drugs, and to effectively monitor them once they are on the market, harm to consumers and class action lawsuits are the first sign that a drug or device is a human health hazard.
According to an FDA whistleblower, "I would argue that the FDA as currently configured is incapable of protecting America against another Vioxx." Graham, a 20-year FDA doctor, before the Senate Finance Committee."
http://www.cbsnews.com/stories/2004/12/07/health/main659529.shtml
SUBSTANCE PROFILES
REPORT ON CARCINOGENS, ELEVENTH EDITION, NATIONAL TOXICOLOGY REPORT
Progesterone
CAS No. 57-83-0
Reasonably anticipated to be a human carcinogen
First Listed in the Fourth Annual Report on Carcinogens (1985)
Carcinogenicity
Progesterone is reasonably anticipated to be a human carcinogen based
on sufficient evidence of carcinogenicity in experimental animals
(IARC 1982). When progesterone was implanted subcutaneously,
mammary carcinomas were induced at a significantly earlier age and at
a higher incidence in female mice. Long-term subcutaneous implants
induced ovarian granulosa cell tumors or endometrial stromal
sarcomas in female mice (IARC 1974, 1979). Subcutaneous injections
of progesterone induced increased incidences of mammary tumors in
adult female mice and lesions of the vaginal or cervical epithelia and
genital tract lesions in newborn female mice. Hyperplastic alveolarlike
nodules and other dysplasias were also induced in female neonatal
mice (IARC 1979). Long-term subcutaneous injections in female dogs
induced endometrial hyperplasia, inhibition of ovarian development,
marked mammary hyperplasia, and some fibroadenomatous nodules
of the mammary gland (IARC 1979, 1982).
:The David Graham testimony didn't touch on progesterone or devices. I don't think it's relevant to this discussion. Allegations of corruption etc are extremely serious but should not be made part of any Wikipedia article until the sources are clear and incontrovertible, and preferably not until there has been affirmation of such allegations in a court of law.
:Your data on the carcinogenicity of progestagen is not specifically relevant of IUS, as virtually every contraceptive uses a progestagen. At the doses used in humans, there is very little trial data confirming cancer risk (e.g. breast cancer, uterine cancer). That's because the doses used in the mice and dogs trials were far above human physiologic doses. At such dose equivalences, any beneficial substance may become a carcinogen. JFW | T@lk 23:16, 26 July 2006 (UTC)
replies: text: I was the one who moved your comments.  It is Wikipedia custom to add new topics at the bottom of the page, and I misread your comments as being new topics, not expecting them to be a reply to a four-month-old statement.  Please accept my apologies. Lyrl    Talk     Contribs   01:41, 27 July 2006
 (UTC)
I have moved them back to their original location.Cindery 03:05, 27 July 2006 (UTC)
replies: text: Progesterone has only been shown to be carcinogenic at high doses in animals.  Lower doses of progestins have been used in humans in the form of the pill, minipill, and other hormonal contraceptives for decades without reports of heightened risk of cancer.  I have read all the reports you have referred to so far, and I have not found any evidence that the doses of levonorgestrel released by Mirena are carcinogenic. Lyrl    Talk     Contribs   01:41, 27 July 2006 (UTC)

text: Combined hormonal contraceptives and HRT involve estrogens.  Mirena does not contain estrogens, so studies that have linked estrogen exposure to cancer are not applicable to Mirena.  Most substances are carcinogenic at very high doses; this does not mean they are carcinogenic at lower doses. Progesterone-only pills and other progesterone-only contraceptives such as Depo have been used for decades without (to my knowledge) reports of heightened risk for cancer.  Depo's effects on bone marrow density are well-documented - why would that serious adverse side effect be so well-known, and yet a supposed increased risk of cancer be unheard of? Lyrl    Talk     Contribs   00:50, 28 July 2006 (UTC)

text: Content on talk pages is generally not deleted, so that future editors can review the conversations that went on previously.  Content on talk pages is also not subject to the same reliability and verifiability requirements as article content is.  For these reasons, I have no plans to delete my previous link to the Health Science article.  For a less biased source, consider that the Breast Cancer Fund's State of the Evidence report states that progesterone is added to hormonal treatments to lower the risk of uterine cancer.  Even this anti-hormonal organization states without dispute progesterone's ability to lower the risk for this cancer. Lyrl    Talk     Contribs   00:50, 28 July 2006 (UTC)
thread_title: Neutrality disputed

message: Accuracy Dispute: Sidebar listing "disadvantages" excludes most of them, per the manufacturer's own site.
::The sidebar is meant to be a very brief summary.  A more thorough discussion of disadvantages should occur in the article itself, not in the infobox. Lyrl    Talk     Contribs   01:41, 27 July 2006 (UTC)
thread_title: Disadvantages

message: ::I have seen no evidence that the amount of progestin transmitted to the infant (7% of the amount present in the mother's blood) causes any harmful effects.  Progestin in the form of the mini-pill is very commonly given to breastfeeding women, and has been for decades.  I am open to new evidence, but am unwilling to include speculative warnings. Lyrl    Talk     Contribs   01:41, 27 July 2006 (UTC)
thread_title: No Studies Done on Mirena and Breastmilk

message: (been trying to post this explanation of my revert but repeated edit conflicts as above discussion held)
The issue is less the specific side-effects you are trying to add Cindery, but rather the inappropriate alarmist language used and the failure to give balance to the risks by placing them so prominantly.
:I felt compelled to assign prominence to them because so many of them were absolutely absent or downplayed, in the guise of an "impartial" article.  If you are impartial, why leave out the risks?  the New York Times, The LA Times, and CBS News are not exactly alarmist, fringe publications.  I wish the things in those article were merely alarmist dystopian musings.  Sadly, they are not. Cindery 02:08, 27 July 2006 (UTC)
replies: text: Risks need to be included, and total absence I agree is wrong, but the degree of "prominance" is where we disagree. Most wikipedia drug articles are of format Introduction (what it is and what used for, with possibly mention if notable controvesy over its use), method of action, pharmacology details, indications, contraindicateions, side-effects (common, uncommon & rare may be listed separately in that order), history, controversy. Latter last partly because not a bland description of what-it-is, but more a commentary on the real-world existance of the controversy, and far more importantly last because reader needs the previous somewhat dull dry information as a background to what can then be a complicated discussion about risks, studies, eveluations etc. David Ruben  Talk  04:34, 27 July 2006 (UTC)
replies: text: Then the article should accurately reflect the findings of the studies conducted by the manufacturer. Perhaps you should read the FDA document, which is based on them. Cindery 05:20, 27 July 2006 (UTC)

text: ok, that is one place where we strongly disagree--i do not believe that a perforated uterus is an acceptable risk to take for birth control, when safer methods are available.  Under the informed consent principles, doctor are required to explain comparative risks to patients.  Any doctor who would say, hey, I think you should check out this snazzy new device which could perforate your uterus instead of using a diaphragm or condoms is just not ok with me.  That is my opinion, but ignoring/deleting/refusing to include the long list of risks associated with Mirena--why?  I believe it is because if patients are aware of the risks, they will not want to take them.   Cindery 02:07, 27 July 2006 (UTC)
replies: text: Depends what one means by "safer methods" - COCP have all sorts of risks (DVTs, breast cancer perhaps best reported) but reduction in ovarian cancers probably outweighs these negative. No comfort of course to a women on the pill who has a DVT, but no one campaigns or appears in the newspaper under heading "Pill prevented me from having ovarian cancer", so complications always easier to identify and report than preventative benefits.David Ruben  Talk  04:34, 27 July 2006 (UTC)
replies: text: There is no evidence that the pill has ever prevented a specific person from having ovarian cancer.  The best prevention of ovarian cancer is provided by diet, exercise, and avoidance of environmental carcinogens.  The idea that anyone should take the birth control pill to prevent ovarian cancer is as idiotic as the idea that anyone should take HRT to prevent oseteoporosis: there are more effective ways to prevent osteoporosis, and the risk/benfit ratio is NOT acceptable. Cindery 05:52, 27 July 2006 (UTC)
replies: text: No removal of a risk factor can ever be proven to have effect in any one specific index case, but epidemiology gives strong evidence as to alteration in risk rates. A quick search on PubMed came up with "Mortality associated with oral contraceptive use: 25 year follow up of cohort of 46 000 women from Royal College of General Practitioners' oral contraception study." , which found for current & recent (10yr) users of oral contraceptives relative risk of death from ovarian cancer was 0.2 although from cervical cancer 2.5. This year "Oral contraceptive use and cancer. Findings in a large cohort study, 1968-2004." , which concludes "Combining data for cancers of the cervix, uterine body and ovary, the age adjusted RR for women ever using OCs compared with those never doing so was 0.7 (95%CI, 0.5-0.8). Beneficial effects of OCs on the gynaecological cancers thus outweighed adverse effects" with the specific cancer relative rates being neutral for Breast cancer (rate ratio) RR=1.0 (95% confidence interval (CI) 0.8-1.1), positive for Cervical cancer RR=6.1 (95%CI, 2.5-17.9), and negative for Uterine body cancer RR=0.1 (95%CI, 0.0-0.4) (77 cases) and Ovarian cancer RR=0.3 (95%CI, 0.1-0.5). David Ruben  Talk  04:05, 28 July 2006 (UTC)

text: HRT for osteoporosis prevention is not idiotic, it was the best treatment option of its time. The previous view that women only had significant rates of heart disease similar to that of men after the menopause (a wrong assumption) lead therefore to good grounds for suspecting that HRT might reduce heart disease. Of course the possible effects on coagulopathy, such as DVTs and thrombus formation on a coronary plaque, had not been considered. As studies highlighted the increase cardiac and breast cancer risks of HRT, so studies came in showing the newer biphosphonates to have superior efficacy. So with HRT risk/benefit profile changing and a more effective alternative, HRT fell from its No 1 pedestal. However HRT still has a role for osteoporosis prevention, namely for those women unable to take biphosphonates or the even newer product of strontium ranelate - so about No 4 on the list. David Ruben  Talk  04:05, 28 July 2006 (UTC)
thread_title: re my Reversion of alarmist pushing of risks (=POV agenda)

message: Issues of progestagen effects re cancer are not limited to just IUS, so to devote most of the article length to this, or to state that this is a carcinogen is over alarmist. As a topic it would be better mentioned in the one place of progestagen (or progestin - precise term to use and which article to link to here in wikipedia gets regularly disputed). Breast cancer risks of HRT seem largely associated with combined HRT's progestagens, against this the progestagens do protect against endometrial cancers compared to unopposed oestrogen-only HRT. So just calling it a carcinogen is too simplistic and thus is alarmist. Whilst some of the progestagen from IUS does enter circulation and thus cause progestagen symptoms, this is generally lower than POP/Depo-Provera/combined HRTS. Given any effect on breast cancer rates must mirror circulating progestagen levels, the IUS might be expected to cause less breast cancers (if any) than the other more systemic progestagen delivery methods. Against this, the IUS's progestagen is at "full concentration" and effect at the endometrial lining. So one might expect the IUS to show full endometrial cancer prevention as seen in the COCP but far less risk breast cancer. The overall cost/benefit rates for cancers as a whole might therefore be a positive one. Sure studies will actually look into this supposition, and the degree of overall benefit might be very little or even marginally negative (which I would not expect), but it is not going to be entirely negative.
:oh, I'll be making my way over to "progesterone" and plenty of other drug sites, believe me.  I found this one first, pretty much by accident, because it linked from the Dalkon Shield entry.  the Dalkon shield entry read like propaganda from an IUD manufacturer who wanted to mitigate "bad publicity" leftover from the Shield to clear the way for a new IUD.  Based on a CNN article from 2000, it is clear to me that that is highly likely what the marketing dept. of Berlex/Schering wanted to do--claim that the Shield made Americans wary of IUDs, to increase profits of Mirena.  I have looked over the Paxil and Effexor Wikipedia entries also, and am very very suspicious that the unseen hands of Big Pharma play a role in Wikipedia authorship and editing.  (And  I am hardly as alarmist as the person on the Effexor site who wrote "a PR company is erasing everything unfavorable about pharmaceutical drugs from Wikipedia" or somesuch. (Someone kept deleting the link to a patient petition about a request to the FDA to chnage the Effexor warning, based on their experience of side effects.) Cindery 02:34, 27 July 2006 (UTC)
replies: text: Interested parties tweeking articles about themselves is not limited to medical articles - there was quie a stir over US elections and candidates buffing up their biographies and talking down articles on their opponents - suffice to say practice is strictly prohibited in wikipedia and generally results in a prompt ban of the user. However WP:Assume good faith policy means that one must assume editors are working for the same greater good, whatever ones private thoughts might be. David Ruben  Talk  04:34, 27 July 2006 (UTC)
thread_title: Big Pharma in Editing?

message: :And the FDA, the New York times, a class action suit--those are not sources of "minority" opinion. (Especially the FDA, for crying out loud.  The argument the Times et al make is that something has to be pretty awful for the FDA to sanction it/attach warnings. So if the FDA says, for example, that ovarian cysts are one of the most common side effects of Mirena, that had better be included on the most cursory product information on Wikipedia. If the FDA lists untested carcinogeneity as a WARNING, take note.)
::yes but "take note" is not same as should be banned. Iron replacement tablets have warning about not taking with milk, but that is only because milk prevents the iron tablet from being properly absorbed. Cancers and perforations are obviously "bad" events, but if any degree of risk is seen as unacceptable then we are going to end up pressuring patients as to what the "right thing" to do is going to be. If someone has experienced condom falure despite good technique and put themselves through the ordel of an abortion, small risks of an alternative method may be quite reasonably viewed by that patient as a acceptable   
:::That is NOT comparable.  A risk presented by a carcinogen is NOT on par with un-absorbed vitiamin tablet. I would say the lack of further testing on intrauterine progestin in Mirena is THE reason the FDA should not have approved it (and it is what I suspect the class action will hinge on, and why Mirena will probably be banned.)Cindery 05:52, 27 July 2006 (UTC)
thread_title: Cancer Risk

message: :Also, I notice that you have refused to answer my questions regarding any compensation you may receive viz Mirena.  If you have no financial conflict of interest--why not disclose it?  All your arguments will carry more weight. I have had the good faith in you to pose the question as a question. Cindery 02:34, 27 July 2006 (UTC)
replies: text: WP:Assume good faith. This is a collabrative venture and I'm not obligated to anyone to answer questions on talk pages. Not having responded must not be taken to imply refusal - how dare you. For your information I also read wikipedia articles and contribute to other topics than just IUS. I'm hardly a fast typist, so writing what was a long and detailed explanation of my previous reversion took some time. Individual GP contraceptive service fees were discontined in the Global Sum system of the new General Medical Services contract, so as a UK GP has no financial incentive particularly for any method. IUD/IUS generally inserted by community Family Planning Clinics (ie not within a General Practice surgery) and Mirena awkward in that their higher costs generally not funded for by the health authorities, so GPs often have to prescribe for the patient then to take to the outside clinic - hence Mirena ends up eating into our indicative drug budgets. Suppose it could be argued that a patient with a IUS/IUD does not take up an appointment slot with us every 6 months for a repeat prescription of the pill, but there again such repeat issues are nice quick appointments that allow us to try and keep to time :-) David Ruben  Talk  04:34, 27 July 2006 (UTC)
replies: text: What is the "Global sum system of the new general medical services contract"?  did you previously receive some sort of per-device subsidy for prescribing Mirena? Do you feel that prescribing the device to patients as part of your paid job exempts you from compensation? (I would say no. Making a living from widgets means one has an investment in the continued sale of widgets.) And do you think that prescribing the device gives you a clear bias, to which you should admit?  I admit I am not familiar with UK Tort law, but in the US, you could be held liable in a potential negligence tort case for anything you knew or reasonably should have known about Mirena, if a patient sued you for prescribing it without informed consent. For example, if the manufacturer includes the risk of uterine perforation in their data to you--but you do not pass this on to a patient--and the patient sustains a perforated uterus, you could be sued, not the manufacturer. Admitting in this forum or any other that uterine perforation is a risk of which you are aware--and a risk which may not be acceptable/warranted when safer options are available--could constitute admission of liability for you, as a doctor who has prescribed this device. Same for cancer, levonorgestrel passed to infants in breast milk, ovarian cysts, etc. Do you feel that you are fully capable of assessing the importance of these risks for inclusion in the article, or that perhaps it would be better to recuse yourself, as you may have compelling conflicts of interest? Cindery 05:52, 27 July 2006 (UTC)
replies: text: UK funding for GPs previously mixture of per capita payment for having patients of various ages registered and per-fee items (e.g. antenatal care, postnatal checks, contraception (same fee for advice as prescribing), IUD fee, childhood immunisations, minor ops etc). New system eliminated the per-item fees for a "Global sum" based just on number patients and Quality Outcome Framework points & money for various targets (eg summarised notes, appointment availability, having recent recording of blood pressure for those with hypertension, reaching a target level of hypertension control). Old and new systems had their pluses and weaknesses. David Ruben  Talk  04:05, 28 July 2006 (UTC)
replies: text: You are correct that it is the prescriber in the UK who retains ultimate responsibility for the prescription item, although the IUD/IUS fitter is also responsible for correct fitting technique. Awkwardness also applies to fact that a patient having been to a Family Planning Clinic (FPC) and supposedly counselled by the doctor at the clinic on the method in order to obtain the consent for the insertion procedure, was then asked to request from their GP a prescription. The GP then was responsible for the prescription, yet had not themselves done the counselling or obtaining of consent for the insertion procedure. To overcome some of these issues, the local Primary Care Trust (PCT) health board, who fund their Family Planning Clinics and pay the independently contracted GPs, would often draw up shared care protocol guidelines as to how their commissioned FPC services were to run and then communicate with the local GPs that the required counselling had been undertaken. This transferred some responsibility for appropriate service provision and counselling/consent procedures to the PCTs and the FPC doctor (but not entirely of course, and not to my knowledge ever tested in a UK court). This was a typical UK administrative fudge (an item coming from a GPs drug budget is ultimately paid for by the local PCT, so why they could not do the simpler option of allowing the FPCs to dip directly into the PCTs reserves as they already did for IUDs and pills remains unfathomable to most GPs). In some areas the PCTs have now assessed the funding levels required for IUS and added this to their FPCs budgets, allowing them to prescribe IUS directly and drop the GPs out of the loop. David Ruben  Talk  04:05, 28 July 2006 (UTC)

text: re my capability – please be civil. Are no medical articles to be edited by anyone who is a doctor, pharmacist or a patient as all "may have compelling conflicts of interest". If all reasonable risks are mentioned  (and yes I do mention rate of perforation, systemic hormonal side effects and irregular spotting amongst others) and the patient after considering the risks (frequency and severity), benefits, other options etc then signs a consent form, then some degree of responsibility lies with the patient (that is partly what "Informed consent" is about). David Ruben  Talk 
I think doctors who prescribe devices can contribute to articles about them--if they disclose thier conflict of interest. This allows readers to take the conflict of interest into account when they read what the doctors say. I also think this means you have to be careful regarding your edits to dissenting edits. I have noticed that after days of sustained debate, you have begun to allow some changes to the article. Thank you.Cindery 13:36, 28 July 2006 (UTC)

text: As for cancer risks there is reasonable evidence for an overall net benefit of oral hormonal pills ("Oral contraceptive use and cancer. Findings in a large cohort study, 1968-2004." , amongst others) which failed confirm increased risk previously reported for breast cancer, higher than previous reported rise in cervical cancers, but numbers offset by reduced endometrial & ovarian cancers.  And yes I do mention for the pill the changes to these cancer rates, although on finding this study I wonder if previous reciting of a local gynaecologist’s advice that risks endometrial & ovarian cancer were halved by COCP was unduly conservative, as  this study suggests just 10% & 30% of rates compared to non-use of COCP. David Ruben  Talk  04:05, 28 July 2006 (UTC)
thread_title: Conflict of Interest?

message: Might I suggest, by way of compromise, that if those who dispute overall safety (rather than just minor disagreement over values of some of the small risks) are notable in themselves (e.g. million women march or a successful conclusion to a legal class action), then the minority view point might be better included (and thus less liable to POV disputing) under a separate section titled "Controversy" or something similar. Then using appropriate references the fact of there being a dispute (as opposed to carrying out the dispute itself here in wikipedia) is mentioned as required by NPOV. David Ruben  Talk  01:52, 27 July 2006 (UTC)
replies: text: Nope--I don't agree, and will bring in reinforcements.  First of all, I'm really going to be a stickler about including the full risks described by the FDA, which were not included in the first article, and which someone keeps deleting. As  it stands, the entry is still "marketing," not even a "patient insert" (which is what it is designed to emulate.  Patient insert minus all the scarier risks= marketing fluff. And progesterone/artificial hormones/carcinogenesis/no testing thereof is a big issue.  The only thing I might concede to "controversy" is the larger issues surrounding the for-profit medical/pharmaceutical industry (As long as they are still linked to/a part of this page.) Cindery 02:34, 27 July 2006 (UTC)
replies: text: No this is an encyclopedia, not a facsimily of data sheets or FDA information - go visit the FDA site for all their information. If you start dumping data-sheet or masses of unabridged FDA discussion documents this will not help the project and will result in WP:RfC on this article, which gets messy for everyone. I basically agree with you - the article needs to discuss risks, progestagen side effects (most commonly minor symptoms of breast discomfort or nausea) and te imprtant but rare risks =. Most editors will agree with this, but add information in stages, don't rush or push as this will just antagonise - make a small change, see how other editors improve teh wording or update a citation with a better or more recent one. But dumping long lits of all risks known is likely to be seen as poor encyclopaedic style (whether or not true) and get revised.David Ruben  Talk  04:34, 27 July 2006 (UTC)
replies: text: No, you do not basically agree with me. I do not agree that uterine perforation is acceptable/too rare to be mentioned, given the benefit in exchange).  The carcinogenesis warning from the FDA, and the notes regarding ovarian cysts are not minor things, and must be included.  Claims for the device, such as that it is good for menopausal or breastfeeding women, are not based in fact.  the list of side effects from the class action claimants should be included on the article page as "other possible side effects."  Hormonal contraceptive implants have presented clear and present dangers in the past to women. I don't believe this is a safe device--and at the very least the FULL FDA warnings should be listed, as they are directly from the manufacturer's own studies, and because it is so easy for drug companies to obtain approval for drugs/devices hwich are not adequately tested for safety. Cindery 06:06, 27 July 2006 (UTC)
replies: text: I (partially) disagree - rate of perforation is rare at less than 1 in 1000, else what level would one set for common, uncommon, rare & very rare events ? I would agree that the risk, at whatever frequecy, is of such a major nature if it occurs that it needs be discussed with patients, but it is open to personal assessment of acceptability and cost/benefit analysis.David Ruben  Talk  04:05, 28 July 2006 (UTC)

text: Agree - I was always told this quote is from Mark Twain, and yes presentation of statistics is important ("men kill many women" is as alarmist as "insignificant number of women killed" is minimising reductionist) and affects the POV/NPOV of a passage.David Ruben  Talk  14:10, 28 July 2006 (UTC)
thread_title: Separate Controversy Section?

message: Article curently has a link http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm?fuseaction=Search.Label_ApprovalHistory#apphist but this seems to be generating a site-error on trying to follow it - is this just my browser or does the URL need amending ? David Ruben  Talk  11:45, 27 July 2006 (UTC)
thread_title: Broken Link?

message: http://www.guardian.co.uk/medicine/story/0,11381,1101706,00.html
:The concerns of Cindery seem to be getting addressd on the talk page.  Is there objection to removing the dispute tag now? Lyrl    Talk     Contribs   13:48, 29 July 2006 (UTC)
replies: text: Wikipedia does not allow references to the talk page.  Other sources are allowed to copy/publish/distribute Wikipedia articles under the GNFL, and WikiMedia itself is beginning to release CDs containing selected articles, with plans for more coverage in the future.  These copies/distributions have to stand alone, without reference to things that won't get copied such as the talk page. Lyrl    Talk     Contribs   02:24, 30 July 2006 (UTC)
thread_title: Reliability of Pro-product Medical Sources

message: There are a lot of (religious) groups/people who were upset that they felt they were not informed that one of the ways in which Norplant seemed to work was not by preventing conception, but by preventing implantation; that is was not a contraceptive but an abortificent. Mirena appears to work in the same way.  The marketing-spin on Mirena has been adjusted "we don't know excatly how it works!" to avoid informing people who may have conscientious objections to forms of birth control which are abortificent rather than contraceptive.
Cindery 19:50, 29 July 2006 (UTC)
replies: text: The issue is already mentioned under the 'mechanisms of action' section.  Feel free to incorporate a wikilink to the Controversy over beginning of pregnancy article. Lyrl    Talk     Contribs   22:20, 29 July 2006 (UTC)

text: We know that Mirena has all the effects listed in the mechanisms section.  It seems fairly straightforward that having fewer ovulations (a known effect of Mirena) reduces pregnancy risk.  Therefore, reducing the frequency of ovulation is one way it protects from pregnancy.  Right?  Considering that hostile cervical mucus is a major cause of infertility, and the stacks of research on fertility awareness methods involving observation of cervical mucus, it also seems fairly obvious that the known changes in CM caused by Mirena (making it more acid, preventing the ferning patterns needed to guide sperm through the cervix) is one way it protects from pregnancy.  These are known ways in which the method works, so it is inaccurate to say that "we don't know how it works."  There are other suspected mechanisms, primarily the known changes to the endometrium, but these are in addition to the mechanisms that are known. Lyrl    Talk     Contribs   02:02, 30 July 2006 (UTC)

text: Hormones in Mirena normally get outside the uterus.  Systemic concentrations of levonorgestral are typically 100-200 pg/mL.  Other contraceptives systems using the same progestin (mini-pill, Norplant) can also cause amenorrhea.  It doesn't surprise me that the proximity of the device (while located in the abdominal cavity) to the ovaries and uterus caused sufficient local concentrations of the progestin to induce amenorrhea. Lyrl    Talk     Contribs   02:02, 30 July 2006 (UTC)
thread_title: Is Mirena an Abortificent or a Contraceptive?

message: The citation for the Adverse Reactions newsletter is NOT a press release. Neither is the Mirena product information (which includes all the study info/required FDA warnings).  ("medpundit" is a blog, written under a psuedonym. many web sources just reiterate marketing materials word-for-word, and may as well be press releases.) —The preceding unsigned comment was added by Cindery (talk • contribs) 07:22, 28 July 2006  (UTC)
::The citation templates are here: WP:CITET
::Feel free to change them to whatever you feel is more appropriate. Lyrl    Talk     Contribs   02:48, 29 July 2006 (UTC)
replies: text: The information that cites medpundit is that Progestasert was discontinued on 2001.  This seems an interesting bit of information, that I feel adds to the discussion of IUS history, but uncontroversial enough to let the blog source slide.  If you have another source of information on Progestasert, feel free to replace it. Lyrl    Talk     Contribs   02:05, 30 July 2006 (UTC)
thread_title: Press Release Citations

message: Regarding the FDA warnings, (Lyrl--that was you, right?  I am sorry that I don't know how to post comment to you another way) I think they should be listed in the section, under a section heading. I also think there should be a "Study Bias" heading/section, explaining such facts as that 1) only 2339 women were studied, and less than 700 for five years 2) that %75 of them were previous IUD-users 3) that the study was paid for by the manufacturer 4) that not even the "perfect use" statistics on pregnancy-prevention accuracy are "facts," given that no pregnancy testing was done when subjects a) left the studies b) the studies ended c) %6 of them were no followed-up with. —The preceding unsigned comment was added by Cindery (talk • contribs) 03:04, 28 July 2006  (UTC)
::You can post comments on my Talk page (here) if you want something to only be seen by me.  If it is part of article discussion other editors might be interested in, it is fine to post on the article Talk page.
::My concern on the FDA warnings as a section is two-fold.  Firstly, duplication of information.  Ectopic pregnancy and perforation, for example, have discussion of their topics elsewhere in the article.  Why should they be mentioned twice?  Secondly, the topics in the side effect/complications section lend themselves to expansion as editors find more information on them.  Just copying a list from the FDA seems limiting. Lyrl    Talk     Contribs   02:48, 29 July 2006 (UTC)
thread_title: How FDA Warnings Should be Included in Article

message: ::Similar criticisms can be raised for perfect use statistics of all birth control methods.  There are no perfect studies.  The topic of study bias affects a large number of articles.  I would support making a new article on study bias (relating to prescription drugs and devices) and linking to it in relevant articles - this would prevent information being repeated (with varying degrees of accuracy and writing skill) over and over again.  This approach seems to be working with Controversy over beginning of pregnancy, which is currently linked to by several hormonal contraception articles and will probably gain more "what links to here" as time goes on and articles are expanded. Lyrl    Talk     Contribs   02:48, 29 July 2006 (UTC)
replies: text: I have no objections to including results from other studies.  Heavy bleeding and pain seem important to note as side effects, especially if there is some indication of how common they are. Lyrl    Talk     Contribs   01:51, 30 July 2006 (UTC)
thread_title: Study Bias in Mirena?

message: This discussion seemed important, as people will be (hopefully) getting information on IUS from other sources; knowing that sometimes they are called by a different name (IUD) seems like it would help a reader interpret information from these other sources. Lyrl    Talk     Contribs   03:15, 29 July 2006 (UTC)
replies: text: I think too many names mucks up clarity--the Mirena is known by: "Mirena," "Mirena Coil," "IUS," "Mirena IUS," "IUD," "levornogestrel-releasing intrauterine device,"(how it is usually referred to in pubmed articles), "LNG-IUS," "Mirena IUCD," "MIRENA," and "MirenaTM"...Maybe towards the bottom there could be an "aka" section listing them?  It's confusing/not relevant in the first sentence of article?
Cindery 08:02, 29 July 2006 (UTC)

text: No, I don't think so. Nor do I think there is any "debate." I think the only reason for pushing this in the intro is  "branding,"-a form of advertising. It's both an implant device and hormonal contraceptive. Not a "system."Cindery 18:54, 30 July 2006 (UTC)
replies: text: I have never seen "debate" on the subject, but some sources (which Wikipedia readers may also be reading) provide naming information that conflicts with other sources.  I guess I'm not understanding how providing useful information to readers (explaining why they may see conflicting information when reading about hormonal intrauterine devices in other places) is advertising. Lyrl    Talk     Contribs   21:37, 30 July 2006 (UTC)
thread_title:  IUD/IUS name discussion removed? 

message: : "According to the Netherlands Pharmacovigilance Centre
Lareb, which registers and evaluates adverse side effects and
complications with drugs, at least 24 LNG IUS-related
uterine perforations were reported in the Netherlands (LNG
IUSs inserted before 2003) since registration of the LNG IUS
in February 1996. None of the 21 uterine perforations
reported in the present study had been reported to the Lareb.
This indicates a considerable underreporting of this complication.
Apparently, a perforation with an IUD is not considered
to be an event that has to be reported to the Lareb. After
consent was obtained from the doctors who performed the
insertion of the LNG IUS, the 21 uterine perforations
discussed here were reported to the Lareb by the authors.
According to sales figures of the LNG IUS in the region
where the study was performed (regional wholesale figures;
IMS View), 1189, 2492 and 2941 LNG IUSs were provided
in the second half of 2000, 2001 and 2002, respectively. Data
on the number of LNG IUSs provided in 1999 and the first
half of 2000 could not be retrieved. Assuming that all
provided LNG IUSs were inserted, that insertion took place in
the region and year of provision, and that no expulsions
occurred nor devices removed because of side effects, the
estimated incidence of uterine perforations in the studied
region is at least 2.6 per 1000 insertions. The actual incidence
of LNG IUS-related uterine perforations cannot be calculated
because of incomplete data of the provided numbers of LNG
IUSs in 1999 and the first half of 2000, failure to recollect all
cases and possible negligence in reporting cases."
Cindery 18:36, 29 July 2006 (UTC)
thread_title: Considerable Underreporting of Perforation

message: i don't have access to the full text of this first article, so i am not sure exactly what they mean by "raises important issues regarding the use of Mirena IUS to treat menorrhagia."  Has anyone read it? 
Gynecol Oncol. 2002 Nov;87(2):216-8. 	
    
Endometrial adenocarcinoma following the insertion of a Mirena IUCD.
Jones K, Georgiou M, Hyatt D, Spencer T, Thomas H.
Ashford and St. Peter's Hospital, London Road, Middlesex, TW15 3AA, United Kingdom.
BACKGROUND: The case histories of two patients who developed endometrial adenocarcinoma with a Mirena intrauterine system (IUS) in place are reported. CASE: Two patients had a Mirena IUS inserted to treat abnormal vaginal bleeding. After 12 and 36 months with the device in place they presented with a recurrence of their heavy, irregular menstrual bleeding. Endometrial biopsies confirmed the presence of endometrial adenocarcinoma, and hysterectomies were performed. In one patient the cancer was localized and below the stem of the device, in the other metastatic disease had developed. CONCLUSION: These cases raises important issues regarding the use of the Mirena IUS to treat menorrhagia.
Publication Types:
Case Reports
PMID: 12477456 [PubMed - indexed for MEDLINE]
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=15943993&dopt=Abstract
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=Display&DB=pubmed
Cindery 01:10, 31 July 2006 (UTC)
thread_title: Endometrial Adenocarcinoma and Mirena

message: The reversibility note on the sidebar has been changed from "2-6 months" to "2-12 months or more".  What is the rationale behind this? Lyrl    Talk     Contribs   03:23, 30 July 2006 (UTC)
thread_title:  Reversibility 

message: The contraindications section currently lists "Women at risk for certain sexually transmitted diseases (STDs) that can cause pelvic inflammatory disease (PID), or with or at risk for HIV." It then lists seperately "Women who have more than one sexual partner, or whose partners have more than one sexual partner."  These are really the same contraindication.  Can they be combined? Lyrl    Talk     Contribs   03:23, 30 July 2006 (UTC)
thread_title: STD risk / sexual partners

message: I think there should be some mention that because there is a risk of infertility, it is recommended for women who have already had one child. This is commonly cited for IUDs, and is cited in Schering product insert. The reason manufacturers' typically cite is liability insurance/that "juries are highly sympathetic to otherwise healthy people who suffer a terrible tragedy from a minor complication." Aside from their reasons,  it IS a greater tradegy for a woman who would like to be a mother to risk not being able to have any than it is for a woman who has already had one...Cindery 07:26, 30 July 2006 (UTC)
replies: text: I don't have any objections to including that discussion the article.  I would be careful with the wording on nulliparous women (saying "some doctors believe this is a less acceptable risk for nulliparous women" or something along those lines rather than simply stating it as less acceptable, and ideally finding a source with the nulliparous advisory), as not everyone believes it's more acceptable for parous women to risk infertility. Lyrl    Talk     Contribs   13:01, 30 July 2006 (UTC)
thread_title: Nulliparous Women

message: shulman, nelson, and darney. they are the authors of the 2nd article cited as reference for American Family Physician article: 2. Shulman LP, Nelson AL, Darney PD. Recent developments in hormone delivery systems. Am J Obset Gynecol 2004;190(4 suppl):S39-48.  i have removed the afp article as a reference.  since the main ref for the article is the berlex product insert, refs used from that can revert to that. any other refs can be cited separately from the bibliography of afp article. 
(what's worse, darney is heading the long term study of levornogestrel iud...)
darney and shulman are listed here, where they were required to disclose conflicts of interest:
[PDF] Contraceptive Methods and Sexually Transmitted Infections
File Format: PDF/Adobe Acrobat - View as HTML
PHILIP D. DARNEY, MD, MSc Grant/Research Support: Pharmacia Corporation. Consultant:. Organon Inc. Speakers’ Bureau for Commercial Sponsors: Berlex ...
 
anita l. nelson is here:
Anita L. Nelson, MD
Professor, Department of Obstetrics and Gynecology, UCLA School of Medicine, Los Angeles, California
Dr. Nelson holds undergraduate degrees in economics, from Occidental College, and in biology, from the University of California at Irvine. Her medical degree was conferred by the University of California at Los Angeles (UCLA) School of Medicine. She completed her residency in obstetrics and gynecology at the Harbor-UCLA Medical Center.
Dr. Nelson is currently a Professor of Obstetrics and Gynecology at both the UCLA School of Medicine and Harbor-UCLA Medical Center. She also serves as Medical Director of both the Women's Health Care Clinic and Women's Health Care Nurse Practitioner Program at Harbor-UCLA Medical Center, as well as for the Research Division of the California Family Health Council. She is also Program Director of Women's Health Care Teams for the Coastal County Health Centers within the County of Los Angeles.
Board certified by the American Board of Obstetrics and Gynecology, Dr. Nelson has written extensively in the areas of contraception, menopause, and gynecologic infection. An author of Managing Contraception and Contraceptive Technology, she is also an Editor for Contraceptive Technology Update. Dr. Nelson is the recipient of many professional awards.
Dr. Nelson is engaged in research for Berlex Laboratories, NIH, NICHHD, Organon, Ortho-McNeil, and Pharmacia. She is a member of the Speakers Bureau of Barr Laboratories, Berlex, Columbia Laboratories, Eli Lilly, 3M Pharmaceuticals, Ortho-McNeil, Organon, Pfizer, Pharmacia, Solvay, Women's Capital Corp., and Wyeth.
here is an example of dr. darney's (undisclosed) flacking for mirena (it is remarkably similar to the press-release-y info repeated in web articles everywhere on mirena; the party line):http://www.kaisernetwork.org/Daily_reports/rep_index.cfm?DR_ID=5188
Cindery 01:55, 1 August 2006 (UTC)
thread_title: All three authors of article on Berlex speakers' bureau

message: In this study, Obstet Gynecol. 2005;105:46-52 lower efficacy of OCs is correlated with higher BMI, with the arguments that steroid hormone metabolism is affected by greater body weight, and/or lipid metabolism. (steroid hormones are lipophilic. I think it is already commonly known that anesthesia drugs are lipophilic, and higher BMI means more drugs are needed??) It seems possible that women with a lower BMI would be more strongly affected by a lipophilic drug like levonorgestrel. (That could at least partly explain why some women have more/more intense hormonal side effects than others?) 
Also to consider: genes. Especially genes and activity of enzymes which metabolize progesterone. Variety does exist. 
And: levonorgestrel is derived from testesterone, is a "nortestosterone," with high relative androgenic activity in comparison to other synthetic progestins. (Isn't high BMI estrogenic?  Might not then women with low BMI and less genetic ability to metabolize testosterone/higher genetic susceptility to testosterone in the form of receptors, be more sensitive to levonorgestrel, explaining heightened effects for a minority?)
I have been reading more about women having intense hormonal side effects from LNG (mirena dose)--all their hair falling out, bad acne, significant weight gain, terrible depression. And other women on LNG (mirena dose) having none. I believe that a minority of women are having these problems, and also that they are the minority. There has to be an explanation. Cindery 07:56, 1 August 2006 (UTC)
thread_title: BMI and hormonal BC

message: "The first International Conference on Intrauterine Contraception in 1962 promoted the IUD. The conference was sponsored by the Population Council, a group concerned with curbing worldwide population growth. In his opening statement for the conference, Dr. J. Robert Willson said "We have to stop functioning like doctors, thinking about the one patient with pelvic inflammatory disease [...] how serious is that for that particular patient and for the population of the world in general? Not very [...] perhaps the individual patient is expendable in the general scheme of things" (Perry and Dawson, 23).
The Population Council was founded by Rockefeller. Rockefeller had a strong interest in "eugenics," and donated money to the Nazis. Its last CEO was a former VP of J.P Morgan. (This is a "nonprofit organization"--but one with "unsavory origins" and huge financial support from corporations which had/have vested interest in maintaining American financial self-interest in developing countries via "population control.") Cindery 18:32, 1 August 2006 (UTC)
thread_title: Population Council

message: have conflicts of interest, either they have to go, or mention of the conflict of interest has to cited *whenever* they are referenced. i am all for inspiring readers to think about possible conflicts of interest whenever they read something, but i think that would be clunky/inelegant in the article, and so these references should just go. (if they come from a conflict-of-interest source--and can't be duplicated by another source--that's further proof they don't belong here.)
:The "conflicts of interest" issue gets brought up on contentious topics quiet often, and often risks becoming a rather pedantic source of edit-warring over allowable papers to quote; the problem being that if the journal is a WP:Reliable sources then all of its papers are "reliable" in as much as they may be cited (whether a paper is good/bad, innovative/duplicative is a personal opinion). The requirement is of course that the text in the article meets NPOV and a reference is provided from a reliable source. It is not wikipedia's role to pass judgement on any given paper (that's the role of the peer review process undertaken at the Reliable Source itself). So unless one finds a source to cite as stating that a paper had a conflict of interest, this risks being seen as a personal opinion (i.e. WP:NOR). I take a more relaxed view on references, namely I expect the text to be NPOV and  refs used to verify a claim is made but not prove "the whole truth" (example: many articles on aspirin reducing heart disease in otherwise well population and any paper could be quoted even if from manufacture. The problem is not if independant researcher or manufacture make such a claim, as effect is true enough, but rather that offset by increase in gastric ulcers and bleeds (i.e. cardiology journals conflict with gastroenterology journals) - in real life, consensus of medical practice is not based on "whole accurate truth" of any given paper, but the integration of knowledge from multiple papers, experience, practicle considerations etc). David Ruben  Talk  04:07, 2 August 2006 (UTC)
replies: text: All that somewhat long winded (sorry). As for ref 3, this is a claim for IUS role in reducing need for hysterectomy and thus not fanciful thoughts of an editor (my seeing clinic letters from local gynaecologists advising & doing this can't be cited in wikipedia, but its true enough and such a paper acts as some form of real-world verification). Other refs can be provided showing there may be a problem with the cost-benefit analysis, namely that may prevent need of hysterectomy in short term, but some patients over a longer time frame may still need hysterectomy (not clear if IUS failling to help, or underlying disease gets worse and nolonger can be controlled by medical means). I don't think the Ref 3 is therefore wrong, just that like most topics, no one paper gives whole picture. Or have I missed some terrible feature of that paper ? :-) David Ruben  Talk  04:07, 2 August 2006 (UTC)

text: Yes I did read the link you gave re "ghost writting" (Guardian newspaper if I recall) - and very alarming. I had only relooked at Ref 3 of those that your querried. Woud this Cochrane review be better (it comapres diferent studies and independantly weighs usefulness of evidence eg study designs, numbers, duration of followups etc) ?
* 
it seems entirely reasonable and unbiased to me. Cindery 19:24, 2 August 2006 (UTC)
thread_title: citations 3, 7, and 14

message: Is the information itself being questioned?  Is there reason to believe Mirena does not actually reduce the frequency of ovulation?  Or cause changes in cervical mucus detrimental to fertility?  Or anything else in that list?
I guess I'm just puzzled as to why the reference for those particular facts is being questioned.  I have seen discussion along the lines of "that's not true, look at this other source that is more reliable than the one that has the non-true statements." 
But it's frustrating to spend time trying to find a website with some sort of substance (vs. just a college birth-control infopage or other source that just lists statements), and then be told "nope, what you're saying is true, but we're going to delete it from the article because there's something completely unrelated wrong with the source." Lyrl    Talk     Contribs   01:03, 3 August 2006 (UTC)
thread_title: Reference on what Mirena does to reproductive system (currently #7)

message: i can't find the word "bioidentical" in any dictionary. (but i didn't check the OED.) it is used in a few very recent pubmed articles, but it is used in quotes, as in, so-called "bioidentical." the only places it seems to be used as a word are in ads for progesterone cream. my conclusion is that it is not a commonly accepted term/a word in general usage.
as far as i understand: progesterone is synthesized in labs, from plant steroid compounds like stigmasterol. (which comes from soy.) it has to go through many synthetic steps to ferment and bio-convert it, and be treated with solvents like acetate. at the end of the process, it can be left at as it is, micronized for easier absorption, or a molecule can be added to make it more bioavailable (that's MPA, aka, depo). all the progesterone is exogenous and synthetic. (pfizer doesn't get their soy stigmasterol from a different source than "natural" progesterone creams do.  it's the same stuff: soy. has to be highly chemically processed to be usable by the human body.) 
for a while, it seems that wild yam was believed to be a "natural" progesterone, but that proved to be false. wild yam contains the plant steroid diosgenin, which chemists can break down into progesterone--as with stigmasterol-- but which the human body can not break down into progesterone. there is no natural source from which the human body can make it own extra progesterone. all progesterone used by the human body is manufactured in chemical labs.
in addition to not being a word in general usage, "bioidentical" is misleading, i think. or meaningless. USP progesterone is a synthetic chemical derived from plants, which can have the same chemical structure, after processing, as human progesterone. that's all. 
Cindery 23:06, 12 August 2006 (UTC)
replies: text: The word progesterone has been conflated with progestin (as in the common usage 'progesterone-only pill' when the pill actually contains a progestin).  When one is talking about progesterone, as in a molecule with an identical chemical structure to that produced in the human body, it is useful to have some identifier to distinguish from progestins.  Some sources use 'bioidentical', others use 'natural'. Lyrl    Talk     Contribs   00:03, 13 August 2006 (UTC)
thread_title: "bioidentical" progesterone

message: Here is a study which asserts it is possible that only MPA and the nortestosterones are the bad actors in breast cancer risk (because they are androgenic (MPA and nors) and estrogenic (just nors), while synthetic exogenous progesterone which is chemically identical to endogenous progesterone does not have androgenic/estrogenic effects.
this one also:
Cindery 22:38, 18 August 2006 (UTC)
thread_title: some exculpatory evidence for "natural" progesterone

message: ...that paragraph seems so fuzzy with fresh eyes, but want to check in before reworking/maybe someone else would rather do it.  the main clinical use is contraception, but we don't start off by saying that, we say it thins the endometrium...kinda confusing.  then we list the secondary uses, then we list what it is not used for.  maybe the contraceptive mechanism of action/the main clinical use as contraceptive should be focus of first paragraph, with second paragraph detailing secondary uses, and non-uses go somewhere else further down?
Cindery 00:32, 4 September 2006 (UTC)
thread_title: clinical uses

message: *I moved the "Removal" section to below the "Mechanisms" section.  Reading about fitting -> contraception -> removal seems to be a logical order.
*I moved the "Location" section to the top of the side effects section.
*I fixed the url in a citation of Planned Parenthood (PP had redesigned their webpage), and combined the duplicate ref of that webpage.
*I changed the wording of the string discussion per #cutting strings discussion.
*I made a new sub-section "Pelvic inflammatory disease and sexually transmitted diseases" and removed the sentence on that from the "Contraindications" section.  I combined the information in the "HIV" section into the new "Pelvic..." section and modified the information per #HIV discussion.
*I made a new sub-section "Postpartum and Postabortion insertion" and removed that sentence from the "Contraindications" section.
*I broke out the discussion of cancer into its own subsection and removed that sentence from the "Contraindications" section.
*Benign trophoblast disease was the only thing left in the "not usually recommended" portion of the "Contraindications" section, so I put it below the "may not be inserted" list.  As malignent trophoblast disease is at the end of that list, the readability seems to be improved.
*I made "Bone density" a sub-section of "Side effects".
*I made the references small.
*Minor spelling and grammar changes.
*Re-add citetemplate for FDA patient insert that was accidently deleted several edits ago.
Lyrl    Talk     Contribs   01:20, 9 October 2006 (UTC)
replies: text: Good edit - yes seems to improve the flow of the article. David Ruben  Talk  01:47, 9 October 2006 (UTC)
thread_title:  Edit 8-October