BackTable Women's Health

In this episode of BackTable Urology, Dr. Aditya Bagrodia speaks with PGY4 urologist Dr. Chloe Peters (University of Washington) and OB/GYN Dr. Beverly Gray (Duke University) about their work in women's health and advocacy, and how the Dobbs ruling has impacted their respective medical fields.

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SHOW NOTES

First, the doctors explore the implications of state abortion laws on the OB/GYN and urology workforces and how they may directly impact where people choose to live and work. Dr. Peters and Dr. Gray explain the complexities of state abortion policies, as well as the differences between restrictive and nonrestrictive states. The Dobbs ruling in June 2022 gave individual states the power to regulate any aspect of abortion not protected by federal law, thus overturning Roe v. Wade. Both doctors emphasize that this ruling affects all urologists and OB/GYNs in private and academic settings, because they provide unsafe environments for patients who need them.

Recent studies and surveys show how restrictive abortion laws are impacting the urology rank lists and applications. One in five applicants to the urology match took programs off their list because they are located in states with illegal abortion laws, and almost 60% said they would worry about their health and safety if they matched in a state with restrictive laws. In summary, all three doctors agreed that restrictive laws can have a direct impact on residency and urology recruitment efforts.

Finally, they observe that the increasing diversity in the field of urology has encouraged younger, female members to advocate for better access to healthcare. They remain optimistic that the current generation can use their voices to create change and provide better access to care for all.

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RESOURCES

American Urologic Association (AUA) Position Statement on the Supreme Court’s Decision to Overturn Roe v. Wade

https://www.auanet.org/about-us/aua-statement-on-overturning-roe-v-wade

American College of Obstetricians and Gynecologist (ACOG) Abortion Policy

https://www.acog.org/clinical-information/policy-and-position-statements/statements-of-policy/2022/abortion-policy

Ryan Residency Training Program

https://ryanprogram.org/

In this episode, Drs. Mark Hoffman and Amy Park invite Dr. Isabel Green, fellowship director of MIGS at Mayo Clinic, to speak about persistent pain in endometriosis patients.

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SHOW NOTES

Dr. Green begins by defining endometriosis as endometrium-like tissue that grows outside the uterus, but emphasizes the complexity of the disorder with its varying phenotypes and inadequate knowledge about the disease process. Patients with superficial endometriosis can have terrible pain while others with deep disease may have little pain. It’s also common for people to have comorbid conditions, like IBS, fibromyalgia, migraine, myofascial pain, and central sensitization disorders. This makes it a difficult disease to diagnose and treat, and highlights the need to tailor therapy for individual patients. The doctors discuss the lack of data to support pain medications like gabapentin or amitriptyline, and even the typical treatments of birth control pills or excision surgery can fail to help patients.

The doctors then go on to discuss the pathophysiology of endometriosis. Dr. Green believes it may be different for different people as retrograde menstruation fails to explain all cases of endometriosis. There is research on immune dysregulation and inflammatory cytokines that could show the disease is systemic and not just contained in the pelvis. Additionally, some believe it could be cells transforming similar to a malignancy or even a nervous system issue, but more research is needed on the topic. There is a lot we still don’t know about endometriosis.

Next, Dr. Green explains the challenges in diagnosing endometriosis. Patients have variable symptoms, people may dismiss pelvic pain and normalize the symptoms, and ultrasound/MRI is only good at visualizing deep lesions. It is often years by the time patients go to surgery and endometriosis is visualized.

The episode ends with the doctors discussing how to manage patients long-term, especially if the typical treatment of hormonal and pain medications and excision surgery fail. Listening to the patient’s history, knowing exactly what the patient’s lesions looked like during surgery, repeat imaging, and learning the degree of neural involvement can help tailor the next steps. It’s important to remember that the treatment of endometriosis is a marathon, and it’s necessary to acknowledge the patient’s pain.

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RESOURCES

ACOG Guidelines:

https://www.aafp.org/pubs/afp/issues/2000/0915/p1431.html

In this episode, Drs. Mark Hoffman and Amy Park invite Dr. Brett Einerson to speak about the diagnosis and management of placenta accreta spectrum (PAS) disorders.

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Dr. Einerson is an assistant professor of OB/GYN in the division of Maternal Fetal Medicine (MFM) and Director of the Utah Placenta Accreta Program at the University of Utah, one of the busiest referral programs for PAS in the United States.

The doctors first discuss Dr. Einerson’s career path toward specialization in PAS. During his MFM fellowship in Utah, he encountered many difficult cases of PAS. He has had patients who have delivered 6-10 babies, and in Utah, family size is almost twice as large as the national average. PAS studies from overseas show that the median number of C-sections is 0 to 1 while Dr. Einerson's average accreta patient has had 2-3 prior C-sections. Given that there was not alot of research informing treatment for patients with PAS, Dr. Einerson was motivated to fill the void and embraced the diagnostic and surgical challenges associated with PAS.

The physicians go on to review the grading and classification of PAS. Although the traditional nomenclature uses accreta, increta, and percreta, pathologists and clinicians are noting that these descriptions of placenta accreta may not fully capture what the disease looks like in the hands of a surgeon. Now, there is increasing use of FIGO clinical grades 1, 2, and 3, which describes how PAS looks at the time of delivery. FIGO stage 1 involves attachment with no other changes, 2 describes vascular changes appearing on the outside of the uterus but no placental extension into the serosa, and stage 3 involves placenta that extends to the serosa with significant vascular changes.

Dr. Einerson goes on to discuss the difficulties of diagnosing PAS. Early PAS diagnosis starts with vigilant screening. Ultrasound is an important tool for screening, however even more critical is identifying patient risk factors such as prior C-sections and low-lying placenta. Caesarean scar pregnancy (CSP) and early placenta accreta spectrum are overlapping pathologies that have almost identical risk factors and very similar appearances. Dr. Einerson believes that most CSPs are early accretas. He advocates for high suspicion in patients with risk factors and a low threshold for referral to a specialty center for a second opinion.

Next, Dr. Einerson discusses what happens after PAS is diagnosed. His recommendation for black-and-white CSP deep within the scar at less than 10 weeks is pregnancy termination. The outcomes of early CSP treatment are much better than waiting for an ultrasound at 11 weeks, at which point the patient already has accreta and hysterectomy is almost unavoidable. Counseling patients with borderline PAS is much more difficult, according to Dr. Einerson. For these patients, overpreparation is key. This is likely to involve monthly ultrasounds as well as introducing the patients early on to the anesthesiology team, pelvic surgeons, and labor and delivery triage in case of a bleeding event. Unfortunately, patients may have to spend most of their pregnancy in the hospital.

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RESOURCES

Find this episode on BackTable.com to review the full list of resources.

In this episode, Drs. Mark Hoffman and Amy Park invite Drs. Rebecca Stone and Kara Long Roche to speak about opportunistic salpingectomy to prevent ovarian cancer, specifically serous carcinoma.

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The episode begins discussing ovarian cancer as a whole and how it affects 1 in 78 women in their lifetime with high mortality rates, no screening tests, and hardly any symptoms before it becomes metastatic. Most ovarian cancers (80-90%) are epithelial, and of those, most are high grade serous carcinomas, which are very lethal.

Drs. Stone and Long Roche go on to explain how ovarian cancer is actually disseminated tubal cancer, and that there is data showing dysplasia in the fallopian tube before it turns into ovarian cancer. In fact, the fimbriated ends of the fallopian tube are very high in p53 mutations, and there is data showing a decreased risk of ovarian cancer with tubal ligation. As a result, salpingectomy can be used as primary prevention for ovarian cancer. They have been doing opportunistic salpingectomies on women already in the OR for hysterectomies, Cesarean sections, ovarian cystectomies, etc. They would like to expand it to women receiving abdominal or urologic surgeries, including hernia repairs or cholecystectomies, which would require education, training, and communication across multidisciplinary teams.

The physicians continue to discuss the impact of opportunistic salpingectomies, mentioning 2000 lives could be saved every year in addition to 0.5 billion health care dollars saved as a result. They compare it to the HPV vaccine with a number needed to treat around 1 in 300 to 1 in 500 and a risk reduction of 65% or greater.

Technically speaking, the physicians mentioned the difficulties of ensuring adequate fimbriae removal of the ovary without causing more harm; overall, data shows that if done correctly, this procedure does not result in early menopause or impaired ovarian function. They also stated there is no specific procedure code for opportunistic salpingectomy along with conflicting state laws on reimbursability for the procedure, which could affect data collection and implementation.

Finally, the episode ends with talk about the future of opportunistic salpingectomies. Data shows there is a decreased incidence of high grade serous ovarian carcinoma, but more data is needed on mortality effects. The physicians strive to educate providers and patients about the procedure while ensuring no woman becomes sterilized before she is ready. Their target population is women in their 40s who will be in the OR already, as they don’t see opportunistic salpingectomies becoming indicated for the general population soon.

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RESOURCES

Break Through Cancer Organization:

https://breakthroughcancer.org/

ACOG Guidelines:

https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2019/04/opportunistic-salpingectomy-as-a-strategy-for-epithelial-ovarian-cancer-prevention

In this episode, Drs. Mark Hoffman and Amy Park invite Dr. Susan Khalil, a board-certified OB/GYN and fellowship-trained Minimally Invasive Gynecologic Surgeon at Mount Sinai in New York, to speak about the topic of second victim and fostering resilience in the field of Obstetrics and Gynecology.

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SHOW NOTES

Dr. Khalil’s efforts to improve quality and patient safety began almost a decade ago. When discussing how she is involved with quality and safety, Dr. Khalil describes her experiences with programs outside of her institution, such as Schwartz Rounds through the Schwartz Center for Compassionate Healthcare, as well as those within her institution, including those conducted by the Vice Chair for Wellness and the Chief Wellness Officer at Mount Sinai. Throughout these programs, Dr. Khalil explains that the common thread is the opportunity to discuss a negative patient outcome or a harmful situation within the workplace within a safe environment. In Dr. Khalil’s personal experience, these programs have covered topics such as improving communication in a multidisciplinary team.

The physicians then transition to discuss the topic of “second victim,” which Dr. Khalil describes as the caregiver who witnesses a patient undergoing a traumatic event and that caregiver’s personal trauma they are then left to cope with. She expresses that these situations often require mental health support, especially from a community that understands clinically what is happening and also has the resources to provide the caregiver with the support they need to return to work more resilient. Ultimately, Dr. Khalil believes that culture is the key to fostering a safe environment for physicians, as well as all other people involved in a patient’s care. Dr. Khalil encourages those who may not have access to these resources to consider online resources (e.g., the Schwartz Center) or to look to other institutions as a framework to tailor programs that may work within your own hospital or institution.

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RESOURCES

The Schwartz Center for Compassionate Healthcare:

https://www.theschwartzcenter.org/programs/schwartz-rounds/

Khalil S, Ascher-Walsh C. Advancing Patient Safety Science While Not Losing Focus of the Big Picture: Improving Patient Care. J Minim Invasive Gynecol. 2022 May;29(5):581-582. doi: 10.1016/j.jmig.2022.03.003. Epub 2022 Mar 11. PMID: 35283322.

Association of Academic Surgery Presidential Address by Dr. Carrie Cunningham Lubitz:

https://www.youtube.com/watch?v=JaNBH4UPHv4

In this episode, Dr. Leslie Appiah, who is fellowship-trained in Pediatric and Adolescent Gynecology and is the Director of the Fertility Preservation Program at the University of Colorado, discusses oncofertility and fertility preservation.

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Dr. Appiah begins the episode by defining oncofertility as a multidisciplinary field that improves fertility and reproductive health outcomes for patients with cancer diagnoses. She emphasizes the growth of the field, with the term “oncofertility” being coined in 2009 by Dr. Teresa Woodruff at Northwestern University. Now, 13 states have legislation that mandates insurance providers to cover fertility services for patients with and without cancer.

The primary patient population that may benefit includes patients with a cancer diagnosis, although additional populations who may benefit, including patients with Sickle Cell Anemia undergoing bone marrow transplant, systemic lupus erythematosus using alkylator therapies, transgender populations undergoing gender-affirming treatments, and patients born with genetic conditions that may result in infertility (e.g., Turner Syndrome). The main agents that are harmful to fertility include alkylator and radiation therapies.

The physicians then transition to discuss fertility preservation, and Dr. Appiah highlights that it is the responsibility of medical providers to offer counseling for every patient who is at risk for infertility. She then describes types of fertility preservation, including sperm banking, testicular tissue preservation, egg freezing, and ovarian tissue cryopreservation. Dr. Appiah then shares 3 different procedures that are used for ovarian tissue cryopreservation, the most common approach begin a laparoscopic procedure to retrieve one ovary, which is then preserved and later transplanted back into the pelvic peritoneum once the patient has completed cancer therapies and is ready to start a family.

The episode concludes with Dr. Appiah shares future directions in the field of oncofertility, which includes streamlining the process for male patients, ensuring every state is able to allow fertility preservation services that are covered by insurance providers, optimizing the process of transplanting ovarian tissue, and utilizing ovarian tissues for hormone replacement.

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RESOURCES

ReproTech, Fertility Preservation:

https://www.reprotech.com/fertility-preservation-network/

Oncofertility Consortium:

https://oncofertility.msu.edu/about/

Alliance for Fertility Preservation, Fertility Scout:

https://www.allianceforfertilitypreservation.org/about-fertility-scout/

In this episode, Dr. Camille Clare, the Chair of the Department of Obstetrics and Gynecology at SUNY Downstate College of Medicine, joins Drs. Mark Hoffman and Amy Park to discuss social determinants of health in the field of OB/GYN.

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SHOW NOTES

Dr. Clare identifies social determinants of health as factors that prevent patients from accessing healthcare multiple times. She describes examples as housing (e.g., safe environments to live and raise families, school district locations), access to transportation, and occupation. The physicians discuss the impact of social determinants of health in the field of OB/GYN, involving how certain conditions (i.e., rates of preterm birth, infertility, and cancer) present. The group also acknowledges the concept of “political determinants of health,” which involves policies that lead to certain health outcomes, such as redlining and how it has contributed to food insecurity and many other negative effects.

The physicians also discuss how groups are addressing the downstream effects of health inequities. Dr. Clare is personally involved in lobbying and encourages those around her to advocate at the local, state, and federal levels to improve policy. In addition, Dr. Clare utilizes social media as a way to promote health equity and empower students/trainees to make positive impacts on their communities.

The episode ends with Dr. Clare expressing current improvements among the medical community when it comes to addressing social determinants of health and health inequities. Ultimately, Dr. Clare is grateful that the medical community is now more open to discuss difficult conversations that focus on improving patient care. She has also appreciated the active effort to make the medical school recruitment process more inclusive in order to diversify the future physician workforce.

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RESOURCES

Dr. Camille A Clare:

@cclareMDMPH (https://twitter.com/cclareMDMPH)

Claire Cain Miller, Sarah Kliff, Larry Buchanan. “Childbirth Is Deadlier for Black Families Even When They’re Rich, Expansive Study Finds” The New York Times. https://www.nytimes.com/interactive/2023/02/12/upshot/child-maternal-mortality-rich-poor.html

In this episode, Dr. Elliot Richards, a true physician-scientist and Director of Research in the Department of Reproductive Endocrinology and Infertility at the Cleveland Clinic, shares about his experience and studies regarding uterine transplant.

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Dr. Richards describes uterine transplant in the modern era as truly “patient-driven” and due to “patient-demand.” He begins the episode by detailing the history of uterine transplant, which was initially attempted in the 1930s, even before the first successful renal transplant 20 years later. More recently, successful uterine transplants were first conducted in Saudi Arabia, Sweden, Turkey, and now in a few United States institutions (e.g. Cleveland Clinic, University of Alabama at Birmingham, University of Pennsylvania, and Baylor).

He then addresses arguments or concerns against uterine transplant. Ultimately, Dr. Richards encourages listeners to identify infertility as a disease and one that warrants treatment, prompting the use of uterine transplant.

The physicians then discuss the process of uterine transplant. In current trials, the majority of patients are people with a diagnosis of mullein agenesis. Dr. Richards highlights that this population does not reflect the actual population that suffers from absolute uterine factor infertility (AUFI) and that he hopes that access to the procedure will expand for a more diverse patient population. He then describes the types of uterine donors (e.g., directed donor, non-director donor, deceased donor model, etc.) that are utilized by different institutions; the surgical process of the transplant itself; immunosuppression and pregnancy; as well as fertilization via IVF.

The episode ends with Dr. Richards discussing success rates by citing his prior studies, which includes a 74% 1-year graft survival and 83% live birth rate among those with a viable graft at 1 year. Specifically within the Cleveland Clinic study population, one patient delivered the first second baby last September. Future directions regarding uterine transplant include better understanding the costs of the procedure, shortage of available donors, identifying the true demand, leveraging minimally invasive surgical techniques, and fallopian tube preservation.

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RESOURCES

“The Danish Girl” 2015 film directed by Tim Hooper

“Uterus Transplant Animation Recipient” by Cleveland Clinic - ​​https://www.youtube.com/watch?v=13DwQ0HbuXc

“Cleveland Clinic Delivers Second Baby from Uterus Transplant” by Cleveland Clinic - https://www.youtube.com/watch?v=XJuedpL14AQ

Lefkowitz A, Edwards M, Balayla J. The Montreal Criteria for the Ethical Feasibility of Uterine Transplantation. Transpl Int. 2012 Apr;25(4):439-47.

Johannesson L, Richards E, Reddy V, Walter J, Olthoff K, Quintini C, Tzakis A, Latif N, Porrett P, O'Neill K, Testa G. The First 5 Years of Uterus Transplant in the US: A Report From the United States Uterus Transplant Consortium. JAMA Surg. 2022 Sep 1;157(9):790-797.

In this episode of BackTable, Dr. Bagrodia interviews Dr. William Flanary, a physician-comedian popularly known as Dr. Glaucomflecken, about lessons he has learned as a two-time testicular cancer survivor and the importance of humor in medicine.

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First, Dr. Glaucomflecken shares about his first diagnosis of testicular cancer. During his third year of medical school he felt a lump in his testicle, which led to a quick workup, diagnosis, and a full orchiectomy. The diagnosis was emotionally difficult, as he was in his mid-twenties and healthy. He returned to comedy, a skill he had developed in high school and college, to cope with his diagnosis. This time, however, he started to practice medical-based comedy with his new experiences as a medical student. He recounts other discussions he had about his cancer, such as fertility, the possibility of chemotherapy, and active surveillance.

Four years after his first orchiectomy, he received his second diagnosis of testicular cancer during his last year of residency. He recounts feeling distraught and overwhelmed, as questions about fertility, hormone replacement, medical expenses, and postponing residency became more serious. He decided to have a full orchiectomy and testosterone replacement therapy, which solved his issues with fatigue and irritability. Additionally, his wife got him involved in testicular cancer support groups and foundations, including one called First Descents, an organization that encourages young adults with cancer to explore the outdoors. He notes that young patients are often overlooked in cancer support groups and encourages cancer patients to find their support networks outside of friends and family as well.

Then, Dr. Flanary discusses his experience with suffering from cardiac arrest in 2020, which led to his wife doing ten minutes of chest compressions to keep him alive. He reflects on this event and concludes that it taught him how to be a better physician to his patients by making sure he involves patients’ families and encouraging him to address medical insurance issues directly.

Finally, Dr. Flanary discusses how he uses humor to advocate and educate patients on social media. He notes that comedy can stimulate conversation and debate and encourages physicians to have social media presence.

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RESOURCES

Knock Knock Hi Podcast

https://podcasts.apple.com/us/podcast/knock-knock-hi-with-the-glaucomfleckens/id1659572053

First Descents

https://firstdescents.org/

Dr. Cholkeri trained in minimally invasive gynecology surgery (MIGS) during the early years of the field’s establishment. She provides an overview of her involvement in starting a MIGS fellowship, becoming faculty for the American Association of Gynecologic Laparoscopists (AAGL), working with industry partners to develop products, and serving as a consultant for medical device companies.

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In this episode, Dr. Aarathi Cholkeri, a minimally invasive gynecologic surgeon and the Interim Chief Medical Officer for Karl Storz Endoscopy-America, shares about her experience transitioning from clinical practice to industry.