Dr Mark Whitty – Ireland
29th April 2011, Melbourne, Australia

WOOMB International Conference
OMR&RCA Biennial International Conference, Melbourne 2011
2nd Dr John J. Billings Memorial Lecture; 29 April, 2011

Pockets of Wonder
“Wilfred Shaw and Erik Odeblad –
the critical importance of the para-urethral pockets”.

Introduction

Dr John Billings was asked in 1953 to research what means were available to help couples under pressure manage their fertility. He committed himself to do this for a few weeks, and began a lifetime’s service to women, to couples, to families, and to society.
In December the same year, on Wednesday the 9th in London, the obstetrician and gynaecologist Mr Wilfred Shaw died a few days before his 56th birthday.

This evening, I want to introduce to you Wilfred Shaw, and then show you something of his contribution to science and to medicine, especially that most relevant to our work.
Then I will re-introduce Erik Odeblad, and briefly scan some of his extensive body of work that is so closely involved with our service in health education and social needs.
This will result in showing the importance of the Pockets of Shaw for all natural family planning.

1953 and onwards – Dr John Billings

Dr John Billings identified the means currently available, reviewed the known research and uncovered neglected results, and rapidly identified the mucus sign as the central and critical signal of the beginning and end of the potentially fertile phase of the ovulatory cycle. Other indicators and means were gradually discounted, and when Dr Evelyn Billings officially joined the work, the scope of the Method and its teaching, (to no-one’s surprise, then or later) took a leap forward. Professor Brown became involved from 1962, and Professor Odeblad from 1977.

The Natural Family Planning Common indicators were, in final total:
(a) Rhythm calculations. (b) Cervical mucus response to ovarian hormones.
(c) Basal body temperature (BBT). (d) Pain. (e) Vulval swelling. (f) Bleeding. (g) Self-examination of the cervix. (h) Inguinal lymph gland sign. (i) Vaginal response to ovarian hormones. (j) Ovarian hormone monitoring, using Professor J. B. Brown’s Ovarian Monitor.

The time-scale for these developments may be outlined as follows:
1953-1969 individual indicators studied.
1953-1956 correcting rhythm errors.
1956 mucus symptom research & studies.
1950s, 1960s BBT added and perfected; separate recordings kept of BBT and mucus.
1960s Rhythm discontinued.
Late 1960s BBT discontinued, hormonal studies confirmation began;
major Billings Ovulation Method® expansion began. [It was still called the Ovulation Method for another 20 years.]
1970s onwards field studies, cervix studies confirmation, ultrasound confirmation,
hormonal studies, services’ expansion.
1990 onwards a variety of gadgets found defective, and inferior to the Billings Ovulation Method®
2000 onwards major revisions and updatings.

1953 and onwards – Professor James B. Brown

That same year, age 34 and on a National Research Fellowship, Dr Brown worked in Edinburgh with Professor Marrian. Published ultimately in 1955 his citation classic standard work was in the measurement of oestrogen.

It helps very much for the understanding of a number of issues to see that hormones are produced and released in bursts or pulses rather than in steady streams. The result is seen in peaks and low levels of these hormones. The practical point in seeking to help couples is that it is not possible to perform frequent blood tests to track these levels, and the laboratory analysis took longer than could be of use to couples seeking to avoid or to achieve pregnancy in real time.

Another aspect of understanding hormones is to see how brief their existence is once made and released into the blood. This is measured and commonly expressed as the “half life”- the time taken for half of the amount released into the bloodstream to be utilised by the target organ, metabolised by the liver, and removed by the kidney – mostly a combination of all three.The four hormones of particular interest to us show a half-life from five minutes to four hours. The point is that if you combine the release of the bursts of hormones with their short life, it is impractically difficult to try to rely on their measurement in the blood to identify ovulation.

One of Professor Brown’s achievements was to even out these jagged lines to smoother, meaningful curves by his use of timed urine sampling, reflecting a three-hour window on the hormonal levels of the day. Moreover, if the hormonal effect on the target organ can be observed, a much smoother, steadier pattern becomes apparent; and this is usable. Billings Ovulation Method® observations over the course of the day, recorded each evening, offers this to couples; and Professor Brown’s work proved its accuracy and reliability. His huge contribution, in a way, came full circle in producing this proof. As he said in Rome in November 2005: “It is a huge come-down as a scientist to have to acknowledge that the mucus sensation turns out to be a better and more precise indicator of ovarian activity than any laboratory testing”. Professor Brown’s life’s work underscores the reliability of the Billings Ovulation Method®. This does not demean his work, but shows it culminating in a vindication of Nature as adequately demonstrating the couple’s combined potential fertility to them.
All of this in practice involves two patterns [changing or unchanging] and two points of change, and four simple rules.

1953 and onwards – Associate Professor Erik Odeblad

The same year the Billings Ovulation Method began, and Wilfred Shaw died, a 31-year-old Erik Odeblad was a Rockefeller Foundation Fellow spending a year in the USA. A physician, he studied new imaging and identification techniques for the analysis of the elements in biological samples.

After more training in obstetrics and gynaecology, and a PhD in physics in 1966, he was involved in the new University of Umeå where he was Professor of Medical Biophysics for 22 years, and has researched steadily all through his ‘retirement’.

He has had a wide range of other involvements in academic life and health promotion, and received many forms of recognition for his work. He has lectured in over 18 countries, and been published over 450 times. Perhaps his best-loved quote is that “The cervix is a precision organ as complex as the eye”.

1897 – 1953 Wilfred Shaw MD, FRCOG – an extraordinary life*

Interim Notes on the Pockets of Shaw

1 The Structure of the Pockets of Shaw

The Pockets were first described by the pioneering English gynaecologist in the late 1940s. He referred to them initially as paraurethral recesses .

In a unique international symposium in New York just six years after his early death, the North American authority on gynaecological anatomy Kermit Krantz called them the folds of Shaw .

Professor Erik Odeblad has been working on cervical mucus since that time, and he has included the vaginal structures and their function since the late 1950s. He consistently refers to these recesses as the Pockets of Shaw.

The lumen of the vagina is bulbous and widest (though resting folded or flattened) at the top where the cervix intrudes into it; the middle part is narrowed; and the lower part is flared and folded in on itself so that (especially in youth) the lumen takes on the shape of the capital letter H, with longer arms of the H towards the front of the body than towards the back, “two indentations…in the wall, one either side, large enough to admit the tip of a finger” .

Finally the external sphincter gathers the folds together, closed off from the outside, so that these folds effectively become pockets.

The lining surface of the upper ¾ (approx.) of the vagina is impermeable to water, but the lower 1/4 is not, and resorbs the water content of whatever fluids flow down onto it, to the extent that the influence of progesterone levels is dominant over oestrogen levels.

This resorption has the effect of drying the mucus and thus altering the mucus sensation at the vulva.

2 The Pockets and the Points of Change

The first point of change [in an ovulatory cycle] charted by the Billings Ovulation Method® when experienced at the vulva reflects the interruption of the Basic Infertile Pattern by the initial rise in oestrogen levels.

The second point of change in an ovulatory cycle (at the Peak) reflects the rising level and returned dominance of progesterone. It is a dramatic change, as seen in the correlated graphing and charting of the combined analyses of the Drs Billings and Professors Erik Odeblad and James Brown . Its occurrence depends on the health of the cervix and of the Pockets, and on satisfactory hormonal function.

The first point of change is long understood as the result of the release of the G mucus plug from the cervix.

The second point of change, the dramatic end of the most slippery sensation that occurs with ovulation, demanded some explanation. Seasoned Billings Ovulation Method® users were quite certain of this change, whereas speculum examination would show some mucus release at the cervical os over the three days following the Peak day.

Professor Erik Odeblad documented (1) women’s sensation at the vulva (2) the amounts of mucus produced (3) the types and their proportions of the mucus produced over this time. This data was correlated with the Billing’s clinical records, and with Professor Jim Brown’s extensive hormonal analyses, demonstrating that the set sequence of hormone production and mucus secretion and vulval sensation was part of the body’s handling of ovulation. “Progesterone strongly reverses the action of oestrogen on the cervix and the vaginal epithelium and causes the discharges to rapidly lose their fertile characteristics. This change due to progesterone (the “progesterone change “or “PC”) is readily recognised” : Professor Brown’s work was later summarised as the “Continuum of ovulatory activity”.

Even this correlation did not explain the “how” of the abrupt change of sensation. Professor Odeblad proceeded to study vaginal fluid dynamics, and showed that the lower part of the vagina can absorb water, whereas the upper and middle parts cannot do so, being impermeable to water.

He further showed that the resorption mechanism operates when progesterone is dominant. This allows us to appreciate that the mucus giving rise to the sensation during the potentially fertile time is due to temporary oestrogen dominance.

Graphing of the hormones, the mucus and sensation show a great and sudden change at the Peak, with an abrupt resumption of the resorption of the water content of the mucus in the lower vagina, while the S mucus release ends and the G mucus plug at the mouth of the cervix is being reformed, over the three days following the Peak.

This completes the picture of the “logic” of the Early Day Rules, and of the Peak Rule of the Billings Ovulation Method®.

The activity of the Pockets of Shaw also explains why at the end of the ovulatory cycle, if progesterone levels fall faster and thus earlier than oestrogen levels, some mucus is experienced at the vulva before the next menstruation.

Below, combined, are charts of (1) the hormone levels from Professor Brown’s work (2) the proportions of types of mucus analysed by Professor Odeblad during a cycle (3) charting of vulval sensation during the cycle, from Professor Odeblad’s earlier work . The blue line joins them at the time of ovulation. Underlining them all is the Billings Ovulation Method® chart.

3 The Mechanism of Resorption of Water Content

Cervical mucus is 85-99% water , and so significant reabsorbing of the water content can greatly change the sensation of mucus passing over the region of the inner labia at the vulva.
Reabsorption of water happens elsewhere in the body, and is not unique to the vagina, although there the progesterone involvement is exceptional.

Much fluid is reabsorbed in the body, to conserve and re-use the water we need to drink.
The fluid around the brain and spinal cord circulates about four times a day, being produced at the top and reabsorbed at the bottom; about 300ml of fluid in the lung tissue is conserved; the kidneys produce up to 200 litres a day and reabsorb 99% of it; different parts of the bowel produce a total of about 10 litres a day and reabsorb 98% of it. Mid-cycle, about 2/3 of vaginal fluids are reabsorbed7.

Groups of hormones have different effects on the conservation or loss of types of salts or electrolytes, and these “bring” water molecules with them.

The mechanism of water resorption in the vagina was for years theorized to be related to the element manganese, based on NMR, ESR and allied studies identifying changing levels of manganese in vaginal fluid at various times in the ovulatory cycle. Recently, Professor Odeblad has updated his model for understanding this phenomenon: –
(1) following the work of Agre and MacKinnon in discovering micro-channels for water transport through the walls of cells. These surface cell membrane structures are channels that can actively transport water molecules rapidly in single file into and through cells, as distinct from the lesser and passive water osmosis that happens through the fatty elements of the surfaces of other cells.
(2) Other studies have documented the vaginal flora, showing that its numbers vary with the acidity (pH) of the vaginal fluid ; and this changes during the time of potential fertility.

Oestrogen produces mucus that makes the vagina temporarily alkaline. Manganese is more easily absorbed by bacteria in mildly acid fluid. Many bacteria accumulate and use manganese in the repair of their DNA; lactobacilli use manganese to scavenge toxic oxygen radicals . Therefore the changing levels of manganese in the vaginal fluid now seems to reflect the population size of the bacterial colony, and not the water resorption activity. Manganese also speeds the growth rate of lactobacilli . “It is not clear at all what the manganese really is doing. I previously thought it was something to do with water reabsorption but the water channels seem to be well understood without the manganese”; and later “not until the end of 2010 it became evident for me that the manganese could be present in the lactobacilli” .

The subject of vaginal flora is complex and not yet fully understood. In general, either lactobacilli or candida will predominate, and unhelpful bacteria may outnumber normal flora
in acid conditions. Healthy oestrogen levels seem to encourage the growth of normal lactobacilli .

As ever, in the scientific study of the Billings Ovulation Method®, new developments are not found to change the understanding or the use of the Method; they add another layer of detail to its explanation.

4 Loss of Mucus Production or Resorption

Gradual reduction in mucus production is seen in health, approaching the menopause. Professor Brown’s extensive hormone analyses for women charting in pre-menopause showed that the response of the cervix to oestrogen may lessen in some women before the ovarian follicles cease to respond to FSH at menopause.

Levels of FSH and LH rise to new levels at menopause, being unsuppressed by rising oestrogen or progesterone levels as would have been the case during the reproductive years.

Surgery to the cervix is less commonly undertaken now than some years ago, when part of the cervix would be removed, thus removing some of the mucus-producing crypts, especially the lower ones that produce more of the G mucus. Earlier detection and newer treatments of cervical pathology have made this fairly exceptional.

Inflammation seems to reduce the capacity for resorption by a thickening of the surface and some smoothing out of the mucosal folds, reducing the surface area by as much as half . Increased discharge also occurs especially with infections.

Older hormonal contraception used commonly show long-delayed recovery of fertility, with uninterrupted Basic Infertile Pattern and little sign of hormonal activity for months after stopping the medication. This is not seen as extensively in charting after hormonal contraception in current Billings Ovulation Method® practice. Though lower in dose, newer progestagens are more powerful and persist longer in the body. Chemical contraception atrophies S mucus crypts to some extent and causes excess development of G crypts ; such effects are seen after relatively prolonged use.

Lessened resorption, – reduced activity and size of the Pockets of Shaw due to long term use of hormonal contraception – has long been observed also.

Natural ageing of the cervix, rejuvenation of the cervix by pregnancies, and premature cervical ageing by prolonged hormonal contraception use has been documented in detail with clear graphics by Professor Odeblad.

Teaching the Billings Ovulation Method, Part Two (ISBN 0 908482 11 6, 1997; page 40) notes the effect of hormonal contraception on the drying effect of the Pockets of Shaw: “This mechanism is often deranged by the Pill so that the reabsorption of the vaginal fluids does not take place. The woman suffers a constant thin watery discharge” and later “In a very few cases…the mucus becomes excessively dried in the lower vagina making it difficult for the woman to detect the presence of mucus. The derangement of the delicate…balance has been known to cause a woman to miss the beginning of the mucus symptoms in about 1 to 2 per 1000 post-Pill cases (Odeblad)” , .

This is described in more detail, in the understanding of the time, in the 5th edition of the Billings Atlas of the Ovulation Method [ISBN 0 908482 02 7, 1989]. Both books are published by the Ovulation Method Research and Reference Centre of Australia, Melbourne.

* The text on the Pockets of Shaw, subsequently published in The Bulletin of WOOMB International Vol 40, No 1 April, 2011.