OB/Gyn

Episode 11.2 Rethinking VBAC Risk and a Lot More!

We unpack new studies that reshape how we counsel on VBAC after short intervals, update what we tell BRCA carriers about estrogen therapy, and explore how self-collected HPV tests can reduce screening gaps. We also question surgical marketing, workforce trends, and the shaky evidence behind aspirin dosing for preeclampsia.

• Short interpregnancy interval as a VBAC risk factor, not a contraindication
• Absolute uterine rupture rates in spontaneous vs induced labor
• Estrogen therapy in BRCA carriers and treated gyn cancers
• Cervical screening overuse and underscreening in insured populations
• Self-collected HPV testing intervals and access benefits
• OB-GYN workforce shortages and rural distribution gaps
• Endometriosis surgery indications versus fertility claims
• Robotics versus laparoscopy outcomes and training priorities
• Aspirin dose trials, lack of placebo arms, and abruption signals
• Reading statistics correctly and demanding better editorial standards

0:00 Setting The Agenda: New Studies

0:40 Short Interval Pregnancy And VBAC Risk

3:10 Quantifying Uterine Rupture By Spacing

8:10 Induction, Augmentation, And Rupture Math

9:40 HRT In BRCA Carriers: New Evidence

13:05 Estrogen After Gyn Cancers: Practice Gaps

17:40 Cervical Screening: Overuse And Underscreening

22:30 Self-Collected HPV Testing Guidance

27:00 OB-GYN Shortages And Distribution

33:20 Endometriosis Surgery And Fertility Claims

41:20 Robotics Vs Laparoscopy: Outcomes And Training

47:20 Aspirin Dosing For Preeclampsia: No Signal

55:30 Interpreting Stats And Editorial Standards

59:20 Closing Notes And Next Steps

Links Discussed

Transcript

ANNOUNCER: 0:01

Welcome to Thinking About OBGYN. Today’s episode features Howard Herrell and Antonia Roberts discussing several new studies.

ANTONIA: 0:15

What are we thinking about on today’s episode?

HOWARD: 0:19

Well, we’re going to catch up on a whole bunch of new literature from the last few months that we’ve not had time to talk about, but why don’t we do it old school and first talk about a thing we do without evidence?

ANTONIA: 0:30

All right. Well, how about telling patients that a short interval pregnancy is a contraindication to a trial of labor after cesarean?

HOWARD: 0:39

Okay, sure. Well, this is a tough one because it obviously there is some meaning behind that, or at least that’s that’s our understanding. But it’s a good example, though, of where folks may take a risk factor for failure, or in this case, a risk factor for uterine rupture for an adverse outcome, and then act like that the presence of essentially any risk factor or anything that changes your baseline odds to success is a contraindication. They do this with external cephalic version a lot, like you haven’t had a baby before, so maybe you we shouldn’t try to vert you, which will lower your chance of success, perhaps, but it’s not a contraindication to trying. And neither is this. These are just simply risk factors to consider and to counsel the patient about. So that means that you need to be able to tell the patient precisely what the risk factors are and what how they change the statistics, and then let them make an informed decision. I think we also, in all cases, we have a tendency to emphasize risk factors, but not protective factors. So what I mean by that is let’s say that you had a patient who had two prior vaginal deliveries, and then in her third pregnancy she had a cesarean for breach, and now she’s got a short interval pregnancy in a fourth pregnancy, and she wants to have a trial of labor. So that patient actually has protective factors in the form of two prior vaginal deliveries, and that issue may more than mitigate the risk factor on the other end of it that she’s had a short interval pregnancy. So our job is really just to inform the patient about the risks and benefits of what she wants to do, about what we think her best statistics are based upon both her risk and protective factors. Is a patient with one prior cesarean in a short interval pregnancy at higher risk than a patient with two prior cesarean deliveries and no prior vaginal deliveries? And we currently allow patients with two prior cesareans to V back, but you have to know the numbers to really answer that. So I think there’s definitely a culture around talking patients out of trials of labor after cesarean, just like there is around external cephalic version or vaginal delivery of twins or a lot of things like that. And so anything that comes up at all that might be a predisposing negative factor will be presented to the patient as a contraindication.

ANTONIA: 2:50

Well, there was some new data about this published last year in a journal called e-clinical medicine. So January 2025, they looked at interpregnancy intervals and risk of uterine rupture during a subsequent trial of labor in patients who had one prior caesarean delivery and no prior vaginal births. And this was based in the US. They looked at data over a 10-year period and found a total of nearly half a million trials of labor meeting that inclusion criteria specifically. So then they looked at the odds ratio of uterine rupture for each, they broke it down into three-month inter-pregnancy intervals. And they found that the risk of uterine rupture progressively decreases with every additional three months between pregnancies up until about 21 months. And then it just stabilizes out. And that is consistent with what I think we already knew, roughly at least, and with prior data that says the risk of rupture is less if there’s let’s say two years between your pregnancy, even compared to one year. Obviously, one year then is better than six months, which is better than three months. So that this is a study that provides some absolute numbers on that.

HOWARD: 4:16

Yeah, because you hear people say that it’ll double or triple the risk of rupture, but you have to know what the baseline risks are. So there’s a nice graph in this paper that shows their results, and they also model for us the upper 95th percentile probability of the risk of uterine rupture. And they have a separate data set for both spontaneous labors and then induced or augmented labors. But for the patient with spontaneous labor, the uterine rupture rates are never higher than 0.36%, so a little bit over a third of a percent, even with back-to-back pregnancies, a zero minor zero month interval. And then that rupture rate drops off to 0.27% with a 10-month interval. In other words, those rupture rates are lower even with a back-to-back pregnancy, no interval essentially, than most patients are counseled about in the first place regarding uterine rupture, because we generally talk to patients and say something like there’s a 1% risk. And that’s viewed as an acceptable choice. The highest risk was one in 275, to put it in terms of numbers needed to harm. And an interval of 21 plus months, that dropped down to 0.19%. So one thing that you note is that these numbers, these baseline numbers are lower than we commonly cite. And we’ve talked about a couple of studies recently that talked about rupture rates being lower. But one of the things I would say is when we talk about uterine rupture rates in a population, we’re including the folks with two prior cesareans, the people getting induced, the people getting oxytocin, all those other things. So that those numbers I just gave are in spontaneous pregnancies. So when you hear a rupture rate is two to three times higher with a short interval pregnancy, that might scare people because they’re thinking, oh, it’s 1% baseline, and now it’s 2 or 3%. And I’ve actually seen that in some reports from maternal fetal medicine doctors counseling patients against it, citing basically that logic. And it is higher, but we’re using the wrong baseline when we multiply it. A more typical scenario might be someone who gets pregnant, say, four months accidental unintended pregnancy after they’ve had a C-section. So therefore there’s a they’re going to deliver it around 13 months after their last C-section. And that person would have a rupture rate in this data of 0.32% with the trial of labor, again with spontaneous labor. If she waited to conceive at 14 or 15 months, so that she would have two years of spacing, then that rupture rate would be 0.23%. So neither of those numbers b both of those numbers are lower than we traditionally counsel patients, and neither should be unacceptable in terms of the risk profile that we’re looking for.

ANTONIA: 7:05

Yeah. So I guess what they’re typically hearing is we kind of round often round to that overall 1% risk of uterine rupture. Oh no, you have a short interval pregnancy, it must it’s two to three times higher. So it must it must be two to three percent. And I don’t even recommend trialing labor. That’s what a lot of patients are being told. Like basically it is a contraindication. But yeah, as you said, based on this study of the typical scenario is about a third of that. And maybe, yeah, of course, it is higher when you induce or augment, but even then it’s probably those are spontaneous. Yeah, even then it’s probably still not a contraindication. It’s just another risk factor.

HOWARD: 7:50

Well, they include data on induced or augmented labors. And the worst case scenario, again, with back-to-back pregnancies, you get pregnant right after you delivered is a rupture rate of 0.91%. So that’s I got pregnant right after my cesarean and I got induced or augmented. And that compares to about a half a percent rupture rate at the two-year interval. So it is about double the rupture rate, but it’s still under the 1% that we so commonly consider acceptable for this issue. And for the average person who, again, say has a 13-month time between cesareans, so they got pregnant four months after their last cesarean, with induced or augmented, that rupture rate is still less than a percent. So patients should be given that sort of data. Those numbers are similar to the rupture and augmentation rates that we see with longer interval or not short interval pregnancies, because when we augment or induce trials of labor, the rupture rate goes up, and those numbers scale similarly to that, and we find those risks acceptable. So the idea that a short interval pregnancy makes a person ineligible for a trial of labor after cesarean is certainly not evidence-based. It’s just one of many risk factors to counsel the patient about. And other things too, did they have an infection while they were healing? Things like that. What was the reason why they had it? There’s a lot that goes into counseling, and this isn’t meant to be a contraindication.

ANTONIA: 9:13

All right then. Well, let’s look at some studies. So, first up, we’ll talk about is one relating to something else we’ve recently discussed, which is hormone replacement therapy in women who are BRCA positive. There’s an article in December 2025 in the Journal of the National Cancer Institute that was a prospective matched cohort analysis of women who used hormonal therapy in menopause and were BRCA positive. So they had 676 matched pairs where one woman used hormones and the other didn’t, but otherwise were similar demographically and in their BRCA positive status. And these women were all followed for about five and a half years out. There ended up being, in that follow-up period, 87 breast cancers in the women who were taking hormones compared to 128 breast cancers in the women not taking hormones. So this was a rate of just about 13% versus 19%, roughly. The women who used estrogen alone without progesterone had a significantly decreased risk of breast cancer. So their hazard ratio was 0.37. And just like the article we discussed, I think last month, there there was no real protective or harmful effect for the women who use estrogen plus progesterone. Technically, their risk was still a little lower. The hazard ratio was like 0.94, but not statistically significant.

HOWARD: 10:50

So again, this, as we said before, corresponds with the findings from the Women’s Health Initiative group, and it corresponds with that data we reviewed from that was presented at the San Antonio conference last month. At this point, I think we really should be able to say fairly definitively that estrogen alone decreases the risk of breast cancer, which was the conclusion of the authors of the WHI study in 2012. But we have multiple studies, multiple data sets done by different groups with different strategies that have confirmed this effect. But also we can say that using combination hormone therapy does at least not increase the risk of breast cancer. The same in this data, same we talked about last month, the E plus P at least doesn’t increase it.

ANTONIA: 11:35

We really have to get this word out, not just to our own colleagues in our specialty, but really to all the primary care providers and even oncologists who continue to steer women away from estrogen who could greatly benefit from it. In the last episode you had with Dr. Jamie Perry, you had also mentioned a study on the cognitive benefits of estrogen therapy. So it’s not obviously we use it for vasomotor or genito urinary symptoms, but there’s other benefits too, if it started at a certain time at least.

HOWARD: 12:08

Yeah, breast cancer reduction and cognitive benefits. And for these ladies who are BRCA positive, of course, a lot of them are undergoing risk-reducing surgery at a younger age. So the benefits, the protective benefits, the osteoporosis benefits and things like that, are even going to be greater along with quality of life. So we need to desperately revisit, too, I think, some of the breast cancer risk tools, which ask about previous hormone replacement therapy and use that as a negative risk factor that, if you play around with it, will increase your risk of breast cancer based upon old flawed data. So these tools are known to be inaccurate, and hopefully we’ll soon have a new tool that better reflects our current knowledge of risk factors.

ANTONIA: 12:49

All right. Well, let’s move on. This is still on topic. There is a study from September 2025 in the Journal of Menopause that surveyed gynecologists and oncologists in the U.S. about their use of estrogen therapy in patients with prior gynecologic cancers.

HOWARD: 13:07

Yeah, and these were gynecologic oncologists, so all folks in the specialty. And in this case, this was considering women with endometrial cancer or epithelial ovarian cancers. So it’s similar to what we’re talking about because we know that estrogen therapy is safe in these patients, in patients who’ve had endometrial or epithelial ovarian cancers. And yet even endometrial cancer patients, once they’ve been treated at least, these were all patients who had received treatment. But the study wanted to look at whether gynecologists and gynecologic oncologists were shying away from using estrogen therapy in those patients. So this was just a web-based survey that was sent to members of either the Society for Gynecologic Oncology or the American College of Obstetricians and Gynecologists, and they had 293 respondents, and they were asked if they were willing to provide estrogen replacement therapy to treated patients, and only 64% said yes for endometrial cancer and 65% for epithelial ovarian cancer. However, 97% of them said that they would do it for a patient with cervical cancer. So they’re specifically shying away from those two malignancies. They did find that the gynecologic oncologists were more likely than the generalist OBGYans to prescribe estrogen therapy, but sadly they also found that the physicians who had been in practice longer than 10 years, or those who were identified as male, were more likely to prescribe it, which is worrisome because it seems like the newer graduates are less likely to prescribe it. And so you wonder what they’re learning.

ANTONIA: 14:40

Yeah, you definitely have to wonder. In this paper, they did ask the providers who would not prescribe estrogen why. And I think they just I don’t think it was a free tax thing. I think it was just select the best answer. And the most common selected reason was hormones are contraindicated, or saying that the risks outweigh the benefits.

HOWARD: 15:02

Right. Just in general, we’re just scared of estrogen, is what it seems like. I suspect if we had a similar survey of OBGYNs for estrogen therapy for BRCA carriers, we would find worse results. And I’m sure if we had a survey of non-OBGYNs, it would get worse still. So I’m not sure where this demonization of estrogens come from or why over a third of new graduates from OBGYN programs would be afraid of using estrogen in endometrial patients and in treated endometrial cancer patients and treated epitheliovarian cancer patients, but you know, let alone BRCA carriers. But I do think it shows how much we, meaning physicians, are influenced by persistent false beliefs and social media and things like that. These aren’t cognitive decisions, they’re emotional, fear-based decisions.

ANTONIA: 15:52

Yeah, it is kind of telling that the guy and onks are more likely to prescribe it, and they’re the experts in those cancers, so that tells you that they know more. You’d still think they they would just all prescribe it. My guess is 100% one of them. Yeah. My guess is at least with endometrial cancer, there’s some kind of quick, not well thought out logic that, well, unopposed estrogen can cause the cancer. It’s responsive to estrogen when it’s active in their body and they’re needing to get treatment. And we know that estrogen therapy is contraindicated if someone presents with abnormal bleeding that you haven’t ruled out the cancer yet, like you need to work it up first before you just give them estrogen. So I’m guessing some providers think if any of these have ever applied to a patient before, God forbid they have a recurrent endometrial cancer. I’m just gonna make that spread even more if I give them estrogen. And then they just assume that they can’t ever have estrogen again when they’re in surveillance, even after all the cancer’s been presumably treated or surgically removed. But then with ovarian cancer, I don’t know. I I don’t know if that’s just they’re confusing the two somehow, or maybe they think DVT risk, which doesn’t really make sense because if they would give it to cervical cancer patients.

HOWARD: 17:15

So it overall it’s I think they’re confusing patients with BRCA because of the ovarian and estrogen risk. I think just amalgamating all that together and thinking estrogen is a m it causes breast cancer, it’s bad. I think it’s just emotion, it’s not logic.

ANTONIA: 17:32

And we’re seeing that it protects people with BRCA. So it does sound like just a gap in education to me. I would hope that it’s not something that’s being actively taught to trainees, that these are contraindications that that wasn’t taught to me, I don’t think. So it shouldn’t be getting taught at all, but maybe that’s just people not thinking it through. And remember, again, we mentioned timing of treatment where the best benefits, at least the least risks of hormone replacement therapy, come when it’s started within a shorter period from the onset of menopause. And so many of these BRCA patients will, like you said, will have had surgical menopause due to risk-reducing surgery at a younger age. And guidelines do recommend that they go on estrogen at least until when they would have gone through menopause naturally, so maybe age 50 or so. There there was an abstract of a survey in 2017 published in the Journal of Clinical Oncology, and it found that only 13% of BRC-positive women who had no history of cancer were put on hormone replacement therapy. And then only 28% of those who had survived a breast cancer. The survey indicated that only one in four healthcare providers were comfortable prescribing it to their risk reduction surgery patients who had BRACCA. And then only 8% were comfortable prescribing it to the survivors, despite guidelines that are essentially promoting estrogen therapy.

HOWARD: 19:12

Well, and that paper is a few years old, so the situation might be better today. The Journal of Gynecologic Oncology had a study from Italy in 2024, and the respondents were mostly young female gynecologic oncologists, and they found that 70.5% of respondents believe that hormone replacement therapy was safe for BRACA-mutated patients after risk-reducing salpingophorectomy. So I’m not sure if the Italians are doing better than the Americans or if 24 is better than 2017, but still that’s a 30% plus were not actively promoting it, I guess, or believe that it was safe.

ANTONIA: 19:49

All right. Let’s shift topics a little bit. There was an interesting article in JAMA Network Open in December 2025 looking at non adherence to cervical care. Cancer screening guidelines among commercially insured US adults between the years 2013 and 2021. They were able to find over 670,000 eligible patients in this database. And within that group, only about 7% were receiving cervical cancer screening according to our current guidelines. Of the rest, the 93% or so, 62% were being overscreened. And we’ve both seen this a lot. I’ve definitely seen it more now that I’ve shifted out of military medicine. And then there were 31% who were underscreened. And this was broadly true regardless of racial or ethnic groups. The overscreening seems to be more common among patients of higher socioeconomic status, though.

HOWARD: 20:52

Yeah, it’s very interesting. We’ve talked a lot about non-adherence to guidelines in general, but certainly cervical cancer screening guidelines over the years. And I suspect that this population of commercially insured and more affluent patients is probably more vulnerable to receiving extra screening than poor patients or those certainly with Medicaid or government insurance. But I don’t know that for sure based on that data, because they didn’t have those government insurance plans in there. It’s hard to get a handle on what’s going on with the current data, but needless to say, nearly two-thirds of these commercially insured patients were getting unnecessary and extra cervical cancer screening. And you would think that being better reimbursing for those plans was a factor in why they’re getting too much screening. Who knows? But these patients are being harmed by this extra testing, though. We’ve established that. But even in this data, you can see that the degree of affluence was associated with over-screening, even for patients who all had commercial insurance. The folks in the study that got less screening had insurance, but were less affluent. And the reality is that they may not be able to take time off from work to go get the screening. They may be more likely to miss appointments, or they may live in areas where there’s less access to OBGYNs, and so they get less screening due to their socioeconomic status. It’s amazing, though, that only 7% of patients received appropriate guideline consistent screening when I guarantee you that everyone, every OBGYN in the country knows what the guidelines are. And I bet that those numbers are going to be similar and maybe even less screening for folks and I bet that’s going to be true for people outside of our specialty, too, because a lot of cervical cancer screening is done by primary care. But it would be interesting to see this same study done in patients with Medicaid and Medicare.

ANTONIA: 22:43

Yeah. Also, this past December in the American Cancer Society’s journal, they released their new guidelines for self-collected vaginal specimens for cervical cancer screening. And you had mentioned this in just the last episode too with Dr. Perry. This guideline was published December 4th, 2025. So, in theory, if people do have access issues or other reasons why they’re not able to undergo the standard in-person cervical cancer screening, or I think another big one is they have access, but they’re not willing to have a pelvic exam to do so. This can definitely help that subset of patients who otherwise probably wouldn’t receive the sufficient cervical cancer screening. I highly doubt that there’s gonna be over-screening with home. There’s home swab collection, then there are some that are meant to be in office or in the lab. You still have to physically go there, but then you can privately self-collect. Or at least I don’t think there’d be over-screening to the 62% extent that we’re seeing in this study we just talked about. And I’ve been very excited about this whole self-collection option for a while. I have a lot of patients that they’ll come to the office but really be hesitant about it or say, I’ve been really nervous about this. They just don’t like the pelvic exams. And I understand that. So I’ve been following along from what I can find at this moment in the US. I believe that there’s two companies that will send it to your house, let you do it at home, and send it back in. One is called the Teal Wand, and I think another is my lab box, and hopefully there’s gonna be more. But both of these so far seem to have at least a small out-of-pocket cost to the patient and different eligibility rules, even with insurance coverage. I think these are not gonna be totally free right now. And then, like I mentioned, there are also some other companies that we don’t have these right now in my office, but you can go to the lab and then they’ll give you the swab and they say, go follow these instructions and then come back out and give us the specimen.

HOWARD: 25:00

And there’s a lot of patients who don’t come to your office because they’re anticipating that when they get there, they’re gonna get a cervical exam. And so even office collection numbers may see higher attendance for those vulnerable patients because they know that when they get there, they can self-collect. So we have to educate them about that. So this was an update to the American Cancer Society’s 2020 cervical cancer screening guideline. And it’s that had already moved towards HPV testing, much more so than the other societies. But now they include the self-collection for HPV testing. So they say in the guideline that when the clinician collects the cervical specimen used for HPV testing, then repeat screening is every five years for those, of course, who have a negative test. But for the self-collected vaginal specimens, which I assume is both office collected and home collected, then they recommend repeat testing every three years instead of five. And they do endorse a preference for clinician collected specimens, but obviously that’s why they have a difference in the timing. So it’s mitigated by the more frequent collection schedule. Now, all of this is obviously for patients who are low risk and they’ve had negative tests. They also slightly change their recommendations about ending screening. Now, this is an HPV-based screening, this is not what we’re doing if you’re doing cytology-based. But the current recommendation was just to stop at 65, and they’ve refined that a bit and said that you can exit screening if you’ve had a negative primary HBV at 60 and 65. So essentially end with two negative HPV tests in a row.

ANTONIA: 26:30

Yeah. And just to reiterate, these are the American Cancer Society recommendations. They’re not exactly identical to the USPSTF or ACOGs. I’m sure they’re fairly similar, but they are now an option for providers to follow. And this pathway will become, I think, more widely available. And probably because it’s a guideline by some society, it that means insurance will cover this pathway as well as the other guidelines. And regardless, hopefully it’ll decrease the gap in underserved and underscreened populations and just maybe make this a more accessible option for primary providers who otherwise are still often referring kindents just to get a PAP and just to get a routine speculum exam.

HOWARD: 27:29

So Yeah, there might be folks who don’t have speculums in their office or things like that, and they could have the self-collection ones and let patients collect in in the bathroom or in the exam room.

ANTONIA: 27:38

Yeah. We’ve reviewed some of the literature already showing that this has happened in other parts of the world and it’s been a successful strategy.

HOWARD: 27:46

Yeah. Okay. Well, did you see this article in the January 2026 Green Journal that looked at the projected shortages and distribution challenges for OBGYNs in the US over the next 10 years?

ANTONIA: 27:59

I did. I was very interested in it. I mean, I think this is very interesting. At least we know we’ve got some job security, but then also may maybe in it also on the flip side means there’s too much work to do and not enough people to do it. So I was especially interested in the graphic that breaks down the shortages now and projected in 10 years by each of the 50 states. So on average in the US overall and in most individual states, there’s at least mild shortages, and pretty much all of them are going to worsen in the next 10 years. But if there’s a few, and especially Hawaii apparently is oversaturated. They have 135% of the OBGYNs that they need, according to this paper.

HOWARD: 28:49

Huh. I wonder what it is about Hawaii that attracts so many OBGYNs to go there and practice when they’re not needed.

ANTONIA: 28:56

I don’t know if maybe more of them are just I can speculate all day, but like maybe maybe there’s more that are working part-time and just enjoying Hawaii. I don’t know what cost of living is like out there, but I don’t know. If they’re oversaturated, I’m sure they’re not going there for the the salaries, but there’s probably some other perks and maybe I don’t know, patient population kind of stuff either.

HOWARD: 29:19

So maybe we should take a trip and check it out and report back to folks what it is about Hawaii that attracts people there.

ANTONIA: 29:26

For science, yeah, we should do that. For science, yeah. Yeah. Okay. Well, the other thing I noticed in this paper was at the very bottom of the list, the worst states for supply versus demand were Utah and Idaho. They only have about 66% of the OBGYNs that they need currently. And that’s projected to fall closer to 50% over the next decade. And we know those are both states that have a big burden of rural, needing rural access. And they also both have some pretty restrictive abortion laws. And especially in Idaho, we’ve I’ve read all the articles about there’s this exodus of OBGYNs after the Roe v. Wade was overturned and blaming it on that. And maybe that’s a I mean, that that’s gotta be at least partially true.

HOWARD: 30:22

But it’s bad. They’ll have half as many OB OBGYNs as they need because they’re all in Hawaii, I guess.

ANTONIA: 30:27

Yeah.

HOWARD: 30:28

Well, listeners can go look up their own state on the table. I’ll tell you that Alaska also seems to have an adequate amount, which surprised me because I don’t like cold weather. But I do think a lot of folks are interested to go and live there for a while just to the the last frontier, maybe. I don’t know. I’ve known a lot of folks that have worked in Alaska. But in any event, in 10 years, only six U.S. states are projected to have an adequate number of OBGYNs, and only 14 do right now. Tennessee, where you and I currently live, is only at 89% adequacy, and that’s projected to fall to 74% in 10 years. And that pretty much tells a story for the average state in America.

ANTONIA: 31:05

Yeah. Yeah, not as bad as Idaho, but still, still not good. They also note that about 15 out of every 16 OBGYNs, so a pretty big majority, currently practice in metropolitan areas. But but that’s that doesn’t really match up with the birth rates. So one in eight babies are born in what we would consider rural hospitals. So automatically, if you do the math, the delivery to provider ratios are double if you’re a provider in a rural area compared to metropolitan.

HOWARD: 31:39

Yeah. And it actually might be a little worse than that because the bigger metro areas are more likely to use nurse midwifery in their programs. So the actual number, because this is just OBGYNs, and the rural areas are less likely to. So the actual number of providers per patient could be even worse than two to one. So it’s a hard thing to track. And one of the difficulties in understanding all this data is knowing how clinically active in obstetrics a particular doctor might be. So the methodology that they use, I don’t believe adequately controls for that. Many OBGYNs in practice aren’t delivering babies, and they might do GYN only or something like that. The American Board of Obstetrics and Gynecology is working on trying to nail down this data more specifically to understand what our workforce is actually doing. We’ve had quite a change in what graduates of OBGYN programs do in practice in the last 20 years or so. A lot more of us are going into subspecialties, and many of those subspecialties don’t deliver babies, although someone might do a subspecialty and still deliver. For example, someone might have a focus in minimally invasive gynecologic surgery but still take obstetrics call for their hospital, whereas another person might not. So we also have more and more hospitalist and laborist programs, and that has a potential to cause OBGYNs in the community to have more of an office-heavy or even office exclusive practice, and then eventually lose their skill set and credentialing for doing deliveries and hospital-based obstetrics if they stop taking call or take too little call. So our workforce is changing dramatically, and most OBGYNs are not full scope OBGYNs. So my guess is the shortages actually might be a little worse than this study makes them appear. And some of those full-time equivalent positions listed in the survey just don’t deliver babies anymore, and that’s where the real shortage is.

ANTONIA: 33:24

Yeah, and it could also be that in places with very well-developed hospitalist programs, there’s less need for full scope general OBGYNs because each hospitalist is that’s all they’re doing, really, is deliveries for the most part. And so each of them can do a lot more than they could if they also had office or guind surgery responsibilities. And this study also doesn’t take into account some of those family medicine physicians who also have had obstetric training and do carry obstetric patients and do have good experience in deliveries. In some parts of the country, this is fairly common. And it is something that we need to encourage, especially in the face of such big shortages in rural areas where there may not be enough work for a full-time OBGYN specialist. But if there’s a well-trained family medicine physician who’s also seeing all kinds of other types of patients and then also does obstetrics, that could serve the community and make that kind of job sustainable for the doctor also quite well.

HOWARD: 34:34

Yeah. Well, speaking of the Green Journal, there was an article in December 2025 that I don’t want to overlook. And this was a clinical perspective article. I love these types of articles, about endometriosis surgery and restorative reproductive medicine, which we’re going to do an episode with a reproductive endocrinologist about restorative reproductive medicine, hopefully, this year. But I would highly commend this article for anyone to read because you’re probably seeing a lot about this in your practice or patients coming in from social media and talking about it. So the author is a reproductive endocrinologist and has additional training in minimally invasive gynecologic surgery, and she essentially focuses on advanced surgeries for endometriosis and discusses how endometriosis surgery has been politicized in what people are calling restorative reproductive medicine. Like I said, we’ll do an episode on this later, but I really appreciated the literature review about the potential impact of endometriosis surgery on fertility. This is something that is confusing, and the literature basis is muddled at best, and we need to spend some time to kind of weigh all that out. But one of the points that I would make from this literature review and this summary is that most patients with endometriosis likely don’t benefit from most surgeries from for endometriosis in terms of enhancing fertility. And that’s one of the main problems with this restorative reproductive movement is that the physicians who brand themselves as such are telling patients that they can do surgery and restore fertility, especially, of course, if they have endometriosis. And so they’re doing a lot of surgery that may be unnecessary and maybe even potentially harmful. The data about surgery, as I said, for endometriosis and infertility is very mixed. And when you do see benefit, it seems to come sometimes from normalizing distorted anatomy so that you can do IVF. And it is difficult. There were some early studies in the 90s, a study in 1997 that an author, it was in the New England Journal of Medicine where an author randomized several patients to endometriosis surgery for low stage endometriosis and found higher rates of fertility. A couple of years later in 1999, an Italian group that did a lot of work on endometriosis in that time, they replicated that study and found that there was no benefit from surgery for low-stage endometriosis. And then what you see is you see meta-analysis or Cochrane reviews will take those two randomized trials and they’ll just average them together. And we can talk about that later. Philosophically, I look at that as an initial study showed promise, but a follow-up study failed to replicate the results. Other people look at it as, well, there might be some minimal benefit by averaging the two together, and that’s a philosophical thing about the role of meta-analysis and the need for replication of studies. But in any event, endometriosis for low-grade lesions is not that promising. Even if there is some benefit, it’s minimal. And for high-stage endometriosis, a lot of those patients need IVF out of the bat, out of the gate, because their tubes are blocked or things like that. So the role of surgery for endo is controversial at best. But there is a summary of four main situations where a person should consider surgery, and I’m just going to read from that. So, number one, patients with significant pelvic pain that disrupts the quality of life, like dysmenorrhea, dysprunia, and dyschisia. And as an aside, I’ll say that maybe one of the reasons why surgery for low-stage endometriosis might be beneficial for infertility is because you fix the dysparunia and the patients have more sex. That could be true. Who knows? Okay, number two, are those patients with deeply infiltrating disease that threatens bowel, bladder, or renal function, the ureters, in other words. Number three, those patients who have distorted pelvic anatomy that prevents access to the ovaries for in vitro fertilization. And these are that’s a rare case. Can you get the needle up safely? Is the ovary really distorted? Is it above the pelvic brim? Things like that. And then number four is those who, after shared decision making with their surgeon or their REI subspecialists, elect to pursue surgery before instead of or alongside fertility treatments. And there’s some new literature, there’s a new study last year about this. We’ll get into that on a future episode. But there’s a lot there, and the counseling has to be appropriate. And the author talks more about this informed discussion and what the information needs to be to lead to such a shared decision and the choice to pursue surgery. Surgery for endometriosis, in fact, is not commonly indicated for fertility, and it’s not a panacea, and it’s ultimately less effective for restoring fertility than I think most people, most of us, think it is, certainly less effective than the general population believes. It has been overutilized in the past among reproductive endocrinologists, but that’s changing. And more importantly, even when it is effective for restoring anatomy and leading to fertility, in vitro fertilization is still much more effective. So the restorative surgeons are leading another surge, perhaps, of overutilization of surgery and skewing the counseling about its efficacy in order to encourage that. It’s definitely not a replacement for in vitro fertilization.

ANTONIA: 39:53

Yeah, and we’ll frequently see patients who maybe had a couple endometriosis lesions. They had those fulgurated with three seconds of cottery or argon laser, or maybe it was snipped out. And then they’re given to believe that suddenly now their fertility chances have doubled or tripled. So you mentioned these studies already. This article does seem to cut it seems to rely on on this one statement about the earlier study from 97 that 1997. Yeah, it so this article says that there’s moderate quality evidence to support using operative laparoscopy, so excising or ablating endometriosis for superficial peritoneal disease in patients who are trying to conceive. And in in that specific study, the rates were 30% to achieve full-term pregnancy versus 17% if they didn’t if they didn’t have those lesions treated somehow. But then this wasn’t replicated. So really I don’t know why this article, this clinical perspective didn’t.

HOWARD: 41:11

And so I love the article, but I can also acknowledge that folks who do this for a living are going to cite the study that agrees with them, not necessarily the studies that don’t agree. But we can talk about that and review all of this literature later on. I guess again, I wouldn’t doubt that there might be some minor benefit, but the question is it in those patients, like we said, that have bad dysperonia and they’re just not able to have sex, and then they have surgery and they’re able to have sex and they achieve a natural pregnancy or something. So we can get into that later.

ANTONIA: 41:41

Yeah, and I think but at least you and I usually will take someone to surgery for pain, not for infertility.

HOWARD: 41:47

Yeah.

ANTONIA: 41:48

But in in contrast, this author, I think somewhat surprisingly said that in moderate to severe endometriosis, so stage three to four, which would include ovarian endometriomas or rectal or other pelvic organ involvement, there is no high quality evidence that even ovarian cystectomy or more aggressive surgery like bowel resection is going to help improve fertility. It might help for other things like she listed in those four, in those four indications for surgery. But if patients have severe endometriosis and are asymptomatic and they’re trying to conceive, then there’s really no reason for surgery. You really should only be considering surgery for other reasons, like she already listed. And if they are infertile and they’re wanting help with that, then they should be getting the least invasive, effective reproductive assistance. So you probably need to see are their tubes open or blacked. If they’re black, just they’re gonna need to go straight to IVF. Um, some of them may be able to conceive with some lesser treatments, but the surgery is not gonna help them.

HOWARD: 43:00

Yeah. Tubal patency is key.

ANTONIA: 43:02

Yeah. So so let’s move on. Uh if we’ve said enough about this. You wanted to talk about something from JAMA surgery about colosystectomies, which I don’t do, and I didn’t think you did, so I’ll just leave that one up to you.

HOWARD: 43:19

Okay, well, I’m allowed to read the general surgery literature if I choose to. And I sometimes do in my spare time. Anyway, this was a cohort study of over 800,000 patients who underwent laparoscopic versus robotic assisted cholesectomies in acute care surgery. And I’ve been seeing a lot of clinical trials like this in the last two or three, four years in the general surgery literature, and they always catch my eye because this sort of study, in a way, is a surrogate for similar concepts and similar studies in the debate of laparoscopic versus robotic hysterectomy. Similar promises are made to general surgeons about the marvels and wonders of the robot for coal’s hystomy compared to a laparoscopic approach, as are made to gynecologists about the marvels and wonders of robotic hysterectomy compared to uh laparoscopic hysterectomy, or dare I say a vaginal hysterectomy.

ANTONIA: 44:10

I think I see what you’re doing. So you told Jamie Perry in the last episode, who does robotic history hysterectomies that you wouldn’t talk trash about it. So instead you’re just gonna trash robotic cholecystectomy now.

HOWARD: 44:24

Okay, you don’t have to go all Freudian about this. But let me tell you the results of this study. So in this match cohort of over 800,000 patients, there were similar bile duct injury rates, but the robotic assisted group was associated with a higher rate of postoperative complications, longer hospital stays, and increased usage of drains. And of course, it costs more money. So this is similar to several randomized controlled trials now that we have available of laparoscopic versus robotic assisted colosyssectomy. And I say all that, though, at the same time as general surgeons are switching en masse to robotic colsyssectomies. For me, this is just another cautionary tell about how marketing and product reps are pushing non-scientific narratives, making claims that haven’t been validated in the literature, but then they change the face of the practice of medicine without scientific evidence. And that’s nothing new, but I like to draw attention to it when I see it.

ANTONIA: 45:19

Fair enough. Well, I wish I also had time or could make time to read other specialties journals. I did not read this study, but I’ll just pose the de Devil’s Advocate argument that I wonder if there are any differences, at least sometimes in pre-op risk factors between robotic versus straight stick patients, or I don’t know how often these are done open, whether whether they’re real or just perceived differences, maybe more obesity or more concerning surgical history, or like maybe they’re sicker and they’re worried about more scarring or something. And I wonder if that could also play into the rates of post option.

HOWARD: 45:59

Yeah, are we doing harder cases with the robot than straight stick laparoscopy? But that’s the importance of the randomized trials. So this literature has several randomized trials in it where the choice wasn’t made by the surgeon. And of course, even in non-randomized trials, you can control for some of those factors. But it may make the promise is that it may make some cases less likely to convert, and you never know when you’re going to find that case. It might end up in a conversion. But most of these studies over and over again show very similar conversion rates.

ANTONIA: 46:30

Yeah, and I well, I think that is the obvious answer. Just like in gynecology, general surgery trainees now are probably increasingly graduating with more robotic skills, but at the cost of straight-stick laparoscopic skills and just having less straight stick laparoscopy experience compared to the prior generation of general surgeons. And they’re just focusing more heavily on robotics. And so naturally, over time, with each sort of graduating class, we’re probably going to see robotic outcomes improve compared to laparoscopic outcomes because the surgeons are being trained more to use the robot more and more. And then there’s going to be an increasing number of surgeons out there who become very expert at it and they’re disseminating their expertise either directly as preceptors or practors or putting out different surgical videos. And then in comparison, there’s going to be less of that with the straight stick.

HOWARD: 47:29

Yeah, I agree with that. And that phenomenon may already be happening in gynecology because we’re ahead of the general surgeons in adoption a little bit with the robot. But that also means that at many hospitals, if you have an emergent gallbladder on a Saturday night and the robotic team isn’t there, well, you may very well have a general surgeon who doesn’t know how to do that case particularly well laparoscopically. And then you’ll see those complications because that’ll be a poor surgery, a higher conversion rate, and a poor outcome. And the point is that it’s important in training in particular that we emphasize the right skill sets and both in general surgery and gynecologic surgery. And for listeners who don’t do this, if it’s not obvious, the skill set from laparoscopic surgery and the skill set from robotic surgery don’t have a lot of transfer in terms of just being having muscle memory of how to use laparoscopic instrumentation. You can be a great roboticist and an absolutely horrible laparoscopist because there’s not a direct transfer of skill set. So we have to decide in our training programs what we’re going to emphasize.

ANTONIA: 48:34

I’m sure it’s the robotic manufacturer’s dreams that all laparoscopy one day will just be robotic by default, and every OR team at any hour of the day is a robotics team. But unless they ever make that cheap, then that just can’t happen. They certainly haven’t made it cheap.

HOWARD: 48:50

Yeah. And it’s also just a question of how many of these systems are available and how many ORs have them. So it’s a bit impractical to think that all laparoscopy that we’re going to do salp injectomies with the robotic system and we don’t need to know how to do laparoscopic salp injectomies. And the same for general surgery. So there will be new robot platforms. There are two new robot platforms being marketed this year in the United States. And that may cause some cost improvements in some competition where there hasn’t been, but we’ll see. But none of that stops us from training our graduates to be able to do laparoscopy and robotics. If even if that’s the future or there’s common utilization, we should not present it as robot as the entire solution.

ANTONIA: 49:39

Well, do you think you’ve got the robot bashing out of your system for now?

HOWARD: 49:43

Sure. I let off some steam, so we can go on.

ANTONIA: 49:46

Okay. If we’ve got time, we need to talk about aspirin again. There was a trial published in January 2026 in the Green Journal comparing 162 milligram to the 81 milligram baby aspirin dose for preventing preeclampsia. We already teased this in a prior episode and said we would talk about this, so let’s talk about it.

HOWARD: 50:05

Yeah, I’ve been waiting on a trial like this to compare the common American regimen, the 60 the 81 milligrams, to the common European regimen, which is 150 or 162. And it does this for us very well, but it’s missing one big key component.

ANTONIA: 50:20

The placebo arm.

HOWARD: 50:22

It doesn’t have a placebo arm. So we’re at a great risk here of doing what early tocolytic studies did, where we compare one potentially ineffective treatment to another potentially ineffective treatment and find they’re equally ineffective, but tell everybody that they’re equally effective, right? Meaning we don’t know if it’s better than placebo. So if they had instead found that 162 milligrams of aspirin does a better job than the 81 milligrams of aspirin, then not having a placebo arm might be less of a problem.

ANTONIA: 50:51

Right, but I’m guessing that’s not what they found.

HOWARD: 50:53

No, they randomized 400 patients. This was open label, but we’ll take what we can get. In any event, the rates of preterm preeclampsia and preeclampsia with severe features were similar in patients who were randomized to start either 81 or 162 milligrams of aspirin all before 16 weeks of pregnancy. The dose didn’t matter. So the absence of a dose effect is in itself some information, but what the study truly needed was a placebo arm so that we can see if both of these or either of these were different than placebo.

ANTONIA: 51:24

Yeah, we reviewed here previously, there was a study showing that the 81 milligram dose was ineffective. There is at least one study that’s often cited from Europe that showed 150 milligrams of aspirin did reduce the risk of preeclampsia in high-risk patients. This was the aspirin trial, A-S-P-R-E. But as you said, there’s at least the risk here that one trial with an outlier finding leads to systematic reviews and meta-analyses concluding effectiveness overall, even when that outlier is combined with multiple other contrary or negative trials. So this one here from 2026 that compares the 81 to 162 milligram aspirin doses is essentially another negative trial, but you can’t state that fully because there’s no placebo arm.

HOWARD: 52:25

Right. They also found a higher incidence of placental abruption, so this might be a more important finding with the higher dose of aspirin. And if that’s true, if that’s validated, that might be a good reason to avoid the higher dose, especially if it’s not any better than a lower dose, even if the lower dose is effective. But then again, we’re stuck with a reality that no study has shown that the lower dose is effective. And a placebo arm would have also told us if both doses of aspirin increase the risk of abruption compared to placebo. Maybe 81 milligrams increases the risk of abruption compared to placebo, although we have that data from some other studies. In the totality of the currently available evidence, I see this as another damning study for the efficacy of aspirin to reduce the rate of recurrent preoclampsia and at-risk patients. People don’t want to give it up because they understand the methodology. They can explain in a quick elevator ride why it works. And people then continue to anchor to the aspiry trial until someone has the courage to conduct a high-quality trial that includes a placebo arm. And it took years for this to finally happen with tocolytics. And of course, 30 years later, people are still using tocolytics.

ANTONIA: 53:31

And it’s still in our guidelines. It’s still rec like the aspirin, yeah, for sure. Yeah. So for our listeners, can you quickly summarize the issues with that aspirin trial that make it questionable compared to all the other literature?

HOWARD: 53:45

Well, after randomization, that trial had 798 women who were receiving 150 milligrams of aspirin compared to 822 who received a placebo. And the incidence of preeclampsia in and these were high risk patients, not average patients. The incidence of preocclampsia in this high risk group was just 1.6% in the aspirin cohort compared to 4.3% in the placebo cohort. These were high risk patients. And so that is an unreasonably low rate of preocclampsia. In this new trial that we’re discussing, the rate of preeclampsia was 17% in the 162 milligram group, and we don’t even have a placebo group to compare to, but it was 17%, not 1.6%. So there’s just something abnormal about that data. And that’s why we do replication. That’s why we repeat things and don’t just anchor to the one thing that found a positive finding and don’t just average bad studies in with good studies and call it a systematic review. It’s not consistent with all the other studies that have looked at this. And it doesn’t mean that the authors were nefarious or anything like that. It just means that by random chance they had some unreliable data. So that information should probably be excluded from the meta-analysis and systematic reviews. And then you’ll see those reviews say that aspirin is ineffective. This is similar to what happened with 17 hydroxy progesterone caproweight, where the original study just had an arm that was messed up and it and the rate of recurrent preterm birth wasn’t what we expected. And then finally, we replicated and we did real-world studies and we found it didn’t work. And that’s what we’re seeing with aspirin.

ANTONIA: 55:13

Yeah. So that’s why studies need replication and they need placebos.

HOWARD: 55:17

Right. And we’ve attempted to replicate it, and essentially we keep failing. So I say we shouldn’t be including these unreplicated data in systematic reviews. And that’s like we talked about at the beginning of the podcast. And so with the endometriosis study. So we’ll have to talk about that philosophically at some point this year as well.

ANTONIA: 55:36

Okay. I think we’re getting low on time. We haven’t done anything from the gray journal, at least today.

HOWARD: 55:43

Well they’re all online now, so you won’t get it in your mailbox anymore if you have been used to getting it. As of January 2026, it’s all online. But you can go there and you can download the issue and read it. You just won’t get that reminder each month that it’s in because it’s in your mailbox.

ANTONIA: 55:58

I guess it’s the end of a paper journal era. I I actually never never had started subscribing every so often I thought I need to do that. But now I guess I can’t anymore. But for me, the Monthly Green Journal is quite enough reading for right now.

HOWARD: 56:13

Well, I have maybe one thing from this current edition online of the online gray journal, and it’s but it’s actually a letter to the editor about a previous publication and a similar trial to what we just discussed. So there was a trial published before that compared retrospectively 160 milligrams of aspirin to 81 milligrams of aspirin in twin pregnancies. So again, this was retrospective, but the author concluded that 160 milligrams of aspirin for the prevention of hypertensive disorders in pregnancy may offer superior outcomes in twins compared to the 81 milligrams, with no discernible rise in complications, and and they had 80 to 100 milligrams actually in that lower dose range. But Dr. Cutter from the University of Tennessee Memphis, along with Dr. Sabai, who used to be at the University of Tennessee Memphis but is now in Houston, wrote a letter to the editor chastising this article and called for a correction since the confidence interval for this finding was 0.22 to 1.81, obviously crossing one, a very wide confidence interval that crosses one, the p-value was 0.388. In other words, this finding was not statistically significant, nowhere near statistically significant. And I would add that the methodology wasn’t appropriate for making such a claim anyway. But I commend the two gentlemen for writing this letter and chastising the editors of the Gray Journal for allowing the authors of this prior paper to claim an effect based upon a point estimate of a hazard ratio that was not statistically significant. And you see a lot of this where people see that the relative risk or the hazard ratio or the odds ratio is something different from in one arm compared to the other, or something not different than one if it’s a ratio, and they make a claim and say something like, There was less preeclampsia in this one group compared to that other group, because there were fewer cases numerically, or the odds ratio was something other than one. But you can’t interpret that into anything when you have such a wide confidence interval and an insignificant p-value. They should have concluded that the that there was no difference in the two dosages of aspirin. It actually agrees with this study, but that’s not what they concluded. So I love that these letters to the editor, that’s where a lot of the richness in the medical literature is. And it’s concerning that the previous paper was published because most folks don’t read beyond the abstract or the conclusion, and these sort of myths creep into our specialty. Now, I’ve written in the past that whenever an author says something like may offer that subjective tense rather than does offer, then you know something’s wrong. But the average reader of these journals may not see much of a difference between those two statements. The editors of our journals have to stop allowing insignificant findings to be published without clear and straightforward explanation that the findings were not statistically significant. So anyway, that’s your gray journal. That article in twins agreed with the article we just talked about in Singletons.

ANTONIA: 59:01

Well, I am glad that the Gray Journal published that letter to the editor, even though it was about it was kind of a negative letter towards them.

HOWARD: 59:09

I don’t think they’re going to say no to Baha Sabai ever.

ANTONIA: 59:12

Okay. Well, let’s let’s wrap it up. I think next time we have another episode, I’ll probably have a another baby at home.

HOWARD: 59:20

So will we hear baby sounds on our next episode?

ANTONIA: 59:24

Yeah, we used to. Those guys are not babies anymore, but got another one coming.

HOWARD: 59:29

So all right. Well, by the time listeners hear this, I think so. Or there’s a real problem.

ANTONIA: 59:35

Yeah. Better not. Better not be baby.

HOWARD: 59:38

Well, you’ll see everybody in a month, and I’ll see everybody in two weeks.

ANNOUNCER: 59:42

Sounds good. Thanks for listening. Be sure to check out thinking about obgyn.com for more information, and be sure to follow us on Instagram. We’ll be back in two weeks.