You don’t need to have a period

In light of my post on times not to tamper with the body, here’s one case where I’m very much in favor of tampering.

You don’t need to have a period.

Painful menstruation impairs daily activities for around 20% of women. That’s not including mood changes or menstrual migraines, both of which are also common. As a cause of disability, it’s not taken particularly seriously.

I was told my menstrual cramps would probably improve in my twenties. When they got worse instead, I didn’t know what to do except tough it out. My primary care provider just recommended more painkillers.

It’s a doctor’s job to warn you about the risks that come with various kinds of birth control, but we never talked about the risks I faced from unpredictable, crippling pain. Once it struck while I was babysitting two young children, and their father had to leave work to take care of them because I couldn’t stand up long enough to fix them lunch. When I worked at the jail I was in a back office having a counseling session alone with a detainee, when my skin went cold and my vision started to go dark as my body went into shock. I brought the session to a hasty conclusion, gripping the desk to keep upright, and waited until he had left to lie down on the floor until I could get up and walk. I never had to drive with bad cramps, but I can’t imagine that would be very safe.

After three and a half years of pregnancy and breastfeeding, the idea of returning to all that is not appealing at all.

Here are some ways to have fewer or no periods. This is basically the same list from actual doctors.

  • Take regular birth control pills and skip the week of dummy pills at the end, starting right away on a new pack. Some sources say this is best done with monophasic pills (where the first three weeks are all the same, rather than ones where different weeks have different doses).
    There’s no medical reason for the dummy pills. When the pills were originally developed, market research indicated that women preferred to have a period as reassurance that they weren’t pregnant. Now that pregnancy tests cost less than a dollar on Amazon, there are easier ways to get that reassurance.
  • Extended cycle birth control pills where you get dummy pills only every three months, or not at all. If you pay for birth control, this is cheaper than the above method because you’re not paying for dummy pills.
  • IUDs. The Mirena is FDA-approved to treat heavy bleeding, it lasts 5 years, and 20% of women don’t menstruate at all after the first year. You’ll probably get more spotting for the first few months, though. Skyla and Liletta are smaller ones specifically tested for women who haven’t had a baby, though the American Congress of Obstetricians and Gynecologists consider all IUDs safe for women of all ages regardless of whether they’ve given birth. All types of IUD except the Paraguard are likely to improve menstrual cramps.
  • Birth control implant. Nexplanon lasts 4 years and 20% of women don’t menstruate after the first year. Again, spotting is likely.
  • Depo-Provera shots last 3 months and also cause some women to stop menstruating, again with irregular bleeding at first.
  • I’ve seen some doctors say it’s ok to use the patch or NuvaRing continuously, and others say not to.

The US may be about to go back to the bad old days of no guaranteed insurance coverage for birth control, so this might be a good time to get something long-term. If you do want to get pregnant, all of these options except the shot let you return to fertility within about two weeks of stopping/removal.

There are health risks with anything you do or don’t do. Although are no known health risks of avoiding menstruation, there are no long-term studies of it. There are also no long-term studies of operating a car while in crippling pain, or of passing out in an isolated office with a random detainee, and I’d much rather use a tested contraceptive than take my chances with those.

Different methods will have different side effect profiles, so you should consider which ones you particularly care about. There are also different levels of hassle with methods that require renewing prescriptions, remembering what day to do this or that, checking that the strings are in the right place, etc.

If you’re using these for actual contraception, remember that you have a 9% chance of getting pregnant during a year of typical use with the pill, patch, or ring. Long-lasting methods work a lot better, and personally, I prefer a small risk of birth control problems over a 9% chance of either abortion or childbirth, both of which obviously come with risks as well.

If you’re not menstruating, you shouldn’t take women’s multivitamins because they have an amount of iron that’s intended for people losing blood every month. After several years, you might want to get your iron level checked.

If your period pain is really bad, get checked out for endometriosis, which is under-diagnosed. (Literally the first doctor to mention this possibility to me was the psychiatrist at work as he was helping me prop my feet on a bookshelf while I lay on my boss’s office floor after I nearly passed out in a staff meeting.)

Obviously you should talk to your health care provider about any of this. If you get a provider whose answer is basically “more painkillers,” I’d push back or get a different provider.

Chesterton’s fence in health

[Epistemic status: mostly informed guesswork.]

I started writing down some beliefs I have about health, and realized most of them kind of echo Chesterton’s fence:

There exists in such a case a certain institution or law; let us say, for the sake of simplicity, a fence or gate erected across a road. The more modern type of reformer goes gaily up to it and says, “I don’t see the use of this; let us clear it away.” To which the more intelligent type of reformer will do well to answer: “If you don’t see the use of it, I certainly won’t let you clear it away. Go away and think. Then, when you can come back and tell me that you do see the use of it, I may allow you to destroy it.”
– G. K. Chesterton

In terms of health, my belief is something like: don’t mess with bodies too much, because they probably function best under conditions that existed well before the 20th century. I certainly also have beliefs that don’t fit this pattern (C-sections and formula are literally lifesavers if you need them!) A lot of these ended up being about child health, because apparently that’s what I read a lot about right now.

Specific beliefs:

Shoes are a pretty new development for the human body. Community Paediatrics Committee: “Children’s feet should be left alone as much as possible.”

Most modern advice is to use shoes sparingly for kids, and to use lightweight flexible shoes when needed. We’ve found that Robeez, Pediped, and See Kai Run are brands with nice bendy soles. Here’s a more complete list.

I’m not as sold on the barefoot running thing for most adults. Jeff used to have a lot of knee problems and also used to walk with a strong heel-strike, which is only viable in padded shoes. He found that walking barefoot or in minimalist shoes for a while changed the way he walked, and that combined with some other changes (stretches and exercises, not walking pigeon-toed) has resolved his knee pain. Now he’s fine in normal shoes. Unless you have a problem, I think sensible shoes for adults are probably fine.

Then there are high heels. I don’t want to do the thing where we shame women for engaging in (and enjoying) behaviors that society rewards them for doing, but I do think people (and particularly young people) should understand what heels can do to your body.

Moving throughout the day
People seem to agree that sitting down all day is bad for you. Having short movement breaks throughout the day (“nutritious movement”) might be better than working straight through and doing one longer workout. Katy Bowman‘s work on this seems 40% woo, 60% solid.

Set up your life to make this easy: wear clothes you can move in. Have a quick workout app on your phone, weights or a pull-up bar out where you see them and they’re easy to grab. Work in different positions: standing, sitting in different postures. (I realize this is much easier said than done unless you work from home, but a lot of us spend plenty of time sitting at home too.)


Use it or lose it
By the time you get old and stiff, it’s a lot harder to develop habits that improve flexibility and balance. I try to include motions that I want to be able to do throughout life: our bed is on the floor and we don’t have a baby changing table, so Jeff and I are up and down from floor-level many times a day. I can do a pretty good squat now, too. Early parenthood (after your body has recovered some from pregnancy) is a good time to work on this stuff because there’s so much bending, lifting, and getting down on the ground.

Vestibular input
Children’s vestibular (balance) systems need stimulation to develop. They need to rock, bounce, roll, tip, and spin. An overview. I think it’s likely that a lot of modern kids aren’t getting enough physical play.

Toys like swings, seesaws, rocking horses, balance beams, bicycles, hammocks, big exercise balls, jump-ropes, trampolines, office chairs, obstacle courses, tunnels, and balance boards, as well as lots of other activities, encourage motion in all different directions.

There’s some evidence that people with clinical anxiety are disproportionately likely to have vestibular problems (they literally feel off-balance and insecure!), and that balance exercises can help with anxiety.

I suspect that giving children plenty of opportunity for lots of kinds of motion helps them be more at ease, less fidgety, and better able to focus.

Back pain is really common and really debilitating. I think helping your spine be in the right shape is important, and I’m pretty sold on Esther Gohkhale’s book 8 Steps to a Pain-free Back. She draws on posture from historical images and pre-industrial societies to argue that humans are designed to stand, sit, and bend differently than we now do (though she could be cherry-picking and I would have no way of knowing).


More picture comparisons of S-shaped vs. J-shaped posture.

Reviews I’ve seen basically indicate that at worst this method is probably harmless, since it doesn’t advise special treatment or gear or doing any time-consuming exercises, just moving differently during your normal activities.

The major part of the book that I disagree with is about lifting from the back rather than the knees: I believe that people who’ve been lifting from the back all their lives can do it fine, but starting abruptly seems like a bad idea. I try to do straight-back bending while emptying the dishwasher and so forth when not bearing extra weight.


Baby formula is pretty good now (and to be clear, it’s absolutely a blessing when breastfeeding isn’t cutting it for whatever reason). There are a few randomized controlled trials of breastfeeding vs. formula feeding which indicate advantages to breastmilk, but they were from before we started putting DHA (a fatty acid thought to be good for brain development) in formula in 2002, so it’s possible they’re more similar now. But given that after 100 years of commercial formula they’re still trying to improve the recipe, I’m guessing it’s probably still not as good as the original.

Light and vision
Children who sleep with night lights are more likely to be short-sighted, and sleeping with a normal light on is worse. Apparently you need actual darkness in early childhood for your eyes to develop properlyb.

Potential confounder: maybe short-sighted parents are more likely to leave the lights on, and also more likely to have short-sighted kids. But I’d expect it to be more based on dark vision. Jeff can see ok in conditions where I can’t see at all; I do night feedings entirely by memory, touch, and echolocation (luckily it’s not that hard to find a crying baby in the dark).

Several studies also suggest that kids who spend more time outdoors are less likely to be short-sighted, maybe because of brighter light, different spectrum of light, or higher vitamin D. Could be confounded of course if short-sighted kids don’t enjoy outdoor play as much because they can’t see as well.

Gut health
In 20 years I think this will be a much more mainstream component of how we think about health.

We know that antibiotics mess up gut flora, particularly in young children.

(I was about to write that early antibiotic use makes children more prone to asthma, but apparently that’s not likely. It does seem to increase risk of food allergies, though.)

About 1/3 of mothers in the US and UK are given IV antibiotics during labor to prevent group B strep infections in their babies. Right now the reasoning seems to be that antibiotics are pretty harmless, so why not give them? But I hope we’ll develop better ways of targeting which children most need the antibiotics. In think we may also see a trend toward narrow-spectrum antibiotics for shorter periods of time.

During pregnancy and breastfeeding, I also try to be extra-careful about hand-washing, keeping cuts covered, and so forth to reduce the chance that I’ll need antibiotics. Mastitis is a common reason breastfeeding moms take antibiotics, and knowing how to deal with it before it gets bad can help avoid the need for medication.

Babies are born with a sterile intestinal tract, and they get colonized with their mother’s microflora during and after birth. There’s growing interest in how to facilitate this for babies born by cesarian section, for example by swabbing babies with fluids from the birth canal. I can imagine that this will catch on, but it might also end up being more risky than it’s worth because of group B strep, herpes, etc which you don’t want colonizing your baby.

I think water birth looks worse for this reason — you don’t want to be washing babies as soon as their born.

Right now we don’t know much about how exactly to help gut health once something is wrong, and how to add and nurture the specific microflora that you want for specific problems. The best we can do is eat fiber (prebiotics) which serves as food for the good bacteria (probiotics), and maybe eat foods with live cultures like yogurt and kimchi. These seem like a good idea, since they’re basically what people have been doing for thousands of years. Packaged commercial probiotic supplements seem generally safe, including for kids, though I think in 20 years we’ll know a lot more about which strains you want.

I think we’ll learn things we don’t currently know about ways that plastics are bad for us. In college, before they decided BPA was bad, I used to microwave my lunch in my Nalgene bottle every day. It’s not clear that what they’re using instead is much better, we might just not have as much evidence about it. I expect it’s just a matter of time until they find long-term effects from things we haven’t been using very long. I don’t put hot food in plastic containers anymore. We use Pyrex glass containers for most food.

Recognizing problems as temporary

Sometimes a situation becomes worse because you interpret your inclination to do a bad thing as a prediction that you will actually do it. Realizing that it’s possible to successfully get past this feeling has been helpful to me. Three examples I’ve noticed:

  • Several older women in my family speak openly about the times they felt like hurting their babies. It’s been really helpful to hear them—successful matriarchs who have loving relationships with their adult children—say this, and know that wanting to throw your baby at 3 am after six months of sleep deprivation is normal and doesn’t mean you are actually going to do it. It’s reassuring to have the interpretation “I am going to get through this somehow, and in thirty years we’ll all laugh about it” rather than “I am a terrible mother who is actually going to throw this baby.”

    Of course, you also have to take steps to not hurt the baby! Lily’s great-grandmother, when raising kids on an isolated farm, would put the baby in the baby carriage and wheel it out into the field until she couldn’t hear the crying anymore from the house. When she could see the carriage stop shaking, she knew the baby was asleep and would wheel it back within earshot. This is the kind of thing the health pamphlets tell you to do (“step away right away”), but it’s more reassuring to know that your husband’s beloved grandmother did it and not something that only bad parents in pamphlets need to do.

  • Many of the older dancers in my folk dance group have been part of the team since the 1970s or early 80s. Some of them brought their little kids to every event, but others took time off and one central member took about a decade off when she had a child. These days I’d often rather fall into bed as soon as possible than go to practice, and I don’t go to most of the gigs because traveling with baby in tow feels like more trouble than it’s worth. If this were a group with less institutional memory, I’d assume this meant I was drifting away from the team and that it soon wouldn’t be a part of my life anymore. But because I have the model of people rejoining the team after early parenthood, I see this as a temporary and not a permanent separation.
  • A friend noted that sometimes when he feels he wants to sleep forever, he worries a lot about the fact that he’s feeling suicidal. He found that if he takes a nap he usually feels much better, and that the problem is temporary exhaustion more than ongoing suicidality. So now he doesn’t assign much importance to the feeling when it happens.

Out-of-fashion music, two ways

If you’re an urban, college-educated nontheist singing 19th-century Southern rural religious music, there are two options. You can take out the weird and uncomfortable bits and make it be about friendship:

What wondrous love is this, O my soul, O my soul?
What wondrous love is this, that brings my heart such bliss,
and takes away the pain of my soul.

When I was sinking down, sinking down, sinking down
When I was sinking down, beneath my sorrows ground,
friends to me gathered round, O my soul.

(Unitarian Universalist hymnal)

Or you can sing it un-retouched:

What wondrous love is this, O my soul, O my soul,
What wondrous love is this that caused the Lord of bliss
To bear the dreadful curse for my soul!

When I was sinking down, sinking down, sinking down,
When I was sinking down beneath God’’s righteous frown,
Christ laid aside His crown for my soul.

(anon, published 1811 in Lynchburg Virginia, A General Selection of the Newest and Most Admired Hymns and Spiritual Songs Now in Use)

The obvious thing for a blog post to do here is to make a point about one of these being better than the other, but I’m not sure. I find it kind of icky to tidy up and happify music that is at its heart deeply concerned with Hell and who is going there.

But the hipster approach, to sing the original lyrics with no connection to the value system of people who made them, also feels weird. If this weren’t white Americans singing music by other white Americans, it would be called cultural appropriation.

But I don’t think anything bad is happening, or at least not worse than leaving urban atheists without this weirdly beautiful music.

Three vegan desserts

I’m not easily satisfied when it comes to food substitutions, but here are three I’m happy with (e.g. things I would voluntarily make vegan

Things with puff pastry: A lot of frozen puff pastry in a normal grocery store is vegan. Try it with chocolate and nuts or as apple pie.

Poached pears: there are a million recipes for different syrups and sauces to do these in. Here’s a simple version.

Chocolate mousse: two-ingredient chocolate mousse lives up to its hype. You truly do need at least 70% cocoa solids or it will not firm up – I like the big bars of bittersweet chocolate from Trader Joe’s. You can chill the mousse in wine glasses or teacups. Or pour it into a baked piecrust for a chocolate mousse pie – I like a graham cracker or nut crust (use oil or vegan margarine instead of butter if you want to keep it vegan).

Note that the pears and mousse don’t have flour, meaning they are kosher for Passover! And gluten-free! The chocolate pie can be too, if you use a nut crust.




On grieving timelines

I was reading a theory that European and North American grieving practices transformed from a Victorian model (with elaborate years-long process of commemorating a death) to a post-WWI model where death was expected to be processed more efficiently, perhaps because of the sudden death of a large percentage of the population in the war and the 1918 Spanish flu pandemic.

My mother-in-law died a year and a half ago, and I think our family has benefitted from a pretty spread-out grieving process. Some steps:

  • Family gathered for Suzie’s last days. She died the night after coming home from the hospital, earlier than expected. A few hours for family members to visit her body, lying in her bedroom. Medical school staff came to collect her body later that morning (she wished to donate her body for study).
  • 1 week: neighbor sits shiva for Suzie (week-long memorial time observed in home).
  • Next several months: Suzie’s body is studied by medical students at her daughter’s medical school. At end of semester, memorial ceremony at medical school with students and families of the donors.
  • 2 months out: Memorial service, held at the same hall where Suzie and Rick were married and where the family enjoyed folk dancing over the years. We found that 2 months meant that friends and family could plan to travel, and that we weren’t still in the first shock of grief. (I’ve seen some hard feelings among family members organizing a speedy funeral without everyone being able to make it, and I’m glad we avoided that.) Quaker-style ceremony with attenders gathered in silence, and people rising to speak and share thoughts or memories as they wished. Meal afterward, functioning as a kind of family reunion. Sharing of Suzie’s jewelry with relatives who are visiting.
  • 2 months out: Memorial book produced in paper and digital form. It’s made of pictures from Suzie’s life, writings from family and friends, and her newspaper obituary. Shared with family and friends.
  • 3 months out: Suzie’s birthday. We bought the kind of flowers she always got for her birthday.
  • 4 months out: Rick’s coworkers gave money for the family to do something together. Ferry trip to harbor islands that Suzie loved.
  • 11 months out: first Christmas without her. Sucks. Suzie’s sister makes the annual family photo calendar including pictures of Suzie throughout the years on every page.
  • 1 year out: Spent day of her death with the family visiting a seaside town she liked to visit.
  • 1 year out: family received ashes from medical school.
  • 1.5 years out: Suzie’s daughter has her first baby. Presentation of a baby sweater that Suzie and I planned for two days before her death for Alice’s eventual baby, and I that knit in Suzie’s style.
  • 1.5 years out: family scattered 1/3 ashes at beach with extended family.
  • Still to happen, planned for 2 years out and 2.5 years out: scattering other 2/3 of ashes in two other locations important to Suzie.
  • Still to happen: presenting family with recording of Suzie reading from “The Wind in the Willows” shortly before her death.

I think these ongoing occasions to remember together have been good for the family. I’m particularly glad we didn’t have to spend the first week organizing a funeral. Because Suzie wanted to donate her body, we also didn’t pay any funeral expenses – the only part that cost money was the hall for the memorial service. A typical US funeral costs $7,000 between the funeral home, burial, and headstone, which is not a financial stress a grieving family needs.

I’d like to have a process similar to this for my family when I die.

I particularly like the way Mexico observes the Days of the Dead, with bittersweet celebration of lost loved ones. Families visit graveyards to decorate gravestones, and they make altars with flowers, candles, and the favorite foods and belongings of loved ones. Having a concrete action to take seems helpful, and I imagine it might work particularly well for children.

Planning for altered mental states

On Friday night I helped my sister-in-law while she gave birth. (I had my own baby strapped to my front the whole time, so I wasn’t particularly hands-on, but I helped Skype in the baby’s father who was in England at the time.)

My own labors were unusually easy, and seeing someone go through a more typical labor was eye-opening. This woman is a medical student who’s done her obstetrics rotation, but the pain made a different person out of her. A frightened, exhausted, anguished person.

One childbirth book I read (The Birth Partner, which is my favorite for women giving birth as well as support people) advocates using safe words for pain relief. It gives you the freedom to say “I want morphine” in the heat of the moment when you don’t fully mean it, and if you really mean it you’ll say “eggplant” or whatever and your support people will know to take it seriously. A birth plan is also good for this. In this case, my sister-in-law had asked in advance not to be given an epidural unless she repeatedly asked for one over a period of time, so when she said things like “I want an epidural” and “I want a c-section” her doula and midwife helped her find other ways to cope rather than calling an anesthesiologist.

It felt very strange to watch her in agony, to hear her asking for relief, and to know that the person she had been 6 hours ago and the person she would be in 6 more hours wouldn’t want her to get it. (Women who get epidurals report less pain but no greater satisfaction with their overall experience, probably because the side effects are so annoying.)

For both medical and psychiatric care, some people use some form of Ulysses contract, named for Ulysses who tied himself to a mast to be able to hear the Sirens’ tempting song without following it to his doom. It’s the act of a person who knows they’ll be in an altered state in the future. It’s treating your future self as a different person with different preferences, and forcing them to obey your current preferences.

The last day of her life chronicles Sandra Bem’s plan for her own death after an Altzheimer’s diagnosis, knowing that by the time her mind had deteriorated she would no longer want the death she had planned. My lovely wife in the psych ward is from the viewpoint of the husband of a woman with serious psychiatric problems.

DuBrul introduced me to the concept of mad maps. Like advanced directives for the dying, DuBrul explained, mad maps allow psychiatric patients to outline what they’d like their care to look like in future mental health crises. . . . We started trying to create Giulia’s map by discussing the pills in the medicine cabinet. Under what circumstances would Giulia take them, and how much would she take? I took a hardline approach: No sleep for one night, pills at maximum dosage. Giulia wanted more time before jumping to medication, and favored starting the dose out light.

They’re not failsafe: a birth plan only communicates your preferences, and you should go in with the understanding that you may need an emergency c-section or whatever. A mad map can plot out actions in anticipated situations, but unanticipated situations may throw the old plans out the window.

But I think we’re much better off planning, to the extent that we can, for times when our preferences will be different than they are now. From my coworker who’s set her computer to shut off the internet at 11 so she’ll go to bed on time, to a person planning how they want their death to go, sometimes it’s better for your self-in-the-moment not to have the reins.