Women who undergo total abdominal hysterectomy with bilateral salpingo-oophorectomy surgeries lose most of their ability to produce the hormones estrogen and progesterone, and lose about half of their ability to produce testosterone. Although removal of the ovaries is often referred to as surgical menopause it is an incorrect term. A menopausal woman has intact functional female organs, a woman who has been hysterectomized and castrated does not. In natural menopause, the ovaries generally continue to produce low levels of hormones, while in surgical menopause, the ovaries are absent and those low levels of hormones are absent. The uterus is a hormone responsive sex organ that supports the bladder and bowel. When only the uterus is removed women are at three times greater risk of cardiovasular disease–removal of the uterus often interferes with blood flow to the ovaries, so women who undergo hysterectomy experience menopausal symptoms an average of 3.7 years sooner than the average age of natural menopause. When the ovaries are removed a woman is at a seven times great risk of cardiovascular disease. As in the case of other glands, ovarian hormones cannot be replaced and substitute hormones cannot replicate the functions of the ovary. The ovaries produce dozens of hormones a woman needs throughout her entire life,, released directly into the blood stream in a continuous fashion, in response to and as part of the complex endocrine system.

In women, a tubal ligation can be done in many forms, through a vaginal approach, through laparoscopy, a minilaparotomy (“minilap”), or through a regular laparotomy. Also, a distinction is made between postpartum tubal ligation and interval tubal ligation, the latter not being done after a recent delivery. There are a variety of tubal ligation techniques; the most noteworthy are the Pomeroy type that was described by Ralph Pomeroy in 1930, the Falope ring that can easily be applied via laparoscopy, and tubal cauterization done usually via laparoscopy. In addition, a bilateral salpingectomy is effective as a tubal ligation procedure. A tubal ligation can be performed as a secondary procedure when a laparatomy is done, i.e. a cesarean section. Any of these procedures may be sometimes referred to as having one’s “tubes tied.”

Less commonly used is the Essure procedure, developed in 2002, of occluding the fallopian tubes by the scarring effects of desposited pellets inserted by a catheter passed through the cervix and womb.

Reversal

Generally tubal ligation procedures are done with the intention to be permanent, and most patients are satisfied with their sterilizations. However, some types of procedure can be reversed with surgery, notably those that leave a sizable amount of tubal tissue in place, i.e. the Pomeroy type of tubal ligation or the Falope ring application. In contrast, tubal ligation with the use of cautery, or a salpingectomy are generally poor or no candidates for reversal. However, in vitro fertilization can overcome fertility problems in patients with tubal occlusion due to any type of tubal ligation.

Examination

It is typically a consultant specialty. In most countries women must see a general practitioner (GP; also known as a family practitioner (FP)) first. If their condition requires knowledge or equipment unavailable to the GP they are referred to a gynaecologist. However in the United States law and many health insurance plans allow gynaecologists to provide primary care and some women select that option.

As in all of medicine the main tools of diagnosis are clinical history and examination. Gynaecological examination is special in that it is quite intimate and that it involves special equipment—the speculum. The speculum consists of two hinged blades of concave metal or plastic which are used to retract the tissues of the vagina and permit examination of the cervix the lower part of the uterus located within the upper portion of the vagina. Gynaecologists typically do a bimanual examination (one hand on the abdomen two fingers in the vagina) to palpate the cervix uterus ovaries and bony pelvis. It is not uncommon to do a rectovaginal exam for complete evaluation of the pelvis particularly if any suspicious masses are appreciated. Male gynaecologists often have a female chaperone (nurse or medical student) for their examination. An abdominal and/or vaginal ultrasound can be used to confirm any abnormalities appreciated with the bimanual examination or when indicated by the patient’s history.

Advisory

The Department of Plastic Surgery at the University of Virginia School of Medicine recommends that surgical devices such as gloves with dusting powders including talc should not be used during surgery because of acute and chronic problems that may occur if it finds its way into adominal cavity via the vagina. It also makes an analogy to condoms which have the very same dusting powders used on them.[1]

Investigations

Some of the investigations used in gynaecology are:

1. Abdominal ultrasound to give a low-power view of the pelvic organs.
2. Vaginal ultrasound. An ultrasound probe is passed into the vagina which allows a more detailed view of the cervix ovaries and uterus and its contents (such as a fetus polyp fibroid endometrium or collection of fluid).
3. Blood tests. Levels of hormones such as estradiol luteinizing hormone follicle stimulating hormone and progesterone are measured as well as prolactin. Thyroid function may be analyzed. Routine blood tests for sexually transmitted diseases (STDs) such as HIV syphilis and hepatitis are also done by the gynecologist.
4. Vaginal swabs: samples collected for gonorrhea and chlamydia testing are performed this way. A wet prep may be performed in order to diagnose candidiasis or bacterial vaginosis.
5. Pap smear: Short for Papanicolau smear this test checks the cervix for abnormal changes in the cells called dysplasia caused by the Human Papilloma Virus (HPV) and may eventually lead to cervical cancer if left untreated. This term is often confused with the pelvic exam itself though a woman receiving a pelvic exam would usually only have a pap smear done if it was at her annual well-woman visit or another indicated interval.
6. Colposcopy: This procedure is the recommended followup for most abnormal results obtained from a Pap smear. This in-office procedure uses a binocular microscope to look at the vulva vagina and cervix with a coating of acetic acid which makes abnormal (pre-cancerous) cells show up white. A biopsy may be taken for further testing and in the case of an abnormal Pap smear. An endocervical currettage (ECC) is usually performed at the same time as the colposcopy.
7. Hysteroscopy: a small telescope is passed into the uterus using either direct visualization or aided by video. The telescope may be flexible or rigid. If the procedure is done in the office the patient may have the discomfort alleviated via local anesthesia administered to the cervix and uterus. If the hysteroscopy is performed as part of a series or of a larger procedure regional or general anaesthia would likely be administered and the patient would be in an operating room.
8. Laparoscopy: A small telescope and instruments are passed into the peritoneal cavity which is then insufflated with carbon dioxide. This is commonly used to diagnose endometriosis though increasingly procedures traditionally done through an abdominal incision are being accomplished entirely laparoscopically—including hysterectomy.
9. Magnetic resonance imaging (MRI) and computed axial tomography (CAT) scans are rarely used. They can be helpful in tumor staging in gynecological cancer and diagnosis of uterine malformation.
10. Pelvic X-ray is rare. It can be used to delineate the uterine cavity with an injected dye (hysterosalpingogram a frequent test ordered by fertility specialists) and to measure the pelvic girdle for assessment of a woman’s likelihood of successful vaginal delivery.

Diseases

The main conditions dealt with by a gynaecologist are:

1. Cancer of the reproductive organs including ovaries, fallopian tubes, uterus, vagina, and vulva
2. Incontinence of urine.
3. Amenorrhoea (absent menstrual periods)
4. Dysmenorrhoea (painful menstrual periods)
5. Infertility
6. Menorrhagia (heavy menstrual periods). This is a common indication for hysterectomy.
7. Prolapse of pelvic organs

Obviously there is some crossover in these areas. For example a woman with incontinence may be referred to a urologist.

Therapies

Occasionally gynaecologists will use drugs such as clomiphene (which stimulates ovulation) and most famously hormonal contraceptives (which are also used for dysmenorrhoea).

Surgery, however, is the mainstay of gynaecological therapy. For historical reasons gynaecologists are not usually considered “surgeons”—this has always been the source of some controversy—though modern advancements in both fields have blurred many of the once rigid lines of distinction. The rise of sub-specialties within gynaecology which are primarily surgical in nature (for example urogynaecology and gynecological oncology) have strengthened the reputations of gynaecologists as surgical practitioners and many surgeons and surgical societies have come to view gynaecologists as comrades of sorts. As proof of this changing attitude gynaecologists are now eligible for fellowship in both the American and Royal Colleges of Surgeons and many newer surgical textbooks include chapters on (at least basic) gynecological surgery.

Some of the more common operations that gynaecologists perform include:

1. Termination of pregnancy
2. Dilation and curettage (removal of the uterine contents for various reasons including miscarriage and menorrhagia; procedurally very similar to the above);
3. Hysterectomy (removal of the uterus);
4. Oophorectomy (removal of the ovaries);
5. Tubal ligation;
6. Exploratory laparoscopy or laparotomy (used to diagnose and treat sources of pelvic and abdominal pain dysmenorrhea vaginal bleeding etc.)
7. Colposuspension (“tightening” of the ligaments around the vagina a common therapy for incontinence and discomfort in older women);
8. Large Loop Excision of the Transition Zone (LLETZ) where the surface of the cervix containing pre-cancerous cells identified on Pap smear are removed).

In the last few years, medical malpractice suits and skyrocketing insurance premiums have forced many American obstetricians and gynaecologists to leave or limit their practice. Medical students are increasingly choosing not to specialize in obstetrics (see Bower 2003). This all adds up to fewer obstetricians in some states and fewer health care options for women, though it has led to higher average salaries, as an article by Medical Economics points out.