Natural history of vaginal intraepithelial neoplasia.

The natural history of vaginal intraepithelial neoplasia (VAIN) was studied in 23 patients followed for at least 3 years with no treatment. The mean age of the patients was 41 years of age. A large proportion of the VAIN lesions (50%) were multifocal, and approximately one half of the lesions were associated with concomitant cervical or vulvar intraepithelial neoplasia. Progression to invasive vaginal carcinoma occurred in two (9%) cases, persistence of VAIN occurred in three (13%) cases, and regression of VAIN occurred in 18 (78%) cases. The risk for progression to invasive carcinoma emphasizes the significance of colposcopic examination of the vagina with directed biopsy specimens obtained from all lesions.

Persistence of chlamydial antibodies after pelvic inflammatory disease.

The persistence of chlamydial immunoglobulin G (IgG) antibodies and long-term sequelae of pelvic inflammatory disease (PID) were studied in 70 women who had been treated for PID 3 to 6 years previously. Fifty-one women had had PID associated with Chlamydia trachomatis infection (Chlamydia group), and 19 women had had PID not associated with C. trachomatis (non-Chlamydia group). Chlamydial IgG antibodies, as determined by the indirect immunofluorescence test with inclusions of C. trachomatis L2 as antigens, persisted at stable levels in 43% of the women for up to 6 years; 43% of the women showed a decrease in IgG titer, and 13% showed an increase. IgA antibody levels in serum correlated with IgG antibody levels in serum and with the presence of cervical IgA antibodies. Both serum antibodies and cervical IgA antibodies were more often found in the Chlamydia group. Forty-two percent of the women were infertile. Every fifth subsequent pregnancy was ectopic. The presence of cervical IgA antibodies might protect the women from tubal damage.

Volatile fatty acid findings in vaginal fluid compared with symptoms, signs, other laboratory results, and susceptibility to tinidazole of malodorous vaginal discharges.

The relevance of volatile fatty acids as a diagnostic test in 79 women with abnormal vaginal discharge was evaluated by a blind, randomised, and placebo controlled trial of tinidazole as a single oral 2 g dose. Automated gas chromatography of ether extracts of discharges taken before treatment showed volatile fatty acids in 18. Volatile fatty acids correlated with malodorous, colour, and microscopically assessed altered bacterial flora and clue cells. At follow up one week later, the odour, colour, and volatile fatty acids in the vaginal discharge of women treated with tinidazole had become normal more often than in those receiving placebo. The disappearance of volatile fatty acids correlated with clinically assessed improvement in women treated with tinidazole. The volatile fatty acid test as an indicator of anaerobic bacterial flora is objective, technically simple and fast, has few problems of sample size and transportation, and may be useful in the aetiological classification and follow up treatment of non-specific vaginal discharges.

Prognostic significance of tissue carcinoembryonic antigen in mild dysplasia of the uterine cervix.

Two murine monoclonal antibodies to carcinoembryonic antigen (CEA) were used to detect CEA by the immunoperoxidase staining method in mild dysplasia of the uterine cervix in order to evaluate the prognostic significance of the expression of this antigen. The high affinity antibodies (Ha) detected CEA determinants in 53% of the 47 lesions studied while 40% of the epithelial changes were positive with the low affinity antibodies (La). Ha antibodies stained ten out of the 16 progressive lesions (62%), while La antibodies detected CEA determinants in 38% of these. Forty-eight per cent of the 23 regressive lesions were CEA positive with Ha and 39% with La antibodies respectively. The eight persistent lesions expressed CEA equally frequently (50%) with both antibodies. The results indicate that tissue CEA in patients with mild cervical dysplasia does not reflect malignant potential.

Topical treatment of flat vaginal condyloma with human leukocyte interferon.

Human leukocyte interferon cream was evaluated in a double blind placebo-controlled trial in 13 patients with widespread vaginal flat condylomatous dysplasia. Patients applied 12 million units of interferon vaginal cream daily into vagina during four two-week treatment courses separated by one-week intervals. Five of eight patients treated with interferon showed clear remissions in colposcopy. Cytologic examinations, however, revealed cells typical of condyloma in all cases. Two responding patients relapsed one and two months after the treatment. Among five patients using placebo, the lesions remained unchanged in three patients and progressed in two. Interferon treatment did not alter the microbiologic or cytologic picture of Papanicolaou smears, but lymphocytic infiltrations in the stroma next to condylomas were seen in histologic samples. No overt side effects were observed during interferon treatment.

Single dose of tinidazole in the treatment of vaginal discharge.

Seventy-nine unselected women whose main symptom was abnormal vaginal discharge were seen at the Department of Obstetrics and Gynecology at Helsinki University Central Hospital between October 1980 and September 1981. All patients and their current sex partners were randomly treated either with a 2-gram single dose of tinidazole or with identical placebos. Those excluded were 9 patients who did not attend the follow-up examination, 15 who had specific cervicovaginal infections (6 with chlamydial infection, 4 with trichomoniasis and 5 with yeast infection), and 22 with normal Döderlein flora seen on vaginal Pap smear. Response to the treatment was analysed among the remaining 33 women, of whom 17 received tinidazole and 16 placebo. The symptoms and signs that best discriminated between those who had normal Döderlein flora and those who had non-Döderlein flora were malodour, other than white colour of the discharge, and the presence of clue cells on Pap smear. When these findings were used to evaluate the response to treatment, tinidazole proved to be more effective than placebo. Disappearance of clue cells best (p less than 0.01) discriminated between tinidazole and placebo.

Condyloma and cervical epithelial atypias in young women.

One hundred and three adolescent women with cervical cytology suggestive of mild to moderate dysplasia were studied for the presence of condylomatous lesion. The analysis of smears revealed cells suggestive of condyloma in 81% of the cases. In histopathologic studies cervical lesions typical of condyloma were observed in 59 preparations. Of these 16 were papillary and 35 were flat condylomas, and in 8 cervices both papillary and flat condylomatous lesions were present. Colposcopic examination showed an atypical transformation zone in 57 cases. Papillary condylomas were present in 24 cervices in 7 cases combined with an atypical transformation zone. In addition to the cervical epithelial atypias there were 18 cases in which colposcopic and histologic examination of vagina revealed papillary warts, 13 of them combined with cervical condylomas. In four patients vaginal leucoplakia was seen and all were histologically flat condylomas. Thus, in 68 cases or in 66% of adolescent women having abnormal cervical cytology, histological investigation revealed condylomatous changes.

Routine cytology as a diagnostic aid in chlamydial cervicitis.

The cytological abnormalities seen in connection with cervical inflammation due to Chlamydia trachomatis are briefly reviewed. Severe inflammatory changes and the occurrence of metaplastic cells and tissue repair cells, which are indicative of severe tissue damage, are common findings in chlamydial cervicitis. However, these changes may also be found in inflammatory states not caused by Chlamydia. Differentiation between the intracytoplasmic inclusions pathognomonic of chlamydial infection and the inflammatory degenerative cytoplasmic formations currently seen in exfoliated cervical cells cannot confidently be made from Papanicolaou-stained specimens. Routine cytology, therefore, is not the proper method for diagnosing chlamydial infection.

[Actinomycosis and IUD's]. / Aktinomykoosi ja kohtuehkäisin.

PIP: The use of IUDs can contribute to the incidence of actinomycosis. Actinomycosis, formerly regarded as a fungal disease, is now known to be caused by bacteria of the genus Actinomyces. The diagnosis of actinomycosis is difficult because the disease usually does not manifest itself in any specific symptoms. The most common diagnostic method uses histological slides. It is difficult to do cultures, and they require good anaerobic techniques. Pap smears are usually reliable but not unambigous since, in a heavy concentration of bacteria, Actinomyces may be mistaken for similar organisms. More specific results can be obtained using immunofluorescence. Before 1973, actinomycosis was considered a rare disease, a secondary one often resulting from an outbreak of appendicitis. Now it is commonly believed that women who have worn a plastic IUD for at least 2 years, and possibly women whose copper IUDs have not been changed for some time, are highly susceptible to actinomycosis. The 1st case of genital actinomycosis was discovered in 1973, with 10 cases reported in 1975 in which the patients had been using IUDs for at least 2 years. In 1979, 2 deaths from genital actinomycosis were reported. Also in 1979, a study reported actinomycosis in 19% of 330 women using IUDs. 1980 study found the disease in 40 of 128 women using plastic IUDs and 2 out of 165 women using copper IUDs for over 2 years. In Finland, physicians have always favored copper IUDs and frequent changes of any kind of IUD. A Swedish physician advocated in 1980 that all plastic IUDs be removed, that copper IUDs be changed frequently, and that no IUD be inserted if any gynecological infection is present. Annual pap smears are advisable and, only where necessary, antibiotics should be taken and IUDs removed. Actinomycosis can be cured with penicillin, tetracyclines, and erythromycin.^ieng

Susceptibility of abortion patients to infection: Correlation to cervical flora.

Cervical bacterial microflora was studied with a semiquantitative method in 29 women both before and after the termination of their pregnancy. The main findings were high prevalence of anaerobic bacteria (in 72%-79% of the specimens) consisting predominantly of Bacteroides species and anaerobic Gram-positive cocci, and low prevalence of aerobic bacteria (in 24%-38% of the specimens). Among the other microbes studied, the prevalence of Chlamydia excretors was high (24%), probably reflecting a promiscuous study population. Seventeen percent of the women developed febrile postabortion endometritis or salpingits. However, the cervical culture results predicted neither the patient prone to infection nor her response to antimicrobial treatment, suggesting the need for more data concerning the virulence properties of the bacteria, together with isolation of the organism from an infected site.

Cytologic findings in cervical chlamydial infection.

A study population of 240 young women who were sexual partners of men suffering from nongonococcal urethritis was investigated to establish whether it is possible, using routine cytology, to identify morphologic changed of diagnostic value in cervicitis due to Chlamydia trachomatis. Nonspecific severe inflammatory cellular atypias were significantly more frequent in the group of 93 C. trachomatis culture-positive women (38%) than in the control group of 147 C. trachomatis culture-negative women (18%). Tissue repair cells, appearing as a result of marked tissue destruction, were fond in 12% and in 3%, respectively. Intracytoplasmic inclusion bodies, pathognomonic of C. trachomatis, were not discovered in smears stained by papanicolaou's method. Hence, routine cytology is not the proper diagnostic method for chlamydial cervical infection. Dyskaryotic changes showing mild dysplasia occurred significantly more often in the C. trachomatis culture-positive women. This observation justifies the assumption that chlamydial infection may play a part in the development of dysplastic epithelial atypias of the cervix.

Management of vaginal agenesis.

Long-term results obtained through different methods of treatment were analysed in a series of 39 patients with congenital absence of the vagina. Thirty-three patients were treated with the McIndoe skin graft technique, 6 of them by the modification of Counseller and Davis. In three patients the neovagina was grafted with amnion and three were treated with the Frank nonoperative method. The result was graded good in 27 and satisfactory in 11 patients. In one patient the McIndoe operation resulted in a complete failure. There was no obvious difference between the results obtained by different methods except for the modification of Counseller and Davis which gave a good result in all cases. Judging from the general appearance and cytological pattern of the artificial vagina a more physiological result was achieved in patients with an amnion graft as compared with those with a skin graft. The nonoperative method is suggested as the first alternative in the treatment of patients with congenital absence of the vagina.

Genital Chlamydia trachomatis infections in patients with cervical atypia.

Of 177 gynecologic outpatients with cervical dysplasia studied, 29 (16%) were found to excrete Chlamydia trachomatis from their urogenital tract. Sera collected from 93 of these patients were significantly more often positive for and showed higher levels of antichlamydial micro-complement fixation (CF) and immunofluorescence (IF) antibodies than sera obtained from the controls. However, when the sera were tested for anti-herpesvirus type II (HSV-II) and cytomegalovirus (CMV) antibodies, no difference between the cases and the controls were encountered.

Oestrogenic activity associated with ovarian cystadenomas after the menopause.

In a group of 59 patients over the age of 55 years with ovarian serous and mucinous cystadenomas, a total of 29 (49%) showed moderate or strong oestrogenic activity as determined by maturation index in vaginal cytologic smears, in contrast to nine (13%) of 70 control patients with other gynecological disorders than ovarian tumours. The bacterial flora was dominated by Döderlein type bacilli in 24 of the 27 test patients with an elevated maturation index, also reflecting the abnormal oestogenic activity in these patients. When the serous and mucinous cystadenoma groups were compared, a striking difference was found: of the 30 patients with mucinous cystadenomas, 23 (77%) displayed moderate of strong oestrogenic activity, while this was the case with only six (21%) of the 29 patients with serous cystadenomas. These findings stress the importance of an abnormal oestrogenic activity, revealed by an elevated cytologic maturation index, as memento for the possibility of post-menopausal ovarian cystadenoma.