A prospective randomized study between cryosurgical endometrial ablation and rollerball ablation was performed in over 200 premenopausal women. Preoperative evaluation included endometrial biopsy as well as pelvic ultrasound. Half of the patients who had cryoablation had light sedation and paracervical block as anesthesia. All patients who had cryoablation had pelvic ultrasound to monitor the progress of the ice-zone. Post operative, mild cramps were noted in less that 1/4 of the cryo-treated patients, Significant vaginal dischrge did not occur in any of the cryosurgical treated patients. At 12 months after treatment 44% of the women managed by cryosurgery had only amenorrhea or spotting.Four sites that performed over half of the cases had an amenorrhea or spotting rate of 54%. When the first cryosurgical session was longer that the protocol required 67% had a 90% reduction in their bleeding.The results of this study demonstrate the ease, effectiveness and safety of cryosurgical endometrial ablation in managing women with menomenorrhagia.

Between January 1960 and December 1982, 142 patients with carcinoma in situ of the vulva were treated at Cedars-Sinai Medical Center and UCLA Medical Center. Primary treatment consisted of wide excision in 45 patients; vulvectomy in 23 patients; topical chemotherapy in 9 patients; and CO2 laser therapy in 42 patients. Twenty-three patients were also treated with the CO2 laser for recurrent disease. Multifocal disease was present in 59% of the cases. Lesions involving the posterior vulva recurred most commonly, for both initial and recurrent disease. Results utilizing the CO2 are compared with the other methods of treating carcinoma in situ of the vulva. The CO2 laser is well suited for treatment of both multifocal and unifocal vulvar lesions, as it allows for maximal retention of vulvar integrity with no decrease in therapeutic efficacy.

Eighteen patients with advanced epithelial ovarian cancer were given 36 courses of cis-platinum-containing chemotherapy at Cedars-Sinai Medical Center. Patients were given lorazepam (Ativan) prior to chemotherapy. Amnesia for the day of chemotherapy was reported in 29 courses. Lack of recall for the chemotherapy infusion and the subsequent 8 hr or greater was reported in 33 of the 36 courses. In two courses, no amnesia effects were noted. No serious side effects of lorazepam therapy occurred and all patients believed that the amnesic effect was beneficial during chemotherapy. Lorazepam (Ativan) appears to be a safe medication to induce amnesia for cis-platinum chemotherapy and deserves further study to determine its effect on anticipatory vomiting, nausea and vomiting, and patient compliance with continued chemotherapy.

Among women exposed in utero to diethylstilbestrol (DES) and enrolled in the Diethylstilbestrol Adenosis (DESAD) Project, structural anomalies of the cervix or vagina were found in 25% of the 1,655 subjects identified by review of prenatal records, 43% of the 800 who themselves requested entry into the project, and 49% of the 1,089 referred by physicians but in only 2% of the 963 control subjects. Among the 367 cases found by record review to have complete information on the DES exposure, multivariate analysis indicated close association of the anomalies with the gestational week of first exposure and the total dose. Also, the prevalence rate of the anomalies was lower among subjects who had been pregnant and higher among those with later age at menarche.

Two hundred patients with cervical intraepithelial neoplasia were treated alternately by cryotherapy and carbon dioxide laser therapy on an outpatient basis after appropriate triage with colposcopy, cervical biopsy, and endocervical curettage. Results of treatment were not significantly different from one another, with failure occurring in 7% of patients treated with cryotherapy and 11% of those treated with carbon dioxide laser therapy. The cryotherapeutically treated patients had less pain but more discharge than those treated by the carbon dioxide laser. The laser patients' cervices healed more rapidly than did the cervices treated with cryotherapy. There appears to be no advantage in replacing cryotherapy with carbon dioxide laser therapy.

A total of 452 women with documented exposure in utero to diethylstilbestrol (DES) with epithelial findings present at the time of their initial examination have been evaluated prospectively to determine whether these findings changed over a period of 3 years. The examinations were all performed according to a strict protocol. Findings present at the time of the third annual examination were verified at a fourth examination. A verified decrease in the extent of epithelial findings occurred in 29.2% of these women and a verified increase in 6.6%; 53.1% had no change in the extent of epithelial findings, and 11.1% had a change that could not be verified at the time of the fourth visit. Analysis of many variables failed to identify a strong association between any variable and a decrease in the extent of the findings. It appears that the most important factor in the occurrence of changes in DES-associated findings is the passage of time.

We reviewed 65 intraepithelial lesions of the vulva and distal vagina and compared the presence of koilocytosis, abnormal mitoses, and parabasal or basal nuclear enlargement with DNA microspectrophotometric distribution patterns and the presence of human papillomavirus antigen as determined by immunoperoxidase. Abnormal mitoses and cytologically atypical nuclear enlargement were specific predictors of aneuploidy and were reliable for distinguishing vulvar intraepithelial neoplasia (VIN) from condylomas. Koilocytosis was present in 100% of condylomas and 71% of aneuploid (VIN) lesions, but there were qualitative and quantitative differences in the distribution of koilocytic cells in the two classes of lesions. On the basis of these findings, criteria for distinguishing between VIN and condyloma are proposed.

The reintroduction of colposcopy and the introduction of outpatient therapy have significantly altered the management of the woman with an abnormal Pap smear. Routine conization is no longer considered mandatory, particularly for the lower grades of CIN. We estimate that over 10,000 gynecologists in North America have received instruction in colposcopy. Virtually every teaching hospital and medical center has colposcopy available. It is a valuable evaluative tool, particularly with the increasing risk of CIN in young women and the fact that more women are delaying childbearing until the third and fourth decades of life. The technique does, however, require a rigorous period of training, significant experience, and strict adherence to an established evaluation protocol. In the hands of the neophyte, the consequences of in-appropriate evaluation of the woman with an abnormal Pap smear can be tragic.

Fourteen cases of primary carcinoma of the Bartholin gland were treated between 1955 and 1980. Follow-up information was available on all patients. Ten patients have survived free of disease for 5 or more years. Three patients with positive inguinal lymph nodes have survived 5 years. Histological patterns and lymph node involvement are analyzed. The authors' data and a review of the literature support the concept that radical vulvectomy with bilateral inguinal-femoral lymphadenectomy is required for all histologic types of Bartholin gland carcinoma. Routine pelvic lymph node dissection is not necessary when the inguinal-femoral nodes are negative for metastases.

Thirty-three patients with vulvar intraepithelial neoplasia were treated with the carbon dioxide (CO2) laser. In 31 of these patients the lesion was completely eradicated by the laser treatment. All patients experienced moderate pain following the procedure, and 2 had severe pain. The only other complications were 1 case of bleeding and 1 of infection. The CO2 laser appears to be an acceptable treatment modality for vulvar cancer precursors provided patients are carefully evaluated prior to treatment and invasive carcinoma is ruled out.

Thirty-six patients with vaginal intraepithelial neoplasia were treated with the carbon dioxide laser. More than half of the patients had grade 3 vaginal intraepithelial neoplasia (carcinoma in situ). The majority of patients were treated in a single session; six patients were treated twice, and two patients were treated three times. In 92% of the patients, the lesions were completely removed by the laser without significant side effects.

There is a premium placed upon the detection of cervical squamous cell cancer precursors in their earliest stages as they are most amenable to nonsurgical management techniques in the early stages and the risk of missing an invasive cancer is substantially reduced. For the patient with an abnormal Papanicolaou smear, examination by a skilled colposcopist followed by multiple punch biopsies of the colposcopically abnormal areas and a thorough endocervical curettage is the diagnostic method of choice unless the patient is pregnant or there are other contravening clinical factors. The patient with a lesion with a size and distribution which makes it amenable to outpatient therapy and in whom invasive cancer has been excluded may be treated by a variety of outpatient modalities, including hot cautery, cryotherapy, or carbon dioxide laser. These techniques appear to be equally effective, and the patient appears to have a relatively low risk of developing a new lesion once the original disease has been eradicated and she has had three negative Papanicolaou smears.

In this study, 59 vulvar intraepithelial squamous neoplasms (8 atypia and 51 carcinoma in situ) and 33 invasive squamous carcinomas were analyzed for their nuclear DNA content using Feulgen microspectrophotometry. Four cases of atypia had a polyploid DNA distribution. The remaining 4 cases of atypia and all cases of carcinoma in situ had an aneuploid pattern, and nearly two thirds of these had high ploidy stem cells (greater than 3N). This is in contrast to the low ploidy stem cells (less than 3N) seen in 70% of the invasive carcinomas and in 82% of the intraepithelial neoplasms in the vicinity of invasive carcinomas. This observation suggests that not all vulvar intraepithelial neoplasms have the same propensity to become invasive. Invasive carcinomas of comparable size and depth of invasion with low ploidy stem cells had a higher frequency of lymph node metastasis than those having high ploidy stem cells. The significance of nuclear DNA findings related to gynecologic neoplasms is discussed.

Fertility and outcome of pregnancy were examined in women participating in the National Cooperative Diethylstilbestrol Adenosis (DESAD) Project. We compared 618 subjects who had prenatal exposure to DES with 618 control subjects. Fertility, measured in terms of pregnancies achieved, did not differ between the women exposed to DES and the controls. An increased risk of unfavorable outcome of pregnancy was associated with DES exposure (the relative risk of any unfavorable outcome of pregnancy was 1.69; P less than 0.001). Speculation on biologic mechanisms that might produce this difference is premature, since additional data about these subjects must be collected. Among DES-exposed women who became pregnant, 81 per cent had at least one full-term live birth.

Two thousand eight hundred thirty-nine patients who had been treated by cryotherapy for cervical intraepithelial neoplasia (CIN) in nine different institutions were followed longitudinally after three negative Papanicolaou smears to ascertain the risk of recurrence. The cumulative risk of developing CIN after successful cryotherapeutic management of CIN was 0.41% at year 5, 0.44% at year 10, and 0.44% at year 14. There was no significant difference in risk between patients originally treated for CIN 1, CIN 2, or CIN 3.

A review of 41 evaluable patients was made in order to study vaginal intraepithelial neoplasia (VAIN) and to investigate new methods of treatment. Colposcopic examination of the vagina revealed white epithelium alone in 20 patients and white epithelium associated with vascular punctation in 15. No lesion had a vascular mosaic pattern. Most patients had multifocal disease located in the vaginal apex. Iodine staining was positive in six patients with negative colposcopic examinations. Twenty-four patients had severe dysplasia or carcinoma in situ, and 17 had minimal or moderate dyplasia. Associated genital disease occurred in 17 patients with antecedent cervical or vulvar squamous neoplasia, and six additional patients had coexistent lesions. The chronology of vaginal disease that appeared after treatment of cervical neoplasia suggests a persistent but decreasing likelihood of the development of VAIN with the passage of time. In patients followed without therapy, six had spontaneous remission of disease. Treatment was successful in 12 of 15 patients with topical 5-fluorouracil and in nine of 10 patients with the carbon dioxide laser. The advantages of these methods of treatment for patients with VAIN relative to surgical procedures and radiation therapy are considered.