Diethylstilbestrol (DES) Update: Recommendations for the Identification and Management of DES-Exposed Individuals

Barbara Hammes, CNM, MS, Cynthia J. Laitman, PhD

Disclosures

J Midwifery Womens Health. 2003;48(1) 

In This Article

Gynecologic Care for DES Daughters

Although many of the components of an annual gynecologic examination are the same for women exposed to DES in utero as for non-exposed women, there are some noted exceptions ( Table 3 ).

Parts of the routine annual gynecologic examination that are unchanged for the DES in utero-exposed woman include clinical breast examination, bimanual, and rectal examination. Because changes of the vulva have not been associated with DES exposure, inspection of the vulva is routine. The National Cancer Institute guidelines for women of the same age category should be followed regarding mammogram scheduling.

In conducting a speculum examination, excess mucous, which is sometimes present in a DES-exposed woman, may be gently removed with a moist cotton swab. Carefully rotate the speculum so that both the anterior and posterior vaginal walls are visible, allowing the epithelial portion of the vagina to be carefully inspected. Gross adenosis may appear red and granular, whereas squamous metaplasia may be indistinguishable from normal epithelium.

A routine cervical Papanicolaou test is not adequate for DES-exposed daughters. The cervical Papanicolaou test must be supplemented with a special Papanicolaou test of the vagina called a "four-quadrant" Papanicolaou test, in which cell samples are taken from all sides of the upper vagina. One method is to sample the upper third of the vagina thoroughly with a plastic spatula. If gross epithelial changes are evident, the middle and lower thirds of the vagina should also be sampled at the same time. The spatula should be rotated along the entire circumference of the vaginal fornices and the entire ectocervix. The sample should not be taken from the vaginal secretions, which may contain inflammatory exudate. The material should be promptly transferred to a liquid base or to a slide and immediately fixed. A second sample from the endocervix should be obtained using a cytobrush. DES daughters can have small cervical openings, making it more difficult to obtain good endocervical samples. It is not necessary to place the vaginal and cervical samples on separate slides.

Because superior sensitivity and improved adequacy of Papanicolaou tests have been shown with use of the thin prep, instead of the conventional slide method,[57] most practitioners seeing DES daughters recommend that it be used for these women. Consult with your cytologist for recommended sampling technique. Some may prefer that samples be placed in two different specimen containers. Notation of history of DES in utero exposure must be included on the labels for these specimens. These Papanicolaou smear samples need to be evaluated by a cytologist/pathologist who is thoroughly familiar with the changes in samples from DES-exposed women because immature squamous metaplasia is frequently difficult to distinguish from intraepithelial neoplasia. If an abnormal smear is reported, it is necessary to consult a specialist experienced in evaluating and treating DES-exposed daughters.

Vaginal and cervical palpation is a crucial part of the DES examination and may provide the only evidence of a clear cell adenocarcinoma, especially on the rare occasion when it is located beneath the mucosa. The entire length of the vagina and fornices should be carefully assessed. Vaginal ridges and structural changes of the cervix may be noted. Areas of thickening or induration should raise suspicion and be biopsied.

Diagnostic Procedures Used to Assess Adenosis in DES Daughters

The chief benefits of colposcopy are that it permits adequate assessment of the extent of epithelial changes on the cervix and vagina and can be used as an aid to detect those areas most likely to disclose abnormalities on biopsy. Colposcopy has not proved to be essential due to lack of specific vascular changes with clear cell adenocarcinoma and to the fact that some tumors may be located interior to the vaginal and cervical surfaces. If performed, colposcopy should be done before iodine staining. Colposcopy is most effectively used to provide a baseline assessment or to follow demonstrated pathologies but does not have to be performed routinely.

As part of the colposcopic examination, iodine staining of the cervix and vagina is used to temporarily stain the linings of the cervix and vagina to detect adenosis (a non-cancerous but abnormal growth of glandular tissue) or other abnormal tissue by indicating the boundaries of epithelial changes (Figure 3). The iodine stains only the mature squamous epithelium lining. It cannot be used to detect lesions beneath the surface. Normal squamous epithelium will stain a mahogany color. Dysplastic tissue lacks glycogen and will not stain. Squamous metaplasia stains lightly. Schiller's solution is not recommended because it causes burning of the vagina. After ruling out iodine allergy, use Lugol's solution at half strength (half strength is 2.5% iodine with 5% potassium iodide in water).[58] Rotate the speculum as it is withdrawn so that the entire vaginal surface can be visualized. It is important to be aware that adenosis itself, non-staining areas of the vagina or cervix, does not need to be biopsied. It is advisable to refer patients to DES-knowledgeable specialists rather than to overbiopsy. After visualization, the speculum will need to be reinserted if biopsy is indicated. Jelly may be used to facilitate reinsertion because iodine is dehydrating.

Biopsy should be performed whenever the vagina or cervix is indurated, granular, contains a palpable nodule or mass, has discrete areas that appear to be of a different color or texture than the surrounding tissue, or if there are highly atypical colposcopic findings. Random sampling of simple adenosis, non-staining areas of the vagina or the cervix is not recommended because these areas rarely disclose neoplastic changes. To stop bleeding after biopsy, use pressure and Monsel's solution or a silver nitrate stick. Follow other normal precautions and educational follow-up for biopsy.

Cryosurgery, laser therapy, and conization procedures may result in excessive scarring in women exposed prenatally to DES.[59] Furthermore, these procedures are not necessary to "treat" or "correct" common structural anomalies associated with DES exposure. To avoid unnecessary tissue damage, refer patients to a DES-knowledgeable gynecologist.

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