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Ablative Methods   Cryotherapy   This outpatient method was the most commonly used treatment for CIN lesions in the 1970s and 1980s, but has largely been supplanted by LEEP. If patients are carefully selected, the success rate is approximately 95%. Larger CIN lesions have higher failure rates, most likely because the whole lesion is not covered by the cryoprobe. It is not appropriate to use cryotherapy if the lesion extends into the endocervix.             The procedure is simple. After colposcopy and sampling has shown that the lesion is confined to the exocervix, a probe is selected that will cover the entire lesion. In most systems, N2O is used as the refrigerant. The probe is applied to the cervix and the system is activated. The cervix will freeze quickly, but the probe must remain in place until the ice ball that forms extends to at least 5 mm beyond the edge of the instrument. In most cases, this takes 3 to 4 minutes. The refrigerant is then turned off, and the probe allowed to thaw and separate from cervix. Several studies have suggested that repeating the freeze- thaw cycle a second time results in a higher success rate, whereas others have shown equal success with a single freeze.             Most patients experience almost no discomfort during the procedure, although some complain of menstrual-type cramping. Because the tissue that was destroyed remains on the cervix, within a few hours to a day, the patient will begin to experience vaginal discharge. As the tissue sloughs, the amount of discharge increases, and malodor is common. It may take as long as 3 weeks for the discharge to stop. The patient should be cautioned to place nothing in the vagina for at least 3 weeks after the procedure to avoid causing dislodgment of the escar.             The first follow- up should occur in approximately 4 to 6 months and include cytology and colposcopy. The cytology sample should include the endocervix.             Short- term complications from the procedure include the nuisance of the discharge and occasionally bleeding. Long- term complications include cervical stenosis and a small increase in preterm labor. Unfortunately, the instrument was sometimes used by inexperienced individuals, and cases of invasive cancer following treatment were reported. In almost every case, an appropriate evaluation had not been performed before treatment.   Thermoablation   This technique is almost never used in the United States at present. Various loops, needles, and paddles were used to destroy CIN lesions. Although the success rate was as high as other techniques, it often required general anesthesia and perhaps resulted in more cervical stenosis than other methods.   CO Laser Ablation   This technique became available to clinicians in the 1980s. When a focused CO2 laser beam is directed at the cervical epithelium, the laser energy is absorbed by the water in the cells. The water turns to steam and the cell wall disrupts, killing the cell. The cell protein is largely “exploded” in a plume of smoke that is drawn out of the vagina by suction. Because very little dead tissue is left after the procedure, there is no prolonged vaginal discharge as there is with cryotherapy. The success rate is similar to other techniques.             The technique became popular both because the area of tissue destruction could be minimized and there was no prolonged discharge as with cryotherapy. In addition, because the instrument is attached to a colposcope, usually those who used the technique were very familiar with CIN. Additional training is required as treatment success depends on the correct choice of laser energy delivered (calculated as a “power density”) and proper depth and extent of treatment.             For several years, CO2 laser ablation was the method of choice for treatment of CIN. It can be performed in the office with no anesthesia. (I have personally treated several hundred patients in the office with this technique). However, the equipment is very expensive. When LEEP became available, laser treatment began to wane. Currently, it is used almost exlusively in those cases in which there the lesion extends far out onto the exocervix. In these cases, CO2 laser can be effective wit less tissue destruction than other methods.   Physical Examination   The ability to detect breast lumps varies widely from physician to physician. Fletcher and coworkers tested the physical examination techniques of 80 different physicians using manufactured breast models. The simulated breast of the mannequins

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