William Harvey 15781657

General Considerations

Records of obstetrics and gynecology date back to the time of Hippocrates in 400 bce. He was probably the first physician to describe midwifery, menstruation, sterility, symptoms of pregnancy, and puerperal (the period after labor) infections. Most of the early gynecologic history stems from Soranus in the second century ce. His works included chapters on anatomy, menstruation, fertility, signs of pregnancy, labor, care of the infant, dysmenorrhea (painful menstruation), uterine hemorrhage, and even the use of vaginal specula.

William Harvey, who devised the theory of blood circulation, was also responsible for a monumental treatise on obstetrics. This work, published in 1651, included a detailed assessment of uterine changes throughout life.

The 18th century was a period of a further understanding of pregnancy, labor, and fertility. However, it was not until the 19th century that diseases of the female genitalia were better understood. As recently as 1872, Emil Noeggerath published his investigations on gonorrhea, which ultimately changed the opinion of the medical world about the significance of this disorder. He was the first to suggest that ''latent gonorrhea'' was associated with sterility in women. Although the first cesarean section was described in 1596 by Scipione Mercurio, the development of the current technique of Max Sanger was described as recently as 1882.

In 2007, cancer of the uterine corpus, also known as endometrial cancer, the most common cancer of the female reproductive organs, accounted for 6% of all cancers and 3% of all cancer deaths in women in the United States. It is the fourth most common cancer found in women, after breast cancer, lung cancer, and colorectal cancer. In 2007, there were 39,080 new cases and 7400 deaths from cancer of the uterus. The lifetime risk for development of cancer of the uterus is 1 per 38. For all cases of cancer of the uterus, the 5-year relative survival rate is 84%. Although the mortality rate has declined slightly since the 1980s among white women, it has remained stable among other racial and ethnic groups. Although the incidence rate of uterine cancer is lower for African-American women than for white women, the mortality rate among African-American women is nearly twice as high.

Between the mid-1950s and 1992, deaths from invasive cancer of the cervix in the United States dropped by 74%. The decline in mortality from cervical cancer is largely attributed to early detection by physical examination. It has been estimated that noninvasive cervical cancer (carcinoma in situ) is about four times more common than invasive cervical cancer. In the United States, the widespread use of the Papanicolaou (Pap) test has decreased the incidence and mortality rate by 40% since the mid-1970s. Most invasive cervical carcinomas are found in women who have not had regular Pap tests. In 2007, there were 11,150 new cases of invasive cervical cancer diagnosed, and 3670 women died from this disease. The death rate continues to decline by about 2% per year. An American woman has a 0.78% lifetime risk (1 per 128) for development of cervical cancer and a 0.27% risk of dying from the disease. The 5-year relative survival rate for the earliest stage of invasive cervical cancer is 92%, and the overall (all cases considered together) 5-year survival rate is 71%.

Of the many risk factors that have been evaluated, young age at first sexual intercourse, multiple sexual partners, infection with the human papillomavirus (HPV), infection with herpes simplex virus, infection with human immunodeficiency virus (HIV), immunosuppres-sion, and a history of cervical dysplasia are most often associated with an increased risk of cervical cancer. The most important risk factor for cervical cancer is infection by the HPV. Because the course of dysplasia development takes several years from the time of initial HPV infection, the guidelines indicate that a woman should be screened after being sexually active for 3 years. HPVs are a group of more than 100 types of viruses, some of which can cause warts, or papillomas; these are noncancerous (benign) tumors. Certain other types of HPV can cause cancer of the cervix. These are called high-risk or carcinogenic types of HPV, and about 70% of all cervical cancers are caused by HPV types 16 and 18. In women older than 30, an HPV test may be conducted at the same time as a Pap test.

Vaccines have been developed that may protect against infection with some types of HPV, which may reduce cervical cancer rates in the future. One of these, Gardasil, protects against types 6, 11, 16 and 18 and is now available for girls and women aged 9 to 26 years. Another vaccine, Cervarix, protects against types 16 and 18. The Gardasil vaccine entails a series of three injections over a 6-month period. To be most effective, the vaccine should be given before a person becomes sexually active. At the time of this writing, the American Cancer Society recommends that the vaccine be routinely given to girls aged 11 to 12 and as early as age 9 years at the discretion of clinicians.

Although ovarian carcinoma accounts for only 3% of all cancers in women, it is the cause of 6% of all cancer deaths in women. It is the fourth leading cause of cancer death and the leading gynecologic malignancy in women in the United States. Cancer of the ovary accounts for nearly 50% of all deaths from gynecologic malignancies. In 2007, there were 22,430 new cases of ovarian cancer and 15,280 deaths from it. The lifetime risk for development of ovarian cancer is 1 per 59; the incidence is 1.4 per 100,000 women younger than 40 years, but it increases to 45 per 100,000 women older than 60 years. The carefully performed pelvic examination has been shown to be the cornerstone of diagnosis of ovarian cancer.

Structure and Physiology

The external female genitalia are shown in Figure 19-1. The vulva consists of the mons veneris, the labia majora, the labia minora, the clitoris, the vestibule and its glands, the urethral meatus, and the vaginal introitus. The mons veneris is a rounded prominence of fat tissue overlying the pubic symphysis. The labia majora are two wide skinfolds that form the lateral boundaries of the vulva. They meet anteriorly at the mons veneris to form the anterior commissure. The labia majora and the mons veneris have hair follicles and sebaceous glands. The labia majora correspond to the scrotum in the man. The labia minora are two narrow, pigmented skinfolds that lie between the labia majora and enclose the vestibule, which is the area lying between the labia minora. Anteriorly, the two labia minora form the prepuce of the clitoris. The clitoris, analogous to the penis, consists of erectile tissue and a rich supply of nerve endings. It has a glans and two corpora cavernosa. The external urethral meatus is located in the anterior portion of the vestibule below the clitoris. Paraurethral glands, or Skene's glands, are small glands that open lateral to the urethra. Secretion of sebaceous glands in this area protects the vulnerable tissues against urine.

The major vestibular glands are known as Bartholin's glands, or vulvovaginal glands. These pea-sized glands correspond to the male Cowper's glands. Each Bartholin's gland lies postero-laterally to the vaginal orifice. During sexual intercourse, a watery fluid is secreted that serves as a vaginal lubricant.

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