Clinical application of intrauterine sonography with high-frequency, real-time miniature transducer in gynecologic disorders. Preliminary report

Our purpose was to determine whether intrauterine sonography with high-frequency, real-time miniature transducer (20 MHz) is useful for the diagnosis of gynecologic disorders. The study consisted of 37 women: 8 normal volunteers, 2 with molar pregnancy, 4 fibromyoma, 4 endometrial polyp, 1 intrauterine adhesion, 1 septate uterus, 5 atypical hyperplasia, 8 endometrial cancer, and 4 with cervical cancer. Comparison of diagnostic efficacy for gynecologic disorders between transvaginal and intrauterine sonography was made. The probe was easily introduced into the endometrial cavity in all patients. No notable complications were encountered. In subjects with a normal uterus, higher resolution for endometrial texture was obtained with intrauterine sonography than with transvaginal scanning. In patients with molar pregnancy, typical vesicular echoes were clearly identified. In patients with fibromyoma, myoma nodules were not clearly visualized because of poor attenuation of ultrasound. In subjects with endometrial polyp, intrauterine adhesion, and septate uterus, intrauterine lesions were clearly identified. In patients with atypical hyperplasia, high echogenicity of the endometrium was characterized. Myometrial invasion of the endometrial cancer was estimated correctly in 6 of 8 patients (75%). Intrauterine sonography could clearly detect early cervical invasion of the cervical cancer in all 4 patients, but transvaginal sonography could not do it. Intrauterine sonography with a high-frequency, real-time miniature transducer might be a useful diagnostic modality in gynecologic disorders, especially in the evaluation of early cervical cancer, endometrial cancer, and possibly in infertility practice.     

Assessment of myometrial invasion in endometrial cancer by transvaginal ultrasonography

Transvaginal ultrasound was used in 52 women to characterise endometrial cancer with respect to myometrial invasion according to International Federation of Gynaecologist and Obstetricians (FIGO) recommendations for surgical staging of endometrial cancer. Endometrial cancer was diagnosed on the basis of dilatation and curettage and the degree of invasion was evaluated preoperatively by transvaginal ultrasound. The ultrasound data were compared to macroscopic finding of the uterine specimen and to histopathology. Evaluation with transvaginal sonography was accurate in 46 of 52 cases (accuracy 88%, sensitivity 86%, specificity 90%, positive predictive value 92%, negative predictive value 83%). Cervical tumor extension was correctly diagnosed in seven of ten women in which it was present. Transvaginal ultrasound seems to be a reliable method for assessing tumor invasion. This non-invasive method could be included as an important tool in te establishment of individualised treatment program in case of women with endometrial cancer.     

Ultrasound endometrium diagnosis

Ultrasound has been gaining significance in the recent past as diagnostic tool not only in obstetrics but also in general gynecology. Improvements of image resolution by transvaginal sonography [TVS] allow the investigation of even delicate anatomical structures such as the endometrium. Various diagnostic criteria including thickness of endometrium, internal structure and myometrial involvement help to identify endometrial abnormality. The benefits of new technologies such as colour Doppler and 3D sonography are currently being assessed. In the postmenopausal patient without hormonal substitution endometrial carcinoma may be diagnosed by measuring endometrial thickness alone. In women with postmenopausal bleeding endometrial atrophy as the must common cause has been differentiated from endometrial cancer with a high success rate. Considering that more than 70% of diagnostic currettages reveal benign sonography may significantly reduce the number of these procedures. In patients with hormonal replacement therapy the measurement of endometrial thickness is not reliable because the endometrium is subject to cyclical changes. Advantageous in this situation is the examination of the endo/myometrial borderline. The potential of sonography in reducing the number of currettages has to be assessed in larger scale prospective studies. Therefore a general screening for endometrial carcinoma is not advocated for the time being and should be restricted to high risk patients.     

Contrast hysterosonography: indications and technic]

Contrast-enhanced sonography constitutes a new way of visualizing the uterine cavity. Indeed, real-time transcervical instillation of sterile saline inside the uterine cavity during transvaginal sonography (saline infusion sonography, SIS) allows a precise diagnosis of various intrauterine pathologies such as endometrial polyps, submucous myomas, intrauterine adhesions and various anatomical malformations. The aim of this article is to detail the technique of saline infusion sonography, its indications, contra-indications and semiology.     

Stromal invasion by carcinoma of the cervix: assessment with dynamic MR imaging

OBJECTIVE: The purpose of this study was to evaluate dynamic MR imaging in assessing the depth of stromal invasion by carcinoma of the cervix and to compare dynamic MR imaging with T2-weighted and contrast-enhanced T1-weighted MR imaging. SUBJECTS AND METHODS: Forty-one patients with carcinoma that was clinically considered to be confined to the cervix were examined with T2-weighted, dynamic, and contrast-enhanced T1-weighted MR imaging before surgery. We evaluated enhancement patterns of the cervix and tumor and assessed the degree of stromal invasion with MR imaging. The degree of stromal invasion was divided into two groups: superficial disease (no stromal invasion or invasion of < or = 3 mm) and deep invasion (> 3 mm of stromal invasion). Then we compared these MR findings with histologic results for the depth of stromal invasion. RESULTS: With dynamic MR imaging, cervical carcinoma with deep invasion was seen as a focal enhanced area in the early dynamic phase. The cervical epithelium and stroma enhanced less vividly. In distinguishing deep invasion from superficial disease, we found the accuracy of T2-weighted MR images, dynamic MR images, and contrast-enhanced T1-weighted MR images to be 76%, 98%, and 63%, respectively. In particular, the detectability of 3.1-5.0 mm of stromal invasion with dynamic MR images was significantly higher than that with the other techniques: with T2-weighted MR images, we saw 3.1-5.0 mm of stromal invasion in 23% of patients; with dynamic MR images, in 92%; and with contrast-enhanced T1-weighted MR images, in none. Superficial disease was not revealed with any of the three MR techniques. CONCLUSION: We believe that dynamic MR imaging is superior to T2-weighted MR imaging and contrast-enhanced T1-weighted MR imaging when assessing the depth of invasion of cervical carcinoma.     

Perinatal factors predicting severe intracranial hemorrhage

Wertheim-Meigs hysterectomy is used in the treatment of cervical cancer, but since 1988 we have also used it to stage and treat endometrial carcinoma. To evaluate the morbidity of Wertheim Meigs hysterectomy as well as node invasion incidence and its correlation with other prognostic factors, the authors made a retrospective study of 112 patients, from October 1986 to March 1996. Among the 112 cases evaluated, 52% had cervical carcinoma and 48% had endometrial carcinoma; mean ages were 45 +/- 10 and 60 +/- 8 years (p < 0.005). FIGO stage distribution was: I-94.8 and 33.3%; II-5.2 and 51.9%; III-0 and 13%; IV-0 and 1.8%, for cervical and endometrial carcinoma. Hemorrhagic and traumatic accidents happened in 24.3% and 1.7% respectively. We had 15.5% early post operative complications and 1.7% late post operative ones. The mean duration of surgery and hospitalization was 163 +/- 29 minutes and 10 +/- 5 days. Pelvic lymphadenectomy was performed in 70% of patients and para-aortic nodes were also excised in the other 30%. The mean number of lymphatic nodes excised were 17 +/- 9. Pelvic node invasion was found in 9% and in 3.7% of para-aortic ones. When we studied endometrial cancer, we found a positive correlation between external myometrium invasion and lymphovascular invasion and positive node (p < 0.05). From the data available we may conclude that the complication rate of Wertheim Meigs is quite important, even though all but one complication were transitory. It may be possible to make a better selection of patients who need this surgical procedure by correct evaluation of risk factors.     

Squamous cell carcinoma in situ involving mesonephric remnants. A potential diagnostic pitfall

A case of uterine cervical squamous cell carcinoma in situ (CIS) in which there was extensive endocervical glandular involvement was found to have, in addition, a deep-seated squamous epithelial lesion within the cervical stroma. Because of the deep location of this lesion, which was composed of nests of pleomorphic squamous epithelial cells, found at a site not usually occupied by endocervical glands, it was initially thought to be an invasive squamous cell carcinoma (SCC). However, on review it was found that there was CIS in the deep cervical stroma that appeared to involve small tubular structures and dilated ducts that were lined by mucin-free cuboidal epithelial cells. There was no stromal reaction to this lesion. Tubules had a poorly defined lobular arrangement and had intraluminal bright eosinophilic hyaline material. Tubular epithelial cells demonstrated immunohistochemical staining for low-molecular-weight keratin (LMWK) and vimentin but showed no staining for carcinoembryonic antigen (CEA) and high-molecular-weight keratin (HMWK). It was apparent that these tubular structures and ducts were mesonephric remnants and that this lesion represented involvement of mesonephric remnants by CIS. Although involvement of endocervical glands by CIS is well recognized, a similar lesion involving mesonephric remnants has not been previously described. Familiarity with the histological features of these lesions is essential to avoid a misdiagnosis and potential mismanagement.     

Diagnostic methods compared in neoplastic pathology of the endometrium

Preoperative staging is fundamentally important in endometrial carcinoma. The presence of lymph node metastasis and the risk of tumour recidivation are correlated to the degree of myometrial invasion by the tumour. The preoperative diagnosis of the absence of myometrial invasion may render pelvic lymphadenectomy superfluous. A group of 24 patients suffering from endometrial carcinoma underwent transvaginal ultrasonography and nuclear magnetic resonance prior to surgery in order to evaluate possible myometrial invasion. The study was integrated by computerised tomography (CT) to obtain a clearer image of the retroperitoneum. The authors aim to ascertain the accuracy, sensitivity and specificity of these methods in the preoperative evaluation other degree of myometrial infiltration.     

Comparative study of diagnostic hysteroscopy and transvaginal ultrasonography in patients with abnormal uterine hemorrhage during the peri- and post-menopausal period

BACKGROUND: The aim of this study was to determine the diagnostic value of hysteroscopy and transvaginal ultrasonography in patients with abnormal uterine bleeding (AUB) in the peri and postmenopausal period. METHODS: 302 patients with AUB, underwent hysteroscopy and in 86 cases, also a transvaginal ultrasonography before hysteroscopy was performed. Results were compared with the histological diagnosis. RESULTS: The diagnostic accuracy of hysteroscopy was very high in the cases of endometrial carcinoma (sensibility 100%, specificity 99%), and lower in the cases of endometrial hyperplasia (sensibility 69%, specificity 72%) and endometrial atrophy (sensibility 29% and specificity 97%). Sonography proved to be less reliable in the diagnosis of endometrial pathology (carcinoma: sensibility 57%, specificity 100%, hyperplasia: sensibility 62.5% specificity 63%). The results of this study show that sonography may be used as a first choice diagnostic test in the investigation of women with AUB. CONCLUSIONS: Hysteroscopy represent a second diagnostic step for achieving a proper histologic diagnosis.     

The detection of endocervical gland involvement by high grade squamous intraepithelial lesions in smears prepared from endocervical brush specimens

The cytologic features of squamous cell carcinoma in situ with endocervical gland involvement have been described in cervical smears. We evaluated the presence of two types of cellular fragments in 43 cervical smears of high grade squamous intraepithelial lesions (HGSIL) to assess their ability to predict glandular involvement by HGSIL in subsequent cone biopsies. An endocervical brush was used to obtain all endocervical specimens. Of 16 cases without glandular involvement, fragments were present in 13 smears. Of 27 cases with glandular involvement, fragments were absent in 11 smears. No statistical association was identified between the presence of abnormal cellular fragments on cervical smears of HGSIL and endocervical gland involvement on cone biopsies.     

Comparison of sonography, sonohysterography, and hysteroscopy for evaluation of abnormal uterine bleeding

We compared transvaginal sonography, sonohysterography, and diagnostic hysteroscopy in the evaluation of abnormal uterine bleeding, Sixty-eight women 40 or older with abnormal uterine bleeding were assigned to undergo either transvaginal sonography or sonohysterography. All subjects then had diagnostic hysteroscopy and endometrial biopsy. Patients with abnormal findings underwent operative hysteroscopy or definitive therapy. Transvaginal sonography, sonohysterography, and diagnostic hysteroscopy revealed a sensitivity of 95%, 90%, and 78%, and a specificity of 65%, 83%, and 54%, respectively. The average cost for transvaginal sonography of sonohysterography was $195 and the cost for diagnostic hysteroscopy was $675. Transvaginal sonography and sonohysterography are cost-effective alternatives and more sensitive diagnostic tests than office diagnostic hysteroscopy.     

Endometrial ultrasonography - An alternative to invasive assessment in women with postmenopausal vaginal bleeding

AIMS AND BACKGROUND: To test the reliability of endometrial sonography in selecting women with abnormal postmenopausal vaginal bleeding for further diagnostic assessment. METHODS: Endometrial thickness was measured in 368 consecutive women by abdominal or vaginal sonography prior to invasive assessment (hysteroscopy, curettage). The association of abnormal and endometrial thickness (4 mm or greater) with endometrial cancer was determined. RESULTS: Abnormal endometrial thickness was observed in 116 of 368 women. Subsequent assessment diagnosed endometrial carcinoma in 16 subjects, 15 of whom had abnormal endometrial thickness. One case with normal endometrial thickness was suspected at sonography because of the irregular appearance of the endometrium. CONCLUSIONS: Had it been used to select subjects for further assessment, sonography would have missed no cancer, and unnecessary invasive assessment (under general anesthesia in 20% of cases) would have been spared in 68% (251/368) of the subjects. Endometrial sonography should be routinely used to select women with postmenopausal vaginal bleeding for further investigations.     

Calcium channel blocker decreases pentagastrin-stimulated alkaline-tide: a role for extracellular calcium in gastric acid secretion

The value of magnetic resonance imaging (MRI) in the diagnosis and staging of endometrial carcinoma was studied in 43 cases of clinically suspected endometrial carcinoma and 7 normal women. All of the 43 cases showed abnormal endometria measured by MRI, among which were pathologically proven 40 cases of endometrial carcinoma, 2 cases of endometrial polyps and 1 case of adenomyosis. This suggested that MRI showed a high susceptibility in the diagnosis of endometrial carcinoma, and a lack of specificity. MRI could predict myometrial invasion, its accuracy being verified by surgico-pathological findings in 11 of 13 cases. MRI staging was correct in 10 of the 13 primarily operated cases, and only half of the clinical staging was in conformity with surgical staging. The results suggest that MRI is useful in the staging of endometrial carcinoma and therefore is of value in the choice of treatment planning, although it is not yet an ideal diagnostic aid to detect small metastatic pelvic lesions.     

Complete excision of the lower trunk and C8 and T1 nerve roots in a patient with Pancoast tumor with a resulting fully functional hand

OBJECTIVE: To establish the frequency of the atypical glandular cells of uncertain significance (AGCUS) category, and its subcategories, as defined by the Bethesda System (TBS). METHODS: Our computerized records of cervical/vaginal cytology specimens submitted from January 1, 1993, through December 31, 1995, were retrospectively reviewed for specimens diagnosed as AGCUS. When appropriate, our subcategory of "AGCUS favor premalignant/malignant lesion" was further qualified as "favor endocervical adenocarcinoma in situ" or "suspicious for endometrial carcinoma." The number of specimens and patients diagnosed for each subcategory were grouped by calendar year. Differences in frequency between time periods were tested for statistical significance using chi 2 analysis. RESULTS: AGCUS was diagnosed in 1181 of 177,715 submitted specimens (0.66%). The frequency of subcategories was as follows: "favor reactive" (65%), "unable to further classify" (30%), "favor premalignant/malignant" (2.9%), "suspicious for endometrial carcinoma" (1.9%), and "favor endocervical adenocarcinoma in situ" (0.4%). From 1993 to 1995 there was an increase in the rate of diagnosis of AGCUS (0.55 to 0.73%; P < 0.001) and a decrease in the percentage of specimens with AGCUS subclassified as "favor premalignant/malignant" (6.2 to 0.5%; P < 0.001). Other subcategories showed no significant change in frequency over this time period. The rate of biopsy-proven preinvasive or invasive lesions in AGCUS patients also showed no significant change from year to year over this time period. CONCLUSION: The AGCUS diagnosis can be anticipated at a low but consistent rate from a cytology laboratory using TBS. Any comparison of laboratories should take into consideration the change in reporting frequencies that occurs as part of the "learning curve" following introduction of TBS reporting. Uniform diagnostic criteria and additional reports with large numbers of cytologic specimens will be needed to establish the expected frequency of AGCUS and its subcategories.     

Transvaginal ultrasonographic diagnosis of bladder-wall invasion in patients with cervical cancer

OBJECTIVE: To evaluate the use of transvaginal ultrasonography for diagnosing invasion of the bladder by cervical cancer. METHODS: Twenty-one women with stages Ib-IIIb cervical cancer underwent radical hysterectomy or staging laparotomy. All had computed tomography (CT) scans and cystoscopic examinations, and five also underwent magnetic resonance imaging (MRI). During transvaginal ultrasonography, a transvaginal transducer was inserted into the anterior fornix of the vagina and the bladder wall was studied in the sagittal plane. The moveability of the bladder wall was assessed by the ability of the bladder to slide along the uterine cervix when the probe was pushed up against the bladder from the anterior fornix. Moveability was considered to indicate an intact bladder wall. RESULTS: The accuracy of transvaginal ultrasonography was superior to that of the other methods for detecting bladder-wall invasion by cervical cancer. The accuracy was 95% for transvaginal ultrasonography, 76% for CT, 86% for cystoscopy, and 80% for MRI. CONCLUSION: Transvaginal ultrasonographic examination is useful for detecting invasion of the bladder wall by cervical cancer.     

Indications for laparoscopic surgery in cases of gynecological malignancies (endometrial cancer)

The role of surgery in the treatment of patients with invasive cervical cancer is undisputed, but how radical surgery should be is debatable. Every case requires detailed knowledge of the development and spread of cervical cancer. Tumor volume is the most important diagnostic factor in cervical cancer and also correlates with vascular invasion and lymph node involvement. As radical hysterectomy requires in cervical cancer besides the laparoscopically easy performable lymphadenectomy also the resection of parametria with sceletonisation of ureters we started to treat endometrial cancer with a combined laparoscopic and vaginal approach. In patients with the suspicion of stage I endometrial cancer prior to laparoscopic staging, the prerequisites of histological grading with ploidy and measurement of monoclonal antibodies were performed. All patients underwent a general check with radiography, computer tomography, liver scan, bone scan and lymphography. The performance of lymphadenectomy in cases of stage I endometrial cancer remains a controversial subject. We believe that laparoscopic assisted surgical staging of stage I endometrial cancer is an attractive alternative to the traditional laparotomy-surgical approach. The change from laparotomy to a laparoscopic assisted vaginal approach allows for a similar success rate with the less invasive approach. No complications occurred in this series and the results of our pilot study were satisfactory.     

Cervical length at 23 weeks of gestation: relation to demographic characteristics and previous obstetric history

OBJECTIVES: To examine the feasibility of introducing routine measurement of cervical length at 23 weeks of gestation, to establish the distribution of cervical lengths in a routine population of singleton pregnancies and to examine the relation between cervical length and demographic characteristics and previous obstetric history. METHODS: Cervical length was measured by transvaginal sonography at 23 weeks of gestation in women with singleton pregnancies attending for routine antenatal care. The distribution of cervical lengths was established and the significance of differences in median cervical length between subgroups according to maternal age, ethnic origin, maternal ponderal index, cigarette smoking, alcohol drinking, drug abuse and previous obstetric history was calculated. In addition, 100 women were asked to complete a questionnaire aimed to assess the degree of discomfort, pain or embarrassment caused by the scan. In 100 pregnancies, cervical length was measured in each patient by two of four operators to determine intraobserver and interobserver variabilities. RESULTS: During the study period, 2702 (80%) of the 3358 women attending for a 23-week scan agreed to participate in the study and, in all cases, the cervical length was measured successfully. The median cervical length was 38 mm and in 1.6% of cases the length was 15 mm or less. More than 90% of the women reported that the procedure was associated with no or only mild discomfort and embarrassment, whilst 85% found the ultrasound scan to be equally or less uncomfortable than a speculum examination. Measurement of cervical length was highly reproducible and, on 95% of occasions, the difference between two measurements by the same observer and by two observers was < or = 3.5 mm and < or = 4.2 mm, respectively. Cervical length was significantly shorter in women of Afro-Caribbean origin compared to Caucasians, those aged less than 20 years, those with a low ponderal index, those with a history of previous miscarriage or preterm delivery and in drug abusers. CONCLUSIONS: Transvaginal sonographic measurement of cervical length is highly reproducible and it is associated with a minimal degree of discomfort to the patients. At 23 weeks, the median cervical length is 38 mm and, in 1.6% of the population, the length is 15 mm or less. There is an association between cervical length and demographic characteristics and previous obstetric history.     

Artificial antibodies for affinity chromatography of homologous proteins: application to blood clotting proteins

OBJECTIVE: To determine whether pituitary down-regulation after gonadotropin-releasing hormone analogue (GnRH-a) administration can be accurately predicted by transvaginal ultrasonographic measurement of endometrial thickness. DESIGN: Prospective study. SETTING: An IVF unit of an academic medical center. PATIENT(S): One hundred eighty-one patients undergoing 265 IVF-ET treatment cycles using GnRH-a in the long protocol. MAIN OUTCOME MEASURE(S): Serum concentrations of E2 were determined, and endometrial thickness was measured by transvaginal sonography. The accuracy of endometrial thickness for predicting pituitary down-regulation was calculated. RESULT(S): Pituitary down-regulation, defined as a serum E2 concentration of < or = 55 pg/mL, was achieved in 77% (204 of 265) of the cycles. An endometrial thickness of < or = 6 mm was found in 92.2% (188 of 204) of cycles in which down-regulation was achieved. An estradiol level of < or = 55 pg/mL was present in 95.9% (188 of 196) of cycles with endometrial thickness of < or = 6 mm. CONCLUSION(S): A state of relative hypoestrogenism after GnRH-a administration, indicative of pituitary down-regulation, can be predicted with a high degree of accuracy by ultrasonographic measurement of endometrial thickness. Thus, routine testing for serum E2 concentration may be safely omitted. This may allow further simplification of IVF protocols and increase both cost-effectiveness and patients' convenience.     

Preoperative assessment of advanced gastric carcinoma using computed tomography

OBJECTIVES: The role of computed tomography (CT) for the staging of gastric carcinoma is controversial. The purpose of this study was to evaluate the utility of CT in assessing the perigastric spread of advanced gastric carcinoma. METHODS: The study included 56 patients who underwent dynamic CT and laparotomy for the treatment of node-positive gastric adenocarcinoma. Preoperative CT findings were compared with surgical findings, and diagnostic accuracy was estimated. RESULTS: Sensitivity, specificity, and accuracy of preoperative CT in determining the perigastric tumor spreads were 33, 97, and 73% in pancreatic invasion, 36, 97, and 70% in level III lymph node involvement, and 89, 98, and 96% in liver metastasis. Peritoneal dissemination was not detected in 15 of 56 patients (27%), and stage IV disease was not diagnosed correctly in 18 of 40 patients (45%). CONCLUSIONS: Radiologists and surgeons must remember that pancreatic invasion, extended lymph node metastasis, and peritoneal dissemination are sometimes overlooked in CT examination in patients with advanced gastric carcinoma.     

Osteochondritis dissecans of the humeral head

ISSUES: The colposcope was developed in 1925 and is well established in clinical gynecologic practice for defining and delineating cytologically detected lesions mainly of the cervix but also the vagina and vulva. Additionally, various endoscopic procedures in gastroenterology, pulmonary and urologic lesions enhance the cytologic detection and histologic verification of precancerous and cancerous lesions. The cost-effectiveness of all these devices and their applicability, particularly in countries with a limited health budget, is a major issue. This task force considered aspects of the present state of the art and the challenges in the 21st century. CONSENSUS POSITION: Automated cytology can interface with colposcopic examination in a number of significant ways. Automated cytologic analysis of conventional cervical smears can potentially direct colposcopic examination by predicting the nature of a lesion, assist in determining which patients should receive colposcopy and, in some settings, thereby reduce the number of colposcopies. Potentially, various combinations of automated cytology and colposcopy may be used to generate screening protocols that might result in more effective and inexpensive screening. The role of cervicography, or high-resolution cervical photography, as a screening device remains to be defined. Sensitivity for high grade lesions is generally no greater than that in cytology, and specificity appears lower. The interpretation of cervical photographs in triage of mildly abnormal cytology may prove to be useful in countries with established cytology programs. In areas of the world where cytology screening programs are not in place, the interpretation of cervical photographs may have its most dramatic effect. Cost-effectiveness analyses are needed. There are, at present, insufficient data for the evaluation of speculoscopy, a procedure using chemiluminescent illumination of the cervix for visualization of acetowhite areas. Basic training in colposcopy should be integrated into the residency programs of obstetrics and gynecology. Criteria for the adequate training of colposcopists should be developed. Continuing education programs in colposcopy should be developed when they are not already in existence. The cost-effectiveness of integrating colposcopy as a primary screening technique should be evaluated. Following a high-grade squamous intraepithelial lesion (HSIL) cytology result, colposcopically directed punch biopsy should be taken with or without endocervical curettage. This generally should precede the loop electrosurgical excision procedure (LEEP); however, in certain circumstances direct LEEP may be indicated. LEEP under colposcopic vision is an efficient way to treat an HSIL lesion of the cervix because the histologic extent and margins can be determined, unlike with laser surgery or cryosurgery. It is also more cost-effective than cold knife conization because general anesthesia and an operating room are unnecessary. Following LEEP, the endocervical canal should be examined colposcopically for any evidence of involvement. Lesions in the endocervix can then be removed with a different-shaped loop. Further research into Raman spectroscopy as a diagnostic aid in cervical pathology is needed, as is the use of micrococolpohysteroscopy for in vivo cytologic analyses, especially of the endocervical canal and transformation zone. Hysteroscopy is the most direct method for the diagnosis and treatment of intrauterine diseases. Hysteroscopic endometrial biopsy is more accurate than conventional biopsy methods. Cervical invasion of endometrial cancer can be detected by hysteroscopy. The depth of invasion, however, is more accurately determined by magnetic resonance imaging or computed tomography. ONGOING ISSUES: Many topics for ongoing research and/or implementation are mentioned under "Consensus Position," above. (ABSTRACT TRUNCATED)