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Gynaecology

Gynaecology literally means 'the science of women', but in medicine this is
the specialty of diseases of the female reproductive system (uterus, vagina
and ovaries).

Examination

Gynaecology is a consultant specialty. In most countries, women must see a
general practitioner first. If their condition requires knowledge or
equipment unavailable to the GP, they are referred to a gynaecologist.

As in all of medicine, the main tools of diagnosis are clinical history and
examination. Gynaecological examination is special in that it is quite
intimate, and that it involves special equipment -- the speculum. The
speculum consists of two hinged blades of flat metal, which are used to open
the vagina, to permit examination of the cervix uteri. Gynaecologists may
also do a bimanual examination (one hand on the abdomen, two fingers in the
vagina), to palpate the uterus and ovaries. Male gynaecologists often have a
female chaperone (nurse or medical student) for their examination. Virgins
are not usually examined vaginally. An abdominal ultrasound is used normally
to confirm the bimanual examination.

Investigations

Some of the investigations used in gynecology are:

  1. abdominal ultrasound, to give a low-power view of the pelvic organs.
  2. vaginal ultrasound. A probe is passed into the vagina, which allows a
     detailed view of the uterus and its contents. Good in early pregnancy.
  3. blood tests. Levels of hormones such as estradiol, lutenising hormone,
     follicle-stimulating hormone and progesterone are measured.
  4. hysteroscopy -- a fine tube is passed into the uterus via the cervix
     under a general anesthetic.
  5. laparoscopy -- tubes are passed into the peritoneal cavity, which is
     then insufflated with carbon dioxide. This is commonly used to diagnose
     endometriosis.

MRI and CT scans are not used. Pelvic X-ray is rare. It can be used to
delineate the uterine cavity with an injected dye (hysterosalpingogram) and
to measure the pelvic girdle.

Diseases

The main conditions dealt with by a gynaecologist are:

  1. cancer of the cervix. The Papanicolaou (Pap) smear is a means of
     detecting this, by obtaining a sample of cervical epithelial cells and
     examining them under a microscope for malignant changes. All women are
     encouraged to have pap smears at regular intervals (2 years in
     Australia) after commencing intercourse.
  2. incontinence of urine.
  3. amenorrhoea (absent periods)
  4. dysmenorrhoea (painful periods)
  5. infertility
  6. menorrhagia (heavy periods). This is a main indication for
     hysterectomy.

Obviously there is some crossover in these areas. Amenorrhoea in a young
girl may be referred to a paediatrician, incontinence to a urologist.

Therapies

Occasionally gynaecologists will use drugs, such as clomiphene (which
stimulates ovulation), and, most famously, oral contraceptives (which are
also used for dysmenorrhoea).

However, surgery is the main area of therapy. For historical reasons,
gynaecologists are not actually surgeons (this is the source of some tension).

Operations that gynaecologists do include:

  1. termination of pregnancy
  2. dilatation and curettage (removal of the uterine contents, for various
     reasons, including miscarriage and menorrhagia; procedurally very
     similar to the above);
  3. hysterectomy (removal of the uterus);
  4. colposuspension ('tightening' of the ligaments around the vagina, a
     common therapy for incontinence and discomfort in older women);
  5. Large Loop Excision of the Transition Zone (LLETZ), where the surface
     of the cervix, containing pre-cancerous cells identified on Pap smear
     are removed).

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