Podcast Summary: Dr. Chapa’s OBGYN Clinical Pearls

Episode: IUD, Cytology, and Actinomyces: Management
Date: November 30, 2025
Host: Dr. Chapa

Episode Overview

This episode addresses a common yet confusing clinical scenario: what to do when a routine cervical cytology (Pap smear) in a woman with an IUD incidentally reports organisms compatible with actinomycosis. Dr. Chapa humorously and enthusiastically walks through the evidence-based approach to management, dispelling myths and clarifying guidelines for both asymptomatic and symptomatic patients. His aim is to provide practical pearls for medical students, residents, and practicing providers, using real-world cases and updated guidelines.

Key Discussion Points & Insights

1. The Clinical Scenario and Common Reaction

[03:36]

• Dr. Chapa describes the frustration when a perfect cytology result is “spoiled” by an incidental finding of actinomycosis in IUD users.
  • “You see words right underneath. Oh. Incidental finding of organisms that are compatible with actinomycosis. Well, what do we do for that? No, God, no. God, please, no, no.” – Dr. Chapa ([04:08])

2. Actinomycosis: Background & Prevalence

[06:08]

• Actinomycosis is a misunderstood, poorly named bacterial infection (not a fungus!).
• About 7% of healthy women may harbor actinomyces as normal flora, with prevalence up to 20% in copper IUD users and around 3% in levonorgestrel IUD users.
  • “We now know that that’s not the case... about 7% of otherwise just healthy women can actually have this as part of their natural vaginal and urogenital tract flora.” ([07:22])
  • This finding is much more common in copper IUDs.

3. The Clinical Conundrum: What Do We Do?

[08:37]

• Dr. Chapa outlines the approach:
  • Asymptomatic patients (the vast majority)
  • Symptomatic patients (pelvic pain, etc.)

Key Take-Home

• “Just because actinomyces is suspected on a cytology result does not make it diagnostic.” ([11:42])

4. Limitations of Cytology for Diagnosis

[12:41]

• Cytology (Pap or liquid-based) is neither sensitive nor specific for actinomycosis.
  • “You cannot use a liquid-based cytology test for diagnoses of either actinomycosis or trichomoniasis… it is simply not as sensitive or specific for either trichomoniasis or actinomyces.” ([11:55])

5. Guideline-Based Management: Asymptomatic Patients

[15:05]

• ACOG, CDC, and IDSA all agree:
  • Leave the IUD in place.
  • No need for antibiotics or IUD removal in asymptomatic individuals.
  • The risk of progressing to pelvic infection is about 1%.
    • “In asymptomatic patients, what you do is nothing short of maybe a little message to the patient... It’s not a sexually transmitted infection... and that’s the end of that.” ([17:27])

Counseling Message Example

• “The Pap smear or the cytology found something that may or may not be real. I’m not worried about it. It’s not a sexually transmitted infection. Just be aware.” ([17:53])

6. Management: Symptomatic Patients (Pelvic Pain, etc.)

[18:45]

• Don’t assume all pelvic pain with actinomyces is serious infection—other causes are more likely.
• First step: Transvaginal ultrasound to screen for pelvic abscesses or masses.
• If negative: Highly reassuring.
• If abnormal/abscesses: Further imaging with CT or MRI as needed.

Notable Quote

• “If an ultrasound, transvaginal ultrasound is negative, it is highly reassuring.” ([19:50])

7. Confirming Diagnosis: The Importance of Histology

[21:16]

• Gold Standard: Endometrial biopsy (EMB) with histopathology.
  • The pathologist must know the clinical question.
  • Sulfur granules or evidence of tissue damage are diagnostic.
  • Microbiology (anaerobic culture) and PCR are less sensitive, not widely available, and not standard ([23:01]-[24:20]).
• “Endometrial biopsy with histopathological analysis of this thing is nearly always the way that this thing is diagnosed. Extremely high sensitivity and specificity... even over microbiological tests.” ([25:33])

8. Treatment of Confirmed Symptomatic Actinomycosis

[26:15]

• Remove the IUD (as it is a potential nidus for infection).
• Antibiotics:
  • IV high-dose penicillin G for 4-6 weeks
  • Then oral penicillin or amoxicillin for at least 6 months (can be up to a year for full eradication)
• Surgical intervention is rare, reserved for abscess drainage only if needed ([27:24]).

Notable Quote

• “It is a prolonged course of penicillin... literally is six months to a year of antibiotic therapy for these things to clear.” ([27:35])

Notable Quotes & Memorable Moments

• “Actinomycetes or actinomyces, which results in actinomycosis. I know it’s complicated. What kind of stupid name is that?” – Dr. Chapa ([12:25])
• “Just be aware. And it’s not unusual for women to have this, especially with an IUD or an IUS in place, and that’s the end of that.” ([17:49])
• “If you suspect true infection, you really have to do some kind of workup. You have to prove that it’s there.” ([13:25])
• “So back to endometrial biopsy. Endometrial biopsy with histopathological analysis of this thing is nearly always the way that this thing is diagnosed. Extremely high sensitivity and specificity.” ([25:33])
• “Podcast family, as always, we’re thankful for your messages…There’s always stuff to talk about, even if there’s not stuff that’s hot in press.” ([29:34])

Timestamps for Key Segments

| Segment | Description | Timestamp | |---------|-------------|-----------| | The clinical scenario & emotional reaction | Dr. Chapa’s humorous intro to the scenario | 03:36–05:55 | | Prevalence & natural history of actinomyces | Evidence about rates, copper vs. LNG IUDs | 06:08–08:16 | | Not diagnostic: cytology limitations | Explaining why actinomyces on Pap isn’t enough | 11:42–13:12 | | Asymptomatic management | Evidence, guidance, patient messaging | 15:05–17:58 | | Workup for symptomatic women | Imaging, gold standard biopsy, other tests | 18:45–25:33 | | Treatment of confirmed infection | Removal of IUD, prolonged antibiotics | 26:15–28:20 |

Summary Table: Management Pearls

| Scenario | Management | |-----------------------------------|--------------------------------------------------------| | Asymptomatic, IUD in place | No action; leave IUD. Patient reassurance. | | Symptomatic (pelvic pain, etc.) | Evaluate for other causes. Start with TV ultrasound. | | Pelvic abscess or suspicion persists | Endometrial biopsy for histology. CT/MRI if needed. | | Confirmed actinomycosis | Remove IUD; prolonged penicillin (IV then oral 6–12 mos). |

Tone & Engagement

Throughout the episode, Dr. Chapa uses energetic, relatable language, humor, and clear analogies to make a dry, often anxiety-provoking clinical scenario approachable and actionable. Recurring comedic references to the “stupid name” actinomycetes keep the tone light, while practical clinical pearls anchor the educational value.

Conclusion: Core Clinical Pearls

• Don’t panic about actinomyces on Pap in asymptomatic IUD users—no action required.
• True actinomycosis is rare, with very low risk of infection even in IUD users.
• Diagnosis requires histology (endometrial biopsy), not culture or cytology.
• Treatment for confirmed infection is lengthy and involves both IUD removal and prolonged antibiotics.
• Effective patient counseling focuses on reassurance and clear communication.

“Expectant management for asymptomatic patients is the way to go… get ready for a prolonged course of antibiotics to take care of actinomycetes. What kind of stupid name is that?” – Dr. Chapa ([28:20])

For providers:
Follow established guidelines, save patients unnecessary anxiety or intervention, and keep the “clinical pearls” coming.