The authors concur that the peritoneal cavity must not be exposed to Monsel solution, and that the consequences of spillage may be catastrophic. The authors disagree, however, with Dr Witter’s interpretation that Monsel solution “caused a full-thickness necrosis of the uterus” in the case report of Shuhaiber et al. It seems more likely that the physician who performed the cone biopsy (who also unknowingly damaged the bilateral uterine arteries leading to the patient’s exsanguination with a hemoglobin of 4 g/dL within 60 minutes of departing the operating room) may also have created an unintentional posterior colpotomy/defect in the posterior aspect of the uterus through which the Monsel solution leaked into the peritoneal cavity.

Iatrogenic colpotomy has been described as a complication of excisional biopsies, and may be particularly easy to incur in the setting of prolapse or distorted anatomy. The authors would like to emphasize that Monsel solution has been studied extensively and used safely for hemostasis after treatment of cervical intraepithelial neoplasia.