Carl W. Tyler

Local versus general anesthesia: Which is safer for performing suction curettage abortions?

The relative safety of suction curettage abortions performed with either local or general anesthesia has not been clearly established. To compare the safety of these two anesthetic techniques, we studied 36,430 women who received local anesthetics and 17,725 who received general anesthetics for this operation in the United States from 1971 through 1975. The aggregated major complication rates for the two groups were similar, but there were significant differences between local and general anesthesia for specific complications and treatments. Local anesthesia was associated with higher rates of febrile and convulsive morbidity; however, general anesthesia was associated with higher rates of hemorrhage, cervical injury, and uterine perforation. Both anesthetic techniques appear to be safe, with similar degrees of overall safety, although each is associated with a different spectrum of complications.

Endometrial cancer: How does cigarette smoking influence the risk of women under age 55 years having this tumor?

This analysis of the Cancer and Steroid Hormone Study, a multicenter, population-based case control investigation of hormone use by women of reproductive age and endometrial, breast, and ovarian cancer shows that cigarette smoking is not associated with either an increased or a decreased risk of endometrial cancer. This study included 437 women with endometrial cancer and 3200 control subjects, all of whom were between the ages of 20 and 54 years at the time of interview. The absence of any alteration of the risk of endometrial cancer and smoking was found consistently no matter which variable was used as a measure of smoking--ever or never smoked cigarettes, former or current smoking, light or heavy smoking, or age smoking began.

Postmenopausal smoking, estrogen replacement therapy, and the risk of endometrial cancer

Previous studies of the association between cigarette smoking and endometrial cancer have yielded inconsistent results. There is some evidence that this discrepancy may be explained by differences in menopausal status between the groups of women studied. We addressed the issue of the effects of postmenopausal smoking on endometrial cancer risk using data from the Cancer and Steroid Hormone Study, a multicenter, population-based, case-control study of gynecologic cancers in the United States. We found that smoking after natural menopause is associated with a 70% reduced risk of endometrial cancer among estrogen users and a 50% reduced risk among nonusers of estrogen. These findings are consistent with previously proposed biologic effects of smoking on estrogen metabolism, which may have important clinical implications.

An association between the Dalkon Shield and complicated pregnancies among women hospitalized for intrauterine contraceptive device-related disorders

A nationwide mail survey of virtually all physicians likely to be involved with intrauterine contraception resulted in 3,502 unduplicated reports of intrauterine contraceptive device (IUD)--related hospitalizations during the first six months of 1973. Dalkon Shield use was significantly more frequent among women hospitalized for a complicated pregnancy than those hospitalized for a non-pregnancy-related disorder. Although the observed association was not substantially altered by stratifications of the mail survey reports by the patients age, race, or geographical region, the association did not apply to those women whose IUDs were explicitly reported to be of the nulliparous size. Interviews conducted with a probability sample of physicians who had not responded to the survey confirmed that the association between the Dalkon Shield and complicated pregnancy also existed in their experience. An association between the standard Dalkon Shield and complicated pregnancies might reflect an increased rate of pregnancy with this device, an increased rate of complications occurring after zygotic implantation, or perhaps both. Whatever the explanation, the observed association is sufficiently widespread to require further investigations.

Abortion deaths associated with the use of prostaglandin F2α

Six abortion-related deaths associated with the use of prostaglandin F2alpha were reported through the Center for Disease Controls surveillance of abortion deaths between 1972 and 1975. Prostaglandin may have had only indirect association with these deaths. The patients ages ranged from 16 to 38 years, their length of gestation ranged from 15 to 24 menstrual weeks, four were white, and three were nulliparous. Four patients had pre-existing conditions that increased their risks and contributed to their death. The estimated death-to-case rate for prostaglandin F2alpha was 10.5 per 100,000 abortions. Although lower than the rate for intra-amniotic saline instillation, this death-to-case rate is only an approximation. The relative safety of intra-amniotic prostaglandin F2alpha as a second-trimester abortifacient, compared to saline, remains to be established.

Legalized abortion: Effect on national trends of maternal and abortion-related mortality (1940 through 1976)

Both non-abortion-related maternal and abortion-related mortality declined prior to the Supreme Court decisions of 1973. In order to determine the effect of legalized abortion on maternal mortality, we have analyzed the secular trends in national abortion mortality ratios for 1940 through 1976, compared the trends to those maternal mortality ratios, and hypothesized reasons for differences between these trends. Between 1940 and 1950 and after 1965, deaths from abortion declined more rapidly than deaths from other causes associated with childbirth. However, between 1951 and 1965, maternal mortality related to pregnancy of childbirth declined more rapidly than abortion-related mortality. Five possible explanations exist for the more rapid decline in abortion deaths since 1965--selected underreporting, changes in coding practices, improved safety of illegal abortion, introduction of more effective contraception, and increased availability of legal abortion. We consider the last two explanations as the most likely reasons for the accelerated decline in abortion-related deaths.

The Association Between Oral Contraception and Hepatocellular Adenoma — A Preliminary Report

Women with long‐term use of oral contraception (OC) are at increased risk of developing a serious, though nonmalignant, liver tumor—hepatocellular adenoma (HCA)—according to a case‐control study conducted by the Center for Disease Control (CDC) in collaboration with the Armed Forces Institute of Pathology (AFIP). The tumor is sometimes fatal, deaths usually being due to sudden rupture and hemorrhage. This study suggests that, in addition to long‐term OC use, a womans age and the hormonal potency of the OC she uses affect her chances of developing HCA. Women 27 years old and older who have used OC with high hormonal potency for 7 or more years are at the greatest risk.

Contraceptive choice and prevalence of cervical dysplasia and carcinoma in situ

Whether use of oral contraceptives is associated with subsequent development of cervical neoplasia is an important public health question. Before evaluating this issue, we must determine if choosing oral contraceptives identifies a woman who is intrinsically at high risk of developing cervical neoplasia. We have examined the demographic and reproductive characteristics as well as cervical premalignant changes manifest by 15- to 44-year-old black women who enrolled in a public family-planning clinic. When compared to IUD acceptors, oral contraceptive acceptors did not have a disproportionately large number of women with traits which predicted for high risk of developing cervical neoplasia. Oral contraceptive acceptors, compared to IUD acceptors, did not have a higher prevalence rate of carcinoma in situ. Oral contraceptive acceptors with no Pap smears prior to initial choice of contraceptive method did have a 1.4-fold higher prevalence rate of cervical dysplasia than IUD acceptors. These results suggest that the deicision to use oral contraceptives, per se, does not identify a group of women at higher risk to develop cervical carcinoma in situ. Such a decision may, however, identify a group with a small increased propensity for developing cervical dysplasia.

Methods of midtrimester abortion: which is safest?

In the United States, the three principal methods of abortion for patients at 13 or more menstrual weeks gestation are intraamniotic instillation of saline or prostaglandin F2α (PGF2α) and dilatation and evacuation (D&E). The relative safety of these methods, however, has not been established. This report compares the three methods using data on 17467 abortions collected by the Joint Program for the Study of Abortion under the auspices of the Center for Disease Control (JPSA/CDC). Abortion by D&E was found to be significantly safer than abortion by saline instillation (p<0.001), and abortion by saline instillation was significantly safer than by PGF2α (p<0.01). Moreover, midtrimester D&E is both safe and practical; it is a direct and rapid procedure which can be performed on an outpatient basis. Although PGF2α accelerated the time required for abortion, it also significantly increased serious morbidity.

Pelvic inflammatory disease, 1980

n The term pelvic inflammatory disease (PID) is used to refer to diseases caused by acute ascending genital tract infection. Over 500 of the worlds leading researchers met at the Center for Disease Control, Atlanta, Georgia, in April 1980, to review many facets of PID from their various perspectives. Since PID occurs more frequently among women younger than 25, its economic and social consequences are very serious. The risk of PID increases among women who use IUDs; in some Asian countries illegally induced abortions are among the most common causes of PID: in some African countries PID is associated most frequently with female circumcision. The microbiologic causes of PID are highly controversial. An accurate differential diagnosis of PID is very difficult since the clinical symptoms and signs are highly variable; laparoscopy is essential for accurate diagnosis. Antimicrobial treatment requires an extremely accurate microbiologic diagnosis; there is a great need for careful, therapeutic studies. Prevention of PID is tied to the design and implementation of control policies for sexually transmitted diseases.n