AFP: American Family Physician Podcast

Episode 229 — May 2025 (Part 1)
Release Date: May 16, 2025
Hosts: Residents and faculty of the University of Arizona College of Medicine–Phoenix Family Medicine Residency
Contributing editor: Dr. Steven Brown

Episode Overview

This episode presents concise, evidence-based highlights from the May 2025 issue of American Family Physician, focusing on essential topics for family medicine clinicians. Discussions include key clinical takeaways about trigeminal neuralgia, early medication abortion, SGLT2 inhibitors for CKD and diabetes, female sexual dysfunction, the health impacts of per- and polyfluoroalkyl substances (PFAS), and the effectiveness of methotrexate for juvenile idiopathic arthritis.

Main Topics and Key Discussion Points

1. Trigeminal Neuralgia: Rapid Evidence Review

(01:25–04:22)
Contributor: Dr. Ameche

• Definition and Types:

  • Chronic neuropathic facial pain involving the trigeminal nerve
  • Subtypes:
    • Classic (vascular compression-related)
    • Secondary (due to MS or tumor)
    • Idiopathic (no identified cause)
  • Quote:

    “The hallmark is recurrent episodes of unilateral facial pain... severe with an electric shock like shooting, stabbing or sharp quality.” — B (02:23)

• Symptoms:

  • Brief, severe, shock-like, triggered by minimal stimuli (e.g., breeze, shaving, chewing)
  • Often misdiagnosed as dental pain (80% see a dentist first)

• Diagnosis:

  • Clinical; all suspected cases should get brain MRI to rule out secondary causes (SOrC evidence).

• Treatment:

  • First-line: Carbamazepine (SOrA evidence).
  • Quote:

    “A Cochrane review...identified a response rate of 72% in the treatment group compared to 12% in the placebo group; NNT=2.” — D (03:45)

  • Refractory Cases: Consider surgery.
  • Other therapies: Research ongoing in herbal medicine and TENS.

2. Early Medication Abortion

(04:39–06:00)
Contributor: Dr. Mark Abell

• Clinical Question: Is medication abortion prior to confirmation of intrauterine pregnancy safe/effective?
• Study: RCT of 1,500 women (9 countries), compared early med abortion vs. standard protocol with confirmed IUP.
  • Results:
    • 95% had complete abortion
    • Surgical intervention less in early group (1.8% vs 4.5%)
    • Ongoing pregnancy higher in early group (3% vs 0.1%)
    • Slightly shorter bleeding and greater satisfaction in early group
    • Quote:

      “In short, early medication abortion is as safe and effective as standard of care treatment.” — D (05:52)

3. Cochrane for Clinicians: SGLT2 Inhibitors for Chronic Kidney Disease & Diabetes

(06:00–08:22) Contributor: Dr. Tracy Johns

• Question: Are SGLT2 inhibitors effective for people with CKD and type 2 diabetes?
• Evidence:
  • 53 RCTs, 65,000+ patients, broad range of kidney disease (not type 1 diabetes, few on dialysis)
  • Benefits:
    • Reduces all-cause mortality (NNT=119/year)
    • Kidney failure risk halved (NNT=35)
    • Reduces CV events, heart failure hospitalizations (NNT=42 for MACE in severe CKD)
    • Lower risk of severe hypoglycemia
  • Risks:
    • Increased genital infections (NNH=38)
    • No increase in DKA vs standard of care
  • Notable quote:

    “SGLT2 inhibitors decrease the rate of cardiac events, progression of kidney disease and the rates of heart failure hospitalizations.” — C (08:12)

4. Female Sexual Dysfunction (FSD)

(08:49–12:15) Contributors: Drs. Dalrymple, Hogue, and Thacker

• Definition & Prevalence:

  • FSD covers issues of desire/arousal, orgasm, and pain; affects 40–50% of women.
  • Quote:

    “The most important part of diagnosis is that the symptoms cause significant distress, impact quality of life.” — D (09:20)

• Diagnosis:

  • DSM-5, validated questionnaires (FSFI, Distress Scale)
  • Review medications; many can contribute (beta-blockers, SSRIs, etc.)
  • Physical exam focused on dermatologic, anatomic, neurologic, and signs of secondary causes

• Treatment:

  • Desire/Arousal Disorders:
    • First-line: CBT, couples/mindfulness therapy
    • Meds: flibanserin, bremelanotide (limited efficacy & expensive)
    • Consider bupropion for SSRI-induced dysfunction
    • Topical testosterone for certain postmenopausal patients (monitor closely)
  • Orgasmic Disorders:
    • CBT, sex therapy, directed masturbation, OTC vibrators
  • Genitopelvic Pain Disorders:
    • Pelvic floor PT, self-dilation for vaginismus, topical estrogens or non-hormonal agents for dryness
  • Referral:
    • All patients: consider mental health referral; procedural or failed therapy: refer to gyn/urogynecology

5. Curbside Consultation: PFAS Exposure and Testicular Cancer

(12:31–16:47) Contributors: Drs. Cervantes and Gurbo

• Case: 46-year-old firefighter with testicular mass, occupational PFAS exposure (firefighting foams)

• PFAS Background:

  • Group of “forever chemicals,” resistant to oil/water; used in non-stick cookware, fabrics, firefighting
  • Prevalent in >50% of US tap water
  • Environmental/health concern due to their persistence and bioaccumulation

• Health Effects:

  • Associated (observationally) with decreased vaccine response, dyslipidemia, fetal growth issues, kidney/liver/thyroid/testicular/breast cancers, ulcerative colitis
  • Quote:

    “There is an association between PFAS and decreased antibody response after vaccination, elevated risk for dyslipidemia… and heightened risk for kidney cancers in adults.” — C (14:48)

• Clinical Guidance:

  • No specific screening or treatment recommended; PFAS blood tests only show exposure, not disease risk or causation
  • Home exposure mitigation possible (filtering, water testing)
  • Occupational risk acknowledged; compensation/VA referral possible; some states have “presumptive” laws for job-related cancers

6. Medicine by the Numbers: Methotrexate for Juvenile Idiopathic Arthritis

(17:25–20:14) Contributors: Drs. Sonoda and Dougherty

• Condition: JIA = most common childhood rheumatic disease, onset <16 yrs

• Recommendation:

  • Methotrexate = preferred over leflunomide/hydroxychloroquine for active JIA (2021 ACR guidance)

• Evidence:

  • 2024 Cochrane review: 5 RCTs, 575 kids/teens globally
  • Results:
    • Low-certainty evidence: may improve treatment response vs placebo
    • Little or no difference vs other DMARDs or injected steroids in inactive disease or AEs
    • Quote:

      “Low certainty evidence also showed that...methotrexate plus intra-articular glucocorticoids may have little to no effect on sustained clinically inactive disease at 12 months.” — D (19:19)

• Caveats:

  • Most trials used low doses, short duration, small sample sizes
  • Authors rate evidence as “yellow” (unclear benefit); recommend more robust studies
  • Quote:

    “Further research with optimal dosing of methotrexate and longer follow up is needed to properly assess the use of methotrexate in JIA treatment.” — D (20:14)

Memorable Quotes and Moments

• “Over 80% of patients initially seek a dental evaluation because [trigeminal neuralgia] can mimic dental pain.” — B (02:57)
• “In short, early medication abortion is as safe and effective as standard of care treatment.” — D (05:52)
• “PFAS are highly concerning to environmental regulators because of their prevalence in water…they are extremely long lasting, receiving the nickname forever chemicals.” — D (14:13)
• “Low certainty evidence...weekly oral methotrexate may have little or no effect on treatment response, function…with low certainty of evidence.” — C (19:41)

Useful Timestamps

• Trigeminal Neuralgia Deep Dive: 01:25–04:22
• Early Medication Abortion Evidence: 04:39–06:00
• SGLT2 Inhibitors for CKD/Diabetes: 06:00–08:22
• Female Sexual Dysfunction: 08:49–12:15
• PFAS & Testicular Cancer Curbside: 12:31–16:47
• Methotrexate for JIA: 17:25–20:14

Original Language and Tone:
The discussion is collegial, thorough, and practical, offering family docs rapid evidence reviews, nuanced clinical context, and thoughtful comments on patient care and counseling. There is a strong focus on actionable pearls, realistic limitations, and patient-centered considerations.

Summary

This episode delivers essential, up-to-date clinical pearls relevant for primary care, blending evidence reviews with pragmatic advice on tricky, evolving, or controversial topics. The discussions favor clarity and practicality for busy clinicians, address common diagnostic pitfalls, and underscore areas for ongoing research or vigilance in patient care.