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Preface
The first edition of Williams Obstetrics was published over a century ago. Since then, the editors of this seminal text have presented a
comprehensive and evidence-based discussion of obstetrics. Patterned after our patriarch, Williams Gynecology provides a thorough presentation
of gynecology's depth and breadth. In Section 1, general gynecology topics are covered, whereas Sections 2 through 4 offer content on the
gynecologic subspecialties. Of note, the developing field of female pelvic medicine and reconstructive surgery is presented.
Traditionally, gynecologic information has been offered either within the format of a didactic text or that of a surgical atlas. However, because
the day-to-day activities of a gynecologist blend these two, so too do we. The initial five sections of our book describe the evaluation and
medical treatment of gynecologic problems. The remaining section offers an illustrated atlas for the surgical correction of these conditions.
Discussions of disease evaluation and treatment are evidence based, and our text strives to assist the practicing gynecologist and resident.
Accordingly, chapters are extensively complemented by illustrations, photographs, diagnostic algorithms, and treatment tables.
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Copyright Information
Williams Gynecology
Copyright © 2008 by The McGraw-Hill Companies, Inc. All rights reserved. Printed in China. Except as permitted under the United States
copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a data base or
retrieval system, without the prior written permission of the publisher.
ISBN 978-0-07-147257-9
MHID 0-07-147257-6
Notice
Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy
are required. The authors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information
that is complete and generally in accord with the standards accepted at the time of publication. However, in view of the possibility of human
error or changes in medical sciences, neither the authors nor the publisher nor any other party who has been involved in the preparation or
publication of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all
responsibility for any errors or omissions or for the results obtained from use of the information contained in this work. Readers are encouraged
to confirm the information contained herein with other sources. For example and in particular, readers are advised to check the product
information sheet included in the package of each drug they plan to administer to be certain that the information contained in this work is
accurate and that changes have not been made in the recommended dose or in the contraindications for administration. This recommendation is
of particular importance in connection with new or infrequently used drugs.
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Contributors
Editors
John O. Schorge, MD
Holder, Patricia Duniven Fletcher Professorship in Gynecologic Oncology
Director, Division of Gynecologic Oncology Fellowship Program
Associate Professor, Department of Obstetrics and Gynecology
University of Texas Southwestern Medical Center at Dallas
Joseph I. Schaffer, MD
Director, Division of Gynecology
Director, Division of Urogynecology and Female Pelvic Reconstructive Surgery
Professor, Department of Obstetrics and Gynecology
University of Texas Southwestern Medical Center at Dallas
Chief of Gynecology, Parkland Memorial Hospital, Dallas
Lisa M. Halvorson, MD
Director, Division of Reproductive Endocrinology and Infertility
Associate Professor, Department of Obstetrics and Gynecology
University of Texas Southwestern Medical Center at Dallas
Barbara L. Hoffman, MD
Assistant Director, Third-year Medical Student Clerkship
Assistant Professor, Department of Obstetrics and Gynecology
University of Texas Southwestern Medical Center at Dallas
Karen D. Bradshaw, MD
Holder, Helen J. and Robert S. Strauss and Diana K. and Richard C. Strauss Distinguished Chairmanship in Women's Health
Director, Lowe Foundation Center for Women's Preventative Health Care
Associate Residency Program Director, Department of Obstetrics and Gynecology
Professor, Department of Obstetrics and Gynecology
Professor, Department of Surgery
University of Texas Southwestern Medical Center at Dallas
F. Gary Cunningham, MD
Holder, Beatrice & Miguel Elias Distinguished Chair in Obstetrics and Gynecology
Chairman Emeritus, Department of Obstetrics and Gynecology
Professor, Department of Obstetrics and Gynecology
University of Texas Southwestern Medical Center at Dallas
Atlas Art Director
Lewis E. Calver, MS, CMI, FAMI
Chair, Biomedical Communications Graduate Program
Director, Biomedical Illustration Graduate Studies
Associate Professor, Department of Biomedical Communications
University of Texas Southwestern Medical Center at Dallas
Contributors
Raheela Ashfaq, MD
Charles T. Ashworth Professor
Director, Cytopathology
Director, OncoDiagnostic Laboratory
Professor, Department of Pathology
Professor, Department of Obstetrics and Gynecology
University of Texas Southwestern Medical Center at Dallas
Coordinator of Surgical Pathology Images for Williams Gynecology
Karen D. Bradshaw, MD
Holder, Helen J. and Robert S. Strauss and Diana K. and Richard C. Strauss Distinguished Chairmanship in Women's Health
Director, Lowe Foundation Center for Women's Preventative Health Care
Associate Residency Program Director, Department of Obstetrics and Gynecology
Professor, Department of Obstetrics and Gynecology
Professor, Department of Surgery
University of Texas Southwestern Medical Center at Dallas
Chapter 13: Psychosocial Issues and Female Sexuality
Chapter 18: Anatomic Disorders
Chapter 21: Menopausal Transition
Chapter 22: The Mature Woman
Anna R. Brandon, PhD
Coordinator, Behavioral Assessment Core in the Department of Clinical Sciences
Assistant Professor, Department of Psychiatry
University of Texas Southwestern Medical Center at Dallas
Chapter 13: Psychosocial Issues and Female Sexuality
Bruce R. Carr, MD
Holder, Paul C. MacDonald Distinguished Chair in Obstetrics and Gynecology
Professor, Department of Obstetrics and Gynecology
Director, Division of Reproductive Endocrinology and Infertility Fellowship Program
University of Texas Southwestern Medical Center at Dallas
Chapter 10: Endometriosis
Marlene M. Corton, MD
Associate Residency Program Director, Department of Obstetrics and Gynecology
Associate Professor, Department of Obstetrics and Gynecology
University of Texas Southwestern Medical Center at Dallas
Chapter 25: Anal Incontinence and Functional Anorectal Disorders
Chapter 38: Anatomy
F. Gary Cunningham, MD
Holder, Beatrice & Miguel Elias Distinguished Chair in Obstetrics and Gynecology
Chairman Emeritus, Department of Obstetrics and Gynecology
Professor, Department of Obstetrics and Gynecology
University of Texas Southwestern Medical Center at Dallas
Chapter 5: Contraception and Sterilization
Chapter 6: First-Trimester Abortion
Chapter 7: Ectopic Pregnancy
Chapter 38: Anatomy
Kevin J. Doody, MD
Director, Center for Assisted Reproduction, Bedford, Texas
Director, In Vitro Fertilization Program at the University of Texas Southwestern
Associate Professor, Department of Obstetrics and Gynecology
University of Texas Southwestern Medical Center at Dallas
Chapter 20: Treatment of the Infertile Couple
David M. Euhus, MD
Holder, Marilyn R. Corrigan Distinguished Chair in Breast Cancer Surgery
Professor, Department of Surgery
University of Texas Southwestern Medical Center at Dallas
Chapter 12: Breast Disease
Rajiv B. Gala, MD
Assistant Professor, Department of Obstetrics and Gynecology
University of Texas Southwestern Medical Center at Dallas
Chapter 4: Benign Disorders of the Lower Reproductive Tract
Chapter 7: Ectopic Pregnancy
Chapter 39: Perioperative Considerations
William F. Griffith, MD
Assistant Professor, Department of Obstetrics and Gynecology
The University of Texas Southwestern Medical Center at Dallas
Chapter 29: Preinvasive Lesions of the Lower Genital Tract
Lisa M. Halvorson, MD
Director, Division of Reproductive Endocrinology and Infertility
Associate Professor, Department of Obstetrics and Gynecology
University of Texas Southwestern Medical Center at Dallas
Chapter 6: First-Trimester Abortion
Chapter 15: Reproductive Endocrinology
Chapter 16: Amenorrhea
Chapter 19: Evaluation of the Infertile Couple
David L. Hemsell, MD
Holder, Frank C. Erwin, Jr. Professorship in Obstetrics and Gynecology
Professor, Department of Obstetrics and Gynecology
University of Texas Southwestern Medical Center at Dallas
Chapter 3: Gynecologic Infections
Barbara L. Hoffman, MD
Assistant Director, Third-year Medical Student Clerkship
Assistant Professor, Department of Obstetrics and Gynecology
University of Texas Southwestern Medical Center at Dallas
Chapter 1: Well Woman Care
Chapter 8: Abnormal Uterine Bleeding
Chapter 9: Pelvic Mass
Chapter 11: Pelvic Pain
Chapter 40: Intraoperative Considerations
Chapter 41: Surgeries for Benign Gynecologic Conditions
Chapter 42: Surgeries for Female Pelvic Reconstruction
Diane Hughes, MD
Assistant Professor, Department of Obstetrics and Gynecology
University of Texas Southwestern Medical Center at Dallas
Chapter 24: Pelvic Organ Prolapse
Jayanthi S. Lea, MD
Assistant Professor, Department of Obstetrics and Gynecology
University of Texas Southwestern Medical Center at Dallas
Chapter 30: Cervical Cancer
Chapter 31: Invasive Cancer of the Vulva
David Scott Miller, MD, FACOG, FACS
Holder, Dallas Foundation Chair in Gynecologic Oncology
Director, Division of Gynecologic Oncology
Professor, Department of Obstetrics and Gynecology
University of Texas Southwestern Medical Center at Dallas
Chapter 33: Endometrial Cancer
Chapter 35: Uterine Sarcoma
Elysia Moschos, MD
Assistant Professor, Department of Obstetrics and Gynecology
University of Texas Southwestern Medical Center at Dallas
Chapter 2: Techniques Used for Imaging in Gynecology
Coordinator of Radiologic Images for Williams Gynecology
Karen J. Nishida, MD
Assistant Professor, Department of Obstetrics and Gynecology
University of Texas Southwestern Medical Center at Dallas
Chapter 32: Vaginal Cancer
Phuc D. Nguyen, MD
Associate Professor, Department of Radiation Oncology
University of Texas Southwestern Medical Center at Dallas
Chapter 28: Principles of Radiation Therapy
Joseph I. Schaffer, MD
Director, Division of Gynecology
Director, Division of Urogynecology and Female Pelvic Reconstructive Surgery
Professor, Department of Obstetrics and Gynecology
University of Texas Southwestern Medical Center at Dallas
Chief of Gynecology, Parkland Memorial Hospital, Dallas
Chapter 24: Pelvic Organ Prolapse
Chapter 42: Surgeries for Female Pelvic Reconstruction
John O. Schorge, MD, FACOG, FACS
Holder, Patricia Duniven Fletcher Professorship in Gynecologic Oncology
Director, Division of Gynecologic Oncology Fellowship Program
Associate Professor, Department of Obstetrics and Gynecology
University of Texas Southwestern Medical Center at Dallas
Chapter 27: Principles of Chemotherapy
Chapter 33: Endometrial Cancer
Chapter 34: Uterine Sarcoma
Chapter 35: Epithelial Ovarian Cancer
Chapter 36: Ovarian Germ Cell and Sex Cord-Stromal Tumors
Chapter 37: Gestational Trophoblastic Disease
Chapter 43: Surgeries for Gynecologic Malignancies
Geetha N. Shivakumar, MD
Assistant Professor, Department of Psychiatry
University of Texas Southwestern Medical Center at Dallas
Chapter 13: Psychosocial Issues and Female Sexuality
Gretchen S. Stuart, MD, MPHTM
Assistant Professor, Department of Obstetrics and Gynecology
University of North Carolina at Chapel Hill
Chapter 5: Contraception and Sterilization
Diane M. Twickler, MD, FACR
Holder, Fred Bonte Professorship in Radiology
Director, Diagnostic Radiology Residency Program
Professor, Department of Radiology
Professor, Department of Obstetrics and Gynecology
University of Texas Southwestern Medical Center at Dallas
Chapter 2: Techniques Used for Imaging in Gynecology
Coordinator of Radiologic Images for Williams Gynecology
Clifford Y. Wai, MD
Assistant Professor, Department of Obstetrics and Gynecology
University of Texas Southwestern Medical Center at Dallas
Chapter 23: Urinary Incontinence
Chapter 26: Genitourinary Fistulas and Urethral Diverticulum
Claudia L. Werner, MD
Associate Professor, Department of Obstetrics and Gynecology
University of Texas Southwestern Medical Center at Dallas
Chapter 29: Preinvasive Lesions of the Lower Genital Tract
Ellen E. Wilson, MD
Associate Professor, Department of Obstetrics and Gynecology
University of Texas Southwestern Medical Center at Dallas
Chapter 14: Pediatric Gynecology
Chapter 17: Polycystic Ovarian Syndrome and Hyperandrogenism
Larry E. Word, MD
Professor, Department of Obstetrics and Gynecology
University of Texas Southwestern Medical Center at Dallas
Chapter 41: Surgeries for Benign Gynecologic Conditions
Artists
Artist renderings in our surgical atlas were produced by Lewis Calver, the Chairman of the Biomedical Communications Graduate Program, and
students and faculty within that program.
The world's first degree in medical illustration was awarded by Southwestern Medical School in 1947. This is one of five accredited medical
illustration programs in North America. For those accepted into the program, a Master of Arts degree in Biomedical
Communications—Biomedical Illustration is offered by Southwestern Graduate School of Biomedical Sciences at The University of Texas
Southwestern Medical Center. The program is two years in length and a maximum of seven students is now enrolled annually.
The program is offered through the Department of Biomedical Communications, and courses are taught by faculty of The University of Texas
Southwestern Medical School, Southwestern Graduate School of Biomedical Sciences, and Southwestern Allied Health Sciences School. The
program is accredited by the Commission on Accreditation of Allied Health Education Programs and the Association of Medical Illustrators. Mr.
Lewis E. Calver has been Program Chairman since 1980.
The program is interdisciplinary. It is designed to provide opportunities for development of special knowledge and skills in the application of
communications arts and technology to the health sciences. Study of human anatomy, cell biology, neurobiology, and pathology is combined
with experience in anatomical, surgical, editorial and advertising illustration, computer graphics and animation, graphic design, multimedia
production, interactive computer assisted instruction, and instructional design. Additional skills may also be developed in biological illustration,
three-dimensional media production, exhibit design, and photography.
Primary Atlas Artists
Lewis E. Calver, MS, CMI, FAMI
Chair, Biomedical Communications Graduate Program
Director, Biomedical Illustration Graduate Studies
Associate Professor, Department of Biomedical Communications
University of Texas Southwestern Medical Center at Dallas
Maya Chaphalkar
Graduate, Biomedical Communications Graduate Program
University of Texas Southwestern Medical Center at Dallas
Erin Frederikson
Graduate, Biomedical Communications Graduate Program
University of Texas Southwestern Medical Center at Dallas
Jordan Pietz
Graduate, Biomedical Communications Graduate Program
University of Texas Southwestern Medical Center at Dallas
Marie Sena
Graduate, Biomedical Communications Graduate Program
University of Texas Southwestern Medical Center at Dallas
Contributing Atlas Artists
Katherine Brown
Graduate, Biomedical Communications Graduate Program
University of Texas Southwestern Medical Center at Dallas
Richard P. Howdy, Jr.
Instructor, Biomedical Communications Graduate Program
University of Texas Southwestern Medical Center at Dallas
Anne Matuskowitz
Graduate, Biomedical Communications Graduate Program
University of Texas Southwestern Medical Center at Dallas
Belinda Klein
Graduate, Biomedical Communications Graduate Program
University of Texas Southwestern Medical Center at Dallas
Anne Matuskowitz
Graduate, Biomedical Communications Graduate Program
University of Texas Southwestern Medical Center at Dallas
Constance Tilden
Graduate, Biomedical Communications Graduate Program
University of Texas Southwestern Medical Center at Dallas
Kimberly VanExel
Graduate, Biomedical Communications Graduate Program
University of Texas Southwestern Medical Center at Dallas
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Copyright © The McGraw-Hill Companies. All rights reserved.
Updates: Williams Gynecology >
6/17/2008: HUMAN PAPILLOMA VIRUS AND HUMAN IMMUNODEFICIENCY
VIRUS-INFECTED WOMEN
WILLIAM F. GRIFFITH
ASSISTANT PROFESSOR, DEPARTMENT OF OBSTRETRICS AND GYNECOLOGY, UNIVERSITY OF TEXAS SOUTHWESTERN MEDICAL CENTER, DALLAS
Related To: Chapter 29. Preinvasive Lesions of the Lower Genital Tract
View in chapter
Overview
Human immunodeficiency virus (HIV) infected women are known to have a high burden of human papilloma virus (HPV)-associated
anogenital disease. This lower genital tract disease manifests as a spectrum of lesions, which ranges from condyloma to high-
grade, high-malignant potential cervical intraepithelial neoplasia (CIN), vulvar intraepithelial neoplasia (VIN), and anal
intraepithelial neoplasia (AIN) lesions.
The association between cervical dysplasia, cervical carcinoma, and human papilloma virus (HPV) infection is clearly established
(Bosch, 2002). However, the etiologic contribution of human immunodeficiency virus (HIV) in the development of lower genital
tract disease is unclear and currently under evaluation. Specifically, areas of attention include the effect of HIV serostatus in the
acquisition, regression, persistence, or progression of HPV infection. The relationship between HIV and HPV infections may involve
mechanisms that integrate virus to virus interactions, immune factors, and molecular pathogenesis, and all of these mechanisms
can impact normal cell cycle machinery (Clarke, 2001).
Although evidence to date establishes HPV as the etiologic agent causing cervical intraepithelial and invasive neoplasia (Mahdavi,
2005), HPV infection is generally uneventful and transient in HIV-seronegative women. In contrast, recent studies have shown that
HIV-positive women have a higher prevalence and longer persistence of cervical HPV infection. HPV is detected in more than 60
percent of women with HIV (Stover, 2003). In addition, these women have a higher probability of carrying multiple oncogenic HPV
types than that of HIV-negative women (Ahdieh, 2001; Brown, 1994; Palefsky, 1999).
The effects of HIV can also be seen in the rates of disease progression. For example, early during the acquired immune deficiency
syndrome (AIDS) epidemic, Maiman and colleagues (1990) noted in a study cohort that all HIV-positive women with cervical cancer
died from their cancer compared with only 37 percent of HIV-seronegative women with cervical cancer. Because of this and similar
studies, cervical cancer is now designated as an AIDS defining condition by the Center for Disease Control and Prevention.
Lower Genital Tract Intraepithelial Neoplasia
Studies consistently suggest that HIV-positive women have much higher rates of CIN compared with HIV-uninfected women
(Ellerbrock, 2000; Wright, 1994). For example, in women infected with HIV, up to 60 percent of Pap smears exhibit cytologic
abnormalities, and as many as 40 percent have colposcopic evidence of dysplasia. Maiman and associates (1998) report that these
rates are approximately 10 times greater than those observed among HIV-negative women.
In contrast, much less information is available regarding vulvar, vaginal, and anal intraepithelial neoplasia in these women.
However, a recent 6-year prospective study did compare HIV-positive with HIV-negative women at high risk for HIV and found an
eightfold increase in the rates of vulvar, vaginal, and perianal lesions in HIV-positive women (Jamieson, 2006). Moreover, Chin-
Hong and associates (2005) found a higher prevalence of HPV-associated anogenital disease in women with HIV compared to age-
