Polycystic ovary syndrome (PCOS) is the most prevalent endocrine condition amongst females of reproductive age, leading to lifelong cardiometabolic, reproductive, psychological, and dermatologic symptoms as well as a reduced quality of life. Lifestyle interventions, which can include structured exercise programmes delivered by appropriately trained exercise professionals such as clinical exercise physiologists, are considered first-line strategies in PCOS management due to their therapeutic effects on various health outcomes and quality of life. This position statement builds on the 2023 International Evidence-based Guideline for the Assessment and Management of PCOS and describes the role of the exercise professional in the context of the multidisciplinary care team which includes physicians and allied health professionals. This position statement aims to equip exercise professionals with a broad understanding of the pathophysiology of PCOS, how it is diagnosed and managed in clinical practice, and evidence- and consensus-based recommendations for physical activity and exercise in PCOS management. In line with the physical activity recommendations for the general public, individuals with PCOS should aim to undertake between 150 to 300min of moderate-intensity or 75 to 150min of vigorous-intensity aerobic activity per week, or an equivalent combination of both spread throughout the week. Additionally, muscle-strengthening activities on two non-consecutive days per week are recommended to maintain health and prevent weight gain. For further health benefits and to achieve modest weight loss, individuals with PCOS should aim for a minimum of 250min of moderate-intensity or 150min of vigorous-intensity aerobic activity per week, or an equivalent combination of both spread throughout the week, plus muscle-strengthening activities on two non-consecutive days per week. Adolescents with PCOS should aim for a minimum of 60min moderate- to vigorous-intensity activity each day, incorporating muscle- and bone-strengthening activities three times per week. Finally, exercise professionals should consider the significant psychological burden, including weight stigma, and the high prevalence of comorbidities amongst individuals with PCOS and take appropriate measures to deliver safe and efficacious exercise interventions.

Endometriosis affects women of reproductive age. Increasing attention is being given to the characterization of comorbidities in endometriosis to enhance clinical phenotyping. Among these comorbidities, migraine has been reported to be significantly more common in individuals with endometriosis compared to the general population. However, the true epidemiological burden remains uncertain, and no conclusive evidence links specific subtypes of endometriosis to migraine. Seven electronic databases were searched from inception until July 22nd, 2024, using combinations of relevant keywords. PROSPERO Registration CRD42023449492. Two independent reviewers screened the records according to inclusion/exclusion criteria and abstracted data. The risk of bias assessment was undertaken using the ROBINS-E tool. Random effects models were implemented to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for the association between endometriosis and migraine. Fourteen studies were included in the qualitative synthesis, and 13 in the meta-analysis, accounting for a total of 331,655 individuals (32,489 with endometriosis vs. 299,166 controls). There was a serious risk of bias in the majority of the included studies, with 50% being at very high risk of bias. The risk of migraine was higher in individuals with endometriosis compared to those without (OR 2.25, 95%CI = 1.85–2.72; n = 13 studies; I2 = 81%). This association remained significant in the sensitivity analyses: (i) when excluding studies at very high or high risk of bias (OR 2.64; 95%CI = 1.62–4.31; n = 4 studies; I2 = 77%), (ii) when including only risk estimates adjusted for clinically relevant confounders (OR 2.35; 95%CI = 1.77–3.13; n = 6 studies; I2 = 88%), and (iii) when including only risk estimates adjusted for hormonal therapy (OR 1.95; 95%CI = 1.42–2.66; n = 3; I2 = 92%). Endometriosis was significantly associated with migraine without aura (OR 2.64, 95%CI 1.89–3.69; n = 3 studies; I2 = 0%), but not migraine with aura (OR 3.47, 95%CI = 0.53–22.89; n = 3, I2 = 73%). This meta-analysis highlights the high prevalence of migraine in patients with endometriosis. However, due to observed high heterogeneity and risk of bias, caution is advised when interpreting and applying these findings in clinical practice. Future research should address these issues by limiting variations in diagnostic criteria, stratifying study populations, accounting for key confounders, and investigating potential underlying pathophysiological mechanisms to enhance understanding of the endometriosis-migraine relationship.

Background: Cardiovascular disease is the leading cause of death globally. Non-malignant gynaecological diseases (NMGD) significantly affect patient health and well-being and may be associated with cardiovascular or cerebrovascular disease (C/CVD). Methods: Seven databases were searched for relevant studies up to 21 April 2024. Observational studies reporting risk estimates and 95% CIs for the association between NMGD and C/CVD were included. Data were extracted by two independent reviewers. Random effects models were used to calculate summary relative risk (SRR) with 95% CI. Composite C/CVD outcome was defined as a combination of ischaemic heart disease, cerebrovascular disease, heart failure, and peripheral vascular disease. The ROBINS-I tool defined study quality and risk of bias. Results: We screened 6639 studies, of which 59 were eligible for full-text review and 28 were included in our analysis, comprising a total of 3 271 242 individuals. The majority (53.5%) of the studies were scored as having a ‘serious’/‘critical’ risk of bias. Overall, individuals with an NMGD had a significantly greater risk of composite C/CVD with low heterogeneity among contributing studies (SRR 1.28, 95% CI 1.20 to 1.37; n=16 studies, I²=65.3%), ischaemic heart disease (SRR 1.41, 95% CI 1.31 to 1.51; n=21 studies, I²=73.7%), and cerebrovascular disease (SRR 1.33, 95% CI 1.18 to 1.51; n=16 studies, I²=91.5%). In NMGD-specific analyses, the risk of C/CVD and its components was greater among those with a history of endometriosis or polycystic ovary syndrome. Conclusions: We found an overall association between NMGD and C/CVD across all studies. However, estimates from individual studies varied substantially.

Background/Objectives: Breast cancer (BC) is the most commonly diagnosed cancer worldwide. Estrogen receptor (ER) status is a key determinant in the diagnosis and treatment of BC. Although immunohistochemistry (IHC) is the gold standard for ER assessment, it has limitations. This umbrella review aims to evaluate the role of 16α-18F-fluoro-17β-estradiol ([¹⁸F]FES) PET/CT as a non-invasive imaging tool for assessing ER expression and its implications in BC management. Methods: A comprehensive search was conducted in PubMed/MEDLINE and Cochrane Library for systematic reviews and meta-analyses published in the last decade. Studies eligible for inclusion evaluated the diagnostic accuracy and clinical utility of [¹⁸F]FES PET/CT in BC based on a predefined research question “What is the role of fluoroestradiol ([¹⁸F]FES) PET/CT in breast cancer?”. Data extraction and quality assessment were performed independently by two reviewers using the AMSTAR-2 tool. Results: Eight systematic reviews met the inclusion criteria. [¹⁸F]FES PET/CT demonstrated high sensitivity (81–94%) and specificity (78–95%) in detecting ER-positive lesions. It provided a real-time, whole-body assessment of ER expression, outperforming IHC in detecting functional ER activity. Additionally, [¹⁸F]FES PET/CT showed promise in predicting treatment response and guiding therapy decisions, particularly in metastatic settings. Conclusions: This review highlights the clinical value of [¹⁸F]FES PET/CT in BC management, offering a non-invasive alternative for ER assessment with high diagnostic accuracy. Its integration into clinical practice may enhance personalized treatment strategies for BC patients.

Is expectant management (EM) of tubal ectopic pregnancy (EP) an effective and safe treatment strategy when compared to alternative interventions? There is insufficient evidence to conclude EM yields a difference in the resolution of tubal EP, the avoidance of surgery or time to resolution of tubal EP when compared to intramuscular methotrexate in stable patients with β-hCG <1500 IU/l. The utilisation of medical and surgical management for EP is well established. EM aims to allow spontaneous resolution of the EP without intervention. We performed a systematic review and meta-analysis, searching Ovid MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, OpenGrey.eu, Google Scholar, cross-referencing citations and trial registries to 15 December 2019. There were no limitations placed on language or publication date. Search terms included tubal EP and EM as well as variations of these terms. We considered studies that included patients with tubal EP, EM as a comparator, and that were randomised controlled trials (RCTs). The primary outcome was resolution of tubal EP. Secondary outcomes included avoidance of surgery and the time to resolution of EP. Two reviewers independently selected the studies, assessed bias and extracted data. Relative risk (RR) and mean difference with 95% CI were assessed using a random effects model. The certainty of evidence was scored according to Grading of Recommendations Assessment, Development and Evaluation guidelines. In total, 920 studies were screened. Five studies were eligible for inclusion in the systematic review. Two RCTs comparing methotrexate to EM were identified as being eligible for inclusion in meta-analysis. No RCTs comparing surgery to EM were identified. Compared with EM, there was insufficient evidence that methotrexate yields a difference on resolution of tubal EP (RR 1.04, 95% CI 0.88–1.23, P = 0.67; two RCTs, moderate-certainty evidence), avoiding surgery (RR 1.10, 95% CI 0.94–1.29, P = 0.25; two RCTs, low-certainty evidence) or the time to resolution of tubal EP (−2.56 days (favouring EM), 95% CI −7.93–2.80, P = 0.35; two RCTs, low-certainty evidence). Only two RCTs with a total of 103 patients were eligible for inclusion in this meta-analysis. Further RCTs comparing EM to medical and surgical management are needed and these should also report adverse events. Patient preference should also be evaluated. We found insufficient evidence of differences in terms of resolution, avoidance of surgery and time to resolution between expectant and medical management. Given the imprecision in the effect estimates as demonstrated by the wide CIs, resulting in the downgrading of certainty of evidence for all outcomes in this meta-analysis, larger RCTs comparing interventions for tubal EP are needed. Caution should be exercised when trying to decide between EM and methotrexate to treat tubal EP. There was no funding for this study. NICM receives funding from various sources; none specifically supported this research. M.L. reports grants from Australian Women and Children's Research Foundation, outside the submitted work. M.A.: As a medical research institute, NICM Health Research Institute receives research grants and donations from foundations, universities, government agencies and industry. Sponsors and donors provide untied and tied funding for work to advance the vision and mission of the Institute. This systematic review was not specifically supported by donor or sponsor funding to NICM. M.A. reports a partnership grant with Metagenetics outside the submitted work. G.C. reports grants from Australian Women and Children's Research Foundation, personal fees from Roche and GE Healthcare, outside the submitted work. The remaining authors report no conflicts of interest. CRD42020142736

Endometriosis is a chronic, debilitating condition characterized by heterogenous clinical manifestations. It has a prevalence of 5–10% in women of reproductive age, and 30–50% of individuals with endometriosis are affected by infertility. There are multiple mechanisms through which endometriosis can lead to infertility: reduced ovarian reserve, distorted pelvic anatomy, chronic inflammation, altered immunity, dyspareunia, and/or altered hormonal and cell-mediated endometrial function. The revised American Society for Reproductive Medicine (rASRM) classification was one of the initial methods to stage disease severity. The Endometriosis Fertility Index (EFI) score, based upon the rASRM score and other factors, can help guide management. Medical treatment for endometriosis is predominantly contraceptive; therefore, surgery and medical reproduction techniques are the mainstay of management for endometriosis-related infertility. The evidence regarding the benefit of surgery for endometriosis-related infertility is conflicting; however, ablative techniques for endometriomas may enhance conception spontaneously and via assisted reproduction techniques (ART). Medically-assisted reproduction techniques include intra-uterine insemination and ovarian stimulation, as well as ART such as in vitro fertilization or intracytoplasmic sperm injection. ART has similar outcomes in individuals with rASRM stage I to II endometriosis as it does in individuals without endometriosis; however, live birth rate, mean number of oocytes retrieved, and clinical pregnancy rate are reduced in individuals with rASRM stages III–IV. Ultimately, endometriosis-related infertility treatment plans should be patient-centered, individualized, and holistic, considering alternative factors which may influence which treatment option can be offered.