Episode 12.2 Cuff Dehiscence and Classic Papers

Howard Herrell and Stuart Winkler question long-standing OB-GYN habits that feel “routine” but do not add value, then replace them with evidence and practical decision-making. We move from hysterectomy follow-up and cuff dehiscence management to the data behind cesarean sutures, endometrial cancer evaluation in postmenopausal bleeding, and the ongoing shift to HPV-based cervical cancer screening. 
• why routine 6 to 8 week vaginal cuff exams after hysterectomy may not prevent or predict dehiscence 
• how telehealth post-op care can improve access while keeping symptom-driven safety nets 
• four tips for evaluating and managing vaginal cuff dehiscence, including when laparoscopy matters 
• what Ethicon discontinuing chromic and plain gut could mean for cesarean technique choices 
• how the CORONIS trial informs chromic vs Vicryl decisions and why transfusion risk is part of the conversation 
• where the 4 mm endometrial stripe rule came from and why it can fail in real-world care 
• why persistent postmenopausal bleeding still warrants endometrial biopsy despite reassuring ultrasound 
• how race, tumor subtype, and fibroids affect endometrial cancer detection and counseling 
• the arc from Pap smear cytology to HPV DNA testing, vaccines, and primary HPV screening 
• why self-collected HPV testing may raise screening uptake for patients avoiding speculum exams 

Be sure to check out thinking about obgyn.com for more information, and be sure to follow us on Instagram.

0:00 Welcome And Today’s Game Plan

0:35 Rethinking The Six-Week Pelvic Exam

13:25 Four Practical Tips For Cuff Dehiscence

24:42 Chromic Gut Is Disappearing

35:40 CORONIS Trial And Cesarean Sutures

42:22 Postmenopausal Bleeding And The 4 mm Rule

53:12 HPV Testing Takes Over Screening

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Transcript

Welcome And Today’s Game Plan

SPEAKER_00 0:01

Welcome to Thinking About OBGYN. Today's episode features Howard Harrell and Stuart Winkler discussing Cufty Hissons and much more.

SPEAKER_02 0:15

Howard. Stuart? What are we thinking about on today's episode?

SPEAKER_01 0:20

Well, we're glad to have you back, and we're going to discuss some classic papers in gynecology, especially that have to do with stuff you're interested in, like cancer screening. We have to like make it relevant to you somehow. Thanks. But first,

Rethinking The Six-Week Pelvic Exam

SPEAKER_01 0:35

what's the thing we do without evidence?

SPEAKER_02 0:37

Yeah, I was thinking about this, and I think one that might be something our listeners would appreciate is the pelvic exam at six weeks after a hysterectomy. So I personally stopped doing them about a year ago. And so now I only do an exam if they're bleeding or they have some other symptoms. And actually I don't even see my patients at six weeks anymore, at least in person. I just do a two-week post-op visit, give them instructions to follow up if they're having issues and really just send them back at that point to the referring provider or to really recover on their own. So I feel like I was taught that the pelvic exam before clearing a patient for resuming intercourse was important, but I just don't know that it is. And I generally tell them to wait eight weeks before resuming intercourse. I don't have hard and fast evidence for that, but that's my practice. The last dehistance I actually took care of was a patient who was four months out from her surgery and had been having sex for the previous two months. So that's not one where an early exam or guidance about intercourse really would have been helpful at all.

SPEAKER_01 1:45

Yeah. I well, I think you're probably doing the right thing. I wonder if in your situation, if some of the patients are referred back to their primary, if the primary doesn't end up doing the exam later, maybe that happens. But they're probably not seeing them that soon. It would still be delayed. But there was a study, actually, and I've known about this study. I read it when it came out, and I'll admit that inertia is a big deal, and so I've I have not completely transitioned to doing what you're doing, but I've been aware of this study. It came out in 2024 in the Journal of Minimally Invasive Gynacology, and it directly evaluated this clinical practice. So as you said, historically, standard postoperative care after any sort of total hysterectomy mandated an in-person speculum exam or maybe a bimanual pelvic exam between six to eight weeks to check the integrity of the vaginal cuff before a patient was cleared for intercourse and heavy lifting and all the other restrictions.

SPEAKER_00 2:41

Trevor Burrus, Jr.

SPEAKER_01 2:41

And we've talked a lot on here about a lot of those lifting restrictions, which I have been very liberal about not giving them restrictions other than penetrative intercourse. And I distinguish that too. Like just don't penetrate. But if you want to do other things that don't have all the things that are telling that could be creative, just yeah. Yeah. But I so I've been still doing them. I also think that I don't know, this study we can talk about it, but it wasn't necessarily a lot of pelvic reconstructive stuff. I still I bet I'll still do them for patients that had vaginal vault prolapse or those sorts of things, primarily just to like assess did it work well, where are we at, to reassure them. But for a regular hysterectomy, that's what this study looked at by Kaski and colleagues. So this was a retrospective cohort study that analyzed 703 patients who underwent, in this case, total laparoscopic hysterectomies between 2016 and 2022. And 216 of them, which is about 31%, underwent a routine in-person, standard what we're talking about, postoperative vaginal cuff check at six to eight weeks. And then 69% of them didn't. And percent of those patients actually completed their entire visits as part of a telehealth visit. Now I have started doing my two-week visits or one-week visits as telehealth. So if practical, almost all of my post-ops in that earlier phase are two weeks. And if it's not a hysterectomy, that may be the only post-op visit. So that's a transition too. But patients love it. Patients love not having to drive. Well, gosh, in your case, they might drive an hour or longer to see you.

SPEAKER_02 4:07

Absolutely. Yeah.

SPEAKER_01 4:08

And then you come in and say, Well, it sounds like you're doing great, and talk to them about their pathology, maybe or whatever, and that's the whole visit. And it just feels very unrewarding to drive an hour and a half, sit in the waiting room for 45 minutes, and then the doctor speaks to you for three minutes. But people don't care at all. They love telehealth visits for stuff like that. So that that's but it's culturally, but we have to get used to that. But anyway, they found in this study no difference in vaginal cuff dehiscence rates. So the incidence was extremely low, obviously, in both groups, and but it showed no statistical significance. It was about 1.3% in the routine group and a little bit under 1% in the no cuff check groups. It was lower in the people who didn't get cuff checks, but it wasn't statistically significant. So they just didn't find any utility, as you said, in asymptomatic patients.

SPEAKER_02 4:54

Right.

SPEAKER_01 4:55

So remarkably, or or perhaps not remarkably, there were no cases of vaginal cuff dehiscence identified in asymptomatic patients. So you're not going to find, oh gosh, your cuffs open if in a patient who didn't have symptoms. And every patient in the study who ultimately did experience a cuff dehiscence, they presented acutely with the symptoms that you would expect them to, the sudden pelvic pain, watery discharge, bleeding, and that prompted a non-routine evaluation. And of course, these happen at different times. They don't actually happen at six or eight weeks, right? They happen sometimes nine months later, or like you said, four months later. So And they talked too about the false reassurance patients may get from this. So when the routine check group, the patients who later developed vaginal cuff dehiscence, they actually were noted to have normal healing and intact cuffs. They could go back and look, right? And so it was like the note says everything's great at their six weeks visit, but that median time to dehiscence was longer than the six weeks. It was actually 70 days, but a pretty widespread in some cases many months longer than that. Now, the routine exams, we've all had some minor asymptomatic, incomplete healing, granulation tissue. Maybe you put some silver nitrate on it, or maybe you tell them to wait on sex for a couple more weeks or something like that. They found things like that in 3% or so of the patients. But those findings had no relationship to who would later have a cuff dehiscence. And honestly, we're probably over-treating things like that. I have had patients, I'm sure you have too, who come back a year or two later and they've got some spotting and there's granulation tissue.

SPEAKER_02 6:26

Right.

SPEAKER_01 6:26

And yeah, I've very surprised symptoms.

SPEAKER_02 6:29

Yeah, and I've been surprised, yeah, exactly how far I find it out. I could, of course, in my practice too, I do a lot of cuff checks for endometrial cancer follow-up. So I'm looking at cuffs every three months, and so I see kind of that evolution in my own practice of that. But I agree with you. I'll see granulation tissue really far out. Yeah, so I thought this was a good study, and it basically showed that routine postoperative vaginal cuff exams don't prevent, predict, or mitigate the risk of future vaginal cuff dehiscence. And thinking about why we do this in the first place, just looking at my my previous practice, this might be a case of just carrying forward something learned in residency that might have actually had good utility at the time. As a resident or a med student, it makes sense to look at a healing vaginal cuff. You want to know what normal looks like so that you can identify abnormal. That's all part of the learning process. But and for a long time I continued to do this in my practice as I was taught, like kind of famous, you know, as as I was trained. But it could potentially cause harm or at least discomfort for the patient, which is in its own way a harm. And then in private practice, I I hate to talk about the money side of things, but in private practice, all this is can part of the global fee for your surgery. So there really is no benefit to that. And uh, Howard, you might know, but I know recently we've started getting paid for pelvic exams, being able to code for those, but I don't think that's included in the global either. So I really think this is a visit that you're doing as part of the whole care of the hysterectomy. But it the bottom line is if it's unnecessary and it's uncomfortable and it takes time and costs resources, then why are we even doing that? So back to the CASCI study, the authors had the nine patients that did have dehiscence in the study you mentioned, two of them had cuff checks, and they were told that the cuff was healing appropriately. So at least for those patients, the cuff check really didn't seem to make a difference. So I've kind of changed my approach.

SPEAKER_01 8:22

Yeah. As far as I know, you don't get paid extra for because it is in the global, it's the same like with IED insertion, it's part of the global. So as far as I know, you should not be able to build that separately with the pelvic exam code. And also to wrench it back from the economics of medicine, I would think of it actually differently than that. You are a subspecialist in high demand who takes care of anxious patients who have who may or do have cancer, and every visit slot you're filling in with an unnecessary in-person exam is delaying an opportunity for another patient to see you. And that's true for all of us to various degrees. Absolutely. So I personally like despise visits that don't add value to that patient because there's another patient out there who couldn't see me that day or whose care got delayed because there were no appointment slots. So that's another way of thinking about that too. We've got to promote access if we're gonna promote the triple aim, which is to improve patient outcomes, population health, lower the cost of health care, and improve the patient experience. So it sounds like cuff exams don't do those things. So I need to stop doing them as well then. And I can't recall ever having a meaningful finding in an asymptomatic patient. But of course, if the patient's having persistent bleeding or they've got other symptoms at six to eight weeks, they can always come in and perhaps maybe we'll find granulation tissue and we'll take care of it. And we can tell them that at their postoperative visit, hey, if you're still spotting by whenever, come back and see me and we'll take a look. I will say they also talked about focusing on minimally invasive surgery in this study, since the prevalence of minimally invasive surgery is rising and g in in gynecology and it's becoming dominant. But I I just have to point out that their definition of minimally invasive surgery was laparoscopic and robotic hysterectomy, and they excluded abdominal hysterectomy in their definition, completely understand that. But they also excluded vaginal hysterectomy in their definition. Which, okay, I just need to remind folks that vaginal hysterectomy is the minimally invasive way to do a hysterectomy. And by the way, it carries a lower rate of cuff dehiscence than laparoscopic hysterectomy, if I haven't already mentioned that 500 times.

SPEAKER_02 10:35

I knew you were going to say that. I knew that was coming, but you're right. You're absolutely right. Yeah, so as far as the techniques in the study, it wasn't really homogenous, although you did you rightly said it was all laparoscopic. They mentioned that two of the surgeons used monopolar energy and one used like an ultrasound device, like the harmonic. All three used barb suture, and I think there are benefits to that. I'll talk about my own approach here in a second. One used interrupted PDS and one used two-o sutures instead of the zero caliber. And then a couple used two-layer closures. So anyway, a lot of variation. And honestly, I know real word real world studies, it's a catchphrase now, but it is the way it is in the real world. We don't all have the same approach. I I do quite a lot of laparoscopic cases, and I do typically close mine with a like a nine-inch 2-0 stratifix, is my approach. I really like the the V34 needle. This is an ethicon needle. The I like the nine inches because it lets me do the back stitches, which can help with some of that. I would say almost said not security, but it's not a knot, but it's the suture security. I like the 2-0 because it's delayed absorbable but not too bulky. And then I've changed recently, I really like the V34 needle, which is actually a taper cut needle, as opposed to just the taper needle of a CT1. And so I think it it's a little smoother through the tissue, especially in younger patients. And then I I never try to I try to never grab the tip of the needle while I'm sewing, but sometimes in placing the needle through the trochars or whatnot, you might have a little bit of trauma to the end of the needle, and the V34, I think, gets a little, it can protect against that a little bit. Anyway, not evidence-based, but that's my practice. And all my partners have different practices. I know one of my partners reinforces the corners with Vicral, which is a practice that he said he actually incorporated after a cufety hissance of the corner. So I think all of us do tend to change our practice when we have a complication as well. At least that's the tendency. Yeah.

SPEAKER_01 12:35

Which may or may not be a good thing.

SPEAKER_02 12:36

Right, exactly.

SPEAKER_01 12:37

Yeah. Sometimes we we oversimplify what happened and don't understand the reasons, but we have a knee-jerk response. The other thing about this real-world study and the variation there is just thinking about all these permutations and variations, different needles, different sutures, different suture bites, different like all the all the things. How do you even do a randomized controlled trial? Now you could do one. You could define two very well-defined techniques, train people up to do them, and then randomize patients to them. But even in that, when you think about how rare these complications we are talking about, to see a statistically significant difference, we're doing a huge study. So a lot of this stuff does remain expert opinion. And then you think about like cuff dehiscence, like what's the best approach to a cuff dehiscence? This is all expert opinion.

Four Practical Tips For Cuff Dehiscence

SPEAKER_01 13:25

Speaking of which Cuff dehiscence, let's do an impromptu four tip. So we did an episode on surgical complications, but I'm pretty sure we didn't talk about cuff dehiscence as a surgical complication, at least how to repair them. So let's think about this for a minute. Yeah. I don't because I do vaginal hysterectomies. But but you think about this. So give us four tips for evaluating and managing a cuff dehiscence.

SPEAKER_02 13:53

Aaron Ross Powell Sure. Yeah, I'll say like you said, there's no consensus to this to this approach. I I personally do about 300 hysterectomies a year. I'm picking up a little bit, so if you ask me this time next year, it may be more than that. But I'm also called in to consult on cuff dehiscances too. So I do get to see maybe even more than just my own complications, particularly if bowels exposed and that sort of thing. Whenever I'm talking to the residents, I always talk about surgery as either being like classical music or jazz. So you think of surgery as like with classical, it's like a cold knife cone, for instance. There's defined steps and you're it's almost like you're playing off of it off of sheet music. But for something like a vaginal cofdihiscence, I think it's more like jazz. So you can apply the principles of good surgical technique and management. Really, the approach depends on the patient in front of you. So that was my thought when I came up with these four tips. So the first tip is to have a high index of suspicion. So cofdehiscence is not common. The incidence varies, but it's probably less than 1% of hysterectomies. And as you said, Howard, it depends on the type. Most GY insurgents probably won't have more than one or two every few years. And if a patient has an acute history of gushing fluid or watery discharge, you know, a lot of times this is not going to end up being a comfy essence. Maybe this is a seroma or something else, but your index of suspicion does need to be higher when you hear these sort of catchphrases or sort of things that you watch out for. Obviously, if your patient has visible bowel, that's an easy one. The patient calls and it's like proverbial snakes in the bed where they wake up and have bow coming out. But yeah, sometimes it can be a diagnostic conundrum. I remember one call I got, this was within the year, uh patient called and said her bladder was falling out a few weeks after a hysterectomy, which was kind of usual. I asked a few more questions. She was distended and bloated and wasn't passing gas. So I saw her in the ER, and that ended up being actually a loop of bowel that was that was in her vagina. So that would be my first one.

SPEAKER_01 16:01

I have a high mix of suspicion. That reminds me, I have to tell you this story. I had a med student once, probably believed from your class, it was around that time, and we were on call in the middle of the night and got an ER consult, and I dutifully sent the med student down first to assess the patient. And the history was a woman had had a pessary in her vagina that left there for about five years, but it fell out in the toilet, and something else fell out as well. So the student goes down and takes a look and calls back down, what'd you see? And he said, I'm not sure. But there's a it's about twelve inches long and it's black and brown, and it's got like little fat things coming out of the back of it, like a dinosaur's back. And I'm like, and you don't know what that is, so you don't have any ideas what that is. So she got a bowel resection later that night. But yeah. Anatomy guys, anatomy.

SPEAKER_02 16:53

Yeah, yeah. Getting stosis. High index of suspicions, number one. Number two? So this is do a good exam. This is a little easier said than done, honestly. So this is not the time, though, to do a poorly lit exam on an uncomfortable patient. So you get the patient in a pelvic bed. Obviously, in clinic, I feel like it's a little easier. Sometimes in the ER or heaven forbid on the floor, it can be quite a bit tougher. But you want to get a patient in a pelvic bed, have the right speculums available, lots of fox swabs, good lighting, all of that. You know, you'd think you'd be able to palpate a dehiscence on bimanual, and a lot of times you can, but sometimes the cuff is honestly just hard to reach, particularly in a maybe an obese patient or a patient where you did a really good cul deplasty. It can be a little bit tough to feel. So use all your tricks. One of the tricks I like actually is using a plastic proctoscope. We actually have these in clinic because I share clinic exam rooms with a colorectal surgeon. So I just stole one of his practiscopes one time. It was a patient who was uncomfortable, really hard to get to the top of the cuff, and we don't have plastic speculums in our office. It's all metal. So I did this. I put a, it's like a clear cylinder essentially, placed it into the top of the cuff, and was able to shine a light through. That patient actually did have an intact cuff, thankfully, but it was really cool to be able to see the corners that way. So little tricks like that, everybody has their own tricks. But your exam really determines your next step. So that's why you've got to be really intentional about it. And you need to see with the extent of the separation and whether or not the bowels involved, because that really determines your surgical approach. If it's a really small separation, less than a centimeter, maybe even a little bigger, you might be able to maybe kind of treat the cuff with some silver nitrate and just manage conservatively if there's a really low risk of anything coming through. If you see infection, you might want to culture or give antibiotics or even potentially take the patient for a cuff debridement and then oversowing. And obviously, if you see bell, you know what to do there. But if you can't see the whole cuff, I've had this situation too where you just can't get a good exam for whatever reason. You might need to just do an examinary anesthesia for that patient. So that would be my second tip is to do a good exam. All right. So high index of suspicion, do a good exam.

SPEAKER_01 19:05

Number three.

SPEAKER_02 19:06

Number three is repair in the OR. And this is a little bit, I cheated a little bit on this tip because it's kind of a potpourri of tips. So mostly gain these from experience or from talking to my partners. So one that you really want to make sure of is make sure you let your anesthesiologist know if there's a chance that you might need to do a laparoscopy. That if you don't know, the approach for anesthesia for somebody who's getting a laparoscopic surgery is different than just getting an exam or vaginal surgery. So it's important to let them know that they know how to paralyze and put a tube in and all that sort of stuff. Otherwise, I might just place an LMA. The other thing is to ask for a vaginal hysterectomy tray. This isn't again, not really the time just to sort of make do with a routine DNC tray. You may need things like a Bratsky Navertil retractor to help with exposure. And these aren't usually available on a DNC tray. It's also helpful to have some suction available. From a technique standpoint, make sure you dissect the bladder off of the cuff if you need to allow for enough purchase on the vaginal mucosa. That can be an important tip as well. And then as far as the actual closure, this is a little bit of a preference, but you can use Vicral Figure of Eights or consider PDS if there's a risk of infection or poor wound healing or something like that, if you need something that's going to stick around a little bit longer. I know I've I have a partner who always repairs these with PDS standardly. So I think you can use your judgment there. Unless bowel is coming through, the peritoneum is actually usually intact in these cases, although it can be hard to see. So you don't really need to incorporate that into the edge. We do that when we close a vaginal cuff for bleeding purposes, but you could actually run the risk of tacking the underlying bowel to the cuff if you do that here. So I would just sort of close the cuff proper. And then if you close the cuff in a running fashion, you may want to put a reinforcing suture to overlap that in case it comes, continues to come done, undone. And then finally, you can consider a cystoscopy if the dissection was complex or if the cuff is distorted. We'd hate to accidentally put a stitch through the bladder and trade aid dehysants for a vescovagel fistula down the road. So that was a lot of tips for one, four tips, sorry.

SPEAKER_01 21:31

And then I wondered, you mentioned Bresky Navertil retractors. Did we talk did we talk about them when we went on the other?

SPEAKER_02 21:38

I know, I don't think we did. I think they are they're both white males, so I don't think that we're not going to be able to do the top. We did all the women.

SPEAKER_01 21:46

They're both Austrians. And Navertil was a descendant of Bresky's work, but they their lives didn't actually overlap.

SPEAKER_02 21:55

Yeah.

SPEAKER_01 21:56

He was does the 19th century and Navertil's 20th century. And Bresky, if uh anything, is famous for originally saying that similvice was nuts, but then later when the science was convincing, he became a big proponent for the germ theory. Yeah. So he that's typical 19th century gynecologist. And then Navratil carried on his work, but so it's named after people whose lives didn't even overlap. But okay. So high index of suspension, do a good exam, repair it in the OR, get the right tools, all that. And then fourth tip?

SPEAKER_02 22:27

I think the the tip here would be to know when to do a laparoscopy. There really isn't much evidence on this, but I would typically do a diagnostic laparoscopy on a patient with exposed bowel. I think that just makes sense to do that. And the reason is you want to look at the bowel when it's back in situ to make sure that it's well vascularized. So even bowel that looks dusky coming out of the vagina can actually pink up pretty well when you put it back into the abdomen. And so the actual amount of time that I've done a bowel resection for these is pretty pretty uncommon, to be honest. So I've also used, I talked about this with the previous tips, but I've used IVIG in this situation before as, or sorry, IV I C G. I was about to say, Yeah, I do not I do not give IG IVIG. But the ICG that we use for sentinel lymph node mapping, you can give that IV. Usually give about 2.5 cc's of that, or sorry, it's about a sorry, it's 2.5 cc's. Sorry, 25 milligrams in 10 cc's of water, and you give one milligram of that. So it ends up being 2.5 milligrams. So you can give that IV, and then just you can actually you don't need a robot for this. There are near infrared scopes that you can use as well. And sometimes that helps. You can see the bowel pink up or actually green up, and that's a a kind of an extra helpful thing that I'll do sometimes. So exposed bowel, like I said, doesn't usually need to be resected, but you want to be thinking ahead and make sure you have somebody available to do that if necessary. And then I would also do a laparoscope in patients who have signs of infection or might need a washout for any other reason or just an exploration to make sure there's not like a uh abscess behind the cuff that maybe was the cause of the cuff dehiscence in the first place. So mechanisms of how that happened matter.

SPEAKER_01 24:21

So Okay, well we can we can throw a link up about this retractor because Stuart and I geek out about this stuff. Yeah, absolutely. But if you geek out too, then we'll throw up a paper about the the history of that retractor and those guys. Okay, well have the right cool have the right tools, have the right equipment, all that stuff. Speaking of right tools and the right equipment.

Chromic Gut Is Disappearing

SPEAKER_01 24:42

Have you heard that Ethicon is going to stop making chromic and plain gut suture? There's actually a whole list of things that they're going to be discontinuing. Like it's been announced. It was announced a while back. We can put an announcement notice, but like the inventory is ending, I think September, August, something like that. It's very soon. Yeah, they're getting rid of the whole line of chromic and the whole line of plain gut. And they're focusing, I mean, I think it's a business decision, they're focusing on well, that suture that you mentioned, they're they're focusing on that stuff, and they're not going to make chromic and plain gut anymore. So I'm sad. Because I use chromic suture for closing the hysterotomy at the time of cesarean. And I know that frankly might sound weird to a lot of our listeners. I would guess that most people at this point in most training programs are using Vicral suture to close the hysterotomy at the time of cesarean. I think that's very common. I think personally one of the reasons why it's so common is it's an easier suture to work with. It doesn't break as easily. It's easier to tie secure knots with. It doesn't get twisted up when you're taking your throws and somebody's following you. And I use plain gut usually for closing the fat in the subcutaneous space at the time of cesarean. So they're taking away two-thirds of my sutures.

SPEAKER_02 26:02

Yeah, I I like that idea for using it for the sub Q fat. I think that's a great use of the plain gut. I I've gone to using Vicral to close the sub Q. I don't really have a particular reason, but I I honestly do miss the smell of plain gut. I really do like that smell.

SPEAKER_01 26:18

Yeah. Yeah, it's the substance it's, I guess, in and it just sets there. But okay, well, other manufacturers are going to make similar products. So if you're like me and you're looking for a chromic equivalent suture, there are several other smaller manufacturers that make it. You just have to see if your hospital will order it for you. It won't be called chromic or plain gut, it'll use the more scientific names, but it is available.

SPEAKER_02 26:40

I remember using chromic with you as a med student, but remind me why you use chromic at the time of C-section. I I'd like to hear what your thoughts. And then you'd mentioned the Vicrils used now. I will say I used monocryl primarily when I was doing C-section. I don't do that many anymore, but I did feel like I preferred them over the Vicral because I felt like that braided suture had a tendency to kind of have a serrated saw effect. Yeah.

SPEAKER_01 27:04

So yeah, and I think that's I think that's 90% of my argument. And I know a lot of people who have used monocryl. I I considered monocryl for a while, and I think when I didn't use it, it was a cost thing. Like, and maybe that'll be different now if you have to procure this from a a smaller manufacturer, maybe monocryl becomes cheaper, so maybe I'll switch. But my evidence-based reasoning for this, other than just preference and what we do what we're used to, is the Coronas trial, which, okay, I know I had you on here to talk about GYN studies, but you said you do some C-sections.

SPEAKER_02 27:36

Yeah. I do some.

SPEAKER_01 27:37

Yeah. Yeah. So we're going to talk about influential trials in gynecology. We did an episode a long time ago, not you and I, but Antony and I did an episode about important epistetrics one studies, and we said we'd come back and do GYN. So we're going to do that. But first, let's talk about one epistetrix trial.

SPEAKER_02 27:54

All right, let's do it.

SPEAKER_01 27:55

So the Coronas trial. So this was a randomized controlled trial that looked at five elements of cesarean section technique in a little bit over 15,000 patients. So the five elements were blunt versus sharp entry, exterior repair versus intraabdominal repair of the uterus, a single layer versus a double layer closure of the uterus, and then closure versus non-closure of the peritoneum, and relevant to your question, chromic versus vicral for the uterus for the hysterotomy repair. And they had a composite outcome with all the usual suspects, death, infection, reoperation, blood transfusion, all those things. And they found no difference in any of those five variations or permutations of technique for the primary outcome.

SPEAKER_02 28:38

Okay, so that's why you use chromic? It doesn't seem to make a lot of sense, but I know you have your reasons, so I'm waiting to hear it.

SPEAKER_01 28:44

Yeah. Well, okay, well, that is important though, because the the trial finding those different things. This is one of the reasons why we don't do two-layer closures or emphasize two-layer closures anymore, because there was also a follow-up study, which I'll mention. But but yes, they didn't find a difference in any of those in the primary composite outcome. But there were about 4,600 patients who got chromic and about 4,600 who got vicral. And there were fewer cases of the primary outcome in the chromic group. It just wasn't statistically significant, and I'm not gonna act like I'm not gonna be hypocritical about that. But what was significant, in fact, the only statistically significant finding in the whole original Coronas trial was the need for blood transfusion. So there were 32 transfusions in the chromic group and 60 in the vicral group. That's a rate of 0.7% compared to 1.3%. None of the other four differences in technique for that outcome, blood transfusion, none of the other four differences showed a difference. In other words, there was no difference in two-layer closure versus one layer closure or anything like that. But for hemorrhage, the suture type mattered. And there were also half the number of interventions for postpartum hemorrhage in the chromic group, which makes sense if you're doing half the amount of blood transfusion. Although that particular finding, uh even though it was half, it didn't reach statistical significance. It was underpowered, essentially. But they also found this finding to be true or to be, well, to be statistically significant, that in other words, the decreased need for transfusion, even after a lot of robust techniques were used to adjust for other factors, patient-specific factors, technique-specific factors, whether that it was an emergency or plan cesary, and lots of things they adjusted for, it was a consistent and robust finding that the need for transfusion was doubled if you use Vicral suture.

SPEAKER_02 30:32

That's kind of that's interesting. I know you'll talk about your thoughts on this here in a second. I was also thinking with chromic, you're right. It's a little bit more of a I try to think of the right word for it, but it's it's a delicate suture in some ways. So if you pull too hard, you'll break it, right? Whereas Vicral, you can pull really hard. And so I so the the finding of transfusion makes a little bit less sense. But I was thinking about things like cesarean scarf thickness and things like that, and thinking of corollaries like the stitch trial. So I'm getting it back to a GYN thing. But the stit- the stitch trial, which looked at mass closure of uh uh midline laparotomy versus these small bit closures, and it was counterintuitive, but basically the smaller bites that were closer and didn't incorporate as much fascia had lower learner lower hernia rates, and even on follow-up it had lower hernia rates. And the thought is you're not causing as much devascularization, right? So I think, and you can correct me if I'm wrong, but I know we looked at like locked versus unlocked hysterotomy closures as well. And I think if I remember right, the locked were associated with a little bit thinner uterine scars. So I don't know, I just I was thinking about the chromic versus vicral for that, if there was any difference there. But I'll let you give your ideas for the transfusion piece.

SPEAKER_01 31:52

Yeah, so that's the empiric data. But yeah, I mean I think we could spit fire ideas. I think from a lot of experience using both, I'm getting ready to deliver my 5,000th baby in a few hours.

SPEAKER_02 32:02

Oh, congratulations. That's that's awesome.

SPEAKER_01 32:04

But I think the it's what you said. I think Vicral cuts into the tissue more so than chromic does. And I guess that's an opinion, but also what you said about the knots. So you can't pull as hard with the chromic because it will break. And so the technique of suturing the uterus with chromic by its nature is more delicate, and yes, perhaps less devascularizing, I don't know. But the suture is not braided. So either way, you can't pull so hard. When you've got a vicral, you could cut a tree down with that stuff. Absolutely.

SPEAKER_02 32:35

Yeah.

SPEAKER_01 32:36

And it's braided and you can pull very hard, and I think it cuts and it digs into the tissue, and then the dance of figures of eight and bovey, which I don't have on the C-section tray, of course, but all that other stuff happens, and so you just end up with all these little wounds on the uterus that have been that have been sawed on with vical suture. So I think that's what the difference is for me, and it's my anecdotal opinion.

SPEAKER_02 33:01

Yeah. Yeah, I think we like we think tighter is better, but that's not necessarily true. I think that as surgeons, we need like a Goldilocks approach, not too tight, not too loose, and that comes down to technique. But back to the Coronas trial, I understand there was some long-term follow-up. So what are your thoughts about the long-term outcomes?

SPEAKER_01 33:20

Yeah, I will say, I and I tell learners sometimes like you're only trying to be greater than the blood pressure. Like it doesn't have to be zero.

SPEAKER_02 33:29

Right, right.

SPEAKER_01 33:29

Like it's a great you don't have to cut it off completely. And that does probably affect some of those the reperfusion of the surrounding tissues and stuff. Yeah. Which you'd think you might see that like in future rupture rates. So the long-term follow-ups, well, they're we learn a little bit there. So they did a three-year follow-up to the study. The first paper was published in 2013 in the Lancet. And then in 2016, they published a follow-up in the same journal, and they looked to see if there was a difference in hernias with the blunt versus sharp entry. That maybe that's a difference. There was no difference. There was no difference in any of the subsequent pregnancy outcomes for or fertility or risk of ectopic pregnancy or things like that. And importantly, for the argument about single and double layer closure, there was no difference in things like uterine rupture or scar dehiscence of the uterus or anything like that in subsequent pregnancy. So this again, the important part about that was this was one of the big things that led to us saying there's no good evidence. The best trial about two-layer closures versus one-layer closure says it doesn't matter. Yeah, that's good. Okay. Well, they also did some follow-up on the chromic versus vicral, because that was just one of the five things. And there was no difference in subsequent pregnancy outcomes for either group that were significant. So I guess what I'm saying is there's no evidence that vicral is superior in any way to chromic, either for immediate or long-term outcomes when closing the uterus. And but there is apparently from this trial robust evidence that it cuts the need for transfusion in half and appears to be associated with less hemorrhage. So for me, the evidence-based answer is to use chromic. So for now, I'm going to try to get it from another manufacturer.

unknown 35:06

Trevor Burrus, Jr.

SPEAKER_02 35:07

Or you could try monocryl. I know that wasn't included in this study. And I don't know that there's a trial that addresses the transfusion rates and monofilament versus braided multifilament on the uterus. I think we take a trial like this. I think we learned a lot from this trial, and I think we'd try to apply it as best we can.

SPEAKER_01 35:25

I do think monocryl makes conceptual sense in terms of the quality of it, the monofilament, and all that. But yes, it's just not a study that compares them, so a lack of data.

SPEAKER_02 35:34

So All right. Howard, I'm ready to talk about a gynecology paper now.

SPEAKER_01 35:39

Okay. We're more than halfway

CORONIS Trial And Cesarean Sutures

SPEAKER_01 35:40

done, and now you get a gynecology paper. Okay. So just some classic papers that are in your bellywick. So one recently relevant classic paper that you and I were talking about is from 1995. So this was published in the Gray Journal and was written by Carlson and colleagues, and they studied whether we could use transvaginal ultrasound to evaluate the endometrium in patients with post-wendopausal bleeding. So some notable things. This was done in a primarily Nordic population. It was done in Sweden, Finland, and Denmark and in Norway. They had about 1,200 women in a study, and roughly a third of those had actually been on hormone replacement therapy. So a little bit different risk profile, maybe. And they all underwent an ultrasound and an endometrial curatage as part of the study.

SPEAKER_02 36:26

Yeah. So from these curatage specimens, they had 667 cases of atrophy, 77 cases of hormonal effect, 140 polyps, 114 endometrial cancers, and 112 cases of hyperplasia. So actually, that's a lot of cancers and hyperplasia for the group. So 1,200 total, and almost 250 of them had cancer or hyperplasia. When I do my counseling for patients, I usually, if I have a woman who comes to me with post-menopausal bleeding, just and no other incorporation of risk factors, I tell her that she has about a 10% risk of cancer, or at least I think that in my head. But I do want to say, and you mentioned this with the saying that it was done in Nordic countries, these were most almost exclusively white patients, and that will be important in a minute when we talk about the recent changes. But the authors concluded that the endometrial thickness of less than or equal to four millimeters in that group, there was only a 3.6% chance of finding an abnormality. And this included six cases of polyps and six cases of just benign hyperplasia, but no cancers. If they changed that cutoff to five millimeters, there were two cancers that went undiscovered. So this is the paper that gave us that four millimeter rule that so many of us know and until recently loved for avoiding an immaterial biopsy in postmenopausal patients. I will see sometimes people try to apply this to pre-menopausal patients, and I'm like, you can't do that. You can't do that.

SPEAKER_01 38:05

Well, they were also in in that study, they were unable to measure the thickness accurately in about 30 patients. And among those women, in those 30, there was a case of atypical hyperplasia and a stage four cervical cancer. So initial criticisms of this paper was that one, that measurement was very technique dependent. This was in the 90s. Vaginal ultrasound is way better today than it was in the 90s. We've all gotten better at it. We've all learned standard techniques. But I am constantly re-measuring endometrial linings on ultrasounds that I see done at outside places and disagreeing with the radiologists that read them. So it is very technique dependent. People need to know what they're looking at. And so that could get a person in in in harm's way. I actually had a recent patient who had endometrial cancer and had been reassured about five months before I saw her by a radiologist reading of an ultrasound report and implementation of this rule. And she came in and I biopsied her and she already has stage two cancer, I think.

SPEAKER_02 39:05

Yeah.

SPEAKER_01 39:05

So and as you said, this was primarily a population that was Caucasian. So we don't know how applicable this finding would be to other populations. And that's what's become an issue recently. So yeah, from this paper though, we got the ACOG adopted sort of long-standing policy that no biopsy was necessary. I mean, use common sense if it's something that you're worried about, but typically speaking, no biopsy necessary if the lining was less than or equal to four millimeters. However, if they had persistent or recurrent bleeding, or if they were on tamoxifen, then you should still proceed with the biopsy.

SPEAKER_02 39:40

Yeah. Yeah, and I know you guys covered this recently a couple of episodes ago. That new guidance was found in committee opinion 734. And so, in just in a nutshell, I read it and said it's really a reminder not to rely 100% on the ultrasound endometrial stripe thickness, and especially when it comes to black women. So this has been an evolving area of research that has recognized these limitations from this Carlson study. And then, as you mentioned, that homogeneous group of white women from the landmark study really comes into questions of generalizability. We know that black women are two to three times more likely to have what we used to refer to as type 2 endometrial cancers. So these are these P53 mutated high-grade endometrioid, uterine papillary cirrus, carcinosarcomas, altogether less than 10% of endometrial cancers, but they are a higher proportion of endometrial cancers in black women. And these cancers are less likely to present with thickened endometrium in the same way that these hormone-driven low-grade endometrial cancers are. There was a retrospective study done by Kimmy Dahl and her colleagues. This was published in 2024. There was nearly 1,500 black women from 10 different institutions. And these they all had pre-op ultrasound and went on to have a hysterectomy. There's a lot of interesting findings from this study, but one was that using the four millimeter cutoff would have missed an underlying cancer 9.5% of the time. So that's huge, much, much different than sort of the landmark study. And black women have a higher incidence of these cancers. And it's also much harder to get a reliable endometrial stripe in patients with fibroids, which we know black women also have more are more likely to have fibroids. And you talked a little bit about some of the difficulty in that technique-dependent measurement. So yeah.

SPEAKER_01 41:38

And I'll admit, after since that DAL study, I had already been universally biopsing black women.

SPEAKER_02 41:43

Yeah.

SPEAKER_01 41:44

So in anticipation of that. And I think I found one that that would have I'm pretty sure I had one, it might have been a uh an EIN, but I found pathology that would have been missed with the four millimeter rule. So I'd already started doing that, and now I've just extended that obviously to all my patients. So Yeah.

SPEAKER_02 42:03

I think the thing too, and I think we do this or we should. But when we if you have a patient and you see her and say the stripe is then, if she continues to bleed, don't just be reassured. Like you've got to kind of use your approach there and say, okay, we've got to figure out what exactly is going on here. So Yeah.

Postmenopausal Bleeding And The 4 mm Rule

SPEAKER_01 42:22

Okay, well let's pivot to cervical cancer. So this is another area that's again rapidly changing, at least in terms of how we do screening. So we've got to start with the beginning. There's a the paper called The Diagnostic Value of Vaginal Smears and Carcinoma of the Uterus. This was published in 1941 by George Papinicoli and Herbert Trout. So before this paper, cervical cancer was one of the leading causes of cancer death in women globally. It still is a problem in many countries, but in developed countries, it's decreased dramatically. And it was usually only diagnosed after patients became very symptomatic and therefore at a very or a more advanced stage than we would like to diagnose it or you'd like us to diagnose it. So Dr. Papanicola discovered that malignant cells shed from the cervix and that they can be easily collected and then identified under a microscope long before visible tumor formed.

SPEAKER_02 43:17

Yeah. And we should mention that his wife was a hero because uh many of the techniques that he used to develop the pap smear were developed on her own cervical cells. So so she should I think her name was Mary, if I remember right. Sorry, I should have looked that up, but I think it was Mary.

SPEAKER_01 43:34

But yeah, this is the listeners can't see, but Stuart and I collect books, and I'm showing him Dr. Dr. Papanikolai's monograph from 1948. Oh yeah, and it and in the back of it it actually has a color fold out of how he mapped the the cervixes, and these are all drawings basically of his wife's he mapped his wife like every day through different parts of the cycle until he he left. So Yeah.

SPEAKER_02 43:58

A true hero. All right. Yeah. So this single paper really launched the PAPSMIR, which really has been one of the most successful cancer screening interventions, or maybe the most in medical history. It shifted oncology away from reactive treatment to proactive prevention. And it cut cervical cancer mortality rates by over 70% in developed nations. And I still see that from time to time, obviously, but it was a much, much bigger deal before we were able to screen for these things. So Papua Nicolas was at Cornell primarily, and then Herbert Trout actually joined him there in 1931. Trout was had gone to med school at Johns Hopkins after serving in World War I, and Papua Nicola had been working on his research for years and presented the data actually way back in 1928, but at that point wasn't received well. There was also a Romanian researcher named Arl Babes, or Babez, who was doing similar research, interestingly, but both of them really were ridiculed by colleagues. It was probably the kind of the clout that Trout had coming in the 1940s that really helped to lead in getting this paper published and the findings publicized. And really, ultimately, their work has gone on to save at least 12 million lives.

SPEAKER_01 45:30

Yeah. Trout gets a lot of credit for getting this across the finish line and getting it popularized. So Trout graduated, as you said, from Hopkins in 1923, did his internship there, went to Europe and studied a bit, which was very common back then, pick up some new skills, learn some set with some eminent pathologists, that sort of thing. And then came back and finished his training in gynecology and pathology, as well as some general surgery training at Johns Hopkins. So his pedigree goes right to Howard Kelly. He overlapped towards the end of Howard Kelly's career.

SPEAKER_02 46:00

Yeah. As most American gynecologist pedigrees do. They go back to him.

SPEAKER_01 46:06

Okay, well, related to this paper, next the next big step was we have a paper published in the Green Journal in 1992 by Lawrence and colleagues entitled Human Papillomavirus Infection of the Cervix, Relative Risk Associations of 15 Common Anogenital Types. So this paper reported on work that was started in the 1980s in the United States and in South America, and they took cervical specimens that had collected, had been previously collected during the early 1980s. They already had been pathologically analyzed and categorized as either normal or abnormal with lower high-grade cancer cells or whatever. But then they went back and took these specimens and they did an HPV genome analysis, which had just become possible on those results, to see if there was a correlation between the cervical disease and different HPV types.

SPEAKER_02 46:55

Yeah. So this is the one where they found high-risk strains and included 18, 45, and 56 in this early study. And they were found in 6.5% and 26.8% of high grade lesions and invasion carcinomas, respectively. So basically a little over a fourth of the invasive carcinomas had one of these three positive. HPV16 was associated with 47% of high grade lesions and 47% of the cancers. And then the intermediate risk strains were also identified in this study. So that included 31, 33, 35, 51, 52, and 58. And those were detected in about a quarter of the high grade lesions and then about 10% of the cancers. They also identified some low-risk strains, so 6 and 11, which we know of as being the cause of papillomas, and then also 42, 43, and 44. And these were present in about 20% of low-grade lesions, but in none of the cancers. So this was not the whole picture, and obviously testing wasn't as reliable then as it is today. And there were a few high-risk strains that they didn't include, which we know now are oncogenic. But this is the study that showed that HPV was largely responsible for most cervical cancers, and that the different strains had different impact on the severity of disease. And really this led to the idea that a vaccine against some of these HPV strains, specifically HPV 16 and 18, would have utility in preventing cervical cancer.

SPEAKER_01 48:38

Yeah, and this study was actually found funded by the Dye Gene Corporation, but they're the group that developed the original high-risk HPV DNA test. And some of those authors also were from Johns Hopkins. So just to continue, the theme, the idea of the ability to test for this, had a quite a pedigree back to Hopkins as well. But not all industry-funded work is bad, just be skeptical. But some HPV or some industry-funded work saves lives. And this is how things like this get accomplished in a practical way. So they actually weren't the ones that discovered the link between HPV and cervical cancer. They just took the work and validated it with this commercially available test that Dygene was bringing out and trying to determine which strands should we test for and how should we screen, and of course, ultimately informing attempts to make a vaccine and which strands we should try to make a vaccine for. I'm going to call him HH, I like the initials. Hypothesized in actually 1976, goes back that far, that it might be the HBV virus. And eventually his lab was able to isolate and clone HBV 16 and 18 from cervical cancer biopsies in 1983 and 84. And this really was a foundational shift, very important understanding and breakthrough in understanding how oncogenic cancers worked, or oncogenic viruses, I should say, worked. And of course, those two strains, 16 and 18, are responsible for about 70% of invasive cervical cancers worldwide. And eventually, that's what we attacked first with our initial vaccines. And those two strains in particular were in the initial vaccines that were developed. So kudos to HH.

SPEAKER_02 50:58

Yeah. Yeah, those HHs, they're pretty smart.

SPEAKER_01 51:01

Yeah, you know he's a good guy.

SPEAKER_02 51:03

That's right. Good. So the vaccine development was also its own challenge because you couldn't just use a traditional live attenuated or killed virus since the virus itself is actually oncogenic, right? So the breakthrough actually came because researchers were able to work together independently, but bring their work together. And they figured out that the major capsid protein, L1, was really the important thing to sort of allow this vaccine to be made about around that. And this L1 is important in recombinant expression systems, causing the proteins to self-assemble into what are called these virus-like particles or VLPs. So VLPs mirror the outer shell of the actual virus and are very immunogenic, but they don't have the actual viral DNA in them, so they're not infectious, they're just the outer shell. So Merck developed the quadravalent Gardasyl vaccine, and that was released in 2006, so actually 20 years ago. And this protected against two alkogenic strains, so 16 and 18, and then also the two strains that can cause venereal warts, so 6 and 11. People actually forget that Glaxo Smith Klein also developed a vaccine in 2009. This was a bivalent vaccine against 16 and 18 only. But they and they also had actually an indication for use in males for the Gardasil, it didn't come till later. Then eventually, of course, we had the nine valent vaccine in 2014, which was is the one that we essentially most people have gotten today. And that's that the that's for men and women up to age 45. So in other countries, specifically Australia and some of these other Nordic countries where there's been a better uptake of the vaccine, we've seen a 90% reduction in cervical cancer rates.

SPEAKER_01 53:03

Yeah. And mortality rates, of course, concordant with that. So Okay, well that gets us to the next important paper or a couple of papers.

HPV Testing Takes Over Screening

SPEAKER_01 53:12

So the CC CAST trial. I don't know how they intend for us to say that, but it's three C's. The C I think it's CC CAST trial, was published in 2007. So this is the Canadian cervical cancer screening trial. And there was also several long-term European cohort trials. The chief one is the artistic trial. God, I'd love to name studies for a woman. That's so great. I know. The artistic trial. I hope they had a pain name.

SPEAKER_02 53:37

I think that's the first thing you do when you design a study. You have to come up with a name and then you design the study, right? Yeah.

SPEAKER_01 53:42

You decide what to study based on the name, yeah. Yeah. But these trials looked at the use of HPV screening as a supplement to traditional cytology screening. So at that point, for nearly half a century, the PAP smear was how cervical cancer screening was done. And it shifted around the late 90s and early 2000s to liquid-based cytology, and that improved it quite a bit. Liquid-based cytology was a much better test than the traditional PAPS mirror with a sprayed fixative. But it still relied upon cytologists spotting an abnormal cell under a microscope, and that introduces human error and still a need for more frequent testing to mitigate the lower sensitivity of the testing and compound for potential human error and all that. So this trial changed that.

SPEAKER_02 54:25

Yeah, right. So the CCCAS trial followed about 10,000 women in Canada. These women received both the HPV test and a PAP test. And they found that screening with HPV as a primary modality detected high-grade lesions with fewer false negatives than the traditional cytology alone. The HPV DNA test was more accurate with 94.6% sensitivity compared to 55.4% with the PAP test alone and detecting premalignant lesions.

SPEAKER_01 55:00

Right. So that shifted our entire philosophy or began to shift our philosophy of cervical cancer screening away from cytology to virus detection, and it laid the foundation for where we're heading today. So it in in the meantime, it's led to various strategies. The thing most people are familiar with, of course, is doing HPV screening after age 30 with co-testing and every five years. But other countries they've been doing HPV screening as a primary or they've instituted HPV screening at age twenty-five. And there's different strategies around that and a lot of studies that inform that. But we're shifting finally to a preferred strategy of HPV screening without cytology. And we have that now from the American Cancer Society, and that's what's in most other developed countries. I will say that we've not adopted in the United States the HPV screening under the age of 30 as fully as European and other countries have. And that probably has something to do with our poor uptake of the HPV vaccine compared to other countries. So if you're in Australia and you're doing your first test as an HPV primary screen at age 25, you're going to have very low rates of detection of HPV in that well-vaccinated population. But if you're in the United States, where a very significant number of people have not received the HPV vaccination prior to the onset of sexual activity, you're going to get a lot more HPV tests. And so we're still balancing the risk of overintervention with an HPV infection in a younger patient that's likely to get better on its own. So that's one of the differences, but we're definitely moving towards HPV primary screening.

SPEAKER_02 56:36

Yeah. And I like that. I mean, I a lot of people ask me that as an oncologist. Are you worried that going away from PAP misses things? I mean, I I think people still need patients still need exams and obviously to see their OBGYN. This isn't saying you shouldn't you should get your test and then forget about your OBGYN for three to five years. I think that what it does do, can it's obviously more sensitive. It's just a better screening test, really. It has all the marks of a better screening test. But the the other thing I do like about it is the self-collection option, I think, is a good one. One thing people will ask sometimes about incorporating this into their clinic, and I do think it's important to know that you need to coordinate this with your lab. You can't really there's a specific, essentially, uh uh way to analyze these self-collected and HPV only tests that are different than what you might add as a co-test. And so that's just something to discuss with the lab so that they know what you're doing there. But I do think it's something we'll see a lot more of soon.

SPEAKER_01 57:40

Aaron Powell And I've had uh one this week, but I think three or four in the last month, patients referred to me for colposcopy who did self-collected HBV testing, who had not had PAPS in 10 or 15 or 20 years because they didn't want to undergo a speculum exam. And I know the one this week was HBV 16 positive, and we'll see what the culposcopy shows. I don't know the results as of the day of recording, but this is a patient who did not want to be subjected to a pelvic exam, but was fine doing a self-collected test. And then was also fine confronted with the knowledge of, hey, you have HBV 16, will you go get a culposcopy? And and so this will increase the uptake of people. I think we probably underestimate how many folks really do not want to come in and have a speculum in their vaginas.

SPEAKER_02 58:28

Yeah, absolutely.

SPEAKER_01 58:29

But if you're a woman who's ever had one, which Stuart and I are not, you probably know what we're talking about. Okay.

What We Still Want To Cover

SPEAKER_01 58:35

Well, there's a bunch more we could have talked about in this hour, but you wasted so much time talking about obstetrics. But maybe we can one thing that we should talk about, we did some cervical, we did some uterine, we should talk sometime about Crumb's work on identifying the ovarian cancer target lesions that are outside the ovary and how that's obviously transformed our thoughts about ovarian cancer and led to things like prophylactic salp injectomy, too. So there's plenty more we could do, but we'll do that on another episode. Sounds great. I'm always happy to be on, so I appreciate it. 300 hysterectomies a year, huh?

SPEAKER_02 59:14

Yeah. Picking up.

SPEAKER_01 59:15

Picking up. He's a busy boy.

SPEAKER_02 59:17

Yeah.

SPEAKER_01 59:18

All right. Well, we'll have you on again in a few months. People love it when you're on, and thanks for tuning in, and we'll see everybody in a couple of weeks.

SPEAKER_00 59:27

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.