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 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.

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.

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.

The fertility of women after cervical laser surgery.

OBJECTIVE: To retrospectively survey our population of women who had undergone cervical laser surgery to determine if it adversely affected their ability to conceive or to carry a pregnancy to term. METHODS: Women who had undergone laser surgery during the period 1979-1989 were contacted and surveyed regarding each of their pregnancies. Information obtained included their age at the time of each pregnancy, pregnancy outcome, how long they were trying to conceive, and their use of contraception. The post-laser experience of the study group was matched individually for age and parity with a control population taken from the pre-laser interval of the same patients. RESULTS: We contacted 1069 women; 512 responded to the survey and 433 were matched with controls. The mean study interval was 3.8 years. The study group had significantly more total pregnancies (277 versus 177 for controls, P < .001), total births (163 versus 112 for controls, P < .002), full-term pregnancies (145 versus 100 for controls, P < .005), and terminations of pregnancy (75 versus 28 for controls, P < .001). There was no significant difference in the number of spontaneous abortions (31 for the study group and 33 for controls), premature deliveries (18 for the study group and 12 for controls) or ectopic pregnancies (eight for the study group and four for controls). There was no difference in the pregnancy rate (compared with controls) between laser vaporizations and excisions. CONCLUSION: Cervical laser surgery does not appear to impair a woman's ability to conceive or carry a pregnancy to term. There is no difference in the effect on fertility between laser vaporization and laser excisional cone biopsies.

Colposcopic evaluation of patients with abnormal cytologic smears during pregnancy.

One-hundred thirty-two patients with abnormal Papanicolaou smears of the cervix uteri during pregnancy underwent colposcopic evaluation. Seventy-five patients had biopsies during pregnancy, and 34 patients had colposcopic evaluation without performing any biopsy. Postpartum colposcopic evaluation was performed on 95 patients. In 93 patients of this group, the postpartum cytologic and histologic information obtained was the same or less than that obtained in antepartum evaluation. In only 1 case, antepartum colposcopically guided biopsy at 38 weeks' gestation revealed moderate dysplasia, and postpartum cold conization showed carcinoma in situ. In another case, colposcopic evaluation and biopsy during pregnancy showed mild dysplasia while colposcopic biopsy as well as examination of a hysterectomy specimen taken at 16 months after delivery revealed severe dysplasia. No case of invasive carcinoma was missed during pregnancy. The results of this study, in support of previous reports, show that colposcopic evaluation is a simple, safe, and accurate method of investigating abnormal Papanicolaou smears during pregnancy.

Comparative utility of repeat Papanicolaou smears, cervicography, and colposcopy in the evaluation of atypical Papanicolaou smears.

In an attempt to establish the significance and management of the atypical Papanicolaou smear, 97 patients with atypical Papanicolaou smears were each evaluated with a repeat Papanicolaou smear, cervicography, and colposcopy. In the detection of significant lesions, cervicography was more sensitive than a repeat smear, but less so than colposcopy. Forty-two percent of the colposcopically detected lesions would have gone undetected by repeat Papanicolaou smears, compared with 11% by cervicography. However, Papanicolaou smears were more specific than cervicography (55 versus 29%). The cost per case detected using cervicography for triage was equal to that using follow-up Papanicolaou smears, but was a third higher than referring all patients directly to colposcopy. Merely using repeat smears in patients with atypical Papanicolaou smears may result in nondetection of many significant lesions, especially in populations where follow-up is poor.

Colposcopic evaluation of patients with abnormal cervical cytology.

A total of 1580 new patients underwent colposcopic evalution in the Dysplasia Clinic at Nassau County Medical Center. Of these patients, 186 had abnormal Papanicolaou smears associated with pregnancy, 150 were referred because of in utero exposure to diethylstilbestrol, and 1244 were referred because of abnormal cervical cytologic smear or suspicious cervical or vaginal lesion. Further analysis of this latter group revealed that 1184 (95%) patients had satisfactory colposcopic evaluation, and directed biopsy showed the following: 10 cases of invasive cervical carcinoma, 9 of carcinoma in situ with microinvasion, 118 of cervical carcinoma in situ, 110 of severe dysplasia, and 424 cases of mild to moderate cervical dysplasia. All of these patients subsequently were treated accordingly. Evaluation of final histologic specimen revealed a very high correlation with colposcopically guided biopsies. In 54 patients, where colposcopic evaluation was unsatisfactory, diagnostic cold knife conization was performed. Final histologic diagnosis disclosed a more advanced lesion in 30 patients (or 56%) of this group. The result of this study shows that satisfactory colposcopic evaluation is a highly accurate method of evaluation of abnormal cervical and vaginal cytologic smear.

Human papillomavirus--related diseases in the female patient.

Human papillomavirus (HPV) has been strongly associated with malignancy in the female lower genital tract. Because squamous-cell carcinoma of the cervix is preceded by a spectrum of easily detectable and treatable premalignant changes, it is very preventable. The management of the patient with an abnormal Papanicolaou smear and the treatment of cervical, vaginal, and vulvar disease are outlined.

Photodynamic therapy in gynecology.

PDT is a technique in which visible light is used in combination with photosensitizing agents to achieve a tumoricidal effect. Hematoporphyrins are the most commonly used photosensitizers in clinical practice. DHE is the active fraction of hematoporphyrin. Intravenously injected DHE is found in highest concentration in the liver followed by the spleen, kidney, tumor, skin, muscle, brain, and lungs. The strongest absorption bands for DHE are in the blue region of the spectrum, and this helps to account for the skin toxicity associated with PDT. Red light, at the wavelength of 630 nm, is usually used clinically because of its greater tissue penetration. Techniques such as photobleaching and use of photosensitizers that have weak absorption bands at the lower wavelengths may reduce cutaneous toxicity in the future. Other approaches, such as the use of monoclonal antibody-linked photosensitizers or cationic photosensitizers that are specifically localized in tumor cells, may also increase the effectiveness of PDT while decreasing toxicity. Light for PDT is usually provided by argon-pumped dye lasers or metal vapor lasers. Diode lasers will be used in the future. The use of fiber-optics and diffusing lenses allows the endoscopic and interstitial use of PDT. The mechanism of action of PDT involves the formation of singlet oxygen, which oxidizes biologic molecules and causes irreversible subcellular damage. The major in vivo effect of PDT is caused by its destruction of tumor vasculature, causing anoxia and necrosis. The use of PDT in gynecology has been limited. Several investigators have reported mixed results in treating lower genital tract intraepithelial and recurrent malignant tumors using a variety of approaches involving PDT. The use of PDT in other similar, though nongynecologic, tumors offers a direction for future research.

The "unsatisfactory" colposcopic examination.

One hundred nine of 735 patients (14.8%) referred for colposcopic evaluation had "unsatisfactory" examinations. Of 108 women 40 years of age or over, 81 had unsatisfactory examinations (45%) as compared with 28 of 555 women under 40 (5%) (p less than 0.001). Thirty-five of the 109 patients with unsatisfactory examinations (32%) had had prior cautery or conization as compared with 141 of 626 in the "satisfactory" group (22.5%) (p less than 0.04). Seventy-three of the 99 patients on whom follow-up information was obtained had cervical conization biopsies for final diagnoses. Correlation with previously performed endocervical curettage and colposcopically directed biopsies was poor. Careful correlation of cytology, colposcopy and histopathology is necessary to achieve optimal results in the management of patients with unsatisfactory examinations. Diagnostic conization continues to play an important role in the management of patients with abnormal cervical cytology.

Coloscopy clinic: an evaluation of 500 new patients.

Among the many responsibilities of the gynecologist in modern practice is the detection of neoplasia at the earliest possible opportunity. The advances made in the field of cytology as related to the practice of gynecology are well known and have significantly changed the detection of cervical carcinoma. The resurgence of colposcopy in the evaluation of patients with abnormal cervical cytology has added valuable new dimensions in the understanding of early cervical neoplasia and our ability to diagnose and treat these lesions. The complete acceptance of colposcopy as an essential step in the study of such patients requires a re-education and alteration in the philosophy of management which has been prevalent in American gynecologic practice to date.

Regression of cervicovaginal abnormalities in DES-exposed women. A comparison of changes in sexually inactive women and the effects of the onset of sexual activity.

Sequential colpophotographs were reviewed from a group of 1,139 female progeny exposed to diethylstilbestrol (DES) in utero and who were not yet sexually active on initial examination. Forty had ectopy. For 27 the normalized yearly rate of squamous metaplasia (replacement of columnar epithelium) was 28.8 +/- 3.7% (SEM). For the 18 who became sexually active the normalized yearly rate of squamous metaplasia was 54.6 +/- 6.2%. Thus, the sexually active women demonstrated a more rapid rate of squamous metaplasia; that rate was statistically significant (T = 3.8, p less than 0.001). The cervicovaginal hood was observed to regress slowly, and no effect of sexual activity could be demonstrated. Cervical intraepithelial neoplasia 2 was found in three patients. It occurred only in those who became sexually active, and the incidence was significantly different from that in the group that remained sexually inactive. The development of a small cervical os was found in two of the sexually active women without any local therapy.

PIP: Sequential colpophotographs were reviewed from a group of 1139 female progeny exposed to diethylstilbestrol (DES) in utero and who were not yet sexually active on initial examination. 40 had ectopy. For 27, the normalized yearly rate of squamous metaplasia (replacement of columnar epithelium) was 28.8 +or- 3.7% (SEM). For the 18 who became sexually active, the normalized yearly rate of squamous metaplasia was 54.6 +or- 6.2%. Thus, the sexually active women demonstrated a more rapid rate of squamous metaplasia; that rate was statistically significant (T=3.8, P0.001). The cervicovaginal hood was observed to regress slowly, and no apparent effect of sexual activity was demonstrated. Cervical intraepithelial neoplasia was found in 3 patients. It occured only in those who became sexually active, and the incidence was significantly different from that in the group that remained sexually inactive. The development of a small cervical os was found in 2 of the sexaully active women without any local therapy.

Detection of conditions related to human papillomavirus. Comparison of cytology, colposcopy, histology and hybridization.

The diagnosis of lesions associated with human papillomavirus infection can be difficult because the results of the tests used can be contradictory. Our goal was to compare some of these tests and to evaluate their comparative strengths and weaknesses as clinically useful tools in confirming the diagnosis, especially in borderline cases. Twenty-one consecutive patients from our colposcopy clinic were screened with cytology and colposcopy. Biopsies were taken from representative areas on the cervix and vulva and divided. One-half was evaluated with Southern blot hybridization and the other half with histology and with RNA and DNA in situ hybridization. Cytology and histology were interpreted as either "positive" (showing definite evidence of human papillomavirus infection or cervical intraepithelial neoplasia [CIN]), "negative" (showing no evidence of human papillomavirus infection or CIN) or "equivocal" (atypical [class II] Papanicolaou smears or histology suggestive but not diagnostic of condyloma). In order to determine the clinical significance of equivocal results the sensitivity and specificity of these tests were calculated, with the equivocal results reclassified as either positive or negative. Colposcopy was the most sensitive technique but was not very specific. Cytology was a very sensitive screening tool when the atypical (class II) smears were considered positive but not when they were considered negative. The specificity of the histologic diagnosis was doubled with the equivocal results considered negative when compared to the specificity of the histologic diagnosis with the equivocal results considered positive, with no loss of sensitivity. Each technique has drawbacks, and therefore no one should be used to diagnose and treat these lesions to the exclusion of all others.

Atypical glandular cells of undetermined significance and adenocarcinoma in situ: summoning colposcopic expertise?

In comparison with cervical squamous neoplasia, glandular cell neoplasia is uncommon. The evaluation of a patient with atypical glandular cells of undetermined significance is challenging because subtle colposcopic signs are frequently inaccessible to view and cytologic interpretations are extremely challenging for many cytopathologists.