Before Your First: Infertility Clinic

Your first vaginal delivery will probably happen when you’re pulled into a room mid-shift, with little time for chart review and a patient who is already pushing well. In this episode, Dr. Mahima Krishnamoorthi and Dr. Sonia Hamilton walk through what you need to know before delivery, how to communicate with your patient, how to deliver the baby and placenta safely, and how to identify and repair your first perineal laceration. Topics to Review Over Time: Shoulder dystocia: recognition and maneuvers Third- and fourth-degree laceration repair Postpartum hemorrhage and uterotonic selection Cervical laceration repair Operative vaginal delivery About the Speakers: Host: Lucy Brown, MD, MPH – Resident physician at Johns Hopkins GYN/OB. Dr. Brown is passionate about medical and resident education and will be pursuing a Fellowship in Complex Family Planning after residency. Guest Speaker: Sonia Hamilton, MD – Second-year resident in Gynecology and Obstetrics at Johns Hopkins. Originally from Madrid, Spain, she earned her bachelor’s degree in Neuroscience, with a minor in Human Rights, at The Ohio State University and her medical degree at Johns Hopkins University School of Medicine. Guest Speaker: Mahima Krishnamoorthi, MD – Gyn/Ob resident at Johns Hopkins Hospital. She attended Stanford University for undergrad and graduated from the Johns Hopkins School of Medicine. Intern Ready: Ob/Gyn is a podcast aimed at interns and off-service residents beginning their post-graduate training in Obstetrics and Gynecology. The views expressed are the speakers’ own and do not constitute medical advice.

Induction of labor now accounts for roughly 1 in 3 deliveries in the U.S., so as an intern you'll be part of inductions almost every shift, whether scheduled or a same-day plan from triage. In this episode, Dr. Veena Bhagavathi walks through who gets induced and why, how to use the Bishop score, the cervical ripening options, what to do once the cervix is favorable, and how long to wait before calling an induction "failed." Indications & Contraindications Elective induction means induction at 39 weeks without a medical indication. 39 weeks is the cutoff because the neonatal risks of late-preterm and early-term birth are well established. ARRIVE trial: in low-risk nulliparas, induction at 39 0/7–39 4/7 weeks reduced cesarean delivery (18.6% vs 22.2%, RR 0.84) and hypertensive disorders of pregnancy (9.1% vs 14.1%, RR 0.64), with no significant difference in neonatal outcomes. Induction between 41 0/7 and 42 0/7 weeks can be considered; induction by 42 6/7 weeks is recommended given increased perinatal morbidity and mortality beyond that. Don't defer delivery to 39 weeks if there's a medical or obstetric indication for earlier delivery — always run the risk-benefit calculation. Medically indicated induction, maternal: chronic HTN, gestational HTN, preeclampsia (with or without severe features), diabetes. Medically indicated induction, fetal: growth restriction, multiple gestation, PPROM/PROM. PPROM delivery timing has an interim ACOG update (Committee Opinion 831). Pull the current ACOG page before finalizing a plan, and discuss and document the added neonatal risk of prolonged expectant management with unknown or positive GBS status. Contraindications are essentially any contraindication to vaginal delivery: placenta or vasa previa, malpresentation or non-cephalic lie, prior classical cesarean, active herpes infection, and severe fetal or maternal compromise requiring faster delivery. The Bishop Score Dilation, effacement, and station are scored 0–3; consistency and position are scored 0–2. Total range: 0–13. Score ≥8 → favorable ("ripe") cervix, with a good chance of vaginal delivery on induction. Score ≤6 → unfavorable ("unripe") cervix, with a lower chance of vaginal delivery; cervical ripening is indicated. A simplified Bishop score using only dilation, station, and effacement may be just as predictive — a simplified score of 5 performs similarly to a full score >8. Ask the patient if she's had a cervical exam before, or what her prior inductions looked like. Parity and history both factor in, and the vast majority of people undergoing induction will need some form of cervical ripening. Cervical Ripening Methods Before using prostaglandins, check the contraction pattern (no more than 3 contractions in 10 minutes, averaged over 30 minutes) and consider fetal status (decels, severe FGR). Foley balloon — mechanical. Supplies: speculum, ring forceps, betadine swabs, flushes, chux. Cook catheter — mechanical double-balloon device, sometimes used with a stylet. Misoprostol (PGE₁) — oral 20–25 mcg q2h, or vaginal 25 mcg q3–6h (ACOG CPG No. 9, 2025); can be given vaginally or buccally. AVOID in prior cesarean or uterine surgery entering the cavity (e.g., myomectomy) because of uterine rupture risk. Dinoprostone (PGE₂) — vaginal insert (Cervidil) or gel. Osmotic dilators — mechanical alternative, less commonly first-line. Outpatient cervical ripening — an option in select low-risk candidates; discuss with your team. Membrane stripping/sweeping — a gloved finger sweeps over the membranes (requires partial cervical dilation) and may release natural prostaglandins. If a patient presents already ruptured and not dilated, and no balloon...

Preeclampsia complicates roughly 10% of pregnancies and accounts for up to 9% of pregnancy-related deaths in the U.S. — which makes it one of the highest-stakes diagnoses you'll manage as an intern. In this episode, Dr. Anna Jarvis walks through the hypertensive spectrum, how to get the diagnosis right, when to worry about severe features or HELLP syndrome, how to rule out the mimics, and how fast you need to move when things get acute. Resources: ACOG Practice Bulletin No. 222 — Gestational Hypertension and Preeclampsia (2020) Magee LA, Nicolaides KH, von Dadelszen P. "Preeclampsia." N Engl J Med. 2022;386:1817–1832 Sibai BM. "Imitators of Severe Preeclampsia." Obstet Gynecol. 2007;109(4):956–66 ACOG/SMFM Practice Advisory — Low-Dose Aspirin Use for Prevention of Preeclampsia (2021, reaffirmed) Topics to Review Over Time: Chronic hypertension in pregnancy: antihypertensive selection and BP targets Low-dose aspirin prophylaxis — who qualifies and when to start Eclampsia: seizure management and post-seizure stabilization Postpartum antihypertensive management and medication safety in lactation Long-term cardiovascular risk counseling after a hypertensive pregnancy disorder About the Speakers: Host: Lucy Brown, MD, MPH – Resident physician at Johns Hopkins GYN/OB. Dr. Brown is passionate about medical and resident education and will be pursuing a Fellowship in Complex Family Planning after residency. Guest Speaker: Anna Cardall Jarvis, MD – First-year Maternal-Fetal Medicine fellow at The Johns Hopkins Hospital, where she completed her residency in Obstetrics and Gynecology. Her clinical and research interests focus on hypertensive disorders of pregnancy, maternal cardiovascular disease, and improving outcomes for pregnant patients with chronic medical conditions. She is also actively involved in medical education, teaching and mentoring medical students and residents. Intern Ready: Ob/Gyn is a podcast aimed at interns and off-service residents beginning their post-graduate training in Obstetrics and Gynecology. The views expressed are the speakers' own and do not constitute medical advice.

Placing an IUD is one of the most common procedures you'll be asked to help with as an intern — and one of the easiest to feel unprepared for if you haven't reviewed the device differences ahead of time. In this episode, Dr. Lillian Chen breaks down the five IUDs you'll encounter, how their insertion mechanics differ, what changes in the postpartum and postabortion setting, and the high-yield points you're likely to be tested on. IUD Types at a Glance Mirena — LNG-IUD, 52 mg levonorgestrel, FDA-approved for 8 years (effective 8+ years), 4.4 mm tube, 6–10 cm uterine sound range. Lighter bleeding/amenorrhea common. FDA-approved for heavy menstrual bleeding (HMB). Liletta — LNG-IUD, 52 mg levonorgestrel, FDA-approved for 8 years (effective 8+ years), 4.8 mm tube, 6–10 cm uterine sound range. Lighter bleeding/amenorrhea common. Uses a different inserter than the Bayer products. Kyleena — LNG-IUD, 19.5 mg levonorgestrel, FDA-approved for 5 years, 3.8 mm tube, 6–10 cm uterine sound range. Less bleeding and less amenorrhea than Mirena; smaller frame. Skyla — LNG-IUD, 13.5 mg levonorgestrel, FDA-approved for 3 years, 3.8 mm tube, 6–10 cm uterine sound range. Regular menses more common; good option for smaller uterine cavities. Paragard — Copper T380A (hormone-free), FDA-approved for 10 years (effective 12+ years), ~4.7 mm tube, 6–9 cm uterine sound range. Heavier menses/cramping. Insertion Pearls Mirena, Kyleena, and Skyla use the Bayer one-handed slider system and have very similar deployment mechanics. Liletta has a unique loading sequence and should be reviewed separately before insertion. Paragard requires loading the arms into the insertion tube and is often considered the least intuitive inserter for trainees. Always confirm fundal placement before release. Routine antibiotic prophylaxis is not recommended. Postplacental & Postabortion Pearls Immediate postpartum insertion is safe and effective but has higher expulsion rates. IUDs can be placed immediately after first- or second-trimester abortion when no contraindication exists. Counsel patients that expulsion risk is higher after postpartum placement. Board-Style High-Yield Points Copper IUD is the most effective form of emergency contraception. LNG-IUDs reduce menstrual blood loss and dysmenorrhea. Mirena is FDA-approved for heavy menstrual bleeding. Amenorrhea rates increase with higher-dose LNG-IUDs. Same-day insertion is appropriate when pregnancy can reasonably be excluded. Resources: Mirena — Insertion and Removal Kyleena — Insertion and Removal Skyla — Insertion and Removal Liletta — Insertion and Removal Paragard — Placement and Removal ACOG Paragard Insertion Animation ACOG Kyleena Insertion Animation Topics to Review Over Time: IUD removal technique and management of a lost or malpositioned string Managing IUD-related bleeding and cramping complaints Contraindications and medical eligibility criteria (US MEC) for IUD placement Counseling on non-contraceptive benefits (HMB, dys...

Gynecologic oncology clinic can feel intimidating for a new intern — the patients are complex and the terminology is dense. In this episode, Dr. Liang breaks down the three visit types you'll encounter (new patient, chemo clearance, and surveillance), what to prechart, and what your role is as the resident in each one. Visit Type 1: New Patient Visits BEFORE CLINIC — PRECHARTING Ask: Why are they here? Confirmed cancer diagnosis (pathology in hand)? Concern for cancer only — no pathology yet? Seeking second opinion after treatment elsewhere? Hereditary cancer syndrome (Lynch, BRCA)? HPI — how did the patient present? What symptoms? Workup by primary cancer type: Uterine: endometrial sampling, TVUS, CT abdomen/pelvis Ovarian: CA-125, imaging Cervical/vulvar: Pap history, colposcopy, biopsies, LEEP, CKC Medical & surgical history — comorbidities, medications, prior abdominal surgeries Family history — relatives affected, cancer type, age at diagnosis Preventive screening — Pap, mammogram, colonoscopy up to date? DURING THE VISIT Ask the patient: what is their understanding of why they're here and of next steps? Confirm and fill in gaps from chart review Assess functional status → ECOG performance status (impacts candidacy for surgery/treatment) Exam: heart, lungs, abdomen — defer pelvic exam until attending is present "The tissue is the issue" — cancer cannot be confirmed without pathology (endometrial sampling, biopsy, or surgical pathology) Visit Type 2: Chemo Clearance Visits KEY TERMINOLOGY Cytotoxic agents (e.g., carboplatin, paclitaxel) — target rapidly dividing cells Immunotherapy / checkpoint inhibitors (e.g., pembrolizumab) — immune system targets cancer PARP inhibitors (e.g., olaparib) — prevent DNA repair; used in ovarian cancer Hormonal therapy (e.g., letrozole, an aromatase inhibitor) — for ER/PR+ tumors Adjuvant — chemo after surgery (most common) Neoadjuvant — chemo before surgery (to downsize disease; often used in advanced ovarian cancer) Maintenance therapy — additional treatment after initial surgery + chemo to delay recurrence (PARP inhibitors, bevacizumab) BEFORE THE VISIT — FOCUSED CHART REVIEW Pull up last clinic note → one-liner + oncologic summary Cancer type, stage, date of diagnosis Prior surgeries and procedures Current regimen — cycle #, date of last treatment First regimen or has there been a prior line? Review prior side effects and tolerance Labs: ANC, Hgb, Plts, Cr, electrolytes, tumor markers Imaging: no evidence of disease? Partial response? Progression? DURING THE VISIT How did they tolerate the last cycle? Ask about previously reported side effects — better or worse? Any new ones? Look up key side effects for their specific regimen ahead of time Brief ROS: fatigue, appetite, nausea/vomiting Exam: heart, lungs, abdomen Goal: confirm labs are acceptable, patient is tolerating treatment, and disease is not progressing. You are not expected to manage the regimen as a resident. Visit Type 3: Surveillance Visits PURPOSE Patients who have completed treatment and currently have no evidence of disease (NED) Monitor for signs of recurrence — frequency and duration vary by cancer type and stage Example: early-stage endometrial cancer → H&P every 3–6 months for first 2–3 years, then every 6–12 months up to 5 years BEFORE & DURING THE VISIT Use last clinic note: cancer type, surgeries/treatments, du...

Walking into your first infertility clinic visit and not sure what to expect? In this episode, Dr. Valdez-Sinon walks through the definition of infertility, how to take a thorough history for both partners, the key workup for ovulatory, tubal, uterine, and male factors, and when to refer to REI. Definition What is infertility? Failure to achieve pregnancy after 12 months of regular unprotected intercourse — for patients under 35 Shorten to 6 months for patients 35 and older Anyone 40+ should be seen as soon as they start trying — don't wait Immediate evaluation warranted for: Oligomenorrhea or amenorrhea Known uterine or tubal disease Stage III/IV endometriosis Resource: ACOG Committee Opinion No. 781 and ASRM guidelines History & Exam HISTORY — PATIENT Comprehensive medical and surgical history Menstrual history — are cycles regular? (regular cycles suggest ovulation, but ~1/3 of regular cyclers can still be anovulatory) Full GYN history — pelvic infections, STIs, known fibroids, endometriosis Prior pregnancies with previous partners? (establishes primary vs. secondary infertility) Ask about: thyroid disease, galactorrhea, hirsutism, pelvic/abdominal pain, dyspareunia Family history: developmental delay, early menopause, reproductive problems Social history: tobacco, alcohol, recreational drugs HISTORY — PARTNER Obtain medical and reproductive history — pregnancy takes two Prior pregnancies with previous partners? Intercourse frequency — ideally unprotected sex ~2x/week PHYSICAL EXAM Vitals, weight and BMI — extremes affect fertility Thyroid exam; breast exam (look for galactorrhea if indicated) Signs of androgen excess — acne, hirsutism, male-pattern hair Pelvic exam — uterine size, shape, mobility; adnexal masses or tenderness Ovarian & Ovulatory Evaluation COMMON CAUSES PCOS — most common cause of ovulatory-related infertility Primary ovarian insufficiency (POI) Thyroid disease, hyperprolactinemia WORK-UP Mid-luteal progesterone — obtain ~day 21 of a 28-day cycle; value >3 ng/mL suggests ovulation For PCOS evaluation: LH, FSH, testosterone Thyroid function studies and prolactin as indicated Ovarian reserve: Antral follicle count on early-cycle ultrasound AMH — value <1 ng/mL suggests diminished ovarian reserve A low AMH does not mean infertility — it only takes one egg. AMH estimates ovarian reserve and responsiveness to gonadotropins for IVF/oocyte preservation. TREATMENT FOR ANOVULATION Ovulation induction with clomiphene (estrogen receptor antagonist) or letrozole (aromatase inhibitor) Tubal Evaluation HSG (hysterosalpingogram) — gold standard for tubal patency Radio-opaque dye injected through cervix; X-ray visualizes "fill and spill" through tubes Low positive predictive value — non-patency needs follow-up Hydrosalpinx: salpingectomy often recommended before IVF — fluid impairs implantation Known tubal factor → IVF required for conception Uterine Evaluation Look for: polyps, fibroids, septum, adhesions (synechiae) — >16% of patients with infertility have a uterine abnormality on sono Saline infusion sonogram (SIS) — preferred over standa...

Headed into the OR for your first hysteroscopy? In this episode, we walk through everything you need to know before you scrub in — from indications and pre-op preparation to OR equipment, distension media, fluid deficit management, and how to handle complications when they arise. I. Introduction & Learning Goals Purpose: Guidance for an intern's first hysteroscopy in the OR. Objectives: Review indications, pre-op preparation, OR setup/equipment, fluid media, and complications. II. Indications for Hysteroscopy Diagnostic Hysteroscopy: Abnormal uterine bleeding (AUB) or postmenopausal bleeding Infertility workup Evaluation of abnormal imaging findings Operative Hysteroscopy: Polypectomy (removal of polyps) Myomectomy (removal of submucosal fibroids) Septum resection Lysis of adhesions (Asherman syndrome) Foreign body removal (e.g., "lost" IUD) III. Pre-Operative Preparation Chart Review Checklist: Indication: Understand the clinical reason for the procedure Imaging (US/MRI): Confirm uterine size (to avoid over-dilating) and location of pathology Comorbidities: Check cardiac, renal, and pulmonary history to set fluid management thresholds Cervical History: Assess risk for stenosis (prior procedures or menopause) Menstrual Cycle: Check current phase (bleeding can obscure visualization) Patient Counseling (Benefits & Risks): Benefits: Superior diagnostic sampling and therapeutic symptom relief Standard Risks: Pain, bleeding, infection (low risk) Specific Risks: Uterine perforation (may require laparoscopy if energy was used or if there is concern for bowel injury) IV. Equipment & OR Setup The Hysteroscope Components: Telescope: The lens (0-degree for forward viewing vs. 30-degree for lateral angles) Sheaths: Inner and outer sheaths to house the telescope and allow fluid flow Inflow/Outflow Ports: For fluid delivery and drainage (use under-the-butt drapes to catch fluid for deficit calculation) Light Source: Warning — becomes extremely hot; keep away from drapes/patient Camera System & Monitor Working Channel: For operative instruments (graspers, scissors) V. Distension Media (Fluids) Isotonic Solutions (Preferred): Normal Saline: Compatible with bipolar electrosurgery; same osmolality as blood Hypotonic Solutions: Glycine (1.5%), Sorbitol (3%), Mannitol (5%) Used only for monopolar surgery; higher risk of hyponatremia Fluid Deficit Management: Definition: The difference between fluid into the uterus vs. fluid recovered ACOG Threshold: Max 2,500 mL for isotonic; however, many surgeons stop at 1,500 mL (or 750–1,000 mL for high-risk patients) VI. Procedural Steps & Tips Cervical Dilation: Can use mechanical dilators or "hydrodilation" using fluid pressure through the scope Tenaculum Tip: Take a "sturdy bite" of the cervix to prevent tearing/lacerations Pressure Management: Keep intrauterine pressure lower than the patient's Mean Arterial Pressure (MAP) to limit fluid extravasation into the body VII. Complications Uterine Perforation: Often occurs during dilation; recognized by a "loss of resistance" Fluid Overload: Can lead to hyponatremia, distributive shock, or flash pulmonary edema Hemorrhage: More common in operative cases (3% for myomectomy); manage with massage, uterotonics, or intrauterine balloons Vasovagal Reaction: Can occur during cervical manipulation or distensio...

Fetal therapy is a subspecialty of maternal-fetal medicine focused on treating fetal disease before birth — from prenatal cures (anemia, TTTS) to improving outcomes (myelomeningocele, CDH), optimizing conditions at birth, and transplacental therapy (SVT, congenital heart block). In this episode, Dr. Michelle Kush walks us through the major fetal therapy procedures you may encounter as an OB/GYN resident and what your role will be. Topics Covered: What Is Fetal Therapy? – Subspecialty of MFM treating fetal conditions before birth. Contact the fetal therapy team at 844-543-3825. Fetal Anemia and Intrauterine Transfusion Busiest fetal transfusion center in the Mid-Atlantic (600+ transfusions to date). Most common indications: alloimmunization, parvovirus infection, hydrops/hereditary spherocytosis. Performed on L&D once fetus reaches viability, with betamethasone course completed. Risks: preterm labor, PROM, fetal bradycardia, emergent delivery (<1%). General care path: arrive → H&P → OB anesthesiology → NPO, IVF, continuous fetal monitoring → transfusion (usually in triage room) with OR, anesthesiology, and NICU on standby. Post-transfusion: Continuous monitoring (fetus is paralyzed — change mother's position for decels). Advance to clears at 1 hour if no contractions and reassuring tracing. Earliest discharge at 2 hours if Category I tracing and fetal movements have returned. Twin-to-Twin Transfusion Syndrome (TTTS) Occurs in monochorionic pregnancies — unequal sharing of volume between donor and recipient twins. Fetoscopic laser ablation of placental vascular anastomoses offered for Stage 2+ (or progressing Stage 1), performed 16–26+6 weeks. Risks: preterm labor, PROM, membrane separation, demise of one or both fetuses, bleeding, maternal transfusion (<2%). Pre-op: consents in the Center, H&P, OB anesthesiology, NPO, IVF, Foley catheter prior to OR. Post-op: magnesium 2 g/hr (titrate up by 0.5 g/hr for >6 contractions/hr). POD 1: stop mag, remove Foley, AM CBC, regular diet, ultrasound in Center, may discharge home. Myelomeningocele (MMC) Closure Performed 24–26 weeks for isolated anomaly with normal genetics (open or fetoscopic approach). MOMs trial showed: less hindbrain herniation, decreased/delayed shunt placement, improved ambulation at 30 months. Maternal risks: preterm delivery, PROM, uterine incision complications. Admit night prior. Morning of: A-line placed, indomethacin at 6 AM, magnesium started, Foley placed. Post-op: highest risk for pulmonary edema — strict I&O, incentive spirometry is a must, continuous fetal monitoring, epidural for pain, SCDs in place. If concerns: see the patient, listen to lungs, check I&O, and CALL. POD 1: AM labs (CBC, CMP), continue indomethacin/heparin/SCDs/IS. Remove A-line if all agree. Mag and Foley discontinued. Transition to PO pain control (Tylenol, Dilaudid, gabapentin, Flexeril, abdominal binder). Fetal Arrhythmias and Transplacental Therapy Most common admission: fetal SVT (FHR >180 bpm for more than 10% of observation time). Indications for transplacental therapy: tachycardia ≥180 bpm with biphasic DV, tachycardia ≥280 bpm regardless of duration, or SVT with fetal hydrops. May need 24 hours of continuous monitoring to determine if transplacental therapy is needed. Risk for hydrops and fetal death. Most commonly treated with flecainide; additional agents include digoxin and amiodarone. Maternal baseline: EKG and CMP with ionized Ca, then continuous cardiac monitoring while initiating. Must have normal EKG indices (PR ≤0.2 sec, QRS ≤0.12 sec, QTc ≤0.47 sec).<...

Your first Labor & Delivery triage shift is coming up — here's how to handle it. In this episode, we walk through the full workflow: from chart-checking a patient before you walk in the room, to gathering a focused history, performing your exam, staffing efficiently, and writing a solid triage note. Topics Covered: Where to Start Chart check the patient — age, parity, gestational age, medical and OB problems. Confirm dating with your own eyes. Trust but verify. Skim prior encounters for chronic conditions and what's worked before. Check if they're up to date on routine OB care (e.g., GBS swab at 36 weeks). Start a note using premade templates to save time. Bring your ultrasound, stethoscope, mask, and something to keep notes. If the patient is on the NST, don't wait for it to complete before performing your sono. Gather a focused but detailed history, then do a focused physical exam. Perform a pelvic exam as indicated (with patient consent), with or without your chief. Most Common Chief Complaints Rule out labor / preterm labor, general abdominal pain Rule out PPROM / SROM Decreased fetal movement (DFM) Rule out PIH / preeclampsia Vaginal bleeding/spotting or abnormal discharge Urinary symptoms, nausea/vomiting, constipation, headaches, URI symptoms How to Staff Gather all data before staffing — evaluate the NST, review your slides, listen to lungs if needed. Follow the standard SOAP format: Age, parity, GA, chief complaint → HPI → vitals, PE (including SSE/SVE) → your plan. Think through: labs needed, ECG, formal sono, how long to monitor pressures, admission vs. discharge, and whether other services need to be consulted. Your plan doesn't need to be 100% right — that's what intern year is for. Track patterns so you can apply them next time. Closing the Loop with the Patient – Update them as things progress. If you don't know the answer, say so, then find out (UpToDate, Open Evidence, institutional resources, your chief/senior). Writing Your Triage Note – Thorough but concise. Think through the differential. Update the note as labs return and the plan is finalized. Use dictation or EMR AI tools. Have your chief review notes the first few weeks. After the Visit – Update the patient's problem list with any new diagnoses (e.g., pyelonephritis, gestational hypertension). About the Speakers: Host: Lucy Brown, MD, MPH – Resident physician at Johns Hopkins GYN/OB. Dr. Brown is passionate about medical and resident education and will be pursuing a Fellowship in Complex Family Planning after residency. Guest Speaker: Ore Afon, MD – Gyn/Ob resident at Johns Hopkins Hospital. She attended Cornell University for undergrad and graduated from the University of Toledo College of Medicine & Life Sciences. Intern Ready: Ob/Gyn is a podcast aimed at interns and off-service residents beginning their post-graduate training in Obstetrics and Gynecology. The views expressed are the speakers' own and do not constitute medical advice.

Join this episode to learn about postmenopausal bleeding (PMB) — the incidence, the etiologies, and the diagnostic approach to a patient presenting with uterine bleeding after menopause. A special focus is placed on endometrial hyperplasia and endometrial malignancy, including associated risk factors and the use of transvaginal ultrasound and endometrial sampling in the evaluation. Critical evaluation of PMB is important as the leading concern is cancer until proven otherwise in this patient population. Keywords: Postmenopausal bleeding, Transvaginal ultrasound, Endometrial hyperplasia, Endometrial malignancy/cancer, Endometrial sampling Topics Covered: Overview of PMB – Definition, incidence (5% of office GYN visits, 4–11% of menopausal patients), and why the leading concern is endometrial cancer until proven otherwise. Etiologies Polyp (~35%) – Localized overgrowths stimulated by estrogen; mostly benign but higher concern for malignancy/hyperplasia in PMB patients. Atrophy (~30%) – Low estrogen leads to endometrial/vaginal atrophy, micro-erosions, and spotting. Uterine Fibroid (~5%) – Less common postmenopausally; if a PMB patient has fibroids, still assume endometrial pathology. Endometrial Carcinoma (6–14%) – Most common gynecologic cancer in the U.S. Type I (estrogen-driven, favorable prognosis) vs. Type II (high-grade, aggressive). Endometrial Hyperplasia (with and without atypia) – May coexist with or progress to carcinoma in 30–50% of cases. Other causes – Proliferative/secretory endometrium, medications (HRT, anticoagulants, tamoxifen, SSRIs), post-radiation, infection, and non-uterine sources. Risk Factors for Malignancy – Increasing age, obesity, unopposed estrogen, tamoxifen, early menarche, late menopause, nulliparity, PCOS, Type 2 DM, Lynch syndrome, Cowden syndrome, and family history. Diagnostic Approach History and physical exam Transvaginal ultrasound (TVUS) – Endometrial thickness measurement; normal <4 mm in postmenopausal women; sensitivity 94–97%. Endometrial sampling – In-office EMB vs. OR-based hysteroscopy with D&C, including benefits, risks, and how to choose. Follow-Up and When to Refer – Management by pathology result, when to proceed to HSC D&C, and indications for Gyn Oncology referral. Resources: UpToDate: Approach to the Patient with Postmenopausal Uterine Bleeding ACOG Committee Opinion: The Role of Transvaginal Ultrasound in Evaluating the Endometrium of Women with Postmenopausal Bleeding ACOG Clinical Consensus: Management of Endometrial Intraepithelial Neoplasia or Atypical Endometrial Hyperplasia APGO Topic #54: Endometrial Hyperplasia and Carcinoma ASCCP Cervical Cancer Screening Guidelines About the Speakers: Host: Lucy Brown, MD, MPH – Resident physician at Johns Hopkins GYN/OB. Dr. Brown is passionate about medical and resident education and will be pursuing a Fellowship in Complex Family Planning after residency. Guest Speaker: Emily Stock, MD – Chief...