Background Endometrial cancer is the 6th most common cancer affecting women worldwide, yet early detection remains challenging due to increasing diagnostic volumes, limited triaging workflows, and a shortage of specialized pathologists. Existing AI approaches are constrained by labor-intensive region-level annotations and single-stage models that do not reflect the hierarchical reasoning used by pathologists in clinical practice. Methodology This research proposes a weakly supervised framework for classifying hematoxylin and eosin-stained endometrial biopsies using only slide-level labels. The dataset was retrospectively curated from archived biopsies and included 490 benign, 425 neoplasia, and 382 hyperplasia cases. The dataset supports multiple diagnostic tasks from broad classification (benign vs. neoplasia vs. hyperplasia and benign vs. non-benign) to fine-grained subtype identification (benign, neoplasia, and hyperplasia subclassifications). Multiple feature extractor–classifier combinations were systematically trained, tuned, and evaluated to determine optimal configurations. Novel data augmentation strategies were also explored to improve robustness. In addition, a web-based interactive platform was developed to deploy the models, enabling clinicians to upload slides, visualize model attention maps, and review case-level reports within a hierarchical diagnostic workflow. Results The models achieved AUCs of 99.39% for three-class classification and 99.89% for binary classification. Subtype-level performance reached AUCs of 98.01% for benign, 95.25% for hyperplasia, and 93.19% for neoplasia. RankMix augmentation specifically improved performance across primary tasks and hyperplasia subclassification. Conclusions This framework demonstrates strong performance for automated endometrial biopsy classification across multiple diagnostic tasks. These findings support its potential as a decision-support tool for future pathology triage workflows, subject to external validation and workflow-level evaluation.

OBJECTIVES:To determine the relationship between cesarean delivery (CD) incision size, and acute postoperative pain and longer-term outcomes. METHODS:This prospective cohort study was conducted at a tertiary hospital in Ontario, Canada from 2021 to 2023. Participants were women aged 18-45 years who delivered via low transverse cesarean incision. CD incision size was reported as a continuous exposure per centimetre, and further dichotomized into CD incision size <15 cm and CD incision size ≥15 cm. The primary outcome was pain via numeric rating scale (NRS) on postoperative day (POD) 1, with NRS ≥4 considered clinically significant. Other outcomes included intraoperative outcomes, postoperative opioid use, and 6-week postpartum complications. Statistical analyses included Mann-Whitney U tests (continuous variables), χ2 or Fisher exact tests (categorical variables), and logistic regression for adjusted models. RESULTS:A total of 117 participants were enrolled, with 58 having CD incision size <15 cm and 59 with CD incision size ≥15 cm. The primary outcome demonstrated that 36.2% of participants in the CD incision size <15 cm group and 54.2% in the CD incision size ≥15 cm group reported NRS ≥4 on POD 1 (OR 2.09; 95% CI 1.02-4.38, P = 0.05). Each additional centimetre of CD incision size had an OR 1.30 (95% CI 1.02-1.66, P = 0.03) for clinically significant pain in univariate analysis. There were no differences in fetal extraction or total procedure times based on incision size. The relationship between CD incision size and postoperative pain was maintained after adjustment for potential confounders. There were no significant differences 6-week postpartum outcomes (e.g., wound complications, maternal mental health, scar satisfaction). CONCLUSIONS:This study suggests that smaller cesarean incisions are associated with less postoperative pain, without detriment to fetal extraction time or total cesarean time.

OBJECTIVES:To determine whether a paracervical block (lidocaine 1% with epinephrine 1:100,000 10 mL) decreases pain during intrauterine device (IUD) placement STUDY DESIGN: We conducted a randomized, double-blind trial of three arms: paracervical block, saline injection, or capped needle from June 30, 2022, to August 16, 2024. The primary outcome was the global pain score, rated on a 100 mm visual analog scale. Secondary outcomes included pain perception at procedural timepoints using a numeric score and patient satisfaction. RESULTS:We included a total of 246 patients (n = 82 per group). Overall, participants who received a paracervical block reported lower global pain scores during IUD placement (median 30 mm, interquartile range [IQR] 10-50) compared with those receiving saline injection (median 45 mm, IQR 25-60) or a capped needle (median 45 mm, IQR 20-70) (p = 0.003 and p = 0.001, respectively). Among nulliparous participants, the paracervical block also reduced pain (median 40 mm, IQR 25-53) compared with saline (median 50 mm, IQR 30-68) and capped needle (median 60 mm, IQR 33-70) (p < 0.001). Paracervical injection pain was minimal with a median of 1 out of 10 (IQR 0.00-2.00). Secondary outcomes demonstrated reduced patient pain at all timepoints of IUD insertion (eg, tenaculum placement, uterine sounding, and IUD insertion) as well as higher patient satisfaction (p < 0.01) in comparison to the capped needle group. CONCLUSIONS:The paracervical block reduced global pain score during IUD insertion, particularly for nulliparous participants, and is associated with minimal injection pain. IMPLICATIONS:Findings from this randomized, double-blind trial support incorporating the paracervical block into routine IUD insertion, especially for nulliparous patients who experience higher pain. Wider adoption may improve procedural comfort, satisfaction, and acceptability of IUD use. Future research should evaluate implementation, patient preferences, and variations in technique.

OBJECTIVE:To evaluate the safety and feasibility of cesarean myomectomy in patients with fibroids greater than 5 cm. METHODS:This was a retrospective case series of 45 patients undergoing cesarean delivery with concurrent myomectomy for fibroids >5 cm at a tertiary care center. Primary outcomes included operative time, estimated blood loss (EBL), hemoglobin drop, transfusion rates, and postoperative complications. RESULTS:Mean operative time was 74 min. On average, 2.5 fibroids were removed, with the largest averaging 10.1 cm in diameter. The mean hemoglobin drop was 2.5 g/dL, significantly associated with fibroid size. Average EBL was 827 mL. No patients required intraoperative transfusion, and only 4.4% required postoperative transfusion. Complication rates were comparable to standard cesarean delivery. CONCLUSION:Cesarean myomectomy for larger fibroids is feasible and safe within experienced surgical programs, allowing patients to avoid additional surgery without significantly increased risk.

Background Enhanced recovery after caesarean delivery (ERAC) is a multidisciplinary, evidence-based bundle of interventions developed from Enhanced Recovery After Surgery principles, designed to improve patient outcomes, reduce complications and save healthcare resources. Despite these benefits, the implementation of ERAC within the Canadian healthcare context is unknown. In addition, previous ERAC studies typically excluded patients undergoing unplanned caesarean deliveries (CD). The objective of our study was to evaluate the results of a quality improvement initiative that implemented a comprehensive ERAC pathway for both planned and unplanned CD in a large Canadian obstetric unit, with a specific focus on patient-reported outcomes.Methods A pre-implementation post implementation design was used. The primary outcomes were Obstetric Quality of Recovery Score (ObsQoR-10) and patient satisfaction at 6 weeks postpartum. Secondary outcomes included postpartum length of stay, postoperative pain and maternal infectious morbidity.Intervention Antenatal, intraoperative and postoperative ERAC bundles were developed with multidisciplinary input.Results 513 patients were included: 290 pre-implementation (149 planned CD, 141 unplanned CD) and 223 post- implementation (128 planned CD, 95 unplanned CD). Baseline demographics were similar, except the post implementation groups had significantly higher median Body Mass Index (BMI). In planned CD, ObsQoR-10 scores were on average 3.4 points higher in the post-implementation group (95% CI (−0.19 to 6.99); p-value=0.063). Patient satisfaction assessed at 6 weeks postpartum was significantly improved by 12 points in the post-implementation group (95% CI (5.58 to 18.62); p-value<0.001). In unplanned CD, implementation was not associated with ObsQoR-10 (p-value=0.92) or patient satisfaction assessed at 6 weeks postpartum (p-value=0.43). Pain scores were higher in both post-implementation groups, but there were no differences in morphine milliequivalents or requirement for breakthrough opioids. Length of stay and maternal infectious morbidity were similar.Discussion Implementation of ERAC in a large Canadian tertiary care obstetrics unit was feasible and resulted in improved recovery and increased satisfaction in patients undergoing planned CD. There were no differences in other outcomes, including infectious morbidity; however, the contribution of BMI needs to be explored. Patients undergoing unplanned CD face additional challenges related to outcomes, recovery and satisfaction and should be targeted in future studies.

PURPOSE:To evaluate physicians' barriers and facilitators, as well as knowledge, practices, attitudes, and beliefs, regarding analgesia for IUD insertion. METHODOLOGY:A multi-center online survey was conducted from January to July 2023 in Ontario, Canada. Data was analysed using descriptive statistics, chi-square tests, ANOVA, and thematic analysis. RESULTS:Among 85 providers who responded to the survey, there was a lack of consensus regarding provision of analgesia for IUD insertion, as only 52.9% routinely provided pain control. The remaining 40 providers (47.1%) stated that they do not routinely provide pain control for IUD insertion, although 87.5% of participants stated that they would provide pain control if the patient specifically requested analgesia. No differences were found between academic and community staff (p = 0.94) or less experienced providers in provision of pain control (p = 0.24). Reasons for provision of pain control included patient comfort, care, and procedure safety. Conversely, other physicians believed the pain was minimal or short-lived, or faced logistical barriers in providing analgesia. CONCLUSIONS:Patients and providers should engage in shared decision-making regarding pain control for IUD insertion.

BACKGROUND: Hereditary leiomyomatosis and renal cell carcinoma (HLRCC) is a rare autosomal dominant syndrome that is characterized by renal cell carcinoma, cutaneous leiomyomas, and uterine leiomyomas. Although HLRCC is usually identified in individuals with multiple cutaneous leiomyomas or a personal or family history of renal cell carcinoma, advances in histopathology have allowed detection of HLRCC in myomectomy and hysterectomy specimens. CASE: A 36-year-old patient with a large leiomyoma was referred to gynecology for heavy menstrual bleeding. After no response to medical management, she proceeded with elective myomectomy. Fumarate hydratase (FH) immunohistochemical staining of the myomectomy specimen and subsequent molecular genetic analysis of the FH gene confirmed a diagnosis of HLRCC. CONCLUSION: As more patients with HLRCC are identified with a primary presentation of leiomyomas, it is essential that gynecologists are familiar with this diagnosis. Health care professionals should inquire about skin lesions and family history of renal cell carcinoma in patients with symptomatic leiomyomas and refer patients with risk factors or pathology findings suggestive of HLRCC for genetic counseling.

STUDY OBJECTIVE:To evaluate the effect of video-based coaching on technical skill development in surgical education. DESIGN:Randomized controlled trial with video-based coaching (intervention group) in addition to standard surgical curriculum or the standard surgical curriculum alone (control group). SETTING:Laparoscopic vaginal vault closure in the operating room at 3 academic hospitals. PARTICIPANTS:Senior Obstetrics and Gynecology residents (year 3-5) on their chief resident or gynecologic oncology rotation. INTERVENTIONS:All residents were recorded performing laparoscopic closure of the vaginal cuff prior to randomization. Surgical coaching sessions followed the Wisconsin Surgical Coaching Framework over 30 minutes on Zoom with one surgical coach. All residents were recorded subsequently performing the same surgical technical skill. Blinded, expert surgeons performed the video assessment using the OSATS, GOALS, and global rating scale. The mean change in operative time and the mean change in video-assessment score between the 2 video-recorded attempts were compared between groups. Qualitative semi-structured interviews were conducted to understand the residents' perspective on video-based surgical coaching. MEASUREMENTS AND MAIN RESULTS:Twenty residents participated with 10 in the coaching and 10 in the control group. Mean operative time to complete the suturing task was reduced by 32.8% (SD = 21.3%) in the coached group vs 7.2% (SD = 25.1%) in the control group (p = .025). There was no significant change in surgical assessment scores within the coached or control group. Residents identified the core components of a surgical coaching program to include: (1) the resident: focused skill development, (2) the coach: focused on feedback, (3) and the coaching program: a structured activity. Residents envisioned monthly coaching with the opportunity for deliberate practice, the importance of a positive relationship between the coach and coachee, and the importance of faculty development in surgical coaching. CONCLUSION:Video-based surgical coaching is an effective tool to enhance technical skill development in surgical education.

Intrauterine device (IUD) insertion and endometrial biopsy are two common and essential procedures routinely performed in office-based gynecology. IUDs offer highly effective contraception and also serve as important treatments for dysmenorrhea, abnormal uterine bleeding, and endometrial hyperplasia or cancer. Endometrial biopsy remains a first-line diagnostic tool for evaluating abnormal uterine bleeding. Despite their utility, both procedures are often associated with moderate to severe pain, which can discourage patients from pursuing them. As patient comfort becomes an increasing priority for both patients and providers, clinicians should become familiar with the effective analgesic strategies available in this setting.

BACKGROUND:High-grade serous ovarian cancer is the most common and lethal form of ovarian cancer, responsible for up to 80% of ovarian cancer-related deaths. Current screening methods are ineffective, and most patients present with advanced disease. Evidence shows that many cases originate in the distal fallopian tube rather than the ovary itself, prompting adoption of opportunistic salpingectomy during gynecologic surgery to reduce ovarian cancer risk. Cesarean delivery, one of the most commonly performed surgeries globally, provides a valuable opportunity to offer salpingectomy to patients already undergoing abdominal surgery, reducing future ovarian cancer risk without an additional procedure. TECHNIQUE:After fetal delivery and uterine closure, the uterus is exteriorized to improve access. The fallopian tubes are gently compressed to relieve vascular congestion and elevated with atraumatic graspers, then windows are created within the avascular spaces of the mesosalpinx using monopolar electrocautery. Skeletonized vessels are coagulated and transected, and the remaining pedicles are clamped, transected, and suture ligated. Complete removal of both tubes, including the fimbriae, is performed. Specimens are sent to pathology, and the cesarean closure proceeds in the usual fashion. EXPERIENCE:At our institution, opportunistic salpingectomy is offered to patients undergoing cesarean delivery who have completed childbearing. Prenatal counseling addresses the procedure's benefits, risks, and permanent nature. In our experience, it adds 7-10 minutes of operative time without increasing blood loss, infection, or hospital stay. CONCLUSION:Opportunistic salpingectomy at cesarean delivery is a safe and feasible evidence-based strategy to reduce ovarian cancer risk. With appropriate technique, counseling, and patient selection, opportunistic salpingectomy at cesarean delivery provides a valuable risk-reduction opportunity during an already indicated procedure.

KEY POINTS Polycystic ovarian syndrome (PCOS) causes irregular menstrual cycles and symptoms of hyperandrogenism and affects 10% of females ([Figure 1][1]).[1][2] Symptoms most often begin between the ages of 18 and 39 years, but diagnosis and treatment of PCOS are often delayed or patients remain

Objective: This study sought to determine if a presacral nerve (PSN) block affects early postoperative pain, opioid use, and rates of urinary retention after laparoscopic hysterectomy.Materials and Methods: Patients who had elective total laparoscopic hysterectomy (TLH) without histories of chronic pain or opioid use were assigned randomly to either a PSN block of 10 mL of 0.5% bupivacaine or a sham block of 10 mL normal saline post surgery. The primary outcome was pain assessed on a visual analogue scale (VAS) at 3 hours postoperatively and secondary outcomes included pain at 1, 2, and 3 hours, and opioid use post surgery. Participant recruitment was halted due to cancellation of elective surgeries during the COVID-19 pandemic, and, therefore, the data of the patients who were already recruited, was analyzed as an interim analysis for a pilot study design.Results: Thirty-four patients were recruited, with 21 in the intervention group and 13 in the sham-block group. Operative times were similar between both groups. Postoperative pain (measured at 1, 2, and 3 hours post surgery) was not significantly different between the 2 groups. Fewer patients in the PSN group required fentanyl for pain control in the recovery room (28.6% versus 53.8%; p = 0.041), although there was no statistically significant difference in terms of overall opioid consumption. There were no complications related to PSN-block administration.Conclusions: PSN block appears to be feasible and may contribute to decreased opioid use following laparoscopic hysterectomy. As participant recruitment was halted, a robust, well-powered, randomized control trial is necessary. (J GYNECOL SURG 20XX:000)

This study explores the impact of a patient education portal on the informed consent process. We hypothesize that a preoperative patient education portal will improve patient comprehension, preparedness, and satisfaction prior to undergoing hysteroscopy.

ObjectiveThe primary objective was to evaluate the prevalence of undiagnosed iron deficiency in patients with endometriosis.MethodsWe performed a multi-center, cross-sectional study at two tertiary care hospitals. We included 251 non-pregnant women (18-50 years old) presenting with a clinical or surgical diagnosis of symptomatic endometriosis. Patients who consented to the study underwent screening bloodwork (including complete blood count, ferritin, and transferrin saturation) and completed the study survey assessing demographics, medical and surgical history, and validated questionnaires to assess iron deficiency and endometriosis symptoms.ResultsThe prevalence of iron deficiency in our endometriosis cohort was 53.4% (134/251), and the prevalence of iron deficiency anemia was 13.5% (34/251). Patients with iron deficiency were more likely to have heavy menstrual bleeding (HMB) compared with patients without iron deficiency (66/133, 49.6% vs. 40/115, 34.8%, p = 0.022). Nonetheless, 58% (142/251) of our study population did not endorse HMB. Despite absence of HMB, 47% (67/142) of these patients were iron-deficient. Transferrin saturation was diagnostic for iron deficiency in 63 of 176 patients (35.7%) who had a normal ferritin (>= 30 ng/mL). Patients with iron deficiency had a significantly lower adjusted median Functional Assessment of Chronic Illness Therapy Fatigue Subscale score compared with those without iron deficiency (26.3. vs. 29.8, p = 0.025).ConclusionThis study highlights the high prevalence of iron deficiency, which remains undiagnosed in over half of patients with endometriosis presenting to a gynecologist. Future research should focus on assessing the effectiveness of iron therapy in improving symptoms and overall well-being in this population.

No effective screening test is available for HGSOC, and patients often present in an advanced stage of disease. Around 70%–80% of deaths from ovarian cancer are caused by HGSOC.[1][1] This cancer develops via a stepwise progression within the distal fallopian tube epithelium. The precursor lesion

[Voir la version anglaise de l'article ici: www.cmaj.ca/lookup/doi/10.1503/cmaj.231251][1] Points clés Le syndrome des ovaires polykystiques (SOPK) s'accompagne d'une irrégularité des cycles menstruels et de symptômes d'hyperandrogénie; il affecte 10 % des femmes ([figure 1][2])[1][3