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Background Hysteroscopic resection is the first-choice treatment for symptomatic type 0 and 1 fibroids. Traditionally, this was performed under general anesthesia. Over the last decade, surgical procedures are increasingly being performed in an outpatient setting under procedural sedation and analgesia. However, studies evaluating safety and effectiveness of hysteroscopic myomectomy under procedural sedation are lacking. This study aims to investigate whether hysteroscopic myomectomy under procedural sedation and analgesia with propofol is noninferior to hysteroscopic myomectomy under general anesthesia. Methods and findings This was a multicenter, randomized controlled noninferiority trial conducted in 14 university and teaching hospitals in the Netherlands between 2016 and 2021. Inclusion criteria were age [greater than or equal to]18 years, maximum number of 3 type 0 or 1 fibroids, maximum fibroid diameter 3.5 cm, American Society of Anesthesiologists class 1 or 2, and having sufficient knowledge of the Dutch or English language. Women with clotting disorders or with severe anemia (Hb < 5.0 mmol/L) were excluded. Women were randomized using block randomization with variable block sizes of 2, 4, and 6, between hysteroscopic myomectomy under procedural sedation and analgesia (PSA) with propofol or under general anesthesia (GA). Primary outcome was the percentage of complete resections, assessed on transvaginal ultrasonography 6 weeks postoperatively by a sonographer blinded for the treatment arm and surgical outcome. Secondary outcomes were the surgeon's judgment of completeness of procedure, menstrual blood loss, uterine fibroid related and general quality of life, pain, recovery, hospitalization, complications, and surgical reinterventions. Follow-up period was 1 year. The risk difference between both treatment arms was estimated, and a Farrington-Manning test was used to determine the p-value for noninferiority (noninferiority margin 7.5% of incomplete resections). Data were analyzed according to the intention-to-treat principle, including a per-protocol analysis for the primary outcome. A total of 209 women participated in the study and underwent hysteroscopic myomectomy with PSA (n = 106) or GA (n = 103). Mean age was 45.1 [SD 6.4] years in the PSA group versus 45.0 [7.7] years in the GA group. For 98/106 women in the PSA group and 89/103 women in the GA group, data were available for analysis of the primary outcome. Hysteroscopic resection was complete in 86/98 women (87.8%) in the PSA group and 79/89 women (88.8%) in the GA group (risk difference -1.01%; 95% confidence interval (CI) -10.36 to 8.34; noninferiority, P = 0.09). No serious anesthesiologic complications occurred, and conversion from PSA to GA was not required. During the follow-up period, 15 serious adverse events occurred (overnight admissions). All were unrelated to the intervention studied. Main limitations were the choice of primary outcome and the fact that our study proved to be underpowered. Conclusions Noninferiority of PSA for completeness of resection was not shown, though there were no significant differences in clinical outcomes and quality of life. In this study, hysteroscopic myomectomy for type 0 and 1 fibroids with PSA compared to GA was safe and led to shorter hospitalization. These results can be used for counseling patients by gynecologists and anesthesiologists. Based on these findings, we suggest that hysteroscopic myomectomies can be performed under PSA in an outpatient setting. Trial registration The study was registered prospectively in the Dutch Trial Register (NTR 5357; registration date: 11 August 2015; Date of initial participant enrollment: 18 February 2016)., Author(s): Julia F. van der Meulen 1,2,*, Marlies Y. Bongers 1,2, Lisa G. van der Zee 3, Jaklien C. Leemans 1, Ruben G. Duijnhoven 4,5, Robert A. de Leeuw 4, [...]

Introduction: Many women experience bleeding disorders that may have an anatomical or unexplained origin. Although hysterectomy is the most definitive and common treatment, it is highly invasive and resource‐intensive. Less invasive therapies are therefore advised before hysterectomy for women with fibroids or bleeding disorders. This study has two aims related to treating bleeding disorders and uterine fibroids in the Netherlands: (1) to evaluate the regional variations in prevalence and surgical approaches; and (2) to assess the associations between regional rates of hysterectomies and less invasive surgical techniques to analyze whether hysterectomy can be replaced in routine practice. Material and methods: We completed a register‐based study of claims data for bleeding disorders and fibroids in women between 2016 and 2020 using data from Statistics Netherlands for case‐mix adjustment. Crude and case‐mix adjusted regional hysterectomy rates were examined overall and by surgical approach. Coefficients of variation were used to measure regional variation and regression analyses were used to evaluate the association between hysterectomy and less invasive procedure rates across regions. Results: Overall, 14 186 and 8821 hysterectomies were performed for bleeding disorders and fibroids, respectively. Laparoscopic approaches predominated (bleeding disorders 65%, fibroids 49%), followed by vaginal (bleeding disorders 24%, fibroids 5%) and abdominal (bleeding disorders 11%, fibroids 46%) approaches. Substantial regional differences were noted in both hysterectomy rates and the surgical approaches. For bleeding disorders, regional hysterectomy rates were positively associated with endometrial ablation rates (β = 0.11; P = 0.21) and therapeutic hysteroscopy rates (β = 0.14; P = 0.31). For fibroids, regional hysterectomy rates were positively associated with therapeutic hysteroscopy rates (β = 0.10; P = 0.34) and negatively associated with both embolization rates (β = −0.08; P = 0.08) and myomectomy rates (β = −0.03; P = 0.82). Conclusions: Regional variation exists in the rates of hysterectomy and minimally invasive techniques. The absence of a significant substitution effect provides no clear evidence that minimally invasive techniques have replaced hysterectomy in clinical practice. However, although the result was not significant, embolization could be an exception based on its stronger negative association. [ABSTRACT FROM AUTHOR]

Objective: To evaluate patient satisfaction on gynaecological examination with metal, plastic and biobased plastic vaginal specula, and to investigate whether patients are willing to compromise on comfort for a more sustainable healthcare system. Design: Cross‐sectional study: population‐based survey. Setting: Gynaecological outpatient clinics in five Dutch hospitals. Population: Patients during general gynaecology consultation hours. Methods: A survey containing two questions about patient demographics, four about comfort and five about sustainability and healthcare was distributed. Main outcome measures: Comfort score (scale 1–10). Secondary outcomes: (1) temperature, size and ease of insertion, (2) willingness to compromise for a more sustainable healthcare system. Results: In all, 196 patients completed the survey. Biobased plastic vaginal specula scored significantly higher on comfort than the metal ones (mean 8.03 ± 1.65 versus 7.26 ± 1.51 respectively; P < 0.001). The biobased plastic vaginal speculum is significantly the most comfortable on temperature, whereas the metal speculum is the least comfortable (P < 0.007). Most patients are willing to compromise on comfort or are open to the reuse of disposables to contribute to a more sustainable healthcare. The majority of patients (77%) urge healthcare organisations to combat climate change. Conclusions: There is a small but statistically significant difference in favour of a biobased plastic speculum regarding comfort score, although it might be questioned whether this is clinically relevant. Furthermore, patients are willing to compromise on comfort for a more sustainable healthcare, which should be a contributing factor in speculum selection. [ABSTRACT FROM AUTHOR]

Relative energy deficiency in sport (RED‐S) refers to an impaired physiological functioning caused by low energy availability in both male and female athletes. It may affect many physiological processes, causing, among others, stress fractures and disturbed menstrual cycles. Athletes may present these symptoms to different health care workers. The purpose of this research was to investigate the awareness and knowledge of physiotherapists, general practitioners, gynaecologists, sports physicians and orthopaedic surgeons on RED‐S. An online questionnaire on awareness and knowledge of RED‐S was developed for the above‐mentioned health experts. A total number of 799 respondents were included for analysis, and 22.0% of the respondents had heard of the existence of RED‐S. The highest percentage was reported by sports physicians (92.9%) and the lowest among general practitioners (10.1%). Sports physicians scored highest on knowledge questions about RED‐S with a mean score of 8.9, and physiotherapists scored lowest with a mean score of 5.7. Of all respondents, 57.6% reported feeling competent discussing possible underlying problems of RED‐S and 7.4% felt qualified treating RED‐S. Of the responding gynaecologists, 46.6% would suggest starting oral contraception when presented a patient with symptoms of RED‐S, thereby only masking the symptoms of amenorrhoea but not treating the underlying cause: a low energy availability. This research reports a low awareness and knowledge among participating physiotherapists, general practitioners, gynaecologists and orthopaedic surgeons on RED‐S. Therefore, further education for these specialists on this topic is needed, since most athletes will initially consult these health care providers first. Highlights: The great majority of all participating general practitioners are not aware of the existence of relative energy deficiency in sport (RED‐S).Awareness of RED‐S needs to be increased among at least physiotherapists, general practitioners, gynaecologists and orthopaedic surgeons to improve diagnosis and treatment of RED‐S.Sports physicians have the highest knowledge on RED‐S. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic uterosacral ligament suspension (LUSLS) is a technique to correct apical pelvic organ prolapse (POP) by shortening the uterosacral ligaments with sutures. Objective: A systematic review with meta‐analysis of the effectiveness and safety of LUSLS as treatment for apical POP. Search strategy: PubMed and Cochrane search using 'pelvic organ prolapse', 'laparoscopy' and 'uterosacral', including synonyms. Selection criteria: All articles in English presenting outcome of an original series of women with LUSLS as treatment of apical POP. Case reports were excluded. Data collection and analysis: Study enrollment was performed by two reviewers. Our primary outcome measures were objective and subjective effectiveness of the procedure. Secondary outcome measures regarded complications and recurrence. Bias was assessed with the Newcastle Ottawa Scale. Main results: Of 138 hits, 13 studies were included with 933 LUSLS patients. The average follow‐up was 22 months. All were nonrandomised cohort studies. The pooled anatomic success rate is 90% for all LUSLS procedures (95% confidence interval [CI] 83.3–95.5). LUSLS with hysterectomy resulted in an anatomic success rate of 96.6% (95% CI 87.5–100) and LUSLS with uterus preservation 83.4% (95% CI 67.7–94.6). The pooled subjective cure rate was 90.5% (95% CI 81.9–96.5). The rate of major complications was 1%. Conclusions: Laparoscopic uterosacral ligament suspension (with or without uterus preservation) seems to be an effective and safe treatment for women with apical POP, but long‐term prospective trials and randomised controlled trials are necessary to confirm these findings. [ABSTRACT FROM AUTHOR]

Objective: To determine whether laparoscopic sacrocolpopexy (LSC) or vaginal sacrospinous fixation (VSF) is the most optimal surgical treatment in patients with POP‐Q stage ≥2 vaginal vault prolapse (VVP). Design: Multicentre randomised controlled trial (RCT) and prospective cohort study alongside. Setting: Seven non‐university teaching hospitals and two university hospitals in the Netherlands. Population: Patients with symptomatic post‐hysterectomy vaginal vault prolapse, requiring surgical treatment. Methods: Randomisation in a 1:1 ratio to LSC or VSF. Evaluation of prolapse was done using the pelvic organ prolapse quantification (POP‐Q). All participants were asked to fill in various Dutch validated questionnaires 12 months postoperatively. Main outcome measures: Primary outcome was disease‐specific quality of life. Secondary outcomes included composite outcome of success and anatomical failure. Furthermore, we examined peri‐operative data, complications and sexual function. Results: A total of 179 women, 64 women randomised and 115 women, participated in a prospective cohort. Disease‐specific quality of life did not differ after 12 months between the LSC and VSF group in the RCT and the cohort (RCT: P = 0.887; cohort: P = 0.704). The composite outcomes of success for the apical compartment, in the RCT and cohort, were 89.3% and 90.3% in the LSC group and 86.2% and 87.8% in the VSF group, respectively (RCT: P = 0.810; cohort: P = 0.905). There were no differences in number of reinterventions and complications between both groups (reinterventions RCT: P = 0.934; cohort: P = 0.120; complications RCT: P = 0.395; cohort: P = 0.129). Conclusions: LSC and VSF are both effective treatments for vaginal vault prolapse, after a follow‐up period of 12 months. [ABSTRACT FROM AUTHOR]

Background: The International Society on Thrombosis and Haemostasis bleeding assessment tool (ISTH‐BAT), is used during the diagnostic workup of bleeding disorders. Data on ISTH‐BAT scores in women with heavy menstrual bleeding (HMB) undergoing endometrial ablation (EA) could be essential in optimizing HMB counselling. Objective: To investigate the postsurgical incidence of amenorrhea, dysmenorrhea, quality of life, re‐intervention after EA, and ISTH‐BAT score. Methods: This study included women who have undergone EA because of HMB. During a follow‐up of 2 to 5 years, ISTH‐BAT, pictorial blood assessment chart (PBAC), and Short Form‐36 survey (SF‐36) were administered. At 10 years of follow‐up surgical re‐interventions were evaluated. Results: Seventy‐one women were included of whom 77% (n = 55) had an ISTH‐BAT score < 6, versus 23% (n = 16) ISTH‐BAT score ≥6 (mean age 46.3 versus 42.3, p = 0.004). In the ISTH‐BAT ≥6 group versus < 6 group, amenorrhea occurred in 63% (10/16) versus 82% (45/55) (p = 0.111), dysmenorrhea in 38% (6/16) versus 18% (10/55) (p = 0.111), and surgical re‐intervention in 19% (3/16) versus 25% (14/55) (p = 0.582). SF‐36 item (Bodily) pain was lower in the ISTH‐BAT ≥6 group versus < 6 (median score 58.7 vs. 80.0, p = 0.104). Conclusions: An ISTH‐BAT score ≥6 may be related to a lower amenorrhea incidence and higher dysmenorrhea rate after EA. [ABSTRACT FROM AUTHOR]