Gynaecology

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.

Gynecology
A dilating vaginal speculum, a tool for examining the vagina, in a model of the female reproductive system
SystemFemale reproductive system
SubdivisionsOncology, Maternal medicine, Maternal-fetal medicine
Significant diseasesGynaecological cancers, infertility, dysmenorrhea
Significant testsLaparoscopy
SpecialistGynaecologist

Almost all modern gynaecologists are also obstetricians (see obstetrics and gynaecology). 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.[1]

Texts of Ayurveda, an Indian traditional medical system, also provides details about concepts and techniques related to Gynaecology.[2][3]

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. [4] 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.[5] Now criticized for his practices, Sims developed some of his techniques by operating on slaves, many of whom were not given anaesthesia.[6][7] 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.[8] 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.[9]

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:

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.

For lists of gynaecological drugs (by the ATC classification system), see ATC code G01 and ATC code G02.

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:

  1. 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)
  2. Hysterectomy (removal of the uterus)
  3. Oophorectomy (removal of the ovaries)
  4. Tubal ligation (a type of permanent sterilization)
  5. Hysteroscopy (inspection of the uterine cavity)
  6. Diagnostic laparoscopy – used to diagnose and treat sources of pelvic and abdominal pain; perhaps most famously used to provide a definitive diagnosis of endometriosis.
  7. 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.
  8. Various surgical treatments for urinary incontinence, including cystoscopy and sub-urethral slings.
  9. Surgical treatment of pelvic organ prolapse, including correction of cystocele and rectocele.
  10. 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.
  11. 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
Gynaecologist
Occupation
NamesDoctor, 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.[10] Despite this, male gynaecologists typically make more on average than their female counterparts, although both groups work the same number of hours on average.[11]

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[12] and questions about their overall character,[13] as well as a concern about being associated with other male gynaecologists who have been arrested for sex offences and limited future employment opportunities.[14]

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.[15] This, when coupled with more women choosing female physicians[16] has decreased the employment opportunities for men choosing to become gynaecologists.[17]

In the United States, it has been reported that 4 in 5 students choosing a residency in gynaecology are now female.[18] 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.[19][20] In Turkey, due to patient preference to be seen by another female, there are now few male gynaecologists working in the field.[21]

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.[22] 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.[23] 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".[22]

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.

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See also

References
  1. Laurinda S. Dixon. Perilous Chastity: Women and Illness in Pre-Enlightenment Art and Medicine, Cornell University Press 1995, pp.15f.
  2. S. V. Govindan (November 2002). Fundamental Maxims of Ayurveda: Prepared for the Common People. Abhinav Publications. pp. 142–143. ISBN 978-81-7017-417-2.
  3. Md. Nazrul Islam (4 April 2017). Chinese and Indian Medicine Today: Branding Asia. Springer Singapore. p. 134. ISBN 978-981-10-3962-1.
  4. Lesley Dean-Jones, "The Cultural Construct of the Female Body" In Women’s History and Ancient History, ed. Susan B. Pomeroy (Chapel Hill: The University of North Carolina Press, 1991), 113.
  5. Semple, Henry Churchill (1923). J. Marion Sims, the Father of Modern Gynecology. Retrieved 11 October 2013.
  6. Daly, Mary (1990). Gyn/ecology: The Metaethics of Radical Feminism. Beacon Press. pp. 225–. ISBN 9780807014134. Retrieved 11 October 2013.
  7. Adekunle, Julius O.; Williams, Hettie V. (2010-02-24). Color Struck: Essays on Race and Ethnicity in Global Perspective. University Press of America. pp. 397–. ISBN 9780761850922. Retrieved 11 October 2013.
  8. Wall, L. Lewis (2006-11-02). "Did J. Marion Sims Deliberately Addict His First Fistula Patients to Opium?". Journal of the History of Medicine and Allied Sciences. 62 (3): 336–356. doi:10.1093/jhmas/jrl045. PMID 17082217. Retrieved 2019-09-23.
  9. Wallace-Sanders, Kimberly (2002). Skin Deep, Spirit Strong (PDF). Mastering the Female Pelvis.
  10. "From Past to Present: The Changing Demographics of Women in Medicine". 2008-02-01. Archived from the original on 2014-07-03. Retrieved 2014-06-24.
  11. "Women dominate ob/gyn field but make less money than male counterparts: Gender gap in pay extends to reproductive endocrinology and infertility specialists". ScienceDaily. Retrieved 2019-11-23.
  12. "Why Are Men Gynaecologists?". 2013-12-04. Retrieved 2014-06-24.
  13. "Are Male Gynecologists Creepy?". 2013-12-09. Archived from the original on 2014-06-27. Retrieved 2014-06-24.
  14. Gerber, Susan E.; Lo Sasso, Anthony T. (2006-11-01). "The evolving gender gap in general obstetrics and gynecology". American Journal of Obstetrics and Gynecology. 195 (5): 1427–1430. doi:10.1016/j.ajog.2006.07.043. ISSN 0002-9378. PMID 17074550.
  15. Hall Judith A, Roter Debra L (2002-12-02). "Do patients talk differently to male and female physicians?: A meta-analytic review". Patient Education and Counseling. 48: 217–224. doi:10.1016/S0738-3991(02)00174-X. PMID 12477606.
  16. "Patient choice: comparing criteria for selecting an obstetrician-gynaecologist based on image, gender, and professional attributes". 2007-03-15. Retrieved 2014-06-24.
  17. "Career Trends for OB/GYN Physician Jobs". Archived from the original on 2014-12-17. Retrieved 2014-06-24.
  18. "Enhancing the Representation of Women as Senior Leaders in Obstetrics and Gynaecology" (PDF). Archived from the original (PDF) on 2014-12-17. Retrieved 2014-06-24.
  19. "Discrimination against male gynaecologists? Swedish clinics ban women from choosing female doctors". 2007-01-29. Retrieved 2014-06-24.
  20. Trysell, Katrin (11 April 2018). "Byta doktor ingen rättighet" [Switching Doctor Not a Right]. Läkartidningen (in Swedish). Retrieved 25 April 2018.
  21. "Male Gynaecologist in Turkey: Dying profession?". 2014-05-22. Archived from the original on 2016-03-04. Retrieved 2014-06-25.
  22. "Women's Health Is No Longer a Man's World". 2001-02-07. Retrieved 2014-07-14.
  23. "Nurse questions all-female OB-GYN practice". 2014-02-02. Retrieved 2014-07-14.
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