Endometrial cancer is the most common gynecological malignancy in Europe and its management involves a variety of health professionals. In recent years, big discoveries were made concerning the management of patients diagnosed with endometrial cancer, particularly in the field of molecular biology and minimally invasive surgery. This requires the continuous updating of guidelines and protocols over the years. In this paper, we aim to summarize and compare common points and disparities among protocols for management of patients diagnosed with endometrial cancer by leading international gynecological oncological societies. We therefore systematically report the parallel among the guidelines based on the various steps patients with endometrial cancer usually undergo. The comparison between American and European protocols revealed some relevant disparities, in particular regarding surgical staging, molecular biology application as a prognostic tool and follow up regimens. This could possibly cause differences in interpreting and applying protocols in clinical practice in small centers, leading to a lack of adherence to guidelines or even prompting a confusing mix of them.

This study was performed to evaluate the systemic oxidative stress balance in women with either ovarian or deep infiltrating endometriosis (DIE) and any alterations of the same during hormone therapy. Free oxygen radicals (FORT) and free oxidant radical defense (FORD) were measured in the capillary blood of 24 women without endometriosis, 26 women with endometrioma, and 26 women with DIE with or without endometrioma. Endometriosis was diagnosed by clinical and ultrasound assessment. Dietary factors, lifestyle habits, and intake of any substances interfering with the oxidative status were recorded. Women were prescribed contraceptive hormones, and the baseline assessments were repeated at the 3rd month of use, revealing a higher oxidative stress balance (FORT/FORD) in women with endometriosis than in controls (4.75 ± 4.4 vs. 2.79 ± 2.2; p = 0.05). The highest values were found in women with DIE (5.34 ± 4.6; p = 0.028 vs. controls). Regression analysis revealed an independent link between FORT/FORD and endometrioma (b 2.874, 95% CI 0.345, 5.403; p = 0.027) and DIE (b 4.419, 95% CI 1.775, 7.064; p = 0.001) but a negative correlation with HDL-cholesterol (b −0.063, 95% CI −0.125, −0.002; p = 0.043). In controls, the hormone therapy increased FORT (p = 0.003), but also FORD (p = 0.012), with the FORT/FORD balance remaining stable (2.72 ± 2.2 vs. 2.73 ± 1.8; p = 0.810). In women with endometriosis, FORT remained unchanged, but FORD increased (p = 0.004), and the FORT/FORD ratio significantly decreased (4.75 ± 4.4 vs. 2.57 ± 1.76; p = 0.002) to values similar to the control levels. These data indicate that systemic oxidative stress balance increased in women with endometriosis, particularly in those with DIE. The hormonal therapy did not change the oxidative stress balance in control women but significantly improved it in women with endometriosis, particularly those suffering from DIE.

Introduction: Dienogest is a synthetic fourth‐generation progestin that has been approved for the medical treatment of endometriosis, and its efficacy on pain symptoms and quality of life is well established even in the long term. Nowadays, only a few controlled trials evaluating the safety of dienogest compared with other hormonal therapies have been published. This systematic review and meta‐analysis aims to compare efficacy and tolerability data between dienogest and combined oral contraceptives (COC) in patients taking hormonal therapy for endometriosis treatment in order to inform evidence‐based guidelines.Material and Methods: PubMed (Medline), Web of Science, and Google Scholar were systematically searched from the inception of each database until October 2024. Selection criteria included any articles comparing efficacy outcomes and at least one tolerability data between dienogest and COC in patients diagnosed with endometriosis. Studies comparing COC containing Dienogest or another type of hormonal treatment were excluded. A random‐effects meta‐analysis was conducted if adequate data were available from at least three studies, reporting pooled mean differences and odds ratios between groups using Review Manager V.7.9.0. PROSPERO registration number: CRD42024598455.Results: A total of four randomized control trials and one observational study were included, showing moderate risk at bias assessment. Meta‐analysis did not show any statistical difference in improving pelvic pain after treatment [CI 95% (−1.45–1.17); I² = 86%; p = 0.84]. In contrast, dyspareunia after treatment was significantly lower in the COC group [CI 95% (0.64–1.33); I² = 0%; p < 0.00001]. No statistical difference was found in terms of vaginal bleeding [OR = 0.88; CI 95% (0.39–1.96); I² = 41%; p = 0.75], nausea and vomiting [OR = 0.51; CI 95% (0.16–1.63); I² = 67%; p = 0.26], headache [OR = 0.91; CI 95% (0.38–2.21); I² = 59%; p = 0.84], hot flushes [OR = 1.16; CI 95% (0.54–2.48); I² = 0%; p = 0.71], and hair loss [OR = 1.69; CI 95% (0.52–5.53); I² = 46%; p = 0.39]. Treatment discontinuation rate was similar between groups.Conclusions: Dienogest is comparable to COC in terms of efficacy and tolerability. The therapeutic choice should be based on the patient's preference, clinical history, and experience.

Uterine rupture is a rare and life-threatening condition. It usually occurs in patients with uterine scars (most commonly for a previous myomectomy or caesarean section), but it can also affect an unharmed uterus. This complication is more frequent in the third trimester and during delivery. There is not yet a recognised method of prediction of uterine rupture and the ultrasound features still need a consensus. In this article, we have reported a case of uterine dehiscence diagnosed by a pelvic ultrasound and magnetic resonance (MRI) at 24 weeks of gestation. The finding was confirmed intraoperatively at the caesarean section at 29 weeks of gestation. The 40-year-old patient has had a previous pregnancy complicated by uterine rupture at 22 weeks of gestation, following six previous abdominal surgeries for stage IV endometriosis, diffuse and nodular adenomyosis, and pelvic adhesion syndrome. The early detection of uterine dehiscence allowed us to prolong the pregnancy and perform a subsequent fertility-sparing surgery, reducing maternal and neonatal morbidity and mortality. Our case report proves that women with severe endometriosis/adenomyosis are at a high risk of uterine rupture and scar dehiscence. The antenatal ultrasound can describe a uterine dehiscence (even in asymptomatic patients) and prevent complications.

Background: The tumor microenvironment offers a new perspective in gynecologic oncology. In ovarian cancer, numerous preclinical studies, especially organoid models, have highlighted cellular, immune, and biochemical mechanisms. Beyond these sophisticated findings, more practical aspects require attention, such as the role of vaginal microbiota, which represents an interplay between external agents and internal genitalia, and its potential profiling role in early detection beyond the promise of microbiota-targeted therapies. Objectives: This review aims to assess whether such a correlation is speculative or scientifically grounded. Methods: A focused literature search was conducted on vaginal microbiota and its correlation with ovarian cancer to define the current state of knowledge. Results: Mixed outcomes have been reported, yet there is a rational and scientific basis supporting further investigation. Clinical approaches increasingly consider vaginal microbiota as relevant. However, we have to say that most available evidence is still preliminary and largely preclinical to set realistic expectations for readers. Although additional studies are needed, emerging insights highlight its importance and practical implications. We present a diagnostic–therapeutic management flowchart summarizing current evidence). Discussion: Most links between the vaginal microbiota and ovarian cancer are correlational rather than causal. The idea that microbes ascend from the vagina to the ovaries is proposed but still definitely not demonstrated. Confounding factors like age, hormones, and BRCA status complicate interpretation, and ovarian cancer itself could secondarily alter the microbiota. Mechanistic studies and longitudinal data are still needed to clarify whether dysbiosis contributes to carcinogenesis or is merely a consequence. As gynecologists, we summarize key aspects and emphasize to colleagues the importance of incorporating these findings into daily clinical practice. Vaginal dysbiosis should be considered not only a local imbalance but also a potential strategy for primary cancer prevention. Conclusions: Future research on the tumor microenvironment and vaginal microbiota will expand scientific knowledge and guide innovative preventive and therapeutic strategies.

STUDY QUESTION: Are endometriotic lesions affecting bilateral organs or anatomical structures distributed symmetrically on both sides of the body? SUMMARY ANSWER: The left-sided preponderance of pelvic endometriotic lesions, and the right-sided dominance of thoracic and inguinal lesions, suggest that endometriotic lesions exhibit a non-random, asymmetric lateral distribution. WHAT IS KNOWN ALREADY: Evaluating the anatomical distribution of endometriotic lesions may elucidate the underlying pathogenic mechanism(s) of the disease. If the coelomic metaplasia or embryonic cell remnant theory is correct, a symmetrical right-left pattern would be expected. Conversely, retrograde menstruation would likely result in asymmetrical distribution, influenced by gravity, peritoneal fluid circulation, and anatomical niches. STUDY DESIGN, SIZE, DURATION: This systematic review with meta-analysis included full-length, English-language articles published up to 10 June 2024. Literature searches were performed in PubMed/Medline and Embase databases with the keyword ‘endometriosis’, ‘lateral’, ‘distribution’, ‘right’, ‘left’, and ‘asymmetry’. PARTICIPANTS/MATERIALS, SETTING, METHODS: The review focused on anatomical structures commonly affected by endometriosis with surgically defined right or left laterality: ovaries, uterosacral ligaments, colon, ureters, inguinal regions, and hemithorax (diaphragm, pleura, lungs). Case reports were excluded. Risk of bias was assessed using ROBINS-I for non-randomized studies and a dedicated tool for case series. Meta-analyses of proportions were conducted in R. Heterogeneity was quantified using the I2 statistic. Funnel plots for publication bias and Egger tests were performed using Stata. MAIN RESULTS AND THE ROLE OF CHANCE: Of 6356 articles screened, 154 met the inclusion criteria. A statistically significant left-sided preponderance was observed for ovarian (58%; 95% CI: 57–60%; P < 0.001), uterosacral ligament (56%; 95% CI: 54–59%; P < 0.001), ureteral (71%; 95% CI: 67–76%; P < 0.001), and bowel (72%; 95% CI: 64–79%; P < 0.001) lesions, whereas thoracic (98%; 95% CI: 96–100%; P < 0.001) and inguinal (92%; 95% CI: 83–98%; P < 0.001) lesions were predominantly right-sided. These findings were confirmed in the sensitivity analyses. Egger’s test indicated a possible small study effect only for ovarian lesions (P = 0.012). LIMITATIONS, REASONS FOR CAUTION: The preponderance of retrospective studies, the variability in surgical procedures, and the potential difficulties in accurately distinguishing unilateral from bilateral lesions may have influenced the magnitude of the estimated difference. However, the large patient cohorts, geographical diversity, and consistent asymmetry across lesion types strengthen the results’ validity and generalizability. WIDER IMPLICATIONS OF THE FINDINGS: The pattern of endometriotic lesion distribution, including the opposite asymmetry observed in the pelvis and upper abdomen/thorax, can be explained by factors influencing dissemination and implantation of refluxed endometrial cells. However, it cannot be explained as well by the coelomic metaplasia or embryonic cell remnant theories. This may have important clinical implications, providing a pathogenic basis for secondary prevention strategies. STUDY FUNDING/COMPETING INTEREST(S): The open access facility of this paper was funded by the Italian Ministry of Health, Current research IRCCS Ca’ Granda Ospedale Maggiore Policlinico. P.V. is a member of the Editorial Board of Human Reproduction Open, Journal of Obstetrics and Gynaecology Canada, and International Editorial Board of Acta Obstetricia et Gynecologica Scandinavica; has received royalties from Wolters Kluwer for chapters in UpToDate. All other authors declare no conflicts of interest. REGISTRATION NUMBER: CRD42024511356 (PROSPERO).