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Ovarian tumours.—An ovarian tumour has been detected
in 4 cases. The 1st patient had bilateral serous papillary
tumours of " borderline " malignancy. She was symptom-free.
In the 2nd, a single large and easily palpable pseudomucinous
cystadenoma was found. This patient volunteered a family
history of cancer and complained of pain in the left side since
a fall six weeks earlier. The 3rd complained of menorrhagia
and had a solid ovarian fibroma which was easily felt. The
4th had no complaint, but an endometrioma was removed by
ovarian cystectomy. One other laparotomy was carried out
on the diagnosis of ovarian cyst, but in fact this patient had a
broad-ligament cyst. A further small fibroma of the ovary
was removed in a case in the following section where hysterectomy
was performed for fibromyomata.
Fibromyomata.—Fibromyomata have been detected in 43
patients and, although giving rise to no symptoms, have been
of sufficient size to warrant removal in 6. Symptoms in conjunction
with tumours of more moderate size have influenced
advice to undergo hysterectomy in 8 other patients. 12
operations have been carried out at St. Bartholomew's,
and, of the 2 remaining patients, 1 has been put on the
waiting-list of another hospital, and the other is arranging
her operation privately. The largest fibromyoma so far
seen in this series measures 28 x 15 x 10 cm. and caused no
symptoms.
Cervical erosion.—64 " erosions " have been diagnosed, 54
in the absence of symptoms. Particularly where symptoms
were present, treatment has been offered after consultation
with the family doctor.
Cervical polypus.—46 patients have been found to have
cervical polypi; 36 had no symptoms. These polypi have been
removed by avulsion, and have subsequently been examined
histologically. All have been benign.
Vaginitis.—The vaginal flora has not been examined
routinely, unless the patient complained of excessive discharge
or this was noted on inspection. 11 cases of vaginitis due to
Trichomonas vaginalis (9 symptom-free) and 10 of atrophic
vaginitis (8 symptom-free) were found.
Vulvitis.—1 case of diabetic vulvitis was noted; the diabetes
was subsequently confirmed by tests of urine and blood, and
the patient's own doctor referred her to a diabetic clinic. This
patient complained of frequency of micturition. Another, who
presented with irritation, was found to have leukoplakia
vulvae; this was confirmed by biopsy, and treated by local
excision.
Other gynaecological conditions.—We have encountered
Bartholin's cyst (1), urethral caruncle (2), and different
degrees of uterovaginal prolapse (10) with and without stress
incontinence of urine. Of the latter group, operative repair
has been carried out in 2.
Positive smears.—2 patients had smears warranting full
investigation. In the 1st, subsequent smears were negative and
serial sections of material removed by cone biopsy were normal.
This patient is being followed up. The 2nd patient had
repeated suspicious smears, and biopsy showed carcinoma in
situ. She was treated by amputation of the cervix as she was
thirty-six and anxious to have a child. Subsequent smears
have been normal. (Although this two-year survey covers only
the first 678 patients to attend the clinic, it is of interest that the
697th patient had an early clinical stage-i carcinoma of the
cervix, which has now been confirmed by smear and biopsy,
and has been treated.)
DISCUSSION
McLaren and Attwood maintain that nowadays no
gynaecological or obstetrical examination is complete
without cytology. In their unit in Birmingham, all
gynecological patients have been screened in this manner
for the past ten years. The number of cases of carcinoma
in situ discovered by this means has been about 3-4 per
1000 with, in addition, 1 case per 1000 of cervical carcinoma
which, but for the cytological test, would have
been missed in the outpatient department. This, then,
is a diagnostic test of proven value, and attention
should be directed to an extension of facilities so that all
gynaecological outpatients—and not only those fortunate
enough to attend a pioneer centre—may have smears
taken.
Many of the abnormalities detected at the City of
London Clinic are of minor significance; yet, ideally, they
should be treated. The only invasive carcinoma (of the
endometrium) so far detected, however, was found not by
cytology but by the further investigation necessitated by
a history of postmenopausal bleeding. True, this patient
might eventually have gone to her doctor with persisting
bleeding, but she may have preferred the anonymity of
the clinic and thus come forward earlier. The case of
papillary ovarian tumours was well worth treating and,
again, was asymptomatic. In the diagnosis of malignant
disease of the ovary, cytology alone has little if anything
to offer. The disease is insidious, diagnosis is usually
late, and surgical cure depressingly infrequent. The
patient with an ovarian carcinoma, who has her condition
diagnosed and treated early, is indeed fortunate. Patients
with cervical polypi may be without symptoms; but
whether they would remain so indefinitely is uncertain.
The usual practice is to remove the polypi because they
are often associated with bleeding; further, a small
proportion are said to undergo malignant change.
678 patients have been seen over 2 years. 204 (30%)
showed some abnormality. 498 said they attended the
clinic solely because it was a sensible precaution to take;
they did not admit to any symptom or menstrual
abnormality, and they did not volunteer a family
history of cancer. They came because they thought
the clinic a good idea. They represent 73% of the 678
patients.
127 of these 498 were found to have some abnormality
of which they were unaware. The condition was often
worth treating, and was occasionally of considerable
importance to future health. Thus, routine gynaecological
examination is evidently rewarding, and is conveniently
combined with the taking of cytological smears.
McLaren and Attwood cite the opinion of McLennan
that, with careful propaganda, many women will come to
regard prophylactic cytology and routine examination as
not very different from an annual visit to the dentist.
summary
Two years' experience in a well-women's clinic is
described. Cervical cytology is valuable, but clinical
examination of the patient at the same time will confer as
great a benefit. Any cancer-diagnosis clinic of the future
should sensibly combine both procedures.
We are grateful to the Corporation of the City of London for
financing the services of the cytological pathologist.
I wish to thank Dr. Greenwood Wilson, Mr. John Beattie and
Mr. Donald Fraser for their help and encouragement.
1 The Lancet, 1962, ii, 395.
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