Obstetrics and Gynecology E-Book

E. Albert Reece

• Herausgeber: Thieme
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 1415

Veröffentlichungsjahr: 2010

Beschreibung

An up-to-date textbook on the clinical essentials in women's healthcare

Written by an international team of OB/GYN practitioners, this book offers an overview of the most important and common clinical issues in obstetrics and gynecology, including reproductive endocrinology, gynecologic oncology, maternal–fetal medicine, and sexuality. It provides readers with current information on evidence-based approaches to the management of normal pregnancy, labor and birth, as well as the diagnosis, treatment, and prevention of high-risk pregnancy, infertility, and acute and chronic diseases, and psychiatric disorders in women of all ages. For each condition the authors give a clear definition, discuss its epidemiology, etiology and pathophysiology, and present the most up-to-date protocols for its detection, screening, and clinical management. They also provide a thoughtful evaluation of why certain therapies and approaches are more effective than others.

Features:

• Clearly and consistently organized chapters for optimal comprehension of the material
• A section dedicated to the legal and ethical issues related to reproductive health
• 240 illustrations, most in full color, demonstrating critical concepts and data
• A summary of key points at the end of most chapters and "Evidence" boxes that focus on evidence-based research

A comprehensive introduction to the field, Obstetrics and Gynecology: The Essentials of Clinical Care is an excellent textbook for medical students on clinical rotation in OB/GYN, and for residents and practitioners in the specialty. Nurses, midwives, and physician assistants will also benefit from its wealth of information.

Leseprobe

To my wife Sharon with love, and for a debt I cannot repay.

E. Albert Reece

To all the physicians, teachers, and students who arepassionate about improving women's health throughout the world.

Robert Barbieri

Library of Congress Cataloging-in-Publication Data is available from the publisher.

Illustrator: Dr. med. Katja Dalkowski, Buckenhof, Germany

© 2010 Georg Thieme Verlag,Rüdigerstrasse 14, 70469 Stuttgart, Germanyhttp://www.thieme.de Thieme New York, 333 Seventh Avenue, New York, NY 10001, USAhttp://www.thieme.com

Cover design: Thieme Publishing Group Typesetting by medionet, Berlin, Germany Printed by L.E.G.O. S.p.A., Vicenza, Italy ISBN    978-3-13-143951-2

1 2 3 4 5 6

Important note: Medicine is an ever-changing science undergoing continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book.

Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any dosage instructions and forms of applications stated in the book. Every user is requested to examine carefully the manufacturers' leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Every dosage schedule or every form of application used is entirely at the user's own risk and responsibility. The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed. If errors in this work are found after publication, errata will be posted at www.thieme.com on the product description page.

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Contributors

Robert L. Barbieri, MD

Chairman Department of Obstetrics, Gynecology and Reproductive Biology Brigham and Women's Hospital Kate Macy Ladd Professor Harvard Medical School Boston, MA, USA

Daniela Carusi, MD, MSc

Instructor of Obstetrics, Gynecology and Reproductive Biology Harvard Medical School Brigham and Women's Hospital Boston, MA, USA

Jon I. Einarsson, MD, MPH

Director of Minimally Invasive Gynecologic Surgery Brigham and Women's Hospital Boston, MA, USA

Jenifer O. Fahey, CNM, MPH

Assistant Professor of Obstetrics, Gynecology and Reproductive Sciences University of Maryland Medical Center Baltimore, MD, USA

Alberto Fernández, MD

High Risk Pregnancy Unit Department of Obstetrics and Gynecology Center of Medical Education and Clinical Research (C.E.M.I.C.) University Buenos Aires, Argentina

Vanina S. Fishkel, MD

Department of Obstetrics and Gynecology Center of Medical Education and Clinical Research (C.E.M.I.C.) University Buenos Aires, Argentina

Tanya S. Ghatan, MD

Instructor, Harvard Medical School Brigham and Women's Hospital Department of Obstetrics and Gynecology Boston, MA, USA

Carolina Ghia, MD

Department of Obstetrics and Gynecology Center of Medical Education and Clinical Research (C.E.M.I.C.) University Buenos Aires, Argentina

Avi Harlev, MD

Instructor, Department of Obstetrics and Gynecology Soroka University Medical Center Ben-Gurion University of the Negev Beer-Sheva, Israel

Melody Y. Hou, MD, MPH

Department of Obstetrics and Gynecology Boston University School of Medicine Boston, MA, USA

Julieta E. Irman, MD

Department of Pediatrics British Hospital Buenos Aires, Argentina

Natasha R.Johnson, MD

Instructor, Harvard Medical School Brigham and Women's Hospital Department of Obstetrics and Gynecology Boston, MA, USA

Arie Koifman, MD

Instructor, Department of Obstetrics and Gynecology Faculty of Health Sciences Soroka University Medical Center Ben-Gurion University of the Negev Beer-Sheva, Israel

Jan Kriebs, CNM

Assistant Professor of Obstetrics, Gynecology and Reproductive Sciences University of Maryland Medical Center Baltimore, ML, USA

Gustavo F. Leguizamón, MD

High Risk Pregnancy Unit Department of Obstetrics and Gynecology Center of Medical Education and Clinical Research (C.E.M.I.C.) University Buenos Aires, Argentina

Hugh E. Mighty, MD, MBA

Associate Professor of Obstetrics, Gynecology and Reproductive Sciences Chairman, Obstetrics, Gynecology and Reproductive Sciences University of Maryland Medical Center Baltimore, ML, USA

Felicitas von Petery, MD

High Risk Pregnancy Unit Department of Obstetrics and Gynecology Center of Medical Education and Clinical Research (C.E.M.I.C.) University Buenos Aires, Argentina

Benjamin Piura, MD, FRCOG

Professor, Unit of Gynecologic Oncology Soroka Medical Center and Faculty of Health Sciences Ben-Gurion University of the Negev Beer-Sheva, Israel

Fernenda Peres, MD

Head of Adolescent Gynecology Unit Department of Obstetrics and Gynecology Faculty of Health Sciences Soroka University Medical Center Ben-Gurion University of the Negev Beer-Sheva, Israel

Luciana Prozzillo, MD

High Risk Pregnancy Unit Department of Obstetrics and Gynecology Center of Medical Education and Clinical Research (C.E.M.I.C.) University Buenos Aires, Argentina

Jill A. RachBeisel, MD

Associate Professor of Psychiatry Director, Community Psychiatry University of Maryland School of Medicine Baltimore, ML, USA

E. Albert Reece, MD, PhD, MBA

Vice President for Medical Affairs University of Maryland The John Z. and Akiko K. Bowers Distinguished Professor of Obstetrics, Gynecology and Reproductive Sciences, and Dean University of Maryland School of Medicine Baltimore, ML, USA

Shimrit Yaniv Salem, MD

Instructor, Departments of Obstetrics and Gynecology Faculty of Health Sciences Soroka University Medical Center Ben-Gurion University of the Negev Beer-Sheva, Israel

Ruthi Shako-Levy, MD

Lecturer, Institute of Pathology Soroka Medical Center and Faculty of Health Sciences Ben-Gurion University of the Negev Beer-Sheva, Israel

Eyal Sheiner, MD, PhD

Senior Lecturer, Departments of Obstetrics and Gynecology Faculty of Health Sciences Soroka University Medical Center Ben-Gurion University of the Negev Beer-Sheva, Israel

Adi Y. Weintraub, MD

Instructor, Departments of Obstetrics and Gynecology Faculty of Health Sciences Soroka University Medical Center Ben-Gurion University of the Negev Beer-Sheva, Israel

Arnon Wiznitzer, MD

Professor of Obstetrics and Gynecology Faculty of Health Sciences Soroka University Medical Center Ben-Gurion University of the Negev Beer-Sheva, Israel

Natalia P. Zeff, MD

Diabetes in Pregnancy Unit Department of Obstetrics and Gynecology Center of Medical Education and Clinical Research (C.E.M.I.C.) University Buenos Aires, Argentina

Foreword

All too often “handbooks” are dismissed as not providing the necessary and essential information required to practice OB/GYN medicine in the real world. This is a common complaint among both professors and clinicians.

This handbook is an exception to that rule. It is well organized and devotes extensive discussion to the major expected topics (e.g., labor and delivery). However, where appropriate it delves deeply in subtopics that are of current clinical interest and/or where controversies exist. For example, it presents an extensive discussion of the management and prevention of infectious diseases and also discusses the ethical issues involved in recommending specific preventive vaccines, such as the HPV vaccine. Most importantly, it clearly addresses all the major subspecialties, including gynecologic oncology, reproductive endocrinology, and maternal-fetal medicine.

Most importantly, the information contained in these almost 60 chapters is clinically relevant and concisely presented. The sections devoted to breast disease, ethics, human sexuality, and preventive care should be read by all clinicians, not just obstetrics and gynecology medical students and trainees. Most importantly, the information contained in these comprehensive chapters is clinically relevant and concisely presented.

As the title of this book-Obstetrics and Gynecology: The Essentials of Clinical Care-suggests, what it presents are the evidence-based essentials of high-quality OB/GYN practice; not speculations or possibilities, but the tried and true approaches. Most importantly, in many sections it discusses what the minimum standards are for safe, professional, and ethical clinical care under often difficult circumstances.

Indeed, the sections devoted to ethics, psychiatric issues, legal issues, and patient-provider communications is a must read for all clinicians and healthcare workers, not just obstetrics and gynecology practitioners and medical students. Thus, it is a valuable resource for the students, trainees, practicing physicians, and other healthcare professionals who manage women of reproductive age. I hope all groups get as much out of reading it as I did.

Norman F. Gant, Jr, MD

Preface

The volume of information that today's OB/GYN practitioner needs to know is staggering and growing rapidly because of new basic research and clinical discoveries made daily. There is a critical need for both medical students and practicing physicians to have easy access to relevant information in a concise and carefully organized manner. This goal is difficult to achieve because 21st century medicine is characterized by a vast quantity of clinically relevant information. That is why the goal of this textbook is to clearly and concisely present the essential knowledge needed to practice state-of-the art obstetric and gynecologic medicine.

Women's health and the field of obstetrics and gynecology are critically important to the overall health of every society. Indeed, the health of women and their newborn children are key determinants of the potential of a society for advancing. The Association of Professors of Gynecology and Obstetrics has developed consensus learning objectives for medical students on clinical rotations in obstetrics and gynecology. These objectives, modified to focus on the most important and common clinical problems, are the basis for the extensive amount of material presented in this handbook.

Each chapter is presented in a clear, consistent manner and, where appropriate, begins with the definition of a particular condition, its common manifestations, and how it is routinely diagnosed. This is followed by a discussion of the prevalence and epidemiology of the condition, its etiology and pathophysiology, detailed information about the methods and protocols for its screening and/or detection, and the most recent, evidence-based information about its management. Each chapter uses photographs, tables, and other figures to present critical data and ideas, and ends by emphasizing the key clinical points. Within most chapters, an “Evidence” box is included to provide readers with exposure to how high-quality research information is used to guide clinical diagnosis and treatment. These “Evidence” boxes provide the kind of clinical information that inform the modern practice of OB/GYN medicine.

Medical students do not learn by a bolus infusion of a massive quantity of information. Rather, they learn through a continuous cycle of reading, thinking, talking, and doing. The purpose of this handbook is to assist the student and practitioner in this constant cycle of life-long learning and, more importantly, to offer the most evidence-based approach to the diagnosis and treatment of real OB/GYN patient problems.

E. Albert Reece, MD, PhD, MBARobert L. Barbieri, MD

Acknowledgements

The editors are deeply indebted to all of those who contributed so generously to the conceptualization, research, and writing of this project. Thanks to their enormous energy and creative input, we have developed an extremely informative, up-to-date handbook on the essentials of practicing modern OB/GYN medicine.

We greatly appreciate the efforts of Mr. Jim Swyers, MA, Director of Academic Outreach and Special Programs at the University of Maryland School of Medicine, office of the dean, who assisted in coordinating the entire project and was instrumental in helping to locate evidence-based studies and guidelines for many of the chapters as well as relevant photographs, figures, and tables.

We also are deeply indebted to our project editors at Thieme Publishing, Stephan Konnry and Rachel Swift, who kept us on task and on schedule and provided extremely valuable insights and recommendations throughout every stage of this project. Without their superior organizational skills and expert input, our task would have been much greater and taken significantly longer to complete.

Finally, we would like to express our sincere appreciation to all of the contributors to the various chapters of this book. The quality of this handbook is a testament to their commitment, selflessness, and outstanding scholarship. We are forever indebted to them.

E. Albert Reece, MD, PhD, MBA,Robert Barbieri, MD

Table of Contents

Part I Patient Care

1 Life-Long OB/GYN Care for Women

From Birth to Adolescence

The Reproductive Years

Menopause

2 OB/GYN Examinations and Evaluations

Definitions

History

Physical Examination

Laboratory Evaluations

Diagnostic Imaging Procedures

3 Embryology of the Female Reproductive System

Definitions

Genital Embryogenesis

Anatomy

4 The Menstrual Cycle and Fertilization

Definitions

The Menstrual Cycle

Fertilization

5 Genetics and Genomic Applications in OB/GYN Practice

Definitions

Impact of Genetics and Genomics on OB/GYN Practice

Basic Concepts of Genetics

Types and Mechanisms of Genetic Abnormalities

Diagnosis and Management

6 Pap Smear and Human Papilloma Virus Testing

Pap Smear Terminology

Types of Pap Smear, Their Sensitivity, and Screening Guidelines

Human Papilloma Virus DNA Testing

Management

7 Genetic Screening and Obstetric Procedures

Definitions

Screening Strategies

Diagnostic Testing

Part II Obstetrics

Section I Normal Obstetrics

8 Maternal—Fetal Physiology

Maternal Physiology

Fetal Physiology

9 Preconception and Antepartum Care

Definitions

Preconception Care

Summary

Antepartum Care

Summary

10 Intrapartum Care and Fetal Surveillance

Definitions

Fetal Heart Rate: Normal and Pathologic Patterns

Other Methods for Intrapartum Fetal Surveillance

Fetal Metabolic Status Assessment

Interventions for Altered Heart Rate Patterns

11 Labor and Delivery

Labor Physiology

Mechanics of Labor

The Fetus

Cardinal Movements of Labor

Progress of Labor

Operative Vaginal Delivery

12 Immediate and Postpartum Newborn Care

Definitions

The Respiratory Transition

The Circulatory Transition

The Thermoregulatory Transition

Newborn Management

Discharge Procedures

Managing Neonatal Jaundice

General Laboratory Evaluation

Section II Abnormal Obstetrics

13 Ectopic Pregnancies

Definition

Diagnosis

Prevalence

Etiology and Pathophysiology

History

Treatment Options

14 Spontaneous Abortion

Definitions

Incidence and Risk Factors

Etiology

Diagnosis

Treatment

Post-Treatment Evaluation and Counseling

15 Pathological Labor and Delivery

Preterm Labor

Abnormal Labor

16 Pre-Eclampsia—Eclampsia Syndrome

Definition and Diagnosis

Prevalence and Epidemiology

Etiology and Pathophysiology

History

Physical Examination

Laboratory Testing

Treatment of Pre-eclampsia

Treatment of Severe Pre-eclampsia

Treatment of Eclampsia

Antihypertensive Therapy

17 Rhesus Isoimmunization

Definition

Diagnosis

Prevalence and Epidemiology

Etiology

Pathophysiology

History

Physical Examination

Laboratory Testing

Treatment

18 Multifetal Pregnancy

Definitions

Diagnosis

Prevalence and Epidemiology

Etiology

Pathophysiology

History

Laboratory Testing

Management

Labor and Delivery in Multifetal Births

Triplets

19 Preterm Birth and Fetal Growth Restrictions

Preterm Birth

Fetal Growth Restriction

Prevalence and Epidemiology

Etiology and Pathophysiology

History Taking: Preterm Labor

History Taking: Fetal Growth Resriction

Physical Examination: Preterm Labor

Physical Examination: Fetal Growth Restriction

Laboratory Testing: Preterm Labor

Treatment Options

20 Premature Rupture of Membranes and Third Trimester Bleeding

Definitions

Diagnosis

Prevalence and Epidemiology

Etiology and Pathophysiology

History

Physical Examination

Laboratory Testing

Treatment

21 Hypertension in Pregnancy

Definition

Diagnosis

Prevalence and Epidemiology

Etiology and Pathophysiology

Medical History

Physical Signs

Laboratory Studies

Treatment

Prognosis

Special Concerns

22 Postpartum Hemorrhage and Infection

Definitions

Diagnosis

Prevalence and Epidemiology

Etiology and Risk Factors

History

Physical Evaluation

Management

23 Infectious Diseases in Pregnancy

Definitions

Viral Infections

Pregnancy in the HIV Era

Bacterial Infections

Toxoplasmosis

24 Perinatal and Maternal Mortality

Definitions

Epidemiology and Etiology

Management and Prevention

25 Psychiatric Issues during and after Pregnancy

Family Planning

Genetics of Psychiatric Disorders

Risk Factors for the Expectant Mother during Pregnancy

Risk Factors for the Fetus during Pregnancy

Postpartum Complications

Addressing Psychiatric Issues during Pregnancy

Postpartum Mood Disorders

26 Other Medical Complications in Pregnancy

Definitions

Diagnosis

Prevalence and Epidemiology

Etiology and Pathophysiology

History

Laboratory Testing

Treatment

27 Post-Term Pregnancy

Definition

Diagnosis

Prevalence

Etiology

Pathophysiology

History

Physical Examination

Management and Treatment

Part III Gynecology

Section I General Gynecology

28 Contraception and Sterilization

Addressing Contraception with Patients

Contraceptive Methods

29 Therapeutic Abortion

Definition

History and Legality

Epidemiology

30 Vaginitis and Vulvitis

Vaginitis

Vulvitis

31 Sexually Transmitted Diseases

Screening and Risk Factors

Non-Ulcerative Lesions

Ulcerative Lesions

Viral Infections

32 Pelvic Inflammatory Disease

Definition

Risk Factors

Signs and Symptoms

Long-Term Complications

Diagnosis

Treatment

33 Endometriosis and Adenomyosis

Endometriosis

Adenomyosis

34 Chronic Pelvic Pain

Definition

Diagnosis

Prevalence and Epidemiology

Etiology

History

Physical Examination and Laboratory Studies

Treatment

Interdisciplinary Pain Practice

35 Pelvic Relaxation, Urinary Incontinence, and Urinary Tract Infection

Pelvic Relaxation

Urinary Incontinence

Urinary Tract Infection

Section II Breasts

36 The Breast and Benign Breast Disease

Breast Structure and Function

Breast Examination

Lactation

Breast-Feeding

Mastitis, Breast Abscess, and Galactocele

Breast-Feeding and Amenorrhea

Breast-Feeding and Contraception

Nipple Discharge

Breast Pain

Breast Problems in Children and Adolescents

Approach to the Palpable Breast Mass

37 Breast Cancer: Prevention, Screening, Diagnosis, and Treatment

Epidemiology

Breast Cancer Genetics

Prevention

Screening

Diagnosis

Treatment

Medical Care for Breast Cancer Survivors

Section III Procedures

38 Surgical Procedures in Gynecology

Historical Perspective

Vaginal Surgery

Abdominal Surgery

Laparoscopy

Hysteroscopy

Common Gynecologic Procedures

Office Procedures

Part IV Reproductive Endocrinology, Infertility, and Related Topics

39 Amenorrhea and Dysfunctional Uterine Bleeding

Amenorrhea

Secondary Amenorrhea

Primary Amenorrhea

Dysfunctional Uterine Bleeding

40 Polycystic Ovary Syndrome, Hirsutism, and Virilization

Definition and Diagnosis

Prevalence and Epidemiology

Etiology and Pathophysiology

History

Physical Examination

Laboratory Tests

Treatment

Hirsutism

Virilization

41 Dysmenorrhea: Painful Menstruation

Definition

Diagnosis

Prevalence and Epidemiology

Etiology

History

Physical Examination and Laboratory Studies

Treatment

Treatment Failure

42 Infertility

Definition

Causes

Diagnostic Tests

Treatment

Lifestyle Changes to Improve Fertility and Pregnancy Outcome

Assisted Reproductive Technology

Ovarian Hyperstimulation Syndrome

Adoption

Psychosocial Aspects

Social and Ethical Issues

43 Premenstrual Syndrome

Definition

Diagnosis

Prevalence and Epidemiology

Etiology

History

Physical Examination and Laboratory Studies

Treatment

44 Perimenopause, Menopause, and Postmenopause: Consequences of Ovarian Reproductive Aging

Definition and Diagnosis

Etiology and Epidemiology

Physiology of Ovarian Aging

Clinical Presentation

Premature (Primary) Ovarian Failure

Surgical Menopause

Treatment

The Future of Hormone Therapy

Part V Gynecologic Oncology

45 The Biology of Cancer

Cervical Cancer is Caused by the Human Papilloma Virus

Endometrial Cancer is Caused by Unopposed Estrogen Stimulation

Endometrial and Ovarian Cancers are Caused by Germ-Line Mutations in DNA Mismatch Repair Genes

Breast and Ovarian Cancers can be Caused by Mutations in BRCA1 and BRCA2

Evolving Issues in Cancer Biology

46 Gestational Trophoblastic Disease: Molar Pregnancy

Definition

Hydatidiform Mole

Malignant Disease: Gestational Trophoblastic Neoplasia

47 Vulvar and Vaginal Lesions

Types of Lesion

48 Cervical Neoplasia and Cancer

Cervical Neoplasia

Cervical Cancer

49 Uterine Leiomyomas

Etiology

Epidemiology

Symptoms

Diagnosis

Treatment for Uterine Fibroids

Uterine Sarcomas

50 Endometrial Cancer

Definition

Etiology

Epidemiology

Prevention

History

Physical Examination

Diagnosis

Screening

Staging and Surgical Treatment

Adjuvant Treatment

Post-treatment Follow-up

Uterine Sarcoma

51 Ovarian and Fallopian Tube Cysts and Tumors

Ovarian Tumors

Fallopian Tube and Mesosalpingeal Cysts

Fallopian Tube Cancer

Part VI Human Sexuality

52 Sexuality

Sexual Identity

Sexual Response in Men and Women

Sexual Dysfunction in the General Population

The Sexual History

Common Sexual Problems in Women

Treatment of Female Sexual Dysfunction

Adolescent Sexuality

Postpartum Sexual Dysfunction

Sexuality in Chronic Illness

Sexuality in Older Adults

53 Domestic Violence and Sexual Assault

Domestic Violence

Sexual Assault

Part VII Professional Behavior, Ethics, and Legalitis

54 Medical Economics and Social Issues

Population Health Promotes Economic Growth and Stability

Health Economics Issues in Developed Countries

Health Economics Issues in Countries with Rapidly Growing Economies

Health Economics Issues in Developing and Poor Countries

55 Provider—Patient Communications and Interactions

Core Values

Provider—Patient Communications

Special Challenges in the Provider—Patient Relationship

Physician—Physician Interactions

56 Clinical Ethics in Obstetrics and Gynecology

Medical Ethics

Ethical Dilemmas in Obstetrics: the Fetus as Patient

Ethical Dilemmas in Obstetrics: the Neonate as Patient

Ethical Dilemmas in Gynecology

General Guidelines for Making Ethical Decisions

57 Legal Issues in Obstetrics and Gynecology

Licensure, Certification, Credentialing, and Privileges

Standard of Care

Adverse Outcomes

Informed Consent

Risk Management

Elements of Medical Negligence

Common Areas of Increased Liability Risk

Special Legal Provisions in the United States

Index

Part I Patient Care

1 Life-Long OB/GYN Care for Women

2 OB/GYN Examinations and Evaluations

3 Embryology of the Female Reproductive System

4 The Menstrual Cycle and Fertilization

5 Genetics and Genomic Applications in OB/GYN Practice

6 Pap Smear and Human Papilloma Virus Testing

7 Genetic Screening and Obstetric Procedures

1 Life-Long OB/GYN Care for Women

E. Albert Reece and Robert L. Barbieri

The health of women and children is the foundation for the wellbeing and economic prosperity of a society. Quality obstetric and gynecologic (OB/GYN) health care is critical not only to a woman's health, but is absolutely essential to giving the children she bears a healthy start in life.

OB/GYN care includes the entire spectrum of a woman's life and life style, not just pregnancy and childbirth. When it comes to health care, women face a myriad of unique health and wellness issues compared to men. In addition to their unique gynecologic and reproductive challenges, women grow and mature physically and emotionally in different ways from men.

Women often have different responses to drugs than do men; the amount of drug getting to their cells can vary and their metabolism of drugs is often different from a man's. They also are at greater risk for certain mental illnesses, such as depression and generalized anxiety, compared with men. Finally, certain medical problems, such as osteoporosis, can impact women differently from men.

If physicians are not acutely aware of these sex differences, * some serious medical issues, such as cardiac disease or a heart attack, may be overlooked because their symptoms in many women are not as clear-cut as they are in men. Additionally, although women get some cancers, such as lung cancer, at lower rates than men they have a much higher mortality rate than men, for unknown reasons. Therefore, their care has to be more intensive.

There are also health disparities among different groups of women. For example, Black women in many developed countries live fewer years and acquire life-threatening conditions, such as heart disease and breast cancer, at younger ages than do White women. The majority of women and children infected with human immunodeficiency virus throughout the world, for example, are Black. This is particularly true in the United States (Fig.1.1), where Black women also have higher rates of other sexually transmitted infections and pelvic inflammatory disease than do women of other ethnic groups.

Fig. 1.1 Human immunodeficiency virus (HIV) infection takes a significantly larger toll on Black women compared with all other groups of women in the United States This bar diagram shows the numbers of adolescent and adult females living with HIV/AIDS by race/ethnicity, and includes persons with diagnosis of HIV infection (not AIDS), diagnosis of HIV infection and AIDS, or concurrent diagnoses of HIV infection and AIDS for 33 States in the year 2006 (Data do not refect improved estimates of HIV incidence released in August 2008) *Includes 1051 females of unknown race/ethnicity Adapted from the Centers for Disease Control and Prevention HIV/AIDS Surveillance Report.

Thus, it is essential for physicians specializing in women's health to have an in-depth understanding of the unique sets of medical challenges faced by most women. They must also be well versed in the new sets of medical and psychological challenges that often occur in each phase of a woman's life, as well in her living environment. More importantly, physicians must be knowledgeable regarding the important, and often life-saving, preventive measures to follow at each life stage of a woman's life, or any dramatic changes in her environmental situation (e.g., a divorce) in order to be able to detect and prevent any potential medical risks.

* The Institute of Medicine of the US National Academy of Sciences recommends the term “sex difference” to describe biological processes that differ between genetic males and females and the term “gender difference” to describe differences largely influenced by the social environment.

From Birth to Adolescence

From birth to their teenage years, major health issues for young girls involve optimal physical and sexual growth, including the psychological aspects of puberty and gender identification within and outside the family.

Puberty

Puberty is the stage in life when a female first becomes capable of reproducing and is marked by maturation of the genital organs, development of secondary sex characteristics, acceleration in growth, and the occurrence of menarche.

The pubertal process is important in the transition from childhood to adolescence. Three important aspects of the pubertal process are adrenarche, somatarche, and menarche. Milestones in the pubertal process include the onset of breast development (average age10–11 years), growth of pubic hair (average age 11–12 years), and first menses (average age 12–13 years) (Fig.1.2).

Adrenarche is often referred to as the “awakening of the adrenal glands,” where the hypothalamic—pituitary— adrenal (HPA) axis is activated. The HPA axis usually begins to mature in girls between the ages of 6 and 8 years. During adrenarche, there is an increase in the concentrations of three adrenal androgens: dehydroepiandrosterone (DHEA), its sulfate (DHEAS), and androstenedione.

In the early part of adrenarche, there are typically no external physical changes. However, as the concentrations of adrenal androgens increase, pubic hair becomes evident along with body odor, and often acne. These are first physical signs of the onset of puberty.

Although both girls and boys go through puberty, girls reach puberty and sexual maturity at earlier ages than do boys. Starting at around age 9 years, girls experience a significant growth spurt and weight gain. Breast development is an early sign of puberty in girls. This can happen before age 9 years in some girls, but later in others.

Although for most girls, breast development is the first sign of puberty, others might first notice pubic hair. An increase in hair on the arms and legs, in the armpits, and around the pubic area happens to girls early in puberty.

Soon after they develop breasts, most girls have their first period. This usually happens between ages 12 and 13 years, but menstruation can start earlier or later. During a menstrual period, there are 2–3 days of heavier bleeding, then 2–4 days of lighter flow.

Fig. 1.2 Age range of pubertal milestones in young girls From Semin Reprod Med © 2003 Thieme Medical Publishers.

Preventive Vaccinations

In addition to the normal vaccinations that children receive as part of routine pediatric care (e.g., mumps, measles, rubella), there is an ongoing controversy about whether young girls also should be vaccinated against the human papilloma virus (HPV).

Recent studies suggest that half of all sexually active women between 18 and 22 years of age in the United States are infected with HPV. Although most cases clear up on their own, sometimes infection persists and can cause cervical cancer decades later. The US Centers for Disease Control and Prevention predicts that deaths worldwide from cervical cancer could jump fourfold—to a million a year—by 2050.

The US Food and Drug Administration (FDA) recently licensed an HPV vaccine for use in girls/women of age 9–26 years. The vaccine is given through a series of three shots over a 6-month period. The HPV vaccine is recommended for 11–12-year-old girls, and can be given to girls as young as 9 years. The vaccine is also recommended for 13–26-year-old girls/women who have not yet received or completed the vaccine series.

Females who are sexually active may also benefit from the vaccine. But they may receive less benefit from HPV vaccination, since they may have already acquired one or more HPV type(s) covered by the vaccine. Few young women are infected with all four of these HPV types and would still get protection from those types they have not acquired. Currently, there is no test available to tell whether a girl/woman has had any or all of these four HPV types.

The HPV vaccine, nevertheless, is controversial. Many groups object to it on moral grounds, suggesting that it will encourage promiscuity among young people. Many parents are reluctant to immunize their preteen daughters against a sexually transmitted disease. Others believe the risk has been overstated and the vaccine over-marketed by pharmaceutical companies. There also is a common misconception that the HPV vaccine protects against all types of HPV.

Physicians need to be aware of these controversies and discuss them in a frank and open manner with parents of young girls. Chapter 23 contains a detailed discussion of the control and management of infectious diseases during pregnancy, including sexually transmitted diseases, such as HPV.

Exercise, Nutrition, and Weight Control

Proper weight control is particularly important for women. Compared to men, women suffer a disproportionate burden of disease attributable to overweight and obesity. Health-related drops in quality of life are nearly four times steeper for overweight women than for overweight men, and more than twice as great for obese women as for obese men.

Statistics indicate that 39% of boys and 58% of girls aged 7–18 years do not achieve the recommended levels of exercise; that is, spending at least an hour each day in a physical activity of at least moderate intensity. Furthermore, nearly two-thirds of US women are overweight and more than one-third are obese. This puts them at significantly higher risk of a range of acute and chronic diseases, including hypertension, heart disease, stroke, diabetes, and cancer. Women who are obese and diabetic and become pregnant are also at significantly higher risk of having a child with a serious birth defect compared with nonobese, nondiabetic women.

Obesity also has an important relationship with early puberty in girls. A recent study published in the in the journal Pediatrics found that 6–9-year-old girls who had started developing breasts or pubic hair were significantly more overweight than girls of the same age who had not. It also found that this association was stronger for White girls than for Black girls; however, it could not account for the finding that Black girls started puberty, on average, 1 year earlier than white girls.

Another study of 354 girls from 10 different regions in the United States found that increased body fat in girls as young as age 3 years and large increases in body fat between age 3 and the start of first grade schooling were associated with earlier puberty, defined as the presence of breast development by age 9 years.

Based on these findings, physicians should anticipate that overweight girls are more likely to show signs of early puberty. Physicians should take obesity and racial status into account when deciding how to manage early-maturing 6–9-year-old girls.

The Reproductive Years

The reproductive age span of a woman is typically assumed for statistical purposes to be 15–49 years of age. When a woman reaches the reproductive age, many more health care issues come into play including: reproductive health matters, such as childbearing, infertility problems, and pregnancy; depressive illnesses as well as anxiety disorders; sexually transmitted diseases; and autoimmune disorders. Furthermore, if she becomes pregnant at too early an age, she may face a whole new set of issues.

Thus, it is an important time period in a woman's life, and clinicians caring for young women must be able to recognize and reduce risk-taking and other unhealthy behaviors, such as smoking or unprotected sexual intercourse, and discuss contraceptives when is appropriate to protect from unplanned pregnancy.

Contraception

Nearly 15 million teenage women worldwide give birth each year, accounting for up to 10% of all births globally. The figure may be even higher as the number of mothers under 15 years of age is not recorded. Childbearing in adolescence is known to be a considerable health risk. Teenage mothers have more complications of pregnancy and delivery, including toxemia, iron deficiency anemia, premature delivery, prolonged and obstructed labor, hypertensive disorders of pregnancy, and even death. One quarter of the 500 000 women who die every year from causes related to pregnancy and childbirth are teenagers. Thus, the use of highly effective methods of contraception by teenagers at risk for unintended pregnancy may significantly decrease the number of other co-morbidities among this group.

The World Health Organization (WHO) has developed “eligibility” criteria for the population most likely to benefit from a particular method of contraception without unnecessary side effects (Table 1.1). Specifically, the WHO assigns categories to each contraceptive method for use in women under the age of 20 years. Category 1 is for methods for which there is no restriction on use. Category 2 is for methods where the advantages generally outweigh the risks. Category 3 is for methods where the risks usually outweigh the advantages. Category 4 is for methods that represent an unacceptable health risk to adolescent girls. Thus, these latter two categories are not listed in Table 1.1

Although the use of contraceptives by adolescents is extremely controversial in most countries, scientific evidence suggests that condoms and long-acting contraceptives, including condoms, implants, and intrauterine devices (IUDs), are highly effective in preventing pregnancy. Use of these methods by adolescents has the potential to significantly decrease the rate of unintended pregnancy and its complications in this age group.

Endocrine and Autoimmune Disorders

Autoimmune disorders can cause great morbidity and have the highest prevalence in the reproductive years. Many of these diseases are influenced by changes in estrogen levels, particularly during pregnancy.

Thyroid disorders are the second most common endocrinologic disorder found in pregnancy. Overt hypothyroidism is estimated to occur in 0.3–0.5% of pregnancies. Subclinical hypothyroidism appears to occur in 2–3%, and hyperthyroidism is present in 0.1–0.4%.

Autoimmune thyroid dysfunctions remain a common cause of both hyperthyroidism and hypothyroidism in pregnant women. Graves disease accounts for more than 85% of all cases of hyperthyroid, whereas Hashimoto thyroiditis is the most common cause of hypothyroidism.

Postpartum thyroiditis (PPT) reportedly affects 4–10% of women. PPT is an autoimmune thyroid disease that occurs during the first year after delivery. Women with PPT present with transient thyrotoxicosis, hypothyroidism, or transient thyrotoxicosis followed by hypothyroidism. This presentation may be unrecognized, but is important because it predisposes the woman to develop permanent hypothyroidism.

Of interest, symptoms of autoimmune thyroid diseases tend to improve during pregnancy. A postpartum exacerbation is not uncommon and perhaps occurs because of an alteration in the maternal immune system during pregnancy. The improvement in thyroid autoimmune diseases is thought to be due to the altered immune status in pregnancy.

Table 1.1 World Health Organization Guidelines/Information for contraceptive use in adolescent girls

Contraceptive typeWHO categoryAdditional WHO recommendations/informationBarrier methods CondomsDiaphragmCervical capSponge1Women with conditions that make pregnancy an unacceptable risk should be advised that barrier methods for pregnancy prevention may not be appropriate for those who cannot use them consistently and correctly because of their relatively higher typical-use failure ratesCombined estrogen-progestin1 (no restrictions for women up to the age of 40 years)WHO guidelines specifically state “theoretical concerns about the use of combined hormonal contraceptives among young adolescents have not been substantiated”Depot medroxyprogesterone acetate2The advantages of using the method generally outweigh the theoretical or proven risks of the method, for up to 17 years of age However, for women ages 18–45 years, this is a WHO category 1 (no restrictions) contraceptiveOther progestin-only hormonal Progestin-only pillsEtonogestrel implant1Although it should be considered as a safe and highly effective method for this age group, more research is nevertheless needed on the use of the etonogestrel inplant in adolescentsIntrauterine device2WHO does state that there is concern about expulsion and increased risk of sexually transmitted infections in nulliparous and younger women, respectively However, the advantages of using the method generally outweigh the theoretical or proven risks of the method) for use in women younger than 20 years of age

Endometriosis

Endometriosis occurs in roughly 5–10% of women of reproductive age. Endometriosis in postmenopausal women is rare. Symptoms vary depending on where the cells implant outside the uterine cavity, but its main symptom is pelvic pain. Some women will have little or no pain despite having extensive endometriosis affecting large areas, or having endometriosis with scarring. On the other hand, women may have severe pain even though they have only a few small areas of endometriosis.

Endometriosis is commonly found in women with infertility. The link between infertility and endometriosis is still not fully understood. However, as the complications of endometriosis include internal scarring, adhesions, and cysts, it is believed that infertility is related to the scar formation and other anatomical distortions caused by endometriosis. It also has been postulated that endometriosis interferes with fertility by releasing cytokines and other chemical agents that interfere with reproduction.

A thorough history and a physical examination can lead to a suspected diagnosis of endometriosis in many patients. However, further tests are needed to confirm the diagnosis. The two most common imaging tests are ultrasonography and magnetic resonance imaging (MRI). Normal results on these tests do not eliminate the possibility of endometriosis—areas of endometriosis are often too small to be seen by these tests.

Laparoscopy is the only way to confirm a suspected endometriosis diagnosis. The diagnosis is based on the characteristic appearance of extrauterine growth and, if necessary, a tissue biopsy. Laparoscopy also allows for surgical treatment of endometriosis. Fig.1.3 shows the potential management options for endometriosis following laparoscopy.

In women of reproductive age, the goal of management is to provide pain relief, to restrict progression of the process, and to relieve infertility, if needed. In younger women, surgical treatment tends to be conservative, with the goal of removing endometrial tissue and preserving the ovaries without damaging normal tissue. In women who do not want to preserve their reproductive potential, hysterectomy and/or removal of the ovaries may be an option. A hysterectomy, however, will not guarantee that the endometriosis and/or the symptoms of endometriosis will not come back. Indeed, surgery may induce adhesions, which can lead to further complications.

Uterine Leiomyomas

Uterine leiomyomas, or fibroids, are common, benign, smooth muscle tumors of the uterus. They are found in nearly half of women over the age of 40 years. Fibroids tend to grow under the influence of estrogen, and regress when the estrogen levels are reduced. Thus, after the onset of menopause, fibroids generally regress.

Most women with uterine fibroids have no symptoms, but some do. Symptoms that might be experienced include:

heavy menstrual flowsbleeding between periodspaininfertilitypelvic pressurestress urinary incontinenceureteral obstruction

In women with fibroids, the uterus is irregularly enlarged and usually somewhat asymmetrical. It may be tender and, unlike the soft uterus containing a pregnancy, the fibroid uterus is very firm.

The diagnosis is usually based on the clinical findings of an enlarged, irregularly shaped, firm uterus that may or may not be tender. Sometimes, the diagnosis is unclear and diagnostic tests are used to delineate the fibroids and rule out other problems. These include:

ultrasonographyMRI and computed tomographic scanning

Because fibroids often regress after menopause, in most cases no treatment is necessary. Fibroids often regress at menopause. Thus, the conservative approach is to measure and observe fibroids over time. For women with significant symptoms or very large or rapidly growing fibroids, a number of treatments can be considered.

Hysterectomy is the only permanent cure for fibroids. It provides definitive treatment, but requires major abdominal, vaginal, or laparoscopic surgery. For women who wish to preserve their childbearing capacity, removal of just the fibroids (myomectomy), with conservation of the rest of the uterus, is an option to be considered. Unfortunately, myomectomy is often a more complicated procedure than hysterectomy, involving a longer recovery period and an increased risk of needing a blood transfusion or developing an infection.

Good results have been reported with embolization in a limited number of cases. This procedure involves threading a catheter through the uterine arteries and injecting a bolus of tiny plastic pellets, which lodge in the small arterioles leading to the fibroids, reducing their blood flow and causing necrosis. Serious complications have been associated with this procedure, however, leading to emergency surgery and life-threatening problems. Whether this approach will prove to be widely accepted remains to be seen.

Fig. 1.3 Management scheme for cases of endometriosis positively identified via laparoscopic visualization. GnRH, gonadotropin-releasing hormone; IVF, in vitro fertilization; GIFT, gamete intrafallopian transfer. Modified with permission from Johnson N. Laparoscopic treatment of endometriosis In: Adamson GD, Martin DC, eds Endoscopic management of Gynecologic Disease Philadelphia, Pa: Lippincott-Raven; 1996:147–187

In some cases, progestins may be useful in controlling the aberrant growth of uterine cells until the patient reaches menopause, at which time the fibroids usually resolve on their own. Substances that suppress the release of gonadotropins have been shown to actually shrink fibroids. However, they can only be given for short periods, after which the fibroids rapidly regrow. On the other hand, this method may be useful for reducing the size of fibroids in women who require surgery. Important factors in deciding which therapy to administer are the severity of the symptoms, associated symptoms, age, and whether there is a need to preserve fertility.

Mental Health Issues

Mental illnesses affect women and men differently—some disorders, such as depression, are more common in women. Some express themselves with different symptoms in women compared to men.

Research is only just beginning to tease apart the contributions of various biological and psychosocial factors to mental health and mental illness in both women and men. In addition, researchers are currently studying the special problems of treatment for serious mental illness during pregnancy and the postpartum period.

Depression

Major depression is the leading cause of disease burden among females aged 5 years and older worldwide, and it affects females at twice the rate of men (12% women and 6% men). The reasons for this disparity are still unclear, but it is believed to be due to a number of factors, including the multiple roles women must assume at home and work, poverty, their increased risk for violence and abuse, the stress of raising children alone (single-mothers), and postpartum depression.

There is a direct correlation for this increased risk of depression and a higher rate for suicide ideation among women compared with men. Although men are more likely to die from a suicide attempt, a higher rate of women attempt suicide compared with men. Girls are more vulnerable to depression during periods of transition such as entering puberty or changing schools, and family changes, such as separation and divorce.

Clinical depression affects twice as many women as men, both in the United States and in many societies around the world. It is estimated that one out of every seven women will suffer from depression in their lifetime. Additionally, women experience higher rates of seasonal affective disorder and dysthymia (chronic depression). Although the rates of bipolar disorder (manic depression) are similar in men and women, women have higher rates of the depressed phase of manic depression and rapid-cycling bipolar disorder.

The gender gap in depression is most evident during the female reproductive years. Some women experience behavior and mood changes premenstrually. As many as 10–15% experience a clinical depression during pregnancy or after the birth of a baby (i.e., postpartum depression).

Postpartum depression, which is major episode of depression occurring within 4 weeks of delivering a baby, strikes one to two of 10 pregnant women. Scientists believe that hormonal changes involved in childbirth combined with psyschosocial stresses combine to make women particularly vulnerable to depression during this time.

Symptoms of postpartum depression include anxiety, a worsening mood in the evening, irritability, phobias, feelings of inadequacy, inability to cope, not feeling loving or caring enough for the baby, and excessive worry about the wellbeing of the baby.

Anxiety Disorders

Women also outnumber men in rates of anxiety and panic disorders, except for obsessive compulsive disorder (OCD) and social phobias. Female risk of post traumatic stress disorder (PTSD) following trauma is twice that of the male. The impact of these disorders is enormous. The economic cost, for example, of anxiety disorders in the United States has been estimated at $47 billion per annum. Fortunately, anxiety disorders are highly treatable conditions for the majority of sufferers.

There are also many medications, both prescription and over the counter, that can precipitate anxiety. The patient's nutrition should also be considered. Look carefully at the amount of caffeine in coffee, soda, diet soda, chocolate, and some aspirin preparations (e.g., Excedrin) likely to be circulating in her system. Even small amounts of caffeine in some at-risk individuals can precipitate or exaggerate anxiety.

Eating disorders are a type of anxiety disorder, and research has shown that anxiety caused by social and cultural factors contribute to the increasing prevalence of dieting and eating disorders in this group. However, there really is no single cause for an eating disorder. Anyone can have an eating disorder, though they most often affect girls and women. Eating disorders such as anorexia nervosa and bulimia are prevalent in up to 10% of adolescent girls.

Most girls who develop anorexia do so between the ages of 11 and 14 years (although it can start as early as age 7), and there are many reasons why. Some kids just don't feel good about themselves on the inside and this makes them try to change the outside. They might be depressed or stressed about things and feel as though they have no control over their lives. They see what they eat (or don't eat) as something that they can control.

Sometimes girls involved in certain sports, like ballet, gymnastics, and ice-skating, might feel they need to be thin to compete. Girls who model also might be more likely to develop an eating disorder. All of these girls know their bodies are being watched closely, and they may develop an eating disorder in an attempt to make their bodies more “perfect.”

Eating disorders also may run in families. Therefore, if someone in a girl's family has an eating disorder, she might be at risk for developing one too. A girl may be more likely to develop an eating disorder if a parent is overly concerned with appearance, or if the parent isn't comfortable with his or her own body.

The person with an eating disorder may need to see a dietitian and a counselor or therapist in addition to her doctor. Together, the team can help the person achieve the goals of reaching a healthy weight, following a nutritious diet, and feeling good about herself again. Chapter 25 contains a detailed discussion about treatment approaches for depression and other psychiatric disorders during pregnancy.

Nutrition

Women are more likely to suffer from a variety of nutritional deficiencies than are men, for reasons including women's reproductive biology, low social status, poverty, and lack of education. Adequate nutrition, a fundamental cornerstone of any individual's health, is especially critical for women because inadequate nutrition wreaks havoc not only on their own health, but also on the health of their children. Children of malnourished women are more likely to face cognitive impairments, short stature, lower resistance to infections, and a higher risk of disease and death throughout their lives (Fig.1.4).

After pregnancy, women's energy requirements remain high, especially when they are breast-feeding. Women require approximately 50% more calories while breast-feeding than they need during pregnancy. Maintaining adequate levels of vitamin A is particularly important for nursing mothers, since vitamin A is passed on to the infant through breast milk and can help reduce the risk of maternal and infant illness and death. Nursing mothers should receive supplements of vitamin A, if necessary.

Menopause

Menopause is a natural process that happens to every woman as she grows older. Although it is not a medical problem, disease, or illness, many women have a difficult time adjusting to it because of the changes in hormone levels. The changes leading up to menopause happen over several years. The average age for menopause is 52 years. But menopause commonly happens anytime between the ages of 42 and 56 years. A woman can say she has begun her menopause when she has not had a period for a full year.

Fig. 1.4 The potential consequences of poor nutrition for pregnant women and their offspring.

There are many possible signs of menopause, and each woman feels them differently. Most women have no or few menopausal symptoms, while some women have many moderate or severe symptoms. Research has shown that women's experience of menopause can be related to many things, including genetics, diet, life style, and social and cultural attitudes toward older women.

The clearest signs of the start of menopause are irregular periods (when periods come closer together or further apart), and when blood flow becomes lighter or heavier. There may be other physical and mental changes such as vasomotor hot flushes and vaginal symptoms. The physical and psychological symptoms related to menopause are detailed in Chapter 44.

Death rates for menopausal women have declined dramatically during the past several decades. Although previously, the leading cause of death for women was heart disease, cancer is now the major cause, and heart disease is the leading cause of death in women 65 years of age and older. The decline in heart-related mortality is attributed to changes in life style including smoking cessation, exercise, lowering of cholesterol levels, and controlling hypertensive disorders.

Breast Cancer and Hormone Replacement Therapy

Women 65 years or older account for about half of all new breast cancer cases, and the chances of developing the disease increase with age. About 70% of women diagnosed with breast cancer each year are over age 50 years, and almost half are age 65 and older. Other risk factors include:

previous cancer in one breastlate menopause (after age 55)starting menstruation early in life (before age 12)having a first child after age 30never having had childrenhaving used hormone replacement therapy

Besides age, hormone replacement therapy (HRT) has been found to significantly contribute to the risk of breast cancer. HRT often is given to postmenopausal women who have severe symptoms.

However, evidence suggests that the longer a woman is exposed to female hormones (either made by the body, taken as a drug, or delivered by a patch), the more likely she is to develop breast cancer. Thus, the longer a woman is on HRT, the greater her chances may be of being diagnosed with breast cancer.

In 2002, the Women's Health Initiative study revealed an increase in breast cancer, heart attacks, and stroke in older women given conventional HRT. This resulted in a significant decline in HRT prescriptions.

HRT is particularly contraindicated in women who have already been diagnosed with the disease. A recent large-scale clinical trial conducted in Sweden** found that breast cancer survivors who took HRT to relieve menopausal symptoms had more than three times as many breast cancer recurrences as survivors who did not take HRT. Results from a longer period of follow-up confirmed the link between HRT and an increased risk of breast cancer recurrence.

The United States Food and Drug Administration has since recommended that women discuss with their doctors whether the benefits of taking estrogen and progestin outweigh the risks. The FDA added that, if used, the hormones should be taken “at the lowest doses for the shortest duration to reach treatment goals.”

It is particularly important for all menopausal women to get regular mammograms because menopause has effects on breast tissue that are greater than the effects of age. In order to prevent breast cancer, most menopausal women receive mammograms every year, as recommended by their doctors.

HRT not only increases a woman's risk of developing breast cancer, but also it makes detection of any breast cancer harder, should it occur. It has been demonstrated that use of postmenopausal HRT increases breast density (Fig.1.5). Thus, benign mammographic findings, primarily cysts, in women undergoing HRT result in an increased use of diagnostic mammography and sonography.

** Holmberg L, Anderson H; HABITS steering and data monitoring committees. HABITS (hormonal replacement therapy after breast cancer--is it safe?), a randomised omparison: trial stopped. Lancet. 2004 Feb 7;363(9407):453-5.

Fig. 1.5 a, b A woman's mammogram before (a) and after 2 years of hormone replacement therapy (b) showing much denser breast tissue after therapy From: Hashimoto B, Bauermeister D Breast Imaging: A Correlative Atlas New York: Thieme; 2003

Heart Disease

Before menopause, women have less risk of cardiovascular disease (CVD) than do men. However, as women age, their risk of heart disease and stroke begins to rise. CVD is the most common cause of death in postmenopausal women. Owing to a greater female life expectancy, women who develop CVD tend to be older or elderly, and are therefore more likely to suffer from co-morbidities such as diabetes and hypertension.

It is beyond the scope of this chapter to discuss the management approach to CVD in postmenopausal women. This would typically be done in conjunction with a cardiologist. However, disease prevention, pharmacotherapy, percutaneous intervention, surgical revascularization, and cardiac rehabilitation are all viable approaches, depending on the condition of the patient.

Urinary Incontinence

Some women develop bladder control problems, or urinary incontinence, after menopause. Urinary incontinence can be slightly bothersome or totally debilitating. Incontinent women may lose a few drops of urine while exercising. Others may feel a strong, sudden urge to urinate just before losing a large amount of urine. Many women experience both symptoms. For some women, the risk of public embarrassment keeps them from enjoying many activities with their family and friends. Urine loss can also occur during sexual activity and cause tremendous emotional distress. Fig.1.6 presents a management scheme for urinary incontinence, depending on whether it is the result of stress or urge symptoms.

Osteoporosis

During menopause, estrogen levels in a woman's body drop rapidly, significantly impacting bone health. Estrogen keeps the osteoclasts in check, allowing the osteoblasts to build more bone. Unless the estrogen that is lost is being replaced, a woman's bones can become thin and brittle quite rapidly. This condition is known as osteoporosis.

The definitive method for diagnosing osteoporosis is a bone density scan. Bone density is measured on a point scale, called a T-score. Normal bone density has a T-score of 0 to 1. If a woman's T score is between 1 and 2.5, she has a high likelihood of being diagnosed with osteopenia, a milder form of osteoporosis. If her T-score is less than 2.5, osteoporosis is diagnosed.

Osteoporosis treatment can be quite effective, especially when taken quickly after diagnosis. A variety of new treatments for osteoporosis have also been introduced into the market. Fig.1.7presents a scheme for the optimal management of osteoporosis, which depends on whether or not a fragility fracture is diagnosed.

Fig. 1.6 Management scheme for urinary incontinence symptoms Adapted with permission from O'Neil B, Gilmour D Approach to Urinary Incontinence in Women Diagnosis and Management by Family Physicians Can Fam Physician 2003; 49:611–618

Fig. 1.7 Nonpharmacological versus pharmacological management of osteoporosis based on differential diagnosis. HRT, hormone replacement therapy.

Key Points

OB/GYN care includes the entire spectrum of a woman's life and life style, not just pregnancy and childbirth.There is an ongoing controversy about whether young girls should be vaccinated against the human papilloma virus Physicians need to be aware of these controversies and discuss them in a frank and open manner with parents of young girls.OB/GYN physicians should anticipate that overweight girls are more likely to show signs of early puberty, and take obesity and racial status into account when deciding how to manage early-maturing girls.Clinicians caring for young women must be able to recognize and help them reduce any risk-taking and other unhealthy behaviors, such as smoking or unprotected sexual intercourse, and discuss contraceptives when appropriate to protect them from unplanned pregnancy.OB/GYN physicians should be aware and alert to a number of endocrine and autoimmune disorders, such as thyroid disease, that are more common to pregnancy.OB/GYN physicians should be well-versed in the conservative management of uterine fibroids, which often grow rapidly during pregnancy but regress following delivery After the onset of menopause, fibroids generally regress as well.Postpartum depression strikes 1–2 out of 10 pregnant women OB/GYN physicians need to be keenly aware of the symptoms of postpartum depression and take immediate steps to prevent unnecessary risk to the mother and her newborn baby.Adequate nutrition is especially critical for pregnant women because inadequate nutrition wreaks havoc not only on their own health, but also on the health of their babies.Although menopause is not considered a classic medical problem, disease, or illness, OB/GYN physicians should be aware that many women have a difficult time adjusting to it because of the changes in hormone levels.Hormone replacement therapy presents a serious breast cancer risk, and such risks must be discussed with a patient in great detail before she considers whether to use it to address serious menopausal symptoms.Heart disease and urinary incontinence are two conditions that are exacerbated in menopausal women OB/GYN physicians need to be aware of this increased risk and competent to take appropriate management steps, which have been clearly established.

Further Reading

Holmberg L, Iversen OE, Rudenstam CM, et al; HABITS Study Group. Increased risk of recurrence after hormone replacement therapy in breast cancer survivors. J Natl Cancer Inst 2008;100(7):475–482

Holmberg L, Anderson H; HABITS steering and data monitoring committees. HABITS (hormonal replacement therapy after breast cancer—is it safe?), a randomised comparison: trial stopped. Lancet 2004;363(9407):453–455

Menopause and Hormones. Available at: http://www.fda.gov/ womens/menopause/pdfFiles/FSeng.pdf. Accessed October 31, 2009.

Rossouw JE, Anderson GL, Prentice RL, et al; Writing Group for the Women's Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women's Health Initiative randomized controlled trial. JAMA 2002;288(3):321–333

2 OB/GYN Examinations and Evaluations

Avi Harlev, Eyal Sheiner, and Arnon Wiznitzer

Achieving the right diagnosis and suggesting the proper treatment is a process that is greatly dependent upon the confidence the patient has in her caregiver. This process begins with an open, patient—physician dialogue, in which the patient feels comfortable relaying all relevant medical information to enable her physician to make the best medical decision.

Since intimate details are to be discussed, a private and quiet environment is required to allow the patient to relax and not only share enough details for her physician to understand her medical condition, but also voice her concerns and expectations. After a thorough medical history is taken, the next steps involve a physical examination as well as the appropriate imaging procedures and laboratory tests, depending on the setting (i.e., ambulatory care, outpatient, or in-patient hospitalization).

In addition to the history, this chapter focuses primarily on the gynecologic physical examination. Complete examination of the breast, abdomen, and pelvis are the core, vital elements of the gynecologic examination. The remainder of the examination depends upon the patient's specific symptoms and complaints. For example, a thyroid gland examination should be performed for infertile women or women with menstrual disorders. Additionally, patients using hormonal therapy should be examined for any hypercoagulability event, such as deep vein thrombosis (DVT). Thus, the examining physician must be flexible about the questionnaires and specific tests that will be administered, and stay attuned to the patient's specific verbal and other cues in order to guide this process.

Definitions

Ascites: This is an accumulation of fluid in the peritoneal cavity. Although most commonly due to cirrhosis and severe liver disease, its presence can portend other significant medical problems. Diagnosis of the cause is usually with blood tests, an ultrasound scan of the abdomen and direct removal of the fluid by needle or paracentesis (which may also be therapeutic). Treatment may be with medication (diuretics), paracentesis, or other treatments directed at the cause.

Auscultation: This is a technical term for listening to the internal sounds of the body, usually using a stethoscope. Based on the Latin verb auscultare “to listen,” auscultation is performed for the purposes of examining the circulatory system and respiratory system (heart sounds and breath sounds), as well as the gastrointestinal system (bowel sounds).

Ectopic pregnancy: This is a complication of pregnancy, in which the fertilized ovum is implanted in any tissue other than the uterine wall. Most ectopic pregnancies occur in the fallopian tube (so-called tubal pregnancies), but implantation can also occur in the cervix, ovaries, and abdomen.

Endometriosis: