Successful management of a viable cervical pregnancy by single-dose methotrexate.

Cervical pregnancy is very uncommon and carries a high risk for hysterectomy with surgical treatment. Prior reports of medical treatment included various regimens of high-dose systemic methotrexate (MTX) with citrovorum rescue and local injection. This is the first report of successfully treating a viable cervical pregnancy with single-dose i.m. MTX, followed by a vaginal delivery.

Adenocarcinoma in situ of the uterine cervix: management and outcome.

OBJECTIVE: To retrospectively review the management of adenocarcinoma in situ of the uterine cervix, to determine the outcome of conization versus hysterectomy, and to compare the results achieved by different methods of conization. METHODS: We performed a retrospective pathology and chart review of 46 patients with cervical adenocarcinoma in situ from January 1980 to October 1994. RESULTS: Nine patients were managed during the first half of the study period and 37 were managed in the second half. The mean age of patients was 38.4 years (range 25-72). Forty-five of 46 patients were diagnosed as a result of an abnormal Pap smear, although only 19 smears indicated adenocarcinoma in situ or other glandular abnormalities. Cold knife conization resulted in a 33% rate of positive margins for adenocarcinoma in situ compared to 50% for large loop excision of the transformation zone (LLETZ). Among 24 conservatively managed patients with negative conization margins, there have been 2 (8.3%) recurrences of adenocarcinoma in situ. Among patients not undergoing hysterectomy as definitive treatment, 1 of 18 (6%) patients undergoing cold knife conization recurred, compared to 4 of 14 (29%) managed with LLETZ, despite a 63.4-month shorter mean follow-up interval for the LLETZ patients. CONCLUSIONS: Cold knife conization is associated with a lower rate of recurrence of cervical adenocarcinoma in situ compared to LLETZ. We recommend cold knife conization for patients who are not treated with hysterectomy.

Comparison of saline infusion sonography with office hysteroscopy for the evaluation of the endometrium.

OBJECTIVE: Intrauterine infusion of saline solution during transvaginal ultrasonography enhances visualization of the endometrium. We compared the accuracy and pain rating of saline infusion sonography with those of flexible office hysteroscopy. STUDY DESIGN: The uterine cavities of 130 patients with abnormal bleeding were evaluated by two physicians in an office setting. Findings of endometrial polyps, submucous myomas, synechiae, endometrial hyperplasia, or cancer were recorded independently and subsequently compared. Patients rated their pain after each procedure. RESULTS: Both procedures were performed in 113 of 130 patients. With saline infusion sonography pathologic findings were identified in 61 patients (54%). For all findings combined, sensitivity was 0.96 and specificity was 0.88, compared with hysteroscopy. The results of saline infusion sonography and hysteroscopy did not differ significantly (p = 0.18). The former was less painful for patients than hysteroscopy (p < 0.0001). CONCLUSION: Saline infusion sonography is an accurate and well-tolerated method to evaluate abnormal uterine bleeding, compared with hysteroscopy.

Gynecologic history of women with inflammatory bowel disease.

OBJECTIVE: To describe the gynecologic history of women with inflammatory bowel disease. METHODS: Questionnaires were sent to the 1000 women age 20-60 who had been hospitalized for inflammatory bowel disease at the Cleveland Clinic Foundation during 1989-1993. There were 692 responses, and those from 662 women who had undergone surgery for inflammatory bowel disease were analyzed. Of the 117 women who had undergone hysterectomy, 85 responded to follow-up questionnaires. RESULTS: Three hundred sixty women had Crohn disease, 251 had ulcerative colitis, and 51 had inflammatory bowel disease of indeterminate or unknown type. Menstrual abnormalities were reported by 58%. Symptomatic vaginal discharge, reported by 40%, was more likely to occur in those with Crohn disease than with ulcerative colitis (odds ratio [OR] 2.09, 95% confidence interval [CI] 1.47-2.99; P < .001). Infertility was reported by 25% of the women in this series. Abdominal pain with sexual intercourse (50% overall) was more common in women with Crohn disease than in those who had ulcerative colitis (OR 1.64, 95% CI 1.13-2.40; P = .01), but pain with penetration (55% overall) did not differ statistically by type of inflammatory bowel disease. Half of the women reported the loss of pleasure or desire for sex. Ovarian cysts had been diagnosed in 39% of women and resulted in surgical treatment in 57% of these. One hundred seventeen women (18%) had undergone hysterectomy, 52 (44% of total) at age 35 or younger. CONCLUSION: Gynecologic conditions are common in women with inflammatory bowel disease, including menstrual abnormalities, vaginal discharge, infertility, and gynecologic surgery. All physicians providing care for women with inflammatory bowel disease should be familiar with the frequency and nature of concurrent gynecologic conditions.

State-of-the-art flexible hysteroscopy for office gynecologic evaluation.

STUDY OBJECTIVE: To evaluate office flexible hysteroscopy without anesthesia with regard to pain, inconvenience and cost. DESIGN: A survey of patients to evaluate the level of pain they experienced during office hysteroscopy, and a comparison of costs for these procedures with those of hospital dilatation and curettage. SETTING: Office-based hysteroscopy suite in the outpatient building of a tertiary institution. PATIENTS: Women referred to this institution for gynecologic evaluation between February 1992 and December 1993. INTERVENTION: Diagnostic flexible hysteroscopy without anesthesia, cervical dilatation, or paracervical block. MEASUREMENTS AND MAIN RESULTS: A total of 417 women (mean age 42 yrs, range 16-84 yrs; 78 postmenopausal) were referred for evaluation during the study period. The most common indication for referral was abnormal uterine bleeding (86%). Hysteroscopy could not be completed in 29 women (7%), primarily because of cervical stenosis. Pain ratings obtained from 387 patients were as follows: easily acceptable discomfort, minimal discomfort during procedure, 133 (34.5%); acceptable discomfort, uncomfortable but easily bearable, 86 (22.2%); tolerable discomfort, equivalent to menstrual cramps and spasms, 106 (27.4%); barely tolerable pain, tolerable for short time only, 48 (12.4%); and intolerable pain, severe enough to stop the procedure before completion, 14 (3.6%). A single adverse event, a postprocedure temperature elevation, was easily treated with oral antibiotics. No pathology was identified in 183 (43%) of the women; 95 (22%) had polyps and 90 (21.5%) had fibroid tumors. The average duration of a procedure was 5 minutes. The charge for office hysteroscopy was $475. CONCLUSION: Flexible office hysteroscopy without anesthesia was well tolerated by the majority of the women. In addition, the procedure is far less expensive and time consuming than when it is performed in an operating room. We believe that it is a safe, well-tolerated, and cost-effective procedure of great diagnostic value.