GYNÆCOLOGY IN GENERAL PRACTICE

CLEGG, J. B., NAUGHTON, M. A., and WEATHERALL, D. J. (1965), An improved method for the characterization of human hremogiobin mutants: Identification of a,f3l""u, hremoglobin N (Baitimore), Nature ( Lona.), 207: 945. DACIE, J. V., and LEWIS, S. M. (1968), Practical Hrematolooy, 4th edition, Churchill, London. Dozy, A. M., KLEIHAUER, E. F., and HUISMAN, T. H. J. (1968), Studies on the heterogeneity of bremogiobin XIII. Chromatography of various animal and human hremoglobin types on DEAE-Sephadex, J. Chromatog., 32: 723. GILCHER, R. 0., BROMBERG, P. A., FINN, F. M., and JENSEN, W. N. (1968), Hremoglobin J Oxford: Effects on hremoglobin and erythrocyte function, Blood, 32: 260. HOCKING, I. W., and IBBOTSON, R. N. (1966), The effect of the beta thalassremia trait on pregnancy with particular reference to its complications and outcome, MED. J. AUST., 2: 397. IBBOTSON, R. N., and CROMPTON, B. A. (1963), The incidence of thalassremia in Greek and Italian migrants in Australia and Its effects in pregnancy, Brit. J. Htematol., 9: 523. LEHMANN, H. (1971), Introduction in Genetical, Functional and Physical Studies of Hmmoglobins, Proceedings of the 1st Inter-American Symposium on Hremoglobins, Caracas, 1969, Karger, Basel: 2. LEHMANN, H., and CARRELL, R. W. (1968), Differences between alphaand beta-chain mutants of human hremoglobin and between alphaand beta-thalassremia. Possible duplication of the alpha-chain gene, Brit. med. J., 4: 748. LIDDELL, J., BROWN, D., BEALE, D., et alii (1964), A new heemoglobin J Oxford found during a survey of an English population, Nature (Lond.), 204: 269.


Brush Up Your Medicine
, Frequency and distribution of abnormal hremogloblns and thalassremia in Colombia, South America, in
THE role of the general practitioner in the management of non-surgical gynrecological conditions is one aspect of the broader issues currently being debated in relation to the future of general practice in Australia. Of particular interest therefore is the presentation, in booklet form,' of a series of articles published during 1971 in the British Medical Journal; the common theme being that of gynrecology in general practice. Predictably, the subject matter includes such topics as pelvic pain, family planning, dysmenorrhrea, dyspareunia, backache, the menopause, abnormalities of the menstrual pattern, and the place of exfoliative cytology and other screening procedures.
Because these articles are addressed primarily to the practitioners working under the United Kingdom National Health Scheme, it must be assumed that the provision for paid attendance at postgraduate courses under this scheme is adequate for an understanding of such fairly complex matters as the investigation of hirsutism in the 1For review see MEl>. J. AUST., 1972, 2: Review Suppl. page 169.
Address for reprints: Dr G. Shedden Adam, 217 Wickham Terrace, Brisbane, Q. 4000. female; antifibrinolysin therapy for dysfunctional uterine bleeding, ultrasound in the diagnosis of abdominal tumours, and the indications for and limitations of laparoscopy. None the less, reference to these sophisticated techniques only serves to emphasize the fact that there remains a substantial clinical area in which an interested practitioner can use his knowledge of reproductive physiology, both normal and disturbed, to offer rational, and for the most part effective, therapy in a variety of gynrecological situations.
In the treatment of primary dysmenorrhrea, hormone therapy, if used, should be primarily a diagnostic test to determine whether inhibition of ovulation is, in fact, the only effective mode of therapy. In view of the age group chiefly affected by primary dysmenorrhrea, prolonged therapy by ovulation suppression should be approached with caution, having in mind the not uncommon incidence of "post-pill" amenorrhrea and apparent infertility in those women who are ready and anxious to start a family. By contrast, the treatment of endometriotic dysmenorrhrea by inducing pseudopregnancy with synthetic progestogens for 6 to 9 months has much to recommend it, although cyclic rather than continuous therapy will sometimes be equally effective in inducing regression of endometriotic nodules.
Many women whose chief complaint is that of chronic pelvic pain, with or without associated low backache, will have no demonstrable organic pathology in the reproductive organs. This does not mean that the pain is other than real, nor does it absolve the clinician from the need to use his basic professional skills to provide the type of supportive therapy that can contribute significantly to the relief of such symptoms. The thinking behind this approach is that the type of stress that may in some women lead to the development of peptic ulcer or colonic spasm, will in others cause a disturbance in the control of blood flow through the pelvic organs that can, by venous congestion and its consequences, lead to pelvic pain without demonstrable signs. The occurrence of psychogenic menorrhagia or metrorrhagia is cited in support of this concept of a finely balanced nervous control over the vasculature of the pelvic organs. Experienced gynrecologists will have no difficulty in recalling patients who admit to the need to take a vulval pad (as well as a good supply of handkerchiefs) when attending a "weepie" type of movie.
Vulval pruritus and anogenital irritation in the female are no respecters of age, the possibilities ranging as they do from the threadworm infestation of the child to the chronic epithelial dystrophy of the aged. During the child-bearing period of a woman's life, retiological factors tend to be more clear cut-monilial, trichomonal or coccal -but the astute clinician will keep in mind the possibilities of occult diabetes and stress-induced pruritus.
Dyspareunia and vaginismus are gynrecological conditions which lend themselves readily to supportive and other appropriate therapy by the family doctor, especially if adequate rapport obtains. The situation is less satisfactory if investigation or treatment is perfunctory, or if too much emphasis is placed on finding a pathological or mechanical explanation. If in the presence of deep dyspareunia, careful bimanual pelvic examination reveals equivocal evidence of pelvic pathology, laparoscopy, in experienced hands, may clear up the diagnosis with a minimal stay in hospital. The "exploratory section" of bygone days is no longer an acceptable procedure in this 5itua tion.
Low backache in women may have an obvious l-\ynrecological basis, but more commonly the diagnosis is less clear-cut. Backache above the level of the fifth lumbar vertebra is rarely due to gynrecological causes. A positive association is more likely to be justified if a slow and careful bimanual pelvic examination reproduces the backache when a certain stage of the examination (which includes testing for uterine mobility and uterosacral tenderness) is reached. Mobile malpositions of the uterus are seldom a cause of low backache; but a different assessment may be made if the uterus is fixed in retroversion by the complications of earlier infection or endometrfosis. When backache is associated with pelvic infection (often chronic), the later tends to be either in the cervix or in the adnexre. Involvement of the parametrium and uterosacral ligaments leads to deep dyspareunia, and concomitant trigonitis is not unusual. Such a eombinatlon clearly presents the practitioner with a very unhappy woman and is, most emphatically, an area where prevention is not only better, but easier than the cure. Meticulous care in the management of complicated confinements and in handling already infected incomplete abortions offers the most rewarding lines of prevention.
Bleeding from the female genital tract is a physiological function with a wide range of normality, but by the same token, it can be a most important sign of gynrecological disease, What then constitutes abnormal bleeding? Labels such as menorrhagia, polymenorrhrea, epimenorrhagia and metrorrhagia, whilst useful, sometimes give rise to confusion, and the current tendency is to use descriptive phrases to supplement these broad classifications. Thus, abnormal bleeding before the normal age of menarche may be simply due to precocious pufrerty, but it may be necessary to exclude such conditions as acute leukremia, oestrogen-productng tumours of the ovary such as granulosa cell tumour, theca cell tumour, and even such rare local conditions as cervical sarcoma. Generally speaking, if there is no evidence of secondary sex characteristics, the bleeding is probably caused by a local lesion in the vagina, including the possibility of trauma caused by insertion of a foreign body.
Bleeding during the reproductive period of a woman's life may be frequent, scanty or heavy, short or prolonged, irregular, intermenstrual, or postcoital. The abnormality may be simply due to an aberration of function, or it may herald gross pelvic pathology. Any assessment must have, as its basis, the normal menstrual pattern for that particular patient. Abnormal bleeding during the reproductive period is broadly due either to dysfunctional uterine bleeding or to organic disease which may be either local or general.
Dysfunctional uterine bleeding is, by its very nature, associated with either anovular or ovular menstrual cycles. Metropathia hremorrhagica (benign cystic endometrial hyperplasia), with its episodes of amenorrhoea followed by menorrhagia, represents an extreme degree of the unopposed restrogen activity of the anovular cycle. By contrast, ovular dysfunctional bleeding tends to produce short cycles with protracted bleeding. It tends to be associated with either inadequate maturation of the corpus luteum causing the premenstrual type of epimenorrhagia, or with a persistent corpus luteum leading to the postmenstrual type of epimenorrhagia. The diagnosis of dysfunctional uterine bleeding can be confirmed by suttably timed endometrial biopsy or uterine curettage, and treatment by synthetic progestogens between the thirteenth and twenty-sixth days of the cycle is usually effective.
General organic disease as a cause of abnormal uterine bleeding is comparatively rare, but includes a number of blood dyscrasias, which lend themselves t9 accurate diagnosis on hrematological study. As the doctor of first contact, the general practitioner will constantly be on the alert for local organic causes for abnormal bleeding from the genital tract. In particular he must keep in mind the limitations of exfoliative cytology as applied to the cervical smear test. Adenocarcinoma of the corpus uteri cannot be excluded by a favourable report on such a smear test, and some invasive carcinomas of the cervix do not exfoliate cells very readily. This applies particularly, of course, to the 5% of cervical carcinomata that arise from the endocervix. Postmenopausal bleeding may be due to recent cessation of oestrogen therapy, but this point can be readily checked. Because of the higher incidence of malignancy in this age group, there can be a danger of accepting obvious lesions such as polypi, urethral caruncles or vaginitis as the definitive cause without further investigation.

Special Articles
Overall then, there is a considerable clinical area of gynrecology in which the general practitioner may well accept total responsibility, especially if he has more than a passing interest in this aspect of medicine. There are other areas where an exact diagnosis may tax the clinical acumen of the most experienced gynrecologist. Teamwork, as with abnormal obstetrics, can be most rewarding.

Sydney
Med. J. Aust., 1973, 2: 132-135. Current medico-legal opinion recommends that elective vasectomy should always be followed by seminal examinations, repeated over a period of at least several months.
A review of the literature, and experience of a personal series of 600 cases, leads the writer to the conclusion that the insistence on such investigation can no longer be justified by logic or clinical experience, and that It imposes an unnecessary burden on the patient. If a suitable technique Is used to perform the vasectomy, seminal examinations may reasonably be discarded from the postoperative regime, and carried out only In those few cases where the patient seeks proof of sterility.
VASECTO~IY is but one of many birth-control methods, )'et it is uniquely beset by legal anxieties, doubts, and fears. Although it has a valuable place in the family planning armamentarium, doctors were dissuaded for years from making use of the method on the ground that it might be illegal. Quite recently, medico-legal authorities have come around to the view that the operation is, after all, a legal one, but the position is still far from being satisfactory.
Alone among birth-control measures, vasectomy still carries the risk that a failure will result in legal action against the doctor. There is no logical reason why this should be so. One does not expect to be sued if a patient taking oral contraceptives, or one using an intrauterine device, becomes pregnant. It is recognized that all birthcontrol methods carry a risk of failure. With the analogous operation of tubal ligation in women, there will be a small proportion who later become pregnant after spontaneous reanastomosis of the tubes, yet no one suggests that it is Address for reprints: Dr I. S. Edwards, 19 Gerrale Street, Cronulla, N.S.W. 2230. necessary for all patients to have a test for tubal patency. Failure to do so would not be considered a ground for legal action.
On the other hand, medico-legal authorities advise that after a vasectomy every man should have prolonged and repeated investigation in an attempt to assure 100% effectiveness. It is my purpose to demonstrate that such advice is no longer justified.
The proposition that post-vasectomy seminal investigations need not be insisted on as a routine can be substantiated by a careful reading of the literature, and is confirmed by the results of a personal series of 600 patients, 500 of whom have had a year or more elapse since the time of operation.
Those who are concerned with the whole field of family planning allot an important place to vasectomy. In any particular case, however, it is only one of a number of methods that may be chosen after there has been a full discussion with the patient of the advantages and disadvantages of these methods, including their failure rates.
As a method of family planning, vasectomy becomes less acceptable if it is believed that months or years must elapse before it can be relied on as a method of contraception. It is also unsound medical practice for patients to be subjected to prolonged, distasteful and anxietyproducing investigations, when by the use of suitable techniques, sterility can be reliably achieved within, at most, a few weeks.
The patient should have the option of deciding whether or not he will have postoperative investigation. He should understand that a sperm count is the only way of proving sterility, and this should be stated on the consent form, as should be the possibility of spontaneous reversal occurring later. Investigation retains a useful place in those few cases where the patient requests proof of his sterility.