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with CAH, oral megestrol acetate in doses of 40 to 80 mg daily is an acceptable regimen Intramuscular medroxyprogesterone acetate is also acceptable in patients in whom compliance might be an issue Repeat endometrial biopsy should be done in 3 to 6 months Systemic progestins have a success rate of eliminating hyperplasia in up to 80% of cases28 Alternatively, there is a growing body of evidence that local progestin therapy with a progestin-containing IUD is effective in treating endometrial hyperplasia as well as early endometrial cancer27,30 34 In a comparative study, 26 patients with all grades of endometrial hyperplasia were treated with a levonorgestrel (LNG)containing IUD and compared to a historic cohort of patients treated with an oral progestin All 26 patients in the IUD group showed resolution of the hyperplasia by 3 months, while 14 of the 31 patients treated orally had persistent hyperplasia at 3 months.

class evolve: def init (self, ccy, seed = 1234, antithetic = True): self. ccy = ccy self. seed = seed self. antithetic = antithetic def evolve(self, t, T, state, req, env):

Perhaps the most critical issue in existing CBT for the eating disorders is that it is based on cognitive-behavioural formulations that fail to re ect contemporary knowledge about the cognitive psychology of the eating disorders This point has been identi ed in restrictive anorexia by Fairburn, Shafran and Cooper (1999), although their control-based model is still in the early days of testing Recent conceptualisations of psychopathology (eg Wells & Matthews, 1994; Williams et al, 1997) have stressed the importance of understanding both cognitive content (beliefs and emotions) and cognitive process (attentional processes, cognitive avoidance, dissociation, etc) Both of these aspects have begun to be addressed in contemporary research into the eating disorders.

It should be noted, however, that only 4 of the 26 IUD patients had atypical hyperplasia, while 10 of the 31 oral progestin patients had atypical hyperplasia32 Another study of 20 women with hyperplasia, 8 with atypical hyperplasia, treated with an LNGcontaining IUD, demonstrated that 19 had complete histologic resolution of their hyperplasia One patient with atypical hyperplasia had persistent non-atypical hyperplasia 3 years after initiation of treatment with the LNG IUD No one progressed to carcinoma34 A third retrospective study looked at 258 patients with hyperplasia (with and without atypia) treated with obsevation, oral progestins, or LNG IUD One-hundred percent of patients with the IUD regressed to normal within 6 months, while 55% of those receiving oral progestins showed regression Interestingly, patients with hyperplasia without atypia had a similar regression rate whether they received oral progestins or observation only.

As has been mentioned above, cognitive-behavioural formulations have stressed the role of two levels of cognitive representation negative automatic thoughts (which are largely immediate, conscious cognitions) and underlying assumptions (conditional rules, such as: Gaining one pound will mean that I put on a hundred pounds ) These can be characterised as super cial levels of cognition, and each primarily involves beliefs that are focused on weight, shape and eating However, it has been suggested that this super cial level of analysis is responsible for the failure of much contemporary CBT for the eating disorders (Hollon & Beck, 1994) Recent research has supported Kennerley s (1997) and Cooper s (1997) arguments that we need to understand the role of deeper schema-level representations in the eating disorders.

In the United States, women have a 5% to 10% chance of developing an ovarian neoplasm. Of these patients, 1% to 2% will have a malignant neoplasm. Approximately 300,000 women are hospitalized every year for management of an ovarian neoplasm. About 1 in 10 women will have surgery for an adnexal mass in their lifetime. The incidence of malignant adnexal tumors varies according to age. Patients less than 45 years old who have an adnexal mass will have a malignancy in 6% to 10% of cases, 33% to 50% in patients over 45 years of age, and 50% of cases in patients less than 10 years of age.13 In patients with adnexal masses, there are many features and physical ndings than may

27 In a large, prospective observational study in England, 105 women with hyperplasia were treated with an LNG IUD There was regression in 90% of patients, but only 67% among patients with atypical hyperplasia This study was limited because only 9 patients had atypical hy-.