Abstract

PIP: The Diethylstilbestrol Adenosis (DESAD) Project purpose is to study the frequency and natural history of genital tract changes in women exposed prenatally to diethylstilbestrol (DES). The intention is to update the medical community with current information on the health status of DES exposed persons, methods available for their identification, and plans for continuing examination and management. It is estimated that up to 6 million persons--mothers, daughters, and sons--were exposed to DES during its use for high risk pregnancy between 1940 and 1971. This risk of development of clear cell cancer is estimated to be no more than 1.4/1000 and possibly as few as 1.4/10,000 exposed daughters. By 1979, approximately 400 cases of this form of cancer were reported to the Registry for Research on Hormonal Transplacental Carcinogenesis from various parts of the world. Approximately 2/3 of these tumors were associated with intrauterine exposure to the nonsteroidal synthetic estrogen DES. Recent studies have indicated that DES exposed women may be at an increased risk for late pregnancy loss. Limited studies in males have shown no association between in utero DES exposure and cancer of the genitourinary tract. Mothers of the DES exposed daughters are also being studied. A practical method to alerting individuals about DES is for health care providers to display educational materials in their waiting rooms. Palpation is a crucial part of the DES examination and may provide the only evidence of clear cell adenocarcinoma. After palpation, a speculum of appropriate size is inserted. During the course of gross inspection, the speculum should be gently rotated as it is withdrawn in order to assess properly the entire length of the vagina. The secretions and epithelium in the upper 3rd of the vagina should be thoroughly sampled with a wood or plastic spatula, as should be the middle or lower 3rd of the vagina if gross epithelial changes are evident there. When an abnormal smear is reported, a physician may want to consult a gynecologist experienced in evaluating DES daughters. Colposcopy has not proved to be essential in the detection of clear cell adenocarcinoma. The order of gynecologic portion of examination of women exposed to DES in utero is as follows: vulvar inspection; vaginal and cervical palpation (digital); vaginal and cervical inspection (speculum); cytology (separate slides of vaginal fornices and cervix); colposcopy (optional); iodine stain of cervix and vagina; tissue biopsy of atypical findings; and bimanual (recto-vaginal) examination. Initial examination of known or suspected DES exposed females should be performed after menarche or by the age of 14 years if menarche has not occurred. The interval for follow-up examination is determined on an individual basis. The importance of education and counseling is identified and questions reflecting areas of concern to the DES exposed daughter are presented.