Lynch, John J.

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The Linacre QuarterlyVolume 22 | Number 1 Article 52-1-1955Dysmenorrhea and StilbestrolJohn J. LynchFollow this and additional works at: https://epublications.marquette.edu/lnqPart of the Ethics and Political Philosophy Commons, and the Medicine and Health SciencesCommonsRecommended CitationLynch, John J. (1955) "Dysmenorrhea and Stilbestrol," The Linacre Quarterly: Vol. 22 : No. 1 , Article 5.Available at: https://epublications.marquette.edu/lnq/vol22/iss1/5-. -resolution recommendin th (atholic hospitals make grov7s�o:�s�rff a genera] practice section in� o r ganiza ti o n. It waspointed out that the model b lalso sug t d b Y- aws is encouraged and the al l -i m p o r tan t family physician.recognized i 1 capacity of 1 ges e Y the Cath 1· H ftal Association indud; ip\ov�s?i­or a 1 1s1on genera practice section. th The committee recomme n dedNURSING th The_ committee recognized tha .ere is a sh o r  t a  g e of d N •gra uat .urses salaries have not kept ac.at_ an annual review be made ofme�1caJ staffs With a view to eJimi­nating those who d th J O not avail with other salaries Th Pb f h C · e mem ero t e ommittee felt that th are too many instances of inaJ:·quate cHare, of carelessness an,e;;se ves of privileges and thus ma e a place for those who errors ow . that . . ever, it was admitte, more wo th . ] are r y, Inc uding qualified the att��::i�t�f �hoef ��i:es pNalleI:·general practitioners. Most g 1 P r t · t · enera ac I i o ners realize th . do not write d or. urse, sh ld d at merit ou etermine a physic. • tus on a staff. ian s sta-The committee hoped that ple could be educated to pleo­fa ·1 h consu t a hmi Y P ysician who will r f t em to a . 1. e er A f specia ist if necessary �a� was expressed that som�spec1al1sts are attempt· as 1 mg to actth. genera practitioners and thatThis �ould be a medical hazard e mcreasing b f · ist . num er o special-. s is such that doctors do notwish. t� make house calls. and ifspecialist does niake a h a th f · ouse call � ee 1s usually $25.00.d· he . committee concluded thata�8JuJs1on by stating that hospitals octors have a resp 'b·J· th goo notes, becausee doct o r s are not f 'thf I . k · a1 U JI eepmg up charts and nurses be-come careless · because doctors d not take time to read t c . no es or k supervise and check on th work. e nurses SPIRIT OF CHARITYThe �embers of the committeewere as ed to comment h · · f h on t ('spmt o c arity in Cath 1· h tals Th o 1c osp1-that· the ey_ �txprfessed. a convictionspm o charity d vail, but that the pubJ1·c does pre­re J ·  · I oes not a ize it. t was pointed out thatno mathematical amount ca b for h · I n e set c . anty. n times of finan . ldepression, the need for charit;i� to see that th ons1 I ity e general practitioner greater and the need ·11JS f w1 varyrom community to . commumty.26 LINACRE QUARTERLYDysmenorrhea and Stilbestrol by JOHN J. LYNCH, S.J.A. MONG generally accepted pro­fi. cedures in the managementof primary dysmenorrhea, the ad­ministration of estrogen receivesrather frequent mention in medicalliterature.1 The calculated effect ofthis hormone, commonly prescribedin the form of diethylstilbestroltablets, is to achieve painless men­struation through temporary sus­pension of the ovarian function,since usually "primary dysmenor­rhea does not occur in the absenceof ovulation." 2 If it is true that oneeffect of the medication is to in­hibit ovulation, and that it is onlythrough th� attainment of this firstresult that painless flow is achieved.then immediately a question canarise regarding the lawfulness ofthe temporary sterility which nec­essarily occurs. It may in factappear at first sight that the useof stilbestrol would have to becondemned . for the very reasonswhich have been adduced againsthesperidin as an antifertility fac­tor.3There is, however, a distinct and important difference between fer­tility c o ntrol as previously dis­cussed and estrogen therapy in the 1 Greenhill, J. P., Year Book of Obstet-rics & Gyriecology, 1953-1954 Series, 512-515.2 [bid., 513 f. 3 Cf. Linacre Quarterly, Aug. 1953, 83-88, and Nov. 1953, 118-122. In these articles fertility control is shown to be morally objectionable on two counts: (a) as an unjustified mutilation of thehuman generative function, and ( b) asa species of contraception.FEBRUARY, 1955 present instance. First of all, it is clear that the natural function of the ovaries is at least two-fold, generative and endocrine. Hence whenever ovarian activity is sus­pended, two immediate results are necessarily produced: the subject is rendered sterile, temporarily at least; and the system is deprived of certain glandular secretions which are u su a l ly beneficial. but some­times harmful. to bodily health. Now it is entirely conceivable that either one of those results could be desired and intended without the other. One might, for example, intend sterility while disclaiming completely any deliberate intent to affect secondary sex characteristics. Or, by the same token, one might be intent on preventing metastasis of breast carcinoma and repudiate all direct intention to bring about sterility. Of those two examples involving the same morally indif­ferent act ( suspension of ovarian activity). we recognize the first as illicit and the second as potentially permissible, since in the one casethe direct intention is illicit, where­as in the other all direct intent is legitimate. And that is why we condemn fertility control as commonly un­derstood.. There the directly in­tended object of medication is ster­ility itself, and any other possible consequences are incidental by­products as far as subjective in­tention is concerned. Sin c e  the 27 natural law p roh ib it ion againstdirect sterilization of this kind isuniversal. there can be no dispute about the immorality of deliberate fertility control. But in the management of dys­menorrhea, it is relief · from painwhich is sought-pain which canbe controlled, it seems, by control­ling the endocrine activity of the ovaries. Su bs e qu e nt  temporarysterility can now be considered asthe incidental by-product of ovari­�n suppression, whose only directlymtended effect is to achieve pain­less menstruation. And hence we have here a possible application ofthe principle of double effect.Before concluding, however, thatstilbestrol is morally permissible medication for dysmenorrhea, acertain number of medical ques­tions would have to be answeredin such a way as to establish some real necessity for using this pro­cedure in pr e f ere n c e to o t h e r swhich do not affect fertility. One of the postulates of the principle of double effect is that there be proportionately grave reason foreven permitting an evil result. Andsuch a reason would be lacking ifit could be shown, for instance,that painless menstruation couldjust as conveniently and just as effectively be achieved by a meth­od which would not involve tem­porary sterility, or if it could be established that relief from pain is not. of itself important enough tocompensate for the extent of th eevil permitted. Since the ultimate decision requires medical experi­ence combined with moral judg­ment, both physician and theolo­gian have a share of responsibility28 in determining proper procedure.VARIOUS MEDICALPROCEDURES Judging from available literatur,on the subject of dysmenorrheaand from the testimony of physicians consulted personally, thenwould appear to be no universa medical rule either recommendincor discouraging stilbestrol for al cases indiscriminately. Althoughconsideration is given to a numbel'of possible treatments, general con­sensus seems to be that none isentirely without its disadvantages.Drug therapy may prove satis­factory, especiaHy in milder cases;but my impression is that it isfrequently useless, always laborsunder the handicap of obliteratingonly the symptom without correct­ing the cause , and cannot com­pletely escape the risk of addictionif recourse must be had to the more powerful but habit-forming drugssuch as codeine . ( Even though the prescribed monthly dosage of co­deine should create no more thana negligible danger of habituation,doctors are instinctively reluctantto prescribe a r e g i me n  of such drugs if it can be r easona b l yavoided.) Hormones, of which stilbestrolis but one · species, represent an­other possible solution. On the theory that menstrual pain is some­times caused by uterine · spasms,progesterone is employed at timessince it tends to relax the uterus.Greenhill, however, alleges that itis seldom successful and is com­paratively costly. Methyltestost­erone, a male hormone, is likewise rated as relatively expensive , andLINACRE QUARTERLY may also in some cases affect sec­ondary sex characteristics, though it does apparently have the adv.an­tage of not suppressing ovul�tion.And regarding less costl)'. st1lbes­trol. which occasioned this �ho�ediscussion, it is said that �am isrelieved in a large proportion ofcases, but that relief is by nomeans permanent and that ofteneither the menstrual cycle is upseteven they may have l e gitima t egro�nds for disagreement to some extent on that question. _But . inchoosing a procedu�e. w�1c� in­volves temporary stenhty, mdirec�­ly intended though it be, a physi­cian would have to satisfy him�elfthat there is l e git ima t e medicalreason for re jecting other methodswhich do not affect fertility. ItWell be that other treatmentsor profuse menstruation results. Itschief disadvantage. even medically,is the sterility which it induces­and in proportion to the frequencywith which treatment must be re­peated, sterility becomes progres-.sively less a temporary state of affairs and verges on permanency.Surgery appears to be consid­ered a procedure of last resort.Presacral neurectomy is ra.thercommonly mentioned as somet1m�s successful and as recommended inselected cases after other means o!effective relief have been excluded. Dilatation and curettage is anotherpossibility. Doyle favors paracer­vical denervation through culdot­omy. and proposes this m�thod ashighly effective in affordmg pe�­manent relie f when surg e r y  isindicated.5 It is not my purpose . nor is it. within my competence, to judge th e  relative medical merits of th�se various procedures. That rema insthe prerogative of doctors, and4 For some comments on the moral aGspec{d of presacral neurec t o m y. cf. era K 11 SJ Medico-Moral Problems, V,40 �h� �ame article also appeared inH;spital Progress, Feb. 1954, 6�. 5 0 1 J B "Uterine Oenervatlon Byc�id�to�y_;: Irish ,. Med. �C., Feb.1953 73-76; "Use of the Pelv1scope m C ld, t .. 1 A M A 151 : 605-608u o omy, · · · ., (Feb. 21) 1953. FEBRUARY, 1955may . . are recognized as useless m a given. e or at least considerably lesscas . 1 C effective than stilbestro . ompara-tive expense is another item to_ be considered, as would be surgicalrisk or inconvenience to whateverextent they may be en�isioned. In general. any serious disadvantage to the patient, which would resulteither from failure to treat or fromthe choice of an alternate ther�py,·11 contribute towards estabhsh-w1 . t' ing reason sufficient for permit mgthe mutilating effect of temporarysterility as produced by estrogentreatment. PAIN RELIEF AS A JUSTIFYINGCAUSE Let us suppose that in the con­sidered judgme n t  of a _capablephysician there is good medica_l rea­son ( in the sense just exp lamed) for preferring estrogens to �therpossible treatments. Does pain r�­lief alone constitute reason suff 1-ciently serious to justify temp�rar?'sterility as the indirect but mev1-table result of inducing anovula­tory menstruation via stilbestrol?First of all it should be conceded-and physicians would doubtless­ly be the last to disagree. - . thatpain of itself is not to be d1smiss�dli htly as something necessarilyi;considerable in the order of phy-29 sical inconvenience or hardship.Pain relief can be the moral justi­fication for the medical use of nar­cotics, sometimes even at the riskof possible addiction or at least tothe point of temporary privationof one's rational faculties. Sometheologians have also admitted thelawfulness of prefrontal lobotomyin certain cases, exclusively for thepurpose of relieving otherwise in­tractable pain, and they do so withfull realization of the other possibleeffects of that species of mutila­tion. 6 The immediate point I wishto make is that moralists do allow,for the sole purpose of pain relief,procedures which have very seri­ous mutilating effects on the veryhighest of human faculties.It is unquestionably true that inthe examples just cited one is deal­ing with pain so severe that it iscommonly t ermed i ntolerable;whereas the suffering proper todysmenorrhea may not ordinarilydeserve that classification in theobjective order of things. Thatpoint can be .conceded, it seems,. without detriment to the conclusioneventually to be offered in thepresent discussion. The fact is thatwe are now dealing with a type ofpain which, though varying in in­tensity from one case to another,can correctly be called severe inmany of the cases which find theirway to a doctor's office. Even·though it may not be objectivelycomparable to the pain alleged injustification of lobotomy or the useof dangerous narcotics, it is stillnot to be dismissed as trivial.6 Cf. G. Kelly, S.J., "Lobotomy for Pain Relief," Medico-Moral Problems, III, 29-32. 30 Furthermore, any attempt to ai:- -praise pain in the objective ordt::alone would be as unreal as it 1 ; inadequate. The truth of the mat ·ter is that pain is a highly sul: ·jective phenomenon whose sever ·ity must be measured also in term.of the victim's individual perception of it and reaction to it. Th common medical term "threshokof pain" recognizes that subjectiv,and variable element as somethin(inescapably real and essential i;measuring grada tions of p ain What one person can bear witr·equanimity may prove excruciatintfor another.Besides, how· great is averagehuman capacity for tranquil suf­fering? Persistent pain over notable period of time-even pai considerably less than excruciating-can be a severe test of almostanyone's powers of endurance; andmeasured even in terms of minutes,time can assume gigantic propor­tions in the mind of one who issuffering without prospect of relief.Even the common head-ache ortooth-ache, or the pangs of indi­gestion, can make release frompain seem the summum bonum ofthe moment for most of us, andvery soon find us turning to ourfavorite nostrums for relief. Nb realist cari deny that placidity inthe grip of continued pain reflectseither crass stoicism or virtue ofmore than o rdinary dimensions,and is not the sort of reactionusually encountered.And even if asceticism shouldprevail over physical distress, it is the rare person even among thevirtuous who can long end·urewithout betraying marked loss ofLINACRE QUARTERLY ff. . . cy power to concentrate,e ic1en , k ability to do his ordinar)'. wo� •capacity to cope satisfac�o�1ly withthe normal routine of hvmg. �11true that they are then thinking interms of preserving, or . at _ least markedly p r olonging' life itself,d are not primarily concerned�v�th relief from pain which, rela­tive to life and death, is unques_­tionably of less importance. But itis also true that the evil they pe_r­mit in that case ( permanent stenl­ity) is almost immeasurably greaterthan the temporary effect involvedhere, and that a proportionatelyless serious cause would theref�resuffice to justify the latter. Reheffrom pain would seem to _ ?e aof these disabilities, not to mentionthe ordinary effects of prolo��edpain on one's natural dispos1t_1on,can constitute a serious hand�capfor the average individual.-senou_sh ·t would seem, to meritenoug , 1 ff' careful consideration when �u �-cient cause is being sought to JUStt­fy certain undesirable but concom­itant effects of therapy. In trying to estimate, _therefo�e,the gravity of pain associated withany physical affliction, one shouldtake into account not only the ob­·ective nature and measure of _the�ain involved, but also the subjec­tive and no less real element ofindividual susceptibility to su�er­ing, especially of a p�rsist�nt kmd.Furthermore, if a patient finds th�tpain constitutes a real ha_ndic_a� mthe normal routine of da_1ly hvmg •that measure of inconvemence can­not properly be ter_med slight. Ailthings considered, it does not seemunreasonable to propose that r_e­lief from pain in many such _cir­cumstances can qualify as seriousin the category of justifying causes.Is it serious enough to warra�ttemporary sterility as a c�nc�m1-tant indirect effect? I am mch�edt that it can be. Moralistso say .1.t d ·t that even permanent steri I ya m1 .. th may be permitted when it is e. necessary indirect result of t�erapyrequired to prevent metastasis, andtheir teaching on that scor7e h�sbeen confirmed by Pius XII. It isFEBRUARY, 1955. cause in that legitimatesenous ff' . tl sense of the word, i.e. su icien yserious in view of the temporarynature of the evil permitted. It goes without saying, of course,that stilbestrol should not be em­ployed if some other pr_o_cedure,which does not affect fertility, canbe used as effectively and as con­veniently in a given instance. Inaddition, neither patient nor doctorcould legitimately intend contra­ception as another effect of themedication. But with these precau­tions stipulated, there would seemto be good reason to allow a phy­sician to prescribe stilbestr�l f�rdysmenorrhea if and �h�n '.n his'd ed op1'nion it is md1catedcons1 er . as a reasonably necessary medicalprocedure.7 Allocution to the 26th Annual Con".en­f on of the Italian S ociety of Urologists,Oct 1953. For the pertinent_ excerptfro� this address. togeSthJer wf ithL· come-F Kelly, .. , c . macr ments by -Nr. 1953 106-107. Cf. alsoQuarterly, ov. ' p bl G. Kelly, S.J., Medico-Mora/ ro ems,I, 21-29.31 

Dysmenorrhea and Stilbestrol

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Dysmenorrhea and Stilbestrol

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