The abnormal Papanicolaou smear

Despite its limitations, the Pap smear is a widely accepted, powerful screening technique for cellular abnormalities of the cervix. Abnormal Pap smears are found in 1% to 5% of the screened population, depending on the population characteristics. It is therefore important for all clinicians caring for women to be familiar with the principles of Pap smear screening, its strengths and weaknesses, the terminology used to interpret results, and the options for appropriate response to an abnormal smear. High-grade lesions require colposcopic examination and treatment; low-grade lesions require colposcopic examination and either treatment or close follow-up; atypical smears require some response, either repeated cytology or further investigation; glandular lesions require colposcopic examination and investigation of the endocervix. A tremendous amount of research is going on to assess the safest, most cost-effective approach to the detection, evaluation, and management of cervical epithelial lesions. It can be expected, therefore, that these recommendations will change over the next several years. All physicians providing health care for women should keep abreast of these changes.

Short term treatment with leuprolide acetate is a successful adjunct to surgical therapy of leiomyomas of the uterus

Gonadotropin releasing hormone analogs (GnRHa) have been used to induce a reduction in the size of leiomyomas of the uterus after three to six months of therapy. However, none of the studies have noted a significant decrease in size by the first month. Additionally, the results of two reports have suggested long term therapy with GnRHa induced significant aberrations of serum lipoproteins. To evaluate whether or not analog treatment for a short course (two months) would be efficacious, 27 patients with leiomyomas documented by examination of the pelvic area and vaginal ultrasound, who desired to preserve reproductive potential, had myomectomies two and one-half months after commencing depot leuprolide acetate therapy. The reduction in size of the uterus was 35 percent by the first month and the average reduction in the total volume was 44 percent after two months of treatment (474 +/- 364 to 265 +/- 173 milliliters; p less than 0.01). Furthermore, the size of the uterus, determined by examination, decreased significantly from 13.6 +/- 4.0 weeks initially to 10.1 +/- 3.0 weeks preoperatively (p less than 0.0001). Estradiol levels became menopausal by one month of therapy and remained suppressed preoperatively. Menopausal symptoms were well tolerated. Cholesterol, high density lipoprotein, extremely low density lipoprotein and triglyceride levels were not altered by analog treatment, although low density lipoprotein increased from 117 to 130 milligrams per deciliter. A short course of depot leuprolide acetate reduced the size of leiomyomas and surgical tissue planes were preserved, facilitating removal of leiomyomas, and furthermore, there was no significant clinical alteration in lipoprotein or triglyceride levels.

Endometrial morphology in asymptomatic postmenopausal women

Few data are available regarding endometrial histologic features in asymptomatic perimenopausal and postmenopausal women. This study encompasses endometrial biopsy specimens obtained from 801 such women before enrollment in a multicenter study of estrogen-progestin replacement. One endometrial cancer was found (0.13%); four additional biopsy specimens showed atypia (total 0.63%). The endometrium was atrophic in 373 (46.9%), proliferative in 133 (16.7%), secretory in 54 (6.8%), and hyperplastic in 41 (5.2%). Insufficient tissue for diagnosis was obtained in 195 (24.5%). We conclude that the yield for neoplasia is so low that screening endometrial biopsy is not justified in asymptomatic perimenopausal and postmenopausal women.

Detection of human papillomavirus DNA in genital lesions by using a modified commercially available in situ hybridization assay

A modified, commercially available DNA-DNA in situ hybridization test that uses biotinylated probes for the identification of human papillomavirus (HPV) DNA types 6/11, 16/18, and 31/33/35 was evaluated. HPV DNA was detected in 314 of 787 (40%) histologically abnormal genital biopsy specimens by using the ViraType in situ assay (Life Technologies, Gaithersburg, Md.), in which the hybridization time was increased from 2 to 16 h. Ninety percent of positive condyloma acuminata specimens contained HPV type 6/11 DNA. The prevalences of HPV DNA for cervical intraepithelial neoplasia I, II, and III lesions by this in situ hybridization test were 42, 54, and 55%, respectively. The combined prevalence of HPV type 16/18 and 31/33/35 DNAs increased with the severity of the lesion, while the prevalence of type 6/11 DNA decreased. HPV type 6/11 DNA was found only in 1 of 16 (6%) positive cervical intraepithelial neoplasia III specimens. HPV type 16/18 and 31/33/35 DNA was detected in 11 of 16 (69%) and 4 of 16 (25%) in situ hybridization-positive cervical intraepithelial neoplasia III specimens, respectively. Thus, the observation that certain "higher-risk" HPV genotypes are associated with upper-grade cervical precancer lesions was confirmed by this commercial hybridization system. In general, the assay was found to be well suited for use in the clinical laboratory. The ViraType in situ procedure modified for a longer hybridization time may be helpful in identifying lesions containing higher-risk HPV strains.

Detection of human papillomavirus DNA in cervical lesions by in situ hybridization using biotinylated DNA probes

In situ hybridization (ISH) for human papillomavirus (HPV)-6, -11, -16, -18, and -31 DNA was performed on 615 formalin-fixed paraffin-embedded cervical biopsies using biotinylated DNA probes. Results were obtained from 584 samples with 266 (45.5%) containing HPV-DNA sequences. Ninety percent of condyloma acuminatum specimens were positive for HPV-DNA with 18 of 19 positive cases containing HPV-6 or -11 DNA. The detection rate of HPV in cervical intraepithelial neoplasia (CIN) lesions was 50.6% (239 of 472), while only 8 of 91 (8.9%) cervical biopsies considered to be histologically normal or with minimal dysplasia contained HPV-DNA as demonstrated by ISH. The prevalence of HPV-16, -18, and/or -31 DNA increased with the severity of the lesions, with 20 of 20 (100%) positive CIN-III lesions containing these viral types compared with 102 of 157 (65.0%) positive CIN-I lesions. ISH with biotinylated DNA probes appears helpful in identifying lesions containing higher risk viral strains.

'Polyposis vaginalis' of pregnancy

Clinical and pathologic findings in a pregnant 15-year-old with vaginal polyposis disclosed numerous polyps throughout the vagina and portio of the cervix that disappeared spontaneously 6 weeks post partum. These polyps can be confused microscopically with sarcoma botryoides, although they are benign and may regress completely.

The role of gender in an obstetrics and gynecology residency program

A brief historical review of the role of female medical students and female physicians in American medicine is presented. The 1985-1986 Council on Resident Education in Obstetrics and Gynecology Residency Data Bank was analyzed for gender distribution. Questionnaire studies were undertaken to study the possible effect of the increasing number of female residents in an obstetrics and gynecology residency program. Queries were sent to current and former residents, the attending staff, and the nursing and anesthesiology staffs. In order to evaluate the national scene, letters were mailed to directors of programs with 20 or more residents. The overall results indicated female residents have a positive effect on residency training.