Cope, Adela G.

Abstract Introduction: Laparoscopic salpingectomy is a commonly performed procedure and is often one of the first laparoscopic procedures performed by novice residents in Obstetrics and Gynecology (OB/GYN). Opportunities to practice before the operating room can be limited. Methods: We developed an animal tissue model and incorporated it into a laparoscopic salpingectomy simulation for OB/GYN residents in a single academic program. The simulation included a pre-simulation video describing the steps of laparoscopic salpingectomy, the laparoscopic salpingectomy simulation using an electrosurgical device, a post simulation survey, and debriefing with learner targeted feedback. Validity evidence for the simulation model was gathered using the Messick framework. Resident performance was assessed using the Objective Structured Assessment of Laparoscopic Salpingectomy (OSA-LS) and the Global Operative Assessment of Laparoscopic Skills (GOALS). Performance was correlated to the year of training with upper-level residents grouped for analysis. Results: Twenty-five simulations of laparoscopic salpingectomy were performed by 14 learners (first through fourth year). The tool was highly rated by participants. We found a significant correlation between the mean OSA-LS score and surgical experience. The mean GOALS score also increased with experience and was significantly different between 1st and 2nd years and between 1st and upper-level residents. A passing score of 12 was established for each assessment rubric. Discussion: This low-cost surgical model addresses a gap in simulation options for preoperative use of electrosurgical devices. This simulation can be used in OB GYN residency as a method to assess competency or provide feedback.

Abstract Disclosure: A. Zhang: None. J. Kapoor: None. C. Deveney: None. A.G. Cope: None. M.M. Walther-Antonio: None. N. Chia: None. C.W. Pattanayak: None. M.J. Tetel: None. The vaginal microbiome (VM) consists of the microorganisms and their metabolites residing in the vaginal tract and is critical for maintaining female reproductive health. The Lactobacillus species predominate most VMs and produce lactic acid, which has been cited as a key protector of vaginal health. Alterations in the finely balanced vaginal microbiome can cause infections, such as bacterial vaginosis, and may contribute to the development of endometrial and ovarian cancer. While it is well-established that stress and the gut microbiome impact each other via the gut-brain axis, the influence of stress, hormones, and lifestyle factors on the VM composition remains poorly understood. We investigated the relationship between stress, hormones (menstruation, hormonal contraception), lifestyle factors (diet, exercise, sleep), and the VM composition. In this 10-week study, healthy, young female volunteers (n=62) provided daily vaginal and fecal swabs, weekly stress ratings, daily data on sleep and activity (via FitBit) and diet information. High-throughput 16S rRNA sequencing was used to identify the vaginal microbial composition of each sample. Types of hormonal birth control were none (n=30), local progestin (n=9), systemic progestin-only (n=7), or systemic estrogens and progestin combined (n=16). Consistent with our previous study, vaginal microbial diversity, as measured by the Shannon index, varied by type of hormonal birth control, with participants not on hormonal birth control having the highest average diversity. There was a positive relationship between average stress and vaginal microbial diversity, with preliminary results suggesting that this relationship depends on hormonal birth control status. Participants who menstruated during the 10-week study had a higher vaginal microbial diversity than those who did not. We are currently analyzing which microbes contribute to these differences in vaginal microbial diversity. Microbiota and fungal data from the daily vaginal and fecal swab samples will be analyzed to determine how stress, hormones and/or lifestyle factors relate to crosstalk between the vaginal and gut microbiomes. These findings may provide long-term, time-longitudinal insights into how these two important microbiomes are involved in important aspects of women’s health. Presentation: Sunday, July 13, 2025

Purpose of review We present a review of the natural progression, response to hormonal therapy, and risk of malignancy associated with deep endometriosis (DE) to guide evidence-based discussion of conservative treatment. Recent findings Advanced imaging protocols have enhanced nonsurgical detection of DE, allowing noninvasive diagnosis, treatment, and surveillance. While some DE is progressive, 50% of disease appears stable over time, and progression is reduced by half with hormonal treatments (21 versus 12%). Hormonal treatment can reduce the size of DE lesions by 1 cm³, with reductions occurring after 6 months and remaining stable up to 3 years. Most hormonal therapies improve symptoms and quality of life, regardless of changes in DE size, with combined contraceptives and progestins being the most studied. DE may present a higher risk of ovarian and extraovarian cancer than previously hypothesized, though further research is needed to confirm findings. Limitations of DE research include differing imaging strategies, definitions of disease and progression, short follow-up, focus on rectosigmoid DE only, and lack of randomized trials. Summary DE is a subtype of endometriosis that is increasingly diagnosed and treated with noninvasive strategies. Hormonal treatments improve symptoms and reduce progression of DE. Further research on optimal conservative management and risk of malignancy is warranted.

Abstract Background: Rectosigmoid endometriosis (RSE) presents with a diverse array of MRI findings that impact surgical planning. No standardized reporting and data system has been established for RSE. Purpose: We propose a novel MRI scoring system designed to predict the likelihood of muscularis propria (MP) involvement in RSE, which would, in turn, influence surgical planning. Material and Methods: The records of patients with bowel endometriosis treated surgically from May 2018 to June 2022 were retrieved. Surgery was classified as partial thickness discoid, full thickness discoid, or segmental resection. Each pre-treatment MRI was scored based on the mutual agreement of two abdominal radiologists (reference score). The MRI score was defined as (1) score 0: no evidence of RSE, (2) score 1: minimal tethering involving the serosal surface without MP involvement, (3) score 2: intermediate soft tissue thickening involving the rectosigmoid colon with indeterminate MP involvement, or (4) score 3: definite mushroom cap sign or definite MP involvement. In the reader study, two radiologists independently scored each exam. The area under the curve (AUC) was evaluated for predicting the need for segmental or full thickness discoid resection. Results: The cohort consisted of 95 patients (median age: 36 years); 16, 14, 30, and 35 patients had MRI score 0, 1, 2, and 3, respectively. Patients with MRI scores 3 and 2 underwent partial thickness discoid (6% vs 50%), full thickness discoid (6% vs 17%), and segmental resection (89% vs 33%), respectively. All patients with MRI scores 1 or 0 either underwent partial thickness discoid resection or did not undergo rectosigmoid surgery. The AUCs were 92.2%, 84.5% and 93.9% for MRI scores of the reference, reader 1, and 2, respectively. Conclusion: Our MRI scoring system based on suspected depth of bowel invasion showed good diagnostic performance to predict the type of surgical intervention needed. Summary Statement This novel MRI scoring system for rectosigmoid endometriosis is a concise and qualitative scale based on suspected depth of bowel wall invasion to best guide operative planning.

Purpose of review Endometriosis is a complex benign gynaecologic condition with heterogenous presentations and a large impact on the global healthcare system and on the quality of life for millions of women. Currently, the gold standard for diagnosis involves direct visualization of lesions during surgery confirmed by histopathological diagnosis, resulting in an average delay in its initial diagnosis of 8–10 years. Therefore, the search for noninvasive diagnostic testing options has been subject to a large body of research. Recent findings Multiple potential biomarkers have been explored for noninvasive testing for endometriosis, including glycoproteins, inflammatory cytokines, immunological molecules, angiogenesis markers, hormones, micro RNAs (miRNAs), proteomics, metabolomics, genomics and the microbiome. Summary Although there are challenges to consider, areas for real promise and advancement in the noninvasive diagnosis of endometriosis are currently being explored with real promise in the area of miRNAs, proteomics, metabolomics, genomics and the microbiome.

INTRODUCTION: Emergencies during gynecologic office procedures are uncommon. However, knowledge in management of these complications is essential as more gynecologic procedures move from the operating room to the office. Our goal was to develop an interactive curriculum to address a gap in residency training in the management of office-based procedural emergencies. METHODS: A curriculum including management of unanticipated bleeding, anaphylaxis, vasovagal response, and local anesthetic systemic toxicity (LAST) was developed and implemented using a combination of simulated patient sessions, a “choose-your-own-adventure” PowerPoint, and a mock oral board session. Pre and post intervention surveys queried participants’ confidence in recognition and management. The curriculum was delivered as in-person simulation sessions or virtual sessions due to COVID restrictions. Institutional review board (IRB) approval was obtained. Mean pre and post intervention scores were compared using paired t-test. RESULTS: Four accredited obstetrics and gynecology residency programs participated. Twenty-nine trainees completed the curriculum, and 24 submitted pre and post surveys (82.8% response rate). There was significant improvement in confidence scores for management of unanticipated bleeding (mean difference 0.96, P<.001), anaphylaxis (mean difference 1.7, P<.001), vasovagal response (mean difference 1.0, P<.001), and LAST (mean difference 2.5, P<.001). Additionally, significant improvement in confidence scores for identification of risk factors and signs/symptoms of vasovagal response (mean difference 0.96, P<.001, and 0.46, P=.005) and LAST (mean difference 2.3, P<.001, and 2.2, P<.001) was noted. CONCLUSION: Implementation of an office emergencies curriculum significantly increased confidence in identification and management of unanticipated bleeding, anaphylaxis, vasovagal response, and LAST. Future studies evaluating knowledge-based assessments of learners are needed.

INTRODUCTION: Nonrelaxing pelvic floor dysfunction (PFD) is a condition characterized by tension of the pelvic floor musculature, often resulting in pelvic pain. The objective of this study was to review patient-reported pain outcomes following treatment of nonrelaxing pelvic floor dysfunction to identify gaps in current evidence. METHODS: A systematic review of the following databases from inception to July 2020 was performed: Ovid MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus. Two authors reviewed titles and abstracts for relevance, and full articles were obtained and evaluated for inclusion. Studies were included if they assess interventions for nonrelaxing PFD characterized by pelvic pain. The third author was consulted in instances of disagreement. RESULTS: Of the 1,184 abstracts identified and reviewed, 36 full text articles were reviewed. Treatments for nonrelaxing PFD included biofeedback, botulinum toxin injections, electrical stimulation, intravaginal diazepam, massage, osteopathy, psychiatric interview, physical therapy, sacral nerve stimulation, trigger point injection, and combined therapies. Nineteen studies assessed the effectiveness of treatment based on patient reported pain outcomes. All studies demonstrated an improvement in pelvic pain. Several limitations were identified including varied pre-treatment diagnostic evaluation, small sample size, retrospective and single arm design, heterogeneity in treatment administration within and between studies, lack of standardized pain assessments, and limited long term outcome data. CONCLUSION: Nonrelaxing PFD is a debilitating condition. There is a paucity of high-quality clinical trials evaluating the effectiveness of pelvic floor muscle dysfunction treatments. Although preliminary studies support multi-modal treatment options, robust trials assessing patient-centered outcomes are necessary.

INTRODUCTION: While rare, emergencies encountered during office procedures have the potential for significant morbidity if the team is caught unprepared. The aim of this study was to evaluate current availability of and needs for training in office emergencies in residency programs in the United States. METHODS: This was a cross-sectional survey of residents from accredited obstetrics and gynecology residency programs. Identified programs were those with representation in the American College of Obstetricians and Gynecologists Simulation Working Group (ACOG SWG). A multi-item instrument was developed, designed, and edited by representatives of the ACOG SWG for accuracy and content validity. Participants were asked to rate their level of agreement with statements on importance of training in the recognition and management of obstetrics and gynecology emergencies and their confidence in management of those emergencies. Specific emergencies encountered in the office, gynecologic surgery, and obstetrics were queried. RESULTS: Six programs participated for a total of 116 residents and a response rate of 62% (116/188). Most residents agreed office emergency (97.5%) and obstetric emergency training (94.8%) were important in residency training. While 65.5% were confident in managing a vasovagal episode in the office, 0.9% were confident in managing lidocaine toxicity. In contrast, the majority of residents felt confident in obstetric emergency management across all listed emergencies (hemorrhage, cord prolapse, shoulder dystocia, eclampsia). CONCLUSION: While rated as important to residency training, significant gaps exist within resident preparation for identification and management of office-based emergencies, providing an opportunity for curriculum development and education.

Objective: To determine if gastrointestinal (GI) symptoms can predict deep endometriosis (DE) of the posterior pelvic compartment on magnetic resonance imaging (MRI). Methods: Patients with suspected endometriosis undergoing endometriosis protocol MRI at an academic center between 9/1/2015 and 7/31/2018 were identified. Presenting GI symptoms were collected via a standardized survey instrument prospectively at initial presentation. MRI and interdisciplinary conference notes were reviewed to identify posterior compartment DE (rectosigmoid, uterosacral ligaments, posterior cul de sac, and pelvic side walls). Associations between symptoms and DE were evaluated. Results: A total of 104 patients met inclusion criteria, and 89 (85.6%) presented with at least one GI symptom. Posterior compartment DE was identified on MRI in 47 patients (45.2%). The GI symptom that most strongly predicted DE was a bowel movement resulting in pain relief (OR 3.36, 95% CI 1.31–8.61, p = 0.012), with sensitivity, specificity, positive and negative predictive values 0.42, 0.82, 0.67, and 0.63, respectively. Other GI symptoms such as nausea, vomiting, rectal bleeding, change in frequency of bowel movements, and pain exacerbation by bowel movements did not significantly correlate to having DE. Of the 15 patients with no GI symptoms, 5 were found to have posterior compartment DE. Conclusion: In patients with suspected endometriosis, those who noted that bowel movements relieved their pain had more than three times the odds of having DE of the posterior compartment on MRI. Preoperative evaluation with MRI may be of value in these patients; however, lack of gastrointestinal symptoms does not exclude the possibility of posterior compartment DE.