Dr. Chapa’s Clinical Pearls.

On Sept 10, 2023, er released an episode titled, “CS Ut Closure: Decidua or No Decidua?”. We highlighted the importance of AVOIDING the decidua at hysterotomy closure at CS. Now, in Sept 2025, in Obstetrics and Gynecology (the Green Journal), there is a new systematic review and meta-analysis on this very topic. Does this new study CONFIRM or REFUTE what we explained 2 years ago? Listen in for details. 1. Sept 10, 2023 Chapa Clinical Pearls Podcast: CS Ut Closure: Decidua or No Decidua?2. Lino GM, Galvão PVM, da Silva MLF, Conrado GAM. Not Closing Compared With Closing the Endometrial Layer During Cesarean Delivery: A Systematic Review and Meta-analysis. Obstet Gynecol. 2025 Jun 12;146(3):e55-e63. doi: 10.1097/AOG.0000000000005974. PMID: 40505112.

According to the J Am Acad Orthop Surg Glob Res Rev. (2024), the incidence of pelvic ring injuries is 34.3 per 100,000 with trauma being the most obvious causation. Women account for approximately 69.7% of these injuries, 23% of which occur in women of childbearing age. In this specific patient population, concern is raised about one's future reproductive capability and method of delivery. The normal bony pelvic movements that occur during vaginal delivery are crucial for accommodating the passage of the fetus through the birth canal; this allows for the normal cardinal phases of labor to occur. These movements involve the widening and shifting of various pelvic joints and bones, primarily influenced by hormonal changes and the mechanical forces exerted by the baby. So, it is reasonable to ask if a patient with pelvic fractures and fixation can safely allow a trial of labor. Is a history of pelvic fractures with surgical fixation an indication for primary cesarean section? If it’s not, in what scenario would a primary c-section be best after a pelvic fracture? Listen in for details. 1.Pelvic Fractures in Women of Childbearing Age.Cannada LK, Barr J. Clinical Orthopaedics and Related Research. 2010;468(7):1781-9. doi:10.1007/s11999-010-1289-5.2.Birth Outcomes Following Pelvic Ring Injury: A Retrospective Study. Hsu CC, Lai CY, Chueh HY, et al. BJOG : An International Journal of Obstetrics and Gynaecology. 2023;130(11):1395-1402. doi:10.1111/1471-0528.17487.3.Pregnancy and Delivery After Pelvic Fracture in Fertile-Aged Women: A Nationwide Population-Based Cohort Study in Finland. Vaajala M, Kuitunen I, Nyrhi L, et al. European Journal of Obstetrics, Gynecology, and Reproductive Biology. 2022;270:126-132. doi:10.1016/j.ejogrb.2022.01.008.4.Pregnancy Outcomes After Pelvic Ring Injury.Vallier HA, Cureton BA, Schubeck D. Journal of Orthopaedic Trauma. 2012;26(5):302-7. doi:10.1097/BOT.0b013e31822428c5.5.Caesarean Section Rates Following Pelvic Fracture: A Systematic Review. Riehl JT. Injury. 2014;45(10):1516-21. doi:10.1016/j.injury.2014.03.018.6.Unstable Pelvic Fractures in Women: Implications on Obstetric Outcome. Davidson A, Giannoudis VP, Kotsarinis G, et al. International Orthopaedics. 2024;48(1):235-241. doi:10.1007/s00264-023-05979-4.7.Management of Pelvic Injuries in Pregnancy.Amorosa LF, Amorosa JH, Wellman DS, Lorich DG, Helfet DL. The Orthopedic Clinics of North America. 2013;44(3):301-15, viii. doi:10.1016/j.ocl.2013.03.0058.Effect of Trauma and Pelvic Fracture on Female Genitourinary, Sexual, and Reproductive Function.Copeland CE, Bosse MJ, McCarthy ML, et al. Journal of Orthopaedic Trauma. 1997 Feb-Mar;11(2):73-81. doi:10.1097/00005131-199702000-00001.9. The Rate of Elective Cesarean Section After Pelvic or Hip Fracture Remains High Even After the Long-Term Follow-Up: A Nationwide Register-Based Study in Finland. Vaajala M, Kuitunen I, Liukkonen R, et al.European Journal of Obstetrics, Gynecology, and Reproductive Biology. 2022;277:77-83. doi:10.1016/j.ejogrb.2022.08.10. Bajerová M, Hruban L. Movements of the pelvic bones of expectant mothers during vaginal delivery. Ceska Gynekol. 2024;89(4):335-342. English. doi: 10.48095/cccg2024335. PMID: 39242210. 11. Lewis AJ, Barker EP, Griswold BG, Blair JA, Davis JM. Pelvic Ring Fracture Management and Subsequent Pregnancy: A Summary of Current Literature. J Am Acad Orthop Surg Glob Res Rev. 2024 Feb 6;8(2):e23.00203. doi: 10.5435/JAAOSGlobal-D-23-00203. PMID: 38323930; PMCID: PMC10849384.12. Childbirth after Pelvic Fractures: Debunking the Myths: https://ota.org/sites/files/legacy_abstracts/ota09/otapa/OTA090132.htm13. Davidson A, Giannoudis VP, Kotsarinis G, Santolini E, Tingerides C, Koneru A, Kanakaris NK, Giannoudis PV. Unstable pelvic fractures in women: implications on obstetric outcome. Int Orthop. 2024 Jan;48(1):235-241. doi: 10.1007/s00264-023-05979-4. Epub 2023 Sep 15. PMID: 37710070

Traditionally, we have learned that any imbalance in the estrogen: progesterone relationship can trigger irregular uterine bleeding. That makes sense, right? During anovulation, prolonged unopposed estrogen can result in HMB. In such a case, we give progesterone as both a therapeutic as well as diagnostic intervention. On the contrary, with progestin only contraception, we consider estrogen predominant products when progesterone breakthrough bleeding (BTB) occurs to restore endometrial stabilization. But a new RCT (AJOG) adds credence to adding MORE progesterone in cases of progesterone associated BTB. Listen in for details.1. Zigler RE, Madden T, Ashby C, Wan L, McNicholas C. Ulipristal Acetate for Unscheduled Bleeding in Etonogestrel Implant Users: A Randomized Controlled Trial. Obstet Gynecol. 2018 Oct;132(4):888-894. doi: 10.1097/AOG.0000000000002810. PMID: 30130351; PMCID: PMC6153077.2.ANDRADE MCR, et al. Norethisterone for Prolonged Uterine Bleeding Associated with Etonogestrel Implant (IMPLANET): A Randomized Controlled Trial, American Journal of Obstetrics and Gynecology (2025), doi: https://doi.org/10.1016/j.ajog.2025.08.029.

Routine vaginal examinations (VEs) are a standard component of intrapartum care, traditionally performed at regular intervals to monitor cervical dilation, effacement, and fetal station, which are indicators of labor progression. Yet, the American College of Obstetricians and Gynecologists states that there is insufficient evidence to recommend a specific frequency for cervical examinations during labor, and examinations should be performed as clinically indicated. Now, a recently published RCT form AJOG MFM is adding additional credence to that. Can we space out clinical exams in otherwise “low-risk” laboring women to 8 hours? Listen in for details. 1. AJOG MFM: (08/18/25) Routine Vaginal Examination Scheduled At 8 vs 4 Hours In Multiparous Women In Early Spontaneous Labour: A Randomised Controlled Trial https://www.sciencedirect.com/science/article/abs/pii/S25899333250016122. Nashreen CM, Hamdan M, Hong J, et al.Routine Vaginal Examination to Assess Labor Progress at 8 Compared to 4 h After Early Amniotomy Following Foley Balloon Ripening in the Labor Induction of Nulliparas: A Randomized Trial. Acta Obstetricia Et Gynecologica Scandinavica. 2024;103(12):2475-2484. doi:10.1111/aogs.14975.3. First and Second Stage Labor Management: ACOG Clinical Practice Guideline No. 8. Obstetrics and Gynecology. 2024;143(1):144-162. doi:10.1097/AOG.0000000000005447.4. Moncrieff G, Gyte GM, Dahlen HG, et al. Routine Vaginal Examinations Compared to Other Methods for Assessing Progress of Labour to Improve Outcomes for Women and Babies at Term. The Cochrane Database of Systematic Reviews. 2022;3:CD010088. doi:10.1002/14651858.CD010088.pub3.5. Gluck, O., et al. (2020). The correlation between the number of vaginal examinations during active labor and febrile morbidity, a retrospective cohort study. [BMC Pregnancy and Childbirth]6. Pan, WL., Chen, LL. & Gau, ML. Accuracy of non-invasive methods for assessing the progress of labor in the first stage: a systematic review and meta-analysis. BMC Pregnancy Childbirth 22, 608 (2022). https://doi.org/10.1186/s12884-022-04938-y

Breast cancer is an hormone responsive malignancy, meaning it may use estrogen and progesterone, reduced in high quantities during a pregnancy, for growth. However, as medical evidence evolves quickly, physicians have come to understand that breast cancer diagnosis during pregnancy doesn't always mean worse prognoses. While older studies- including meta analysis-reflected worse prognoses for pregnancy related breast cancer compared to non-pregnancy related cases, these studies either included studies from the 1960s and 70s when diagnosis and treatment were radically different, had inconsistent definitions of PABC, and/or were poorly age and staged matched. Therefore, as stated in the new UK (Aug 2025) guidance, “the applicability to modern day practice of the findings from these reports is limited”. The more updated clinical stance is that, “By using diagnostic and treatment pathways for women with {pregnancy related breast cancer} which are as close as possible to women with non-pregnancy related breast cancer, similar outcomes can be achieved” (RCOG Green Top recommendations No 12). In this episode, we will summarize key points from the recently released Green Top Guidance No 12 (25 Aug 2025) which has shifted the perspective on treating breast cancer DURING pregnancy. 1. Cubillo A, Morales S, Goñi E, Matute F, Muñoz JL, Pérez-Díaz D, de Santiago J, Rodríguez-Lescure Á. Multidisciplinary consensus on cancer management during pregnancy. Clin Transl Oncol. 2021 Jun;23(6):1054-1066. doi: 10.1007/s12094-020-02491-8. Epub 2020 Nov 16. PMID: 33191439; PMCID: PMC8084770.2. https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/pregnancy-and-breast-cancer-green-top-guideline-no-12/3. Sundermann AC, Cate JM, Campbell AK, Dotters-Katz SK, Myers ER, Federspiel JJ. Maternal morbidity and mortality among patients with cancer at time of delivery. Am J Obstet Gynecol. 2023 Sep;229(3):324.e1-324.e7. doi: 10.1016/j.ajog.2023.06.008. Epub 2023 Jun 7. PMID: 37295633; PMCID: PMC10593119.

YEP…Its another episode of You Asked, We Answered! In this episode, we will look at the data to answer 2 questions that came into the show within the last 24 hrs: 1. Is oral or topical therapy best for first treatment of uncomplicated vulvovaginal candidiasis? (We have new data- AJOG, Sept 2025, to answer that), and 2. Is urine PCR testing for UTI diagnosis a “routine practice”? (We will look at 4 sources of information to answer that one). Listen in for details. 1. Gardella, Barbara et al. Treatment of uncomplicated vulvovaginal candidiasis: topical or oral drugs? Single-day or multiple-day therapy? A network meta-analysis of randomized trials. American Journal of Obstetrics & Gynecology, Volume 233, Issue 3, 152 - 1612. Invited Commentary: JAMA Netw Open: Published Online: November 26, 20242024;7;(11):e2446711. doi:10.1001/jamanetworkopen.2024.467113. March 2025 (AAFP): Are the Advantages of Urine PCR Testing Worth the Higher Costs? https://www.aafp.org/pubs/afp/afp-community-blog/entry/are-the-advantages-of-urine-pcr-testing-worth-the-higher-costs.html4. July 2025: PALTmed: https://paltmed.org/news-media/paltmed-calls-providers-stop-using-routine-pcr-urine-tests-utis5. https://pathnostics.com/limitations-of-pcr-only/

In the last 2 episodes we covered new updates in menopausal hormone therapy. However, we did not address TESTOSTERONE use. This episode idea comes from one our podcast family members and good friend, Eric. Eric is 100% correct: Testosterone replacement, when done correctly, has come along way. When is this indicated? Is this endorsed by professional medical/endocrine groups? What’s the dose? We have fun stuff to review, so listen in!1. Davis SR, Baber R, Panay N, Bitzer J, Perez SC, Islam RM, Kaunitz AM, Kingsberg SA, Lambrinoudaki I, Liu J, Parish SJ, Pinkerton J, Rymer J, Simon JA, Vignozzi L, Wierman ME. Global Consensus Position Statement on the Use of Testosterone Therapy for Women. J Clin Endocrinol Metab. 2019 Oct 1;104(10):4660-4666. doi: 10.1210/jc.2019-01603. PMID: 31498871; PMCID: PMC6821450.2. Sharon J. Parish, James A. Simon, Susan R. Davis, Annamaria Giraldi, Irwin Goldstein, Sue W. Goldstein, Noel N. Kim, Sheryl A. Kingsberg, Abraham Morgentaler, Rossella E. Nappi, Kwangsung Park, Cynthia A. Stuenkel, Abdulmaged M. Traish, Linda Vignozzi, International Society for the Study of Women’s Sexual Health Clinical Practice Guideline for the Use of Systemic Testosterone for Hypoactive Sexual Desire Disorder in Women, The Journal of Sexual Medicine, Volume 18, Issue 5, May 2021, Pages 849–867, https://doi.org/10.1016/j.jsxm.2020.10.0093. Levy, Barbara MD, MSCP; Simon, James A. MD, MSCP. A Contemporary View of Menopausal Hormone Therapy. Obstetrics & Gynecology 144(1):p 12-23, July 2024. | DOI: 10.1097/AOG.00000000000055534. NAMS The 2022 hormone therapy position statement of The North American Menopause Society: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://menopause.org/wp-content/uploads/professional/nams-2022-hormone-therapy-position-statement.pdf

This is a requested follow up to our most recent episode. Menopausal hormone therapy (HT) prescribing practices have evolved over the last few decades guided by the changing understanding of the treatment’s risks and benefits. We know that dose, route of administration, and choice of agent (estradiol versus a more synthetic option, and micronized progesterone over other progestins.) alter the risk benefit ratio. Compared to natural progesterone, synthetic progestins have 10-100- fold greater activity. Synthetic MPA is vasoconstrictive while natural progesterone and drospirenone cause vasodilation and lower blood pressure. Micronized progesterone is bioidentical to the hormone made endogenously and has efficient oral absorption. Progestogens come in oral and transdermal forms, and it can also be given vaginally. Is there data that micronized progesterone is safer for the breast for a menopausal hormone therapy? This podcast topic recommendation comes from one of our podcast family members. Listen for details. 1. Gompel A. Micronized progesterone and its impact on the endometrium and breast vs. progestogens. Climacteric. 2012 Apr;15 Suppl 1:18-25. doi: 10.3109/13697137.2012.669584. PMID: 22432812.2. Stute P, Wildt L, Neulen J. The impact of micronized progesterone on breast cancer risk: a systematic review. Climacteric. 2018 Apr;21(2):111-122. doi: 10.1080/13697137.2017.1421925. Epub 2018 Jan 31. PMID: 29384406.3. Eden J. The endometrial and breast safety of menopausal hormone therapy containing micronised progesterone: A short review. Aust N Z J Obstet Gynaecol. 2017 Feb;57(1):12-15. doi: 10.1111/ajo.12583. PMID: 28251642.4. Asi N, Mohammed K, Haydour Q, Gionfriddo MR, Vargas OL, Prokop LJ, Faubion SS, Murad MH. Progesterone vs. synthetic progestins and the risk of breast cancer: a systematic review and meta-analysis. Syst Rev. 2016 Jul 26;5(1):121. doi: 10.1186/s13643-016-0294-5. PMID: 27456847; PMCID: PMC4960754.5.AHA J Circulation: Rethinking Menopausal Hormone Therapy: For Whom, What, When, and How Long? 2023

There’s a lot of fear and misinformation around HRT, and one of the biggest myths is that HT is a highly significant cause of breast cancer. That is not the case. This is a remnant concept from 2002, with MANY caveats. Calls for the removal of the black box warning on hormone replacement therapy (HRT) stems primarily from the outdated and limited nature of the data from the Women's Health Initiative (WHI) study published in 2002. The WHI, while groundbreaking at the time, focused predominantly on a specific formulation of conjugated equine estrogens (CEE) and medroxyprogesterone acetate (MPA) in older, postmenopausal women, leading to concerns about its generalizability to the broader population of women considering HRT. This is why on July 17, 2025, the FDA met with a panel of experts, in open forum, to hear the petition of removing the black box warning on hormone replacement therapy. Listen in for details. 1. Writing Group for the Women's Health Initiative Investigators. Risks and Benefits of Estrogen Plus Progestin in Healthy Postmenopausal Women: Principal Results From the Women's Health Initiative Randomized Controlled Trial. JAMA.2002;288(3):321–333. doi:10.1001/jama.288.3.3212. Manson JE, Crandall CJ, Rossouw JE, Chlebowski RT, Anderson GL, Stefanick ML, Aragaki AK, Cauley JA, Wells GL, LaCroix AZ, Thomson CA, Neuhouser ML, Van Horn L, Kooperberg C, Howard BV, Tinker LF, Wactawski-Wende J, Shumaker SA, Prentice RL. The Women's Health Initiative Randomized Trials and Clinical Practice: A Review. JAMA. 2024 May 28;331(20):1748-1760. doi: 10.1001/jama.2024.6542. PMID: 38691368.3. NAMS: The 2022 hormone therapy position statement of The North American Menopause Society (Menopause)

Well, I hate to say it, but I'm going to say it: "I Told You So". Back in 2019, we released an episode called "Mycoplasma genitalium: An Overlooked STI". Then, in Sept 2023, we released an episode called, "The Neglected STI", referring to trichomoniasis. Well, on July 22, 2025, a new commentary was released in the AJOG which is making the case why both Trich and MGen SHOULD be reportable STIs, yet they are currently not reportable. Listen in for details and a quick summary/reminder on therapy. 1. https://www.ajog.org/article/S0002-9378(25)00498-3/fulltext2. https://www.cdc.gov/std/treatment-guidelines/trichomoniasis.htm3.https://www.cdc.gov/std/treatment-guidelines/mycoplasmagenitalium.htm