In the first episode of our new season, we introduce a new segment with Four Tips for managing fetal heart tracings. Then we discuss the new mammography guidelines. And finally we discuss a case of a viable pregnancy in a woman who had had a hysterectomy.
00:20:45 Mammography Guidelines
00:30:12 Debating the Effectiveness of Mammography Screening
00:41:01 Breast Cancer Screening and Overdiagnosis
00:55:50 Pregnancy After Hysterectomy
Follow us on Instagram @thinkingaboutobgyn.
In the first episode of our new season, we introduce a new segment with Four Tips for managing fetal heart tracings. Then we discuss the new mammography guidelines. And finally we discuss a case of a viable pregnancy in a woman who had had a hysterectomy.
00:20:45 Mammography Guidelines
00:30:12 Debating the Effectiveness of Mammography Screening
00:41:01 Breast Cancer Screening and Overdiagnosis
00:55:50 Pregnancy After Hysterectomy
Follow us on Instagram @thinkingaboutobgyn.
This is Thinking About OBGYN with your hosts Antonia Roberts and Howard HErrell.
Howard:Antonia.
Antonia:Howard.
Howard:What are we thinking about on today's episode?
Antonia:Well, a few different things. So it'll be a new year when this comes out, new season. We've got a new profile picture. We also have a new assistant with this podcast. She's actually been helping for the last year or so, so we want to acknowledge and recognize her behind the scenes efforts, especially with editing and social media and ideas and that kind of stuff. So her name is Maddie White. She is a med student right now in a future OBGYN with, I think, very promising career, I'm sure, and we'll just call her our little podcast ninja. So thanks, maddie.
Howard:Well, it definitely takes a village and she's been a tremendous help to us and she'll be taking on some more responsibilities over time.
Antonia:Yeah.
Howard:We of course do this in our spare time, but you know it takes a lot of work to have the number one OBGYN podcast in the world.
Antonia:Are we actually number one in some specific kind of sense?
Howard:Well, in my opinion we are. Objectively, we're the number one OBGYN related podcast, at least based out of East Tennessee, if not the whole state, I don't know. We're number one at some things.
Antonia:Okay, okay, sure, yeah, I guess we're at least in the top 10 in that category, if you say so. Okay, well, we also thought of some more new standard segments for this year. We teased some at the end of the last episode. So, besides the listener Q&A bit we want to do and the regular historical tidbits we're going to do, we are going to continue with our things we do for no reason, but we'll alternate those with a four tips segment. So these are meant to be like four practical tips or reminders for certain core OBGYN skills.
Antonia:You used to write a segment like this on your Howardisms blog and I know those must still be very popular with, especially with students and residents. I've enjoyed them as well. So we'll bring those into our episodes and chat about them some more, and we'll try to have a balanced rotation between spending a whole episode on a deep dive of one topic, which could span sometimes decades of literature, versus having episodes where we rapidly jump from one topic to the next of all new, different studies and maybe just a few minutes on each topic.
Howard:Yeah, changes.
Antonia:Yeah, not huge changes really. These are all things we've done. We're just going to try to make them more structured. So today's topic is going to be the new mammography guidelines from the US Preventative Services Task Force, or the USPSTF. We did have a short blurb about this a couple seasons ago when it first came out, so this today is going to be more of a deep dive. But first we'll do our four tips segment, and this one is going to be about managing fetal heart tracings. So there's probably no other area of medicine which is treated quite as defensively and subjectively as fetal heart tracings. And even though we all know that fetal monitoring has almost 100% false positive rate it's like 99.9% we know that tracings inappropriately drive a large number of cesarean deliveries and in that way have contributed immensely to the rise in maternal mortality, especially since the 1980s when we really started adopting this regularly.
Howard:Yeah, and when we talk about ways to reduce the cesarean rate, this is always, I think, the hardest area.
Howard:It's easier to focus on some objective criteria like arrest of dilation or how long the patient should be allowed to push or something like that.
Howard:It's much harder to tell a physician how to manage fetal heart tracings because we lack a lot of scientific certainty about what we should be doing with them and how we should be using this technology.
Howard:But it's likely that most cesareans that are done due to some abnormality on the fetal heart tracings that they're unnecessary and they may be defined these tracings as persistent category two and they usually result in a screaming vigorous baby with perfect blood gas as an apgarse, which is technically the outcome we want, making it difficult to criticize, because we'll never know how the baby would have done if we hadn't done the cesarean and continued laboring with that tracing.
Howard:But even when we very strictly use Stephen Clark's criteria from his 2013 article in the Gray Journal and I know a lot of residents and attendings use that article religiously even Clark himself is later made a point of de-emphasizing reliance on these tracings. He called them castles in the air in a 2022 article in the Green Journal, which we've also talked about, but the rates of cesareans done for abnormal intrapartum tracings very widely by institution and the C-section rates very widely by institution, ranging from 15 to 70% at different hospitals in the US, even when you control for the different types of patients that might be there. So a lot of subjectivity in this topic.
Antonia:All right. So we've got four practical tips for managing these tracings. Let's go through them. The first tip is to use the three-tier system, which hopefully most people are already doing. Certainly, if you've trained in the last 15 years or so, this is probably very ingrained in your practice.
Howard:Yeah, the three-tier system came about many years ago through a collaboration between ACOG, smfm and the NICHD, and it refers to category one, two and three tracings. But these categories are often either used inappropriately or maybe ignored, and when they're labeled correctly, there are a lot of other options out there besides the three-tier system, and we may, in the future, replace it with something with more specificity as research gets better. But for right now, this is what we have, and the big takeaway from the three-tier system is that category one tracings are normal and reassuring. In category three, tracings are not, and should be either resolved or the pregnancy should be delivered rapidly, and both of these are very clear and that's easy to define. But then category two tracings encompass everything else, which includes a wide span of reassuring to ominous patterns, depending on how you think about them, that don't fit into the other two extremes, and this is what Stephen Clark was trying to delineate better in his 2013 article. What features, what sequence of events with the category two tracings make it serious enough for us to do a section, versus continue observing it and doing you know nothing? Or maybe conservative management and nobody could legitimately debate doing an urgent operative delivery for category three tracings.
Howard:That's not what we're talking about. It's just that category three tracings aren't that common. So when you see a cesarean related to the fetal tracings, it's usually a category two tracings and these are indeterminate. If we knew that certain types of category two tracings were abnormal and consistently associated with negative outcomes bad gas, bad outgars, et cetera well we just move them into category three. But the outcomes are not consistent. It's not predictive. So if it's these category two tracings where we have to do some work to improve the number of cesareans related to fetal heart tracing, yeah, so as a typical example, you can have recurrent late or recurrent deep variable decelerations and those always look horrible.
Antonia:But it can still be category two if you also have moderate variability, which means you can keep watching them, maybe under certain time limits and stuff, but you don't have to section those right away. But a lot of people would tend to section any tracings with recurrent decelerations, which is probably an unnecessarily defensive approach. But the difference is the variability. So tip number two is appreciate the importance of variability.
Howard:Yeah, certain types of fetal heart rate decelerations, like variable or late or prolonged decelerations, do represent at least temporary interruptions in fetal oxygen transfer. But these interruptions are a normal part of the labor process in most cases and most fetuses are built to withstand this in placentas and they don't cause injury unless there is a progression to metabolic asidemia. And what we're really trying to assess is whether or not metabolic asidemia is present. And the important thing here is that the presence of fetal heart rate variability and or fetal heart rate accelerations predict the absence of metabolic asidosis. But the opposite of this is not always, or even usually, true, meaning that absent variability or absent accelerations does not predict the presence of asidosis. So the most important question that I ask when someone wants me to evaluate a tracing or has a concern about it is question number one how's the variability?
Antonia:Yeah, so there's a progression from starting from some disruption in the oxygen transfer to get to fetal injury. So we wanna assess the fetus's response to that oxygen disruption, because that response can tell us where they are in that progression of that process. So the pathway starts with hypoxemia. So this is where you would usually see the deceleration on the tracing and if this is not resolved it will progress to tissue hypoxia. You can also get straight to tissue hypoxia just from having fetal anemia, even if they're normally oxygenated, and that's not quite as common of an event.
Howard:But that's another way to get to tissue hypoxia, sign your solar pattern, which would be category three.
Antonia:Yeah, but unresolved hypoxemia and then unresolved hypoxia will then progress to metabolic acidosis, which their bodies can still compensate for. And this is where you would see absent variability and no accelerations. They're trying to compensate for acidosis and then ultimately, if that's not corrected, that'll lead to the uncompensated metabolic acedemia. So if their oxygen still can't be corrected, so this is where you would see the abnormal cord gases and then that is what can potentially progress to injury.
Howard:Exactly in understanding this pathway from initial interruption of oxygen, say with cord compression or something like that, to ultimate tissue injury is important. This physiology is vital to understand. So if you see variability and or accelerations, then that predicts the absence of metabolic acidosis, which is the step before metabolic acedemia. And that's why, at tracing, even with those decelerations that you might subjectively and qualitatively think of as bad or something like that and we have too much stigma about that frankly it's still category two as long as that variability is present. Now Stephen Clark and his colleagues actually just published a paper in the August 2023 grade journal analyzing 10 years worth of universal blood gases at a large institution, including over 45,000 deliveries, and they found that the average gases were the same between elective cesareans, urgent cesareans done for so-called abnormal fetal heart tracings and also for vaginal deliveries. So that just shows how the average section done for fetal distress was done before fetal acedemia and well before any fetal hypoxic injury that could be attributable to labor events.
Antonia:Yeah, so probably you could argue that at least some of those might not have been necessary. Maybe a large number.
Howard:Maybe almost all of them, yeah.
Antonia:Yeah, okay. So tip number three is ask if the fetus is responding appropriately to its environment. I just alluded to this. I'm mainly talking about a response to contractions or other interruptions in oxygen. We do other things too that are less stressful, like fetal scalp stim or fibroacoustic stim. They haven't really been shown to correlate that consistently with neonatal outcomes or blood gases, for example. And of course we also hopefully most people know that fetal scalp blood sampling went out the window long ago because those values didn't even match up with the cord gases.
Howard:Yeah, and if you think about it, the blood flow at the fetal scalp during active labor, when that head is getting pushed into the cervix repetitively, well, it may be locally altered compared to the systemic blood flow and not representative of the fetus's circulating acid-based status.
Howard:But we're using the fetal tracings, with its very limited utility, to try to assess the fetal response to these oxygen transfer disruptions and then intervene before a potential injury occurs. So a fetus that's responding appropriately to its environment usually has an intact central nervous system and it's not in a state of metabolic acidemia or distress. So this is a sort of a continuation of that second tip. But think about the physiology that's going on. Early decelerations, for example, are normal and show that a fetus is responding to its environment. Variability is this constant tug of war between the sympathetic and parasympathetic nervous systems that a fetus will only participate in if it's not in a state of metabolic acidosis. Because in that situation the parasympathetic nervous system in particular just becomes drowned out by sympathetic tone and that variability, which is a tug of war between those two states, it goes away.
Antonia:Yeah, I guess you could almost think of it as like a fight or flight, like the baby's in distress and it's fighting for it.
Howard:That's what you're potentially seeing when you see that loss of variability.
Antonia:Yeah well, a lot of unnecessary cesareans. That's the tongue twister.
Howard:The necessarians.
Antonia:There we go that are done for decelerations that are observed during the transition from the first to the second stage of labor, and that's when the head compression and rapid descent tend to cause a vagal response, which is normal. So try to understand why you're seeing a certain pattern in what the physiology is behind that and then look for evidence of whether the fetus is or is not in metabolic acidosis. And just by thinking, just asking those questions, you'll likely spare a lot of patients from unnecessary. And obviously every obstetrician wants all of their deliveries to result in a perfectly healthy, normal baby and usually with these C-sections that are done for abnormal tracings, the obstetrician is either hoping for a totally normal blood gas, because then they'll think they can't be blamed if they're still a bad outcome because the gas was normal, or maybe they would hope for perhaps just a slightly abnormal gas with a healthy baby that shows.
Antonia:Yeah, we were starting to transition from acidosis to acidemia, but not yet injuries, so we were still good, but maybe we were acting at the appropriate time.
Antonia:On the flip side, there's generally not much liability that's put on us that we worry about in terms of having done that unnecessary cesarean and caused maternal injury or at least increased risk when we get a totally normal gas and a totally normal baby after a stat C-section and maybe there should be more of that, a little more accountability and then usually if we do that C-section and we see a bad gas, we're still not exactly happy. We'll assume that we intervened way too late, even if the baby is still vigorous. But if we see like a 6.9 pH in a vigorous baby, I think most of us would dwell on that for a little bit and think we just had dumb luck there. But it's good to remember that the acidemia, which is the bad chord gas, precedes the injury. So you could actually argue that if you end up with a bad gas and a vigorous baby it means that's when you truly intervened, at the perfect time.
Howard:Yeah, and remember we talked last year of vis-a-vis Stephen Clark in that castles in the air, that these gases just are not as predictive as people think they are. They don't mean what people think and I think you just explained the reason why Too many people are unable to differentiate between oxygen disruption from acidosis and tell that difference between acidemia and ultimately tissue injury. So they won't even wait for signs of acidosis, which is the absent variability, the loss of acceleration. So they'll have this knee jerk, catastrophizing reaction that the very first signs of oxygen disruption, a variable deceleration for example, leads straight to hypoxic ischemic encephalopathy if they don't sharpen their scalpels and do a stat section.
Antonia:Yeah, and I think that's probably a subconscious, like a subconscious tendency, rather than a deliberate and objective thought process. It's just one of those things where you see it and you might tend to get worried, especially if you are in a setting where all of your colleagues will look at one D cell or your nurses will look at one D cell and say, oh no, we better open the OR. And we've probably all had times where we've just been staring at a tracing for way too long and we'll get stressed out about it. We're just reaching for our antacids and thinking the worst, even when there's moderate variability. But we've watched every little D cell and over time we'll get more and more stressed and look for the tiniest blip to trigger us to finally jump in and intervene so we can just put ourselves out of our misery with stressing and watching the ups and downs. So this gets us to our fourth tip, which is use a standard algorithm for resuscitation and for intervention.
Howard:Right. So the key, I think, to these category two tracings and how to put some objectivity back into that emotional, visceral response you're describing is understanding that there are certain patterns that over time, with repetitive oxygen disruption, will lead to fetal metabolic acidosis if uncorrected. Now again, this technology is not great, the science is not great, and we're not good at telling which fetuses have metabolic acidosis, only at telling us with some reasonable confidence which ones do not, as we've discussed. So we don't really know how much time we have to watch tracings that are category two with these oxygen disruption decelerations. But in that 2013 Stephen Clark paper that we talked about and all love and use, well, they attempted to help us with this question and their proposed standard algorithm for tracing management is not only very user friendly and visually easy to reference at the moment, but it also helps facilitate research and, frankly, helps you out if you get sued.
Howard:Most of us who do expert witness testimony in this regard also rely on it. I certainly do. They do a good job of defining what significant decelerations are and then, depending on how often they're occurring, you get about an hour to perform intrauterum resuscitation and various interventions to make it look better, to restore that fetal oxygenation and continue with the labor process. But if you don't have moderate variability present, you only get 30 minutes, and this is for the case where these decelerations are present with more than half of the contraction. So the algorithm if you've not seen it goes through that.
Antonia:Yeah, it's definitely not the only algorithm out there, but so far it hasn't really been superseded by anything else, at least in the 10 years since it was published. But people should read between the lines here and note that if you have moderate variability and, for example, you have late decelerations with 40% of the contractions, then this timeline and this algorithm doesn't even apply. They're not even worried about that enough to address it. You could technically watch that indefinitely. So just knowing that really you're worried about when the decels are more than half of the time with contractions could go a long way also to reducing the unnecessary cesarean deliveries for fetal chasings, because a lot of category two chasings that are being treated with operative delivery probably still don't even warrant consideration by this Stephen Clark algorithm.
Howard:Yeah, please read it if you haven't print it off. Put a copy on labor and delivery of the algorithm, save it to your phone screenshot, et cetera, and maybe we can do another four tips later this year about some tips on resuscitating those category two chasings.
Antonia:Yeah, and resuscitating category two chasings. That also applies to resuscitating category three chasings as well, just in that case.
Howard:Yeah, you said last time.
Antonia:Yeah, just immediate attempt, immediate resolution or immediate delivery. So now let's get into the new USPSTF from a Mography Guidelines. This came out earlier in 2023, and we had mentioned it in an episode at that time, but we didn't really go into the details. But there does continue to be different guidelines that exist out there, because different professional societies don't agree with each other on at least all of the details of the optimal timing and frequency of breast cancer screening.
Howard:Well, I think in my view, there's three main organizations that issue guidance about mammography, not including the Radiologist Society, which we can mention briefly, but, frankly, we can discard them. They have an overwhelming financial incentive for people to over screen and that is, of course, what they recommend. But the first legitimate set of guidelines, I think, come from the American Cancer Society, which states that average to low risk women should get mammography yearly from the ages of 45 to 54, and then every two years starting at age 55, for as long as she's in good health and has a reasonable life expectancy. They don't recommend clinical breast exams or self breast exam. Then there is ACOG, which frankly doesn't recommend what people think it does. So Practice Bulletin 179, which was released in 2017, recommends a model of shared decision making between the clinician and the patient and recommends discussing the risks and benefits with women in their 40s and then starting at age 50 to recommend a mammogram.
Howard:It also says that mammograms can be either annual or every other year, depending upon that shared discussion of risks and benefits with the patient, and they recommend reassessing whether we should continue them when you get to age 75, based upon the patient's health status and expected longevity.
Antonia:Yeah, I think when people read that part in the ACOG Bulletin that says offer a mammography to women as early as 40 years old, after discussing risks and benefits, they just assume that means order the mammogram 40 years old, just order it. And the same goes for whether to do it yearly or every other year. So someone could easily interpret the ACOG guideline as recommending yearly mammography from ages 40 to 75. But on that same token, you could also just as easily interpret it as saying no mammography in the 40s and then every other year, starting from age 50 going to 75, depending on what you know about mammography and how the discussion goes with the patient.
Howard:Yeah, that's exactly right, and I think that's a surprise to a lot of folks. People tell me, just in summary, that ACOG recommends yearly mammography starting at age 40 and that simply is not the case. Now, all of these guidelines recommend joint decision making where we discuss the risks and benefits with the individual patient in front of us for her individual risk factors. I don't think that that conversation happens that often, though. In fact, I'll be so bold as to say that most practicing OBGYNs don't know enough about the risks and benefits of mammography to have that conversation with patients. Instead, they just order mammography and assume.
Howard:It's this amazing thing. They emphasize in the table, in that practice bulletin, that all of these recommendations are predicated upon an informed decision making approach. That emphasizes the uncertainty of the benefits and harms. They say this also for clinical breast exams in women under the age of 40. And so you have to understand the purported benefits and harms in their mammography initiation timing and things like that and screening recommendations, and they have a footnote that specifically says that this should be a decision made after appropriate counseling, not just an automatic for everybody. So if you're not doing the counseling about risks and benefits for these things before ordering the mammogram or doing breast exams, then you violated that guideline.
Antonia:We can discuss some of those risks and benefits, because I think most providers really don't consider there to be risks of mammography outside of minor discomfort and inconvenience for the patients. But let's review first the other guidelines out there besides the ACS, the Rhythm Cancer Society. So next is the USPSTF.
Howard:Right. So up until 2023, the US Preventive Services Task Force recommended against clinical breast exam and then recommended mammography, starting at age 50 and doing that every two years and stopping at age 75. And before the age of 50, they recommended assessing an individual woman's risk factors and again having this discussion. Now what they've done is they've shifted their recommendation to starting at age 40 and doing a mammogram every other year, with most of the rest of the guideline unchanged, except for that bit.
Antonia:I think the individual discussion takes time and so people don't always do that, and they're also afraid of missing risk factors or things that might influence that discussion and change it. So they just probably tend to err on the side of caution, especially if they have a limited amount of time with the patient and then they just go ahead and just order the mammogram. And if patients are getting yearly mammograms starting at age 40 and essentially getting them every year until they die, then they're not following any of these three guidelines at all. They're not following the Cancer Society, not ACOG unless of course they've done the extensive counseling, in which case it shouldn't result in a low to average risk patient opting to go for mammography every year from age 40. And then they're definitely not following either the old or the new USPSTF guidelines.
Howard:Well, there are a couple of other guidelines out there that they might be following, and this is one of the problems is that there's so many special interest groups and quasi-scientific recommendations about mammography. Anybody can issue one, we can make our own and put it on the website, and there isn't a general consensus that we all agree on, but I think that puts the onus even more on the individual clinician to understand the risks and benefits of mammography and explain these to the patients before routinely ordering potentially harmful tests.
Antonia:So there is also the NCCN, the National Comprehensive Cancer Network Guidelines, which do also recommend yearly mammography from age 40 up until about 10 years of presumed life expectancy. And then there's the Radiology Society that essentially recommends the same thing and I'd say, although most OBGYNs or primary care providers probably have no reason to favor those guidelines over the other three we just reviewed, they may fear the liability of missing a cancer diagnosis, especially if they have an anxious patient or even if the patient doesn't really care one way or another. But they're looking at this radiology report from the year before that said buy RADS-1, recommend repeat mammogram in one year at the bottom. Then they'll feel compelled to follow that.
Howard:Yeah, well, cue the hate mail. Maddie can answer it.
Howard:But yes mammography and subsequent follow-up imaging, et cetera, is a huge moneymaker for radiologists and radiology centers and that National Comprehensive Cancer Network is essentially a trade group that represents 33 of the largest cancer treatment centers in the United States. So, realizing this, most physician scientists would point to either the American Cancer Society recommendation or the US Preventive Services Task Force or ACOG, our professional society, which disagree with those two guidelines. The radiology and NCCN recommendations essentially haven't been updated and they're not based upon our current literature. They're using 30-year-old points of view.
Antonia:So let's talk about the risks and benefits of yearly mammography, starting at age 40. The default used to be that women would start the year they turned 40 and do a mammogram every year and in fact once upon a time baseline mammograms were even recommended at age 35. And along with that we also used to do a lot of x-rays during pregnancy and x-rays for all sorts of other things routinely before we understood the harms of repetitive x-ray exposure and the cumulative effects of that radiation over time. So in general we do less of this sort of imaging now than we used to, but there is still this culturally popular idea within medicine and, I think, society at large that mammography has to start at age 40 and it has to be yearly. It's part of the annual checkup and annual visit. So we should talk to patients about the data on the risks and benefits of specifically that practice.
Howard:Yeah, and I'll put a link to the Harding Center for Risk Literacy that has a bunch of stuff for conversations like this. But they have a couple of excellent graphic representations. They last updated this in 2019 and they make graphical comparisons that are good for patients. There's no new data since they updated it, but they show what would happen if you had a thousand women who got no mammograms at all in their 40s compared to a thousand women who started mammography at age 40 and did a yearly mammogram. So I use this graphic routinely when I counsel women about mammography and release the data on it, and I've been following the US Preventive Services Task Force recommendations or the ACOG ones, if you will by having an informed conversation with women about their individual risks and benefits and the risks and benefits of mammography. And then we have a mutual decision and patients do different things when you have that conversation, so I have to give them this data in order for that mutual informed decision to occur.
Antonia:And we'll just emphasize again this is for women who are average to low risk for breast cancer, not someone with, like a super morbid family history or something. But yeah, tell us about this graphic a little more.
Howard:Okay, so among the thousand and this is essentially the counseling you can do in a minute but among the thousand women who had no mammograms performed by age 50, there are five women who died from breast cancer and 22 women who died of any type of cancer, including breast cancer. But among the women who got yearly mammography, there were still four women who died of breast cancer, but the same number 22 women died of all types of cancer.
Antonia:All right. So that means starting the mammography 10 years earlier and doing it 10 times extra saved one woman from a breast cancer death. And so that's where you'll hear the statistic that there's a 20% reduction in the breast cancer mortality. But it didn't lower the total cancer mortality. So the chance of dying of cancer of any type was still the same whether or not you did mammography. So that radiation exposure of doing the 10 mammograms cumulatively just traded one breast cancer death for a different type of cancer death. So it really didn't help.
Howard:And the radiologists will push back on that, but that's what the data shows. I think it's interesting that despite annual mammography 80% four out of those five women who are going to develop and die of breast cancer, despite getting nearly mammography, they still developed and died of breast cancer. So the one who was saved from breast cancer death traded off, as you said, with a different type of cancer and there was still a cancer death. So mammography isn't as good as we think is one of key takeaway there. It's not as life-saving or preventative as we think. But yeah, technically the American Society of Radiologists is correct when they say in their guideline that mammography has a proven benefit of reducing death from breast cancer. But total mortality from cancer is what really matters to most patients and that's not improved.
Antonia:Yeah, and I wonder how many of those, even those four breast cancers, were caused by the mammography, in addition to that, one other cancer.
Howard:You never know. You can just look at the total numbers.
Antonia:Yeah, well, okay, so that's just looking at mortality. What about like less, like morbidities?
Howard:Well, 100 women out of the thousand during that decade who got mammography will have false alarms that lead to extra imaging and additional testing, biopsies or lumpectomies but turns out not to have cancer. So 10% of women will get these interventions.
Antonia:Yeah, that really shouldn't be minimized. It's definitely anxiety-provoking and expensive for the healthcare system and expensive for patients who have co-pays. We've talked about this before about how people feel when that happens to them. When you're finally told that you don't have cancer after there's a scare on a mammogram or something, hopefully you'll feel relief that everything turned out okay. Maybe you'll feel that the system worked for you and you got lucky. But some people might also feel anger that the test had such a high false positive rate and that put you through all these unnecessary tests and biopsies and potentially even surgeries, all for nothing. Not saying it's more correct to feel one way or the other, but if you happen to know that you are actually being over screened against the recommendations of multiple professional societies, then you might lean towards anger rather than gratitude in that case.
Howard:Yeah, Well, and some of the women will also have either a diagnosis of breast cancer that's truly not cancer In other words, an overhaul by pathology or they may have caught a true cancer, but one that's indolent and non-progressive and then get over treated. In fact, five women in the mammogram group out of that thousand will receive full treatment for breast cancer unnecessarily.
Antonia:Yeah, and I bet even a lot of doctors probably think if something is cancer, that means it's invasive, malignant, you have to get aggressive right away.
Antonia:But that's not true.
Antonia:And even in gynecology we know of plenty of other examples of very kind of good prognosis slow growing cancers like, for example, early stage borderline ovarian tumors or early microinvasive cervix cancers and even some of the more rare gestational trophoblastic neoplasias like placental site trophoblastic.
Antonia:These are all things that are just treated with a simple surgical resection followed by surveillance, not a bunch of chemo and lymph node dissection and stuff. So, as far as breast cancers go, there was a study in 2023 in Norway that estimated that about 15% of all detected breast cancers were also of that type, that they were not progressive, and they define that as meaning that by age 85, they would not have developed into anything that would cause any kind of illness or any clinical signs of a mass or symptoms or anything. But of course these women don't know that when they're told they caught an early cancer on mammogram and they go forth and get a full treatment and a full cure, of course they'll think their lives were saved. But in fact, in at least in 15% of cases, their diagnosis may have been an error and their treatment may have been totally unnecessary.
Howard:Yeah, and think about papillary thyroid cancers or prostate cancers with low glycine scores or things like that. The stage zero DCIS cancer diagnosis is likely, or quite possibly one of these cancers you're talking about.
Antonia:Yeah.
Howard:But exactly. And the other thing I'll point out is that none of what we're talking about is any different. This guideline didn't change this year as past year, based upon new evidence, as we can just talk about more in a few minutes.
Antonia:We've talked before about making sure to pick the outcome that matters when thinking about the benefits and harms of anything we do in medicine and, broadly speaking, probably what matters in most cases is always some kind of measure of life duration, overall life duration, life quality, and with cancer screenings and treatments, the benefit we should be looking at should be overall survival and then maybe cancer related survival, and those are not improved with annual mammography starting at age 40. There could potentially be some other side benefits, like maybe less need for advanced treatments or really aggressive chemotherapy, but that's going to be hard to judge, knowing that some fraction of the women who are receiving even the less aggressive treatments are even receiving those unnecessarily due to over diagnosis or misdiagnosis, when they really could have been just as well off with no treatment at all.
Howard:Right and you have to think about the statistics being reported. So things like breast cancer mortality rate, breast cancer diagnosis rate, stage of detection, disease free intervals, need for advanced or aggressive treatments, total years of survivorship after diagnosis and other similar metrics are all made to look better if you simply over diagnose and over treat breast cancers. So it's hard to remove the effect of false positive diagnoses and unnecessary treatment of not progressing tumors from statistics like those, because all of those appear better with a simple addition of a few false positive diagnoses in the denominator.
Antonia:Yeah, so yeah, all of those little outcomes you mentioned are very enticing to focus on, but it should be overall survival Because of course we don't want a screening or intervention that itself is going to cause a different type of cancer, which the mammography does, or some other significant health risk, and a lot of patients and clinicians probably don't realize that.
Antonia:We're having debates over very subtle benefits and risks that, on the whole, just tend to cancel each other out. I think patients assume if they're getting mammograms every year starting in their 40s, then they're definitely staying on top of things and they're definitely not going to die of breast cancer, when in fact, as we said, 80% of the women who would have died of breast cancer without mammograms during that 40 to 50 year old decade still do, even if they do a mammogram every year. Plus, in addition to that 80%, then there's another 20% that die from a different cancer that they wouldn't have gotten without the mammography because of the excess radiation most likely. So in addition to having 100%, the same amount of cancer death, we also get false positives for 10% of all women that are going through those yearly mammograms, including lots of unnecessary treatments that could include even mastectomy, chemo radiation, lymphotonectomy and then they get swollen arms later on in life, maybe hormone blocking therapy and the associated menopausal symptoms all in cases where it wasn't needed.
Howard:Yeah. And so if you sum all that up, for most average to low risk women, mammography starting at age 40, especially certainly yearly mammography. That's what we're talking about. It's not just a wash, it's a losing prospect. That's why we're not recommending yearly mammography. Not even this new guideline is that cumulative radiation exposure for continued yearly mammograms adds up over time and likely is the cause of breast cancers and other cancers that you see in women in many later years. Down the road I've seen patients diagnosed with breast cancer after 35 or 40 years of yearly mammography and they're thankful that that mammogram finally caught that cancer when in fact it might have been the cause of that cancer all those decades of radiation exposure.
Howard:There's another issue involved in cancer screening and that's the concept of risk transfer. There is an inherent asymmetry between the clinician and the patient in that both the patient and clinician are incurring a risk when it comes to screening for a disease like cancer. The clinician incurs a risk of misdiagnosis and the legal entanglements associated with that, and the patient of course suffers a risk of misdiagnosis dealing with the disease process. So, even though many of these mild and situ type cancers don't satisfy a break-even point between the risk of treatment and benefits in an absolute analytical model like we're discussing, and we probably shouldn't treat them. Our incentives favor intervention due to this risk transfer process, where the clinician transfers the risk of misdiagnosis and the liability associated with that to the patient, who now incurs the risk of unnecessary treatments. This is a more sophisticated way of saying that doctors sometimes do harm to patients to cover their own butts.
Antonia:Yeah, defensive medicine. I think you have an article that kind of goes further into this concept. We can post a link to that. But the doctors are, I think, thinking of the alternative risk of not screening and risking a missed or delayed diagnosis. So they're opting for the other kind of risk instead it's the CYA. But breast cancer screening is also a very emotional topic for a lot of patients, and so that influences how we think about it, along with the financial incentives and the breast cancer screening industry. We want to find these cancers and breast cancer is one of the leading causes of death for women and it is scary. So, just like sometimes with tokylidic drugs and preterm labor, we want to try whatever we can, on the off chance that it might be helpful, even though it's actually not helpful. We just want to do something, but this tends to create a false sense of how effective or how important that intervention actually is.
Howard:Yeah, we're definitely emotionally affected by the numbers about cancer diagnosis and how many women, of course, in their lifetime will develop at breast cancer in particular.
Howard:The concept of over diagnosis, I think, is hard for folks to grasp.
Howard:But essentially an over diagnosis happens when we diagnose something clinically that would never have affected that person's life.
Howard:So finding more cancers is not always a good thing. There's a recent article that I'll put a link to in OBG Management, which just ended publication at the end of last year but this is from the end of last year by the incomparable Barbara Levy that summarizes the results of a recent Medicare analysis of mammography after the age of 70 and concludes that mammography after the age of 70 is useless, not because it doesn't detect cancers but because so many of those cancers detected would not have affected the woman's life. So, specifically, the incidence of over diagnosis increased from 31% for women aged 70 to 74 to 54% for women aged 85 and older and there was no difference in the stage of diagnosed cancers and no difference in the reduction of breast cancer specific mortality for those patients after 70 who continued mammography compared to those who did not. But all of those diagnoses do affect people psychologically and socially and it affects their family histories of their children and grandchildren and our cultural perception and our sort of attitudes about cancer and how it impacts our society.
Antonia:Yeah, it's a trickle down effect. You do like Barbara Levy, don't you?
Howard:She is the queen of Agile Histrectomies, but yeah.
Antonia:Yeah, okay, well, yeah, so those diagnoses made with mammography after age 70 don't impact even the breast cancer mortality rates, let alone total mortality rates, but they still do inflate the numbers of cancer diagnoses and probably make us more scared of breast cancer than we should be. And they do change those patients' family histories. I see so many patients who have already gone ahead and started screening early, like even before age 40, because they had a great aunt or someone who had breast cancer. And this includes a lot of cases where the family history definitely doesn't warrant the earlier screening.
Howard:Yeah, imagine if the great aunt didn't have cancer.
Antonia:Right right.
Howard:But yeah, she was 79 and they're worried about it. I think that the concept of cancer mortality rates not from the idea of total numbers of deaths, which is easy to report, from a particular cancer, or even total numbers of cancers diagnosed each year, but in terms of how many years are robbed from patients due to a particular cancer.
Antonia:Yeah, so the most common cancers in women actually are skin and then breast, lung, colorectal and uterine cancer by incidence. But if you think about cancer in terms of deadly cancers and what are the most common causes of cancer death, then we get it in a little bit different order. So lung, again, followed by breast, colon, pancreatic, ovarian leukemias and then uterine cancers, and then further on down that list is lymphoma, liver and brain cancer. So still in both cases, breast cancer is number two by incidence and by cancer mortality.
Howard:Right, but it's still not number two by number of quality years of life lost. So there's a paper in 2021 in JAMA Oncology that looked at the global impact this wasn't the United States specifically of cancers ranked according to disability-adjusted years lost, and from that global perspective, the cancers with the most real impact then are lung, followed by colon, then stomach, then breast, liver and esophageal cancers. So for breast cancer then moves down from number two to number four, which obviously means it's still very important, but it shows that, even though it's a very common diagnosed cancer, a lot of the attributive mortality is for very elderly patients who don't lose that many years, or maybe not any at all. And, by the way, ovarian cancer is 14th on that list and cervical cancer and uterine cancers are 22nd on that list. Now, those are not United States numbers, as I said, were mortality from both breasts and cervical cancers are actually much, much better than compared to other countries. So the global data makes it actually look worse. The US is better, but I don't have US specific digits.
Antonia:That? Yeah, that would be interesting to know. Well, so on the one hand, of course, we would really like to detect these breast cancers in a way that has an impact especially on the younger women, to affect those quality life years and avert them from early death, but, on the other hand, mammography does not seem to be very good at achieving this goal, and so that's the real question is why are we applying mammography to something that it's not really that good at younger women, more dense breast tissue and that kind of thing? So there are some important criticisms of this change in the USPSC guidelines that we should still try to talk about, and still try to talk about with our time left on this episode.
Howard:Yeah well, all that's level setting really. But I'll put a link to a wonderful article in the September 21, 2023 edition of the New England Journal of Medicine that everyone really should read before you should pretend to have an informed opinion about this guideline change and the guidelines in general. But we can summarize their points fairly quickly, I think.
Antonia:Yeah, so this was a dissenting kind of like an opinion piece. It was really concise and well written. I enjoyed reading it and it was by a collection of doctors from Dartmouth, duke, brigham and women's and also the Denmark Cochran Collaborative Group. So, yeah, let's go through their overarching points. We don't want people to think that you're the only naysayer out there.
Howard:I'm not very original, I just read a lot.
Howard:But yeah, let me summarize the points.
Howard:The first one is that there's no new evidence that mortality for breast cancer is increasing, and in fact they point out that breast cancer mortality is decreasing and that their reduction has been most significant in women under 50, where it's been cut in half, and this decline has happened in countries that didn't do mammography in the 40s, like Denmark and the United Kingdom, which suggests that that decrease in mortality is not due to mammography but due to better treatments. Their second point is that there have been no new randomized trials to suggest or warrant a change in the guidelines since the previous US Preventive Services Task Force guidelines were published. In fact, the most recent data from randomized controlled trials shows no impact from mammography in this decade of life on mortality, if anything. Better treatments may actually make the impact of mammography for women in their 40s or, of course, any other decade for that matter even less than it was before, and the most aggressive, fast growing cancers are often missed by mammography, and so they don't tend to have much impact on those aggressive tumors either.
Antonia:Yeah, ironically, as our treatments have gotten better, then the screenings have become that much less valuable. But it is an important point there that there's no new trials, no new information, so how did they justify making this change now?
Howard:Well, they use a complex statistical model that made some assumptions about what might happen to mortality if more screening were to occur. The authors of this editorial point out that relying on such a model like this is very problematic because the outcomes are very sensitive to key assumptions in the model and that any model, of course, is only as good as its predicate assumptions and the level of sophistication that the model employs. They point out that the model makes predictions that far exceed any observed reductions in mortality that we've seen with real life data, and this suggests that the model's flawed or at least based upon some incorrect predicate assumptions.
Antonia:Yeah, we're not really good at predicting actual outcomes from these sorts of models. These are all just with hypothetical information, and that's why in most cases we would prefer to rely on actual randomized trials or at least actual observational data to make guidelines. But the only clinical trials that we have on breast cancer screening now are still going by the old sets of guidelines. So I'm wondering what motivated them in the first place to run these models. Maybe they felt that making a new clinical trial outside of current guidelines just wouldn't be feasible.
Howard:Well, maybe, but unfortunately the model still doesn't agree with observed reality, but really overestimated the current rates of breast cancer mortality. And despite that overestimation, the authors of this dissenting editorial argue that the estimated survival benefit with the newer guidelines would be so small that it almost certainly doesn't outweigh the known risks of doing mammography that we've been discussing. Basically, they found that it would take a thousand women getting screened, starting at age 40, to save one breast cancer related death, which we already knew. Yet it recommended that anyway. The model also predicts 36% of women who undergo the recommended new screening will have a false positive scare. That, too, actually exceeds what we've observed and what we discussed earlier and, of course, is highly problematic. If it's true, 6.6% will require a biopsy and 0.2% will be overdiagnosed and treated for a cancer that they didn't need treatment for, and that's according to their model. That means that there's a significant cost for the one life per 1000 predicted to be saved in that decade, and this is at least consistent with some of the data that we've been discussing.
Howard:Another issue that the authors discussed as motivation perhaps for the task force to change this was the disparity being observed between black and white mortality related to breast cancer in their 40s. They feel that this was a motivator for the change and I've read that elsewhere and some other stuff I've read about it. But they point out that there's absolutely no data to suggest that increasing mammography overall in both groups will help fix that disparity. Black and white women already undergo similar rates of mammography in their 40s, suggesting that the amount of mammography is not the cause or the reason for the disparity in outcomes.
Antonia:Yeah, they talked a little bit about how black women are disproportionately affected by the more aggressive types of cancers that are less detectable by screening. What they really call for is better treatment, because that's what already had led to the improved breast cancer survival numbers that we've seen. In this article. They don't really talk about alternative screening methods, like maybe ultrasound or MRI that could potentially be more sensitive, less harmful, but definitely cost prohibitive and would not be feasible right now. But so they just focused on the mammography.
Antonia:So they conclude their article by arguing that starting screening earlier is a huge mistake. It pulls resources in the wrong direction, away from treatment into screening. That's not beneficial, and they encourage policy makers to reconsider adopting these guidelines. So overall, I think it's worth reading. This is a quick article to read to get the full flavor of it, and I think it'll talk with their patients about it. But this whole thing just feels reminiscent of a lot of other interventions that we like to talk about on here, where there's just a desire to do something to make a difference, even in the absence of any evidence that we're making a difference.
Howard:Yeah, and it also detracts sometimes from more important things we could be doing, like you said, improving treatment for women of color. If we spend the next 10 years talking about mammography programs as a way of fixing this disparity, then we may be ignoring the other important issues that's led to that disparity. They also point out that black women are twice as likely as white women to have triple negative breast cancers, and this is perhaps one of the main reasons for the differences observed in mortality. And, of course, mammography doesn't change the type of tumor you're gonna be diagnosed with.
Antonia:So what are you gonna do?
Howard:Well, I've been having this risk-benefit discussion with my patients that we've had on this podcast for many years now.
Howard:I think the big thing I want listeners to realize is that there's no data that yearly mammography is beneficial or that mammography after age 70 is beneficial, and that they shouldn't take this change in the task force guidelines to support what they might already be doing, which might be yearly mammography in the 40s.
Howard:The only real debate that we're having here is whether they should have one every other year perhaps, which would be a total of five mammograms in their 40s versus zero. But unfortunately, most women are getting yearly mammography from age 40, frankly, until they die, and this is a net harm that needs to be stopped. That's not in accord with any of these guidelines. So I do tend to follow the guidelines as they are and then argue about it on here and try to change them, but in this case, we have three sets of guidelines to choose from, and that means we need to still be having this risk-benefit discussion with our patients and we still need to be fighting against the culture of monthly self-breast exams and yearly mammography, starting at age 40, that's so pervasive and helping to change the public's understanding of the risks and benefits of mammography by having these discussions.
Antonia:Yeah, and that'll definitely be a long view kind of challenge, especially if we're only able to tackle it in the exam room one patient at a time. I remember, even as a kid years ago, seeing ads in the movie theater during previews that promoted monthly self-breast exams, and I know for certain that there's still healthcare organizations out there that are stuck on that. They're still handing out little cards of like put this card in your shower to remind you every month to do the self-breast exam, which we talked about that before. So I feel like a public service announcement that highlights actual helpful and beneficial practices would be really nice, but with this new USTSD of stance I don't really see that happening.
Howard:It would actually be great if most docs actually followed the new guideline from the Preventive Test Force.
Antonia:It would decrease the number of mammograms being done. Yeah, yeah, that would be a good start. So do we have time for a historical tidbit?
Howard:We're running fast, let's do it.
Antonia:All right, let's do it so well, what's our tidbit for this month then?
Howard:Well, I think one of the things we can do on segments like this is not just straight history, like we did last time with the hormone stuff, but also older significant articles of interest. There's a lot of important literature out there and fascinating things.
Antonia:All right, well, let's do it.
Howard:Okay, well, I have an article that I was reminded of by the recent reports that I know you and I have seen in the news media of a 31 week abdominal ectopic pregnancy. So there's an interesting MRI picture that I'll probably use as the thing for this episode's tag that shows this extra uterine pregnancy going around. I've seen it on social media and it's very interesting, but it's also not that interesting in some ways. There are lots of extra uterine pregnancies that have been reported where children have lived and survived and been delivered at some viable gestational age, even very near term. In fact, your senior partner published a case report and a review of the literature at that time about treatment of an advanced extra uterine pregnancy back in 1984, and I'll put a link to that too.
Antonia:He is quite a legend.
Antonia:So yeah, of course this kind of thing can really only happen in a case where either they don't know they're pregnant until they're already at viability or they just can't get an early ultrasound. It would be unlikely to diagnose in the first trimester and then just keep watching it. But I'm always most fascinated by these extra uterine pregnancies, by how the placenta can implant somewhere else and then actually grow enough to support a live baby, and then, more so, how to manage it at delivery when you don't have the normal uterine contractions that are just going to shear it off. So yeah, in this new report I have seen it happen in France, and she didn't know she was pregnant. They talked about a delivery removing most of the placenta two weeks later, which that's not what my senior partner did in his case. But all of this is in the realm of expert opinion and case by case assessment, because they're so rare, and especially today when everyone does get ultrasounds, that this is not likely to happen. But it probably was a lot more common in the pre-ultrasound era.
Howard:Yeah well, my only point here is that a viable extra uterine pregnancy, that's just old hat at this point. I wasn't impressed by this new study. Nothing really new to talk about here.
Antonia:Okay, so you have an article on something different then.
Howard:I'm a one upper, so I do. How about a successful pregnancy following a hysterectomy?
Antonia:Oh goodness, so I guess nothing is 100%. So yeah, tell us more about this one.
Howard:Well, there was a paper in the British Journal of Cetricus and Gynecology in May of 1980 called a successful pregnancy following total hysterectomy. Now they reviewed the literature at that time and actually found 22 pregnancies reported following total hysterectomy. But in none of those previous cases at least up until 1980, had there been a viable fetus delivered. Also of note in that series was a maternal death from hemorrhage in 1974. These were also very dangerous pregnancies, but in this report in 1980, the baby survived.
Antonia:So interesting, and the mom too, I presume. Well, I'm sure we'll learn how this happened, but who would think to take a pregnancy test after having?
Howard:an hysterectomy. Yeah well. So this patient had previously had four healthy pregnancies, as well as three first trimester miscarriages, and she'd had a left tuberlic topic that had been treated with a left self-injectomy. So she was admitted for hysterectomy due to abnormal uterine bleeding on the 14th day of her menstrual cycle, and hysterectomy was performed two days later, on September 20th 1978.
Antonia:All right, so that's a little bit interesting. Firstly, you were already alive when this happened.
Howard:Calling me old. I feel like.
Antonia:I'm just saying I wasn't yet. I don't think my parents had even met each other yet.
Howard:But just thought that was interesting. Well, Elvis was dead, so Okay, fair enough Well then the other, and I think your senior partner was in practice.
Antonia:Yeah, definitely was. He was definitely delivering babies by then. And secondly, they admitted this patient two days before a routine hysterectomy.
Howard:Yeah, stuff like that was common back then. The length of stay for hysterectomies could be up to a week and patients were admitted for bowel preps and other preoperative evaluations before surgery and then kept in many cases five to seven days after a hysterectomy. Anyway, the important thing here is that she had sex the night before her admission and that was the first time she'd had sex in the last six months.
Antonia:That is. I have some more question there, but I suspect that probably happens a lot when people realize suddenly they're gonna be cut off for some period of time and not have the option. So then they just have one last night of fun before they're not allowed to have sex for a while. So are you saying that she conceived from that?
Howard:Yeah, well, you're getting a little ahead.
Howard:But yeah, she did go home on the seventh postoperative day, which means she spent nine days in the hospital and she had a total abdominal hysterectomy but kept her ovaries and that right fallopian tube and remember she'd already had the left one removed because of the ectopic.
Howard:But yeah, she had been in pain in this sort of right iliac fossa area that this pain would come and go with persistent nausea and frequent episodes of pain and increasing urinary frequency. And the pain extended into her right thigh and her abdomen started getting bigger and she was discovered eventually to have a cystic mass in her pelvis. And then on March 1st 1979, which was 23 weeks after her hysterectomy, this mass was at the level of her umbilicus and somebody discovered a fetal heart rate with a Doppler. And then she had an ultrasound which showed a fetus whose size was consistent with the conception occurring within three days before the hysterectomy and the placenta was partly down over the interior abdominal wall. The patient said at that point that she'd been having breast tenderness and thought she felt movement as well, but she didn't tell anybody because she thought people would think she was crazy.
Antonia:Yeah, they probably would have, and I'm sure ultrasound technology back then was a lot less quality compared to today. So even if she had had a uterus, you might not have even been able to tell whether fetus was in the uterus or not.
Howard:Well, they monitored her weekly and did lots of different labs and ultrasounds and things like that, and I guess they did everything they could think to do for a pregnancy of that sort at that time. And she started to get some elevated blood pressures around 34 weeks and eventually she was given beta methazone for fetal lung maturity. And then on May 15th 1979, I was a little bit over a year old they delivered this baby at 36 weeks in two days via a laparotomy and their main reason for that was just she had developed preeclampsia, rather than any other specific pregnancy issue.
Antonia:Well, okay, what did they do with the placenta?
Howard:Well, it wasn't herent to loops of small bowel and also parts of the ascending colon, so they left it. It probably resorbed slowly over time and it caused some permanent scar tissue there. They had a baby girl, a healthy baby girl who had an average growth size for her gestational age, no obvious abnormalities. They did re-emit the patient about six weeks later and she got a blood transfusion after she had some intra-abdominal bleeding behind the placenta. But that also resolved and the mother and daughter did fine after that.
Antonia:Okay, so just reflecting on this, she probably had sperm and egg already in that fallopian tube at the time of her hysterectomy and they left the fallopian tube there, of course, today. Now we usually would take them to reduce the risk of ovarian cancer. So this probably would not have happened if she had been getting her procedure today. So we'll admit someone on the morning of surgery and typically do a pregnancy test, and if it's negative we're not gonna say like oh, did you have intercourse yesterday? We can't do your surgery today.
Howard:But we are removing the tubes instead.
Antonia:Yeah, yeah, so, but they had found 22 other cases before of non-viable pregnancies, right? So in this case we can figure out how the conception occurred it went up through her cervix and uterus and then implanted in that right tube. But yeah, is that how it happened in all those other hysterectomy pregnancies?
Howard:Well, they actually think that the conceptions occurred in 12 of the 22 previous reports, just like this one, right before the hysterectomy. So not through a cuff defect after the fact or something like that, but instead the sperm swam up through the cervix and uterus just like normal. The uterus is removed, but the sperm was in the tube at that point. But the other 10 post-hysterectomy pregnancies all occurred well after the hysterectomy. It's one of them over 11 years later. So presumably this happened through a fistula of the vaginal wall, perhaps a prolapse fallopian tube or something like that.
Antonia:So it seems like the fallopian tubes are potentially a common denominator here, so it's maybe another reason to remove them routinely with hysterectomy.
Howard:Maybe. Yeah, we don't really think about fallopian tube prolapse that much anymore, and it was also common back in the day to not close the cuff in the way we do, believe it or not. They thought it would reduce infection by allowing drainage and that sort of thing. And so I think that prolapse of the fallopian tube and these little micro fistulas were more common because there wasn't a primary pair and the tubes were left, of course, and the method of healing was slower and different than we would normally see today.
Antonia:I guess life finds a way, as Jeff Goldblum says.
Howard:I guess it does.
Antonia:All right, I think that should wrap it up for our first episode of season seven. The thinking about OBGYN website will have links to all the stuff we discussed today, and then we'll keep continuing. We'll be back again soon with a new baby. At that point.
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