Chromosomes and the gynecologist.

Recent advances in cytogenetic techniques made a valuable contribution toward the modern practice of obstetrics and gynecology. The state of the art regarding the application of these techniques is reviewed in the following areas: the clinical features related to the various sex and autosomal chromosomal anomalies, the cytogenetics of gynecologic malignancies, the chromosomal analysis of spontaneous abortion and of parents with habitual abortions. Chromosome studies in male infertility revealed abnormalities in 11.5 per cent of 69 patients with azoospermia and 9.1 per cent of 165 patients with oligospermia. Among 77 patients with primary amenorrhea, 27.3 per cent revealed chromosomal abnormalities compared to 3.8 per cent in 103 patients with secondary amenorrhea. The term "ovotesticular dysgenesis" is used for the first time in the literature to describe a specific histologic type of streak gonad which contains ovarian stroma and dysgenetic testicular tubules.     

The gynecologist and breast disease.

Most gynecologists have accepted their role in reducing mortality from breast cancer as giving a thorough breast examination to all patients. They must also be involved in the interpretation and treatment of symptoms, the use of diagnostic aids, the recognition and understanding of pathology, and in following and counseling those who have been treated for cancer. Many of the surgical procedures are within their technical abilities. Specialty organizations and residency training programs must assist in bringing the gynecologists' educational level up to their degree of involvement.     

The gynecologist and breast disease.

The designation of the obstetrician-gynecologist as a principal physician for women may impose new responsibilities on them, but in reality it merely reaffirms what most obstetrician-gynecologists have long regarded as standard practice. The gynecologist has always insisted that breast examination is an integral part of the evaluation of every patient and the basic knowledge of breast disease is certainly as essential as any understanding of obstetric and gynecologic problems. The obstetrician-gynecologist should follow certain guidelines that will help achieve in making an early diagnosis. These include: Integrate breast examination into the routine gynecologic examination of all patients. Instruct patients in the technique of life-long, periodic breast self-examination. Develop proper ambulatory surgical facilities suitable for performing breast biopsies. Perform biopsy for all true, solid, three-dimensional masses. The final diagnosis of pathologic condition rests on a careful histologic examination of a biopsy specimen. Encourage research, both basic and clinical, and etiology, diagnosis and treatment of breast lesions including innovative screening programs for high risk patients. Include obstetric and gynecologic residency programs with specific instructions in early breast cancer detection techniques. Previously, breast cancer was viewed as a stereotype disease that progressed from the breast to the nodes to the systemic area. This has changed. Breast cancer is now viewed as a systemic disease, which spreads to local and distant sites at the same time. Breast cancer is best viewed as occultly metastatic at the time of presentation. Therefore, dissemination of tumor cells has occurred by the time of surgery in many patients, and it is not surprising that radical mastectomy and local irradiation do not prevent metastatic disease.     

Sexual violence and the obstetrician/gynecologist.

Sexual violence is a pathological entity that requires urgent attention. The gynecologist/obstetrician (G/O), as a medical professional in charge of women's health, especially as it pertains to women's reproductive organs, should become an active agent in the management of the sociomedical processes that constitute sexual violence. The results of a survey conducted in Mexico on the opinions and practices of G/Os regarding violence against women--especially sexual violence--are reported. It is necessary to sensitize and train G/Os and other physicians in bio-ethics, and to look for formal support of such activities in the legislative branch of government.     

Women and the gynecologist. Difficulties in comprehension

In the woman-gynaecologist relationship there is very often extreme difficulty, unease and incomprehension in that the request for help, and consequently the symptoms put forward, does not represent the real need. It is up to the gynecologist to decode the female code and understand the woman's request, by putting aside his personal point of view and his medical code. Otherwise a vicious circle is created which merely leads to disappointment and frustration on both sides. The main factors which impede a true and fruitful understanding between the woman and the gynecologist are described.     

Lawson Tait: the forgotten gynecologist.

The development of gynecology as a specialty, although primarily American in origin, was influenced in large degree by Robert Lawson Tait, a brilliant Scottish/English surgeon who practiced in the late 19th century. Tait, a self-proclaimed gynecologist, is perhaps most widely known as the first to perform salpingectomy to treat ruptured tubal pregnancy. He was also the first to record removal of an ovary for relief of pelvic pain and to induce menopause, perform salpingectomy for the treatment of tubal disease, and develop the technique of transverse transperineal repair of low rectovaginal fistulas. His scrupulous cleanliness was undoubtedly the forerunner of our modern aseptic methods. Tait's bold, innovative surgical techniques led to a significant decrease in surgical mortality, and his prescient, aggressive approach was at the forefront of changes in the practice of obstetrics, which resulted in a marked decrease in maternal morbidity and mortality. This master teacher, whose contributions inspired the next great generation of abdominal and pelvic surgeons, deserves greater recognition within our specialty.     

Inflammatory atypia on cervical smears. A diagnostic dilemma for the gynecologist

In light of the current controversy on the significance, follow-up and management of women with cervical smears showing "inflammatory atypia" (IA), a study was conducted to correlate the initial cytologic diagnosis of IA with the follow-up findings in colposcopically directed cervical biopsies and smears. From March 1988 through June 1989, 70 women had two consecutive smears reported as IA; all underwent colposcopy and cervical biopsy. In 58 patients (83%) the biopsies and smears obtained during colposcopy were negative for condyloma and/or cervical intraepithelial neoplasia (CIN). Ten patients (14%) had condylomas, and two (3%) had condylomas with CIN (one CIN I and one II). The initial IA smears from those 12 patients were reviewed retrospectively: 2 showed condylomas (they had been undercalled), 5 were "suggestive of condyloma" (the atypical cells were too few or poorly preserved for a definitive diagnosis), and 5 showed IA. None showed cytologic evidence of CIN, most probably because of sampling error. Our results suggest that colposcopy is warranted after two consecutive diagnoses of IA on cervical smears, considering that 17% of the patients in our study showed underlying intraepithelial lesions of the cervix.     

The oncologic patient and the gynecologist]

Affliction from cancer imposes heavy stress on the patient and her family, which raises important psychological problems. Adequate information, that is an adaptative strategy based on gradual explanation of the various steps of illness, can help the patient to accept it. Telling the simple truth is the best tool in the phase of prevention. In cancer management, too, information must respect the truth but it must also respect the patient's personality and the word "cancer" should be relieved of its terrible weight, leaving a window open to hope. The cancer patient must therefore be assisted by a team of experts in which the gynaecologist-oncologist has the fundamental role as coordinator.     

HIV infection. Managing exposure risks for the obstetrician/gynecologist

Human immunodeficiency virus infection in women is geographically widespread throughout the US. Infected blood is the single most important source for HIV transmission in the health care setting. Occupationally acquired HIV infection appears to be an uncommon event, with prospective studies thus far reporting an incidence of 0.6 per cent or less. Strategies for preventing transmission of HIV infection in an obstetric/gynecologic setting are a matter of appropriate barrier protection, good infection control technique, and a large measure of common sense.     

The role of the gynecologist in the diagnosis and management of breast disease.

As women depend on their gynecologist for advice regarding their reproductive organs, including the breasts, it is mandatory for the gynecologist to obtain extensive experience in diagnostic and management procedures of breast disease. Postgraduate teaching in breast disease should be integrated in the basic training schemes for all resident gynecologists/obstetricians. These teaching programs should include all aspects of diagnosis, management and follow-up of breast disease.     

The adolescent and the gynecologist: our experience

To evaluate adolescents' knowledge about sex, we conducted a study divided in two parts: 1) Distribution of a questionnaire; 2) Impromptu conversation with adolescents. The sample consisted of 205 questionnaires and 115 talks with students at a high school. The gathered data let us deduce that the relationship with parents was regarded as pleasant and good. As was expected the whole emotional sphere was related to friends. In order to understand which structures can help adolescents our data revealed that the mother holds first place, followed by the school and by friends. Sex education during adolescence should be carried out by other institutions so that a relationship free from conflicts can be established. In this way the figure of the expert takes shape--someone who can communicate within the structure of the school and the family and beyond--the limits of the information given by friends.     

The role of the gynecologist in first aid in cases of sexual violence. A protocol proposal

The aim of this report is to provide a medical form to use in case of sexual assault, prepared taking into consideration the information lacking at present in most medical reports on the subject. This call for the necessity to conform the medical approach to the same protocol which may also be used from the forensic medicine point of view. More precise information should be obtained about the assault and the injuries inflicted, and also an immediate psychological support should be given to the victim. This information will then serve as a guide to the medical staff.