[Secrets of women: gynaecology in the Middle Ages]

A fifteenth-century Dutch manuscript entitled Der vrouwen heimelijcheit (Secrets of women) presents medieval knowledge on gynaecology and obstetrics in the form of an educational poem. Practical knowledge of women's physiology is combined with what we now consider to be superstition. It mentions, for example, that menstruating women often suffer from headaches and back pain, but also that they should not look in the mirror during their periods because it might get stained. The development of the unborn child is discussed and there are instructions for midwives on how to act in case of a difficult birth, e.g. when the child has a very big head, when the child is in the breech position or when an arm or a foot comes out first. The author also explains how to evoke abortion, but changes the subject quickly, because abortion was a sin. A recent edition including an English introduction and translation makes this text available for a broad audience.

[NVOG celebrates 125 years]

In light of the 125th anniversary of the Dutch Society of Obstetrics and Gynaecology (NVOG), the Netherlands Journal of Medicine (NTvG) will publish a series of articles over the coming months. The articles will cover various topics from the specialty areas of gynaecology and obstetrics. We hope that these articles will inspire you, so that, in another 25 years, we can report again on positive developments of our specialty for patients, doctors and the community.

Cervical cancer prevention - current perspectives

This report addresses several areas including the progress made toward global implementation of currently licensed human papillomavirus (HPV) vaccines, and monitoring impact of HPV vaccination programs that can be implemented within developed and less-developed countries. For the sake of completeness, a short update on the evolution of HPV testing in primary screening programs at present and after HPV vaccine introduction has also been included.

Trends in the provision of preventive women's health services by family physicians

BACKGROUND AND OBJECTIVES

Family medicine has experienced variations in scope and comprehensiveness of care in recent years. To investigate whether these changes in practice have impacted women's health services, we measured trends in the proportion of preventive women's health visits provided by family physicians nationally.

METHODS

We analyzed the National Ambulatory Medical Care Survey to identify the trend in the proportion of preventive women's health visits to family physicians and obstetrician-gynecologists and others between 1995 to 2007.

RESULTS

A total of 6,088 sample records were included in the study, representing 239 million preventive women's health visits. The percentage of preventive women's health visits provided by family physicians remained stable over the 12-year study period from 18.6% in 1995-1996 to 20.3% in 2007. Family physicians provided care for 28% of total preventive women's health visits occurring in non-metropolitan statistical areas.

CONCLUSIONS

Family physicians provided a stable amount of preventive women's health services between 1995 and 2007. Family medicine should continue to foster comprehensive residency training in preventive women's health care and inclusion of such services in future scope of practice.

[Obstetrics and gynecology workforce planning: the Israeli experience 1995-2025]

BACKGROUND

Currently, there is no current obstetricians and gynecologists' workforce (OBGW) planning in Israel. Forecasting the OBGW is a challenge in order to achieve optimal obstetrics and gynecology care in the next decades.

OBJECTIVE

To examine the current Israeli OBGW and to describe, using an equation, the future supply of OBGW, until 2025.

METHODS

A descriptive study of past (1995-2006) and future (through 2025) OBGW trends in Israel. An equation was developed to project physician supply until 2025.

RESULTS

No "optimal ratio" exists regarding OBGW to female population ratio. In addition, information regarding OBGW planning is scarce. In Israel, the ratio of OBGW aged < 65 years per 1000 females aged > or = 15 years, was 0.35 in 2006, 23% more than the higher projected ratio from USA for 2005. In 2020, for comparison, the ratio in Israel will be 18% higher than the US ratio. The ratio calculated by the equation presents a plateau of the supply of Ob-Gyn specialists in Israel until 2025. A continued significant growth in the number of Ob-Gyn female specialists, compared with males, is noted. The interpretation of this data requires further evaluation.

CONCLUSIONS

In order to preserve the quality of care, there is a need for continuous monitoring and structured planning of health care human resources and OBGW in particular. Research and data in this field are scarce and, therefore, there is a need to conduct many additional research studies. Furthermore, additional data collection is needed to evaluate quality of care and its availability according to the relation between manpower needs and expected demands in Israel's health system.

[The feminization of obstetrics and gynecology]

Contemporary data indicate female dominance of obstetrics and gynecology. The authors sought to look for the effects of this domination on the discipline and further understand the reasons for these effects as reflected from the relevant current literature. Data clearly show a worldwide "creeping" process of female domination in the field of obstetrics and gynecology. Gender bias is present in hiring policies both for residency and afterwards. Female physicians encounter specific gender problems such as pregnancy, maternity leave and the additional burden of taking care of their family. These tasks may interfere with academic medicine. Furthermore, personal characteristics of women, which favor them for patients, may affect their productivity within the framework of community medicine. None of the alleged problems, which were linked to female obstetrician-gynecologists, is irresolvable, assuming professional establishment, as well as government acceptance and proper planning.

21st European Congress of Obstetrics and Gynaecology

The 21st European Congress of Obstetrics and Gynaecology took place in Antwerp 5-8 May 2010. The congress provided the participants with an overview of recent scientific and clinical developments throughout the field of obstetrics and gynaecology, and these are summarized in this article.

Women gynecologists' attitude toward their own health

BACKGROUND

Following the publication of the results of Women's Health Initiative in 2002 there have been gross changes in the attitude of women and physicians towards the risks and benefits of hormone replacement therapy (HRT). We evaluated the attitude of women gynecologist towards their own health, including adherence to recommended screening tests and self usage and prescription of hormone replacement therapy.

MATERIAL/METHODS

Questionnaires regarding performance of screening tests, self usage and recommendation of HRT were posted by mail to all Israel's women gynecologists.

RESULTS

Ninety questionnaires were eligible for analysis (43.2% response rate). Average age was 48+/-7.7 years. Only 7/90 (7.8%) gynecologists smoke regularly and average body mass index was 25+/-3.8 kg/m2. Most participants performed at least one screening tests in the past 2 years. The median interval from the last self breast exam, mammography, gynecologisy exam, Papanicolaou test, colonoscopy and bone density test was 0.2, 1.82, 1.79, 1.95, 3.27 and 1.41 years, respectively. Most of them (68.3%) did not routinely recommend HRT to their patients. The duration of self HRT usage ranged between 1-20 years (average 5.1+/-3.4 years). Most gynecologists (87.7%) recommended continuous estrogen and progesterone for women with their uterus in place.

CONCLUSIONS

The health profile of Israeli women gynecologists is chracterized by a high performance of screening tests for cancer and low rate of smoking. Our study also demonstrates that the impact of the results of the WHI trial is still well manifested and most Israeli women gynecologists do not routinely recommend HRT to postmenopausal women.

The time is now for a new approach to primary ovarian insufficiency

OBJECTIVE

To articulate the need for a new approach to primary ovarian insufficiency. The condition, also known as premature menopause or premature ovarian failure, is defined by the presence of menopausal-level serum gonadotropins in association with irregular menses in adolescent girls or women younger than 40 years. It can be iatrogenic as related to cancer therapy or may arise spontaneously, either alone or as part of a host of ultrarare syndromes. In a large percentage of spontaneous cases no pathogenic mechanism can be identified.

DESIGN

Literature review and consensus building at a multidisciplinary scientific workshop.

CONCLUSION(S)

There are major gaps in knowledge regarding the etiologic mechanisms, psychosocial effects, natural history, and medical and psychosocial management of primary ovarian insufficiency. An international research consortium and disease registry formed under the guidance of an umbrella organization would provide a pathway to comprehensively increase basic and clinical knowledge about the condition. Such a consortium and patient registry also would provide clinical samples and clinical data with a goal toward defining the specific pathogenic mechanisms. An international collaborative approach that combines the structure of a patient registry with the principles of integrative care and community-based participatory research is needed to advance the field of primary ovarian insufficiency.

[Gynecology]

Widespread use of the Pap test for cervical cancer screening has dramatically reduced cervical cancer incidence and mortality rates. The knowledge about optimal use of cervical cancer screening has evolved these last year and conducted to improve new cervical prevention. The American College of Obstetricians and Gynecologists (ACOG) recommend that cervical cancer screening should not begin before the age 21 years and that screening tests should be performed at less frequent intervals. CA 125 is considered to be the best test to detect relapse among women previously treated for ovarian cancer. However, a recent randomized trial has reported that there is no benefice to initiate the therapy before presence of symptoms. In 2009, the FIGO published a revised staging for cervical, endometrial and vulvar cancer to improve prognostic disease and therapy decision.

Progestins and medical treatment of endometriosis - physiology, history and society

The transitory effect of hormonal treatment is the alleged main reason to criticize progestins (PGS) and combined pills (OP) in the managment of endometriosis. To the contrary their poor efficacy in the long run is often underlined. As a result, medical treatment is too seldom advised in endometriosis. In this article, we shall focus on the analysis of the reasons of the paucity of the medical interest given to progestins, reasons, which are not of a scientific or objective nature. The ultimate aim of this analysis is to develop arguments in favour of continuous administration of hormones as to obtain not simply an anovulation but a state of prolonged amenorrhea much more efficacious than the simple suppression of ovulation too often advised. And, with an emphasis on the fundamental role of surgery in the treatment of endometriosis, to give the greatest consideration to the specific nature of this disease, which is a chronic disease, justifying the long duration of hormonal administration.

Impact of robotic surgery on obstetric-gynecologic resident training

OBJECTIVE

To compare the volume and type of surgical techniques for hysterectomies performed prior to and after the introduction of robotic surgery at our institution and to assess the potential impact on obstetric-gynecologic resident training.

STUDY DESIGN

A retrospective study examined the number and types of hysterectomies performed at our institution during the 18 months prior to, and the 18 months after, the introduction of a robotic surgical system. Procedures performed during both time periods were compared by number and percentage using the chi2 or Fisher's exact test for counts < 5.

RESULTS

A total of 903 hysterectomies were performed from July 1, 2005, to July 1, 2008. There were 444 hysterectomies in the prerobotic surgical system group and 459 hysterectomies in the postrobotic surgical system group. There was a statistically significant decrease in the number of laparoscopically assisted vaginal hysterectomies (94 vs. 36; p < 0.001) and total abdominal hysterectomies (249 vs. 203; p < 0.001) performed.

CONCLUSION

This study demonstrated a significant impact on the volume and type of surgical techniques for hysterectomies performed prior to and after the introduction of robotic surgery at our institution. This observation may have direct consequences for obstetric-gynecologic resident surgical experience.

Suboptimal management of severe menopausal symptoms by Nigerian Gynaecologists: a call for mandatory continuing medical education for physicians

BACKGROUND

Effective management of menopause is an important way to improve the quality of life of the increasing number of older women. The study sought to find out if Nigerian Gynaecologists offer effective treatment for severe menopausal symptoms.

METHODS

126 Nigerian Gynaecologists representing the six health zones of Nigeria were interviewed to determine the menopausal symptoms they had ever encountered in their practices, frequency of the symptoms, treatments ever offered for severe symptoms including their attitude to, and practice of hormone replacement therapy.

RESULTS

A Nigerian Gynaecologist encountered an average of one patient with menopausal symptoms every three months (range: 0-3 patients per month). The commoner symptoms they encountered were hot flushes (88%), insomnia (75.4%), depression (58.0%), irritability (56.3%), night sweats (55.6%) and muscle pains (54.8%) while urinary symptoms (16.7%) and fracture (1.6%) were less common. Treatments ever offered for severe symptoms were reassurance (90.5%), anxiolytics (68.3%), analgesics (14.3), HRT (7.9%), Vitamins (4%), Beta-blockers (3.2%) and Danazol (2.4%). These treatments were offered as a matter of institutional traditions rather than being based on any evidence of their efficacy.

CONCLUSION

The result revealed that most Nigerian Gynaecologists prefer reassurance and anxiolytics for managing severe menopausal symptoms instead of evidence-based effective therapies. A policy of mandatory continuing medical education for Nigerian physicians is recommended to ensure evidence-based management of gynaecological problems, including menopause.

Neurobiology of stress urinary incontinence: New insights and implications for treatment

Stress urinary incontinence (SUI) is a significant problem for millions of women, many of whom remain untreated for years, sometimes for life. One reason for this is the lack of effective pharmacologic therapy. The drugs used for urge incontinence have little or no effect on leakage occurring without detrusor contraction under conditions of increased intra-abdominal pressure. Recent studies suggest that extrinsic urethral sphincter closure may be controlled by enhancing neurotransmission in pudendal pathways. A new agent, duloxetine, which inhibits serotonin-norepinephrine re-uptake in these pathways, is now in clinical trials and appears to be the first effective pharmacologic therapy for SUI.

[Research and medicine in obstetrics and gynecology]

The current issue of "Harefuah" is dedicated to original and descriptive research as well as to reviews of obstetric and gynecological topics. Original research includes the study on the progesterone receptor's profile in endometrial carcinoma cell lines, as well as the correlation of maternal serum and amniotic fluid Leptin Levels with neonatal birth weight. There are three descriptive articles and one review that are related to pain in gynecology and post partum, and two articles describing one complication and the second presenting a simulation of gynecological surgery. ULtrasound is represented in one descriptive case and two reviews describe sonographic signs for chromosomal abnormalities and fetal viral infection.

[Use of laparoscopy in gynecological oncology]

In gynecological oncology, patients particularly with early-stage endometrial or cervical carcinomas can benefit from minimally invasive procedures. In cases of cervical carcinoma, laparoscopic lymphonodectomy can help identify patients who should first undergo chemoradiotherapy. In cases of advanced ovarian carcinoma, laparoscopy is only a diagnostic option and not a therapy of its own. The use of robot-assisted laparoscopy (DaVinci) in gynecological oncology is currently evaluated.

A challenge for the 21st century: whither physician-scientists in obstetrics, gynecology, and the reproductive sciences?

As we begin a new century, research in obstetrics and gynecology and its subspecialties face a crisis. Federal support to academic departments of obstetrics and gynecology through the National Institutes of Health is distressingly low in relation to that for other major specialties. In addition, academic departments face a shortage of clinically trained investigators and physician-scientists who will respond to the challenge of contributing to a greater understanding of the reproductive sciences and to the amelioration of diseases of women.

Cervical screening in Hungary: why does the "English model" work but the "Hungarian model" does not?

A comparison has been made between the English practice and the "Hungarian model" of cervical screening. In England, until 1986, extensive opportunistic screening was the practice, but--as it had no effect on cervical cancer mortality--afterwards, the screening policy was changed to be strictly in line with international recommendations. On the other hand, in Hungary, the "old practice" has been petrified: gynaecologists are the "gatekeepers", a "gynaecological examination completed with smear-taking for cytology" makes up the screening strategy. Although in the frame of a National Public Health Programme all the prerequisites for nationwide organised screening have been provided, and an up-to-date screening strategy declared, 20-times as many smears are taken and analysed outside as inside the programme, and the efforts have had no impact on cervical cancer mortality. This is because "old habits die hard". There is an urgent need to reconsider the screening strategy, and to reorganise the cervical screening practice in Hungary.

Change of the guard in obstetrics and gynaecology: projected retirement to 2025

The purpose of the paper is to forecast retirement of the specialist obstetricians and gynaecologists in Australia to 2025. The gender and hours of work of younger and older cohorts were compared to determine the likely impacts of the transition from older to younger cohorts. The paper used the Australian Institute of Health and Welfare's annual Medical Labour Force Surveys to examine trends in attrition of obstetricians and gynaecologists over the age of 45 years from the workforce and to predict their rate of retirement to 2025. The projection results show that between the years 2000 and 2025, 59% of the obstetricians and gynaecologists would retire. The rising proportion of women in obstetrics and gynaecology and shorter working hours of both men and women will have a compounding effect on physician retirement. The paper concludes that the changes in practice, increasing feminisation and retirement from the workforce coupled with higher female population growth in the childbearing years and slightly higher fertility mean that ensuring an adequate obstetricians and gynaecologists in Australia will be a significant challenge over the next 20 years. There is the potential for shortages in obstetric care with particular risks for rural areas.

Predictors of abortion provision among practicing obstetrician-gynecologists: a national survey

OBJECTIVE

The objective of the study was to identify the factors that predict whether physicians include pregnancy termination in their practices.

STUDY DESIGN

We surveyed all 5055 obstetrician-gynecologists who became board certified between 1998 and 2001 about personal characteristics, career plans, intention to provide abortions before residency, residency training, and current abortion practice.

RESULTS

Of 2149 respondents (43%), 22% had provided elective abortion in the past year. In multivariate analysis controlling for preresidency intentions, personal beliefs, and other variables, the following were independently associated with current abortion provision: completing a residency program with abortion training (odds ratio [OR], 1.6; confidence interval [CI], 1.1-2.3; P = .007) and performing a greater number of abortions during residency (>25 abortions: OR, 2.8; CI, 1.9-4.1; P < .001). Factors negatively associated with working in a practice (OR, 0.4; CI, 0.2-0.6; P < .001) or hospital (OR, 0.4; CI, 0.3-0.6; P < .001) that prohibits abortion.

CONCLUSION

Regardless of intention to provide abortion before residency, abortion training availability was positively correlated with providing abortion in future practice.

A comparison of 19th century and current attitudes to female sexuality

The 19th century medical attitude to normal female sexuality was cruel, with gynecologists and psychiatrists leading the way in designing operations for the cure of the serious contemporary disorders of masturbation and nymphomania. The gynecologist Isaac Baker Brown (1811-1873) and the distinguished endocrinologist Charles Brown-Séquard (1817-1894) advocated clitoridectomy to prevent the progression to masturbatory melancholia, paralysis, blindness and even death. Even after the public disgrace of Baker Brown in 1866-7, the operation remained respectable and widely used in other parts of Europe. This medical contempt for normal female sexual development was reflected in public and literary attitudes. Or perhaps it led and encouraged public opinion. There is virtually no novel or opera in the last half of the 19th century where the heroine with 'a past' survives to the end. H. G. Wells's Ann Veronica and Richard Strauss's Der Rosenkavalier, both of which appeared in 1909, broke the mould and are important milestones. In the last 50 years new research into the sociology, psychology and physiology of sexuality has provided an understanding of decreased libido and inadequate sexual response in the form of hypoactive sexual desire disorder. This is now regarded as a disorder worthy of treatment, either by various forms of counseling or by the use of hormones, particularly estrogens and testosterone.

Bleeding disorders and heavy menses in adolescents

PURPOSE OF REVIEW

The aim of this article is to review the current evidence for optimal management of the adolescent who presents with heavy periods.

RECENT FINDINGS

A recent survey of clinicians involved in adolescent gynaecology revealed a lack of consistency in the management of acute adolescent heavy menses. Very few randomized trials have been undertaken for acute heavy menses in women of any age, although one recent trial compared the oral contraceptive pill with oral medroxy progesterone acetate in adult women and showed them to be equally effective. The applicability of this trial to adolescents is unclear. Furthermore, although guidelines have been produced for menorrhagia management in adults, there is again only limited clinical research specific to adolescents and thus room for concern that the approaches for adult women may not always be appropriate for teenagers. One small study on the successful use of the levonorgestrel intrauterine system in teenagers does mean that this management option can now be considered.

SUMMARY

There is a need for careful assessment of the menstrual problem for, although anovulatory bleeds are the most common cause, bleeding disorders also need to be considered. Pelvic pathology is uncommon. Adolescents can also present with acute ongoing heavy bleeding. Whilst a range of approaches is reported, there are no studies to guide optimal management.

Bariatric surgery and adolescent gynecology

PURPOSE OF REVIEW

This review summarizes the impact of bariatric surgery on gynecologic complications in the context of the extremely obese adolescent and reviews contraceptive considerations before and after adolescent bariatric surgery.

RECENT FINDINGS

Eighteen percent of children and adolescents have a body mass index greater than the 95th percentile, with 4% of adolescents being greater than the 99th percentile. Gynecologic morbidities identified in obese adolescents include anovulatory complications such as acute menorrhagia, polycystic ovary syndrome and endometrial hyperplasia, and cancer. When conventional dietary and behavioral therapy fail to result in weight loss, specific criteria have been identified to justify bariatric surgery in extremely obese adolescents. Bariatric surgery in adult women often results in resumption of ovulatory menses, resolution of clinical and laboratory evidence of hyperandrogenism, and return of fertility. Adolescents are at risk for unintended pregnancies, and there are special concerns regarding pregnancy in bariatric patients. Specific contraceptive methods have particular potential risks, benefits, and drawbacks for use in obese adolescents.

SUMMARY

Clinicians who provide care for extremely obese adolescents must be aware of the potential for gynecologic morbidities including polycystic ovary syndrome, dysfunctional bleeding and endometrial hyperplasia, expected gynecologic and fertility outcomes of weight loss surgery for teens, as well as the implications on contraceptive options.

The Role of Genetic Testing for Cancer Susceptibility in Gynecologic Practice

Genetic counseling and testing for inherited disorders are part of every obstetrician-gynecologist's practice. Family history, ethnicity, and race are routinely evaluated as a part of the prenatal assessment. The discovery of genes responsible for inherited cancer susceptibility and the wide availability of clinical genetic testing for mutations in these genes have made similar assessments an integral part of gynecologic practice as well. The indications for genetic testing for mutations in BRCA1, BRCA2, and the mismatch repair genes responsible for the hereditary nonpolyposis colon cancer (HNPCC) syndrome need to be individualized. As in obstetrics, genetic counseling can provide critical assessment of the family history to help determine the likelihood of an inherited cancer susceptibility syndrome and the appropriateness of genetic testing. The subsequent clinical recommendations for mutation carriers need to take into account the patient's age, desire for future childbearing, and other medical history when prescribing screening interventions or prophylactic surgery. Practical applications of genetic testing for cancer susceptibility have the ability to reduce the burden of hereditary cancers by saving lives, decreasing medical morbidities, and reducing psychological stress.

ACOG Committee Opinion No. 372: The Role of Cystourethroscopy in the Generalist Obstetrician_Gynecologist Practice

Cystourethroscopy can be performed for diagnostic and a few operative indications by obstetrician-gynecologists to help improve patient care. Perhaps the most important indications for cystourethroscopy are to rule out cystotomy and intravesical or intraurethral suture or mesh placement and to verify bilateral ureteral patency during or after certain gynecologic surgical procedures. The granting of privileges for cystourethroscopy and other urogynecologic procedures should be based on training, experience, and demonstrated competence. Postgraduate education, including residency training programs in obstetrics and gynecology and continuing medical education, should include education in the instrumentation, technique, and evaluation of findings of cystourethroscopy, and in the pathophysiology of diseases of the lower urinary tract.

Twin goals: continuing professional development and improved patient care: report of an ACOG District I retreat focused on the future of obstetrics and gynecology

On April 8 and 9, 2006, District I of the American College of Obstetricians and Gynecologists (ACOG) held a retreat to assess the future of the specialty. The retreat leaders were Dr. Fredric D. Frigoletto Jr, MD, and Dr. Michael Tesoro, MD. Dozens of issues were identified, analyzed, and prioritized for action. The participants identified the twin goals of continuing professional development and improved patient care as critical and central to the healthy evolution of the specialty. The participants also identified nine major issues that greatly influence our ability to realize these twin goals. The nine issues include 1) ensuring career longevity, 2) balancing family life and work life, 3) optimizing residency training and medical student recruitment, 4) developing the careers of a cadre of physician-scientists, 5) enhancing competency-based continuing professional education, 6) supporting practice development, 7) improving patient safety, 8) securing patient access to care, and 9) advancing our legislative agenda, including tort reform. The retreat leaders identified the need for the specialty to develop a "road map" to constructively address these key issues.