Recurrent urinary tract infections (rUTIs) are common in peri- and postmenopausal women and impose substantial symptom, quality of life, and antimicrobial stewardship burdens, with particularly high incidence and hospitalization costs documented in England and UK primary care populations. Vaginal estrogen, by restoring urogenital epithelium and the lactobacillus-dominant microbiome, is recommended in several guidelines for preventing rUTI; including UK antimicrobial prescribing guidance for rUTIs and European Association of Urology recommendations. However, most formulations are licensed only for genitourinary syndrome of menopause, not for UTI prophylaxis. This creates a mismatch between the growing clinical evidence base and the absence of a specific regulatory indication for rUTI prevention across major regulatory agencies, including the U.S. Food and Drug Administration (FDA), the European Medicines Agency (EMA), and the UK Medicines and Healthcare products Regulatory Agency (MHRA), which may contribute to underuse and clinician uncertainty. To review and summarize the evidence on vaginal estrogen for prevention of recurrent urinary tract infections in peri- and postmenopausal women, with a particular focus on its use alone and in combination with antibiotic therapy, and on the gap between clinical guideline recommendations and regulatory product labelling. We conducted a structured narrative review focusing on randomized controlled trials and clinical practice guidelines that evaluate intravaginal estrogen for the prevention of rUTI in peri- and postmenopausal women. PubMed and Embase searches were performed using key terms for estrogen, urinary tract infection, and menopause, and were supplemented with targeted searches of major guidelines. Data were described in terms of study design, participant characteristics, estrogen formulations and dosing regimens, timing of initiation, comparators, outcome measures, and reported safety outcomes. Evidence from five RCTs reported that low-dose vaginal estrogen, administered as creams, tablets, rings, or gels, reduced culture-confirmed rUTI episodes and improved vaginal health indices, with no clear superiority of any single formulation and a favorable local safety profile. One trial found estriol pessaries less effective than nitrofurantoin prophylaxis, indicating that estrogen may complement rather than fully replace antibiotics in some women. Initiation was predominantly prophylactic or post-antibiotic, and no identified trial evaluated co-initiation of vaginal estrogen with antibiotics at the onset of acute UTI, highlighting a persisting evidence gap regarding optimal timing of therapy. Vaginal estrogen is an evidence-based yet underutilized strategy for rUTI prevention in peri- and postmenopausal women, supported by RCT data and guideline recommendations, but not recognized in current FDA-approved indications for vaginal estrogen products. Closing this evidence licensing gap will require regulatory reconsideration informed by existing trial data, alongside new pragmatic studies to refine timing, dosing, and formulation choices, to evaluate co-administration with antibiotics, and to explore women's knowledge, preferences, and adherence to support patient-centered implementation in routine care.

Objective The aim of the study was to compare the effectiveness, complications, and treatment preference parameters of long-term pessary therapy versus vaginal obliteration (colpocleisis) in elderly, sexually inactive female patients with severe POP. Design Single-center, retrospective observational study. Participants/Materials In our study we included elderly, sexually inactive women treated for advanced POP between January 2015 and November 2023. Long-term pessary therapy was applied in 30 cases, while 46 patients underwent vaginal obliteration. The mean follow-up duration was 41.9 ± 31.9 vs. 61.9 ± 40.1 months, respectively. Setting The study was performed at the Department of Urology of our University (n = 76). Methods Data collection was carried out based on clinical patient documentation and telephone interviews. We used a standardized, non-validated questionnaire specifically designed for this study covering four domains: patient characteristics; POP-related symptoms; treatment effectiveness and complications; socioeconomic and health-related parameters, treatment preferences. Pre- and post-treatment parameters and intergroup differences were statistically analyzed. Results The mean age of the patients was 74 ± 5.6 years, and the mean BMI was 25.6 ± 4.4. Following both pessary therapy and surgery, high rates of symptom resolution were observed regarding vaginal foreign body sensation, discomfort and/or palpable bulge (93.5% vs. 95.5%) and obstructive voiding difficulty (100% vs. 96.4%). The rate of patient satisfaction was high in both groups (90% vs. 97.8%, p = 0.15); however, symptom improvement was significantly greater following vaginal obliteration (VAS: 8.9 ± 1.1 vs. 7.7 ± 1.7, p < 0.001). Pessary therapy was discontinued in 23.3% of cases, and 20% later required surgical POP intervention. No reoperations due to recurrence were required following obliterative surgery. Adverse events occurred in 26.6% of pessary patients and complications in 17.3% of surgically treated patients. The most frequent reason for choosing pessary therapy was fear of surgery (76.6%), while the most common reason for choosing surgery was refusal of pessary therapy (58.5%). Limitations The retrospective design and relatively small sample size limit the generalizability of the findings. Conclusions In elderly, sexually inactive women requiring treatment for advanced POP, both vaginal obliteration and long-term pessary therapy provide excellent therapeutic alternatives. The two modalities demonstrate comparable outcomes, high effectiveness, and an acceptable rate of non-severe complications, making both options suitable for appropriately selected patients.

To evaluate the therapeutic effects of dehydroepiandrosterone (DHEA) and DT56a (Femarelle®) on systemic and genitourinary symptoms of menopause in post-menopausal women. Comparative effectiveness research of seventy postme-nopausal women (mean age: 53 years) experiencing postmenopausal symptoms. Participants 70 patients randomly assigned to receive either DHEA (60 mg/day) or Femarelle® (644 mg/day) for three months. Assessment of serum estradiol, luteinizing hormone, follicle stimulating hormone, Greene climacteric scales scores, female urinary symptoms and female sexual function index in subjects. Results Both DHEA and Femarelle® demonstrated comparable efficacy in reducing total Greene Climacteric Scale scores. No significant differences in serum FSH and E2 levels were observed between the two groups. However, DHEA showed superior efficacy in improving quality of life regarding urinary symptoms, with significant improvements in OABSS, UDI-6, QII-7, ICIQ, and POPDI scores. FSFI results indicated that DHEA had significantly greater effects on sexual function measures, including desire, arousal, lubrication, orgasm, and satisfaction, though dyspareunia did not differ between groups. Limitations The absence of testosterone measurements limits assessment of androgenic effects of DHEA. Femarelle® has never been studied for sexual function; our findings are preliminary and require long-term validation. Conclusions While both DHEA and Femarelle® were effective for treating climacteric symptoms, DHEA significantly improved genitourinary syndrome symptoms in Taiwanese postmenopausal women compared to Femarelle®.

Endometriosis is characterized by a persistent inflammatory process and is commonly shown to be associated with pelvic pain, dysmenorrhea, and a deterioration in overall quality of life. Due to limitations and side effects of current medical and surgical treatments, nutrition-based adjunctive strategies have gained attention. The purpose of this research is to critically examine the latest scientific evidence based on randomized controlled trials about dietary supplement treatment and the therapeutic management of endometriosis-related symptoms. The conduct of this systematic review adhered to PRISMA methodological principles, with prior registration of the protocol in PROSPERO (CRD42024624094). PubMed, Scopus, and Web of Science databases were comprehensively explored. Eleven randomized controlled trials involving 739 participants were included. The mean intervention duration was 12.3 ± 6.03 weeks. Eight trials evaluated vitamin supplementation and three assessed herbal or bioactive compounds. Combined vitamin C and E supplementation consistently demonstrated reductions in pain-related outcomes across five trials. In contrast, findings regarding vitamin D were inconsistent, with only one of three studies reporting significant improvement compared to placebo. Among herbal interventions, two of three trials reported significant reductions in pain-related symptoms. Overall methodological quality ranged from good to fair. However, the available literature restricts conclusions due to limited sample sizes and methodological differences. Larger, well-designed trials with standardized protocols and biomarker-guided approaches are needed.

Postpartum hemorrhage (PPH) remains one of the leading causes of maternal mortality worldwide. A rare but potentially life-threatening cause of secondary PPH is uterine artery pseudoaneurysm (UAP). In this case report, we present two clinical cases of UAP and review the available literature summarizing clinical symptoms, diagnostic approaches and treatment options. The first case involved a patient presenting with abdominal pain and syncope six days after vaginal delivery, subsequently diagnosed with a right-sided UAP and hemoperitoneum. The second patient presented with painless yet heavy vaginal bleeding and was also diagnosed with a right-sided UAP. Both patients were successfully managed with uterine artery embolization. UAP may present atypically, either with or without vaginal bleeding. Possible reported risk factors include cesarean delivery, uterine curettage, endometriosis, inflammation, cervical conization, myomectomy, and excision of cesarean scars. Transvaginal sonography (TVS) is the first-line diagnostic tool due to its accessibility, while computed tomography (CT) or magnetic resonance imaging (MRI) are helpful for confirmation and treatment planning. Endovascular embolization is the treatment of choice in hemodynamically stable patients due to its minimally invasive nature and favorable outcomes.

This prospective study aimed to evaluate whether β-human chorionic gonadotropin (β-hCG) levels in uterine cavity lavage fluid can serve as a diagnostic tool to differentiate ectopic pregnancy from failed intrauterine pregnancy in patients with pregnancy of unknown location (PUL). This prospective interventional study was conducted at a tertiary referral center, enrolling a total of 113 hemodynamically stable patients with PUL. All enrolled patients underwent endometrial aspiration (EA), which was performed using a flexible Karman cannula to obtain tissue samples for histopathological examination. Based on histopathological results combined with clinical follow-up data, participants were subsequently categorized into two groups: those diagnosed with ectopic pregnancy and those with failed intrauterine pregnancy. Prior to performing EA, uterine lavage was performed to collect fluid samples from the endometrial cavity, and β-human chorionic gonadotropin levels were quantitatively measured in the lavage specimens. The primary outcome measure was the comparison of lavage β-human chorionic gonadotropin concentrations between the ectopic and failed intrauterine pregnancy groups, with the intent to establish a diagnostic cutoff value for clinical application. Secondary outcome measures included comparisons of serum β-human chorionic gonadotropin levels, endometrial thickness assessed via imaging, and clinical and demographic parameters between the groups. Results After exclusion criteria and incomplete data removal, 103 patients were included in the final analysis, comprising 81 individuals diagnosed with ectopic pregnancy and 22 with failed intrauterine pregnancies. Statistical analysis showed that the mean age was significantly higher in the failed intrauterine pregnancy group versus the ectopic pregnancy group (p = 0.03), while other demographic and clinical variables did not differ significantly between the groups. β-human chorionic gonadotropin concentrations in uterine lavage fluid were lower in the ectopic group compared to the failed intrauterine pregnancy group. This difference was significant in absolute terms (mean ± SD: 122.78 ± 115.41 mIU/mL vs. 321.09 ± 495.19 mIU/mL, p = 0.008) and after normalization to total protein content in the lavage fluid (100.67 ± 208.19 mIU/mg vs. 294.32 ± 510.69 mIU/mg, p = 0.001). In contrast, serum β-human chorionic gonadotropin levels and endometrial thickness did not show statistically significant differences between the two groups. Conclusions Lavage β-human chorionic gonadotropin appears promising as a tool for early pregnancy of unknown location assessment by identifying the pregnancy location. This standardized methodology could expedite the diagnosis of high-risk pregnancies through a less invasive approach, thereby enhancing ectopic pregnancy management. Further research is needed to improve accuracy.

Objectives Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders among women of reproductive age and is associated with significant metabolic, reproductive, and psychological morbidity. Although international evidence-based guidelines exist, patient reports continue to indicate unmet needs, particularly in areas that most affect quality of life. The primary objective of this study was to assess PCOS-related knowledge, as well as general practitioners` (GPs) perceptions and interdisciplinary communication practices. A secondary objective was to examine whether identified knowledge gaps among GPs align with symptom domains reported by patients as most bothersome. Design This study employed a cross-sectional survey design targeting practicing GPs. Quantitative findings were descriptively analyzed and contextualized using published data from an independent, large-scale patient survey. Participants/Materials A total of 918 GPs practicing in the federal state of Hesse, Germany, were invited to participate. The final analytical sample comprised 118 GPs who completed the survey. The GP questionnaire included demographic and professional characteristics as well as a 21-item knowledge assessment derived from the 2018 international PCOS guideline. To contextualize GP findings, data from a published patient survey including 1,926 individuals with PCOS were used to identify patient-prioritized symptom domains. Setting The study was conducted in primary care settings across Hesse, Germany. Methods The GP survey assessed awareness of PCOS prevalence, familiarity with guideline recommendations, perceived relevance of guidelines to daily practice, and interdisciplinary collaboration, particularly with gynecologists. Knowledge accuracy scores were calculated as the percentage of correct responses across the 21 items. Subgroup analyses explored associations between GP characteristics and knowledge levels. Published patient survey data were used to determine symptom burden and domains perceived as most distressing, allowing comparison with GP knowledge gaps. Results 93.2% of GPs estimated a PCOS prevalence in their practice below 5% and 69.5% considered the international PCOS guideline irrelevant to routine practice. PCOS-related knowledge among participants showed a mean accuracy of 54.6% (95% CI 50.4-58.8) across all domains, with the lowest scores in reproductive aspects, (45.5%, 95% CI 40.6-50.4) and hyperandrogenism (43.7%, 95% CI 38.7-48.7). Notably, cosmetic manifestations of hyperandrogenism were identified by patients as among the most burdensome symptoms. Furthermore, 45.8% of GPs reported suboptimal communication with gynecologists, highlighting deficiencies in interdisciplinary care pathways. Limitations Limitations include a low response rate with potential nonresponse bias, the newly developed questionnaire without formal psychometric validation and reliance on self-reported data. In addition, variation in patient populations across practices and the lack of linkage between physician responses and patient outcomes may limit generalizability. Conclusions PCOS-related knowledge gaps among GPs are most pronounced in clinical domains that patients perceive as most distressing, highlighting a critical mismatch between care provision and patient needs. These findings underscore the necessity for targeted educational interventions, improved dissemination and implementation of PCOS guidelines in primary care, and strengthened interdisciplinary collaboration to enhance patient-centered PCOS management.

The article "Use of Intramuscular Progesterone versus Intravenous Albumin for the Prevention of Ovarian Hyperstimulation Syndrome" [Gynecol Obstet Invest. 2000;50(3):182-185; https://doi.org/10.1159/000010306] by Loredana Costabile, Vittorio Unfer, Claudio Manna, Sandro Gerli, Dario Rossetti and Gian Carlo Di Renzo has been retracted by the Publisher and the Editors.After publication of this article, concerns were raised about the uneven group sizes following randomization, the reported rate of pregnancy following transfer, which was higher than described in contemporary global statistics, and the significant difference between groups in the number of oocytes retrieved, though the differential intervention occurred post-retrieval. These raised concerns about the study's randomization. When asked to comment, the authors stated that they cannot address the concerns due to the fact that the article was published more than 25 years ago and data and documents are no longer available.The concerns raised and the authors' response were reviewed by the Editors. As the concerns, which may impact the reliability of findings presented in the article, cannot be addressed or resolved, and due to the relevance of the difference between the groups for the conclusions of the study, the article is being retracted.Vittorio Unfer does not agree to the retraction. Sandro Gerli stated that he bears no responsibility for this article. The remaining authors did not respond to the notification about this retraction within the timeframe specified.

To evaluate the clinical significance of late-onset cervical shortening diagnosed between 24.0 and 34.0 weeks of gestation following normal midtrimester screening, and to assess its association with spontaneous preterm birth (sPTB) and adverse neonatal outcomes. We also examined whether obstetric history modifies this risk. Retrospective cohort study. Participants/Materials: A total of 500 singleton pregnancies with normal midtrimester cervical length (CL) who were subsequently diagnosed with cervical shortening (<25 mm) between 24.0 and 34.0 weeks of gestation. Tertiary, university-affiliated medical center (Galilee Medical Center, Israel), March 2020 to May 2025. Patients with asymptomatic late cervical shortening were categorized into three groups: <10 mm, 11-15 mm, and 16-25 mm. CL measurements were further stratified by gestational age at diagnosis (24.0-27.6, 28.0-31.6, and 32.0-34.0 weeks). The primary outcome was sPTB <37 weeks. Secondary outcomes included sPTB <34 and <32 weeks and neonatal morbidity. Multivariable logistic regression was used to estimate adjusted odds ratios (ORs). Receiver operating characteristic (ROC) curve analysis was performed to determine gestational age-specific CL thresholds for predicting sPTB. Results: A total of 500 patients were included: 24/500 (4.8%) with CL <10 mm, 80/500 (16.0%) with CL 11-15 mm, and 396/500 (79.2%) with CL 16-25 mm. Baseline characteristics were comparable across groups. Rates of sPTB <37 weeks were 18/24 (75.0%) in patients with CL <10 mm, 42/80 (52.5%) in those with CL 11-15 mm, and 99/396 (25.0%) in those with CL 16-25 mm (p<0.001). Similarly, sPTB <34 weeks occurred in 14/24 (58.3%), 20/80 (25.0%), and 33/396 (8.3%), and sPTB <32 weeks in 11/24 (45.8%), 12/80 (15.0%), and 20/396 (5.1%) (all p<0.001). When stratified by cervical length groups, sPTB rates did not differ according to obstetric history among patients with CL <10 mm and 11-15 mm. In contrast, among patients with CL 21-25 mm, sPTB occurred in 7/26 (26.9%) of those with a prior sPTB, 17/78 (21.8%) of nulliparas, and 10/78 (12.8%) of those with a prior term birth (p=0.041). ROC analysis identified gestational age-specific thresholds for predicting sPTB <37 weeks: 22 mm at 24.0-27.6 weeks (AUC 0.69, p<0.001), 20 mm at 28.0-31.6 weeks (AUC 0.62, p=0.002), and 18 mm at 32.0-34.0 weeks (AUC 0.72, p<0.001). Correspondingly, sPTB rates were higher below these cutoffs: 49.1% vs. 18.2% (p<0.001), 49.1% vs. 23.2% (p<0.001), and 43.9% vs. 18.8% (p<0.001), respectively. The retrospective design may introduce selection and information bias. Measurements were performed by multiple clinicians, potentially leading to inter-observer variability. Residual confounding cannot be excluded. Late-onset cervical shortening after normal midtrimester screening is strongly associated with spontaneous preterm birth and adverse neonatal outcomes. The degree of shortening and obstetric history significantly influence risk, particularly in patients with moderate late shortening. Gestational age-specific cervical length thresholds may enhance late pregnancy risk stratification and support individualized surveillance and management strategies.

Plain Language SummaryUterine fibroids are common noncancerous growths in the uterus that can cause heavy bleeding, pain, and fertility issues. Many women need surgery to remove fibroids while keeping the uterus. One minimally invasive approach is called vaginal natural orifice transluminal endoscopic surgery (vNOTES) – in short, surgery done entirely through the vagina using a small camera, with no cuts or scars on the abdomen. However, standard vNOTES only works well for small, few, and lower position fibroids. We studied a new “flipping technique” that lets surgeons gently turn the uterus inside the body to reach and remove fibroids that are higher, more numerous, or harder to expose. We compared 42 women using this new method with 46 using standard vNOTES. Both procedures were safe. The flipping technique removed more fibroids and treated high-position growths that standard vNOTES could not. It took slightly longer with a bit more blood loss, but pain, recovery, and complication rates were similar. This new method expands who can benefit from scar-free vaginal fibroid surgery.