General Considerations in Gynecology

The History as Art

In gynecology, as in other specialties, a diagnosis depends on many things. Of course a microscopic appraisal of the diseased tissue is the final diagnosis, but sometimes subtle aspects of a patient's history are needed before getting to a point where surgery provides the tissue for the pathologist.

The medical history can be crucial in getting the full picture of a particular illness. Medicine is an art because it calls for judgement. Although there are flow sheets of the proper steps to take for any disease, still we often come across patients that won't fit into this or that tidy niche. Judgement is frequently needed to choose how aggressive or how conservative we should be when presented by a patient's complaints. There are certain things we doctors pay careful attention to when trying to decide how intensely to investigate a potential diagnosis.

One of the most important aspects of the patient's history is the family history. Although cancer of the cervix doesn't usually follow a family predisposition, cancers of the ovary, uterus, and breast do. I'll use cancer of the uterus as one example. This usually presents with irregular uterine bleeding (irregular cycles). A young woman with irregular uterine bleeding may only need an office biopsy and then hormonal regulation if she has no family members who have had uterine cancer, but a woman who claims her mother had it would represent a higher degree of danger. A full, more thorough tissue evaluation via d&c (scraping of the womb over 360 degrees) would be a better idea here, since there is a chance that the random sampling of the simpler office biopsy may miss something. It all comes down to odds.

A low risk patient, for instance, may make do with the office biopsy that has an 80% success rate in picking up abnormalities; but a high risk (family history or menopausal) situation would benefit from the thoroughness of the d&c. But the d&c has its own complication rate--general anesthesia, increased cost, and danger of perforation. So limiting it to more highly suspicious persons makes sense. And even though the lesser office biopsy is not as thorough and has more of a chance of missing something, the statistics are good on the safety of using it in low risk histories. The risk of general anesthesia outweighs the benefit when the rate of catching a real cancer in a low risk history is separated from the higher risk histories. Additionally, vaginal ultrasound, unequaled in showing the thickness of the lining of the womb, has completely reinforced this thinking.

Ovarian cancer also follows a family predisposition. A simple cyst, normally watched with extreme patience in the low risk history, becomes quite a concern if a woman has a strong family history of cancer there. The history could make the difference in whether watchful waiting with hormonal suppression or aggressive diagnostics via a laparoscope or abdominal operation are used.

The personal history is also important. How long has a woman had the complaints of pelvic pain associated with an ovarian cyst? A year would make me want to look into surgery more quickly than a history of discomfort for only a few weeks. Is she on birth control pills? If so, then a cyst is more suspicious, because birth control pills are used to treat the harmless ovarian cysts in the first place. How old is the patient? The older the patient, the more suspicious the cyst. Has she had a history of misleading harmless cysts in the past?

There is no substitute for the thorough history--not even the physical exam. They go hand in hand as part of the complete evaluation of a problem. They require no special machinery or technologies--those can come later. All they require is the art of judgement...the art of the practice of medicine.

The ObGyn Physical Exam

Above I talked about the importance of a patient's history--how it can influence a doctor's judgement regarding possible diagnoses and what tests make the most sense. In other words, it gives a perspective to what a doctor investigates next, which is called the physical exam. Depending on the specialty, the physical exam usually concentrates on one area, although a routine screening of the rest of the body is essential. This is especially important in gynecology, because a gynecologist is considered what's called a primary care specialist. That is, he or she cares for a patient globally, as well as concentrating on obstetrical and gynecological considerations as well. Whereas you wouldn't expect an ear, nose, and throat specialist to do a pelvic exam, it's customary for a gynecologist to check the thyroid in the neck for enlargement.

Obstetrics and gynecology is a strange specialty indeed, because we're often the only doctor a woman ever sees, so we're expected to be thorough with our physical exams from head to toe. Yet we're the ones of all of the specialists who have the final say on opinions regarding pelvic disease. Certainly there are some gray zones, like when a general surgeon tries to make a diagnoisi between an inflamed appendix versus an ovarian cyst. But usually these confusing presentations are eliminated by the history. Once an exam fails to show any obvious problems with the rest of the body, a gynecologist then focuses on the pelvis.

Occasional tenderness in this area is normal in a cycling woman, because the pelvic organs are busy every month putting up, then shutting down because of the possibility of pregnancy. Ovulation can present as a discrete pain on one side or the other. The follicle of ovulation can enlarge into a cyst, adding weight to the ovary which hangs on a stalk. This extra weight can "twang" the area, giving the pain she feels. When she ovulates, fluid--sometimes blood-tinged--will drain into the pelvic cavity, giving a vague, burning-like sensation. Again, all of this is normal. A gynecologist can usually tell this discomfort which reflects normal physiology from infection or dangerous tumors that may also cause pain.

The uterus (womb) can enlarge with child-bearing, fibroids, or adenomyosis. Fibroids are benign, harmless growths that add weight to the uterus, making it flip-flop with activity. This can cause back pain and a feeling of pelvic heaviness by the end of the day. Adenomyosis is a benign glandular enlargement inside the womb, making it very tender to activity or intercourse. Both conditions can cause increased menstrual pain and heavier bleeding.

The tubes that carry eggs to the womb for pregnancy can become infected, leading to a painful exam accompanied by fever. Difficulty in holding in urine may be due to a distortion of the support under the bladder; difficulty with bowel movements can be due to a thinning out of the separation between the vagina and rectum.

All in all, it's pretty amazing all of the things a gynecologist can check or rule out in that "routine" visit. But that's the beauty of the physical exam. If the art of medicine depends on the history, it's the success of treatment that begins with the physical exam.

Preventative Medicine

Nowhere is the concept of preventative medicine more important than in women's health. Women have a unique set of medical aspects related to not only childbearing potential but also to their gender in general. Below are some key points that need to be addressed in the seeking of well-being.

Breast disease

The breast is a specialized organ that responds to a hormone called prolactin, which is the milk let-down organ. Too much prolactin production can make her body think it's breast-feeding, making conception difficult in a woman seeking pregnancy. Any discharge from the breast should warrant a prolactin level (blood test). If it is elevated, this could possibly indicate abnormalities in the brain (specifically, the Pituitary Gland). Also, a glass slide can be pressed to the nipple so that microscopic studies can be done to rule out pre-malignant changes. And speaking of that, there's the spectre of the century for women, breast cancer. Routine breast exams by a women's doctor in addition to mammograms according to accepted protocols will be protective for the most part from this deadly disease. Mammography has come a long way in the last ten years, progressing from the vise-like torture it was to gentle application of low-dose X-ray devices it is today.

Infertility

Most women may think that this will not be a problem, but single women who have multiple sex partners before settling into their final monogamous relationship should ask for STD (Sexually Transmitted Screens) every visit. The main emphasis is on Chlamydia, because it's so silent, colonizing and scarring the reproductive tract, often with no symptoms, with diagnosis finally coming when a woman who has tried to get pregnant later on contiues to fail. The culture for this can be done at the same time as a Pap smear.

Gonorrhea should also be screened for, because there is a reportable percentage that will have both.

Other sexually transmitted diseases

If a woman can be exposed to chlamydia, then she may be exposed to hepatitis, syphilis, AIDS, and the virus that causes vaginal warts and cervical cancer. Any woman has a legitimate request when asking for the total STD screening if her sexual activity involves people she can't trust completely, and let's face it--that only means someone who is a virgin.

Other female cancers

Cancer of the cervix, uterus, and ovaries are all different diseases.

The Pap smear can detect risk for cervical cancer, which if positive, can be ruled out or investigated further by a technique called colposcopy. The colposcope is nothing more than a microscope on a stick. It uses a microscopic evaluation of the cervix from which the pap smear was taken to evaluate the areas that might have produced the abnormalities in the pap. The pap smear is a good screen, but the colposcope is the definitive test.

Uterine cancer often gives a warning signal with irregular periods of some sort. A change in the heaviness of flow or in the frequency or duration of flow should be investigated. Although most women consider the menstrual period a major pain in the neck (or elsewhere), when it is normal it is nevertheless a signal that everything is pretty much O.K. When it isn't, a gynecologist is necessary to evaluate for dangerous conditions. Luckily, most of the time it's just menstrual dysrythmia (the proverbial "imbalance of hormones"), and the evaluation will send a patient off with peace of mind. Common in these evaluations for abnormal bleeding are ultrasounds, D & Cs (scraping the womb under anesthesia to study the tissue), and/or endometrial biopsy (office procedure limited sampling of the womb).

Ovarian cancer is the sneakiest female cancer. Frequently undiagnosed until too late, it is usually without symptoms. It is often diagnosed quite by accident on a regular well-woman visit during a routine pelvic exam. The sign gynecologists look for is enlargement of an ovary during this check-up. This underscores the importance of regular visits, the regularity of which can be determined by a family history of this familial risk.

Always the possibility of pregnancy

The reason obstetrics and gyenecology are two interrelated specialties is because a woman being seen for a gynecological check-up may walk out, whether she has planned it or not, as an obstetrical patient. Preventative medicine is prudent in all women of childbearing age especially, because when the diagnosis of pregnancy is made, one must wonder what has happened in the weeks prior to the diagnosis when a developing fetus is at most risk for developmental abnormalities. Preventative medicine includes responsible contraception, but it also includes abstinence from many abusive substances if no contraception is being used, i.e., alcohol, cigarettes, and drugs (prescription and otherwise).

One of the best forms of preventative medicine is the use of barriers during sexual activity. By that I mean condoms when women are not in a monogamous relationship. Effective contraception by birth control pills does not give effective protection from STDs. In fact, no method is foolproof except abstinence. My advice to any woman is to:

1. Make sure you're screened for STDs if you've been in sexual relationships that are not permanent and monogamous.
2. Keep up with a routine physical exam for checks on the pelvic organs.
3. Keep up with the protocol for mammograms your doctor recommends.
4. Report any abnormalities of the menstrual cycle to your doctor, whether it's more bleeding than normal or less than normal.
5. If of childbearing age, live your life as if you could be pregnant, for there are some of you who are.

Selecting the Right Gynecologist

The difficult decision of choosing a doctor is all the harder when it means selecting a gynecologist, because this special kind of doctor must treat a personal aspect of health. That doctor better be perfect. At least in a woman's (and her husband's) eyes. Everyone realizes that perfection is an unattainable ideal. But different women have different priorities as to what constitutes an "acceptable" level of perfection. Some want the hand-holding type who will do all the worrying for her, taking her through the GYN exam in a mystic cloud of vague pronouncements of well-being. Some want the opposite, a Carl Sagan who will explain the millions and millions of details, pointing out all of the risks and benefits of every option this or that option has to offer. Still others want a pal, somewhere in between the first two types, but with enough empathy to agonize with the patient over every decision.

All of these types have successful practices because they attract adequate numbers of patients who seek them out because of their specific mindsets. But all gynecologists hope to blend the three types perfectly so that the care is knowledgeable, caring, and endearing.

But there is also another type of gynecologist. This is the one who has an agenda. This one is inflexible in his or her attitude about lifestyle, morality, sexual activity or orientation. There is one way to do things and if a patient disagrees, she is propagandized until she leaves the practice. Luckily, this type is rare, because such a practice doesn't get a lot of business.

Being an OB-GYN and also the father of four children, I've had ample opportunity to consider all of the intricacies of what's important in an doctor-patient relationship. A lot of my training in this insight comes from patients switching to me for reasons I remember and fine-tune out of my practice:

"I called my doctor for three days and he never returned my call." This is a frequent complaint that drives patients to seek another doctor. Either this doctor's too busy or the protocol on handling patient calls is too sloppy.

"There are several doctors in the practice, and they all tell me different things." Having several doctors in a practice enhances their skills, because they all sharpen each other. But then again, ten different doctors will have eleven different opinions, so a patient must be willing to forgive minor variations on matters that are relatively inconsequential. However, if one doctor tells you it would be dangerous to have a certain treatment option, nd another says it will be dangerous not to, there could be a problem here.

"I asked my doctor about this and she just blew me off." Patients should give the doctor the benefit of the doubt. Never should a patient leave the office without all of her questions answered. Stop the doctor, who may have just misunderstood you, and tell him or her that you still have a question. I sometimes have a patient who might apologize to me for having too many questions, admitting guiltily that she may be taking too much of my time. The truth is that, yes, I am busy--but with her! Once I'm in the exam room or consultation room, she's the most important person in my practice, no matter how long it takes. And she should feel that way too.

Strangely enough, the medical world and patients' reasons for selecting doctors have changed in a very short time. I no longer see people switching doctors because they feel some are "knife-happy" or too greedy. Managed care took care of that. They seem to switch for failures in the doctor-patient relationship; such a relationship should be professional, but always personable as well. This isn't taught in medical school. A lot of it is innate, but there is a lot learned about human nature in the first years of unsupervised private practice, too. A woman wants what's best for her body, her quality of life, her gender--and she will usually know after a first visit whether a certain gynecologist is for her. Besides our board exams, we doctors must also pass the feminine instinct.

Is Ray Charles really God?

In the Woody Allen movie, Sleeper, our hero finds himself hundreds of years into the future. There's a particular scene in which an authority figure regards a cigarette and mutters, "Remember when they used to think these things were actually bad for you?" This scene always comes to mind whenever I see some reversal of medical thought brought about by a new study in a journal.

The way I practice obstetrics and gynecology today is vastly different from ten years ago--probably for the most part due to what I've applied from journals. I've seen thinking altered, fine-tuned, and even reversed on different subjects. What may have been accepted a decade ago might now be considered malpractice. And while it's not likely that we may some day scoff at cigarettes being bad for you, there are always surprises in store for us with each journal. It is up to each individual doctor, however, to judge the merits of the conclusions in each article.

One of the most frequent reasons for the reversal in thinking on a certain subject is the size of a study described. A larger study will outrank a smaller one in determining an opinion. If there are ten patients testing the merits of some new drug, the findings are going to be less trustworthy than a study involving thousands of patients. It's very much like the throw of dice. If the dice are thrown ten times, it may be that box cars come up on one of those throws. A gullible player may deduce that the odds are one in ten of throwing a twelve, but even though it happened doesn't change the odds from the one in thirty-six that is the reality. It's the same with studies. If a new drug accidentally kills a thousand people out of every million who take it, a study of hundreds, perhaps even a few thousand , may never demonstrate this lethal property. Similarly, if a wonderful new drug were to kill one patient out of twenty-five in a small study--even though this may represent incredibly bad luck--the study would exaggerate the mortal danger unfairly. It wouldn't matter that there were an additional 100,000 safe encounters, the chances would still start out by appearing to be a one in twenty-five chance of dying. Small studies make for falsely good or bad publicity.

Another consideration are what are called "controls." A new drug or therapy must be compared fairly. For instance, Tylenol taken for hangovers may falsely incriminate this pain-reliever as causing cirrhosis of the liver. But a closer look at the controls will show that there are a lot of alcoholics taking Tylenol, too, for their hangovers.

Another big consideration in assessing a study is whether it is retrospective or prospective. A retrospective study sees some result and tries to look back to explain it. This is a poorer way to deduce conclusions. For example, it might be concluded that drinking milk causes cancer, because an interview with cancer patients demonstrates quite readily that they all drank milk as children. A prospective study--one that looks ahead-- would divide people into two groups: one that drinks milk from now on and one that will not--and then watch both groups over years to see if there's any difference in the cancer rate of each group. I think it will be found that milk will not increase the risk.

A study can also be flawed by assumptions. A well-constructed study will make no assumptions. Sometimes a study may use an assumption as a definition and reach conclusions that way.

So...if God is love, and love is blind, and Ray Charles is blind, then Ray Charles must be God. Right?

Numbers, the quality of the controls, whether a study is retrospective or prospective, and assumptions help each doctor draw his or her conclusions and change the way medicine is practiced. So the next time you see an elderly man enjoying a cigarette, don't say, "Look at how old that smoker is!" Instead, say, "I wonder how many of his friends are no longer with him because they died from cigarettes." Studies are nothing more than observations, and you can make a study say anything on how the observations are constructed. Which, if I didn't know any better, would be particularly bad news as I eye that glass of milk.