Obstetrics and Gynecology (eBook)

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...