Gynaecology

For the book by Mary Daly, see Gyn/Ecology.

Gynaecology
A dilating vaginal speculum, a tool for examining the vagina, in a model of the female reproductive system
SystemFemale reproductive system
Subdivisions
  • Oncology
  • Maternal medicine
  • Maternal-fetal medicine
Significant diseasesGynaecological cancers, infertility, dysmenorrhea
Significant testsLaparoscopy
SpecialistGynaecologist

Gynaecology or gynecology (see American and British English spelling differences) is the area of medicine concerned with conditions affecting the female reproductive system. It is often paired with the field of obstetrics, which focuses on pregnancy and childbirth, thereby forming the combined area of obstetrics and gynaecology (OB-GYN).[1]

Gynaecology encompasses both primary and preventative care of issues related to female reproduction and sexual health, such as the uterus, vagina, fallopian tubes, ovaries, and breasts; subspecialties include family planning; minimally invasive surgery; pediatric and adolescent gynecology; and pelvic medicine and reconstructive surgery.

While gynaecology has traditionally centered on women, it increasingly encompasses anyone with female organs,[2] including transgender, intersex, and nonbinary individuals; however, many men face accessibility issues due to stigma, bias, and systemic exclusion in healthcare.[3]

Etymology

The word gynaecology comes from the oblique stem (γυναικ-) of the Greek word γυνή (gyne) meaning 'woman', and -logia meaning 'study'.[4] Literally translated, it means 'the study of women'.[5][6] Its counterpart is andrology, which deals with medical issues specific to the male reproductive system.[7]

History

Antiquity

The Kahun Gynaecological Papyrus, dated to about 1800 BC, deals with gynecological diseases, fertility, pregnancy, contraception, etc. The text is divided into thirty-four sections, each section dealing with a specific problem and containing diagnosis and treatment; no prognosis is suggested. Treatments are non-surgical, consisting of applying medicines to the affected body part or delivering medicines orally. During this time, the womb was at times seen as the source of complaints manifesting themselves in other body parts.[8]

Ayurveda, an Indian traditional medical system, also provides details about concepts and techniques related to gynaecology, addressing fertility, childbirth complications, and menstrual disorders among other things.[9][10] These writings provide a post and prenatal care, integrating lifestyle practices, meditations and yoga, and a dietary regime for overall well-being.

The Hippocratic Corpus contains several gynaecological treatises dating to the 5th and 4th centuries BC. Aristotle is another source for medical texts from the 4th century BC with his descriptions of biology primarily found in History of Animals, Parts of Animals, Generation of Animals.[11] The gynaecological treatise Gynaikeia by Soranus of Ephesus (1st/2nd century AD) is extant (together with a 6th-century Latin paraphrase by Muscio, a physician of the same school). He was the chief representative of the school of physicians known as the "methodists."

During the Middle Ages, midwives dominated women's health concerns through experienced-based knowledge, traditional remedies, and herbal medicines. Midwifery was often regarded unscientific and was challenged with the rise of gynecology as an official medical field. The Renaissance period, 16th century, brought about a resurgence of classical scientific advancements, including the rise of medical advancements in the field of gynecology and obstetrics. Figures like Ambroise Pare were imperative in improving obstetrics techniques during this period. Peter Chamberlen developed the forceps, an important surgical tool that transformed childbirth and lessened maternal mortality.[12]

18th, 19th and 20th Centuries

As medical institutions continued to expand in the 18th-19th centuries, the authority of midwives was challenged by men involving themselves in women's health practices and research.[13] The formalization of midwifery training by male doctors and advancements in medical knowledge of women's health and anatomy was seen during this period. Figures such as William Smellie, William Hunter, Paul Zweifel, Franz Karl Naegele, and Carl Crede contributed to understanding of childbirth and women's health in Europe.[12]

In the early 18th and 19th centuries, in the United States, the field of gyneacology had ties to slavery and black women's reproduction. For example brothers Henry and Robert Campbell were editors of the first medical journal in the deep south. Henry worked as gynaecologist on enslaved women, whilst publishing medical case narratives of operations in the journal the brothers edited. Their biased writing and journal reflected the medical racism that was common at that time.[13] Others, such as Dr. Mary Putnam Jacobi, challenged the exclusion of women from medical education and shifted gynaecology to a scientific practice.[14]

J. Marion Sims is regarded as the father of modern gynecology.[15] Some of his medical contributions were published, such as development of the Sims' position (1845), the Sims' speculum (1845), the Sims’ sigmoid catheter, and gynecological surgery. He was the first to develop surgical techniques for the repair of vesico-vaginal fistulas (1849), a consequence of protracted childbirth which at the time was without treatment. He founded the first women's hospital in the country in Alabama 1855 and subsequently the Woman's Hospital of New York in 1857. He was elected president of the American Medical Association in 1876. Sims died in 1883 and was the first American physician of whom a statue was erected in 1894.[16]

Sims’ legacy is controversial and debated as he conducted therapeutic experimental operations on black enslaved women, as recounted in his autobiography.[17][18] In this era, anesthesia use was novice and considered dangerous. Sims developed his techniques and instruments by operating on slaves, without anesthesia.[19][20] On one woman, named Anarcha, he performed 30 surgeries without anesthesia.[21] During the antebellum era, due to racism some believed that black people had higher pain tolerance, and white women were unable to endure as much pain.[18] One view is that a lack of informed consent and experimentation on black enslaved women during this era was unquestioned in the medical community from an ethical perspective.[18] Sims’ experimentation on black enslaved women is widely discussed in the Journal of Medical Ethics and by academic scholars, some of whom have been able to argue there was an element of consent and provided explanations that do not involve medical racism as to why anesthesia was not used, whilst showing that white women were also subject to experimental procedures.[22][23] During his career, he was invited by European Royalty to treat their female relatives for gynecological problems.[18] When he left Alabama in 1853, a local newspaper called him "an honor to our state."[24]

Obstetrics and gynaecology were recognised as specialties in the mid-19th century, in the United Kingdom. Specialist societies came into being but it became clear that to become disciplines in their own right a separate college was required. William Fletcher Shaw (Professor of Midwifery at Manchester University) and William Blair-Bell (Professor of Obstetrics at Liverpool University) worked to establish The British College of Obstetricians and Gynaecologists in 1929[25], this later became the Royal College of Obstetricians and Gynaecologists.[26]

By the 20th century, the American College of Obstetricians and Gynecologists (1951) was founded. There were advances in antiseptic techniques, anesthesia, and diagnostic tools, like the Pap smear, which transformed gynaecological care.[27] Some medical racism continued in the United States with forced sterilizations and eugenic policies that disproportionately targeted minorities. In addition to black women, coerced sterilisation was used as a method to restrict perceived undesirable groups from reproducing, such as immigrants, poor people, unmarried mothers, disabled and mentally ill people.[28] Between 1909 and 1979, an estimated 20,000 forced sterilizations occurred in California, primarily in state run mental institutions and prisons.[29] Healthcare became more focused on the importance of informed consent.[30]

Puerto Rican Trials

Main article: Contraceptive trials in Puerto Rico
See also: Gregory G. Pincus

The birth control trials were initiated by Gregory Pincus, an American biochemist that contributed to the development of the first oral contraceptive pill.[31] Clinical trials of these contraceptions took place in Puerto Rico, commonwealth of the United States, with the rationale of a necessary population control that closely followed eugenic ideology.[32][33][34] The place of the trials was also facilitated by Puerto Rico’s ambiguous political relationship to the United States.[32] Furthermore, Puerto Rican women were already practicing other forms of birth control, thus Pincus established these trials to expand accessible contraceptives and develop an oral pill.[34] Trials began in Rio Piedras in 1956, and women were offered the pill, developed and named Envoid in 1960, on the basis that it prevented pregnancy without knowing the pills were unapproved by the Food and Drug Administration (FDA) in the United States.[34] Dr. Edris Rice-Wray, a professor at the Puerto Rico Medical School was aware and vocal of the negative side effects of the pill.[35] However, the side effects were dismissed without further testing on the safety of the contraceptive.[35]

Today, this event still affects many Puerto Rican women with reproductive health complications and permanent sterilization as a consequence of the trials.[33] Although these trials do not follow modern medical ethic practices, these trials spearheaded the development of the first oral contraceptive and currently propel the establishment of equity rubrics and further medical ethics research in the field of gynecology.[36] The women affected by these trials have been outspoken about their experiences with forced sterilization and birth control trials through a variety of medias, such as interviews, books, and documentaries like La Operación by Ana Maria Garcia.[37]

Examination

The historic taboo associated with the examination of female genitalia has long inhibited the science of gynaecology. This 1822 drawing by Jacques-Pierre Maygrier shows a "compromise" procedure, in which the physician is kneeling before the woman but cannot see her genitalia. Modern gynaecology no longer uses such a position.[38]

In some countries, women must first see a general practitioner or family practitioner prior to seeing a gynaecologist. If their condition cannot be diagnosed or treated and requires a specialist the patient is referred to a gynaecologist. In other countries, laws may allow patients to see gynaecologists without a referral. Some gynaecologists provide primary care in addition to aspects of their own specialty.[39]

As with all of medicine, the main tools of diagnosis are clinical history, examination and investigations.[40] Gynaecological examination is quite intimate, more so than a routine physical exam. It also requires unique instruments such as 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 may do a bimanual examination (one hand on the abdomen and one or two fingers in the vagina) to palpate the cervix, uterus, ovaries and pelvis.[41] It is not uncommon to do a rectovaginal examination for a complete evaluation of the pelvis, particularly if any suspicious masses are suspected. Gynaecologists may have a chaperone for their examination or a patient can request this. An abdominal or vaginal ultrasound can be used for diagnostic purposes.[42]

Diseases

Main article: Female genital disease

Examples of conditions dealt with by a gynaecologist are:

There is some crossover in these areas. For example, a woman with urinary incontinence may be referred to a urologist.

Therapies

Surgeries

As with all surgical specialties, gynaecologists may employ medical or surgical therapies (or many times, both), depending on the exact nature of the problem that they are treating. Pre- and post-operative medical management will often employ many standard drug therapies, such as antibiotics, diuretics, antihypertensives, and antiemetics. Additionally, gynaecologists make frequent use of specialized hormone-modulating therapies (such as Clomifene citrate and hormonal contraception) to treat disorders of the female genital tract that are responsive to pituitary or gonadal signals.

For lists of gynaecological drugs (by the ATC classification system), see ATC code G01 and ATC code G02.

Surgery, however, is the mainstay of gynaecological therapy. For historical and political reasons, gynaecologists were previously not considered "surgeons", although this point has always been the source of some controversy. Modern advancements in both general surgery and gynaecology, however, 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 gynaecological 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 College of Surgeons and Royal Colleges of Surgeons, and many newer surgical textbooks include chapters on (at least basic) gynaecological surgery.

Some of the more common operations that gynaecologists perform include:[47]

  1. Dilation and curettage (removal of the uterine contents for various reasons, including completing a partial miscarriage and diagnostic sampling for dysfunctional uterine bleeding refractive to medical therapy)
  2. Hysterectomy (removal of the uterus)
  3. Oophorectomy (removal of the ovaries)
  4. Tubal ligation (a type of permanent sterilization)
  5. Hysteroscopy (inspection of the uterine cavity)
  6. Diagnostic laparoscopy – used to diagnose and treat sources of pelvic and abdominal pain. Laparoscopy is the only way to accurately diagnose pelvic/abdominal endometriosis.[48]
  7. Exploratory laparotomy – may be used to investigate the level of progression of benign or malignant disease, or to assess and repair damage to the pelvic organs.
  8. Various surgical treatments for urinary incontinence, including cystoscopy and sub-urethral slings.
  9. Surgical treatment of pelvic organ prolapse, including correction of cystocele and rectocele.
  10. Appendectomy – often performed to remove site of painful endometriosis implantation or prophylactically (against future acute appendicitis) at the time of hysterectomy or Caesarean section. May also be performed as part of a staging operation for ovarian cancer.
  11. Cervical Excision Procedures (including cryosurgery) – removal of the surface of the cervix containing pre-cancerous cells which have been previously identified on Pap smear.

Recent discoveries

Newer advancements in gynecology are using integration of artificial intelligence (AI) in clinical practice, specifically with diagnostics and predictive analytics. AI algorithms are able to interpret complex gynecological imaging and pathology data, which improves diagnostic accuracy. These technologies are especially used in identifying cervical and ovarian cancers and predicting treatment outcomes.[49]

In terms of surgery, research has led to minimally invasive approaches, such as vaginal natural orifice transluminal endoscopic surgery. This technique allows surgeons to access the pelvic cavity through the vaginal canal, reducing recovery times, postoperative pain, and complication rates in comparison to traditional methods.[50]

Specialist training

Gynaecologist
Occupation
Names
  • Physician
  • Surgeon
Occupation type
Specialty
Activity sectors
Medicine, Surgery
Description
Education required
Fields of
employment
Hospitals, Clinics

In the United Kingdom, the Royal College of Obstetricians and Gynaecologists, based in London, encourages the study and advancement of both the science and practice of obstetrics and gynaecology. This is done through postgraduate medical education and training development, and the publication of clinical guidelines and reports on aspects of the specialty and service provision. The RCOG International Office works with other international organisations to help lower maternal morbidity and mortality in under-resourced countries.[51]

In the United States, obstetrics and gynecology requires residency training for four years. This encompasses comprehensive clinical and surgical education. OBGYN residents participate in a yearly in-training exam that is administered by the Council on Resident Education in Obstetrics and Gynecology (CREOG). Research suggests that combining curriculum and focused mentorship can improve residents' performance on the exam and overall educational outcomes.[52]

Gynaecologic oncology is a subspecialty of gynaecology, dealing with gynaecology-related cancer. Procedures in this field include surgery for endometrial cancer, ovarian cancer, pelvic masses, and vulvar disease.[53]

Urogynaecology is a subspecialty of gynaecology and urology dealing with urinary or fecal incontinence and pelvic organ prolapse.

Gender of physicians

Improved access to education and the professions in recent decades has seen women gynaecologists outnumber men in the once male-dominated medical field of gynaecology.[54] In some gynaecological sub-specialties, where an over-representation of males persists, income discrepancies appear to show male practitioners earning higher averages.[55]

Speculations on the decreased numbers of male gynaecologist practitioners report a perceived lack of respect from within the medical profession, limited future employment opportunities and questions to the motivations and character of men who choose the medical field concerned with female sexual organs.[56][57][58][59][60]

Surveys of women's views on the issue of male doctors conducting intimate examinations show a large and consistent majority found it uncomfortable, were more likely to be embarrassed and less likely to talk openly or in detail about personal information, or discuss their sexual history with a man. The findings raised questions about the ability of male gynaecologists to offer quality care to patients.[61] This, when coupled with more women choosing female physicians[62] has decreased the employment opportunities for men choosing to become gynaecologists.[63]

In the United States, it has been reported that four in five students choosing a residency in gynaecology are now female.[64] In several places in Sweden, to comply with discrimination laws, patients may not choose a doctor—regardless of specialty—based on factors such as ethnicity or gender and declining to see a doctor solely because of preference regarding e.g. the practitioner's skin color or gender may legally be viewed as refusing care.[65][66] In Turkey, due to patient preference to be seen by another female, there are now few male gynaecologists working in the field.[67]

There have been a number of legal challenges in the US against healthcare providers who have started hiring based on the gender of physicians. Mircea Veleanu argued, in part, that his former employers discriminated against him by accommodating the wishes of female patients who had requested female doctors for intimate exams.[68] A male nurse complained about an advert for an all-female obstetrics and gynaecology practice in Columbia, Maryland, claiming this was a form of sexual discrimination.[69] In 2000, David Garfinkel, a New Jersey-based OB-GYN, sued his former employer[70] after being fired due to, as he claimed, "because I was male, I wasn't drawing as many patients as they'd expected".[68]

Health Disparities in Gynecology and Obstetrics

See also: Gynecologic cancer disparities in the United States

Significant health disparities persist in gynecology, disproportionately affecting women of color, low-income women, and those living in rural areas.[71] Black, Indigenous, and Latina women face higher rates of maternal mortality, cervical cancer, and untreated reproductive health conditions compared to white women, often due to systemic racism, implicit bias in healthcare, and limited access to quality medical services.[72] These disparities are compounded by barriers such as lack of insurance, transportation challenges, and restrictive state policies around reproductive care.[72] Additionally, marginalized groups are less likely to have their pain and symptoms taken seriously by providers, leading to delayed diagnoses and worse outcomes.[73]

Addressing these gaps requires not only expanding access to comprehensive gynecologic care but also dismantling structural inequities that have long shaped women’s health in America. Furthermore, having physicians practice cultural humility, a life-long reflection where a physician not only partakes in the learning of other's cultures but also in the biases of the physician's own culture and teachings, helps battle systemic health inequalities.[71]

See also

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Sources

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