David A. Edelman

On the causation of pelvic inflammatory disease

The classic descriptive model of pelvic inflammatory disease (PID) omits any direct statement that sexual intercourse leads to the development of the lower genital or cervical infection which ultimately leads to upper genital or tubal infection. Despite this, clinicians treating patients with PID frequently, either implicity or explicitly, link its onset to sexual activity. In the past decade numerous authors have commented on the strong association between the widespread changes in sexual attitudes and behavior (without describing them in detail) and the enormous rise in sexually transmitted diseases and PID. With the advent of the case control study, the epidemiologist viewed sexual activity as only 1 of many risk factors for the development of PID. Yet, the clinician often maintanied that this relationship was too obvious to require case control studies to prove the point. The sum, the classic hypothesis on the pathogenesis of PID has remained virtually unchanged for nearly 8 decades in spite of its limitations, such as the failure to consider the endogenous and exogenous risk factors for the development of PID in a given patient. Possibly the greatest defect of the classic theory is its failure to address the precise mechanisms by which the infectious agents that cause PID travel from the lower to the upper genital tract. Existing literature suggests that 3 mechanisms may be operative. The 1st mechanism is that motile trichomonads are capable of ascending from the vagina to the level of the fallopian tubes and may carry with them a variety of infectious agents. The 2nd suspected mechanism for transport of microorganisms to the fallopian tubes is by attachment to sperm. If this occurs, then clearly spermatozoa may serve as vectors of pelvic infection. Abundant evidence exists to support the concept that sperm intimately associate with a variety of infectious agents, many of which are unrecognized as pathogens in the female. The 3rd suspected mechanism for transport of bacteria from the lower to the upper genital tract in the female appears to be that of passive transport. The literalture lacks reference to bacteria per se gaining entrance to the uterus but contains abundant references to the transport of particular matter and sperm. The current orientation of most American textbooks and much of the literature in regard to the pathogenesis of PID is oversimplified. More attention must be devoted to the mechanisms by which infectious agents arrive at the fallopian tubes.

Reproductive History of Women Exposed to Diethylstilbestrol in Utero

The menstrual and reproductive histories of 276 female offspring of women who had received diethylstilbestrol (DES) during pregnancy were evaluated. Mean age was 24.6 years, and mean age at menarche was 12.6 ± 0.3 years. Reported menstrual abnormalities included increased menstrual flow and cycle irregularities, primarily anovulation and oligomenorrhea. An apparent increased incidence of urinary tract manipulation was detected, and cervical stenosis was noted to follow cryosurgery in 75% of women treated. Of 106 women attempting pregnancy, there were 129 conceptions and 58 live births. The fetal wastage rates were 43% for the first pregnancy and 37% for all pregnancies. The losses were due to spontaneous abortions (25%), ectopic pregnancies (5%), molar pregnancies (2 of 129), and in utero fetal death (4%). In the subgroup of women with vaginal adenosis or cervical hoods, the fetal wastage rate was 53%. Of 35 women unable to conceive for more than 1 year, only three pregnancies have resulted after infertility evaluations. Although abnormalities of the uterine cavity were identified, tubal and/or ovulatory defects were also present. DES, given to mothers in hope of maintaining threatened pregnancies, appears to have a deleterious effect on the reproductive ability of female offspring. Menstrual and structural abnormalities identified in this study may be associated with the reported reproductive difficulties.

Intrauterine Devices and Their Complications

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Cryosurgery for the treatment of cervical intraepithelial neoplasia during the reproductive years.

Cervical intraepithelial neoplasia (CIN) is so rampant that simpler, effective, and less costly methods of therapy are being evaluated to replace the aggressive surgical therapeutic measures of the past. Cryosurgery is one alternative method. A review is presented of 152 patients in the child-bearing age group with biopsy confirmation of CIN II (moderate dysplasia) and CIN III (severe dysplasia and carcinoma in situ). The persistence of CIN 3 months after therapy was deemed a treatment failure. Initial failure rates (24.2% for CIN II and 31.6% for CIN III) were high by this stringent definition. However, follow-up smears, further treatment, and a review of the literature definition of “treatment failure” lowered the failure rate to acceptable levels such that cryosurgery should be utilized in the therapy of cervical intraepithelial neoplasia.

Contraceptive practice and tuboovarian abscess.

The hospital and operative records of 318 women with a discharge diagnosis of tuboovarian abscess (TOA) were reviewed to evaluate the possible relationship between contraceptive usage and the occurrence of TOA. A significantly higher (p < 0.10) proportion of the intrauterine contraceptive device (IUD) users had acute pelvic inflammatory disease and a significantly lower proportion (p < 0.10) compared to users of other contraceptive methods were surgically treated. The proportions of women with unilateral and bilateral TOAs were similar, regardless of the contraceptive method used. This was true whether diagnosis was based on physical examination alone or confirmed at operation.

Laparoscopic Tubal Clip Sterilization Under Local Anesthesia

Tubal anesthesia with lidocaine during laparoscopic tubal clip appli cation was evaluated in 149 women; 147 tubes received no lidocaine and 151 received 1 or 2 ml of 1% or 4% lidocaine. For unanesthetized tubes the mean pain rating depended on the dose of diazepam and fentanyl given to the patient (p less than .1); pain ratings were higher in women who received no drug. When any diazepam and/or fentanyl was given the anesthetized tubes were given a significantly lower pain rating (p less than .01). 23.8% of unanesthetized tubes received a pain rating of 2 12.9% a rating of 3 or 4 while no anesthetized tube received a 3 or 4 (on a scale of 0 to 4) and only 4% received a 2. 68.5% patients were their own control; 42% rated the pain equal in each tube (1 was anesthetized) while 58% rated the anesthetized tube less painful. 3.4% of the patients experienced vasovagal reflex stimulation. It is concluded that using a local anesthetic solution substantially reduces discomfort associated with fallopian tube manipulation during sterilization.

Laparoscopic sterilization with electrocautery, spring-loaded clips, and silastic bands: technical problems and early complications

Among 2283 patients, rates of technical failure, technical difficulty, and operative and early postoperative complications were evaluated for different methods of tubal occlusion at laparoscopy: electrocoagulation (980 cases), spring-loaded clip application (991 cases), and Silastic band application (312 cases). Rates of technical failure and technical difficulty at surgery were significantly higher (P less than 0.05) for the spring-loaded clip technique than for the electrocoagulation and Silastic band techniques. Mechanical and optical difficulties with the prototype spring clip applicator were the major sources of technical difficulties. Rates of operative (1.2%) and early postoperative (1.9%) complications were not significantly different for the three techniques of tubal occlusion. It is concluded that all three study techniques appear to be practical, and large, long-term, randomized, comparative studies to determine rates of failure and subsequent gynecologic problems are necessary to determine the best method of sterilization.

Cervical intraepithelial neoplasia during pregnancy

The evaluation and management of the pregnant patient with abnormal results of cytology is a special challenge to the physician. We present a study of 109 patients with abnormal cervical cytologic findings during pregnancy, with detailed guidelines for the evaluation and management of these patients. The use of cytology, colposcopy, and directed biopsies is encouraged.

9 – Menstrual regulation

Publisher Summary This chapter explains what menstrual regulation (MR) is. Postcoital methods of fertility control, MR, and induced abortion represent a continuum of procedures that may be used to limit fertility or terminate pregnancy. Postcoital methods and MR are employed before the diagnosis of pregnancy can be reliably established and thus are often used when the woman is not pregnant. These procedures are differentiated primarily by the time at which they are performed. Postcoital methods may be defined as procedures performed after coitus up to the time of the expected onset of a menstrual period. MR may be defined as any procedure used to terminate a suspected pregnancy no later than 14 days after the expected onset of a menstrual period. MR has also been referred to as endometrial aspiration, menstrual extraction, menstrual induction, and mini-abortion. Some amenorrheic women who undergo MR will not be pregnant at the time of the procedure. While it is desirable to eliminate unnecessary MR procedures, this is not presently feasible based on standard pregnancy tests.

A comparative study of intra-amniotic saline and two prostaglandin F2α dose schedules for midtrimester abortion

The efficacy, side effects, and complications of two intra-amniotic PGF2alpha dose schedules and the unaugmented intra-amniotic instillation of saline are compared. All three methods resulted in satisfactory rates of abortion within a relatively short period of time and within clinically acceptable rates of complications. Each method has its advantages and disadvantages. Further large comparative studies were needed.