Episode 8.10: Birth Control Counseling, MOC Article Highlights, and Feminine Forever
In this episode, we discuss four tips for effective birth control counseling. By dissecting communication techniques, we highlight how striking a balance between relational and task-oriented approaches can maximize patient interactions and ensure comprehensive, evidence-based care regarding birth control choices.
Then we delve into several studies from the recent ABOG MOC cycle that we found interesting or curious and point out several informative nuggets.
Finally, we discuss the book “Feminine Forever” and its impact on estrogen replacement therapy perceptions.
00:00:02 Communication Strategies for Birth Control Counseling
00:11:56 Effective Communication of Birth Control Risks
00:21:08 PAS After Myomectomy
00:23:03 Risk-Reducing Surgery Adherence Discussion
00:30:33 Issues With Modern Labor Curves
00:38:49 Stopping ASA Early
00:42:17 Prophylactic Slings
00:46:01 Clinical Updates on UTIs
00:51:34 Mental Health Guidelines and Other Articles
00:55:51 Feminine Forever
Links Discussed
Risk of placenta accreta spectrum following myomectomy: a nationwide cohort study
Aspirin versus Placebo in Pregnancies at High Risk for Preterm Preeclampsia
Cost-effectiveness of prophylactic retropubic sling at the time of vaginal prolapse surgery
Urinary Tract Infections in Pregnant Individuals
Transcript
Announcer: 0:02
This is Thinking About OB-GYN with your hosts Antonia Roberts and Howard Herrell.
Antonia: 0:17
Howard.
Howard: 0:18
Antonia.
Antonia: 0:19
What are we thinking about on today’s episode?
Howard: 0:21
Is it feeling more natural now to go first?
Antonia: 0:23
Not yet.
Howard: 0:24
Well, we’re going to discuss some articles from our recent maintenance certification cycle that ABOG lists for us to do from the last year, and today, as of listening to this, is November 13th, so if you haven’t finished everything, remember it’s due by November 15th. They moved it up a month and we’re not going to give you any answers to the quiz questions, so no luck there if you’re still behind. But we are going to discuss some of the articles that you or I thought were interesting or significant for some reason, ones we picked, obviously and we’ll summarize some of that literature that ABOG has suggested for us. And, yeah, that’s what we’re going to do.
Antonia: 0:57
Yeah, for the last probably week or so it was telling me in flashing red do immediately. So I’m all done. So hopefully all of you ABOG people out there are done too.
Howard: 1:09
And it’s a cheat for us, because this is stuff we’re having to work on, obviously, and you are too, so it’s writing this episode a little easier.
Antonia: 1:16
Yeah.
Howard: 1:17
But first we have four tips for talking about birth control with our patients.
Antonia: 1:22
All right, great, this is quite bread and butter.
Antonia: 1:25
But when we look at birth control utilization in the US right now, it seems to be backwards because patients tend to use less effective methods of birth control with worse side effect profiles and worse safety profiles compared to the other available choices that we also have, so specifically that patients tend to underutilize long-acting reversible contraceptives.
Antonia: 1:50
We’ve discussed before how this seems to be getting worse. There seems to be some kind of anti-birth control movement or sentiments, at least on social media, and I think that really affects all forms of birth control right now. But it really seems to hit on the IUDs and the nexplanons and patients in general. Probably since before I started training, but certainly since the start of my training, a lot of times seem to be averse to any kind of hormones. But some of the issues here may also be not just because of misinformation and social media, but because of how OBGYNs themselves talk about birth control and counsel patients, because there’s still a lot of evidence that ultimately patients do trust their physicians on average more than they trust social media, even though it may not seem like it to us all the time.
Howard: 2:46
Yeah, and I think we fall into bad habits too, because we’re so frustrated with what we assume are people coming in already dissuaded by social media, but we have to remember to do our job well and that they do ultimately trust physicians. Most patients do if we present the information correctly.
Antonia: 3:03
Yeah yeah. If it seems like one person just rejects everything, we say that doesn’t represent everybody and we need to not get in our heads about that Jaded. Yeah yeah, need to not get jaded about that. So our first step here, our first tip, is to employ both relational and task-oriented communication strategies.
Howard: 3:24
Right. So relational communication techniques help to develop the therapeutic relationship between the provider and patient and that in turn hopefully builds trust. So we do get frustrated that patients will seemingly trust a stranger on social media over our own recommendations. But we’re a stranger to them too and, whether you realize it or not, the videos and social media interactions, they do things that help promote a relationship between the creator of those posts and the consumer, the influencer and the consumer. Our patients feel oftentimes more of a connection to people whom they follow on social media and have some interaction with regularly than they do their own physicians, whom they see once a year maybe. So we need solid relational communication skills and work on our therapeutic relationship with our patients if they’re going to trust us.
Howard: 4:14
But then you also need effective task-oriented communication. So these are two different skill sets and two different styles. Task-oriented is where we provide evidence-based and essential information about the options and outcomes of the methods and pros and cons that we’re discussing just the facts. Many times we’re really good at that task-oriented communication style. That’s probably my better style. I’m always full of facts. But then that may mean we’re not as effective with the relational communication styles, and that’s just as important, if not more important.
Antonia: 4:46
Yeah, of course, with medical training we just get crammed with facts constantly. Facts cram it, regurgitate it, cram some more. That’s just what we live and breathe and then that ends up being how we talk. And there is, I think, a stereotype out there in culture that doctors tend to be nerdy, awkward, use big words, can’t connect with normal people, maybe they’re very cold, don’t even make eye contact.
Howard: 5:18
Speak for yourself.
Antonia: 5:21
I think that’s an extreme caricature of what probably is to some degree true, for some people at least. But then there is the other extreme where people can be very good at the relational part, and maybe these are people that get a lot of rave reviews on the internet, social media and mom groups and stuff, and that’s good for them. But they may or may not be good at the task oriented communication of facts as well. Sometimes it does feel like those two different styles can be at odds, Like how do you employ those both at the same time?
Antonia: 5:58
And many providers out there are good at building great rapport, developing a great therapeutic relationship, but then they’ll present the birth control options in a way that just makes them all seem equally good, like here’s the menu, pick whatever you want, because they view this as a patient-centered approach and maximizing autonomy and all of that. But our patients do want to know a lot of times what are our recommendations like, what are the risks and what’s the efficacy. So we need to be good at both. That’s the whole tip here. The left-brained and the right-brained communication like the analytical and also maybe the emotional and practical, maybe be emotional and practical.
Howard: 6:43
Yeah, and you’re not being paternalistic just to ultimately say, hey, an IED is what I would get. It is very effective and low side effect profile. It’s okay to make a recommendation about what you think is best. If you were going to an oncologist with a malignancy and you said, what should I do? The oncologist doesn’t present all of the chemotherapy options and all of the alternative medical recommendations and all these sorts of things on equal footing, they say I think you should get X number of rounds of cisplatin plus this or that or the other, because that’s what our evidence says. So it’s okay to make a recommendation and give your medical opinion. That’s why you went to medical school.
Antonia: 7:21
Yeah, and maybe the trick is to not make the recommendation in a pushy or judgmental way or act like oh why are you picking this thing that I’m not recommending?
Howard: 7:32
Yeah, it’s also okay. If the patient doesn’t want to take your recommendation, that’s fine.
Antonia: 7:36
Yeah, exactly, all right. So second tip is to just consider some do’s and don’ts associated with these types of communication strategies as they relate to birth control.
Howard: 7:48
Yeah, and I’ll put a link to a great article that goes through these strategies specifically in reference to birth control counseling, with some suggestions that go into more detail than we will here and some of the literature basis and evidence basis behind it. But for the relational communication style, you do obviously want to build rapport and trust and use a method that focuses on shared decision making which incorporates the patient’s preferences and her own concerns. What you don’t want to do is dismiss patient’s concerns or seem to pressure them, as you said, towards a specific method. You also shouldn’t assume that effectiveness of birth control is the most important thing that your patients care about regarding birth control. The other thing here is you don’t want to use self-disclosure in order to direct a patient to a specific method. There are plenty of female providers who will talk about their own use of birth control and use this as a way of steering or it may seem like pressuring a patient towards that specific method of birth control, but this sort of self-disclosure is almost always a mistake.
Antonia: 8:50
Yeah, we can get caught up in the long-acting reversible contraceptives spiel because, well, they are the most effective in terms of pregnancy rates and we always think that fact alone makes it the best thing for a patient. But obviously the percentage rates of pregnancy are not always the patient’s sole priority. So in this phase of the communication we really need to focus in on what’s important to them with open-ended questions and just understand what their priorities and fears are, and then we can inform and recommend whatever method seems to most closely align with those priorities and optimize the things that they’re most looking for. And we need to make sure that we’re emphasizing the details and the facts of why is this method best for this thing that you’re looking for, that specific concern. So the point is don’t make assumptions about what other people’s priorities or preferences are. They’re looking for birth control, but they may not care. Like 90% versus 93% success, I’m just throwing those numbers out. They may care a lot about some of the other more peripheral details.
Howard: 10:05
And just understanding what’s important to them. Maybe menstrual control is the most important factor.
Antonia: 10:09
Yeah.
Howard: 10:10
Well, and then you can emphasize instead of emphasizing the efficacy or side effect profile or complication rate of an IED, you might emphasize it’s amenorrhea or eumenorrhea rates, because that’s what’s important to her, and you’ll still maybe end up at the same point, but you have to get there through the way that she wants to go. So for task-oriented communication do’s and don’ts. Now, task-oriented communication is where you want to provide that evidence-based information about side effects and potential barriers to consistent and correct use things like that information about effectiveness. What you don’t want to do is make patients hyper-focus on a litany of non-specific side effects, especially if replicated scientific evidence says that there’s not actually side effects of that nature associated with the method of birth control. This tends to cause the nocebo effect and patients find side effects, feel side effects, experience side effects that aren’t even real and talk about them with their friends on social media. Now, the placebo effect is just the opposite of the placebo effect. So if you warn a patient that she might have problems with breastfeeding when she initiates birth control, well, she’s more likely to notice and actually more likely to have those problems. But our job is to know that these various methods, for example, don’t cause those methods. So why would you warn a person about a side effect that they don’t have? You want to minimize those things, to minimize the nocebo effect. And that’s the problem with TikTok. It’s full of videos and reels about patients with at least perceived side effects and they may or may not be real. In many cases they’re not real side effects of the methods of birth control. So things like these breastfeeding problems or weight gain or tons of other things that a lot of times people will package into their birth control counseling and then you’re actually causing a problem that’s not real.
Howard: 11:56
You also don’t want to neglect the health literacy of your patient and you have to assess for this and make sure you communicate effectively and on the level of health literacy that they have and not just throw out numbers or statistics that your patient might not understand. And you don’t want to put barriers to switching methods. If they’ve used a particular method and they don’t want to use it and they want to use another one, it’s tempting to sit and fight and be like, no, that side effect that you’re experiencing isn’t really there or you really should continue this. I know you’ve only had that IED for a month. Just give it more time. A very little bit of that’s okay, but if they want to switch, let them switch. If a patient’s unhappy and wants to do something different, then that’s what you need to do, even if you personally think it’s the wrong decision or that they’re making a mistake. And again, be careful with statistical ideas that you throw at them that they may not understand and we’ll talk more about that in a second.
Antonia: 12:44
Yeah, just from my observations. If someone wants to switch and then they’re told that this, you don’t need to switch A lot of times, they’ll just go somewhere else. They’ll just keep shopping until they find someone willing to more willing to work with them.
Howard: 12:58
So leave a negative complaint about you on Right Online.
Antonia: 13:02
So just just work with them, Just about you on right online.
Howard: 13:06
So just just work with them, Just meet them, meet them halfway. I think I used to be worse about that than I am now, because people would come in and they want to switch for what seems to them to be a valid reason and in my analytical mind I’m like but your breast control doesn’t cause that problem that you’re claiming that it does or whatever, and I still do that. But I also make it very easy for them to switch. I still tell them what the science says, but we switch.
Antonia: 13:25
Yeah, I just remember very early in my training I would encounter people that want a tubal and then I had just learned an IUD is just as effective as a tubal. Then they’d still want the tubal and I’d just think why do they want to go under surgery? They don’t have?
Howard: 13:42
to.
Antonia: 13:43
Like this is wrong, but yeah, same for me.
Howard: 13:47
I will say that one of the things that I’ve changed a little bit on that is I think I’m more cognizant of reproductive coercion problems now. So I realized that she may want a tubal because, even though it might be reversible or something like that, it has a permanence and she’s not going to be. She’s less likely to be coerced into her partner, into having a child that she doesn’t want to have if she’s had her tubes tied, whereas if she has an IED. So I talk about that to patients now who are talking about that issue of tubal versus whatever. But we also have to remind them about regret rates and things like that. So we have to give them all the information but, in the end.
Howard: 14:22
If she wants her tubes tied, I tie her tubes.
Antonia: 14:24
Yeah, all right. Third tip understand what statistics best communicate risk and benefit to patients. So we don’t need to talk in terms of relative risk, for example, or to use confusing terms like the perfect use rate or the Pearl Index or things like that that, frankly, probably most physicians don’t even understand.
Howard: 14:47
That well, yeah, a lot of the fact-based side of these conversations are us knowing the efficacy and the side effect rates and being able to make comparisons from one group, one method to another. And when we tell people the failure rate, such as 8.4% for birth control pills, that in itself, though, is insufficient. People don’t. Humans aren’t good at just hearing numbers and understanding them. We have to communicate the number of failures for a given time. So is that 8.4% per year? Is it 8.4% for the entire use of the product? Your patient doesn’t know that inherently, and don’t assume that they do. So I usually will talk about the methods of birth control over a period of time. That’s interesting for the conversation in terms of, like a comparison to a LARC, so a three-year or five-year comparison, and it helps me make those direct comparisons. So I might say something like if I prescribe birth control pills to 100 women today and they use them consistently over the next five years, 42 out of that, 100 will have an unattended pregnancy. If the same 100 women were to get an IUD, less than one woman out of the 100 will have an unattended pregnancy in that five-year time period. And so you can compare similar time periods and from method to method.
Howard: 15:58
Using relative and absolute risk can be problematic, particularly with birth control, when discussing things like, for example, ectopic pregnancy. So let me illustrate the difference between relative and absolute risk. Many providers will tell a patient that if they get an IED, that they have an increased risk for ectopic pregnancy, because they want to make sure that the patient knows that if she becomes pregnant she’ll need to get evaluated quickly, and that’s true. But the relative risk of ectopic with an IED is about 15% and that’s what they’ll communicate to the patient this relative risk. But the absolute risk of an ectopic pregnancy is actually the lowest when a woman uses an IED compared to any other thing she could do, including permanent sterilization. So if the patient were to come to you and say my chief concern is I want to use something that gives me the lowest rate of ectopic tubal pregnancy, she should get an IED.
Howard: 16:50
So we need to communicate absolute risk to patients and we also need to use things like numbers needed to treat or numbers needed to harm or relative factors between different methods. So if you’re going to communicate to them about potential ectopic pregnancy, you can say you can do that, but you should be doing that with all of your patients, even if they’re not on birth control. Their risk of ectopic is higher if they give them a birth control pill than if you were to give them an IUD. And this gets into giving them risks like the nocebo factor thing, giving them things to worry about that they don’t need to worry about. And they hear that.
Howard: 17:23
And I actually know of providers who don’t do IEDs because they don’t want to increase a person’s risk effect topic when the exact opposite is true. So this is something you have to practice and develop, as you said a spiel about, so that you can communicate these risks and benefits in a way that patients understand them and again, emphasize absolute risk and comparable risks from one method to the other, so they can make a comparison that’s simple to understand and oftentimes using numbers needed to treat or numbers needed to harm are very useful One perforation per 1,000 IED placements, for example and then explain to them what that means, what would happen if it happened, things like that.
Antonia: 17:59
Yeah.
Antonia: 17:59
So the rate is one in a thousand generally, but a few of those stories again on whatever TikTok or word of mouth makes it seem like that is 100% going to happen to me if I get one.
Antonia: 18:14
So patients will identify some of these rare risks and worry about them. And then the, let’s say, the need for surgery for IUD perforation or the need for surgery for ectopic with an IUD. But when you compare the risks of one method to another, you can communicate that a patient is much more likely to need a surgery for an ectopic or for a miscarriage at that for that matter if she uses matter, if she uses birth control pills. But if your patient is worried about needing an emergency surgery because of the birth control choices, she’s much more likely to need some kind of surgery if she uses pills than an IUD, because that’s going to include ectopics on birth control pills being more common, pregnancies resulting in miscarriage being more common, or pregnancies carrying to term and then needing an emergency C-section. All of that is going to be way more common than any of those including the risk of perforation with an IUD. So that gets to our last recommendation, which is to use a visual graphic comparison chart to aid your communication.
Howard: 19:30
Yeah, patients really understand risks and benefits best when they see them graphically presented. So in my exam rooms I have those bedside charts. You can order those from bedside and they show efficacy comparisons for different methods of birth control in a graphical way, and I also use a graphical frequency charts to show comparisons of the two methods. So these again in studies have been found to be the most effective way of communicating to folks all sorts of medical data.
Howard: 19:56
So these are charts that use individual icons to represent each different patient, or different colors of different icons, things like that, and show the various outcomes. And we’ll put on the Instagram a chart that I’ve used for a long time that compares five years of IED use to five years of birth control, of OCP use or, I guess, patch or ring for that matter. And in my experience, when I show patients who are torn between an IED and say a birth control pill or something like that, when I show them these aggregate outcomes total numbers of pregnancies, cesareans, ectopics, miscarriages, all those things uterine perforation, all those things on there they’ll almost always choose the IED when they actually see that contrast.
Antonia: 20:37
All right, so a little bit more work for Maddie, our podcast ninja, then. So let’s get into some of our certification articles that we’ve been reading Some of them. It gives us a big, vast menu of options and we don’t have to pick the same ones, we only have to pick a small selection. So I think you and I picked a lot of different ones. So that just doubles the things we have to talk about here.
Howard: 21:00
And a lot of them we’ve talked about on the podcast over the last year anyway.
Antonia: 21:03
Yeah.
Howard: 21:04
Aog and we agree on some that’s good news on some of the articles that are important, but okay. Well, there was an article that looked at the risk of placenta accretive spectrum abnormalities following myomectomy. We think a lot about placental accretive spectrum disorders after cesarean, but this paper they focused on myomectomy and they found a little bit over 11,000 patients with a prior history of myomectomy and, of course, as you would expect, the rate of placenta accretum spectrum disorders was higher in the patients who had myomectomies. The incidence of PAS was basically 1% in the patients who had a prior myomectomy, so that’s a good number to have for counseling. And this was higher in the group of patients who had hysteroscopic myomectomies, with a rate of almost 2% in that group, compared to those who had either laparotomic or endoscopic myomectomies, which was a bit under 1% when you looked at that.
Antonia: 21:57
That’s a surprisingly high number to me, but I think that could make sense because hysteroscopically the surgery is only on the endometrium and it’s internal to the cavity, whereas probably a lot of laparoscopic or abdominal ones. So yeah, this number is not something I knew before. But well, now that we know it, that this study has been done, patients definitely should be counseled that there’s this high of a risk in future pregnancies for placenta accreta, for invasive placenta, and of course this is important for a lot of reasons. But we know that many patients are getting these myomectomies, as opposed to getting just medical management or just getting a full hysterectomy, because they want to get pregnant in the future. This is actually part of the standard pre-IVF is do a cavitary inspection and remove any lesions in the cavity, and it does make me wonder a little bit if other potentially similar procedures like polypectomies or DNCs might also increase the placenta accreta risk.
Antonia: 23:03
We have seen a huge uptake in the use of the hysteroscopic morcellator devices, not just for fibroids but also for polyps, and also, I’d say, recently more. I’m seeing more articles about using it for retained tissue after a miscarriage, for example, and it is nice to be able to visualize the lesion or the tissue that you’re removing while you’re removing it, and it is also nice to be able to avoid using heat, like was once done with the old receptive scopes, and they had to use this hypertonic solution that caused all kinds of other risks to the patient. But this is still a surgical device that’s being marketed by its manufacturing companies and of course they want to push its use out as much as possible because that’s going to increase their stock. So we have to think about that and whether some of these surgeries are maybe being driven by marketing rather than by patient need, especially when we see an article saying hey, have you thought about using it for this use?
Howard: 24:07
Yeah, I think it’s analogous to when endometrial ablation kits came out and they’re fantastic.
Howard: 24:14
As you said, they’re better than at least easier let’s say they’re easier than resectoscope surgeries and things like that. But then what happened, especially 10 or 15 years ago, was we started doing endometrial ablations on people who normally we would have never considered doing them on and, frankly, just patients who had heavy periods that were promised amenorrhea with a simple in-office procedure. So the company really drove a dramatic uptake in the use of these devices for just getting rid of periods, rather than what would have been considered before for somebody who was considering a hysterectomy and trying to avoid a hysterectomy. So the standard of use went down and then years later we see increased advanced endometrial cancers and things like that and other problems related to it because we were overusing them and the danger here is that people start using these kits every time they have a patient who needs a hysteroscopy. And now, two or three years from now, we see a 2% rate of can you imagine a 2% rate of placenta accreta in patients who were exposed to devices when they didn’t need to be exposed to them?
Antonia: 25:14
Yeah, like what if someone doesn’t even have a lesion but now they’re just using this morcellator just to obtain a sample of a normal cavity? So just because we can use something doesn’t always mean we should. Obviously, if it’s a patient that wants to get pregnant, she has a big endometrial fibroid. That’s probably still going to be a very necessary thing to do. So we also then have to consider this type of surgical history. When the patients do get pregnant and we’re providing care, especially if we’re reviewing their ultrasounds and maybe there’s a questionable point of invasion. It should be something with a 2% risk that we should keep in mind.
Howard: 25:58
And it’s going to be different, because we’re very used to thinking about low anterior placentas in a patient with a prior cesarean, where the risk is nowhere near 2% and going in and doing that double look to make sure there’s no evidence of invasion. But if somebody had one of these procedures on the posterior fundus or something like that, we’re not thinking about that. Oh, her placenta is posterior, near the fundus, and five years ago she had one of these procedures done to remove something there and we’re not giving it the same due diligence. So it’s important, okay, and again note that these risks are higher than they are with somebody with a prior cesarean delivery. So as these become more and more common, we’re going to have to pay more attention to those ultrasounds.
Antonia: 26:41
Okay. Next, those ultrasounds Okay. Next, there was an article that looked at adherence to risk-reducing salpingo-ophorectomy guidelines among GYN oncologists and general gynecologic surgeons. And now this wasn’t a very big study it only included 185 patients and about half of them had this surgery by a gyne-onc and the other half had the surgery by a generalist. And in this study they found that the gyne-oncs were at least more likely to document adherence to all five recommended components of this, specifically risk-reducing surgery, in their notation they did not find any difference in adherence to the pathologic guidelines, which suggests that the pathologists were always consistent and doing the right thing, regardless of who or what type of surgeon sent them the specimen.
Antonia: 27:31
One of the interesting parts here was what the five steps are recommended. I think the biggest issue here is they’re trying to underscore surgeons might not be fully aware of these, that they might be aware of them, but they might not be aware that these all have to be documented. They might just think like, oh, I was taught it’s good practice to do it this way, so I’m just going to do it this way, but I have my normal BSO dictation and they might not underscore that they did it a certain way because it was risk reducing. So, yeah, so we’ll get into some of the details of that here in case people, that here in case I’m losing people but these are steps that were created by the Society of Gynecologic Oncology and also endorsed by ACOG way back in 2005.
Howard: 28:16
Yeah, and adherence with all five steps was very low and wasn’t perfect even among the G1 oncologists. So I do think this might be a case of surgeons needing to know that these steps exist and that they should be doing them. But also, how much is it? As you said, just not documenting? Them.
Howard: 28:33
I think we could have a separate discussion about whether all these steps are necessary 20 years later. Does the evidence bear out their necessity and that sort of thing. But they did find in this 185 patients. I think they did find five malignancies unexpected in the patients who were undergoing risk-reducing surgery. Two of these were stick lesions in the fallopian tubes, one was actually a B-cell lymphoma and one was a high-grade serous adenocarcinoma and one was a serous carcinoma.
Antonia: 28:58
Well, these are the five steps that are recommended according to these SGO guidelines. So the first step is obtain a complete survey of the peritoneal surface of the abdomen and cephalad of any identifiable ovarian tissue. Step four is divide the fallopian tubes and the utero-ovarian ligaments as close as possible to the uterus. And the fifth step is place the specimens in a specimen bag in the body when the surgery is performed, so that you’re minimizing the spread or the touch of the specimen where it doesn’t need to touch when you’re removing it.
Howard: 29:55
Potential spillage, yeah yeah. And the hardest of these, I think, is going to be separating the ovarian pedicle two centimeters north of any identifiable ovarian tissue. That does often require the retroperitoneal dissection, and my guess is that this is the step least accomplished, particularly by general gynecologists of the ones you mentioned. If you don’t know how to do that, well, learn how. It’s not that hard, but you should probably have somebody proctor you if you’ve never done it before, or refer your patient who needs risk-reducing surgery to someone like a G1 oncologist or just a generalist colleague who does know how to do that.
Antonia: 30:28
Yeah, to someone like a G1 oncologist or just a generalist colleague who does know how to do that. Yeah, that would actually be a good reason to refer. If you’re not confident, you can safely do that.
Howard: 30:33
Okay. There was an article I was interested in that looked at cesarean delivery rates in nulliparous women in the second stage of labor when using the Zhang, compared to Friedman labor curves. So several years ago, when we changed our labor criteria for the first and second stage arrest disorders based upon these more modern labor curves, many of us were optimistic that the cesarean rate for arrest disorders in particular would decrease. What more and more literature, though, is showing is that it has not gone down, and I think a big reason for this is that most people aren’t compliant with the guidelines. They’re still just doing what they’ve always done For second stage arrest disorders.
Howard: 31:10
It’s a fairly easy thing to follow the guidelines, and the current guidelines would say that a nulliparous woman should be given three hours with no epidural to push and four hours with an epidural to try to achieve a vaginal delivery during the second stage. This essentially just added an hour of time compared to what we previously recommended with the Friedman curve. This paper was a systematic review of seven other publications that have looked at the rates of cesarean for second stage arrest disorders in the context of with the modern guidelines, and they concluded from their review that nulliparous women have a similar cesarean rate, regardless of which labor curve or which set of guidelines is used.
Antonia: 31:51
Yes, and this is still tough because, as you said, our worst case scenario, fears about the potential negatives of prolonged pushing are going to creep in and we may be looking proactively for any other reason to call it off and do a cesarean. Maybe a soft call and say, oh, fetal distress. There was one variable there, when the real concern really truly is this labor taking so long Been pushing more than two hours now. Is it because the baby is too big to fit through the pelvis? Is this baby going to get injured? Are these patients going to sue me and rip me apart on the internet oh no and start this panic cycle. Obviously you have to look at the whole picture in a given case and decide based on objective findings rather than these fears.
Antonia: 32:40
But the Zhang curve was based on good outcomes of healthy infants and healthy vaginal births and when they gave patients more time than what the Friedman curves had previously set up then, provided that they had a reassuring fetal tracing, they were making good progress in their pushing, adequate, clinically adequate pelvis, etc. There were all these patients that were having vaginal deliveries after four hours of pushing who previously would have been taken to the OR just because of those older time cutoffs and for no other reason. But still, despite that, the Zhang curves came out over a decade ago, so they’ve been in practice for a while. But four hours and beyond is still not that common. It’s the 95th percentile of patients will have had a baby before this time. So it’s possible that many providers and even nurses, especially earlier on in their careers, have never seen anyone push that long. So at a certain point and in certain environments, people may not believe it’s possible and they may think four hours no, I’m, I don’t believe it. I’m going to take people to the OR after three.
Howard: 33:57
Yeah, and unfortunately, in general, we’re at a point now where people have abandoned ACOG itself, has abandoned the bulletin several years ago about preventing primary cesareans because, basically, because studies like this are showing it hasn’t worked. But there’s a difference between it not working because the science is bad and it not working because compliance is bad, and it’s a point that real life implementation hasn’t moved the needle much. But I do want to point out about this review. I wish this review hadn’t been included and I’ll tell you why. There’s only two trials of the seven that were randomized controlled trials. Now one is from the Lancet in 2019, and this was a study done in Norway, where they already have a very low rate of cesarean delivery. They had a 9.5% risk of cesarean in their control group, which would have been sort of Friedman curve, and a 9.3% rate of cesarean in the intervention group, which would have been sort of Friedman curve, and a 9.3% rate of cesarean in the intervention group, which would have been the Jeanne curve, and both of these rates are incredibly low compared to most US-based hospitals. So these obstetricians are already doing a great job and for them well, the guideline didn’t contribute much. It didn’t matter.
Howard: 35:01
The other RTC was done in the US and only involved 78 women. In the control group they had a 43.2% risk of cesarean. Go Norway and then the intervention group. Using the Zhang criteria, there was, after implementation, a 19.5% rate of cesarean Still double Norway, but half of their control group. So in this US-based hospital with a more typical U US-based primary cesarean rate, they were able to cut their risk of cesarean for this indication at least in half, with no difference in maternal or neonatal morbidity.
Howard: 35:38
The main problem with this trial was that the number of enrolled patients was relatively low, and so this massive effect size well in a controlled. In the systematic review it was washed out of its significance when you see it on the forest plot and all that. But these are the only two RTCs and so, if anything, the thing to take away I think from this is if you’ve especially if you look to the articles in detail is that if you’re already doing a great job and you’ve got a sub 10% NTSV rate, well, you probably don’t need the guidelines weren’t for you, my friends and you’re probably not going to get it much lower. But if you’ve got a high primary cesarean delivery rate for second stage arrest disorders, you should really be considering these modern guidelines.
Antonia: 36:19
Yeah, and this is also a reminder that doing systematic reviews of low quality data produces a low quality conclusion of low quality data produces a low quality conclusion.
Antonia: 36:31
And it’s a reminder that a lot of things that are studied that show some benefit may not show benefit for the high performers that don’t need that help.
Antonia: 36:39
So if you have a low rate of infection after cesarean, then lots of the interventions that were designed to further lower that may not benefit your patients, like the addition of vaginal antiseptic preps and a whole bunch of other things that we’re seeing in bundles to reduce infection, that a lot of them really have not shown individually to make any difference, but they’re still getting implemented, especially in I’ve seen implemented in a lot of training programs.
Antonia: 37:11
But if you are in a training program where infection rates do tend to be higher at baseline, then maybe those interventions do make a big difference. So again, good job for the Norwegians for having such a low cesarean rate. They probably don’t need to update their labor curves to anything. The total cesarean rate in Norway was 16%, whereas in the US it’s closer to 34%. So I wish publications like this would put that into context, because people are going to take away from this article that there’s no benefit to the modern labor curve, but that’s simply not what this evidence actually says. What it does say is that outcomes are safe with either curve, and maybe you should still at least adhere to some standard, pick a standard and actually follow it, and that’s good information to have.
Howard: 38:05
And if you’re worried about the safety, that’s good information to know that they’re safe. Yeah so why wouldn’t you use the Zhang data? Yeah?
Antonia: 38:12
Yeah, and just on this topic, and actually another one of the maintenance articles was that new first and second stage labor management, the ACOG clinical practice guideline number eight, which basically pulls back, like it gives a little more conditions for how long when you’re letting someone push for three or four hours. Now it’s saying you can stop this earlier if you think they’re not making progress.
Howard: 38:37
They should be making progress. It was never meant to be that they’re at plus one and two hours later they’re still at plus one. That was never meant to be that.
Antonia: 38:47
Right, okay, next article there’s a paper from JAMA that was a randomized clinical trial published in February 2023, that looked at discontinuing aspirin in patients at high risk for preeclampsia at 24 to 28 weeks, and they found that this was not inferior to continuing aspirin until 37 weeks, but this was only discontinued in patients who had a normal SFLT1 lab result I believe it was SFLT1 to the PIGF ratio about this article previously, so this could be one case for using that blood test because it has been FDA approved, but this still doesn’t really apply to what we’re doing in mainstream practice in the US right now. The patients in this study were using 150 milligrams of aspirin, which, of course, is the only dose that actually has been shown to reduce the risk of preeclampsia. But there is also a cost benefit analysis that would be needed to justify doing this blood test, even if it’s only for the purpose of. Can we tell them to discontinue the aspirin now, or do they need to continue it?
Howard: 40:05
Yeah, we did talk about a lot of this data before, and the thing that stuck out to me about this article was, again, a US audience of OBGYNs reading it might assume not thinking about the doses that this applies to us. We discussed that there is just a lack of data showing that the 81 milligram baby aspirin is effective at reducing your risk of preeclampsia. But this publication comes from Europe and there they’re using 150, and it included patients who were on 150 milligrams of aspirin. And one of the things that this paper says just outright right when you first started reading it, is that aspirin has been proven to reduce the incidence of preterm preeclampsia by 62%. So if you read that and wondered, hey, I thought Howard and Antonia said it didn’t work. Well, hey, I thought Howard and Antonia said it didn’t work.
Howard: 40:47
Well, yeah, but we talked about that trial. That comes from a 2017 trial that was in the New England Journal of Medicine, but those patients were on 150 milligrams of aspirin. So that’s the whole point. Really, is that 150 milligrams of aspirin? Maybe there’s something there, but in the United States, ACOG is still just saying and the US Preventive Task Force Service really is the originator it’s just saying the 81 milligrams of aspirin is what we should be using, so this again, this article doesn’t apply to our patients.
Antonia: 41:13
Yeah, it really is interesting that we and our societies still just recommend 81 milligrams when we could easily say, bump it up to two and take 162. And some of us individually will take that liberty, but our societies are still saying 81 milligrams. And it’s confusing because I think when most US-based physicians read studies like what we’re discussing now and maybe they’re doing their maintenance articles just like us they don’t even really catch that it doesn’t apply to their practice, because both the intervention studied and the data referred to are something different than what we’re doing the 81 milligram aspirin which is not evidence-based the way the 150 is, and the fact that we don’t use that SFLE SFLT test. It’s approved but it’s really not been adopted widespread.
Howard: 42:10
Well, maybe we’re not far away from a new 150 milligram recommendation. We’ll see. Maybe that’s why it was included. Okay, there was a paper I thought was interesting from the Gray Journal actually almost a couple of years old now that looked at the cost effectiveness of prophylactic retropubic slings at the time of vaginal prolapse surgery.
Howard: 42:27
So a lot of patients who have significant prolapse may have paradoxical continence and when their prolapse is corrected then they may have new onset de novo stress, urinary incontinence because the angulation of the urethra is reversed at the urethra vesicular junction. It’s been corrected when you lifted their apex and bladder and interior vaginal wall up. So the question is which of three approaches is best A staged approach in which you repair the prolapse and don’t do a sling. So this is for a patient who’s not reporting stress incontinence at the time she presents for selecting her surgery. Or a routine sling placement with every prolapse you repair. Or a selective sling placement with every prolapse you repair. Or a selective sling replacement placement in patients who have demonstrated stress incontinence preoperatively, when you reduce the prolapse on exam urogynecology I saw all three approaches be done and also be explained to me.
Antonia: 43:31
Each of the different urogyns said yeah, I only do it. If they come back post-op and they have stress incontinence. It’s not a big deal to do another surgery for them. So this is a pretty classic question and it’s great that it was actually done in a study like this. A lot of gynecologists who don’t specifically treat incontinence are again more likely to just do the hysterectomy and maybe some prolapse repairs and then just plan on if they need a sling. Either then I’ll do it or then I’ll send it to my urogyn colleague. Many urogynecologists will do prolapse reduction and then look for the demonstrated stress incontinence and only do the sling if they also have stress incontinence. So, for example, they might put in a pessary and say, okay, are you leaking now. You weren’t leaking before, but are you leaking now and then make that decision before they go to the OR. So what did the authors of this study find?
Howard: 44:33
Well, this isn’t an interventional trial, but it is use available data to make a decision analysis model to compare the three strategies, because there’s data available about rates of incontinence et cetera. For all that and then a cost-effective analysis. So in this scenario, what they found was that the selective sling placement was the most cost-effective of the three strategies. And so if you’re planning a prolapse repair, you would perform a prolapse-reduced cough stress test and that could be with a pessary. It could be just reducing it to with like a sponge stick or something too. But you do this as part of your preoperative assessment and many of the patients in this model would.
Howard: 45:13
In the model that they designed, many of them were actually just stage two prolapses. And there’s also the thought, in addition to what you explained, that the greater the prolapse you’ve got stage twos and you’ve got procedentias right and everything in between Well, the greater the prolapse you’ve got stage twos and you’ve got procedentias right and everything in between Well, the greater the prolapse, the more likely it is that they’ll benefit from a sling, the more likely it is that they’ll have incontinence after the repair. And this analysis doesn’t really break that down Like could it be appropriate that you do all stage fours but selective on stage twos and threes or something like that. So I think that’s still an unanswered question. But if you can do the prolapse reduction and then test for stress incontinence, that seems to be the at least more cost-effective approach.
Antonia: 45:56
Yeah, and I think that’s really logical. So, yeah, this was a good one, all right. Next article I did want to point out and highlight a couple of things from the ACOG consensus document on urinary tract infections on pregnant individuals. That was another one of the options this year.
Antonia: 46:13
One thing I see frequently that the document discusses is that people are getting treated for low colony forming unit cultures in pregnancy and sometimes even I’ll do this if they say they’re very symptomatic it burns when they pee but it feels like a gray area. But this document addresses that practice and they say it should be at is present at lower colony forming units, then that just means they definitely need treatment in labor to prophylax against group B strep. But that does not require treatment at that moment before labor as a UTI if it’s less than 100,000 colony forming units as a UTI if it’s less than 100,000 colony forming units. The other thing I would highlight from that document is you really should not be using amoxicillin or ampicillin empirically to treat UTIs unless you have a culture result that shows sensitivity, because there’s really high rates of resistance to E coli against those antibiotics. But we do see those prescribed often enough by, especially by walk-in clinics and ERs and primary care.
Howard: 47:31
Yeah, just not the right antibiotic for that. Well, several of the articles that ABOG chose to highlight, as I said, are articles we’ve discussed over the last year or so on the podcast, including the article we recently talked about Twin Specific Growth Charts, Go Us. We also discussed first trimester ultrasound for anatomic abnormalities and early amniotomy after Foley. There were several, but there’s a paper we haven’t discussed about manual rotation of occiput, posterior or transverse fetal heads. But we’re going to save that till the next episode because we actually have a great listener question about that, and I’ll briefly highlight a paper that looked at vaginal preparation prior to hysterectomy with an iodine solution versus a chlorhexidine solution and they found that infectious morbidity rates were slightly better with the iodine group, but almost identical, and therefore that chlorhexidine provides a safe and nearly effective alternative for patients who report an iodine allergy. So that’s important for our hysterectomy patients to know. There continues, I think, to be this belief that chlorhexidine is somehow toxic in the vagina and you shouldn’t use it, but it’s actually great and nearly as effective as iodine.
Antonia: 48:38
I’ll just briefly run through a few of the other articles I did. I chose to focus more on the sort of guideline type overview articles instead of focusing more on randomized individual trials or systematic reviews. Some of these articles I found were expert opinion. Some of them were created by a whole meeting of multiple different societies, and some of them also described a neat qualitative survey process of how they got statements from the different experts and then compiled them together and refined them and developed a final consensus statement. So there was one about prolonged fetal heart rate decelerations. That was from the Gray Journal. That was really interesting. There was one on PCOS just an update on the diagnosis and management 2023. That’s worth just saving, and a lot of it was just lists of their recommendations.
Antonia: 49:36
I remember one takeaway was in people that are not adolescent, you can potentially use AMH as an alternative to ultrasound for diagnosis if your diagnosis would hinge on the ultrasound. But it didn’t give any cutoffs of AMH of this level meets the diagnosis or not, so just maybe more food for thought. It didn’t really give any other huge groundbreaking information, but it was very thorough and a good refresher for anyone. Another one was a proposed treatment algorithm for high tone, pelvic floor dysfunction. They have a nice little graphic and it just gives, I think, good direction, especially on when you’re resorting to trigger point injections how often, how frequent, when, at what point is it reasonable to move on to the next thing?
Antonia: 50:27
Another one was a discussion. It was a paper in the fertility and sterility from the ASRM on mosaic results on pre-implantation genetic testing of embryos for IVF. I was interested in this. Of course I’ve gone through the process myself and I remember being told I had a mosaic result and they couldn’t tell me what that meant, and this paper details why. It’s actually a very ambiguous and mysterious type of result. The reporting is not standardized and a mosaic result from this type of testing really could almost mean anything. It could mean that the fetus or the embryo actually is chromosomally normal. It could be a false result or it could just be confined to the placenta. It could be actually full-blown aneuploidy rather than a mosaic and it almost seems like the least likely cause for that test result would be that this is actually a truly mosaic individual with, for example, like partial Turner syndrome, whatever, whatever.
Antonia: 51:34
My favorite articles from this maintenance certification cycle actually were the two different practice guidelines on mental health conditions in pregnancy. One was on diagnosis and one was on treatment. They were, I believe, ACOG clinical practice guidelines number four and five respectively. These definitely are worth fully reading through and saving and rereading periodically, maybe once a month or so. So they rightfully emphasize just how common mental health conditions are in pregnancy and postpartum and also how much they contribute to maternal mortality and even in bad outcomes for the baby, including infant mortality.
Antonia: 52:15
That they mainly limited their discussion here just to depression, anxiety and bipolar disorder, and one thing that I didn’t really know beforehand was that they recommended that if there’s a positive depression screen on a pregnant or postpartum patient, you should follow it up with a screening for bipolar disorder, especially if they’re not already on medications and you’re considering starting something for them, because women are more likely when they have bipolar to present with the depressive symptoms of that and you could just push them over into full-blown mania if you don’t screen for that and then you start them on a depression medication.
Antonia: 52:59
The treatment guidelines specifically was also a great review and it had some good, fine points, especially about treating bipolar. Of course that’s not in our main scope of practice, but of course a lot of times we might detect it in a really emergent situation and we need to know at least what do we need to do now to maintain safety while we’re getting the patient established with inpatient psychiatry or with some other kind of expert. And the other valuable thing out of these two articles was that I didn’t know there’s a national consult helpline for physicians. So if any one of us are dealing with a more complicated patient treatment scenario like, let’s say, it’s a pregnant or postpartum patient, she’s on multiple different meds for her mental health disorder and they’re not helping, or they have some specific medical condition that they have questions about we can call this helpline and discuss it with an expert, because a lot of times we don’t have really good access to a psychiatry consultant, and especially not one that’s an expert in pregnancy and postpartum maternal psychiatry.
Howard: 54:08
So we’ll add links to both of these articles and, yeah, I really like the one about prolonged accelerations, and that’s one of those that you just have to read.
Howard: 54:16
We’re not going to do any justice by talking about it, but it’s really good. And one quick summary from that one is they talk about if you’re managing an acute prolonged acceleration and you’ve ruled out irreversible causes. So that’s things like abruption, rupture, cord prolapse, vasoprevia, things like that irreversible causes. So that’s things like abruption, rupture, cord prolapse, vasoprevia, things like that irreversible causes.
Howard: 54:35
They do propose this sort of algorithm, if you will, that they call the 369-1215 rule, based upon the summary of their evidence. So that’s at time at minutes. So at three minutes you call for help, you’re obviously examining for these irreversible causes and doing your immediate resuscitation. At six minutes you’re continuing to do that and then they note that 90% of prolonged decelerations are expected to return to normal baseline. If you don’t have an irreversible cause within that six minutes, at nine minutes you should be moved to the operating room because by that point 95% should have returned and so you need to move or be moving, and of course you have to adapt this to where your facility is and what your staffing is and your availabilities. By 12 minutes you should be reassessing.
Howard: 55:24
You should be in the operating room and seeing what the heart rate’s doing and at that point giving anesthesia. If you’re still down, at 12 minutes you should be putting her to sleep and at 15 minutes you should be doing the surgery. Or there’s a room here where this could be an operative vaginal delivery, but you should be delivering the patient. But a really great article that folks should take a look at.
Antonia: 55:42
All right, yeah, that one had some good visuals too and just really good physiology review. Well, do we have time for a history segment? Maybe a quick one.
Howard: 55:53
Yeah, I did recently get a book that I’ve written about on Howardisms a while ago, but I finally found a copy of Feminine Forever, which was a 1966 book written by a gynecologist named Robert Wilson.
Antonia: 56:06
Oh, did you get, like the first edition, signed copy of this?
Howard: 56:09
It’s not signed, but I did get a first edition the first printing in fact but there’s no price on the dust jacket and I think that means it was a book club edition. I’m not sure if any collectors know what I’m talking about, so if anybody has one that has a price on the dust jacket, let me know. But this book was a hit in 1966 and was considered a bestseller at the time, and in it Wilson made sweeping claims about menopause being this preventable disease caused by estrogen deficiency and that with estrogen replacement women essentially would maintain their femininity and health and quality of life and whatever. For as long as they were on the estrogen. It really started the uptick in cells of what eventually became the most dominant hormones on the market, which were Premarin and Prempro back then. But based upon well unsubstantiated and far sweeping claims about the benefits of estrogen. On the cover he says that women can safely live a fully sexed life for her entire life.
Antonia: 57:07
I don’t think he knows what being sexed actually means. I know when you’re examining an animal and trying to tell what is it a male or female?
Howard: 57:17
and you assign it.
Antonia: 57:19
That’s you’re sexing the animal when you’re determining is it a male or female by looking at it. So I don’t know if he knows what that word actually means.
Howard: 57:27
Yeah, I don’t know no-transcript. And for that matter, men too. Except the hormone, there is testosterone. It also promoted the idea of menopause as this disease state rather than just a natural phase of life. I’ll put the link to the article I wrote about this book and what about the book? But mentioned it a while ago and then also has some very interesting but sketchy pictures of advertisements for Premarin and Prempro from that era. That will probably cause some alarm when you look at them if you’ve never seen these old advertisements before. But anyway, it was later discovered that this book, written by Wilson, was in fact a paid for and promoted publication of Wythe Pharmaceuticals, who was the manufacturer of Premarin and Prempro.
Antonia: 58:32
Well, I have to say, you understand why a lot of people are completely skeptical about science. When you hear this kind of thing.
Howard: 58:41
Yeah Well, Wilson, this is the way stuff still is done. There’s different laws and different rules, but then people learn to react to them. This is one of the things we try to highlight on here. So, Wilson, what he did back at the time was he started a foundation called the Wilson Research Foundation, and his son, Ronald, later revealed that Wythe Pharmaceuticals. They had paid for all the fees and expenses and everything related to publishing and writing the book, and then they funneled money directly into his foundation that he made a living off of.
Howard: 59:08
But you would never know that by looking at the book or by any contemporary documentation of his foundation or anything written contemporaneously about the book. This was a secret project and essentially an advertising mechanism, and it worked, and within a decade of the book’s publication, Premarin became the fifth most prescribed drug in the United States, and by the early 90s it was number one. Now there were some newspapers at the time contemporaneously that syndicated this book as a serialized document over a few weeks in 1966. And so they weren’t even making you buy it. It was just going to be in your local paper, and so this was a tour de force of drug company propaganda secretly imposed on the American public and Wilson was referred to as one of the nation’s best gynecologists and all this stuff and all these newspaper headings that helped to sell the book and stuff. And of course he was just a tool of the pharmacy company.
Antonia: 1:00:01
A sellout.
Howard: 1:00:02
Yeah, and I guess Wilson never cared if he sold a copy with all of it appearing in newsprint or made any money off of it at all, because he was getting his money from wife through payments to his foundation. I found an old newspaper version, though, of chapter 10 of the book, from a newspaper in Iowa, I think in August, and it was in several though, and in that particular section. I just thought it was funny. Dr Wilson also recommended that women get twice yearly pap smears.
Antonia: 1:00:29
I know they used to be more frequent than they are now, but even then it wasn’t twice yearly that it was recommended.
Howard: 1:00:36
It’s interesting to reading that stuff.
Howard: 1:00:37
It’s almost like I’m going to make that recommendation because it makes me sound even more pro-woman and concerned about health, where I’m just overly cautious Somebody who is because you’re recommending this hormone to the American public, that was a little skeptical and whatever, but obviously he’s so concerned and cautious because he even does twice yearly pap smears on patients.
Howard: 1:00:57
Well, books and newspaper serials and other things like that, they were the tick tock of their day and they were equally filled full of misinformation. We still see this phenomenon where doctors are promoted and become virally famous on social media, but they tend to be full of it and they promote quackery and nonsense. So think about Dr Oz or any of the physicians on the Doctor Show on television or any number of famous and notable social media celebrity doctors, the vast majority of whom are promoting just nonsense, and so it’s nothing new. The medium has changed. The media has changed, if you will, and today a lot of the anti-birth control nonsense that you see on TikTok is yeah, it’s indirectly sponsored or funded by companies that stand to make money off of alternatives to hormonal birth control, or even just from folks who are part of the natalist movement who believe that it’s their life’s mission to rid the world of birth control.
Antonia: 1:01:48
What’s the natalist movement?
Howard: 1:01:54
Ah, yeah, well, the natalist movement. It’s pretty big right now, Elon Musk, and comes from all sorts of directions. All of them, for various reasons, are geared around promoting more childbirth, as people are worried about declining birth rates. That could be for religious reasons, it might be just for economic or political reasons and it’s not really linked to any particular political party or affiliation. It’s all over the place.
Howard: 1:02:17
Elon Musk is, I think, one of the most famous pro-natalists and folks like him are typically against birth control and talk about how birth control is bad. He’s tweeted about this a lot. And for political funding. They promote, they lobby for political funding that will pay women to have more babies or encourage economic policies that do that. But people who are concerned about declining birth rates, they think that birth control is bad, and some of them and they make up reasons for why it’s bad to discourage people in general to not use it. And some of them are concerned again for economic and those sorts of reasons or just national reasons declining birth rates and stability and all that. In some of them it has a religious foundation.
Antonia: 1:02:56
Well, that seems to be a little bit more fringe of a voice. But I’ve heard of Elon Musk. Obviously I know he has like 20 kids or something like that. So yeah, I guess that’s one thing to look out for when you’re seeing things that seem to suggest be fruitful and multiply, or blessed be the fruit and all that kind of stuff.
Howard: 1:03:19
May the Lord open. Right From Handmaid’s Tale. Yeah Well, that’s a natalist movement and we’re in a moment right now that is rife with anti-birth control misinformation and disinformation. It spawned for all different sorts of reasons People have different reasons why they get in on it. But then information it spawned for all different sorts of reasons. People have different reasons why they get in on it. But then hormones and birth control are the cause of everything bad in the world. And it does come too from companies like Paragard or Sphexxy, whose business is selling so-called hormone-free birth control, and they promote influencers or ads on TikTok and things like that, who make hormones a bad thing, because that’s what helps sell non-hormonal birth control. And again, their main method of doing that is things like TikTok. But back in the day, why? Pharmaceuticals just paid Robert Wilson to secretly write a book and promoted it through newspapers and whatever to be a bestseller, and they made billions and billions of dollars for doing so?
Antonia: 1:04:07
Well, I’m still holding out on all the noise of TikTok right now, but I guess that doesn’t mean I’m immune If things can get printed on a written paper.
Howard: 1:04:18
You’re going to end up with a TikTok account soon.
Antonia: 1:04:22
I’m afraid of this, but that’s just how I’m resisting it.
Howard: 1:04:27
All right. Well, everybody has two days left to get their MOC stuff done. If you’re not done by now, stop listening to this podcast and go finish your articles and we’ll put links for everything we discussed on the website and we’ll put that one graphic for sure on the Instagram and we’ll see you in two weeks.
Antonia: 1:04:44
All right, nice wrap up.
Announcer: 1:04:51
Thanks for listening. Find us online at thinkingaboutobgyn.com. Be sure to subscribe. Look for new episodes every two weeks.
