Obstetricians & Gynecologists--women's health care physicians

Last year the American College of Obstetricians and Gynecologists (ACOG) celebrated its 50th anniversary as a specialty society. ACOG's fellowship has increased from 12,400 members in 1975 to 40,800 in 2000. OB/GYN remains an attractive career choice for approximately 6% of graduating US medical students, offering a mix of medicine, surgery, primary care, and obstetrics. It is a particularly popular field among female medical students; for the academic year 2000-2001, 69.6% of all OB/GYN resident positions were filled by women. Hopefully male students will not be discouraged; a 2001 Gallup poll reported that just under half (47%) of women surveyed said they prefer a female OB/GYN, while 15% preferred a male, and 37% had no preference.1 As one might expect, the results varied by age group with the younger women more likely to prefer a female provider.

Like most fields of medicine, Obstetrics and Gynecology has benefited greatly from the technical advances of the past few decades. Physicians practicing in the 1960s and 70s can recall the excitement that accompanied the introduction of the oral contraceptive and Rh immune globulin. The former empowered young women to safely and effectively control their reproductive futures. The latter eliminated Rh sensitization, allowing Rh-negative women the opportunity to conceive again without fear of a tragic intrauterine or newborn death. Yet, as significant as these events were, they are now taken for granted - overshadowed by increasingly sophisticated technical and scientific achievements.

Obstetrics and Gynecology has three formally recognized subspecialty areas. Maternal-Fetal Medicine (MFM) specialists provide care to the highest risk pregnant women. Prenatal genetic diagnosis (by chorionic villous sampling or amniocentesis), new screening tests for neural tube defects and trisomy 21, and advances in ultrasound imaging are just a few of the tools available to assist couples in having the healthiest possible babies. These advances in the management of high risk pregnancies, combined with the advances in neonatal care, have resulted in dramatic increases in the survival and subsequent normal development of infants born prematurely. Intrauterine transfusions and fetal surgery are also realities (see Medicine ea& Health/Rhode Island, May 2001 issue for more in depth discussions on the intrauterine diagnosis and management of several fetal conditions).

The subspecialty of Reproductive Endocrinology and Infertility (REI) has received a great deal of visibility and generated considerable controversy during the past decades. Beginning in 1978 with the birth of Louise Brown, the first "test tube baby," reproductive specialists and medical ethicists have had to deal with increasingly sophisticated methods of assisted reproductive technology (ART) - e.g., in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), and intracytoplasmic sperm injection (ICSI). Most recently the potential for human cloning has taken center stage in the reproductive technology arena; reproductive specialists, politicians, ethicists, and theologians are all concerned about the implications of cloning research.

Gynecologic Oncologists, like medical and surgical oncologists, are continually finding new ways to screen, diagnose, and treat pre-malignant and malignant disease. Research in the field of tumor markers holds the promise of detecting cancers at very early, asymptomatic stages. Interdisciplinary strategies and new approaches such as sentinel node biopsy have resulted in integrated therapy and less radical surgery.

Urogynecology, which will likely achieve formal subspecialty status in the next few years, is finding new ways - both surgical and non-surgical - to treat women who suffer from the embarrassment and discomfort of incontinence. Urethral injections for sphincter deficiency can now be performed under local anesthesia, and preliminary reports indicate that a new surgical procedure using tension-free vaginal tape may be as effective as current retropubic approaches.

During the past decade, while the subspecialists have captured the technological limelight, general obstetricians and gynecologists have increasingly been called upon to serve as primary care physicians for women, a designation which approximately half of eligible OB/GYNs in Rhode Island have accepted. Data from the 1989 and 1990 National Ambulatory Medical Care Surveys revealed that obstetrician-- gynecologists provided more office-- based, general medical examinations to women 15 years and older than did general-family practitioners and internists combined.2 By 1995 more than half of US women surveyed viewed their obstetrician-gynecologist as their primary care physician.3 It is noteworthy that these statistics pre-dated the increased time and emphasis placed on primary care by the OB/GYN residency programs; thus it is likely that the current level of primary care provided by OB/GYN physicians is considerably higher than these reports indicate.

Recognizing that the target audience for Medicine & Health/Rhode Island is the Rhode Island Medical Society's general membership, encompassing all fields and specialties, the manuscripts selected for this issue describe current approaches for four of the more common health issues facing women today. Dr. Kacmar's article succinctly describes new contraceptive options. After decades of very little innovation in the field of contraception aside from altering hormone concentrations - several new delivery systems have recently been approved, including the patch and the intravaginal ring.

Perhaps one of the most frustrating diagnostic and therapeutic dilemmas facing both women and their physicians is chronic pelvic pain (CPP). As many as 1 in 7 adult women may suffer from CPP, accounting for 10% of all outpatient gynecology visits. As Dr. Fox points out, many of these women will have endured their pain for months or years, and many will have been seen by one or more doctors for their problem. Dr. Fox's article presents a practical approach to the diagnosis and management of this common, yet frequently unrecognized condition.

The recognition of insulin resistance as a risk factor for coronary artery disease and type 2 diabetes mellitus has important public health implications. Recently a strong association between polycystic ovarian syndrome (PCOS) and insulin resistance has become apparent. Since PCOS affects approximately 5% of reproductive age women, primary care providers and others who provide care to women in this age group will find Dr. Plosker's article helpful and informative.

Dr. Frishman's article emphasizes the importance of preconceptional counseling. Women who are contemplating pregnancy should maximize their chances for a healthy outcome by seeking medical advice prior to conception. Aside from the obvious benefit - the ability to diagnose and treat potentially harmful conditions -- preconceptional counseling can identify inheritable and environmental factors, as well as personal behaviors such as diet, exercise, and the use of medications, which can have a profound effect on embryonic and early fetal development. Primary care providers should remind sexually active women of childbearing age that waiting to alter harmful behaviors like smoking and alcohol use until the pregnancy is confirmed (usually after a missed period and/or a positive pregnancy test) will not prevent very early embryonic exposure.

Finally, it is important to acknowledge the ongoing debate over the risks and benefits of hormone replacement therapy (HRT). In the weeks following the National Institutes of Health's announcement that it was halting the arm of the Women's Health Initiative (VMI) study evaluating combined estrogen and progestin use in postmenopausal women, the offices of ACOG were flooded with calls from physicians, patients, and journalists. Women are understandably confused. An in-depth analysis of the WHI study is beyond the scope of this article. However, providers who counsel and treat postmenopausal women should read the report and avail themselves of additional resources (Table 1). Each patient should be evaluated individually, taking into account her family and personal health history, as well as her reason for taking HRT. Is she taking it to prevent heart disease, osteoporosis, or acute menopausal symptoms? For some women, HRT will continue to be appropriate, particularly for short term use. Others - e.g. those at risk for cardiovascular disease - may wish to consider the use of statin drugs and/ or lifestyle changes (exercise and smoking cessation). Women who discontinue HRT should probably do so slowly over time, perhaps three to six months, to avoid sudden recurrence of symptoms.

The future of Obstetrics and Gynecology offers tremendous opportunities for both researchers and clinicians. Despite decades of research, some fundamental questions remain unanswered, e.g. what initiates labor? The link between preterm labor and the mechanisms that underlie it will continue to be a major focus of research in the field. New HPV vaccines will likely reduce the incidence of early cervical cancer. As the Human Genome project nears completion and we discover a genetic basis for more and more diseases, the implications of genetic research will be particularly important to obstetricians, placing them in the forefront of preventive medicine. It has been said that gene technology will be the new scalpel. In addition to biochemical advances obtained through pharmaceutical research, the 21st century will undoubtedly witness the development of diagnostic equipment and surgical techniques beyond our current imagination. Obstetrician-gynecologists, as women's health care physicians, will continue to strive to see that the women they serve reap the benefits of this research and technology.

REFERENCES

1. American College of Obstetricians and Gynecologists. Ob-gyns get high marks in survey of US women. ACOG Today Washington, DC: American College of Obstetricians and Gynecologists, July, 2001.

2. Leader S, Perales PJ. Provision of primary-preventive health care services by obstetrician-gynecologists. Obstet Gynecol 1995;85:391-5.

3. Hale RW. Obstetrician/gynecologists: primary care physicians for women. Prim Care Update Ob/Gyns 1995;2:67-- 70.

Patrick J. Sweeney, MD, MPH, PhD

Patrick J. Sweeney, MD, MPH, PhD, is Director of Ambulatory Care, Women & Infants Hospital, and Professor of Obstetrics & Gynecology, Brown Medical School.

CORRESPONDENCE:

Patrick J. Sweeney, MD, MPH, PhD

Women & Infants Hospital

101 Dudley Street

Providence, RI 02905

phone: (401) 274-1122, x2721

fax: (401) 453-7684

e-mail: PSweeney@wihri.org

Copyright Rhode Island Medical Society Jan 2003
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