---

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https://www.backtable.com/app

---

Timestamps

00:57 - Introduction
02:22 - Mentorship Mission and Career Focus
06:13 - Social Media Referrals
08:10 - What Is Endo Surgery and Targeted Excision
13:27 - Multidisciplinary Care
16:53 - Lesions and Adhesions Approach
22:20 - Imaging and Case Triage
24:07 - Hysterectomy Expectations
27:28 - Going Solo on Bowel Endo
31:25 - Team Support and Mentors
34:27- Residency Training Gaps
40:39 - Call for Help Culture
43:07 - Challenging Surgeries
48:10 - Noninvasive Tests and Therapy Limits
51:26 - Conclusion

---

More about this episode

Dr. Ramirez discusses why endometriosis surgery varies by patient, pathology, and surgeon experience. She emphasizes careful symptom-based assessment, recognizing atypical lesions, and setting realistic expectations. The conversation contrasts radical peritoneal stripping with her preference for targeted excision to reduce complications, highlights multidisciplinary management for central sensitization and overlapping bowel/bladder symptoms, and covers imaging triage, robotic vs. laparoscopic approaches, collaborating with colorectal specialists, and diaphragmatic endometriosis as an ongoing surgical challenge.

---

BackTable OBGYN is the go-to podcast for gynecologists, gynecologic surgeons, and other healthcare professionals focused on women’s health.
Download the free BackTable app to get early access to new episodes, cases, and courses curated by physicians in your specialty.

► https://www.backtable.com/app

---

Get the BackTable app

https://www.backtable.com/app

---

Timestamps

00:00 - Introduction
01:15 - Dr. Chen’s Origin Story
06:34 - Coaching Framework
08:08 - Second Victim Phenomenon
10:10 - Four Phases Of Stress
15:07 - Managing OR Chaos
19:22 - Delegation as Surgeons
22:11 - Peer Review Programs
25:09 - How Coaching Programs Work
30:52 - Timeline After Complications
33:16 - Avoiding The Advice Trap
35:37 - Debriefing With Residents
40:51 - Future of Coaching and AI
47:13 - Resolution of Complic

---

More about this episode

Dr. Chen reflects on a serious complication during his fellowship that exposed an “emotional gap” in surgical training beyond technical solutions. This experience shaped his focus on psychological safety, crisis-management frameworks, and supportive coaching. He outlines the phases following an adverse event, from the initial chaos and cognitive overload to reflection, identity challenges, and resolution. Do these factors influence whether one experiences burnout, survival or growth.
This episode also recommends practical strategies such as focused breathing, effective delegation, and simulation training to improve performance under pressure. Dr. Chen discusses the “second victim” phenomenon, reviews data on surgeons’ emotional responses after complications, and emphasizes the importance of allowing time before debriefing. They advocate for peer support, non-punitive systems, and coaching programs to improve surgeon well-being, patient safety, and operating room efficiency. Finally, they explore future roles for AI and video review in surgical learning.

---

Resources

Medical error: the second victim. The doctor who makes the mistake needs help too
https://pubmed.ncbi.nlm.nih.gov/10720336/

Dare to Lead by Brené Brown
https://brenebrown.com/book/dare-to-lead/

Atlas of the Heart by Brené Brown
https://brenebrown.com/book/atlas-of-the-heart/

The Advice Trap by Michael Bungay Stanier
https://www.mbs.works/advice-trap-book/#purchase-options

---

BackTable OBGYN is the go-to podcast for gynecologists, gynecologic surgeons, and other healthcare professionals focused on women’s health.
Download the free BackTable app to get early access to new episodes, cases, and courses curated by physicians in your specialty.

► https://www.backtable.com/app

---

Get the BackTable app
https://www.backtable.com/app

---

Timestamps

00:00 - Introduction
03:06 - 2024 AUA/SUFU Idiopathic OAB Guideline
07:32 - Patient Experience with OAB
11:59 - Beta-3 Agonists vs Anticholinergics
15:15 - Botox Counseling and Dosing
18:11 - Tibial Nerve Stimulation
25:47 - Sacral Neuromodulation
32:09 - Cost Burden of OAB
39:38 - Evolution of OAB Care
41:39 - Future Research Directions

---

More about this episode

The conversation positions OAB as a clinical diagnosis, supported by focused initial evaluation and selective use of advanced testing, with attention to the emerging role of ambulatory urodynamics. Dr. Kim and Dr. Kapur review management across the care continuum, including behavioral strategies, pelvic floor physical therapy, and pharmacologic options, with consideration of beta-3 agonists in older patients. The discussion also focuses on earlier use of minimally invasive therapies such as intradetrusor Botox and neuromodulation, and how introducing these options sooner may improve follow-up, reduce delays, and help patients achieve symptom control more efficiently.

---

Resources

The AUA/SUFU Guideline on the Diagnosis and Treatment of Idiopathic Overactive Bladder (2024)
https://www.auanet.org/guidelines-and-quality/guidelines/idiopathic-overactive-bladder

Anticholinergic Drug Exposure and the Risk of Dementia
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2736353

Randomized trial of percutaneous tibial nerve stimulation versus Sham efficacy in the treatment of overactive bladder syndrome: results from the SUmiT trial

https://pubmed.ncbi.nlm.nih.gov/20171677/

Trends in Utilization of Sacral Neuromodulation for Overactive Bladder: Insight From the AUA AQUA Registry
https://www.auajournals.org/doi/10.1097/UPJ.0000000000000916

A retrospective longitudinal evaluation of new overactive bladder patients in an FPMRS urologist practice: Are patients following up and utilizing third-line therapies?
https://pubmed.ncbi.nlm.nih.gov/33197059/

---

BackTable OBGYN is the go-to podcast for gynecologists, gynecologic surgeons, and other healthcare professionals focused on women’s health.
Download the free BackTable app to get early access to new episodes, cases, and courses curated by physicians in your specialty.

► https://www.backtable.com/app

---

Get the BackTable app

https://www.backtable.com/app

---

This podcast is supported by

Natural Cycles
https://www.naturalcycles.com/

---

Timestamps

01:29 - Introduction
03:02 - Contraception Pain Points
06:16 - Natural Cycles Origin
09:46 - How The App Works
12:44 - Effectiveness And Variability
15:18 - Ideal Users And Red Days
17:34 - Modes Beyond Birth Control
19:19 - Clinical Insights From Data
22:04 - Future And Privacy
24:31 - Counseling And Adoption Tips
27:19 - Conclusion

---

More about this episode

Dr. Krauss shares her journey into tech and wearables and provides insights into the functionality, effectiveness, and future prospects of Natural Cycles, a digital contraceptive app. The discussion covers the utility of basal body temperature tracking, the unique features of the Natural Cycles algorithm, and real-world applications and user experiences. They also explore the broader implications and potential surrounding the integration of digital health tools into patient care, emphasizing the importance of meeting patients where they are.

---

Get the BackTable app

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Timestamps

01:17 - Introduction
03:35 - How Kaiser Works
07:24 - Research Using Big Data
09:19 - Changing Hysterectomy Culture
13:36 - Ending Racial Disparities
15:22 - Handling Large Uteri
17:52 - Vaginal Hysterectomy Trends
20:38 - Myomectomy Reintervention Rates
24:23 - Shared Decision Making
26:30 - Mini Lap Versus Robotic
27:41 - Hybrid Extraction Strategy
29:08 - Credentialing Robotic Myomectomy
30:19 - MIG Referral Pathways
32:03 - Fibroids Across Asian Subgroups
34:55 - Mentoring Research Pipeline
36:44 - Funding Analysts Through GME
40:49 - Endometriosis Disparities Findings
43:59 - Mentorship Mindset

---

More about this episode

Dr. Zaritsky describes how a coordinated, system-wide effort transformed hysterectomy care, shifting from 80% open procedures to nearly 90% minimally invasive within five to eight years through focused training, reducing low-volume practice, and tracking system metrics, ultimately decreasing racial disparities once minimally invasive rates exceeded 90%. She also highlights Kaiser-based research on variation in vaginal hysterectomy by service area and surgeon volume, long-term reintervention rates for fibroids across procedures, increasing use of minimally invasive myomectomy, and a JAMA analysis showing differences in fibroid diagnosis among Asian subgroups with the highest rates in South Asians. The episode concludes with Dr. Zaritsky calling attention to how Kaiser’s research infrastructure creates robust opportunities for meaningful mentorship across all levels of training, supporting the development of physicians, residents, and medical students.

---

Resources

Minimally Invasive Hysterectomy and Power Morcellation Trends in a West Coast Integrated Health System

https://pubmed.ncbi.nlm.nih.gov/28486359/

Racial Disparities in Endometriosis and Pelvic Pain Treatment Within an Integrated Health Care Delivery System

https://pubmed.ncbi.nlm.nih.gov/40839882/

Uterine Fibroid Diagnosis by Race and Ethnicity in an Integrated Health Care System
https://pubmed.ncbi.nlm.nih.gov/40172885/

---

Get the BackTable app

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---

Timestamps

00:00 - Introduction
01:37 - Why Hereditary Cancer Matters
04:51 - Family History Red Flags
09:01 - Who Should Order Genetic Testing
11:32 - Variants and Counseling Pitfalls
13:30 - Access and Remote Testing Options
19:27 - BRCA1 Positive Patient Walkthrough
24:52 - Risk-Reducing Surgeries
29:11 - Prevention and Screening Limits
32:38 - Why Ovarian Cancer Is Hard
34:04 - Combining Breast and Gyn Surgery
35:41 - Preop Ultrasound and CA-125
36:27 - BRCA Timing and HRT Nuance
42:32 - Nonhormonal Menopause Options
47:14 - Lynch Syndrome Screening Basics
54:22 - Endometrial Biopsy Debate
56:43 - Insurance and Coverage Pitfalls
59:00 - Fertility Preservation and REI
01:01:41 - Cascade Testing
01:02:45 - Conclusion

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More about this episode

Dr. Guo and Dr. Ciccone discuss how careful family history can identify patients who may benefit from genetic evaluation and highlight key red flags, including a family history of ovarian cancer, breast cancer at age 50 or younger, and metastatic prostate cancer. They explain the role of genetic counseling, including pre- and post-test discussions and how to approach variants of uncertain significance. They then cover BRCA counseling and risk-reduction strategies, including the timing of risk-reducing bilateral salpingo-oophorectomy, ongoing salpingectomy trials, and considerations for hysterectomy. Additionally, they touch on pathology protocols, breast cancer screening, and the potential protective effect of hormonal contraception.

The doctors address the limitations of ovarian cancer screening and outline patterns suggestive of Lynch syndrome, such as endometrial cancer occurring alongside gastrointestinal or urinary tract cancers. They review the Lynch workup, including tumor mismatch repair immunohistochemistry and MLH1 hypermethylation testing. Finally, they discuss practical considerations like barriers to access, Medicare coverage challenges, fertility preservation referrals, menopause management, and cascade testing in families, including the timing of testing in children.

---

Resources

NCCN Guidelines: Detection, Prevention, and Risk Reduction
https://www.nccn.org/guidelines/category_2

---

SYNPOSIS

Dr. Ackenbom shares her journey from studying finance at Ohio State to ultimately specializing in urogynecology. The conversation mainly focuses on perioperative cognitive health, particularly in aging populations, and how conditions like frailty and comorbidities impact surgical risk and recovery. Dr. Ackenbom highlights the importance of individualized patient care, early mobility, enhanced recovery protocols, and prehabilitation in improving postoperative outcomes. The episode also explores the prevalence of postoperative cognitive decline and offers practical insights on counseling and managing older patients undergoing urogynecologic surgery.

---

TIMESTAMPS

00:00 - Introduction
02:18 - Dr. Ackenbom’s Journey to Urogynecology
04:47 - Research on Brain Fog
06:18 - Personal Support and Hobbies
09:54 - Age vs Frailty in Surgery
13:05 - Procedures with Perioperative Complexity
16:11 - Counseling on Operative Risk
20:10 - ERAS and Earlier Discharge
23:35 - Patient Goals and Tradeoffs
27:53 - Surgical Clearance and Preop Consults
33:30 - Prehabilitation Basics
36:24 - Minimally Invasive Surgery Benefits
37:15 - Surgical Cognitive Complications with Age
41:42 - Finding the Surgery Window
46:05 - Cognitive and Frailty Screening
50:01 - Guidelines for Perioperative Care
52:52 - Future Research
54:07 - Conclusion

---

RESOURCES

Incidence of postoperative cognitive dysfunction in older women undergoing pelvic organ prolapse surgery
https://pubmed.ncbi.nlm.nih.gov/32827107/

ACS NSQIP/AGS Optimal Perioperative Care of the Geriatric Patient
https://www.facs.org/media/y5efmgox/acs-nsqip-geriatric-2016-guidelines.pdf

---

SYNPOSIS

The conversation covers detailed diagnostic methods like manometry and defecography, various surgical options, and the crucial role of pelvic floor physical therapy in patient recovery. They also provide insights into setting up effective multidisciplinary clinics and emphasize the need for teamwork and administrative support in delivering optimal patient care. This episode is a valuable resource for both specialists and generalists aiming to enhance their understanding and treatment of pelvic floor dysfunctions.

---

TIMESTAMPS

01:05 - Introduction
05:40 - Multi-Compartment Prolapse & Second Opinions
08:14 - Pelvic Floor Compartments Explained
10:36 - When Internal Prolapse Becomes Surgical
11:56 - Incomplete Emptying, Splinting, Fragmentation & Leakage
16:55 - Fluoro vs MRI and When to Order It
23:47 - Anorectal Manometry
26:56 - Physical Therapy, Biofeedback, Meds, Injections, & Motility Workup
29:08 - Robotic Mesh Repairs vs Vaginal/Perineal Approaches
34:43 - When (and Why) to Consider Biologics
36:46 - Resection Rectopexy
38:10 - Treating Ehlers-Danlos syndromes (EDS) & Eating Disorders
42:55 - Pelvic Floor PT After Surgery and Recovery Timelines
47:29- Perineal Prolapse Repairs (Altemeier vs Delorme)
49:53 - Symptom Improvement vs Retraining the 'New Normal'
52:20 - Fecal Incontinence & Sacral Neuromodulation
57:08 - Diarrhea-Driven Incontinence
58:56 - Building a Multidisciplinary Pelvic Floor Program
01:04:04 - Conclusion

---

RESOURCES

Pelvic Floor Disorders Consortium (American Society of Colon & Rectal Surgeons) https://fascrs.org/Web/Web/My-ASCRS/Education/Pelvic-Floor-Disorders-Consortium.aspx

---

SYNPOSIS

Dr. Salazar shares her introduction to hysteroscopy and the mentors who shaped her early training. She discusses her expertise in hysteroscopic surgery and its broad applications, with a focus on the complexities of Asherman syndrome, dysmorphic uteri, and the critical role of endometrial health assessment. The conversation also covers surgical techniques, post-operative care, and emerging technologies in hysteroscopic and reproductive care. Dr. Salazar concludes by emphasizing the need for improved classification systems for Asherman syndrome and future directions in reproductive health innovation.

---

TIMESTAMPS

00:00 - Introduction
05:34 - Training and Mentorship in Hysteroscopy
11:21 - Dr. Salazar's Practice and Techniques
14:00 - Challenges and Trends in Surgical Practices
18:58 - Referral Practices and Advanced Hysteroscopy
21:58 - Understanding Dysmorphic Uterine Population
24:08 - T-Shaped Uteri Description
26:09 - Hysteroscopic Metroplasty: Methods and Risks
29:17 - Innovations in Hysteroscopy
32:38 - Value of Ultrasound in Hysteroscopy
36:35 - Post-Operative Management and Estrogen Therapy
39:23 - Challenges and Future Directions in Hysteroscopy
44:23 - Concluding Thoughts

---

RESOURCES

The epidemiology, clinical burden, and prevention of intrauterine adhesions (IUAs) related to surgically induced endometrial trauma: a systematic literature review and selective meta-analyses
https://academic.oup.com/humupd/article/31/6/588/8248883

Hysteroscopy Newsletter
https://hysteroscopynewsletter.com/

---

SYNPOSIS

Dr. Aluru describes her experiences on various task forces, including the ACOG 75th Anniversary Task Force, and emphasizes the importance of education, advocacy, and community within the organization. She offers insights into the challenges and benefits of participating in ACOG, provides tips for getting involved, and highlights the ongoing efforts to address critical issues in women's health. The conversation also touches on adapting to the changes brought by the COVID-19 pandemic and the value of staying organized and connected in a demanding field.

Find out what ACOG is working on, how it benefits patient care, how it benefits provider education and resources, how it builds community. Get involved! Go to meetings! There are so many roles. If you don’t get your role on the first go, try again. Showing up is huge!

---

TIMESTAMPS

00:00 - Introduction
03:41 - Residency and Early Involvement in ACOG
07:29 - Advocacy and Government Affairs
18:40 - Balancing Professional and Organizational Work
24:28 - Listening to Members' Needs
26:36 - Challenges and Value of ACOG Membership
29:00 - The Importance of In-Person Meetings
34:45 - ACOG's Legislative Advocacy and Future Plans
35:48 - Advice for Getting Involved with ACOG
40:16 - Conclusion

---

RESOURCES

ACOG (American College of Obstetricians and Gynecologists)
https://www.acog.org/

ACOG CAARE Delegation https://www.acog.org/about/diversity-equity-and-inclusive-excellence/collective-action-strategy/caare-delegation

ACOG CREOG (Council on Resident Education in Obstetrics and Gynecology) https://www.acog.org/education-and-events/creog/about

---

SYNPOSIS

Dr. Kim’s educational journey began with medical school at Emory, followed by residency at Beth Israel Deaconess Hospital, and fellowship training at MGH. She discusses the founding of Fruits of Labor, which began with the Perry Peach—a warm compress device designed to reduce severe perineal tearing during childbirth and now acquired by Medicines360. Dr. Kim also talks about her creative process, the importance of addressing historically neglected areas in women's health, and the potential impact of her new project, Mellomallows, which aims to reduce discomfort during gynecological procedures such as IUD placement. The conversation concludes with a discussion of the challenges and opportunities in women's health innovation, the significance of supportive networks, and the role of passion and commitment in driving meaningful change.

---

TIMESTAMPS

00:00 - Introduction
02:03 - The Birth of PeriPeach: Addressing Severe Tearing
06:51 - New Medical Devices: Mellomallows
08:41 - The Creation and Mechanism of PeriPeach
11:11 - Company Development: Mentorship and Resources
17:37 - Pitching Practice and Experience
19:26 - Project Funding and Working with Medicines360
21:51 - Advice for Aspiring Innovators
23:52 - Concerns About AI in Healthcare
26:48 - Innovations in Women's Health
29:06 - Challenges in Academic Medicine
32:01 - The Importance of Female Innovators
34:00 - Forming a Startup in Women's Health
36:10 - Parting Advice for Future Innovators
37:37 - The Future of Women's Health Innovations
40:10 - Conclusion

---

RESOURCES

Fruits of Labor website:
https://www.fruitsoflabormed.com/home

PeriPeach website:
https://www.peripeach.com/

---

SYNPOSIS

Dr. Song, a veteran in the field with nearly 20 years of experience, shares her journey from Michigan to Duke, current treatments in fibroid management, and the importance of personalized care. The team explores new surgical techniques, the role of medical therapies such as Ella GnRH antagonists, and the importance of patient education. They also address challenges such as access to care, the significance of research funding, and the evolving understanding of fibroid genetics and long-term management. This episode provides a comprehensive overview of the state of fibroid care and the strides being made in this vital aspect of women's health.

---

TIMESTAMPS

00:00 - Introduction
02:21 - Evolution of Fibroid Treatment
05:50 - Advancements in Minimally Invasive Surgery
08:47 - Longitudinal Care and Personalized Treatment
13:00 - Modern Approaches to Fibroid Treatment
21:15 - New Technologies and Procedures
27:01 - Preoperative Assessment and Imaging
31:15 - Preoperative Counseling and Risk Assessment
33:14 - Medications for Fibroid and Endometriosis
37:59 - Challenges in Access to Care
38:43 - Racial Disparities in Fibroid Research
42:35 - The Importance of Specialized Care
49:22 - Future Directions in Fibroid Treatment

---

This podcast was developed in collaboration with:

Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU)
https://sufuorg.com/home.aspx

---

SYNPOSIS

The discussion revolves around the broad definition of vaginal rejuvenation, distinguishing between medical and cosmetic interventions. They address common misconceptions, the roles of different health professionals, and emphasize the importance of pelvic floor physical therapy and the appropriate use of systemic and vaginal estrogen therapy. The conversation also highlights critical gaps in research surrounding laser and radiofrequency interventions, underscoring the need for stronger evidence, clearer patient education, and continued advocacy around menopause care and sexual function.

---

TIMESTAMPS

00:00 - Introduction
02:11 - Defining Vaginal Rejuvenation
04:35 - Common Procedures and Misconceptions
10:04 - Insurance and Coverage of Procedures
12:04 - Laser and Radiofrequency Therapies
18:10 - Vaginal Estrogen and Lift of Black Box Warning
19:59 - The Role of Systemic Hormone Therapy
26:56 - Vaginal Rejuvenation Misconceptions
32:21 - Pelvic Floor Physical Therapy and Timing of Procedures
34:24 - Regional Variations in Therapeutic Availability
38:40 - Gender Inequity in Healthcare
40:16 - Final Thoughts

---

RESOURCES

Joint Report on Terminology for Cosmetic Gynecology
https://journals.lww.com/fpmrs/abstract/2022/06000/joint_report_on_terminology_for_cosmetic.2.aspx

---

SYNPOSIS

Dr. Christianson discusses her journey into the field of fertility preservation, inspired by an early encounter with a breast cancer patient. The conversation covers various aspects of fertility preservation, including the preservation of eggs, embryos, ovarian and testicular tissue, and planned fertility preservation. Dr. Christianson elaborates on the protocols, patient demographics, and the evolving collaboration between oncology and reproductive endocrinology. The discussion also highlights technologies like ovarian tissue transplantation and in vitro maturation, as well as practical tips for healthcare providers on improving patient access to fertility preservation services.

---

TIMESTAMPS

00:00 - Introduction
03:34 - Understanding Fertility Preservation
07:56 - Consultation Process for Fertility Preservation
17:36 - Advancements in Egg Freezing Technology
25:55 - Egg Freezing Recommendations
26:34 - Collaboration Between Oncology and REI
26:52 - Pediatric Oncology and Fertility Preservation
28:58 - Ovarian Tissue Transplantation
33:17 - Uterine Transposition Surgery
40:05 - Gene Editing and Fertility Preservation
43:01 - Financial and Emotional Aspects of Fertility Preservation
48:02 - Practical Advice for OBGYNs
51:12 - Resources and Final Thoughts

---

RESOURCES

Livestrong Fertility
https://livestrong.org/how-we-help/livestrong-fertility/

Resolve: The National Infertility Association
https://resolve.org/

Society for Assisted Reproductive Technology
https://www.sart.org/

American Society for Reproductive Medicine
https://www.asrm.org/

---

SYNPOSIS

They cover Dr. Moore's journey into expert witness work, including how the pandemic shifted her career focus and ultimately led to the creation of a platform to assist OBGYNs in navigating legal cases. They discuss the challenges of managing extensive medical records, the importance of adhering to the standard of care, and the unique nature of obstetrics cases. They also emphasize the need for precise, evidence-based report writing to avoid unnecessary trials and address the emotional and financial toll legal processes can take on physicians. Finally, the episode explores the need for better systems to protect both patients and healthcare providers while offering insight into future challenges, including AI and private equity involvement in legal cases.

---

TIMESTAMPS

00:00 - Introduction
05:08 - First Experiences in Medical-Legal Work
08:57 - The Role of Education in Legal Cases
11:37 - Challenges and Rewards of Medical-Legal Work
13:58 - Understanding Standard of Care and Malpractice
15:59 - The Importance of Detailed Reports and Depositions
20:02 - The Jury System and Its Challenges
25:45 - Balancing Professional and Personal Life
29:43 - Getting Started in Medical-Legal Work
32:07 - Recognizing Patterns in Medical Litigation
33:51 - Educating Attorneys for Fair Trials
36:33 - Concerns and Improvement of Medical Expert Testimonies
45:54 - The Role of Systems in Reducing Medical Errors
51:52 - Future Challenges and Opportunities in Medical Legal Work
56:07 - Final Thoughts

---

RESOURCES

ACOG Technical Bulletin 365: Seeking and Giving Consultation
https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2007/05/seeking-and-giving-consultation

MooreExperts OBGYN Consulting Medical Legal Expert Witness Masterclass
https://www.mooreexperts.com/

Bless This Mess: A Picture Story of Healthcare by Dr. Stephen Klasko
https://www.amazon.ae/Bless-This-Mess-Picture-Healthcare/dp/1483479625

---

SYNPOSIS

Dr. Singh shares his extensive career journey, from his education in Canada and Australia to his current role as department chair of OBGYN at the Ottawa Hospital. The conversation delves into the integration of MIGS into obstetric surgery, including procedures like laparoscopic cerclages, placenta accreta management, and cesarean scar pregnancies. The hosts and guest discuss the challenges and importance of building a robust team, regionalization of care, maintaining work-life balance, and the eventual transition of leadership roles to sustain the high standards of care. This episode highlights the crucial role of minimally invasive specialists in advancing OBGYN practices while promoting a sustainable work culture.

---

TIMESTAMPS

00:00 - Introduction
02:08 - Dr. Singh’s Journey
07:37 - The Role of MIG Surgeons in Obstetrical Surgery
16:06 - Building a Collaborative Team
18:38 - Challenges and Best Practices
25:26 - Expanding the Scope of MIG Surgeons
30:19 - The Evolution of Urogynecology and MIGS
31:31 - Leadership and Building Programs
37:54 - Scaling Up and Regionalization of Care
42:53 - Balancing Work and Personal Life
54:37 - Concluding Thoughts

---

RESOURCES

Canadian Society for Advancement of Gynecologic Excellence
https://cansage.org/about/

From Strength to Strength, by Arthur Brooks
https://www.arthurbrooks.com/books

---

SYNPOSIS

Dr. Dahlman begins by sharing her career path and fellowship experience before the conversation expands to explore the shift from MIGS (Minimally Invasive Gynecologic Surgery) to CBG (Complex Benign Gynecology), current reimbursement challenges, the difficulty of balancing obstetric and gynecological practice, and how these forces influence training and clinical life. They also discuss the stressors new graduates face while building viable practices, broader healthcare system challenges, resource allocation, and potential solutions to improve practice sustainability and patient care.

---

TIMESTAMPS

00:00 - Introduction
03:06 - Fellowship Training and Career Pathways
11:43 - Impact of Reimbursement on Fellowship Applications
15:20 - Workforce Issues and Future of GYN Surgery
28:02 - Advocacy and Leadership in Healthcare
29:27 - Understanding Hospital Revenue and Efficiency
31:54 - The Role of Physician Leadership in Healthcare
35:35 - Navigating Healthcare System Mergers
36:47 - The Future of Healthcare Amidst Financial Cuts
41:40 - Addressing Healthcare Costs and Reimbursement
45:11 - The Importance of Women's Health Services
47:37 - Strategies for Improving Healthcare Systems
53:48 - Concluding Thoughts

---

RESOURCES

Trends in gynecologic surgery reimbursement and physician pay
https://pubmed.ncbi.nlm.nih.gov/40305043/

---

SYNPOSIS

The conversation delves into the management of TOAs, both non-ruptured and ruptured, and the underexplored connection to the female reproductive tract microbiome. They also touch on the integration of AI in clinical practice, particularly in streamlining administrative tasks. The episode underscores the need for updated guidelines and more research into the microbiological aspects of TOAs to improve patient outcomes.

---

TIMESTAMPS

00:00 - Introduction
02:20 - Understanding TOAs: Early Interventions and Challenges
04:43 - Clinical Management of TOAs
08:06 - Surgical Approaches and Considerations
22:25 - Microbiome and Infection Insights
32:10 - Discussing Patient Reactions and Education
32:47 - Teaching Practices and Medical Education
34:18 - Clinical Observations and Data
36:55 - Surgical Management of Ruptured TOAs
40:50 - Challenges in Treating Infected Endometriomas
50:13 - Exploring the Role of AI in Medical Practice
54:23 - Concluding Remarks

---

RESOURCES

ACOG Recommends Concurrent Sexual Partner Treatment for Recurrent Bacterial Vaginosis for the First Time
https://www.acog.org/news/news-releases/2025/10/acog-recommends-concurrent-sexual-partner-treatment-recurrent-bacterial-vaginosis-first-time

Strange Bedfellows, Ina Park MD, MS
https://www.inapark.net/the-book

---

SYNPOSIS

The conversation explores the management of endometriosis and fibroids, the use of office hysteroscopy, and the intricacies of hysteroscopic and laparoscopic procedures. Dr. Robinson covers the importance of individualized patient care, the latest advancements in reproductive technology, and insights from his unique career blending academic medicine with a focus on enhancing fertility outcomes. Listeners will gain a comprehensive understanding of the critical role surgical interventions play in reproductive endocrinology and the nuanced approach required to optimize patient outcomes.

---

TIMESTAMPS

00:00 - Introduction
05:17 - Understanding Reproductive Surgery
08:51 - Hysteroscopy in Reproductive Surgery
16:28 - Endometriosis and Infertility
23:50 - Diagnosing and Treating Adenomyosis
28:10 - Surgical Interventions for Reproductive Health
33:52 - Balancing Endometrioma Removal and Fertility
35:49 - Surgical Approaches and Patient Goals
36:46 - Complexities of Fertility Consultations
42:48 - Impact of Fibroids on Reproductive Health
45:33 - Adhesion Prevention in Myomectomy
48:33 - Innovations in Fibroid Ablation
52:10 - Understanding Isthmoceles and Their Impact
58:11 - Concluding Thoughts

---

RESOURCES

ReceptivaDx: What does it mean to test positive for high levels of bcl6
https://receptivadx.com/what-does-it-mean-to-test-positive-for-high-levels-of-bcl6/

Impact of hysteroscopic surgery for isthmocele associated with cesarean scar syndrome: https://pubmed.ncbi.nlm.nih.gov/28892298/

The discussion covers the roles of advanced imaging techniques like MRI and ultrasound, the importance of pre-surgical planning, and the need for multidisciplinary collaboration. They share their approach to managing symptomatic and asymptomatic patients, the use of hormonal treatments, and the significance of monitoring potential malignant transformations in endometrioma cases. The episode underscores the critical role of imaging in planning effective surgical interventions for patients while highlighting the progression of endometriosis management protocols.

TIMESTAMPS

00:00 - Introduction 

01:07 - Discussing Endometriosis Management

02:18 - Imaging Techniques and Their Importance

04:24 - Interdisciplinary Collaboration

05:40 - Advanced Imaging Protocols

08:12 - Monitoring and Follow-Up Strategies

08:50 - Concerns About Malignancy

11:04 - Future Directions

CHECK OUT THE FULL EPISODE

OBGYN Ep. 69

https://www.backtable.com/shows/obgyn/podcasts/69/imaging-protocols-to-guide-endometriosis-treatment

The discussion covers the roles of advanced imaging techniques like MRI and ultrasound, the importance of pre-surgical planning, and the need for multidisciplinary collaboration. They share their approach to managing symptomatic and asymptomatic patients, the use of hormonal treatments, and the significance of monitoring potential malignant transformations in endometrioma cases. The episode underscores the critical role of imaging in planning effective surgical interventions for patients while highlighting the progression of endometriosis management protocols.

TIMESTAMPS

00:00 - Introduction 

01:07 - Discussing Endometriosis Management

02:18 - Imaging Techniques and Their Importance

04:24 - Interdisciplinary Collaboration

05:40 - Advanced Imaging Protocols

08:12 - Monitoring and Follow-Up Strategies

08:50 - Concerns About Malignancy

11:04 - Future Directions

CHECK OUT THE FULL EPISODE

OBGYN Ep. 69

https://www.backtable.com/shows/obgyn/podcasts/69/imaging-protocols-to-guide-endometriosis-treatment

---

SYNPOSIS

Dr. Rachel Rubin shares her career journey, expertise in sexual health, and the critical role of hormone replacement therapy (HRT) in managing menopause. She addresses common challenges and misconceptions, particularly around estrogen use, by demystifying the Women’s Health Initiative studies and emphasizing the proven safety and benefits of systemic and vaginal HRT. Dr. Rubin offers practical guidance on prescribing estrogen, progesterone, testosterone, and DHEA, while highlighting her advocacy to remove outdated FDA black box warnings on vaginal estrogen. Through personal anecdotes and professional insights, she empowers practitioners with evidence-based strategies and underscores the importance of education and research in advancing women’s health.

---

TIMESTAMPS

00:00 - Introduction
03:41 - Challenges in Menopause Medicine
07:21 - Misconceptions and Risks of HRT
15:35 - Understanding Bioidentical Hormones
18:48 - WHI Studies and Their Impact
23:21 - Practical Guide to Prescribing HRT
33:47 - Understanding Estrogen Levels and Risks
36:04 - Debating Gels vs. Patches
37:51 - Concerns with Compounded Products and Pellets
38:50 - Patient Education and Meeting Them Where They Are
42:12 - Progesterone Benefits and Sensitivities
46:38 - Testosterone Therapy for Women
51:36 - The Importance of Lab Tests
55:39 - DHEA and Vaginal Health
57:14 - Advocacy for Accurate Hormone Therapy Information
01:00:05 - Conclusion and Final Thoughts

---

RESOURCES

The Peter Attia Drive episode with Dr. Rachel Rubin:
https://peterattiamd.com/rachelrubin/

FDA Expert Panel on Menopause and Hormone Replacement Therapy for Women:
https://www.youtube.com/live/_2ZRlOivC5M?si=-Xynb_BmWz2sWf4m
Dr. Rachel Rubin’s Hormone Therapy for Early Adopters Course:
https://rachelrubinmd.thinkific.com/courses/MHTCME

They explore how hospitals have leveraged billing structures for financial gain, often driving up patient costs, and highlight how procedures like hysteroscopies and endometrial ablations can be performed more efficiently and cost-effectively in office settings. The conversation also touches on how insurance companies and healthcare policy shape both patient expenses and physician practice. Dr. Levy emphasizes the importance of understanding the broader healthcare system to effectively advocate for positive changes in patient care and outcomes.

TIMESTAMPS

00:00 - Introduction

00:48 - Hospital Lobbying and Facility Fees

02:43 - Impact on Patients and Physicians

04:06 - Insurance Companies and Healthcare Economics

08:34 - Office vs. ASC vs. Hospital Procedures

12:59 - Cryoablation and Patient Experience

14:53 - Conclusion and Final Thoughts

CHECK OUT THE FULL EPISODE

OBGYN Ep. 55

https://www.backtable.com/shows/obgyn/podcasts/55/insights-on-obgyn-coding-reimbursements 

The way you code and calculate costs might be affecting your practice more than you realize. In this episode of BackTable OBGYN, hosts Dr. Mark Hoffman and Dr. Amy Park welcome back Dr. Barbara Levy, a clinical professor at George Washington University and UCSD. They discuss the complexities of practice expenses and coding in medical specialties, emphasizing the differences between direct and indirect expenses which vary by geography and specialty. 

The conversation covers the challenges in surveying costs, the importance of accurate representation in surveys, and the strategic implications of coding. They also touch on the complications arising from procedure revaluation and the impact of site-of-service on reimbursements.

TIMESTAMPS

00:00 - Introduction 

00:48 - Understanding Practice Expenses

02:28 - Survey Challenges and Fraud Concerns

03:19 - Valuation of Medical Procedures

07:39 - Impact of Code Changes on Payments

11:01 - The Complexity of Medical Coding

15:18 - Site of Service and Facility Fees

CHECK OUT THE FULL EPISODE

OBGYN Ep. 55

https://www.backtable.com/shows/obgyn/podcasts/55/insights-on-obgyn-coding-reimbursements

Every procedure has a price, but how is it set? In this BackTable OBGYN Brief, Dr. Mark Hoffman and Dr. Amy Park welcome back Dr. Barbara Levy, a clinical professor at George Washington University and UCSD, to discuss her work with the key organizations influencing medical billing and reimbursement.

They explore Dr. Levy's extensive involvement with ACOG, AMA's CPT Editorial Panel, and the RBRVS Update Committee (RUC), offering an overview of the complex systems governing coding and reimbursement in medicine. From how new procedures receive codes to the financial impact on physicians, this brief offers valuable insights for OBGYN practitioners navigating the world of medical billing and coding.

TIMESTAMPS

00:00 - Introduction 

00:48 - Personal Anecdotes and Career Beginnings

02:01 - Understanding Medical Reimbursement

03:17 - Roles and Responsibilities in Medical Committees

05:34 - The Coding Process Explained

09:16 - The Role of the RUC and CPT Editorial Panel

15:16 - RVUs and Practice Expenses

17:48 - Final Thoughts

CHECK OUT THE FULL EPISODE

OBGYN Ep. 55

https://www.backtable.com/shows/obgyn/podcasts/55/insights-on-obgyn-coding-reimbursements

---

SYNPOSIS

Dr. Casperson breaks down the differences between the hormones used in WHI and the safer, more targeted options available today. The conversation explores the broad benefits of modern HRT, including reduced risks of cardiovascular disease, osteoporosis-related fractures, and even dementia. Beyond the science, the episode also addresses the urgent need for better medical education and updated guidelines around menopause care.
Dr. Casperson and Dr. Sutherland make the case for empowering patients through informed consent and better clinician training. They also discuss Dr. Casperson’s upcoming book, The Menopause Moment, which aims to equip women with the tools and knowledge to navigate this life stage with confidence.

---

TIMESTAMPS

00:00 - Introduction
02:50 - Focus on Menopause and Hormone Replacement Therapy
04:20 - The Women's Health Initiative (WHI) Study
05:39 - Understanding Risks and Misconceptions
12:43 - Reevaluation of the Women’s Health Initiative Study
18:31 - Impact of Media and Physician Education
19:58 - Current State of Hormone Therapy
22:17 - Broader Implications and Future Directions
27:17 - Evaluating FDA Warnings and Gender Bias in Hormone Treatments
29:49 - The Impact of Hormone Therapy on Women's Health
32:11 - Risks of Not Using Hormones
35:44 - Hormones and Brain Health: Debunking Myths
40:41 - The Timing Hypothesis and Long-Term Hormone Use
46:32 - Advocacy and Education for Menopause Awareness
48:04 - Conclusion and Upcoming Resources

---

RESOURCES

PBS: The M Factor: Shredding the Silence on Menopause:
https://www.pbs.org/show/the-m-factor-shredding-the-silence-on-menopause/

The Menopause Moment by Dr. Kelly Casperson: https://kellycaspersonmd.com/the-menopause-moment-book/

Systematic review and meta-analysis of the effects of menopause hormone therapy on risk of Alzheimer's disease and dementia:
https://pmc.ncbi.nlm.nih.gov/articles/PMC10625913/

---

SYNPOSIS

They explore the historical context and far-reaching influence of the 1990s Women’s Health Initiative (WHI) study, asserting that its misinterpretation continues to shape misconceptions and hinder effective menopause care. The discussion highlights recent data refuting the risks associated with vaginal estrogen therapies and underscores the urgent need for updated, evidence-based guidelines to support women throughout menopause. Dr. Santiago-Lastra also draws attention to gender-based inequities in hormone treatment, the robust evidence contradicting the current black box warning, and the multi-faceted advocacy required to bring about change. This episode is part of a broader series focused on various aspects of menopause.

---

TIMESTAMPS

00:00 - Introduction
02:01 - Menopause Series Overview
03:55 - History of the Black Box Warning on Estrogen
07:26 - Understanding the Black Box Warning
12:11 - The Citizen's Petition and FDA Process
18:11 - Gender Inequity in Medical Treatment
22:45 - Factors Resulting in Gender Inequity
29:02 - Genital Urinary Syndrome of Menopause (GSM)
29:32 - Benefits of Vaginal Estrogen
33:33 - Legislative Advocacy and Medicare
34:43 - Professional and Patient Advocacy
36:35 - Challenges and Progress in Label Change
43:35 - Historical Context and Gender Equity
45:07 - Recap and Future Directions

---

SYNPOSIS

Dr. Mustafa elaborates on the intricacies of fetal interventions, including procedures for complications in monochorionic twins, spina bifida repair, and new emerging therapies. They also touch on research methodologies like the Delphi consensus technique and summarize key findings from recent studies on conditions such as hemolytic disease, gastroschisis, lower urinary tract obstructions, and preterm birth in twin pregnancies. Dr. Mustafa shares insights on how to stay sharp in the field, the importance of teamwork in surgical procedures, and advice for those aspiring to enter the field of fetal therapy.

---

TIMESTAMPS

00:00 - Introduction
02:45 - The Role of a Fetal Interventionalist
04:00 - Dr. Mustafa’s Training Journey
07:42 - Fetal Surgery Fellowships
16:43 - Conditions Treated by Fetal Interventionalists
21:17 - Monitoring and Referrals for Monochorionic Twins
30:04 - Understanding Percutaneous Procedures
31:10 - Navigating the Equator in Fetal Surgery
32:31 - Laser Surgery Techniques and Outcomes
33:18 - The Importance of Placenta Delivery
33:47 - In Utero Spina Bifida Repair
36:19 - Minimally Invasive Techniques for Spina Bifida
38:28 - Maintaining Skills in Fetal Interventions
42:11 - Delphi Consensus Technique in Medical Research
46:19 - Key Takeaways from Recent Research
51:55 - Future of Fetal Therapy and Personal Insights

---

SYNPOSIS

The conversation highlights the importance of anatomical knowledge, thinking beyond conventional surgical approaches, and the significance of teamwork and efficiency in the operating room. A central focus is placed on the development and application of single-port techniques, highlighting the associated learning curves and the evolving role of robotic surgery. The discussion also explores how surgical team dynamics, effective communication, and ongoing innovation collectively contribute to better patient outcomes and advancement in the medical field.

---

TIMESTAMPS

00:00 - Introduction
03:50 - Pioneering Single Port Laparoscopy
10:10 - Challenges and Advantages of Single Port Surgery
13:52 - Cosmetic Considerations and Incision Techniques
27:27 - Innovative Approaches and Future Directions
30:40 - Understanding 3D Anatomy in GYN Surgery
32:10 - Sustaining Innovation in Urogynecology
33:53 - Efficiency in Surgical Procedures
39:20 - Advancement of Surgical Educational Materials
42:47 - Single Port and Robotic Procedures
50:50 - Building a Team through Positive Surgical Culture
01:02:13 - Continuous Improvement and Humility in Surgery

---

SYNPOSIS

The discussion covers the development and benefits of monthly multidisciplinary conferences that include gynecologists, radiologists, colorectal, urologic, and thoracic surgeons. The conferences aim to improve preoperative planning, intraoperative accuracy, and postoperative care through detailed imaging techniques, primarily MRI. They also highlight the importance of educating fellows and colleagues, the role of ultrasound screening, and future directions like AI and PET imaging. The episode emphasizes the challenges and rewards of treating endometriosis and fostering better patient outcomes through teamwork and innovation.

---

TIMESTAMPS

00:00 - Introduction

01:55 - The Journey to Specialization

07:02 - Building a Multidisciplinary Team

15:07 - The Value of Postoperative Reviews

22:49 - Patient Counseling and Personalized Care

29:36 - Challenges in Endometriosis Treatment

31:00 - Educating Beyond the Clinic

33:05 - Innovations in Imaging

46:22 - Future Directions in Endometriosis Research

53:15 - Conference Highlights and Final Thoughts

---

RESOURCES

Recommendations for MRI technique in the evaluation of pelvic

endometriosis: consensus statement from the Society of Abdominal

Radiology endometriosis disease‑focused panel:

https://drive.google.com/file/d/1VRBpw5V3AH-rWGEG43K1CMCx2flCXl2M/view?usp=sharing

---

SYNPOSIS

Dr. Anderson begins by detailing the history of abnormal uterine bleeding alongside the evolution of the endometrial ablation techniques that have been used to treat it. Shifting focus to current day practice, he then shares his approach to endometrial ablation, covering patient selection and the technical aspects of his approach.

Throughout the conversation, Dr. Anderson emphasizes the importance of how we define success in endometrial ablation, explaining that eumenorrhea (normal bleeding that no longer interferes with life events) is the goal, as opposed to the more traditional view that amenorrhea is the target outcome. The episode closes with a discussion on the role of alternative treatments, such as the Mirena IUD and hysterectomy for abnormal uterine bleeding.

---

TIMESTAMPS

00:00 - Introduction

09:29 - History of Abnormal Uterine Bleeding and Endometrial Ablation

23:31 - Evolution of Endometrial Ablation Devices/Techniques

31:11 - Selecting the Right Patient for Ablation Success

34:38 - Post-Tubal Sterilization Ablation Syndrome

38:27 - The Role of IUDs in Managing AUB

44:07 - Reevaluating Endometrial Ablation Success Metrics

49:55 - Innovative Ablation Techniques: Cryoablation and Steam

51:48 - Adenomyosis and Fertility-Sparing Treatments

57:28 - Final Thoughts

---

SYNPOSIS

The surgeons delve into the critical importance of understanding anatomy and ensuring proper exposure during surgeries, particularly the challenges and techniques for operating during pregnancy. Key discussions include the use of liver retractors, the management of symptomatic ovarian cysts, and the methods for performing and evaluating abdominal cerclages. They also explore the physiological changes in pregnant patients and the adjustments needed for anesthesia, laparoscopic entry, pressures during surgery, and pre/post-operative care.

---

TIMESTAMPS

00:00 - Introduction

07:20 - Laparoscopy in Pregnant Patients

11:23 - Common Surgeries During Pregnancy

15:56 - Laparoscopic Surgery Techniques

24:04 - Physiologic Changes in Pregnancy

27:33 - Access Methods and Pressure Considerations

28:53 - Managing Torsion and Cysts in Pregnancy

30:21 - Energy Use and Safety in Pregnant Patients

31:38 - Preoperative and Postoperative Care

34:15 - Cerclage Procedures and Counseling

47:46 - Professional Reflections and Conclusions

---

SYNPOSIS

The doctors cover financial incentives and constraints faced by hospitals in the US vs. Canada, the role of insurance companies, and how resource limitations impact clinical practice. Dr. Solnik shares insights from his career journey, emphasizing the challenges and opportunities he has encountered in Canada, including longer wait times for elective surgeries and the intricacies of the Canadian global budget system. The conversation also covers the impact of robotics in surgery, standardization of care, and the differences in the handling of high-acuity medical cases. The episode provides an insightful discussion on how different healthcare models affect patient care, physician practices, and hospital administration.

---

TIMESTAMPS

00:00 - Introduction

01:39 - Dr. Solnik’s Career Journey

03:30 - Healthcare System Differences: US vs Canada

09:57 - Balancing Quality and Volume in Healthcare

12:18 - Private Practice in Canada

25:03 - Wait Times and Capacity Issues

34:44 - Oncology and Semi-Salaried Positions

39:03 - Negotiating CPT Codes and RVUs

42:14 - Access to Care in Remote Areas

44:42 - Robotics in Surgery

55:09 - Incentives and Productivity in Healthcare Systems

01:01:33 - Concluding Thoughts

Key topics include what to look for during a pelvic exam, the importance of external skin inspection, prolapse evaluation, urethra assessment, and pelvic floor muscle strength testing. The doctors also address effective treatment options, the necessity (or lack thereof) of specific diagnostic tests, the significant role of bladder diaries, and the benefits of pelvic floor physical therapy. Practical advice for behavioral management, therapy for stress and urgency incontinence, and the reasons for structured evaluation methodologies are also highlighted.

TIMESTAMPS

00:00 - Introduction

00:30 - Conducting a Thorough Pelvic Exam

02:45 - Evaluating Pelvic Floor Muscle Strength

04:28 - Initial Diagnostic Workup

06:07 - The Role of Bladder Diaries

09:49 - Treatment Algorithms for Urinary Incontinence

15:03 - Conclusion

CHECK OUT THE FULL EPISODE

OBGYN Ep. 61: Evaluating Female Urinary Incontinence: Essential Steps for the Generalist

https://www.backtable.com/shows/obgyn/podcasts/61/evaluating-female-urinary-incontinence-essential-steps-for-the-generalist

The conversation dives into the different types of incontinence, including stress, urgency, mixed, and overflow incontinence, and the importance of accurate diagnosis and appropriate treatment plans. The discussion also emphasizes essential diagnostic steps, including urinalysis and measuring post-void residuals, and points out the importance of patient education and expectation management.

TIMESTAMPS

00:00 - Introduction

00:30 - Prevalence of Female Urinary Incontinence

01:25 - Impact on Quality of Life

03:01 - Types of Urinary Incontinence

07:35 - Diagnostic Approaches

CHECK OUT THE FULL EPISODE

OBGYN Ep. 61: Evaluating Female Urinary Incontinence: Essential Steps for the Generalist

https://www.backtable.com/shows/obgyn/podcasts/61/evaluating-female-urinary-incontinence-essential-steps-for-the-generalist

---

SYNPOSIS

The doctors cover the importance of high-functioning teams, the unexpected challenges of hospital administration, and the impact of clinical experience on decision-making. Additionally, they explore the broader responsibilities and skill sets required for effective leadership in a hospital setting, and offer advice for others considering a similar career shift. Dr. Hoffman emphasizes the value of servant leadership, the benefits of focusing on strengths, and the necessity of building strong, resilient teams.

---

TIMESTAMPS

00:00 - Introduction

05:16 - Transitioning to Hospital Administration

07:17 - Balancing Workload

10:33 - Teamwork and Leaning into Strengths

13:30 - Decision Making in Administration

26:20 - Unique Challenges for OBGYNs in Hospital Administration

31:48 - Engagement in Leadership

35:03 - Focusing on People to Improve Patient Care

44:18 - Building Effective Leadership Teams

45:25 - Transitioning to Hospital Administration

52:07 - Finding Joy in Leadership and Mentorship

---

SYNPOSIS

Dr. Mikhail shares his journey from medical school in Egypt to his current expertise in deep endometriosis surgery in Tampa, Florida. The conversation covers preoperative evaluation, the importance of understanding patient history, and surgical approaches for complex cases. He emphasizes the need for multidisciplinary collaboration, advanced imaging, and specialized surgical techniques to ensure optimal patient outcomes.

---

TIMESTAMPS

00:00 - Introduction

05:52 - The Role of Hysterectomy in Endometriosis

08:58 - The Role of Ovaries in Endometriosis

11:12 - Surgical Techniques and Considerations

18:11 - Evaluating Deep Endometriosis

24:32 - Post-Hysterectomy Pain and Symptoms

31:26 - Surgical Approaches Post-Hysterectomy

39:49 - The Importance of Continuous Learning

43:09 - Scar Tissue vs. Lesion

51:47 - Comprehensive Preoperative Assessment

53:59 - Conclusion and Final Thoughts

---

SYNPOSIS

Dr. Brown shares her journey from Nigeria to the United States, detailing her path from middle school teacher to a leading advocate in diversity, equity, and inclusion (DEI) within the medical field. The conversation touches on systemic barriers in healthcare, the impact of historical practices like redlining, and practical steps institutions can take to foster a culture of equity. Dr. Brown emphasizes the importance of sustained engagement, multi-level interventions, and action-oriented solutions to create a more diverse and inclusive medical workforce.

---

TIMESTAMPS

00:00 - Introduction

05:44 - Equity in OBGYN: Workforce and Patient Care

08:41 - Advocacy for Medication Access

15:25 - Systemic Barriers and Social Determinants of Health

20:22 - Understanding Redlining and Its Impact

25:10 - Efforts to Address Inequities

34:14 - Equity and Diversity in Healthcare

36:39 - The Role of Leadership in Promoting Equity

44:08 - AI and Technology in Addressing Gaps

50:00 - Vision for a More Equitable Future

58:26 - Final Thoughts and Encouragement

Female sexual wellness is a topic that deserves more research, education, and attention, both for our patients and for providers. In this BackTable OBGYN Brief, Dr. Kelly Casperson speaks with host Dr. Suzette Sutherland about a range of issues related to women's sexual health.

The conversation highlights the disparities between men's and women's sexual health resources and focuses on the gaps in sex education, communication, and healthcare training. Dr. Casperson emphasizes the biological, psychological, and social aspects of female sexual dysfunction and draws attention to the lack of adequate research and resources for women. The episode explores the importance of understanding the clitoris, the biases in sexual pleasure, and the role of informed consent in surgical procedures affecting sexual function. These insights aim to destigmatize female sexual health issues and promote better awareness and education.

TIMESTAMPS

00:00 - Introduction

00:24 - Challenges in Women's Sexual Health

01:01 - Sex Education, Communication Gaps, and Bias

02:29 - Prevalence and Misconceptions

03:23 - Education about Clitoral Stimulation

03:59 - Impact of Medications and Relationships

07:16 - Orgasm Gap and Pleasure Inequality

09:23 - Understanding the G-Spot and Clitoral Anatomy

10:35 - Sling Surgery and Sexual Function

CHECK OUT THE FULL EPISODE

OBGYN Ep. 44: https://www.backtable.com/shows/obgyn/podcasts/44/urologys-role-in-advancing-female-sexual-health

The discussion focuses on the importance of reducing opioid use in women's health through various strategies, including the use of Exparel and ERAS protocols. Dr. McCarus and Dr. Bilica share compelling arguments for covering costs and enhancing patient satisfaction, and also touch on hospital administration's role in adopting non-opioid analgesics. The doctors emphasize the need for a team approach and the presence of a dedicated champion to advocate for better pain management practices in women's health.

TIMESTAMPS

00:00 - Introduction

00:44 - Advocating for Better Pain Management

02:09 - Opioid Use and Women's Health

04:45 - Benefits and Safety of Exparel

07:03 - Team Approach to Pain Management

08:12 - ERAS Protocols and Exparel

12:45 - Getting Healthcare Administration Buy-In

CHECK OUT THE FULL EPISODE

OBGYN Ep. 67: https://www.backtable.com/shows/obgyn/podcasts/67/non-opiod-pain-management-in-gyn-surgery

---

SYNPOSIS

Dr. Mourad shares his extensive experience with robotic platforms and his techniques for addressing complex cases such as transabdominal cerclage in pregnant patients and the management of endometriosis and uterine niche. The conversation covers best practices, the importance of continuous learning through observations and video analysis, and practical tips for improving surgical outcomes. The episode also emphasizes the importance of interdisciplinary collaboration and mentorship in advancing surgical skills and patient care.

---

TIMESTAMPS

00:00 - Introduction

04:05 - Single Port vs. Multi-Port Approach

06:08 - Robotic Surgery on Pregnant Patients

08:20 - Anesthesia During Pregnancy

10:39 - Transabdominal Cerclage Techniques

19:27 - Techniques for C-section Scar Ectopic Pregnancy

23:45 - Surgical Considerations in the Pregnant Patient

28:37 - Diagnosing and Treating Ovarian Torsion

32:20 - Managing Placenta Accreta Spectrum

35:29 - Innovations in Robotic Surgery

39:26 - Mentorship and Continuous Learning

54:50 - Concluding Thoughts and Advice for Early Learners

The doctors highlight the opioid epidemic and the need for alternative pain relief methods. They share insights on how the introduction of Exparel has transformed their practices by reducing the reliance on opioids, enhancing patient recovery post-surgery, and improving overall patient outcomes. Specific techniques and procedures for using Exparel in various types of surgeries such as C-sections, hysterectomies, and myomectomies are detailed, along with the benefits observed in clinical practices.

TIMESTAMPS

00:00 - Introduction

00:42 - The Opioid Epidemic and Pain Management

02:46 - The Role of Exparel in Pain Management

04:53 - Multimodal Pain Control

06:12 - Techniques for Using Exparel

10:08 - Patient Outcomes and Benefits

CHECK OUT THE FULL EPISODE

OBGYN Ep. 67: https://www.backtable.com/shows/obgyn/podcasts/67/non-opiod-pain-management-in-gyn-surgery

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SYNPOSIS

Dr. Mueller delves into her personal involvement in peer review, the challenges faced by providers, and the importance of these processes. Key topics include shifting from a punitive to a quality improvement focus, best practices for peer review committees, the integration of human and system factors, the role of multidisciplinary teams, and transparency. The conversation also highlights the ethical considerations and the impact of peer review on provider well-being, emphasizing the need for structured support systems. Dr. Mueller shares insights into the future trends in peer review, advocating for higher physician involvement and leadership in creating more effective and transparent processes.

---

TIMESTAMPS

00:00 - Introduction

02:21 - Diving into Peer Review

04:14 - The Peer Review Process Explained

07:07 - Challenges and Improvements in Peer Review

13:14 - Changing the Culture Around Peer Review

21:14 - Moving Away from a Punitive Mindset

25:12 - Education to Become a Reviewer

31:39 - Legal Considerations

32:42 - Ethical Considerations

38:31 - Future Trends in Peer Review

41:20 - Closing Remarks

---

SYNPOSIS

Dr. Geynisman-Tan shares her extensive experience in caring for survivors of human trafficking and discusses the complexities surrounding this issue. She emphasizes the importance of trauma-informed care, recognizing signs of trafficking, and providing support to survivors. The conversation covers her journey into this field, the challenges faced by survivors, and practical steps that healthcare professionals can take to aid these vulnerable patients. The episode underscores the need for multidisciplinary approaches and the critical role of healthcare providers in identifying and assisting those affected by human trafficking.

---

TIMESTAMPS

00:00 - Introduction

05:08 - Identifying Signs of Human Trafficking in Patients

09:14 - Referral and Support Systems for Trafficking Survivors

11:31 - Common Health Issues Among Trafficking Survivors

13:17 - Understanding the Complexities of ‘The Life’

18:13 - Immigration and Human Trafficking

20:48 - Providing Trauma-Informed Care

25:55 - Identifying Resources for Victims

29:23 - Healthcare Protocols

32:50 - Addressing Needs and Building Trust

36:58 - Psychosomatic Effects of Trauma

40:50 - Impact on Pregnancy

42:55 - Supporting Survivors and Long-Term Rehabilitation

48:30 - Conclusions

---

RESOURCES

Human Trafficking Hotline:

https://humantraffickinghotline.org/en

HEAL Trafficking:

https://healtrafficking.org/

---

SYNPOSIS

Dr. Falcone shares his journey from McGill University to his current roles at the Cleveland Clinic, offering insights into advancements in minimally invasive surgery, the role of teamwork in medical innovation, and the complexities of treating endometriosis. The episode covers the evolution of surgical techniques, postoperative care, and fertility strategies, emphasizing the importance of managing patient expectations and the future directions for research and treatment.

---

TIMESTAMPS

00:00 - Introduction

02:09 - Dr. Falcone’s Journey and Career

08:09 - Evolution of REI and MIGS

13:35 - Innovations in Endometriosis Treatment

20: 45 - Excision vs Ablation

25:30 - Challenges and Future Directions in Endometriosis Research

32:39 - Understanding the Placebo Effect in Chronic Pain

34:18 - Exploring Fibrosis in Endometriosis

35:31 - Challenges in Diagnosing and Treating Endometriosis

40:57 - Innovations in Surgical Techniques

53:56 - Managing Patient Expectations and Complications

56:06 - Concluding Thoughts

---

SYNPOSIS

The doctors delve into the importance of advanced imaging techniques such as MRI and dedicated protocols, the critical need for a multidisciplinary approach with radiologists and GYN surgeons, and the future potential of imaging in improving endometriosis diagnosis, treatment, and surgical planning. The discussion also covers the upcoming International Endometriosis Imaging Congress aimed at advancing standardized care and collaboration in the field.

---

TIMESTAMPS

00:00 - Introduction

05:15 - Dr. VanBuren’s Journey to Endometriosis Imaging

08:24 - Dr. Burnett’s Surgical Training and Insights

11:57 - Challenges in Diagnosing and Understanding the Pathophysiology of Endometriosis

13:24 - The Role of Imaging in Surgical Planning

25:51 - Imaging Follow-Up, Monitoring for Malignant Transformation

32:03 - Protocol for MRI Imaging of Endometriosis

34:47 - The Role of Radiologists in Endometriosis

36:12 - The Complexity of Bowel Endometriosis

48:02 - The Future of Endometriosis Imaging

---

RESOURCES

International Endometriosis Imaging Congress-March 8-9, 2025

https://eice.ltd/international-endometriosis-imaging-congress/

---

SYNPOSIS

The discussion covers evolutionary strides in robotic-assisted surgeries such as sacral colpopexy and myomectomies, the transition from traditional laparoscopy, and the intricacies of handling large uteri procedures. The episode also navigates the global adoption of these technologies, particularly in South Korea and Japan, and the varying applications in different specialties. Key topics include surgical skill requirements, training needs, innovative techniques, FDA approvals, and the future potential of single port surgeries. Overall, this discussion provides a well-rounded perspective on the current state and forward-looking innovations in the field of gynecologic surgery.

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TIMESTAMPS

00:00 - Introduction

03:57 - Single Port Robotic Surgery

08:27 - Benefits of Robotics with Sacral Colpopexy

11:37 - Technical Aspects of Single Port Surgery

14:40 - Training for Single Port Surgery

19:43 - Global Adoption and Future Potential of Single Port Surgery

25:35 - Access into the Abdomen

29:39 - Challenges and Innovations in Single Port Surgery

31:34 - Evaluating Risks and Success Rates

33:16 - Cost Analysis

35:16 - Training and Simulation for Single Port Surgery

39:35 - Future of Single Port and vNOTES Surgery

45:05 - Patient Reactions and Satisfaction

46:34 - Closing Techniques

52:14 - Future Prospects and Final Thoughts

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RESOURCES

Oh S, Yi J, Song AY, Jee J, Bae N, Shin JH. Intraoperative Complications and Perioperative and Surgical Outcomes of Single-Port Robotics-Assisted Sacrocolpopexy. Int Urogynecol J. 2024 Jul; 35 (7):1521-1526 Epub 2024 June 20.

They identify the severity of symptoms such as pain, urinary issues, and recurrent infections that are often inadequately addressed. Dr. Rubin advocates for the use of vaginal estrogen, emphasizing that its benefits outweigh any perceived risks, contrasting it with other treatments like tamoxifen. The discussion includes the efforts to create guidelines for GSM through the American Urological Association (AUA) to standardize care, and the use of systemic and localized hormonal therapies, particularly in cancer patients. The session highlights the importance of updated medical practices and shared decision-making in treating GSM and related conditions.

TIMESTAMPS

00:00 - Understanding Genitourinary Syndrome of Menopause (GSM)

01:33 - Challenges, Misconceptions, and Advocacy

02:31 - Developing GSM Guidelines

04:34 - Hormonal Replacement Therapy and GSM

05:46 - Vaginal Rings

06:59 - Cancer Survivors and Vaginal Estrogen

09:17 - Shared Decision Making

CHECK OUT THE FULL EPISODE

OBGYN Ep. 33 - Genitourinary Syndrome of Menopause (GSM): Improving a DRY Topic

https://www.backtable.com/shows/obgyn/podcasts/33/genitourinary-syndrome-of-menopause-gsm-improving-a-dry-topic

They address common factors leading to inadequate results and the safety of low-dose vaginal estrogen. The doctors emphasize the importance of patience with treatment, correct understanding of hormone products, and education of patients to combat misinformation. Dr. Rubin and Dr. Sutherland also challenge misleading black box warnings associated with vaginal estrogen and stress the necessity for advocacy to update these labels and educate patients.

TIMESTAMPS

00:00 - Introduction

00:20 - Debunking Myths About Estrogen Cream Usage

04:10 - Safety and Proper Usage/Dosage of Estrogen Products

05:48 - Patient Education and Compliance

08:23 - Addressing the Black Box Warning on Vaginal Estrogen

10:48 - Conclusion

CHECK OUT THE FULL EPISODE

OBGYN Ep. 33 - Genitourinary Syndrome of Menopause (GSM): Improving a DRY Topic

https://www.backtable.com/shows/obgyn/podcasts/33/genitourinary-syndrome-of-menopause-gsm-improving-a-dry-topic

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This podcast is supported by:

Pacira

https://www.pacira.com/

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SYNPOSIS

Highlighting the use of Exparel, a liposomal bupivacaine formulation, the discussion addresses how it has transformed post-operative pain management by reducing opioid exposure. The episode covers techniques for Exparel application in surgeries such as hysterectomies and C-sections, with positive patient outcomes noted. The conversation also emphasizes the importance of collaboration among healthcare professionals to advocate for better pain management protocols and patient satisfaction, spotlighting upcoming initiatives like the No Pain Act.

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TIMESTAMPS

00:00 - Introduction

04:47 - Introduction to Liposomal Bupivacaine (Exparel)

07:10 - Techniques and Applications of Exparel

20:13 - The No Pain Act

25:07 - Patient Success Stories with Exparel

26:30 - Administrative Hurdles and Solutions

30:24 - Safety and Efficacy of Exparel

32:42 - Educating Staff and Implementing Protocols

38:05 - Final Thoughts

Frequent UTIs and vaginal atrophy/dryness are common signs of genitourinary syndrome of menopause (GSM). In this Brief, Dr. Rachel Rubin discusses the management of GSM and why estrogen is so vital to these tissues.

They address the lack of information and awareness about GSM among urologists and gynecologists while emphasizing its impact on the urinary and genital symptoms experienced by menopausal women. Dr. Rubin details how GSM is not just a matter of vaginal atrophy but involves broader symptoms like urinary tract infections and bladder issues. The doctors also discuss a range of treatment options available, including local vaginal supplementation products like estradiol creams and DHEA suppositories, and their benefits for urinary health.

TIMESTAMPS

00:00 - Introduction

00:20 - Understanding Genitourinary Syndrome of Menopause (GSM)

01:42 - Symptoms and Implications of GSM

03:00 - Vaginal Supplementation Products

05:09 - DHEA and SERM Therapy

08:44 - Estrogen and Vaginal Health

CHECK OUT THE FULL EPISODE

OBGYN Ep. 33 - Genitourinary Syndrome of Menopause (GSM): Improving a DRY Topic

https://www.backtable.com/shows/obgyn/podcasts/33/genitourinary-syndrome-of-menopause-gsm-improving-a-dry-topic 

TIMESTAMPS

00:00 - Introduction

00:28 - Cranberry Supplements for UTI Prevention

01:22 - Choosing the Right Cranberry Product

03:05 - Effectiveness and Dosage

05:27 - Cranberry Juice vs. Supplements

06:45 - Exploring Hiprex and Vitamin C

07:08 - Methenamine Hippurate: An Old Medication Revisited

08:59 - Overall Strategy for Managing Recurrent UTIs

11:09 - Vaginal Estrogen

11:48 - Final Thoughts

CHECK OUT THE FULL EPISODE

BackTable OBGYN Ep. 42 - Recurrent UTIs: Controlling Those Nasty Little Bladder Infections

https://www.backtable.com/shows/obgyn/podcasts/42/recurrent-utis-controlling-those-nasty-little-bladder-infections

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CHECK OUT OUR SPONSOR

PearsonRavitz

https://pearsonravitz.com/backtable

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SYNPOSIS

The discussion covers the importance of accurate diagnosis through physical exams and intake surveys, approaches to pain and symptom management, the significance of vestibulectomy, and the implementation of different treatments for conditions such as vulvodynia, lichen sclerosus, and hidradenitis suppurativa. Dr. Haefner emphasizes the importance of early treatment, the multidisciplinary approach in their clinic, the use of different types of steroids for lichen sclerosus, and innovative treatments and diagnostics. She discusses next-step treatments if common treatments aren’t working, such as the “lichen sclerosus cocktail.” Finally, the episode highlights the need for ongoing professional education and provides resources for further learning.

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TIMESTAMPS

00:00 - Introduction

04:21 - Common Symptoms and Initial Diagnosis

07:19 - Examination and Workup

13:44 - Treatment Approaches for Vulvodynia

20:27 - Managing Lichen Sclerosus

32:27 - Products to Avoid

36:29 - Anoscopy for HPV

40:34 - Addressing Hidradenitis Suppurativa

44:39 - Final Thoughts and Resources

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RESOURCES

Resources for Everything Vulvovaginal Disorder (by Dr. Haefner):

https://www.dropbox.com/sh/r8nhr1j8c19tn9n/AACRLvxGGSgEtZCi6Zzh-yBQa?e=2&dl=0

Cultures are key when it comes to managing UTIs. In this brief, Dr. Anne Cameron discusses the definitions, symptoms, prevalence, and management of urinary tract infections (UTIs). They delve into the differences between bladder infections and kidney infections, the importance of symptomatology along with bacterial evidence for proper diagnosis, and the higher susceptibility of women to UTIs compared to men. The brief emphasizes the complexities of recurrent UTIs, including the challenges in treatment due to improper antibiotic use, persistence of infection, and anatomical or physiological risk factors. Dr. Cameron also explains the necessity of urine cultures in ensuring effective treatment and the various factors that contribute to recurrent UTIs.

TIMESTAMPS

00:00 - Introduction

00:15 - Definitions and Symptoms of UTIs

01:49 - Prevalence of UTIs in Women and Men

02:44 - Recurrent UTIs: Definitions and Challenges

04:48 - Investigating and Treating Persistent UTIs

CHECK OUT THE FULL EPISODE

BackTable OBGYN Ep. 42 - Recurrent UTIs: Controlling Those Nasty Little Bladder Infections

https://www.backtable.com/shows/obgyn/podcasts/42/recurrent-utis-controlling-those-nasty-little-bladder-infections

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SYNPOSIS

The guests emphasize the systemic discrepancies between gynecologic and other surgical disciplines. The conversation delves into the origins of these disparities, the complexities of revising current codes and creating new codes, and potential legislative and legal remedies to address gender-based inequities. The guests also stress the importance of patient care outcomes and the role of proper reimbursement in enhancing healthcare delivery.

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TIMESTAMPS

00:00 - Introduction

06:28 - Background on RVUs and Disparities in OBGYN

12:39 - Gender Disparities in Medical Billing

18:00 - Efforts to Address Inequities

31:22 - RUC Structure and Surgical Specialties

32:42 - Billing and Reimbursement Inequities

35:15 - Diagnosis Related Groups

36:42 - Turnover Times and Gender Disparities

40:21 - Advocacy and Legislative Solutions

48:23 - Legal Approaches for Change

52:44 - Conclusion

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RESOURCES

Watson KL, King LP. Double Discrimination, the Pay Gap in Gynecologic Surgery, and Its Association With Quality of Care. Obstet Gynecol. 2021 Apr 1;137(4):657-661. doi: 10.1097/AOG.0000000000004309. PMID: 33706362.

Robertson, Christopher T. and Kupke, Annabel and King, Louise P., Structural Sex Discrimination: Why Gynecology Patients Suffer Avoidable Injuries and What the Law Can Do About It (May 9, 2024). Emory Law Journal, Forthcoming, Boston Univ. School of Law Research Paper Forthcoming, Available at SSRN: https://ssrn.com/abstract=4800783 or http://dx.doi.org/10.2139/ssrn.4800783

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CHECK OUT OUR SPONSOR

PearsonRavitz

https://pearsonravitz.com/backtable

---

SYNPOSIS

First, Dr. Boyles explains the importance of patient history and physical examination, along with the need for certain diagnostic tests for proper characterization of the type of urinary incontinence in a patient. She also explores behavioral treatments, pelvic floor physical therapy, vaginal pessaries, and advanced interventions such as urethral bulking and surgery for stress incontinence. The doctors further discuss innovative pharmaceutical and neuromodulation options for urge incontinence.

Dr. Boyles concludes with a mention of patient education resources that are available on her platform, thewomensbladderdoctor.com.

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TIMESTAMPS

00:00 - Introduction

02:35 - The Women’s Bladder Doctor Initiative

07:03 - Types of Urinary Incontinence

11:49 - Diagnostic Approaches to Urinary Incontinence

28:39 - Treatment Algorithms for Urinary Incontinence

31:12 - Bladder Retraining and Pelvic Floor Therapy

40:00 - Urethral Seals and Vaginal Pessaries

50:47 - Treatment for Urgency

57:51 - Future Directions

---

RESOURCES

Pearson Ravitz

https://pearsonravitz.com/

The Women’s Bladder Doctor

https://thewomensbladderdoctor.com/

The physicians first explore the limitations and practicalities of patient surveys, and move on to discuss the importance of thorough history taking along with specific symptoms to look for. The conversation also delves into the diagnostic challenges and delay of diagnosis in endometriosis patients. They explain the role of surgical diagnosis in endometriosis, emphasizing the necessity of listening to and believing patients’ experiences with chronic pelvic pain.

TIMESTAMPS: 

00:00 - Introduction

00:14 - Initial Patient Workup: Surveys and History

01:19 - Key Patient History Indicators

04:24 - Endometriosis Symptoms

07:49 - Treatment Approaches and Surgical Considerations

09:32 - Barriers to Diagnosis

CHECK OUT THE FULL EPISODE

BackTable OBGYN Ep. 30: Ambulatory Workup of Endometriosis Patients

https://www.backtable.com/shows/obgyn/podcasts/30/ambulatory-workup-of-endometriosis-patients

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SYNPOSIS

Dr. Advincula shares his journey from training to pioneering robotic-assisted procedures, emphasizing the benefits and challenges faced along the way. The conversation delves into the future of robotics, including the potential of AI in surgery and the integration of digital tools to enhance surgical outcomes. Listeners gain insights into the importance of ergonomic surgery, the advancements in robotic technology, the future of minimally invasive gynecologic surgery, and the collaborative efforts required to elevate patient care in gynecology.

---

TIMESTAMPS

00:00 - Introduction

06:05 - Pioneering Robotic Surgery

12:50 - Challenges and Innovations

24:43 - Allure of Robotic Surgery

28:05 - Challenges in Rural Healthcare

35:00 - Future of Minimally Invasive Surgery

42:00 - Advancements in Surgical Training

43:35 - Ergonomics

49:28 - The Future of Gynecologic Surgery

53:06 - Closing Thoughts

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RESOURCES

BackTable OBGYN Ep. 2: Surgeon Ergonomics

https://www.backtable.com/shows/obgyn/podcasts/2/surgeon-ergonomics

Dr. Lee explains the importance of detailed patient history and various examination techniques, including palpation and rectovaginal exams, to identify potential signs of endometriosis. He emphasizes the specificity of these exams in differentiating endometriosis pain from other causes. The discussion also covers the role of imaging, such as MRI, particularly in advanced cases, and the collaborative approach with colorectal surgeons for bowel-related complications. Dr. Lee shares insights on the use of physical therapy and managing musculoskeletal pain related to endometriosis, highlighting the importance of multi-disciplinary care for optimal patient outcomes.

TIMESTAMPS

00:00 - Introduction

00:15 - Initial Patient Assessment for Endometriosis

01:00 - Detailed Physical Exam Techniques

07:00 - Imaging and Further Diagnostic Steps

10:55 - Collaborative Surgical Approach

CHECK OUT THE FULL EPISODE

BackTable OBGYN Ep. 30: Ambulatory Workup of Endometriosis Patients

https://www.backtable.com/shows/obgyn/podcasts/30/ambulatory-workup-of-endometriosis-patients

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SYNPOSIS

The discussion begins with talk of the doctors’ practices and friendship. They then cover comprehensive patient evaluations and various surgical techniques, including skeletonizing the uterines, colpotomy tricks, uterine manipulators, and morcellation. Dr. Acholonu also shares his personal routines and preferences, including the use of a flexible scope to get around the big uterus. The duo exchange insights on surgical techniques, patient-centered care, and the continuous learning necessary in the medical field. They emphasize the significance of safety, adequate planning, and the benefits of engaging in community networks for better surgical outcomes. The conversation concludes with a light-hearted note on their shared experiences and camaraderie, offering both educational value and a glimpse into the dynamic relationship between two seasoned professionals.

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TIMESTAMPS

00:00 - Introduction

04:01 - Building a Subspecialty Practice

07:34 - Patient Referrals

12:41 - Surgical Approach

16:06- The Big Uterus

28:36 - Surgical Steps in TLH, Skeletonizing the Uterines

32:56 - Challenges and Solutions

36:49 - Energy Sources and Surgical Tools

42:34 - Colpotomy

44:43 - Tissue Extraction and Morcellation

50:27 - Closing and Post-Operative Care

52:05 - Use of Lupron

53:16 - Final Thoughts

First, Dr. Hoffman discusses the nuances of laparoscopy, particularly the preference for smaller incisions to reduce hernia rates and postoperative pain. The conversation covers the specifics of performing colpotomy and the risks associated with different types of incisions, including vaginal and abdominal. Dr. Baekelandt emphasizes the importance of proper training and starting with simpler cases when introducing new surgical techniques like vNOTES.

TIMESTAMPS

00:00 - Introduction

00:32 - Concerns About Hernia Rates and Incisions

01:05 - Vaginal Incisions and Their Implications

02:35 - Vaginal Deliveries After vNOTES

03:55 - Dyspareunia After vNOTES

04:13 - Technical Details on Incision Placement

05:53 - Closing Techniques

06:45 - Advice for Surgeons Introducing vNOTES

CHECK OUT THE FULL EPISODE

BackTable OBGYN Ep 31: The vNOTES Procedure

https://www.backtable.com/shows/obgyn/podcasts/31/the-vnotes-procedure

They discuss the nuances of uterine artery management and the benefits and risks of the Alexis ring, especially for hemostasis. The doctors go on to discuss contraindications for vNOTES, including complex endometriosis and pelvic scarring. Dr. Baekelandt also shares insights on avoiding ureteric and bladder injuries and future direction of vNOTES.

TIMESTAMPS

00:00 - Introduction

00:14 - Understanding vNOTES Complications

00:50 - Techniques for Uterine Artery Management

02:13 - Hemostasis

03:24 - Challenges with Ureter and Bladder Management

09:44 - Contraindications to vNOTES

12:07 - Future Directions

CHECK OUT THE FULL EPISODE

BackTable OBGYN Ep 31: The vNOTES Procedure

https://www.backtable.com/shows/obgyn/podcasts/31/the-vnotes-procedure

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SYNPOSIS

First, the physicians discuss trends in endometrial cancer rates and delve into the factors driving these trends, such as the obesity epidemic and aging population. They explore the differences between endometrioid and non-endometrioid cancers, along with the impact of racial and geographic disparities. The conversation also covers advances in diagnostics and treatments—including immunotherapy and targeted therapies—and the critical need for better awareness, screening practices, and research funding to combat this public health threat.

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TIMESTAMPS

00:00 - Introduction

03:11 - Types of Endometrial Cancer

04:44 - Rising Rates and Risk Factors

08:03 - Disparities in Endometrial Cancer Care

10:37 - Symptoms and Diagnosis

13:52 - Ultrasound vs. Biopsy

16:17 - Challenges in Biopsies

20:58 - Management/Treatment Approaches

23:03 - Geographic Disparities/Access to Care

26:07 - Vaginal Brachytherapy

32:11 - Innovations in Treatment and Research

40:34 - Future Directions: Endometrial Screening

43:54 - AI in Gynecologic Oncology

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RESOURCES

Beavis, A. L., Blechter, B., Najjar, O., Fader, A. N., Katebi Kashi, P., & Rositch, A. F. (2023). Identifying women 45 years and younger at elevated risk for endometrial hyperplasia or cancer. Gynecologic Oncology, 174, 98–105. https://doi.org/10.1016/j.ygyno.2023.04.019

Mirza, M. R., Sharma, S., Roed, H., Landrum, L. M., Gilbert, L., Gold, M. A., Novák, Z., Edelson, M., Meirovitz, M., Diaz, J. P., Huygh, G., Buscema, J., Pothuri, B., Eshed, H. D., Coleman, R. L., Slomovitz, B. M., Kostadinov, R., Stevens, S., Ronzino, G., & Powell, M. A. (2024). Post hoc analysis of progression-free survival (PFS) and overall survival (OS) by mechanism of mismatch repair (MMR) protein loss in patients with endometrial cancer (EC) treated with Dostarlimab plus chemotherapy in the ruby trial. Journal of Clinical Oncology, 42(16_suppl), 5606–5606. https://doi.org/10.1200/jco.2024.42.16_suppl.5606

Society of Gynecologic Oncology (SGO):

https://www.sgo.org/

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SYNPOSIS

Their conversation covers the capabilities and benefits of using an AI-driven medical scribe that ensures HIPAA compliance, reduces physician burnout, and enhances patient interactions. Elie also shares his insights about the technology’s adaptability across various medical fields. Finally, Dr. Bagrodia and Elie discuss ethical considerations surrounding applications of AI in other aspects of healthcare, such as medical workup and diagnosis.

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TIMESTAMPS

00:00 - Introduction

06:00 - How ScribeMD AI Works

14:14 - Integration with EMR

20:31 - Legal Considerations with AI Technology

26:34 - Cost Implications of AI Scribes

38:46 - Future of AI in Medical Diagnosis

41:45 - Conclusion and Final Thoughts

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RESOURCES

ScribeMD.ai

https://www.scribemd.ai/

---

SYNPOSIS

Dr. Morozov shares his insights on the basics of AI as well as how it is currently being used in medicine and research. He shares his experiences working with AI to develop algorithms for robotic gynecologic procedures. Furthermore, he predicts the direction AI is going in medicine and highlights the complexities and ethical considerations of integrating AI into medical practice. The conversation delves into the advancements, potentials, and concerns surrounding AI, addressing its impact on surgery, privacy, and the future of medical practice.

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TIMESTAMPS

00:00 - Introduction

03:52 - AI in Gynecologic Surgery

06:10 - Understanding AI Basics

13:24 - AI in Medical Applications

17:09 - Future of AI in Medicine

33:24 - AI in Surgery

45:10 - Data and Privacy Concerns

57:35 - Call to Action: Get Involved

---

RESOURCES

BUMP Study:

Goodday, S.M., Karlin, E., Brooks, A. et al. Better Understanding of the Metamorphosis of Pregnancy (BUMP): protocol for a digital feasibility study in women from preconception to postpartum. npj Digit. Med. 5, 40 (2022). https://doi.org/10.1038/s41746-022-00579-9

Dr. Baekelandt highlights the aesthetic advantages of minimized scarring in vNOTES alongside clinical benefits such as reduced postoperative pain, lower analgesia use, and shorter hospitalization times. They discuss the outcomes of randomized controlled trials that compare vNOTES with laparoscopy and the specific groups of patients who benefit most from vNOTES. The episode also delves into the technical aspects of vNOTES and its potential advantages in oncology procedures.

TIMESTAMPS

00:00 - Introduction

00:14 - Benefits of vNOTES

03:21 - Special Patient Groups

06:10 - Technical Aspects and Surgical Techniques

08:31 - Oncology Applications and Future Potential

CHECK OUT THE FULL EPISODE

BackTable OBGYN Ep 31: The vNOTES Procedure

https://www.backtable.com/shows/obgyn/podcasts/31/the-vnotes-procedure

Dr. Baekelandt explains the benefits of performing gynecological operations through the vagina rather than the abdominal wall, allowing for quicker recovery and reduced invasiveness. They discuss the historical context of vNOTES, the integration of laparoscopic tools, and the challenges and learning curves associated with mastering this dual-skillset procedure.

TIMESTAMPS

00:00 - Introduction

00:14 - Understanding vNOTES

02:10 - Dr. Baekelandt’s Journey with vNOTES

04:03 - History and Technological Advancements

05:00 - TLH vs. vNOTES

07:36 - Challenges and Learning Curve in vNOTES

CHECK OUT THE FULL EPISODE

BackTable OBGYN Ep 31: The vNOTES Procedure

https://www.backtable.com/shows/obgyn/podcasts/31/the-vnotes-procedure

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CHECK OUT OUR SPONSOR

Cerene Cryotherapy

https://cerene.com/healthcare-professionals/

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SYNPOSIS

Key topics from this episode include the impact of indirect practice expenses, the role of different organizations in surveying costs and implementing new codes, the importance of coding for procedure reimbursement, and a task force’s findings on gender disparities in coding. The conversation transitions into the practical implications of where procedures are performed (office vs. surgical center vs. hospital) and how this impacts payment and patient costs. Dr. Levy emphasizes the efficiency and patient benefits of office-based procedures, exemplified by the Cerene cryotherapy ablation device. The complexities of the reimbursement system, including work Relative Value Units (RVUs), facility fees, and the push towards bundling services, are unpacked. The episode underscores the importance of understanding healthcare economics to advocate effectively for patient care improvements.

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TIMESTAMPS

00:00 - Introduction

02:24 - History of Medical Coding

11:32 - The Process of Medical Code Creation

21:15 - Understanding RVUs and Practice Expenses

26:35 - Challenges of Accurately Valuing Procedures

32:05 - Changing Codes/Reimbursement: Endometriosis Example

36:06 - The Art and Science of Medical Coding

39:26 - Site of Service and Facility Fees

51:15 - Benefits of Outpatient Procedures

55:46 - Example: Cerene Cryoablation

58:14 - Addressing Gender Disparities in Medical Reimbursement

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RESOURCES

ACOG Resources on Coding and Billing:

https://www.acog.org/practice-management/coding

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SYNPOSIS

The discussion first covers the evolution of post-operative care protocols, emphasizing the lack of evidence behind traditional post-op restrictions and highlighting recent studies that suggest liberal post-operative activities might lead to better recovery outcomes without compromising surgical results. Additionally, the episode touches on the impact of minimally invasive surgical techniques, such as single port surgeries, on patient recovery times and hospital system efficiencies. Finally, the conversation delves into the shift towards team-based care, where nurses and nurse practitioners actively participate in pre-op counseling, educating patients, and enhancing the overall healthcare team’s efficiency. The overarching theme is the crucial role of evidence-based practice in improving patient care and recovery in obstetrics and gynecology.

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TIMESTAMPS

00:00 - Introduction

02:57 - Exploring Postoperative Restrictions in Gynecologic Surgery

20:56 - Adapting Postoperative Visits

26:02 - Recovery Times, Hospital Stays, and the Impact on Patients and Healthcare

35:58 - Team-Based Care and Communication Strategies

44:38 - Surgical Techniques and Recovery Insights

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RESOURCES

Mueller MG, Kenton K. Activity Restrictions After Gynecologic Surgery. Obstet Gynecol. 2024 Mar 01; 143(3):378-382. PMID: 38207325; PMCID: PMC10863662.

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SYNPOSIS

Dr. Tova Weiss, a urology resident at the University of Washington, discusses her development of a safer urinary catheter so that if a patient were to pull out their catheter, the distal part would disconnect from the catheter inside the urethra, preventing urethral trauma. Dr. Jay Shakuri-Rad, a practicing urologist specializing in robotics and neuromodulation, shares his creation of the Foramen Finder to enhance sacral neuromodulation procedures. Dr. Allie Haessler, a practicing urogynecologist, talks about her invention of a novel vaginal ring aimed at providing neuromodulation therapy for pelvic floor issues. They each discuss the inspiration behind their inventions, challenges faced, and the importance of failure in the path to innovation. The episode emphasizes the role of physicians in identifying healthcare gaps, collaborating across disciplines, and pushing the boundaries of medical technology to improve patient care.

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TIMESTAMPS

00:00 - Introduction

01:54 - Dr. Tova Weiss and the Urinary Catheter Accessory

08:49 - Dr. Jay Shakuri-Rad and the Foramen Finder

22:04 - Dr. Allie Haessler and the Neuromodulation Vaginal Ring

27:29 - Navigating the Patent Process and Protecting Innovation

29:52 - The Path to FDA Approval

37:11 - Advice for Aspiring Innovators in Medicine

40:52 - Embracing Failure and the Inventor’s Mindset

Dr. Isaacson describes the pivots in the field’s understanding of adenomyosis and endometriosis, including the impact of these conditions on fertility and potential treatment pathways. Adenomyosis has been redefined in the past five years as a disease that affects women of all reproductive ages and causes dysmenorrhea, heavy menstrual bleeding, and infertility. Because the disease is found in the myometrium of the uterus, it has historically been difficult to diagnose unless through pathology following hysterectomy; however, imaging has since improved and there are now criteria seen on ultrasound that are consistent with adenomyosis.

Dr. Isaacson then discusses the differences and misconceptions about adenomyosis compared to endometriosis. Additionally, the episode touches on the evolution of treatment strategies over the years, including medical therapy versus surgery. Furthermore, Dr. Isaacson highlights the crucial role of research in uncovering disease pathophysiology and new therapeutic approaches.

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SHOW NOTES

00:00 - Introduction

04:06 - Definitions, Symptoms, and Insights

11:33 - Exploring Treatment Options for Adenomyosis and Infertility

21:30 - The Intersection of Endometriosis and Adenomyosis

30:09 - Imaging, Surgery, and Pathology

36:31 - The Future of Research and Patient-Centric Care

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RESOURCES

Moawad G, Fruscalzo A, Youssef Y, Kheil M, Tawil T, Nehme J, Pirtea P, Guani B, Afaneh H, Ayoubi JM, Feki A. Adenomyosis: An Updated Review on Diagnosis and Classification. J Clin Med. 2023 Jul 21;12(14):4828. doi: 10.3390/jcm12144828. PMID: 37510943; PMCID: PMC10381628.

The episode begins with Dr. Ritch, a minimally invasive gynecologic surgeon, describing her path into menopause care, including the development of her podcast, EnRitched Menopause. She touches on the role of laboratory workup in menopause, but emphasizes the patient’s symptoms are more important to address than numerical values on labs. She then delves into treatment options, including the complexities of hormone replacement therapy, and the multifactorial nature of sexual function issues. Most importantly, the physicians emphasize listening to patients, offering comprehensive care beyond hormone therapy, and utilizing resources like podcasts to educate both practitioners and patients. Finally, they explore new treatments and the potential future advancements in menopause care.

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EARN CME

Reflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs: https://earnc.me/I7Ougz

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SHOW NOTES

00:00 - Introduction

08:52 - The EnRitched Menopause Podcast: A Resource for Patients and Practitioners

15:22 - Common Patient Presentations of Menopause

20:43 - The Role of Laboratory Evaluation of Hormone Levels

24:20 - Testosterone in the Menopausal Patient

27:13 - Navigating Hormone Therapy: Estrogen, Progesterone, and Testosterone

31:03 - Physiologic Hormonal Changes in Menopause

35:00 - Shared Decision-Making

39:00 - Exploring Sexual Function and Libido in Menopause

45:38 - The Power of a Physician’s Support and Trusted Advice

50:09 - Innovative Approaches and Future Directions in Menopause Care

---

RESOURCES

EnRitched Menopause Podcast:

https://podtail.com/en/podcast/enritched-menopause/welcome-to-enritched-menopause/

Rosy App:

https://play.google.com/store/apps/details?id=com.rosywellness&pli=1 (Google)

https://apps.apple.com/us/app/rosy-womens-sexual-health/id1444780510 (Apple)

Dr. Miller shares his extensive experience in diagnosing and treating isthmoceles, discussing various surgical techniques including hysteroscopic, laparoscopic, and robotic-assisted resection. He emphasizes the importance of an aggressive surgical approach for achieving higher success rates in terms of future fertility and resolving symptoms such as abnormal bleeding. Moreover, Dr. Miller highlights the need for standardized treatment protocols and reflects on the mentorship, the ongoing journey of learning and adapting in medicine, and the noble profession of healthcare. The episode offers insightful perspectives on a lesser-known gynecologic issue, underscores the value of experience and mentorship in medicine, and advocates for concerted efforts toward establishing best practices in surgical procedures.

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SHOW NOTES

00:00 - Introduction

07:18 - Defining Isthmocele and the History of Isthmocele

10:00 - The Diagnosis of Isthmocele and Its Impact on Fertility

19:31 - Exploring Surgical Techniques for Isthmocele Repair

27:54 - Understanding Hysteroscopic Resection

30:12 - Addressing C-Section Ectopics and Isthmocele Repairs

36:46 - Adapting the Surgical Approach to Different Patient Scenarios

39:35 - Postoperative Complications and Safety Measures

40:55 - The Future of Isthmocele: Surgical Standardization

50:51 - Closing Thoughts and Acknowledgements

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RESOURCES

Ban Y, Shen J, Wang X, Zhang T, Lu X, Qu W, Hao Y, Mao Z, Li S, Tao G, Wang F, Zhao Y, Zhang X, Zhang Y, Zhang G, Cui B. Cesarean Scar Ectopic Pregnancy Clinical Classification System With Recommended Surgical Strategy. Obstet Gynecol. 2023 May 1;141(5):927-936. doi: 10.1097/AOG.0000000000005113. Epub 2023 Apr 5. PMID: 37023450; PMCID: PMC10108840.

The physicians emphasize that how surgical teams treat each other can significantly affect patient outcomes. They suggest under-promising and over-delivering to patients, their family, and members of the surgical team. The doctors recommend having a care culture, allowing everyone to voice their concerns without fear of reprisals. They also discuss the importance of self-management, leadership, and taking responsibility inside and outside the OR for complications and places where the surgery could have gone smoother. They agree that those who nurture a positive OR culture have higher success rates, noting that complications demand more than technical skills to handle - it takes emotional intelligence, humility, and a good support network.

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SHOW NOTES

00:00 - Introduction

02:07 - Dealing with Surgical Complications

04:24 - The Emotional Impact of Complications on Surgeons

07:24 - The Importance of Patient Communication and Care Post-Complication

08:35 - The Role of Consent and Preoperative Counseling in Managing Complications

11:18 - The Importance of a Supportive and Open Culture in Medicine

15:32 - The Importance of Learning from Mistakes in Medicine

24:28 - The Role of Leadership and Teamwork in the Operating Room

29:56 - The Value of Familiarity in a Medical Team

30:38 - The Importance of Recognizing and Appreciating All Roles in a Medical Team

34:31 - The Role of Care and Empathy in Medical Practice

37:28 - The Role of Preparation in Avoiding Complications

40:53 - The Importance of Scheduling and Time Management in Medical Practice

50:31 - The Impact of Culture on Reporting and Addressing Adverse Events

51:19 - The Importance of Feedback and Self-Reflection in Medical Practice

The conversation dwells mostly on the intricate relationship between pain, trauma, and the patient’s psychological state as it relates to chronic pelvic pain. Dr. Carrillo emphasizes the importance of adopting a trauma-informed care approach that creates a safe environment for patients. The discussion also covers the use of surveys for patient information, the importance of organizing thoughts during patient evaluation, and an outline of the four major categories of pelvic pain: gynecologic, urologic, gastrointestinal, and musculoskeletal. Dr. Carrillo shares valuable insights into managing complex conditions such as pelvic pain, providing an education-first approach for patients with emphasis on shared decision-making, and outlines how he and his team operate within a multidisciplinary framework for patient treatment.

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SHOW NOTES

00:00 - Introduction

04:32 - Dr. Carrillo’s Journey in the Medical Field

08:51 - The Importance of Trauma-Informed Care in Chronic Pelvic Pain

14:54 - Understanding the Biopsychosocial Model in Chronic Pelvic Pain

19:49 - The Initial Approach to Evaluating Patients with Chronic Pelvic Pain

25:25 - Understanding Nociplastic Pain and Sensitization

28:00 - Treatment Approaches for Sensitization

29:26 - The Importance of Organized Thinking in Pain Management

30:20 - The Role of Questionnaires in Patient Assessment

35:10 - The Importance of Multimodal Approach in Pain Management

43:00 - The Role of the Provider in Organizing Patient Care

45:37 - The Importance of Education in Pelvic Pain Management

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RESOURCES

International Pelvic Pain Society Handouts for Different Disorders of Chronic Pelvic Pain:

https://www.pelvicpain.org/public/resources/educational-resources/informational-handouts

Both Dr. Davé and Mark emphasize TATA, or tools, access, tissue handling, and anatomy, when practicing and teaching how to master surgery. They discuss the benefits of fostering a “sandbox-learning” environment, or a zone of safety where learners can practice techniques on patients. They also delve into systematic approaches for surgical training and the challenges in measuring the progress of trainees. Most importantly, Dr. Davé and Mark explore how to teach trainees not just surgery, but how to learn about surgery so that they feel competent doing new surgeries as their career in medicine progresses.

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SHOW NOTES

00:00 - Introduction

04:34 - The Role of Teaching in Medicine and Lifelong Learning in Surgery

07:15 - The Challenges of Surgical Training Volume

09:22 - The Journey of Learning and Teaching Surgery

17:59 - Understanding TATA: Surgical Tools, Access, Tissue Handling, and Anatomy

27:01 - The Importance of Practice in Surgical Training

30:04 - The Role of Tissue Handling in Surgical Training

31:20 - Creating Zones of Safety in Surgical Practice

33:31 - The Concept of “Sandboxing” in Surgical Training

34:27 - The Importance of Incremental Learning in Surgery

35:22 - The Importance of Breaking Down Surgical Procedures into Steps

42:32 - The Meaning of “Access” in Surgery

47:26 - How to Teach Trainees to Handle Tough Surgeries and the Unknown

50:05 - The Future of Surgical Training and Education

RhoGAM is traditionally administered to Rh- women at 28 weeks gestation, within 72 hours of birth, and frequently after an abortion in order to prevent Rhesus alloimmunization in future pregnancies. However, with recent data showing negligible Rh- blood cell exposure in early pregnancy terminations, the need for RhoGAM in such cases is being questioned. Additionally, considering the scarcity of RhoGAM and the reality of smaller family sizes globally, the importance of RhoGAM in Rh alloimmunization prevention might not be as significant as previously thought. However, limited evidence and ingrained medical practices may cause the transition to be slow.

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SHOW NOTES

00:00 - Introduction

03:09 - Understanding RhoGAM: Origin and Development

06:06 - The Science Behind RhoGAM and Its Role in Pregnancy

08:13 - The Controversy and Debate Around RhoGAM Usage

11:52 - The Impact of RhoGAM on Public Health and Medical Practice

15:25 - The Future of RhoGAM: Perspectives and Predictions

29:24 - Closing Thoughts and Further Resources

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RESOURCES

Horvath, S., Goyal, V., Traxler, S., & Prager, S. (2022). Society of Family Planning committee consensus on Rh testing in early pregnancy. Contraception, 114, 1–5.

https://doi.org/10.1016/j.contraception.2022.07.002

Horvath S, Huang Z, Koelper NC, et al. Induced Abortion and the Risk of Rh Sensitization. JAMA. 2023;330(12):1167–1174. doi:10.1001/jama.2023.16953

They explore topics such as the role of estrogen and testosterone in women’s sexual desire, FDA-approved medications for hypoactive sexual desire disorder, and the importance of sex education and communication within relationships. They also highlight the topic of gender inequality in sexual health care delivery and the lack of clinical resources specifically tailored to women’s needs. In sum, they aim to provide a deeper understanding of female sexual health and offer strategies for practitioners to provide more effective care.

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SHOW NOTES

00:00 - Introduction

05:53 - The Role of Urologists in Women’s Sexual Health

07:18 - The Importance of Communication in Addressing Sexual Dysfunction

10:23 - The Role of the Clitoris in Female Orgasm

19:52 - Understanding the Hormones Behind Female Sexual Desire

25:32 - The Misconceptions and Gender Bias Surrounding Hormones

26:04 - The Role of Testosterone in Menopause and Sexual Desire

30:02 - The Challenges of Commercially Available Testosterone Products

32:52 - Non-Hormonal Treatments for Low Libido

42:41 - The Importance of Referring to Sex Therapists and Other Resources

---

RESOURCES

Dr. Kelly Casperson’s Website

https://kellycaspersonmd.com/

You Are Not Broken Podcast

https://kellycaspersonmd.com/you-are-not-broken-podcast/

“You Are Not Broken” by Kelly Casperson

https://kellycaspersonmd.com/you-are-not-broken-book/

“Magnificent Sex” by Peggy Kleinplatz

https://www.amazon.com/Magnificent-Sex-Lessons-Extraordinary-Lovers/dp/0367181371

American Association of Sexuality Educators, Counselors, and Therapists

https://www.aasect.org/

First, they emphasize the importance of dispelling misconceptions about recurrent UTIs being a result of poor hygiene or incorrect behaviors, explaining that they can stem from genetic or hormonal risk factors. Dr. Cameron describes her algorithm for managing UTIs in specific patient populations. She further discusses the impact of factors such as fluid intake, bowel habits, and vaginal health on the incidence of UTIs. Dr. Cameron also highlights the potential for UTIs in diabetic patients on certain medications and the importance of a collaborative approach with diabetic healthcare teams. Additionally, the doctors explore various treatment strategies, such as cranberry supplements and gentamicin bladder installations, cautioning against antibiotic overuse due to the risk of resistance.

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---

SHOW NOTES

00:00 - Introduction

02:13 - Understanding UTIs: Definitions, Symptoms, and Prevalence

04:39 - Recurrent UTIs: Definitions, Causes, and Treatment Challenges

12:00 - Understanding Asymptomatic Bacteriuria

15:00 - Cystitis vs. Pyelonephritis vs. Urosepsis

20:57 - Antimicrobial Resistance and Antibiotic Stewardship

24:36 - Treatment Guidelines for UTIs

31:13 - Self-start Antibiotic Therapy for UTIs

34:37 - Preventing UTIs: Hydration, Lifestyle Factors, and Bowel Health

38:33 - The Connection Between Vaginal Health and UTIs

42:40 - The Role of Supplements in UTI Prevention: D-Mannose and Cranberry, and Methenamine Hippurate

57:18 - Identification and Treatment of UTIs in Patients with Indwelling Catheters

01:00:04 - The Role of Gentamicin Bladder Installations in UTI Prevention

01:04:27 - The Impact of Diabetes Medications on UTIs

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RESOURCES

AUA Guidelines for UTI Treatment:

https://www.auanet.org/guidelines-and-quality/guidelines/recurrent-uti

Drs. Hoffman and Rassier discuss the various factors they consider when deciding on the most suitable approach for a myomectomy. Specifically, they touch on pre-surgical patient optimization, the use of laparoscopic techniques in surgery, and the significance of efficient incision planning and closure. Dr. Rassier also highlights the practice of using preventative measures, such as iron infusions and Lupron, in certain patients to manage fibroids before surgical intervention. The conversation wraps up with a discussion about how future developments could potentially revolutionize fibroid management.

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SHOW NOTES

00:00 - Introduction and Overview of the Podcast

03:32 - Discussion on Fibroids and Their Different Treatment Options

06:40 - The Future of Fibroid Treatment

09:17 - Patient-Centered Decision Making in Fibroid Treatment

11:40 - Preparation and Approach for Myomectomy

13:18 - Discussion on the Use of MRI in Fibroid Treatment

15:55 - The Role of Laparoscopy in Myomectomy

29:00 - Umbilicus vs. Suprapubic Approach

32:04 - Cosmetic Considerations in Surgery

32:27 - - C-sections After Myomectomies?

34:51 Instruments and Techniques for Fibroid Removal

36:28 - Minimizing Blood Loss in Surgery

38:47 - The Importance of Efficient Closure in Surgery

44:46 - Tissue Extraction Techniques

49:02 - The Future of Myomectomy

They focus mainly on midurethral slings and a new urethral bulking agent called Bulkamid. They further analyze how conditions like product expectations, surgeon expertise, data availability, patient preferences, and financial costs influence the choice of procedure. Additionally, they discuss the impact of mesh-related complications and how they affected the usage of synthetic slings in the UK. Finally, they touch on the role of shared decision making in choosing treatment strategies.

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---

SHOW NOTES

00:00 - Introduction

03:48 - Discussion on Midurethral Slings

11:05 - The Mesh Controversy and Its Impact

22:21 - Shared Decision Making in Treatment Options

26:47 - The Role of Urethral Bulking Agents

32:51 - Comparative Trial and EAU Guidelines

42:12 - Conclusion and Closing Remarks

---

RESOURCES

Bulkamid Injections

https://bulkamid.com/en-US

---

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SHOW NOTES

01:14 - Introducing the Guest: Dr. Princess Urbina

01:46 - Dr. Urbina's Background and Journey

02:44 - First Mission Trip to the Philippines

05:23 - Logistics and Challenges of the Mission Trip

07:47 - Sustainability and Impact of the Mission

16:54 - Patient Selection and Care in the Mission

19:03 - Cultural Competence and Professional Culture

21:12 - Sustainability and Education in Surgical Teams

21:41 - Leaving Behind Equipment and Training

23:08 - Addressing Health Issues: HPV Vaccination and Cervical Cancer

28:59 - Patient Follow-up and Communication

30:59 - Support from Academic Institutions

38:09 - Getting Started with International Medical Missions

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SHOW NOTES

The episode begins with Dr. Fitzgerald describing her pathway into urogynecology, including training with MIGS physicians. This allowed her to make the connection between many young, reproductive-aged women with painful urination who also have endometriosis. She then goes into how to define IC, which can be difficult. Officially, it is bothersome urinary symptoms lasting more than 6 weeks without other identifiable causes. It is almost always a diagnosis of exclusion after negative urine cultures and other tests. Cystoscopy is no longer needed for diagnosis as it is often normal. However, the best understood phenotype of IC is bladder-centric IC, and these have Hunter lesions seen with cystoscopy. This type responds very well to fulguration, Kenalog, or steroid injections with 85% of patients experiencing improvement.

Dr. Fitzgerald further discusses treatments for IC. Behavior modification is essential, and she advises that patients avoid alcohol, coffee, tea, soda, spicy things, acidic things, and any other dietary triggers. She is also doing trials of giving patients an “IC bundle” which includes neurogenic medications like amitriptyline or gabapentin, vaginal estrogen, scheduled Pyridium, Hiprex, and aloe vera tablets. For some patients, she offers bladder instillations (comprised of heparin, lidocaine, bicarbonate, kenalog, +/- gentamicin), pelvic floor injections of bupivacaine and kenalog, and pelvic floor PT.

Next, Dr. Fitzgerald discusses the basic science research she has done that connects pain pathways throughout the pelvis. Chronic pelvic inflammatory disorders cross-talk through central sensitization. The lumbosacral plexus nerve roots receive pain signals from the bladder, colon, and other pelvic organs, explaining the relationship between IBS, endometriosis, and IC. The pathways are well understood, but we don’t yet know how to reverse central sensitization.

Finally, Dr. Fitzgerald ends by describing the multidisciplinary clinic for endometriosis at Pittsburgh: MIGS, urogynecologists, pelvic floor PT, and behavioral health teams all work together to care for these complex patients holistically. She stresses the importance of teamwork and great administrators who have made this happen. She finishes by discussing how researching more about mast cells, especially through COVID patients, can help us learn more about these chronic inflammatory disorders of the pelvis.

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RESOURCES

Fitzgerald JJ, Ustinova E, Koronowski KB, de Groat WC, Pezzone MA. Evidence for the role of mast cells in colon-bladder cross organ sensitization. Auton Neurosci. 2013 Jan;173(1-2):6-13. doi: 10.1016/j.autneu.2012.09.002. Epub 2012 Nov 24. PMID: 23182915; PMCID: PMC3715122.

AUA Guidelines for Diagnosis and Treatment of IC:

https://www.auanet.org/guidelines-and-quality/guidelines/diagnosis-and-treatment-interstitial-of-cystitis/bladder-pain-syndrome-(2022)

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SHOW NOTES

The episode begins with Mark describing his journey to becoming a minimally invasive gynecologic surgeon, with more exposure to traditional laparoscopic surgery (“straight stick”) throughout his career, but with a recent revival of robotic surgery as well. Overall, Mark still prefers traditional laparoscopy. However, there are certain instances where robotics is especially helpful – namely in patients with a high BMI and in myomectomies where robots make the extensive suturing more manageable. Additionally, robotic surgery is easier to do in a situation where students and residents are not available to assist. Most importantly, he likes to get an MRI, look at the anatomy, and decide what the best approach is for each individual patient. And of course, the doctors emphasize the importance of having a strong team to operate with.

Next, Mark discusses his tips and tricks to a successful laparoscopic hysterectomy. He likes to be in the operating room before the patient is there to ensure it is set up correctly. Once the patient arrives, he stresses the importance of proper patient positioning on the bed, with the arms always tucked at the patient’s side, and then inserting the Foley catheter after draping. The doctors then discuss incision locations and sizes, with Mark preferring all 5 cm incisions. Mark continues with the steps of the procedure – he starts with the fallopian tubes, then gets the utero-ovarians and carries around the round ligament to move the ovaries laterally. He then emphasizes skeletonizing the uterines/posterior peritoneum. He saves the anterior incisions for last as they can get complicated with adhesions from prior C-sections, for example. Mark highlights the “critical view,” which is the anterior cup, posterior cup, ring, and vessels on the other side. The doctors go on to discuss colpotomy, barbed sutures, visualization, antibiotics, and more.

The physicians end by expressing the importance of asking for help, knowing your limits as a surgeon, and ensuring patient safety.

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RESOURCES

ACOG: Choosing the Route of Hysterectomy for Benign Disease

https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/06/choosing-the-route-of-hysterectomy-for-benign-disease

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SHOW NOTES

Both Amy and Mark stress the critical importance of selecting a surgical approach that aligns with a patient's medical history and anatomical considerations. Amy asserts that a patient is a suitable candidate for a vaginal hysterectomy when they possess a tall and mobile uterus, with ample vaginal space, and a pelvic outlet of sufficient width. Furthermore, she highlights that patients with a cervix located within 6 cm from the hymenal remnant are good candidates for vaginal hysterectomies.

The physicians delve into the topics of competency and confidence within the operating room. They agree that the volume of surgeries, repeated practice, pattern recognition, and experience in managing complications are pivotal factors contributing to a surgeon's growing competence with each case. Both doctors concur that it typically takes approximately three to five years to achieve confidence and a reduction in anxiety levels regarding surgical cases.

Amy proceeds to describe each step of a vaginal hysterectomy and shares her preferred practices in the operating room. To ensure patient comfort and safety, she positions her patients in the dorsal lithotomy position, taking special care to avoid exerting pressure on the peroneal and femoral nerves. While providing sacral support, she positions the remainder of the perineum as close to the edge of the table as possible to maximize vaginal access. Amy initiates the procedure with a posterior colpotomy using a 10-blade after administering lidocaine. Gradually, she progresses anteriorly, retracting the vaginal epithelium until the peritoneal folds become visible. She tags the uterosacral ligaments and proceeds to access the pelvis anteriorly, paying careful attention to avoid injuring the ureters. She systematically advances to the utero-ovarian ligament and artery, concluding by addressing the fallopian tube and ovary. Amy emphasizes her preference for two-handed knotting in all vaginal cases to achieve optimal tension and mentions her infrequent use of energy devices.

Finally, Mark and Amy discuss the evolution of training within the operating room over the years, acknowledging the changing landscape due to advancements in technology and varying case volumes. They underscore the significance of mastering technical skills outside of the operating room, which enables trainees to dedicate the necessary time to enhancing their operative abilities.

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SHOW NOTES

The episode begins with Linda describing the utility of hysteroscopy: it is a great option to visualize the endocervix, endometrium, uterine healing after complicated surgeries, foreign bodies, broken IUDs, and hyperplasia. It should be used for uterine bleeding, retained products of conception, evaluating women for Asherman’s, and evaluating why the endometrium is thick on ultrasound. Hysteroscopy has two main roles: diagnosis and therapeutics. Hysteroscopic surgery allows for the uninterrupted visualization and removal of pathology, as opposed to other measures like D&C where the uterus is scraped blindly. It is also great for visually-directed, targeted biopsies and treating pathologies like fibroids and polyps. Linda emphasizes that it is a disservice to women to go in blind because fibroids or cancer can be missed with blind biopsies--in fact, pipelle biopsies picked up zero polyps in their study. Hysteroscopy surgery has a faster recovery, is less invasive, has less risks of bleeding or damaging other structures, and has low risk of infection.

The physicians then discuss techniques involving hysteroscopy. Linda prefers using a flexible hysteroscope that is 3.2 mm wide because dilation isn’t needed. She also explains that there isn’t a need for a paracervical block (just oral ibuprofen) as the patients have minimal pain when the walls of the uterus are appropriately avoided.

Linda focuses on the need to believe women when they are bleeding. It takes 3-5 doctors and 3-5 years for many women to get their bleeding appropriately treated instead of trying the same medicines without success. We have the technology to do something different, and hysteroscopy is the best option to look into the uterus and understand what is going on. Mark asks about the training of physicians in hysteroscopy, and Linda responds that simulators are key in addition to having courses and mentors to teach the technique properly. Finally, the doctors finish by talking about future applications of hysteroscopy.

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RESOURCES

Orlando, Megan S. MD; Bradley, Linda D. MD. Implementation of Office Hysteroscopy for the Evaluation and Treatment of Intrauterine Pathology. Obstetrics & Gynecology 140(3):p 499-513, September 2022. | DOI: 10.1097/AOG.0000000000004898

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SHOW NOTES

GSM is not only a condition of "vaginal dryness", but rather a multi-faceted symptom set including pain with sitting, urinary frequency and urgency, bladder pain, opioid use, and recurrent UTIs. First, the doctors discuss the myths and misconceptions about the use of estrogen creams, suppositories, and rings to treat GSM . However, Suzette and Rachel also discuss the importance of advocating against the misrepresentation of vaginal estrogen in box labeling. They conclude that the benefits of using a low-dose vaginal estrogen far outweigh the risks, and doctors should advocate for better labeling and understanding of this treatment.

Suzette and Rachel also discuss the American Urologic Association (AUA) guidelines for GSM and its importance. Systemic hormone therapy is rarely enough to address GSM symptoms, so screening for GSM symptoms is essential. They also talk about estrogen therapy for special patients, such as those on hormone replacement therapy (HRT) and cancer survivors. Suzette and Rachel emphasize the importance of understanding the general hormone fluctuations of patients particularly oral contraceptives, those with disordered eating, those who are breastfeeding, and those who are transgender. They end the episode by encouraging the production of more research and data to back up treatment options for GSM in premenopausal women.

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RESOURCES

WellPrept

https://wellprept.com/

Femring

https://www.femring.com/

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SHOW NOTES

First, Suzette and Olivia discuss the value of keeping the uterus in place for women undergoing prolapse repairs, as well as the indications for apical suspension surgery. They also note the historical context of hysterectomy and why it has been the go-to treatment for so long. Next, the doctors discuss the advantages of hysteropexy over hysterectomy for prolapse repair, such as a shorter operative time, less bleeding, and a quicker recovery. The doctors then go into more detail about the best approaches for prolapse repair, like weighing the options of permanent sutures versus delayed absorbable sutures. They also analyze recurrence rates after prolapse surgery, specifically in the anterior compartment.

Then, they explore the data on how the choice to keep the uterus in place can stem from a woman's personal and cultural views. Olivia shares about the Value of Uterus questionnaire, a six-question survey instrument that can quantify how a woman values her uterus. It can streamline clinic visits and help to predict whether a woman would choose a uterine-preserving procedure. The doctors note that there is research demonstrating a correlation between valuing the uterus and sexual activity.

Finally, Suzette and Olivia contraindications for leaving the uterus in place. They emphasize the importance of assessing for abnormal uterine bleeding and cervical pathology before recommending uterine preservation. They suggest that listeners review the current guidelines around preoperative workup and consider transvaginal ultrasound or endometrial biopsy first. Lastly, they emphasize the importance of symptom and risk stratification and shared decision making when it comes to uterine preservation.

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RESOURCES

Chang OH, Walters MD, Yao M, Lapin B. Development and validation of the Value of Uterus instrument and visual analog scale to measure patients' valuation of their uterus. Am J Obstet Gynecol. 2022 Jun 25:S0002-9378(22)00483-5. doi: 10.1016/j.ajog.2022.06.029. Epub ahead of print. PMID: 35764134.

https://pubmed.ncbi.nlm.nih.gov/35764134/

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The episode begins with the physicians discussing the difficulties of diagnosing endometriosis, including: the stigma of pelvic pain/not believing women’s pain, recognition that pelvic pain is not normal, the discomfort of physicians asking the appropriate questions for pelvic pain, and the hesitancy towards surgery by physicians and patients all play a role. Many patients have been having pain for years that may have been covered up by OCP use or misdiagnosed as IBS or interstitial cystitis.

Ted emphasizes the importance of a thorough history in diagnosing endometriosis. Essential information includes age of onset of symptoms, gravidity and parity, prior C-section (abdominal wall endometriosis) and the “3 D’s” of dyspareunia, dyschezia, and most importantly dysmenorrhea. A quality physical exam can also elucidate endometriosis. Ted starts by palpating the anterior vaginal wall, then the levator ani muscles and cervix, and finally the rectovaginal exam. Palpation of the uterosacral ligament and posterior cul-de-sac in endometriosis patients causes a visceral reaction, and advanced disease may also have nodules felt. The majority of patients don’t require additional imaging since ultrasound is insensitive for stage 1 and 2 endometriosis. Indications for MRI include endometrioma, nodularities felt on exam, and abdominal wall endometriosis. When it comes to surgery, both doctors emphasize the importance of having other surgeons on your team, including colorectal surgery, general surgery, and urology. Ted dives into some surgical tips and techniques from his years of experience.

Finally, the physicians end by discussing the future of endometriosis diagnosis. A Japanese study has recently found fusobacterium in the uterine microbiome in endometriosis patients more often than those without. Also, a French study has taken saliva samples and found signature microRNAs for endometriosis. It will be interesting to see how studies like these change the future of endometriosis diagnosis and if it will bring new challenges, such as overtreatment and overdiagnosis.

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RESOURCES

Muraoka, A., Suzuki, M., Hamaguchi, T., Watanabe, S., Iijima, K., Murofushi, Y., Shinjo, K., Osuka, S., Hariyama, Y., Ito, M., Ohno, K., Kiyono, T., Kyo, S., Iwase, A., Kikkawa, F., Kajiyama, H., & Kondo, Y. (2023). Fusobacterium infection facilitates the development of endometriosis through the phenotypic transition of endometrial fibroblasts. Science translational medicine, 15(700), eadd1531. https://doi.org/10.1126/scitranslmed.add1531

Bendifallah, S., Suisse, S., Puchar, A., Delbos, L., Poilblanc, M., Descamps, P., Golfier, F., Jornea, L., Bouteiller, D., Touboul, C., Dabi, Y., & Daraï, E. (2022). Salivary MicroRNA Signature for Diagnosis of Endometriosis. Journal of clinical medicine, 11(3), 612. https://doi.org/10.3390/jcm11030612

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SHOW NOTES

The episode begins by discussing the core principles of a Chief Quality Officer and how a typical week demonstrates those values. Dr. Bajaj emphasizes the importance of measurement as a key tool for quality and safety assessment. Information is helpful, however data literacy and transparency is also important to help the healthcare community to better understand a set of data. A significant challenge in ensuring quality and safety is identifying a precise dataset and developing an effective measurement methodology, which may be costly and labor intensive.

Dr. Bajaj discusses how a culture of safety adopted by the entire healthcare team protects the patient and adds to the quality of care. An additional key principle is learning from events through risk management; each event should be thoroughly discussed as an opportunity for future changes.

According to Dr. Bajaj, a crucial aspect of her role as the quality and safety officer is to take into account regulatory and accreditation standards. These guidelines aid healthcare systems in identifying areas of care that require improvement. Dr. Bajaj often looks at her hospital as a functioning ecosystem, with multiple interplaying parts, each which interact with one another to help make patient care of the best quality. She stresses the importance of physicians as leaders understanding the interlinking between the different parts of the system to improve patient safety and outcomes.

Dr. Hoffman and Dr. Bajaj engage in a discussion about the prevalent issue of resistance when it comes to finding solutions for enhancing quality and safety. They strongly advocate for empowering providers to take initiative in identifying problems within their institutions and seeking necessary changes. The two doctors believe that unanimity is not always essential to make a positive impact on quality and safety. Rather, they acknowledge that some providers may require more time to embrace change in their routines.

Dr. Hoffman and Dr. Bajaj then delve into the relationship between quality, safety, and the financial aspects of healthcare. They reach a conclusion that emphasizes how quality and safety initiatives in a healthcare system provide financial incentives for all stakeholders, including staff, patients, and the entire ecosystem. The level of care patients receive directly influences crucial factors such as hospital funding, ratings, and assessments by national organizations.

The future of quality and safety in OBGYN is explored last. Dr. Bajaj introduced the idea of a person-centeredness approach to quality and safety that incorporates staff and patients' voices into initiatives. Then she shared how an emphasis on the basics, safety, an empowering culture, and strong leadership are being re-examined as key goals for the future. Lastly, she touched on sustainability as an emerging area for improvement in healthcare delivery.

---

RESOURCES

Accreditation Standards:

https://www.accme.org/accreditation-rules/standards-for-integrity-independence-accredited-ce

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SHOW NOTES

Dr. Park and Harm-Ernandes dive deep into the definition of pelvic floor therapy. They emphasize the significance of a comprehensive initial exam to determine the specific assessments that a patient may require. For instance, internal assessments may include evaluating muscle strength, endurance, trigger points, and fascial restrictions. Another key component to pelvic floor therapy is the importance of behavioral therapy integration with physical therapy. For example, it is important to provide patient education over bladder relaxation to reduce urinary urgency and pelvic floor relaxation to prevent constipation. Assessing all body systems, particularly other areas of musculature, can help providers understand how the pelvic floor interacts with other symptoms. Overall, the key feature of pelvic floor therapy is individualized treatment. Pelvic floor physical therapists form the treatment plan around each patient’s goals.

During the discussion, Harm-Ernandes places a significant emphasis on the numerous indications for pelvic floor therapy, as well as common misconceptions surrounding it. For instance, she highlights that many women are often taught to believe that occasional urinary incontinence, particularly with age or after childbirth, is entirely normal. However, she stresses the importance of dispelling these myths and encourages women to seek professional help rather than accepting incontinence, pain during sexual intercourse, or chronic constipation as inevitable experiences. By dispelling these misconceptions and seeking appropriate treatment, individuals can significantly improve their quality of life and overall well-being.

Collaboration among health professionals is pivotal in treating patients holistically and addressing the complexities of pelvic floor disorders. Harm-Ernandes’ extensive knowledge and commitment to educating both patients and providers has been instrumental in highlighting the essential role of pelvic floor therapists.

---

RESOURCES

Book: “The Musculoskeletal Mystery: How to Solve Your Pelvic Floor Symptoms”

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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.

---

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/

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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.

---

RESOURCES

ACOG Guidelines:

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

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SHOW NOTES

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.

---

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SHOW NOTES

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

---

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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

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SHOW NOTES

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/

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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

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SHOW NOTES

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.

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SHOW NOTES

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/

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SHOW NOTES

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.

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SHOW NOTES

Dr. Lerner is an Associate Professor at the Zucker School of Medicine at Hofstra/Northwell. She is on the Editorial Board of Obstetrics and Gynecology, and she is an associate editor for Simulation in Healthcare Journal.

The episode begins with Dr. Lerner describes her journey and training regarding simulation in gynecologic surgery, including her participation in the Center for Medical Simulation at Harvard and involvement in the American College of Obstetricians and Gynecologists Simulations Working Group, which are both involved in validating and advancing the use of simulation in healthcare. During this time, Dr. Lerner provides a framework for developing a simulation center at an institution, which begins with needs assessment and defining learning objectives. She also emphasizes the financial costs for simulation, as well as concern for institutions without adequate resources for simulation. She then defines 3 terms regarding fidelity: cost, technology, and actual fidelity. For example, Dr. Lerner has built her own mobile simulation lab, which she describes as a high-fidelity, low-cost initiative.

The physicians then discuss the role of individualized learning plans in regard to simulation. Dr. Lerner references the book, “Make It Stick,” to emphasize the importance of tailoring training to the learning strategy of the learner. She also encourages listeners to acknowledge the risk of moral injury and to combat it by acknowledging the difficulty that may come with developing competency in simulation. Lastly, she describes how listeners should leverage resources and time in order to promote simulation at individual institutions.

The episode ends with the group recognizing the benefits of simulation, as well as its relation to the field of Quality and Safety. While simulation in obstetrics is well-studied, its role in the field of gynecology has lagged due to lack of financial incentives. To address this, Dr. Lerner urges listeners to take advantage of surgical simulation in a safe environment prior to operating in the OR. During this discussion, Dr. Lerner expresses the importance of trainees to gain exposure to simulation early on and to develop an “education portfolio” over the period of residency. In order to help continue the information learned through simulation, it is important to “teach the teacher, train the trainer, and disseminate that knowledge.” Ultimately, Dr. Lerner advocates for the endless opportunity that simulation brings to the field of gynecology surgery.

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RESOURCES

ACOG simulation consortium:

https://www.acog.org/education-and-events/simulations/about

“Make it Stick” by Henry L Roediger III, Mark A McDaniel, Peter Brown

EMIGS Assessment:

https://www.abog.org/specialty-certification/surgical-skills-program-standard/essentials-in-minimally-invasive-gynecologic-surgery-emig

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SHOW NOTES

First, Dr. Pearson shares about her struggle with disability. Early in her career, she suffered a traumatic injury that led to the development of a frozen shoulder and ended her clinical practice. Her group disability insurance did not cover work-related injuries, and she had to sue in order to receive her worker’s compensation insurance. She did not feel like she was properly educated about insurance policy and was promptly terminated from her OB/GYN job after her medical leave was over. Her emotional recovery was challenging, but she found support from her spouse, children, and dog. She eventually found her identity outside of her role as a physician, which helped ease her guilt of being a financial burden on her family.

Her personal disability journey motivated her to co-found a personal insurance brokerage firm with an insurance broker. PearsonRavitz was started five and a half years ago and has nationwide clients, the majority of whom are medical professionals. She frequently gives online and in-person lectures about the importance of buying disability insurance to residents and new attendings. Dr. Wei agrees and compares working in a surgical subspecialty to physical labor, as repetitive motions may increase injury risk.

Both doctors agree that standardized education for residents and medical students about disability insurance is needed. Some common myths that Dr. Pearson debunks the myths that group insurance benefits are adequate, healthy doctors do not need insurance coverage, and residents cannot afford disability insurance. Finally, the doctors end the episode by discussing unique health concerns of female surgeons, such as Infertility risk and delivery complications.

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RESOURCES

PearsonRavitz

https://pearsonravitz.com/

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SHOW NOTES

Dr. Ian Fields completed a fellowship in Female Pelvic Medicine & Reconstructive Surgery and received a Master of Clinical Research degree from Oregon Health & Sciences University. His research focuses on changes in the urinary microbiome and their association with lower urinary tract symptoms.

Dr. Fields begins the episode by describing the microbiome as “all of the things outside of our cells that make up the human body,” which includes bacteria, viruses, and fungi. He explains that the microbiome may play a role in how humans maintain states of health, in addition to having large impacts on the pathophysiology or development of disease states. Dr. Fields references the Human Microbiome Project, a United States National Institutes of Health research initiative that was aimed to improve the understanding of microbiota in relation to human health and diseases.

The physicians then transition to cover the role of the microbiome, specifically in the field of obstetrics and gynecology. Dr. Fields explains that the most studied condition is bacterial vaginosis. From a urogynecology perspective, he expresses a particular interest in urinary tract disorders, such as urinary incontinence, recurrent urinary tract infections, and interstitial cystitis. Dr. Fields emphasizes to listeners that urine is not sterile. In addition, he highlights how the use of vaginal estrogen increases the presence of lactobacillus within the genital microbiome, and thus is beneficial in the settings of genitourinary syndrome of menopause and recurrent menopause.

Dr. Fields concludes the episode by briefly addressing other areas of study regarding the microbiome in the field of obstetrics and gynecology. For example, studies have revealed a link between vaginal microbiota and risk of preterm birth, as well as neonatal gut microbiota and the mode of delivery. Ultimately, Dr. Fields states that the microbiome is an underfunded and understudied aspect of medicine, and he urges listeners to acknowledge the large potential the field has.

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RESOURCES

The Human Microbiome Project:

https://hmpdacc.org/hmp/overview/

Brubaker L, Nager CW, Richter HE, Visco A, Nygaard I, Barber MD, Schaffer J, Meikle S, Wallace D, Shibata N, Wolfe AJ. Urinary bacteria in adult women with urgency urinary incontinence. Int Urogynecol J. 2014 Sep;25(9):1179-84.

Wolfe AJ, Toh E, Shibata N, Rong R, Kenton K, Fitzgerald M, Mueller ER, Schreckenberger P, Dong Q, Nelson DE, Brubaker L. Evidence of uncultivated bacteria in the adult female bladder. J Clin Microbiol. 2012 Apr;50(4):1376-83.

Hoffman C, Siddiqui NY, Fields I, Gregory WT, Simon HM, Mooney MA, Wolfe AJ, Karstens L. Species-Level Resolution of Female Bladder Microbiota from 16S rRNA Amplicon Sequencing. mSystems. 2021 Oct 26;6(5):e0051821.

Richter HE, Carnes MU, Komesu YM, Lukacz ES, Arya L, Bradley M, Rogers RG, Sung VW, Siddiqui NY, Carper B, Mazloomdoost D, Dinwiddie D, Gantz MG; Eunice Kennedy Shriver National Institute of Child Health and Human Development Pelvic Floor Disorders Network. Association between the urogenital microbiome and surgical treatment response in women undergoing midurethral sling operation for mixed urinary incontinence. Am J Obstet Gynecol. 2022 Jan;226(1):93.e1-93.e15.

Fettweis, J.M., Serrano, M.G., Brooks, J.P. et al. The vaginal microbiome and preterm birth. Nat Med 25, 1012–1021 (2019).

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SHOW NOTES

Dr. Iglesia is the Director of the Section of Female Pelvic Medicine and Reconstructive Surgery at MedStar Washington Hospital Center, as well the current President of the Society of Gynecologic Surgeons. In addition to being involved with a consensus document regarding cosmetic gynecology, Dr. Iglesia has contributed numerous studies to the growing field and hopes to educate other providers on the topic.

The episode begins with Dr. Iglesia sharing how she became passionate about cosmetic gynecology. Her experience initially began with a weekend course in California learning about topics such as “laser vaginal rejuvenation” and “designer laser vaginoplasty,” which were early marketing terms used for the field. After multiple years of training and education within a field filled with gray areas and limited evidence-based medicine, she later helped develop a consensus document about cosmetic gynecology procedures, which provides clarification for patients and opportunity for future research studies.

Dr. Iglesia then describes the field of cosmetic gynecology, which includes the elective intervention to alter the aesthetic appearance of the external genitalia or modify the genital organs. These elective, functional procedures may be performed in the absence of any pathology (e.g., no incontinence, prolapse, etc.) with the goal of improving a person’s quality of life (e.g., sexual function). She describes two pillars of the field, including cosmetic (e.g., labiaplasty) versus functional (e.g., surgical tightening of the vagina for vaginal laxity) procedures. The physicians then address the concerns of societal pressure, agreeing that the goal is to help patients make well-informed, ethical decisions, which requires discussing goals with patients.

After discussing the field as a whole, Dr. Iglesia then highlights different procedures and technologies. For example, a fractionated laser may be used to stimulate tissue growth and may be utilized for diagnosis such as genitourinary syndrome (GSM) of menopause or lichen sclerosis. In addition, she briefly mentions aesthetic procedures, including a clitoral frenulum reduction (frenulectomy) or clitoral amplification with platelet rich plasma or the O-Shot. She addresses that a lot of the procedures and technologies are proprietary, have limited evidence, and are not risk-free. Ultimately, Dr. Iglesia states that there is a need for more data, urging the need for future level I trials.

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RESOURCES

Developed by the Joint Writing Group of the International Urogynecological Association and the American Urogynecologic Society. Joint Report on Terminology for Cosmetic Gynecology. Int Urogynecol J. 2022 Jun;33(6):1367-1386.

Li FG, Maheux-Lacroix S, Deans R, Nesbitt-Hawes E, Budden A, Nguyen K, Lim CY, Song S, McCormack L, Lyons SD, Segelov E, Abbott JA. Effect of Fractional Carbon Dioxide Laser vs Sham Treatment on Symptom Severity in Women With Postmenopausal Vaginal Symptoms: A Randomized Clinical Trial. JAMA. 2021 Oct 12;326(14):1381-1389.

Paraiso MFR, Ferrando CA, Sokol ER, Rardin CR, Matthews CA, Karram MM, Iglesia CB. A randomized clinical trial comparing vaginal laser therapy to vaginal estrogen therapy in women with genitourinary syndrome of menopause: The VeLVET Trial. Menopause. 2020 Jan;27(1):50-56.

Burkett LS, Siddique M, Zeymo A, Brunn EA, Gutman RE, Park AJ, Iglesia CB. Clobetasol Compared With Fractionated Carbon Dioxide Laser for Lichen Sclerosus: A Randomized Controlled Trial. Obstet Gynecol. 2021 Jun 1;137(6):968-978.

Cosmetic Gynecology and the Elusive Quest for the “Perfect” Vagina:

https://journals.lww.com/greenjournal/Citation/2012/10000/Cosmetic_Gynecology_and_the_Elusive_Quest_for_the.34.aspx

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SHOW NOTES

Dr. Chaudhari discusses how her inspiration to advocate for physician wellness began when she herself was experiencing feelings of burnout. Initially an open ear for colleagues on an individual level, Dr. Chaudhari was later trained on the topic of wellness through the Scholars of Wellness Program and received her Organization Leadership and Coaching Certificate at Northwestern University.

Dr. Chaudhari then explains that, through the program, volunteers from both medical and non-medical backgrounds are trained to provide support for those experiencing adverse events, “compassion fatigue,” and discriminatory patient experiences. In addition, peers are also available to provide feedback or education. Specific metrics for the program include retention, wellbeing scores, and culture surveys to identify “pain points'' within the Institution.

Next, the doctors discuss the topic of “work-life integration,” rather than work-life balance, and how to promote this in your own practice. While acknowledging that it may be difficult to advocate for yourself and set boundaries early on in your career, the group emphasizes the role of mentorship and how this can empower trainees/learners to take action sooner rather than later.

The episode ends with a discussion on creating culture in your workplace. The doctors express sentiments that maintaining an intentional, positive outlook and treating all colleagues with respect is a key aspect in promoting wellness. In addition, they encourage listeners to acknowledge difficult situations and to share personal experiences to further promote an environment of support and growth.

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RESOURCES

Define Measure Analyze Improve Control (DMAIC) Process:

https://asq.org/quality-resources/dmaic

Stolarski A, Moseley JM, O’Neal P, Whang E, Kristo G. Retired Surgeons’ Reflections on Their Careers. JAMA Surg. 2020;155(4):359–361. doi:10.1001/jamasurg.2019.5476

The CE experience for this Podcast is powered by CMEfy - click here to reflect and earn credits: https://earnc.me/29D37F

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SHOW NOTES

The episode begins with Dr. Branham describing her day-to-day work schedule. As she shares the workflow of her clinic and OR days, as well as call shifts, she emphasizes how her patients’ care is typically subject to herself as their sole medical provider (e.g., handling a postpartum hemorrhage without access to Interventional Radiology). Due to this, Dr. Branham routinely thinks multiple steps ahead in regard to her patients’ care in order to decide if she can continue herself or if the patient has to be transported to a higher-acuity center.

Dr. Branham then transitions to discuss the challenges that she faces as a physician practicing in a rural setting. Using personal anecdotes and published data, she emphasizes barriers such as decreasing numbers of OB/GYNs choosing to practice in rural areas, as well as the weather conditions dictating whether or not a patient may be transported via helicopter or ambulance to an alternative hospital. In addition, she covers the impact of the opioid use epidemic that largely impacts the Appalachian region.

Lastly, Dr. Branham ends the episode by sharing why she passionately chooses to practice in rural Kentucky, despite the challenges she may face: her dedication to serving patients who are often in the most need of medical care. She also describes current systems in place to help improve care for her patients, including the Blue Angels Program, which provides telehealth visits with Maternal Fetal Medicine specialists at the University of Kentucky and traveling ultrasound clinics to specific areas in rural Kentucky counties.

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RESOURCES

The Blue Angels Program:

https://kytelecare.med.uky.edu/kytelecare-telehealth-mobile

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SHOW NOTES

Dr. King begins the episode by describing surgical coaching as an act of asking open-ended questions, determining where a “coachee” is currently at, identifying their goals, and then empowering them to make specific actions that are needed to close this gap. During the discussion, she emphasizes the importance of prioritizing self-assessment as a coach.

Dr. King then explains how to find a surgical coach through the Academy for Surgical Coaching. The process requires a “coachee” to complete a form that identifies their personal goals, and then the “coachee” is paired with a coach from the pool of physicians from various specialties. Coaching experiences are performed through various platforms (e.g., in-person, video-based, etc.) and are ideally conducted for 3-, 6-, or 12-month periods. Dr. King also covers how outcomes and metrics are evaluated, describing the differences between technical and non-technical (e.g., judgment) skills.

The doctors transition to emphasize the importance of incorporating coaching into a surgeon’s practice. Dr. King shares 2 methods to do so, including (1) replacing 1-hour of grand rounds or meetings with 1 hour of coaching sessions, as well as (2) integrating coaching at the level of national societies (e.g., American Association of Gynecologic Laparoscopists). The doctors go on to highlight also incorporating coaching at the level of medical schools and residency in order to instill the mentality of continual improvement early on in a physician’s career.

The episode ends with Dr. King sharing the steps to becoming a surgical coach through the Academy for Surgical Coaching, which includes a paid certification program.

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RESOURCES

Atul Gawande, “Personal Best”:

https://www.newyorker.com/magazine/2011/10/03/personal-best

The Academy for Surgical Coaching:

https://surgicalcoaching.org

Greenberg CC, Byrnes ME, Engler TA, Quamme SPR, Thumma JR, Dimick JB. Association of a Statewide Surgical Coaching Program With Clinical Outcomes and Surgeon Perceptions. Ann Surg. 2021 Jun 1;273(6):1034-1039.

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SHOW NOTES

First, the doctors discuss the definition of culture, which Dr. Kane defines as the norms of behavior and relationships within an organization. Culture can include dress code, meeting rules, and punctuality. Most of the time, institutional culture is established in an unspoken way. Dr. Kane emphasizes the importance of having a conscious strategy to create a healthy culture and reiterates that trust is a crucial foundation for motivating cultural changes.

Next, the doctors discuss helping team members find meaning in their work. Dr. Kane recommends that surgeons share patient gratitude with their other colleagues who are not frontline medical workers. He acknowledges his staff’s contributions during meetings and expresses his gratitude through written notes. He also recommends communication training for everybody on his team. Then, he shares tips for assessing organizational culture. He believes that it is most important to ask team members what they think the overarching goal of the institution is and to assess the attrition rate through exit surveys. He emphasizes that behavioral norms matter most, as department leaders often lead by example. One detrimental practice is favoritism, which Dr. Kane regards as disrespectful to other team members. Additionally, he shares his personal experiences with changing cultures at different institutions and utilizing change management theories.

Finally, Dr. Kane shares general leadership advice. He highlights the importance of creating a patient-centered environment, leading by influence rather than authority, and the power of positivity.

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SHOW NOTES

Dr. Melissa Wong, MD, MHDS is a board-certified Maternal Fetal Medicine specialist and an Assistant Professor of OB/GYN at Cedars-Sinai in Los Angeles, California. She also works in the division of informatics and with the National Institutes of Health Office of Research on Women’s Health. Dr. Wong has studied the use of VR to mitigate the pain associated with labor, and she is continually finding opportunities for the use of VR to enhance the field of OB/GYN.

Dr. Tony Shanks, MD, a co-host of BackTable OBGYN, joins the podcast again as a Maternal Fetal Medicine specialist at Indiana University. He currently serves as the Vice Chair of Education at the institution, as well as the Maternal Fetal Medicine Fellowship Director.

In this episode, Dr. Wong describes the methods and conclusions of her study, “Virtual Reality Reduces Pain in Laboring Women: A Randomized Controlled Trial,” which ultimately determined that the use of VR was associated with a reduction in pain during labor compared to patients who received no intervention.

The group also discusses the potential for VR within the obstetrical and gynecologic sides of the field, as well as the field of medicine in general. Some topics that were mentioned include the use of VR for in-office procedures and patient education through visualization of complicated surgical procedures. In addition, the group highlights the potential for additional technological advancements in medicine through augmented reality, artificial intelligence, and informatics.

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RESOURCES

Wong MS, Spiegel BMR, Gregory KD. Virtual Reality Reduces Pain in Laboring Women: A Randomized Controlled Trial. Am J Perinatol. 2021 Aug;38(S 01):e167-e172. doi: 10.1055/s-0040-1708851. Epub 2020 Jun 2. PMID: 32485759.

Sridhar A, Shiliang Z, Woodson R, Kwan L. Non-pharmacological anxiety reduction with immersive virtual reality for first-trimester dilation and curettage: a pilot study. Eur J Contracept Reprod Health Care. 2020 Dec;25(6):480-483. doi: 10.1080/13625187.2020.1836146. PMID: 33140989.

“Rewiring Education” by John D. Couch

“Deep Medicine” by Eric Topol

“Measure What Matters” by John Doerr

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SHOW NOTES

Dr. Leonardi is a minimally invasive gynecologic surgeon and sonologist (ultrasound specialist) in Hamilton, Canada. He received his PhD at the University of Sydney, studying the role of ultrasound for diagnosis of endometriosis and its influence on surgical management of the disease. He then completed a 2-year fellowship in advanced gynecological surgery and ultrasound in Sydney, Australia. He now conducts a comprehensive clinic for the diagnosis and management of endometriosis.

The episode begins with Dr. Leonardi describing his initial fascination with ultrasound as an OB/GYN resident and discussing his various training internationally for advanced gynecological surgery and ultrasound. He highlights specific steps he took, colleagues he collaborated with, as well as barriers he encountered and overcame along the way.

The group then talks about the current role of ultrasound within gynecologic care and its potential in the field. Dr. Leonardi explains how he built a gynecologic ultrasound unit, detailing the workflow of his clinic. During this time, he also compares the use of ultrasound versus alternative imaging (e.g., MRI), ultimately favoring the dynamic, efficacious, and cost-effective benefits of ultrasound.

Lastly, the group discusses the topic of bowel endometriosis. Dr. Leonardi describes the limitations of ultrasound in this setting, such as diagnosis of disease that spreads beyond the pelvic brim. The group then transitions to describe the involvement of colorectal surgeons in these cases and brings to light the need for additional training and exposure for minimally invasive gynecologic surgeons.

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RESOURCES

Leonardi M, Espada M, Condous G. Closing the communication loop between gynecological surgeons, diagnostic imaging experts and pathologists in endometriosis: building bridges between specialties. Ultrasound Obstet Gynecol. 2021 Apr;57(4):523-525. doi: 10.1002/uog.23595. PMID: 33491846.

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SHOW NOTES

To set the stage, Drs. Rampersad and Shanks explain the definition of PPH based on the American College of Obstetricians and Gynecologists (ACOG) guidelines. They further describe the differences between early / acute versus late blood loss, in addition to the most common etiologies using the “Four T’s” pneumonic: tone, trauma, tissue, thrombin. Drs. Rampersad and Shanks then describe their approach to the workup and management of PPH. The group discusses topics such as uterine massage, oxytocin, hemabate / methergine, tamponade (e.g. Bakri balloon, the JADA System), embolization, and hysterectomy.

The physicians then describe the role of cross-specialty collaboration between OBGYN and IR, specifically in the management of PPH. When highlighting the role of IR, Dr. Beck describes how he counsels patients for uterine artery embolization (UAE), and he provides an anecdote regarding a repeat UAE. He also shares his perspective with utilization of gel foam versus coils. The group then transitions to describe diagnosis and management of placenta accreta spectrum (PAS), its association with PPH, and the role of radiology in this disease process.

Lastly, Drs. Rampersad and Shanks allude to what the future may hold for PPH, including more personalized medicine and potential technologies to prevent PAS. The group ends the episode by providing IR colleagues with insight to what may strengthen the collaboration between OBGYN and IR in order to provide optimal care for patients with PPH.

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RESOURCES

Silver RM, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol. 2006 Jun;107(6):1226-32. doi: 10.1097/01.AOG.0000219750.79480.84. PMID: 16738145.

Bienstock RM, Eke AC and Hueppchen NA; Postpartum Hemorrhage. New England Journal of Medicine 2021 Vol. 384 Issue 17 Pages 1635-1645. Accession Number: 33913640 DOI: 10.1056/NEJMra1513247.

https://www.nejm.org/doi/full/10.1056/NEJMra1513247

ACOG Postpartum Hemorrhage:

https://www.acog.org/en/clinical/clinical-guidance/practice-bulletin/articles/2017/10/postpartum-hemorrhage

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SHOW NOTES

Dr. King, who works in the Division of Minimally Invasive Gynecologic Surgery, is also an Assistant Professor and Obstetrics, Gynecology and Reproductive Biology and the Director of Reproductive Bioethics at Harvard Medical School. Initially a lawyer of constitutional law, Dr. King utilizes the combination of her legal training with her medical knowledge to educate patients and colleagues on the essential and compassionate delivery of abortion healthcare.

The episode begins with Dr. King providing the legal history of reproductive care in the United States. She walks listeners through a timeline that includes the Comstock laws, as well as U.S. Supreme Court decisions, including Griswold v. Connecticut, Roe v. Wade, and Dobbs v. Jackson Women’s Health Organization. When discussing the history, Dr. King emphasizes the role of healthcare professionals in combating the current legal state. Specifically, she urges listeners to go beyond simply stating that discussions about abortion should remain between physicians and patients. Instead, she shares how providers should continue the conversation by vocalizing what abortion is, why it is essential, what makes it a complex topic, and why each person should defend the right for themselves and others.

Dr. King then describes how to develop a space that promotes others to engage in conversation about abortion. Her approach to this dialogue includes allowing people to identify what gives them pause and determining ways to validate someone’s discomfort about the topic. Dr. King provides examples of how she frames her discussion with medical students at Harvard Medical School, which involves utilization of the pillars of ethics as a scaffolding for conversation. She then goes on to define reproductive justice for listeners.

Lastly, Dr. King charges the audience to practice their first amendment right and educate about abortion care. She also discusses the developing course for OBGYN residency programs and acknowledges the varying levels of training based on geographical location. The episode concludes with Dr. King sharing avenues of support for physicians who regularly practice abortion care.

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SHOW NOTES

The co-hosts begin by briefly discussing the workup for pelvic organ prolapse (POP). Dr. Park identifies common symptoms of prolapse and special exams (e.g. Pelvic Organ Prolapse Quantification System or POP-Q and urodynamics) that may be utilized for initial evaluation. She then explains the clinical indications for treatment of isolated POP, in addition to POP with concomitant urinary incontinence.

Drs. Park and Silva then transitioned to cover the management of urinary incontinence. The two co-hosts reveal the benefits of pelvic floor physical therapy and other conservative management options, such as core-centric exercises and weight loss. In length, they elaborate on the benefits and takeaways of using sling procedures versus urethral bulking agents (e.g. Bulkamid). When discussing these topics, the co-hosts bring to light the possible differences in approach between Urogynecologists and Urologists. In regard to urethral bulking agents for treatment of urinary incontinence, Drs. Park and Silva highlight the potential role for stem cell injections. In addition, Dr. Park provides a tip to maximize patient comfort during in-office periurethral injections for urethral bulking. When focusing on sling procedures, Dr. Park highlights her preferred approach and encourages listeners to become proficient in the approach of their choosing.

Lastly, they describe their approaches to treatment of stress urinary incontinence. In their discussion, Drs. Park and Silva consider factors such as patient age, desire for future fertility, and pregnancy. When wrapping up the episode, Dr. Park emphasizes the importance of patient counseling when it comes to management of these conditions, as well as practicing shared decision making to determine the best next steps for her patients.

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RESOURCES

Nager CW, et al. Design of the Value of Urodynamic Evaluation (ValUE) trial: A non-inferiority randomized trial of preoperative urodynamic investigations. Contemp Clin Trials. 2009 Nov;30(6):531-9. doi: 10.1016/j.cct.2009.07.001. Epub 2009 Jul 25. PMID: 19635587; PMCID: PMC3057197.

Erin A. Brennand, Shunaha Kim-Fine. A randomized clinical trial of how to best position retropubic slings for stress urinary incontinence: Development of a study protocol for the mid-urethral sling tensioning (MUST) trial, Contemporary Clinical Trials Communications, Volume 3, 2016, Pages 60-64, ISSN 2451-8654, https://doi.org/10.1016/j.conctc.2016.04.004.

M. Abdel-Fattah, D. Cooper, T. Davidson, M. Kilonzo, M. Hossain, D. Boyers, et al. Single-Incision Mini-Slings for Stress Urinary Incontinence in Women New England Journal of Medicine 2022 Vol. 386 Issue 13 Pages 1230-1243. DOI: 10.1056/NEJMoa2111815 https://doi.org/10.1056/NEJMoa2111815.

Persu C, Chapple CR, Cauni V, Gutue S, Geavlete P. Pelvic Organ Prolapse Quantification System (POP-Q) - a new era in pelvic prolapse staging. J Med Life. 2011 Jan-Mar;4(1):75-81. Epub 2011 Feb 25. PMID: 21505577; PMCID: PMC3056425.

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SHOW NOTES

Dr. Park, a co-founder of the Society of Surgical Ergonomics, begins the episode by sharing her personal experience with a work-related shoulder injury and how it inspired her to prioritize surgeon ergonomics in her daily practice. She and Dr. Hoffman then encourage listeners to acknowledge the role of optimizing factors such as table height, body posture, and more in order to maximize the longevity of a surgeon’s career and thus patient care.

The co-hosts then cover pitfalls commonly identified in normal, open surgery (e.g. excessive neck flexion, truncal deviation, arm abduction) and laparoscopic surgery (e.g. body posture, monitor height). They transition to highlight possible resolutions to these pitfalls, including anti-fatigue mats, appropriate footwear, and proper posturing; ultimately addressing a need for further research in this aspect of medicine. Lastly, they cover the role of robotic surgery and the potential to either mitigate or worsen the risk for work-related MSK injuries.

The episode wraps up with a call to bring awareness to the value of surgeon ergonomics and to proactively impart this knowledge onto trainees, as the overall goal for surgeons is likely to continue operating and impacting patient care.

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RESOURCES

Epstein S, Sparer EH, Tran BN, et al. Prevalence of Work-Related Musculoskeletal Disorders Among Surgeons and Interventionalists: A Systematic Review and Meta-analysis. JAMA Surg. 2018;153(2):e174947. doi:10.1001/jamasurg.2017.4947

Society of Surgical Ergonomics:

https://www.societyofsurgicalergonomics.org

The FIRST Trial:

http://www.thefirsttrial.org

The SECOND Trial:

http://www.thesecondtrial.org

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SHOW NOTES

Dr. Wright is the Director of the Division of Minimally Invasive Gynecologic Surgery at Cedars-Sinai Medical Center. She has served on various hospital committees regarding patient safety and cost-optimization. She actively researches operating room cost-effectiveness and waste minimization, most recently publishing a manuscript titled, “Sustainability in Healthcare: A Call to Action for Surgeons and Healthcare Leaders.”

Drs. Park and Hoffman begin the episode by asking Dr. Wright to bring to light the overall carbon footprint of healthcare in both the US and the world, as well as what should be included in biohazardous waste containers in the operating room (OR). During this conversation, Dr. Wright demystifies the common assumption that single-use products are related to better patient outcomes postoperatively. The group then breaks down the utilization of reusable, re-processable instruments in the OR, ultimately agreeing upon a reduced carbon footprint when using these products in comparison to those that are single-use.

Dr. Wright further explains what surgeons can do in order to mitigate these issues. She discusses various approaches at the individual, institutional, and federal levels. She highlights options that include making conscious efforts to reduce waste, demanding the industry to develop reusable products, and advocate for tighter regulation to reduce carbon emissions in hospital facilities. Throughout the episode, Dr. Wright charges listeners to collaborate with members of their institutions / hospitals who are directly involved in OR waste (e.g. human factors groups, quality and safety officers, heads of linen services) to find ways to mitigate waste and engage in sustainable practices.

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RESOURCES

Schwartz KM, Wright KN, Richards EG, King LP, Park AJ. Sustainability in Healthcare: A Call to Action for Surgeons and Healthcare Leaders. J Minim Invasive Gynecol. 2022 Sep;29(9):1040-1042. doi: 10.1016/j.jmig.2022.06.024. Epub 2022 Jul 1. PMID: 35788396.

Malhotra GK, Tran T, Stewart C, Battey H, Tegtmeier B, McNeese K, Flood A, Melstrom L, Fong Y. Pandemic Operating Room Supply Shortage and Surgical Site Infection: Considerations as We Emerge from the Coronavirus Disease 2019 Pandemic. J Am Coll Surg. 2022 Apr 1;234(4):571-578. doi: 10.1097/XCS.0000000000000087. PMID: 35290277.

https://practicegreenhealth.org

https://noharm.org

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SHOW NOTES

Dr. Hoffman shares the story of his training in minimally invasive surgery and chronic pelvic pain, and discusses the challenges he faced when starting his practice at the University of Kentucky where he treats complex, benign gynecologic concerns. Notably, he started a uterine fibroid embolization program alongside the Division of Vascular and Interventional Radiology. He also discusses caring for an underserved population in rural Kentucky may look like, in addition to factors that influenced his decision to practice in an academic versus community-based setting. Lastly, Dr. Hoffman highlights the role of podcasting and collaboration in medicine, which inspired his involvement in BackTable OBGYN.

Drs. Hoffman and Fritts wrap up the episode by previewing the upcoming episodes for BackTable OBGYN, such as cross-specialty treatment of postpartum hemorrhage and the legal perspective of Roe versus Wade. The hosts encourage listeners to prepare for authentic, open conversations that address women’s health in both realms of obstetrics and gynecology.

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RESOURCES

BackTable OBGYN Twitter and Instagram:

@_backtableobgyn

BackTable website:

www.backtable.com