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Abstract Objective: This study aimed to evaluate the hemodynamic characteristics of fetuses with isolated Aberran Right Subclavian Artery (ARSA) and compare them with a control group of normal fetuses using Doppler ultrasonography. Methods: A total of 93 fetuses were included in this prospective case-control study. Forty fetuses with isolated ARSA and 53 control fetuses with normal right subclavian arteries were analyzed. Doppler ultrasonographic parameters (Peak Systolic Velocity (PS), Pulsatility Index (PI), Resistive Index (RI), Time-Averaged Maximum Velocity (TAMAX), Heart Rate (HR)) were assessed and compared between the two groups. Results: No significant differences were found in the Doppler parameters (PS, PI, RI, TAMAX, HR) between the ARSA and control groups. Furthermore, there was no correlation between gestational age, fetal weight, and Doppler parameters in either group. Conclusion: The study supports the hypothesis that isolated ARSA is a benign anatomical variant without significant hemodynamic impact on fetal development. ARSA cases without associated cardiac or chromosomal anomalies do not appear to affect fetal growth.

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Abstract Objective: To characterize the maternal clinical, ultrasound, and laboratory parameters, maternal and perinatal outcomes of mirror syndrome, and to discuss the role of sFlt-1/PlGF biomarkers in diagnosis and management. Methods: We conducted a case series including all cases of mirror syndrome diagnosed at a tertiary reference center in Brazil. Clinical, laboratory, ultrasound, and biomarker data were collected, along with maternal and perinatal outcomes. Results: Nine cases of mirror syndrome were identified, with a mean gestational age at diagnosis of 27+6 weeks. The most frequent maternal findings were lower limb edema (n=7), hypertension (n=8), and proteinuria (n=8). Ultrasound demonstrated fetal hydrops (n=7), polyhydramnios (n=6), and placentomegaly (n=7). Laboratory abnormalities included abnormal proteinuria/creatinuria ratio in 5/8 women tested, elevated 24-hour proteinuria in all 5, anemia in 7, thrombocytopenia in 3, and elevated creatinine in 1. The sFlt-1/PlGF ratio was measured in 5 women; 4 had abnormal results, with 3 above 85, all of whom developed maternal complications or fetal death. Resolution occurred after a mean of 3.4±3.6 days, due to fetal death (n=3), delivery (n=5), or fetal surgery (n=1). In one monochorionic twin pregnancy complicated by twin–anemia–polycythemia sequence, biomarker normalization after intrauterine death of the hydropic twin allowed safe prolongation of the pregnancy and term delivery of the co-twin. Conclusion: Mirror syndrome should be suspected in pregnancies presenting with preeclampsia-like features in the setting of fetal hydrops or polyhydramnios. The sFlt-1/PlGF ratio may assist in differentiating mirror syndrome from preeclampsia and in identifying women at risk for adverse outcomes.

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Abstract Objective: To compare the effectiveness of pixel CO2 laser and vaginal promestriene in treating genitourinary syndrome of menopause (GSM). Methods: A quasi-randomized controlled trial was conducted with 48 patients. CO2 Laser Group (24 patients) received 3 sessions of vaginal pixel CO2 laser, and promestriene group (24 patients) used vaginal promestriene daily for 14 days, then twice weekly for 3 months and 3 weeks. Patients were evaluated before and after treatment using a visual analog scale (VAS), FSFI-6, ICIQ-SF, Vaginal Health Index (VHI), and vaginal wall biopsy. Results: Of the 48 patients, 22 in CO2 Laser Group and 21 in promestriene group completed the study. Both groups showed significant symptom reduction by VAS, with improvements in desire, lubrication, and total FSFI-6 scores. CO2 Laser Group had greater improvements in lubrication, orgasm, and satisfaction (p<0.001). Urinary incontinence improved in both groups (p<0.01). VHI scores increased significantly in both groups (p<0.001). Biopsies revealed improvements in collagen, glycogen, vascularity, epithelial thickness, and reduced neutrophil count (p<0.01). Conclusion: CO2 laser appears to be a viable non-hormonal alternative for treating GSM, particularly for women unable or unwilling to use hormonal therapies.

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Abstract Objective: To analyze the adequacy of gestational weight gain (GWG) and associated factors, according to the Brazilian GWG charts, and compare with the Institute of Medicine (IOM) recommendations. Methods: This was a cross-sectional study. Sociodemographic, clinical, and obstetric data were collected from interviews and medical records. The sample was divided into three groups according to the Brazilian charts: insufficient GWG, adequate GWG, and excessive GWG. The chi-square and Kruskal-Wallis tests were used to compare frequencies and medians, respectively, and Dunn's test was used to verify differences between groups, assuming statistical significance of p<0.05. Results: Seven hundred and twenty-five women with low-and high-risk pregnancies were evaluated. Using the Brazilian charts, the prevalence of insufficient, adequate, and excessive GWG was 25.8%, 21.1%, and 53.1%, respectively. Compared with the classifications given using the IOM method, there was a lower prevalence of insufficient and adequate GWG and a higher prevalence of excessive GWG. The sensitivity and specificity of the Brazilian charts versus the IOM recommendations were 100% and 76.6%, respectively, for excessive GWG and 72.3% and 20%, respectively, for insufficient GWG. The modifiable factors related to GWG were pregestational BMI (p=0.001) and number of consultations with a nutritionist (p=0.008). Conclusion: Studies evaluating the Brazilian GWG charts are scarce. The Brazilian charts indicated a higher prevalence of excessive GWG than the IOM recommendations. The sensitivity and specificity of the Brazilian charts were better for excessive GWG than for insufficient GWG, using the IOM recommendations as the standard.

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Abstract Objective: This study aimed to characterize tricuspid valve sound signals in healthy fetuses during the first trimester of pregnancy using Doppler ultrasound and computational analysis. Methods: A cohort of pregnant women at 11–14 weeks of normal-risk gestation was assessed at the Instituto de Medicina Integral Prof. Fernando Figueira (IMIP) between December 2019 and May 2020. Eligible participants were over 18 years old with no pregnancy complications. Doppler recordings of the fetal tricuspid valve were obtained, and linear (wave duration) and non-linear analyses were performed, including approximate entropy (ApEn), Lempel-Ziv complexity (LZC), and detrended fluctuation analysis (DFA). Follow-up in the second trimester with a fetal medicine team and postnatal follow-up with physical examination by an experienced neonatology team confirmed normal cardiac results. Results: Early diastolic (E) wave presented a mean duration of 70.89±9.26 ms, with ApEn 0.25±0.15, LZC 0.77±0.15, and DFA 0.73. Atrial contraction (A) wave had 79.77±7.56 ms, ApEn 0.25±0.15, LZC 0.77±0.19, and DFA 0.52. Systole showed 225.95±15.88 ms, ApEn 0.15±0.17, LZC 0.78±0.15, and DFA 0.75. Diastole had 150.66±13.99 ms, ApEn 0.18±0.11, LZC 0.83±0.22, and DFA 0.66. The full cardiac cycle lasted 376.61±16.40 ms, with ApEn 0.18±0.11, LZC 0.83±0.22, and DFA 0.81. The diastole/cardiac cycle ratio was 0.4±0.3, with ApEn 0.22±0.12, LZC 0.72±0.15, and DFA 0.62. Conclusion: This study offers a detailed characterization of tricuspid valve wave segments in healthy fetuses during early gestation. The integration of linear and non-linear analyses may enhance our understanding of fetal cardiac physiology. Further research is needed to evaluate whether these parameters can assist in the early detection of congenital heart diseases. We highlight the potential of these parameters for early screening of congenital heart disease and chromosomal abnormalities, while emphasizing the need for further studies to confirm their diagnostic value.

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Abstract Objective: This study investigated the association between gestational weight gain based on the new weight gain curve adopted by the Brazilian Ministry of Health for pregnant women and the risk of developing Gestational Diabetes Mellitus (GDM). Methods: Cross-sectional study was conducted with 104 pregnant women—52 with GDM and 52 without—matched for age, self-reported skin color, pre-existing hypertension, and family history of type 2 diabetes. Statistical analyses were performed using SPSS version 19.0. Categorical variables were analyzed using the Chi-square or Fisher's exact test, and continuous variables with the Student's t-test or Mann–Whitney U test. Two multivariate logistic regression models were applied: one using BMI and GWG as continuous variables and another using their categorical classifications. Odds ratios (OR) were calculated as exp(b), and models were adjusted for age, skin color, income, education, and family history of diabetes. A p-value < 0.05 was considered significant. Results: Women with GDM reported less physical activity before (26.9% vs. 46.2% p = 0.042) and during pregnancy (17.3% vs. 40.4% p = 0.009). Regarding pre-gestational nutritional status, women with GDM showed a higher prevalence of overweight (53.9% vs. 30.8%), while obesity was more frequent among women without GDM (40.4% vs. 26.9%), although these differences were not statistically significant (p = 0.059). Women with GDM had lower median gestational weight gain (4.5 kg vs. 8.0 kg, p < 0.001) and a higher proportion exceeded the recommended values (84.6% vs. 40.4%). Excessive GWG was significantly associated with GDM: each additional kilogram gained increased the odds of developing GDM by 28% (aOR 1.28; 95% CI: 1.12–1.47, p < 0.001). Conclusions: Excessive gestational weight gain was significantly associated with GDM, underscoring the importance of monitoring maternal weight gain to prevent complications.

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Abstract Objective: To assess the risk of postpartum depression (PPD) in women with twin pregnancies using the Edinburgh Postnatal Depression Scale (EPDS), and to explore associations between maternal and neonatal complications and depressive symptoms during the postpartum period. Methods: This prospective, mixed-methods study was conducted at the Multiple Pregnancy Outpatient Clinic. Fourteen women with twin pregnancies received psychodynamic psychological prenatal care throughout the pregnancy-puerperal cycle. Postpartum depressive symptoms were screened using the EPDS, with scores ≥13 indicating probable PPD. Associations between EPDS scores and obstetric or perinatal variables were analyzed using Pearson correlation and contingency tables. Results: A high prevalence of depressive symptoms was observed among participants, with 28.6% screening positive for probable PPD and an additional 21.4% at mild risk. Higher EPDS scores were associated with intrapartum hemorrhage, low APGAR scores (1st and 5th <7), cesarean delivery, and neonatal intensive care unit (NICU) admission. Breastfeeding was associated with lower depressive symptom scores. Despite the presence of depressive symptoms in part of the sample, improvements in emotional domains such as anxiety and sadness were noted, suggesting a potential benefit of continuous psychodynamic support. Conclusion: Women with twin pregnancies are at increased risk of postpartum depression, particularly when compounded by obstetric and neonatal complications. Routine mental health screening and structured psychological support—such as psychodynamic prenatal care—should be considered integral components of care for women with multiple gestations. Further studies with larger samples and comparison groups are needed to refine preventive strategies.

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Abstract Objective: To develop and test an instrument in Brazilian Portuguese to evaluate KAP regarding GDM. Methods: We developed an instrument with 22 items (10 items for practice, 4 for knowledge and 8 for attitude), which was tested in a population of pregnant women (24 – 28 weeks) with GDM. We performed an Exploratory Factor Analysis to evaluate the items included in the instrument, the covariance among the domains evaluated by the instrument, and the robustness of the instrument. Results: One hundred seventy-five participants were included in this study (mean gestational age: 25.4±7.1 weeks). The majority of them did not present adequate KAP regarding diabetes. The average knowledge score was 0.84±1.02 points; the attitude score was 32.46±2.94; and the practice score was 4.65±1.65. The model with the best robustness to evaluate KAP was composed of 3 items for knowledge, 6 for attitude, and 5 for practice. Conclusion: The levels of KAP regarding diabetes among Brazilian pregnant women are low. The moderate association between knowledge and practice underscores the need for targeted educational interventions within prenatal care. Implementing a specific Brazilian Portuguese instrument to evaluate KAP among this population can bring evidence regarding the dimension of the problem in the country.

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Abstract Objective: To evaluate the behavior of pituitary adenomas following cessation of cabergoline (CAB) treatment, postpartum, and postmenopause, in comparison to idiopathic hyperprolactinemia (HPRL). Methods: This retrospective cohort study included women with HPRL treated with CAB under three conditions: treatment for at least two years and follow-up for a minimum of one year after treatment discontinuation, postpartum, and postmenopause. The evaluated parameters included tumor size, prolactin (PRL) levels, and clinical symptomatology. Results: A total of 160 women with idiopathic HPRL, micro- or macroadenomas, with symptom onset at 29.3±9.0 years, were included. Menstrual alterations occurred in 70% and galactorrhea in 63% of cases. PRL normalization occurred more rapidly in idiopathic HPRL than in tumors. However, symptom resolution required a similar time across all groups. All macroadenomas regressed to <10 mm. After CAB withdrawal, reintroduction was necessary in all macroadenomas, 53% of microadenomas, and 23% of idiopathic HPRL. Following postpartum CAB withdrawal, mean serum PRL levels increased by 300% in macroadenomas, 218% in microadenomas, and 11% in idiopathic HPRL; approximately 75% of all patients experienced symptom recurrence. Postmenopausal PRL normalization occurred in over 40% of cases. One untreated idiopathic HPRL case developed a microadenoma 12 months after menopause. Conclusion: HPRL presented a high recurrence rate following CAB discontinuation, regardless of tumor presence or treatment duration, with no reduction in recurrence observed after the postpartum period.

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Abstract Objective: To evaluate the accuracy of neural networks and Naïve Bayes models in diagnosing ectopic pregnancy, using clinical data, hCG levels, and transvaginal ultrasound findings from a real dataset. Methods: This was a retrospective cohort study based on a public dataset of 2,495 first-trimester pregnant women with confirmed pregnancy under 13 weeks, documented transvaginal ultrasound reports, and follow-up on pregnancy outcome. The cohort presented a natural imbalance (8.5% ectopic, 91.5% intrauterine pregnancies), reflecting real-world clinical prevalence. Data on risk factors, clinical symptoms, ultrasound findings, and serial hCG levels were included. The dataset was preprocessed and split into training (80%) and testing (20%) sets using stratified sampling based on pregnancy outcome to preserve the proportion of ectopic cases in both sets. The main outcome measures were accuracy, sensitivity, specificity, and F1 score. Results: The neural network model achieved an accuracy of 99.4%, sensitivity of 94.6%, specificity of 97.2%, and an F1 score of 95.9%. The Naïve Bayes model showed an accuracy of 96.5%, sensitivity of 98.1%, specificity of 71.2%, and an F1 score of 82.5%. Both models were validated without evidence of overfitting. Conclusion: The neural network model demonstrated statistically significant superior accuracy and reliability in diagnosing ectopic pregnancy compared to the Naïve Bayes model (McNemar's test, p < 0.001), suggesting the potential of machine learning models, particularly deep learning, to enhance early diagnosis and clinical decision-making.

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Abstract Objective: Vitamin D has a direct influence on musculoskeletal health, and vitamin D deficiency is related to lower bone density and greater bone resorption and to a higher incidence of fractures. To assess knowledge, attitudes and practices regarding vitamin D and osteoporosis in postmenopausal women. Methods: This was a cross-sectional study carried out with 260 postmenopausal women who underwent routine consultations at the menopause outpatient clinic of Campinas State University-São Paulo. Women aged 50 years or older with amenorrhea for at least 12 months were included. From an interview, sociodemographic information and health data were collected, and knowledge about vitamin D, habits related to vitamin D, and knowledge about osteoporosis were evaluated using the Facts on Osteoporosis Quiz (FOOQ) questionnaire. Results: A total of 67.31% of women answered less than half of the questions about knowledge of vitamin D, 58.85% performed their day-to-day activities mostly outdoors, and 53.85% said they did not expose themselves sufficiently to the sun in their daily lives. The average knowledge score on the FOOQ was 15.83 (± 3.75). The variables education level, number of correct FOOQ answers and total self-care score were associated with the highest score for knowledge of vitamin D. Conclusion: Knowledge about vitamin D and osteoporosis in this group of postmenopausal women was limited. High levels of education, knowledge about osteoporosis and self-care were factors associated with knowledge about vitamin D.

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Abstract Objective: To describe genital hiatus area, pelvic floor muscle (PFM) function, pelvic floor dysfunction symptoms and sexual function characteristics of transgender women submitted to gender-affirming surgery. Methods: Six participants were included in this case series conducted in a referral hospital which treats transgender individuals in Brazil. An individual assessment was performed with sociodemographic variables, clinical symptoms, PFM function, neovaginal depth and genital distances. Two and three-dimensional translabial ultrasound were used to measure hiatal dimensions. The results were shown with absolute and relative frequencies, mean and standard deviation. Results: The genital hiatus area had an average of 11.09 (SD 3.49) cm² at rest and 14.36 (SD 3.00) cm² during the Valsalva maneuver. The mean distances of clitoris-vagina, genital hiatus and perineal body were 9.30 (SD 1.57) cm, 6.60 (SD 1.43) cm and 4.00 (SD 1.90) cm, respectively. The mean vaginal depth was 9.50 (SD 3.51) cm. Most volunteers had satisfactory PFM strength and tone. Transgender women reported an increase in daytime urinary frequency (100%), nocturia (83.3%), sensation of incomplete evacuation (66.7%), straining during defecation (50%), flatal incontinence (16.6%), dyspareunia (50%) and anodyspareunia (16.6%). There were no reports of urinary or fecal incontinence, vaginal bulging, perineal pain or dysuria. Conclusion: This is the first study reporting genital hiatus area by translabial ultrasound in transgender women. Adequate levator hiatal area and neovaginal depth were found, preserved PFM tone and strength, preserved urinary and fecal continence, increased daytime urinary frequency, nocturia, sensation of incomplete evacuation, dyspareunia during vaginal sex and moderate vaginal sexual satisfaction.

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Abstract Objective: Maternal pro-inflammatory responses have been implicated in pregnancy complications. This study examined the association of maternal serum IL-2, IL-4, and IL-13 levels with intrauterine growth restriction (IUGR) and umbilical artery Doppler indices. Methods: This case-control study was conducted at Alavi Teaching and Referral Hospital, Ardabil, Iran, from August 2024 to June 2025. Sixty singleton pregnant women (30 with IUGR and 30 with normal pregnancies) between 28–36 weeks of gestation were included. Umbilical artery resistive (RI) and pulsatility (PI) indices were assessed by a single sonographer, and serum cytokine levels were measured using ELISA. Statistical analyses (t-test, chi-square, Pearson's correlation, logistic regression) were performed with SPSS v25. The study was approved by the Ethics Committee of Ardabil University of Medical Sciences (no. 1403.049). Results: Compared with controls, the IUGR group had higher IL-2 and lower IL-4 and IL-13 levels, as well as increased PI and RI (all P<0.05). Elevated IL-2 (OR=1.027; 95%CI: 1.011–1.044; P=0.001) and reduced IL-4 (OR=0.963; 95%CI: 0.929–0.999; P=0.042) and IL-13 (OR=0.978; 95%CI: 0.962–0.995; P=0.009) were independently associated with IUGR. IL-2 correlated positively, while IL-4 and IL-13 correlated negatively, with both Doppler indices (all P<0.05). Conclusions: Pregnant women with IUGR exhibited a pro-inflammatory Th1-biased cytokine profile, characterized by increased IL-2 and decreased IL-4 and IL-13, which correlated with elevated umbilical vascular resistance. These findings suggest an immunologic contribution to placental dysfunction. However, given the observational design and small sample size, causal inferences cannot be made, and confirmation in larger multicenter studies is warranted.

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Abstract Objective: To evaluate the clinical differences in the presentation of vulvar lichen sclerosus in pre- and postmenopausal women, aiming to provide insights to improve disease management and promote the health and well-being of affected patients. Methods: This was a retrospective analytical study involving 287 women diagnosed with vulvar lichen sclerosus, conducted between January 2009 and December 2023 at Erasto Gaertner Hospital, in Curitiba, Brazil. Clinical, epidemiological, and therapeutic management aspects were assessed and compared between pre- and postmenopausal patients. Results: Most cases (87%) occurred in women over 50 years of age, showing a strong association with menopause. Systemic arterial hypertension and type II diabetes mellitus were the most frequent comorbidities. Complaints of vulvar atrophy and anatomical deformities predominated among women over 50 years. Pruritus was the most common symptom in both groups, while dyspareunia was more prevalent among younger women. High-potency topical corticosteroid therapy was effective in more than half of the patients in both groups. Additionally, contrary to previous literature, 2% testosterone cream showed significant clinical improvement in the younger group. Progression to in situ neoplasia was observed in 11 cases, and progression to invasive neoplasia occurred in 6 cases. Conclusion: Differences in clinical presentation according to hormonal status reinforce the importance of individualized management strategies. Further studies with larger samples are necessary to optimize treatment approaches and improve quality of life for women affected by this chronic, mutilating, and often neglected dermatosis.

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Abstract Objective: The aim of the study was to analyze the role of the neutrophil to lymphocyte ratio (NLR) as a prognostic factor in metastatic breast cancer (MBC). Methods: A retrospective cohort study including 359 recurrent MBC patients was performed. Clinical and pathological attributes were retrieved from patients’ medical files and their importance in the overall survival were evaluated using the Cox univariate and multivariate proportional hazard models. A confidence interval of 95% was used to select significant variables and the Wald test was used to infer the best NLR cutoff value to discriminate into low and high categories. Results: In univariate analyses, the variables estrogen receptor (ER) and progesterone receptor (PR) expressions, previous treatment with adjuvant chemo, NLR, PLR (platelet-lymphocyte ratio), age at diagnosis and the main metastatic site (bone/lymph node, visceral or central nervous system) variables were significant to determine the hazards. After filtering the collinear variables, the final model was tested with 6 variables based on 339 patients and the NLR at the time of the recurrence diagnosis (NLR_rec), the hormone receptor (ER or PR) status and the age at diagnosis were considered significant. The best NLR_rec value to discriminate against patients was 4.43 (Wald test= 51.7) and there were 239 patients categorized as low and 111 as high NLR category. The median overall survival time was 18 and 4 months in NLR-low and NLR-high groups, respectively (p< 0.001). Conclusion: NLR is an independent prognostic factor in recurrent MBC patients.

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Abstract Objective: To translate and culturally validate the VALue of the UteruS (VALUS) instrument in Brazilian Portuguese language and to identify predictors for VALUS score. Methods: A cross-sectional study (February to November 2024) at a tertiary, academic hospital was performed with 164 women presenting symptomatic uterine fibroids (UF) (n=139) or endometrial polyps (n=25) that underwent hysterectomy or myomectomy/polypectomy. The VALUS instrument was translated and culturally validated first. Psychometric variables (internal consistency, test-retest, discriminant validity) were calculated. Women completed the VALUS instrument prior to the decision-making process to undergo surgery. The Uterine Fibroid Symptoms-Quality of Life (UFS-QOL) was also completed for women with UF. Uni- and multivariate linear regression was calculated to seek for associated factors with the VALUS total score. Results: Women that underwent hysterectomy were older, with higher education, higher parity and frequency of abdominal/pelvic surgeries than the non-hysterectomy group. VALUS scores were statistically higher in the non-hysterectomy for some questions and total score. Internal consistency of the VALUS instrument was excellent (alpha=0.890) and test-retest analysis did not differ between the groups (p=0.891). The UFS-QoL quality of life score presented a negative correlation with VALUS instrument. Multivariate linear regression demonstrated that the presence of abdominal/pelvic surgeries was associated with a lower VALUS score. Conclusion: VALUS demonstrated adequate internal consistency and reliability, but with low discriminant validity for the prediction of hysterectomy versus uterine-preservation in women with UF or endometrial polyps. Presence of abdominal/pelvic surgery is associated with a lower VALUS score.

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Abstract Objective: Recurrent pregnancy loss (RPL) is known as a significant reproductive issue globally, which affects almost 5% of couples. Various factors contribute to the incidence of RPL. Considering the crucial role of male factors in the incidence of RPL, this study investigates the relationship between sperm parameters and RPL. Methods: This cross-sectional study was performed on 253 infertile couples who were eligible to participate and referred to the infertility center of BentolHoda Hospital from February 2022 to March 2023. The information was collected through demographic, medical, and infertility assessments, as well as laboratory examinations. Participants were categorized into two groups: couples experiencing RPL and couples facing primary or secondary infertility, which served as controls. Data were analyzed using descriptive statistical tests, the chi-square test, and logistic regression. Variations in different sperm parameters, as well as other demographic factors, were investigated between the two groups. Results: According to the findings, 32.4% of infertile couples had a history of RPL. The Chi-Square test results demonstrated a statistically significant association between motility and viscosity in couples with a history of recurrent pregnancy loss (p < 0.05). The results of the logistic regression analysis showed that the variables age (B = 0.103), drug therapy for infertility (B = -2.826), sperm viscosity (B = -1.440), and sperm motility (B = 1.113) could significantly relate to the PRL. Conclusion: The findings of this study suggest that low sperm motility, female age, and high sperm viscosity are factors that influence the occurrence of RPL.

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Abstract Objective: To evaluate the association between high Anti-Müllerian Hormone (AMH) levels and key outcomes of In Vitro Fertilization (IVF)/Intracytoplasmic Sperm Injection (ICSI) in women with Polycystic Ovary Syndrome (PCOS). Data sources: A systematic search was performed in MEDLINE (via PubMed), Web of Science, and Scopus, on September 17, 2024. Selection of studies: We included observational studies in PCOS patients stratified by AMH levels that reported any of the IVF/ICSI outcomes of interest, namely: live birth rate, clinical pregnancy rate, miscarriage rate, oocytes retrieved, MII oocytes and fertilization rate. Data collection: Two reviewers independently extracted data and assessed risk of bias using the National Heart, Lung, and Blood Institute Study Quality Assessment Tool. Discrepancies were resolved by consensus. Data were pooled using meta-analysis when appropriate. Sensitivity analyses were conducted using a leave-one-out approach. Data synthesis: Thirteen studies met the inclusion criteria. Ten were rated as low risk of bias, two as unclear, and one as high risk, indicating overall fair to strong methodological quality. Women with high AMH levels had a lower live birth rate (odds ratio [OR]: 0.85; 95%CI: 0.71–1.02), which became significant after leave-one-out analysis (OR: 0.80; 95%CI: 0.64–0.99). Clinical pregnancy rates were 2% lower in women with elevated AMH levels (OR: 0.98; 95%CI: 0.82–1.17). Miscarriage rates showed a non-significant 25% increase in women with high AMH levels (OR: 1.25; 95%CI: 0.88–1.76). High AMH levels were associated with more retrieved oocytes in the overall meta-analysis (mean difference: 3.52; 95%CI: 1.70–5.33), with consistent findings in sensitivity analyses. There was no significant difference in fertilization rate between the two groups. Conclusion: While high AMH levels indicate greater ovarian reserve, they negatively influence reproductive outcomes in PCOS patients. These findings highlight the need for individualized ART strategies and further research to clarify underlying mechanisms. PROSPERO: CRD42024596056

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Abstract Objective Human papillomavirus (HPV) is a leading cause of cervical cancer (CC) worldwide. There is growing interest in the potential role of HPV vaccination as adjuvant measure in patients with active infection. This study aimed to assess whether the nonavalent HPV vaccine (9vHPV) promotes faster disease clearance in women with low-grade (LGD) and high-grade disease (HGD). Methods Retrospective study including women aged 25–60 years who began follow-up in 2018 at a central Portuguese hospital after referral through organized CC screening. A total of 126 patients with HGD (69 vaccinated, 57 unvaccinated) and 277 with LGD (131 vaccinated, 146 unvaccinated) at baseline were followed with HPV cotesting (HPV test + cervical cytology) at 12, 18, 24, 36, and 48 months. Disease clearance was defined as the first negative cotest result. Kaplan-Meier curves and the Log Rank test were used to compare time to clearance between groups. Results Among HGD patients, the vaccinated group showed a shorter mean time to disease clearance (17.4 months; 95% CI: 14.88–19.93) compared to the unvaccinated group (20.2 months; 95% CI: 17.07–23.34), although the difference was not statistically significant (p=0.228). In the LGD group, both vaccinated and unvaccinated patients had similar mean clearance times (25.9 months; 95% CI: 23.44–28.43 vs. 26.9 months; 95% CI: 24.41–29.37), also lacking statistical significance (p=0.637). Conclusion Main findings suggest a negligible effect of 9vHPV in significantly reducing time to clearance in patients with active infection. Further research is needed to clarify its role in secondary prevention strategies.

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Abstract Objective: To prospectively evaluate the effects of transcutaneous tibial nerve electrical stimulation (TTNS) on urinary symptoms and quality of life in women with neurogenic overactive bladder (nOAB) secondary to ischemic stroke (IS). Methods: This was a prospective case series with a six-month follow-up. Women with clinically and radiologically confirmed IS who developed nOAB symptoms persisting for more than six months after the cerebrovascular screened for eligibility. TTNS was administered twice weekly for six weeks, with 30 minute-minute sessions. Electrical stimulation was delivered at the sensory threshold using a fixed frequency of 10Hz and a pulse width of 250 µs. Outcomes were evaluated at baseline, immediately after treatment, and at six months using a one-week bladder diary and the King's Health Questionnaire (KHQ). Statistical analysis was performed using the Friedman test for repeated measures, with a significance threshold of p < 0.05. Results: Among 236 screened women with IS, 34 (21%) reported persistent nOAB symptoms; 31 completed the study protocol and were included in the final analysis. Mean age was 59.3 ± 13.6 years, and 67.7% were postmenopausal. Detrusor overactivity was identified in 51.6% of urodynamic studies. TTNS produced significant reductions in daytime frequency (11.95 to 6.99 voids/day post-treatment; 7.21 at follow-up), urgency episodes (13.32 to 0.97; 1.35 at follow-up), urge incontinence (9.19 to 0.26; 0.58 at follow-up), and nocturia (2.99 to 0.40; 0.64 at follow-up) (all p < 0.001). Significant improvements were observed across all KHQ domains, including general health perception (58.06 ± 24.48 to 30.65 ± 22.09), incontinence impact (60.22 ± 24.97 to 11.83 ± 22.02), physical and social limitations, emotional well-being, sleep and energy, and severity measures (all p < 0.001). Improvements were sustained at six months, with partial symptom recurrence in 19.6% and complete recurrence in 6.7% of participants. Conclusion: TTNS was associated with significant and sustained improvements in urinary symptoms and quality of life in women with post-stroke nOAB.

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ABSTRACT Objective: To evaluate the hemostatic profile of estetrol/drospirenone (E4/DRSP) compared with ethinylestradiol/drospirenone (EE/DRSP) in adult women. Methods: A systematic review and meta-analysis of randomized controlled trials (RCTs) was performed according to PRISMA guidelines. Eligible studies compared E4/DRSP with EE/DRSP in adult women and assessed coagulation, anticoagulation, or fibrinolytic markers. Three RCTs (n=183) met inclusion criteria. Data were extracted independently, and pooled mean differences (MD) were calculated using random-effects models. Results: Compared to EE/DRSP, E4/DRSP was associated with higher protein S activity (MD = 21.23; 95% CI: 11.83 to 30.64; p<0.00001) and lower levels of fibrinogen (MD = −24.17; 95% CI: -39.15 to -9.19; p=0.002), plasminogen (MD = −27.28; 95% CI: -27.28 to – 22.89; p<0.00001), and SHBG (MD = −183.38; 95% CI: -183.38; 95% CI: -210.93 to -155.84; p<0.00001). No significant differences were observed for D-dimer and antithrombin. Protein C activity was higher in the EE group, though this was an isolated finding with limited interpretability. Conclusion: E4/DRSP demonstrates a more favorable hemostatic profile than EE/DRSP, potentially reducing thrombotic risk. Despite the limited number of RCTs, consistency across markers supports E4 as a safer estrogenic component for contraceptive formulations, with implications for women at increased risk of venous thromboembolism. PROSPERO registry: #CRD420251074961

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ABSTRACT Objective: Evaluate the effectiveness of Methotrexate in clinical treatment of ectopic pregnancy and analyze the influence of clinical and laboratory variables on the treatment outcome. Methods: It was a retrospective study of 95 patients undergoing clinical treatment with Methotrexate at a private tertiary hospital in the metropolitan region of Belo Horizonte. Variables such as age, presence of pelvic pain, previous ectopic pregnancy, initial beta-hCG level and largest adnexal mass measurement were analyzed. The theoretical framework followed a data search in PubMed, selecting 17 articles in total. Results: The clinical success rate with a dose of Methotrexate was 71,6%. Among the variables evaluated, only the initial beta-hCG value showed statistical significance with the outcome, therefore, higher the beta-hCG, lower the chance of treatment effectiveness, with a p-value of 0.002. The other variables analyzed did not show any significant association. Conclusion: Methotrexate has been shown to be effective in most cases of ectopic pregnancy, with the initial beta-hCG value standing out as a predictor of treatment failure. The findings reinforce the importance of adequate patient selection and laboratory monitoring in clinical follow-up.

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ABSTRACT Objective: The aim of this study was to assess the Ureaplasma parvum variation of genital colonization during pregnancy with an exploratory approach among women with term and preterm birth histories. Methods: Prospective case-control study of 24 pregnant women with history of full-term pregnancy and 26 pregnant women with history of prematurity whose endpoint was to assess the colonization pattern of these agents with a vaginal/cervical sample collected at the beginning of each trimester of gestation. Collected data: sociodemographic characteristics, previous diseases, gynecological and obstetric history, and microorganisms in vaginal secretion samples by real-time polymerase chain reaction (PCR). Results: The overall number of cases positive for at least one microorganism was 18 (36.0%). A significantly higher positivity rate was observed in the second and third trimesters in both study groups compared with the first trimester (p<0.001). The microorganisms identified in the vaginal environment were Ureaplasma parvum (66.6%), Mycoplasma hominis (16.7%), and both (16.7%), and the frequency of both these microorganisms was comparable in both groups at each pregnancy trimester (p for all = nonsignificant), but with a difference between the trimesters. Prematurity in the current pregnancy occurred in a single case (6.7%) in a pregnant woman without history of prematurity in the previous pregnancy (p=1.00). Conclusion: The most frequently identified microorganism was Ureaplasma parvum, and the overall incidence of positive cases including all microorganisms was 36.0%. Although Ureaplasma parvum was the most frequently identified microorganism, the sample was not powered to assess its association with prematurity.

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ABSTRACT Objective: Autoimmune progesterone dermatitis (APD) is a rare hypersensitivity to high levels of progesterone, with an as-yet unknown etiology. The objective of this study is to gather epidemiological data on patients with APD at an outpatient dermatology clinic. Methods: Medical records of patients diagnosed with APD, from menarche to menopause, seen at the dermatology clinic between 2004 and 2020 were reviewed. Results: Thirteen patients with APD were included. The mean age of symptom onset among APD patients was 24 years. The most prevalent clinical manifestation was urticaria, and the most common associated symptom was pruritus. The perimenstrual period was the most frequent aggravating factor, reported in 100% of cases. The intradermal progesterone test and autologous serum skin test were positive in approximately 60% of cases. Conclusion: Autoimmune progesterone dermatitis is an important differential diagnosis in female patients with dermatitis and should be considered during clinical evaluations.

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ABSTRACT Objective: To assess sexual behavior, use of sexually transmitted infection prevention methods and the sexual function, among women who have sex with women. Methods: This nationwide cross-sectional study was conducted from February 2023 to April 2024 using the Respondent Driven Sampling method. Women who have sex with women (WSW) with vaginas and neovagina, aged 18–40 years were included. Data on sociodemographic, clinical history, sexual behavior, and STI prevention were collected. Sexual function was assessed using the Female Sexual Function Index (FSFI). Results: A total of 371 forms were analyzed (mean age: 28.7 ± 6.9 years). 82.0% participants reported having penile-vaginal intercourse. Nearly all reported both performing (367; 98.0%) and receiving (360; 97.0%) oral sex. 351 participants (94.6%) reported receptive and 324 (87.4%) reported insertive penetration. Insertive anal sex was reported by 94 participants (25.3%), and receptive anal sex by 87 (23.4%). Only 10 participants (2.7%) reported using barrier methods during oral sex. Based on FSFI scores, 115 participants (31.0%) were at risk for sexual dysfunction. Conclusion: Most WSW in Brazil engage in oral and vaginal sex, but the report of STI prevention remains mostly limited to the male condom, with little use of barriers in oral or digital practices. HPV and hepatitis vaccination status are high. 115 participants (31.0%) scoring below the cutoff of 26.55. No significant difference in risk of development of sexual dysfunction between age, educational level, sexual orientation and gender identity.

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ABSTRACT Objective: to analyze the prevalence of congenital anomalies among women who had preterm births, their association with gestational age, characteristics of pregnancy termination and perinatal outcomes. Methods: A secondary analysis of the Brazilian Multicenter Study on Preterm Birth (EMIP), a multicenter cross-sectional study in 20 maternity hospitals, comparing cases of preterm birth with and without anomalies. A random sample of term births served as controls. The risk of malformations was estimated by maternal age, gestational age, type of onset of labour, mode of delivery, and neonatal outcomes using OR (95%CI) for categorical variables. Results: Among 4,150 preterm births and 1,146 selected term controls, congenital anomalies were found in 7.21% of cases (8.36% in preterm vs. 3.1% in term). Preterm birth increased the risk of anomalies by 2.89-fold (95% CI: 2.03–4.13). Cardiovascular anomalies were most common (19.1%), followed by central nervous system anomalies (18.8%) and abdominal wall defects (12.5%). The highest risk was observed at 28–31 weeks (OR 4.57, 95%CI 3.01–6.94). Elective cesarean delivery was more frequent among neonates with abnormalities (40.1% vs. 32.1%, OR 1.41, 95% CI: 1.13–1.77). Neonates with abnormalities had a higher risk of low 5th minute Apgar scores (OR 2.68, 95% CI: 2.01–3.56), birth weight <1.5 kg (OR 1.46, 95% CI: 1.14–1.87), and adverse outcomes such as NICU admission, sepsis, and neonatal mortality (OR 6.0, 95% CI: 4.58–7.85). Conclusion: Prematurity is associated with congenital anomalies, leading to increased neonatal morbidity, mortality, and admission to NICU.

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ABSTRACT Objective: To compare the clinical outcome of women with gestational trophoblastic neoplasia (GTN) treated with the conventional EMA/CO (etoposide, methotrexate, actinomycin-D, cyclophosphamide, vincristine) with those treated with the modified EM/CO regimen. Methods: Brazilian multicenter retrospective cohort study evaluated medical records of women diagnosed with GTN who were treated with the standard EMA/CO or with the modified regimen in which actinomycin-D was suppressed (EM/CO). The primary outcome was the occurrence of remission following chemotherapy treatment. Results: Remission rate with EMA/CO was 85.3%, with 14.7% of women showing chemoresistance, while with EM/CO, the remission rate was 72.7%, with 27.3% of women chemoresistance, without statistical difference between the groups. A total of 142 women were analyzed, of whom 109 were treated with EMA/CO and 33 received EM/CO. Women who used the EM/CO had higher prevalence of invasive mole (51.5% vs. 14.7%, p<0.0001), lower prevalence of choriocarcinoma (9.1% vs. 26.6%, p=0.035), and lower prevalence of metastases (33.3% vs. 61.5%, p=0.004) compared to women who received the EMA/CO. Women with risk score ≥ 7 had higher prevalence of recurrence (61.5% vs 10.0%, p=0.005) and chemoresistance using the EM/CO (53.8% vs 10.0%, p=0.013) compared to women with score ≤ 6. The pre-treatment serum hCG levels was a moderately significant predictor (AUC: 0.77, 95%CI 0.66-0.88, p<0.0001) for identifying chemoresistance. The number of EM/CO cycles was a strong significant predictor (AUC: 0.81, 95%CI 0.66-0.96, p<0.0001) for identifying toxicity to chemotherapy. Conclusion: EM/CO had higher prevalence of need for second-line treatment, and chemoresistance.

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ABSTRACT Objective: To estimate the prevalence and neonatal mortality of isolated gastroschisis, assess temporal trends, identify risk factors for neonatal death, and describe its spatial distribution in a middle-income setting. Methods: This population-based study included all live births in São Paulo State, Brazil, from 2004 to 2017. Cases of isolated gastroschisis were identified from live birth and death certificates. Temporal trends in prevalence and neonatal mortality (0-27 days) were analyzed using Prais-Winsten regression to estimate annual percent change (APC). Maternal and neonatal factors associated with neonatal death were examined using Poisson and multivariate logistic regression. Spatial distribution across municipalities was described by quartiles according to maternal residence. Results: Among 8,441,498 live births, 1664 cases of isolated gastroschisis were identified (prevalence: 1.97 per 10,000). Neonatal mortality rate associated with isolated gastroschisis was 0.35 per 10,000 live births, with a lethality rate of 17.7%. Prevalence (APC 3.0%; 95% CI: –1.3 to 7.5) and mortality (0.6%; –3.5 to 4.8) remained stable over time. Lower gestational age, fewer prenatal visits, and severe growth restriction were independently associated with higher risk of neonatal death. Spatial analysis showed heterogeneous distribution, with most municipalities reporting no cases and higher prevalence and mortality concentrated in few areas. Conclusion: In this middle-income setting, isolated gastroschisis showed stable but higher prevalence and neonatal mortality than in high-income countries. The heterogeneous spatial pattern suggests regional disparities in risk and outcomes, highlighting the need for targeted public health strategies and further research on gastroschisis epidemiology.

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Abstract Objective: To evaluate the performance of HPV-based testing compared to cytology in primary cervical cancer screening. Study selection: This meta-analysis included randomized trials comparing HPV-based screening with cytology in women aged 20–69 with at least one year of follow-up. Studies with overlapping populations, combining screening methods, lacking outcomes of interest, or study protocols were excluded. CENTRAL, PubMed/MEDLINE, and Embase were searched on April 12, 2025. The main outcome is the detection rate of cervical neoplasia grade 2 or worse (CIN2+). Data collection: Analyses followed Cochrane and PRISMA guidelines. Data synthesis: A total of 1,707 articles were identified. After removing duplicate records and excluding studies according to the pre-established criteria, 24 were selected for full-text review. Finally, eight were included in the statistical analysis, totaling 414,846 patients in a per-protocol assessment. The detection rate of CIN2+ by HPV-based tests was 61% higher compared to conventional or liquid-based cytology [RR 1.61; 95% CI 1.30, 1.98; p < 0.00001]. While our findings demonstrate the superior sensitivity of HPV testing, there are concerns about potential overdiagnosis and overtreatment. The absence of defined management protocols for HPV-positive patients contributes to this challenge. Therefore, risk-stratification strategies, such as HPV DNA genotyping, are essential to optimize clinical care and reduce these risks. Conclusion: HPV-based screening has a greater capacity to identify cervical neoplasia than cytology. PROSPERO registry: ID CRD420251027259.

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Abstract Objective: To map risks related to uterus transplantation. Methods: Scoping review based on the Joanna Briggs Institute method. Were included studies published in scientific journals that described complications, adverse events, and risks in women who were uterine transplant recipients, living uterine donors, and newborns, infants and children born from transplanted uteri. A modified version of Failure Modes and Effects Analysis was used for data collection, and the data were quantitatively analyzed through the development of risk categories and risks rates calculation. Results: In total 44 studies from 13 countries were included. Mapped 115 patients, 62 recipients, 34 donors, and 19 newborns, infants, and children born from transplanted uteri, 324 complications and adverse events across 25 risk categories. An online system (UTx Observatory) was developed. Among recipients, 77.5% received uteri from living donors, and 22.5% from deceased donors with most prevalent immunological, vascular, infectious, and prematurity risks. Recipients of deceased donor uteri had a higher adjusted risk rate. Among living donors, most prevalent risks were neurological, infectious, and urological risks. Laparotomy (76.5%) was associated with a higher adjusted risk rate than robotic-assisted surgery (23.5%) for uterus donation. Mainly risks mapped from newborns, infants, and children were respiratory, development-related, and malformations. Conclusion: The study and the UTx Observatory provide a foundation for developing targeted risk-mitigation strategies, shaping future studies and interventions, and informing health teams, authorities, and patients involved in uterus transplantation. Open Science Framework (OSF): https://doi.org/10.17605/OSF.IO/524UT

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Abstract Objective: Evaluate the effectiveness and safety of adding metformin to insulin (M+I) versus insulin alone for pregnant women with type 2 diabetes mellitus (T2DM) or gestational diabetes mellitus (GDM), focusing on stillbirth as the primary outcome. Sources of data: PubMed, Embase, and Cochrane Central were searched. No date limits. Last search: January 2025. Eligibility criteria: Randomized clinical trials including women with T2DM or GDM were eligible. Trials restricted to type 1 diabetes were excluded. Data collection and synthesis: Two reviewers extracted maternal and neonatal outcomes and assessed risk of bias with the Cochrane RoB 2 tool. Evidence certainty was graded using GRADE. Data were pooled with random-effects models and reported as risk ratios (RRs) or mean differences (MDs) with 95% confidence intervals. Results: Nine RCTs (2,420 women) were included, most with GDM and some with T2DM. Moderate-quality evidence indicated reduced stillbirth risk with M+I (6 RCTs, 2,196 participants; RR 0.36, 95% CI 0.14–0.90; NNT 111). Low-quality evidence suggested lower risks of gestational hypertension (4 RCTs; RR 0.68, 95% CI 0.48–0.97) and neonatal hypoglycemia (7 RCTs; RR 0.49, 95% CI 0.30–0.80). No significant differences were found for cesarean section, preterm delivery, or other neonatal outcomes. Heterogeneity, baseline imbalances, and small samples limited certainty. Conclusions: M+I may reduce stillbirth and some adverse outcomes compared with insulin alone, but most evidence remains low certainty. Further high-quality RCTs are needed. Registered in PROSPERO: CRD42024617330

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Abstract Objective To assess the utility of p57 in differentiating histological subtypes of hydatidiform mole and its applicability in clinical practice. Methods A scoping review was conducted following the Joanna Briggs Institute methodology and PRISMA-ScR guidelines. The article search was conducted in the PubMed, EMBASE, BVS, Cochrane, Web of Science, and Scopus databases. Studies published between 2015 and 2025 that evaluated the use of p57 in suspected cases of hydatidiform mole were included. Results Nine studies met the inclusion criteria. Most demonstrated high specificity of p57 for CHM diagnosis and a significant reduction in diagnostic discordance compared to morphology alone. However, p57 does not distinguish PHM from non-molar abortions. In addition, rare cases of divergent p57 expression were reported, associated with genetic alterations that may require complementary evaluation using molecular techniques. Conclusion IHC for p57 is a widely accessible, low-cost, and effective tool in clinical practice, particularly useful in resource-limited settings. Its routine use, in association with morphology and molecular methods when available, contributes to more accurate diagnoses and safer clinical management of GTDs.

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Abstract Objective To summarize the available evidence on the association between endocrine disruptors and polycystic ovary syndrome (PCOS). Methods A search was conducted in the MEDLINE (via PubMed); Science direct, Scopus and LILIACS databases for relevant studies published between 2013 and 2025. The inclusion criteria covered cohort, cross-sectional, and case-control studies published in English or Spanish. Data extraction and quality assessment were performed using the Joanna Briggs Institute (JBI) checklists, and the results were synthesized descriptively. The articles retrieved were reviewed by two evaluators; 49 were chosen for full-text review, 30 were included in the qualitative analysis. Results This systematic review found that bisphenol A (BPA) is the most frequently associated endocrine disruptor with PCOS. This compound interferes with steroidogenesis by mimicking estrogen, which may contribute to insulin resistance and androgen dysfunction. Additionally, phthalates were found to be related to elevated androgen levels and ovarian dysfunction, while triclosan and cadmium were associated with hormonal imbalances affecting ovarian reserve and testosterone levels. Furthermore, perfluoroalkyl and polyfluoroalkyl substances (PFAS) were linked to reduced ovarian reserve and a higher prevalence of PCOS. Conclusions The results of this review highlight the role of endocrine disruptors in the pathophysiology of polycystic ovary syndrome, emphasizing the need for further research to identify emerging disruptors and their potential mechanisms in the development of this disease. Therefore, it is crucial to adopt public health measures aimed at minimizing exposure to these compounds, particularly in women who are more susceptible to developing PCOS.

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ABSTRACT Objective: Vulvovaginal candidiasis (VVC) is a common infection traditionally treated with fluconazole. Oteseconazole is a new oral antifungal offering a promising alternative. However, it is essential to assess if it has better efficacy than the treatment already used in VVC. Methods: This systematic review and meta-analysis followed PRISMA guidelines, searching PubMed, EMBASE, and Cochrane for studies comparing oteseconazole and fluconazole in acute VVC. Three randomized controlled trials were included. Odds ratios were calculated using a random-effects model. Results: The initial search yielded 203 results, but only three RCTs with 593 patients were included. Oteseconazole showed significantly higher rates of therapeutic and sustained clinical cure at day 14 and 28 compared to fluconazole (OR 2.56 and 2.08, respectively), with similar rates of mild to moderate adverse events. Risk of bias was high due to selective reporting. Conclusion: Oteseconazole appears to be a safe and more effective alternative to fluconazole for acute VVC, but further research and more robust studies are needed to confirm these findings. PROSPERO Registry: #CRD420251010309

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Key points Apical genital prolapse represents a failure of DeLancey’s level I support. Isolated vaginal hysterectomy does not correct apical prolapse. All surgery for uterine or vaginal vault prolapse should include apical suspension. Sacrocolpopexy is the most durable technique for correcting vaginal vault prolapse, with the exception of colpocleisis. Vaginal techniques remain valid options in selected patients. Uterine preservation, when based on shared decision-making, is possible and safe for carefully evaluated patients. Recognition of the apical component in advanced cystocele is essential to prevent recurrence. Correction of the genital hiatus reduces the risk of recurrence, regardless of the surgical approach. Intraoperative cystoscopy is mandatory in vaginal uterosacral suspensions. Concomitant correction of stress urinary incontinence should be considered when diagnosed clinically or functionally.

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Key points • Surgical outcomes in endometriosis vary substantially according to disease phenotype, symptom profile, and reproductive priorities. • Excisional surgery for ovarian endometriomas is associated with lower recurrence rates but carries a consistent risk of postoperative ovarian reserve impairment. • Surgery for deep infiltrating endometriosis is associated with meaningful improvement in pain and quality of life when clinical indications are appropriate and execution is precise, but entails higher surgical complexity and morbidity. • Repeat surgical interventions are associated with diminishing symptomatic benefit and increasing cumulative risk, including adhesion-related morbidity and the loss of both organ function and ovarian reserve. • Postoperative hormonal therapy may reduce symptom recurrence and the likelihood of repeat surgery in women not seeking immediate pregnancy. • Endometriosis surgery should be integrated into a long-term, multidisciplinary care model focused on symptom control and quality of life rather than disease eradication.