← Dr. Chapa’s OBGYN Clinical Pearls 
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Hey, podcast family. Well, true to form, we're going to cover something that is not yet out in print but is coming out very soon, like February of 2026. And we're going to cover in this episode very briefly, ACOG's new clinical consensus number 11. Now, this has to do with gynecology, not obstetrics, and it is a very niche topic, right? Very nich, kind of rare, doesn't happen a lot. But it is a good reminder of two things. Number one of what HCG is and where it lives in the world of our neuroendocrine transmitters and hormones. All right, so we're going to talk about hcg. That's the focus of this new clinical consensus guidance and the topic of today's episode. So we're going to talk about hcg. And the second reminder why we're doing this is to remind all of us that tests that we order guys have a consequence. So if you're going to order something, be prepared to deal with a weird result and potentially going down a rabbit hole. All right, now, very niche. Again, a little rare. And it is talking about a gynecological issue because the title of this is Management of Positive Human Chorionic Gonadotropin Test results in. Listen to this, non pregnant patients, that's the easy one. And those without gynecological malignancy, end quote. So following up hcg and when it comes out positive, they're not pregnant and they don't have GTT or gtn, some kind of weird gestational trophoblastic tumor, we're not Talking about that. And they don't have some kind of ovarian mass like a germ cell tumor. What do we do with these weird HCG results? Again? Good reminder that tests that we order have a consequence. Now, I learned this historically and I've taught this. Oh, you know what if it's a weird beta hcg, super low levels based on their age, we'll talk about that. Because HCG being quote, end quote, negative, really depends on a patient's age, y'. All. In patients who are a little older, perimenopausal, it shouldn't be 5. The cutoff should be a little bit higher, some say 10, some say 14. And I'll tell you why. The HCG may be artificially higher and they're not pregnant and they don't have a malignancy in those that are perimenopausal or menopause. Menopausal. We're going to talk about it. So HCG is actually age dependent outside of pregnancy and outside of a gin malignancy. So tests that we order, do you have consequences? And I remember telling patients, oh, if their HCG is low level positive, even for age, just check a urine. And if the urine is negative, don't worry. That's called the phantom hcg. The ghost hcg? Yeah, the phantom hcg. Like Phantom of the Opera. I never saw that. I thought that was weird. All right, stop that, stop that, stop that. All right, so Anyway, not all HCGs that we find where they're not pregnant and don't have a gin malignancy. Not all of them are false positive. So here's the idea, guys. This new clinical consensus number 11 is a good reminder that if you order, if you believe that there's a reason to get hcg, and you get it, maybe it's because she wants to make sure she's not pregnant and she's perimenopausal. And you're like, there's nothing in the uterus. It's this weird low level positive. They don't have an ovarian mass. This is not just to go automatically. Ah, don't worry. It's just a false positive. Wait a minute. It is true. It very well could be a phantom hcg. I think every time I say that. Are we going to do this? Michael? It's not a phantom hcg. Oh, my God. All right, so that's so dumb. All right, so here it is. Phantom HCG actually applies only to one caveat. There's only one, one specific niche explanation for that, which is you have a low level positive beta HCG appropriate for age, but the urine HCG is negative. So that's the catch. That is called the phantom hcg because in the serum there's a heterophil antibody that's cross reacting. But not all patients have that. So in this new clinical consensus, it does remind us of some weird things that you may discover in a patient who has this low positive hcg. And you're like, oh, my gosh, it's actually a weird non gynecological malignancy. Or maybe it's some weird genetic familial gene defect. That's a thing. So we're gonna talk about this, so we're Gonna cover again, ACOG's new clinical consensus number 11, coming out February 2026. It is a little. It's a little bit weird what to do with positive HCG test results in a patient who's not pregnant and does not have a gynecological malignancy. My best explanation for this, if you're thinking, well, why would I even know that? Easy. Let's say she's 46, having weird periods, she's having unprotected sex and wants to make sure she's not pregnant. And lo and behold, you get the beta HCG back. We're talking about serum, and it's this weird low level positive that just doesn't go away. What do we do with that? And again, we've ruled out pregnancy. Again, non pregnant and without gynecological malignancy. This is what this is covering. Now, some things move fast in medicine, some things not so fast. Because the last time ACOG covered this was ACOG's committee opinion number 278, which apparently somebody put on the shelf and forgot about because that committee opinion number 278 was released back in November of 2002. 2002, yep. Nothing like an update 20 years later. It's fine. It's all good. ACOG clinical consensus number 11 is the focus of our episode, what to do with a positive HCG when the patient is clearly not pregnant and does not have a gynecological malignancy. They are not all the Phantom hcg. Have I irritated anybody with this thing already? Now, I didn't watch Phantom of the Opera, but our producers telling me this is the intro to Phantom of the Opera song. If that is great, I don't know. Didn't watch it, don't like it. Not my vibe. All right, I think I've set it up enough. Oh, my goodness, we're Gonna cover clinical consensus number 11, coming out February 2026, what to do with a positive HCG in a non pregnant, non gynecological malignant patient. We're going to go through a very simple, easy algorithm, and I want to do this very focused, very fast. It's kind of niche, but still interesting. I think I've set it up enough. We'll be right back. This is Dr. Chapa's obgyn no spin podcast. Okay, so just to remind everyone, we're talking about what to do in a patient who has a serum low level positive HCG but is not pregnant and does not seem to have a gynecological malignancy, meaning not some kind of trophoblastic tumor and it's not an ovarian source. So very quickly, in this new clinical consensus number 11, just a quick reminder of HCG. Yes. While it definitely does have an origin in trophoblastic tissue, there's other sources that can release it. Even the pituitary. Right. There is some pituitary release of hcg. We'll touch on this in just a minute. Especially in late perimenopause or postmenopausal women where the HCG maybe this kind of borderline low level positive, but it must be interpreted along with a serum FSH or lh, because all of those are kind of related. Do you all remember this? We all learned this in medical school or nursing school. That HCG is dimeric. All right, so it's a heterodimeric glycoprotein. It has an alpha and a beta subunit. That's why we order a beta 8 CG to be much more specific, ideally, and not get some cross reactivity. However, the alpha subunit is not unique. Remember that the alpha subunit is shared with four hormones. Lh, fsh, tsh, and hcg. Right. They all have the same alpha. Remember, that's ssh, lh, TSH, and hcg. Now, the beta subunit of hcg, which is unique because it has a C terminal peptide. It does. Without that C terminal peptide, though, the beta subunit looks pret pretty darn similar to LH beta subunit. All right, so I know we always hear, oh, no, the beta subunit is super unique. That is true. But they say beta subunit is kind of homologous, kind of similar to the beta subunit of lh, but it's distinguished by a very unique C terminal peptide that the assay is supposed to pick up. All right, so it is true that the alpha subunits are the same across the four that we discussed, but yet the beta subunit of HCG still kind of similar to S LH and therefore peripherally down the road, a little bit similar to fsh, which is why whenever there's FSH elevation, as the pituitary is screaming to the ovary to wake up, like in perimenopause or especially in postmenopause, you can get a kind of pituitary release of hcg. Yes, I'm not nuts. The pituitary definitely can release hcg. There is some crossover there. That's why elevated levels of HCG need to be looked at with an FSH and an lh, especially in patients who are older. All right, guys, so that's a good clinical pearl as we start right here. One of the causes of false positive hcg, which again, it's not necessarily false. It's being produced by something. But we say false because it's not a gin malignancy and it's not a pregnancy. But we still have to explain it. It could be, especially in postmenopausal women coming from the pituitary. Okay, so first of all, got get out of our mindset that HCG is only a tropoblastic origin. It is not. Another potential cause of elevated hcg, especially in peri or postmenopausal women, is the pituitary. All right, now, there's been different numbers that have been offered as to what is normal in a postmenopausal patient. Some have used an FSH of 10. In this clinical consensus, they say, you know what, it's pretty reasonable, especially in a patient who is older or postmenopausal, to use a number like 14. The point is a lot higher than our typical negative cutoff of 5. Okay? So if you're going to get a test in a patient who is perimenopausal or postmenopausal, if you're going to get an HCG and it's not pregnancy and the ovaries look good, then consider an FSH or lh, which is how we're supposed to interpret this, because it may be of pituitary origin. All right, so again, according to this clinical consensus, it is reasonable to raise the value in an older patient who is perimenopausal or postmenopausal from 5 up to about 14. All right, 1, 4, 14. And again, that's not just for a one time value. That's if it's. If you check it once and it's a little weird, you check it again and it hasn't gone away. If it persists. This is the kind of workup that we're talking about here. Okay? So in those patients who have a low level positive, especially again, postmenopausal or perimenopausal, typically a normal should be considered anything less than 14. Okay? So up to about number 14 is considered. Okay, that's the upper limit. My point is, if you get an FSH, I'm sorry, a, an HCG on a, let's say 54 year old and it's, you know, a thousand, please don't say that's pituitary related. We're talking about. These are, these are still low level positives, but you move the limit from 5 up to 14. All right, so let me read this directly here from this clinical consensus and then we'll leave the pituitary source and go on to others.
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Quote in postmenopausal patients with elevated FSH levels and stable low level HCGs, typically less than 14 international units per liter, it is most likely that the HCG detected is produced by the pituitary. End quote so just like you interpret a hyprolactin with a tsh, right? Because thyrotropin releasing hormone can also hit prolactin releasing cells, so you shouldn't evaluate prolactin by itself. You should always evaluate prolactin with a tsh. Same thing here in postmenopausal or perimenopausal patients. Evaluate HCG with An fsh if it is a little bit higher, but still use a cutoff of 14. All right, so once again, I am not saying to ignore all HCGs as just, you know, quote, end quote, false positive. If they're postmenopausal and it's a thousand. No, no, no. But move the minimum from five, which is otherwise considered an HCG. Serum level of negative up to 14. All right, up to 14. So very quickly, just because I was onto that, and then let me answer this whole issue of the phantom hcg. That is the first step in the algorithm. So you have a patient with low level HCG just won't go away in the blood work. We're talking about blood work. Positive serum hcg. That will not go away. The first, first step is to perform a urine qualitative test. Very easy, because if it's negative, you go, ah, no worries. It's the blood in your blood. You got a little benign antibody. It's cross reacting with the assay. Remember, the assay is kind of a sandwich assay, looking for hcg. So something is reacting with that. Don't worry about it. As long as your urine is negative, we're going to call that a heterophilic antibody. The old term for that was the phantom hcg. This is so tacky. I think I've annoyed myself with this. I don't know, it's kind of catchy. All right, so if you check a serum hcg. Guys, I don't know. I've listened to other podcasts. They're so damn boring. I'm just honest. Geez, great information. But they all talk like this and they today take the urine. Urine is a negative. Then cedrophilic antibody. It's boring. And we are definitely not boring. That's our mission. Give you good information and not be boring. Especially when we talk about the phantom hcg. One more. Michael, come on. Jeez Louise. All right, anyway, can you believe I held an ACOG leadership position? Anyway, so positive serum hcg. First step, check the pp. And if the PP is negative, ma', am, don't worry about it, you're good. Heterophilic antibody, you're fine. Remember, we're talking about low level positive. And she's not pregnant and you've done your due diligence and her ovaries are normal. Because you should check her ovaries, make sure it's not coming from a ovarian source. All right, now here's the catch. Serum is positive, you check her pp and the PP has a qualitative positive test. So it's not a phantom hcg. There's something else going on. All right, this is now. Now what to do. Now, keep in mind, remember what I said earlier. This is kind of rare. We've already put to bed the pituitary. Cause we've already put to bed the phantom. Don't do it. Don't play the phantom hcg. What do we do when the urine test is positive? This is a weird little list of differential and it's stuff that I totally had forgot until this clinical consensus came out again. It'll officially come out in February 2026. I'm just going to list a couple of things quickly because, wow, it's like cell free DNA, right? We do cell free DNA to look for fetal aneuploidy. And then you're like, well, that's a weird result. Or some kind of weird funky aneuploidy here or triploidy. But the kid is normal or the amnio is just fine. Do not just go cell free. DNA was negative. You're fine. No, no, no. That weird jank DNA circulating in her body is coming from somewhere, y'. All. So it could be a malignancy. We've talked about this. We recently covered this in the Suffragette DNA episode. So again, be careful what you get and don't just discard something as that's just false. Don't worry about it. If you have a persistent low level positive on a patient and she's not pregnant and is not a gin malignancy and it's even found in the urine, something is happening that is not a phantom hcg. That is a low level positive. That is. You need to explain somehow. All right? And again, one of the causes of that could be pituitary release based on her age specific norms in relation to FSH and lh. Everybody good? Okay, now let me just read you a couple of weird stuff out there. Now remember, these are in patients who have persistent positive serum and the urine is also positive. Let me just read you some things to keep in mind. It could be chronic kidney disease, so check out creatinine. Get a bun. Call your medicine friends. If you don't remember how to check for kidney disease, you should, because OBGYN is still considered primary care even though we're a specialty. So do some evaluation. Consider pituitary release in those patients who are of that appropriate age. Now here's some weird things. Make sure her bladder is her bladder. Now what? There is the issue of enterocystoplasty. If they've had some kind of bladder augmentation. Yeah, I'm not even going to get into it. But bladder, urinary bladder augmentation. Trust me, it's related. HCG can be off kind of as a. As a marker of that surgery. Weird. I get it. Now. Here's the big one. Really? There's three big ones here. Okay. But one is super rare. Let me just tell you the rare one first. There is something called familial HCG syndrome. Super rare. It's like 1 in 60,000. But this is a weird genetic defect. Happens in men and women. They produce this kind of low level hcg, but it has absent or modified C terminal peptide. Right? So what they get is elevated HCG levels in some assays, not in others. It's kind of weird. You kind of have to ask a family history, maybe check a family member, but that is pretty darn weird. All right? So you've got to rule out other things before we just go. It's familial, especially the other two weird things that you really got to consider. All right? But there is something called familial HCG syndrome, about 1 in 60,000, where they just kind of produce HCG with a weird C terminal peptide. Right? So very weird. However, the ones that you don't want to miss. Guys, here it is. And we're going to start wrapping this up pretty quick because we're moving fast. You get an hcg? Cause I just want to make sure you're not pregnant. It's low level positive. It doesn't go away. The urine is still positive on a qualitative test. You're like, man, what is going on? No bladder surgery. She's not postmenopausal. She doesn't have chronic kidney disease. You have to consider that there's a non gynecological malignancy. Did you all hear me? A non gynecological malignancy. Because HCG can be released. Here it is, guys. As a paraneoplastic response. So it has been found, again, not common, but it has been found in breast cancer, gastrointestinal cancers, gu cancers, cancers of the lung, head and neck, and even osteosarcoma in a man. It's been found with testicular cancer. Okay, so non gynecological malignancies. Breast gi, gu lung, head and neck osteosarcomas and. Or testicular in men. It's a flag. This is what I'm trying to say. Don't just write off a quote unquote false positive pregnancy test. Oh, look, Haha. Your blood shows it's positive, but you're clearly not pregnant. Your ovaries look good, you don't have gestational trophoblastic tumor. Don't worry about it. You're fine if the urine also picks it up. So you can't explain it by the heterophilic antibody. In other words, if it's, if it's. It's definitely not a. A phantom hcg. You have got to look for a possible explanation. Is it pituitary in the age appropriate patient? Is it chronic kidney disease? Does she have a history of bladder augmentation? Is it a familial issue or one of the things you don't want to miss? Non gynecological malignancy. Now how to work that up? Just ask her. Have she had recent mammogram? You need to get that done. Any other GI symptoms? Is there weight loss associated night sweats? Go through, do a WHO physical exam and look for that same thing. Guys, here's the catch. Here's a relation to SE DNA. Quote, end quote. False positive results that aberrant DNA found on cell free DNA on the OB side. If you can't explain it on by the baby side, it's coming from somewhere. Okay, so that's the weird deal. So if you're. I know we just finished oral boards because we're in January, but for next fall, if it's a good board question, give me causes of low level positive HCG in the serum not related to pregnancy or a gin cancer and you go, it's heterophilic antibody. Really? Is that it? Is that all you got? I mean. Well, easy, check the urine. Urine is negative. Fine, but what if it's positive? You've got to know where it's coming from. And the answer is. Oh man, there's some weird stuff out there. Like the pituitary can do it in older women. It could be chronic kidney disease, it could be bladder augmentation, otherwise known as enrocystoplasty. It could be unfortunately, a non gynecologic malignancy. Now here's the last one I don't want you to miss and I'm gonna start wrapping this up. You gotta make sure that they are not dosing themselves up with some little shots or pills or something to improve their performance, especially if they're an athlete. Because exogenous HCG has been used for weight loss, is being used to stimulate androgen production in athletes. And then the other weird thing that we don't want it to be, which is much more worrisome and bothersome, is Munchausen's syndrome. All right, so do you all see mind blown? Right. So, number one, here's the algorithm. Get a positive HCG by serum. Won't go away easy. Get her pp. Check her pp. PP is negative. That's called a heterophilic antibody. In other words, it's a phantom result. You can relax from that because you can explain it. As long as the urine is negative, that is the phantom hcg. I thought we weren't doing that anymore. Apparently we are, so. But if the urine is also positive, look for causes. Ask. Hey, are you juicing it up for a little bit? You know, little weight loss? Remember? I remember when this was a thing. HCG for weight loss. Yes, it can give you some weight loss, but also you just in general don't want to take hcg. And if you don't have to. So ask. Hey, man, I'm getting this weird test result. Anything that you're taking, I need to know about. So the short list of differential is make sure it's not a true false positive, called a ghost value, by checking for heterophilic antibodies. And then if the urine is also positive and it's low level and you've ruled out ovarian or gynecological sources, Pituitary, kidney, bladder augmentation. GIN cancer. I'm sorry, non gin cancer. Breast, gi, gu lung, head, neck, osteosarcoma, or testicular. Make sure it's not some weird genetic issue by familial clustering called familial ACG syndrome. Super rare. And make sure that they're not taking HCG to getting it to themselves or giving it to somebody else as a Munchausen's syndrome. Weird, huh? So this was clinical consensus number 11 coming out February of 2026. Replace the one all the way from 2002. It was about time. One more phantom and then we'll start wrapping up. Michael, come on. Hit me. I don't know if this is right. You're telling me this is Phantom of the Opera? I'm gonna take your word for him because I have no idea. All right, stop it, stop it, stop it. All right, so on that note, on that note, podcast family, we have covered up ACOG's new Clinical Consensus Number 11, coming out February 2026. The title is Management of Positive HCG Gonadotropin Test Results in non pregnant patients without gynecological malignancy. As always, we're thankful for you. We're glad you're part of our podcast community. Now that I've done all that, Michael, let's take it home. This has been Dr. Chapa Zobi Gyn no Spin podcast Podcast family. Thank you for your support. Thank you for listening, and as always, we'll see you on another episode of the no Spin Podcast.