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Objective: To determine the perceptions and practices of American obstetrics and gynecology residents concerning primary care immediately before the institution of Residency Review Committee Special Requirements for Obstetrics and Gynecology.

Objective: To evaluate the conservative management of pain after systemic methotrexate therapy for ectopic pregnancy; identify prognostic factors for success; and compare hCG resolution time for patients with and without pain.

Objective: To evaluate and compare the safety and efficacy of leuprolide versus placebo in managing chronic pelvic pain in women with clinically suspected endometriosis.

Objective : To establish the current level of instruction in practice management in obstetrics and gynecology residency programs; review recommendations of medical school practice management executives and current and former residents on design of practice management instruction programs; and develop recommendations for future management instruction by residency programs in obstetrics and gynecology. Methods : A questionnaire was sent to 101 practice plan executives of obstetrics and gynecology departments at medical schools in the United States and Canada. A modified version was sent to 44 current obstetrics and gynecology residents and 72 former residents from the University of Tennessee, Memphis. Results : The response rates were 71% (practice executives), 93% (current residents), and 81% (former residents). There were no formal management programs at 87% of responding institutions, although most respondents (62%) thought there should be mandatory participation in management programs, probably given by organizations outside the university. Potential subjects that received high ratings were current procedural terminology and diagnosis coding, managed care, billing procedures, contractual agreements between medical doctors, patient record management, and practice economics. Conclusion : Residency programs should establish formal practice management instruction programs and make participation mandatory. Funding should come from the medical school and university. Instructional help should come from extradepartmental organizations and individuals.

Objective: To establish the current level of instruction in practice management in obstetrics and gynecology residency programs; review recommendations of medical school practice management executives and current and former residents on design of practice management instruction programs; and develop recommendations for future management instruction by residency programs in obstetrics and gynecology.

To evaluate the conservative management of pain after systemic methotrexate therapy for ectopic pregnancy; identify prognostic factors for success; and compare hCG resolution time for patients with and without pain.

To determine the perceptions and practices of American obstetrics and gynecology residents concerning primary care immediately before the institution of Residency Review Committee Special Requirements for Obstetrics and Gynecology.

A program teaching laparoscopic sterilization using local anesthesia was developed and implemented in a large residency program in which sterilization using general anesthesia was already being taught in a traditional fashion. Important steps for the development of such a program included the designation of an individual with overall responsibility for the program, identification of potential obstacles along with feasible solutions, and training of residents and staff in the new techniques. The major obstacles to implementation included opposition from anesthesia personnel, the need for additional training in the new techniques for both residents and faculty, nursing staff resistance, and the uncertainty of patient acceptance. Solutions included involving anesthesia personnel in program planning as well as in the ultimate performance of the procedures, practicing local techniques during cases under general anesthesia, limiting initial cases to candidates anticipated to be uncomplicated, and using nondirective counseling of patients. Similar strategies can be useful both to other residency programs and individuals wishing to offer local anesthesia as an option for laparoscopic sterilization at their hospitals.

This study describes the first use of biofeedback, in addition to standard sex therapy, for low sexual arousal presented by a 26-year-old married nursing student. Despite glowing self-reports of improvement, only 4 or 5 out of 32 physiological and cognitive measures, both within and between therapy sessions, showed evidence of change. The findings of this study underscore those of others, which have raised doubts about the efficacy of sex therapy.

Dilation and evacuation (D&E) is the most common procedure for second-trimester pregnancy termination currently used by United States obstetrician-gynecologists. Although this method carries morbidity and mortality rates significantly lower than methods requiring labor induction, the procedure most commonly used for second-trimester genetic terminations seems to be labor induction (eg, vaginal prostaglandin suppositories). Many geneticists appear reluctant to recommend D&E over induction methods of pregnancy termination because they perceive that fetal abnormalities cannot be consistently confirmed by evaluation of the products of conception obtained by D&E. We report here 60 consecutive patients who underwent D&E (14-22 weeks' gestation) after detection of fetal abnormalities. The prenatal diagnoses were confirmed in all cases. Our experience thus indicates that D&E is reliable in confirming most prenatal diagnoses and should be the procedure of choice when second-trimester pregnancy termination is chosen because of fetal abnormalities.

This study evaluates the long-term outcome of 99 women who underwent hysterectomy for pelvic pain of at least 6 months' duration. All had symptoms and physical examination findings suggestive of disease confined to the uterus. Patients were excluded if there was previously documented extrauterine pelvic disease, extrauterine pelvic disease at the time of surgery, or uterine weight exceeding 200 g. Histopathologic analysis revealed leiomyomata in 12 (12.1), adenomyosis in 20 (20.2), and both leiomyomata and adenomyosis in two (2.02). The average uterine weight was 91.1 g (range 24-198). Patients were followed after hysterectomy for an average of 21.6 months (range 15-64), with 77 of 99 (77.8) showing significant improvement and 22 (22.2) having persistent pelvic pain. Despite preoperative history and physical findings suggesting and histologic findings confirming uterine disease, nearly a quarter of the patients had persistent pelvic pain after hysterectomy for chronic pelvic pain. These findings should have a significant impact on the therapeutic choices recommended by gynecologists and may alter the informed consent that patients give in such cases. (Obstet Gynecol 75676, 1990)

A study of peritoneal healing after specific types of peritoneal injury was conducted in rabbits. Histologic specimens were examined at four, eight, 12, 24, and 48 hours, and at five, seven, and 14 days postperitoneal injury. Comparison of types of injury and attempts at peritoneal repair revealed differences in healing mechanisms. Histologic evidence of rapid reperitonealization was associated with those types of repair that involved minimal tissue necrosis and absence of foreign body reaction.

To answer questions about obstetric-gynecologic resident salary, night call, vacation, outside employment, gender mix, and training experiences using data from a national directory of residency programs in obstetrics and gynecology.

Splenosis is the autotransplantation of splenic tissue that usually follows traumatic rupture of the spleen. These splenic implants may be located anywhere within the peritoneal cavity. Although a relatively rare entity, when present these implants may mimic endometriosis or even metastatic carcinoma. As splenosis may compensate in part for the asplenic state, it is recommended that these splenic implants not be removed. It is important to correctly diagnose this condition to avoid unnecessary therapy. Diagnosis and management are discussed as well as a review of the literature.

To compare objectively the pain associated with tubal occlusion by Silastic rings versus electrocoagulation during laparoscopic tubal ligation under local anesthesia.

To compare outpatient laparoscopy-assisted vaginal hysterectomy with standard outpatient vaginal hysterectomy

This report describes an individualized, reduced dose, methotrexate (MTX) and citrovorum factor (CF) treatment regimen for outpatient management of unruptured ectopic pregnancy (EP). One hundred sixteen laparoscopically documented EPs, the majority (90%) of whom were symptomatic, were diagnosed from an Emergency Department population. Eighty of 116 (69%) were unruptured, 37 (46.3%) of whom were eligible for MTX-CF chemotherapy. One patient refused chemotherapy. Thirty-four of the 36 (94.4%) patients treated with MTX-CF had complete resolution of their ectopics, whereas 2 experienced rupture after chemotherapy, 1 of them 23 days after MTX initiation. While there were no major chemotherapy-related side effects, 3 of the 36 (8.3%) patients experienced minor side effects. The authors conclude that: (1) individualized dosing of outpatient MTX-CF chemotherapy for symptomatic EP can be safely managed, even in an indigent population; (2) rupture can occur up to 23 days after chemotherapy initiation; (3) fetal cardiac activity is an absolute contraindication to chemotherapy; (4) chemotherapy in patients with symptoms is of limited value because the disease is too far advanced; therefore, it is essential that the diagnosis of EP be established before symptom onset; and (5) chemotherapy offers no significant immediate advantages to outpatient laparoscopic surgery. However, increasingly reliable nonlaparoscopic diagnosis will soon give wider application to this approach.

Premenstrual syndrome is a cyclical disorder involving behavioral, emotional, and physical symptoms during the premenstruum. Because of its unknown etiology, a variety of treatment options exist; yet no therapy has consistently reduced symptoms. Most recent advances have occurred in relaxation techniques and psychotropic therapies

In a rat model, sodium carboxymethylcellulose (SCMC) was compared with normal saline and 32% dextran 70 in the prevention of surgically induced intraperitoneal adhesions. The 32% dextran 70 was similar to normal saline in the initial prevention of adhesions, and both appeared less effective than SCMC. After lysis of the initial adhesions, SCMC was significantly more effective than 32% dextran 70 in the prevention of the reformation of adhesions. Possible mechanisms of action, complications of SCMC, and the need for further research in finding an ideal solution for use in adhesion prevention are discussed.

Nineteen women trained in the technique of pelvic examination taught both the technical and interpersonal aspects of the procedure to sophomore medical students in a physical diagnosis course. Working in teams of two, the women functioned as the primary instructors. A medical professional served as resource person only. The training and teaching programs are described. Because of the success of both, a similar learning experience for third‐year medical students entering the obstetric/gynecology clerkship and for obstetric/gynecology residents has been initiated.

Figure 2 outlines the management protocol used at the University of Tennessee. Expectant management either in the presence or absence of tubal abortion offers an alternative to surgical management of ectopic pregnancy. With proper patient selection and follow-up, surgery can be avoided in a significant number of patients who once would have required operative intervention.

The approach to the patient with CPP with a history of PID remains a diagnostic challenge even for the experienced clinician. From the initial diagnosis of presumed PID to managing the pain that may result, using an approach that looks at all factors, not just antecedent PID, allows the practicing physician to avoid becoming too narrowly focused in his or her approach. A clinical starting point would assume all possibilities for pelvic pain and evaluate for each. Given the history of one or more episodes of PID, especially if documented with a prior laparoscopy, earlier investigation for adhesions could be justified in selected patients. If the pelvic examination further suggests a pelvic source, a laparoscopy performed early rather than late in the work-up would seem appropriate. The key to management of the patients who have CPP following PID is to use any and all available diagnostic and therapeutic modalities to identify the source(s) before assuming that the patient suffers only from the known sequelae of PID.

The presence of dyspareunia as a specific complaint should be a routine part of the gynecologic history. Even if the patient does not present with this as a chief complaint, the regular inclusion of the question of whether the patient has pain during intercourse can address emotional and physical concerns the patient may leave unspoken unless given the opportunity. Once identified, the symptoms should be dealt with by the clinician potentially as both an organic and as a sexual problem. This will allow the clinician to keep in mind that secondary sexual dysfunction can arise from initially simple organic problems. Patients should be advised at the outset that the process is ongoing and that therapy may be more than just one single treatment approach. Dyspareunia that occurs after a period of good sexual adjustment may be more amenable to an office-based counseling and educational approach, assuming that the patient and her partner are comfortable and cooperative in approaching the problem. Dyspareunia of long standing or in a more complicated relationship may require skills possessed by more highly trained professionals.

The purpose of this prospective clinical trial was to determine the reliability of the Pipelle endometrial biopsy instrument in recovering adequate tissue for confirmation of the diagnosis of endometrial cancer in patients with known endometrial carcinoma, and to compare endometrial histology of the sampling specimen with that of the subsequent hysterectomy specimen. Forty patients were enrolled in this study. All biopsies were performed in the office without anesthesia. The patients had a median age of 62 years (range 40-83). Discomfort was reported by the patient as mild, moderate, or severe; only two patients (5.0) reported severe pain. There were no complications experienced with endometrial sampling. Thirty-nine of 40 specimens (97.5) confirmed endometrial carcinoma; therefore, this study yielded a 97.5 sensitivity for the Pipelle endometrial sampling device. Comparing Pipelle and hysterectomy histology for individual patients, the histologic grade was the same in 29 (74.4), while the Pipelle demonstrated a more advanced degree of differentiation in five (12.8) and a lesser degree in five (12.8). There was no residual tumor identified in one hysterectomy specimen (2.5). Among the 12 patients who had a D&C for diagnostic purposes before referral, the Pipelle biopsy correlated with the D&C histology in ten of 12 (83.3) and revealed a more advanced grade of tumor in one (8.3) and a more differentiated grade in one (8.3). In one patient, the D&C histology was adenocarcinoma grade 1, with the Pipelle demonstrating atypical hyperplasia and the hysterectomy specimen interpreted as endometrial adenocarcinoma in situ. This study demonstrates the Pipelle to be an accurate device for endometrial sampling in patients with endometrial carcinoma. (Obstet Gynecol 77954, 1991)

Ovarian abscess is a rare gynecologic entity; only 120 cases have been reported in the world literature. In contrast to the more commonly encountered tubo-ovarian abscess, tubal involvement is absent in the ovarian abscess. This report describes a case of an ovarian abscess arising de novo within an endometrioma. The woman presented with a 20-cm pelvic-abdominal mass with paracaval adenopathy and bilateral ureteral obstruction. Treatment with broad-spectrum antibiotics was unsuccessful. The surgical specimen revealed endometrial glands, stroma, hemosiderin-laden macrophages, and evidence of abscess formation.

Solutions of sodium carboxymethylcellulose (SCMC) were studied in rats to determine their longevity within the peritoneal cavity and their potential for prevention of postoperative intraperitoneal adhesions. In 18 rats, test solutions of SCMC and 10% dextran 40 were instilled at laparotomy. At 48hours copious amounts of SCMC remained, whereas no 10% dextran 40 could be detected. In addition, standardized surgical injury was produced on the ceca of 100 rats at laparotomy. All control animals had significant adhesions at 2weeks. Eighty-two percent of the 10% dextran 40 group had significant adhesions, while only 16% of the 0.9wt% SCMC and 17% of the 1.0wt% SCMC groups had significant adhesions. Solutions of SCMC were significantly more effective than 10% dextran 40 in the prevention of adhesions (P<0.001). Properties of SCMC and a possible mechanism for its striking effectiveness in adhesion prevention in this study are discussed.

Presently, methotrexate is a common treatment for tubal ectopic pregnancy. In this trial, the investigators examined the role of several pretreatment factors on the outcome of intramuscular methotrexate therapy in 350 women with tubal ectopic pregnancies. They included the baseline serum chorionic gonadotropin (CG) and progesterone levels, the size and volume of the conceptus, blood in the peritoneal cavity, and fetal cardiac activity. The criterion for success was resolution of the pregnancy without the need for surgery. Methotrexate was given in single doses of 50 mg/m2. With one exception, surgery was performed if the serum CG did not respond after three doses or if fetal cardiac activity remained evident. At baseline, about three-fourths of women had an ectopic tubal mass on transvaginal ultrasonography, and one-third had free peritoneal fluid, presumably blood, limited to the pelvis.