Despite a plethora of theories, premenstrual syndrome (PMS) has remained an enigma. There has persisted in the literature a constant conflict as to the existence of the syndrome, a question as to whether it is one syndrome or several, and a debate as to whether the origin is psychic, somatic, or both. Advances in endocrinology, specifically in radioligand assays, allowing for accurate hormone measurements, have precipitated a more scientific evaluation of PMS in recent years. Nonetheless, diffi culties have persisted in accumulating well-documented data because of the protean nature of the syndrome. Indeed, even at this time, the question of what requires measurement during the follicular phase of the cycle and the premenstrual phase remains unresolved, and is difficult to place in perspective. In view of the persisting conflict between the organic and the psychological schools of thought, we, the editors of this book, considered the Sixth International Congress of Psychosomatic Obstetrics and Gynecology to be an ideal venue for a workshop in which both parties could be encouraged to participate. Towards this end, the organizing committee of the Inter national Society of Psychosomatic Obstetrics and Gynecology (ISPOG) was approached, and their response was extremely encouraging. In this respect, we wish to record our thanks to the Scientific Committee oflSOPG for allowing this workshop to be organized under their auspices, but totally under our direction. We, in turn, stand responsible for the format and content of the workshop."

Most textbooks are cumbersome to carry, expensive to buy, difficult to read, and boring. They have no plot, no characterization, no suspense, no climax. What they have are facts. If Dragnet's Sgt. Friday were Scientist Friday, the script wouldn't be much different "just the facts, ma'am." Students can't escape textbooks. But like death and taxes, they are necessary evils. of old ideas makes room for new ones. Death makes room for new people and the death Taxes are the dues we pay to live in a country. Everybody gets stuck with paying some kind of dues and students are no exception. Students pay dues in the form of tuition to listen to professors lecture, and they also pay dues in what a former governor of California called' 'psychic bucks" -time, concentration, independent study, reading textbooks like this one-to come up with the correct answers to exam questions. Textbooks on economics will tell you about where our tuition bucks come from. This book is about where our psychic bucks come from and the forces that can bankrupt our psychic nest eggs."

The strength of this collection of essays is its careful consideration, from a variety of perspectives within the Catholic tradition, of the practice of embryo adoption. It approaches the question in an open and reasonable way by allowing proponents of diverse positions within the tradition. This method both sheds a great deal of light on the particular question and at the same time introduces the reader to the relevant general principles that guide Catholic moral thought.

A. CORBIN Investigations on LHRH and its analogs have just completed their first decade. We have witnessed a veritable explosion of chemical, physiologic and pharmacologic data on this hypothalamic peptide and the approximately 1500 agonist and antagonist analogs that have been synthesized. In order to track this expanding field, I was asked to organize an international symposium on basic and clinical aspects of LHRH analogs as part of the Reproductive Health Care: CDS Symposium held in Maui, Hawaii, in October 1982. This meeting brought together a number of the leading investigators in the field. Much new state-of-the-art information was presented which I and my colleagues felt deserved a wider audience. Drs Vickery, Nestor, and Hafez consented to undertake this task. Upon review of the literature, it was apparent that there was no recent text which fully covered the breadth of developments in the field. Accordingly, the editors decided to use the symposium as a nucleus on which to build a singular, comprehensive state-of-the-art analysis of this rapidly growing discipline, and the application of such knowledge to reproductive medicine. As exemplified by the various areas of expertise provided by the individual contributors, it becomes obvious that the scope of the subject matter, while relating solely to a well-defined chemical class (LHRH analogs) and a circumscribed physiologic and pharmacologic entity (reproduction), has expanded enormously.

The most common abnormal growth of the female reproductive system, fibroids, are thought to affect the majority of women at some point during their reproductive years. This text from leading fibroid experts looks at the latest evidence on how the problem impinges on reproduction and the most up-to-date management and treatment options available to help patients with fibroids hoping to conceive. Print versions of this book also include access to the eBook version with links to procedural videos.

The enormous expansion seen over the last decade in the mammo graphic detection of breast cancer lesions, especially the use of screen ing procedures for the early detection of clinically unsuspected tumors, has made it necessary to summarize the experience made by various centers in the world. The 2nd International Copenhagen Symposium on Detection of Breast Cancer afforded an opportunity of gathering scientists from all over the world to discuss the various problems of early breast cancer detection with special reference to screening procedures. This book forms a synthesis of the information presented by leading scientists from many of the world's mammo graphic centers, particularly those in Sweden and the USA. Hence, the reader will have the opportunity to study the outstanding work carried out by various institutes and centers of breast cancer screening. It is our sincere hope that a study of this volume will encourage other scientists to join in the work on screening procedures. S. Brunner B. Langfeldt P. E. Andersen Contents S. A. Feig: 1 Hypothetical Breast Cancer Risk from Mammography S. A. Feig: Benefits and Risks of Mammography 11 R. L. Egan and M. B. McSweeney: Multicentric Breast Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . 28 M. B. McSweeney and R. L. Egan: Breast Cancer in the Younger Patient: A Preliminary Report 36 M. B. McSweeney and R. L. Egan: Bilateral Breast Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . ' 41 N. Bjurstam: The Radiographic Appearance of Normal and Metastatic Axillary Lymph Nodes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 M. Moskowitz, S. A. Feig, C. Cole-Beuglet, S. H."

Risk management is a relatively new process that can sometimes evoke feelings of suspicion among clinicians. However, when used proactively, it offers the opportunity to act at the root cause of an incident to expose de? ?ci- cies in the system rather than in individuals. This process encourages a s- portive approach to patients, relatives, and staff. The overall aim should be to learn lessons rather than to attribute blame. References 1. Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: a p- liminary retrospective record review. Br Med J. 2001;322:517-519. 2. Neale G, Woloshynowych M, Vincent C. Exploring the causes of adverse events in NHS hospital practice. J R Soc Med. 2001;94:322-330. 3. Walshe K. The development of clinical risk management. In: Vincent C, ed. Clinical Risk Management. London: BMJ Publishing Group; 2001, p. 45-60. 4. Department of Health. An Organization with a Memory. London: HMSO; 2000. 5. National Patient Safety Agency. Reporting incidents. Available at: http: //www.npsa. nhs.uk/health/reporting. Assessed June 25, 2007. 6. National Con? ? dential Enquiry into Perioperative Deaths. Changing the way we operate. The 2001 Report of the National Con? ? dential Enquiry into Perioperative Deaths. London: National Con? ?dential Enquiry into Perioperative Deaths; 2001. Available at: http: //www.ncepod.org.uk. Assessed June 25, 2007. 7. General Medical Council. Good Medical Practice. London: General Medical Council; 2006. Available at: http: //www.gmc-uk.org/guidance/good_medical_practice/index. a

This comprehensive volume covers the entire field of uncomplicated incontinence ranging from current concepts, to surgical management, to medical management. It includes a special focus on the latest diagnostic tests, new surgery including laparoscopy, and medical therapies. Additional coverage includes special topics such as prolapse, male incontinence, and costs and education. It is a state-of-the-art reference work on continence management for all urologists and gynecologists.

This volume summarizes advances in the optimal clinical management of preterm labour, using the best available evidence of the time. The contributors (mostly practising clinicians) are all actively involved in research into the mechanisms, aetiology, treatment and associated outcomes of preterm labour. The chapters are based on common clinical scenarios and each provides a comprehensive literature review followed by evidence-based recommendations on appropriate management. A summary of the pathophysiology of parturition is provided, and the obstetric scenarios cover management of threatened preterm labour, management of preterm premature ruptured membranes and management of preterm labour with specific complications (such as intrauterine growth restriction). Other chapters include the epidemiology, prediction and prevention of preterm labour. Anaesthetic and paediatric issues are explored in depth, and there are chapters on the legal and organizational issues surrounding preterm labour.

Congenital adrenal hyperplasia (CAH) consists of a group of disorders of adrenal steroidogenesis. Each disorder results from an inherited deficiency of one of the several enzymes necessary for normal steroid synthesis. The different enzyme deficiencies produce characteristic patterns of hormonal abnormalities; the clinical symptoms of the different forms of CAH depend on the particular hormones that are deficient or that are produced in excess. The earliest documented description of CAH was by DeCrecchio in 1865 (DeCrecchio 1865). This Neapolitan anatomist described a cadaver having a penis with first degree hypospadias but no externally palpable gonads. Dis- section revealed a vagina, uterus, fallopian tubes, ovaries, and markedly enlarged adrenals. It is interesting that the subject suffered a confusion of sex assignment, being declared a female at birth and a male 4 years later. He conducted himself as a male sexually and socially. Since the original descrip- tion of this case, investigators have unravelled the pathophysiology of the inborn errors of steroidogenesis. 1 Steroidogenesis and Enzymatic Conversions of Adrenal Steroid Hormones A. Steroidogenesis The adrenal synthesizes three main classes of hormones: mineralocorticoids (17-deoxy pathway), glucocorticoids (17-hydroxy pathway), and sex steroids.

The purpose of this series of volumes is to present a comprehensive view of the complications that result from the use of acceptable diagnostic and thera peutic procedures. Individual volumes will deal with iatrogenic complications involving (1) the alimentary system, (2) the urinary system, (3) the respiratory and cardiac systems, (4) the skeletal system and (5) the pediatric patient. The term iatrogenic, derived from two Greek words, means physician-in duced. Originally, it applied only to psychiatric disorders generated in the patient by autosuggestion, based on misinterpretation of the doctor's attitude and comments. As clinically used, it now pertains to the inadvertent side effects and complications created in the course of diagnosis and treatment. The classic categories of disease have included: (1) congenital and developmen tal, (2) traumatic, (3) infectious and inflammatory, (4) metabolic, (5) neoplastic, and (6) degenerative. To these must be added, however, iatrogenic disorders a major, although generally unacknowledged, source of illness. While great advances in medical care in both diagnosis and therapy have been accomplished in the past few decades, many are at times associated with certain side-effects and risks which may result in distress equal to or greater than the basic condi tion. Iatrogenic complications, which may be referred to as "diseases of medical progress," have become a new dimension in the causation of human disease."

We often hear physicians, health care professionals, poli ticians, and patient advocates that "nothing has happened in the treatment of breast cancer," since patients with breast cancer, the most frequent neoplastic condition in women in industrialized countries, are continuing to suffer relapse and succumb to this dreadful disease This negativistic attitude does not seem to be justified, but, why is the transmission of clinical trial results into general practice, and with it progress, such a slow process? After many decades of frustrating stagnation of long-term survival expectations, in all stages of early, oper/lble breast cancer treated only by surgery and locoregional radio therapy, adjuvant systemic therapy (chemo- as well as endocrine treatments) clearly showed to significantly benefit in terms of disease-free and overall survival. This evolution has been extensively expounded on by the Worldwide Oxford Overview and the Expert Consensus Panel at the fourth International Conference 'on Adjuvant Therapy of Primary Breast Cancer in St. Gallen (Early Breast Cancer Trialists' Collaborative Group 1992; Glick et al. 1992). What has happened since then? During the past 3-5 years, several new concepts and treatment strategies have emerged and have been studied in various major breast cancer groups and treatment centers worldwide. Some of these can already be considered to assist in the primary treatment of operable breast cancer today, while others are . still undergoing clini, cal trials for better definition of their practical usefulness."

The European School of Oncology came into existence to respond to a need for informa tion, education and training in the field of the diagnosis and treatment of cancer. There are two main reasons why such an initiative was considered necessary. Firstly, the teaching of oncology requires a rigorously multidisciplinary approach which is difficult for the Univer sities to put into practice since their system is mainly disciplinary orientated. Secondly, the rate of technological development that impinges on the diagnosis and treatment of cancer has been so rapid that it is not an easy task for medical faculties to adapt their curricula flexibly. With its residential courses for organ pathologies and the seminars on new techniques (laser, monoclonal antibodies, imaging techniques etc.) or on the principal therapeutic controversies (conservative or mutilating surgery, primary or adjuvant chemotherapy, radiotherapy alone or integrated), it is the ambition of the European School of Oncology to fill a cultural and scientific gap and, thereby, create a bridge between the University and Industry and between these two and daily medical practice. One of the more recent initiatives of ESO has been the institution of permanent study groups, also called task forces, where a limited number of leading experts are invited to meet once a year with the aim of defining the state of the art and possibly reaching a consensus on future developments in specific fields of oncology.

Perinatal medicine, which is concerned with the problems of the fetus and newborn, has rapidly developed in the last two decades as an important and challenging specialty. Rapid advances in the field, coupled with tech nological advances, now are making survival of infants with weights as low as 500 grams possible. Ventilator care for severe respiratory problems is on the verge of being replaced by surfactant replacement therapy; on the other hand, development of such technologies as extracorporeal mem brane oxygenation and jet ventilation has revolutionized the care of these sick infants. The advances taking place today in the field of perinatal medicine make periodic updates, like the one provided by this volume, a virtual necessity for clinicians and paramedical personnel alike. A distinguished group of specialists in various aspects of perinatal medicine has contributed to this book. Their wide-ranging experience and points of view should make this book a valuable reference for all physicians and allied health personnel involved in the care of the high-risk fetus and newborn. MANOHAR RATHI, M.D. Acknowledgements. I am grateful to the contributors for their cooperation in preparing the manuscripts, to my associates for their help and support, and to the publishers for their continued interest in this work. Above all, I thank Ms. Rose Aiello-Lech and Ms. MaryAnn Cichowski for their hard work in making this publication possible."

This new edition of an acclaimed text reviews the evidence for best practice in obstetrics to present the reader with the right information, with appropriate use of proven interventions and avoidance of ineffectual or harmful ones. The information is presented in the right format by summarizing evidence succinctly and clearly in tables and algorithms. The aim is to inform the clinician, to reduce errors, and "to make it easy to do it right." The volume can be purchased separately or together with the companion volume on Maternal-Fetal Evidence Based Guidelines (set ISBN 9780367567033). The Series in Maternal-Fetal Medicine is published in conjunction with the Journal of Maternal-Fetal and Neonatal Medicine. From reviews of previous editions: Obstetric Evidence Based Guidelines is a text that will prove useful to residents and fellows as well as to practicing obstetric clinicians. Furthermore, it can be used as a source for the development of hospital policies for the management of these obstetric problems ... The major advantage of this text is that it provides guidelines for the management of commonly encountered obstetric issues in a single book. -JAMA This is a welcome addition to a physician's library. Its use of current studies and easy-to-read format allow for easy fact-checking and referencing. -Doody's Review Service

The first few months of any pregnancy are of supreme importance to the success of that pregnancy. This statement is so obvious as to be almost a platitude, yet it must be said that no aspect of pregnancy has been more neglected in the human than the first three months. Little is known of the morphological changes that occur at that time and our knowledge of the mechanisms that control this vital stage of pregnancy is almost non-existent. The explanation for this neglect of what is an obvious area for study is the difficulty of obtaining normal material. It is rare to have material to study from a healthy first trimester pregnancy and the study by Hertig and Rock!l) of early conception found by chance in hysterectomy speci mens must be unique. The information that we do have about early pregnancy is mostly gained from animal studies or single miscarriages in humans. Chromosomal defects are common but are not an explanation for the majority of recurrent miscarriages. Obstetricians have hypothesised many causes for this condition and have deve loped numerous metQods for treating it, but the studies have been poorly con trolled so that our understanding of the cause(s) has not advanced. Treatment of women with a history of recurrent miscarriage by paternal leuco cyte infusion (immunotherapy) may be yet another form of treatment that is hailed as a new advance only to be rejected when subject to rigorous testing.

The subject of the Sixth Symposium on Clinical Oncology of the Royal College of Radiologists held in February 1984 was ovarian cancer. This publication presents the collected papers delivered at that meeting, but excludes much useful discussion which also took place. The annual clinical oncology symposia have been designed to re- view topics of current interest in cancer therapy from a multidis- ciplinary point if view. It was gratifying to the organisers and all who took part that the aims were so well met by both the contrib- utors and discussants. We believe that this can only be to the ad- vantage of future research and our present and future patients. Ovarian cancer is a common gynaecological cancer which freqently presents late. Its clinical management is bedevilled by the variable referral routes through which patients present for treatment. Thus, many are first seen by general abdominal sur- geons who may not be expert in their treatment, rather than gynaecologists or gynaecological oncologists. There are many in- teresting features about it which have been discussed by the var- ious speakers. Early spread within the abdomen is common, spread outside the abdomen less common. There is a variety of histopathological types, each with distinct aetiological, prognos- VI Preface tic and therapeutic assocations. In contrast to most cancers, sur- gical debulking of tumour is considered valuable even when there is no possibility of removing all tumour by the knife.

The term polycystic ovary syndrome (peOS) is meant to describe a clinical endocrinopathy characterized by menstrual irregularity and evidence of hyperandrogenism. While recognized since the 1800s, a clinical composite was not constructed until 1935 when Stein and Leventhal reported their findings of seven women with infertility, menstrual dysfunction, hirsutism, and enlarged ovaries. Notably, the ovaries contained numerous multiple cysts and the ovarian capsule was thickened. At the time, this preciseness of definition was sufficient to entitle the entity Stein-Leventhal syndrome. Subsequently, over the intervening years as investigators attempted to un ravel the pathophysiology and genesis of this disorder and the number of reported studies increased, there ensued a gradual and distinct terminologic conversion to polycystic ovary syndrome, which, whether intentional or not, connoted a less well-defined condition. Perhaps this is appropriately so, given the seemingly broadening spectrum of clinical presentations and the continuing debate over what constitutes peos. The expansive new knowledge about peos was discussed to a significant degree at an international symposium organized by Serono Symposia USA and held in Boston in the late spring of 1995. Ovarian physiology, including the fate of the follicular unit, was a central focus with several presentations on the genesis, growth, and death of ovarian cellular components. A discus sion of the regulation of ovarian cell function was also highlighted and comprised a major portion of the program."

Endometriosis is a complex gynecological disorder with multifactorial etiology. An estrogen-dependent condition, it affects 6% to 10% of women in the general population, and in 35% to 50% of these women often experience pain, and sometimes infertility. Exploring this benign but chronic disease, the book covers the different aspects of endometriosis from basic to advanced levels, including diagnoses, management, treatment modalities, complications, and fertility. Features Provides an overview of the guidelines, expert opinions, and ethical dilemmas involved with endometriosis. Covers the various complications that these women can experience Presents informative illustrations that complement the text discussion An overview of surgery, hormone therapy, and other options is provided In-depth coverage of novel treatments, including alternative medicine, diet, nutrition, and lifestyle modifications

During recent decades, it has been firmly documented that chlamydiae are com mon and important pathogens in humans and animals. In humans, chlamydiae are known to cause trachoma (which is still one of the major blinding diseases in the world) and are also one of the most common etiological agents of sexually transmitted diseases and the sequelae thereof, such as infertility. In the last few years, it has also become evident that chlamydiae, i.e., the so-called TWAR agents, are common respiratory tract pathogens. Chlamydiae are also important pathogens in birds and lower mammals, in whom they cause a variety of infectious conditions, a spectrum which has in creased every year. Some of these infections occur as zoonoses, e.g., psit tacosis/ornithosis and, as recently discovered, abortion. Know ledge of the molecular biology and immunobiology of chlamydiae has expanded rapidly during recent years. Insight into the pathophysiology of chla mydial infections has also increased, and new methods for the diagnosis of chlamydial infections have been introduced. The importance of establishing control and preventive programs for chla mydial infections has become obvious in order to combat the present chlamydial epidemic. We hope that this book can usefully serve those who want to increase their general knowledge of Chlamydia and that it can act as a handbook and reference source for those involved in chlamydial research as well as for those working with chlamydial infections in medical and veterinary clinical disciplines, includ ing clinical laboratories."

In vitro fertilization has resulted in an estimated 4000-5000 births in the world. The procedure has been accepted in Europe, America and Australia and several hundred IVF clinics are operating successfully. The newer procedures of GIFf, embryo freezing and donor oocyte IVF have become established and are dealt with in several chapters. GIFf has become the procedure of choice for patients with infertility of unknown origin. Oocyte freezing represents an important new technology which is being developed. The routine IVF procedure has improved slightly; variation in results can be reduced by quality control of laboratory and clinical techniques. Male factor infertility has been dealt with by IVF in mild and moderate cases, but newer techniques will be required to deal with severe problems in the male. Most countries have accepted that the straightforward IVF pro cedure is ethical. Limitations concerning the use of donor oocytes and embryo experimentation exist in some religions and countries; legal control of the new reproductive technologies ranges from the passage of statutes to no control at all. Many countries are still considering the need for legislative control. The text endeavours to indicate new areas of importance and to guide those organizing services as to how to introduce newer technolo gies.

The introduction of prostaglandins into clinical practice has been one of the most important advances in obstetrics and gynaecology in recent years. During the last decade obstetricians have become familiar with these drugs for inducing labour and for terminating second-trimester pregnancy. Within the last year their use has been extended, in association with antiprogestin, to first-trimester termi nation. Although the effectiveness of prostaglandins in these pharma cological roles is clear, their full potential has still to be explored, and much remains to be learned about their physiology. Prostaglandins playa central role in the initiation of labour. Further clarification of this role could lead to improvements in preventing or treating preterm labour, which still remains the most important cause of perinatal mortality in this country. Prostaglandins are also inti mately involved in the mechanism of menstruation. More detailed understanding of this role should lead to more effective treatments for menorrhagia and dysmenorrhoea. These substances also playa part in the mechanism of implantation, and further research in this area may lead to more effective therapy for infertility.

Infertility, as with many aspects of medicine, is at the mercy of rapid technological advance. Many of these developments initially seem attractive to both clinicians and patients, but need to be rigorously assessed if their real value is to be understood and clinical practice is to develop. In this book issues of importance to the management of infertile patients are discussed. The gaps in our knowledge which prevent a better understanding of the condition are identified, and recent developments, both clinical and scientific, are subjected to peer review and discussion. An important feature of the book is an acceptance that training in infertility practice is a real problem. This is perceived not only by the practising clinicians, both doctors and nurses, but particularly by the clinical scientists, including embryologists, who now provide such an essential part of the service. Similarly the provision of the clinical service has been examined in detail from a variety of standpoints, in an attempt to make sensible recommendations which balance real need with limited resource. The book is based on the papers presented and discussed at the 25th RCOG Study Group held in April 1992. The discussion after each paper was civilised but uncompromising and forms an important part of this publication. The rapid processing of the written and recorded material by the staff at the RCOG, and particularly Miss Sally Barber, has ensured that the book has been produced while the issues are live, the reviews contemporary and the discussion relevant.

This volume contains all the invited papers, symposium contributions and workshop reports of the 7th International Congress of Human Genetics, held in West Berlin from September 22 to 26, 1986. The organizers of this congress made sure to gain the cooperation of the leading scientists in the field from all over the world. These contributions therefore document the enormous progress made in human genetics research in recent years. The volume covers a wide range of topics, from analysis of the human genome to basic mechanisms, diagnosis and therapy of hereditary diseases, and to distribution of normal and pathological genes and DNA variation in human populations. Ethical issues raised by modern developments are discussed thoroughly. The volume is a must for all scientists and medical doctors working in human genetics research, its teaching and practical applications.