Gynaecology
it is the medical practice dealing with the health of the femalereproductive system (uterus, vagina, and ovaries). Literally, outside medicine, it 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 (see obstetrics and gynaecology). In many areas, the specialties of gynaecology and obstetrics overlap. Gynaecology has been considered to end at 28 weeks gestation, but practically there is no clear cut-off. Since 1st October 1992, this cut-off may be considered to occur at 24 weeks gestation in the United States, since the law and definition of abortion changed to bring it closer to the gestation at which a fetus becomes viable.
Gynaecology assures best care for women affected by various unique ailments, especially for those on the verge of motherhood and ensures that both the mother and the baby stay healthy. An expected mother needs special care during the pregnancy and post pregnancy periods. Physical or mental disorders during pregnancy affect the child as well as the mother.
Miscarriage
A miscarriage is a very common event. Approximately 10 to 15% of pregnancies result in a miscarriage. The majority of patients develop bleeding and sometimes pain in the early stages of pregnancy. The commonest time of miscarriage is between 7 and 12 weeks from the last period. Approximately 50% of miscarriages are caused by chromosomal abnormalities. This means that the pregnancy was developing abnormally and was never going to develop into a full grown baby. Most chromosomal abnormalities are spontaneous or sporadic. They are not usually caused by something inherited. Either the growth of cells in the early stage of pregnancy has not occurred perfectly or an egg which did not consist of a perfect compliment of chromosomes is fertilised. Many people describe the consequence of miscarriage as being nature's way of dealing with an abnormally growing pregnancy.
There are many other less common causes of miscarriage. Smoking or use of cocaine and other recreational drugs as well as certain chemical agents, such as lead, solvents and pesticides, have been implicated in miscarriages. Certain infections such as listeria or malaria are also causes of miscarriage. In recent years we have discovered that certain blood clotting problems can also be the cause of miscarriage.
Etymology
The word "gynaecology" comes from the Greek ancient Greek gyne, ????, modern Greek gynaika, ???a??a, meaning woman + logia meaning study, so gynaecology literally is the study of women.
History
The Kahun Gynaecological Papyrus is the oldest known medical text of any kind. Dated to about 1800 B.C., it deals with women's complaints—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.
Gynaecology is typically considered a consultant specialty. 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, or equipment unavailable to the GP, the patient is then referred to a gynaecologist.
Diseases
The main 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). This is a common indication for hysterectomy.
Prolapse of pelvic organs
Infections of the vagina, cervix and uterus (including fungal, bacterial, viral, and protozoal)
There is some crossover in these areas. For example, a woman with urinary incontinence may be referred to a urologist.
First gynae visit guide:
A gynae visit can be a daunting experience, especially for those going for the very first time. Health24 spoke to gynaecologist Dr Stan Sandler, author of What Worries Women, to get a step-by-step account of what to expect when you're going for that first gynae visit.
When should you go for your first gynae visit?
Once a woman/girl becomes sexually active she should see a gynae. The gynaecologist will advise her on contraception and protection against sexually transmitted diseases (STDs).
A woman/girl of any age, whether sexually active or not, should see a gynae if she, or her mother, thinks something might be wrong – for example, an unusual discharge, abnormal periods, etc.
Young women who are not sexually active but use tampons, should go for their first gynaecological check-up around the age of 21. The use of tampons facilitates an internal examination, which might not be possible otherwise.
Why should you see a gynae?
A gynaecologist instructs you on how to look after yourself when having sex - what contraception is best for you, and how to protect yourself from STDs.
A gynae will help you understand how your body works and instruct you on how to do breast self-examination.
A gynae will also detect problems early – such as cysts or cancer – and treat it before it gets worse.
Where to find a gynae?
The best way to find a good gynae is by way of a referral from your mother, friend, or someone else you trust. "Ask someone who has actually been to the doctor, and knows he/she has a good 'bedside manner'," says Sandler. A personal recommendation gives you confidence that the doctor has a good reputation.
Your GP can also refer you a good gynaecologist.
Does it have to be a gynae, or can your GP do a check-up?
Yes, your GP can do a check-up and pap smear. However, Sandler believes that a gynaecologist will probably be better equipped to spot and deal with any irregularities, as this is his/her field of expertise.
Preparing for the visit
Some things to keep in mind when you go for a check-up:
The Pap smear checks that the cells on your cervix are normal and can detect certain infections as well. The doctor will swab your cervix during your pelvic exam to gather cells, but if the sample is mixed with menstrual blood it will be difficult to get an accurate reading.
Workings of your body
As part of the consultation the gynae will ask you routine questions about yourself, so get familiar with the workings of your body. The questions may include: When did you have your last period? At what age did you start your period? etc.
Time of the month
Don't go for the check-up and Pap smear while you are menstruating. Gynaecologists often recommend you time your visit for halfway through your menstrual cycle.
What to expect?
The gynae visit consists of the following:
History
The gynae will ask questions about your medical history, menstrual cycle, sexual activity, and so on. This gives him/her necessary background information about your lifestyle and needs.
After the talk, the doctor will ask you to undress completely in a private area, and to put on a gown. The doctor will only expose the areas that he/she is examining and you should never be fully exposed.
General check-up
The doctor will check your blood pressure, do a urine test, and possibly a finger prick to check for haemoglobin, and record your weight. He/she should also check your heart, lungs, chest and thyroid gland. This enables the gynae to detect any abnormalities.
During the breast exam the doctor will check your breasts to make sure you don't have abnormal lumps or pain.
Internal Examination
The pelvic exam enables the doctor to check if your reproductive organs are healthy. First he/she will check the outside of your genital area (the vulva, clitoris and urethral opening).
Summary
While maternal mortality represents a readily identifiable outcome measure for women’s health,
estimating the burden of gynaecological disease is more problematic. However, the importance of
including gynaecology and care for non-pregnant women within the remit of Primary Health Care has
been suggested more than a decade ago. Since then, various studies have used self report in
population based morbidity surveys, purposive laboratory studies and ‘syndromic’ approaches to
estimate prevalence rates. Routine health facility data, although flawed, represent another
complimentary source. For policy development, a critical overview is required to identify firstly the
extent of a systematic list of gynaecological conditions, and secondly the social burden of these
diseases which clearly have an impact on the quality of the lives of women in developing countries. A
prototype categorization of gynaecological conditions relevant to the developing world is presented.
As examples, menorrhagia is identified as a common but usually non lethal problem with an impact on
general health because of associated anaemia. Cervical cancer is uncommon but lethal, and potentially
amenable to mortality reduction through early case finding or screening interventions. Uterine fibroids
and prolapse are of interest as conditions showing marked ethnic variation. We suggest an approach
to the application of the above overview, highlighting the extent of the disease burden currently borne
by women in the developing world, whose impact is potentially obscured by an exclusive
consideration of mortality data. Lack of appropriate categorisation and data collection represents a
serious barrier to the implementation of policy and services directed towards reproductive health.
3
1. Introduction
16 years ago Rosenfield and Maine ‘put the M back into MCH’, giving women’s health a new place;
worthy of study in its own right (Rosenfield and Maine, 1985). Four years later Bang and colleagues
brought gynaecological morbidity to international attention by the publication of extremely high
prevalence rates in rural India and a call to give more attention to the health of non-pregnant women
by including gynaecology in Primary Health Care (Bang et al, 1989). This study inspired several
subsequent investigations in other developing country settings, all pointing to the low level of met
need for health services and the ‘culture of silence’ which prevents women from seeking health care
for gynaecological problems (Bulut, Dixon-Mueller, Bhatia et al, Younis et al). However, most of the
conditions that can be categorised as “gynaecological disease” remain unquantified in the WHO
Global Burden of Disease (GBD) calculations for reproductive health (Murray & Lopez 1998).
Moreover, and perhaps more importantly, apart from some notable qualitative studies (Bang and Bang
1994, Oomman, 2000) there are still very few evaluations of the social burden associated with
gynaecological disease. This aspect of women’s health and the importance of social contexts and
correlates did not go unnoticed by analysts during the last decade with the prevailing emphasis on
women’s powerlessness and the links with reproductive health (Cairo Plan of Action 1994). However,
health services and health personnel training in developing countries remain poorly attuned to these
problems, and maternal mortality remains as the sole indicator of women’s reproductive health to be
found among the international development targets.
Part of the problem is that list of conditions considered under the heading of gynaecological disease is
extremely variable. Associated or underlying morbidities are similarly not systematised.
Furthermore, an emphasis on studies designed to estimate prevalence has obscured the need also to
study determinants and consequences for women – both social and physical. Apart from suffering
from a lack of consistent definitions, prevalence estimations have also been undermined by a the
variability between testing techniques, inconsistency of physician diagnoses, and the poor
performance of self report as a tool to predict biomedically defined disease given a disease profile
which is often asymptomatic. However, the body of knowledge on instruments for self-reported
morbidity is now broad enough for comparative studies to yield useful approaches (cf Koenig et al
1998) and the improvement in affordable laboratory diagnostics holds promise for more systematic
and influential information to be produced in the near future.
After an initial justification for the pursuit of quantitative as well as qualitative measures of
gynaecological disease, this paper has three aims: 4
1. We offer a critique of the DALY approach in relation to gynaecological morbidity, criticising both
the methodology as applied to morbidities with a strong social component, and also the omission of
some key gynaecological conditions from any of the previously calculated disease groups.
2. A summary of findings is presented on physician diagnosis, and self report, syndromic approaches
and an update on affordable lab testing appropriate in community studies and also for clinical settings
in resource poor areas.
3. As no study ever has the same definition of gynaecological disease, we aim to enumerate an
exhaustive list based on the International Classification of Diseases. Although this is a predominantly
biomedically determined initial approach, we argue that building a consistent list can only begin here –
then extensively tested ‘quality of life’ indicators should be used to understand these conditions in
relation to the associated physical and mental distress as suffered by women. We therefore advocate a
biomedical list built on by a quantitative as well as qualitative assessment of women’s loss of quality
of life.
“Gynaecological disease” covers a range of conditions with a wide spectrum of lethality and
chronicity and a substantial impact on women’s quality of life. Racial and geographic variations in
disease and social conditions mean that biomedical as well as social science perspectives should come
together in providing consistent information for policymakers on this important aspect of women’s
health.
2. Policy background: Why seek to provide quantitative measures of
gynaecological disease?
Various studies have sought to quantify the burden of gynaecological disease in order to influence
policy. Those in India (Bang and Bang 1994, Bhatia et al, 1997) and the Arab world (Younis et al.,
1993, Zurayk, et al., 1993) led the field in regions where the ‘culture of silence’ among women was
likely to imply high unmet need for services. Despite the array of methodological problems
encountered in such studies (Bulut et al., 1995), the evidence is now compelling to suggest high
prevalence rates of gynaecological disease in developing countries and associated serious impairment
in women’s quality of life. The second phase of studies should seek to build on the initial research to
set gynaecological disease in international perspective. Geographical, cultural and also racial
characteristics in different parts of the developing world could imply the need for the provision of a
range of different and culturally sensitive health services. 5
Most quantitative assessments of women’s health status are still based on maternal health measures.
Indicators such as the Maternal Mortality Ratio (MMR), the proportion of births attended by a skilled
attendant, and the percent of women who attend an antenatal check up are now established in the list
of International Development Targets (IDTs). The emphasis on maternity is very appropriate where
fertility levels are high, and maternal health services are in great need of improvement, which is the
case in most developing countries. Indeed the quality of maternal health and family planning services
can have a significant impact on gynaecological health as well as maternal and child outcomes,
through the minimisation of iatrogenic transmission of infections (Elias, 1996, Wasserheit and
Holmes, 1992).
However, the reliance on the MMR as the main indicator of women’s health and status within health
systems has problems over and above those of measurement, data collection and definition which are
commonly cited (Hulton et al 2000). The focus on mortality ignores the prevalence of many treatable
conditions that cause disability and significant distress in women’s lives. But also the neglect of nonpregnant women, whether in adolescence, between pregnancies, or after menopause, means that
women’s health is conceptualised narrowly in terms of maternity and family planning. The former of
these problems is tackled to some extent by the development of ‘near miss’ indicators of severe
obstetric morbidity occurring to living women (Stones et al 1991, Hulton et al 2000, Fillippi et al
1998), but these measures still neglect gynaecological illness. Thus the lack of appropriate
categorisation of women’s health problems, specifically those relating to gynaecological conditions
has lead to a policy vacuum in this aspect of reproductive health. There is a commensurate deficit in
advocacy and training materials as well as curricula for gynaecology. This may be in part because, in
contrast to many reproductive health activities, the main focus of gynaecological services is curative
rather than preventive.
More recently, with the rise of HIV/AIDS, and the establishment of gynaecological infection
(sometimes asymptomatic) as an important risk factor for HIV in women, there is an added impetus
for the more careful investigation of gynaecological conditions in women. Moreover, it is clear that
the calculation of prevalence rates or the ‘burden’ of these diseases is only the starting point for an
understanding of their importance. Determinants and consequences must also be investigated, with
due attention to the construction of conceptual frameworks which seek to elucidate linkages between
causes and effects of individual gynaecological outcomes. The burden of health care falls upon health
services worldwide, but currently, the burden of stigma and adverse the social burden is borne, for the
main part silently by women. The challenge is for service providers to create more socially attuned
facilities, for medical educationalists to underline the importance of gynaecology in reproductive
health, for policymakers to recognise the significance of gynaecology in international perspective, and 6
for researchers to find ways to understand and monitor unreported gynaecological ill-health in
community and facility studies. To set out the remit of gynaecological health and make the list of
relevant conditions can form a foundation from which quantification can emerge. The WHO global
programme to quantify the burden of reproductive disease has a possible approach to estimating the
extent of this problem.
3. Global burden of gynaecological disease
Given the desirability of moving away from mortality-based indicators as measures of women’s health
status, the estimation of disease burden via Disability Adjusted Life Years (DALYs) (Murray et al.
1996) offers a promising alternative. The rationale behind this approach, first developed by the World
Health Organization (WHO) for their 1993 World Health Report (WHO 1993), emphasises priority
setting by selecting health interventions that give the best value for money. It has been suggested that
calculating DALYS can help to set priorities within the domain of reproductive health and in relation
to other health problems (Vos, 2000).
The DALY is a single, comparable measure of health outcome designed to quantify both premature
mortality and disability from groups of diseases at all ages. More specifically it is a discounted and
age-weighted composite indicator of the future stream of life lost due to premature deaths added to the
future stream of healthy life foregone due to disabilities caused by disease. Having calculated DALYs
lost from a disease or group of diseases, cost effectiveness is then measured in terms of cost of
interventions ‘per DALY saved’. The calculation of life years lost due to mortality from disease is
reasonably straightforward to calculate, through the use of cause-specific mortality rates and
subsequent comparison with ‘ideal’ life table rates such as would be found in modern day Japan. The
calculation of the magnitude of disabilities is, however, more problematic. DALYs lost through life
lived with a disability are calculated by experts who estimate the incidence of disease, the age of
onset, and the duration of disability for each specific disease based on community based data, health
facility data or expert judgement. Disability weights are also applied. These are based on subjective
opinions of disease experts using person trade off methods which determine the proportion of a year of
healthy life deemed ‘lost’ in the presence of disabling disease.
Many criticisms of the DALY approach have been made with respect to the in-built discounting and
age weighting assumptions (Williams, 1999, Barendregt et al, 1996, Anand and Hanson, 1997). The
use of an idealised life table pattern is also questionable. But these factors are insignificant compared
with the debatable nature of the disability weights and the quality of epidemiological estimates of
incidence and duration. Particularly in the case of gynaecological disease, the application of disability 7
weights is not appropriate. Most gynaecological conditions disable women socially, which can be far
more crippling, and medical expert opinion will not be able to gauge the extent of such effects.
Measurement of distress, or social or mental stress, would be required as well as the estimation of the
extent of disability. It is difficult to see how selective decisions about health care spending could be
based on such an indicator. It does not capture women’s distress from their own perspective.
Moreover, the DALY calculations that have been carried out in association with reproductive health
have excluded key components of gynaecology. There are several definitions of ‘reproductive health
that DALY analysts have been able to use (Murray & Lopez1998), the main four being expressed as
follows:
• Consequences of sex in adults…
• Consequences of sex in children and adults…
• Conditions of the reproductive system…
• Conditions managed through reproductive health services…
Important conditions such as fistula, prolapse and menorrhagia are not to be found in any of these lists,
which concentrate more on maternal conditions and HIV. It may be a first step towards recognising
the importance of gynaecological disease to calculate the DALY burden, but initially there is a need to
enumerate all of the possible conditions before data can be brought together. The omission of social
distress also implies that measurement tools should also be developed specifically for this element. In
addition, there is a need to draw up give a critical overview of the likely mortality, disability and
distress of each listed condition worldwide.
In summary, although DALY estimates go some way to recognising morbidity as well as mortality,
they have not, to date, included gynaecological disease systematically, and the approach does not
provide a sufficient tool by which to capture the nature and extent of gynaecological disease. Nor can
the estimations help to understand causes and consequences, nor is it easy to set international goals
and targets incorporating DALY estimates.
4. Determination of disease status
Classification of disease depends on accurate diagnosis, which is subject to the limitations of
particular medical settings and is variably feasible in different circumstances. There are essentially
three types of diagnostic method: 8
1. Obtaining a self report of symptoms. The best example would be a painful condition of the
reproductive tract in the absence of an identifiable pathological process, such as primary
dysmenorrhoea. Assessment of pain depends entirely on self report and attempts to validate
self reported pain by some form of test would be fruitless. Self report pain measures are
widely used and have good psychometric reliability in different cultures and settings.
2. History, examination and limited investigations through contact with a health worker. Many
conditions can be diagnosed with reasonable sensitivity and specificity using learned
algorithms relating to clinical presentations. This model forms the basis for the bulk of
medical practice in both primary and secondary care settings and its learning is increasingly
systematised in medical education using curriculum models based on the finite numbers of
ways in which disease can manifest (Woloschuk et al. 2000). Similar models have been
applied to mid level service provider training. An example might be the diagnosis of
incomplete miscarriage based on the history of pain and vaginal bleeding, confirmed by
vaginal examination. The most variable aspect of this model is the extent to which
investigations are available: in limited resource settings either no tests might be performed or
would be limited to haemoglobin estimation, whereas in highly resourced settings
ultrasonography might be advised and the patient’s blood group would be determined to
assess her need for anti-D immunoglobulin if rhesus negative. In this example the additional
information obtained from ultrasonograhy would be confirmatory rather than essential to the
diagnostic process.
3. Definitive laboratory studies or imaging. While some lab studies with high sensitivity and
specificity can be undertaken in limited resource primary care settings such as a gram stain of
a cervical mucus sample for gonorrhoea, diagnosis of some gynaecological conditions requires
laboratory or imaging facilities which are of limited availability in the developing world, but
essential for effective provision of services. An example is carcinoma of the cervix: while
women may present to health workers with suggestive symptoms such as postcoital bleeding,
or be identified in case finding programmes on the basis of inspection of the cervix during an
internal examination, histological confirmation of the diagnosis is required, as many suspected
cancers will not be confirmed as such. A programme requiring cytological screening of Pap
smears for the detection of the pre-malignant phase of the disease is entirely dependent on the
availability and quality of laboratory staff, notwithstanding the complex service organisational
issues relating to screening in developed as well as developing countries
Symptoms of Gynaecological conditions
The list of signs and symptoms mentioned in various sources for Gynaecological conditionsincludes the 9 symptoms listed below:
Vaginal bleeding
Vaginal discharge
Dyspareunia
Bleeding after intercourse
Incontinence
Infertility
Pelvic pain
Vaginal pain
Vaginal pruritus
Research symptoms & diagnosis of Gynaecological conditions:
Overview -- Gynaecological conditions
Diagnostic Tests for Gynaecological conditions
Home Diagnostic Testing
Doctors & Specialists
Misdiagnosis and Alternative Diagnoses
Hidden Causes of Gynaecological conditions
Other Causes -- causes of these or similar symptoms
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• Bleeding from the anus: This can occur before, during or after stools. This will be bright red blood, not usually mixed with the stools, but often seen on the toilet paper