Thinking About Ob/Gyn
A fresh and evidence-based perspective of all things related to obstetrics and gynecology. Follow us on Instagram @thinkingaboutobgyn or visit thinkingaboutobgyn.com for show notes and more.
Thinking About Ob/Gyn
Episode 10.13 Estrogen, Free Birth, And Misinformation
We unpack what WHI actually showed about estrogen-only therapy and breast cancer in light of new supporting data, then confront the free birth trend’s preventable harms and the business model behind it. We share clear tools to spot false claims, review new aspirin data on preeclampsia, and outline twelve practical ways to cut waste in gyn surgery.
• estrogen-only therapy associated with lower breast cancer diagnosis and mortality
• combined estrogen plus progestogen neutralizing estrogen’s protective signal
• rare abdominal pregnancy case illustrating basic testing safeguards
• free birth movement risks, censorship of bad outcomes, and money incentives
• red flags in birth-related posts and the SIFT fact-checking method
• four quick filters to vet social content before sharing
• nuanced view on aspirin for preeclampsia with mixed trial evidence
• twelve surgical sustainability steps that save cost and reduce waste
Be sure to check out thinkingaboutobgyn.com for more information and be sure to follow us on Instagram
1:11 Estrogen Therapy And Breast Cancer Risk
6:41 What WHI Actually Showed
11:22 Progesterone, HRT Fads, And Risks
15:35 Wild Case: Abdominal Pregnancy Behind Tumor
20:42 Free Birth Trend And Tragic Outcomes
25:37 How The Misinformation Business Works
30:10 Red Flags In Birth Content Online
35:10 The SIFT Method For Fact-Checking
40:20 Four Tips To Vet Social Posts
46:25 Live Walkthrough: Debunking A Viral Post
52:40 Digital Hygiene And Curating Feeds
56:48 Aspirin For Preeclampsia: Mixed Evidence
Follow us on Instagram @thinkingaboutobgyn.
Welcome to Thinking About OBGYN. Today's episode features Howard Harrell and Antonia Roberts discussing new articles and misinformation.
SPEAKER_02:Howard.
SPEAKER_00:Antonia.
SPEAKER_02:What are we thinking about on today's episode?
SPEAKER_00:Well, we're going to be talking about our theme of this whole past season, which was protecting our patients and ourselves from harmful social media misinformation. We started out with that in 10. I don't know if we did a good job of it, but we'll also have a couple of updates on some things we've talked about through this past season or at least year, 2025. And we've even got a four tips segment, which we should do more of, but we've got four tips on misinformation, and we've got some tips on environmental sustainability for gynecologic surgery. So tips abound.
SPEAKER_02:All right. Well, let's start with some quick scientific updates. So this will be our end-of-the-year episode for 2025. And then we just keep going and switch into a new season after that, too. So recently there was reporting from the San Antonio Breast Cancer Symposium, where data was presented on over 19,000 women that were BRACA positive. And they found there was a lower risk of breast cancer in these women if they had used estrogen-only hormone replacement compared to any women who had not used it, or not used any, or used estrogen plus progesterone. So the risk was 24.9% in the women who used estrogen compared to 42% in the women who did not use estrogen. And then also for the women who used estrogen plus progesterone, they didn't have an increase or decrease from the baseline. So they also had about 42% breast cancer risk.
SPEAKER_00:Yeah, and we haven't seen this data published yet. The New England Journal of Medicine and other folks are cover the data as it comes out of this group, but it hasn't been reviewed yet. So there's a MedPage Today article that reported on this data that was reporting from the event. And it was interesting because they listed a question from one of the attendees who was present, and the attendee asked how this data could be contextualized or reconciled, I think is what they really were wanting to know with the WHI data, which the question asker at least felt reported the opposite finding. But I think the question from the attendee shows the continued broad misunderstanding about what WHI, the Women's Health Initiative, actually found. The estrogen-only arm of the WHI did show a reduced risk of breast cancer, just like this data. In fact, they found a 63% reduction in mortality due to invasive breast cancer in the 12-year follow-up of the estrogen-only users versus placebo users in the WHI. And somehow that finding from the WHI is not broadly understood or talked about much.
SPEAKER_02:We have the distorted and sensationalized reporting on the WHI to thank for that, and we've talked about that before. So there were three key findings from the estrogen-on group from the WHI that are relevant here for this new study that I'm sure we'll hopefully hear about more. So the first one you just quoted, there were fewer deaths from invasive breast cancer. The hazard ratio was 0.37, meaning just six deaths in the estrogen group from breast cancer compared to 16 deaths in the control group. And that's strictly deaths relating to breast cancer. Second, the second finding is that there were also fewer all-cause deaths in women that diagnosed with breast cancer. So 30 deaths in the estrogen group compared to 50 deaths in the non-estrogen group. So hazard ratio of 0.62. Another way to say that is a 38% reduction in all-cause mortality in women with breast cancer that had taken estrogen. And then the third finding is that also the actual diagnosis of breast cancer was lower in the estrogen group. So the women on estrogen, there was 151 cases in that group compared to 199 cases in the placebo group, hazard ratio of 0.77 or a 23% reduction in the rate of diagnosis of breast cancer for people that were on estrogen. So the takeaway from the WHI that we, as we've said before, has basically said estrogen is evil. The actual takeaway is that estrogen only use was associated with fewer cases of breast cancer, less mortality from breast cancer, and less mortality overall from all other causes. So it basically you're better off if you're a postmenopausal woman and you're on estrogen, even at the time of diagnosis of breast cancer.
SPEAKER_00:Right. And you could speculate about the reasons for that, but that's what the data showed from WHI. And that's at odds with what most people, even in the medical community, tend to believe. And the clearly the person who asked the question at the meeting that was reported on, I don't think that they understand that that's actually the finding of the WHI, let alone lots of oncologists and lots of breast surgeons, and certainly lots of media reporters and social media. In the data that was presented at the meeting, this new data, there was roughly a 40% risk reduction in the diagnosis of breast cancer, but they don't provide mortality data, at least not yet, we may see that published. But to me, that seems consistent with the findings of the BHI, not at odds with it, as that person asked. This is what's been publicly known and available since at least 2012. We talked about it many years on the first season of the podcast, actually. But despite that being publicly known since 2012, obviously people still operate under the opposite assumption.
SPEAKER_02:Yeah, so that's estrogen only. Estrogen only seems to be a good thing, at least when we're looking at breast cancer. But what conclusions then should we draw when people are come on combined estrogen plus progesterone?
SPEAKER_00:Right.
SPEAKER_02:At least relating to breast cancer.
SPEAKER_00:Yeah, and I think we have to be careful of making any new narrative fallacies about progesterone. All we can say is that the benefit observed for breast cancer reduction, breast cancer mortality reduction in taking estrogen seems to be eliminated when someone also takes progesterone. Now, that doesn't have to mean that progesterone increases the risk of breast cancer. It just means that it neutralizes the protective benefit of estrogen. So in both WHI and apparently in this new data that we're talking about today, there wasn't a meaningful difference in the rate of breast cancer, positive or negative, in women who took estrogen plus progesterone. I do think this can fuel a conversation, though, about the current fad of giving women progesterone who don't need it as part of the bioidentical hormone replacement therapy. And there's actually a lot to that. We should talk about sometime this idea of progesterone being the primary hormone that women need in the menopause. There's a pretty neat history around that and a history in the literature, but it's caught on. It's not evidence-based. I'll give you the end of the conversation up front. But there's almost no known benefits to taking progesterone for hormone replacement therapy if you don't have a uterus. And there are some actual harms, including with DVT risk. And this may be one of the harms, not that it causes breast cancer, but that it robs you of a protective benefit from estrogen vis-a-vis breast cancer risk. So this is definitely one of the shaky areas of biodentical hormone replacement quackery that we're seeing out there today. But it does have an interesting history, and maybe we'll get into that next season.
SPEAKER_02:Yeah, and it would be interesting to compare. There's obviously different types of progesterone therapy, like the WHI used the progestin. We often used, we often use micronized progesterone. And then of course there's IUDs. So lots more to talk about later.
SPEAKER_00:But maybe when that data is published, we'll see how many folks they had on different types of progestogen. I don't know if that data is available, but of course, that's always the moving target is that somehow the microgias micronized progesterone won't have the same risks as the synthetic progestogens. But of course, that's not actually been shown in any literature. That's just a claim. So maybe that data will help inform that some.
SPEAKER_02:Yeah. Well, I want to move on because there was a crazy story. This didn't seem real, but this is real. So this just came out, I think, earlier this month, December 2025. There's an ER nurse in California who had a huge and thankfully benign ovarian tumor. It was one of those big, like 20 plus pound ones, and apparently unknown to her for most of her, most of the time, also had a full-term extrauterine pregnancy hiding behind this tumor. So we'll link to it. It seems like it's not real, but it's a crazy real life story.
SPEAKER_00:Yeah, and the baby weighed eight pounds, six ounces.
SPEAKER_02:Yeah.
SPEAKER_00:So I and I guess they dubewitz it out to 41 weeks. Uh they said it was 41 weeks. So she had apparently a we don't know much obviously from this kind of reporting, but she had a history of infertility and irregular menses. That's where you see a lot of these occult pregnancies. Those folks that just didn't think they could be pregnant and their periods are weird anyway. So it's not clear how long it was known that she was pregnant or how long the growing pregnancy might have been confused with the tumor that was essentially masking it. But it sounds like they didn't realize that she was pregnant until they did a pregnancy test, I'm guessing, as a tumor marker panel, or some sort of preoperative evaluation, when they were deciding to operate on this large tumor. And then of course the surgery itself sounds incredibly scary due to the parasitic vasculature that you get with these sort of abdominal pregnancies. The story said that she received 11 units of blood, even for a planned, I'm sure, carefully done surgery, knowing that this was parasitic.
SPEAKER_02:Yeah, yeah, I would love to know more details. I don't think we ever will. Thankfully, this was a good outcome, but it of course could have been really terrible. We've talked about these sorts of abdominal ectopic pregnancies before. They're very rare today because people are able to get pregnancy tests even before their period is due and get imaging, see a heartbeat as early as six weeks if they know to go seek an ultrasound. So, but not everyone apparently knows. And this was one of those cases where even the growing belly was attributed to had another good reason, and she just didn't know. So I guess the moral here is if your belly's getting bigger, take a pregnancy test, even if you think you're just getting fat or bloated or you have a huge ovarian mass, and take a pregnancy test anyway. But but if someone has a problem like a tumor, it doesn't mean they don't also have a separate problem. Yeah. And we talked like an ectopic pregnancy. Yeah.
SPEAKER_00:We talked last year about even a pregnancy after hysterectomy. So if in doubt, get a pregnancy test. It's not a hard thing to do. But okay, another thing that's been making the circles, at least in our social media communities, is a story from also from December of 2025 in Australia about a wellness influencer who had a quote free birth, in quote, at home and then died from massive hemorrhage. And so she was eventually taken to the hospital. The hospital reportedly used all of its blood products trying to save her life, but ultimately could not.
SPEAKER_02:Yeah. Very tragic, obviously. So this idea of free birth means no, no medical care, no midwife, no doctor, no clinic, nothing. The whole pregnancy from beginning to end and delivery is unassisted, no testing, no treatment in all aspects. But that's I think the the free birth groups, they don't really mean that because they do promote a paid membership to their groups with access to like coaching and message boards. And they probably talk about different supplements and exercises to do. And they'll give advice, they'll keep giving advice not to seek medical care, even when complications do arise, like severe headaches, severe pain. And they do promote free birth-minded other people that they they call doulas, or they have another term for it, to attend the deliveries at these other people's homes and introduce some things maybe that they think are useful or natural as quote interventions, just non-medical interventions. So yeah, essentially the this is a small but maybe growing trend, and social media has helped it spread quite a bit, and it really the point is pregnancy and birth without any kind of assistance from the medical community. So, so there was a really good article on this in The Guardian in November 2025, and it was about the Free Birth Society, which is a business that has made millions of dollars based out of North Carolina in the US, and it promotes the idea of free birth, and it uses social media to encourage women not to get prenatal care or see any midwives or physicians. So The Guardian did a year-long investigation. They were able to find 48 cases of either late pregnancy stillbirth or of neonatal deaths or other forms of serious harm involving mothers that were linked to this free birth society group. And they were able to do some in-depth interviews in 18 of those cases, and they determined that each one of those tragedies were easily preventable. And oftentimes these women had said that once they notified their little message boards about their terrible outcome, they were immediately deleted, taken down, silenced, as if to prevent other group members from becoming aware that these things had happened. And in the article, they some of these interviewees gave examples of even during their often prolonged, complicated labor process, they'd describe things like green fluid coming out, brown fluid coming out, severe pain, can't feel the baby move. They would be getting real-time advice from within this group saying, you've got this, just don't go to the hospital. You can stay at home, you don't need the hospital. And first, and of course, you can imagine how that turns out. They deliver a dead baby. And for some reason, they also got into how the philosophy of these rebirth society business owners is that once a baby is born, if it's trying to breathe, it's best to let the baby figure it out on its own, not try to give it any rescue breaths or resuscitate it, even if the baby's clearly having trouble or even starting to look dusky, which is just incomprehensible what why. So, so this article was really well written and also really horrific to read. Obviously, I don't think any of these women were happy or grateful that their babies died or that they themselves almost died. I think one of them experienced severe preeclampsia and became blind and could have gotten treated, but didn't. There was another instance where one of them really was dwelling on the death of her little boy and paid, was able to get a debriefing counseling session with one of these coaches and was essentially told it's not really a bad thing that her baby died. And I think that's where a lot of these people have started to get disillusioned, but they're not able to go back to the message boards and expose it for what it is anymore.
SPEAKER_00:Yeah, sounds like a cult. I also like, though, how you described it as a business. It's the boundaries between what's a business and what's not a business, and what's a cult and what's not a cult are so gray, and I guess that's one of the things we focused on with thinking about some of the social media stuff this year. It's interesting they in that article they estimated that just the last few years the two women that run this group, this business, have made about$13 million off of selling courses to their students, though they present themselves, of course, as these sort of grounded, folksy, just average, well-intended healers of some sort. But in fact, they're shrewd business women who have become very wealthy at the cost of women and children suffering. Free birth is not something we don't have an experience with. It existed historically, and two to three percent of children died in childbirth, and one in one in eight women in their lifetimes died in the act of giving birth historically. And we even have data in the United States from Ohio from a group who would not undergo any medical treatment, and we saw in their data, we saw similar rates of maternal and neonatal death when you just don't have care at all. And it's another thing if you run to the hospital in the end, but as we saw with the lady in Australia, that was too late even for her. We can't save a person who's already exanguinated by the time they bring them into the door. I think that consumers of misinformation and disinformation on social media underestimate how much money there is to make off of some of these claims, all of the click below for 20% off. And these are multi-level marketing businesses that sell misinformation. But women and children are clearly being harmed by the lies that are being told.
SPEAKER_02:Yeah, and it trickles down. It's not just things that are directly posted by the Freebird Society itself, but some of it gets viewed and then borrowed by other people who then use it in their own posts. And so that the impact becomes bigger than just this one organization or this one group. You, for example, you may read something on a local doula's page and not realize that she's got some misinformation she's sharing and promoting secondhand or third hand from organizations like the Free Birth Society. And so this really raises the question about how mothers can protect themselves and their babies from wrong information. We've been tackling this issue recently on this podcast here, and we're trying To highlight some of the spread of bad information on social media. So you had your friend, the pseudonym Anna, representing some of this on as a guest. And then we also just had that recent excellent vaccination episode with the infectious disease doctor. So what can the average mom do who's just trying to educate herself? She's using the internet and whatever good resources she has available. She's asking around. And let's say she has some distrust for her obstetrician who may be pushy, maybe she's had a bad experience, maybe she experiences them as dismissive. Maybe they have a high caesarean or epesiotomy rate, and that really concerns her.
SPEAKER_00:Yeah. It's ironic. I love these moms. The women who come in and they're trying to be educated and do best. Those are such opportunities for us for patients who want to be educated and do the right thing. But we have to protect them a little bit from, I don't know, the vultures. I'll call the Free Birth Society the vultures out there. But it's not just the moms. This stuff trickles down into the medical community too, where doctors are saying or repeating or parroting things that have had some popularity on social media, but they don't realize the source of some of this information. So protecting yourself from misinformation about birth and health topics in general requires shifting from just being a passive scroller to an active filter, if you will. The birth content is particularly vulnerable to this information because it targets very deep emotions, fear, hope, the desire to protect your child and raise your child well, and all of those things are just very emotionally laden.
SPEAKER_02:Yeah, and I think a lot of the social media engines and algorithms have figured out that this kind of information hijacks the nervous system. They know how to get clicks.
SPEAKER_00:Yeah, the algorithms know how our brains work. So when we see that and we understand that, we need to first just pause and check that emotional payload. If the post says that doctors are lying to you about something, or that this common and widely accepted practice is actually abusive, or it's if it's using emotional leverage and not necessarily facts, we need to identify this, they call it the secret knowledge trope. We we should be skeptical of anyone who's claiming to have some hidden truth that the whole medical establishment and scientists everywhere have been suppressing. In healthcare, consensus is usually very public and also widely debated. It's nearly impossible to hide important information from large numbers of scientists and physicians who are all all around the world working on a problem, let alone hide it from the general public. But when these incendiary posts activate our nervous systems with these emotional stimuli, there's probably an underlying sales pitch. They're trying to convince us of something. They give you some terrifying information about a hospital birth or a medication that's standard and used by millions of people. But of course, like the free birthers, they're selling a course, or maybe they're selling a supplement or a coaching package, and then they're potentially huge financial incentives. That's how the Free Birth Society made$13 million. And I'll say also the alternative health movement and the supplement industry is actually bigger than the pharmaceutical industry. I think people don't realize that when they're told about big pharma and the profits and the total dollars are actually bigger on the other side.
SPEAKER_02:That's yeah, there needs to be a punchy like big maha or something. Um but there are some specific red flags in birth content on social media to look out for. So the natural birth and parenting communities on let's say Instagram or TikTok will often show signals of these. So one of them is this all or nothing narrative. So this is a trope where they'll maybe focus on a common medical intervention like labor induction, epidural, caesarean, vitamin K shots, always 100% is harmful and traumatic. Never take it. All or nothing. Oxytocin is always bad. Whereas nuanced health advice will discuss risks and benefits and how these interventions can be life-saving in certain situations and when they're used when necessary. They're not typically supposed to be used all the time. I mean we typically do the vitamin K universally after birth, but especially in certain situations, it's even more helpful. So to present them as all bad in all cases, or to present some other alternative as always good in all cases, is is always misleading.
SPEAKER_00:Yeah. Life's a lot more nuanced than that. And these complex scientific discussions can't be reduced down to 144 characters. Another red flag is anything involving the free birth movement. The free birth movement at this point is a major red flag. So you should be wary of influencers who are glamorizing free birthing. It's presented as this ultimate empowerment, but it downplays the incredibly significant risks like the stillbirths or the permanent neurologic injuries or the hemorrhage that we've been discussing and that trained professionals are equipped to handle and intervene on, or should be, or they're not they're not trained professionals. Remember, we already did this free birthing thing and the organic diet thing and no vaccines. We did all this in the 19th century, and it was common for moms and babies to die, as I mentioned. So we we're not trying to go back to 1850. So anything that uses the term free birth or references that movement in a positive way, huge red flag.
SPEAKER_02:Yeah. A third red flag then is demonizing clinical tools. A lot of these little reels will frame standard safety checks like cervical exams or fetal monitoring as assault or somehow dangerous in and of themselves. And of course, we can have some debate on how often should cervical exams be performed or whether a patient might be a good candidate for intermittent monitoring. And of course, we always need someone's consent for what we're doing that involves touching them in any way. But when people frame these tools as always malicious, that's just their own malicious tactic to erode trust with midwives, obstetricians, so so that they can promote their own gainful alternative. And you can subscribe to their coaching course. And they create these extreme absolutes that, of course, no sensible midwife or obstetrician or nurse is going to agree with. And it's really a cult tactic that's designed to divide and conquer. It's not nuanced, it's not personalized, it doesn't consider any pros and cons or risks and benefits or anyone's specific health status. And like I don't see these free birth people saying that if you break a leg or have a heart attack or get in a car accident, just let nature heal it. Don't go to the ER. We know things can go wrong in the body in other ways, and that there are benefits to having medical care. So it really doesn't make sense to deny that things can also go wrong in the body during pregnancy and birth. Usually it doesn't, but it can, and sometimes it does.
SPEAKER_00:Right. Well, our last red flag is what we call the wellness pipeline. So a lot of accounts on social media will present themselves as crunchy or wellness, but they're actually gateways to more dangerous content and conspiracy theories, such as the anti-vaccine rhetoric. But they're promoted under the guise of natural living. So some of that type of content is a red flag. The same influencer who tells you that vaccines cause autism or that vitamin K is bad for newborns is probably not a reliable source of information about anything related to birth or other things. It's beware of the pipeline and you have to look at their claims in total.
SPEAKER_02:Yeah, anything that you're seeing on social media, you you need to see where is this coming from? Verify the source.
SPEAKER_00:Well, we'll put a link to a guide from the University of Chicago that talks about something called the SIFT method. So this acronym SIFT, the S stands for stop. Don't share or internalize the information you've just seen. Avoid that emotional triggered response. The I stands for investigate the source, as you just said. Is this a board-certified OBGYN, or is it a certified nurse-midwife, or is this a board-certified pediatrician? Or conversely, is it a free birthkeeper or a coach or a wellness advocate? Don't trust when people say they are researchers, when by research they mean that they've read things online and not that they conducted clinical trials in that regard. The F stands for find better coverage. So this means don't just read the post, open a new tab and search for the claim being made, plus ACOG or some other reputable organization. The scientific method is to try to disprove what's being claimed. So look for evidence that what's being claimed is false. Most misinformation could be stopped deadness tracks if people just search for information that disagrees with what's being posted and honestly assess and compare it. The T stands for trace the claim to its original context. If they cite a study, does that study actually say what the claim being made is? Influencers often cherry pick one sentence from a study, which might actually conclude the opposite of what they're claiming.
SPEAKER_02:Yeah, like how we just said the WHI estrogen was actually protective of breast cancer, but the claims were that it causes. So look at the actual source that's being cited. And people need to try to help to use those alg algorithms to curate their own feeds in a way that is beneficial for them. So this is digital hygiene. One thing that both you and I have noticed by looking at some of these posts is that whatever platform we're on, if we click on something, that platform assumes we want more of that information, and then it'll feed us more of the same thing. And that tricks our brains into believing that this is widespread mainstream information when in fact we're just seeing this little niche, this insignificant fringe of all of the influencers that are making that content. And the platform's little code has just picked it all out for us because we clicked on one thing. So you've got to actively make sure that your little news reel is well-rounded and includes a wide variety of people who can bring balance to a topic so you can be more of the judge and not just passively take in whatever you're seeing. We can make a link on our podcast Instagram to at least some Instagram accounts that might be nice to follow just to see some more balanced, why a wider range of scientific opinions. And these aren't all people that we f a hundred percent agree with all the time. And that's not the point either. The point is to hear science-based influencers. And if you just spend a week using your social media and having these people pop up on your newsfeed as opposed to spending a week with all Free Birth Society people in your newsfeed, it's gonna be a dramatically different impact just on your overall outlook and thought process on some of this stuff. And you should definitely unfollow and maybe even block the alarmist accounts and just don't promote them.
SPEAKER_00:Yeah. And I'll tell you for our colleagues, and we will, we'll put a list of some folks that that we look at sometimes on these accounts and check them out. It's also just a good place to hear and understand some of the data. Patients come in asking a new question every week, it seems like. Some the newest conspiracy theory or the newest whatever. And if you have a good feed of people like some we're going to suggest, well, you'll hear where this is coming from and what the science says and be able to answer your patients better. So if so if you're a physician, then definitely have these people and others like them in your feed so that you can be ready for what your patients need to ask you. But also your patients may ask you who you follow or what good sources of information are. And having a list of folks, this is how people consume information today. So we have to provide it to them. Even having a paper that you give folks of good birth-related influencers online for them to follow is a great start. Let's help our patients curate their news feeds as well. And then ultimately, of course, for patients, they should talk to their midwife or their obstetrician about what they're seeing and hopefully assume that give them some deference to the advanced training that they have. If you're a patient, bring the things in that you've seen online to your appointment and ask questions. But please have an open mind about it and realize that your midwife or your obstetrician is better suited to answer this question than some random no-name person with an Instagram account. Okay, but we've made four tips to try to help with this.
SPEAKER_02:Yeah, we haven't done our four tips segment in a while. And usually we do it on some kind of surgery or manual procedure, but we're gonna stay on topic. And this is gonna be four tap four tips for assessing the validity of a social media post. So tip number one, ask yourself are they selling a product or a course that claims to fix a problem that they just scared me about?
SPEAKER_00:Right. Yeah. Is a post designed to emotionally activate you and then convert you, funnel is the term, to a sale. That's a huge red flag.
SPEAKER_02:Yeah. So that's tip one. Tip two, are they using any absolute or extreme language, words like always or never or toxic or poison?
SPEAKER_00:Right. Do they present things as all good or all bad without appreciating the incredible amount of nuance and complexity and grayness that exists in the medical sciences?
SPEAKER_02:All right. Tip three, does this poster have appropriate clinical credentials and training like MD or DO or CNM?
SPEAKER_00:Yeah, or so or a foreign equivalent degree or something like that. So yeah, you see all sorts of folks in this space who advertise themselves as doctor talking about things that are specifically the expertise of pediatricians or obstetricians or midwives, and then you click on their bios and they're a chiropractor or a naturopath or some other unrelated degree, or they don't even have a relevant degree. And I do wish people would realize that if you want to know more about flying a jet airplane, you don't ask a passenger on the plane. Please give deference to people with qualifications. And even among there, there's some bad actors, but go with a consensus of what trained professionals say.
SPEAKER_02:Okay. And tip number four, can I find the claim that's been mean being made on this post verified by any major health organization?
SPEAKER_00:Right. And obviously, in on this podcast, we spend a lot of time dismantling and pushing forward the science, pushing back at outdated claims, even in our own professional organizations, that we internally debate and looking for that nuance, and we question guidelines and we push for their revision and improvement based on new scientific evidence. But when literally every medical organization in the world recommends certain interventions, and then an unknown influencer with no credentials disagrees with that, that should be just a huge red flag. And that's how you get people dying, like the poor lady in Australia who listened to this sort of nonsense.
SPEAKER_02:All right, let's do a practice run with these four tips on an actual social media post.
SPEAKER_00:Yeah, okay. Well, I've been all year, I feel like I've been screencapping things I see when I see them, and now I just want to delete them all. But anyway, I've got one here from an Instagram account, and I'll give the name since we're going to talk about it. It's ToxR-EE Doc. So this person posts a lot of what I would call functional medicine and wellness type posts that probably look very appealing to the average health-oriented consumer. It feels natural, it feels wholesome, it feels health promoting. So the one I screen capped is entitled, Are You Worried About Cancer? And for various types of cancers and even some conditions that aren't cancers, it recommends certain tests that are sold mostly by functional medicine and naturopathic doctors. So really nothing in this list is accurate, but he recommends things like heavy metal and mycotoxin tests and GI map tests and the Dutch complete hormone tests and things like that for a variety of cancers and conditions and things like that. Now, to a scientific physician, this is immediately recognized as garbage. Like when I see this post, I immediately recognize this is none of this is real. But to a lay consumer, it may look like a physician recommending extensive testing for problems that maybe their primary care simply doesn't care enough about to order, or maybe they believe that their insurance just doesn't pay for it, but it's a good test, or they can learn something more about their bodies. And maybe they they assume that the evil insurance company has blocked it because they believe this we believe insurance companies are evil too, right? So it's an easy it's an easy one to believe, and they won't get reimbursed for the test, something like that. So some narrative is usually used to draw you in and purchase this more extensive or comprehensive testing scheme. So let's go through the four tips and see how it works.
SPEAKER_02:Yeah. So tip one, is he selling a product to fix this problem?
SPEAKER_00:Well, of course he does, yes. He sells consultations, he sells courses, he has a storefront that sells things like a PDF called the Fertility Guide that claims to be a functional medicine approach to PCOS and endometriosis. It's a PDF that's 50 bucks, and he's got several that are 50 or more dollars that are just PDFs that he's had. I don't know, maybe he's had AI create, I'm not sure, but I didn't buy any of them. They're very expensive.
SPEAKER_02:That's pretty steep. Okay. Tip two, is he using any extreme absolute language?
SPEAKER_00:Oh, he loves it. Now, this particular post I picked isn't the best one to show that, but when you scroll through his other posts, he has lots of very fear-oriented absolutes. He tells us that vaccination causes almost all of Sid's deaths, for example, and he simplifies very complex health issues down to what they love to call root causes, that one neat trick, that one simple thing that everybody else has overlooked that you can fix with a simple detox treatment. And so he makes very bold and outrageous claims.
SPEAKER_02:Okay. Tip three, does he have appropriate credentials?
SPEAKER_00:He does not, even though he calls himself a doctor. He has a PhD in an unrelated field. And he does have a degree called a holistic health practitioner from the New Eden School of Natural Health and Herbal Studies.
SPEAKER_02:Okay, I don't think I've heard of that school before.
SPEAKER_00:Not surprised. It's an online school, and I looked, and his degree can be earned in about nine months online for$2,500. There are no prerequisites to enter, there's no licensure test to take, no qualifying organization to see that you're competent. All exams are open book. That's actually listed on the website. It's not accredited by any recognized organization, and it seems to be run by one man in his family. And that person has no actual health-related degrees either.
SPEAKER_02:Okay, well, tip four, can you find these claims validated by any major health organization anywhere in the world?
SPEAKER_00:No. And when you and of course when you take each of them and look for relevant health organizations around the world, you find the exact opposite is is true.
SPEAKER_02:Okay, that was easy. That didn't take too long. That was definitely easier than going through a journal club in the systematic way we've talked about before. And we've already addressed this, but you're being asked to believe that everyone else in the world is wrong, and this person who's untrained in this field is right. So maybe that's a bonus red flag, the special hidden knowledge flag. But that kind of a vast conspiracy type thinking, it's one of the hallmarks of cults.
SPEAKER_00:Yeah. Well, folks should try this on their own social media posts. I actually picked one that that I think would be appealing to a lot of people because it just seems to be science-y, we're ordering tests, we're dealing with real diseases, things like that. But of course, it's completely off track. It did take me a bit of time to Google to find out about the person who posted its education and the school they went to and things like that. But anyway, it doesn't take you that long to find out about the information for someone who's making a living essentially or trying to make a living by lying to people and promoting distrust and disinformation.
SPEAKER_02:I'll still try to put in a plug like this might be reach, but it is possible to just cut off social media if some of this is a little too hard to not get completely drawn in. There are apps that can you can download that will block Instagram, TikTok, Reddit, whatever it is that's that feels addicting to you on your smartphone that make it really hard to override. Like you I have one that it makes me wait five minutes with the screen open. And so I never do that. And that way I don't have to constantly use self-discipline to stop doom scrolling or whatever term you want to call it that sucks hours out of the day. These are all built to be so addictive that when we open the apps, we're not even wanting to open it. I maybe wanted to see what time it was, and then by the time I have my phone, I forgot what I was doing, and I'm in one of those apps. So so it's sometimes nice to make a completely clean break, and it's very possible. So if anyone's desperate enough to give that a try, I think you'll never regret it. But I know most people stay on social media and maybe they're able to be to moderate it more than I am, and these are not going away anytime soon. They're pretty much universal. So we definitely still want to promote mindful and responsible use. So, okay. I think maybe that's enough on that for right now. We might have a little bit more time at the end here for a few more updates before we close out.
SPEAKER_00:Yeah, let's do it.
SPEAKER_02:Okay. So we've talked more than once about aspirin and preeclampsia. There was an article in the October 24th, 2025 Gray Journal that found that early risk assessment and aspirin prophylaxis did not reduce preterm preeclampsia. This was in Sweden. It was a population-based retrospective cohort of over 61,000 births across five different obstetric centers from 2012 to 2022. And they implemented the fetal medicine foundation's method for identifying patients at risk for preeclampsia. And they used an intent-to-treat approach to see if they could affect the rates of preterm pre-eclampsia. 85% of their patients went through this screening, and then their cutoff was anyone that was deemed to have greater than 1% risk of pre-eclampsia by this screening tool was considered high risk. And they were put on 150 milligrams of aspirin until 36 weeks gestation. So that's equivalent to our sort of higher dose version or our double baby aspirin. And that ended up being half of the total population studied. It was identified to have at least 1% risk. And not only did they not show a reduction of preterm preeclampsia, they actually found an increased risk of total preeclampsia, mainly the increased risk of term preeclampsia after implementing this protocol.
SPEAKER_00:Yeah, we've harped a lot about this. HARP's probably the word about aspirin for preeclampsia prevention. And one of the things that I will frequently point out is that no randomized controlled trial has shown that baby aspirin affects the rates of subsequent pre-eclampsia development. In my mind, I keep waiting for us to adopt a higher dose protocol in the United States. And coming in January is a study. We'll foreshadow that a little bit. But in Europe, they've used the 150 or the 162. And this study essentially shows what happened when they adopted the higher dose protocol based upon at-risk patients. There was no impact on the rate of preeclampsia, at least no positive impact. So this is actually a great example of one of those nuanced conversations that we scientists have, where legitimate researchers debate the data and whether or not aspirin is a worthwhile intervention for reduction of preeclampsia. We're not a lockstep group of people all doing the same thing that the emperor said for us to do. We debate this because there's very mixed data with some positive findings, but lots of negative findings. It's complicated because we're debating whether or not an 81 milligram or 150 or 162 or some other dosage is important, and whether or not you should begin at 12 weeks or 16 weeks, and when should you stop it, and what risk factors should cause you to use it to begin with, and all these other variables. And we're debating whether it's effective in a low or moderate or high risk population and all that. So it's an open scientific question, it's a moving target. The science continues to evolve, and a social media influencer who makes a post questioning this practice may have a legitimate opinion, but they should still present the nuance and detail and the unknowns and not use absolute language or claim a conspiracy theory or something like that. The big asp big aspirin is trying to sell everybody aspirin or things like that, and trying to kill us all or something. I will say, we'll talk about this next month, but there is a paper in the January Green Journal that is, and and many of you will be seeing this as you listen, that is a randomized trial of 81 versus 162, and it found no difference in the rates of preeclampsia. And that's going to be informative. We'll look more at that in detail, but of course there's no placebo arm. And this is one of the difficulties is we this is what happened with this with tocolytics, where we decided that alcohol was an effective tocolytic and that magnesium was as good as alcohol and turbutylene was as good as magnesium. So we need a placebo arm. And my assumption is that 81 milligrams versus 162 versus placebo would have found no difference either. So we'll talk more about that next month.
SPEAKER_02:Yeah, there's so many very legitimate debates in medicine and obstetrics too, of course, and this is one of them. And it's why we keep coming back to it as new literature comes out.
SPEAKER_00:Okay, well, another thing we've talked about in this past year, I think, is sustainability and gynecologic surgery. And remember, we talked about types of uterine manipulators at the time of laparoscopic hysterectomy. And I think one point we've made is that sustainability and cost effectiveness tend to go hand in hand. So I was excited to see in the November 2025 Green Journal an article that addressed 12 steps towards sustainability in gynecologic surgery. And so this is good for the environment, but it's also good for the bottom line financially. It's value-based care, which and that helps us keep our hospitals open and give access to our patients. And so we're all for it. And so they have a video on YouTube, which we'll put a link to, that describes and shows how to do these steps, and we can describe them here.
SPEAKER_02:Yeah, so they list 12 specific suggestions and they demonstrate it with in real time, which is really nice. And this is mainly regarding laparoscopy. And the overarching theme is reducing single-use disposable products. Even when they're inexpensive, they can really add up and have a significant environmental impact. And I think some of these tips are probably going to take some extra convincing, especially for OR staff. So luckily in the video, they do throw in some references to quotes from AORN. And one that's not even on their list of 12, for example, is that you can do the, you can do the the prep, like the chloro prep with non-sterile gloves, as long as you're not touching the patient's skin with your gloves. And that's a direct quote from AORN.
SPEAKER_00:Yeah.
SPEAKER_02:Yeah. So it might help if you watch this video, pull up some of those references and print them out if you're going to start trying to make these changes in your practice. So you can say, I'm not just making this up. Like I can do the, we can do the chloroprep with regular gloves, and for example. So how about I'll do three tips and you do three and we'll just alternate.
SPEAKER_00:Let's knock them out.
SPEAKER_02:Okay. So tip one, stop changing your gloves between the vaginal, perineal, and abdominal fields. Instead, treat the whole thing as one single continuous field to reduce waste. You will not increase the risk of infection rates, at least if it's someone that's on standard prophylactic antibiotics. Let's the classic is for a laparoscopic hysterectomy or something where you put in a vaginal manipulator and then you come above and do laparoscopy on the abdomen. We previously talked about a trial that showed this was not associated with increased infection rates. And in the video, they talk about just how many millions of dollars these glove changes actually add up to. And again, this at least you do this for patients that are already on prophylactic antibiotics. And then step two, consider customizing your surgical packs to do away with excess materials that you don't use, like extra gloves. If you don't use blue drapes, don't have them in there. That can significantly reduce waste. I think you've said you you use a custom pack for your cesareans and you don't really use the bovy or boby pad, so you don't even have them open it and because then it just has to be thrown out once it's been opened.
SPEAKER_00:Yeah, I'm proud to say we've done all these steps. And yeah, it's not a big deal to customize your pack your kit, your pack, and get rid of stuff you don't use.
SPEAKER_02:And step three, switch to cloth scrub caps instead of the disposable ones. I know some hospitals will sometimes have policies against cloth scrub caps, but there is no evidence that they increase infection risk and they do reduce the carbon footprint. And a lot of people like to have funny things or cute prints on them too, so that's a fun bonus. So a lot of hospitals do have these non-evidence-based restrictions on the reusable scrub caps. That might be something to advocate for on a systemic level. But if you can use scrub cloth scrub caps, use them.
SPEAKER_00:And wash them. But don't reuse the same one for six months. But yeah.
SPEAKER_02:Yeah, if it gets stained, okay.
SPEAKER_00:Yeah. And and you can even have several and wear different ones in different cases. And just wash them later. The point is they're reusable. Yeah.
SPEAKER_02:Yeah. Okay, you do three.
SPEAKER_00:Okay. Number four, avoid single-use energy devices. So utilize whenever you can reusable or refurbished or reposable devices where only part of the instrument is disposable for energy instruments, so like your ultrasonic or laparoscopic scissors, things like that. So we certainly try to recycle and use recycled devices whenever possible. Number five are we this is the one we talked about before, stainless steel manipulators. So use reusable stainless steel uter manipulators instead of disposable ones. They have a significantly lower carbon impact after just even two to three uses, and they're over time much cheaper. And this idea, again, is supported by the article we discussed before a few months ago.
SPEAKER_02:Yeah, and at least in the video, I didn't see them using a colpotomizer cup. And I don't remember if there is one that's reusable. But I think when we talked about it before, we had concluded that maybe you don't do the colpotomy from above, don't, and you don't need a copotomizer cup in that case, but use that manipulator to do everything else that you might want to do laparoscopically, and then do the copotomy and even the closure from below.
SPEAKER_00:Right. Or and I think there's one that's reposable. Like the one piece is reusable for the cuff, but the rest is not. So yeah, we'll put a link to what we talked about before. Okay, number six, reusable suction irrigator. So replace that disposable suction irrigator one that everybody likes for the batteries with a reusable trumpet valve system that can be used with a syringe for irrigation and tubing for action. I like these trumpets actually. And at least during laparoscopic surgery, I almost never have a suction irrigator device. And but when I do, if there's a nectopic or something, I the trumpet's actually better. So it's and reusable.
SPEAKER_02:Yeah, that's a new one for me. I'll have to look into. Okay, I'll do three. So tip seven, avoid opening specimen retrieval bags for smaller specimens if there's a way that you could just pull straight through the port. So we often will pull out fallopian tubes this way, like with a self-injectomy. And sometimes with fibroids, you can also kind of morcilate it so that you can make it a long skinny specimen using your laparoscopic tools in the abdomen. And they demonstrate this really nicely on the video, and so that they can make it fit straight through the port. And they also demonstrate using a glove or a section of glove to pass in to the body, put in maybe a small cyst, like you can't morcilate everything, and then they just grab it with their tool and pull it back out. Obviously, it's not attached to a string, so you have to just keep a grasp of it and not lose it in the body, but but you can use this method too. And this tip probably only makes sense if you're pretty certain that what you're about to remove is benign.
SPEAKER_00:Yeah.
SPEAKER_02:Okay, next tip only open open the trocars that you're certain you're gonna use. So minimize the use of disposable trocars. There are apparently some reusable trochars out there, and then they also demonstrate using percutaneous techniques where you can pass an instrument or maybe even a specimen bag directly through an incision in the skin to reduce the number of those disposable ports. And of course, that really would only work well if you just needed that access for one specific action and you weren't going to go in and out of that same incision with different instruments multiple times. So you would have to plan that appropriately in your surgical technique. But I know when you put bags in, and let's say you have a five millimeter incision, you don't need to use a trocar. You can put the bag straight in through that incision through the abdomen. So yeah, so people can look for opportunities to avoid using those extra trocars, even if they do need extra access, you can sometimes do it without a trocar.
SPEAKER_00:Yeah, you may need the 10 or 11 millimeter bag, but that doesn't mean you have to open up a 12 millimeter trocar just for that purpose. You you can definitely use it without the trocar. You can use a lot of things without the trocar.
SPEAKER_02:All right, and then another tip, number nine. So instead of using expensive disposable advanced access platforms to maintain pneumoparitinium, like during a mini laparotomy, for example, you can rig up your own using a mini retractor and then have an outstretched glove secured to it to make it airtight. I think this was the original V Notes design before they developed it into its own product. So let's say that you've made a larger incision for specimen retrieval, but you need to go back in again with laparoscopic instruments for some reason. You don't have to ask for a gel port. And same thing, if you were you could insufflate through the vagina, let's say you can't reach the ovaries or something. You can put in you can put in a self-retaining retractor and then do some stuff through a glove. I haven't done it that way, but it is possible. And those gel ports are expensive.
SPEAKER_00:They are. I have. I we were doing what people call V notes 15, 20 years ago with a glove and a blue towel. So yeah.
SPEAKER_02:Yeah. Okay, your turn again.
SPEAKER_00:Yeah, the last three. So number 10 is make the most of every suture. Reuse the same suture for multiple tasks, such as pexing both ovaries or closing multiple incisions, that sort of thing, rather than opening a new one or cutting excess links. And they demonstrate this with laparoscopic suturing, but of course, this is true anytime you use suture. Number 11, use a laparoscoposcope for cystoscopy. So if you routinely perform cystoscopy, say after hysterectomy, using the 30-degree laparoscope from the surgery rather than opening up a separate specific cysto tray. I do this in both ways. I'll also use a cystoscope at the time of agility surgery for that kind of V notes thing we were just talking about, where I need to look up in the vagina and I've got a cystoscope right there, and so I don't need to open up that separate tray. I also don't open up water for the cysto. When we had a shortage of fluids last year due to Hurricane Helene, I stopped using fluid bag routinely for sister and almost never have needed to. If I do need a little bit of fluid, I can just put the straight catheter in and use some of the water that's on the back table by using the bulb syringe and putting it in the catheter, and that saves a tubing and sometimes a liter or three-liter cysto bag that you just didn't need.
SPEAKER_02:Yeah, and most of the time you don't have to go back above with a scope, but let's say you do. Let's say during a hysterectomy, you've finished what you're going to do above, you do your syst, and then you find that you do need to go back above. Maybe you've identified a systotomy that needs to be repaired. We already said you don't have to change your gloves. And on that same logic, you may not need a whole separate new laparoscope for going back above either. That was not addressed specifically in this video, but it I think the same logic could apply.
SPEAKER_00:Yeah, I think you're okay. Okay, and there's already a connection between the bladder and the peritoneum because of the systotomy that you've made, right? Yeah. So if that's what you're doing, then the field separation shouldn't matter in that sense. So that's what the antibiotics are for. All right, well, number 12 is minimize your red bag waste. So dispose of waste in the clear bags unless it's visibly soaked or caked in blood or something like that. Red bag waste is incinerated, which has a much bigger environmental impact and is very often overutilized for items that don't meet red bag criteria. So most of your gowns and your drapes and things like that, they should be going in clear bags, and that will significantly reduce the environmental burden and also the cost, because the cost of processing red bags is a lot higher.
SPEAKER_02:Well, that should at least be an easy Okay. Do you think can you think of any more, or maybe our listeners can think of some more?
SPEAKER_00:I'll bet the listeners come up with some and let us know and we'll talk about them. I think one simple thing to do is you mentioned is just review your preference card too, not just your packs, but there are so many things that get opened automatically because they're on the card, and they really should be held in case they're needed. You should really review your preference cards probably yearly or think about all the stuff that you never used during a case. So that there's less cleaning of instruments. And you can always open up packs as you may need them. Think about a vaginal delivery pack. How many of those instruments do you actually use on a vaginal delivery? If you have a fourth degree, get your fourth degree pack or take them, do whatever you're going to do. But you don't need 500 tools on a vaginal delivery pack. In fact, it's just scary to the patients. So think about what you actually use and let your packs reflect that. That will result in less cleaning of instruments. And again, you can always use them. You open things as you need them. So certainly recycle every single use device that can be recycled. Many of these products, like the energy devices, the harmonic scalpels, they can be remanufactured and reused. So you should be recycling. And from an environmental perspective, even things just like powering down all of the tools and equipment and lights in your operating rooms when they're not in use and over long weekends and nights can make a huge difference in electricity costs over time.
SPEAKER_02:Yeah, just like at your house, turn the light off if you're leaving the room.
SPEAKER_00:So well, we'll see if the listeners have any more ideas for that. And we're also going to we're also going to revisit with a guest host in next month. We're going to revisit the idea of sustainability and value-based care for robotics platforms in particular. So we'll build on this in the next episode. But yeah, Merry Christmas. And we'll be back. Happy New Year.
SPEAKER_02:Happy New Year. Happy holidays.
SPEAKER_00:And we'll be back in a couple of weeks.
SPEAKER_01:Thanks for listening. Be sure to check out thinking about obgyn.com for more information and be sure to follow us on Instagram. We'll be back in two weeks.