Routine Gynecologic Examination Research Articles

The effect of tamoxifen on cervical squamous maturation in Papanicolaou stained cervical smears of post‐menopausal women

Using cervical smears obtained as part of routine gynaecological examinations, a retrospective study of the effects of the drug tamoxifen on squamous epithelial maturation of the cervix of post-menopausal women being treated for advanced breast cancer was made. The degree of squamous epithelial maturation was quantitated by using the Maturation Index and the Maturation Value. Although tamoxifen is a synthetic, non-steroidal compound classified as anti-oestrogenic, the findings indicate that this drug commonly produces a level of squamous maturation indicative of oestrogenic stimulation in Papanicolaou stained cervical smears from post-menopausal patients receiving this drug. Knowledge of the oestrogenic effect of tamoxifen in the cervix can obviate clinical concern about endometrial carcinoma.

Incorporating endovaginal ultrasonography into the overall gynecologic examination

Previously endovaginal ultrasonography was considered an adjunct for use in full-service ultrasound facilities by subspecialists only. The technique, however, has tremendous application for use by the clinician in the examination room for patients at bimanual examination. This is because the procedure is meant to be performed with an empty urinary bladder. It requires very little time once the operator is adequately trained. It provides excellent resolution despite high degrees of magnification. This allows for a distinction between a traditional ultrasound examination and this new concept of examining gynecologic patients with vaginal probe ultrasonography as a part of the routine overall gynecologic examination. Methodology and philosophic issues arising from such a concept are discussed.

The use of fiberoptics in the visual assessment and clinical diagnosis of the endometrium

Essential for a complete reproductive examination of the mare is the inspection of the internal genital organs. Traditionally, a speculum has been used to examine the vagina and cervix. The visual exploration of the uterine body and horns by a speculum is not possible. Just as it is inconceivable that a professional diagnosis can be made without the examination of the vagina and cervix, it is obvious that a more through examination of the female reproductive system is not possible without an endoscopic inspection of the uterine body and horns. Historically, in women, attempts to inspect the uterine lumen were recorded as early as the mid19th century when an instrument with an external light source and resembling a vaginoscope was used to provide a visual inspection of the vagina and cervix. The development of improved optical systems and cold light sources (e.g. fiberoptics) has greatly facilitated the application of this important component to routine and diagnostic gynecologic examinations. In addition, clinical methods that make the internal environment more accessible to the application of the hysteroscope have been improved. For example, the human uterine cavity can be distended with CO a, using a gas insufflation method, permitting an unobstructed view of the inner uterine wall. In human medicine, hysteroscopy is considered an important adjunct to clinical examination and diagnostic evaluation of the reproductive tract and, in some cases, the hysteroscopy serves also as a therapeutic instrument for certain reproductive disorders. In applying the human hysteroscopic procedure to veterinary medicine, the most suitable domestic animal for its adaptation appears to be the mare. The earliest recorded experiments using instruments that facilitated visualizadon of the mare's uterus were performed over 50 years ago. a The

Serous papillary cystadenoma of borderline malignancy of broad ligament. A report of 25 cases.

The clinical and pathological features of 25 serous papillary cystadenomas of borderline malignancy of the broad ligament were analyzed. The ages of the patients ranged from 19 to 67 (average, 32) years. The clinical presentation was lower abdominal pain, pelvic pain or both in five cases, accompanied by menometrorrhagia or amenorrhea in three cases. One patient was thought to have an acute abdominal disorder. The tumors of the remaining 19 patients were discovered either on routine gynecological examination or during an evaluation of the pregnancy status of the patient. In 14 cases the tumor was located in the left broad ligament and in 11 cases it was on the right side; all the tumors were entirely separated from the ipsilateral ovary. On gross examination the tumors were 1-13 cm in greatest dimension, had smooth outer surfaces, and contained straw-colored, watery fluid. The inner lining bore single or multiple 0.3-2.5 cm excrescences. Microscopic examination revealed that the cyst walls and their excrescences were lined by simple to pseudostratified, cuboidal to columnar, focally ciliated epithelium. Slight nuclear atypism, very rare mitotic activity, and focal psammoma body formation were also found. The stroma resembled ovarian stroma but no primary follicles or follicular derivatives were identified. Twenty-three of the patients were alive and well from 0.5 to 11 years after excision of the tumor, one patient was disease-free for 8.5 years but died of an open-heart surgical procedure; and two patients were lost to follow-up examination.

A clinical observation of a program to accomplish pelvic exams in difficult-to-manage patients with mental retardation

Providing routine gynecologic care to patients with mental retardation can be a very difficult task. A program was developed at the University of Michigan to facilitate routine gynecologic examinations of patients with mental retardation so that evaluations could be made without excess physical force or unnecessary inducement of fear. Special techniques allowing for gynecologic examination of mentally retarded women are described. Early experience using intravenous or intramuscular Valium and chloral hydrate was unsuccessful for completion of gynecologic exams without force. As a result, it was necessary to perform eight pelvic examinations under general anesthesia. After instituting a protocol using oral ketamine and midazolam, excellent outpatient sedation was achieved and only 4 of 25 patients subsequently referred for an examination required general anesthesia. The medications were well tolerated and without significant side effects, allowing for discharge home within 60 minutes of achieving effective sedation. A satisfactory gynecologic exam can be accomplished in the vast majority of mentally retarded women while avoiding unnecessary physical and emotional trauma and the need for general anesthesia.

Cytologic anamnesis of patients with invasive cervix cancer

25 patients with invasive cervical carcinoma were asked about their historical data by means of a questionnaire. 7 women (28%) had undergone routine gynaecological examination with PAP smear at least two years before the diagnosis of invasive carcinoma. At the time of clinical admission, symptoms such as postcoital bleeding or metrorrhagia were found in these women as often as in those who had never undergone gynaecological investigation. But in the latter group of patients, stages II and III of the tumour were seen in a twofold higher rate of incidence. After reviewing the PAP smears it is considered that a faulty smear technique was the main reason for failure of prophylaxis. Screening errors committed by the cytologist were less frequent.

Bacterial flora of the cervix in women using different methods of contraception

Bacteriologic culture samples were taken from the cervix in three groups of 10 healthy, sexually active women using barrier contraception, oral contraceptives, or a levonorgestrel-releasing intrauterine contraceptive device. Culture samples for Candida albicans and Trichomonas vaginalis were taken, a cytologic vaginal smear was obtained, and an amine sniff test was performed; these were in addition to a routine gynecologic examination. Multiple bacteria were isolated from the cervix in women using oral contraceptives or an intrauterine contraceptive device, whereas lactobacilli alone dominated the flora of women using barrier contraception. Significantly more anaerobic bacteria were isolated from the cervix in oral contraceptive and intrauterine contraceptive device users when compared with the barrier method users. Symptoms and findings evident of anaerobic vaginosis were associated with the occurrence of anaerobic bacteria in the cervix of three patients using the intrauterine contraceptive device. The results showed that the cervical bacterial flora in sexually active healthy women is rich in anaerobes that can be regarded as a normal finding in women using oral contraceptives or intrauterine contraceptive devices. Barrier contraception with a condom prevents this anaerobic shift and maintains a lactobacilli-dominated flora in the cervix.

Screening for endometrial carcinoma.

Histologic techniques have had widespread acceptance for diagnosis of both malignant and premalignant endometrial abnormalities because of their accuracy. In addition most general pathologists are able to accurately interpret endometrial histologic findings. D and C comes close to perfect accuracy but because of cost and the need for local or general anesthesia there are serious drawbacks to its use. Furthermore since the procedure is generally done only on symptomatic patients D and C cannot be considered a true screening technique. Cytologic techniques such as the Issacs cell sampler and the jet wash have also been accurate in diagnosis of cancer but have been less accurate in diagnosis of hyperplastic lessions of the endometrium. Vabra aspiration has many advantages including the ability to obtain good tissue samples and ease of insertion of the small-diameter cannula and gives the most consistent results with both cancerous and precancerous lesions. Unfortunately because of stenosis of the cervix the Vabra aspirator is difficult to use in postmenopausal women the population at greatest risk. Areas of investigation like human chorionic gonadotropin carcinoembryonic antigen and luteinizing hormone levels appear promising as means of identifying those who are at risk for endometrial carcinoma but further developments must be awaited. Whatever technique is used the clinician must be expert in the technical aspect of obtaining the sample and have confidence in the person who interprets it essential to achievement of a high diagnotic accuracy rate and to acceptance of screening for endometrial carcinoma as a part of the routine gynecologic examination in high risk patients.

Routine Gynecologic Examination and Cytologic Smear

CA: A Cancer Journal for CliniciansVolume 25, Issue 5 p. 281-285 ArticleFree Access Routine gynecologic examination and cytologic smear First published: September/October 1975 https://doi.org/10.3322/canjclin.25.5.281AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Volume25, Issue5September/October 1975Pages 281-285 RelatedInformation

OVARIAN CYSTS IN WOMEN ON CHRONIC INTERMITTENT HAEMODIALYSIS

In a consecutive material of 42 female patients, who were treated with intermittent dialysis for chronic renal failure between May 1964 and Nov. 1971, 21 developed ovarian cysts. The cysts were found only among the 29 women, who had menstrual periods from commencement of dialysis (16 cases) or who started menstruating on dialysis after a period of secondary amenorrhoea (13 cases). No cysts were found in the remaining 13 patients, who had amenorrhoea throughout, and of whom 6 were in all probability postmenopausal. Seven of the 21 patients with ovarian cysts had pronounced symptoms, necessitating acute surgery in 4. Fourteen asymptomatic cases were diagnosed at routine gynaecological examination, which was performed at regular intervals in all patients. There is strong evidence suggesting that the development of ovarian cysts was somehow related to the dialytic treatment and neither to the uraemic state nor to the nature of the primary renal disease. The mechanism by which dialytic treatment may be opertional in the development of this hitherto undescribed complication is discussed, but no clear-cut explanation can be given.

Omentopexy as treatment of a huge presacral epidermoid cyst

A new method of treating unexcisable epidermoid cysts of the presacral region is described. In the case reported the cyst was discovered on routine gynecologic examination. Exploration revealed a huge epidermoid cyst adherent to the bones of the pelvis. Because of the danger of jeopardizing the blood supply of the rectum and its integrity, a strip of omentum was prepared and introduced into the epithelial cavity. The postoperative course was uneventful. Two years after the operation the patient is symptom-free.

Propranolol-induced depression.

OBJECTIVE: To determine the prevalence of and risk indicators for Chlamydia trachomatis cervical infection among women presenting for a periodic medical examination. DESIGN: Prevalence study. SETTING: Centre local de services communautaires (CLSC) Saint-Louis du Parc, Montreal. PATIENTS: All women presenting for a routine gynecologic examination from May 1985 to July 1986. Of the 773 (99%) who agreed to participate 56 were excluded because of inadequate diagnostic tests (34), antibiotic intake in the preceding 6 weeks (19) or loss to follow-up after the initial visit (3). OUTCOME MEASURES: Culture was the diagnostic standard, but rapid diagnostic tests were also used. From the identified cases logistic regression analysis was used to evaluate the following risk indicators: age, place of residence, use of oral contraceptives, sexual partners and frequency, history of sexually transmitted disease (STD) and abnormalities found on genital examination. MAIN RESULTS: Fifty-one of the women were found to have C. trachomatis infection, for a prevalence rate of 7.1%; 32 (63%) were completely asymptomatic. Three independent indicators were found: age of 25 years or less (odds ratio [OR] 3.2, 95% confidence limits [CL] 1.8 and 5.9), cervical erythema, contact bleeding or mucopurulent exudate (OR 2.5, 95% CL 1.4 and 4.5) and residency in the CLSC area (OR 2.3, 95% CL 1.1 and 5.1). A history of STD or vaginitis had a significant protective effect in women 30 years of age or more (OR 0.2). CONCLUSIONS: Case-finding for chlamydial infection could be an effective public health measure among women 25 years of age or less and among those with signs of cervicitis when they present for a Papanicolaou test.

Nonsymptomatic carcinoma of the cervix in elderly women

I N 1927, Lane-Claypon analyzed the ages of 7,381 women with carcinoma of the cervix and found that the highest incidence occurred between the ages of 40 and 49 years. In his series, 8 per cent of cases were over the age of 60 years. Since then, Way in 1951, and Harnett in 1952, have produced series showing that the highest incidence of carcinoma of the cervix occurred between the ages of 50 and 59 years and that 26 and 29 per cent of cases were over the age of 60 years (Table I). These figures indicate that a shift has taken place in the age incidence of carcinoma of the cervix, and that over 25 per cent of cases are now in women over 60 years of age. The incidence of intraepithelial carcinoma in elderly women is difficult to estimate as the majority of surveys include women of all ages. It has been reported in women over 70 years of age,2 yet was not found in 600 women over the age of 60 years undergoing routine gynecological examinations.4 The following study was performed in order to determine the incidence of intraepithelial carcinoma and nonsymptomatic invasive carcinoma of the cervix in older women. Vaginal cytological smears were obtained from 3,168 postmenopausal women undergoing routine gynecological examinations between January, 1959, and January, 1964, at the J. J. Kane Hospital, Pittsburgh. This is a hospital for the treatment of chronically ill patients, the average age of whom is 75 years. The preparations were fixed and stained by the method of Papanicolaou and Traut and graded I through IV. Grade III was considered to be suspicious of malignancy while Grade IV was regarded as being definitely malignant. Patients with Grades III and IV vaginal smears were re-examined and fresh smears obtained. If the findings of the second preparation agreed with those of the first, the patient was transferred to the Magee-Womens Hospital, Pittsburgh, for a cone biopsy of the cervix, dilatation of the cervix and fractional curettage of the uterus. Forty-one of the 3,168 patients had Grades III or IV smears on initial examination. At the time of examination, 24 of these women had clinical evidence of malignancies including carcinoma of the cervix, carcinoma of the endometrium, carcinoma of the vulva, melanoma of the vulva, carcinoma of the rectum, and carcinoma of the bladder extending into the vagina. Eight patients with no clinical evidence of cancer, on re-examination had Grades I or II smears, and were considered to be free of malignancy. Two of the remaining 9 patients died of associated diseases before repeat vaginal smears could be obtained, and 2 who had Grade IV smears on re-examination died before cervical biopsies could be performed. The latter 2 were considered to have probable malignancies. Cervical biopsies on the remaining 5 women showed that 2 had intraepithelial carcinoma and 3 had invasive carcinoma of the cervix. The ages of the patients with intraepithelial carcinoma were 58 and 62 years. The women with invasive carcinoma were aged 63, 72, and 75, and the 2 women with cytologically diagnosed malignancies were 69 and 77 years of age.

Hysterogram in the diagnosis of uterine bleeding

BNORMAL uterine bleeding is a A problem frequently confronting the physician. Since accurate diagnosis is complicated and often burdensome for both the patient and the physician, there is a tendency to rely upon hormone therapy which often yieIds gratifying results. However, the indiscriminate use of injection therapy with a multiplicity of hormones is not without danger. 1 In spite of this injection therapy for uterine bleeding is becoming increasmglg popular with the physician. It is obvious that proper treatment can follow only when an accurate diagnosis is first estabhshed. To establish an etioIogic diagnosis in a case of uterine bleeding, a certain minimum of oflice procedure is required. A complete physical examination is the first essential Careful visual and manual examination of the peIvic organs is extremeIy important. Simple blood studies and a basal metabolic rate and other oflice laboratory procedures may be indicated. After the routine physical and gynecologic examination a number of patients wiI1 fail to show any adequate cause for the bleeding. Pelvic examination may be norma or unsatisfactory because of obesity, tenderness or v-oluntary or invoIuntary spasm. Some of these patients are investigated further with a diagnostic curettage. This procedure requires hospitaIization and anesthesia, is disturbing emotionalIy and may. be burdensome linanciaIly. It is possrbIe that a curettage, even when properly done, may not reveal the cause of the bleeding. (Fig. I .) It is not justifiabIe then, without further investigation, to attribute uterine bleeding to endocrine disturbance even when a pelvic examination fails to reveal any pathologic disorder. Because of these difliculties it was decided to investigate the possible advantages and feasibility of routine hysterography in patients with uterine bleeding. Contraindications. Hysterography is considered by many”” to be contraindicated in bIeeding because oil may be introduced through open sinuses or malignant cells may be diffused through the tubes into the peritoneal cavity. There have been reports ‘.‘) of oil emboli in the vessels of the broad ligaments and death from generalized embolization. These comprications occurred as a result of using an oily radiopaque medium in the procedure. In this study a non-oily radiopaque material is used calIed Rayopake. It is the diethanolamine saIt of 2,+dioxo-3-iodo6-methy tetrahydropyridine acetic acid, with 354 per cent concentration of polyvinyl alcohol. No iI effects were observed in our series and none have been reported. As wiI1 be noted below, smaller amounts of radiopaque material (I .5 to 3.0 cc.) are used. This diminishes the likelihood of dissemination of emboli.’ The objection may be raised that profuse uterine bleeding wouId make the intrauterine injection of radiopaque material impossible or untrustworthy. Experience in reading hysterograms wiI1 eIiminate this error. One of our most concIusive diagnoses (Case III) was made under just such circumstances. Contraindications to hysterography do exist. Most important of these is the presence of acute inflammation. Chronic inflammation is no deterrant since the amount of radiopaque material injected is sufficient only to outline the uterine cavity and there is IittIe opportunity for the spread of disease through the fimbriated ends of the tubes. Bleeding in possible early pregnancy is another contraindication but there have been reports of pregnancies going to term in spite of