The current case report describes the development and medical treatment of an aggressive pelvic endometrioma in a post-menopausal patient, who had undergone abdominal hysterectomy and salpingo-oophorectomy a decade earlier. The patient was referred to the authors' centre because of right-sided sciatic pain. Three months before her admission she was hospitalized elsewhere due to subacute bowel obstruction. She was operated on and a resection of a part of sigmoid colon and an endometrioma, which was the cause of the subobstruction, was carried out. During the clinical investigation for the right-sided sciatic pain, an intrapelvic mass was found, which was compressing the lumbo-sacral plexus mimicking sciatica. The diagnosis of recurrent endometrioma was confirmed by a computerized tomography-guided biopsy and the decision was made to treat it with an aromatase inhibitor (letrozole). Eighteen months later, the endometrioma was almost completely regressed and the patient was free of symptoms. Medical management of recurrent post-menopausal endometriosis with aromatase inhibitors seems to be an effective alternative treatment to surgery.

S_nmary The characteristics of cervicography and the Papamncolaou smear test have been compared for the detection of cervix lesions classified as CIN I or more. A total of 4,015 women were entered into the study. (IARC, 1986;Laara et al., 1987;Day, 1989).Cervicography as a means of screening was introduced by Stafl at the beginning of the 1980s (Stafl, 1981 Screening results qualified as 'atypical' or 'trivial change' were considered to be negative tests. CIN I lesions were considered to be low-grade lesions. CIN II or higher lesions were considered to be high-grade lesions. This distinction is based on the fact that there is a wide consensus that patients with CIN II or higher grade lesions should be subjected to further investigations, whereas the follow-up of CIN I lesions is still controversial (Ellman, 1991;Miller et al., 1991).The reference test was the histopathological examination of the biopsy specimens. All pathology slides were read by two pathologists, each unaware of the evaluation done by the other. In case of disagreement between the two readers, the final diagnosis was established by a senior pathologist aware of the two previous reports. (Morrison, 1985;Brecht & Robra, 1987; Shatzkin et al., 1987;Verbeek et al., 1991

Objective To evaluate in a multicentre setting the performance of cervicography compared with Design Prospective comparative multicentre study. Setting Three hospitals with outpatient gynaecology clinics and three cancer screening clinics. Participants and methods Cervical cytology and cervicography were performed on 5724 women. If one or both tests showed an abnormality suggestive of at least a low grade squamous intraepithelial lesion, a colposcopy with directed biopsy was carried out. Cervicograms were evaluated by four experienced 'senior' assessors and by ten new 'junior' assessors. Results Results were fully analysed for 5192 women (9lY0). A cervical biopsy was carried out on 228 women and this confirmed a true positive lesion in 116 cases (incidence rate: 2.2%). Of these, 72 cases (62-lYO) were detected by cervicography and 64 (55.2Y0) by cytology. This difference was not statistically significant (McNemar: P = 0.475). Only 20 cases of CIN (17%) were concordantly detected by both tests. Senior assessors performed significantly better with a detection capacity of 80.6% compared to a detection capacity of 56.6% for the junior assessors (x2 test: P = 0.034). Conclusions Cervicography must be considered as a complementary test to cytology. Overall detection of CIN is improved, but this is mainly due to the detection of more low grade lesions. The lower sensitivity and specificity in hgh grade lesions compared with cervical cytology is the main limitation of cervicography in screening for CIN. An important finding was that the performance of cervicography was highly dependent on the assessors' experience. cytology for the detection of cervical intraepithelial neoplasia.

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Severe intra-operative and post-operative bleeding is a potentially life-threatening complication of gynaecologic surgery. A sound clinical judgement and the adequate assessment and preparation of the patient are the best pre-operative means to avoid its occurrence. Intraoperative prevention requires knowledge of surgical anatomy and haemostatic techniques. The management of haemorrhagic complications can be extremely challenging. Its success depends on the perfect integration of surgical expertise, the supporting role of the anaesthesiologist and on the availability of a fully equipped interventional radiology team with much experience. A methodical and stepwise surgical approach is needed to selectively dissect and identify the bleeding site without damaging adjacent structures. In case of more diffuse or massive bleeding, the performance of a bilateral ligation of the anterior branch of the internal iliac arteries at an early stage is an appropriate measure. The anaesthesiologist is responsible for the maintenance of the patient's haemodynamic function and the prevention of coagulopathy. Compression or atraumatic clamping of the aorta or placement of a pelvic packing can be temporarily applied to stabilize the patient's condition. Only once this is achieved, can the subsequent option of angiographic arterial embolisation be considered.