{
  "title": "Latest evidence: Mr Haider Jan's weekly literature digest",
  "url": "https://migynaecology.com/evidence/",
  "licence": "The summaries may be quoted with a link to the page; the papers themselves belong to their publishers.",
  "updated": "2026-10-19",
  "streams": [
    {
      "id": 1,
      "slug": "endometriosis-adenomyosis",
      "name": "Endometriosis and adenomyosis",
      "url": "https://migynaecology.com/evidence/endometriosis-adenomyosis/",
      "covers": "Deep and bowel disease, surgical outcomes, imaging and staging, recurrence, medical treatment after surgery, adenomyosis and fertility or miscarriage",
      "conditions": [
        "https://migynaecology.com/endometriosis/",
        "https://migynaecology.com/adenomyosis/"
      ]
    },
    {
      "id": 2,
      "slug": "ashermans-intrauterine-adhesions",
      "name": "Asherman's and intrauterine adhesions",
      "url": "https://migynaecology.com/evidence/ashermans-intrauterine-adhesions/",
      "covers": "Hysteroscopic adhesiolysis, prevention of re-adhesion (barriers, balloons, oestrogen), regenerative therapy for thin or scarred endometrium",
      "conditions": [
        "https://migynaecology.com/ashermans-syndrome/"
      ]
    },
    {
      "id": 3,
      "slug": "caesarean-scar-niche",
      "name": "Caesarean scar niche",
      "url": "https://migynaecology.com/evidence/caesarean-scar-niche/",
      "covers": "Repair techniques, symptom and fertility outcomes, niche measurement on ultrasound",
      "conditions": [
        "https://migynaecology.com/caesarean-scar-niche/"
      ]
    },
    {
      "id": 4,
      "slug": "surgery-before-ivf",
      "name": "Surgery before IVF",
      "url": "https://migynaecology.com/evidence/surgery-before-ivf/",
      "covers": "Endometrioma surgery and ovarian reserve, hydrosalpinx, septum, polyps and fibroids before transfer, recurrent implantation failure",
      "conditions": [
        "https://migynaecology.com/fertility-miscarriage-surgery/"
      ]
    },
    {
      "id": 5,
      "slug": "robotic-gynaecological-surgery",
      "name": "Robotic gynaecological surgery",
      "url": "https://migynaecology.com/evidence/robotic-gynaecological-surgery/",
      "covers": "Outcomes compared with laparoscopy, cost, single-port and new platforms, training and learning curves",
      "conditions": [
        "https://migynaecology.com/robotic-keyhole-surgery/"
      ]
    },
    {
      "id": 6,
      "slug": "fibroids",
      "name": "Fibroids",
      "url": "https://migynaecology.com/evidence/fibroids/",
      "covers": "Myomectomy technique, morcellation safety, newer oral medical treatments",
      "conditions": [
        "https://migynaecology.com/fibroids/"
      ]
    },
    {
      "id": 7,
      "slug": "prolapse-mesh",
      "name": "Prolapse and mesh",
      "url": "https://migynaecology.com/evidence/prolapse-mesh/",
      "covers": "Sacrocolpopexy and sacrohysteropexy outcomes, mesh safety and complications, uterosacral and native-tissue suspension, recurrence after apical repair, pessary and pelvic floor treatment compared with surgery",
      "conditions": [
        "https://migynaecology.com/prolapse/"
      ]
    },
    {
      "id": 8,
      "slug": "chronic-pelvic-pain-hysteroscopy-pain",
      "name": "Chronic pelvic pain and hysteroscopy pain",
      "url": "https://migynaecology.com/evidence/chronic-pelvic-pain-hysteroscopy-pain/",
      "covers": "Chronic pelvic pain assessment and treatment, central sensitisation and pain after surgery, pain relief for outpatient hysteroscopy (inhaled, local and oral), vaginoscopy, patient experience of office procedures",
      "conditions": [
        "https://migynaecology.com/gynaecology/",
        "https://migynaecology.com/hysteroscopy/"
      ]
    },
    {
      "id": 9,
      "slug": "recurrent-miscarriage-ovarian-cysts",
      "name": "Recurrent miscarriage and ovarian cysts",
      "url": "https://migynaecology.com/evidence/recurrent-miscarriage-ovarian-cysts/",
      "covers": "Recurrent miscarriage investigation and treatment, structural causes (septum, adhesions, polyps, fibroids), progesterone and other medical treatment, ovarian cyst assessment and classification, ovary-sparing cystectomy and ovarian reserve, dermoid and endometrioma surgery",
      "conditions": [
        "https://migynaecology.com/fertility-miscarriage-surgery/",
        "https://migynaecology.com/ovarian-cysts/"
      ]
    }
  ],
  "papers": [
    {
      "digest": "2026-10-19",
      "digestId": "2026-10-19-streams-7-9",
      "catchUp": true,
      "rank": 1,
      "streams": [
        "prolapse-mesh"
      ],
      "title": "Mesh placed through the abdomen makes apical prolapse less likely to come back than stitch-only repair, and sacrocolpopexy was the most durable operation: network meta-analysis of 58 randomised trials",
      "authors": "Nguyen TTT, Aryan P, Taheri M, et al",
      "journal": "Int Urogynecol J",
      "year": 2026,
      "pmid": "42776189",
      "doi": "10.1007/s00192-026-06857-4",
      "url": "https://pubmed.ncbi.nlm.nih.gov/42776189/",
      "citation": "Nguyen TTT, Aryan P, Taheri M, et al. Mesh placed through the abdomen makes apical prolapse less likely to come back than stitch-only repair, and sacrocolpopexy was the most durable operation: network meta-analysis of 58 randomised trials. Int Urogynecol J. 2026. PMID 42776189. doi:10.1007/s00192-026-06857-4",
      "study": "Systematic review and network meta-analysis of 58 randomised trials (6,846 women) of surgery for primary apical prolapse, comparing vaginal, abdominal and laparoscopic mesh operations with native-tissue (stitch-only) repair as the reference; trials had to report anatomical recurrence at one year or more; searches to 30 June 2025; the integrity of each trial was checked with the TRACT checklist.",
      "finding": "Vaginal, abdominal and laparoscopic mesh repairs all reduced anatomical recurrence compared with native-tissue repair (relative risk 0.59 to 0.66, that is roughly a third to two fifths fewer recurrences); laparoscopic sacrocolpopexy with posterior plication and vaginal mesh lowered subjective recurrence (relative risk 0.22 to 0.51); abdominal sacrocolpopexy had fewer reoperations for recurrence (relative risk 0.40), whereas vaginal mesh had more reoperations for mesh problems (relative risk 5.19); the abstract gives no confidence intervals and no absolute rates.",
      "quality": "A network meta-analysis of randomised trials is the right design for ranking several operations against each other, 58 trials with 6,846 women is a large body of evidence, and checking each trial's integrity is a strength few reviews have. Follow-up of at least one year is long enough for anatomical recurrence but short for mesh complications, which accrue over many years, and because operations were grouped by clinical similarity a result for laparoscopic mesh repair covers several techniques and does not separate sacrohysteropexy from sacrocolpopexy; the trials come from many countries and one comparator, vaginal mesh, is paused in the NHS. No conflicts of interest are stated. The biggest weakness for a reader of the abstract is that the relative risks are given as ranges without confidence intervals, so the precision of each estimate cannot be judged; the full text was read on 19 October 2026 and confirms the figures, with confidence intervals of 0.44 to 0.79, 0.40 to 0.87 and 0.47 to 0.94 for vaginal, abdominal and laparoscopic mesh. [strong]",
      "qualityGrade": "strong",
      "meaning": "For the woman choosing between a sacrocolpopexy and a vaginal operation with stitches, this confirms what the prolapse page already says from the Cochrane review: mesh placed through the abdomen makes the prolapse less likely to come back, by about a third to two fifths, and sacrocolpopexy was the most durable of the operations compared. It does not tell him how sacrohysteropexy or his stitch-only operation compare, whether the gain lasts beyond the first years, or how many women the relative risks represent, because the abstract gives no absolute figures. It also puts a figure on the mesh penalty he already describes: the higher rate of further operations for mesh problems was found with mesh placed through the vagina, which he does not use.",
      "verdict": "Supports current practice",
      "reason": "It backs sacrocolpopexy as the most durable apical repair and puts numbers on the trade-off he already describes to patients: mesh through the abdomen cuts recurrence by about a third or more, and the mesh penalty in the trials falls on the vaginal route rather than on sacrocolpopexy.",
      "reviewed": true,
      "reviewedOn": "2026-10-19",
      "page": "https://migynaecology.com/evidence/prolapse-mesh/#pmid-42776189"
    },
    {
      "digest": "2026-10-19",
      "digestId": "2026-10-19-streams-7-9",
      "catchUp": true,
      "rank": 2,
      "streams": [
        "recurrent-miscarriage-ovarian-cysts",
        "chronic-pelvic-pain-hysteroscopy-pain"
      ],
      "title": "With a standard retrieval bag, dermoid cyst contents spilled inside the abdomen in about one in four women; none spilled with a fully enclosed device: multicentre randomised trial",
      "authors": "Zhou C, Hou S, Yu H, et al",
      "journal": "J Minim Invasive Gynecol",
      "year": 2026,
      "pmid": "42854831",
      "doi": "10.1016/j.jmig.2026.10.002",
      "url": "https://pubmed.ncbi.nlm.nih.gov/42854831/",
      "citation": "Zhou C, Hou S, Yu H, et al. With a standard retrieval bag, dermoid cyst contents spilled inside the abdomen in about one in four women; none spilled with a fully enclosed device: multicentre randomised trial. J Minim Invasive Gynecol. 2026. PMID 42854831. doi:10.1016/j.jmig.2026.10.002",
      "study": "Multicentre randomised superiority trial (NCT04406597) in four academic hospitals in Beijing; 119 premenopausal women aged 18 to 45 with a unilateral ovarian mass of 3 to 10 cm were randomised to cystectomy carried out inside a totally enclosed protective device or to conventional cystectomy with extraction in a standard retrieval bag; 105 were analysed (53 against 52) after exclusions.",
      "finding": "Macroscopic spillage inside the abdomen, the primary outcome, occurred in 0 of 53 women with the device against 13 of 52 (25.0%, about one in four) with a standard bag (risk difference -25.0%, 95% CI -36.8% to -13.2%, P<0.001); the cyst ruptured during surgery about as often in both groups (32.1% against 25.0%, risk difference 7.1%, 95% CI -10.3% to 24.5%); operating times were similar and the device deployed successfully every time; over a median 34.5 months, 5 of 52 control women (9.6%, about one in ten) developed new chronic pelvic pain and none of the device group did.",
      "quality": "A multicentre randomised trial is the right design and a median follow-up of nearly three years is long for a surgical device study, but the trial is small: 119 women randomised and 105 analysed, with 14 excluded after randomisation, and the abstract does not say whether the analysis was by intention to treat. The primary outcome, spillage seen by the surgeon, cannot be blinded, and the late finding of chronic pelvic pain in five women against none rests on very small numbers. All four centres are academic hospitals in Beijing, the women were premenopausal with masses of 3 to 10 cm, and the device's maker and its availability outside China are not described; the trial was publicly funded and no commercial conflict is stated. The biggest weakness is size with post-randomisation exclusions; this assessment rests on the abstract. [moderate]",
      "qualityGrade": "moderate",
      "meaning": "For a woman having a dermoid cyst removed by keyhole surgery, the useful fact is in the control arm: with a standard retrieval bag the cyst contents spilled inside the abdomen in about one in four, and about one in ten of that group went on to develop long-term pelvic pain, against none when the whole cyst was handled inside a sealed device. It does not tell him whether washing out spilled contents, as surgeons do, prevents that harm, nor whether the device can be obtained in the UK. The 19 October entry took contained extraction to be his standard for dermoids, but EXPERTISE.md and the ovarian cysts page say nothing about spillage yet, so the practice point needs his confirmation before it is written as his.",
      "verdict": "Supports current practice",
      "reason": "Avoiding spillage of dermoid contents is standard careful technique and the trial shows why: one in four spills with a conventional bag, and late pelvic pain only in that arm; it is a small trial of a device whose availability outside China is not described, so it supports strict spillage avoidance rather than a particular product.",
      "conflicts": "Publicly funded (Capital's Funds for Health Improvement and Research, Beijing, No. 2022-2-406); the device's maker is not named in the record.",
      "reviewed": true,
      "reviewedOn": "2026-10-19",
      "page": "https://migynaecology.com/evidence/recurrent-miscarriage-ovarian-cysts/#pmid-42854831"
    },
    {
      "digest": "2026-10-19",
      "digestId": "2026-10-19-streams-7-9",
      "catchUp": true,
      "rank": 3,
      "streams": [
        "prolapse-mesh"
      ],
      "title": "A more advanced prolapse, previous prolapse surgery and a higher BMI raise the chance of recurrence after surgery for uterovaginal prolapse; age, parity and menopause do not: meta-analysis of 25 studies and consensus",
      "authors": "Vendramini A, Page AS, Gottipati V, et al",
      "journal": "Int Urogynecol J",
      "year": 2026,
      "pmid": "42867516",
      "doi": "10.1007/s00192-026-06910-2",
      "url": "https://pubmed.ncbi.nlm.nih.gov/42867516/",
      "citation": "Vendramini A, Page AS, Gottipati V, et al. A more advanced prolapse, previous prolapse surgery and a higher BMI raise the chance of recurrence after surgery for uterovaginal prolapse; age, parity and menopause do not: meta-analysis of 25 studies and consensus. Int Urogynecol J. 2026. PMID 42867516. doi:10.1007/s00192-026-06910-2",
      "study": "Systematic review and random-effects meta-analysis of 25 studies (14,860 women, median follow-up 24 months) of patient-level risk factors for recurrence after surgery for uterovaginal prolapse, with risk of bias assessed by GRADE; the findings fed a Delphi process at the Global Consensus Conference on primary uterovaginal prolapse in April 2026, with consensus set at 80 per cent agreement.",
      "finding": "Of 16 risk factors identified, 9 could be pooled. Advanced preoperative stage (OR 2.75, 95% CI 1.39 to 5.46), prior prolapse surgery (OR 2.09, 95% CI 1.16 to 3.75) and higher BMI (OR 1.10 per unit, 95% CI 1.06 to 1.15) each raised the odds of recurrence, while age, diabetes, smoking, parity, menopause and preoperative oestrogen use showed no significant association; where data were insufficient, expert consensus added levator ani avulsion, an enlarged genital hiatus and connective-tissue disorders as risk factors.",
      "quality": "A systematic review and meta-analysis of 25 studies and 14,860 women is a large pooled sample, with a median follow-up of two years, GRADE applied, and a focus on uterovaginal prolapse, which is the group he counsels for sacrohysteropexy. The included studies are mostly observational, so the pooled odds ratios carry confounding and differing definitions of recurrence, the interval for preoperative stage is wide (1.39 to 5.46), only 9 of 16 factors could be pooled, and the three added by Delphi consensus are expert opinion rather than data; the settings are international and not described in the abstract, and no conflicts of interest are stated. The biggest weakness is reliance on observational data with inconsistent outcome definitions; this assessment rests on the abstract. [moderate]",
      "qualityGrade": "moderate",
      "meaning": "For the woman asking whether her prolapse will come back after surgery, three things raise the odds: a more advanced prolapse to begin with (nearly three times the odds), a previous prolapse operation (about twice) and a higher weight (about 10 per cent more for each unit of BMI), while age, the number of births, the menopause and vaginal oestrogen beforehand made no measurable difference. It gives no absolute rates for any group, so it cannot say one woman in so many, and it does not separate the operations. It sits with the 'Will the prolapse come back?' answer on the prolapse page, which already names weight, and gives him grounds not to treat age or parity as reasons for caution.",
      "verdict": "Supports current practice",
      "reason": "It gives him pooled figures for the three factors he already uses when counselling about recurrence and, usefully, clears age, parity and menopause as predictors; the pooled factors come mostly from observational studies.",
      "reviewed": true,
      "reviewedOn": "2026-10-19",
      "page": "https://migynaecology.com/evidence/prolapse-mesh/#pmid-42867516"
    },
    {
      "digest": "2026-10-19",
      "digestId": "2026-10-19-streams-7-9",
      "catchUp": true,
      "rank": 4,
      "streams": [
        "prolapse-mesh"
      ],
      "title": "Overactive bladder symptoms settle in about three in five women after prolapse surgery, and in about three in four after anterior or apical repair: meta-analysis of 24 studies",
      "authors": "Vacca L, Caramazza D, Pierro M, et al",
      "journal": "Neurourol Urodyn",
      "year": 2026,
      "pmid": "42781723",
      "doi": "10.1002/nau.70444",
      "url": "https://pubmed.ncbi.nlm.nih.gov/42781723/",
      "citation": "Vacca L, Caramazza D, Pierro M, et al. Overactive bladder symptoms settle in about three in five women after prolapse surgery, and in about three in four after anterior or apical repair: meta-analysis of 24 studies. Neurourol Urodyn. 2026. PMID 42781723. doi:10.1002/nau.70444",
      "study": "Systematic review and meta-analysis of 24 comparative studies, randomised and observational (7,739 women, 7,095 analysed), of women with prolapse of stage II or worse and validated overactive bladder outcomes at least three months after surgery; searches to 31 December 2024; risk of bias assessed with Cochrane RoB 2.0 and Newcastle-Ottawa, certainty with GRADE.",
      "finding": "Pre-existing overactive bladder resolved in 58.0% (95% CI 55.9% to 60.1%; I2 83.9%), about three in five women, with no difference between vaginal, laparoscopic or robotic and abdominal routes (p=0.62) or between mesh and native tissue (p=0.48); anterior or apical repair resolved it in 75.8% (95% CI 73.2% to 78.3%), about three in four, against 28.3% (95% CI 20.1% to 37.9%), fewer than one in three, after isolated posterior repair (p<0.001); new overactive bladder after surgery ranged from 0% to 14.3% in the six studies that reported it.",
      "quality": "Twenty-four comparative studies with 7,739 women is a large pooled sample, outcomes had to be validated overactive bladder measures with at least three months of follow-up, and risk of bias and GRADE were assessed. Most studies are observational, the pooled resolution rate has high heterogeneity (I2 84 per cent), and the comparisons by route, by mesh and by compartment are made between studies rather than within them, so women having a posterior repair alone differ from those having anterior or apical repair in more ways than the operation; three months is a short horizon for bladder symptoms and new-onset urgency was reported in only six studies. No conflicts of interest are stated. The biggest weakness is the indirect, between-study comparison; this assessment rests on the abstract. [moderate]",
      "qualityGrade": "moderate",
      "meaning": "For a woman with prolapse who also has urgency or frequency, he can say that the bladder symptoms settle after prolapse surgery in about 3 in 5 women overall, in about 3 in 4 when the front wall or the top of the vagina is repaired, and in fewer than 1 in 3 after a repair of the back wall alone, with no sign that mesh, or the robotic against the vaginal route, changes that. It does not tell him which women will develop urgency for the first time (between none and about 14 in 100 across the few studies that looked), and it cannot promise any individual woman that her urgency will go. The prolapse page lists urgency among the symptoms and stress incontinence among the risks but says nothing about urgency after surgery, so this fills a gap.",
      "verdict": "Supports current practice",
      "reason": "It supports telling women with urgency symptoms that anterior or apical repair, including sacrocolpopexy, improves them in most cases and that a posterior repair alone usually will not; heterogeneity is high and most studies are observational.",
      "reviewed": true,
      "reviewedOn": "2026-10-19",
      "page": "https://migynaecology.com/evidence/prolapse-mesh/#pmid-42781723"
    },
    {
      "digest": "2026-10-19",
      "digestId": "2026-10-19-streams-7-9",
      "catchUp": true,
      "rank": 9,
      "streams": [
        "recurrent-miscarriage-ovarian-cysts"
      ],
      "title": "Transvaginal (vNOTES) ovarian cystectomy gave less early pain and the same safety and sexual function as single-incision umbilical surgery: single-centre randomised trial",
      "authors": "Chen J, Feng D, Liu T, et al",
      "journal": "Surg Endosc",
      "year": 2026,
      "pmid": "42864466",
      "doi": "10.1007/s00464-026-13501-1",
      "url": "https://pubmed.ncbi.nlm.nih.gov/42864466/",
      "citation": "Chen J, Feng D, Liu T, et al. Transvaginal (vNOTES) ovarian cystectomy gave less early pain and the same safety and sexual function as single-incision umbilical surgery: single-centre randomised trial. Surg Endosc. 2026. PMID 42864466. doi:10.1007/s00464-026-13501-1",
      "study": "Single-centre randomised trial (ChiCTR2100053483) in a university-affiliated tertiary women's and children's hospital in China; 160 women with benign ovarian cysts, screened before and after anaesthesia as suitable for both approaches, randomised 1:1 to vNOTES or transumbilical single-site cystectomy; pain by visual analogue scale at 12, 24 and 48 hours, cosmetic satisfaction at one month, Female Sexual Function Index before surgery and at three to six months.",
      "finding": "No conversions; intraoperative complications, operative time, blood loss, postoperative complications (5.0% against 3.8%), rescue analgesia, wound events, incisional hernia and postoperative sexual function scores were comparable, while vNOTES gave lower pain scores at 12, 24 and 48 hours, shorter total and postoperative stay and higher cosmetic satisfaction (all p<0.001); the abstract gives p values but no effect sizes.",
      "quality": "A registered randomised trial of 160 women is a sound design, and measuring sexual function with a validated index before and after is a strength. It is a single centre in China, the women were screened twice for suitability for both approaches so they are a selected group, pain and satisfaction cannot be blinded to the route, follow-up for sexual function is only three to six months, and the abstract gives p values without effect sizes; the comparator is single-incision umbilical surgery, not the standard multi-port keyhole operation he uses, so the pain advantage cannot be read across to his practice. No conflicts of interest are stated. The biggest weakness is the comparator; this assessment rests on the abstract. [moderate]",
      "qualityGrade": "moderate",
      "meaning": "For his patients nothing changes: he does not operate through the vagina for ovarian cysts, and the trial compares that route with a single umbilical incision rather than with the standard keyhole operation he performs. It is reassuring that a vaginal route did not worsen sexual function at three to six months, and a reminder that pain after keyhole surgery depends partly on the incisions chosen. It does not say how either approach compares with his, and it says nothing about dermoids or endometriomas specifically.",
      "verdict": "No change",
      "reason": "A single-centre trial of an approach he does not use, against a single-port comparator rather than conventional laparoscopy; reassuring on sexual function after the vaginal route but not a reason to change technique.",
      "reviewed": true,
      "reviewedOn": "2026-10-19",
      "page": "https://migynaecology.com/evidence/recurrent-miscarriage-ovarian-cysts/#pmid-42864466"
    },
    {
      "digest": "2026-10-19",
      "digestId": "2026-10-19",
      "catchUp": false,
      "rank": 1,
      "streams": [
        "endometriosis-adenomyosis",
        "surgery-before-ivf"
      ],
      "title": "One in six women needs further surgery after an operation for ovarian endometriosis, one in three after ovarian-conserving surgery",
      "authors": "Ylävuo S, Saavalainen L, Saavalainen J, et al",
      "journal": "Am J Obstet Gynecol",
      "year": 2026,
      "pmid": "42869118",
      "doi": "10.1016/j.ajog.2026.10.009",
      "url": "https://pubmed.ncbi.nlm.nih.gov/42869118/",
      "citation": "Ylävuo S, Saavalainen L, Saavalainen J, et al. One in six women needs further surgery after an operation for ovarian endometriosis, one in three after ovarian-conserving surgery. Am J Obstet Gynecol. 2026. PMID 42869118. doi:10.1016/j.ajog.2026.10.009",
      "study": "Finnish national register cohort of 13,912 women whose first surgically verified diagnosis of ovarian endometriosis came with an ovarian procedure between 1987 and 2012, followed through the registers to 2019 (median 20.7 years). Later operations at endometriosis sites were identified from procedure codes; women with a single operation were compared with those reoperated, and removal of the ovary with ovary-conserving surgery.",
      "finding": "The 30-year cumulative risk of any reoperation was 17.3% (about one in six) and of ovarian reoperation 16.5%, with a median 3.4 years to the first and under two years to each later one. Compared with oophorectomy, enucleation or resection carried a higher risk of any reoperation (aHR 1.43, 95% CI 1.28-1.60) and other ovarian procedures higher still (aHR 2.20, 95% CI 1.67-2.89); the authors put this at roughly one in three reoperated after ovary-conserving surgery against one in ten after oophorectomy. Young age, a family history of endometriosis, a primary diagnosis of endometriosis and prior infertility each raised the risk, and hysterectomy before or at the index operation lowered it. Reoperated women had fewer births (61.6% vs 70.7%) and more infertility (51.5% vs 17.1%); reoperation was more common after index surgery in 1996-2012 than in 1987-1995 (19.0% vs 12.4%), and by the fourth or later operation 13.4% of procedures were for deep infiltrating endometriosis.",
      "quality": "A complete national register with a median of 20.7 years of follow-up is the strongest design available for how often women need another operation, and 13,912 women is a very large sample; but nobody was randomised, so the comparison between keeping and removing the ovary is confounded by age, family plans and whether a hysterectomy was done at the same time, and the registers record procedure codes rather than the extent of disease, the completeness of excision or the surgeon's technique. The index operations date from 1987 to 2012, before modern excision and multidisciplinary practice, and reoperation was in fact more common in the later era, so the figures describe Finnish practice over 25 years rather than a UK endometriosis centre today; funding is not stated in the abstract. The single biggest weakness is that the ovary-conserving versus oophorectomy comparison cannot separate the operation from the woman who chose it, so that part of the result is moderate at best. For the national reoperation rate itself the evidence is [strong]",
      "qualityGrade": "strong",
      "meaning": "For a woman deciding about surgery for an endometrioma, this gives a figure I can quote: about one in six women needs another operation over the following decades, sooner in younger women, those with a family history and those with infertility, and keeping the ovary roughly trebles that chance compared with removing it. It does not tell me what happens after careful excision of the cyst wall with the ovary reconstructed and an anti-adhesion gel placed, which is the operation I perform (EXPERTISE, endometrioma technique, 18 October 2026), nor whether hormonal treatment after surgery changes the figure. It sits with what the endometriosis page already says, that I remove the cyst wall while preserving healthy ovary and that the choice is weighed against ovarian reserve and family plans; it adds the long-term number the page lacks.",
      "verdict": "Supports current practice",
      "reason": "Gives long-term national figures for counselling before endometrioma surgery and backs an individualised, fertility-conscious choice between keeping and removing the ovary rather than any change in technique.",
      "conflicts": "Funding not stated in the abstract.",
      "reviewed": true,
      "reviewedOn": "2026-10-19",
      "page": "https://migynaecology.com/evidence/endometriosis-adenomyosis/#pmid-42869118"
    },
    {
      "digest": "2026-10-19",
      "digestId": "2026-10-19",
      "catchUp": false,
      "rank": 3,
      "streams": [
        "fibroids"
      ],
      "title": "Uterine rupture in pregnancy after myomectomy is about 0.3%, higher when the cavity was entered: systematic review",
      "authors": "Groffils C, Paelinck L, van Wessel S, et al",
      "journal": "Obstet Gynecol Int",
      "year": 2026,
      "pmid": "42893144",
      "doi": "10.1155/ogi/6048559",
      "url": "https://pubmed.ncbi.nlm.nih.gov/42893144/",
      "citation": "Groffils C, Paelinck L, van Wessel S, et al. Uterine rupture in pregnancy after myomectomy is about 0.3%, higher when the cavity was entered: systematic review. Obstet Gynecol Int. 2026. PMID 42893144. doi:10.1155/ogi/6048559",
      "study": "Systematic review (MEDLINE, Embase, Web of Science, Cochrane Library; two reviewers) of 31 studies published between April 2013 and October 2023, covering 13,381 pregnancies after a myomectomy; the cavity-entry comparison rests on 380 women.",
      "finding": "Uterine rupture during pregnancy or labour occurred in 0.30% (40/13,381; 95% CI 0.21-0.41), about 3 in every 1,000 pregnancies. It was more frequent when the cavity had been entered at the myomectomy (3/44, 6.82%) than when it had not (4/336, 1.19%), OR 6.07, p = 0.04. The type of myomectomy (laparoscopic, open or robotic) did not significantly influence the risk, the studies gave insufficient data to estimate the risk in a trial of labour, and no other consistent risk factor was found.",
      "quality": "A systematic review across four databases with two reviewers is the right design for a rare outcome, and 13,381 pregnancies is a large denominator, but the 31 studies are observational and of varying quality, the abstract reports no heterogeneity or risk-of-bias assessment, and the denominators are pregnancies rather than labours, so the risk in a trial of labour could not be estimated. The cavity-entry comparison rests on 380 women and seven ruptures (3 of 44 against 4 of 336), with p = 0.04 and no confidence interval given for the odds ratio; the review is Belgian-led with international studies, so broadly applicable to UK practice, and funding is not stated. The single biggest weakness is that the headline risk factor comes from seven events. [moderate]",
      "qualityGrade": "moderate",
      "meaning": "For a woman planning a pregnancy after a myomectomy, the womb tearing is rare: about 3 in every 1,000 pregnancies, with no difference between keyhole, robotic and open operations. Entering the cavity of the womb appears to raise the chance, which is the reason I record it in the operation note and often advise a planned caesarean after an extensive myomectomy or one that entered the cavity (EXPERTISE, fibroids), but the figure of about 7 in 100 after cavity entry comes from only 44 women and should be quoted as uncertain. It does not tell me the risk during labour itself, which is the question most women ask.",
      "verdict": "Supports current practice",
      "reason": "Confirms the rupture figure used in counselling, supports recording cavity entry in the operation note for the obstetric team, and gives no reason to steer patients away from laparoscopic or robotic myomectomy.",
      "conflicts": "Funding not stated in the abstract.",
      "reviewed": true,
      "reviewedOn": "2026-10-19",
      "page": "https://migynaecology.com/evidence/fibroids/#pmid-42893144"
    },
    {
      "digest": "2026-10-19",
      "digestId": "2026-10-19",
      "catchUp": false,
      "rank": 4,
      "streams": [
        "endometriosis-adenomyosis",
        "surgery-before-ivf"
      ],
      "title": "Vasopressin during endometrioma cystectomy speeds haemostasis but does not protect ovarian reserve: randomised trial",
      "authors": "Lee J, Park E, Park H, et al",
      "journal": "Front Reprod Health",
      "year": 2026,
      "pmid": "42890533",
      "doi": "10.3389/frph.2026.1906041",
      "url": "https://pubmed.ncbi.nlm.nih.gov/42890533/",
      "citation": "Lee J, Park E, Park H, et al. Vasopressin during endometrioma cystectomy speeds haemostasis but does not protect ovarian reserve: randomised trial. Front Reprod Health. 2026. PMID 42890533. doi:10.3389/frph.2026.1906041",
      "study": "Single-centre randomised controlled trial at a Korean university hospital, September 2018 to July 2021: 75 women having laparoscopic cystectomy for a unilateral endometrioma, stratified by baseline AMH and randomised to vasopressin injection or no injection; the primary outcome was the change in serum AMH at 12 months, analysed by intention to treat and per protocol.",
      "finding": "Vasopressin shortened bleeding control (2.2 vs 6.5 minutes, p = 0.002) and cyst stripping (8.9 vs 14.4 minutes, p = 0.054), but the fall in AMH at 12 months was the same in both arms (-0.96 vs -1.14 ng/mL, p = 0.488), with the same pattern in women with baseline AMH below 3 ng/mL and 3 to 7 ng/mL. AMH fell significantly at three months and partly recovered at six and twelve months in both groups (group-by-time interaction p = 0.816), and the specimens contained the same thickness and proportion of ovarian tissue in each group.",
      "quality": "A randomised trial stratified by baseline AMH, with a pre-specified 12-month primary outcome, intention-to-treat and per-protocol analyses and histological checking of the specimen, is the right design and carefully run for its size; but 75 women in one hospital is small, so a modest protective effect cannot be excluded, and the difference in stripping time did not reach significance (p = 0.054). The patients (unilateral endometrioma, cystectomy) resemble his, the surgeons' technique is not described in the abstract, and funding is not stated. The single biggest weakness is size. [moderate]",
      "qualityGrade": "moderate",
      "meaning": "For the woman having an endometrioma removed, the loss of ovarian reserve after cystectomy (AMH down by about 1 ng/mL at a year, with partial recovery from three months) happened whether or not vasopressin was used to reduce bleeding and diathermy. That questions the assumption behind my own technique of very little diathermy and haemostasis by suturing (EXPERTISE, 18 October 2026), that heat is the main cause of the loss; some of it may come with the cyst wall itself. It does not test suturing against diathermy, and it is too small to prove that sparing the ovary from heat is worthless, so the technique stands on its own reasoning rather than on this trial, and I should not tell patients that any technique protects their egg supply.",
      "verdict": "No change",
      "reason": "Vasopressin shortens the operation but should not be presented as protecting the ovary; the trial is small and single-centre, and it leaves the egg-sparing technique neither proven nor disproven.",
      "conflicts": "Funding not stated in the abstract.",
      "reviewed": true,
      "reviewedOn": "2026-10-19",
      "page": "https://migynaecology.com/evidence/endometriosis-adenomyosis/#pmid-42890533"
    },
    {
      "digest": "2026-10-19",
      "digestId": "2026-10-19",
      "catchUp": false,
      "rank": 5,
      "streams": [
        "ashermans-intrauterine-adhesions",
        "surgery-before-ivf"
      ],
      "title": "Thin endometrium lowers live birth on a gradient, and a trilaminar pattern partly offsets it: 45,729 transfer cycles",
      "authors": "Li Y, Zhou J, Huang H, et al",
      "journal": "Fertil Steril",
      "year": 2026,
      "pmid": "42874765",
      "doi": "10.1016/j.fertnstert.2026.10.008",
      "url": "https://pubmed.ncbi.nlm.nih.gov/42874765/",
      "citation": "Li Y, Zhou J, Huang H, et al. Thin endometrium lowers live birth on a gradient, and a trilaminar pattern partly offsets it: 45,729 transfer cycles. Fertil Steril. 2026. PMID 42874765. doi:10.1016/j.fertnstert.2026.10.008",
      "study": "Retrospective cohort of 45,729 embryo transfer cycles (16,566 fresh, 29,163 frozen-thawed) between January 2018 and August 2022; the setting is not named in the abstract. Endometrial thickness and pattern were measured by transvaginal ultrasound on the trigger day (fresh) or the day progesterone was started (frozen), and live birth per transfer was modelled with splines and adjusted Poisson regression.",
      "finding": "Live birth rose steeply with endometrial thickness, the slope flattening at about 11-12 mm in fresh and 9-10 mm in frozen cycles. A non-trilaminar (type B/C) pattern lowered adjusted live birth (fresh aRR 0.880, 95% CI 0.832-0.930; frozen aRR 0.892, 95% CI 0.863-0.923), and the pattern mattered most below 10 mm: in frozen cycles live birth ranged from 16.7% (under 7 mm, non-trilaminar) to 44.7% (14 mm or more, trilaminar), about 17 in 100 to about 45 in 100, and in some comparisons a thinner trilaminar lining outperformed the next thicker non-trilaminar one. Thickness and pattern varied with the stimulation protocol in fresh cycles and the preparation regimen in frozen ones.",
      "quality": "At 45,729 cycles this is one of the largest analyses of lining thickness and pattern, with fresh and frozen cycles analysed separately, spline modelling and adjusted risk ratios; but it is retrospective, apparently from a single programme whose country is not named in the abstract, and association is not cause: a thin or non-trilaminar lining may mark women whose embryos or hormones differ. The population is general IVF, not women with Asherman's syndrome or a damaged basal layer, the thresholds are where the curve flattens rather than cut-offs for treatment, and funding is not stated. The single biggest weakness is that it cannot say whether anything that thickens the lining or restores its pattern improves live birth. [moderate]",
      "qualityGrade": "moderate",
      "meaning": "For a woman with a thin lining after Asherman's treatment, the chance of a live birth per frozen transfer rises steeply with thickness up to about 9 to 10 mm and then flattens, and below 10 mm a three-layer (trilaminar) pattern does better at any thickness. It supports my position that the pattern carries weight (EXPERTISE, Asherman's: the trilaminar pattern matters more than thickness), but it does not say that pattern matters more than thickness: both matter, and the pattern counts most when the lining is thin. It does not tell me whether PRP, oestrogen or anything else that changes the measurement changes the outcome, and the women did not have Asherman's syndrome.",
      "verdict": "Supports current practice",
      "reason": "Useful numbers for counselling Asherman's and thin-endometrium patients before transfer, confirming thinness is a graded rather than a threshold problem and that the trilaminar pattern carries weight; observational, so it cannot say whether treating the lining improves outcomes.",
      "conflicts": "Funding not stated in the abstract.",
      "reviewed": true,
      "reviewedOn": "2026-10-19",
      "page": "https://migynaecology.com/evidence/ashermans-intrauterine-adhesions/#pmid-42874765"
    },
    {
      "digest": "2026-10-19",
      "digestId": "2026-10-19",
      "catchUp": false,
      "rank": 6,
      "streams": [
        "endometriosis-adenomyosis"
      ],
      "title": "Structured MRI reports for deep endometriosis are more complete and more useful to surgeons, but take longer: randomised reader study",
      "authors": "Burgart L, Host A, Gabriele V, et al",
      "journal": "Abdom Radiol (NY)",
      "year": 2026,
      "pmid": "42891704",
      "doi": "10.1007/s00261-026-05838-x",
      "url": "https://pubmed.ncbi.nlm.nih.gov/42891704/",
      "citation": "Burgart L, Host A, Gabriele V, et al. Structured MRI reports for deep endometriosis are more complete and more useful to surgeons, but take longer: randomised reader study. Abdom Radiol (NY). 2026. PMID 42891704. doi:10.1007/s00261-026-05838-x",
      "study": "Single-centre randomised reader study in France: 20 radiology residents were assigned to free-text or structured reporting, 15 completed the same 22 pelvic MRI examinations (330 reports: 154 free-text, 176 structured), judged against a reference standard set by two pelvic radiologists; in an exploratory paired assessment two expert gynaecological surgeons rated 44 reports, one of each format per examination.",
      "finding": "Structured reports were more complete (+8.1 percentage points, 95% CI 4.1-12.1; clinically weighted +5.6, 95% CI 1.3-10.0) and were rated higher by the surgeons for completeness, usefulness for decision-making and adequacy to clinical needs, with similar clarity; they took 4.52 minutes longer (95% CI 3.05-5.99) and carried nearly three times as many explicit negative statements that contradicted the expert reference (rate ratio 2.94, 95% CI 1.73-4.98), mainly compartment-based 'no disease' lines.",
      "quality": "Randomising the readers is the right way to compare report formats, and 330 reports against an expert reference standard with mixed-effects models is a careful design; but it is one French centre, the readers were 15 radiology residents rather than the specialist radiologists who report his MRIs, five of the 20 assigned readers dropped out before reporting, and 22 examinations are few. The surgeon-usefulness result is exploratory, from two surgeons rating 44 reports, and funding is not stated. The single biggest weakness is that the readers were trainees, so the gain from structure may be smaller for an expert endometriosis radiologist. [moderate]",
      "qualityGrade": "moderate",
      "meaning": "For the woman with suspected deep endometriosis, this supports asking for an MRI report that works through each compartment of the pelvis, as the specialist endometriosis radiologist in my multidisciplinary team does (EXPERTISE, deep endometriosis; endometriosis page, 'How I assess endometriosis'): structured reports were more complete and surgeons found them more useful. It also warns that a template tempts the reader to write 'no disease' for a compartment that was not properly assessed, nearly three times as often, so a negative line in a structured report is not a clearance. It does not tell me whether structured reports change what is found at surgery.",
      "verdict": "Supports current practice",
      "reason": "Backs asking for compartment-based structured MRI reports before deep endometriosis surgery, with the caveat that an explicit 'no disease' statement for a compartment is not always right and the readers were trainees.",
      "conflicts": "Funding not stated in the abstract.",
      "reviewed": true,
      "reviewedOn": "2026-10-19",
      "page": "https://migynaecology.com/evidence/endometriosis-adenomyosis/#pmid-42891704"
    },
    {
      "digest": "2026-10-19",
      "digestId": "2026-10-19",
      "catchUp": false,
      "rank": 7,
      "streams": [
        "ashermans-intrauterine-adhesions"
      ],
      "title": "Fluoroscopy-guided adhesiolysis for severe Asherman's: what 26 papers show",
      "authors": "Dreisler E, Hansen BB, Kjer JJ",
      "journal": "J Gynecol Obstet Hum Reprod",
      "year": 2026,
      "pmid": "42887819",
      "doi": "10.1016/j.jogoh.2026.103305",
      "url": "https://pubmed.ncbi.nlm.nih.gov/42887819/",
      "citation": "Dreisler E, Hansen BB, Kjer JJ. Fluoroscopy-guided adhesiolysis for severe Asherman's: what 26 papers show. J Gynecol Obstet Hum Reprod. 2026. PMID 42887819. doi:10.1016/j.jogoh.2026.103305",
      "study": "Danish literature review with a systematic search of Embase and Medline from 1974 to February 2026: 617 records, 26 papers included on fluoroscopy-guided hysteroscopic adhesiolysis for severe Asherman's syndrome; no pooled analysis and no comparison with ultrasound or laparoscopic guidance.",
      "finding": "After fluoroscopy-guided adhesiolysis the series report a high rate of restored cavity anatomy and improved menstruation, pregnancy rates of 75-87% and live birth rates of 63-68%, an increased risk of placenta accreta spectrum in later pregnancies, and minimal radiation exposure, with median exposure times and doses well within safe limits.",
      "quality": "A literature review with a systematic search of two databases and 26 included papers, but without stated inclusion criteria, quality assessment, pooling or any comparison with ultrasound or laparoscopic guidance, so the pregnancy and live birth ranges are those of selected case series, mostly from the few units that use the technique; funding is not stated, and the Danish setting is close to UK practice. The single biggest weakness is that there is no comparator, so it cannot say fluoroscopy is better or worse than the ultrasound guidance he uses. [weak]",
      "qualityGrade": "weak",
      "meaning": "For a woman with severe Asherman's syndrome, this confirms that dense adhesions can be divided safely under imaging guidance and that pregnancy after adhesiolysis carries a higher risk of the placenta growing too deeply, which the Asherman's page and my letters already say. It gives no reason to move from ultrasound guidance (EXPERTISE, Asherman's: dense adhesions divided under intraoperative ultrasound in preference to laparoscopic guidance) to fluoroscopy, and the quoted pregnancy rates of 75-87% and live birth rates of 63-68% come from selected series and must not be quoted as expectations; the site promises no success rates.",
      "verdict": "No change",
      "reason": "Series-level evidence that supports fluoroscopy as an option for severe cases, not a reason to change the ultrasound guidance used now; the accreta risk belongs in every post-adhesiolysis pregnancy letter.",
      "conflicts": "Funding not stated in the abstract.",
      "reviewed": true,
      "reviewedOn": "2026-10-19",
      "page": "https://migynaecology.com/evidence/ashermans-intrauterine-adhesions/#pmid-42887819"
    },
    {
      "digest": "2026-10-19",
      "digestId": "2026-10-19",
      "catchUp": false,
      "rank": 8,
      "streams": [
        "endometriosis-adenomyosis"
      ],
      "title": "Estetrol/drospirenone for endometriosis pain: better than placebo, no better than other hormonal treatment, on 198 women",
      "authors": "Leitão MO, Rodrigues de Sousa FT, Cunha GR, et al",
      "journal": "Eur J Obstet Gynecol Reprod Biol",
      "year": 2026,
      "pmid": "42892004",
      "doi": "10.1016/j.ejogrb.2026.115500",
      "url": "https://pubmed.ncbi.nlm.nih.gov/42892004/",
      "citation": "Leitão MO, Rodrigues de Sousa FT, Cunha GR, et al. Estetrol/drospirenone for endometriosis pain: better than placebo, no better than other hormonal treatment, on 198 women. Eur J Obstet Gynecol Reprod Biol. 2026. PMID 42892004. doi:10.1016/j.ejogrb.2026.115500",
      "study": "Systematic review to Cochrane and PRISMA standards (PubMed, Embase, CENTRAL; two independent reviewers, risk-of-bias assessment) of estetrol 15 mg with drospirenone 3 mg for endometriosis symptoms: two randomised trials and two observational cohorts, 198 women in all; no meta-analysis was possible.",
      "finding": "The pill reduced pelvic pain compared with placebo, with no significant difference against other active hormonal regimens; it improved dysmenorrhoea and quality of life (sleep, global improvement, overall health status); dyspareunia results were inconsistent; intermenstrual bleeding or spotting was the commonest side effect. No effect sizes are given in the abstract and nothing could be pooled.",
      "quality": "A systematic review to Cochrane and PRISMA standards with two independent reviewers is the right method, but it found only two randomised trials and two cohorts, 198 women in all, could pool nothing and reports no effect sizes in the abstract; the comparison with other hormonal treatments, which is the question that matters in clinic, showed no difference. Funding of the review and of the included trials is not stated in the abstract; the product is a proprietary pill, so manufacturer involvement in the trials should be checked in the full text before any entry is published. The single biggest weakness is size and the absence of any pooled estimate. [weak]",
      "qualityGrade": "weak",
      "meaning": "For a woman choosing a hormonal treatment for endometriosis pain, this says the newer estetrol pill reduces pain compared with placebo, as combined pills generally do, with no evidence that it beats the pills and progestogens already used, and spotting as its commonest side effect. It does not change what the endometriosis page says about hormonal treatment, which names no medicines (site rule), and it gives no reason to prefer it; it is an option for a woman who wants it or who tolerates other pills poorly.",
      "verdict": "No change",
      "reason": "Too little evidence to prefer this pill over the combined pills and progestogens already used; it is an option for women who want it.",
      "conflicts": "Funding not stated in the abstract; proprietary product, so the included trials' sponsorship should be checked in the full text.",
      "reviewed": true,
      "reviewedOn": "2026-10-19",
      "page": "https://migynaecology.com/evidence/endometriosis-adenomyosis/#pmid-42892004"
    },
    {
      "digest": "2026-10-19",
      "digestId": "2026-10-19",
      "catchUp": false,
      "rank": 10,
      "streams": [
        "endometriosis-adenomyosis"
      ],
      "title": "About 1 in 100 women are first diagnosed with endometriosis after the menopause, mostly after a surgical menopause; HRT after a natural menopause did not raise the risk: Nurses' Health Study II",
      "authors": "Kulkarni MT, Shafrir AL, Eliassen AH, et al",
      "journal": "Maturitas",
      "year": 2026,
      "pmid": "42887272",
      "doi": "10.1016/j.maturitas.2026.109152",
      "url": "https://pubmed.ncbi.nlm.nih.gov/42887272/",
      "citation": "Kulkarni MT, Shafrir AL, Eliassen AH, et al. About 1 in 100 women are first diagnosed with endometriosis after the menopause, mostly after a surgical menopause; HRT after a natural menopause did not raise the risk: Nurses' Health Study II. Maturitas. 2026. PMID 42887272. doi:10.1016/j.maturitas.2026.109152",
      "study": "Prospective analysis of the population-based Nurses' Health Study II in the United States: 80,148 women with no report of endometriosis before the menopause, followed from the first questionnaire reporting menopause (baseline 1989) to 2019 for a laparoscopically confirmed first diagnosis of endometriosis after the menopause, analysed by age at menopause, surgical or natural menopause and hormone use with multivariable Cox models.",
      "finding": "883 women (1.1%, about 1 in 90) reported a first diagnosis of endometriosis after the menopause, at a median age of 50.6 years (48.5 after a surgical menopause, 54.7 after a natural one), a median 4.0 years after it; 69.9% of the diagnoses followed a surgical menopause and 69.5% were in current hormone users. Compared with a natural menopause without hormones (110 cases), hormone use after a natural menopause carried no excess (137 cases; HR 1.16, 95% CI 0.89-1.49), whereas a surgical menopause carried a higher risk both without hormones (78 cases; HR 5.79, 95% CI 4.29-7.81) and, to a lesser degree, with them (477 cases; HR 3.86, 95% CI 3.08-4.82). The authors read the cases as a mixture of unrecognised persistent or recurrent disease and new lesions.",
      "quality": "A large prospective cohort followed for 30 years with a laparoscopically confirmed outcome and adjusted Cox models is strong for a question no trial could answer, and 883 cases give precise estimates; but the women are American nurses, the outcome depends on who was investigated (women after a surgical menopause with gynaecological symptoms are more likely to be looked inside, a surveillance bias the hazard ratios cannot remove), hormone use is self-reported and not separated into oestrogen-only and combined, and the authors cannot tell new disease from disease missed before the menopause. Funding is not stated in the abstract. The single biggest weakness is that it concerns women with no known endometriosis, not the woman who has had endometriosis surgery and is deciding about HRT. [moderate]",
      "qualityGrade": "moderate",
      "meaning": "For a woman considering HRT after a natural menopause, this is reassuring: hormone use did not increase the chance of endometriosis being found. For a woman who has had her ovaries removed, endometriosis can still be diagnosed years later, with or without HRT, so symptoms after a surgical menopause deserve investigation rather than reassurance. It sits beside, but does not test, my position on HRT after endometriosis surgery (oestrogen-only after complete excision; continuous combined where disease is left behind, British Menopause Society, February 2026), because these women had no known endometriosis and the type of HRT is not given; the hysterectomy page's advice on HRT after the ovaries are removed stands.",
      "verdict": "Supports current practice",
      "reason": "Confirms that endometriosis can present after a surgical menopause, which is why combined rather than oestrogen-only HRT is advised where disease is left behind, and that HRT after a natural menopause does not bring it on; it does not test the choice of HRT regimen.",
      "conflicts": "Funding not stated in the abstract.",
      "reviewed": true,
      "reviewedOn": "2026-10-19",
      "page": "https://migynaecology.com/evidence/endometriosis-adenomyosis/#pmid-42887272"
    }
  ]
}