In gynecologic surgery, surgeons are expected to acquire high levels of experience before performing surgeries, but they need to perform surgeries in order to gain experience. One proposed solution to this paradox is using surgical simulators. Here, four physicians discuss the merits of incorporating simulators into surgical training.

Ms. Wetzel: How do surgical simulators work and can they take the place of actual surgical procedures in training and certification? 

: I think simulators have potential to be very useful in training. Low-fidelity simulators-box trainers-are perfectly adequate but the science of simulation is somewhat lacking. Studies show that learner skills do improve after practice with a simulator, compared with results prior to use of the technology.

 To me, that’s not very surprising. I would be much more interested in knowing whether learners retain knowledge and skills gained from simulators over the long term and if that translates into superior clinical outcomes. Those are important questions and I understand that in medicine, we use intermediate outcomes for teachability sake, but I think we need better science in simulation.

Using simulation technology to reduce maternal morbidity

: I agree that the science needs to be better. Many people think that surgical simulation means going into a virtual environment and simulating an entire operation.  However, we are nowhere close to having realistic immersive simulation in which a learner can actually work on a virtual patient with a spectrum of virtual anatomical and pathological circumstances. Instead much of what we have is simple technology that simulates parts of the task or skill that we believe are useful, circumstances that may reflect something about the physical abilities of the individual. And this sort of simulation doesn’t take into account surgical judgment. Truly meaningful outcomes with simulation would include the impact of simulation-based training on safety, efficacy, quality of life, cost reduction, or some combination of those. But assessing these outcomes would be quite expensive. So important questions facing us right now include: Who are the stakeholders for surgical simulation and where is the funding going to come from to study real-world outcomes?

: I have a different perspective on simulation. Simulations are not going to create the surgeon but they can help enhance hand/eye coordination and ambidextrous surgery, among other things, and facilitate the learning curve and help with team-building and managing complications. I believe that the value of simulation lies in shortening the learning curve for the learner and providing a safe environment in which it’s permissible to make mistakes, explore what went wrong, and ask questions.

: Where possible, we also have to try to determine outcomes for simulation training that are meaningful and that will guide us in designing the technology and the way in which it’s used. Simulation is a part of an overall change in the training paradigm that spans a range of components of care such as determining who to operate on and how the surgeon should be prepared to execute the technical aspects of performing the procedures. Our disease state management is basically that of uterine and adnexal disease so our training has to be in that context.

Ms. Wetzel: What kind of simulators are currently available and what do practitioners need to know about using them? Which simulators do you prefer and why? 

: A lot of different simulators are available. The simplest are low-fidelity trainers that are basically a box with a small camera and a light, into which instruments can be placed to practice. The box trainer most widely used right now is the 

And then you have virtual reality (VR) trainers that try to simulate more procedures than the actual intraoperative environment.

 I really like the box trainers because they’re relatively inexpensive and can be used in different places and under varying conditions to gain dexterity and experience with techniques such as intracorporeal and extracorporeal mopping. Developing VR trainers that are meaningful is money- and resource-intensive. We had a VR trainer at our simulation center and every time I used the ectopic pregnancy module, the patient bled to death. I’ve never had a patient bleed to death in real life from an ectopic pregnancy. So, I think that there’s still some developmental work that needs to be done on VR surgical trainers.

: I think the first consideration is framing what is it that you’re simulating. In gynecologic surgery, we have abdominal access, both laparotomic and laparoscopic approaches, the latter done with and without microprocessor assistance. Vaginal approaches include hysteroscopic technique and surgery on the cervix and, hysterectomy when removal of the uterus is necessary. Should all of those aspects be simulated for residency training? The 

American Board of Obstetrics and Gynecology

 (ABOG) has acknowledged the importance of simulation-based training in laparoscopy by requiring that residents in obstetrics and gynecology graduating after May 31, 2020 pass the 

 (FLS) examinations developed jointly by the 

Society of American Gastrointestinal and Endoscopic Surgeons

. Many residency programs, however, have trouble affording a surgical simulator unless it’s inexpensive. But there is really no evidence that VR laparoscopy trainers do a better job at what is being measured than the low-fidelity systems.

On the hysteroscopy side, VR is actually more realistic and more attainable. There are a number of quite decent VR systems for hysteroscopy and one of the reasons that it’s easier to engineer those in that the environment is like being in a small room. In the laparoscopy environment, in contrast, you have to simulate interaction with the bowel and the level of complexity is exponentially greater. Simulation is hardly being done for vaginal hysterectomy and it remains a very low morbidity procedure with no abdominal incisions, but one that requires certain skills. Simulation should be considered for the multiple approaches to and processes associated with vaginal hysteroscopy to see what the likely benefit of the procedure might be. We’ve examined two low-fidelity surgical simulation systems-one for hysteroscopy and one for laparoscopy. Both can be used reasonably well by novices, mid-level trainees, people without extra training in gynecologic surgery, and people who have done a 2-year fellowship in it. Low-fidelity simulation is quite feasible, and quite usable.

: If we’re going to devise surgical simulation, first we need to determine its goal. If we’re looking at training for depth perception, hand-to-hand coordination and ambidexterity, which are the basic principles of surgery, I believe that low-fidelity simulators are always the best. What they lack is the feel of real tissue and plane dissection. The latter can be learned by watching realistic videos. I think virtual simulation has a role if we’re looking at the efficiency of movements and how to maximize it. Calculations can be done about the number of unnecessary moves to establish how efficient a surgeon is.  

But virtual simulations are being marketed as depicting procedures so super-realistic that training on them will give someone the ability to do the real surgery in real life. But they’re very far away from reality in many metrics. I think each simulator adds something but we need a combination of them. For example, using a bell pepper for hysteroscopy, chicken for laparoscopy, and beef tongue for suturing or tissue extraction are really very valuable in terms of immersing trainees in actively performing surgical steps on real tissue.

: A few years ago, we started a research project with our insurance carrier with the eventual goal of trying to find a simulator for use for credentialing or for continuation of privileges. We tried a lot of simulators and decided on the 

 simulator because we thought it was as close to real life, at that time, as we could find. But, there’s really nothing that mimics real surgery, although some of the newer simulators have tactile feedback. My perception is that simulation is good for learning the steps of a procedure, and it may help people who didn’t grow up playing video games to develop the hand/eye coordination necessary for laparoscopy.   However, we’re far from using it learn the intricacies of surgery and create talented surgeons. Things like tissue planes, which experienced surgeons see innately don’t really exist within simulation at this point. 

The role of simulation training for ob/gyns

: I think we may potentially be able to use simulation to help identify who should or shouldn’t be admitted to surgical training programs. Ability to use a surgical simulator could be a criterion for entry, either into residency or into a fellowship. For years now, in North America, dentists have had to demonstrate manual dexterity in order to get into dental school. I don’t know what evidence the dentists had when that criterion was introduced, but it doesn’t matter how smart you are if you can’t do a good job with manual skills. Simulation-based testing also could function as a formative examination for surgical skill, a skill-based component of the CREOG in-training exam (ITE). The ITE is administered to residents annually to evaluate their cognitive knowledge but we have no equivalent for surgery. As was previously mentioned, ABOG will now be requiring that residents in obstetrics and gynecology pass the FLS examinations that were designed for general surgeons. But the only component of gynecologic surgery that’s tested under FLS is laparoscopy and, if we’re restricted to that, then we’re creating one-arm surgeons. There is no testing for hysteroscopy, vaginal surgery, or laparotomy. Maintenance of certification also is another possibility for simulation-based testing. And simulation could be used to train gynecologists on use of new equipment and new techniques that are introduced, much as is done by the US military or in civil aviation. For example when new fighter aircraft are built, training and credentialing systems also are created for that machinery and are used as critical and essential hurdles to the overall process of certification. In my opinion surgical simulation based training and testing should ultimately be used in a similar fashion for surgeons of any discipline. 

: I think the simulators that offer the biggest bang for the buck, so to speak, are the low-fidelity simulators, which could be used to help residents pass the FLS test that will soon be a requirement for graduation. I think both graduating residents and physicians in practice should become familiar with the low-fidelity simulators. They should be made available in every ob/gyn residency program rather than virtual reality trainers, which are more expensive.

: A number of inexpensive and portable low-fidelity simulators are available that incorporate iPhones or iPads as the camera and light source, in a fashion that allows for and supports manual skills training.  They aren’t exactly the FLS trainer that we’ve talked about, but they can be accessible to anyone who wants to learn or hone manual skills. 

: When I was a resident, I made my own simulator out of a cardboard box, a video camera - there were no iPhones then - and a flashlight.  And it worked quite well. So a simulator doesn’t have to be very fancy to be useful.

: I completely agree. I really don’t feel like we’ve come very far with simulation in the last 15 years or 20 years, because the devices we have are still just teaching the basic tools. The fancy simulators can walk you through the steps of a procedure, but you’re really still just using the basic tools of surgery. Simulators don’t create great surgeons but they can give you the simple tools that you need to then become a great surgeon.

: I feel that simulation could play a role in recertification, but unfortunately, recertification is now based on volume rather than multiple metrics that could lead to better outcome. The other thing we need to work on is the whole system. Recertification should enable us to triage people who would benefit the most from simulation or from a specific aspect of simulation to better their skills and make them have better surgical outcomes.

Ms. Wetzel: What other options for simulation are on the horizon and do you see simulators being integrated more completely into your own clinical practices?

: I think that the most exciting thing that’s on the horizon is really the launch of the Essentials in Minimally Invasive Gynecology (EMIG) test, which has been in development for some time now by 

. EMIG is a three-part program designed to aid and evaluate the acquisition of manual and cognitive skills in hysteroscopic and laparoscopic surgery. It includes a curriculum, written examination, and manual skills test. I hope EMIG will be integrated into clinical practice in the near future and hopefully represent a minimum standard of proficiency in hysteroscopy and laparoscopy that providers should have to meet to have the privilege of operating on patients.

: The laparoscopic component of EMIG is performed the FLS box trainer, with exercise and instructions that have been adapted in a way that we believe is appropriate for gynecologic trainees - from novices to mid-level trainees to board-certified ob/gyns and also those who are training for FMIGS and other surgical fellowships. We’ve also created a relatively simple box trainer for hysteroscopy but we’re still challenged by the expenses of having the scope, light source, and camera, and there is currently no way to adapt the trainer for the iPhone or similar easily accessible monitors. We don’t yet have a simulator for laparotomic or vaginal surgery. Hysteroscopy is strikingly missing from a lot of the discussions about simulation on a national level – an omission which is concerning. It is lesions in the endometrial cavity such as polyps and myomas that most often are responsible for infertility and abnormal uterine bleeding, and the hysteroscopic surgeon is the one often best equipped to deal with them in a minimally invasive fashion. And of course, the hysteroscopic surgeon and the laparoscopic surgeon should be one and the same, making decisions on the technique based upon optimal training and skill rather than what they are comfortable with based on limited training. As Dr. Einarsson has said, gynecologic surgeons need to be adept at hysteroscopic, laparoscopic, and vaginal procedures to call themselves gynecologic surgeons. So, the next step in introducing simulation to our trainees is to make them applicable to the two endoscopic approaches we use.

: For me the only way I see simulation getting integrated into clinical practice is for surgeons who don’t operate very much. For high-volume surgeons, simulation in its current state, which is really not very lifelike, doesn’t help us in our clinical practice. But for surgeons who do a dozen cases a year, simulation may be helpful in credentialing or assessing whether to continue privileges. For those low-volume surgeons, I would see simulation as part of their clinical practice in maintenance of skills.  

: Where I see simulation, not only for the novice surgeon but also for the experienced surgeon, is integration of case-specific simulation. For example, anatomy could be reconstructed in three dimensions (3D) based on imaging and then the trainer, the mentor and the learner could use it to review that specific case. We might use it to simulate models for incision of fibroids or to test scenarios for addressing a complex case in a different way. In the future, 3D printing and reconstruction combined with case-specific simulation may prove very helpful before the case itself.

: I agree. There are certain circumstances in which a case may be so challenging that 3D reconstruction could help identify who you need in the room, what resources, and even where to dissect. For example, for complex neurosurgery, surgeons are increasingly using 3D reconstruction using of MRI volumes and 3D printers have been used to assess vascularity and other factors, allowing the surgeons to understand how to dissect in a very difficult field.  As Dr. Ascher-Walsh said, we aren’t even remotely close to that but I think one of the potential advantages of a true virtual reality immersive experience, is the opportunity to actually practice the operation and be a little bit closer to what happens, like commercial or fighter aircraft simulation, where it really is a realistic immersive experience. In fact, the simulation systems for fighter aircraft are so sophisticated, that training planes are no longer made – the pilot goes straight from the simulator to solo flying in aircraft worth hundreds of millions of dollars.

: Until we are there, I think using low-fidelity simulators and watching videos can be very, very helpful for surgeons. I want to put a small plug in for the SurgeryU platform that the AAGL has developed. It has a lot of very high-quality surgical videos that AAGL members can access. There are other sources of surgical videos available as well. I think that those two components are most easily accessible currently and then hopefully this will evolve into a more sophisticated offering in the near future or maybe the far future.

: To go back to the EMIG program, I’d like to emphasize that it isn’t just manual skills. There is an entire cognitive program that comprises 80 training videos which encompass the spectrum of hysteroscopic and laparoscopic surgery procedures and patient preparation. There is an accompanying didactive component is designed to measure judgment that will be mounted on the AAGL’s 

. The cognitive exam that has been validated and, in an ongoing fashion is modified and revalidated using high quality, psychometrician supported methodology. This examination, meant to evaluate judgement, is paired with the manual skills exam to provide an overall assessment of progress. So the EMIG system is more comprehensive than just an assessment of manual skills.

Ms. Wetzel: In conclusion, please sum up for our readers where you see surgical simulation today and what’s on the horizon in terms of simulation science.

: Simulation is still somewhat in its infancy. The low-fidelity simulators are the most easily usable and are probably going to be more integrated with the FLS test and then hopefully the EMIG test. I think we need better science and also probably better technology in the area of surgical simulation. 

: The most important point about surgical simulation, for me, is that use of simulation in isolation from any teaching method will furnish the learner with some skills but the best time and place to learn most of the skills will still be the traditional way, in the operating room (OR). In addition, surgical judgment is really hard to learn and I think simulation could provide a safe environment in which to learn how things can go wrong and how to readdress them. Simulation could help gynecologic surgeons build  confidence to enable you to apply those kind of competencies in a real OR.

: Where we’ve had some early success with simulation is in establishing credentialing. We’ve done some projects with a very large health system looking at a few hundred attendings and correlating their surgical skills on the simulator with their case experience. We were able to find some correlation between the two and we’re now comparing it to actual surgical videos with the hope of being able to use it as a credentialing tool. I think, as everybody else was saying, we’re sort of far away in using simulation as an advanced surgical training tool. I agree that the low-fidelity simulators are the best tools for the surgeon early in training. For low-volume surgeons, it also may be a way to maintain their skills. I hope that in the next decade, as the science improves, we’ll be able to have more realistic simulation, but we’re not there now.

: In gynecology, we are awakening to the notion that we have an increasingly complex challenge in the disease states that we are entrusted to manage. That challenge has to be taken into consideration when developing a structured approach to training and evaluation of residents and fellows at a spectrum of benchmark times in the training process. It’s both a moral and legal imperative. We need to improve how we train gynecologic surgeons, and simulation is only  part of the answer. Right now, simulation is only a nascent adjunct to training, and, at least in present forms, the low-fidelity simulators are at least equivalent to expensive virtual reality systems. The future requires science, investment, creativity, and an understanding that ultimately the patient expects that her physician and surgeon have a consistent and predictable level of skills. The patient’s level of trust should be similar to that vested in the pilot of the commercial aircraft of her selected airline. Finally, simulation isn’t just for laparoscopy. Simulation and surgical training involves hysteroscopic, laparoscopic, laparotomic and vaginal approaches, because all are essential skills for the contemporary gynecological surgeon.

The participants report no potential conflicts of interest with regard to this article.

Alaker M, Wynn GR, Arulampalam T. Virtual reality training in laparoscopic surgery: A systematic review & meta-analysis. Int J Surg. 2016 May;29:85-94.

https://fls-products.com/fls/search/?searchTerm=fls-trainer-box-with-tv-camera-with-tasks

https://simbionix.com/simulators/lap-mentor/lap-mentor-vr-or/

Munro MG, Brown AN, Saadat S, et al. Essentials in minimally invasive gynecology manual skills pilot validation trial. J Minim Invasive Gynecol. 2019 Apr 26. pii: S1553-4650(19)30205-5.

Articles

Four ob/gyns discuss the merits of surgical simulators and what kind of future is in store for the tools.

What is the role of surgical simulators?

Artificial intelligence (AI) is already all around us in our daily lives. It enables smart phones to sort our pictures based on face recognition algorithms, it helps Google guess what you‘re going to search for the second you start typing and it helps Uber figure out what you are willing to pay for various services. 


	AI is also entering medicine. That is, in part, enabled by the large amount of high-resolution digital data that are collected in electronic medical records and from images, genetic screening, and laboratory tests. The other vital component is the ever-increasing capacity of computers to analyze large amounts of data and create a solution on their own, a process called machine learning. Once implemented, machine learning algorithms can continuously improve their performance by using outcomes to improve the fit of the model. These methods have the potential to help with diagnostic accuracy, outcome prediction, cost-effectiveness assessment, and real-time decision-making in surgery.

Can AI improve accuracy and efficiency of mammography?

Han et al discuss use of AI in ob/gyn ultrasound

 As they point out, AI is especially helpful in image detection and automation. It has the potential to reduce clinician errors and help detect rare anomalies, especially among less skilled providers, thereby reducing clinician variability in terms of performance. AI also has a lot of other potential applications in our field and in all of medicine. A recent systematic review identified nine articles that spanned multiple medical subjects, including retinal diseases, skin cancers, pulmonary nodules, and brain tumors.

All of these articles compared the performance of clinicians and AI and found a consistent theme. Current AI algorithm development has a diagnostic performance comparable to that of medical experts, especially in image recognition-related fields. This is especially impressive, given how fairly recently AI has been applied to medical decision-making. It seems inevitable that this technology will improve rapidly over the next few years, which should improve accuracy significantly. 


	This does not mean that clinicians are not needed anymore. AI is not meant to replace clinicians (at least not yet), but rather, to augment their diagnostic and therapeutic capacity. One of the major concerns for using AI in medicine is the lack of transparency about how decisions are generated and the inherent risk of bias if the training database is skewed. Some recent advances in the field aim to mitigate those risks. For example, some of the newest diagnostic machine learning algorithms are able to create saliency maps, which identify the parts of  the image that contributed the most to the diagnosis. 

These AI-powered modalities will increasingly help physicians in their daily tasks in the clinic and lab and also potentially in the operating room. Because most surgeries are now image-based, i.e., either laparoscopic or robotic, there is ample opportunity to use neural networks and machine learning to identify patterns in how surgeons perform procedures and potentially alert them if they are diverting off course. It seems likely that this technology will be incorporated into surgical suites in the not-so-distant future. The increasing incorporation of AI into medicine has the promise to improve patient care and patient outcomes and it merits careful exploration and study. 

Datkhaeva I, Han CS. Artificial intelligence in ob/gyn ultrasound. Contemp Ob/Gyn. 2019;64(10):XX.

Shen J, Zhang CJP, Jiang B, et al. Artificial intelligence versus clinicians in disease diagnosis: systematic review. JMIR Med Inform. 2019 Aug 16;7(3):e10010.

As artificial intelligence increases its presence in medicine, ob/gyns are welcoming the technology with both excitement and trepidation.

AI: Coming to a clinical scenario near you

"Facts” about women’s health that are simply untrue can wreak havoc with the doctor/patient relationship but ob/gyns can help protect women from taking clickbait.

The term “fake news” has dominated our political landscape for the past 3 years, but it has a long and infamous history. The “yellow journalism” that infested the coastal cities in New York and California at the turn of the 20th century was 

 to have led to the US entry into the Spanish-American War.

 The remnants of this type of sensational print reporting can still be seen in supermarket tabloids, with ludicrous headlines about alien abductions and other nonsense. 

The new normal for many of us is that we get our daily information about the world around us from our personal computers, those devices that are always, always attached to us and that can also make phone calls. The sites from which we seek information often require minimal to no verification. To continue to exist, they must maximize their “hits” to generate advertising revenue. The site and the advertisers, depending upon exactly how we have logged in, next use our pattern of clicks to feed us more and more information geared to our apparent personal tastes, as deciphered by a machine-learning algorithm. The eventual result is a barrage of information that contains variable and unknown amounts of disinformation-”fake news”-that we either sift through and try to verify (very rarely), accept and await verification from a second source (hazardous when your content is being curated by a computer that is trying to give you what it thinks you want see), or sink into a funk of cynicism and disbelief of everything and disengage (common response). 

Our inherent belief in our rational ability to sort information, especially when it is now vast and readily accessible, is not well founded.

 We are, therefore, all vulnerable to defective processing and acquisition of “facts” that are simply untrue. As we become further and further insulated within our Internet-curated bubble of beliefs, we may also choose to call unwanted information feeds “fake news” even when they are true, because they don’t appear representative of all else we have been reading. Clearly, the hazards of these patterns of behavior are evident in many walks of life and are considered responsible for our current deeply divided political atmosphere.  

Obstetrics and gynecology is a very personal and powerful field. We are privy to the most private details of our patients’ lives and have the ability to influence future generations with actions that we take today. The trust relationship that we have with our patients is essential to our effectiveness. The ability of fake news to wreak havoc with this trust relationship is a threat to our life’s work that can be, at times, simply annoying, but can take some very negative turns. What follows are a few examples that illustrate “fake news” in its various forms. 

1. Women no longer have to endure the ravages of menopause! (Part 1) 

 touting a new medical procedure that “could delay menopause by 20 years”.

 Two smiling, jogging midlife women are shown. The procedure promises to improve women’s lives by “delaying the onset of more common symptoms of the menopause, which range from low mood, anxiety and difficulty sleeping, to hot flushes, night sweats and a reduced sex drive.” But that’s not all! “Doctors claim the operation could benefit thousands of women who experience serious health problems, such as heart conditions and bone-weakening osteoporosis, that are brought on by the menopause.”

Wait, what?!? Something has gone wrong in the worldwide race for clicks if we are talking about creating a world where menopause occurs at age 70+.  Prolonged lifetime exposure to estradiol and progesterone is associated with increased risks of breast and endometrial cancer-risks that have been appreciated for many decades.

 Cardioprotection from extended ovarian function is far from proven. How can a responsible news source overstate the benefits of such a procedure? How many women would-seriously-want to undergo ovarian transplantation, which includes two surgical procedures, to delay menopause? What if the ovaries are replaced in a position where they might result in pregnancy? And decades more of menstrual periods? Ahem, no thank you.

2. Women no longer have to endure the ravages of menopause! (Part 2) 


	The Wonderful World of “Bioidentical Hormones” is another area where “fake news” abounds unfettered by any reality. Due to the lack of regulation and oversight for compounded hormones (which were exempted from being considered pharmaceuticals but rather are considered dietary supplements, thanks to the 

Dietary Supplement Health and Education Act of 1994

-thank you, Senator Orrin Hatch), there is almost no need whatsoever to provide any proof of claim, and penalties for false advertising are rarely imposed. Here are some claims made by various websites:

Synthetic hormones have a variety of negative side effects, but our approach to bioidentical hormone therapy, also known as BHRT, can help you avoid these.

Many women begin to feel the negative effects of hormone imbalances years before menopause…Our goal is to relieve the unwanted symptoms of aging caused when hormone levels are unbalanced.

Wait, what??!!?? The “bioidentical hormone” (BHRT) industry is arguably the first and one of the most effective “fake news” enterprises in medicine. Capitalizing on the wake of the 

 (WHI), which debunked the myth that estrogen and progesterone were powerful anti-aging drugs and would prevent disease, a proliferation of alternatives were born, reinventing the myth by claiming that the hormones used in the WHI were simply the wrong hormones, and the alternative products being sold had no such side effects and would, indeed, prevent aging. This marketing has been so effective that it is estimated that BHRT is currently one-third to half of the national use of menopausal hormone therapy.

3. HPV vaccines are bad for you…and the medical establishment is covering up! 

 is one of the most effective weapons in the medical armamentarium against cervical cancer, and has already demonstrated unanticipated benefits in reducing anal and oral cancers. The perfect storm of “anti-vaxxers” and religious conservative forces, who fear that vaccinating a young woman against HPV will encourage sexual promiscuity, has impeded the effective implementation and widespread use of this life-saving strategy, aided and abetted by “fake news”-some of which is promulgated by politicians.

The digital era has made the rapid propagation of “fake news” more efficient than ever. By offering up emotionally charged campaigns, based on powerful anecdotes that are repeated over and over again, fake news gets our attention.  Logic and facts are, well, boring when pitted against sensational clickbait. Truth gets replaced with “truthiness”: something that seems or feels like it is true (thank you, Stephen Colbert), so we just go with it. 

How can we and our patients protect ourselves from the clickbait?

. Direct your patients to reputable sources of information at the outset of a web search. Rather than reading the first item that comes up, assuming it is the most important one, it helps to bookmark reputable websites. The American College of Obstetricians and Gynecologists, of course, is an outstanding resource, as are the Centers for Disease Control and National Institutes of Health. Many academic medical centers have readily accessible web posts on a broad range of topics in women’s health. For specialty information, the 

American Society for Reproductive Medicine

American Society for Gynecologic Oncology

 provide excellent, fact-based information.

Reiterate the principles of critical thinking

. Educate your patients on how to tell if a source is reliable. Are the data referenced and peer reviewed?  Are clinical studies described? If they are described, were the studies registered under 

? Are the authors in the bibliography of a scientific piece all the same, small group of authors? This suggests an internally concatenating alternative reality may be behind the thinking. 

. I like to provide my patients with specific information sources on sensitive topics prone to disinformation campaigns.  I anticipate that they will be consulting “Dr. Google” as soon as they leave my office. If you have an electronic medical record, you can create dot phrases for commonly asked questions and avoid rewriting this for every similar patient scenario. Having patient education materials available in your office waiting room can also be an effective way to direct your patients to reliable sources of information.

. Highlight for your patients some of the more outrageous examples of viral information that were subsequently proven to be untrue (e.g., the Hillary Pizzagate Conspiracy), and alert them to be critical of stories that elicit a strong emotional response. Give them tools to sort out the real from the fake (

 is an excellent website for this purpose).

Like it or not, the information highway of the Internet can be a “disinformation highway” that is not under our control, but it is here to stay. Alerting patients to the pitfalls inherent in information access in this era of plentiful information may make them better at sorting it out. And like it or not, that task has now become part of our daily work if we are to promote the health of our patients. I’m off to check my Facebook feed for the week, and I hope I won’t be accosted by too many trolls! 

The author reports no potential conflicts of interest with regard to this article.

Campbell JW. Yellow Journalism: Puncturing the myths, defining the legacies. 2001; 

Ludolph R, Allam A, Schultz PJ. Manipulating Google’s knowledge graph box to counter biased information processing during an online search on vaccination: application of a technological debiasing strategy. 

https://www.theguardian.com/science/2019/aug/04/medical-procedure-delay-menopause

Ketcham AS, Sindelar WF.  Risk factors in breast cancer. 

MacMahon B. Risk factors for endometrial cancer. 

https://www.biotemedical.com/bioidentical-hormone-replacement-pellet-therapy/?gclid=EAIaIQobChMIxOzulJ-K5AIVmSCtBh3dVgMZEAAYASAAEgK3u_D_BwE

https://www.royalmedicalcenters.com/non-menopausal-women-menopause-menopause-age-early-menopause/

Pinkerton JV, Santoro N. Compounded bioidentical hormone therapy: identifying use trends and knowledge gaps among US women. 

Teoh D. The power of social media for HPV vaccination--not fake news! 

As patients are exposed to more and more misinformation, ob/gyns have a responsibility to not just treat but also educate.

Fake news in ob/gyn

Women with no significant medical history have many medically appropriate forms of contraception from which to choose. The options narrow when counseling a woman with episodic or chronic health conditions such as headache disorders. Hormonal options are the most widely used forms of contraception among US women; over 40% of women aged 15 to 44 use hormone-containing forms of birth control, including the pill, intrauterine device, implant, injectable, ring, or patch.

 With up to 20% of reproductive-aged women affected by migraine, it is important for ob/gyns to understand the risks and benefits of contraceptive hormone use in this population.

Migraine must be distinguished from other types of headaches, such as tension-type headache,  prior to contraceptive counseling (Table 1). Migraine headaches are diagnosed clinically and are classified as a recurrent disorder. The 

 (IHS) provides diagnostic criteria for migraine using the the 

International Classification of Headache Disorders III criteria 

 Migraine without aura is the most common subset of migraine, with a 1-year prevalence in women of 11%.

 Migraine with aura includes all of the outlined migraine criteria, with the addition of a variety of neurological symptoms that can occur immediately before or with onset of the headache. Aura symptoms are reversible and can include visual, sensory, speech, language, motor, brainstem, and retinal symptoms.

 Though less common, migraine with aura has a 1-year prevalence of 5% in females (Table 3).


					A 27-year-old G1P1 presents for initiation of contraception. She has no significant medical history but on review of systems, reports experiencing headaches twice monthly. Prior to her headache onset, the patient sometimes sees shimmering lines and other shapes in her vision. Her headaches last 4 to 6 hours and she has associated nausea and occasional vomiting. The woman’s headaches resolve after she lies in a dark quiet room and sleeps. She has a 1-year-old son, is no longer breastfeeding, and would like to wait 1 to 2 years before another pregnancy, and is hoping to start combined hormonal oral contraceptive pills.

 Which of the patient’s symptoms would cause you to recommend against estrogen-containing contraceptive methods?


	Migraine is a risk factor for ischemic stroke.

 Though the overall absolute risk of stroke in reproductive-aged women is low-between 3.5 and 19.0 per 100,000-migraine may be the only risk factor for stroke in younger women.

 Women older than 35 years are likely to have other classic risk factors for stroke, such as hypertension, diabetes, and hyperlipidemia that contribute more to stroke risk than migraine alone.

aura is associated with an elevated relative risk of stroke when compared to migraine without aura. A meta-analysis of 11 case control studies demonstrated that migraine with aura had a relative risk of 2.27 (95% CI, 1.61–3.19) for ischemic stroke, while migraine without aura had a relative risk of 1.83 (95% CI, 1.06–3.15).

 The overall stroke risk is still low, with only 3.8 additional cases of stroke per year per 10,000 women attributed to migraine with aura.

 A complete medical and social history can help elucidate all potential risk factors for stroke before contraception is prescribed.

Migraine/stroke link more complex than originally thought


	The association between hormonal contraception and stroke risk is estrogen dose-dependent. It has been demonstrated that lower-dose estrogen-containing oral contraceptive pills (OCPs) (<50 ug ethinyl estradiol) are not independently associated with increased risk of stroke, but formulations with high levels of estrogen are.

 Use of the patch and ring also may result in an increased risk of stroke.

 Neither level nor type of progestin in combined OCPs appears to contribute to stroke risk.

 There is no evidence that progestin-only contraceptives increase risk of stroke and they are considered safe for use in women with stroke risk factors, including migraine with aura.

Estrogen-containing hormonal contraception 


	In addition, use of combined hormonal contraception increases risk of stroke in women with 

 type of migraine. Multiple studies have indicated an increased odds ratio, ranging from 2 to 14, for ischemic stroke in women with migraine (not separated by subtype) who use combined hormonal contraceptives, as compared to women without migraine who use the drugs.

 Risk of ischemic stroke is further magnified in migraineurs who smoke and use combined hormonal contraceptives, with odds ratios ranging from 3.7 to 34.4.

More recently, a meta-analysis of nine studies suggested that even women younger than age 45 who are migraineurs have an increased relative risk (3.6-7.0) of stroke when using combined hormonal contraception.

However, much data supporting these findings do not reflect new formulations of OCPs. Because low-dose (20- to 30-Î¼g of ethinyl estradiol) and ultra-low-dose (10- to 15-Î¼g of ethinyl estradiol) formulations conceivably have less stroke risk, further research needs to be undertaken on these formulations. 

When type of migraine is further delineated, it appears that the combination of migraine with aura and combined hormonal contraception maximizes risk of stroke. One study found risk of ischemic stroke to be increased by six-fold in women with migraine with aura on combined hormonal contraceptives compared to those without aura-demonstrating safety concerns when prescribing combined hormonal contraception in migraneurs with aura.

 Thus, assessment of migraine type when performing contraceptive counseling is a clinical necessity.


	Given the increased risk of ischemic stroke in women with migraine with aura-and added risk when combined with hormonal contraceptive use-the 

American College of Obstetricians and Gynecologists

Centers for Disease Control and Prevention

 (US MEC) have listed migraine with aura as an absolute contraindication to using combined hormonal contraception (Table 4).

 The US MEC is a helpful resource when providing contraceptive counseling services to women with a history of or existing medical conditions. The summary chart risk-stratifies different forms of contraception based on current and past medical conditions into four different categories. Categories 1 and 2 suggest that the advantages of the method usually outweigh the risk and that a method is safe. Category 3 suggests that the risks outweigh the benefits of using a contraceptive method. Category 4 indicates that there is an unacceptable risk to the patient. Common medical conditions used in the chart include headaches, hypertension, diabetes, and depression. 

Combined hormonal contraception is acceptable in women with migraine without aura who have no additional risk factors for stroke.

 Moreover, ACOG’s recommendations are based on data using old formulations of combined hormonal contraception that include more than 35 µg of ethinyl estradiol (Table 4). Many of today’s popular formulations contain less than 30 µg of ethinyl estradiol and are not independently associated with stroke risk.

The International Headache Society has more lenient guidelines for use of combined hormonal contraception in patients with migraine with aura and recommends an individualized assessment of risk depending on the number of other risk factors a woman has for ischemic stroke (including age > 35, tobacco use, hypertension, obesity, diabetes, and hyperlipidemia). Per these guidelines, patients with migraine with aura who smoke should quit smoking prior to starting combined hormonal contraceptives and those with risk factors such as hypertension, diabetes, and hyperlipidemia should be treated for these conditions prior to starting combined hormonal contraceptives.

 Similarly, the American Headache Society indicates that use of low-dose estrogen-containing formulations can be individualized based on patient risks and benefits because the absolute risk of stroke is low.

It is always important to compare the risk of unintended pregnancy in patients with chronic medical conditions with the risk of contraceptives. Patients should be adequately counseled and the discussion should be documented in the medical record.

 In all cases, once a woman with migraines has been started on a method of combined hormonal contraception, if her migraines worsen or she develops new-onset aura, the formulation should be discontinued.
	 


	During contraceptive counseling, it is important to consider possible medication interactions in women who have headaches. Many classes of medications are used for migraine prophylaxis, including beta blockers, calcium channel blockers, tricyclic antidepressants, and antiepileptic drugs (AEDs). Some AEDs specifically alter the efficacy of combined hormonal contraception through the Cytochrome P450 system. They act as P450 inducers and increase metabolism of contraceptive steroids. Topiramate is a commonly used migraine prophylaxis agent that also decreases efficacy of contraceptives by reducing the circulating dose of ethinyl estradiol. Specifically at doses > 200 mg daily, topiramate decreases efficacy of combined hormonal contraceptives, as well as of progestin-only pills and the progestin implant.

The authors report no potential conflicts of interest with regard to this article.

Kavanaugh ML, Jerman J. Contraceptive method use in the United States: trends and characteristics between 2008, 2012 and 2014. 

Burch RC, Loder S, Loder E, Smitherman TA. The prevalence and burden of migraine and severe headache in the United States: Updated statistics from government health surveillance studies. 

Migraine - ICHD-3 The International Classification of Headache Disorders 3rd edition. ICHD. 

MacGregor EA. Migraine and use of combined hor- monal contraceptives: a clinical review. 

Merikangas KR, Fenton BT, Cheng SH, Stolar MJ, Risch N. Association between migraine and stroke in a large-scale epidemiological study of the United States. 

Cruz-Herranz A, IllÃ¡n-Gala I, MartÃ­nez-SÃ¡nchez P, Fuentes B, DÃ­ez-Tejedor E. Recurrence of stroke amongst women of reproductive age: impact of and on subsequent pregnancies. 

Carolei A, Marini C, De Matteis G, The Italian National Research Council Study Group on Stroke in the Young. History of migraine and risk of cerebral ischaemia in young adults. 

Etminan M, Takkouche B, Isorna FC, Samii A. Risk of ischaemic stroke in people with migraine: systematic review and meta-analysis of observational studies. 

Kurth T, Slomke MA, Kase CS, Cook NR, Lee IM, Gaziano JM, et al. Migraine, headache, and the risk of stroke in women: a prospective study. 

Petitti DB, Sidney S, Bernstein A, Wolf S, Quesenberry C, Ziel HK. Stroke in users of low-dose oral contraceptives. 

Lidegaard O, Lokkegaard E, Jensen A, Skovlund CW, Keiding N. Thrombotic stroke and myocardial infarction with hormonal contraception. 

Bousser M-G, Conard J, Kittner S, et al. Recommendations on the Risk of Ischaemic Stroke Associated With Use of Combined Oral Contraceptives and Hormone Replacement Therapy in Women With Migraine. 

World Health Organization Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception. Cardiovascular disease and use of oral and injectable progestogen-only contraceptives and combined injectable contraceptives. Results of an international, multicenter, case–control study. 

Bartz D, O’Neal MA, Edlow AG. Contraceptive Options for Women with Headache Disease. In: Allen R, Cwiak C, eds. 

Contraception for the Medically Challenging Patient.

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Champaloux SW, Tepper NK, Monsour M, et al. Use of Combined Hormonal Contraceptives Among Women With Migraines and Risk of Ischemic Stroke. 

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Many factors must be considered before prescribing hormones to women affected by migraine.

Migraine headache and hormonal contraception

Joanna is a 17-year-old G2P1 living in Garden City, Kansas who sought a pregnancy test after missed menses and learned that she was 11 weeks pregnant despite placement of an intrauterine device 9 months ago. She moved out of her parents’ home due to domestic violence and lives with her grandmother. They depend on Social Security, Medicaid and Joanna’s part-time job to raise her baby as she works to complete high school. Joanna talked extensively with her grandmother and decided to pursue an abortion. Due to the barriers she encountered (Table 1), Joanna eventually presented to a clinic in New Mexico at 

19 weeks for her abortion and paid $2,000 for her care, plus travel costs and time missed from her job and school.

The case study here is not atypical for many women seeking second-trimester abortion, as barriers mount to abortion care access throughout the country. Women face many obstacles to first-trimester abortion; challenges to second-trimester abortion are even greater, with fewer trained and willing providers, increased costs, and gestational age limits. As of July 1, 2019, 

Access to abortion, including in the second trimester, is critical to maintaining women’s health and autonomy. The timing of a second-trimester abortion may be related to delays in care access, fetal anomalies, or health and life-threatening patient conditions. In this article, we discuss the epidemiology of second-trimester abortion, medical techniques including complex clinical scenarios, and the current status of abortion access in the United States.


	Second-trimester abortions account for only a small fraction of all abortions in the United States; as of 2015, 7.6% of all abortions occurred between 14 and 20 weeks and only 1.4% occurred at 21 weeks or more.

Induced abortion is safer than childbirth, and complications of the procedure are very low even in the second trimester.

 While most abortions occur in the first trimester, women like Joanna who seek second-trimester abortion face obstacles such as transportation, financial difficulties, delayed diagnosis (of pregnancy and of fetal abnormalities), and lack of knowledge about how to access the desired procedure


	Second-trimester abortion can be performed via standard dilation and evacuation (D&E) or through medical induction with mifepristone and misoprostol. When reviewing the two options, most women prefer D&E.

 Few randomized studies directly compare induction to D&E because women are generally unwilling to be randomized; overall D&E is less painful and more acceptable than induction.


	D&E is the most common method of second-trimester pregnancy termination in the United States, accounting for more than 98% of all such procedures and nearly 95% of all abortions after 21 weeks.

 The procedure can be safely performed in the outpatient setting with appropriately trained providers and staff; hospital care is not necessary for most low-risk patients.

 D&E comprises two steps: cervical preparation and uterine evacuation.  

 recommends cervical preparation in the second trimester to facilitate safe uterine evacuation.

 Cervical preparation can be accomplished with osmotic dilators, medications, or both in combination; the necessary amount of dilation depends on factors such as gestational age and parity.  Cervical preparation decreases rates of uterine perforation and cervical laceration, especially in later gestations.

In the early second trimester, misoprostol, a synthetic prostaglandin E1 analog, administered the same day as the D&E is usually sufficient for cervical preparation. It induces uterine contractions and cervical softening. Following misoprostol administration, the cervix is mechanically dilated with dilators, such as Pratt or Hegar dilators at the discretion and preference of the physician, until dilation is adequate for safe uterine evacuation. Common misoprostol regimens include 400 or 600 mcg administered 1.5 to 4 hours prior to the procedure by vaginal, buccal, or sublingual route.

As gestational age advances, cervical osmotic dilators either alone or in combination with misoprostol are required for adequate cervical dilation. Osmotic dilators or tents are small, thin rods that radially expand as they absorb fluid. The proximal end of the dilator is placed through the internal os with the distal end visible at the external os.  The most well-known osmotic dilator is the dehydrated sterilized seaweed 

, commercially available in standard sizes. One or more 

 tents are retained at least 12 hours, usually overnight, to achieve full dilation. More 

tents and serial sets of dilators may be needed for abortions at more advanced gestational ages. The synthetic hygroscopic dilator Dilapan-S expands more quickly and is used for same-day or multiple-day cervical preparation. Dilapan-S dilators are more expensive than 

 tents, although fewer Dilapan-S are needed to accomplish the same cervical dilation. The choice and number of dilators is at the discretion of the surgeon as no minimum number, standard or preferred combination of osmotic dilators has been established for any gestational age.

Although women face many obstacles to first-trimester abortion, challenges to second-trimester abortion are even greater.

Vol 64 No 10

What is the role of surgical simulators?

AI: Coming to a clinical scenario near you

Fake news in ob/gyn

Migraine headache and hormonal contraception

Second-trimester abortion: Update on clinical and legal aspects

The other difficult delivery

Artificial intelligence in ob/gyn ultrasound

Delayed thermal perforation or intraoperative mishap?

Gastrointestinal disorder prevalence among women with endometriosis

Pubic hair grooming and STI risk

Does mammography have benefit for older women with chronic illnesses?

How menopause influences multiple sclerosis

Female cyclists and sexual dysfunction