Lilo T. Strauss

Hysterectomy in the United States, 1988-1990

Objective: To describe patient characteristics and diagnoses associated with hysterectomy in the United States from 1988‐1990 using data from the National Hospital Discharge Survey. Methods: We analyzed data from the National Hospital Discharge Survey, an annual probability sample of discharges from nonfederal, short‐stay hospitals in the United States. A population‐based sample of all women aged 15 years or older in the United States civilian population who had a hysterectomy during 1988‐1990 was examined to characterize factors associated with hysterectomy: patients age and race, diagnoses, surgical approach, and oophorectomy. Results: Approximately 1.7 million women had a hysterectomy during 1988‐1990. The highest rates—100.5 hysterectomies per 10,000 women—were for women aged 30‐54 years. Total rates of hysterectomy for black women were similar to those for white women (61.7 and 56.5 per 10,000 women, respectively); uterine leiomyoma (“fibroid tumor”) was reported as the primary diagnosis for 61% of black women and 29% of white women. Abdominal surgery was used for 75% of all hysterectomies. Concomitant bilateral oophorectomy was done for 37% of the women under 45 years old and 68% of the women 45 years or older. Conclusions: Two‐thirds of all hysterectomies for noncancerous conditions were performed for uterine leiomyoma or endometriosis—conditions that are most common before the age of menopause. Future assessments of the appropriateness of hysterectomy will require better understanding of these disorders. Continued monitoring of hysterectomy rates is critical to understanding the appropriate use of hysterectomy, alternative therapies for uterine disorders, and future trends in womens health care. (Obstet Gynecol 1994;83:549‐55)

The relation between induced abortion and ectopic pregnancy.

Objective To determine whether having had one or more induced abortions increases a womans risk of having an ectopic pregnancy. Methods We conducted a case-control study of all women admitted to a major metropolitan hospital in Georgia with a surgical diagnosis of ectopic pregnancy during the period of October 1988 to August 1990. Controls were randomly selected from women seeking an induced abortion or delivering an infant at the same hospital. After exclusions, this analysis included 182 cases and 1056 controls. Stratified analysis and unconditional logistic regression were used to control for confounding and to estimate the relative risks. Results Approximately 90% of cases and controls were non-Hispanic, black women; 34% of the cases and 36% of the controls reported a history of induced abortion. The crude odds ratio for having an ectopic pregnancy associated with a history of induced abortion was 0.9 (95% confidence interval 0.6, 1.3). The odds ratio remained the same after adjusting for selected confounding variables and stratifying by the number of induced abortions, gestational age at the time of abortion, place where the abortion was performed, and the womans report of medical complications of the abortion. Conclusion We found no evidence that having one or more induced abortions increases a womans risk of having an ectopic pregnancy.

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.

Previous cesarean delivery and the risk of ectopic pregnancy

Objective To determine whether previous cesarean delivery is an independent risk factor for ectopic pregnancy. Methods We analyzed data collected between October 1988 and August 1990 from a case-control study of ectopic pregnancy among parous, black, non-Hispanic women, 18‐44 years old, at a major metropolitan hospital in Georgia. Cases were 138 women with confirmed ectopic pregnancy; controls were 842 women either seeking abortion or delivering an infant. Unconditional logistic regression was used to estimate the relative risk while controlling for the effects of potential confounders selected a priori. Results: Adjusted for age, parity, marital status, history of pelvic inflammatory disease, infertility, douching, and smoking, the odds ratio was 0.6 (95% confidence interval 0.4‐1.1), indicating no significant association. Conclusion We found no evidence of an increased risk of ectopic pregnancy related to previous cesarean delivery.

Oral contraception during lactation: A global survey of physician practice

The use of combined estrogen‐progestogen oral contraceptives (EP‐OC) by lactating women has been associated with suppression of lactation. To determine the extent to which physicians prescribe combined EP‐OC for lactating women, the International Planned Parenthood Federation (IPPF) and the United States Centers for Disease Control (CDC) collaborated in a global mail survey of 3697 physicians affiliated with Family Planning Associations (FPA) in 72 countries. Usable responses were received from 831 physicians (22%) in 65 countries. The percent of clinicians who provide EP‐OC to lactating women was higher in developing regions (63% or more) than in developed regions (40% or less). Patient preference was rated important more often than any other factor in the decision to prescribe EP‐OC for lactating women. The percentage of clinicians who reported complaints of decreased milk production from women using EP‐OC was higher (32% or more) in developing regions where breast milk is often essential to infant nutrition.

Previous experience of induced abortion as a risk factor for fetal death and preterm delivery

As part of a community‐based study in Korea to evaluate the effects of previous induced abortion on length of gestation and pregnancy outcome of subsequent pregnancies, we analyzed data obtained from January 1979 to December 1981 on pregnancies reported to family health workers in Kang Hwa Island, Korea. The preterm, live‐birth rates were not significantly associated with previous induced abortion. Overall, the life table‐estimated fetal death rate for women enrolled at the eighth or earlier weeks of gestation was 13.7%, 10.2% for women with no previous induced abortion and 28.9% for women with previous induced abortion. The relative risk for fetal death for women who had undergone a previous abortion was 2.8; relative risk for parous women compared to nulliparous women was 3.4. After controlling for parity, previous induced abortion was not a significant variable for fetal death rate.

Sterilization-associated deaths: A global survey

Except for data from several geographically limited studies, little is known globally about the number and causes of death associated with surgical sterilization. To identify clinical characteristics and problems leading to deaths related to the procedures, the International Planned Parenthood Federation (IPPF) and the Centers for Disease Control (CDC) in the United States collaborated in a global mail survey of 4642 physicians. Usable responses were received from 1298 physicians (28%) in 80 countries. Fifty‐five sterilization‐associated deaths which occurred from January 1, 1980 to June 30, 1982 were reported. The most frequently reported causes of death were infection, anesthetic complications, and hemorrhage. There were some regional differences in the relative frequencies of these causes. Most cases did not involve surgical accident. The characteristics most frequently associated with the reported fatal procedures were: interval sterilizations, minilaparotomy incision, tubal ligation and general anesthesia. Most deaths were attributable to the surgical sterilization procedure.

Complications of Interval Laparoscopic Tubal Sterilization

In 1978, the Centers for Disease Control initiated a multicenter prospective study to assess the safety of the various female sterilizing operations and the ways in which they could be made safer. During the first 31 months, 3500 women who underwent interval laparoscopic tubal sterilization by electrocoagulation or Silastic banding without other concurrent operations were enrolled in the study. When a standard definition of complications was used, the overall rate of an intraoperative or postoperative complication was 1.7 per 100 women. Several patients factors increased the risk of complications twofold or more: diabetes mellitus, previous abdominal or pelvic surgery, lung disease, a history of pelvic inflammatory disease, and obesity. There was a fivefold difference in complication rates between procedures performed under general anesthesia and those done under local anesthesia.