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PURPOSE: To evaluate the effect of uterine fibroid embolization (UFE) on menstruation and ovarian function. METHODS: The authors performed an observational study of UFE for the treatment of symptomatic fibroids. All patients had regular predictable menses before intervention and none had clinical or laboratory findings of menopause. UFE was performed with use of standard methods with 355-700-microm-diameter polyvinyl alcohol (PVA) foam particles. The incidence of ovarian failure was calculated for women younger than 45 years and for those 45 years or older, based on retrospective stratification by age. The authors assessed statistical differences in ovarian failure between the two age groups with use of the X2 test. RESULTS: Sixty-six premenopausal women (age range, 30-55 years) underwent bilateral UFE and were followed for an average of 21 weeks (range, 12-77 weeks). In 56 of 66 (85%) patients, regular menses resumed after an average of 3.5 (range, 1-8) weeks. In 10 of 66 (15%) patients, regular menses did not resume. Clinical and biochemical findings consistent with ovarian failure and presumed menopause were seen in nine of 10 patients without resumption of menses (14% of total patients). Ovarian failure occurred in nine of 21 (43%) women older than 45 years and in none of the 45 women younger than 45 years (P < .05). There were no differences in presenting symptoms, amount of PVA used, or fibroid size between patients who did and did not resume menses. CONCLUSION: The majority of patients undergoing UFE will have resumption of menses, but the incidence of postprocedure ovarian failure is considerably higher than reported to date. Loss of menses induced by UFE is significantly more likely to occur in women older than 45 years.

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Recurrent vaginal clear cell adenocarcinoma was diagnosed in two DES-exposed patients 17 and 19 years after initial therapy. These cases demonstrate the need for continued clinical evaluation, since patients with clear cell carcinoma of the vagina seem to be at greater risk for developing late recurrences than patients with squamous cell carcinomas.

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Cryosurgical therapy was used to treat 393 patients with cervical intraepithelial neoplasia. Therapeutic success was evaluated in relation to lesion size, grade, and endocervical extension. The overall cure rate with cryosurgical therapy was 84%. Size alone was found to be the major determinant of cryosurgical success. For one-quadrant lesions, there was a 99% cure rate. For two-quadrant lesions, the cure rate was 93%. For three- or four-quadrant lesions, the success rate was only 61%. Lesion size was found to be positively correlated with grade of dysplasia. As the grade of cervical intraepithelial neoplasia progressed, lesion size tended to increase. When this association was controlled for, grade of dysplasia was not a significant determinant of success rate. When endocervical extension occurred, although the upper limits of the lesion were seen, there was a significantly reduced success rate of 64%. Patients with large lesions or endocervical extension are at a much higher risk for failure with cryosurgical treatment. If cryotherapy is chosen for these patients, careful, long-term follow-up is essential to ensure adequate treatment of disease.

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While primary carcinoma of the vagina is relatively rare, metastatic lesions arising from the endometrium are more common, and extension from cervical or vulvar tumors can also affect the vagina. Adenocarcinoma related to diethylstilbestrol exposure in utero is a recently recognized type of vaginal lesion, and melanoma and sarcoma occur rarely in the vagina. Familiarity on the physician's part with these various presentations and their proper management will help ensure early treatment and preservation of normal vaginal function in affected patients.

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PIP: Attention in this discussion of the management of the adolescent girl exposed "in utero" to diethylstilbestrol (DES) is directed to the following: history; scope of the problem; pathogenesis/embryology; management; future fertility; squamous cell carcinoma; and male factors. In the late 1940s and early 1950s, estrogen deficiency was thought to play a role in the high fetal death rate among pregnant diabetic women. DES was 1st used in diabetics and soon thereafter in patients who were threatening to miscarry, who had previous stillbirths, and previous spontaneous abortions. Estrogens were used by some physicians through the late 1960s. In 1970 Herbst and Scully reported 7 carcinomas of the vagina in young women. On careful review, it was found that the mothers of these young women with clear-cell cancer had been treated with DES at various stages of their pregnancies. Subsequent investigation led to the discovery of the condition of vaginal adenosis in many young women exposed "in utero" to DES. It is estimated that 80-90% of patients exposed to intrauterine DES will show gross and microscopic evidence of vaginal and cervical adenosis. It is now felt by most authorities that adenosis coexists with the clear-cell cancer rather than preceding the tumor. A clear-cell tumor registry has been established and, to date, over 400 cases have been registered. The age-range of DES-exposed clear-cell carcinoma is between 7 and 31 years of age. The care of a girl exposed to DES begins when the physician is informed that the patient's mother either received the medication or there was any possibility of such medication. If bleeding occurs before the menarche, the patient should be hospitalized and examined under anesthesia. In the women of menstrual age, management has been somewhat controversial. The use of the colposcope has allowed careful initial examination of the cervix and vagina as well as providing an excellent means of follow-up. The colposcope has been very helpful in delineating the changes caused by DES. There are numerous gross findings that represent adenosis. These include the cervical changes of the "cockscomb" or anterior cervical ridge or "hood," a cervix within a cervix, and a hermicervix. With the colposcope, the areas of adenosis are seen as grape-like projections which, on biopsy, represent columnar epithelium. Areas of metaplastic squamous tissue are easily identified. On occasion dysplasia can occur in areas of adenosis. Of equal importance is the digital examination of the vagina. At this time it is felt that adenosis requires no other treatment than observations. The treatment of clear-cell carcinoma of the vagina or cervix is best determined by a gynecologic oncologist. 80% of DES patients have had live births.^ieng

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Eight patients with choriocarcinoma of the ovary treated at the Choriocarcinoma Research and Treatment Center are presented and the previously reported cases reviewed. A more optimistic prognosis can be offered for these tumors than previously. Four of the 8 patients are in remission and 4 have died. Triple therapy should be used for these tumors despite the increase in toxicity.

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