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Gyanecology & Infertility

Gyanecology & Infertility

‘Change’ is the basic characteristic of evolution. Changes become adaptations and are tools for survival in environment. However, when these changes occur too fast as desired by evolutionary requirements, these assets may become liabilities. Not only have the occupation, activity, and dietary habits changed, but time has also influenced priorities, moralities, and the society as a whole.

India is the second largest country in the world accounting for 17% of world’s population with 25 million births annually. Population of India has increased three times since independence. Female literacy rate is increasing. Last decade has witnessed a great change in women empowerment. Social roles, economic freedom, contraceptive acceptance has increased, but similarly there is an increase in stress, stress-related illnesses, drug and alcohol addiction, sexually transmitted diseases (STDs), and human immunodeficiency virus (HIV) infection, etc.

Because a substantial number of gynaecological maladies follow childbirth, the history of gynaecology has always been closely associated with that of midwifery. The specialty only moved ahead in the first half of 19th century. Progress in obstetrics was dependant on the ability of man to analyse, deduce logically and profit by experience; while gynaecology was more dependent on scientific discoveries. Prior to the mid-19th century, the specialty consisted of only treating disorders of menstruation, displacements of the uterus, and pelvic aches and pains connected with so-called peri- and parametritis. Treatment consisted mostly of blisters, pessaries, and cervical cauterisation. The term gynaecology was first used in 1847.1 So limited was the understanding of gynaecological practice in those days that the practice of ovariotomy—surgical removal of normal ovaries—was supported by distinguished gynaecologists for the treatment of ‘menstrual madness’,2 which equates with today’s premenstrual dysphoric disorder. Since, the surgeons had no idea of menopausal symptoms or osteoporosis, they would perform this operation without guilt and without anticipating the severe medical problems that often ensued. But, since it would cure the woman’s cyclical monthly symptoms, it was gratifying. So little was the insight into menstrual cycle in that era, that amenorrhoea following ovariotomy came as a surprise! However, this surgical procedure was advancement in treatment, because before advent of such operations, common practice among physicians was to apply leeches to the lower abdomen, vulva, and anus to alleviate premenstrual symptoms.2 However, as the practice of obstetrics and gynaecology progressed, so did women. Indeed women changed their lifestyles faster, imposing on the caring speciality to keep pace.

For many years it was assumed that there were very few differences between male and female and knowledge about men could be extrapolated to women as well. The expanding understanding has led to the acceptance of the fact that women’s health is more than health during childbearing and means more than the absence of gynaecological disease. These changes have been discussed in the subsequent paragraphs.

Changed lifestyle has led to small family norms. Female to male sex ratio has been declining and women presenting for selective female foeticide bring about a unique challenge to gynaecologists in terms of ethical, moral, and medical issues. Also, there has been an increase in divorced women and single parenthood. These issues lead to unique problems of single mothers, STDs, and sexual dysfunction among them. The increased life expectancy leads to women living a great part of their lives post menopause and it requires gynaecologists to handle their postmenopausal issues and expectations efficiently and effectively. The educational attainment of women in any society correlates with her health and today more women are literate than ever before.3 However, education makes women more aware and demanding about their health issues making imperative on physicians caring for women’s health to be challenged and become more responsive to their needs.

Career has become important for today’s women leading to late marriages and planning for family, which may not be at the peak reproductive age. This poses problems such as subfertility and patients have to resort to assisted reproduction techniques for more reasons than one. Age itself is a risk factor for many of the medical disorders of pregnancy. The risk of gestational diabetes mellitus, gestational hypertension, and operative interventions are increased.

Smoking among women in India is on the rise. Smoke is a toxin and smoking has multifactorial effects including higher incidence of heart disease and malignancies. In addition, smoking during pregnancy has serious risks for the foetus too, especially that of low birth weight. Similarly, alcohol not only causes psychological dependence, but is especially harmful during pregnancy. It is a preventable cause of birth defects, developmental disorders and foetal alcohol syndrome.4

Drug abuse has increased in the young population. Although the percentage of pregnant patients who use illicit drugs is relatively low, the effects can be devastating to both mother and foetus: growth restriction, placental abruption, and foetal demise.

A woman’s ability to control fertility so that all the pregnancies are wanted and occur at the appropriate time is fundamental to her health. Contraceptive acceptance has increased in all strata but not up to the desired level. Emergency contraception has further given liberation to the females with occasional exposure. Safe abortion services are now easily accessible and well utilised in cases of contraceptive failures. However, some feel that it has increased promiscuity among women.

Women have higher rates of psychological distress, depression, and physical morbidity than men.5 The factors, which have significantly increased stress in women are their increased workforce participation, rise in divorce, single parenthood, and the ageing population. Stress can affect the neurohormonal–endocrinological pathways and can present with menstrual irregularities or changed reproductive behaviour.

Changed dietary habits and reduced activity has already precipitated as an obesity epidemic. Polycystic ovarian syndrome when associated with obesity causes special problems like subfertility and hirsutism for these women. Obesity is more among women of childbearing age than among older women. Obese patients have higher incidence of heart disease, cardiac problems, endometrial cancer, and postmenopausal breast cancer.6 Overweight is a serious problem during pregnancy and increases all complications of pregnancy. Body image means how a woman views her own body. Woman’s feelings about their appearance are particularly important in relational aspect of sexuality. Overweight and obesity has done significant harm to the self-body image and stressed many women who ultimately resort to difficult exercise schedules, dietary regimens, and unnecessary cosmetic procedures.

Women’s sexuality is one of the most complex parts of life. Sexuality is multidimensional, including biologic, psychologic, socioeconomic, and spiritual components. Sexual health requires a positive and respectful approach to sexuality and sexual relationships. A woman’s life experiences shape her sexuality and it is important for the gynaecologist to know what women want and help them achieve that. Also, pre- and extra-marital relationships are common and so are unwanted pregnancies. Multiple partners have significantly increased the risk of sexually transmitted infections especially HIV and human papillomavirus (HPV). With the spread of HPV virus infection there are more chances of genital malignancies like cancer of cervix.

Further, HIV bridges the gap between gynaecology and obstetrics and is increasing in prevalence and affects both women and their children. Changed lifestyles and morality has a role to play in the same. However, whereas sexually transmitted HIV is on the rise for females, the perinatal transmission rate has declined, due to the use of prophylaxis before, during, and after pregnancy and the use of caesarean delivery. Obstetrician–gynaecologists need to counsel their patients and take effective measures to reduce the effect of this disease on the next generation.

Because of greater life expectancy, women substantially outnumber men at all ages > 65. The ageing population has an increased incidence of cardiovascular risks, malignancies, osteoporosis, and fracture.7

In summary, the changed lifestyle, which was the requirement of time, has touched all dimensions of woman’s health. These factors are interdependent and influence each other in multiple ways. A healthy planned lifestyle addressing above issues may act as primary prevention to many of the problems. Great challenges await the gynaecologist in the times to come. Gynaecologists will be expected to play an increasingly important role in the modern woman’s life. This is influenced by four main factors, namely, the world’s ageing population, spread of information technology, advances in molecular-based medical therapy, and above all the ever-changing lifestyle of the woman.8 Our role cannot get any lesser as we continue to advice, educate, and facilitate the lives of women, and we must aspire a new generation of women’s healthcare physicians to continue this ambition to deliver what the women ‘want’.

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