Colposcopy, cervicography, speculoscopy and endoscopy. International Academy of Cytology Task Force summary. Diagnostic Cytology Towards the 21st Century: An International Expert Conference and Tutorial.

ISSUES: The colposcope was developed in 1925 and is well established in clinical gynecologic practice for defining and delineating cytologically detected lesions mainly of the cervix but also the vagina and vulva. Additionally, various endoscopic procedures in gastroenterology, pulmonary and urologic lesions enhance the cytologic detection and histologic verification of precancerous and cancerous lesions. The cost-effectiveness of all these devices and their applicability, particularly in countries with a limited health budget, is a major issue. This task force considered aspects of the present state of the art and the challenges in the 21st century. CONSENSUS POSITION: Automated cytology can interface with colposcopic examination in a number of significant ways. Automated cytologic analysis of conventional cervical smears can potentially direct colposcopic examination by predicting the nature of a lesion, assist in determining which patients should receive colposcopy and, in some settings, thereby reduce the number of colposcopies. Potentially, various combinations of automated cytology and colposcopy may be used to generate screening protocols that might result in more effective and inexpensive screening. The role of cervicography, or high-resolution cervical photography, as a screening device remains to be defined. Sensitivity for high grade lesions is generally no greater than that in cytology, and specificity appears lower. The interpretation of cervical photographs in triage of mildly abnormal cytology may prove to be useful in countries with established cytology programs. In areas of the world where cytology screening programs are not in place, the interpretation of cervical photographs may have its most dramatic effect. Cost-effectiveness analyses are needed. There are, at present, insufficient data for the evaluation of speculoscopy, a procedure using chemiluminescent illumination of the cervix for visualization of acetowhite areas. Basic training in colposcopy should be integrated into the residency programs of obstetrics and gynecology. Criteria for the adequate training of colposcopists should be developed. Continuing education programs in colposcopy should be developed when they are not already in existence. The cost-effectiveness of integrating colposcopy as a primary screening technique should be evaluated. Following a high-grade squamous intraepithelial lesion (HSIL) cytology result, colposcopically directed punch biopsy should be taken with or without endocervical curettage. This generally should precede the loop electrosurgical excision procedure (LEEP); however, in certain circumstances direct LEEP may be indicated. LEEP under colposcopic vision is an efficient way to treat an HSIL lesion of the cervix because the histologic extent and margins can be determined, unlike with laser surgery or cryosurgery. It is also more cost-effective than cold knife conization because general anesthesia and an operating room are unnecessary. Following LEEP, the endocervical canal should be examined colposcopically for any evidence of involvement. Lesions in the endocervix can then be removed with a different-shaped loop. Further research into Raman spectroscopy as a diagnostic aid in cervical pathology is needed, as is the use of micrococolpohysteroscopy for in vivo cytologic analyses, especially of the endocervical canal and transformation zone. Hysteroscopy is the most direct method for the diagnosis and treatment of intrauterine diseases. Hysteroscopic endometrial biopsy is more accurate than conventional biopsy methods. Cervical invasion of endometrial cancer can be detected by hysteroscopy. The depth of invasion, however, is more accurately determined by magnetic resonance imaging or computed tomography. ONGOING ISSUES: Many topics for ongoing research and/or implementation are mentioned under "Consensus Position," above. (ABSTRACT TRUNCATED)

Fatty acids in the subcutaneous adipose tissue of intensively fed SA Mutton Merino and Dorper wethers.

Recent ambiguity about the role of animal fat in causing coronary heart disease, coupled with the controversy regarding the effect of various levels of energy nutrition on ruminant depot fats, prompted an investigation into the influence of high-energy nutrition, breed and slaughter weight on the fatty acid profiles of ruminants. Two isonitrogenous and isomineral diets containing 11·76 MJ ME/kg DM and 10·18 MJ ME/kg DM were fed to Dorper and SA Mutton Merino wethers of ± 20 kg to 37 and 43 kg live weight. Subcutaneous fat samples and feed samples were collected for fatty acid analysis. Treatment significantly affected the subcutaneous fatty acid profiles of wethers, which includes C15:0, C16:0, C17:0, C17:1, C18:0, C18:1, C18:2 and C18:3. Treatment also influenced the concentration of saturated and unsaturated fatty acids in the subcutaneous adipose tissue as well as the concentration of trans-fatty acids. The results obtained suggest that dietary energy levels may significantly affect the fatty acids in the subcutaneous fat of wethers. Breed differences, after correcting for carcass fatness, occurred in C16:0.

Fatty acid composition of subcutaneous fat of sheep grazed on eight different pastures.

The levels of eight long chain fatty acids (14:0, 16:0, 16:1 17:0, 17:1, 18:0, 18:1, 18:2) were measured in the subcutaneous fat of S.A. Mutton Merino wethers (5 months old, 20-25 kg live mass, 8 per treatment) and, including 18:3, in eight pastures grazed for 84 days (maize stubble, Z. mays; Triticale; L. multiflorum; L. perenne; D. glomerata; D. eriantha; C. dactylon; M. sativa). Respectively, percentage fatty acid contents of subcutaneous fat and pastures were 14:0 5·04 ± 0·86 and 0·67 ± 0·37, 16:0 22·85 ± 0·81 and 17·83 ± 3·00, 16:1 2·07 ± 0·22 and 2·42 ± 1·17, 17:0, 1·68 ± 0·04 and 0·42 ± 0·16, 17:1 0·75 ± 0·06 and 0·17 ± 0·19, 18:0 25·94 ± 2·02 and 4·95 ± 1·68, 18:1 32·27 ± 0·93 and 8·12 ± 11·70, 18:2 1·59 ± 0·36 and 15·89 ± 5·16, 18:3 measured in pastures only 34·51 ± 15·91. The palmitoleic acid (16:1) content of pastures increased (P < 0·05) as the ether extractable lipid content of the pastures increased. Pasture treatments influenced the levels of 14:0, 17:1 and 18:2 highly significantly (P < 0·01) and of 18:0 significantly (P < 0·05). Increasing levels of fatness of ribcut samples were associated with a decrease in 14:0 and an increase in 17:1 (P < 0·01) and an increase in 18:2 (P < 0·05).

Some aspects of superovulation and fertilisation of Dorper sheep.

Response of Dorper sheep to treatment with FSH and PMSG and fertilisation after natural service, natural service following application of PGF2 alpha-containing gel on the posterior os cervix and surgical insemination with fresh semen were evaluated. FSH gave a significantly (P greater than 0.05) better response than PMSG. No significant differences between the different methods of fertilisation were observed.

Treatment of vaginal candidiasis in pregnancy with a single clotrimazole 500 mg vaginal pessary.

A single vaginal pessary containing clotrimazole 500 mg (Canesten; Bayer-Miles) was used to treat candidiasis during a prospective, mycologically controlled trial among 46 patients in the second and third trimesters of pregnancy. Positive cultures were obtained from vaginal swabs before commencement of treatment. Swabs were taken 1 week and 1 month after treatment. Four patients were lost to follow-up. One week after treatment 83,3% of the patients were cured on microscopic and mycological examination, and all of the patients had relief of symptoms. The recurrence rate was 5,7% after 1 month. Of the 7 patients in whom treatment was unsuccessful, 3 were available for repeat treatment and all 3 responded successfully to a second course.

[New evidence regarding the etiology and pathogenesis of true hermaphrodites]. / Nuwe kennis met betrekking tot die etiologie en patogenese van ware hermafrodiete.

New evidence has become available regarding certain aspects of the aetiology and pathogenesis of true hermaphroditism. It is evident that the presence of a Y-chromosome in the karyotype of the true hermaphrodite predisposes to the formation of a testis on the one side and an ovary or an ovotestis on the other side. The presence of 46,XX-chromosome complement, however, more commonly results in an ovotestis on the one side and an ovary on the other side. The formation of an ovotestis is possibly due to a difference in the presence of H-Y-antigen in the cells of the ovarian and the testicular portion. The development of the Müllerian and Wolffian ducts is much more interdependent than has previously been known. No cases have been described where two ducts, both of Wolffian and Müllerian origin, were found next to an ovotestis. In humans, fetal androgen does not change hypothalamic activity to a monophasic pattern or produce male sexual behaviour, according to the evidence found in the true hermaphrodites investigated by us.

[The value of hysteroscopy as a gynecological diagnostic procedure]. / Die waarde van histeroskopie as ginekologiese ondersoekprosedure.

There is a worldwide interest in the use of hysteroscopy in the practice of gynaecology. For this reason a prospective study has been undertaken on 168 randomly selected patients admitted to the gynaecological wards to evaluate its usefulness. Pre- and postmenopausal abnormal uterine bleeding were the main indications for evaluating these patients. The picture obtained by hysteroscopic examination was carefully correlated with the histopathological diagnosis in each case. In only 7% of cases the hysteroscopic diagnosis differed from that obtained by histological examination of the endometrium. In 1,8% of cases a hysteroscopic investigation could not be done because of active intra-uterine bleeding. Hysteroscopy could be performed as successfully under paracervical block as under general anaesthesia. The conclusion reached was that hysteroscopy is a most important adjunct in the investigational armamentarium of a gynaecologist.

The gonads of human true hermaphrodites.

Gonadal distribution in 409 cases of human true hermaphroditism is reviewed. An ovary was found on the left side of the body in 62.8% of the cases and the testis on the right side in 59.5%. The ovotestis is the most common gonad of the true hermaphrodite; amongst 806 gonads in 406 cases it was found in 44.3%. In this paper we give a detailed description of the morphology of ovotestis, testis and ovary in the true hermaphrodite. In addition we discuss the effects of fetal androgens and Müllerian inhibiting factor on the Wolffian and Müllerian ducts. Correlations between chromosomal complement and gonadal distribution are presented. True hermaphrodites with a 46,XX karyotype most commonly have an ovary on one side and an ovotestis on the other side; those with a Y-chromosome have a testis in 61% of cases. An analysis of the ratio of ovarian and testicular tissue within ovotestes showed a continuum from very little ovarian tissue to a small portion of testicular tissue. Each type of tissue was clearly demarcated. Hypotheses for gonadal induction in the true hermaphrodite should take cognizance of these facts. True hermaphrodites with a 46,XX chromosomal complement were characterized by a male phenotype in 54% of cases. This group may suggest a greater testicular induction ability in the genome as compared to the 46% with a female phenotype.

Danazol in the treatment of endometriosis externa.

Thirty-six women with endometriosis externa were treated with danazol (Ladogar; Winthrop Laboratories, Division of Sterling Drug (SA) (Pty) Ltd) for 6 months. In 15 cases treatment was combined with conservative surgery. Of these patients 34 presented with the complaint of infertility. The results were evaluated by means of repeat laparoscopy and biopsy. Of 21 patients treated with danazol only 9 (42,9%) were completely healed, and 10 (47,6%) showed a good response, giving an overall response of 90,5% and a corrected conception rate of 52,9%. Of the 15 patients who were treated with danazol combined with conservative surgery, 9 (60%) have completely healed, and 3 had a recurrence of endometriosis. This group had a corrected pregnancy rate of 30,8%. The majority of conceptions (61,5%) occurred during the first 6 months after treatment, 92,3% within the 1st year and 1 a year after conclusion of treatment. Of the 13 conceptions, 11 were successful, 1 ended in an abortion and 1 in an ectopic pregnancy, and 1 small-for-gestational-age infant was delivered.

Chromosome changes in 17 human neoplasms studied with banding.

Chromosome abnormalities from 17 malignancies that were studied using direct preparations and G-, Q-, and C-banding methods are presented and the findings assessed. The material used was from 6 primary cervical carcinomas, 5 primary and metastatic ovarian carcinomas and 6 other metastatic carcinomas. In general, chromosome 1 was found to be involved more frequently than the others in structural aberrations. These included short arm deletions--the most frequent marker over all the cases--long arm deletions, long arm duplications and various translocations including more complex rearrangements involving different breakpoints. Altogether ten common markers were identified among the cases, of which two were shared between two cervical carcinomas and two more, between a pair of ovarian carcinomas. The evidence in this report is in agreement with the finding of widespread involvement of chromosome 1 in malignancy, but with a particular preponderance in ovarian carcinoma.

Chromosomes and the gynecologist.

Recent advances in cytogenetic techniques made a valuable contribution toward the modern practice of obstetrics and gynecology. The state of the art regarding the application of these techniques is reviewed in the following areas: the clinical features related to the various sex and autosomal chromosomal anomalies, the cytogenetics of gynecologic malignancies, the chromosomal analysis of spontaneous abortion and of parents with habitual abortions. Chromosome studies in male infertility revealed abnormalities in 11.5 per cent of 69 patients with azoospermia and 9.1 per cent of 165 patients with oligospermia. Among 77 patients with primary amenorrhea, 27.3 per cent revealed chromosomal abnormalities compared to 3.8 per cent in 103 patients with secondary amenorrhea. The term "ovotesticular dysgenesis" is used for the first time in the literature to describe a specific histologic type of streak gonad which contains ovarian stroma and dysgenetic testicular tubules.

Cervical cytologic screening among females with nongynecologic hospital admissions.

Routine vaginal cytologic screening in nongynecologic admissions to Tygerberg Hospital revealed a detection rate for pelvic neoplasia of 9.3/1000 patients. Of these, 22 (16%) did not derive any benefit from this program because of the severity of the primary extrapelvic disease. However, 57% of those detected were still in the in situ stage and should have a 100% 5-year survival. The treatment was considered to be complete in 54.4% of the cases. As this service is performed by nursing personnel as part of their daily duty, this program seems to be a sound economic proposition.

Comparative contraceptive experience with three-month and six-month medroxyprogesterone acetate regimens.

Three-month (150 mg) and six-month (450 mg) contraceptive regimens of medroxyprogesterone acetate (DMPA) as an intramuscular depot injection are compared in this paper. A total of 19,875 women participated in the study, accounting for 220,530 woman-months of use. A Pearl index of 0.1069 for the three-month regimen was significantly lower than for the six-month group, where the index was 0.4943 (p less than 0.01). Side effects were limited insofar as personal reasons and loss to follow-up were the most important single category for discontinuation of this contraceptive method. No thrombotic incidents occurred. It is concluded that both contraceptive regimens of DMPA appear to be acceptable with regard to use-effectiveness, patient acceptance and prevalence of side effects.

True hermaphroditism: an analytic review with a report of 3 new cases.

Three new cases of true hermaphroditism are described: a 14-year-old patient with a testis on one side and an ovotestis on the other side and a 11-year-old patient as well as a 6-year-old patient both with an ovary on the one side and an ovotestis on the other side. Twenty-four cases, which were personally investigated, were previously reported. Therefore, this analytic review is based upon the author's experience of 27 cases as well as 340 cases reported in the world literature since 1899. The presenting symptoms and age of diagnosis are discussed. Apart from ambiguous genitals, the development of breasts in a patient reared as male is an important presenting symptom. The variations found regarding the external and internal genitals are described. An ovotestis is the most common gonad found in true hermaphroditism. Among 116 ovotestes available for analysis, 46 per cent are located in an ovarian position, 26 per cent in the labioscrotal fold, 24 per cent in the inguinal canal, and 4 per cent in the internal inguinal ring. Evidence of ovulation is found in 50 per cent of ovotestes. Spermatogenesis has not been observed in the testicular portion of an ovotestis. Spermatogenesis was present in only 12 per cent of testes found in true hermaphroditism. Dysgerminomas occur with a frequency of 1.3 per cent. A fallopian tube and a vas deferens were never found together next to an ovotestis. Cytogenetic findings are reported in 115 cases of true hermaphroditism, including the cases described in this paper. A 46,XX chromosomal complement is the most common finding, occurring in 57.4 per cent of cases. It is interesting that 42.6 per cent showed no evidence of a Y chromosome. With the use of the fluorescent technique in metaphase chromosomes as well as the Y chromatin body in interphase cells, no Y chromosome was detected in the three new cases reported here. The various possibilities for the development of testicular tissues in the absence of a Y chromosome are discussed. In the diagnosis of true hermaphroditism the palpation of an ovotestis with a soft testicular portion and a firm ovarian portion is stressed. As far as the treatment of true hermaphroditism is concerned, the external genitals should be changed according to the gender identity which usually correlates with the sex of rearing.

Clinical and cytogenetic aspects of the 21 deletion syndrome.

The clinical, cytogenetic and dermatoglyphic findings in a patient with a ring chromosome 21 are presented. This anomaly acts as a deletion of chromosomal material and results in specific congenital defects. A comparison is made with 24 cases of deletions involving chromosome 21 described in the literature. Six of these have been studied by means of recently developed chromosome banding techniques. Cases presumably arise through somatic non-disjunction or chromosome breakage. When the chromosomes of both parents are normal the recurrence risk is negligible.

[Problems with reference to genetic counseling in arthrogryposis multiplex congenits]. / Probleme met betrekking tot genetiese voorligting vir arthrogryposis multiplex congenita

Arthrogryposis multiplex congenita (AMC) is a rare condition, which presents various problems to the genetic counsellor. Two cases are described and the possible modes of inheritance are discussed. A review of the literature in this respect favours an autosomal recessive inheritance which is, however, not applicable to all cases.

Oligozoospermia: a seven-year survey of the incidence, chromosomal aberrations, treatment and pregnancy rate.

No sperm count should be regarded too low to consider extensive treatment in order to improve semen or to correct any possible abnormalities in femal partners. The infertile couple should be given devoted care and advice to improve their sexual relations and their psychological attitude towards the problem of infertility. A pregnancy rate of 51.9% where the husband's count was less than 10 million/ml, offers adequate support for this statement. In cases of mental trauma inflicted on patients by a verdict of inability to achieve parenthood--on people who have already suffered severe psychological shock and tension resulting from a period of infertility--discouragement lessens the already doubtful chances of achieving pregnancy. In no circumstance should oligozoospermic patients receive treatment for infertility unless a chromosomal analysis has been completed and found normal, since our rate of chromosomal anomalies (11.4%) in a group of oligozoospermic patients is considered to be too high.