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Within a rapidly changing political and economic environment lies the fundamental need to provide continuity of patient care to decrease morbidity and mortality. Not all women need the same care and an attempt should be made by the clinician to focus on issues specific to high-risk categories and age-related variables (Tables 1.1-1.5). Additionally, scientific and economic documentation of the effectiveness of medical care has become an important issue in both clinical settings and policy-making situations. These concepts will also dictate physician reimbursement.

The field of pediatric and adolescent gynecology (PAG) encompasses a host of clinical conditions spanning a variety of disciplines and specialties. Primary care providers including obstetricians and gynecologists are often called upon to diagnose and treat problems of the genitourinary system that occur in children and adolescents, especially when a subspecialist is not available. Even in centers where there is PAG expertise, a working knowledge and understanding of the common clinical problems can be very useful in determining if and when a referral is necessary. Table 2.1 lists those scenarios under the pediatric and adolescent gynecology umbrella and it will serve as a framework for this chapter.

Geriatric gynecology includes the prevention, diagnosis, care, and treatment of illnesses and disabilities in women aged 65 years and older. It is a subdivision of the overall emerging specialty of geriatric medicine. Gerontology, on the other hand, is the study of normal aging and assists us in knowing what to expect as the patient grows old. It is obvious that there is an overlap between geriatric gynecology and gerontology.

Attitudes of health care professionals affect the quality of care we provide to both heterosexual and lesbian populations. Many lesbians feel health care providers are “homophobic” and have negative attitudes toward lesbians. Homophobia is defined as antipathy or disdain for gay men and lesbians. Theories regarding how and why homosexuality occurs abound and reflect genetic, embryologic, hormonal, and personal experiences with and without associated sociopathology as possible contributing factors. The psychiatric literature conveys that gay and lesbian individuals are an integral part of normal expression of the natural diversity of human sexuality. Homosexuality was included in the 1981 edition of the Diagnostic and Statistical Manual , but the Manual has since been revised to exclude homosexuality as a psychiatric disorder. While there are no solid data it is quoted that 10% of the female population is homosexual, yet many health care providers assume everyone is heterosexual. Most often “negative” experiences are with male practitioners. Fear of a provider’s response to the gay patient “disclosing” or “coming out” remains paramount in the mind of lesbians. One report from Oregon noted it was easier for lesbians to be open with “alternative practitioners” than with allopathic health care providers. Several studies indicate that lesbians delay or totally avoid seeking medical care because of the insensitivity of health care providers and poor prior experiences with the system.

The world of genetics and molecular biology has exploded in the past 10 years. With the completion of the first phase of the human genome project, the genetic code has been deciphered. In addition, the rapid expansion of techniques, such as automated sequencing and analysis of gene arrays on microchips, has revolutionized research and will soon create a revolution in clinical medicine as well. The combination of understanding our own genetic sequence and the use of automated high-throughput technology will transform our world. In the near future, the understanding of organisms at a functional level, via proteomics, will expand our knowledge base by another order of magnitude. We start with a description of the fundamentals of genetics and move forward.

Although not widely reported in the literature, emergencies do occur in the office. Types and incidence will vary depending on patient demographics and specific office procedures. Providing definitive care for all emergency situations is obviously impossible, but the prudent clinician prepares to initiate treatment for the most likely and the most rapidly lethal diagnoses. Syncope, perhaps the most common, has many etiologies, some of which are life-threatening. Initial office management of cardiopulmonary arrest, hypoglycemia, seizures, and shock states, including anaphylaxis, can successfully avert morbidity and mortality.

The introduction of the Papanicolaou (Pap) test as a routine screening test has resulted in a 70% reduction in the incidence of cervical cancer in the United States over the past five decades. In 2003 over 50 million women underwent cervical cancer screening, revealing close to 2.5 million abnormalities. Screening is offered by a variety of health care providers in various specialties.

The point prevalence for major depressive disorder has been established as 2.3–3.5% for men and 4.5–9.3% for women; the lifetime risk is 7–12% for men and 20–25% for women. This differential rate of affective disorders is primarily due to higher rates of depression between menarche and menopause. There is an increased incidence of the disorder in the primary care patient population; however, clinical depression has been both underdiagnosed and undertreated by primary care and other nonpsychiatrist physicians. Among “high utilizers” of medical services, there is an incidence of >40%. Risk factors include the following: 1. Female, especially during the postpartum period. 2. Family history of depression. 3. Prior history of depression or suicide attempts. 4. Stressful life events, particularly with first episode of depression. 5. Comorbid medical problems. 6. Lack of social supports. 7. Current alcohol or substance abuse.

Evaluation of breast symptoms and complaints may be appropriately managed by obstetrician-gynecologists in the ambulatory setting. Furthermore, surveillance for signs of breast cancer by mammography and physical examination is the responsibility of the primary health care physician for women, usually the ob/gyn. Diagnosed breast cancer and other breast problems beyond the expertise of the primary care physician should be suitably referred but must be continuously followed to be certain proper treatment is given and the clinical problem is resolved satisfactorily. In most cases, the patient will return to her primary care physician on whom she may rely for lifelong follow-up after her treatment is completed.

The primary role of the obstetrician/gynecologist in the management of hypertension in the past was obstetrical-related hypertension. The role of the gynecologist in overall health care maintenance and disease prevention is expanding and the recognition and treatment of hypertension should be considered in this role. Hypertension is a primary cause of cardiovascular disease, which remains a significant cause of morbidity and mortality in women. More than 60 million persons in the United States have some degree of hypertension, with an incidence of 65% between the ages of 65 and 74 years. The contribution of hypertension to overall cardiovascular morbidity and mortality in women has been considered less important than in men, but this absence of data may be the result of gender bias. Cardiovascular disease is in many cases the manifestation of multiple risk factors including obesity, hyperlipidemia, hypertriglyceridemia, type 2 diabetes, and hyperinsulinemia. Hypertension continues as the most prevalent associated factor in cardiovascular disease and in many cases coexists with other risk factors. Hypertension awareness has resulted in the lowering of average blood pressure in the United States over the past several decades.