Search

Purpose of Review: The purpose of this review is to (i) summarize the current literature regarding the role of magnetic resonance imaging (MRI) in diagnosing adenomyosis, (ii) examine how to integrate MRI phenotypes with clinical symptomatology and histological findings, (iii) review recent advances including proposed MRI classifications, (iv) discuss challenges and pitfalls of diagnosing adenomyosis, and (v) outline the future role of MRI in promoting a better understanding of the pathogenesis, diagnosis, and treatment options for patients with uterine adenomyosis. Recent Findings: Recent advances and the widespread use of MRI have provided new insights into adenomyosis and the range of imaging phenotypes encountered in this disorder. Summary: Direct and indirect MRI features allow for accurate non-invasive diagnosis of adenomyosis. Adenomyosis is a complex and poorly understood disorder with variable MRI phenotypes that may be correlated with different pathogeneses, clinical presentations, and patient outcomes. MRI is useful for the assessment of the extent of findings, to evaluate for concomitant gynecological conditions, and potentially can help with the selection and implementation of therapeutic options. Nevertheless, important gaps in knowledge remain. This is in part due to the lack of standardized criteria for reporting resulting in heterogeneous and conflicting data in the literature. Thus, there is an urgent need for a unified MRI reporting system incorporating standardized terminology for diagnosing adenomyosis and defining the various phenotypes.

Model and compare estimated health system costs and gynecologic practice revenues when hysteroscopic surgery is performed in the office or institutional setting, either an ambulatory surgical center (ASC) or a traditional operating room (OR).Economic modeling exercise.Nonclinical.An economic model was developed that included US reimbursement rates for the office and institutional settings and the inherent expenses required for office hysteroscopic surgery. For Current Procedural Terminology code 58558, hysteroscopic biopsy and/or polypectomy, total health system costs were estimated as follows: office, $1382.48; ASC, $1655.31; OR $2918.10. In the modeled office setting, costs for the same procedure were estimated from instrumentation and supply list prices obtained from vendors and staffing costs from national databases. Revenue and cost modeling were performed and compared both for 1 to 10 monthly procedure volumes and by hysteroscopic systems, whereas other elements of the procedure were standardized, including technique, staffing, generic supplies, and the use of local anesthesia. Four vendors provided system price information: 1 purpose built, 1 electromechanical, and 2 traditional. The projected office-based, per case net revenue with the purpose-built system was always greater than in the ASC or OR and relatively independent of monthly procedure volume (1 per month $743.59; 10 per month $876.17). For the traditional and electromechanical systems, it took from 2 to 5 monthly procedures to realize a net revenue greater than $239.39. Using 3 sets of vendor matched instruments, at 10 cases per month, the per case net revenue for the electromechanical system was $514.00, and for the 2 traditional systems $564.02 and $693.72.Performance of office-based hysteroscopic surgery is associated with reduced health system costs compared with the institutional environment. The net revenue for the practice was dependent on both the volume of procedures performed and the hysteroscopic system and technique selected.

Purpose of Review To provide an update on published classification and reporting systems for adenomyosis. There is an urgent need to standardize reporting of various phenotypes of adenomyosis into a validated and globally recognized system. This can be used to examine the nature and severity of adenomyosis symptoms and inform the design, evaluation, and implementation of appropriate treatment options. Recent Findings In recent years, several new proposals for adenomyosis classification have emerged. Most are MRI-based and include features such as uterine size, junctional zone thickness, size and location of the lesions, and distribution patterns. To date, none of those proposals has been validated. Only one recent classification based on transvaginal ultrasound was validated for interobserver congruence and correlated to clinical findings. However, the differentiation of diffuse and focal adenomyosis still lacks consensus. In addition, only a few authors advocated imaging-based definitions. Summary There is a need for one or a combination of a classification and reporting system for adenomyosis. To date, there is no widely accepted and validated system.

Iron deficiency is a common cause of morbidity and can arise as a consequence or complication from many diseases. The use of intravenous iron has increased significantly in the last decade, but concerns remain about indications and administration. Modern intravenous iron preparations can facilitate rapid iron repletion in one or two doses, both for absolute iron deficiency and, in the presence of inflammation, functional iron deficiency, where oral iron therapy is ineffective or has not worked. A multidisciplinary team of experts experienced in iron deficiency undertook a consensus review to support healthcare professionals with practical advice on managing iron deficiency in gastrointestinal, renal and cardiac disease, as well as; pregnancy, heavy menstrual bleeding, and surgery. We explain how intravenous iron may work where oral iron has not. We provide context on how and when intravenous iron should be administered, and informed opinion on potential benefits balanced with potential side-effects. We propose how intravenous iron side-effects can be anticipated in terms of what they may be and when they may occur. The aim of this consensus is to provide a practical basis for educating and preparing staff and patients on when and how iron infusions can be administered safely and efficiently.Key messagesIron deficiency treatment selection is driven by several factors, including the presence of inflammation, the time available for iron replenishment, and the anticipated risk of side-effects or intolerance.Intravenous iron preparations are indicated for the treatment of iron deficiency when oral preparations are ineffective or cannot be used, and therefore have applicability in a wide range of clinical contexts, including chronic inflammatory conditions, perioperative settings, and disorders associated with chronic blood loss.Adverse events occurring with intravenous iron can be anticipated according to when they typically occur, which provides a basis for educating and preparing staff and patients on how iron infusions can be administered safely and efficiently.

To synthesize the published literature to better understand the association between cesarean scar defects (CSDs) and abnormal uterine bleeding (AUB). In particular, we aimed to evaluate the risk and pattern(s) of CSD-associated AUB in addition to exploring the relationship between defect morphology with bleeding symptoms.Systematic review and meta-analysis.Not applicable.Patients with CSD and reports of uterine bleeding as an outcome were identified in 60 studies from database searches.Studies that investigated CSD (as defined by investigators) and reported uterine bleeding, menstrual bleeding, or AUB as an outcome were included.The prevalence and risk of AUB (intermenstrual, postmenstrual, and unscheduled bleeding) in patients with confirmed CSD.Nine studies reported on the prevalence of AUB in patients with a confirmed CSD. Patients with CSD were more likely to experience AUB, compared with those without CSD (relative risk, 3.47; 95% confidence interval [CI], 2.02-5.97; 6 studies, 1,385 patients; IThere is a strong and consistent association between patients with CSD and AUB. These patients experience a unique bleeding pattern, namely prolonged menstruation and early-cycle intermenstrual bleeding. These data should provide impetus for including CSD as a distinct entity in AUB classification systems. High heterogeneity in our results calls for standardization of nomenclature and outcome reporting for this condition.

Structured laparoscopic and hysteroscopic manual skills testing distinguished novice from mid-level residents, and board-certified obstetrician–gynecologists from fellowship-trained minimally invasive gynecologic surgeons., OBJECTIVE: To establish validity evidence for the Essentials in Minimally Invasive Gynecology laparoscopic and hysteroscopic simulation systems. METHODS: A prospective cohort study was IRB approved and conducted at 15 sites in the United States and Canada. The four participant cohorts based on training status were: 1) novice (postgraduate year [PGY]-1) residents, 2) mid-level (PGY-3) residents, 3) proficient (American Board of Obstetrics and Gynecology [ABOG]–certified specialists without subspecialty training); and 4) expert (ABOG-certified obstetrician–gynecologists who had completed a 2-year fellowship in minimally invasive gynecologic surgery). Qualified participants were oriented to both systems, followed by testing with five laparoscopic exercises (L-1, sleeve-peg transfer; L-2, pattern cut; L-3, extracorporeal tie; L-4, intracorporeal tie; L-5, running suture) and two hysteroscopic exercises (H-1, targeting; H-2, polyp removal). Measured outcomes included accuracy and exercise times, including incompletion rates. RESULTS: Of 227 participants, 77 were novice, 70 were mid-level, 33 were proficient, and 47 were experts. Exercise times, in seconds (±SD), for novice compared with mid-level participants for the seven exercises were as follows, and all were significant (P

Study Objective The aim of this study is to assess the safety and efficacy of the IUB SEAD™ (Intra Uterine Ball: Spherical Endometrial Ablation Device) introducing silver nitrate to the uterus in women suffering from abnormal uterine bleeding. We present results of 6 months follow up period post treatment. Design Open-label multicenter study to assess the safety and efficacy of the IUB SEAD™ device in premenopausal women with predictable menstrual cycles, who suffer from AUB. Women with HMB were enrolled who had an average pictorial blood loss assessment chart (PBAC) score ≥ 150 over for 3 months. Setting The study was performed in the outpatient clinics of 2 Bulgarian medical centres between September 2019 and December 2020. Patients or Participants 16 women with HMB (PBAC>150) at least 3 months before inclusion were enrolled. Interventions Eligible subjects who met all the inclusion/exclusion criteria were treated during the first 7 days following the cessation of menses. The SEAD™ device was inserted into the uterine cavity via vaginal approach. The device was left in the uterus for 30 (±5) minutes and then removed. Measurements and Main Results A total of 16 participants aged 37-50 (mean = 43) were enrolled with a mean baseline PBAC score of 424; 14 of 16 completed follow up requirements and were evaluable at 6 months. All procedures were completed successfully without device/procedure-related adverse events. At 6 months post-treatment the mean PBAC score was 95 with 55% of the overall cohort ≤75 and 72% ≤ 100 and a mean percentage of 83% reduction. The mean procedure related pain score was ≤2 (mild).* Conclusion The IUB SEAD™ device is safe and effective in treating HMB in an outpatient environment. Future studies with larger number of patients are planned. *Results may vary until presentation date.

/

Endometrial ablation (EA) includes a spectrum of procedures performed with or without hysteroscopic direction, designed to destroy the endometrium for the treatment of the symptom of heavy menstrual bleeding (HMB) secondary to a spectrum of causes, but most commonly those that are endometrial in origin (AUB-E) or ovulatory disorders (AUB-O). Resectoscopic endometrial ablation (REA) is often mistakenly referred to as the "first generation" technique, while proprietary devices that do not use the resectoscope (nonresectoscopic EA or NREA) are often misperceived as "second generation" devices. Indeed, the origins of NREA date back to the late 19th century with the use of steam, and the early and mid 20th century, when radiofrequency and cryotherapy based NREA techniques were published - long before the resectoscope was used and reported. The NREA devices have also been mislabeled as "global", a misleading term borrowed from the marketing departments of device manufacturers - there is no device that predictably treats the entire endometrium. Consequently, none can be construed as being "global". Instead, EA is a procedure designed for women as an alternative to hysterectomy, or, perhaps, medical therapy, when future fertility is no longer desired. Women who select EA should anticipate a relatively low risk procedure that will likely reduce their HMB to normal levels or less. This paper will review the spectrum of EA techniques and devices, their clinical outcomes and adverse events, and explore their value compared to hysterectomy and selected medical therapies.

Background: Iron deficiency anemia (IDA) is a multifaceted condition associated with immense obstetrical morbidity and mortality, and is especially prevalent in female patients of reproductive age.Abnormal uterine bleeding (AUB), which often manifests clinically as heavy menstrual bleeding (HMB), is the leading cause of IDA among reproductive age women in the United States, with a prevalence ranging from ~30-50% in this patient population; further, HMB is estimated to account for nearly one-third of all IDA causes worldwide. For these reasons, AUB/HMB is generally accepted as the primary causal source of IDA in daily clinical practice.As frontline clinicians who routinely manage HMB, OB/GYNs are optimally positioned to subsequently recognize, diagnose, and treat the IDA precipitated by HMB. However, to ensure the provision of safe and effective care, adaptive educational initiatives with an emphasis on evolving iron supplementation strategies are needed. Methods: Creative Educational Concepts (CEC) conducted a literature review, needs assessment, and detailed gap analysis to identify prominent clinical and educational gaps that exist among OB/GYNs with regard to IDA sign and symptom recognition, epidemiology, clinical gravity and risk factors, formal diagnosis, and appropriate treatment.Consequently, our team at CEC composed a responsive, multi-pronged educational design targeted to obstetricians, gynecologists, and women's health professionals, in a tailored effort to bridge the aforementioned gaps in current practice and improve outcomes for patients.CEC consulted with top experts in obstetrics and gynecology, maternal fetal medicine, pelvic surgery, and hematology at every stage of the educational design and delivery continuum, from proposal ideation to content development to live, on-site presentation.To dynamically engage the target audience, especially at the community, grassroots level, this educational initiative was delivered at a series of five American College of Obstetricians and Gynecologists (ACOG) District Meetings across the United States; live meetings were held in Lake Geneva, WI; San Diego, CA; Kapalua, HI; Rockport, ME; and Manhattan, NY. Results: 203 total clinicians were educated across the initiative Profession MD/DO - 93%APRN/CNM - 3%RN - 2%Other - 2%Specialty General OB/GYN - 81%Maternal/fetal Medicine - 11%Reproductive endocrinology - 4%Pelvic medicine/surgery - 2%Other - 2%>5,000 IDA patients potentially impacted per month as a result of the initiativeStatistically significant advances in learning and knowledge were achieved from pre- to post-activity for all tested educational gaps: Identification of IDA risk factors (85% post vs. 46% pre; P Conclusions: Our 2019 ACOG District Meeting educational initiative precipitated substantive practice advances in knowledge, competence, and performance among OB/GYNs and women's health professionals related to IDA management.Statistically significant performance improvements in appropriate initiation of IV iron for treatment of HMB-associated IDA were achieved at follow-up assessment.Learning and knowledge endpoints for IDA risk factor recognition and AUB clinical implications were not retained with statistical significance at follow-up assessment, thereby evidencing residual educational gaps and a need for ongoing education in this space. Disclosures Shulman: Bayer: Consultancy; AMAG: Speakers Bureau; Lupin: Speakers Bureau; Vermillion: Speakers Bureau. Munro:Vifor: Consultancy; Abbvie: Consultancy, Research Funding; American Regent: Consultancy; Boston Scientific: Consultancy; Daiichi Sankyo: Consultancy. Martin:Daiichi Sankyo: Consultancy. Nelson:Merck: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Bayer: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; AMAG: Consultancy; Agile Pharmaceutical: Consultancy, Research Funding; EvoFem: Research Funding; Sebela Pharmaceutica: Consultancy, Research Funding; TherapeuticsMD: Membership on an entity's Board of Directors or advisory committees; American Regent: Consultancy, Membership on an entity's Board of Directors or advisory committees.

Study Objective Heavy menstrual bleeding (HMB) associated with uterine fibroids (UF) often leads to anemia, which may cause fatigue and weakness in affected women. This analysis evaluated clinical improvements in menstrual blood loss (MBL), anemia, and quality of life (QoL) in elagolix-treated women who had HMB, UF, and severe or mild anemia at the time of Elaris UF-1 or UF-2 study entry. Design Pooled subgroup analysis of UF-1 and UF-2, two replicate double-blind, randomized, placebo-controlled, 6-month phase 3 studies. Setting Outpatient. Patients or Participants Subgroup of premenopausal women with HMB (>80mL alkaline hematin-measured MBL/cycle), ultrasound-confirmed UF, and severe (hemoglobin [Hgb] Interventions Elagolix 300mg BID with add-back therapy (estradiol 1mg/norethindrone acetate 0.5mg QD) (elagolix+E2/NETA), compared with placebo. Measurements and Main Results In UF-1 and UF-2, a total of 426/591 (72%) women who received elagolix+E2/NETA or placebo had severe (n=189) or mild anemia (n=237) at study entry. Women with severe anemia had a numerically greater mean baseline MBL (301.6±204.1mL) than women with mild anemia (225.8±128.2mL). Of the elagolix+E2/NETA-treated women with severe anemia at study entry, 74.1% met the study's primary endpoint (had both 2g/dL from baseline to month 6, and 51.1% achieved Hgb≥12g/dL at month 6 (P Conclusion Women with HMB, UF, and severe or mild anemia at study entry demonstrated clinical improvements in MBL, anemia, and QoL with elagolix+E2/NETA treatment.

Objective To conduct a review of the available histologic and image-based classification systems to determine which of these systems, if any, provide clinical utility for prognosis or the selection of appropriate therapeutic interventions. Data Sources PubMed in addition to the bibliographies of identified publications. Methods of Study Selection One investigator searched PubMed using Medical Subject Headings terms that included “Adenomyosis,” “Classification,” “Ultrasound Classification,” “MRI Classification,” and “Diagnosis,” Tabulation, Integration and Results Search results were tabulated in a Microsoft Excel workbook that facilitated the identification of duplicate entries. Publications were allocated into separate categories that included histopathologic, ultrasound, and MRI classifications. Identified systems associated with clinical outcomes were separately tabulated. Abstracts of 1669 articles were reviewed and 278 were identified for review of full text. Twenty-five were considered potentially relevant from the PubMed review and an additional 17 were found in bibliographies. In the 42 full-text articles that were reviewed in detail, 9 histologic classifications were identified, 4 of which were accompanied by an attempt at clinical correlation, 1 of which described a correlation with the outcome of medical, procedural, or surgical intervention. There were 9 image-based reporting or classification systems, 2 using transvaginal ultrasound and 7 using MRI, 3 of which included correlations with intervention outcomes, although these were surrogate (imaging) and not clinical outcomes. Conclusion There is inconsistency in histopathologic definitions, and there is no uniformly accepted or validated system of image-based reporting or classification that can inform clinical decision making. There exists a need for harmonized classification systems for both ultrasound and MRI that agree with the histopathologic features of the disorder.

Study Objective To evaluate the Essentials in Minimally Invasive Gynecology (EMIG)- Fundamentals of Laparoscopic Surgery Laparoscopic Simulation System and the EMIG Hysteroscopy Simulation System for face validity and functionality in a pilot testing environment. Design A prospective controlled pilot study. Setting Three teaching institutions in the US Southwest. Subjects Twenty-seven residents and gynecologists, with 22 fitting who fit 1 of 4 categories of exposure to hysteroscopic and laparoscopic surgery and surgical simulation. Eleven were postgraduate year 1 and 5 postgraduate year 3, 1 was American Board of Obstetrics & Gynecology certified, and 5 were either fellows in-training or had completed a fellowship in minimally invasive gynecologic surgery. Interventions After completing a screening survey, each subject was exposed to a structured orientation to the 2 simulation systems and then tested with proctor supervision on the 5 laparoscopic and 2 hysteroscopic exercises. A short 5-point Likert questionnaire designed to determine face validation and question clarity was administered to each subject at sites 2 and 3. Measurements and Main Results Face validity was high for each of the 7 exercises (means ranged from 4.8 to 4.9 of 5), and subjects considered instructions to be clear (means from 4.7 to 4.9). The recorded exercise times generally reduced with increasing levels of training, although the sample sizes were not designed to determine significance given the pilot design. Similarly, exercise errors were generally less frequent with increasing experience. The systems, including the devices and recording mechanisms, performed well, and proctor evaluation and training were satisfactory. Conclusion The EMIG laparoscopic and hysteroscopic simulations systems were considered to have good face validity and appear to be suitable for a construct validation trial to confirm their utility in distinguishing among trainees and practitioners with a wide spectrum of endoscopic surgical experience. The recording and specimen storage mechanisms will allow for multiple proctors to rate a candidate's performance, thereby enhancing evaluation consistency and quality.

Study Objective To investigate the utility of a gynecologic laparoscopy simulation curriculum designed for mid-level obstetrics and gynecology (OBGYN) residents in the five Fundamentals of Laparoscopy Surgery (FLS) skills. The hypothesis was that residents would demonstrate significant improvement in all tasks. Design A cohort study. Setting A community based OBGYN residency education program. Patients or Participants A total of 51 2nd and 3rd year residents. Interventions A comprehensive, 10 – week-long gynecologic endoscopy program, comprising both cognitive and manual skills. After an orientation week, formal assessment of baseline time and accuracy for each of the 5 FLS exercises was obtained on each resident by an FLS-certified faculty. Each week thereafter comprised a 3-hour training session with the same faculty that included approximately 90 minutes of hands-on psychomotor training using the FLS Laparoscopic System. All residents had 24 hour a day access to a training facility. On week 9, formal testing was repeated by the same faculty and the data entered into an Excel database. Measurements and Main Results There were 51 residents in the 10-year period and between 38 and 46 pairs of data for the 5 skills were evaluable. The baseline and week 9 completion times in seconds (SD) were as follows: Peg transfer 90.8 (40.1) and 59.4 (20.5); Pattern cut 190.7 (87.9) and 113.8 (51.0); Ligating loop 92.1 (39.6) and 65.1 (31.2); Extracorporeal tie 230.9 (88.3) and 137.8 (42.2); Intracorporeal tie 249.3 (97.9) and 134.1 (69.5). All differences were significant P Conclusion Mid-level OBGYN residents exposed to this gynecologic laparoscopy simulation training program significantly improved performance in the five FLS skills. Consequently, it may serve as a model for residency training programs. However, the absence of a cognitive and psychomotor hysteroscopic component in FLS is noteworthy and a shortcoming for OBGYN training programs.

We conducted a systematic review and meta-analysis to assess the safety and effectiveness of robotic versus laparoscopic hysterectomy in women with benign uterine disease, as determined by randomized studies. We searched MEDLINE, EMBASE, the Cochrane Library, ClinicalTrials.gov, and Controlled-Trials.com from inception to October 9th, 2014, using the intersection of the themes “robotic” and “hysterectomy.” We included only randomized and quasi-randomized controlled trials of robotic versus laparoscopic hysterectomy in women for benign disease. Four trials met inclusion criteria and were included in the analyses. Data was extracted and studies were assessed for methodological quality in duplicate. For meta-analysis, we used random effects to calculate pooled risk ratios (RR) and weighted mean differences. For our primary outcome, we used a modified version of the Expanded Accordion Severity Grading System to classify perioperative complications. We identified 41 total complications among 326 patients. When comparing robotic to laparoscopic hysterectomy, we found no statistically significant differences in the rate of class 1 and 2 complications (RR=0.66, 95% Confidence Interval (CI) 0.23–1.89) or in the rate of class 3 and 4 complications (RR=0.99, 95%CI 0.22–4.40). Analyses of secondary outcomes were limited due to heterogeneity, but showed no significant benefit of robotic compared to laparoscopic technique in terms of length of hospital stay (weighted mean difference= −0.39 days, 95%CI −0.92–0.14), total operating time (weighted mean difference=9.0 minutes, 95%CI −31.27–47.26), conversions to laparotomy, or blood loss. Outcomes of cost, pain, and quality of life were inconsistently reported and not amenable to pooling. Current evidence demonstrates neither statistically significant, nor clinically meaningful differences in surgical outcomes between robotic and laparoscopic hysterectomy for benign disease. The role of robotic surgery in benign gynecology remains unclear.

Adverse events associated with hysteroscopic procedures are generally rare, but, with increasing operative complexity, it is now apparent that they are experienced more often. There exists a spectrum of complications that relate to generic components of procedures, such as patient positioning, anesthesia, and analgesia, to a number that are specific to intraluminal endoscopic surgery that largely comprise perforation and injuries to surrounding structures and blood vessels. Whereas a number of endoscopic procedures require the use of distending media, the response of premenopausal women to excessive absorption of nonionic fluids used for hysteroscopy is somewhat unique, and deserves special attention on the part the surgeon. There is also an increasing awareness of uncommon but problematic sequelae related to the use of monopolar radiofrequency uterine resectoscopes that involve thermal injury to the vulva and vagina. Furthermore, the uterus that has previously undergone hysteroscopic surgery may behave in unusual ways, at least in premenopausal women who experience menstruation or who become pregnant. Fortunately, better understanding of the mechanisms involved in these adverse events, as well as the use or development of a number of innovative devices, have collectively provided the opportunity to perform hysteroscopic and resectoscopic surgery in a manner that minimizes risk to the patient.

Study Objective Construct validation of the EMIG Laparoscopic Surgery Simulation System. Design A prospective, controlled cohort comparison. Setting Thirteen teaching institutions in the US and Canada and an AAGL Congress Patients or Participants 221 subjects who fit one of 4 categories of exposure to laparoscopic surgery and surgical simulation: 77 novices within 100 days of starting posgraduate year 1 (PGY-1); 71 within the first 100 days of starting PGY-3; 30 American Board of Obstetrics and Gynecology (ABOG) certified and no additional fellowship training (“Proficient”); 43 who had completed the two-year Fellowship in Minimally Invasive Gynecologic Surgery (FMIGS). Interventions Subjects were oriented to the simulation system and then tested under proctor supervision on the 5 EMIG laparoscopic exercises. These included the sleeve to peg transfer (L-1); the circular pattern cut (L-2); extracorporeal knotting (L-3); intracorporeal knotting (L-4); and a running suture (L-5). Time and accuracy scoring were entered electronically on site, but sessions were video recorded and study materials such as cutting and suturing targets were labeled and stored for subsequent review to optimize data quality. Measurements and Main Results Each exercise was timed, and a number of objective metrics recorded that reflected cutting and suturing accuracy and technique. Each exercise had a “time cap”; if a subject had not completed the exercise by the end of the allotted time, they were categorized “Did Not Complete” and the maximum time was entered for data analysis. Preliminary data analysis demonstrates that the novice group consistently demonstrated the poorest performance and the FMIGS cohort consistently the best. The PGY-3 and “Proficient” cohorts were generally similar to each other but each performed better than the PGY-1 group and well below the FMIGS group. Conclusion The EMIG Laparoscopic Simulation System can be used to distinguish amongst PGY-1, PGY-3, Proficient and FMIGS subjects. FMIGS-trained subjects consistently had the best results with almost no “Did not Complete” outcomes.

Study Objective Evaluate the EMIG-FLS Laparoscopic Simulation System and the EMIG Hysteroscopy Simulation System for face validity and functionality in a pilot testing environment. Design A pilot cohort study Setting Three teaching institutions in the US Southwest Patients or Participants Twenty-seven residents and gynecologists who fit one of three categories of exposure to hysteroscopic and laparoscopic surgery and surgical simulation. Twelve were postgraduate year 1 (PGY-1); five were PGY-3, 1 was ABOG certified, and 5 were either fellows in-training or had completed a Fellowship in Minimally Invasive Gynecologic Surgery (FMIGS). Interventions After completing a screening survey, each subject was exposed to a structured orientation to the two simulation systems and then tested with proctor supervision on the 5 laparoscopic and 2 hysteroscopic exercises. A short 5-point Likert questionnaire designed to determine face validation and question clarity was administered to each subject at sites 2 and 3. Measurements and Main Results Face validity was high for each of the 7 exercises (means ranged from 4.8 to 4.9 out of 5) and subjects considered instructions to be clear (means ranged from 4.7 to 4.9). The recorded exercise times generally reduced with increasing levels of training although the sample sizes were not designed to determine significance given the pilot design. Similarly, exercise errors were generally less frequent with increasing experience. The systems, including the devices and recording mechanisms performed well and proctor evaluation and training were satisfactory. Conclusion The EMIG laparoscopic and hysteroscopic simulations systems were considered to have good face validity and appear to be suitable for a construct validation trial to confirm their utility in distinguishing amongst trainees and practitioners with a wide spectrum of endoscopic surgical experience. The recording and specimen storage mechanisms will allow for multiple proctors to rate a candidate's performance, thereby enhancing evaluation consistency and quality.

Menstrual symptoms are the commonest gynecologic complaints presenting to health professionals in most cultures, yet it is only very recently that the FIGO Menstrual Disorders Committee developed a pair of systems focusing on more logical and consistent terminologies, definitions and underlying causes relating to menstrual symptoms, signs, and pathologies. These initiatives have resulted in several ill-defined terminologies such as menorrhagia and dysfunctional uterine bleeding (DUB) becoming obsolete. In addition to intermenstrual spotting or bleeding, symptoms of abnormal uterine bleeding (AUB) are now primarily defined by regularity, frequency, duration and volume, and underlying causes are classified by the PALM-COEIN System. Heavy menstrual bleeding (HMB) is the commonest of these “bleeding symptoms” and has the greatest social and physical impacts on women and society, especially through iron deficiency and anemia.

To evaluate the accuracy of traditional blind uterine sounding in measuring uterine cavity length (UCL), compared with measurement by hysteroscopic guidance.A cross-sectional descriptive study (Canadian Task Force classification III).Academic multispecialty medical center.Fifty-eight women undergoing elective hysteroscopic procedures.UCL measurement.UCL measurements were obtained by the traditional blind sounding technique and by hysteroscopically directed measurement. Hysteroscopic measurements were assumed to represent true uterine cavity length. Differences between the 2 measurements were calculated to analyze error and bias.Mean UCL for blind sounding and hysteroscopically directed measurements were 80.81 mm and 86.55 mm, respectively. The magnitude of error between measurements was10 mm in 36.2% of cases, with underestimation of true UCL in 55.17% of cases.True UCL is underestimated by blind sounding, and the frequency, magnitude, and direction of error may be greater than are clinically acceptable.

Adverse events due to energy device use in surgical operating rooms are a daily occurrence. These occur at a rate of approximately 1–2 per 1000 operations. Hundreds of operating room fires occur each year in the United States, some causing severe injury and even mortality. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) therefore created the first comprehensive educational curriculum on the safe use of surgical energy devices, called Fundamental Use of Surgical Energy (FUSE). This paper describes the history, development, and purpose of this important training program for all members of the operating room team. The databases of SAGES and the FUSE committee as well as personal photographs and documents of members of the FUSE task force were used to establish a brief history of the FUSE program from its inception to its current status. The authors were able to detail all aspects of the history, development, and national as well as global implementation of the third SAGES Fundamentals Program FUSE. The written documentation of the making of FUSE is an important contribution to the history and mission of SAGES and allows the reader to understand the idea, concept, realization, and implementation of the only free online educational tool for physicians on energy devices available today. FUSE is the culmination of the SAGES efforts to recognize gaps in patient safety and develop state-of-the-art educational programs to address those gaps. It is the goal of the FUSE task force to ensure that general FUSE implementation becomes multinational, involving as many countries as possible.

While available evidence shows that diagnostic hysteroscopy can be performed in many patients with little or no analgesia or anesthesia, for some women, there is significant discomfort with the procedure, and many can benefit from the use of local anesthetic techniques. Operative hysteroscopic procedures can also be performed in the office setting, but there are challenges to performing such interventions using local anesthesia. There is little available evidence describing effective anesthetic techniques for operative hysteroscopy, a circumstance that invites both a creative approach and critical evaluation with appropriately rigorous investigation. The uterus possesses at least two distinctly different sources of innervation; the cervix is supplied by S2–4 largely through the uterosacral ligaments while the corpus receives sensory afferents via the T10–L1 roots that access the uterine architecture at the isthmus and via the ovarian ligaments. Theoretically, at least, the strategy for the effective use of local uterine anesthesia must consider these multiple sources of innervation as well as other factors including the procedure to be performed, the instrumentation to be used, selection of appropriate anesthetic agents, and the allowance of adequate elapsed time for a maximal anesthetic effect. An approach utilizing several simultaneously applied techniques is described together with patient pain outcomes suggesting that a wide spectrum of procedures can be performed in an office setting, under local anesthesia.

Operating room (OR) safety has become a major concern in patient safety since the 1990s. Improvement of team communication and behavior is a popular target for safety programming at the institutional level. Despite these efforts, essential safety gaps remain in the OR and procedure rooms. A prime example is the use of energy-based devices in ORs and procedural areas. The lack of fundamental understanding of energy device function, design, and application contributes to avoidable injury and harm at a rate of approximately 1 to 2 per 1000 patients in the US. Hundreds of OR fires occur each year in the US, some causing severe injury and even death. Most of these fires are associated with the use of energy-based surgical devices.In response to this safety issue, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) developed the Fundamental Use of Surgical Energy (FUSE) program. This program includes a standardized curriculum targeted to surgeons, other physicians, and allied health care professionals and a psychometrically designed and validated certification test. A successful FUSE certification documents acquisition of the basic knowledge needed to safely use energy-based devices in the OR. By design FUSE fills a void in the curriculum and competency assessment for surgeons and other procedural specialists in the use of energy-based devices in patients.

Hysterectomy remains one the most common procedures performed in North America. Because of a better understanding of a wide array of disease states and with emerging, more focused minimally invasive treatment options, a relative decline has been documented in the last several years. Although hysterectomy will ultimately eliminate all potential sources of abnormal uterine bleeding, various pharmacologic and surgical alternatives exist that may provide comparable benefit to the majority of women, especially if older than 40 years. Women experiencing chronic pelvic pain; however, should be counseled against hysterectomy until a more clear etiology has been identified.

Historically, the terminology used for abnormal uterine bleeding has been inconsistent and confusing. The Federation Internationale de Gynecologie et d'Obstetrique (FIGO) has recently approved new definitions and a standardized classification system for menstrual disorders and other contributors to the problem of abnormal uterine bleeding. This article describes the need for these changes and aims to encourage their use in routine clinical practice, medical education and scientific research, with the hope that they will lead to improved reproductive healthcare for women.

Acute uterine bleeding unrelated to pregnancy has been defined as bleeding “sufficient in volume as to, in the opinion of the treating clinician, require urgent or emergent intervention.” The Southern California Permanente Medical Group updated its guidelines for the management of this condition on the basis of the best available evidence, as identified in a systematic review of the available literature. Given the paucity of studies evaluating this condition, the guidelines, by necessity, include recommendations largely based on opinion or other sources such as case series that are, in general, categorized as low-quality evidence. Medical interventions with single or combined gonadal steroidal agents administered parenterally or orally show promise, but more high-quality studies are needed to better define the appropriate drugs, dose, and administrative scheduling. There is also some evidence that intrauterine tamponade may be useful in at least selected cases. Special attention must be paid to both diagnosing and treating inherited disorders of hemostasis, such as von Willebrand disease, that may otherwise be underdiagnosed in both adolescent and adult women.

Almost all surgical procedures involve the use of devices that apply energy to tissue. Adverse events can occur if the devices are not used appropriately. The SAGES’ Fundamental Use of Surgical Energy™ (FUSE) program will include a curriculum and certification examination to address this safety issue. The aim of this study was to determine the self-perceived knowledge of practicing surgeons related to energy-based devices and identify areas to emphasize in the assessment component of FUSE. Psychometric experts led the test development process. During a 2-day retreat, a multidisciplinary group defined 63 test objectives assessing the knowledge and skills required to use energy-based surgical instruments safely (job task analysis). A survey was sent to a sample of 103 SAGES leaders and others in the test target audience to determine the number of items to use for the certification examination. Participants rated each objective for frequency, relevance, and importance on a 1–7 scale with the means used to create a weighted scale. The survey also included five self-assessment questions. Fifty surveys were completed; only 28 % of respondents considered themselves “experts.” The most common source of knowledge was “industry sales representative or course” (42 %). The highest weighted topic was “Prevention of Adverse Events with Electrosurgery.” The highest-rated objectives (>6 out of 7) were “Identify various mechanisms whereby electrosurgical injuries may occur,” “Identify patient protection measures for setup and settings for the electrosurgical unit,” and “Identify circumstances, mechanisms, and prevention of dispersive electrodes-related injury.” Although basic and advanced energy-based devices are commonly used, training has been largely dependent upon industry representatives or industry-sponsored courses. Few surgeons consider themselves experts in the mechanisms of action and the appropriate and safe use of energy-based surgical devices. Competencies that emphasize electrosurgical safety were viewed as most important for the FUSE certification examination.