| |
| System | Female reproductive system |
|---|---|
| Subdivisions | Oncology, Maternal medicine, Maternal-fetal medicine |
| Significant diseases | Gynaecological cancers, infertility, dysmenorrhea |
| Significant tests | Laparoscopy |
| Specialist | Gynaecologist |
Gynaecology or gynecology (see spelling differences) is the medical practice dealing with the health of the female reproductive system (vagina, uterus, and ovaries). Outside medicine, the term means "the science of women". Its counterpart is andrology, which deals with medical issues specific to the male reproductive system.
Almost all modern gynaecologists are also obstetricians. In many areas, the specialities of gynaecology and obstetrics overlap.
Etymology
The word "gynaecology" comes from the oblique stem (γυναικ-) of Greek γυνή (gyne), "woman", and -logia, "study".
History
The Kahun Gynaecological Papyrus,
dated to about 1800 BC, deals with women's health
—gynaecological diseases, fertility, pregnancy, contraception, etc. The
text is divided into thirty-four sections, each section dealing with a
specific problem and containing diagnosis and treatment; no prognosis
is suggested. Treatments are non surgical, comprising applying
medicines to the affected body part or swallowing them. The womb is at
times seen as the source of complaints manifesting themselves in other
body parts.
The Hippocratic Corpus
contains several gynaecological treatises dating to the 5th/4th
centuries BC. Aristotle is another strong source for medical texts from
the 4th century BC with his descriptions of biology primarily found in History of Animals, Parts of Animals, Generation of Animals. The gynaecological treatise Gynaikeia by Soranus of Ephesus (1st/2nd century AD) is extant (together with a 6th-century Latin paraphrase by Muscio, a physician of the same school). He was the chief representative of the school of physicians known as the "Methodists".
J. Marion Sims is widely considered the father of modern gynaecology.
Now criticized for his practices, Sims developed some of his techniques
by operating on slaves, many of whom were not given anaesthesia.
Sims performed surgeries on 12 enslaved women in his homemade backyard
hospital for four years. While performing these surgeries he invited men
physicians and students to watch invasive and painful procedures while
the women were exposed. On one of the women, named Anarcha, he performed 30 surgeries without anesthesia.
Due to having so many enslaved women, he would rotate from one to
another, continuously trying to perfect the repair of their fistulas.
Physicians and students lost interest in assisting Sims over the course
of his backyard practice, and he recruited other enslaved women, who
were healing from their own surgeries, to assist him. In 1855 Sims went
on to found the Woman's Hospital in New York, the first hospital
specifically for female disorders.
Examination
The historic taboo associated with the examination of female genitalia
has long inhibited the science of gynaecology. This 1822 drawing by
Jacques-Pierre Maygrier shows a "compromise" procedure, in which the physician is kneeling before the woman but cannot see her genitalia. Modern gynaecology no longer uses such a position.
In some countries, women must first see a general practitioner
(GP; also known as a family practitioner (FP)) prior to seeing a
gynaecologist. If their condition requires training, knowledge, surgical
procedure, or equipment unavailable to the GP, the patient is then
referred to a gynaecologist. In the United States, however, law and many health insurance plans allow gynaecologists to provide primary care
in addition to aspects of their own specialty. With this option
available, some women opt to see a gynaecological surgeon for
non-gynaecological problems without another physician's referral.
As in all of medicine, the main tools of diagnosis are clinical
history and examination. Gynaecological examination is quite intimate,
more so than a routine physical exam. It also requires unique
instrumentation such as the speculum.
The speculum consists of two hinged blades of concave metal or plastic
which are used to retract the tissues of the vagina and permit
examination of the cervix,
the lower part of the uterus located within the upper portion of the
vagina. Gynaecologists typically do a bimanual examination (one hand on
the abdomen and one or two fingers in the vagina) to palpate the cervix,
uterus, ovaries and bony pelvis. It is not uncommon to do a rectovaginal examination
for complete evaluation of the pelvis, particularly if any suspicious
masses are appreciated. Male gynaecologists may have a female chaperone for their examination. An abdominal or vaginal ultrasound can be used to confirm any abnormalities appreciated with the bimanual examination or when indicated by the patient's history.
Diseases
Examples of conditions dealt with by a gynaecologist are:
- Cancer and pre-cancerous diseases of the reproductive organs including ovaries, fallopian tubes, uterus, cervix, vagina, and vulva
- Incontinence of urine
- Amenorrhoea (absent menstrual periods)
- Dysmenorrhoea (painful menstrual periods)
- Infertility
- Menorrhagia (heavy menstrual periods); a common indication for hysterectomy
- Prolapse of pelvic organs
- Infections of the vagina (vaginitis), cervix and uterus (including fungal, bacterial, viral, and protozoal)
- UTI and Pelvic Inflammatory Disease
- Premenstrual Syndrome
- Other vaginal diseases
There is some crossover in these areas. For example, a woman with urinary incontinence may be referred to a urologist.
Therapies
As
with all surgical specialties, gynaecologists may employ medical or
surgical therapies (or many times, both), depending on the exact nature
of the problem that they are treating. Pre- and post-operative medical
management will often employ many standard drug therapies, such as antibiotics, diuretics, antihypertensives, and antiemetics. Additionally, gynaecologists make frequent use of specialized hormone-modulating therapies (such as Clomifene citrate and hormonal contraception) to treat disorders of the female genital tract that are responsive to pituitary or gonadal signals.
Surgery, however, is the mainstay of gynaecological therapy. For
historical and political reasons, gynaecologists were previously not
considered "surgeons", although this point has always been the source of
some controversy. Modern advancements in both general surgery and
gynaecology, however, have blurred many of the once rigid lines of
distinction. The rise of sub-specialties within gynaecology which are
primarily surgical in nature (for example urogynaecology and
gynaecological oncology) have strengthened the reputations of
gynaecologists as surgical practitioners, and many surgeons and surgical
societies have come to view gynaecologists as comrades of sorts. As
proof of this changing attitude, gynaecologists are now eligible for
fellowship in both the American College of Surgeons and Royal Colleges of Surgeons, and many newer surgical textbooks include chapters on (at least basic) gynaecological surgery.
Some of the more common operations that gynaecologists perform include:
- Dilation and curettage (removal of the uterine contents for various reasons, including completing a partial miscarriage and diagnostic sampling for dysfunctional uterine bleeding refractive to medical therapy)
- Hysterectomy (removal of the uterus)
- Oophorectomy (removal of the ovaries)
- Tubal ligation (a type of permanent sterilization)
- Hysteroscopy (inspection of the uterine cavity)
- Diagnostic laparoscopy – used to diagnose and treat sources of pelvic and abdominal pain; perhaps most famously used to provide a definitive diagnosis of endometriosis.
- Exploratory laparotomy – may be used to investigate the level of progression of benign or malignant disease, or to assess and repair damage to the pelvic organs.
- Various surgical treatments for urinary incontinence, including cystoscopy and sub-urethral slings.
- Surgical treatment of pelvic organ prolapse, including correction of cystocele and rectocele.
- Appendectomy – often performed to remove site of painful endometriosis implantation or prophylactically (against future acute appendicitis) at the time of hysterectomy or Caesarean section. May also be performed as part of a staging operation for ovarian cancer.
- Cervical Excision Procedures (including cryosurgery) – removal of the surface of the cervix containing pre-cancerous cells which have been previously identified on Pap smear.
Specialist training
| Occupation | |
|---|---|
| Names | Doctor, Medical Specialist |
Occupation type
| Specialty |
Activity sectors
| Medicine |
| Description | |
Education required
|
|
Fields of
employment | Hospitals, Clinics |
In the UK the Royal College of Obstetricians and Gynaecologists,
based in London, encourages the study and advancement of both the
science and practice of obstetrics and gynaecology. This is done through
postgraduate medical education and training development, and the
publication of clinical guidelines and reports on aspects of the
specialty and service provision. The RCOG International Office works
with other international organisations to help lower maternal morbidity
and mortality in under-resourced countries.
Gynaecologic oncology is a subspecialty of gynaecology, dealing with gynaecology-related cancer.
Gender of physicians
Gynaecology
has historically been dominated by male doctors. However, in recent
times, as many of the barriers to access the education and training
required to successfully practice gynaecology were removed, women have
started to outnumber men in the field.
Despite this, male gynaecologists typically make more on average than
their female counterparts, although both groups work the same number of
hours on average.
Possible reasons reported for the decrease in male gynaecologists
range from there being a perception of a lack of respect from other
doctors towards them, distrust about their motivations for wanting to
work exclusively with female sexual organs and questions about their overall character, as well as a concern about being associated with other male gynaecologists who have been arrested for sex offences and limited future employment opportunities.
Surveys have also shown a large and consistent majority of women
are uncomfortable having intimate exams done by a male doctor. Women are
also more likely to be embarrassed and vague with personal information
if the professional is a man, so as a result talk more openly and in
greater details when discussing their sexual history with another woman
rather than a man, leading to questions about the ability of male
gynaecologists to offer quality care to patients. This, when coupled with more women choosing female physicians has decreased the employment opportunities for men choosing to become gynaecologists.
In the United States, it has been reported that 4 in 5 students choosing a residency in gynaecology are now female. In Sweden,
to comply with discrimination laws, patients may not choose a
doctor—regardless of specialty—based on factors such as ethnicity or
gender and declining to see a doctor solely because of preference
regarding e.g. the practitioner's skin color or gender may legally be
viewed as refusing care. In Turkey, due to patient preference to be seen by another female, there are now few male gynaecologists working in the field.
There have been a number of legal challenges in the US against
healthcare providers who have started hiring based on the gender of
physicians. Dr Mircea Veleanu argued, in part, that his former employers
discriminated against him by accommodating the wishes of female
patients who had requested female doctors for intimate exams. A male nurse complained about an advert for an all-female obstetrics and gynaecology practice in Columbia, Maryland claiming this was a form of sexual discrimination.
Dr David Garfinkel, a New Jersey-based ob-gyn sued his former employer
after being fired due to, as he claimed, "because I was male, I wasn't
drawing as many patients as they'd expected".
So far, all legal challenges by male gynaecologists to remove
patient choice have failed due to there being protection in law for
'bona fide occupational qualification' which in previous cases involving
wash-room attendants and male nurses have recognized justification for
gender-based requirements for certain jobs.
