A colleague is giving a talk called “The Future of Baby Making.”

I would like to hear the one called “The Present.”

Here is the present.

In 2022, fertility clinics in the United States ran 435,426 treatment cycles and delivered 98,289 babies. That is about 2.6% of all babies born in this country. In 2023 there were 3,596,017 births. So roughly 3.5 million babies were made the ordinary way, at home, with no clinic, no laboratory, and no invoice.

That 2.6% gets the conferences. It gets the investment money. It gets the word “future.”

The other 97.4% got this. The share of pregnant women starting prenatal care in the first three months fell to 76.1% in 2023. The share getting no prenatal care at all rose by 5%. The preterm birth rate sat at 10.41% and has barely moved in twenty years. Those are not small problems. They are the main event.

So why does the small group get called the future?

Look at how the money moves.

Embryo selection, the long menu of laboratory add-ons, and surrogacy arrangements are paid for directly, priced per cycle and per journey, and marketed to people who are frightened and hopeful at the same time. Ordinary prenatal care is bundled into one flat fee, and close to half of all births in this country are paid for by Medicaid. One of those is a product. The other is a line item.

SURROGACY IS THE CLEAREST EXAMPLE

Every surrogacy arrangement runs through a fertility clinic. There is no other way to do it. Eggs have to be retrieved. An embryo has to be made in a laboratory. That embryo has to be transferred into another woman’s uterus. Often donor eggs are used, which means a second retrieval and a second set of fees.

Stop and notice what that means. Each arrangement generates laboratory work whether or not the intended parents have any fertility problem at all. A healthy couple who cannot carry a pregnancy, or chooses not to, still produces a full cycle of clinic revenue. Gay couples, single men, and women born without a uterus or who have lost one are entering this market in growing numbers. At this scale, that market did not exist twenty years ago. It is one of the fastest growing parts of reproductive medicine, and it grows for reasons that have nothing to do with infertility.

Then look at the price. Agencies advertise a full surrogacy journey in the United States at roughly $150,000 to $220,000. These are marketing figures, not registry data, and no one publishes an authoritative national average. But the structure is consistent across every agency that posts its prices. The agency takes something like $35,000 to $55,000 for matching and case management. Lawyers take $10,000 to $25,000. The clinic takes its cycle fees. Escrow companies, insurance brokers, and specialty lenders each take a slice. The carrier is usually paid somewhere between $60,000 and $95,000.

She is also the only person in the arrangement who can end up in an intensive care unit.

That is the part I keep coming back to. The gestational carrier is the patient in the way that matters. She is the pregnant one. She carries the risk of preeclampsia, of hemorrhage, of an unplanned cesarean, of a placenta that will not separate, of a hysterectomy she did not plan for. Everyone else in the arrangement carries financial risk. She carries the medical risk in her body.

Now look at who pays for her protection.

Her lawyer is frequently paid for by the people on the other side of the contract.

Her psychological screening is arranged by an agency that gets paid only when she is matched.

Her medical care is directed by a clinic retained by the intended parents.

Many ordinary health plans exclude carrier pregnancies, so a separate policy has to be bought, and the gap is discovered after she has already signed.

When money moves around a pregnant woman from every direction except toward her own independent counsel, the profession should say so out loud instead of calling it a journey.

I want to be careful here. Many carriers do this knowingly, want to do it, and describe it afterward as one of the best things they have done.

Many agencies screen carefully and behave decently. I am not calling surrogacy wrong, and I am not calling the people who work in it bad. I am saying that informed consent means the person taking the physical risk gets her own advisors, her own doctor, and her own honest numbers about what pregnancy can do to a body. That standard is not met by a contract drafted for someone else’s benefit.

And when the American price is too high, the business travels. There are all-inclusive programs advertised overseas at a fraction of the US figure, in countries with far less oversight of how carriers are recruited, where they live during the pregnancy, what care they receive, and what happens to them if something goes wrong. That is not the future of baby making. That is outsourcing the risk to women with fewer options.

I am not saying anyone is acting in bad faith. I am saying that incentives decide which questions get asked, which talks get booked, and which parts of human reproduction get to call themselves the future.

THE EVIDENCE UNDERNEATH THE FUTURE IS THINNER THAN THE MARKETING

A great deal of what is sold as tomorrow has already been tested and did not deliver. Testing embryos for chromosome number, and testing the lining of the uterus to pick a transfer day, were both studied in randomized trials. Neither raised the chance of taking a baby home for the average patient who started treatment. That is the number a woman thinks she is buying. She is often quoted a different one, usually a success rate calculated on a smaller and healthier group than the one she belongs to.

Now the part nobody books a keynote on.

Most fertility treatment is a workaround for problems we failed to prevent earlier. Women are starting families later, and eggs age on a schedule no clinic can renegotiate. Untreated pelvic infections damage tubes. Weight and metabolic disease affect ovulation. And in a large share of couples, sperm is part of the problem, yet the man is often tested last, or not at all.

None of that is glamorous. None of it can be billed as a journey. All of it is where the real gains are.

WHAT THIS MEANS IF YOU ARE TRYING TO GET PREGNANT

Most couples do not need a laboratory.

They need better timing, an honest look at both partners, and a few unglamorous things done early.

1. Know your cycle. The fertile window is short, and most people place it wrong. The Fertility and Conception Calendar walks you through it: https://tools.obmd.com/fertility-calculator

2. Start folic acid before you conceive, not after the test is positive. The neural tube closes in the first month, often before a woman knows she is pregnant.

3. Test the man early, not after a year of testing only the woman. A semen analysis is cheap, fast, and changes the plan when it is abnormal. The male fertility tools are here: https://tools.obmd.com/male-fertility-tools

4. Deal with what can be dealt with. Smoking, alcohol, weight, thyroid disease, diabetes, and medications that should be changed before pregnancy.

Know when to ask for help. Twelve months of trying without success is the usual threshold. Six months if you are 35 or older. Sooner if your periods are irregular or absent, or if there are known problems such as tubal or testicular disease.

The full preconception set is here: https://tools.obmd.com/preconception

CONCLUSION

I have no quarrel with in vitro fertilization. It is one of the genuine achievements of my professional lifetime, and for some couples it is the only road. I have no quarrel with a woman who chooses to carry a pregnancy for someone else, either. My quarrel is with the framing, and with what the framing hides.

When we call the laboratory “the future of baby making,” we tell 97 out of every 100 families that their pregnancy is the past. It is NOT. Their pregnancy is the NOW and the THEN.

We let ourselves off the hook for the things that would help far more people: earlier evaluation, honest counseling, prenatal care that actually reaches women, and prevention that starts before anyone is trying.

And we dress a fast growing commercial arrangement in the language of miracles, while the woman doing the physical work of it is the one person in the room without her own paid advocate.

A field that only gets excited about the expensive 2.6% is not looking at reproduction. It is looking at its own invoice.

Ask what the future holds for the 97.4%. If the room goes quiet, that is the talk worth giving.

If this was useful, subscribe. It is free, and so are the tools.

REFERENCES

1. Centers for Disease Control and Prevention. ART surveillance: 2022 national summary. Atlanta (GA): CDC; 2024. Available from: https://www.cdc.gov/art/php/surveillance/index.html

2. National Center for Health Statistics. Births in the United States, 2023. NCHS Data Brief No. 507. Hyattsville (MD): NCHS; 2024. Available from: https://www.cdc.gov/nchs/products/databriefs/db507.htm

3. Munné S, Kaplan B, Frattarelli JL, et al. Preimplantation genetic testing for aneuploidy versus morphology as selection criteria for single frozen-thawed embryo transfer in good-prognosis patients: a multicenter randomized clinical trial. Fertil Steril. 2019;112(6):1071-1079.e7. [PENDING RefVerify]

4. Doyle N, Jahandideh S, Hill MJ, et al. Effect of timing by endometrial receptivity testing vs standard timing of frozen embryo transfer on live birth in patients undergoing in vitro fertilization: a randomized clinical trial. JAMA. 2022;328(21):2117-2125. [PENDING RefVerify]

Note on the surrogacy figures: all dollar ranges in this piece are taken from surrogacy agency and fertility clinic marketing pages, not from peer-reviewed or registry sources. No authoritative national average exists, and published estimates differ because they include different services. Sources consulted include Hatch (hatch.us), Circle Surrogacy (circlesurrogacy.com), SurrogateFirst (surrogatefirst.com), and Egg Donor and Surrogacy Institute (eggdonorandsurrogacy.com), accessed September 2026.

The recent death of Dolly Parton should remind us all to get a better understanding of what it means to have a “hysterectomy”. There are several mentions of her having had ovarian cancer despite having had a hysterectomy. A “hysterectomy” simply means removing the uterus, not necessarily the ovaries or Fallopian tubes.

Here is what I found online:

Dolly Parton was 36 years old when she underwent a partial hysterectomy.

The surgery occurred in the early 1980s (around 1982–1984) after complications and severe pain caused by endometriosis and abdominal bleeding led to hospitalization. Parton has spoken openly about how the procedure permanently ended her ability to have biological children and contributed to a period of deep depression before she recovered and redirected her focus toward family, music, and philanthropy.

This below is a Substack I wrote about a year ago about the differences in terminologies.

Why Words Count, Yet Often Confuse

Medical words are supposed to bring clarity. Too often they do the opposite. In gynecology, the same term can mean different things to different people. Some words are historical leftovers, some are billing shortcuts, and some are surgical slang that slipped into everyday use.

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Patients hear “total,” “complete,” or “radical” and think everything was removed. Surgeons may mean only the uterus and cervix. Electronic records add to the problem when drop-down menus favor quick clicks over precise anatomy. Another trap is mixing route of surgery with what was removed. “Total laparoscopic hysterectomy” describes the approach and that the cervix came out, but it still says nothing about the ovaries or tubes.

Small language mistakes lead to big clinical mistakes. If a cervix was kept, cervical screening must continue. If both ovaries were removed before natural menopause, hormone plans and bone health need attention. If tubes were removed and ovaries saved, cancer risk drops without sudden menopause. Words should map exactly to the body parts involved.

The fix is simple. Name each structure. Uterus. Cervix. Right tube. Left tube. Right ovary. Left ovary. State how the surgery was done. Clear language is part of informed consent, good follow-up, and patient safety.

She was 42, healthy, and scared. “I had a total hysterectomy at 35,” she told me. “So my ovaries were removed for sure. That is what total means.”
It does not. Many patients confuse “total” with “complete.” Neither word tells us whether the ovaries were removed. That detail matters for hormones, long-term health, and future screening. Let’s clear it up.

My Patient

My patient came in with hot flashes and trouble sleeping. She worried she was in menopause and needed hormones. Her chart said “total abdominal hysterectomy.” That term means the uterus and cervix were removed through an abdominal incision. It does not say anything about the ovaries. When we checked her old operative report, I found that her surgeon kept both ovaries. Her symptoms were not due to surgical menopause. Different problem, different plan.

This confusion is common. Words like total, partial, complete, or simple describe the uterus and cervix. They do not automatically include the ovaries. Ovaries are separate. The fallopian tubes are separate too.

Why This Matters

Your ovaries make estrogen, progesterone, and testosterone. Before natural menopause, removing both ovaries causes an immediate hormone drop. That can raise risks for heart disease, bone loss, memory changes, and sexual discomfort. It can also relieve severe endometriosis or prevent ovarian cancer in high-risk patients. The decision is personal and should be informed.

The cervix matters too. If your cervix remains, you may still need cervical cancer screening, depending on your history. If your cervix is removed and your prior Pap tests were normal, you usually do not need further Pap testing. The fallopian tubes matter as well. Removing the tubes while keeping the ovaries can reduce the risk of the most common type of ovarian cancer. Many surgeons now do this when they perform a hysterectomy for benign reasons.

In short, the exact parts removed determine your follow-up care, your hormone options, and your long-term health plan.

The Names, Translated

Here is a plain-language guide you can keep:

Hysterectomy terms about the uterus and cervix

• Total hysterectomy: Removal of the uterus and cervix. No information about ovaries or tubes or why it was done

• Subtotal hysterectomy (also called supracervical or partial): Removal of the uterus body only, cervix left in place.

• Simple hysterectomy: Another term for total hysterectomy when done for benign disease.

• Radical hysterectomy: Removal of the uterus, cervix, the upper part of the vagina, and the tissues around the cervix called the parametrium and uterosacral ligaments. Pelvic lymph nodes are usually removed and checked.

  • Common indications:

    • Early cervical cancer that has grown beyond a tiny, strictly microscopic area.

    • Some larger precancerous lesions of the cervix that cannot be safely treated with more limited surgery.

    • Selected rare cancers that involve the cervix or upper vagina, based on oncology guidance.

    • Treatment of cervical cancer that recurs after a less extensive procedure, if radiation is not the better option.

  • Not routine for:

    • Benign conditions like fibroids, prolapse, or heavy bleeding.

    • Most uterine or ovarian cancers, which follow different surgical plans.

  • Do the ovaries come out in a radical hysterectomy:

    • Not automatically. Radical describes the extent of tissue taken around the cervix and upper vagina. It does not, by itself, include ovaries.

    • In many premenopausal patients with cervical cancer, the ovaries can be preserved because cervical cancer rarely spreads to them. Sometimes the ovaries are moved up (ovarian transposition) to protect them if radiation might be needed later.

    • In postmenopausal patients, or if the ovaries look abnormal, the surgeon may remove one or both ovaries and tubes at the same time.

    • If both ovaries are removed before natural menopause, this causes surgical menopause, which should be discussed in advance, including options for hormone therapy when appropriate.

Approach or route of surgery

• Abdominal hysterectomy: Through a larger belly incision.

• Vaginal hysterectomy: Through the vagina, no abdominal incisions.

• Laparoscopic hysterectomy: Small keyhole incisions with a camera.

• Laparoscopic-assisted vaginal hysterectomy (LAVH): Combination of laparoscopy and vaginal surgery.

• Total laparoscopic hysterectomy (TLH): Entire operation done laparoscopically.

• Robotic-assisted hysterectomy: Laparoscopic surgery using robotic instruments.

Words about the ovaries and tubes
These are separate procedures that may or may not be done with a hysterectomy:

• Oophorectomy: Removal of an ovary.

  • Unilateral oophorectomy: One ovary removed.

  • Bilateral oophorectomy: Both ovaries removed. This causes surgical menopause if done before natural menopause.

• Salpingectomy: Removal of a fallopian tube.

  • Bilateral salpingectomy: Both tubes removed. Ovaries can be kept.

• Salpingo-oophorectomy: Removal of tube and ovary together.

  • Unilateral salpingo-oophorectomy (USO): One tube and ovary removed.

  • Bilateral salpingo-oophorectomy (BSO): Both tubes and both ovaries removed.

• Opportunistic salpingectomy: Removing both tubes during another pelvic surgery to reduce ovarian cancer risk, while preserving ovaries.

Bottom line: “Total hysterectomy” tells you about the cervix, not the ovaries or tubes.

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What Is New or Overlooked

Two changes in thinking are worth knowing:

1. Fallopian tubes as the origin for many “ovarian” cancers. Many high-grade serous cancers start in the tubes. This is why removing the tubes while keeping the ovaries is increasingly common during benign hysterectomy. It offers cancer risk reduction without instant menopause.

2. Individualized ovarian decisions. For patients under 45, keeping ovaries can protect heart, bone, and brain health unless there is a strong cancer risk or severe disease like endometriosis that warrants removal. For patients with BRCA or other high-risk syndromes, removing ovaries and tubes at the right age can be lifesaving. One size does not fit all.

Practical Takeaways

For patients and families

• Ask these three questions before surgery: Will my cervix be removed. Will my ovaries be removed. Will my tubes be removed.

• Get the paperwork. Ask for the operative note and the pathology report. Keep digital copies. The exact words matter.

• Know your follow-up.

  • Cervix removed and past Pap tests normal: you likely do not need Pap tests.

  • Cervix kept: you still need cervical screening based on routine guidelines.

• Understand hormone changes.

  • Both ovaries removed before natural menopause: talk about menopausal hormone therapy, bone health, and heart risk.

  • Ovaries kept: you will not have surgical menopause, even if your uterus and cervix were removed.

• Cancer risk conversations. If you have a family history of ovarian or breast cancer, ask about genetic counseling before deciding on ovary removal.

For clinicians

• Use exact terms in consent and notes. List uterus, cervix, each tube, and each ovary. Avoid “complete” or “total” without details.

• Document the route and the rationale. State whether an opportunistic salpingectomy was done and why.

• Close the loop. Give patients plain-language discharge instructions that match the actual anatomy removed and the screening plan ahead.

For everyone

• Language shapes care. When words blur, follow-up blurs. Accurate names protect patients.

A Relatable Analogy

Think of a house renovation. Saying “we removed the kitchen” tells you the stove and sink are gone. It does not tell you whether the garage was torn down, whether the roof was replaced, or whether the attic was insulated. In pelvic surgery, the uterus is the kitchen. The cervix is the kitchen doorway. The ovaries are the electrical panel for the whole house. The fallopian tubes are a hallway where trouble can start. The work order must list each part. Your health depends on it.

A Quick Glossary You Can Screenshot

• Total hysterectomy: uterus plus cervix removed.

• Subtotal or supracervical hysterectomy: uterus removed, cervix kept.

• Radical hysterectomy: uterus, cervix, nearby tissues removed, usually for cancer.

• Route: abdominal, vaginal, laparoscopic, robotic.

• Salpingectomy: tube removed.

• Oophorectomy: ovary removed.

• Salpingo-oophorectomy: tube and ovary removed.

• BSO: both tubes and both ovaries removed. Causes surgical menopause if premenopausal.

• Opportunistic salpingectomy: both tubes removed, ovaries kept, to lower cancer risk.

What To Do If You Are Not Sure What You Had

1. Call the surgeon’s office and request the operative note and pathology report.

2. Look for these phrases: “cervix removed,” “ovaries conserved,” “bilateral salpingectomy,” “BSO,” “subtotal” or “supracervical.”

3. Share the documents with your current doctor.

4. Update your medical ID or personal health record so future clinicians see the exact details.

APPENDIX:

All the Names, Expanded

A) Total hysterectomy variants

Uterus and cervix removed. Ovaries and tubes are specified separately.

• Total hysterectomy only: Uterus and cervix removed. Tubes and ovaries status not stated.

• Total hysterectomy with bilateral salpingectomy: Uterus and cervix removed. Both tubes removed. Ovaries kept.

  • Abbrev: TAH-BS, TLH-BS, TVH-BS

• Total hysterectomy with unilateral salpingectomy: Uterus and cervix removed. One tube removed. Ovaries kept.

• Total hysterectomy with BSO: Uterus and cervix removed. Both tubes and both ovaries removed.

  • Abbrev: TAH-BSO, TLH-BSO, TVH-BSO

• Total hysterectomy with USO: Uterus and cervix removed. One tube and the ovary on the same side removed. Opposite ovary and tube kept.

  • Specify side: with right USO or with left USO

• Total hysterectomy with bilateral oophorectomy only: Uterus and cervix removed. Both ovaries removed. Tubes left in place.

  • Less common today because tubes are usually removed too.

• Total hysterectomy with unilateral oophorectomy: Uterus and cervix removed. One ovary removed, the other kept. Tubes status specified separately.

• Total hysterectomy with ovarian preservation and ovarian transposition: Uterus and cervix removed. Ovaries kept and moved higher to avoid radiation exposure. Tubes usually removed.

B) Supracervical or subtotal hysterectomy variants

Uterus removed. Cervix kept.

• Supracervical hysterectomy only: Uterus removed. Cervix kept. Tubes and ovaries not stated.

  • Abbrev: SCH

• Supracervical hysterectomy with bilateral salpingectomy: Uterus removed. Cervix kept. Both tubes removed. Ovaries kept.

• Supracervical hysterectomy with unilateral salpingectomy: Uterus removed. Cervix kept. One tube removed. Ovaries kept.

• Supracervical hysterectomy with BSO: Uterus removed. Cervix kept. Both tubes and both ovaries removed.

• Supracervical hysterectomy with USO: Uterus removed. Cervix kept. One tube and ovary removed. Opposite ovary and tube kept.

• Supracervical hysterectomy with bilateral oophorectomy only: Uterus removed. Cervix kept. Both ovaries removed. Tubes left.

C) Simple hysterectomy variants

“Simple” focuses on uterus and cervix, typically for benign disease. Anatomy combinations mirror “Total.”

• Simple hysterectomy only

• Simple hysterectomy with bilateral salpingectomy

• Simple hysterectomy with BSO

• Simple hysterectomy with USO

• Simple hysterectomy with unilateral or bilateral oophorectomy

Specify as above for tubes and ovaries.

D) Radical hysterectomy variants

Uterus, cervix, upper vagina, and parametrial tissues removed, often with pelvic nodes. Ovaries are not automatically removed.

• Radical hysterectomy only: Ovaries and tubes not specified.

• Radical hysterectomy with bilateral salpingectomy: Ovaries kept.

• Radical hysterectomy with BSO: Both tubes and ovaries removed.

• Radical hysterectomy with USO: One tube and ovary removed.

• Radical hysterectomy with ovarian preservation and transposition: Ovaries kept and moved out of the pelvis.

E) Route-specific names that often pair with the above

These describe how the surgery was done. Always add the adnexal details.

• Total abdominal hysterectomy (TAH)

• Total vaginal hysterectomy (TVH)

• Total laparoscopic hysterectomy (TLH)

• Laparoscopic-assisted vaginal hysterectomy (LAVH)

• Robotic-assisted laparoscopic hysterectomy
  Now combine, for example: TLH-BS, TVH-BSO, LAVH with right USO, Robotic radical hysterectomy with ovarian preservation.

F) Focus on tubes and ovaries that commonly accompany hysterectomy

• Opportunistic bilateral salpingectomy: Both tubes removed during hysterectomy to lower ovarian cancer risk. Ovaries kept.

• Unilateral salpingectomy: One tube removed, often for ectopic or damage.

• Bilateral oophorectomy: Both ovaries removed. Causes surgical menopause if premenopausal.

• Unilateral oophorectomy: One ovary removed. The other continues hormone production until natural menopause.

• USO: One tube and ovary removed on the same side.

• BSO: Both tubes and both ovaries removed.

• Salpingectomy alone with hysterectomy: Tubes only removed, ovaries preserved.

• Salpingo-oophorectomy plus contralateral salpingectomy: For example, left tube and ovary removed, right tube removed, right ovary kept.

G) Common combined phrases you will see in charts

These are highly used in operative notes and discharge summaries.

• TAH only

• TAH-BS

• TAH-BSO

• TAH with right USO or TAH with left USO

• TLH only, TLH-BS, TLH-BSO, TLH with USO

• TVH only, TVH-BS, TVH-BSO

• LAVH-BS, LAVH-BSO

• Robotic TLH-BS, Robotic TLH-BSO

• Radical hysterectomy only

• Radical hysterectomy with BS

• Radical hysterectomy with BSO

• Radical hysterectomy with ovarian preservation

• Supracervical hysterectomy only

• Supracervical hysterectomy with BS

• Supracervical hysterectomy with BSO

• Supracervical hysterectomy with USO

H) Less common but important clarifiers

• Hysterectomy with bilateral salpingectomy and ovarian conservation: Explicitly states ovaries kept.

• Hysterectomy with cystectomy: Ovarian cyst removed. Specify if ovary preserved.

• Hysterectomy with adhesiolysis: Scar tissue removed. Still specify tubes and ovaries.

• Hysterectomy with sentinel lymph node mapping: Mainly in oncologic cases.

• Hysterectomy with ovarian suspension or transposition: Ovaries moved, not removed. State tube status.

I) Quick “read-the-note” recipe

1. Identify the uterus and cervix plan: total, supracervical, simple, radical.

2. Identify the tubes: none, unilateral salpingectomy, bilateral salpingectomy.

3. Identify the ovaries: preserved, unilateral oophorectomy, BSO, USO.

4. Identify the route: abdominal, vaginal, laparoscopic, robotic.

5. If oncologic, look for nodes, parametrium, upper vagina, and any ovarian transposition.

J) Abbreviation key you can paste into patient instructions

• TAH: Total abdominal hysterectomy

• TLH: Total laparoscopic hysterectomy

• TVH: Total vaginal hysterectomy

• LAVH: Laparoscopic-assisted vaginal hysterectomy

• SCH: Supracervical hysterectomy

• BS: Bilateral salpingectomy

• US: Unilateral salpingectomy

• OO: Oophorectomy

• UO: Unilateral oophorectomy

• BO: Bilateral oophorectomy

• USO: Unilateral salpingo-oophorectomy

• BSO: Bilateral salpingo-oophorectomy

Key reminder: “Total” tells you the cervix was removed. It does not tell you anything about the tubes or ovaries. Always spell those out.

Ethical Lens

Words are part of informed consent. If a patient hears “total,” and reasonably assumes “everything,” then we failed to communicate. Real consent requires accurate names, clear teaching, and time for questions. That is respect for autonomy in action.

Reflection and Closing

If you have had a hysterectomy, do you know exactly which parts were removed. If you are planning one, do you feel clear on uterus, cervix, tubes, and ovaries. Precision in language leads to precision in care. Ask for the words that match your body. As clinicians, we should give nothing less.

A patient arrives with a report she paid $159 for.

It lists dozens of bacteria living in her vagina, sorts her into a “community state type,” labels her microbiome “imbalanced,” and offers a plan of supplements to fix it. The sequencing is real science.

Most of the plan is not. The distance between those two things is now a fast-growing industry, and both clinicians and women should know exactly where it sits.

What the vaginal microbiome is

The vaginal microbiome is the community of bacteria that lives in the vagina. In most healthy women of reproductive age, one genus dominates: Lactobacillus. These bacteria make lactic acid, hold the pH low, and crowd out organisms that cause trouble.

Read more

The CDC states that vaginal washing or douching after sexual exposure does not prevent HIV or sexually transmitted infections and may increase the risk of bacterial vaginosis and other infections. ACOG similarly advises women not to douche because it can disturb the normal vaginal microbiome.¹⁻³

Now comes Livi, an FDA-cleared device inserted after intercourse to absorb semen and vaginal discharge.

Livi is not a douche. It does not irrigate the vagina or introduce a cleansing solution. That distinction matters.

But its marketing relies on a remarkably familiar message: something has been left inside the vagina after sex, it disrupts the vaginal environment, and women should remove it.

The website explains that semen is alkaline, the vagina is acidic, and semen can temporarily alter vaginal pH and the microbiome. These statements describe physiology. They do not establish disease.

Semen does temporarily raise vaginal pH. Recent research also suggests that condomless intercourse can produce short-term changes in vaginal bacterial composition.⁴

But demonstrating a biologic change is not the same as demonstrating harm. Eating changes blood glucose. Exercise changes cortisol. Menstruation changes vaginal pH. Not every measurable change requires correction.

The critical clinical question is not whether Livi absorbs semen. It does. The question is whether removing semen improves health.

There is no evidence that it does.

The company says so itself:

“There is no evidence to support that Livi prevents BV.”

That disclosure should frame every claim made about “vaginal wellness,” “pH balance,” and the microbiome.

The published Livi study was manufacturer-funded and nonrandomized. Of 542 enrolled women, 291 completed the post-use questionnaire. Most reported less dripping, discharge, and odor. In a subset of only 48 women, self-measured vaginal pH returned toward baseline somewhat faster with the device.⁵

Those findings may support a convenience benefit. They do not establish a health benefit.

The study did not measure bacterial vaginosis, candidiasis, urinary tract infection, sexually transmitted infection, or any other clinical outcome. It did not analyze the vaginal microbiome. It was not blinded or sham-controlled, and the participants were specifically interested in a product of this kind. The investigators appropriately acknowledged that the clinical significance of the pH change remains unknown.

“FDA cleared” does not fill this evidentiary gap. Livi received 510(k) clearance as substantially equivalent to an unscented tampon for absorbing fluid.⁶ The clearance supports its absorptive function and short-term safety. It does not mean that the FDA determined semen to be harmful, that postcoital pH changes require treatment, or that using Livi prevents disease.

There is nothing inherently unethical about selling convenience. Some women dislike postcoital leakage or odor and may reasonably prefer a device that absorbs fluid. Their discomfort should not be dismissed.

The ethical problem begins when convenience is surrounded by biomedical language that implies prevention or protection without evidence of either. “Supports vaginal wellness” sounds clinical. “Before fluids have time to mess with your pH” sounds preventive.

Discussion of microbiome disruption invites women to infer that leaving semen in the vagina is unhealthy, even while the company carefully avoids claiming that removing it improves health.

Women have spent generations being incorrectly told that their normal bodies are unclean, odorous, or in need of correction. Modern marketing should not revive that message by replacing the language of hygiene with the language of pH and microbiomes.

The Livi website says a great deal about what semen does to the vagina. It does not show that these temporary changes are harmful. Even a superficial reading shows that Livi makes no demonstrated claim that its use produces a health benefit.

That should sit uncomfortably with everyone.

References

1. Centers for Disease Control and Prevention. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1-187.

2. American College of Obstetricians and Gynecologists. Vulvovaginal Health.

3. Brotman RM, Klebanoff MA, Nansel TR, et al. A longitudinal study of vaginal douching and bacterial vaginosis: a marginal structural modeling analysis. Am J Epidemiol. 2008;168(2):188-196.

4. Park DE, et al. Post-coital dynamics of the penile and cervico-vaginal genital microbiomes. Microbiome. 2026.

5. Ingber M, et al. Patient Satisfaction With a Novel Postcoital Intravaginal Fluid-Absorbing Device. O&G Open. 2026.

6. US Food and Drug Administration. Livi Device 510(k) Summary, K252005. 2026.

In 2024, American surgeons performed 1,173,391 cesareans. In every one of them, the fallopian tubes, where most lethal ovarian cancer begins, were in plain view. New population data show that removing them cuts the risk of serous ovarian cancer by about 78 percent. No obstetric guideline requires that any woman be told this before her cesarean. Link in the first comment.

The evidence changed. The consent conversation did not.

In 2024, 1,173,391 American women gave birth by cesarean. That is 32.4 percent of all births, and the rate rose again in 2025 to 32.5 percent.

In every one of those operations, the surgeon opened the abdomen and looked directly at both fallopian tubes. In most of those operations, the woman on the table had never been told what those tubes have to do with ovarian cancer.

She had never been told because nobody is required to tell her.

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Start with the name, because the name is wrong

Ovarian cancer is not one disease. About 90 percent of cases are epithelial, and the most common and most lethal type is high-grade serous carcinoma, which makes up roughly 70 percent of ovarian carcinomas. High-grade serous carcinoma does not usually begin in the ovary. It begins in the fimbria, the fringed open end of the fallopian tube that rests against the ovary.

The idea came from a Dutch doctoral student, Jurgen Piek, who around 2000 began examining ovaries removed preventively from women carrying BRCA mutations. He expected early cancer in the ovaries. He did not find it there. He found precancerous cells in the tubes. In 2001 he proposed that ovarian cancer starts in the fallopian tube. He was told at conferences that he was a lunatic. Twenty-five years later he is the first author of the European Society of Gynaecological Oncology consensus statements on removing the tubes to prevent the disease.

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The lesion has a name: serous tubal intraepithelial carcinoma. It carries the same TP53 mutation as the high-grade serous cancers that follow it. The gene expression of high-grade serous carcinoma resembles fallopian tube tissue, not the surface of the ovary. Cells shed from the open end of the tube, settle on the ovary and the lining of the abdomen, and grow there.

That single fact explains something that has frustrated this field for forty years. Screening does not work. Ultrasound, CA-125, and combinations of both have been tested in two large randomized trials, and neither reduced death from ovarian cancer. Screening looks at the ovary. Early in the process, the disease is not in the ovary.

The stakes, in numbers

In the United States in 2026, an estimated 21,010 women will be diagnosed with ovarian cancer and 12,450 will die of it. A woman’s lifetime chance of being diagnosed is about 1 in 91, roughly 1.1 percent. Her lifetime chance of dying from it is about 1 in 143. Five-year relative survival is about 52 percent, and half of women are 63 or older at diagnosis. Most women who develop it have no known risk factor and no family history, which is why strategies aimed only at BRCA carriers will never move the population number.

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Now the part that has changed. Removing both fallopian tubes during an operation a woman is already having is called opportunistic salpingectomy. British Columbia became the first jurisdiction in the world to recommend it, in 2010. In February 2026, the population data from that experiment were published. Among 40,527 people who had opportunistic bilateral salpingectomy compared with 45,296 who had hysterectomy alone or tubal ligation, the hazard ratio for serous ovarian carcinoma was 0.22, with a 95 percent confidence interval of 0.05 to 0.95. That is a reduction of roughly 78 percent in the deadliest form of the disease.

Why that 78 percent is believable

Observational studies of preventive surgery are usually contaminated by the healthy user problem. Women who get an extra procedure tend to be younger, better insured, and better cared for, so they look healthier for reasons that have nothing to do with the procedure.

The investigators anticipated that. They ran the identical analysis with breast cancer as the outcome. If the salpingectomy group were simply healthier, breast cancer should also have dropped. The hazard ratio for breast cancer was 0.99, with a 95 percent confidence interval of 0.84 to 1.17. Flat. The protection is specific to the organ that was removed.

They then did something more direct. International pathologists submitted every ovarian carcinoma they could find in a patient who no longer had fallopian tubes. Among 26 such cancers, only 6, or 23.1 percent, were high-grade serous, compared with 68.1 percent in a historical series of 942 ovarian carcinomas in women with intact tubes. When you remove the tubes, the cancers that still occur are mostly the other kinds.

This sits on top of earlier work pointing the same direction. A Swedish national cohort found a 65 percent lower risk of ovarian cancer after bilateral salpingectomy, compared with 28 percent after sterilization alone. The first British Columbia outcomes analysis in 2022 found zero high-grade serous carcinomas where several were expected.

The honest limits: this is observational, not randomized. The number of cancers is small, 21 serous carcinomas in the comparison group and five or fewer in the salpingectomy group. Median follow-up in the salpingectomy group was 4.72 years against 8.45 years in the comparison group, and most of these surgeries were performed decades before peak risk age. A randomized trial with cancer as the endpoint would take thirty years and will not be done. This is the evidence that exists, and it points one way.

Who has said what, and who has not

The Society of Gynecologic Oncology issued a practice statement in 2013 supporting salpingectomy in place of tubal ligation and at the time of hysterectomy for women at population risk who have completed childbearing.

The European Society of Gynaecological Oncology published 18 consensus statements in JAMA in 2026, with grades of recommendation from B to D and levels of evidence from II to V. Their conclusion: opportunistic salpingectomy lowers the risk of tubo-ovarian carcinoma, shows no adverse short-term effect on ovarian function, is safe across surgical approaches, adds little operative time, and belongs in preoperative counseling for eligible women, including women having selected nongynecologic abdominal and pelvic operations.

The American College of Surgeons went further in a direction obstetrics has not. At its 2025 Clinical Congress, surgeons were urged to offer tube removal, after informed consent, to post-reproductive women having elective abdominal surgery such as hernia repair or gallbladder removal. Their estimate: performing it in 60 percent of eligible operations could prevent close to 6,000 ovarian cancer deaths every year in the United States.

The American Cancer Society announced a collaboration with Break Through Cancer in September 2025 to build a national awareness campaign, and helped establish a new ICD-10 encounter code for opportunistic salpingectomy so the procedure can be tracked and reimbursed.

Then there is ACOG.

In August 2026, ACOG finally updated its 2019 Committee Opinion on opportunistic salpingectomy. The new Clinical Practice Update announces that its purpose is to “strengthen the recommendation” for complete bilateral salpingectomy at the time of obstetric or gynecologic surgery, citing evidence that the procedure can substantially reduce epithelial ovarian cancer incidence.

That sounds clear. The actual recommendations are not.

ACOG is unequivocal when the surgery is gynecologic. Obstetrician-gynecologists “should routinely perform” bilateral salpingectomy at hysterectomy. Salpingectomy “should be recommended” to patients undergoing other gynecologic operations that enter the peritoneal cavity if they do not desire future fertility. ACOG even tells obstetrician-gynecologists to help other surgical specialists offer salpingectomy during nongynecologic surgery.

Then comes cesarean delivery.

ACOG reviews remarkably reassuring obstetric data. A meta-analysis of 11 studies involving 320,443 patients found no increase in surgical complications when salpingectomy was performed at cesarean delivery, with an average increase in operating time of only six minutes. A subsequent cohort of 18,184 patients likewise found no clinically significant difference in perioperative complications and an approximately eight-minute increase in operative time.

Yet ACOG still does not say:

Patients undergoing planned cesarean delivery who do not desire future pregnancy should routinely be counseled about opportunistic salpingectomy for ovarian cancer prevention.

Instead, ACOG says complete bilateral salpingectomy is the “preferred tubal procedure for patients desiring permanent contraception after shared decision making.”

That qualification matters.

The obligation still appears to arise only after the patient has entered the permanent-contraception pathway. A patient who has completed childbearing but has never asked for sterilization is not clearly included. A patient who does not know that removing the fallopian tubes may substantially reduce her future ovarian cancer risk cannot reasonably be expected to request an option she has never been told exists.

ACOG itself comes remarkably close to recognizing this problem. It states that contraceptive counseling should highlight the cancer-risk reduction associated with salpingectomy because patients who do not desire future pregnancy “may not be aware of this relevant benefit.”

Exactly.

If patients may not know the benefit, the professional obligation cannot logically depend on patients first asking for permanent contraception.

The inconsistency becomes even harder to defend when ACOG turns to nongynecologic surgery. It says salpingectomy should be made available to patients undergoing intraperitoneal operations who do not desire future fertility and directs obstetrician-gynecologists to support other surgeons in offering it. A woman having abdominal surgery for a nonobstetric reason may therefore be affirmatively offered ovarian-cancer prevention, while a woman whose obstetrician is already performing a cesarean may not receive the same discussion unless she has first identified herself as wanting permanent contraception.

That is difficult to reconcile with informed consent.

The issue is not whether every woman undergoing cesarean delivery should have a salpingectomy. Of course not. Salpingectomy permanently eliminates natural fertility, and ACOG appropriately requires counseling, time for consideration, and individualized decision-making.

The issue is whether an appropriate patient should know that the option exists.

ACOG has now strengthened its evidence review, strengthened its recommendations for gynecologic surgery, and even encouraged other surgical specialties to offer salpingectomy. What it still has not done is write the one sentence obstetricians and patients actually need:

Patients undergoing planned cesarean delivery who do not desire future pregnancy should be counseled about the benefits, risks, and permanent contraceptive consequences of bilateral salpingectomy and offered the procedure when clinically appropriate.

In professional ethics, there is an important distinction among what physicians should not offer, what they should offer, and what they should recommend.

After seven years and a new Clinical Practice Update, ACOG still has not clearly told obstetricians which of those applies to opportunistic salpingectomy at cesarean delivery.

What the cesarean data actually show

Feasibility first. A 2020 systematic review and meta-analysis identified 11 studies covering 320,443 women who had either total salpingectomy or standard sterilization at cesarean.

Across the three randomized trials, 163 women, total operative time was not significantly increased: 8.1 minutes, with a 95 percent confidence interval of minus 4.4 to 20.7. Across seven cohort studies, 7,303 women, the difference was 6.3 minutes, with a 95 percent confidence interval of 3.5 to 9.1. There was no increased risk of wound infection, transfusion, readmission, reoperation, internal organ damage, blood loss, change in hemoglobin, or length of stay.

The two randomized trials published in 2018 differ in a way that matters, and the difference is instrumentation, not biology.

At the University of Virginia, 44 women were randomized and salpingectomy was performed with a vessel sealing device. Sterilization procedure time was 5.6 minutes against 6.1 minutes for tubal ligation, a mean difference of 30 seconds, and salpingectomy was completed in 95 percent. At the University of Alabama at Birmingham, 80 women were randomized and salpingectomy was performed with clamps and suture. Total operative time was 15 minutes longer and bilateral salpingectomy was completed in 68 percent against 95 percent for tubal ligation. No adverse outcome related to the sterilization procedure occurred in either trial. The lesson is that technique and available instruments determine the added time, not the concept.

Ovarian function. A randomized trial compared antimullerian hormone before cesarean and again at six to eight weeks after, in women randomized to salpingectomy or tubal ligation. The change did not differ between groups, an average rise of 0.58 against 0.39 nanograms per milliliter. A British Columbia cohort found no evidence that salpingectomy brings menopause earlier. The ESGO review reached the same conclusion for the short term, and stated openly that long-term follow-up is not yet available.

Cost. A 2019 decision analysis modeled 110,000 women having cesarean and desiring permanent contraception. Salpingectomy produced an incremental cost-effectiveness ratio of 23,189 dollars per quality-adjusted life year against tubal ligation. Here is the honest part that rarely gets quoted: in probabilistic sensitivity analysis, tubal ligation had a 49 percent chance of being preferred, and the model flipped to favoring tubal ligation if the true cancer risk reduction from salpingectomy fell below 52 percent. That was the open question in 2018. The 2026 population data put the reduction near 78 percent, above that threshold. The uncertainty that made the economics a coin flip has now been narrowed by data.

Uptake. National inpatient data covering 3,813,823 cesareans between October 2015 and December 2018 show salpingectomy at cesarean rising from 4.6 percent to 13.2 percent while tubal ligation fell from 11.3 percent to 2.4 percent. Among women who receive permanent contraception at cesarean, salpingectomy has become the default. That is genuine progress and obstetrics deserves credit for it.

But add those two numbers together. Roughly 16 percent of women having a cesarean receive any permanent contraception. The other 84 percent are not in the counseling conversation at all, and a substantial share of them have completed childbearing and do not know that the option exists.

What honest counseling contains

This is not an argument for sterilizing more women. It is an argument for telling every woman the truth in advance and then respecting whatever she decides.

The conversation belongs in the prenatal office, in the second trimester, with time to think and time to change her mind. It does not belong in labor, it does not belong on the way to the operating room, and it should never be offered by a surgeon whose hands are already inside the abdomen. Preventive ethics means having the difficult conversation before the moment of pressure rather than during it. A woman being wheeled into an operating room cannot give meaningful consent to a permanent decision about her fertility.

What she should hear is specific. Most lethal ovarian cancer begins in the fallopian tubes. Removing both tubes lowers the risk of the deadliest subtype by roughly 78 percent, and it does not remove the risk entirely, because endometrioid, clear cell and mucinous carcinomas, along with germ cell and sex cord stromal tumors, still arise from the ovary itself. The procedure is permanent and it ends the possibility of surgical tubal reversal, although in vitro fertilization remains available. Ovarian function does not appear to change, measured by antimullerian hormone six to eight weeks afterward. It adds somewhere between five and fifteen minutes to the operation depending on technique. As contraception, the closest comparison is postpartum partial salpingectomy, which carries a ten-year pregnancy probability of 7.5 per 1,000 procedures; complete removal of the tubes should perform at least as well, but that has not been measured directly.

Regret belongs in that conversation too, with its number. In the largest prospective cohort of sterilized women in the United States, the cumulative probability of expressing regret within 14 years was 20.3 percent among women aged 30 or younger at the time of sterilization after cesarean, with a 95 percent confidence interval of 14.5 to 26.0, compared with 5.9 percent among women older than 30. A woman deciding this at 26 is in a different position from a woman deciding it at 38, and she deserves to be told so.

The history belongs in the conversation as well. Forced sterilization of Black women, disabled women, and poor women is American history, and it is not distant history. The federal Medicaid sterilization consent form exists because of it. It requires a signature at least 30 days before the procedure and expires after 180 days. That protection has now become an obstacle: the consent form is estimated to account for 24 to 44 percent of unfulfilled sterilization requests among Medicaid enrollees, and roughly 30 to 50 percent of women who ask for permanent contraception after birth do not receive it before discharge. Counseling in the second trimester is precisely what allows the 30-day clock to run in time. Talking earlier serves both goals at once: it protects against coercion and it protects against the woman who asked, was told yes, and went home without it.

Conclusion

The evidence stopped being ambiguous. Most lethal ovarian cancer starts in the fallopian tubes. Removing them during an operation a woman is already having lowers her risk of the deadliest subtype by roughly 78 percent. At cesarean it adds minutes, not risk, and it does not appear to touch ovarian function. European gynecologic oncologists have said so, the American Cancer Society has said so, and general surgeons have said so about gallbladders and hernias.

Obstetrics is holding the largest opportunity in American surgery and treating it as a footnote in a gynecology committee opinion. ACOG’s conditional sentence should be rewritten. Every woman planning a cesarean who has completed childbearing should hear this during prenatal care, with the absolute numbers, with the permanence stated plainly, with the regret data included, and with complete freedom to decline. Whether she says yes is her decision. Whether she is told is ours.

If she is never told, we did not respect her autonomy.

We just stayed quiet and called it respect.

ObGyn Intelligence is where the evidence gets read carefully and said plainly. If this changed how you will counsel your next cesarean patient, or how you will talk to your own doctor, subscribe and share it with someone who schedules cesareans for a living.

References

1. National Center for Health Statistics. FastStats: births, method of delivery. Data from Births: Final Data for 2024, table 9. Atlanta (GA): Centers for Disease Control and Prevention. Available from: https://www.cdc.gov/nchs/fastats/delivery.htm

2. National Center for Health Statistics. Births: provisional data for 2025. Vital Statistics Rapid Release. Hyattsville (MD): NCHS. Available from: https://www.cdc.gov/nchs/data/vsrr/vsrr043.pdf

3. American Cancer Society. Key statistics for ovarian cancer. In: Cancer Facts and Figures 2026. Atlanta (GA): American Cancer Society; 2026.

4. Sowamber R, Mei AJ, Kaur P, McLeod J, McKay E, Lukey A, et al. Serous ovarian cancer following opportunistic bilateral salpingectomy. JAMA Netw Open. 2026;9(2):e2557267. doi:10.1001/jamanetworkopen.2025.57267

5. Hanley GE, Pearce CL, Talhouk A, Kwon JS, Finlayson SJ, McAlpine JN, et al. Outcomes from opportunistic salpingectomy for ovarian cancer prevention. JAMA Netw Open. 2022;5(2):e2147343. doi:10.1001/jamanetworkopen.2021.47343

6. Falconer H, Yin L, Gronberg H, Altman D. Ovarian cancer risk after salpingectomy: a nationwide population-based study. J Natl Cancer Inst. 2015;107(2):dju410. doi:10.1093/jnci/dju410

7. Piek JM, Schauwaert J, Ellis LB, Zapardiel I, Planchamp F, Koblos K, et al. Opportunistic salpingectomy for prevention of tubo-ovarian carcinoma: the European Society of Gynaecological Oncology consensus statements. JAMA. 2026;335(10):894-902. doi:10.1001/jama.2025.24510

8. Opportunistic salpingectomy as a strategy for epithelial ovarian cancer prevention. ACOG Committee Opinion No. 774. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2019;133:e279-84. Reaffirmed 2020.

9. American College of Surgeons. One surgery could prevent most ovarian cancers, surgeons say. Press release. Chicago (IL): ACS; November 17, 2025.

10. American Cancer Society, Break Through Cancer. American Cancer Society and Break Through Cancer unite to outsmart ovarian cancer. Press release. Atlanta (GA); September 25, 2025.

11. Mandelbaum RS, Matsuzaki S, Sangara RN, Klar M, Matsushima K, Roman LD, et al. Paradigm shift from tubal ligation to opportunistic salpingectomy at cesarean delivery in the United States. Am J Obstet Gynecol. 2021;225(4):399.e1-399.e32. doi:10.1016/j.ajog.2021.06.074

12. Roeckner JT, Sawangkum P, Sanchez-Ramos L, Duncan JR. Salpingectomy at the time of cesarean delivery: a systematic review and meta-analysis. Obstet Gynecol. 2020;135(3):550-7. doi:10.1097/AOG.0000000000003673

13. Garcia C, Moskowitz OM, Chisholm CA, Duska LR, Warren AL, Lyons GR, et al. Salpingectomy compared with tubal ligation at cesarean delivery: a randomized controlled trial. Obstet Gynecol. 2018;132(1):29-34. doi:10.1097/AOG.0000000000002674

14. Subramaniam A, Blanchard CT, Erickson BK, Szychowski J, Leath CA, Biggio JR, et al. Feasibility of complete salpingectomy compared with standard postpartum tubal ligation at cesarean delivery: a randomized controlled trial. Obstet Gynecol. 2018;132(1):20-7. doi:10.1097/AOG.0000000000002646

15. Ganer Herman H, Gluck O, Keidar R, Kerner R, Kovo M, Levran D, et al. Ovarian reserve following cesarean section with salpingectomy vs tubal ligation: a randomized trial. Am J Obstet Gynecol. 2017;217(4):472.e1-472.e6. doi:10.1016/j.ajog.2017.04.028

16. Hanley GE, Kwon JS, McAlpine JN, Huntsman DG, Finlayson SJ, Miller D. Examining indicators of early menopause following opportunistic salpingectomy: a cohort study from British Columbia, Canada. Am J Obstet Gynecol. 2020;223(2):221.e1-221.e11. doi:10.1016/j.ajog.2020.02.005

17. Venkatesh KK, Clark LH, Stamilio DM. Cost-effectiveness of opportunistic salpingectomy vs tubal ligation at the time of cesarean delivery. Am J Obstet Gynecol. 2019;220(1):106.e1-106.e10. doi:10.1016/j.ajog.2018.08.032

18. Peterson HB, Xia Z, Hughes JM, Wilcox LS, Tylor LR, Trussell J. The risk of pregnancy after tubal sterilization: findings from the U.S. Collaborative Review of Sterilization. Am J Obstet Gynecol. 1996;174(4):1161-8.

19. Hillis SD, Marchbanks PA, Tylor LR, Peterson HB. Poststerilization regret: findings from the United States Collaborative Review of Sterilization. Obstet Gynecol. 1999;93(6):889-95.

20. Access to postpartum sterilization. ACOG Committee Opinion No. 827. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2021;137:e169-76.

21. Kolata G. Most ‘ovarian cancer’ isn’t. And that fact can save lives. The New York Times. July 28, 2026.

In 1974, The Lancet published letters debating whether menstruating women give off a toxin that wilts flowers and stops bread from rising.

Not 1874. 1974. The year of the pocket calculator.

The idea had a name, menotoxin, and a respectable father.

Bela Schick published it in 1920.

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He is the same Schick as the Schick test for diphtheria.

He noticed that roses wilted overnight after a maid who was menstruating put them in a vase. He ran some experiments with servants, flowers, and bread dough, and concluded that menstruating women release something poisonous through the skin. Other researchers tested blood, sweat, tears, saliva, and breast milk on seedlings. The results conflicted. They were read as support anyway. The 1974 letters ended only when an epidemiologist pointed out that a photograph of a wilted daisy from 1924 and one dead Italian tree were not enough evidence for a claim in 1974.

Pliny the Elder said the same thing in the first century. He wrote that contact with menstrual blood soured new wine, blighted crops, killed grafts, dimmed mirrors, blunted steel, and killed bees. Eighteen hundred years separate Pliny from Schick. The claim did not change. Only the vocabulary did.

Here is why that idea was so hard to kill.

Nobody knew what a period was.

The old theories were not stupid. They were the best available reading of the only thing anyone could see. The Greek physicians thought women built up more blood than their bodies could use, and that the monthly flow was a necessary purge. Aristotle thought menstrual blood was the raw material of the embryo, shaped by semen. Galen folded both into the theory of humors that ran European medicine for over a thousand years. Every one of these explains the blood, because the blood was the only part anyone could observe.

The part that actually matters is invisible.

An egg is released. The structure left behind in the ovary makes progesterone. Progesterone holds the lining of the uterus in place. If no pregnancy follows, that structure shuts down, progesterone falls, and the lining sheds. The bleeding is not the event. It is the receipt for an event that happened about two weeks earlier and left no visible sign at all.

That was not established until 1929, when George Corner and Willard Allen showed that extract from the corpus luteum transformed the uterine lining and sustained early pregnancy. They called the substance progestin. Four teams isolated it in crystal form in 1934. It was named progesterone in 1935.

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So the arithmetic is this. Two thousand years of theories about what the blood meant. Ninety seven years of knowing what it is.

Religious and cultural rules ran alongside the medical theories and often outlasted them. Leviticus places menstruation in a category of ritual states that includes men, and sets a seven day period of separation. In 601, Pope Gregory the First was asked whether a menstruating woman could enter a church or receive communion. He answered that she should not be barred, because she suffers it involuntarily and nature causes it, so it is no fault. That is a more accurate statement than most medical writing for the next twelve hundred years. His own successor reversed it within ninety years.

What does any of this cost a patient today?

Three things, and all three are still in the room.

When bleeding is treated as shameful, women describe it inaccurately, or not at all. When menstruation is framed as an affliction, pain gets an explanation before anyone looks for a cause. And when nobody talks about periods, nobody learns what normal looks like. That last one is why a girl whose periods have been heavy since her very first one has no way of knowing that this is unusual, and why bleeding disorders in teenagers are still missed. She has no baseline. Nobody gave her one.

My take.

I did not write this history for the entertainment value, though Pliny provides plenty. I wrote it because the pattern has not stopped, and I recognize it in current practice.

Diagnostic delay in endometriosis is still measured in years. The largest contributor is not imaging technology or access to specialists. It is normalization of pain, by patients, by families, and by clinicians. That is the Aristotelian and Levitical inheritance operating in a consulting room in 2026, wearing a white coat.

We also still cannot agree on what a heavy period is. The research threshold is more than 80 milliliters of measured loss. The clinical definition is bleeding that interferes with quality of life. The public health definition is bleeding over seven days, or soaking a pad more often than every two hours. Three definitions, three different groups of women identified, all currently in use.

Menstrual bleeding received standardized international terminology only in 2011, revised in 2018. Before that, menorrhagia meant whatever the person saying it meant. The menstrual cycle was formally described as a vital sign, to be asked about at every visit, in 2015. Both of those are more recent than the smartphone.

We are better than Pliny. We are not finished.

The bottom line is simple. If your period is heavy, painful, or has changed, that is a finding, not a fact of life. It has a cause, and causes can be identified. Two thousand years of people telling women otherwise does not make it true.

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ObGyn Intelligence is free because the work matters. If you want to keep it independent, a paid subscription does that. Share this with a colleague who still tells patients that bad periods run in the family.

References

1. Pliny the Elder. Natural History, Book VII, §64.

2. Schick B. Das Menstruationsgift. Wien Klin Wochenschr. 1920. [CITATION NEEDED — volume and pagination not verified]

3. Ernster VL. Letter. Lancet. 1974 Jun 29:1347. [CITATION NEEDED — verify against journal]

4. Allen WM, Corner GW. Physiology of the corpus luteum. Proc Soc Exp Biol Med. 1929;27:403–5.

5. Allen WM, Butenandt A, Corner GW, Slotta KH. Nomenclature of corpus luteum hormone. Science. 1935;82:153.

6. Simmer HH. Ludwig Fraenkel: ‘spiritus rector’ of the early progesterone research. Eur J Obstet Gynecol Reprod Biol. 1998;83(2):169–74.

7. Bede. Ecclesiastical History of the English People, Book I, Ch. 27. Libellus responsionum, Gregory I to Augustine of Canterbury, 601 CE.

8. Leviticus 15:19–30.

9. Munro MG, Critchley HOD, Fraser IS; FIGO Menstrual Disorders Committee. Int J Gynaecol Obstet. 2018;143(3):393–408.

10. ACOG Committee Opinion No. 651. Obstet Gynecol. 2015;126(6):e143–6.

11. DeLoughery E, Colwill AC, Edelman A, Bannow BS. BMJ Sex Reprod Health. 2024;50(1):21–6.

12. The full history, with verification status marked per source: https://menstria.com/history

Every day, women in Texas, Idaho, and other restrictive states face the same nightmare: a wanted pregnancy goes wrong, doctors hesitate, and by the time they are allowed to act, infection or hemorrhage has already taken hold. These women are not dying because medicine has failed them. They are dying because the law forbids doctors from doing what they know is right.

And while this happens, the very medical societies that claim to represent these physicians hold their conferences, fundraisers, and board meetings in those same states. Some even keep their headquarters there. The symbolism is impossible to ignore: our institutions are thriving in the same places where their patients are suffering.

The Ethics of Geography

Texas is a case study. Its abortion ban has already driven obstetricians out, closed maternity wards, and caused preventable deaths. Yet major national medical organizations continue to meet there, dine there, and thank local officials for hosting them. They talk about “advocacy,” but their physical presence lends legitimacy to a system that endangers women and criminalizes doctors.

A headquarters is not neutral. It is a statement of alignment. When a society rooted in evidence-based medicine plants itself in a state that outlaws that same evidence, it undermines its credibility. It tells its members: we’ll defend your ethics from afar, but we’ll enjoy the hospitality of those who deny them.

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The Quietness

Many societies say they “stand with patients” while issuing cautious, lawyer-reviewed statements that offend no one and protect nothing. They call for “further study” of laws that have already caused deaths. They avoid using the word “abortion” in official publications, replacing it with phrases like “pregnancy termination.”

This is not diplomacy.

History will not remember the tone of their statements. It will remember the women who died while their professional defenders stayed comfortable.

What Leadership Looks Like

Real leadership in medicine means taking risks for patients, not for public relations. It means refusing to hold meetings in states where the law criminalizes standard care. It means relocating headquarters if necessary, the way organizations once boycotted states that violated civil rights. It means turning polite support into visible solidarity.

Some will say this is “too political.” But so was washing your hands in Semmelweis’s time. So was fighting for contraception and racial equality in hospitals. Ethics becomes political whenever law turns unjust.

What Our Societies Could—and Must—Do

They could publish and maintain a public list of women harmed or killed by abortion bans, with verified cases drawn from public health data and investigations. Not as propaganda, but as remembrance and accountability. Every woman lost should have a name, a face, and a date. Numbers move minds, but names move consciences.

They could maintain a companion list of hospitals where physicians have been disciplined or threatened for providing standard care.
They could establish legal-defense funds for clinicians prosecuted under abortion bans.
They could commit to hosting conferences only in states where reproductive care is lawful.
They could move their headquarters out of states that criminalize their own members.
And most of all, they could name—not hint at—the laws that kill.

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The Moral Math

Every time a society chooses Texas or Florida or Idaho as a venue, it sends money, visibility, and legitimacy to states that have chosen ideology over women’s lives. Each banquet, photo-op, and ribbon-cutting takes place under laws that force doctors to wait until a woman is near death before acting.

That is not neutrality. That is endorsement by silence.

Reflection / Closing

Physicians across the country are showing moral courage—treating when the law says wait, speaking out when silence feels safer. Our societies owe them the same.

Ethical leadership is not measured by how carefully one avoids controversy. It is measured by how clearly one names harm and how boldly one refuses to stand on its soil.

If our medical institutions truly believe that abortion is health care, then they must stop holding meetings—and their moral ground—in states where medicine itself is under attack. And they must bear public witness to every woman who suffered because they didn’t speak loudly enough, soon enough, or often enough.

When Robert F. Kennedy Jr. publicly claimed in mid-2025 that antidepressant use in pregnancy causes autism, he wasn’t just spreading misinformation. He was undermining one of medicine’s most important principles: that risk must be measured, not imagined. His statements ignored decades of data and contradicted the consensus of ACOG and others—that the benefits of treating moderate to severe depression during pregnancy often outweigh the potential risks. The challenge is not choosing sides between fear and overconfidence. It’s learning how to balance them.

What SSRIs and SNRIs Actually Are

SSRIs (selective serotonin reuptake inhibitors) and SNRIs (serotonin–norepinephrine reuptake inhibitors) are the most studied psychiatric medications in pregnancy. Introduced in the 1980s with fluoxetine (Prozac), these agents increase neurotransmitters that regulate mood. Common SSRIs include fluoxetine, sertraline, citalopram, escitalopram, and paroxetine. SNRIs like venlafaxine and duloxetine affect both serotonin and norepinephrine.

Over 30 years of research, including large registry studies from the U.S., Denmark, and the U.K., have shown that most SSRIs are not linked to major congenital malformations. Some small associations—like paroxetine and certain cardiac defects—exist, but absolute risks remain low. The most common neonatal effect, transient adaptation syndrome, resolves spontaneously within days. These findings have placed SSRIs among the most evidence-supported medications used in pregnancy.

But data are not the whole story. The question is not only whether SSRIs are “safe,” but whether ObGyns should be the ones to initiate them.

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The Evidence and the Risks

Untreated maternal depression and anxiety carry well-established dangers: increased risk of suicide, preterm birth, preeclampsia, low birth weight, and postpartum depression. Yet medications also have potential downsides—neonatal adaptation symptoms in about 25–30% of late-exposed infants, a very small possible association with persistent pulmonary hypertension, and a modestly higher cardiac-defect risk with paroxetine.

ACOG’s 2023 guideline emphasizes balance:

“The use of SSRIs or SNRIs during pregnancy should be individualized, weighing the benefits of treatment for the mother against potential risks for the fetus. Untreated maternal depression carries significant risk to both.”

That is not a license to prescribe freely. It is a reminder to evaluate deliberately.

When Obstetricians May Consider Initiating SSRIs

In some cases, obstetricians may appropriately initiate SSRI treatment for mild to moderate depression or anxiety, particularly when psychiatric access is limited. However, this decision should always involve collaboration with a mental health specialist and shared decision-making with the patient.

Factors supporting obstetrician-initiated SSRI treatment:

• Frontline access: OB-GYNs are often the first—and sometimes the only—healthcare providers to screen pregnant women for depression or anxiety. Early treatment can prevent worsening illness.

• Established standard of care: ACOG supports the role of ObGyns in initiating treatment when needed, provided systems exist for referral and follow-up.

• Continuity of stable therapy: If a woman is already well controlled on an SSRI before pregnancy, continuing the same medication is usually preferred over switching or stopping.

• Safety profile: Most SSRIs, especially sertraline, have reassuring safety data when used appropriately.

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Even so, “can” does not always mean “should.” Obstetricians occupy a crucial but limited role: we recognize illness, initiate temporary care if necessary, and connect patients to psychiatric management for ongoing treatment.

When to Refer to a Mental Health Specialist

Referral or co-management with a psychiatrist or psychologist is strongly advised in these situations:

• Severe or complex illness: Major depressive episodes with suicidality, bipolar disorder, psychosis, or OCD.

• Lack of response: Failure to improve after an adequate trial or presence of side effects requiring dose adjustments or medication changes.

• Need for psychotherapy: Cognitive behavioral or interpersonal therapy is first-line for many mild and moderate cases and should complement pharmacologic care.

• Diagnostic uncertainty: Overlapping or unclear psychiatric presentations.

• Consultation model: In collaborative care, the ObGyn serves as the primary contact while a psychiatrist provides oversight and treatment guidance.

This model keeps obstetricians within professional scope while ensuring patients receive expert mental health care.

Why Boundaries Matter

Starting an SSRI seems simple: write a prescription and follow up. But that simplicity is deceptive. Psychiatric diagnosis requires nuance—distinguishing major depression from bipolar disorder, anxiety from trauma, despair from adjustment. Missteps can cause harm, including medication-induced mania or undertreatment of serious psychiatric disease.

Obstetricians receive limited psychiatric training. We manage hypertension, diabetes, and hemorrhage expertly, but not complex psychopharmacology.

Professionalism means knowing when our reach should stop. Continuing a patient’s pre-existing SSRI? Yes. Managing her therapy in consultation with a psychiatrist? Appropriate. But initiating long-term antidepressant therapy without collaboration crosses a professional boundary.

Weighing Risks and Benefits

Every decision must be individualized:

Risks of untreated depression:

• Suicide and self-harm

• Preterm birth and low birth weight

• Preeclampsia

• Impaired bonding and increased postpartum depression

Potential risks of SSRI use:

• Neonatal adaptation syndrome (NAS): 25–30% of late-exposed infants, mild and transient

• Persistent pulmonary hypertension (PPHN): Rare, <1%, likely multifactorial

• Paroxetine: Slightly higher risk of cardiac defects; sertraline preferred

The risk-benefit discussion should be explicit, documented, and revisited as pregnancy progresses.

The Ethical Core

The debate about SSRIs is ultimately a debate about trust. Patients trust us to tell them the truth, not to minimize risk or exaggerate it. Kennedy’s falsehoods exploit public fear; uncritical prescribing exploits clinical shortcuts. Both betray that trust.

Ethical practice lies between the two extremes: recognize illness early, provide accurate information, initiate only when appropriate, and partner with psychiatry whenever possible.

Reflection / Closing:
Obstetricians should remain the first eyes, not the final hands, in managing perinatal mental illness. The pen that writes the prescription carries both power and responsibility. Using it wisely means knowing when to put it down—and when to call for help.

A woman goes into labor in a rural county.

The nearest hospital that still delivers babies is 90 minutes away, because the one in her town closed its maternity ward two years ago.

She makes the drive. Most times it ends fine.

Sometimes it does not. This is no longer a rare story. It is the map of American maternity care.

In 2023, 669 women died from causes tied to pregnancy in the United States. That is a rate of 18.6 deaths for every 100,000 births. It is better than the year before, and still worse than almost every other wealthy country. Most of them sit between 3 and 7 deaths per 100,000. We are two to five times higher — and we spend more per person on health care than anyone on earth.

The deaths are not spread evenly. For Black women the rate was 50.3 per 100,000. For white women it was 14.5. Same country, same year, a gap of more than three to one.

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The easy explanation is racism. Racism is real. But it is not the main lever here, and treating it as the only cause lets the real problem hide. The real problem is money. Medicaid pays hospitals and doctors about half what private insurance pays for the same birth. When a service loses money, hospitals stop offering it — and maternity is usually first to go. So the women with public insurance, who are more likely to be Black and more likely to be rural, lose access first. In countries with universal coverage, where that payment gap does not exist, the racial gap in maternal deaths largely disappears. That tells you what is actually driving it.

Maternity care deserts continue to expand across the United States, leaving many pregnant patients to travel long distances or deliver without timely access to obstetric services. Hospital closures disproportionately affect rural communities, where loss of local labor and delivery units can delay emergency care and worsen maternal and neonatal outcomes.

The closures are speeding up. Since the end of 2020, 139 rural hospitals have stopped delivering babies — about two a month. More than a third of all US counties are now maternity care deserts: 1,104 counties with no hospital, no birth center, and no obstetric provider. About 2.3 million women of childbearing age live in them.

Hospitals do not close maternity wards out of cruelty. A labor and delivery unit runs 24 hours a day, 7 days a week, whether it delivers 400 babies a year or 40. At low volume, the payments do not cover the cost of simply being ready. So the doors close.

Here is the part that should make you angry. Keeping every financially at-risk rural hospital in America open — all services, maternity included — costs about $6 billion a year. That is one-tenth of one percent of what the country spends on health care. We are choosing not to spend it.

Now look at what we did choose.

Read that last line again. Spread over 20 years, $150 billion is $7.5 billion a year, or if invested in Treasuries at 4% it’s $6 Billion a year.

More than enough to keep every at-risk rural hospital open the entire time, reopen the maternity wards that already closed, and still have money left over to start closing the payment gap that drives the deaths in the first place.

For a woman in a rural county, this is not abstract. It is the difference between a 10-minute drive and a 90-minute one when her labor goes wrong. In obstetrics, distance kills. The math above is measured in minutes on a dark highway.

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My Take

We are not a poor country that cannot afford to keep mothers alive.

We are a rich country that decided mothers are not the priority.

When we want $150 billion for a war or for enforcement, we find it in weeks.

When mothers need $6 billion a year to keep the lights on in the hospital where they deliver, we are told it is not in the budget.

That is not an economics problem.

It is a values problem.

A budget is not a spreadshee, it is a moral document. It is where a country writes down, in numbers, who it is willing to protect.

Fixing this does not take a miracle. Pay for maternity care the way we pay for a fire department: you fund it to be ready, not per fire. Close the Medicaid payment gap so a hospital is not punished for taking a woman with public insurance. Both are affordable. Both are choices we keep refusing to make.

The next time someone tells you the country cannot afford to keep mothers safe, ask them to explain the $150 billion. The money exists. The will does not.

If this made you think, subscribe. It is free, and the evidence here is better than what you will get from the people who found the money for everything except mothers.

References

1. National Center for Health Statistics. Maternal mortality rates in the United States, 2023 [Internet]. Hyattsville (MD): NCHS; 2025 [cited 2026 Jul 22]. Available from: https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2023/maternal-mortality-rates-2023.htm

2. March of Dimes. Nowhere to go: maternity care deserts across the US (2024 report) [Internet]. Arlington (VA): March of Dimes; 2024 [cited 2026 Jul 22]. Available from: https://www.marchofdimes.org/maternity-care-deserts-report

3. Center for Healthcare Quality and Payment Reform. Stopping the loss of rural maternity care [Internet]. CHQPR; [cited 2026 Jul 22]. Available from: https://ruralhospitals.chqpr.org/Maternity_Care.html

4. Center for Healthcare Quality and Payment Reform. Rural hospitals at risk of closing [Internet]. CHQPR; [cited 2026 Jul 22]. Available from: https://chqpr.org/downloads/Rural_Hospitals_at_Risk_of_Closing.pdf

5. Centers for Medicare & Medicaid Services. National health expenditure data: historical [Internet]. Baltimore (MD): CMS; [cited 2026 Jul 22]. Available from: https://www.cms.gov/data-research/statistics-trends-and-reports/national-health-expenditure-data/historical

6. Hegseth says Iran war has cost $37.5 billion. Bloomberg. 2026 Jul 21 [cited 2026 Jul 22]. Available from: https://www.bloomberg.com/news/articles/2026-07-21/hegseth-says-iran-war-has-cost-37-5-billion

7. What’s in the $70 billion bill funding immigration enforcement. Time. 2026 Jun 10 [cited 2026 Jul 22]. Available from: https://time.com/article/2026/06/10/house-passes-secure-america-act-senate-reconciliation-bill-funding-immigration-enforcement-trump/

Peptides in Women’s Health · Bonus Part

The patient-facing close: what an ObGyn wants every woman to understand about peptides, including the parts a general explainer leaves out.

When a major medical group recently published a patient guide to injectable peptides, the physician answering the questions was a sports medicine doctor.¹

His advice was sound.

But he is not the doctor a pregnant woman, a woman trying to conceive, or a woman in menopause needs to hear from.

That is my chair, and the reproductive lens changes the math.

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Most of what you read treats peptides as a fitness and recovery topic. For women of reproductive age, they are also a pregnancy topic, a contraception topic, a fertility topic, and a menopause topic.

The same injection that is a gamble for a healthy adult becomes a gamble with a second person’s development the moment a pregnancy is possible.

So here is the conversation the way I would have it with you.

The single most useful thing you can do is stop thinking of peptides as supplements and start treating them as medications, including the weight-loss shot, the recovery peptide, and the tanning injection.

Almost every problem I see starts the same way: a peptide nobody asked about, and a patient who did not think it counted.

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Peptides in Women’s Health · Part 7 of 7

The finale: a stage-by-stage action plan, and the single question that sorts tested peptides from untested ones.

This series has walked the spectrum of peptides in women’s health, from the oxytocin in the delivery room to the wellness injection sold online.

This next to last post turns all of it into something you can use: a plan for each stage of reproductive life, and one question to ask at every visit.

The organizing idea is simple.

There are peptides that have been tested in women like you, and peptides that have not.

The tested ones have labels, trials, and known risks.

The untested ones have marketing.

Your job is not to memorize the science.

It is to know which side of that line a given product sits on, and to act accordingly.

The single most useful change a woman can make is to treat every injectable, including weight-loss shots and peptide therapy, as a medication that belongs on her history. The gaps in care this series has described almost all start the same way: a peptide the clinician never asked about, and the patient never thought to mention.

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The least-proven end of the spectrum: the compounded and research-peptide market, and why the absence of a rule is not evidence of safety.

In 2025 the legal pathway that built the compounded GLP-1 industry began to close, and in April 2026 the FDA moved to shut it permanently.

The wider research-peptide market is next.

The reason is not only legal.

For these products, no one can reliably tell you what is in the vial.

Peptides sold outside the approved-drug system come through two side doors. One is compounding, where pharmacies mix a version of a drug. During the GLP-1 shortages, compounded semaglutide and tirzepatide were widely available. The other is the research peptide market, where products like BPC-157 are sold labeled for research use only while being marketed for people. Both bypass the testing that approved drugs go through for safety, purity, and dose.

When a product skips that testing, the patient inherits the uncertainty. Unknown purity.

Unknown dose.

Unknown contaminants.

For a healthy adult that is a gamble.

For a woman who is pregnant, trying to conceive, or breastfeeding, it is a gamble with a second person’s development on the table.

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Menopause is the clearest split in the series: tested drugs that target the brain circuit behind hot flashes, versus an untested peptide market.

Menopause has its own peptide story, and it splits cleanly in two. On one side, two new nonhormonal drugs that quiet hot flashes by targeting the brain circuit that produces them. On the other, a peptide clinic market selling injections for menopause with almost no evidence behind them. Both use the word peptide. Only one side has trials.

Hot flashes start in the brain. A cluster of neurons that helps run the body’s thermostat uses signals including a peptide called neurokinin B. As estrogen falls in menopause, those neurons fire too easily, and the result is the sudden heat and sweat that millions of women know. The new drugs do not replace a peptide. They block the receptor that the overactive signal lands on. That is pathway pharmacology, and it went through clinical trials.

A woman who cannot or does not want to take estrogen now has real nonhormonal options that work. She also faces a market that will sell her unrelated injections labeled peptide therapy for the same symptoms. The difference between the two is the difference between a tested drug and a hopeful guess, and it is worth real money and real safety.

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The most urgent peptide issue in obstetrics now, reduced to three numbers every woman on a GLP-1 should know.

Millions of women of reproductive age now take a GLP-1 drug. That makes semaglutide and tirzepatide preconception drugs, whether obstetrics planned for it or not. And the real risks around pregnancy are not the ones that make people panic.

GLP-1 drugs are not recommended during pregnancy. Animal studies suggest possible harm, and human data are still limited. So the standard advice is to stop before trying to conceive. The drug labels build in a washout window because these medications stay in the body for weeks. The catch is that fertility can return as weight drops, sometimes before a woman expects it.

Three numbers decide how this goes, and most women never hear them: how long before conception to stop the drug, whether the drug weakens the pill, and what happens to the pregnancy if the drug is stopped abruptly at the wrong moment. Get those three right and the picture is reassuring. Miss them and the avoidable problems show up.

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Fertility medicine already runs on peptides. One of them is being oversold, and the mislabel has real consequences.

Fertility medicine already runs on peptides. The drugs that suppress or trigger ovulation in IVF, the hormones that grow the eggs, the brain signal that starts the whole cycle, all peptides. So when a weight-loss peptide starts bringing back ovulation in women who were not ovulating, it gets called a fertility drug. It is not one. And that mislabel can end in a surprise pregnancy on a medication that should be stopped before conception.

Polycystic ovary syndrome, or PCOS, is the most common hormonal cause of infertility. Many women with PCOS carry extra weight and insulin resistance, and that combination disrupts ovulation. GLP-1 drugs like semaglutide and liraglutide lower weight and improve insulin handling. When they do, ovulation can return. That is real, and for some women it is welcome. But improving the conditions that block ovulation is not the same as a drug designed to make you pregnant.

Here is what gets lost. A woman told her PCOS makes pregnancy hard, who then starts ovulating again on a GLP-1, can conceive without expecting to, while taking a drug not recommended in pregnancy. The fertility win and the medication risk arrive together. That is the part the marketing skips.

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The Stoics had a precise name for people who apply principles only when convenient. We should use it.

“Don’t explain your philosophy. Embody it.” -- Epictetus, Discourses

A woman is hemorrhaging. Her doctor knows exactly what she needs. The government has decided she cannot have it.

Somewhere else, a parent is told: the flu shot is a personal choice now. Between you and your doctor. Your body. Your decision. Medical freedom.

Same government. Same week. Same principle -- applied to one patient, denied to another.

The Stoics called this akrasia -- acting against one’s own stated reason. But Epictetus, who began life as a slave and understood power better than most philosophers ever would, had a harsher word. He called it moral cowardice dressed in borrowed language. You do not actually believe the principle. You use it. That is the definition of hypocrisy. And hypocrisy, to a Stoic, was not a personality flaw. It was a corruption of logos -- of reason itself -- the gravest failure a thinking person could commit.

The Words They Used

Let the record be precise, because precision is what this moment requires.

In October 2025, when the CDC moved COVID-19 vaccination from a blanket recommendation to “shared clinical decision-making,” HHS Deputy Secretary Jim O’Neill announced it this way: “Informed consent is back.” (1)

Secretary Robert F. Kennedy Jr. followed: “Government bureaucracies should never coerce doctors or families into accepting vaccines or penalize physicians for respecting patient choice. That practice ends now.” (2)

In December 2025, the White House ordered a restructuring of the entire childhood vaccine schedule -- from 17 recommended vaccines to 11. The stated reason: empowering families and clinicians to make individualized decisions.

Medical freedom.

Patient autonomy.

Shared decision-making.

Write those words down. We will need them.

What They Actually Did

In June 2025, this same administration rescinded the federal EMTALA guidance that had told hospitals across the country what every physician already knew: when a pregnant woman arrives in your emergency room and abortion is the medically necessary treatment to save her life, you treat her. (4)

EMTALA -- the Emergency Medical Treatment and Labor Act -- has been federal law since 1986. The Biden guidance did not invent new rights. It clarified existing law at a moment when clarification was desperately needed, because in the wake of Dobbs, physicians in states like Idaho, Texas, Arkansas, and South Dakota were watching patients deteriorate while they calculated their legal exposure.

That guidance is now gone.

What replaced it is silence. And in medicine, when the government goes silent while state laws threaten criminal prosecution for providing standard care, silence is a decision. It is a decision against the patient.

The same officials who declared “informed consent is back” have made it a crime to exercise it.

In Arkansas, Idaho, Mississippi, Oklahoma, and South Dakota, there are no meaningful health exceptions to abortion bans. A physician can watch a patient’s blood pressure climb toward stroke. She can watch a septic uterus fail to respond to antibiotics. She knows the treatment. And in those states, the government has already made the clinical decision for her. (5)

Doctors describe it now as “waiting for the patient to get sick enough.” Waiting until she crosses whatever invisible threshold might satisfy a prosecutor who was never in the room and who has never managed a hemorrhaging patient at 2 in the morning.

This is not shared clinical decision-making. This is the government making the clinical decision -- and threatening the physician with prison if she disagrees.

Marcus Aurelius on Consistency

“If it is not right, do not do it. If it is not true, do not say it.” -- Marcus Aurelius, Meditations IV.17

Marcus Aurelius wrote that in the 2nd century. He was Emperor of Rome. He had more power than any person today, and he chose to write about the discipline of consistency -- the obligation to mean what you say and to say only what you mean.

The Stoics called the alignment between word and deed homologia -- agreement, coherence, integrity in the literal sense of the word. To live with homologia was the goal of the philosophical life. To live without it was to live against nature, against reason, against everything that made human beings distinct from animals.

Patient autonomy is a real principle. Informed consent is a real principle. A principle is only a principle if it applies universally. The moment you decide it applies to flu shots but not to ectopic pregnancies, you have revealed that it was never a principle at all. It was a political instrument. And the Stoics would say you have not merely failed the patient. You have failed yourself.

The Surgeon General Nomination Explains Everything

The administration’s nominee for Surgeon General -- the nation’s doctor -- is Dr. Casey Means. She holds a medical degree from Stanford. She left her surgical residency six months before completion. Her medical license has been inactive since January 2024. She is a wellness influencer and supplement brand collaborator whose primary professional platform is social media. (6)

This is not an attack on Dr. Means. It is a statement of what this administration believes the nation’s doctor should look like.

The Surgeon General is the most visible public health communicator in America. She issues advisories. She shapes what the public believes about medicine. And this administration chose someone who has not practiced medicine in years, whose license is inactive, and whose credentials are a bestselling book and a podcast audience.

You do not nominate a practicing clinician who might apply evidence consistently. You nominate a communicator who will deliver the message you need delivered -- even when the message contradicts itself from one medical procedure to the next.

Vaccine autonomy for parents who may choose to decline. Criminal prosecution for physicians who choose to save a pregnant woman’s life. Both positions, from the same office, in the same year.

What Epictetus Would Say

“Seek not that the things which happen should happen as you wish; but wish the things which happen to be as they are, and you will have a tranquil flow of life.” -- Epictetus, Enchiridion VIII

That is not the Epictetus I want to invoke here. I want the Epictetus of the Discourses -- the former slave who had seen what it looked like when powerful people used beautiful language to justify cruelty.

He wrote that the hypocrite is the most dangerous person in any community -- not because he does evil, but because he does evil while speaking the language of good. He confuses everyone around him. He makes it harder to name what is actually happening. He borrows the moral authority of real principles and spends it on their opposite.

“First say to yourself what you would be,” Epictetus wrote, “and then do accordingly.” This administration has said what it would be. Patient choice. Medical freedom. Informed consent. It has not done accordingly. It has done the opposite, to the patients who needed those principles most.

That is not a policy difference. That is not a values disagreement. That is a failure of logos -- of reason, of consistency, of basic human integrity.

Epictetus called it exactly what it is. We should too.

What Physicians Must Understand Right Now

If you practice obstetrics in a state with a near-total abortion ban, you are operating in deliberately manufactured legal ambiguity. The federal guidance that clarified your EMTALA obligations is gone. The federal government has no current enforcement position. Your state law may expose you to criminal prosecution for providing treatment that would be standard of care in 37 other states.

That ambiguity was not an accident. It was a choice. The administration that eliminated it had the option to clarify it in the other direction. It chose not to.

Document everything. Know your hospital’s legal counsel. Know your state’s specific exceptions, narrow as they are. And know this: the physician who hesitates while a patient hemorrhages because she is calculating her legal exposure is being asked to be something no physician should ever be asked to be -- a defendant deciding whether to treat.

What Women Must Understand Right Now

The administration using the phrase “between you and your doctor” is not applying that principle to you if you are pregnant.

If you live in a state with an abortion ban and you develop a life-threatening complication of pregnancy, the decision about your care is not between you and your doctor. It is between your doctor and a prosecutor. Your autonomy -- the autonomy this administration invokes loudly in every vaccine press release -- does not reach the emergency room when you need it most.

Know your state’s laws before you need them. Know which hospitals have the strongest legal and ethics support. Know that EMTALA still exists as federal law even without the Biden guidance -- the statute has not changed, only the enforcement posture. If you are denied emergency care you believe was medically necessary, contact the Center for Reproductive Rights, the ACLU Reproductive Freedom Project, or your state’s medical board. Document everything. You have rights that have not been abolished, only obscured.

“Waste no more time arguing what a good man should be. Be one.” -- Marcus Aurelius, Meditations X.16

This administration has wasted considerable time telling us what a patient-centered health system should sound like. It has not been one.

Medical freedom is not a slogan. Patient autonomy is not a press release. Informed consent is not a political instrument to be deployed against vaccines and withheld from pregnant women bleeding in emergency rooms.

Either the principle applies to every patient, or it is not a principle.

Either the doctor-patient relationship is sacred, or it is not.

You cannot have it both ways. You cannot invoke medical freedom at a podium and then criminalize the exercise of clinical judgment in an operating room.

The Stoics understood that a person’s character is revealed not by what they say when it is easy, but by what they do when the principle costs them something. This administration has told us exactly who it is.

We should believe it.

References

1. O’Neill J. CDC Immunization Schedule Adopts Individual-Based Decision-Making for COVID-19. HHS Press Release. October 6, 2025.

2. Kennedy RF. Post on X (formerly Twitter). December 31, 2025.

3. White House Fact Sheet. President Donald J. Trump Begins Process to Align U.S. Core Childhood Vaccine Recommendations with Best Practices from Peer, Developed Countries. December 7, 2025.

4. Center for Reproductive Rights. Trump Administration Attacks Federal Protections for Pregnant People in Emergency Rooms. June 3, 2025.

5. PBS NewsHour. White House revokes guidance requiring hospitals to provide emergency abortions. June 5, 2025.

6. Wikipedia. Casey Means. Accessed February 2026.

7. Epictetus. Discourses. Trans. Oldfather WA. Harvard University Press; 1926.

8. Aurelius M. Meditations. Trans. Hays G. Modern Library; 2002.

9. [VERIFY] -- U.S. maternal mortality comparative data vs. peer nations. CDC/WHO.

The proven end of the spectrum: the peptides that run labor and delivery, and the open questions behind each one.

Oxytocin is one of the oldest and most-used drugs in obstetrics. It starts labor, it strengthens labor, and it stops the bleeding that still kills mothers. It is also classed as a high-alert medication, a category for drugs that can cause serious harm when the dose runs ahead of the evidence.

The delivery room runs on peptides. Three matter most. Oxytocin, the workhorse. Carbetocin, a longer-acting version built for places where refrigeration fails. And atosiban, a peptide that does the opposite job, relaxing the uterus to hold off preterm labor. All three are real drugs with real trials. That does not mean the questions are settled.

Here is the part patients are rarely told. After more than 50 years of using oxytocin, obstetrics still does not agree on the dose. The longer-acting option works about as well as the original and is not a magic upgrade. And the uterus-relaxing peptide that is standard across Europe was turned down by the FDA. These are not fringe debates. They shape what happens to a laboring woman and her baby.

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Here is the problem.

Vitamin D is barely a food vitamin at all. Your body was built to make it in your skin from sunlight, not to pull it off a plate. Very few foods carry a useful amount. The richest is oily fish. A 3.5-ounce piece of wild salmon gives you somewhere around 570 to 650 units. Farmed salmon gives less, often closer to 440. Mackerel runs high, near 640. Canned sardines sit around 190, herring around 170. After that, the list falls off a cliff. An egg yolk has about 40 units. A glass of fortified milk has about 100. Most other foods have almost none.

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Now set that against what an adult needs each day: about 600 units under age 70, and 800 after.

To reach that with food alone, you would need oily fish on your plate nearly every single day. Most people eat fish twice a week if they are trying. And the fish itself is unreliable — wild salmon can carry three or four times the vitamin D of farmed, and you rarely know which one is on your fork. So for the average person, food does not get there. That part is not up for debate. It is arithmetic.

Sunlight is the natural answer, and for most of human history it was the only one. But modern life works against it. If you live in the northern half of the country, your skin makes almost no vitamin D from October to March. Sunscreen blocks it, which is the right trade when the other option is skin cancer. Office work blocks it. Darker skin needs more sun to make the same amount. Age cuts production too. So the natural source is real, but for most people it is not enough.

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This is where the story gets interesting, because the supplement world ran ahead of the evidence. For years the message was that everyone should take high doses, and that more was always better. Then the large trials arrived. VITAL, a study of more than 25,000 American adults, tested 2,000 units a day against a dummy pill. It did not lower cancer. It did not lower heart attacks or strokes. A companion study found it did not prevent broken bones either. In 2024 the Endocrine Society read all of this and made a quiet, sensible call: most healthy adults under 75 do not need to supplement beyond the basic amount, and most do not even need a blood test to check their level.

That sounds like an argument against the pill. It is not. It is an argument against the hype, and against treating a deficiency drug like a daily ritual for people who are already fine. Because the same trials, read honestly, show exactly who does benefit.

Pregnant women sit at the top of that list, and this is my field. The Endocrine Society recommends vitamin D in pregnancy because it is tied to lower rates of preeclampsia, preterm birth, babies born too small, and newborn death. Those are not small things. Children benefit too — vitamin D prevents rickets and lowers respiratory infections. Adults over 75 have a lower risk of death. And there is one finding that matters especially for women: in VITAL, vitamin D cut the rate of new autoimmune disease by about 22 percent — conditions like rheumatoid arthritis, thyroid disease, and psoriasis. The protection held up over seven years of follow-up, with 156 cases on vitamin D against 198 on placebo. Women develop autoimmune disease far more often than men, so this benefit lands harder for them. Then add the simplest case of all: anyone whose level is genuinely low. In VITAL, about 1 in 8 adults started out deficient, and another third were borderline. Fixing a true deficiency is not hype. It is repletion.

So what do I tell patients now?

Diet will not carry this nutrient for most people. Eat the oily fish and the fortified foods, get safe sun when you can, but do not expect your plate to close the gap. Then match the pill to the person, and to a real number.

For a healthy adult, the baseline target is 600 IU a day up to age 70, and 800 IU after that. If you are pregnant, aim higher: the trials behind the recommendation used 600 to 5,000 IU a day and averaged about 2,500, so a daily supplement of 1,000 to 2,000 IU, on top of the vitamin D already in your prenatal, is a sound and common target.

Children aged 1 to 18 do well on about 1,200 IU a day, and a baby under one needs 400 IU. If your blood level is genuinely low, 1,000 to 2,000 IU a day will usually bring it back up. If you are a healthy 40-year-old man with a normal level, you do not need to chase a higher number, and you should stay under the adult ceiling of 4,000 IU a day, because very high doses carry their own risk of harm.

More is not better here. Enough is better.

One honest caveat, because it cuts the other way. The big no-benefit trials enrolled mostly people who already had enough vitamin D. So no extra benefit may really mean no benefit on top of enough. That is a fair criticism, and it is exactly why I aim at deficiency rather than at the supplement aisle.

My take: this is not a debate about whether vitamin D is essential. It is. The real question is how you get it and who needs help getting it.

Food alone rarely gets anyone to the target.

Sunlight is unreliable in modern life.

And a cheap daily pill closes the gap for the people the evidence actually points to — pregnant women first among them. Replete the deficient, protect the pregnant, and stop megadosing the healthy.

Bottom line: skip the megadose, not the basics. If you are pregnant, older, or low, take the small daily dose — your dinner plate cannot do this job. If this helped you think more clearly about what is on your counter, subscribe to ObGyn Intelligence. The evidence here is better than the marketing, and it stays that way.

References

1. Manson JE, Cook NR, Lee IM, Christen W, Bassuk SS, Mora S, et al. Vitamin D supplements and prevention of cancer and cardiovascular disease. N Engl J Med. 2019;380(1):33-44. doi:10.1056/NEJMoa1809944. PMID 30415629.

2. LeBoff MS, Chou SH, Ratliff KA, Cook NR, Khurana B, Kim E, et al. Supplemental vitamin D and incident fractures in midlife and older adults. N Engl J Med. 2022;387(4):299-309. doi:10.1056/NEJMoa2202106.

3. Hahn J, Cook NR, Alexander EK, Friedman S, Walter J, Bubes V, et al. Vitamin D and marine omega-3 fatty acid supplementation and incident autoimmune disease: VITAL randomized controlled trial. BMJ. 2022;376:e066452. doi:10.1136/bmj-2021-066452. PMID 35082139.

4. Costenbader KH, Cook NR, Lee IM, Hahn J, Walter J, Bubes V, et al. Vitamin D and marine n-3 fatty acids for autoimmune disease prevention: outcomes two years after completion of a double-blind, placebo-controlled trial. Arthritis Rheumatol. 2024;76(6):973-983. doi:10.1002/art.42811. PMID 38272846.

5. Demay MB, Pittas AG, Bikle DD, Diab DL, Kiely ME, Lazaretti-Castro M, et al. Vitamin D for the prevention of disease: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2024;109(8):1907-1947. doi:10.1210/clinem/dgae290.

The Distinction That Changes Everything

Empathy is the perception of another person’s emotional state and some resonance with it. It is cognitive and affective. It can be trained, scripted, and, as recent research confirms, convincingly simulated by a large language model. Patients shown AI responses to medical questions rated them as more empathic than physician responses. That finding has been replicated in oncology.

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Compassion is something else. It is empathy plus the moral commitment to act on it. The word means to suffer with. A compassionate oncologist does not just recognize her patient’s terror at a new cancer diagnosis. She is moved by it. She stays in the room with it. She follows this patient through four rounds of carboplatin and paclitaxel, through the scan that shows progression, and sometimes through the death. That staying is not a communication technique. It is a moral relationship.

You can sound empathic and be compassionless. You can produce the right words and be entirely absent. Patients in cancer care know the difference. They remember it. Gynecologic cancer diagnoses are recalled with the kind of detail that marks events that have reordered a person’s life. What patients remember is not tone. It is whether someone was actually with them.

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What the Empathy Scores Are Actually Measuring

Bioethicist John Lantos argues that most empathy research captures communicative empathy: warm tone, verbal acknowledgment, scripted validation. [2] An LLM trained on millions of human conversations produces exactly that output reliably. The scales were not designed to measure what Jodi Halpern calls emotional reasoning: a disciplined, medically-informed attunement to what illness means in a specific patient’s life.

Ovarian cancer has a five-year survival rate of approximately 49 percent for all stages combined, with stage III and IV disease making up the majority of diagnoses. [1] That number sits behind the question am I going to die? A patient who asks it is not asking for a warm acknowledgment that her feelings are valid. She is asking whether the person across from her can tolerate the uncertainty with her and whether she has found someone who will not flinch. An empathy scale cannot detect that.

The AI finding tells us that physicians are not giving patients enough communicative empathy. That is real and worth fixing. It tells us nothing about whether an algorithm can substitute for the gynecologic oncologist who has committed to being with this patient through whatever comes.

What AI Can Actually Do in Oncology

The contribution of AI to gynecologic oncology care is real and underappreciated in these debates. Clinical tools that synthesize trial data, flag deviations from treatment algorithms, identify patients who have not been offered germline testing for BRCA1 and BRCA2 variants, and generate plain-language summaries of complex pathology findings are genuinely useful. They do not replace the oncologist. They make the oncologist more accurate and better prepared for the conversation that matters.

The clinician who walks into a room knowing that her patient’s BRCA status is pending, that the staging CT is equivocal at the para-aortic nodes, that this patient has a 14-year-old daughter, and that her last three portal messages were about fertility preservation, is a different clinician from one who enters without that synthesis. AI can provide that synthesis. Reducing documentation burden means more time in the room. More time in the room creates the conditions for compassion to function.

What AI cannot do is replace the moment when the oncologist says: I do not know exactly what this will look like for you, but I am going to be here for all of it. That sentence, when it is true, is not a communication strategy. It is a compassionate commitment. The machine cannot make it, and the patient knows the difference.

The Training Problem in Oncology

Lantos observes that medical training systematically erodes empathy through structural mechanisms: the hidden curriculum, evaluation systems that reward diagnostic competence over relational quality, and role models who demonstrate efficiency rather than presence. [2] In gynecologic oncology, the consequences are specific.

Fellows learn to manage technically complex surgical and chemotherapy decisions under intense time pressure, with almost no protected time for the relational skills the work requires. A fellow who can deliver a technically perfect radical hysterectomy but cannot sit in silence with a frightened patient has learned half the job. The half she has not learned is where compassion lives. It cannot be outsourced to a chatbot.

Conclusion

AI empathy scores in oncology measure communicative form. They do not measure compassion, which is the moral commitment to be present to and act on a patient’s suffering across the full arc of a cancer diagnosis and treatment. AI tools can and should improve accuracy, reduce burden, and ensure that no patient with ovarian cancer goes without genetic counseling. The relationship between a cancer patient and her clinician, built across treatment cycles and recurrences, requires a human being who has made a genuine commitment to stay. That is not a sentiment. It is a clinical standard, and it is the one worth measuring.

A seven-part series on the peptides that already shape fertility, pregnancy, and menopause, and the booming peptide market that runs years ahead of the evidence.

One word covers the oxytocin running through an IV in the delivery room and the vial of “healing peptide” your patient ordered online last month. The FDA defines a peptide as any chain of 40 amino acids or fewer.¹ The definition is honest. Most of the marketing built on top of it is not.

Peptides are short strings of amino acids. Many of the body’s own signals are peptides. The hormone that starts labor is a peptide. So is the one that drives ovulation, and the one that tells your brain you are full. That is why peptides are easy to sell. A clinic can say the body makes this naturally and be telling the truth while selling you something that has never been tested in a pregnant woman.

The honest way to understand peptides in women’s health is to sort them into three groups, because they are not one thing.

The first group is established peptide drugs. Oxytocin, to start labor and to stop bleeding after birth. Carbetocin, a longer-lasting version that the World Health Organization added to its essential medicines list partly because it does not need refrigeration.³ The GnRH-based drugs that run IVF cycles and treat endometriosis. GLP-1 drugs like semaglutide. These have known mechanisms, regulated manufacturing, and clinical trials behind them.

The second group is the body’s own peptides. GnRH and kisspeptin in the brain, oxytocin, insulin, the peptides the placenta makes in pregnancy. These run the female reproductive system. Some have become drug targets. Most are simply how the body works.

The third group is the commercial market. BPC-157, ipamorelin, CJC-1295, thymosin alpha-1, and a long list of others. They are sold for healing, anti-aging, fat loss, and hormone balance. For fertility, pregnancy, and menopause, this group has little or no human safety data. The FDA has flagged several of these ingredients as compounds that may carry significant safety risks.²

Here is what is at stake. Peptides are not fringe medicine. They already sit at the center of women’s health. But the peptide clinic market has run years ahead of the evidence, and the gap is widest exactly where the danger is greatest: in women who are pregnant, trying to conceive, or moving through menopause.

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