Treatment of pulmonary endometriosis with a long-acting GnRH agonist.

We report the case of a patient who was successfully treated with a long-acting GnRH agonist for pulmonary endometriosis. This 28-year-old woman had symptomatic pleural endometriosis, documented by biopsies, as well as symptomatic pelvic endometriosis. Two surgical procedures, consisting of excision of pleural endometriotic tissue and partial pleurectomies, failed to relieve her chest symptoms. Little relief was achieved with pseudopregnancy treatment. Satisfactory symptomatic improvement was obtained with danazol, but this medication had to be discontinued because of severe side effects. Trial of a GnRH agonist, leuprolide acetate, achieved complete remission of her chest symptoms; in addition, the patient became pregnant immediately after cessation of therapy. Gonadotropin-releasing hormone agonist therapy may be an important therapeutic alternative for women with pulmonary endometriosis who cannot tolerate danazol treatment and in whom surgical therapy fails to relieve the chest symptoms.

Fevers in patients undergoing vaginal laser surgery.

Three patients undergoing laser surgery of the vagina developed high fevers that later regressed, one of them without treatment. The possible causes and implications of these cases are discussed.

The use of large-loop excision of the transformation zone in an inner-city population.

OBJECTIVE: To determine whether large-loop excision of the transformation zone (LLETZ) can be used in our population to treat patients in a routine colposcopy clinic without diminishing the capability to see the large number of patients who require care, and to compare these results to our previous experience with laser surgery. METHODS: Patients found to have squamous intraepithelial lesions on colposcopically directed biopsies were offered treatment with LLETZ during counseling regarding their biopsy findings. Procedures included "ablation equivalents" and "cone biopsy equivalents" using local anesthesia. Follow-up examinations were used to determine cure and included cytology, colposcopy, and directed biopsies when indicated. The cure rate was compared to our previous experience with laser surgery. RESULTS: Two hundred thirty-six patients were treated in the colposcopy clinic without diminishing the capability to see all patients requiring care. Complications were few. The mean (+/- standard deviation) follow-up period was 50.7 +/- 25.3 weeks. The overall cure rate of 91.3% (95% confidence interval [CI] 87.1-95.5) was not influenced by the severity of the disease, but positive endocervical margins significantly lowered the cure rate to 69.2% compared with those who had negative margins. Before this series, only 73.1% of our patients scheduled for laser surgery returned for treatment. Assuming a 90% cure rate among those who returned, this means that the actual cure rate was only 65.8%. The likelihood of cure was 1.37 times greater (95% CI 1.27-1.52; P < .0001) using LLETZ in the clinic at the time the patient was counseled regarding her biopsy findings than using laser at a later date. In 33 patients, the LLETZ specimen showed no evidence of disease. The relative risk of negative histology was 3.31 (95% CI 1.78-6.13; P < .001) when LLETZ was done for a discrepancy between cytology and histology as opposed to any other indication. Cancer was found on the LLETZ specimen in four patients (two microinvasive, two frankly invasive), but was not suspected preoperatively in any of the patients. CONCLUSION: In our inner-city clinic, treatment with LLETZ at the time the patient was counseled regarding her biopsy findings improved the actual cure rate. The LLETZ procedure can be done safely in a clinic setting without diminishing the capability to care for a large number of patients.

Cervical os obliteration after laser surgery in patients with amenorrhea.

Thirty-eight postmenopausal women and one with pituitary amenorrhea underwent cervical laser surgery. The cervical canal of each patient was patent 2 weeks later. Eighteen of the 30 women reevaluated 4-48 months later had total obliteration of the cervical canal. In some patients, the cervix was obliterated and flush with the vaginal vault so that it could not be identified. Five other patients had severe cervical stenosis. Factors contributing to cervical os obliteration appeared to be the depth of the cervical defect, the lack of the physical action of blood passing through the cervical canal, and the hypoestrogenic state. This outcome makes continued adequate cytologic and colposcopic surveillance of these patients impossible and leaves them at risk for developing unrecognized cervical and endometrial disease.

Teenagers' awareness of the acquired immunodeficiency syndrome and the impact on their sexual behavior.

One hundred female teenagers attending a teenage pregnancy program were studied to determine the extent of their awareness about acquired immunodeficiency syndrome (AIDS) and the impact of such knowledge on their sexual behavior. Ninety-eight knew that AIDS is a disease, 45 stated that it is fatal, and all knew that it can be transmitted by sexual intercourse. After becoming aware of AIDS, 59 changed their sexual habits, 41 decreased their number of sexual partners, and 13 who had not used condoms started using them. However, only seven obtained more information about their partners' sexual and social histories, and half of those who decreased their number of partners still continued relationships with more than one. The survey showed that the publicity about AIDS has resulted in a favorable change in the sexual practices of these teenagers. However, it also indicated a need for further improvement in specific areas of education, such as the value of obtaining more information about sexual partners, more awareness of the importance of multiple-partner relationships in the spread of AIDS, and more emphasis on the important role of condoms in preventing AIDS virus transmission.

The multicentric nature of disease related to human papillomavirus infection of the female lower genital tract.

Two hundred fifty-one consecutive patients from our colposcopy clinic were evaluated to establish the extent to which human papillomavirus (HPV) infection is a disease of the entire female lower genital tract. Colposcopic examinations and biopsies of the cervix and vulva were performed on all patients. Two hundred two women had cervical disease, of whom 164 (81%) also had vulvar disease. The percentage was the same regardless of the severity of the cervical disease. One hundred ninety-four of the patients had vulvar disease and of these, 164 (85%) also had cervical disease. Twenty-nine of 37 women (78%) with overt vulvar condylomata had cervical disease; 15 of these presented without a Papanicolaou smear, and 13 had cervical disease. We conclude that HPV infection of the female lower genital tract is a multicentric disease. All patients with evidence of HPV infection should undergo colposcopic evaluation of the entire lower genital tract. The significance that this will have on future attempts to cure this infection needs to be studied.

The occurrence of squamous metaplasia as a precursor of squamous cell carcinoma of the endometrium.

Primary squamous cell carcinoma of the endometrium is a pathologic rarity. The 20th case of this lesion which meets Fluhmann's prerequisite criteria is presented. The etiology of squamous metaplasia is reviewed, and the relative frequency of its occurrence, as previously described, is reconsidered.

Cervical cancer detected by cervicography in a patient with negative cervical cytology.

The existence of false negative cervical cytology is well recognized. Cervicography was introduced in part to minimize the incidence of false negative smears, but its use has been controversial. A case is presented of a patient with occult cervical cancer whose initial Papanicolaou smear was atypical (class II) and follow-up smear was negative. The patient's cancer was detected by cervicography. Detection of the patient's disease would have been delayed were it not for cervicography.

Vaginal glomus tumor: case presentation and ultrastructural findings.

Vaginal glomus tumors are exceptionally rare, and have not been reported in the literature. A case of vaginal glomus tumor is described. Light and electron microscopic views are presented. The differential diagnosis and surgical approach are discussed.

Obstetrics and gynecology residencies: education in preventive and primary health care for women.

OBJECTIVE: To test the hypothesis that the Residency Review Committee program requirements for obstetrics and gynecology residencies, when properly followed, will result in residents being educated in preventive and primary ambulatory health care for women during their residency training program as specialists in obstetrics and gynecology. METHODS: The 60 requisite residency training competencies identified as essential to educate generalist physicians, and viewed by some educators as a benchmarking standard, each were evaluated to determine whether residents in obstetrics and gynecology are now being educated in each of these areas. The answer was considered affirmative if any of the following pertained: 1) the Residency Review Committee program requirements indicate that the competency "must" or "should" be taught, 2) the Residency Review Committee requests numerical verification related to the competency on the accreditation review application, or 3) by virtue of a specific rotation required by the Residency Review Committee it can be assumed that the resident will be educated in the competency. To make our assessment, we identified and listed the section of the Residency Review Committee for Obstetrics-Gynecology program requirements, which, when properly followed, would result in education in the particular competency. RESULTS: Fifty-seven of the 60 competencies were considered applicable to obstetrician-gynecologists (care of infants, care of children, and infant/child preventive care were not), and residents in obstetrics and gynecology were found to be educated in 54 (95%). CONCLUSION: During their residency training programs as specialists in obstetrics and gynecology, residents are being educated to be able to be providers of preventive and ambulatory primary health care for women.

Effect of advancing pregnancy on the glucose tolerance test and on the 50-g oral glucose load screening test for gestational diabetes.

To determine the validity of the 50-g, one-hour glucose screening test for gestational diabetes in relation to the duration of pregnancy, 101 patients from a high-risk population had the screening test in the first trimester and glucose tolerance tests (GTT) in the second and third trimesters. The sensitivity (88%) and specificity (82%) of the screening test were similar to values reported when the test is performed later in pregnancy. However, immediate follow-up GTTs in the second trimester revealed only 25% instead of 88% of the gestational diabetic patients uncovered by the positive screening tests. Guidelines for screening for gestational diabetes should include follow-up with a third-trimester GTT on all patients who have positive screening tests even in the presence of normal follow-up second trimester GTTs.

Serum estradiol as an aid in the diagnosis of ectopic pregnancy.

The value of serum beta-hCG measurement in the diagnosis of ectopic pregnancy is well established, and there have been recent studies on the use of serum progesterone levels. However, we have been unable to find any reports on the potential application of serum estradiol (E2) assays in the diagnosis of ectopic pregnancy. We therefore concurrently measured serum E2, progesterone, and beta-hCG in 100 women with ectopic pregnancies, as well as in 69 controls with normal intrauterine pregnancies and 36 women with threatened abortion. The mean (+/- standard deviation) E2 levels for ectopic-pregnancy patients, the normal controls, and the women with threatened abortion were 281.1 +/- 115.6, 788.2 +/- 45.5, and 788.8 +/- 40.6 pg/mL, respectively; the mean levels in the ectopic group were significantly different (P less than .0001) from those of the other two groups. All but one of the ectopic pregnancies had values below 650 pg/mL for E2 and 23 ng/mL for progesterone, and all but one of the normal intrauterine pregnancies had values above these levels. Our data suggest that the addition of the estradiol assay, with or without progesterone, to the early evaluation of patients suspected of having an ectopic pregnancy may be helpful in diagnosis.

Comparison of the adrenocorticotropic hormone stimulation test with and without prior dexamethasone suppression in the diagnosis of congenital adrenal hyperplasia.

A comparison was made of the ACTH stimulation test with and without prior dexamethasone suppression in 10 patients, each of whom served as her own control. It was found that it is not necessary to administer DEX before the test, the specificity and sensitivity of both tests being the same in the diagnosis of CAH, although the calculated values are lower when DEX is given. Further investigation with HLA typing and ACTH stimulation testing is necessary to establish whether either or both types of ACTH stimulation tests are capable of discriminating between the heterozygotic and homozygotic varieties of CAH.

Prevalence of and markers for the attenuated form of congenital adrenal hyperplasia and hyperprolactinemia masquerading as polycystic ovarian disease.

To determine the prevalence of the attenuated form of congenital adrenal hyperplasia (CAH) and hyperprolactinemia (HPPN) relative to polycystic ovarian disease (PCOD), 100 consecutive women presenting with the classic clinical features of PCOD were evaluated by basal hormonal profiles and subsequent adrenocorticotropic hormone (ACTH) stimulation tests. The study also sought biochemical markers for CAH other than ACTH stimulation. The prevalences were found to be as follows: PCOD, 65%; PCOD with HPPN, 9%; HPPN, 3%, end-organ hypersensitivity (EOH), 4%; homozygotic CAH, 4%; and heterozygotic CAH, 15%. Other than the differential response to ACTH, the only other biochemical markers observed for homozygotic CAH were significantly higher basal levels of testosterone (T) and 17 alpha-hydroxyprogesterone (17-OHP). Luteinizing hormone/follicle-stimulating hormone ratio, androstenedione, and dehydroepiandrosterone sulfate all showed no significant differences between homozygotic CAH, heterozygotic CAH, HPPN, PCOD, and EOH. This study establishes the relative prevalences of the syndromes commonly mimicking PCOD. We also conclude that the observed low incidence of CAH does not justify routine ACTH testing on all patients presenting with features of PCOD--however, our data suggest that patients with basal serum levels of T and 17-OHP greater than 50% above the upper limit of normal should undergo this dynamic test, especially if there are also certain clinical features suggestive of CAH.

Accommodating to restrictions on residents' working hours.

In 1988, New York became the first state to implement regulatory measures limiting housestaff work hours. Because restrictions on residents' work hours will have such profound and far-reaching implications for how obstetrics and gynecology residencies are conducted, the Council on Resident Education in Obstetrics and Gynecology (CREOG) requested that a survey be conducted to solicit information from program directors of U.S. obstetrics and gynecology residencies who had already begun to alter their call schedules. Two hundred and ninety-six programs were contacted, and representatives of those that had implemented changes were requested to respond. Eighty-two responses were received; 26 of these contained information that could be collated. From these 26 responses the authors have structured a prototypic call schedule and presented its application. A key feature necessary to implement the new type of schedule is the use of a night float system. It is concluded that changes can and will be made by obstetrics and gynecology residencies. Creative scheduling, as described in this article, is essential and will facilitate the task; however, the current standards of education and patient care will be difficult to maintain without additional economic and human resources.

Abnormal Papanicolaou smears found in victims of sexual assault.

Four women, at the time of treatment for rape, were concurrently found to have abnormal Papanicolaou (Pap) smears. It is suggested that all women who seek emergency care after sexual assault have Pap smears taken at that time if there is no record of a negative Pap smear within the preceding six months.

Status epilepticus in pregnancy. A case report.

Status epilepticus is a serious emergency that rarely complicates the management of the pregnant patient with seizure disorders. Because of concerns regarding the safety of anticonvulsion medications, this condition may appear with increasing frequency. Our management of such a case resulted in a healthy mother and infant.

Changes and challenges for women in academic obstetrics and gynecology.

In obstetrics and gynecology, more than 60% of current residents and 36% of medical school faculty are women. However, fewer than 10% of professors and only a small number of department chairs and organizational leaders are women. This paper reviews the data on the growing number of women in obstetrics and gynecology, and in medicine in general, during the past 25 years. It reviews some of the challenges that women have faced and some strategies to enhance equitable opportunities.

Perimenopausal bleeding patterns and pathologic findings.

The charts of 500 sequential perimenopausal patients were reviewed and their alterations in menstrual flow were characterized as fitting one of three patterns. Sixty-two patients (12%) had sudden amenorrhea, 347 (70%) had oligomenorrhea and/or hypomenorrhea, and 91 (18%) had menorrhagia, metrorrhagia, and/or hypermenorrhea. All of the patients in the menorrhagia/metrorrhagia and/or hypermenorrhea group had histologic evaluations to rule out the presence of premalignant or malignant disease; 17 women (19%) in this group had premalignant or malignant findings. In addition, 4 of the 5 women with malignancies had intermenstrual bleeding. Of the 9 women in the study with intermenstrual bleeding, 4 had invasive cancer and 2 had endometrial hyperplasia. This study documents and highlights the high incidence of premalignant and malignant findings in perimenopausal patients with bleeding patterns other than amenorrhea or oligomenorrhea/hypomenorrhea, and underscores the need for perimenopausal women with menorrhagia, metrorrhagia, and/or hypermenorrhea to undergo thorough evaluation.