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Uterine fibroids represent the most prevalent genital tract tumours among women, with a disproportionately higher impact on ethnic minority groups, notably black women. These hormonally dependent monoclonal tumours, characterized by excessive extracellular matrix and influenced by genetic, epigenetic, and lifestyle factors, significantly affect women's quality of life and pose substantial economic burdens on healthcare systems. Recent advances in early detection and minimally invasive treatment options have shifted management paradigms towards personalized care, yet challenges in early diagnosis, education and access to treatment persist. This review synthesizes current knowledge on uterine fibroids, highlighting the impact of fibroids on women's health, risk factors, principles of screening, diagnostic tools, and treatment modalities. It emphasizes the importance of early screening and individualized management strategies in improving patient outcomes and reducing healthcare costs. The article also discusses the socio-economic and health disparities affecting the disease burden, underscoring the need for improved patient education, clinician training, and public health strategies to enhance fibroid management. This review proposes a pathway to not only ameliorate the quality of life for women with fibroids, but also to advance global women's health equity., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: Laparoscopic myomectomy is increasingly considered the gold standard uterine preserving procedure and has well documented benefits over the open approach. Barriers that women have in accessing the most appropriate treatment need to be addressed to ensure optimal patient care and outcomes., Objectives: To analyse rates of open and laparoscopic myomectomy at a large NHS trust and identify how many cases could potentially have been performed laparoscopically, and any variation between sites., Materials and Methods: A retrospective review of preoperative imaging reports and a surgical database containing information for all myomectomies performed between 1st January 2015 and 31st December 2022., Main Outcome Measures: Number of procedures suitable for alternative surgical approach; length of hospital stay; estimated blood loss; cost differences., Results: 846 myomectomies were performed; 656 by laparotomy and 190 by laparoscopy. 194/591 (32.8%) open myomectomies could have been performed laparoscopically and 26/172 (15.1%) laparoscopic myomectomies may have been better performed via an open approach. Length of hospital stay, and estimated blood loss were significantly higher in the open group. Had cases been performed as indicated by pre-operative imaging, the cost differences ranged from -£115,752 to £251,832., Conclusions: There is disparity in access to the gold standard care of laparoscopic myomectomy. Due to multifactorial reasons, even at sites where the rate of laparoscopic myomectomy is high, there is still underutilisation of this approach. It is clear that there is scope for change and "levelling up" of this imbalance., What Is New?: Robust pathways and guidelines must be developed, and more laparoscopic surgeons should be trained to optimise care for women with fibroids.

Purpose of Review: Uterine fibroids are very common with a prevalence of over 70%. They present a significant economic and psychological burden. A variety of nonsurgical treatments exist for its management encompassing hormonal and nonhormonal methods. Gonadotrophin-releasing hormone (GnRH) antagonists are a novel treatment for uterine fibroids. They cause a rapid reduction in endogenous GnRH, leading to a dose-dependent reduction in levels of oestradiol and progesterone, thus reduction in bleeding. The addition of hormones, estrogen, and progesterone, known as add-back therapy, helps curb the menopausal side effects. As such, they pose a potential long-term nonsurgical therapy for management of symptomatic fibroids., Recent Findings: There are various uses of GnRH antagonists and the results from the clinical trials are promising. Caution needs to be taken when new treatment options are introduced with audit and data collection tools in place to assess effectiveness as well as any side effects., Summary: This article highlights the uses of GnRH antagonists in practice and reflects on previous novel treatments for fibroids with a focus on Ulipristal acetate. It states the importance of using audit tools and multiinstitutional databases to prevent and allow early discovery of issues such as those that encumbered Ulipristal., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Teamwork is essential for providing safe, effective and women-centred maternity care and several high profile investigations have highlighted the adverse conseqences of dysfuntional teamwork. Maternity teams may need support to identify the most relevant intervention(s) for improving teamwork., Objective: To identify and describe current 'off-the-shelf' teamwork interventions freely or commercially available to support improvements to teamworking in UK maternity services and conduct a gap analysis to identify areas for future development., Design: Rapid scoping review METHODS: A multi-component search process was used to identify teamwork interventions, comprising: (1) bibliographic database search (Medline, PsycINFO, CINAHL, MIDRS, NICE evidence research database); (2) identification of relevant policies and UK reports; and (3) expert input from key stakeholders (e.g., maternity service clinicians, managers, policymakers, and report authors). Data were extracted including the scope and content of each intervention and a gap analysis used to map interventions to the integrated team effectiveness model (ITEM) and structure level (macro, meso, micro) and results presented narratively., Findings: Ten interventions were identified. Interventions were heterogeneous in their purpose and scope; six were classified as training courses, three were tools involving observational or diagnostics instruments, and one was a programme involving training and organisational re-design. Interventions were focused on teamwork in obstetric emergencies (n = 5), enhancing routine care (n = 4) or understanding workplace cultures (n = 1). Users of interventions could vary, from whole organisations, to departments, to individual team members. All interventions focused on micro (e.g., team leadership, communication, decision-making, cohesion, and problem solving), with two also focused on meso aspects of teamwork (resources, organisational goals). Evidence for intervention effective on objective outcomes was limited., Conclusions: Interventions that address key aspects of teamworking are available, particularly for improving safety in obstetric emergency situations. Most interventions, however, are focused on micro features, ignoring the meso (organisational) and macro (systems) features that may also impact on team effectiveness. Evidence-based team improvement interventions that address these gaps are needed. Such interventions would support team ownership of quality improvement, leading to improvements in outcomes for service users, staff and organisations., Competing Interests: Conflict of interest DB is Editor in Chief of ‘Midwifery’. BWL has previously received funding from Health Education England and Cancer Alliances for training cancer MDTs in assessment and quality improvement methods in the UK; CT, JH and JG have previously received funding from NHS organisations within England and Scotland for supporting cancer teamwork improvement; JG is the Director of Green Cross Medical Ltd that developed MDT-FIT for use by National Health Service Cancer Teams in the UK. All other authors have no potential conflicts of interest. All other authors have no potential conflicts of interest., (Copyright © 2022. Published by Elsevier Ltd.)

We present the findings of a prospective cohort study in a single tertiary hospital to review the patient experience and economic benefit of ambulatory hysteroscopy (AH). Data were collected between May 2017 and February 2020. Patient satisfaction was measured with qualitative survey. Hospital level financial data were obtained over two financial years (2017/18 and 2018/19) to identify seasonal variation. The primary outcome was patient satisfaction and the secondary outcome was cost of AH compared to hysteroscopy under GA. Three hundred and twenty-nine patients underwent AH. Two hundred and ninety-eight responses (91%) were collected. Ninety-five percent of procedures were successful. Median pain score was five out of 10. Despite pain, 94% of patients would undergo AH again and 97% would recommend it. The average hospital cost for AH was $259 compared with $3098 for hysteroscopy under GA. These findings support AH as a safe, well-tolerated and economically viable alternative to hysteroscopy under GA.Impact Statement What is already known on this subject? Hysteroscopy is traditionally performed in an operating theatre under general anaesthesia (GA). Technological advancements allow for the procedure to be performed in an outpatient setting. Despite advantages of ambulatory hysteroscopy (AH), GA hysteroscopy is still the predominant intervention in Australia. What the results of this study add ? Patient satisfaction in AH was assessed. The median pain score was five out of 10. Despite pain, 94% of patients would undergo AH again and 97% would recommend it. What the implications are of these findings for clinical practice and/or further research? AH is a well-tolerated alternative to hysteroscopy under GA with significant cost benefits to the hospital and high patient satisfaction. Further research should focus on direct comparison of the two procedure approaches using randomised controlled trials.

Introduction: Health disparities exposed by the Covid-19 pandemic have prompted healthcare professionals to investigate disparities within their own specialty. Racial and ethnic disparities in obstetrics are well documented but inequities in gynaecology are less well known. Our aim is to review the literature on two commonly performed procedures, hysterectomy and myomectomy, and one condition, ectopic pregnancy, to evaluate the prevalence of racial, ethnic and socioeconomic disparities in benign gynaecology and minimal access surgery., Methods: A narrative review of 33 articles identified from a Pubmed using the following search criteria; "race"; "ethnicity"; "socioeconomic status"; "disparity"; "inequity"; and "inequality". Case reports and papers assessing gynaecological malignancy were excluded., Results: Despite minimal access surgery having fewer complications and faster recovery than open surgery, US studies have shown that black and ethnic minority women are less likely than white women to have minimally invasive hysterectomies and myomectomies. Uninsured women and patients on Medicaid are also less likely to receive minimally invasive procedures. Contributing factors include fibroid size, geographic location and access to hospitals performing minimal access surgery, and the discontinuation of power morcellation. Ethnic minority women who receive minimally invasive myomectomy have been shown to have a higher risk of complications and prolonged recovery. Black and ethnic minority women also have a higher risk of morbidity and mortality from ectopic pregnancy and are more likely to receive surgical than medical management., Conclusion: Extensive study from the US has demonstrated disparities in access to minimally invasive gynaecological surgery, whereas in the UK the data is infrequent, inconsistent and incomplete. Little is known about the influence of patient preference and counselling as well as institutional bias on health equity in gynaecology. Further research is necessary to identify interventions that mitigate these disparities in access and outcomes., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021. Published by Elsevier B.V.)

Objectives: Our primary objective was to assess patient awareness by observing Google Trends comparing search terms used in relation to morcellation rather than morcellation alone. Our secondary objective was to review trends and locations of publications on leiomyosarcoma and morcellation following the US Food and Drug Administration (FDA) position statement., Study Design: To assess Internet trends, we obtained the relative search volume (RSV) for each month from 1 January 2004 to 1 March 2019 from Google Trends using the terms 'fibroid', 'morcellation', and 'fibroid cancer'. RSV ranges from 0 to 100 with 100 being peak popularity for the term, and all other monthly search activity relative to the peak. To assess academic trends, we performed a systematic review of published literature discussing fibroid morcellation within the same time period. We used a two-way independent t-test to compare median RSV, and chi-squared test to compare academic output. P < 0.05 was considered statistically significant., Results: Search volume for 'morcellation' peaked during the FDA statement (RSV 0.5 to 2.9, t = 17.5, p < 0.05) but was not sustained. There is an increase in 'fibroid' activity post-FDA statement (RSV 68.8 to 76.3, t = 3.9, p < 0.05). 'Fibroid cancer' remained static throughout (t = 1.5, p = 0.1 and t=-0.5, p = 0.6). Afro-Caribbean countries had the highest RSV for 'fibroid', whereas 'morcellation' RSV was highest in predominantly Western countries. There was a significant increase in the rate of papers published on the subject following the FDA statement (6.8 vs 55.6 papers per year, 95% CI -53.96 to -43.64, p < 0.0001). No academic papers on morcellation were published from countries with the highest RSV for 'fibroid'., Conclusion: Our study suggests that interest in uterine fibroids has increased since the FDA statement, but the public are perhaps unaware or not concerned of the consequent potential risk of leiomyosarcoma following morcellation. Countries where fibroid interest is highest are not necessarily those that can offer power morcellation. Further studies are required to address how the Internet influences patient choice and informed consent, and how medical professionals can use it to further educate patients on the risks and benefits of laparoscopic myomectomy and power morcellation., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Power morcellation remains one of the most significant developments in minimal access surgery over the past decade, allowing many more patients to benefit from the least invasive surgical route. However, its use is not without controversy, particularly with regards to the risks of an undiagnosed leiomyosarcoma. Increased media and, in particular, on-going social media coverage since events in 2014 have only served to intensify the debate, culminating in the Food and Drug Administration essentially 'banning' its use in the USA. Practice however continues to vary and this technique remains widely used in Europe and in particular the UK. The aim of this article was to review the development of power morcellation in gynaecology and the underlying risks, including that of undiagnosed leiomyosarcoma, as well as appraise the evolving literature on patient awareness and informed consent and the wider implications of morcellation restriction., (Copyright© 2019, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background: Transabdominal cerclage can reduce the risk of preterm birth in women with cervical insufficiency., Aims: This study evaluated outcomes following insertion of a laparoscopic transabdominal cerclage in pregnant women., Materials and Methods: A retrospective observational study., Patients: pregnant women who underwent laparoscopic transabdominal cerclage from 2011 to 2017. Eligible women had cervical insufficiency and were not suitable for a transvaginal cerclage., Intervention: the insertion of a laparoscopic transabdominal cerclage in the pregnancy., Measurements: neonatal survival, delivery of an infant at ≥34 weeks gestation and surgical morbidity were evaluated., Results: Of 19 women who underwent laparoscopic transabdominal cerclage in pregnancy, at 6-11 weeks gestation, the perinatal survival rate was 100%. There were no complications. The average gestational age at delivery was 37.1 weeks. Sixteen women delivered after 34 weeks., Conclusions: Laparoscopic transabdominal cerclage is a safe and effective procedure in women with poor obstetric histories. It requires the correct skill, expertise and patient selection., (© 2018 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Background: Cervical insufficiency is a significant cause of morbidity and mortality. Cervical cerclage is one option in the management of cervical insufficiency., Aim: To evaluate obstetric outcomes following insertion of a pre-pregnancy laparoscopic transabdominal cerclage in women at high risk for pre-term labour and/or mid-trimester pregnancy loss., Methods: A prospective observational study of consecutive women who underwent laparoscopic transabdominal cerclage from 2007 to 2017. Eligible women had a diagnosis of cervical insufficiency based on previous obstetric history and/or a short or absent cervix and were considered not suitable for a transvaginal cerclage. The primary outcome was neonatal survival and the secondary outcome was delivery of an infant at ≥34 weeks gestation. Surgical morbidity and complications were also evaluated., Results: During the study period, 225 women underwent laparoscopic transabdominal cerclage. We present the outcomes of 121 pregnancies resulting in 125 babies. The perinatal survival rate of viable pregnancies was 98.5% with a mean gestational age at delivery of 35.2 weeks; 79.7% of babies were delivered at ≥34.0 weeks gestation., Conclusion: Laparoscopic transabdominal cerclage is a safe and effective procedure resulting in favourable obstetric outcomes in women with a poor obstetric history. For optimal success the procedure requires the correct surgical expertise, equipment and appropriate patient selection., (© 2018 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

We assessed the attitudes of UK Obstetrics and Gynaecology (O&G) trainees towards a caesarean delivery for maternal request (CDMR); and identified differences in attitude towards patients requesting CDMR and preferences for their own mode of delivery. An internet survey was constructed with questions covering trainees' personal preferences towards and experience of CDMR; attitudes to CDMR; and how they might treat patients making this request. From 02/2013 to 06/2013, the survey was sent electronically via email to all UK Deaneries to be forwarded to O&G trainees. Two hundred and forty O&G trainees participated; 78% female. 6/101 (6%) respondents had opted for CDMR in their first pregnancy. 28/131 (21%) would choose CDMR in their first pregnancy. Reasons for CDMR included concerns about pelvic floor/perineum, safety of the baby and convenience. 105/226 (46.4%) disagreed or strongly disagreed, and 67 (29.6%) agreed or strongly agreed with CDMR. 75/128 (58.6%) of respondents would grant CDMR to a patient; reasons included maternal choice, psychological concerns of the mother, perineal injury, pelvic floor. Our results are encouraging: positive attitudes of trainees towards vaginal delivery may help to reduce the rising caesarean rate. Impact Statement What is already known on this subject: Over the last 30 years, the rate of caesarean section in the UK has trebled and currently accounts for 25% of all deliveries. The rate of caesarean section in the UK has risen to 25% of all deliveries, incurring a financial burden and an excess clinical risk. With pressure to keep the caesarean rates low, understanding the attitudes and experience of obstetricians in training is important. What the results of this study add: Six percent of obstetric trainees, or their partners who had children had chosen a caesarean delivery for maternal request (CDMR), consistent with the population average. Twenty one percent of those who had not had children would choose CDMR. Both groups cited concerns over the pelvic floor as the predominant reason. Fifty nine percent of respondents would grant patients' request for CDMR. 29.6% of respondents agreed, and 46.4% disagreed with CDMR. Trainees' attitude to CDMR does not appear to be associated with whether or not they have had children, but does appear to be associated with whether they had experienced, or were planning to choose CDMR themselves in the future. What the implications are of these findings for clinical practice and/or further research: Training for obstetric trainees regarding the optimum way to manage patients' requests for, and clearer guidance on CDMR may be of benefit. It is important that obstetricians discuss the reasons behind such requests in order to individualise management.

Introduction: Laparoscopic myomectomy offers women many benefits over conventional open surgery, including an expedited recovery and return to employment. Our study evaluates the time taken for women to return to work after laparoscopic myomectomy and identifies factors prolonging recovery to > 8 weeks., Material and Methods: We prospectively evaluated 94 women undergoing laparoscopic myomectomy by a single surgeon between January 2012 and March 2015. Women had standardized preoperative counseling and completed a validated return to work questionnaire 3 months postoperatively via telephone, post or in clinic., Results: In all, 71/94 (75.5%) women completed the questionnaire. Results were analyzed comparing women who returned to work in ≤ 8 weeks [43/71 (60.6%)] with those who returned > 8 weeks postoperatively [28/71 (39.4%)]. A higher proportion of Asian and Caucasian women returned to work in ≤ 8 weeks (24/29) compared with black African and Caribbean women (19/42) (p = 0.003). Mean number of fibroids removed (2.59 and 5.75, respectively) was the only significantly differing factor between the two groups (p = 0.004). There was a significant difference in body mass index (BMI) and time to return to normal activity between the ≤ 8-week and > 8-week groups (p = 0.027, p = 0.011, respectively). Logistic regression analysis demonstrated that BMI and time to return to normal activity were the only factors prolonging recovery to > 8 weeks (p = 0.039, p = 0.015, respectively)., Conclusions: Time to return to normal activity and BMI significantly influenced the time taken for women to work after laparoscopic myomectomy. Further data would support clinicians in counseling women appropriately and optimizing their postoperative return to employment., (© 2017 Nordic Federation of Societies of Obstetrics and Gynecology.)

Purpose: To systematically evaluate the current evidence on the safety and efficacy of stem cell therapy (SCT) in stress urinary incontinence (SUI) to allow objective comparison with existing surgical techniques., Methods: Systematic literature search of Medline from years 1946-2012 using terms: "stem", "cell", "stress", "urinary", and "incontinence". Included studies presented empirical data on the treatment of SUI using SCT., Outcomes: adverse events, incontinence, quality of life, urodynamic, transurethral ultrasound and urethral EMG findings., Results: Eight studies met inclusion criteria (seven observational and one randomized). Quality score: median 10.75 of 20 (range 2-12.5). Adverse events: one patient had bladder perforation and two procedures could not be completed due to pain. Temporary urinary retention and cystitis were also reported. Incontinence score: Four studies describe significant improvement. Quality of life: significant improvement in four studies. Urodynamic outcomes: four studies show significant improvement in contractility of urethral sphincter; three studies demonstrate no change in bladder capacity and significant reduction in residual volume; significant improvement in urinary flow three studies, although two found no difference; increase in leak point pressure and detrusor pressure in three studies. Urethral ultrasound: three studies found significant increases in rhabdosphincter thickness and contractility. Urethral EMG: two studies found significant increases in the EMG at rest and at contraction., Conclusion: Data suggest that SC treatment for SUI is safe and effective in the short term. However, the quality and maturity of the data are limited. Robust data from better quality studies comparing this to current surgical techniques are needed.

We evaluated in a prospective observational study the use of a 'uterine sandwich' technique (uterine compression sutures in association with intrauterine tamponade) in women who had had unsuccessful medical treatment for postpartum hemorrhage. Ten of the 11 patients had cesarean sections (complicated by placenta previa and uterine atony) and one had a normal delivery. The median estimated blood loss and units of blood transfused were 1500ml (range 750-4000ml) and two units (range 0-9), respectively. B-Lynch sutures were placed in two patients and Hayman's modification was used in nine. Bakri balloon tamponade was in place for a median of 22 hours (range 17-27 hours), while the median volume infused in the balloon was 300ml (range 150-350ml). The combined technique was successful in avoiding hysterectomy in all cases, and there was no documented postpartum morbidity. This is a simple and quick surgical technique that can be used to treat atonic postpartum hemorrhage, particularly in conjunction with placenta previa., (© 2011 The Authors Acta Obstetricia et Gynecologica Scandinavica © 2011 Nordic Federation of Societies of Obstetrics and Gynecology.)

Background: Autistic spectrum disorder encompasses a wide variety of behavioural and communicative problems. Both the core features and non-core features of autism have been targeted in a variety of therapies. Atypical antipsychotic medications, including risperidone, have been used for symptom and behaviour improvement and have shown beneficial outcomes, particularly in certain aspects of the disorder. However, given the nature of the condition presenting in young patients, the risks of these potentially long term therapies must be weighed against the benefits., Objectives: To determine the efficacy and safety of risperidone for people with autism spectrum disorder., Search Strategy: Electronic databases: CENTRAL (Cochrane Central Register of Controlled Trials) 2006 (Issue 3); MEDLINE (1966 to April 2006); EMBASE (1980 to April 2006);PsycINFO (1887 to April 2006); CINAHL (1982 to April 2006); LILACS (1982 to April 2006 ); Clinicaltrials.gov (USA) (accessed April 2006); ZETOC (1993 to April 2006); National Research Register (NRR) (UK) 2006 (Issue 1) were searched. In addition further data were retrieved through contact with pharmaceutical companies and authors of published trials., Selection Criteria: All randomised controlled trials of risperidone versus placebo for patients with a diagnosis of autism spectrum disorder. All trials had to have at least one standardised outcome measure used for both intervention and control group., Data Collection and Analysis: Data were independently evaluated and analysed by the reviewers. Data were evaluated at the end of each randomised controlled trial. Unpublished data were also considered and analysed., Main Results: Only three randomised controlled trials were identified. Meta-analysis was possible for three outcomes. Some evidence of the benefits of risperidone in irritability, repetition and social withdrawal were apparent. These must however be considered against the adverse effects, the most prominent being weight gain., Authors' Conclusions: Risperidone can be beneficial in some features of autism. However there are limited data available from studies with small sample sizes. In addition, there lacks a single standardised outcome measure allowing adequate comparison of studies, and long-term followup is also lacking. Further research is necessary to determine the efficacy pf risperidone in clinical practice.