Dr. Chapa’s OBGYN Clinical Pearls

Today, we are taking a deep dive into a medical truth thatsounds completely counterintuitive, almost upside down, based on everything you think you know about women's health. But here’s the kicker: it’s actually nothing new at all. For over two decades, ever since the landmark Women’sHealth Initiative (WHI) study made global headlines back in 2002, the blanket narrative surrounding menopausal hormone therapy has been clear and persistent: hormones equal breast cancer risk. But there is a massive asterisk in thatscience that got completely lost in the media noise. While combination therapy with conjugated equine estrogens paired with medroxyprogesterone acetate (CEE +MPA) did show an increased risk, the story for estrogen-only therapy (mainly CEE) in women wh had a hysterectomy is entirely different. In fact, an overwhelming mountain of growing data shows that estrogen-only therapy is protectiveagainst both breast cancer incidence and breast cancer mortality. In this episode, we’re unpacking the latest high-level evidence that cements this crucial distinction. We'll examine the broad statistical landscape, including a comprehensive meta-analysis by Qing et al. (officially set for the December 2026 issue of Annals of Medicine, following its ahead-of-print release in March 2026). Their work breaks down how randomized controlled trial data consistentlypoint to estrogen-only therapy having a protective effect, in stark contrast to combination therapy. We'll also dive into a brand-new Clinical Perspective published in mid-August 2026 in Obstetrics & Gynecology (the Green Journal) by Drs. Andrew Kaunitz and Jason Wright. They call urgent attention to this phenomenon, highlighting RCT meta-analyses that demonstrate a 23% reduction in breast cancer incidence with estrogen alone (RR = 0.77), alongside striking cohort data showing a dramatic risk reduction even in high-risk populations, like carriers of the BRCA mutation.  Listenin for details.
1.     Wu Q, Shen L, Hu S, Yang R, Wang Y, Xue D, SunY, Ma H, Dai Z. Relationship between menopausal hormone therapy and incidencerisk of breast cancer: systematic review and meta-analysis. Ann Med. 2026Dec;58(1):2640244. doi: 10.1080/07853890.2026.2640244. Epub 2026 Mar.
2.     Kaunitz, Wright. Menopausal Estrogen Therapy andRisk of Breast Cancer. Obstet Gynecol. Aug 2026
3.     Chlebowski RT, Aragaki AK, Pan K, et al.Randomized Trials of Estrogen-Alone and Breast Cancer Incidence: AMeta-Analysis. Breast Cancer Research and Treatment. 2024.
4.     Writing Group for the Women's Health InitiativeInvestigators. (2002). Risks and benefits of estrogen plus progestin in healthypostmenopausal women: Principal results from the Women's Health Initiativerandomized controlled trial. JAMA, 288(3), 321–333.

Historically, continuous intravenous (IV) insulin infusions were established as the standard of care for pregestational diabetes (Type 1 and Type 2 DM) during labor to prevent acute intrapartum hyperglycemia and minimize the risk of neonatal hypoglycemia. Intravenous insulin offers rapid titration, immediate onset, and a short half-life, allowing precise real-time glycemic control during the physiological stress and fluctuating metabolic demands of labor. Maintaining euglycemia intrapartum is emphasized because elevated maternal blood glucose levels cross the placenta, inducing fetal hyperinsulinemia, which acutely increases the risk of severe post-delivery neonatal hypoglycemia, which can be problematic. Although IV insulin protocols are widely used and are recommended in many practice guidelines, the evidence supporting their superiority over other approaches is limited. Subcutaneous (SC) insulin administration represents a potential alternative strategy to intrapartum glucose management. Continuation of SC insulin, including insulin pump therapy, has been studied most extensively among individuals with type 1 diabetes. However, evidence guiding intrapartum insulin management remains limited for patients with gestational or type 2 diabetes, who represent the majority of pregnancies complicated by diabetes. Institutional protocols frequently default to IV insulin despite limited comparative evidence with SC insulin and the increased workflow burden associated with infusion-based management. Now, a new retrospective study published in SMFM’s PREGANCY journal (25 July 2026; Seattle, Washington) is looking to give routine intrapartum SC insulin some validity. What did the data show? Listen in for details.
1. Savitsky, L.M., Barr, C., Katz, R., Martinez, N., Henderson, J., Saleh, T., White, L. and Simmons, L. (2026), Streamlining intrapartum glycemic control: Subcutaneous insulin for intrapartum diabetes management. Pregnancy, 2: e70371. https://doi.org/10.1002/pmf2.70371

Urge urinary incontinence (UUI) places a significant emotional and physical burden on women affected. Sacral neuromodulation has been and remains a well-established implant-based therapy for UUI. The concept originated in the early 1970s from sacral anterior root stimulation research for neurogenic bladder, with human clinical trials beginning in 1982. Medtronic's InterStim device received FDA approval in 1997 for UUI, and in 1999 for urgency-frequency and nonobstructive urinary retention. This was a game changer for affected women. Now, as of August 5, 2026, the FDA has granted 510(k) clearance for a new, less invasive neuromodulation implant- placed in the ANKLE. This is the Revi Extend Implant system (BlueWind Medical). What was the phase 3 data on this? What does the “wearable controller device” look like? Listen in for details.
1. Lukacz ES, Santiago-Lastra Y, Albo ME, Brubaker L. Urinary Incontinence in Women: A Review. JAMA. 2017;318(16):1592–1604. doi:10.1001/jama.2017.12137
2. Amundsen CL, Sutherland SE, Heesakkers JPFA, et al. Three-year efficacy and safety of Revi implantable tibial neuromodulation from the pivotal OASIS study. J Urol. 2026;216(2):219-229. doi:10.1097/JU.0000000000005062
3. BlueWind Medical receives FDA 510(k) clearance for Revi Extend implant. News release. BlueWind Medical Ltd. August 5, 2026. Accessed August 5, 2026. https://www.businesswire.com/news/home/20260805290667/en/BlueWind-Medical-Receives-FDA-510k-Clearance-for-Revi-Extend-Implant

Today, we are taking a deep dive into an intervention that almost every labor and delivery unit in North America has adopted over the last decade: Quantitative Blood Loss, or QBL. ACOG first recommended quantitative blood loss assessment in Committee Opinion Number 794, published in December 2019. This opinion recommended that every birthing facility implement a standardized, quantitative method for measuring cumulative blood loss at all deliveries, replacing visual estimation as the default approach. This built on earlier ACOG efforts, including the 2015 reVITALize initiative, which standardized obstetric data definitions and defined postpartum hemorrhage using cumulative measured blood loss thresholds (≥1,000 mL regardless of delivery route, or blood loss accompanied by signs/symptoms of hypovolemia). We’ve all weighed sponges, measured calibrated drapes, and run the math. But here’s the million-dollar question: Does measuring blood loss accurately, on its own, actually improve outcomes for patients? The answer is YES….and NO at the same time. Listen in for details as we discuss new data (July 2026 in AJOG) on this topic.
1. White A, Burns RN, Pruszynski JE, Ravindra D, Fin KX, Montgomery T, Jestes E, Ambia AM, Anyaehie B, Duryea EL. Establishing Normal Blood Loss Thresholds at the Time of Delivery Based on Quantitative Blood Loss. Am J Obstet Gynecol. 2026 Jul. DOI: 10.1016/j.ajog.2026.07.028. S0002-9378(26)00395-9. YMOB 16849.
2. Quantitative Blood Loss in Obstetric Hemorrhage: ACOG COMMITTEE OPINION, Number 794.Obstetrics and Gynecology. 2019. Committee on Obstetric Practice
3. Coomarasamy A, Devall AJ, Bell S, et al. Diagnosis and Treatment of Postpartum Haemorrhage: A Race Against Time. Lancet. 2026.

Today, we’re stepping into one of the most clinicallydelicate and emotionally heavy scenarios you can encounter in women's healthcare: a mid-pregnancy loss, say right around that 18 to 20-week mark. It’s a situation where the clinical room feels still, the emotional weight is immense, and every decision you make as a clinician carries profound gravity. Picture the scenario: The delivery has occurred. Both the fetus and the placenta have delivered, and upon gross visual examination on the delivery tray, the placenta appears intact. The immediate crisis of delivery has passed. But as theattending provider, you’re now standing at a critical management fork in the road. Do you routinely order an ultrasound before discharge to confirm the uterine cavity is truly clear? Or do you take a selective, symptom-driven approach, reserving uterine US imaging for patients who present with post-delivery warning signs like unexpected hemorrhage, severe pain, or fever? It sounds like a straightforward question, but in practice, it sparks intensedebate. Listen in, as we review professional society guidelines and the latest published data.
1.     Fox CE, et al. Mid‐trimester Pregnancy Loss GuidelineConsensus Panel. Triage and care for women with symptoms or diagnosis of pregnancy loss between 14 + 0 and 21 + 6 weeks' gestation. Int J Gynaecol Obstet. 2026 Jan;172(1):25-50. doi: 10.1002/ijgo.70621.
2.     Incognito GG, et al. Ultrasound Assessment ofRetained Products of Conception (RPOC): Insights from the Current Literature. J Clin Med. 2025 Aug 19;14(16):5864. doi: 10.3390/jcm14165864.
3.     ACOG PB 135: Second Trimester Abortion
4.     Sundararajan S, Roy S, Polanski LT. The accuracyof ultrasound scan in diagnosing retained products of conception: a systematicreview and meta-analysis. Am J Obstet Gynecol. 2024 May;230(5):512-531.e3.