Residency training in colposcopy: a survey of program directors in obstetrics and gynecology and family practice.

OBJECTIVE: Our goal was to identify how colposcopy is being taught to residents in obstetrics and gynecology and family practice programs and to see if the program directors think their residents receive sufficient clinical exposure to be adequately trained in colposcopy. STUDY DESIGN: A 30-question survey was sent to all obstetrics and gynecology and family practice residency program directors. The survey included questions about the didactic nature of the colposcopy curriculum, the type of supervision, how resident skills are evaluated, estimates of the numbers and types of patients evaluated, the numbers and types of procedures being done by each resident, and the program director's perception of residents' competence in colposcopy. RESULTS: The overall response rate was 485 of 752 program directors (64.5%). Significantly fewer family practice than obstetrics and gynecology program directors thought they had adequate numbers of colposcopy patients to train their residents. By their program directors' estimates, 86% of family practice residents evaluate 10 or fewer patients with high-grade lesions (versus 16.5% of obstetrics and gynecology residents); 51.4% evaluate 10 patients or fewer with low-grade lesions (versus 6.7% of obstetrics and gynecology residents), and 40.6% evaluate 10 patients or fewer with atypical squamous cells of undetermined significance (versus 3% of obstetrics and gynecology residents). Experience with vulvar disease is also limited. Program directors thought their residents' colposcopy skills were roughly comparable with their general obstetrics and gynecology skills. CONCLUSIONS: It is possible that many program directors underestimate the number of colposcopic examinations required to achieve and maintain colposcopic skills. Many training programs have insufficient clinical volume to properly train residents in colposcopy.

The Triage of Women with ASCUS Cytology Using Human Papillomavirus DNA Testing.

OBJECTIVE: Our goal was to determine whether human papillomavirus (HPV) DNA testing is a valuable tool in triage of patients with cytology demonstrating atypical squamous cells of undetermined significance (ASCUS). METHODS: Our study included a total of 355 women who were referred for evaluation of a Papanicolaou smear with ASCUS diagnosed during routine screening. At the first visit, all patients had colposcopic examinations and HPV DNA testing by Hybrid Capture assay. Patients were evaluated every 4 to 6 months. Follow-up included repeat cytology and colposcopy at each visit; biopsy was performed if indicated. Followup continued for up to 2 years. RESULTS: Sensitivity, specificity, and positive and negative predictive values of HPV DNA testing in detecting cervical intraepithelial neoplasia grade 2 (CIN2) or CIN3 were 85%, 77%, 12%, and 99%, respectively. The prevalence of oncogenic HPV types was higher in patients younger than age 35 (35% versus 25%) in whom ASCUS-favor dysplasia/ASCUS-not otherwise specified was diagnosed. The presence of oncogenic HPV types equated with a 12.4% risk of biopsy-proven CIN2 and CIN3. The rate of CIN2 and CIN3 was 0.4% in those who tested negative (95% confidence interval, 0-2.1%). CONCLUSIONS: HPV DNA testing appears to be a valuable tool for triage of women with ASCUS smears. Its high negative predictive value provides needed reassurance for follow-up with only periodic cytology.

The treatment of premalignant lesions of the uterine cervix.

BACKGROUND: Understanding the reasons for treatment of premalignant lesions of the cervix, as well as which lesions require therapy, is key to successful outcomes of therapy. Knowing the treatment modalities available and when to select each one is an essential part of proper patient care. When to observe and when to treat are critical decisions. CONCLUSIONS: Since the two basic approaches to treatment are either local destruction or excision, it is incumbent upon the treating physician to understand the values and complications attached to each method.

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.

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.

Distribution of lidocaine and digoxin in heart tissues and aorta following intrapericardial administration.

The distribution of lidocaine and digoxin in myocardial and aorta tissues of open chest anesthetized dogs was studied, following the administration of 30 ml phosphate buffer solution of the drugs in the pericardial cavity where it was kept for increasing time intervals. Transfer of lidocaine (15 or 30 mg) from the solution to myocardium was almost complete within 60 min, while only 50% of digoxin (2 or 50 micrograms) was removed, and this occurred during the first 30 min. Accordingly, the absorption rate of lidocaine by heart tissues increased with time up to 60 min while that of digoxin decreased with time. Absorption of digoxin by the atria and absorption of both drugs by intrapericardial aorta were higher than that of other heart tissues, between 20 and 60 min. At 30 and 60 min, lidocaine was evenly distributed across the LV wall while digoxin 50 micrograms was mainly concentrated subepicardially. On the contrary, i.v. administration of digoxin resulted in even distribution in the LV wall without preferential concentration in the atria. The uptake of both drugs by aorta was several times lower compared to heart tissues after i.v. administration. Drug concentrations in LV wall almost at therapeutic level, were derived from solution of low concentration of the drug in the pericardial cavity. It is concluded that intrapericardial administration of the drugs may be used when increased concentration of them is desired in specific areas of the heart and the aorta.

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.

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.

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.

Assessment of criteria used in the histologic diagnosis of human papillomavirus-related disease of the female lower genital tract.

The goal of this study was to evaluate the histologic criteria used to establish the diagnosis of human papillomavirus (HPV)-associated disease, especially in borderline lesions. In a completely blinded study, 21 patients had one biopsy each of the cervix and vulva. Each specimen was evaluated by RNA and DNA in situ hybridization, a histologic diagnosis was rendered, and then each was evaluated for 12 histologic criteria commonly associated with HPV. On the cervix only binucleation and dysplasia correlated well with in situ hybridization. Koilocytosis correlated very strongly with the histologic diagnosis. On the vulva, koilocytosis, papillomatosis, elongated rete pegs, binucleation, and hypergranulosis correlated well with in situ hybridization. When four other pathologists reviewed the slides, they agreed on the histologic diagnosis and the presence of koilocytosis, binucleation, and dysplasia on the cervix but on none of the other criteria. On the vulva the pathologists disagreed on the overall diagnosis and the presence of any of the criteria with the exception of papillomatosis. Nonclassic histologic criteria should not, by themselves, be used to make the diagnosis of condyloma. The use of such terminology as "suggestive of condyloma" in histologic diagnoses should be avoided in favor of more descriptive terminology to avoid possibly unnecessary treatment for lesions of questionable significance.

Desquamative inflammatory vaginitis. A case report.

The differential diagnosis of noninfectious desquamative inflammatory vaginitis includes pemphigus vulgaris, erosive lichen planus and benign mucous membrane pemphigoid. A 32-year-old woman had persistent, noninfectious, erosive vaginitis and linear deposits of IgA in the vaginal epithelial basement membrane zone. The differential diagnosis should be expanded to include mucosal involvement by linear IgA disease, a cutaneous vesiculobullous disorder.

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.

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.