Katherine A. O'Hanlan

TRANSVAGINAL ULTRASONOGRAPHY COMPARED WITH ENDOMETRIAL BIOPSY FOR THE DETECTION OF ENDOMETRIAL DISEASE

BACKGROUND Transvaginal ultrasonography is a noninvasive procedure that may be used to detect endometrial disease. However, its usefulness in screening for asymptomatic disease in postmenopausal women before or during treatment with estrogen or estrogen-progesterone replacement is not known. METHODS We compared the sensitivity and specificity of transvaginal ultrasonography and endometrial biopsy for the detection of endometrial disease in 448 postmenopausal women who received estrogen alone, cyclic or continuous estrogen-progesterone, or placebo for three years. RESULTS Concurrent ultrasonographic and biopsy results were available for 577 examinations in the 448 women, 99 percent of whom were undergoing routine annual follow-up. Endometrial thickness was less than 5 mm in 45 percent of the examinations, 5 to 10 mm in 41 percent, more than 10 mm in 12 percent, and not measured in 2 percent, and it was higher in the women receiving estrogen alone than in the other groups. Biopsy detected 11 cases of serious disease: 1 case of adenocarcinoma, 2 cases of atypical simple hyperplasia, and 8 cases of complex hyperplasia. Biopsy also detected simple hyperplasia in 20 cases. At a threshold value of 5 mm for endometrial thickness, transvaginal ultrasonography had a positive predictive value of 9 percent for detecting any abnormality, with 90 percent sensitivity, 48 percent specificity, and a negative predictive value of 99 percent. With this threshold, a biopsy would be indicated in more than half the women, only 4 percent of whom had serious disease. CONCLUSIONS Transvaginal ultrasonography has a poor positive predictive value but a high negative predictive value for detecting serious endometrial disease in asymptomatic postmenopausal women.

Comparison of lesbian and heterosexual women's response to newly diagnosed breast cancer

In a study comparing lesbian and heterosexual womens response to newly diagnosed breast cancer, we compared data from 29 lesbians with 246 heterosexual women with breast cancer. Our hypotheses were that lesbian breast cancer patients would report higher scores of mood disturbance; suffer fewer problems with body image and sexual activity; show more expressiveness and cohesiveness and less conflict with their partners; would find social support from their partners and friends; and would have a poorer perception of the medical care system than heterosexual women. Our predictions regarding sexual orientation differences were supported for results regarding body image, social support, and medical care. There were no differences in mood, sexual activity or relational issues. Not predicted were differneces in coping, indicating areas of emotional strength and vulnerability among the lesbian sample. Copyright

Human papillomavirus-associated cervical intraepithelial neoplasia following lesbian sex

Background Less than 3% of lesbians develop cervical dysplasia, with increasing risk correlating with previous heterosexual activity. Because they are not currently sexually active with men, many lesbians do not perceive themselves to be at risk for developing dysplasia and do not obtain regular Papanicolaou smears. There are no standard recommendations for Papanicolaou smear intervals for lesbians. Case A 36-year-old, nonsmoking woman had a Papanicolaou smear history of a high-grade squamous intraepithelial lesion of the cervix, which was confirmed by biopsy and successfully treated by laser ablation. Human papillomavirus type 16 was identified in the cervical biopsy by polymerase chain reaction amplification and restriction fragment polymorphism analysis. The patient gave a clear history of having had sexual activity only with women. Conclusion Regular Papanicolaou testing should be recommended to all lesbians, regardless of type of sexual activity. Papanicolaou testing intervals should be determined using standards similar to those used for heterosexual women: annually after onset of sexual activity or after age 18, and possibly less often after three normal smears at her physicians discretion. An extensive number of sexual partners, current smoking, and prior dysplasia may influence the physician to advise continued yearly Papanicolaou testing for lesbians, similar to advice given to heterosexual patients.

Methodologic Concerns in Defining Lesbian for Health Research

A recent report from the Institute of Medicine recommends more methodologic and substantive research on the health of lesbians. This study addresses one methodologic topic identified in the Institute of Medicine report and by a subsequent scientific workshop on lesbian health: the definition and assessment of sexual orientation among women. Data are from the Women Physicians’ Health Study, a questionnaire-based U.S. probability sample survey (N = 4,501). The two items on sexual orientation (current self-identity and current sexual behavior) had a high response rate (96%), and cross-tabulation of responses indicated several combinations of identity and behavior. Three conceptually different definitions of “lesbian” are compared on the basis of (1) identity only, (2) sexual behavior only, and (3) both identity and sexual behavior. Suggestions and cautions are given to researchers who will add items on sexual orientation to new or ongoing research on women’s health.

Advocacy for women's health should include lesbian health.

Although research confirms that homosexuality is a normal expression of human sexuality, established scientific studies are often not reflected in laws and judicial opinions for lesbians with regard to employment, taxation, pensions, disability, healthcare, immigration, military service, marriage, custody, and adoption. The expression of homosexual attraction or behavior is sometimes met by disdain or violence. Psychological and epidemiological research confirms that the public discriminatory attitudes and second-class legal status cause physical, emotional, and financial harm to lesbians, their families, and their children. Some lesbians experience discrimination in healthcare and avoid routine primary healthcare. To decrease the harm, and improve the health of lesbians, medical institutions can include sexual orientation and gender identity in their nondiscrimination policies and offer domestic partner coverage in employment benefits. Our specialty societies should review current laws and judicial opinions and advocate for change. Further, specialty societies can effect change by issuing policy statements about issues of orientation and by writing orientation/identity curricula for public schools, colleges, and postcollegiate education to improve their accuracy, reduce sexually transmitted diseases, delay sexual activity, and reduce morbidity from homophobic violence.

Total Laparoscopic Hysterectomy for Female-to-Male Transsexuals

OBJECTIVE: To compare the results of laparoscopic hysterectomy, salpingo-oophorectomy, and incidental appendectomy for female-to-male transsexuals with those of female patients. METHODS: Retrospective chart abstraction of all patients undergoing total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and appendectomy since September 1996. Significance from analysis of covariance or &khgr;2 was set at .05. RESULTS: Five hundred ninety-three patients underwent total laparoscopic hysterectomy, oophorectomy, and appendectomy. Forty-one were identified as transsexual, 552 as females. The transsexuals were significantly younger (mean 32 years compared with 51 years, median 32 years compared with 49 years, P<.001), with lower parity (mean 0.05 pregnancies compared with 1.34 pregnancies, median 0 pregnancies compared with 1 pregnancy, P<.001), yet had similar body mass index and height. Transsexuals’ surgeries had shorter operating times (mean 74 minutes compared with 120 minutes, median 57.5 minutes compared with 116 minutes, P<.001), with less blood loss (mean 27 mL compared with 107 mL, median 20 mL compared with 50 mL, P<.001) and lower uterine weight (mean 118 g compared with 167 g, median 89 g compared with 140.5 g, P<.001). The total complication rates (12.2% compared with 8.3%), as well as the reoperative complication rates (4.9% compared with 4.3%) were not significantly different. CONCLUSION: Total laparoscopic hysterectomy offers appropriate surgical outcomes for those patients identifying themselves as transsexual. LEVEL OF EVIDENCE: III

Age at menopause in women participating in the postmenopausal estrogen/progestins interventions (PEPI) trial: An example of bias introduced by selection criteria

Our objective is to illustrate the bias introduced in assessing factors associated with age at menopause when the population sample has been selected using restricted criteria, i.e. number of years since menopause, by using a cross-sectional analysis of baseline data from a population-based randomized clinical trial. The participants were women who participated in the Postmenopausal Estrogen/Progestins Intervention (PEPI) trial, had not had a hysterectomy, were between 45 and 64 years old, and were menopausal for at least 1 but not greater than 10 years. The outcome measures were self-reported age at menopause and factors thought to be associated with it, including smoking, alcohol use, oral contraceptive use, number of pregnancies, education, income, body mass index, waist-hip ratio, thigh girth, and systolic and diastolic blood pressures. At entry, the mean age of the 601 women was 56.2 years. Mean age at menopause was 51.0 years. Chronologic (current) age was strongly correlated with age at menopause (r = 0.74, p = 0.0001). In bivariate analyses, factors associated with younger age at menopause were ever-use of cigarettes, former oral contraceptive use, and higher thigh girth; factors associated with later age at menopause were greater number of pregnancies, higher waist-hip ratio, and higher systolic blood pressure. After stratification by 5-year age intervals, these associations were no longer statistically significant. Because of restricted sampling, an artificial association was observed between chronologic age and age at time of menopause. This artifact made it difficult to distinguish between factors associated with chronologic age and those that may be independently associated with menopause. Failure to recognize this bias could lead to erroneous conclusions.

First report of a vaginal foreign body perforating into the retroperitoneum

Pelvic examination of a 19-year-old woman with recurrent pain after multiple laparotomies revealed a 4.0 cm paracervical fibroepithelial polyp and tender fullness in the left pelvis. Abdominal exploration had normal findings, but exploration of the retroperitoneum revealed an encysted bottle cap that had eroded through the vaginal wall years before.

Health policy considerations for our sexual minority patients

Homosexuality and transsexuality are still widely viewed by lay individuals as morally negative and deserving of legal proscription. Peer-reviewed data confirm that experiences of legal discrimination are associated with stress-related health problems, reduced utilization of health care, and financial and legal challenges for individuals and families, especially those with children. In the last 3 years, the American Psychiatric Association, American Psychological Association, and American Psychoanalytic Association have each reviewed the research on sexual orientation and identity, and each has confirmed that sexual orientation and gender identity do not correlate with mental illness or immorality. They have each endorsed laws that confer equality to sexual minorities, including nondiscrimination in employment, medical insurance coverage, adoption, and access to civil marriage. The American College of Obstetricians and Gynecologists (ACOG), by virtue of its history of advocacy for womens health, is in a position to promote policy and make similar recommendations, recognizing that sexual minority womens health and their family issues are an integral component of taking care of all women. The College should review the policies of Americas premier mental health associations and consider including sexual orientation and gender identity in its own nondiscrimination policy, and ACOG should issue a policy statement in support of laws to provide safety from violence and discrimination, equal employment opportunities, equal health insurance coverage, and equal access to civil marriage.

Adenoid cystic carcinoma of the submandibular gland with symptomatic ovarian metastases.

We report the clinical and pathologic features of an adenoid cystic carcinoma of the submandibular gland that metastasized to the ovaries 10 years after initial presentation. A 30-year-old woman underwent excision of a right submandibular adenoid cystic carcinoma followed by regional external beam radiation therapy. Three years later, she underwent extended hepatic resection and localized radiotherapy to the hepatic region for metastatic disease. The patient was without evidence of disease for 7 years when she developed pelvic pain and a pelvic mass was found. A solid and cystic 10-cm left ovarian mass and a single metastatic tumor nodule involving the right ovary were excised via the laparoscope. Histologically, the tumor was identical to the patients initial salivary gland neoplasm. The neoplastic cells were CAM 5.2 positive, S100 positive, muscle-specific actin positive, and smooth muscle actin positive. Ultrastructurally, characteristic pseudocysts (pseudolumina) with abundant basal lamina and true glandular lumina lined by short microvilli were present. Other than a single anecdotal account of a parotid gland adenoid cystic carcinoma, this case represents the first documented report of an adenoid cystic carcinoma of salivary gland origin that was associated with symptomatic ovarian metastases. This case demonstrates that the ovary is a potential site for metastatic disease many years following the diagnosis and treatment for a primary neoplasm however uncommon or remote the site of origin. Since metastatic adenoid cystic carcinoma can rarely present as an ovarian mass, a clinical history of this neoplasm should be heavily weighed in the differential diagnosis of any unusual ovarian tumor with a predominant cribriform, trabecular, or tubular pattern.