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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. (Am J Obstet Gynecol 2001;185:507-13.)

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. Follow-up 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.

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.

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.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.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.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.

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.

Objective The study was undertaken to provide consensus guidelines for the management of women with a cytologic interpretation of high-grade squamous intraepithelial lesion (HSIL) on cytologic examination. This review article presents relevant literature supporting the proposed guidelines. Participants An independent panel of 121 experts in various aspects of the diagnosis and management of cervical cancer precursors, including representatives from 29 participating professional organizations, federal agencies, national and international health organizations, and others were invited by the American Society for Colposcopy and Cervical Pathology. Consensus process Guidelines for the management of women with HSIL cytologic results were developed through a multistep process. Draft management guidelines were developed by the HSIL working group after formal literature reviews and obtained input from the professional community at large by way of an interactive internet-based bulletin board. At the American Society for Colposcopy and Cervical Pathology Consensus Conference, September 6 through 8, 2001, in Bethesda, Maryland, the guidelines were discussed, revised, and adopted by formal vote. Conclusions Evidence-based guidelines have been developed for the management of women with HSIL cytologic results.

Diethylstilbestrol (DES), a nonsteroidal estrogen, was widely used in the United States from 1940 through 1971 to prevent pregnancy loss. In the late 1960s, an association was made with an increased incidence of clear cell adenocarcinoma in young women exposed in utero to DES. Additional study of these women over the next 35 years has shown an increased risk of other health problems including intraepithelial neoplasia, ectopic pregnancy, first trimester spontaneous abortion and second trimester pregnancy loss. The National Institutes of Health continues to fund studies to follow cohorts of DES-exposed mothers, daughters, sons and third generation children. The Centers for Disease Control have conducted a large DES Education Project and have established guidelines for management. The following six cases studies illustrate common problems seen in DES exposed daughters and management of problems encountered.

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.

THE INCIDENCE of and mortality from cervical cancer in the United States have decreased dramatically over the past 40 years, in part because of early diagnosis and treatment of cervical cancer precursor lesions. The success of cervical cytological screening has served as a model for early diagnosis of other types of cancer. Although numerous studies have shown that lack of cytological screening is a major risk factor for the development of invasive cervical cancer, 1-3 it is important to emphasize that none of the screening, diagnostic, or therapeutic techniques used in medicine are perfect. Accordingly, a few women will develop cervical cancer despite adherence to accepted screening protocols . In addition, problems inherent with sampling, interpretation, and effective clinical follow-up preclude total prevention of cervical cancer. In recent years it has become evident that the cost and morbidity associated with the detection and treatment of low-grade cervical lesions have escalated, probably

Cervical stenosis is a well-described complication of cervical cone biopsy. Various therapies have been suggested to correct this problem. A case is described in which an abdominal-vaginal approach succeeded after local laser treatment of cervical stenosis failed to establish a patent endocervical canal. (J GYNECOL SURG 5:217, 1989)

We report the case of a 71-year-old woman with advanced squamous carcinoma of the vulva who achieved marked tumor regression following therapy with 5-fluorouracil and mitomycin combined with preoperative radiotherapy. The patient underwent radical vulvectomy. On microscopic examination of the lesion, only a minute intradermal focus of apparently viable squamous cell carcinoma with no connection to the overlying epidermis could be seen. This multidisciplinary approach for advanced carcinoma of the vulva is worthy of further exploration in a larger number of patients.

Florid condylomas from various anogenital sites were examined for the presence of papilloma viruses ( HPVs ) using DNA hybridization techniques. All the condylomas contained HPV DNA, but genetic variability was detected in the form of HPV types, subtypes, and possible recombinants. Morphologically similar lesions contained heterogeneous viral populations. Variation was also detected among the HPV genomes in a single patient, indicating the complex etiology of this disease.

The concentration of a solution of bovine albumin was adjusted so that its spectral absorption was essentially the same as a sample of normal amniotic fluid whose total protein content was 0.20 Gm. per 100 ml. Known amounts of protein bilirubin were added to 10 samples of the bovine albumin solutions and the log ΔO.D. 450 and O.D. 450 were determined. A constant relationship between these measurements was observed and the log ΔO.D. 450 was then related to the known concentrations of protein bilirubin by a specific correction factor. This factor was used to determine the bilirubin concentration of pathologic amniotic fluid samples.

SINCE Liley's introduction of fetal transfusion, 1 there has been a complete revision of thought regarding the management of erythroblastosis fetalis. The following two patients illustrate an additional benefit heretofore unreported. In these patients, in utero transfusion eliminated the necessity of postdelivery exchange transfusions. Further, utilization of a new technique for localization of the fetal peritoneal cavity may significantly reduce the risk of fetal damage. These cases also point to the need for establishing new standards for such procedures, for undoubtedly such cases are more common than one is made to think from reviewing the literature. A review of the literature is included. Report of Cases Case1.—A 34-year-old gravida 4 para 3, was first examined in October 1965. Her last menstrual period was on Aug 5, 1965. Physical examination confirmed the presence of an intrauterine gestation consistent with the period of amenorrhea. Laboratory examination revealed type A blood