Gynecology (and Medicine in General) Continues to Evolve

Gynecology (and Medicine in General) Continues to Evolve

By Robert C. Rankin, MD

I enrolled in medical school in September 1971 when I was 20 years old, and finished my residency in obstetrics and gynecology in July 1978. I was in the full-time private practice of obstetrics and gynecology from then until August 2018, when I chose to electively stop delivering babies and devote all of my professional time to providing gynecological care for my patients. I have been asked to reflect on the changes that have occurred in medicine over that period of time.

To put things into perspective, in 1971 the Pittsburgh Pirates won the World Series. Life expectancy in the United States was 68 years for a male and 75 for a female. Today, life expectancy for males is 76 and 81 for females. In 1971, Richard Nixon was president, Watergate had not yet happened, gasoline was $.40/gallon, and the United States had 500,000 soldiers fighting in Vietnam.

Two things that have happened in medicine that have, in general, improved the quality of lives are the improvement of cataract surgery in ophthalmology and the use of joint replacement surgery in orthopedic surgery. In 1971, cataract surgery was a major three-hour procedure that was done infrequently. It was believed that joint replacement might only last for five years, so it was not performed on the very old. Now cataract surgery takes a mere 15 minutes, and joint replacement surgery is often done as an out-patient procedure. Both are done on patients of any age, and these procedures are among the most commonly performed procedures in America.

I am, of course, more aware of the changes that have occurred in obstetrics and gynecology since 1971. The cesarean section rate in 1971 was six percent. It is now 32%. Most of that increase is attributable to an increase in the diagnosis of the baby being too large to “fit out,” the belief that all breech babies should be delivered by cesarean section, and an increase in the diagnosis of the baby’s heart rate decelerating during labor. The ubiquitous use of the ultrasound today makes the diagnosis of these potential birthing issues easy. In 2018, almost every pregnant patient receives at least one ultrasound examination. That technology was just becoming available in the ’70s. In fact, looking at an ultrasound in the ’70s was similar to watching babies on your television in 2018 when turned to channel 3 without cable. The technology today is so good that it is now easy to see details such as the valves in the baby’s heart and the fingers on the baby’s hands.

In 1971, epidural anesthesia was rarely used and only administered under special circumstances. Today, the vast majority of patients delivering vaginally are given an epidural anesthetic during labor and made to feel quite comfortable.

When I first started practicing medicine, a patient would arrive at the hospital to have a baby and be placed in a delivery room. Her husband would be directed to a waiting room where he was expected to rest quietly or pace nervously, all the while smoking cigarettes. In fact, I remember opening the waiting room door to announce the birth (and sex) of the child, and had to first brace myself to cope with the thick cigarette smoke escaping into the hallway. Some older obstetricians would say that the appropriate amount of time to wait for a patient about to push the baby out was the time it took to smoke a cigar at the nurses’ station. Today, the father of the baby is usually in the delivery room (some still faint), and smoking is prohibited inside the hospital and within ten feet of the building.

In 2003, the human genome project was completed, detailing the 6.7 billion base pairs of human DNA, which revolutionized genetic testing and counseling. A simple blood test from the mother can now determine whether the baby has too many or too few chromosomes and can also test for up to 200 potential genetic mutations in the baby. Simple genetic screening can be done on the mother and father before pregnancy to determine whether or not there are any genetic mutations in the parents.

In the ’70s and early ’80s, the care of the diabetic mother was extremely difficult and resulted in many poor outcomes. Babies who were delivered too early had trouble breathing and babies occasionally died in utero at the end of pregnancy. It was found in the early ’80s that pregnancies did remarkably better if the blood sugar was well controlled. Home glucose monitoring with finger sticks became available, allowing for the precise control of blood sugars. Today, if the blood sugar of a diabetic pregnancy is well controlled, it is at no greater risk than that of a non-diabetic pregnancy.

In the ’70s, the treatment for premature labor was IV alcohol. In my opinion, that treatment never worked very well, but it did lead to some very inebriated patients. Today, we can accurately diagnose premature labor with a lab test and effectively treat it with medicine.

When I went into private practice, there were very few large groups of obstetricians and gynecologists; almost all were in private practice. Most doctors were in solo practice or had, at most, one partner. In fact, Magee-Womens Hosptial had the largest number of private practice deliveries of babies in the country. Today, you would be hard pressed to find an obstetrician at Magee who is in private practice.

Until the mid to late ’70s, most insurance companies considered pregnancy to be elective medical care and, therefore, would not pay for obstetrical care. That changed at the end of the decade with the passage of a well-conceived federal law. Today, insurance companies pay for obstetrical care and hospital stays as they do for any other medical condition.

The length of hospital stays post-surgery has dramatically decreased. After gallbladder surgery, I recall when the length of stay was ten days, and orthopedic and gynecologic post-surgery required a week in the hospital. Today, most surgery is done through small incisions with a laparoscope or by robotics and can be done as an outpatient procedure or with a single, overnight stay in the hospital.

In gynecology, several changes have occurred in the past 45 years that have had quite a positive effect on the lives of women. When I first began practicing medicine, we thought that only women with a significant family history of breast cancer should be given a mammogram. Because of this, about once a month I would feel a breast lump in a patient that was diagnosed cancerous. Since the cancer had grown large enough to feel, these tumors had often already spread to other parts of the body and, as such, the survival rate was poor and length of “quality life” after diagnosis was short. In the early ’80s, the medical community decided that all women were at risk for breast cancer, and we began screening all women over the age of 40 with regular mammograms. I now almost never feel a breast lump that turns out to be cancer. The same number of women have breast cancer, but it is generally discovered by a mammogram when it is too small to detect by examination. Because it is found in its early stages, the tumor has rarely spread and the survival rate is significantly greater than 90%.

The number of hysterectomies performed is significantly decreased due to the fact that various non-surgical treatments are available to deal with problems which, in the past, would have required surgery. Fibroid tumors (benign smooth muscle tumors of the uterus) can be decreased in size either with medication or by stopping the blood supply to the tumor. Multiple medications are now available to relieve symptoms of urinary incontinence and the lining of the uterus can be ablated (burned away) to either eliminate or significantly decrease heavy bleeding. These were the most common indications for having a hysterectomy 40 years ago.

Birth control has also improved remarkably over time. The newer IUDs are dramatically safer than those in use in the ’70s. The amount of estrogen in hormonal contraceptives (i.e., birth control pills) has decreased by at least 50% and up to 80%. The decrease in the amount of hormone in the pill has led to such a drop in the number of major side effects that you rarely see a significant side effect of the pill. There is even an implant, which is inserted under the skin of the arm, that provides contraception for up to three years.

The recent treatment of osteoporosis and osteopenia has been so successful that I almost neglected to include it in this article. In 2006, South Hill OBGYN purchased a DXA scanning machine, exactly like the hospitals have. At that time, no one really knew what percentage of the population had osteoporosis because there was no method of diagnosis. You may remember one condition where many women (and men) had hump backs or severe spinal curvatures. Caused by tiny breaks in the vertebrae, they are painful. That was 12 years ago. Today, there are successful, easily administered medications that not only control and stop the progression of osteoporosis, but actually repair the damage to some degree. Because so many women have had a bone density scan, many characteristics of the disease have been discovered. For example, scans of those without osteoporosis are not required to undergo scanning often unless an adverse event has occurred. If you stop to think about it, you will notice that there are very few gray-haired ladies with a stooped posture. Of course, science has also improved hair dyes, and naturally gray hair is also somewhat uncommon today.

All things considered, life is both longer and of better quality in 2018 as compared to 1971. It leads one to wonder what will happen in the next 47 years. If I was to venture a guess, I would think that the greatest changes in medicine will come from the study of human genetics. The human genome project has been completed for only 16 years, and we have already learned so much from it. It is easy to imagine that once we have a more thorough understanding of how our DNA works, it will be possible to use that knowledge to affect the course of disease.

I look forward to treating all my gynecology patients and introducing them to the continuing improvements in gynecology care for women.

Schedule an appointment today at SOUTH HILLS OBGYN ASSOCIATES with Robert C. Rankin, MD, FACOG

412-572-6127 • www.shobgyn.com