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in the university has brought together all sectors,irrespective of their political persuasions. Teaching has beeninterrupted and many demonstrations have taken place butas yet with little effect in changing the Government’sposition. Rector Federici has sacked 4 deans unwilling tocomply with the arbitrary dismissals. The Association ofAcademics has called all graduates of the university to a massmeeting to protect their alma mater and an appeal has beenlaunched to obtain the help of the international academiccommunity through an international conference ofacademics in Santiago next month. This crisis mayeventually lead to the closure of one of the most respecteduniversities in the Spanish-speaking countries. Chileanacademics deserve widespread support.

GYNAECOLOGICAL ULTRASOUND

ULTRASOUND scanning is an invaluable asset in

obstetrics but the potential benefits for gynaecologicalpractice are less well- recognised. It is a useful method forfollowing the progress of ovarian cysts, most of which inyoung women are symptomless, functional cysts whichresolve spontaneously. Finding an ovarian cyst should nottherefore prompt immediate surgical intervention. For

single, unilocular lesions < 5 cm in diameter, a repeat scan in4-b weeks will often confirm spontaneous resolution. If the

cyst is multilocular or contains solid elements, or if it persistsor increases in size, then it should be removed to excludemalignancy.1,2 In general, however, the accuracy ofultrasound for diagnosis of ovarian malignancy is poor,2,3which restricts its usefulness as a potential screening test.3Ultrasound can also help to differentiate ovarian massesfrom uterine fibroids.1 Solid ovarian tumours may mimic

fibroids; if there is any doubt, a laparoscopy or laparotomy isindicated.

Ovarian scanning is especially useful during the

management of infertility. Follicular development,ovulation, and the luteal phase can all be closely monitoredby ultrasound,4,5 which provides a more accurate assessmentthan 24 h urinary steroid measurements. Regular scansallow accurate identification of ovulation both in

spontaneous cycles, thereby indicating optimum timing forintercourse, post-coital tests, or artificial insemination, andin cycles induced by anti-oestrogens 6 luteinisinghormone releasing hormone (LHRH),’ or exogenous

gonadotropins. In in-vitro fertilisation programmes,

recognition of multiple follicular development facilitatesoocyte recovery.8,9 In women receiving gonadotropintherapy who have multiple follicular development,

1. Morely P, Benett E. The use of ultrasound in the diagnosis of pelvic masses. Br JRadiol 1970; 43: 602-16.

2 Meire B, Farrant P, Gaka T. Distinction of benign from malignant ovarian cysts byultrasound. Br J Obstet Gynaecol 1978; 85: 893-99.

3. Goswawmy RK, Campbell S, Whitehead MI. Screening for ovarian cancer. ClinObstet Gynaecol 1984; 10: 621-43.

4. Hackeloer BJ, Fleming R, Robinson HP, Adam AH, Coutts JR. Correlation ofultrasonic and endocrinologic assessment of human follicular development. Am JObstet Gynecol 1979; 135: 122-28.

5. Kerin JF, Edmonds DK, Warnes GM, et al. Morphological and functional relations ofgraafian follicle growth to ovulation in women using ultrasonic, laparoscopic andbiochemical measurements. Br J Obstet Gynaecol 1981; 88: 81-90.

6. Polson DW, Kiddy DS, Mason HD, Franks S. The difference between respondersand non-responders to clomiphene citrate in women with polycystic ovarysyndrome. 24th British Congress of Obstetrics and Gynaecology, 1986 (abstr 53).

7. Mason WP, Adam J, Morris DV, et al Induction of ovulation with pulsatileluteinising hormone releasing hormone. Br Med J 1984; 288: 181-85.

8. Hillier SG, Parsons JH, Margara RA, Winston RM, Crofton ME. Serum oestradioland pre-ovulatory follicular development before in vitro-fertilisation. J Endocrinol1984; 101: 113-18.

9. Wikland M, Nilsson L, Hansson R, Hamberger L, Janson PO. Collection of humanoocytes by the use of sonography. Fertil Steril 1983; 39: 603-08.

administration of human chorionic gonadotropin to causefollicular rupture can be withheld in order to prevent a

multiple pregnancy.Recognition of ovarian morphology with ultrasound has

confirmed the diagnosis in women who present with

oligo-amenorrhoea and hirsutism and at some centres hasalready replaced costly and often inconclusive endocrinetests.10,1l A small uterus with a thin endometrium and smallinactive ovaries suggests hypo or hyper gonadotropichypogonadism. Multifollicular ovaries are of normal sizeand are characteristic of weight-loss-related amenorrhoea.12 .In contrast, polycystic ovaries contain small follicles withincreased ovarian stroma, resulting in an expanded ovarianvolume. They are usually associated with a bulky uterus andthickened endometrium.13 Similar studies suggest that

pre-treatment ultrasound assessment of the ovaries is

mandatory to ensure that correct ovulation induction

therapy is offered&mdash;eg, women with gonadotropindeficiency or multifollicular ovaries will respond well toLHRH therapy and poorly to clomiphene citrate whereasthe reverse is true for women with polycystic ovaries.

Scanning the uterus and endometrium can assist

management of dysfunctional and postmenopausalbleeding. There is a direct correlation between bothendometrial thickness and uterine cross-sectional area andthe concentration of circulating oestrogens.13 A thickenedendometrium or enlarged uterus therefore reflects

hyperoestrogenism; progestagen therapy reducesendometrial thickness and will revert hyperplasticchange. 14, 15 The finding of a thickened endometrium in apostmenopausal woman suggests hyperplasia or malignancyand a diagnostic curettage is mandatory.

It has been suggested that some women with chronicrecurrent lower abdominal pain and normal findings onpelvic examination and at laparoscopy may have pelvicvenous congestion.16 Venography confirms a significantslowing of pelvic blood flow in these women and ultrasoundcan identify ovarian veins and recognise their congestion.17Ultrasound scanning may therefore be an alternativenon-invasive investigation to confirm this diagnosis.

Gynaecological observations during pregnancy includerecognition of uterine fibroids; this finding may account forepisodes of abdominal pain due to fibroid degeneration,which is common during pregnancy. Serial scans of cervicallength and internal os in women with a history of possiblecervical incompetence, will allow early detection of cervicalchange and provide an objective basis for the decision tocarry out cervical encerclage. US,1’} The value of ultrasound

10. Adams J, Polson DW, Franks S. Prevalence of polyscystic ovaries in women withanovulation and idiopathic hirsutism. Br Med J 1986; 293: 355-59.

11. Franks S. Primary and secondary amenorrhoea. Br Med J 1987; 294: 815-20.12. Adams J, Franks S, Polson DW, et al. Multifollicular ovaries: clinical and endocrine

features and response to pulsatile gonadotropin releasing hormone. Lancet 1985; ii:1375-79.

13. Polson DW, Franks S, Reed MJ, Cheng RW, Adams J, James VHT. The distributionof oestradiol in plasma in relation to the uterine cross-section area in women withpolycystic or multifollicular ovaries Clin Endocrinol 1987; 26: 581-88.

14. Polson DW, Morse AR, Beard RW. An alternative to the diagnostic curettage&mdash;endometnal cytology. Br Med J 1984; 288: 981-83.

15. Franks S, Adams J, Mason HD, Polson DW. Ovul;atory disorders in women withpolycystic ovary syndrome. Clin Obstet Gynaecol 1985; 12: 605-32.

16. Beard RW, Highman JH, Pearce S, Reginald PW. Diagnosis of pelvic varicosities inwomen with chronic pelvic pain. Lancet 1984; ii: 946-49.

17. Adams J, Beard RW, Franks S, Pearce S, Reginald PW, Sutherland IA. Pelvicultrasound findings in women with chronic pelvic pain: correlation with

laparoscopy and venography. 24th British Congress of Obstetrics and Gynaecology1986 (abstr 80).

18. Sarti DA, Sample WF, Hobel CJ, Staisch KJ. Ultrasonic visualisation of a dilatedcervix during pregnancy. Radiology 1979; 130: 417-20.

19. Michaels WH, Montgomery C, Karo J, Temple J, Ager J, Olson J. Ultrasounddifferentiation of the competent from the incompetent cervix: prevention ofpreterm labours Am J Obstet Gynecol 1986; 154: 537-46.

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scanning of the adnexae in pregnancy is more controversial;it is also more difficult since the ovaries rise out of the pelviswith advancing gestation. If an ovarian cyst is detected

during pregnancy, some workers would recommendelective surgery20 in view of the risk of torsion and thepotential risk of malignancy.2122 A study conducted byHogston and Lilford over an eight-year period at QueenCharlotte’s Hospital reported the prevalence of ovarian cystsnoted on the baseline scan in 26 000 pregnancies to be 1 in190 pregnancies;23 earlier studies in pregnancy based onclinical examination and confirmed at laparotomy suggesteda prevalence of 1 in 80 to 1 in 2000.* Of the 137 cystsdetected by ultrasound, all were symptomless and only 45 %were detected by clinical examination, although most of thecysts larger than 6 cm were recognised. Laparotomywas carried out in 21 women, 14 electively and 7 for acomplication arising during pregnancy or in the

puerperium. In 3 cases the ovaries were found to benormal-2 elective operations revealed pedunculatedfibroids and in 1 woman an emergency operation was donefor torsion of a fimbrial cyst. Of the remaining 18 cases, therewere 10 ovarian tumours, 1 of which was malignant, and 8functional cysts. The remaining 116 cysts were all managedconservatively and assumed to be functional because all hadresolved on repeat ultrasound scans carried out later in the

pregnancy. Therefore only 1 in 2500 women had an ovariantumour which required laparotomy but 8 women had anunnecessary operation as a result of the ultrasound findings.Hogston and Lilford concluded that laparotomy should becarried out if the cysts are larger than 8 cm in diameter orhave features suggesting malignancy.

Pelvic scanning with ultrasound will not replace clinicalexamination but, like the physician who will not provide acomplete respiratory assessment without a chest radiograph,so gynaecologists should realise the complementary benefitsof this technique.

OF CABBAGES AND QUEENS

VIEWED from Europe, it is all too easy to get the

impression that in North America coronary surgery hasbeen so readily available that it may have been overused.However, it has now been suggested that a whole section ofthe US population-American women-have been deniedtheir fair share of its benefit.1 Tobin and his colleaguesin New York studied patients undergoing nuclear

cardiological investigations at a group of teaching hospitalsin the Bronx to see if they were subsequently referred forcardiac catheterisation or surgery.Of patients with positive nuclear tests, 40% of men but

only 4% of women went on to definitive investigations. It

20. Dewhurst CJ, ed: Integrated Obstetrics and Gynaecology for Postgraduates. 3rd edOxford. Blackwell Scientific, 1981: 762.

21. Booth RT. Ovanan tumours in pregnancy. Obstet Gynecol 1963; 21: 189-93.22. White KC. Ovarian tumours in pregnancy. Am J Obstet Gynecol 1973, 116: 544-48.23. Hogston P, Lilford RJ. Ultrasound study of ovarian cysts in pregnancy: prevalence

and significance. Br J Obstet Gynaecol 1986; 93: 625-28.24. Grimes WH, Bartholomew RA, Colvin ED, Fish JS, Lester WM. Ovarian cyst

complicating pregnancy. Am J Obstet Gynecol 1954; 68: 594-05.25. Choudhury NNR. Ovarian tumours complicating pregnancy. Am J Obstet Gynecol

1962; 83: 615-18.1. Tobin JN, Wassertheil-Smoller S, Wexler JP, et al. Sex bias in considering coronary

bypass surgery Ann Intern Med 1987; 107: 19-25.

seems evident that, depending on the gender of the patient,there was a clear difference in the attitude of the physician.Tobin et al attempted to analyse the reason for this

apparently discriminatory practice. The study is based on390 patients, with an approximate male to female ratio of 2 to1. In terms of age, symptoms of heart failure, severity ofangina, and anti-anginal therapy, the sexes were similar butthe women were more "symptomatic" overall (80% vs70%). Yet the examining cardiologist considered the

symptoms to be non-cardiac in 33% of women comparedwith 16% of men.

This study also gives an intriging insight into the use ofdiagnostic tests in the USA and in particular the place ofnuclear cardiology. The nuclear tests included gated bloodpool scans (which measure global and regional leftventricular function) and thallium scans (which indicateregional and reversible defects in myocardial perfusion).The fact that 94% of patients were outpatients may beinstructive for those who still follow the extravagant practiceof admitting people to hospital for investigation. On theother hand, less than half the patients (42%) had a chestradiograph, 10 patients did not appear to have had anelectrocardiogram (ECG), and only 20% had an exerciseECG.

It seems that the physicians resorted to expensive scanswithout going through the simpler investigations. In

women, the stated purpose in more than half the cases (53 %)was to confirm the presence of cardiac disease while in men itwas most commonly (40%) to grade its severity. Abnormalresults were twice as common in men as in women (64% vs31 %), which supported this contention. But then came thesurprising finding. Of the 40 women with abnormal tests, 11were still regarded as having a non-cardiac cause for theirsymptoms (27-5% vs 12-7% of men). By this stage in agroup splitting analysis the numbers are small, but multiplelogistic regression, controlling for age, type of symptoms,nature of test result, and history of infarction, revealed thatmen were 6-5 times more likely to be referred for cardiaccatheterisation.

Why should a physician first seek a non-cardiac

explanation for symptoms in his female patients and then,even when confronted with evidence of heart disease, stillnot offer the treatment which he believes to be appropriatein men? The most likely defence for what otherwise wouldseem a blatant example of sexist double-standards would bethat coronary artery surgery is significantly more dangerousin women, a view supported by the Coronary ArterySurgery Study (CASS) data in which the mortality was4-5% for women compared with 1-9% for men among the7000 cases in the non-randomised study.2 Careful analysis ofthese figures indicates that the relatively smaller physicalsize of the female patient and therefore of her arteriesexplains most of the difference; in a technically exactingoperation depending on precise anastomosis of 1-2 mmvessels this would be a sensible explanation for a marginallyincreased risk. However, once this view is accepted itbecomes a self-fulfulling prophecy-when surgery is a lastresort the results are not as good as when it is used for morepositive indications. Surgery can now be carried out with anacceptably low mortality in women, less than that in theCASS. The latest report from New York rightly askswhether female cardiac patients are given a fair deal.

2. Fisher LD, Kennedy JW, Davis KB, et al. Association of sex, physical size, andoperative mortality after coronary artery bypass in the Coronary Artery SurgeryStudy (CASS). J Thorac Cardiovasc Surg 1982; 84: 334-41.