An annual gynecologic exam is of paramount importance. Our patients often ask 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 we would not do a Papanicolaou (Pap) smear, but would offer STI screening 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 had intercourse, it is very important to have a Pap smear on a regular basis after age 21. This is a screening test to look for chronic irritation, precancerous changes, and cervical cancer. The recommendations for how often a woman needs a Pap smear have changed and they depend upon a woman's risk factors and history of abnormal Pap smears or cervical dysplasia. The presence of the high risk Human Papilloma virus demands more frequent testing and often a colposcopy. 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. Also, testing for the high risk types of the Human Papilloma virus can be done with a Pap smear for a more accurate risk assessment. When a Pap smear is abnormal or when high risk HPV is detected, 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.
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.
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.
This is a procedure performed for heavy menstrual bleeding. A lighted instrument, called a hysteroscope, is placed along with normal saline into the uterus. The uterine cavity is examined for any lesions. Then an instrument is placed to destroy the endometrial lining. Currently Dr. Pagette uses the NovaSure device. Afterwards the hysteroscope is placed once more and the uterine cavity is examined. The patient can go home the same day with little or no discomfort. The result is very light menstrual bleeding or no more menstrual periods.
A hysteroscopy is performed, and some sterile coils are placed in the opening of the Fallopian tubes to occlude them. Then scar tissue forms over the next 3 months to cause sterilization.
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. Dr. Pagette performs all of her hysterectomies laparoscopically whenever possible. She performs robotically-assisted total laparoscopic hysterectomies. 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.
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.
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. However, new research has discovered that ovarian cancer seems to start in the Fallopian tube. Therefore, most Gynecologists, including Dr. Pagette, are removing the Fallopian tubes at the time of a hysterectomy.
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. One can also employ the assistance of a robot, as Dr. Pagette does for most of her laparoscopic cases.
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. There is a newer technique to occlude the fallopian tubes which can be performed in the office. It is the Essure procedure.