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Papers by C. Westhoff

Tubal sterilization: focus on the U.S. experience

Fertility and Sterility, 2000

To review the frequency, effectiveness, and clinical sequelae of tubal sterilization with a focus... more To review the frequency, effectiveness, and clinical sequelae of tubal sterilization with a focus on the U.S. experience. Design: A review of U.S. health care statistics and English-language literature using a MEDLINE search, bibliographies of key references, and U.S. government publications. Patient(s): Women seeking tubal sterilization. Intervention: Tubal sterilization. Main Outcome Measure(s): Effectiveness and long-term risks and benefits. Result(s): Half of the 700,000 annual bilateral tubal sterilizations (TS) are performed postpartum and half as ambulatory interval procedures. Eleven million U.S. women 15-44 years of age rely on TS for contraception. Failure rates vary by method with one third or more resulting in ectopic pregnancy. Reversal is most successful after use of methods that destroy the least tube. Evidence of menstrual or hormonal disturbance after TS is weak, although some studies find higher rates of hysterectomy among previously sterilized women. Decreased risk of subsequent ovarian cancer has been observed among sterilized women. Conclusion(s): Tubal sterilization is highly effective and safe. Failures, although uncommon, occur at higher rates than previously appreciated. Evidence for hormonal or menstrual changes due to TS is weak. Tubal sterilization is associated with decreased risk of ovarian cancer.

Smoking and oral contraception continuation

Contraception, 2007

New users of the contraceptive ring and patch are more commonly switching from another method as ... more New users of the contraceptive ring and patch are more commonly switching from another method as opposed to being a new starter of hormonal contraception. We sought to understand if one method was more preferable for women interested in a nondaily combined hormonal contraceptive. Methods: Five hundred women using combined oral contraceptives and happy with the method were randomized to use the contraceptive ring (n=249) or contraceptive patch (n=251) for the next four cycles. Participants returned for a single follow-up visit during the fourth cycle for evaluation, including a questionnaire to assess acceptability and side effects. Results: Continuation rates into the third cycle were 94.6% and 88.2% for ring and patch users, respectively (p=.012). Of these women, 71.0% and 26.5%, respectively, planned to continue their method after the study (pb.001). Women switching to the patch were significantly more likely than women switching to the ring to experience longer periods (38% vs. 9%), increased dysmenorrhea (29% vs. 16%), frequent nausea (8% vs. 1%), frequent mood swings (14% vs. 8%) and frequent skin rash (12% vs. 2%), and less likely to experience frequent vaginal discharge (8% vs. 17%). Nugent scores were not different from baseline to study exit in ring users (p=.53) but did demonstrate an increase in bacterial vaginosis in patch users (p=.01). Most of these women were asymptomatic. Conclusions: Women who are happy with combined oral contraceptives and are willing to use a non-daily method are more likely to continue and will experience significantly fewer side effects with the contraceptive ring than contraceptive patch.

Reproduktionsmedizin und Endokrinologie

kup.at

... and Gynecology, Faculty of Health Sciences, Queen&#x27;s University, Kingston, Ontario, C... more

Does endometrial biopsy miss endometrial carcinoma?

International Journal of Gynecology & Obstetrics, 1995

Curettage After Mifepristone‐Induced Abortion: Frequency, Timing, and Indications

To characterize women who underwent curettage after medical abortion with mifepristone and vagina... more To characterize women who underwent curettage after medical abortion with mifepristone and vaginal misoprostol, to describe when curettage occurred and the reasons for the intervention, and to categorize the indications for curettage according to a simple classification schema. METHODS: These analyses used data from two multisite, randomized controlled trials sponsored by Abortion Rights Mobilization. In the first study, women pregnant less than 63 days received 200 mg of mifepristone and 800 g of vaginal misoprostol to use 48 hours after taking mifepristone. In the second study, women pregnant less than 56 days were randomly assigned to insert vaginal misoprostol at 1, 2, or 3 days after mifepristone administration. Case report forms and clinical case notes of all women who underwent curettage were examined. RESULTS: Of the 4393 women enrolled in both studies, 116 (2.6%, 95% confidence interval 2.1%, 3.1%) curettages were identified. The gestational age and a history of prior elective abortion were associated with the rate of curettage. The distribution of indications for curettage included bleeding, 61 (53%); continuing pregnancy, 17 (15%); patient request, 36 (31%); and indeterminate, 2 (1.7%). The timing of curettage differed by the indication and scheduled interval between study visits. The distribution of the timing was bimodal. One subset of women, 44 (38%), underwent curettage in the first study week and another subset, 43 (37%), during weeks 3-5. CONCLUSION: Curettage after medical abortion with mifepristone and vaginal misoprostol is rare. At least one half of the curettages were performed for persistent bleeding several weeks after treatment. Both acute heavy bleeding and continuing pregnancy are extremely rare.

Randomized trial of oral versus vaginal misoprostol at one day after mifepristone for early medical abortion

Mifepristone was recently approved in the United States. Regimens with shorter intervals may be m... more Mifepristone was recently approved in the United States. Regimens with shorter intervals may be more acceptable. The objective of this study was to determine whether the oral route of misoprostol was as effective as the vaginal route of misoprostol 1 day after mifepristone. A prospective, open-labeled, randomized trial of healthy adult women up to 63 days pregnant and wanting a medical abortion were randomized to use either two doses of oral misoprostol 400 microg taken 2 h apart or misoprostol 800 microg vaginally. Women self-administered misoprostol 1 day after taking one-third of the standard dose of mifepristone (200 mg) orally. Women then returned to the clinic up to 5 days later for a repeat sonogram evaluation. A dose of vaginal misoprostol was administered to women with a continuing pregnancy who then returned 1 day later to Day 15. The primary outcome measures were a complete medical abortion by the first or by the second follow-up visits. Surgical intervention was indicated for continuing pregnancy at the second follow-up visit, excessive bleeding, or persistent products of conception 5 weeks later. One thousand one hundred sixty-eight women were enrolled. Of the 1144 (98%) women who complied with their random assignment, two oral doses of misoprostol (800 microg total) were 90% effective at inducing an abortion by the first follow-up visit, compared with one dose of misoprostol by vagina of 97% (chi(2) = 23.95, p = 0.001). By the second follow-up visit, the complete abortion rate was 95% for oral misoprostol and 99% for vaginal misoprostol (chi(2) = 21.76, p = 0.001). There were minimal differences in side effects. Women preferred the oral route. The trial demonstrated that although two doses of oral misoprostol were effective, the vaginal misoprostol was more effective at inducing an early medical abortion at 1 day after low-dose mifepristone, and the regimen could be extended to 63 days gestation.

Self-treatment patterns among adolescent girls with moderate or severe primary dysmenorrhea

Journal of Adolescent …, 2004

Journal of Adolescent Health, Volume 34, Issue 2, Pages 134, February 2004, Authors:Anne Davis, M... more

Keyes et al. Respond to "Hormonal Contraception and Mood

American Journal of Epidemiology, 2013

Asbestos exposure and ovarian fiber burden

American Journal of Industrial Medicine, 1996

Epidemiologic studies suggest increased risk of epithelial ovarian cancer in female asbestos work... more Epidemiologic studies suggest increased risk of epithelial ovarian cancer in female asbestos workers and increased risk of malignancy in general in household contacts of asbestos workers. Ovaries were studied from 13 women with household contact with men with documented asbestos exposure and from 17 women undergoing incidental oophorectomy. Ovarian tissue was examined by analytic electron microscopy. Significant asbestos fiber burdens were detected in 9 out of 13 women with household asbestos exposure (69.2%), and in 6 out of 17 women who gave no exposure history (35%). Three exposed women had asbestos counts over 1 million fibers per gram wet weight (23%), but only 1/17 women without an exposure history had a count that high (6%). Although asbestos has been documented as a contaminant of some older cosmetic talc preparations, the chrysotile and crocidolite types of asbestos we detected are more indicative of background and/or occupational exposure. This study demonstrates that asbestos can reach the ovary. Although the number of subjects is small, asbestos appears to be present in ovarian tissue more frequently and in higher amounts in women with a documentable exposure history.

Effects of fertility drugs on cancers other than breast and gynecologic malignancies

by Bert Scoccia, C. Westhoff, and B. Trabert

Fertility and Sterility, 2015

To examine the relationship of ovulation-stimulating drugs to risk of cancers other than breast a... more To examine the relationship of ovulation-stimulating drugs to risk of cancers other than breast and gynecologic malignancies. Retrospective cohort study, with additional follow-up since initial report. Reproductive endocrinology practices. Among a cohort of 12,193 women evaluated for infertility between 1965 and 1988, a total of 9,892 women (81.1% of the eligible population) were followed through 2010, via passive and active (questionnaire) approaches. None. Hazard ratios (HRs) and 95% confidence intervals (CIs) for various fertility treatment parameters for select cancers. During 30.0 median years of follow-up (285,332 person-years), 91 colorectal cancers, 84 lung cancers, 55 thyroid cancers, and 70 melanomas were diagnosed among study subjects. Clomiphene citrate (CC), used by 38.1% of patients, was not associated with colorectal or lung cancer risks, but was related significantly to melanoma (HR = 1.95; 95% CI: 1.18-3.22), and non-significantly to thyroid cancer risks (HR = 1.57; 95% CI: 0.89-2.75). The highest melanoma risks were seen among those with the lowest drug exposure levels, but thyroid cancer risk was greatest among the heavily exposed patients (HR = 1.96; 95% CI: 0.92-4.17 for those receiving &amp;amp;amp;amp;amp;amp;gt;2,250 mg). Clomiphene citrate-associated risks for thyroid cancer were somewhat higher among nulligravid, compared with gravid, women, but did not differ according to distinct causes of infertility. Gonadotropins, used by only 9.7% of subjects, were not related to risk of any of the assessed cancers. Our results provide support for continued monitoring of both melanoma and thyroid cancer risk among patients receiving fertility drugs.

Cancer Risk After the Use of Ovulation-Stimulating Drugs

by Bert Scoccia and C. Westhoff

Obstetrical & Gynecological Survey, 2004

Breast cancer risk associated with ovulation-stimulating drugs

by Bert Scoccia and C. Westhoff

Human Reproduction, 2004

BACKGROUND: Despite the recognized role of hormones in the aetiology of breast cancer, there has ... more BACKGROUND: Despite the recognized role of hormones in the aetiology of breast cancer, there has been little evaluation of hormonal preparations used to treat infertility. METHODS: A retrospective cohort study of 12 193 women evaluated for infertility between 1965 and 1988 at five clinical sites identified 292 in situ and invasive breast cancers in follow-up through 1999. Standardized incidence ratios (SIRs) compared breast cancer risks with those of the general population. Analyses within the cohort estimated rate ratios (RRs) associated with medications after adjustment for other breast cancer predictors. RESULTS: Infertile patients had a significantly higher breast cancer risk than the general population [SIR 5 1.29, 95% confidence interval (CI) 1.1-1.4]. Analyses within the cohort showed adjusted RRs of 1.02 for clomiphene citrate and 1.07 for gonadotrophins, and no substantial relationships to dosage or cycles of use. Slight and non-significant elevations in risk were seen for both drugs after $20 years of follow-up (RRs 5 1.39 for clomiphene and 1.54 for gonadotrophins). However, the risk associated with clomiphene for invasive breast cancers was statistically significant (RR 5 1.60, 95% CI 1.0-2.5). CONCLUSIONS: Although there was no overall increase in breast cancer risk associated with use of ovulationstimulating drugs, long-term effects should continue to be monitored.

Fertility drugs and endometrial cancer risk: results from an extended follow-up of a large infertility cohort

by Bert Scoccia, C. Westhoff, and B. Trabert

Human Reproduction, 2013

Do fertility drugs influence the subsequent risk of endometrial cancer in a manner that is indepe... more Do fertility drugs influence the subsequent risk of endometrial cancer in a manner that is independent of other risk predictors, such as parity? In this follow-up of a large cohort of women evaluated for infertility and for whom information was captured on fertility drugs, indications for usage and other risk factors that might influence cancer risk, we found no evidence for a substantial relationship between fertility drug use and endometrial cancer risk. Although the hormonal etiology of endometrial cancer has been well established, it remains unclear whether the use of fertility drugs has an influence on risk. Results regarding the effects of fertility drugs on endometrial cancer risk have been inconsistent, although several studies have shown some evidence for possible increases in risk. The relationship is of particular interest given that clomiphene, a commonly prescribed drug, is a selective estrogen receptor modulator, with chemical properties similar to tamoxifen, another drug linked to an increase in endometrial cancer risk. In a retrospective cohort of 12 193 women evaluated for infertility between 1965 and 1988 at five US sites, follow-up was pursued through 2010 via both passive as well as active (questionnaire) means. Among the 9832 subjects for whom follow-up was allowed and achieved, 259 346 at-risk person-years (i.e. prior to hysterectomy) were accrued, and 118 invasive endometrial cancers identified. Cox regression determined hazard ratios (HRs) and 95% confidence intervals (CIs) for fertility treatments adjusted for endometrial cancer risk factors and causes of infertility. Although we observed slight increases in endometrial cancer risk associated with clomiphene (HR = 1.39, 95% CI: 0.96-2.01) and the less commonly prescribed gonadotrophins (1.34, 0.76-2.37), there were no convincing relationships of risk with either cycles of use or cumulative exposures for either drug. A statistically significant risk associated with the use of clomiphene among women who began use at younger ages (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;30) (1.93, 1.24-3.00) may have reflected indications for drug usage rather than the effect of the drug itself. Women who received clomiphene followed by gonadotrophins were at a non-significantly elevated risk (1.77, 0.98-3.19). Like most studies of endometrial cancer, we were limited by sample sizes, particularly for evaluating subgroup associations. We were also unable to follow all women and were not able to obtain complete risk factor information (including hysterectomy status) for the entire cohort. Although we found no support for a relationship between fertility drugs and endometrial cancer risk, the association should continue to be monitored given that our study population was still young and had not yet reached the age of peak endometrial cancer incidence. This project was supported in part by funds from the intramural research program of the National Cancer Institute, National Institutes of Health. None of the authors has any conflicting interests to declare.

Ovarian cancer risk associated with varying causes of infertility

by Bert Scoccia and C. Westhoff

Fertility and Sterility, 2004

Objective: To evaluate the risk of ovarian cancer as related to underlying causes of infertility.... more Objective: To evaluate the risk of ovarian cancer as related to underlying causes of infertility. Design: Retrospective observational cohort study. Setting: Five large reproductive endocrinology practices. Patient(s): A total of 12,193 women evaluated for infertility between 1965 and 1988. Intervention(s): None. Main Outcome Measure(s): Ovarian cancer ascertained through 1999.

Ovulation induction and cancer risk

by Bert Scoccia and C. Westhoff

Fertility and Sterility, 2005

Objective: To review and critique the literature regarding ovulation induction and cancer risk. D... more Objective: To review and critique the literature regarding ovulation induction and cancer risk. Design: Identification of relevant clinical and epidemiological literature through PubMed and other sources. Conclusion(s): Ovulation and associated hormonal changes have been linked with selected cancers, raising concerns regarding ovulation-inducing agents. Clinical studies have suggested potential links, but more definitive analytic investigations have been difficult to interpret given the small numbers, short follow-up, and imprecise information on drugs or indications for usage. Prospective studies have been limited by inabilities to control for other cancer predictors (including parity), while selective recall has been a concern for retrospective studies. Reports of large increases in ovarian cancer risk associated with fertility medications have not been replicated by more recent investigations. Some findings, based on small numbers, suggest slight increases in risk associated with fertility drugs among nulligravid women or after extended follow-up or for certain tumor subtypes, but further replication is needed. Fewer studies have assessed relationships with other hormonally related cancers, but limited findings support the need for further monitoring of long-term effects for breast and endometrial cancers. Findings regarding other cancers are extremely limited but should be pursued for cancers showing evidence of hormonal influences, including colon cancers and melanomas. (Fertil Steril 2005;83:261-74.

Contraception after second-trimester abortion: characteristics of immediate LARC acceptors and comparative repeat pregnancy rates

by C. Westhoff, Jeanelle Sheeder, and Stephanie Teal

Contraception, 2012

Cancer risk among infertile women with androgen excess and menstrual disorders (including polycystic ovarian syndrome)

by Bert Scoccia and C. Westhoff

Fertility and Sterility, 2009

MATERIALS AND METHODS: Sperm selected via the evaluation of motility and morphology were used in ... more MATERIALS AND METHODS: Sperm selected via the evaluation of motility and morphology were used in the ICSI of the control group and HBsperm meeting the same criteria were used in the study group. The PICSI Ò plate used in the study provides microdots of H for sperm selection. Chisquare analyses for nominal data and independent t tests for normal continuous data were used to evaluate the data with SPSS 15.0.

Ovulation-inducing drugs and ovarian cancer risk: results from an extended follow-up of a large United States infertility cohort

by Bert Scoccia, C. Westhoff, and B. Trabert

Fertility and Sterility, 2013

Objective: To examine the relationship of ovulation-inducing drugs and ovarian cancer. Design: Re... more Objective: To examine the relationship of ovulation-inducing drugs and ovarian cancer. Design: Retrospective cohort study, with additional follow-up since initial report. Setting: Five large reproductive endocrinology practices. Patient(s): In a retrospective cohort of 9,825 women evaluated for infertility at five clinical sites in the United States between 1965 and 1988 with follow-up through 2010, we examined the relationship of ovulation-inducing drugs and ovarian cancer (n ¼ 85). Intervention(s): None. Main Outcome Measure(s): Hazard rate ratios (RR) and 95% confidence intervals (CI) for ovarian cancer. Result(s): Among women evaluated for infertility, there was no association of ovarian cancer risk with ever use of clomiphene citrate (CC) (adjusted RR 1.34, 95% CI 0.86-2.07) or gonadotropins (RR 1.00, 95% CI 0.48-2.08) and no evidence that any of several more detailed subgroups of usage were related to an increased risk with one exception: women who used CC and remained nulligravid did demonstrate much higher risks than those who successfully conceived compared with nonusers (respectively, RR 3.63, 95% CI 1.36-9.72 vs. RR 0.88, 95% CI 0.47-1.63). Conclusion(s): Our overall results were reassuring and consistent with other studies. A reason for an association between CC use and ovarian cancer among persistently nulligravid women remains to be determined. Given the large and increasing number of women treated with ovulation-inducing drugs, the increased risk of ovarian cancer among the subset of women who remained nulligravid should be further monitored.

Causes of Infertility as Predictors of Subsequent Cancer Risk

by Bert Scoccia and C. Westhoff

Epidemiology, 2005

Although studies have found elevated risks of certain cancers linked to infertility, the underlyi... more Although studies have found elevated risks of certain cancers linked to infertility, the underlying reasons remain unclear. In a retrospective cohort study of 12,193 U.S. women evaluated for infertility between 1965 and 1988, 581 cases of cancer were identified through 1999. We used standardized incidence ratios (SIRs) to compare cancer risk with the general population. Analyses within the cohort estimated rate ratios (RRs) associated with infertility after adjusting for other risk predictors. Infertility patients demonstrated a higher cancer risk than the general population (SIR = 1.23; 95% confidence interval [CI] = 1.1-1.3), with nulligravid (primary infertility) patients at even higher risk (1.43; 1.3-1.6). Particularly elevated risks among primary infertility patients were observed for cancers of the uterus (1.93) and ovaries (2.73). Analyses within the cohort revealed increased RRs of colon, ovarian, and thyroid cancers, and of melanomas associated with endometriosis. Melanomas were linked with anovulatory problems, whereas uterine cancers predominated among patients with tubal disorders. When primary infertility patients with specific causes of infertility were compared with unaffected patients who had secondary infertility, endometriosis was linked with distinctive excesses of cancers of the colon (RR = 2.40; 95% CI = 0.7-8.4), ovaries (2.88; 1.2-7.1), and thyroid (4.65; 0.8-25.6) cancers, as well as melanomas (2.32; 0.8-6.7). Primary infertility due to anovulation particularly predisposed to uterine cancer (2.42; 1.0-5.8), and tubal disorders to ovarian cancer (1.61; 0.7-3.8). Primary infertility associated with male-factor problems was associated with unexpected increases in colon (2.85; 0.9-9.5) and uterine (3.15; 1.0-9.5) cancers. The effects of infertility may extend beyond gynecologic cancers. Thyroid cancers and melanomas deserve specific attention, particularly with respect to endometriosis.

Unmet postpartum sterilization demand at an urban tertiary care center: associated factors and alternate contraception

by C. Westhoff and N. Edison

Contraception, 2013

Tubal sterilization: focus on the U.S. experience

Fertility and Sterility, 2000

To review the frequency, effectiveness, and clinical sequelae of tubal sterilization with a focus... more To review the frequency, effectiveness, and clinical sequelae of tubal sterilization with a focus on the U.S. experience. Design: A review of U.S. health care statistics and English-language literature using a MEDLINE search, bibliographies of key references, and U.S. government publications. Patient(s): Women seeking tubal sterilization. Intervention: Tubal sterilization. Main Outcome Measure(s): Effectiveness and long-term risks and benefits. Result(s): Half of the 700,000 annual bilateral tubal sterilizations (TS) are performed postpartum and half as ambulatory interval procedures. Eleven million U.S. women 15-44 years of age rely on TS for contraception. Failure rates vary by method with one third or more resulting in ectopic pregnancy. Reversal is most successful after use of methods that destroy the least tube. Evidence of menstrual or hormonal disturbance after TS is weak, although some studies find higher rates of hysterectomy among previously sterilized women. Decreased risk of subsequent ovarian cancer has been observed among sterilized women. Conclusion(s): Tubal sterilization is highly effective and safe. Failures, although uncommon, occur at higher rates than previously appreciated. Evidence for hormonal or menstrual changes due to TS is weak. Tubal sterilization is associated with decreased risk of ovarian cancer.

Smoking and oral contraception continuation

Contraception, 2007

New users of the contraceptive ring and patch are more commonly switching from another method as ... more New users of the contraceptive ring and patch are more commonly switching from another method as opposed to being a new starter of hormonal contraception. We sought to understand if one method was more preferable for women interested in a nondaily combined hormonal contraceptive. Methods: Five hundred women using combined oral contraceptives and happy with the method were randomized to use the contraceptive ring (n=249) or contraceptive patch (n=251) for the next four cycles. Participants returned for a single follow-up visit during the fourth cycle for evaluation, including a questionnaire to assess acceptability and side effects. Results: Continuation rates into the third cycle were 94.6% and 88.2% for ring and patch users, respectively (p=.012). Of these women, 71.0% and 26.5%, respectively, planned to continue their method after the study (pb.001). Women switching to the patch were significantly more likely than women switching to the ring to experience longer periods (38% vs. 9%), increased dysmenorrhea (29% vs. 16%), frequent nausea (8% vs. 1%), frequent mood swings (14% vs. 8%) and frequent skin rash (12% vs. 2%), and less likely to experience frequent vaginal discharge (8% vs. 17%). Nugent scores were not different from baseline to study exit in ring users (p=.53) but did demonstrate an increase in bacterial vaginosis in patch users (p=.01). Most of these women were asymptomatic. Conclusions: Women who are happy with combined oral contraceptives and are willing to use a non-daily method are more likely to continue and will experience significantly fewer side effects with the contraceptive ring than contraceptive patch.

Reproduktionsmedizin und Endokrinologie

kup.at

... and Gynecology, Faculty of Health Sciences, Queen&#x27;s University, Kingston, Ontario, C... more

Does endometrial biopsy miss endometrial carcinoma?

International Journal of Gynecology & Obstetrics, 1995

Curettage After Mifepristone‐Induced Abortion: Frequency, Timing, and Indications

To characterize women who underwent curettage after medical abortion with mifepristone and vagina... more To characterize women who underwent curettage after medical abortion with mifepristone and vaginal misoprostol, to describe when curettage occurred and the reasons for the intervention, and to categorize the indications for curettage according to a simple classification schema. METHODS: These analyses used data from two multisite, randomized controlled trials sponsored by Abortion Rights Mobilization. In the first study, women pregnant less than 63 days received 200 mg of mifepristone and 800 g of vaginal misoprostol to use 48 hours after taking mifepristone. In the second study, women pregnant less than 56 days were randomly assigned to insert vaginal misoprostol at 1, 2, or 3 days after mifepristone administration. Case report forms and clinical case notes of all women who underwent curettage were examined. RESULTS: Of the 4393 women enrolled in both studies, 116 (2.6%, 95% confidence interval 2.1%, 3.1%) curettages were identified. The gestational age and a history of prior elective abortion were associated with the rate of curettage. The distribution of indications for curettage included bleeding, 61 (53%); continuing pregnancy, 17 (15%); patient request, 36 (31%); and indeterminate, 2 (1.7%). The timing of curettage differed by the indication and scheduled interval between study visits. The distribution of the timing was bimodal. One subset of women, 44 (38%), underwent curettage in the first study week and another subset, 43 (37%), during weeks 3-5. CONCLUSION: Curettage after medical abortion with mifepristone and vaginal misoprostol is rare. At least one half of the curettages were performed for persistent bleeding several weeks after treatment. Both acute heavy bleeding and continuing pregnancy are extremely rare.

Randomized trial of oral versus vaginal misoprostol at one day after mifepristone for early medical abortion

Mifepristone was recently approved in the United States. Regimens with shorter intervals may be m... more Mifepristone was recently approved in the United States. Regimens with shorter intervals may be more acceptable. The objective of this study was to determine whether the oral route of misoprostol was as effective as the vaginal route of misoprostol 1 day after mifepristone. A prospective, open-labeled, randomized trial of healthy adult women up to 63 days pregnant and wanting a medical abortion were randomized to use either two doses of oral misoprostol 400 microg taken 2 h apart or misoprostol 800 microg vaginally. Women self-administered misoprostol 1 day after taking one-third of the standard dose of mifepristone (200 mg) orally. Women then returned to the clinic up to 5 days later for a repeat sonogram evaluation. A dose of vaginal misoprostol was administered to women with a continuing pregnancy who then returned 1 day later to Day 15. The primary outcome measures were a complete medical abortion by the first or by the second follow-up visits. Surgical intervention was indicated for continuing pregnancy at the second follow-up visit, excessive bleeding, or persistent products of conception 5 weeks later. One thousand one hundred sixty-eight women were enrolled. Of the 1144 (98%) women who complied with their random assignment, two oral doses of misoprostol (800 microg total) were 90% effective at inducing an abortion by the first follow-up visit, compared with one dose of misoprostol by vagina of 97% (chi(2) = 23.95, p = 0.001). By the second follow-up visit, the complete abortion rate was 95% for oral misoprostol and 99% for vaginal misoprostol (chi(2) = 21.76, p = 0.001). There were minimal differences in side effects. Women preferred the oral route. The trial demonstrated that although two doses of oral misoprostol were effective, the vaginal misoprostol was more effective at inducing an early medical abortion at 1 day after low-dose mifepristone, and the regimen could be extended to 63 days gestation.

Self-treatment patterns among adolescent girls with moderate or severe primary dysmenorrhea

Journal of Adolescent …, 2004

Journal of Adolescent Health, Volume 34, Issue 2, Pages 134, February 2004, Authors:Anne Davis, M... more

Keyes et al. Respond to "Hormonal Contraception and Mood

American Journal of Epidemiology, 2013

Asbestos exposure and ovarian fiber burden

American Journal of Industrial Medicine, 1996

Epidemiologic studies suggest increased risk of epithelial ovarian cancer in female asbestos work... more Epidemiologic studies suggest increased risk of epithelial ovarian cancer in female asbestos workers and increased risk of malignancy in general in household contacts of asbestos workers. Ovaries were studied from 13 women with household contact with men with documented asbestos exposure and from 17 women undergoing incidental oophorectomy. Ovarian tissue was examined by analytic electron microscopy. Significant asbestos fiber burdens were detected in 9 out of 13 women with household asbestos exposure (69.2%), and in 6 out of 17 women who gave no exposure history (35%). Three exposed women had asbestos counts over 1 million fibers per gram wet weight (23%), but only 1/17 women without an exposure history had a count that high (6%). Although asbestos has been documented as a contaminant of some older cosmetic talc preparations, the chrysotile and crocidolite types of asbestos we detected are more indicative of background and/or occupational exposure. This study demonstrates that asbestos can reach the ovary. Although the number of subjects is small, asbestos appears to be present in ovarian tissue more frequently and in higher amounts in women with a documentable exposure history.

Effects of fertility drugs on cancers other than breast and gynecologic malignancies

by Bert Scoccia, C. Westhoff, and B. Trabert

Fertility and Sterility, 2015

To examine the relationship of ovulation-stimulating drugs to risk of cancers other than breast a... more To examine the relationship of ovulation-stimulating drugs to risk of cancers other than breast and gynecologic malignancies. Retrospective cohort study, with additional follow-up since initial report. Reproductive endocrinology practices. Among a cohort of 12,193 women evaluated for infertility between 1965 and 1988, a total of 9,892 women (81.1% of the eligible population) were followed through 2010, via passive and active (questionnaire) approaches. None. Hazard ratios (HRs) and 95% confidence intervals (CIs) for various fertility treatment parameters for select cancers. During 30.0 median years of follow-up (285,332 person-years), 91 colorectal cancers, 84 lung cancers, 55 thyroid cancers, and 70 melanomas were diagnosed among study subjects. Clomiphene citrate (CC), used by 38.1% of patients, was not associated with colorectal or lung cancer risks, but was related significantly to melanoma (HR = 1.95; 95% CI: 1.18-3.22), and non-significantly to thyroid cancer risks (HR = 1.57; 95% CI: 0.89-2.75). The highest melanoma risks were seen among those with the lowest drug exposure levels, but thyroid cancer risk was greatest among the heavily exposed patients (HR = 1.96; 95% CI: 0.92-4.17 for those receiving &amp;amp;amp;amp;amp;amp;gt;2,250 mg). Clomiphene citrate-associated risks for thyroid cancer were somewhat higher among nulligravid, compared with gravid, women, but did not differ according to distinct causes of infertility. Gonadotropins, used by only 9.7% of subjects, were not related to risk of any of the assessed cancers. Our results provide support for continued monitoring of both melanoma and thyroid cancer risk among patients receiving fertility drugs.

Cancer Risk After the Use of Ovulation-Stimulating Drugs

by Bert Scoccia and C. Westhoff

Obstetrical & Gynecological Survey, 2004

Breast cancer risk associated with ovulation-stimulating drugs

by Bert Scoccia and C. Westhoff

Human Reproduction, 2004

BACKGROUND: Despite the recognized role of hormones in the aetiology of breast cancer, there has ... more BACKGROUND: Despite the recognized role of hormones in the aetiology of breast cancer, there has been little evaluation of hormonal preparations used to treat infertility. METHODS: A retrospective cohort study of 12 193 women evaluated for infertility between 1965 and 1988 at five clinical sites identified 292 in situ and invasive breast cancers in follow-up through 1999. Standardized incidence ratios (SIRs) compared breast cancer risks with those of the general population. Analyses within the cohort estimated rate ratios (RRs) associated with medications after adjustment for other breast cancer predictors. RESULTS: Infertile patients had a significantly higher breast cancer risk than the general population [SIR 5 1.29, 95% confidence interval (CI) 1.1-1.4]. Analyses within the cohort showed adjusted RRs of 1.02 for clomiphene citrate and 1.07 for gonadotrophins, and no substantial relationships to dosage or cycles of use. Slight and non-significant elevations in risk were seen for both drugs after $20 years of follow-up (RRs 5 1.39 for clomiphene and 1.54 for gonadotrophins). However, the risk associated with clomiphene for invasive breast cancers was statistically significant (RR 5 1.60, 95% CI 1.0-2.5). CONCLUSIONS: Although there was no overall increase in breast cancer risk associated with use of ovulationstimulating drugs, long-term effects should continue to be monitored.

Fertility drugs and endometrial cancer risk: results from an extended follow-up of a large infertility cohort

by Bert Scoccia, C. Westhoff, and B. Trabert

Human Reproduction, 2013

Do fertility drugs influence the subsequent risk of endometrial cancer in a manner that is indepe... more Do fertility drugs influence the subsequent risk of endometrial cancer in a manner that is independent of other risk predictors, such as parity? In this follow-up of a large cohort of women evaluated for infertility and for whom information was captured on fertility drugs, indications for usage and other risk factors that might influence cancer risk, we found no evidence for a substantial relationship between fertility drug use and endometrial cancer risk. Although the hormonal etiology of endometrial cancer has been well established, it remains unclear whether the use of fertility drugs has an influence on risk. Results regarding the effects of fertility drugs on endometrial cancer risk have been inconsistent, although several studies have shown some evidence for possible increases in risk. The relationship is of particular interest given that clomiphene, a commonly prescribed drug, is a selective estrogen receptor modulator, with chemical properties similar to tamoxifen, another drug linked to an increase in endometrial cancer risk. In a retrospective cohort of 12 193 women evaluated for infertility between 1965 and 1988 at five US sites, follow-up was pursued through 2010 via both passive as well as active (questionnaire) means. Among the 9832 subjects for whom follow-up was allowed and achieved, 259 346 at-risk person-years (i.e. prior to hysterectomy) were accrued, and 118 invasive endometrial cancers identified. Cox regression determined hazard ratios (HRs) and 95% confidence intervals (CIs) for fertility treatments adjusted for endometrial cancer risk factors and causes of infertility. Although we observed slight increases in endometrial cancer risk associated with clomiphene (HR = 1.39, 95% CI: 0.96-2.01) and the less commonly prescribed gonadotrophins (1.34, 0.76-2.37), there were no convincing relationships of risk with either cycles of use or cumulative exposures for either drug. A statistically significant risk associated with the use of clomiphene among women who began use at younger ages (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;30) (1.93, 1.24-3.00) may have reflected indications for drug usage rather than the effect of the drug itself. Women who received clomiphene followed by gonadotrophins were at a non-significantly elevated risk (1.77, 0.98-3.19). Like most studies of endometrial cancer, we were limited by sample sizes, particularly for evaluating subgroup associations. We were also unable to follow all women and were not able to obtain complete risk factor information (including hysterectomy status) for the entire cohort. Although we found no support for a relationship between fertility drugs and endometrial cancer risk, the association should continue to be monitored given that our study population was still young and had not yet reached the age of peak endometrial cancer incidence. This project was supported in part by funds from the intramural research program of the National Cancer Institute, National Institutes of Health. None of the authors has any conflicting interests to declare.

Ovarian cancer risk associated with varying causes of infertility

by Bert Scoccia and C. Westhoff

Fertility and Sterility, 2004

Objective: To evaluate the risk of ovarian cancer as related to underlying causes of infertility.... more Objective: To evaluate the risk of ovarian cancer as related to underlying causes of infertility. Design: Retrospective observational cohort study. Setting: Five large reproductive endocrinology practices. Patient(s): A total of 12,193 women evaluated for infertility between 1965 and 1988. Intervention(s): None. Main Outcome Measure(s): Ovarian cancer ascertained through 1999.

Ovulation induction and cancer risk

by Bert Scoccia and C. Westhoff

Fertility and Sterility, 2005

Objective: To review and critique the literature regarding ovulation induction and cancer risk. D... more Objective: To review and critique the literature regarding ovulation induction and cancer risk. Design: Identification of relevant clinical and epidemiological literature through PubMed and other sources. Conclusion(s): Ovulation and associated hormonal changes have been linked with selected cancers, raising concerns regarding ovulation-inducing agents. Clinical studies have suggested potential links, but more definitive analytic investigations have been difficult to interpret given the small numbers, short follow-up, and imprecise information on drugs or indications for usage. Prospective studies have been limited by inabilities to control for other cancer predictors (including parity), while selective recall has been a concern for retrospective studies. Reports of large increases in ovarian cancer risk associated with fertility medications have not been replicated by more recent investigations. Some findings, based on small numbers, suggest slight increases in risk associated with fertility drugs among nulligravid women or after extended follow-up or for certain tumor subtypes, but further replication is needed. Fewer studies have assessed relationships with other hormonally related cancers, but limited findings support the need for further monitoring of long-term effects for breast and endometrial cancers. Findings regarding other cancers are extremely limited but should be pursued for cancers showing evidence of hormonal influences, including colon cancers and melanomas. (Fertil Steril 2005;83:261-74.

Contraception after second-trimester abortion: characteristics of immediate LARC acceptors and comparative repeat pregnancy rates

by C. Westhoff, Jeanelle Sheeder, and Stephanie Teal

Contraception, 2012

Cancer risk among infertile women with androgen excess and menstrual disorders (including polycystic ovarian syndrome)

by Bert Scoccia and C. Westhoff

Fertility and Sterility, 2009

MATERIALS AND METHODS: Sperm selected via the evaluation of motility and morphology were used in ... more MATERIALS AND METHODS: Sperm selected via the evaluation of motility and morphology were used in the ICSI of the control group and HBsperm meeting the same criteria were used in the study group. The PICSI Ò plate used in the study provides microdots of H for sperm selection. Chisquare analyses for nominal data and independent t tests for normal continuous data were used to evaluate the data with SPSS 15.0.

Ovulation-inducing drugs and ovarian cancer risk: results from an extended follow-up of a large United States infertility cohort

by Bert Scoccia, C. Westhoff, and B. Trabert

Fertility and Sterility, 2013

Objective: To examine the relationship of ovulation-inducing drugs and ovarian cancer. Design: Re... more Objective: To examine the relationship of ovulation-inducing drugs and ovarian cancer. Design: Retrospective cohort study, with additional follow-up since initial report. Setting: Five large reproductive endocrinology practices. Patient(s): In a retrospective cohort of 9,825 women evaluated for infertility at five clinical sites in the United States between 1965 and 1988 with follow-up through 2010, we examined the relationship of ovulation-inducing drugs and ovarian cancer (n ¼ 85). Intervention(s): None. Main Outcome Measure(s): Hazard rate ratios (RR) and 95% confidence intervals (CI) for ovarian cancer. Result(s): Among women evaluated for infertility, there was no association of ovarian cancer risk with ever use of clomiphene citrate (CC) (adjusted RR 1.34, 95% CI 0.86-2.07) or gonadotropins (RR 1.00, 95% CI 0.48-2.08) and no evidence that any of several more detailed subgroups of usage were related to an increased risk with one exception: women who used CC and remained nulligravid did demonstrate much higher risks than those who successfully conceived compared with nonusers (respectively, RR 3.63, 95% CI 1.36-9.72 vs. RR 0.88, 95% CI 0.47-1.63). Conclusion(s): Our overall results were reassuring and consistent with other studies. A reason for an association between CC use and ovarian cancer among persistently nulligravid women remains to be determined. Given the large and increasing number of women treated with ovulation-inducing drugs, the increased risk of ovarian cancer among the subset of women who remained nulligravid should be further monitored.

Causes of Infertility as Predictors of Subsequent Cancer Risk

by Bert Scoccia and C. Westhoff

Epidemiology, 2005

Although studies have found elevated risks of certain cancers linked to infertility, the underlyi... more Although studies have found elevated risks of certain cancers linked to infertility, the underlying reasons remain unclear. In a retrospective cohort study of 12,193 U.S. women evaluated for infertility between 1965 and 1988, 581 cases of cancer were identified through 1999. We used standardized incidence ratios (SIRs) to compare cancer risk with the general population. Analyses within the cohort estimated rate ratios (RRs) associated with infertility after adjusting for other risk predictors. Infertility patients demonstrated a higher cancer risk than the general population (SIR = 1.23; 95% confidence interval [CI] = 1.1-1.3), with nulligravid (primary infertility) patients at even higher risk (1.43; 1.3-1.6). Particularly elevated risks among primary infertility patients were observed for cancers of the uterus (1.93) and ovaries (2.73). Analyses within the cohort revealed increased RRs of colon, ovarian, and thyroid cancers, and of melanomas associated with endometriosis. Melanomas were linked with anovulatory problems, whereas uterine cancers predominated among patients with tubal disorders. When primary infertility patients with specific causes of infertility were compared with unaffected patients who had secondary infertility, endometriosis was linked with distinctive excesses of cancers of the colon (RR = 2.40; 95% CI = 0.7-8.4), ovaries (2.88; 1.2-7.1), and thyroid (4.65; 0.8-25.6) cancers, as well as melanomas (2.32; 0.8-6.7). Primary infertility due to anovulation particularly predisposed to uterine cancer (2.42; 1.0-5.8), and tubal disorders to ovarian cancer (1.61; 0.7-3.8). Primary infertility associated with male-factor problems was associated with unexpected increases in colon (2.85; 0.9-9.5) and uterine (3.15; 1.0-9.5) cancers. The effects of infertility may extend beyond gynecologic cancers. Thyroid cancers and melanomas deserve specific attention, particularly with respect to endometriosis.

Unmet postpartum sterilization demand at an urban tertiary care center: associated factors and alternate contraception

by C. Westhoff and N. Edison

Contraception, 2013