Thinking About Ob/Gyn

We dig into how good stories and elegant mechanisms can seduce clinicians into using fertility and surgical “add-ons” long before the evidence is ready. We also connect policy, access, and misinformation to a disturbing rise in ectopic pregnancy deaths, then end with what better studies should look like when patient safety is on the line. 

• why low-dose naltrexone becomes a fertility add-on despite unclear mechanisms 
• biologic plausibility versus proof, and why theory cannot replace trials 
• what the available LDN data looks like, including weak endpoints and missing live birth outcomes 
• practice inertia, file drawer bias, and when a therapy belongs in routine care 
• ProPublica’s ectopic pregnancy mortality signal and how to interpret CDC WONDER data 
• COVID-era care disruptions, hospital closures, and delayed early pregnancy evaluation 
• Dobbs-era legal ambiguity, chilling effects, and implications for methotrexate timing 
• a new Nature Medicine finding on ISM2 as an early biomarker for preeclampsia and fetal growth restriction 
• V-NOTES versus vaginal hysterectomy trial design problems, including power, exclusions, and comparators 
• conflicts of interest, blinding failures, and how low-quality studies pollute meta-analyses 
Everybody remember to get your ABOG stuff done in the next month or so. 

Be sure to check out thinkingaboutobgyn.com for more information and be sure to follow us on Instagram. 

0:34 Low-Dose Naltrexone For Fertility

8:38 Evidence Gaps And Practice Inertia

17:14 Ectopic Pregnancy Deaths Are Rising

22:00 Access Problems And Social Media Misinformation

24:15 Abortion Bans And Delayed Ectopic Care

29:32 ISM2 Biomarker For Preeclampsia Risk

32:31 V-Notes Versus Vaginal Hysterectomy Study

41:40 Power, Outcomes, And Unfair Comparisons

47:50 Conflict Of Interest And Broken Blinding

55:09 Where V-Notes Came From

1:01:31 Skills, Tradeoffs, And Final Reminders

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Tara Chettiar joins as we talk through what the Lindsay Clancy case surfaces about postpartum mood disorders and why the public often misunderstands psychiatric illness when it gets filtered through legal arguments and internet certainty. We focus on practical clinical signals, especially sleep disruption, and what real safety planning and system reform should look like for postpartum families. 

• why we avoid diagnosing a public case and instead look for system lessons 
• how legal “insanity” clashes with the clinical spectrum of impairment 
• why med lists get misread and what SSRI activation can signal 
• baby blues versus postpartum depression and postpartum anxiety over time 
• postpartum OCD intrusive thoughts versus psychosis and delusions 
• sleep deprivation as the clearest danger sign and how it presents 
• what families can do in an acute postpartum mental health crisis 
• first line outpatient medication basics for OB GYN care 
• why postpartum psychosis needs emergency level triage 
• mother baby units and why the US has so few 
• what a postpartum mental health safety plan includes, including guns and pills 
• better screening in pregnancy, EPDS versus PHQ-9, and why anxiety matters 
• workforce gaps and why OBs, family medicine, pediatrics, and ER teams need training 
• Resources: Postpartum Support International at 1-800-944-4773 and text help, the National Maternal Mental Health Hotline at 833-TLC-Mama (852-6262), and 988 

Be sure to check out thinking about obgyn.com for more information.
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0:00 Welcome And Trigger Warning

1:30 Meet Tara And Her Work

7:10 Why The Clancy Case Matters

11:55 Legal Binary Versus Clinical Reality

12:50 Med Lists And Public Misreads

14:50 SSRI Insomnia And Bipolar Red Flags

18:15 Baby Blues Through Psychosis Spectrum

24:00 Intrusive Thoughts Versus Psychosis

28:13 Sleep Loss And Family Warning Signs

30:45 First Line Meds And Titration

34:55 ER Triage And Postpartum Advocacy

39:05 Mother Baby Units And Step Down Care

42:30 Safety Plans Means And Support

45:35 Screening Tools EPDS Over PHQ9

48:05 Workforce Gaps And Training Fixes

49:55 Policy Social Support And Paid Leave

52:40 Hotlines Resources And Closing Thoughts

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We move from a Dolly Parton story to the very real ways policy, training, and clinical guidance shape what patients can access and what clinicians can safely provide. We break down the end of global OB billing, the risks of vaccine schedule “tweaks,” and why surgical convenience can quietly drive worse care. 
• rural maternity deserts and why reimbursement must cover facility costs 
• content warnings and protecting our own mental health while learning from high-profile perinatal cases 
• the shift from global maternity fees to E/M problem-based prenatal visits 
• work RVUs, delivery billing and why correct coding matters 
• measles deaths, herd immunity and why splitting MMR increases missed protection 
• robotic surgery dominance, laparoscopic deskilling and training priorities 
• ACOG opportunistic salpingectomy guidance for ovarian cancer prevention 
• practical techniques to complete salpingectomy during vaginal hysterectomy 
• listener question on urinary retention and pudendal nerve injury myths 

0:00 Welcome And A Dolly Parton Story

6:07 Perinatal Mental Health And Content Warnings

8:20 OB Billing Shifts From Global To E/M

15:17 Measles Deaths And The MMR Split

20:05 Robotic Dominance And Laparoscopy Deskilling

31:41 ACOG Salpingectomy Guidance And Ovarian Cancer

40:53 Vaginal Hysterectomy Tube Removal Techniques

53:10 Urinary Retention And Pudendal Nerve Myths

1:06:22 Final Takeaways And Where To Follow

Thanks for listening be sure to check out thinkingaboutobyn.com for more information and be sure to follow us on Instagram 

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JJ Cox joins us as we talk through what actually changes when we perform cesarean delivery in patients with morbid obesity, from incision planning to anesthesia risk to the wound that has to heal at home. We share practical tips, review key trials on negative pressure dressings and antibiotics, and focus on decisions that protect both safe delivery and lower wound complications. 

• panniculus anatomy driving incision choice more than BMI 
• using ultrasound to find the uterus when landmarks mislead 
• paniculus retraction treated as an anesthesia maneuver 
• distance and geometry limiting exposure and delivery technique 
• planning the wound’s postoperative “home” before making the cut 
• negative pressure wound therapy evidence including the 2020 JAMA trial and skin blistering risk 
• skin glue vs standard dressings as competing narratives with limited data 
• closing deep subcutaneous space in layers to reduce dead space 
• avoiding staples and favoring subcuticular suture based on available evidence 
• antibiotic prophylaxis realities including azithromycin dose questions and shortage workarounds 
• extended postoperative antibiotics data shift when azithromycin is already used 
• OR contamination habits including Yankauer discipline and glove-changing debate 
• calling for help early and building a short pre-op plan to prevent downstream problems 

Be sure to check out thinking about obgyn.com for more information. And be sure to follow us on Instagram. 

0:00 Welcome And Guest Introduction

2:55 Why These C-Sections Are Higher Risk

7:00 Picking The Incision With Ultrasound

14:25 Panniculus Retraction Is Anesthesia Critical

17:35 Delivery Tips When Distance Is The Enemy

19:55 Think About The Wound Before Cutting

24:20 Negative Pressure Dressings What Trials Show

34:45 Subcutaneous Closure Sutures Beat Shortcuts

38:55 Antibiotics Dosing Azithromycin Reality Check

45:55 Contamination Control Yankauer And Gloves

52:10 Assistance Planning And Hemorrhage Limits

55:30 Meta-Analysis Takeaways And Closing

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We challenge a few stubborn pieces of OB-GYN “common sense” and ask what the data actually supports, from trying to conceive after miscarriage to how we start and adjust ovulation induction. Then we shift into practical laparoscopy tips for obese patients and end with a sober look at how evidence quality shapes care, from magnesium sulfate debates to the rise in pregnancy-associated overdose deaths. 

• why waiting a full cycle after first-trimester miscarriage lacks evidence for better outcomes 
• why routine progestin withdrawal bleeds before letrozole or clomiphene can be unnecessary and even harmful 
• how stair-stepping ovulation induction dosing can shorten time to ovulation 
• four operating room tips for minimally invasive surgery in morbid obesity, including port geometry and Trendelenburg dry runs 
• what a recent D&E fetal demise paper suggests about DIC and hemorrhage risk beyond 28 days 
• why retrospective birth registry studies can mislead when randomized trial data exist 
• how Medicaid timing findings highlight confounding rather than causation 
• a clever low-port approach to perforated IUD removal using a transabdominal hysteroscope 
• why overdose deaths are rising faster in pregnant and postpartum people and what fentanyl changes 

Be sure to check out thinking about obgyn.com for more information and be sure to follow us on Instagram.

0:00 Welcome And What We’re Reading

0:29 The Myth Of Waiting After Miscarriage

1:08 Skip The Provera Withdrawal Bleed

7:49 Data On Conceiving Sooner

13:52 Laparoscopy Setup For Obese Patients

25:07 D&E After Second Trimester Demise

28:39 Magnesium Sulfate And Study Quality

39:06 Medicaid Timing And Confounding

44:57 Single Port Perforated IUD Removal

49:33 Overdose As Leading Pregnancy Associated Death

57:57 Book Shout Out And Closing

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Howard Herrell and Stuart Winkler question long-standing OB-GYN habits that feel “routine” but do not add value, then replace them with evidence and practical decision-making. We move from hysterectomy follow-up and cuff dehiscence management to the data behind cesarean sutures, endometrial cancer evaluation in postmenopausal bleeding, and the ongoing shift to HPV-based cervical cancer screening. 
• why routine 6 to 8 week vaginal cuff exams after hysterectomy may not prevent or predict dehiscence 
• how telehealth post-op care can improve access while keeping symptom-driven safety nets 
• four tips for evaluating and managing vaginal cuff dehiscence, including when laparoscopy matters 
• what Ethicon discontinuing chromic and plain gut could mean for cesarean technique choices 
• how the CORONIS trial informs chromic vs Vicryl decisions and why transfusion risk is part of the conversation 
• where the 4 mm endometrial stripe rule came from and why it can fail in real-world care 
• why persistent postmenopausal bleeding still warrants endometrial biopsy despite reassuring ultrasound 
• how race, tumor subtype, and fibroids affect endometrial cancer detection and counseling 
• the arc from Pap smear cytology to HPV DNA testing, vaccines, and primary HPV screening 
• why self-collected HPV testing may raise screening uptake for patients avoiding speculum exams 

Be sure to check out thinking about obgyn.com for more information, and be sure to follow us on Instagram.

0:00 Welcome And Today’s Game Plan

0:35 Rethinking The Six-Week Pelvic Exam

13:25 Four Practical Tips For Cuff Dehiscence

24:42 Chromic Gut Is Disappearing

35:40 CORONIS Trial And Cesarean Sutures

42:22 Postmenopausal Bleeding And The 4 mm Rule

53:12 HPV Testing Takes Over Screening

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We follow the footnotes on a common gyn rule, then use that same evidence-first lens to question popular fertility add-ons and persistent pregnancy myths. Along the way, we talk pretest probability, counseling tradeoffs, and why simple cutoffs often replace better clinical reasoning. 

• tracing the “biopsy Bartholin cysts after 40” claim back to weak citations 
• using pretest probability and exam features to decide on selective biopsy 
• weighing hysteropexy versus hysterectomy for prolapse with long-term cancer risk in mind 
• breaking down a Lancet review of IVF add-ons and what actually shows benefit 
• spotting how marketing and online forums amplify unproven fertility interventions 
• reviewing data on sedentary time in pregnancy and why activity restriction persists 
• debunking “walking progresses labor” with randomized trial evidence 
• clarifying early diabetes testing as screening for preexisting diabetes and when A1C makes more sense than early glucose tolerance tests 
Be sure to check out thinkingaboutobgyn.com for more information and be sure to follow us on Instagram.

0:00 Welcome And What’s Ahead

0:23 Bartholin Cyst Biopsy Age Rule

14:17 Prolapse Repair With Uterus Preservation

21:45 IVF Add-Ons And The Lancet Review

37:35 Pregnancy Activity Myths And New Data

50:53 Early Diabetes Testing And A1C

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Howard and guest hose Sivani Aluru unpack why the new PMOS name matters, how PCOS got tied to “cysts,” and what the evidence actually says about diagnosis, metabolic risk, and treatment. We also challenge a few habits we have all inherited, from pre-op antibiotic dosing to the way we talk about hormones, weight, and fertility with patients. 

• the evidence gap behind 2 g vs 3 g cefazolin in obese cesarean patients and how practice inertia forms 
• why PMOS shifts attention toward insulin resistance, metabolic screening, and multidisciplinary care 
• how NIH, Rotterdam, and androgen excess criteria shape who gets diagnosed and who gets missed 
• SHBG and free testosterone as a practical way to explain symptoms when total testosterone looks normal 
• why ovarian follicles are not the same as painful ovarian cysts and why ultrasound can mislead 
• patient frustration with “just take birth control” and how we explain progesterone protection for the endometrium 
• lean PMOS, weight-focused bias, and realistic conversations about lifestyle change, GLP-1s, and bariatric surgery 
• fertility takeaways from PPCOS II, metformin limitations, and what lifestyle trials suggest preconception 
Be sure to check out thinkingaboutobgyn.com for more information, and be sure to follow us on Instagram.

0:00 Welcome And Guest Introduction

2:01 The 3-Gram Ancef Habit

12:02 PCOS Becomes PMOS

12:55 How The Criteria Got Complicated

22:00 Insulin Resistance And Free Testosterone

30:40 Hormone Panels And TikTok Myths

32:30 Ovarian Follicles Are Not “Cysts”

36:03 Treating Symptoms Without Dismissing People

46:12 Fertility Trials And Lifestyle Results

57:27 ACOG At 75 And Why Join

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We push back on the idea that obstetrics “deserves” a malpractice crisis and explain how bad incentives and junk science can turn normal evidence-based care into courtroom blame. We also break down a few widely shared clinical myths and new research so we can practice with clearer eyes and less narrative noise.
• placental grading on ultrasound as low-value data with poor predictive power and high reader variability 
• how malpractice commentary can seed plaintiff-friendly arguments against evidence-based off-label use 
• why blaming misoprostol or “high-dose” oxytocin oversimplifies multifactorial outcomes 
• quality improvement bundles as useful tools but weak proof without controls or causal clarity 
• how massive verdicts and paid expert testimony can clash with modern science on cerebral palsy and HIE 
• the FAA’s five hazardous attitudes and practical antidotes for high-stakes clinical work 
• new data on LEEP versus cold knife cone for CIN, recurrence, HPV clearance, and access tradeoffs 
• genetics and BMI as major drivers of gut microbiome patterns, not influencer narratives 
• what a 1993 Doppler trial can and cannot prove, plus why replication changes conclusions 

Be sure to check out thinkingaboutobgyn.com for more information and be sure to follow us on Instagram.

0:00 Welcome And Season Update

1:15 Placental Grading Myth On Ultrasound

6:44 Calling Out A Malpractice Influencer

14:06 The 2011 Policy Bundle Examined

23:20 What Drives The OB Malpractice Crisis

30:00 How Mega Verdicts Get Made

36:59 Five Hazardous Attitudes From Aviation

44:31 LEEP Versus Cone For CIN

48:04 Genetics And The Gut Microbiome

52:17 Does Doppler Ultrasound Harm Babies?

1:00:37 Recommendations And Closing

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We sit down with Joshua Oommen to get nerdy about clinical reasoning, FDA standards, and why “good evidence” is harder to define than most of us admit. We challenge the reflex to trust p-values and meta-analyses, then test our instincts against real OBGYN examples where the literature has whiplashed practice. 
• why the podcast is called Thinking About OBGYN and how clinical reasoning shapes our work 
• the NEJM proposal to make one pivotal trial the FDA default and what “confirmatory evidence” might mean 
• medical reversal, surrogate endpoints, and how trust erodes when practice changes late 
• why Bayesian thinking fits how clinicians interpret tests, trials, and prior beliefs 
• how meta-analyses fail through small study effects, publication bias, p-hacking, and heterogeneity 
• the amnioinfusion comeback as a case study in applicability and overconfident conclusions 
Be sure to check out thinking about obgyn.com for more information and be sure to follow us on Instagram. 

0:00 Welcome And Today’s Big Question

3:48 Why “Thinking About OBGYN” Exists

11:54 The NEJM Push For One Trial

16:38 Medical Reversal And Trust Problems

24:43 AI Proteins And CRISPR Pressure Tests

32:33 Bayes Thinking Beyond P Values

36:43 Why Meta-Analyses Often Mislead

41:08 Bias And Heterogeneity Red Flags

46:24 Amnioinfusion And A Meta-Analysis Comeback

1:02:29 Final Warnings And How To Learn

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