Baruch,

I am not a gynecologist but I have much experience in endocrinology and cancer epidemiology, as a physician and scientist.

We know that post menopausal hormones can cause problems with endometrial cancer and blood clots. The purpose for those hormone therapies is quite different from premenopausal hormone therapies....namely "the pill". In premenopausal treatments a woman has abnormal cycles, the treatment tries to correct that so that the woman's cycles are natural/normal again. In postmenopausal the treatment is long term and we are forcing the woman's body to do the unnatural.

That's quite different from taking "the pill". Billions of women today do take the pill with relative safety. By this I don't mean that the pill has no risks, it does. But if you have earth-shaking information on the serious dangers of premenopausal hormone therapies or contraception, I would like to see it. There is so much in the literature that unless one is specifically looking for it, one never gets to read it. So I could be "outside the loop" on this one.

BTW,
The Puach Institute has been endorsed by the likes of;
Mordechai Eliyahu Shlita
Ovadia Yosef, Shlita
Bakshi Doron, Shlita
Admor of Biale, Shlita
Meir Lau, Shlita
Lubavitcher Rebbe, Shlita
Admor of Sanz, Shlita
Admor of Belz, Shlita
Not to mention the network of rabbonim in consultation. It is also served by some of the foremost obgyn physicians and ivf scientists in Israel and the US.

quote:

In premenopausal treatments a woman has abnormal cycles, the treatment tries to correct that so that the woman's cycles are natural/normal again. In postmenopausal the treatment is long term and we are forcing the woman's body to do the unnatural.

Dear Dr. Avi!

What are your medical thoughts on the 12-week cycle therapies, such as "seasonelle"? Is this achieving a natural or unnatural result?

I ask because, and please don't think that I endorse using software engineer reasoning in medical matters (since we have no simple reboot function for when mistakes happen), that when a late friend of the family was getting remarried she had a "surprise" state change just before her wedding that created some halachic complications, I wondered, years before seasonelle, if some hormonal therapy might be a useful safety precaution once a wedding date were set?

As a physician myself I am quite amzed at how other physicians don't see a problem with healthy women taking pills for the sole purpose of kepping a rabinical halacha.

Not all hormone therapies are the same.
But we are not discussing women with abnormal cycles. These Women have 100% normal cycles. Normal in terms of physiology and also normal according to Torah law. They have no problem getting pregnant according to Torah law. Their cycles are just abnormal according rabinical chumras of the law.

We know that while the pills that billions of women take are relatively safe they do have risk. There is no justification for Rabinical law to force healthy women to take this unnecessary risk.
In order to justify this we must have clear evidence that such therapy would be safe.
But we don't have any medical research on hormones used for halchic purposes.
Thus we can't ignore the results on research from post menopausal hormone use and we can't ignore the known risks of birth controll pills, even if they aren't all the same.

That is the point the Religous Gynecologist I referred to has made in his article.

Baruch: I don't see any flaw in this logic.

Baruch:
I did not know you were a doctor. Now that I do, would you mind lending your light on the issue I raised earlier on the possibility of public school systems (i.e. American, prone to over-prescribing behavioural modification drugs) being prejudiced against the pre-pubescent boys (specifically with their more tactile learning processes which typically differ greatly from the young girls'?) If you look at the stats on how many of the children (male vs. female) are drugged every year, I think it is nearly inarguable that the system is flawed in its over diagnosing these young boys as having "behavioural issues" simply because they have difficulty sitting for hours on end and being quiet. I have no sons, so am not personally invested inthis opinion per se. I only see a problem here from the outside and wonder why the parents aren't more alarmed. I can only foresee this problem (the adults' not the childrens') getting worse, as now, many schools have eliminated recess altogether. There is now a group of women who have formed a group called "rescue recess". I support the idea completely.

Baruch,

I didn't realize you were referring to women with normal cycles. I thought these women had abnormal cycles and they were correcting them with hormones for the purpose of conception. With this in mind, I clearly agree with what you are saying. The use of hormones in women with perfectly normal cycles is not a good idea because, as I mentioned in my earlier post, it is forcing the unnatural. Whenever we force the unnatural on the body we create new risks. There is plenty of epidemiologic evidence to sonfirm such a notion.

Perhaps we have been talking past each other on this. Relationship between postmenopausal aestrogen supplementation and carcinoma of the endometrium was first reported in the late 70s early 80s by Antunes, I believe. Subsequent to that, much more research confirming it has been published. The safely of the pill is relative. As we both concur there are risks and they are known to most people. But the use of hormones for purely halachic reasons is a first for me. I've never heard of such a thing. I thought that if people were having problems conceiving creative things could be done halachically and medically to fulfill this mitzvah. I wonder how prevalent such a practice is. I cannot imagine a reputable rav allowing the manipulation of a woman's hormones purely for halachic reasons, it makes no sense.

As I mentioned, I have practiced endocrinology as director of a diabetes program. I only did gynecological endocrinolgy as it pertained to my diabetic patients. As you can imagine, it can get very complicated.

Avi

quote:

I have no sons, so am not personally invested inthis opinion per se. I only see a problem here from the outside and wonder why the parents aren't more alarmed.

B"H I am aware that my chiropractor has been involved in providing information to our local public school systems in learning of alternatives to this problematic trend.

Its interesting that an obstetric nurse midwife who delivers babies and performs delivery surgeries is not allowed to sign off on a temporary medical parking permit for a patient who cannot walk; yet a school teacher seems to be allowed to prescribe medicine for a student against a parents' wishes.

Yocheved,

In the US we are an overmedicated society. Depression, ADHD, anxiety are just a few of the overdiagnosed syndromes. Probably half of middle aged women in the US are on some type of anxiolytic or antidepressant. A large percentage of school aged children in certain districts are on ADHD medications.

Part of the problem is the unwise physician who is willing to prescribe anything to get rid of an unrelenting patient. But the underlying issue is that we live high stress lives and no one is really willing to deal with the cause, so we, as a society, are perfectly willing to pop happy pills instead.
Avi

Rob,
I'm not a rav (yet) but when a woman's cycle decides to take a life of its own before chupa there is no halahca that says;

1. if consummation does not occur that night, the chupa and ketuba are not valid (this is the reason the bride a groom go and eat alone...so we can be witness to their being "alone").

2. or, that she cannot go to mikveh a week later and get the kiddushin consummated then.

This is not an ideal scenario but there are many women whose cycles were not predictable before we could manipulate hormones, and they still got married in compliance with all the halachot.

Avi

quote:

bride a groom go and eat alone

Eating at one's own wedding? I thought its nearly a halacha that the couple are to be distracted by sequences of guests who want to speak with them that they don't get to eat!

quote:

but when a woman's cycle decides to take a life of its own before chupa

I'm not certain of your point, but I believe you didn't address my questions. Let me restate them.

By your measure of natural or unnatural cycle, do you consider that which could be achieved by seasonelle, a 13 week cycle, natural?

And regardless, do you think the medical risk of such a hormone outweighs the stress cost health risk to a couple (with caterer and function hall contract, and travel expenses) if they felt a wedding date should be changed at the last minute?

I ask this acknowledging that there is no halachic prohibition of seclusion together.

Rob,
Anytime you begin to mess with nature you are looking for trouble. Seasonelle does just that. During the 70s Depo Provera was introduced onto the market. On it women would have 3 month cycles too. There was such a big outcry in the US from the feminist groups and it was banned. Pharmaceutical companies took it to the 3rd world. There was an outcry about that too.

Within the past 5 years or so, Depo Provera has been re-introduced onto the US market and the same feminist groups were saying "now there is another choice for women." BTW, the side effects of Depo Provera in the "olden days" were pretty severe. Today they are not as bad. They compete with others like Seasonelle. But I would not recommend anything like Seasonelle unless there was a compelling health reason to do so. Doing it for purely "halachic" reasons suspect and potentially dangerous.

I would like to explain so everyone including those who are not in the medical field understand what I was discussing.

The length of a woman's menstraul period can vary from 21 to 40 days. On average it is 28 days. Ovulation generally occurs on day 14 of a 28 day cycle. In shorter cycles it occurs earlier.

For women who have a 28 day cycle their ovulation occurs around the time they go to the mikve. For someone who has a 21 day cycle ovulation can occur beofore she goes to the mikve and by the time she goes to the mikve she has missed her opportunity to become pregnant. While this situation is not common, it does occurs and it is well known to Gynecologists who serve the religous population.
Menstrual Cycles which are 21 days are 100% medically normal. Women who are in this situation are said to be "halachically infertile".
Today we can fix this problem with the use of hormones.

Now this halachic problem is due to rabbinical chumras in the laws of nida and would not be a problem if the laws of nida were observed according to the Tora as they used to be followed in the far past.
--------------------

Nida and Zava according to the Tora

According to Tora Law when a woman is Nida she is in a state of Nida for 7 days. Whether she sees one day of blood or 7 days of blood she is impure for 7 days. After that period she goes to the mikve. (She does not have to count 7 clean days.)

After those 7 days there is a period of 11 days called Zava days. On those days blood that is seen is considered Zava and not Nida.
If she sees only 1 or 2 days of blood she is a Zava ktana and has to wait one day.
If she sees 3 or more days of blood during these 11 days she is a Zava Gdola and will have to wait till the blood ceases and then she counts 7 clean days. At the end of 7 clean days she goes to the mikve. At the times of the temple also had to bring a Zava Sacrifice.


(The 11 days of Zava is very much in line with the physiological menstrual cycle. Even women with a short menstrual cycle should not have their period during these 11 days. Thus blood during this time is abnormal and is Zava)
-------------

Halcha Today

In the Gmara it says that women took on themselves the stringincy of counting 7 clean days for any drop of blood they see.
So today the halacha is that evey Nida actually is considered a Zava and she must count 7 clean days after blood ceases.

----------------

Recent Article in the Hatzofe Newspaper

Now that I explained the medical and halachic backround, I will explain the view given in the article I mentioned earlier.

A religous Gynecologist together with a Rebetze who teaches brides wrote an article in the Religous News Paper Hatzoefe about 2 month ago.

This Gynecologist suggested that this Rabinical Chumra should be reconsidered as it causes various problems. His main point was about women who are "Halachically Infertile". He claimed that the hormones given to these women may be unsafe and that it is wrong to give it to them. He also mentioned that in the past when this problem was unknown and hormone therapy was unavailable women who had this problem simply could not get pregnant. He suggests that if Chazal knew about this they wouldn't have made this Chumra in the first place.
He also discusses other issues but this was his strongest point.

His article recieved very harsh crticism from several very reputable Rabbis.
Although we are dealing here with a rabinical chumra. It is a chumra that has existed for over 1400 years. Rabbis are very reluctant to make any change to a chumra that has been in practice for so long even if we now realize that it is very problematic.
These Rabbis claimed that hormone therapy is used anyways by millions of women all around the world and is safe. They claimed that there is nothing wrong with using medical therapy to continue to keep a rabinical chumra.
After 4 Rabbis responeded to his initial article. He wrote his own response to their claims explaining in more detail the possible risks in such therapy. He emphasized the point that such women are healthy and have no medical problems. Their problem is an halachic problem that should be solved by Rabbis and not by physicians or medicine. After writing his response he recieved an even harsher response from the Head of the Puach institute.

-----------------------------------

In my opinion this is a major problem. We consider a rabinical chumra to be so holy that we are willing to justify anything to continue doing it. This chumra will have to be one day reconsidered anyways. When the temple will be rebuilt we will have to differentiate between Nida and Zava because Zava have to bring a sacrifice and a Nida doesn't.

To me it is totally rediculous that women who are healthy and fertile have to be treated as infertile women with hormones because a rabinical chumra. I also agree with the Gynecologist who wrote the article that there may be quite a risk in such therapy.

Baruch,

This is a very good treatise and your point became much clearer. A woman with a 21 day cycle is perfectly normal and does not need any hormone therapy. I honestly did not know that people used hormone therapy simply for such reasons. Do Puach Institute's physicians really practice endocrinology this way? I thought they used it when the woman had difficulty conceiving.

I have never practiced in a Jewish community....although I did a stint at Hadassah Ein Keren, in Jerusalem, a few years ago.

Now, about the safety; does your "religious gynecologist" friend have more information than we already know about the hazards of such hormones?

Kol HaKavod!

Avi

Avi,

Other than personal experience in his field I don't think that he has any more information than you and I.

However he makes very good points. With the information we do have there is reason to suspect that hormone therapy given to healthy women may not be safe. He has been criticized for exagurating. But when dealing with women who do not require medical treatment there is no justification for any risk.


The articles are available on line in hebrew. I will try to gather them and bring the links.

quote:

Originally posted by Baruch:

Nida and Zava according to the Tora

According to Tora Law when a woman is Nida she is in a state of Nida for 7 days. Whether she sees one day of blood or 7 days of blood she is impure for 7 days. After that period she goes to the mikve. (She does not have to count 7 clean days.)

Baruch,

Well, this seems to have been the crux of the issue, for which cause the Rabbi whose responsum we posted strongly disagreed. He says that from the standpoint of the Torah alone, a woman who saw blood for only one or two days during her menstrual cycle, does "hefsek taharah" when her blood has ceased, immerses herself on that upcoming night, and forthwith is permitted unto her husband. Today, however, no woman is forthwith permitted unto her husband before she has waited seven clean days after the cessation of her blood, although some women will actually wait longer periods of time before accompanying with their husbands again - some as much as twelve or thirteen days.

David

R' David, I think it is clear that according to all opinions it is explictly mentioned in the Torah that a Niddah is for at least 7 days. If, for example, she saw blood on day 1 and then the flow stopped, she still has to wait until after the 7th day before being able to go to the Mikveh.

Your words are also, with respect, somewhat confusing. You refer to the lady doing a hefsek tahara, which is usually understood to mean the check that there is no blood before beginning the Shiva Nekiyim, and then immediately going to the Mikveh. The Rabbi's psak you posted talked about beginning the Shiva Nekiyim even within the first 7 days of Niddus. So clearly we have a misunderstanding here.

The bottom line is that the lady must wait at least 7 days.

David
I am not sure if what you are saying has anything to do with the point I was making.

I simply explained the difference between biblical law and the halacha as it is today and the problems caused by halacha as it is practiced today.

Due to the extreme levity that some on the forum is giving toward Drabanans, I am forced to write a response. RAbanans are never to be taken lightly. the Gemara in Eiruvin 21b as paraphrased by Kollel Iyun hadaf
4. R. Akiva: One who transgresses Divrei Chachamim is Chayav Misah
and even Minhagim it's hard to knock off, especially those that have been around from the days of Chazal
Pesachim 50b
(a) Benei Baishan were stringent not to go from Tzur to
Tzidon on Erev Shabbos [the market day, lest they not
have time to prepare for Shabbos]. The next generation
asked 'Must we must follow this stringency? Our ancestors
could be stringent (they were wealthy) - we cannot!'
(b) (R. Yochanan): Since your ancestors accepted this, you
must follow it - "Shema Beni Musar Avicha v'Al Titosh
Toras Imecha".
furthermore, to rely on the Daraisa nowadays, even if there would be permission to neglect a Derabanan or Minhag Chashuv (see Sugya in Pesachim) how do we know what is red. See Nidah 20b

4) WHO IS QUALIFIED TO CHECK
(a) R. Yochanan: R. Chanina used to contradict my rulings (from Tahor to Tamei and vice-versa), therefore, I do not check blood.
(b) R. Elazar: R. Chanina's humility caused that I do check;
1. Even though he is greatly humble, he checks, risking making a mistake -- surely, I should check!
(c) R. Zeira: I am not skilled at determining the validity of coins -- all the more so, I am unqualified to check blood!
(d) Question: Ability to distinguish different colors of blood does not depend on ability to distinguish coins -- Rabah could distinguish coins, but he could not check blood!
(e) Answer: From Rabah, we see that checking blood is harder -- since R. Zeira was unskilled regarding coins, all the more so he was unqualified to check blood!
(f) When Ula came to Pumbedisa he refused to check blood.
1. Ula: R. Elazar is the master of Eretz Yisrael (regarding blood), he would not check here (for Rav Yehudah is the local Chacham) -- all the more so, I should not check here!
(g) Why was R. Elazar called the master of Eretz Yisrael?
(h) Answer: A woman asked him to look at blood; he smelled it and told her that the blood came on account of her desire (for her husband. Ran - such blood is Tahor (if we know that no other blood is mixed with it); most Rishonim - it itself is Tamei.)
1. When she left, R. Ami inquired; she told him that her husband had been away, and she was longing for him.
2. R. Ami: "Sod Hashem li'Yere'av" (those who fear Hashem understand hidden secrets)!
(i) Ifra Hormiz (the mother of Shevor Malka, the Persian king) showed blood to Rava; he (Rashba - Rav Ovadyah) smelled it, and told her that it came on account of her desire.
1. Ifra (to her son): Yisraelim are so wise!
2. Her son: Perhaps it was a lucky guess -- even a blind person might chance upon the opening to the attic!
3. She sent 60 types of blood to him to inspect; the last was from lice. He knew all the others; Hashem caused him to send her a comb as a gift.
4. Ifra: He hints, the last one was from lice -- Yisraelim know a person's hidden thoughts!
(j) (Rav Yehudah): Originally, I used to check blood. Once, I heard my wife say, "We do not show the first drop of blood to Rabanan, for it is filthy" -- I stopped checking (perhaps I will be Metaher, based on what she shows me, and she is really Teme'ah)!
1. I do check blood of a woman ending the days of Dam Tohar, for she would show the first drop, it is not filthy (Rashi - because she has been seeing blood steadily; Me'iri - because she has not been checking herself, her Edim are clean, the first drop will not appear filthy).
Now, due to this Gemara, since we do not know the differences between reds, any red is Assur, as brought in Shulchon Orech. On the other hand, we don't know when is the real seeing and what was really not Dam Nidah, so we cannot discern when is the beggining of Nidah to say that it's permitted 7 days afterwards, maybe she only saw real Dam Nidah on the last day, brilliant. We don't know then when is the real 7 days or the real 11 days. That's why we're Machmir.
People with such views to just knock off the rabanans are firstly dangerous, and second of all, gives me even less conferdence in their ability to come out with a Halachic answer to going to Har habayis or bring Korbonos or being in Charge of Sanhedrin. It shows a total disrespect to the whole Rabanans (which does tell us why he feels able to curse out Rabanan for disagreeing with him.)
About the problem, my wife had this problem and this is how she dealt with it.
Quote "A short cycle can also be fixed in more natural ways. Vitamin C for instance helps lengthen a cycle. The Vitamin and Health food stores in Heimishe communities have the vitamin regimens down pat for women with such problems. Kallahs regularly go to Zahler's in Boro Park and other frum vitamin stores for advice with problem cycles. " Ad KAn L'Shona Shel Ishti