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Reversible contraception for women at high risk of fetal anomalies
150
Journal of the American Academy of Dermatology
Correspondence
Reply To the Editor: Sampling of patients for our study was as stated, that is, they were suffering from persistent, generalized, symmetric pruritus severe enough to warrant inpatient investigation at a dermatology clinic of a university hospital. Thus, the pruritus was very marked, and most patients had ample excoriation marks. The routine at our clinicmand presumably at most clinics around the world--is to subject such patients to more or less extensive investigations in order to detect any systemic cause for the pruritus, such as cancer. If no such cause is found, the pruritus is usually ascribed to "dry skin" and emollients are prescribed. Most of our patients had received manifold prescriptions for emollients and used them regularly. Despite such "dry skin treatment," 66% o f the patients continued to itch for the 6 years of our follow-up. Our point is that despite persistent pruritus, no more cancers developed than was to be expected in the age groups, with the possible exception of lymphoma. We thus agree with Dr. Frankel that in the majority of patients with persistent pruritus, the itch is unrelated to systemic causes and is of "cutaneous" origin. Still, our clinical experience makes us hesitant to ascribe the pathomechanism of persistent cutaneous pruritus to "skin dryness" alone. Dr. Holdiness makes a very pertinent point in his comment on the Leser-Tr61at sign. On the basis of our study we cannot comment on the importance of cutaneous markers such as this sign as indicators of malignancy, since no such specific cases were encountered by us. Our study was designed to illuminate the relation between chronic pruritus and malignancy as commonly seen by dermatologists. We maintain that the type of pruritus our patients suffered from is not specifically associated with internal malignancies. Robert Paul, M.D., Riitta Paul, M.D., and Christer T. Jansen, M.D. Turku University Central Hospital SF-20520 Turku, Finland
As Dr. Grimes points out, a woman's feelings regarding abortion must be considered in choosing a method of birth control. Why then does he recommend the intrauterine device for women for whom abortion is unacceptable? The intrauterine device prevents implantation of the zygote, which results in abortion. Atso, while the primary method of action of oral contraceptives is the suppression of ovulation, they may also act by preventing implantation when their primary function fails. In keeping with matters of conscience, we must honor our patient's moral choices with information regarding all forms of birth control.
Pamela M. Carr, M.D. 1601 Main, Suite 304, Richmond, TX 77469
Reply To the Editor: I appreciate the opportunity to respond to the important issues raised in Dr. Carr's letter. Dr. Carr implies that the intrauterine device (IUD) is an abortifacient. On the contrary, the World Health Organization, the American College of Obstetricians ant[ Gynecologists, and other major organizations concur that human pregnancy begins with implantation, not with fertilization. Thus, if intrauterine devices prevent implantation of zygotes, this would not be considered abortion. Moreover, recent observations in humans suggest that the intrauterine device exerts other effects that extend beyond the uterus and interfere with reproductive processes prior to fertilization. Thus it is doubtful at present that the contraceptive effect of intrauterine devices lies mainly or exclusively in their capacity to interfere with implantation or the fate of the zygote once it has reached the endometrial cavityJ If ovulation occurs despite use of combination oral contraceptives, several other contraceptive mechanisms may come into play. These include hostile cervical mucus and potentially altered tubal motility. Either or both of these mechanisms could prevent fertilization of an ovum.
Reversible contraception for women at high risk of fetal anomalies To the Editor: Dr. Grimes provides us with a helpful summation of current contraceptive agents (J AM ACAD DERMATOL 1987;17:148-55). He also reviews for us efficacy, risk, and controversy. My thanks to Dr. Grimes for his timely article.
Finally, I agree completely with Dr. Carr that patients should be fully informed about contraceptive options~
David A. Grimes, M.D. Women's Hospital, Los Angeles, CA 90033
REFERENCE 1. Ortiz ME, Croxatto HB. The mode of action of IUDs. Contraception 1987;36:37-53.
Journal of the American Academy of Dermatology
Correspondence
Reply To the Editor: Sampling of patients for our study was as stated, that is, they were suffering from persistent, generalized, symmetric pruritus severe enough to warrant inpatient investigation at a dermatology clinic of a university hospital. Thus, the pruritus was very marked, and most patients had ample excoriation marks. The routine at our clinicmand presumably at most clinics around the world--is to subject such patients to more or less extensive investigations in order to detect any systemic cause for the pruritus, such as cancer. If no such cause is found, the pruritus is usually ascribed to "dry skin" and emollients are prescribed. Most of our patients had received manifold prescriptions for emollients and used them regularly. Despite such "dry skin treatment," 66% o f the patients continued to itch for the 6 years of our follow-up. Our point is that despite persistent pruritus, no more cancers developed than was to be expected in the age groups, with the possible exception of lymphoma. We thus agree with Dr. Frankel that in the majority of patients with persistent pruritus, the itch is unrelated to systemic causes and is of "cutaneous" origin. Still, our clinical experience makes us hesitant to ascribe the pathomechanism of persistent cutaneous pruritus to "skin dryness" alone. Dr. Holdiness makes a very pertinent point in his comment on the Leser-Tr61at sign. On the basis of our study we cannot comment on the importance of cutaneous markers such as this sign as indicators of malignancy, since no such specific cases were encountered by us. Our study was designed to illuminate the relation between chronic pruritus and malignancy as commonly seen by dermatologists. We maintain that the type of pruritus our patients suffered from is not specifically associated with internal malignancies. Robert Paul, M.D., Riitta Paul, M.D., and Christer T. Jansen, M.D. Turku University Central Hospital SF-20520 Turku, Finland
As Dr. Grimes points out, a woman's feelings regarding abortion must be considered in choosing a method of birth control. Why then does he recommend the intrauterine device for women for whom abortion is unacceptable? The intrauterine device prevents implantation of the zygote, which results in abortion. Atso, while the primary method of action of oral contraceptives is the suppression of ovulation, they may also act by preventing implantation when their primary function fails. In keeping with matters of conscience, we must honor our patient's moral choices with information regarding all forms of birth control.
Pamela M. Carr, M.D. 1601 Main, Suite 304, Richmond, TX 77469
Reply To the Editor: I appreciate the opportunity to respond to the important issues raised in Dr. Carr's letter. Dr. Carr implies that the intrauterine device (IUD) is an abortifacient. On the contrary, the World Health Organization, the American College of Obstetricians ant[ Gynecologists, and other major organizations concur that human pregnancy begins with implantation, not with fertilization. Thus, if intrauterine devices prevent implantation of zygotes, this would not be considered abortion. Moreover, recent observations in humans suggest that the intrauterine device exerts other effects that extend beyond the uterus and interfere with reproductive processes prior to fertilization. Thus it is doubtful at present that the contraceptive effect of intrauterine devices lies mainly or exclusively in their capacity to interfere with implantation or the fate of the zygote once it has reached the endometrial cavityJ If ovulation occurs despite use of combination oral contraceptives, several other contraceptive mechanisms may come into play. These include hostile cervical mucus and potentially altered tubal motility. Either or both of these mechanisms could prevent fertilization of an ovum.
Reversible contraception for women at high risk of fetal anomalies To the Editor: Dr. Grimes provides us with a helpful summation of current contraceptive agents (J AM ACAD DERMATOL 1987;17:148-55). He also reviews for us efficacy, risk, and controversy. My thanks to Dr. Grimes for his timely article.
Finally, I agree completely with Dr. Carr that patients should be fully informed about contraceptive options~
David A. Grimes, M.D. Women's Hospital, Los Angeles, CA 90033
REFERENCE 1. Ortiz ME, Croxatto HB. The mode of action of IUDs. Contraception 1987;36:37-53.