Surgical techniques in gynecology vary widely between surgeons, creating both excitement and frustration for residents trying to learn the "right way" to perform procedures. Howard and guest host Maddie White discuss this and more:

• Trocar placement during laparoscopy requires careful consideration of patient factors and potential adhesions
• Elevating the abdomen during trocar placement remains standard practice, though definitive evidence on its necessity would require studies of over 100,000 patients
• Surgeons should understand power analysis to recognize when studies are underpowered to detect meaningful differences in rare complications
• Visceral slide technique using ultrasound can identify adhesions and determine the safest entry point for laparoscopic surgery
• Palmer's point may no longer be the safest entry point for many patients given the prevalence of bariatric surgeries
• Jain's point (lateral to the umbilicus) may now be statistically safer for many patients with complex surgical histories
• Vaginal cuff dehiscence rates are 6-10 times higher with laparoscopic/robotic hysterectomy compared to vaginal approaches
• The higher dehiscence rate stems from using energy devices for colpotomy rather than cold scalpel techniques
• Barbed sutures simplify cuff closure but don't reduce dehiscence rates compared to standard suturing techniques
• Surgery consists of "a thousand little things done well" - mastering these micro-skills distinguishes excellent surgeons

00:00:00 Surgical Techniques: Excited and Frustrated

00:08:00 Elevation During Trocar Placement 

00:17:00 Evidence and Power Analysis

00:21:35 Visceral Slide Technique

00:35:10 Alternative Trocar Entry Points

00:40:10 Cuff Closure and Dehiscence Risk

00:51:45 Laparoscopic vs Vaginal Colpotomies

01:03:00 First Accredited OB-GYN Residency Program

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Howard Herrell and Antonia Roberts explore evidence-based practices in obstetrics and gynecology, examining both established protocols and emerging research with critical perspectives on medical misinformation.

• Serial cervical length monitoring after LEEP procedures lacks evidence for improving outcomes despite being common practice
• SMFM's 2016 recommendation explicitly advises against routine cervical length screening for patients with history of cervical procedures
• Retrospective studies on induction timing require careful interpretation due to inherent biases in methodology
• Understanding the difference between intent-to-treat and per-protocol analysis is crucial when evaluating medical research
• Pseudoscience and alternative medicine have gained mainstream acceptance over decades through celebrity endorsements and media platforms
• Reusable surgical instruments like stainless steel uterine manipulators offer both economic and environmental advantages over disposable options
• Plus, Learn the history of The Green Journal's distinctive color

Be sure to check out thinkingaboutobgyn.com for more information and follow us on Instagram. We'll be back in two weeks.

00:00:35 Monitoring Cervical Length After LEEP

00:10:30 Understanding Intent-to-Treat Analysis

00:28:54 MAHA Movement and Medical Misinformation

00:53:49 Carbon Footprint of Uterine Manipulators

00:57:30 History of the Green Journal

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Cervical cancer represents a success story in developed countries due to screening and vaccination, yet remains a significant global health problem with over 340,000 deaths annually worldwide. We explore the current state of cervical cancer prevention, screening, and treatment while discussing exciting advances that could eventually eliminate this disease.

• Different levels of prevention for cervical cancer: primordial, primary, secondary, tertiary, and quaternary
• HPV vaccination as the most effective primary prevention method, with Australia on track to make cervical cancer rare by 2035
• Evolution from Pap smears to primary HPV testing, with potential future urine-based screening options
• Less radical surgical approaches for early-stage disease, improving quality of life without compromising outcomes
• Immunotherapy advances showing 6-12 month survival benefits in metastatic disease
• Howard Kelly's pioneering work with radium in the early 1900s, establishing foundations for radiation therapy
• Importance of addressing healthcare disparities, as rural Americans are 25% more likely to develop cervical cancer and 42% more likely to die from it

Visit our website at thinkingaboutobgyn.com for more information and follow us on Instagram for updates.

00:00:00 Introduction to Cervical Cancer

00:08:10 Prevention Strategies Explained

00:18:02 HPV Screening Evolution 

00:26:51Treatment of Early-Stage Disease

00:37:09Advances in Locally Advanced Disease

00:50:31 Radium and Howard Kelly's History

01:02:48 Final Thoughts on Prevention

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Howard and Antonia explore the evidence behind pit breaks in labor, cannabis use in pregnancy, and IUD options for hormone replacement therapy.

• Pit breaks in labor lack substantial evidence of benefit when used in active labor
• Current research suggests stopping oxytocin during active labor may slightly increase cesarean rates rather than decrease them
• Long pit breaks (up to 8 hours) in latent labor may be beneficial by allowing rest and promoting patience
• Recent systematic review shows prenatal cannabis use increases risk of low birth weight by 75%, preterm birth by 50%, and perinatal mortality by 29%
• Cannabis use during pregnancy (7.2% of pregnant women) now exceeds tobacco use
• Retrospective studies on doula care show association with better outcomes, but can't establish causation due to inherent differences in patients who seek doulas
• 52mg levonorgestrel IUDs (Mirena/Liletta) are suitable for endometrial protection during HRT, but evidence only supports use up to 5 years
• Most systematic reviews combine heterogeneous studies and shouldn't be considered level 1 evidence

We'd love to hear your questions! Send them to us through our Instagram or website thinkingaboutobgyn.com.

00:04:52 Pit Breaks in Labor

00:15:32 Examining Evidence on Oxytocin Discontinuation

00:26:08 Prenatal Cannabis Use and Adverse Outcomes

00:36:07 Doula Care Study Analysis

00:57:22 Levonorgestrel IUD Use in HRT

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Join Howard and Janeen Arbuckle for this discussion of pediatric and adolescent gynecology essentials. Pediatric and adolescent gynecology is a newer discipline bringing specialized care to young women with unique gynecologic needs, with a focus on counseling, education, and age-appropriate interventions.

• Abnormal uterine bleeding in adolescents is rarely caused by structural problems (unlike in adults) and typically relates to immaturity of the hypothalamic-pituitary-ovarian axis
• Hematologic workup should be considered for adolescents with heavy menstrual bleeding as this may be the first time their clotting system is challenged
• Hormonal therapies are safe to use once menarche has occurred, with no impact on bone growth
• Long-acting reversible contraceptives offer superior pregnancy prevention (1 in 10,000 for implants vs 8 in 100 for typical pill use) but require thoughtful counseling
• Private interviews with adolescent patients create trust while preparing them for independent healthcare navigation
• Tranexamic acid is effective for heavy menstrual bleeding in adolescents but pill size and frequency can limit compliance
• Most ovarian cysts in adolescents represent normal physiologic function and rarely require intervention
• Preservation of reproductive organs should be prioritized in adolescent surgery, including leaving ovaries after torsion when possible
• Vaginal bleeding in pre-pubertal girls requires assessment for secondary sexual characteristics to distinguish precocious puberty from other causes

00:00:00 Introduction to Pediatric Gynecology

00:07:20 Abnormal Uterine Bleeding in Adolescents

00:19:36 Contraception Choices for Young Patients

00:29:40 Managing Difficult Patient-Parent Conversations

00:38:04 Pelvic Pain and Endometriosis

00:46:58 Adnexal Pathology and Ovarian Issues

00:50:51 Congenital Anomalies and Vaginal Bleeding

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In this episode, Antonia and Howard explore the groundbreaking study on treating male partners for bacterial vaginosis, revealing significantly reduced recurrence rates and challenging our traditional understanding of BV pathophysiology.

Plus: 

• Evidence doesn't support treating mild gestational hypertension with antihypertensives
• Studies confirm acetaminophen in pregnancy doesn't cause ADHD or autism
• New research questions the benefit of routine postpartum thromboprophylaxis

• The history of heparin and coumadin

00:00:34 Treating Mild Hypertension in Pregnancy

00:06:14 Distinguishing Chronic vs. Gestational Hypertension

00:15:46 Male Partner Treatment for Recurring BV

00:27:09 Understanding Bacterial Vaginosis Pathophysiology

00:35:42 Ineffective Treatments and Alternative Approaches

00:53:04 Tylenol in Pregnancy: Debunking ADHD Claims

00:58:02 Postpartum Thromboprophylaxis: Evidence Against Overuse

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This episode features our favorite podcast ninja, Dr. Maddie White. She and Howard discuss how medical dramatizations misrepresent obstetric emergencies (yes, we are watching The Pitt). Then, we dissect evidence-based approaches to common triage scenarios including labor evaluation, rupture of membranes, and preterm labor assessment.

• Television shows like "The Pitt" and "ER" portray shoulder dystocia and postpartum hemorrhage inaccurately, lacking proper urgency and technique
• Hospital-based labor triage often costs approximately 10 times more than office-based evaluation, often without clinical benefit
• Understanding pretest probability fundamentally changes how test results should be interpreted for suspected rupture of membranes
• Most expensive tests like Amnisure (>$500) provide minimal additional value over traditional approaches when interpreted properly
• Evidence doesn't support routine use of fetal fibronectin testing in preterm labor evaluation
• We discuss universal cervical length screening for prevention of preterm labor in the midtrimester and later in pregnancy for evaluation of threatened preterm labor

00:00:53 Critiquing Obstetric Emergencies in TV Shows

00:10:13 Proper Management of Shoulder Dystocia

00:14:52 Postpartum Hemorrhage Management Approaches

00:19:59 Evaluating Term Labor Complaints

00:25:35 Rupture of Membranes Testing Strategies

00:34:12 Understanding Test Probability and Performance

00:42:26 Cervical Length Screening Evidence

00:51:23 Preterm Labor Triage Tools

01:00:23 Concluding Thoughts on Evidence-Based Practice

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Antonia Roberts and Howard Herrell review several new articles: 

• Epifoam for postpartum pain lacks evidence of effectiveness compared to simple ice packs while costing nearly $100 per unit
• AMH levels above 5.39 are associated with PCOS diagnosis, providing a specific threshold for clinical use
• External aortic compression demonstrated as a life-saving technique during severe obstetric hemorrhage
• Vaginal estrogen in breast cancer survivors shows no increased risk of cancer recurrence or mortality
• Delayed cord clamping in preterm twins reduces mortality by 30% and significantly decreases transfusion needs

Then they discuss new birth control options while questioning the value of expensive pharmaceutical products compared to established, less costly alternatives.

• New birth control options like Balcoltra ($280/month), FemLyv ($215/month), and Nextstellis ($250/month) offer minimal innovation over generic alternatives costing $10-15/month
• Marketing terms like "bioidentical" and "plant-based" are often misleading as all hormonal contraceptives are synthesized from plant precursors
• Progestin-only pills like Slynd provide only marginal DVT risk reduction (5 vs 4 per 100,000 person-years) compared to low-dose combined pills

Check our Instagram for more information and join us again in two weeks for our next episode.

00:00:00 Introduction and Epifoam Discussion

00:06:27 Financial Impact of Unnecessary Treatments

00:11:09 AMH Levels for PCOS Diagnosis

00:15:11 External Aortic Compression for Hemorrhage

00:20:22 Vaginal Estrogen and Delayed Cord Clamping

00:21:51 New Birth Control Products Overview

00:31:05 Analyzing Dissolvable Birth Control Pills

00:34:22 Slynd: Drosperinone-Only Pill Evaluation

00:42:09 Nextstellis and "Bioidentical" Estrogen Claims

00:56:37 History of Birth Control Development

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We discuss the pressing issues surrounding operative vaginal deliveries, including trends in their usage and the disparities impacting delivery outcomes. Join us as we navigate these critical insights with expert guests Jamie Perry and Howard Herrell, revealing the complexities and nuances surrounding forceps and vacuum deliveries.

• Examining the historical context of operative vaginal deliveries
• Analyzing the decline in forceps and vacuum usage since the 1990s
• Discussing the rise of cesarean deliveries as an alternative
• Revealing racial disparities adjacent to delivery practices
• Outlining effective techniques for both forceps and vacuum-assisted deliveries

Learn more about this pressing topic and gain valuable insights by listening to our episode.

00:00:00 ntroduction and Overview of the Episode

00:01:18 The Decline in Operative Vaginal Deliveries

00:05:24 Forceps

00:24:21 Vacuums

00:49:30 Advice For Trainees

00:55:38 Four Tips for Forceps and Vacuums

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This episode dives into the debate surrounding the efficacy and cost of barbed sutures in surgical practice, questioning whether their time-saving advantages are justified compared to traditional techniques, especially for uterine closure. Additionally, it explores the implications of non-invasive prenatal testing for cancer detection and recent maternal mortality statistics, while advocating for evidence-based practices in both surgical and obstetric care. 

• Analysis of barbed suture use and cost implications 

• Discussion of unexpected cancer detection via NIPS 

• Exploration of maternal mortality statistics and misconceptions 

• The relative value of baby (a discussion of the perverse economics of pediatric and obstetric care)

• Summary of recent findings on aspirin dosages for preeclampsia 

• Examination of venous thromboembolism risks with hormonal contraceptives

00:00:01 Barbed Suture in OBGYN Surgery

00:09:13 Comparing Surgical Sutures

00:17:11 NIPS Results and Maternal Cancer Detection

00:24:04 Maternal Mortality Trends and Data Analysis

00:38:50 Medical Reimbursements and Healthcare Priorities

00:47:20 Risk Factors in Birth Control Thromboembolism

00:54:37 Birth Control and Thromboembolism Risk

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