Gynecology
An annual gynecologic exam is of paramount importance. My patients have often asked when their daughters should have their first examination. The American College of Obstetricians and Gynecologists recommends that women have their first visit to the gynecologist at age 15. At that time I would only do a Papanicolaou (Pap) smear if the young woman had already had intercourse. Otherwise, that would be a good time to get comfortable with myself as a gynecologist, and I would do a general physical and only an external exam. For women who have ever had intercourse it is very important to have a Pap smear annually. This is a screening test to look for chronic irritation, precancerous changes, and cervical cancer. I have seen many patients in my practice who had normal Pap smears each year and then suddenly had an abnormal one, which resulted in surgery. A Pap smear is more sophisticated than prior, and now cervical cells are collected, placed in a solution, and a computer makes the slides that will be read by the cytologist/pathologist. These computer-generated Pap smears are easier for the cytologist to read, and therefore a more accurate assessment can be made. When a Pap smear is abnormal, sometimes further assessment has to be made with a colposcopy, and sometimes a surgery needs to be performed to remove abnormal tissue from the cervix. This type of procedure, known as a LEEP can be performed in the office.
Below are Common Gynecologic Procedures:
OFFICE BASED
Colposcopy
A colposcopy is performed when the screening Papanicolaou (Pap) smear is abnormal. It is looking at the cervix and vagina with a microscope. A mild vinegar solution is placed in the vagina and on the cervix to remove the normal mucus in order to see the abnormal areas. The abnormal areas are anesthetized with a spray, and then biopsies are performed (small pieces of tissue are removed) for analysis by the pathologist.
LEEP (Loop Electrosurgical Excision Procedure)
This procedure is performed to remove precancerous and cancerous changes of the cervix. The cervix is visualized with a colposcope and vinegar, as described above, and then anesthetized with a local anesthetic. The abnormal area is removed with a loop of wire, which both cuts out the tissue and cauterizes to prevent excessive bleeding. The advantage is that the patient can return home directly from the office, and there is very little bleeding. Also, the cervix generally heals with little scarring.
HOSPITAL BASED
Hysterectomy - to remove the Uterus (Womb) only
This can be done through the abdomen with a fairly large incision when a uterus is quite large, or through the vagina, often with the help of a laparoscope using small incisions on the abdomen. A total hysterectomy merely means removal of the entire uterus, including the cervix. A hysterectomy is most commonly performed for heavy menstrual bleeding with anemia, often caused by benign tumors known as leiomyomata (fibroids). Other reasons for a hysterectomy include irregular menstrual bleeding not controlled by medications, persistant cervical cancer after a LEEP, or endometrial cancer.
Oophorectomy
Removal of the Ovary. This is most often performed in the case of a hysterectomy in a postmenopausal or perimenopausal woman, but is otherwise done for tumors of the ovary.
Salpingectomy
Removal of the Fallopian Tube. This is most often performed when removing an ovary, but is sometimes done in the case of a tubal pregnancy (ectopic pregnancy in the fallopian tube) when the ectopic pregnancy is too large.
Laparoscopic Surgery
Surgery performed with the assistance of a long microscopic instrument with a fiber optic light. This involves making small incisions on the abdomen, which are usually more cosmetic and cause less postoperative pain.
Tubal Sterilization Procedure
A procedure that renders a woman sterile. This can be done with a small incision in the umbilicus (belly button) either just after a vaginal birth or at another time with the assistance of a laparoscope. It can be done at the time of a cesarean section as well. The fallopian tubes are damaged by either an electrical source laparoscopically or portions of the fallopian tubes are removed, with the cut ends being cauterized.
Obstetrics
Prenatal care should start as soon as you know you are pregnant. Routine prenatal visits are done to prevent complications. Sometimes problems can occur in your pregnancy and you may be totally unaware of them. By going to the obstetrician, problems can be diagnosed sooner, and further complications avoided. A normal pregnancy is actually 40 weeks long. The first prenatal visits are 4 weeks apart.
Your First Prenatal Visit
At the first prenatal visit routine blood work, a urine culture, and complete history are obtained, and prenatal vitamin samples are given. At the next, a full physical is performed along with a pap smear, if it has been one year or more since you have had one, and routine cultures of your cervix are performed. Between 15 and 18 weeks of pregnancy a quadruple screen is offered to screen for spina bifida, Down's syndrome, an omphalocele, and trisomy 18. If all has been uncomplicated, an ultrasound is performed at 18 weeks of gestation by Dr. Pagette for a survey of your baby's anatomy. She may be able to determine the sex at that time. At approximately 26 weeks of pregnancy a one hour glucose screen is performed for gestational diabetes along with your visit. After that visit, the visits will be every 2 weeks until 35 or 36 weeks. Also, Dr. Pagette will perform a second ultrasound for growth of your baby at approximately 32 weeks of pregnancy. Other ultrasounds will be performed at other times for circumstances, such as verification of position of your baby. At 35 or 36 weeks a culture for Group B Streptococcus will be done along with any other cultures needed at that time. Dr. Pagette will also examine your cervix to see if it is dilated. Then the visits will be every week until your delivery. If your cervix starts to dilate, an elective induction can be performed at 39 weeks or later.
Possible Complications In Pregnancy
Most pregnancies are uncomplicated, but if complications arise, Dr. Pagette will do regular testing to assure the health of yourself and your baby. For example, if a pregnancy is complicated by diabetes mellitus, twins, gestational diabetes, hypertension, or preterm labor, or if you have had a previous stillbirth, nonstress tests will be performed in the office on a regular basis. Sometimes one or more biophysical profiles are performed in the office if the pregnancy is complicated and a nonstress test shows that your baby is not reactive. A nonstress test is a monitoring of the baby's heart beat, like an EKG, which helps to determine the baby's well being. A biophysical profile is a special ultrasound to assure your baby's well being.
Medications in Pregnancy
"I have trusted Dr. Pagette's professional opinion for the last twelve years…Her calm listening spirit soothed my anxiety in more than one instance…when I think of my deliveries, I am convinced my children would not have been as healthy without her watchful eye throughout the pregnancies.”