Transmission of HIV from injecting drug users to their wives in India

We aimed to identify factors associated with transmission of human immunodeficiency virus (HIV) from injecting drug users (IDUs) to their wives in Manipur, northeast India, where the prevalence of HIV among IDUs is 80% via a case-control study. One hundred and sixty-one HIV-infected IDUs and their wives were recruited from September 1996 to August 1997 inclusive. HIV status was determined by enzyme-linked immunosorbent assay (ELISA) plus Western blot, Interviews were administered anonymously. Regression analysis identified factors associated with transmission of HIV from IDU husbands to their non-injecting wives. Seventy-two wives (45%) were HIV-positive. Only 15% of the couples reported regular usage of condoms during intercourse. On multivariate analysis, a sexually transmitted disease (STD) in either member, reported by the husband, estimated duration of HIV in the husband for >8 years, and a history of blood transfusions were associated with infection in the wife. In conclusion, STDs are associated with transmission of HIV from husband to wife. Improved control of STDs, condom promotion, and improved blood screening are urgently needed in Manipur.

What high-risk women are telling us about access to primary and reproductive health care and HIV prevention services

Focus group discussions on barriers to health care and attitudes toward family planning, reproductive health services, and condom use were conducted with 63 women at high risk for HIV due to their own injection drug use, sex with injection drug users, sex industry work, or a history of multiple sexually transmitted diseases. Barriers identified include the high cost of health care, perceived poor quality of care and experiences of discrimination and stigmatization, geographic accessibility, fear of legal/social services punitive actions, misperceptions about the efficacy of birth control methods and condom usage, lack of sterilization services, and lack of male involvement. Where possible, findings from the focus groups are supported with quantitative survey data from a sample of high-risk women (n = 723). Recommendations are made for improving care for high-risk women.

Predicting Neisseria gonorrhoeae and Chlamydia trachomatis infection using risk scores, physical examination, microscopy, and leukocyte esterase urine dipsticks among asymptomatic women attending a family planning clinic in Kenya

BACKGROUND

Sexually transmitted infections (STIs) continue to exert a tremendous health burden on women in developing countries. Poor socioeconomic status, inadequate knowledge, lack of diagnostic facilities, and shortages of effective treatment all contribute to the high incidence of STIs. The use of clinical algorithms for the detection and management of STIs has gained widespread acceptance in settings where there are limited resources. Evaluation of these algorithms have been few, especially in women who are not recognized as members of high-risk groups.

OBJECTIVES

To develop a simple scoring system based on historical and demographic data, physical findings, microscopy, and leukocyte esterase (LE) urine dipsticks to predict cervical gonococcal and chlamydial infection among asymptomatic women.

METHODS

One thousand and forty-eight women attending an urban family planning clinic in Nairobi were randomly selected to participate. After the identification of factors that were associated with infection, we assigned one point each for: age 25 or younger, single status, two or more sex partners in the past year, cervical discharge, cervical swab leukocytes, and a positive LE urine dipstick. Identification of any one of these six factors gave a sensitivity of 85% and a specificity of 30% for the detection of cervical infections. A positive LE urine dipstick had a sensitivity of 63 % and a specificity of 47% when used alone and did not contribute to the identification of infection if a physical examination was performed. The application of existing clinical algorithms to this population performed poorly.

CONCLUSIONS

The use of risk scores, physical examination, microscopy, and the urine LE dipstick, used alone or in combination, as predictors of gonococcal or chlamydial cervical infection was of limited utility in low-risk, asymptomatic women. Accurate diagnostic testing is necessary to optimize treatment.

AIDS-related information exposure in the mass media and discussion within social networks among married women in Bombay, India

Married women are at high risk of acquiring HIV infection in India and health education remains the most feasible preventive tool in their context. In a survey conducted among 350 married women in Bombay, it was found that a majority had acquired information about AIDS from the mass media, especially television. Although 87% of women who knew of AIDS had been exposed to AIDS-related information in the mass media in the past four weeks, only 57% had discussed it within their social networks. Those with more exposure to AIDS information in the mass media were significantly more likely to discuss AIDS within social networks. The women were most likely to discuss AIDS with their husbands as a general social issue, followed by friends and family members and least likely to talk to husbands about AIDS as a personal issue relating to their sexual relationship. Increased frequency and duration of AIDS messages on television will have a positive influence on AIDS knowledge in this group.

Psychosocial factors associated with the stages of change for condom use among women at risk for HIV and STDs: implications for intervention development

This study examined the prevalence of consistent condom use among inner-city women at risk for HIV, measured the distribution of these women across the stages of change for condom use, determined psychosocial factors associated with the stages, and suggested intervention strategies based on the results. The 5-city sample of women aged 15-34 years consisted predominantly of African Americans. Only 18% reported consistent condom use with main partners and 45% with other partners. Logistic regressions compared women in each stage of change with those in higher stages for each partner type. Results indicated that women who practice or intend to practice consistent condom use were more likely to talk with others about condoms, acknowledge the advantages of condoms, have higher self-efficacy for condom use, and indicate that people important to them favored condom use. Intervention approaches are suggested for women in different stages of change for condom use.

Psychosocial factors associated with the stages of change for condom use among women at risk for HIV and STDs: implications for intervention development

This study examined the prevalence of consistent condom use among inner-city women at risk for HIV, measured the distribution of these women across the stages of change for condom use, determined psychosocial factors associated with the stages, and suggested intervention strategies based on the results. The 5-city sample of women aged 15-34 years consisted predominantly of African Americans. Only 18% reported consistent condom use with main partners and 45% with other partners. Logistic regressions compared women in each stage of change with those in higher stages for each partner type. Results indicated that women who practice or intend to practice consistent condom use were more likely to talk with others about condoms, acknowledge the advantages of condoms, have higher self-efficacy for condom use, and indicate that people important to them favored condom use. Intervention approaches are suggested for women in different stages of change for condom use.

Validation of measures of condom and other contraceptive use among women at high risk for HIV infection and unintended pregnancy

This study assessed the applicability of the transtheoretical model of behavior change (J.O. Prochaska & C.C. DiClemente, 1983, 1984) to the measurement of contraceptive use among 296 women at high risk for HIV infection and transmission. Structural equation modeling suggested that a measure of general contraceptive use could be used to assess use of oral contraceptives and hormonal implants but that measurement of condom use required separate assessments for main and other partners. Self-efficacy (SE) and decisional balance scales were internally consistent for general contraceptive use, for condom use with main partners, and for condom use with other partners. Consistent with research on other health behaviors, SE scores rose significantly across stages, from precontemplation to maintenance, and a shift in decisional balance was observed for 2 of 3 behaviors. This measurement strategy may enhance the ability to evaluate prevention programs for women at risk.

U.S. experts warn of Honduras AIDS risk to women. International

Honduras, the Central American country hardest hit by AIDS, may suffer from a particularly aggressive strain of HIV that is especially dangerous to women, US experts said. "We are investigating the presence in Honduras of (HIV) sub-type B, which is more aggressive than others and could be the reason why it is worse in this country," Winslow Klaslala, professor at the University of Miami, Florida, said. According to the Health Ministry, 7664 Hondurans have been infected with HIV since 1985, and 995 have died. That is 60% of the total number of HIV sufferers in the six countries of Central America and the incidence in women is unusually high at 36%. A team of experts, including members from Harvard University and the WHO, have been taking blood samples, primarily from HIV infected women, Klaslala said. They will analyze the blood to look for sub-type B, described by Klaslala as highly "aggressive and adaptable." "If it is present," he said, "women are particularly at risk." Honduran health authorities were paying close attention to the investigations. "If they show that the sub-type that attacks in Honduras is more aggressive, we will have to redesign our campaign for combatting the disease," said Enrique Zelaya, a top Health Ministry official.

Validation of measures of condom and other contraceptive use among women at high risk for HIV infection and unintended pregnancy

This study assessed the applicability of the transtheoretical model of behavior change (J.O. Prochaska & C.C. DiClemente, 1983, 1984) to the measurement of contraceptive use among 296 women at high risk for HIV infection and transmission. Structural equation modeling suggested that a measure of general contraceptive use could be used to assess use of oral contraceptives and hormonal implants but that measurement of condom use required separate assessments for main and other partners. Self-efficacy (SE) and decisional balance scales were internally consistent for general contraceptive use, for condom use with main partners, and for condom use with other partners. Consistent with research on other health behaviors, SE scores rose significantly across stages, from precontemplation to maintenance, and a shift in decisional balance was observed for 2 of 3 behaviors. This measurement strategy may enhance the ability to evaluate prevention programs for women at risk.

A pregnancy-prevention program in women of childbearing age receiving isotretinoin

BACKGROUND

Isotretinoin is effective in treating severe acne, but it is also teratogenic. To minimize pregnancies among exposed women, the manufacturer, together with the U.S. Food and Drug Administration, implemented a multicomponent Pregnancy Prevention Program in 1988. We report the results of an ongoing survey designed to assess compliance with this program.

METHODS

Treated women enrolled in the survey through their physician, by filling out a form in the medication package, or by calling a toll-free telephone number. They were randomly assigned to be followed by telephone or by mail. Telephone interviews were conducted at the start of therapy, in the middle of it, and 6 months after it ended; mailed questionnaires were completed 6 months after therapy ended (median duration of therapy, 20 weeks).

RESULTS

Between 1989 and 1993, 177,216 eligible women enrolled in the survey. Interviews with 24,503 women within one month of enrollment revealed that 99 percent had been told to avoid pregnancy. At that time, approximately 54 percent were not sexually active (of whom 37 percent used contraception) and 42 percent were sexually active (of whom 99 percent used contraception); 4 percent were infertile. Among 124,216 women with completed telephone or mail follow-up results, there were 402 pregnancies during therapy (3.4 per 1000 courses of isotretinoin); 72 percent of the pregnant women had elective abortions, 16 percent spontaneous abortions, 3 percent ectopic pregnancies, and 8 percent live births.

CONCLUSIONS

The pregnancy rate among women receiving isotretinoin therapy was substantially lower than that in the general population and was compatible with the characteristics and behavior of the enrolled women.

Family planning in genitourinary medicine: an opportunistic service?

OBJECTIVE

To evaluate and serve the need for contraception in those not using conventional sources of family planning services.

SETTING

South London outpatient genitourinary medicine department at King's College Hospital.

DESIGN AND SUBJECTS

Prospective study of 200 women seen consecutively in the clinic by the same doctor (LM) during 1993. Women at risk of unwanted pregnancy were identified, and offered immediate contraceptive provision or referral.

RESULTS

15 women (7.5%) were using no contraception, despite being sexually active and not wishing to conceive; of these two presented with an unwanted pregnancy. A further 23 women (11.5%) were not using their chosen contraception effectively, and another 20 women were unclear about contraceptive methods and wanted advice. Young women were most at risk; 14% of those aged 25 years and under were using no contraception. Eight women wished to defer contraceptive advice; of these four defaulted from follow up. Eighteen women (9%) wanted immediate contraceptive supplies. Ten of 18 returned a follow up questionnaire; all these women were satisfied with the contraceptive advice service received.

CONCLUSIONS

Absent or ineffective contraception is common in women attending an inner city genitourinary medicine clinic. Immediate provision of contraceptive education, advice and supplies is welcomed by patients.

[Contraceptives, HIV, and other sexually transmitted diseases]

The large majority of women who acquire Human Immuno-Deficiency Virus (HIV) and other sexually transmitted diseases (STDs) are in their childbearing years and are current or potential users of contraceptive methods. Certain STDs augment women's risk for HIV due to damage which these diseases produce in the integrity of the epithelial lining of the vagina and the vulva. There also exists evidence that some contraceptive methods, such as the intrauterine device and certain hormonal products, may increase the risk of HIV and other STDs. Condoms and spermicides offer good levels of protection against these diseases, but are not highly effective contraceptives. The interrelations among these risks are important and create a great problem for women's reproductive health. Moreover, the high vulnerability of the female population for these diseases is also related to a variety of social factors which are referred to as gender relations (power of females in society relative to that of females). Among the gender-related inequalities which affect women are their lack of power to successfully control many aspects of sexual relations. Another problem has to do with the fact that there are no highly reliable female controlled methods for preventing infection by HIV and other STDs. Improvement in the reproductive health care of women depends on the development of new disease prevention products and structural changes in the delivery of care, as well as continued research efforts on the interrelations among contraceptive methods, HIV and other STD.

Intermediate variables as determinants of adverse pregnancy outcome in high-risk inner-city populations

A probability sample survey of high-risk inner-city women with a live birth in the last 3 years shows that maternal medical risks and health behaviors during pregnancy are important intermediate variables influencing preterm delivery and birthweight. Women who developed two or more medical risks had about three-and-a-half times the risk of preterm delivery and two-and-a-half times the risk of low birthweight compared to those without such risks. Women with prior fetal loss had twofold increase in the risk of preterm delivery and low birthweight. Unintended pregnancy resulted in one-and-a-half to twofold increase in preterm delivery and low birthweight, respectively. Inadequate gestational weight increased the risk of preterm delivery by about 50%. Smoking during pregnancy raised the risk of low birthweight slightly more than one-and-a-half times.

The impact of AIDS on an urban population of high-risk female minority adolescents: implications for intervention

PURPOSE

This study's purpose was to describe acquired immunodeficiency syndrome (AIDS)-related concerns, risk behaviors, and psychosocial/situational determinants of condom use among an urban minority population of sexually active, adolescent girls. In addition we sought to define the accuracy of personal AIDS risk-assessment, the relative importance of AIDS in relation to other concerns, and the broader context of sexual experience and attitudes in this population.

METHODS

A cross-sectional interview study was conducted involving sexually active female adolescents attending a pediatric clinic in an inner-city university-affiliated community hospital. Sixty-nine subjects (ages 13-19 yr, 90% African-American) were enrolled. While the goals of this study were primarily descriptive, subject characteristics felt to impact on condom use were identified prior to data collection and were examined against several measures of usage including: use at the time of last sexual intercourse, overall frequency of condom use, and reported behavior change to include initiation of or increased condom usage.

RESULTS

Forty-one percent of participants reported knowing someone with AIDS. Global concern regarding this disease was high, although worry about poverty-related issues was often greater. Despite concern and high measures of AIDS risk (median number of sex partners, 3; past sexually transmitted disease, 55%; past pregnancy 77%), most participants perceived themselves to be at low personal risk owing to current monogamy, lack of intravenous drug use, and implicit trust in their partner's safety. Discussion with their partner about actual risk and awareness of the importance of past behaviors was generally lacking. Although 98% were aware that condoms may prevent AIDS, 64% used condoms half of the time or less when they had sex and use appeared to be primarily for contraception. Several intrinsic cognitive/psychological and extrinsic social/situational factors were found to correlate with measures of condom use.

CONCLUSIONS

Participants' sexual histories and behavior emphasize the need for concern regarding AIDS risk in this population. Patterns of sexual behavior and beliefs regarding committed relationships raise challenging questions regarding how to motivate sexually active members of this population to use condoms more frequently. Programs aimed at AIDS prevention among urban minority adolescents need to be cognizant of the larger personal and sociocultural context in which these teenagers are making health-behavior choices.

In Chile, improved services and counselling reduce abortion incidence

A major abortion study was carried out in three peri-urban communities of metropolitan Santiago, Chile. Its aim was to assess ways of identifying women at high risk of induced abortion and to lower the rates of induced abortion in areas where the occurrence of induced abortion was known to be high. The first phase consisted of a baseline survey of three low-income urban communities in metropolitan Santiago. On the basis of the results of this survey a predictive instrument was devised that was later used to identify women at high risk of abortion. The survey and work on the predictive instrument was followed by an intervention phase which lasted 18 months. This included: improved family planning services and visits to households of women classified as being at a high risk of induced abortion in one of the communities; improved services but no special home counselling in the second community; and no intervention in the third (control) community. An important finding was that even with highly committed and very well trained interviewers women underreported induced abortions or reported them as spontaneous abortions. The study, however, demonstrated clearly the impact of the intervention. Over a two-year period, the abortion rate fell by 20%, and in the area of some intervention by 9%; the rate increased by 30% in the control community. These findings have been used to improve family planning services in low-income communities and in the design of reproductive health services for adolescents in poor areas of the city.

Contraceptive use and attitudes in Great Britain

In order to update current knowledge on contraceptive use and attitudes in Great Britain (i.e. England, Scotland and Wales), a survey was conducted among 1753 randomly selected British women aged 15-45. Replies were received from 967 women (55.2%). Seventy-three percent (73%) of fertile, sexually active women who wished to avoid pregnancy were using reliable methods of contraception, viz. oral contraceptives (OCs), intrauterine devices (IUDs) or sterilization. However, it was found that adolescents and women over 40 who wished to avoid pregnancy were, nevertheless, especially likely not to be using any contraceptive method at all. The women surveyed were concerned about weight gain, cardiovascular and cancer risks associated with OC use, and infection and infertility risks associated with IUD use. Sixty percent (60%) perceived sterilization as a major and risky surgical operation. It was concluded that contraceptive practice in Britain had not improved greatly in recent years. The latest scientific findings regarding the true advantages and disadvantages of OCs, IUDs and sterilization, therefore, need to be brought to the attention of the lay public more effectively. Special efforts need to be directed towards providing adolescents and women over 40 with proper information. Physicians and the mass media could play a considerable role in this respect.

Patterns of condom use and sexual behavior among never-married women

BACKGROUND AND OBJECTIVES

Use of condoms is one of the main methods sexually active persons may choose to prevent infection with sexually transmitted diseases (STDs) and human immunodeficiency virus (HIV). Little is known about patterns of condom use among women in the United States. We provide a conceptualization of patterns of condom use and factors associated with these patterns.

GOAL OF THIS STUDY

To examine patterns of condom use and associated characteristics among sexually active, never-married women in the United States.

STUDY DESIGN

Analysis of data from the 1988 National Survey of Family Growth, which is a nationally representative sample of women in their childbearing years.

RESULTS

Only a minority of sexually active, never-married women report using condoms, and even fewer report using them consistently. Women with characteristics traditionally associated with increased risk of infection with STD and HIV appear to be less likely to report using condoms and to report using them consistently. Women who report use of condoms to prevent STDs are more likely to report consistent condom use; less likely to cease using condoms; and more likely to initiate consistent condom use.

CONCLUSION

Findings suggest the need for innovative programming targeted for specific sexually active populations to promote both initiation and maintenance of use of condoms.

Physical and emotional abuse in pregnancy: a comparison of adult and teenage women

A sample of 691 African American, Hispanic, and white pregnant teenage and adult women were interviewed in the prenatal setting. On their first prenatal visit, 182 (26%) women reported physical or sexual abuse within the past year. There were significant differences between the teens and adults, with a higher percentage of teens (31.6%) reporting abuse during the prior year than adults (23.6%). The rate of abuse during pregnancy was 21.7% for teens and 15.9% for adult women. Adult women scored significantly higher than teens on two measures of mental abuse. Mental abuse was significantly correlated with physical abuse for all subjects.

Maternal mortality in Ile-Ife, Nigeria: a study of risk factors

The objective of this study was to determine which background factors predispose women to maternal mortality at the Obafemi Awolowo University Hospital in Nigeria. The study examined 35 cases of maternal death occurring in the hospital during the period 1 October 1989 to 30 April 1991. The control group comprised 35 women who were admitted to the hospital with similar complications during the same period, but who survived. Both cases and controls were investigated for their sociodemographic characteristics, their use of prenatal care, and the incidence of delay in clinical management. The results showed that the maternal deaths involved women who were younger and of poorer socioeconomic status than the women in the control group. Both groups showed an equal lack of prenatal care. However, a higher incidence of delayed treatment was found in the management of the cases of maternal deaths. Maternal mortality in the study population can be reduced through improved transportation and institutional management, and, on a long-term basis, through the adoption of measures to improve the socioeconomic status of women.

Patterns and predictors of high-risk sexual behavior in female partners of HIV-infected men with hemophilia

OBJECTIVE

To characterize and quantify high-risk heterosexual activity in HIV-discordant couples.

DESIGN

Analysis of cross-sectional and longitudinal questionnaire data from 217 HIV-negative female sexual partners of HIV-infected hemophilic men.

METHODS

Comparison of prevalence rates of anal sex, oral sex, vaginal intercourse with or without condoms, and use of other contraceptives between 1985 and 1991. Logistic regression analysis of demographic, sexual and clinical variables to predict unprotected vaginal sex. Actuarial estimates of semi-annual relapse rates to unsafe sex.

RESULTS

The proportion of women at low risk increased from 7 to 69% between 1985 and 1991, mainly because more women were using condoms during all acts of vaginal intercourse. Other contraceptive practices did not change during this time. The proportion engaging in oral or anal sex decreased (from 26 to 13% and 13 to 4%, respectively). Unprotected vaginal sex was more common among women who enrolled earlier, had less education, engaged in oral or anal sex, and among those whose partners had not had AIDS. Unprotected vaginal sex before enrollment was the strongest predictor of this high-risk activity during follow-up. Two-year rates of relapse to high-risk behavior were significantly higher among women who enrolled at high risk compared with those who enrolled at low risk (39 versus 8%, P = 0.005).

CONCLUSIONS

Although high-risk sexual behavior became much less prevalent in this population between 1985 and 1991, many continued to have unprotected vaginal sex occasionally. Counseling efforts should target couples who have been the most sexually active or have less education, and should emphasize not only initial risk reduction but also maintenance of low-risk behavior.

Barbados tackles RTIs

The women who gathered on an island in the Caribbean didn't go there for some R&R. They went there to discuss RTIs. The Reproductive Tract Infections (RTIs) Seminar Workshop, held in Barbados last March 16-19, 1992, convened with participants representing various women organizations and medico-legal professionals in various fields of specialization who are specially concerned with reproductive tract infections. It was sponsored by the International Women's Health Coalition and the Women and Development Unit of the University of West Indies. Institute for Social Studies and Action (ISSA) Executive Director Alexandrina Marcelo was one of the participants in the workshop. She presented a paper on the current status of RTIs and sexually transmitted diseases (STDs) affecting Filipinos, particularly women. About 30 participants attended the seminar, which concluded by voicing a growing alarm over these diseases and by emphasizing that immediate action should be part of the world leaders' plans for women's health and reproductive rights. The participants all agreed on the increasing danger of the disease and its widespread infection, and they drafted a "Call to Action" to all governments and world leaders, expressing the delegates' belief that RTIs and STDs should be given importance by not only those suffering from infection but also by governments all over the world.

AIDS and women: an international perspective

This article focuses on HIV infection, HIV problems that are female specific (in the biological, psychological, and sociological spheres), a national and international perspective on HIV infection, and the challenges facing women as "women at risk for HIV infection," including childbearing and childrearing. The article discusses HIV infection in females worldwide, high risk categories (including behaviors, groups, and physiological indicators), physiological parameters of HIV infection in females, and health care challenges throughout the world. The framework for AIDS assessment, risk reduction, and intervention in women is the same as for other major health problems. However, we must first know the female specific HIV risks and "HIV disease course" and incorporate that knowledge in our assessment and intervention strategies.

Combined effect of childbearing, menstrual events, and body size on age-specific breast cancer risk

Pike et al. (Nature 1983;303:767-70) and Moolgavkar et al. (JNCI 1980;65:59-69) proposed quantitative theories for the effect on age-specific breast cancer risk of ages at menarche, first childbirth, and menopause. Here the incidence rate functions predicted by these theories are fit to data for 1,884 women of all ages with breast cancer and 3,432 matched controls admitted to San Francisco Bay area hospitals in 1970-1977. A third function describing age-specific breast cancer risk based on the timing of childbearing and menstrual events is presented, and its fit to the data is compared with that of the functions of Pike et al. and Moolgavkar et al. None of the three fully accounted for the protective effects of early age at first childbirth in premenopausal women or of early age at menopause in parous postmenopausal women. To account for the effects of total parity and body mass (Quetelet) index on risk of breast cancer occurrence, the authors developed a fourth incidence rate function by extending the third. Goodness of fit to the data of the fourth function is demonstrated. Age-specific relative risks of breast cancer according to childbearing, menstrual events, and body size are estimated from the fourth function. The main qualitative findings are that 1) the protective effects of late menarche and of early first full-term pregnancy are greater in premenopausal than in postmenopausal women; 2) first full-term pregnancy initially boosts the level of risk, but incidence rates increase with age more slowly thereafter; 3) among the parous, multiparity is protective both in premenopausal and postmenopausal women, regardless of age at first full-term pregnancy; 4) both nulliparous and lean women are more protected by early menopause than are parous and overweight women; 5) increased body mass index is protective before, but detrimental after, menopause; and 6) postmenopausal incidence rates increase with age more rapidly among overweight than among lean women.

Relative and absolute excess risks of coronary heart disease among women who smoke cigarettes

We prospectively examined the incidence of coronary heart disease in relation to cigarette smoking in a cohort of 119,404 female nurses who were 30 to 55 years of age in 1976 and were free of diagnosed coronary disease. During six years of follow-up, 65 of the women died of fatal coronary heart disease and 242 had a nonfatal myocardial infarction. The number of cigarettes smoked per day was positively associated with the risk of fatal coronary heart disease (relative risk = 5.5 for greater than or equal to 25 cigarettes per day), nonfatal myocardial infarction (relative risk = 5.8), and angina pectoris (relative risk = 2.6). Even smoking 1 to 4 or 5 to 14 cigarettes per day was associated with a twofold to three-fold increase in the risk of fatal coronary heart disease or nonfatal infarction. Overall, cigarette smoking accounted for approximately half these events. The attributable (absolute excess) risk of coronary heart disease due to current smoking was highest among women who were already at increased risk because of older age, a parental history of myocardial infarction, a higher relative weight, hypertension, hypercholesterolemia, or diabetes. In contrast, former smokers had little, if any, increase in risk. These prospective data emphasize the importance of cigarette smoking as a determinant of coronary heart disease in women, as well as the markedly increased hazards associated with this habit in combination with other risk factors for this disease.

Is lactation a risk factor of IUD- and sterilization-related uterine perforation? A hypothesis

A recent article reported a high risk of IUD-related uterine perforation in lactating women in the U.S. This article prompted the authors to examine the large international datasets on IUDs and tubal sterilizations collected by Family Health International. The findings are somewhat suggestive of such a positive association in IUD users as well as in women undergoing laparoscopic or minilaparotomy sterilization. More definitive studies are urged.

The relationship of estrogen and progesterone to breast disease

The rising incidence of breast cancer, coupled with awareness of the effects of hormones on breast tissue, has resulted in fears that estrogen, progesterone or both incite or adversely affect benign and malignant breast disease. An intensive review of the hormone physiology of the breast and of the numerous studies on hormones and breast disease reveals that estrogen and especially oral contraceptives not only do not cause breast cancer but may have a slight protective effect. Also, the overwhelming evidence is that the risk of benign breast disease is substantially reduced in both current and prior users of oral contraceptives.