What's new in endo & adenomyosis research

This document presents Version 1 (2026) of the ISON Neuropelveological Guidelines for Pelvic Nerve-Sparing Surgery in Gynecology, developed under the auspices of the International Society of Neuropelveology (ISON). The guidelines propose a neurofunctional framework for preserving pelvic neurological function during gynecologic surgery, with particular emphasis on radical hysterectomy for cervical cancer and surgery for deep endometriosis. They integrate the historical development of nerve-sparing surgery, pelvic neurofunctional anatomy, mechanisms of surgical nerve injury, intraoperative electrical stimulation and functional mapping, and postoperative assessment of urinary, colorectal, and sexual function. The central principle is that nerve-sparing surgery should be defined by preservation of neurological function rather than by the extent of anatomical nerve exposure. Neural identification and dissection should be tailored to disease distribution and surgical necessity, while uninvolved neural pathways should remain undisturbed whenever possible. In oncological surgery, nerve preservation must not compromise oncological radicality. Practical recommendations address surgical planning, targeted neural identification, unilateral and bilateral preservation, postoperative functional surveillance, and reporting standards. Particular attention is given to bladder emptying, bladder filling sensation, and the prevention of secondary damage associated with unrecognized postoperative dysfunction. Intended for gynecologic surgeons, gynecologic oncologists, endometriosis specialists, neuropelveologists, and clinicians involved in pelvic functional care, this document provides a framework for surgical practice, training, and future research into the preservation and restoration of pelvic neurological function.

Background Adenomyosis (AM) is characterized by ectopic endometrial invasion and myometrial fibrosis, yet the molecular links between local metabolic remodeling, lysine crotonylation (Kcr), and epithelial dysfunction remain poorly understood. We investigated the metabolic and crotonylation-related landscape of AM and sought to identify epithelial molecular features associated with these alterations. Methods Clinical metabolic profiles, public and newly generated tissue metabolomic data, crotonyl-CoA measurements, and tissue crotonylation assays were integrated with single-cell and bulk transcriptomic analyses. Kcr-related transcriptional patterns were characterized using multiple gene-set scoring approaches and co-expression analysis, followed by multi-algorithm feature prioritization. SDC4-associated epithelial states were further examined using trajectory inference, cell-cell communication analysis, transcription-factor prediction, and in silico perturbation. Results Adjusted clinical analyses showed no robust differences in circulating lipid profiles, whereas tissue-level metabolomic analyses revealed alterations in lipid- and lysine-related metabolites in AM. Crotonyl-CoA estimates were higher in AM tissue, accompanied by increased H3K18cr. A higher p65-associated Kcr signal was also observed in a single IP comparison; given that only one IP measurement was available per group, this finding should be considered a preliminary descriptive observation. Single-cell analyses identified prominent Kcr-related transcriptional patterns in epithelial cells and linked this state to adhesion, junctional organization, and epithelial remodeling. SDC4 was consistently prioritized across five machine-learning procedures and was predominantly expressed in epithelial populations. SDC4-positive epithelial cells exhibited distinct inferred differentiation states and intercellular communication patterns, while computational perturbation further implicated SDC4-associated networks in epithelial adhesion, cytoskeletal organization, and junctional regulation. Conclusion These findings connect local metabolic remodeling and crotonylation-related alterations with a distinct epithelial transcriptional state in AM and identify SDC4 as a consistently prioritized candidate associated with epithelial remodeling. The preliminary p65-associated Kcr observation provides additional context for investigating potential associations among Kcr, p65, and SDC4-related epithelial programs.

Endometriosis is a chronic, estrogen-dependent inflammatory disease and a major contributor to female infertility. Endometriosis-associated infertility arises from interacting anatomical and biological mechanisms, including pelvic adhesions and tubal dysfunction, reduced ovarian reserve, altered follicular and oocyte competence, oxidative stress, immune dysregulation, and impaired endometrial function. This narrative review integrates current concepts of disease pathogenesis with evidence-based fertility management. It first examines the molecular, cellular, and immune processes that support ectopic lesion establishment and may impair reproduction. It then discusses diagnostic phenotyping, infertility evaluation, prognostic tools, medical suppression, fertility-preserving surgery, intrauterine insemination, and in vitro fertilization. Particular attention is given to the strength and clinical relevance of current evidence, including surgery for ovarian endometrioma before assisted reproduction, prolonged gonadotropin-releasing hormone agonist pretreatment, fresh versus frozen embryo transfer, and the use of intracytoplasmic sperm injection without male-factor infertility. Emerging anti-angiogenic, immunomodulatory, antioxidant, stem-cell, and gene- or epigenetic-based interventions remain investigational. Because neither a single treatment nor a single assisted-reproduction protocol is optimal for all patients, management should integrate age, ovarian reserve, symptom burden, disease phenotype, prior surgery, coexisting infertility factors, and reproductive priorities. Mechanistically informed clinical trials using live birth and patient-centered outcomes are needed to advance precision fertility care.

A endometriose está associada à infertilidade e pode influenciar os resultados da reprodução assistida por diferentes mecanismos anatômicos, inflamatórios e hormonais. Esta revisão integrativa teve como objetivo analisar as evidências sobre a transferência de embriões congelados (FET) em mulheres com endometriose e/ou adenomiose, com enfoque nas estratégias de preparo endometrial, nas concentrações séricas de progesterona e nos desfechos reprodutivos e obstétricos. Foi realizada busca na base PubMed, em setembro de 2026, utilizando os descritores “Frozen Embryos” e “Endometriosis”, combinados pelo operador AND, considerando estudos publicados entre 2021 e 2026. Dos 41 estudos identificados, quatro estudos observacionais retrospectivos atenderam aos critérios de inclusão. Os resultados demonstraram que a endometriose não esteve associada de forma consistente a menores concentrações séricas de progesterona. Entretanto, níveis de progesterona avaliados em momentos específicos do ciclo apresentaram associação com maiores taxas de gravidez clínica e nascimento vivo, especialmente em determinados subgrupos. Além disso, o tipo de preparo endometrial esteve relacionado a alguns desfechos obstétricos em mulheres com endometriose, embora não tenha sido demonstrada superioridade universal de ciclos naturais ou artificiais. Entre pacientes com adenomiose submetidas a ciclos hormonais, concentrações mais elevadas de progesterona estiveram associadas ao nascimento vivo. Conclui-se que a escolha do preparo endometrial em mulheres com endometriose deve ser individualizada, considerando a presença de adenomiose, o protocolo utilizado e o momento da avaliação da progesterona. São necessários estudos prospectivos e ensaios clínicos para estabelecer parâmetros hormonais e estratégias de preparo mais precisos para essa população.

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Наружный генитальный эндометриоз остается одним из наиболее значимых заболеваний и встречается, по современным эпидемиологическим оценкам, у 6-10% женщин репродуктивного возраста. Тяжелые формы заболевания с поражением ретроцервикальной зоны и кишечника представляют наибольшую сложность для диагностики и хирургического лечения, требуют мультидисциплинарного подхода и тщательного баланса между радикальностью вмешательства и сохранением репродуктивной функции. В представленном клиническом случае было выполнено органосохраняющее лапароскопическое вмешательство в объеме иссечения очагов эндометриоза, билатеральной цистэктомии с энуклеацией капсул эндометриом и адгезиолизиса у пациентки 43 лет с тяжелым наружным генитальным эндометриозом: двусторонними эндометриомами яичников диаметром до 9 см, ретроцервикальным эндометриозом и вовлечением ректосигмоидного отдела толстой кишки.

Low-grade chronic inflammation plays an important role in the pathogenesis of many gynecological diseases, including polycystic ovary syndrome (PCOS), uterine fibroids, premenstrual syndrome (PMS), premenstrual dysphoric disorder (PMDD) and endometriosis. The aim of this paper was to present the assumptions of the anti-inflammatory diet and review the current state of knowledge about its potential importance in these diseases. An anti-inflammatory diet based on increased intake of omega-3 fatty acids, fiber and polyphenols, while reducing the intake of pro-inflammatory foods, has the potential to reduce pro-inflammatory cytokine levels and alleviate clinical symptoms. The Mediterranean diet has the best documented dietary model with anti-inflammatory effects. Available scientific data indicate the beneficial effect of dietary interventions on the hormonal and metabolic profile of PCOS, pain severity in uterine fibroids and endometriosis and the exacerbation of somatic and affective discomfort in PMS/PMDD. However, the quality of scientific evidence remains variable, and an anti-inflammatory diet should be considered an adjunct to standard treatment, rather than an alternative to it. Further randomized clinical trials are required to conclusively define the role of individual components of the anti-inflammatory diet in this disease group.

Folder sobre a conscientização da endometriose, abordando conceito, prevalência, sintomas frequentes, diagnóstico e formas de tratamento. Destaca sinais como dor pélvica crônica, dor durante a relação sexual, alterações menstruais, dificuldade para engravidar e alterações intestinais e urinárias, além de apresentar informações sobre diagnóstico clínico e por exames de imagem e opções terapêuticas.

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Endometriosis is a chronic, estrogen-dependent inflammatory disorder affecting approximately ten percent of reproductive-age women worldwide. Despite its high prevalence and profound impact on quality of life, the biological mechanisms that sustain and amplify the disease remain incompletely understood. This critical narrative review synthesises peer-reviewed evidence published predominantly between 2013 and 2026 to examine how estrogen signalling, immune cell dysfunction, and peritoneal inflammation form a self-amplifying pathological circuit in endometriosis. Ovarian and locally synthesised estrogen acts through genomic receptors, particularly estrogen receptor beta (ERbeta), to confer apoptosis resistance upon ectopic stromal cells and to drive macrophage recruitment via the NF-kappaB/CCL2 axis. Phenotypically altered peritoneal macrophages, expanded regulatory T cells, functionally impaired natural killer cells, and activated mast cells collectively sustain an immune-tolerant microenvironment in which ectopic lesions survive and proliferate. The resulting inflammatory milieu, characterised by elevated interleukin-6, interleukin-8, tumour necrosis factor-alpha, and prostaglandin E2, feeds back to stimulate aromatase (CYP19A1) expression in ectopic tissue, thereby completing a self-reinforcing loop. Epigenetic silencing of ERalpha and progesterone receptor genes prevents effective progesterone-mediated immune regulation and further entrenches the disease. Current hormonal treatments interrupt individual nodes of this circuit but rarely achieve durable remission. Emerging evidence supports multi-target approaches incorporating Janus kinase inhibitors, natural compounds, and immunomodulatory strategies. This review offers a unified mechanistic framework to guide future research into biomarker discovery and therapeutics for endometriosis.

This article analyzes the clinical course of infertility in women of reproductive age, major risk factors, modern diagnostic approaches, and treatment outcomes. The relationship between infertility and ovulatory disorders, menstrual cycle abnormalities, tubal pathology, polycystic ovary syndrome, pelvic inflammatory diseases, reduced ovarian reserve, and endometriosis was evaluated. The importance of comprehensive diagnostic assessment and individualized treatment in improving reproductive function was assessed. The findings emphasize the importance of early reproductive health assessment, timely identification of infertility causes, and selection of individualized treatment strategies.

Corrected R1 release accompanying the revised manuscript submitted to the International Journal of Women's Health (manuscript 643362). This archive contains analysis code, cached inputs, derived result tables, reproducibility instructions and file checksums. The revision corrects variant-identity matching and duplicate handling, recalculates multiple-testing and power analyses, updates complete-window colocalization, and reanalyzes GSE7305 using paired samples. The corrected screen includes 9,157 unique gene–cell-type tests and prioritizes 10 genes across 28 MR/colocalization pairs. These findings support exploratory genetic prioritization and do not establish therapeutic efficacy. The README documents the reproducible analyses, archived ancillary results and remaining limitations.This record provides the corrected R1 analysis code and derived results for manuscript 643362. It supersedes the analysis files in the earlier deposit (https://doi.org/10.5281/zenodo.21234009) for the revised manuscript.

Background: Endometriosis causes pelvic pain and fatigue, impairing physical fitness and sports participation. While physical activity helps manage symptoms, precise exercise programming guidance remains limited. Aim: This narrative review evaluates sports science and clinical evidence relevant to individualized exercise programming for women with endometriosis. Material and methods: PubMed was the principal database, supplemented by Google Scholar and Scopus. The search covered publications from 2016–2026, including systematic reviews, meta-analyses, interventional studies, and guidelines. Evidence was classified as direct, component (multimodal), or extrapolated. Results: A favourable signal arises from progressive multimodal physical activity programmes, though evidence certainty is low and active components cannot be isolated. Yoga and assessment-guided pelvic floor training have direct, population-specific support. No validated endometriosis-specific FITT (Frequency, Intensity, Time, Type) training protocol is established. Modality selection should reflect dominant symptoms, pelvic floor findings, and responses to physical loading. Conclusions: Targeted physical activity is a valuable management component, but a universal training prescription is currently unjustified. A symptom-responsive framework is offered to guide exercise professionals; comparative dose-finding sports science trials are required before firm recommendations can be made.

Background: Abnormal uterine bleeding (AUB) is a frequent gynecological disorder affecting women of reproductive age and beyond. It presents as irregular, heavy, or prolonged bleeding, negatively impacting the quality of life for a significant proportion of women globally. The FIGO PALM-COEIN classification facilitates the distinction between structural and non-structural etiologies of AUB, supporting evidence-based management strategies. Objective: To analyze the pharmacological treatments, causative factors, risk profile, and management approaches for AUB in women attending the Obstetrics and Gynecology Department at MIMS Tertiary Care Hospital, Mandya. Methodology: This prospective crosssectional observational study enrolled 172 women aged 18—50 years who presented with AUB. Patient demographic information, menstrual history, comorbidities, structural findings (via USG and PALM-COEIN classification), diagnostic modalities, and treatment regimens were systematically recorded and analyzed utilizing descriptive statistics and a structured patient profile format. Results: Women aged 39—50 years comprised the majority of cases (51%), with irregular heavy bleeding being reported by 76.2%, frequently accompanied by pelvic pain and dysmenorrhea (55.2%). Thyroid disorders were the predominant comorbidity (87%), followed by PCOS (7%) and diabetes (3%). Structural etiologies determined using PALM-COEIN classification revealed leiomyoma as the leading cause (54.7%), with polyp (19.8%), adenomyosis (15.1%), and endometriosis (10.5%) also commonly seen. Most cases (64%) were managed surgically, while 36% received medical treatment. Meprate (48.4%) and Regesterone (33.9%) were the preferred oral hormonal agents, both representing progestin therapy. Paracetamol was the most commonly prescribed analgesic (51.9%), and Tranexamic acid (53%) was slightly favored over Mefenamic acid (47%) for antifibrinolytic intervention. Postoperative support centered on iron and vitamin supplementation, with Metronidazole and Ceftriaxone as the primary antibiotic regimen. Conclusion: AUB most often affects middleaged women, manifesting with irregular heavy bleeding and thyroid gland dysfunction as the most frequent comorbidity. Leiomyoma remains the principal structural cause. Surgical management predominates, while rational, individualized medical therapy supports comprehensive, patient-centered care. Early diagnosis and tailored treatment improve outcomes in AUB

La endometriosis es una enfermedad inflamatoria crónica, estrógeno-dependiente y heterogénea, asociada con dolor pélvico, infertilidad y deterioro significativo de la calidad de vida. Durante los últimos años, su abordaje ha experimentado una transformación sustancial, particularmente por el abandono progresivo de la laparoscopia como requisito universal para establecer el diagnóstico, el mayor protagonismo de la evaluación clínica y de las técnicas de imagen especializadas, y la incorporación de nuevas alternativas farmacológicas. El objetivo de esta revisión fue analizar críticamente la evidencia contemporánea sobre el diagnóstico y tratamiento de la endometriosis, integrando estrategias farmacológicas, quirúrgicas y reproductivas, así como los avances dirigidos hacia una atención individualizada. Se realizó una revisión narrativa estructurada de literatura científica y guías clínicas, priorizando publicaciones entre 2020 y 2026. El manejo actual debe orientarse por los síntomas, fenotipo y localización de la enfermedad, edad, deseo reproductivo, reserva ovárica, tratamientos previos y preferencias de la paciente. Las terapias hormonales continúan siendo fundamentales para el control del dolor, mientras que los antagonistas de la hormona liberadora de gonadotropinas amplían las opciones en casos refractarios. La cirugía mantiene indicaciones específicas y requiere una valoración individualizada, especialmente ante endometriomas, endometriosis profunda e infertilidad. La evidencia actual favorece un modelo longitudinal, multidisciplinario y centrado en la paciente.

Some women with adenomyosis respond poorly to progestins, and conventional grey-scale ultrasound cannot reliably identify them before treatment. This thesis reviews studies published in 2022–2025 on ultrasound elastography of adenomyotic lesions. Lesion stiffness is higher than that of normal myometrium, is accompanied by higher expression of fibrosis markers and correlates with the severity of dysmenorrhoea. In women treated with dienogest for six months, higher lesion stiffness was associated with symptom relapse after treatment was stopped. No study has yet reported a stiffness threshold that predicts insufficient response during treatment. Elastography therefore deserves evaluation as a component of prognostic models of response to progestin therapy.

Polypoid endometriosis (PEM) is a rare form of endometriosis characterized by polyp-like lesions and atypical clinical and imaging features. Although PEM is generally benign, extensive abdominopelvic involvement and unusual manifestations may create substantial diagnostic challenges. Massive hemorrhagic ascites is exceptionally uncommon in PEM, and its clinical characteristics and management remain poorly described. A 41-year-old woman presented with progressive postmenstrual abdominal distension for four months, with marked worsening during the last week. She had a history of adenomyosis and surgically confirmed ovarian endometriosis. Imaging demonstrated mixed adnexal masses, massive ascites, and omental thickening, while serum CA125 and CA19-9 levels were elevated. Approximately 4000 mL of hemorrhagic ascites was drained by ultrasound-guided paracentesis, and cytologic examination showed no malignant cells. Laparoscopic exploration revealed extensive dense adhesions and multiple friable polyp-like lesions diffusely involving the abdominopelvic cavity, omentum, and mesentery. Intraoperative frozen-section examination revealed benign findings, and final histopathological examination confirmed PEM. Whole-exome sequencing identified a BMP4 p.H251Y missense variant. Postoperatively, the patient received 6 courses of GnRHa therapy followed by Dienogest, with no evidence of recurrence during 9 months of follow-up. This case highlights an exceptionally rare presentation of PEM characterized with massive hemorrhagic ascites and extensive abdominopelvic lesions, closely mimicking advanced gynecologic malignancy. Increased awareness of this unusual presentation, together with appropriate clinical assessment, may facilitate accurate diagnosis and help avoid unnecessarily radical surgery. Given the limited number of reported PEM cases, further studies are needed to clarify the pathogenesis and optimal postoperative management of this rare disease.

В тезисе рассмотрены исследования 2021–2025 гг. о клинических и ультразвуковых признаках, позволяющих до начала лечения заподозрить недостаточный эффект диеногеста у пациенток с аденомиозом. Худший долгосрочный результат связан со старшим возрастом и высоким уровнем CA-125, а объём матки более 352,7 см³ указывает на повышенный риск неудачи терапии. Диффузная форма аденомиоза и сопутствующая миома ассоциированы с более слабым ответом. Длинник матки и толщина миометрия по данным трансвагинального исследования предсказывают кровотечения, из-за которых препарат чаще всего отменяют. Признаки MUSA связаны с тяжестью симптомов, но как предикторы ответа на диеногест не изучались. Предложен минимальный набор показателей для оценки перед назначением препарата.

Диеногест широко применяется для консервативного лечения аденомиоза, однако часть пациенток не получает достаточного облегчения боли или прекращает приём из-за маточных кровотечений. Цель обзора — обобщить опубликованные в 2021–2026 гг. данные о клинических, эхографических и эластографических показателях, которые позволяют выделить таких пациенток до начала лечения. Поиск выполнен в базах PubMed и Europe PMC, в обзор включено 19 публикаций. По данным метаанализов, диеногест снижает дисменорею в среднем на 5,86 см по визуальной аналоговой шкале, но результаты исследований очень неоднородны. С худшим результатом связаны старший возраст, высокий уровень CA-125, объём матки более 352,7 см³, диффузная форма аденомиоза, сопутствующая миома и кровотечения на фоне терапии; размеры матки лучше всего предсказывают кровотечения. Ультразвуковые признаки MUSA связаны с тяжестью симптомов, но как предикторы ответа на диеногест не изучались. Жёсткость очага по данным эластографии отражает выраженность фиброза, коррелирует с тяжестью дисменореи и ассоциирована с рецидивом после отмены препарата. Прогностическая модель, объединяющая три группы показателей, пока не создана и требует проспективной проверки.

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Ectopic adrenal cortical tissue (EACT) is an uncommon developmental heterotopia and is exceptionally rare in the ovary of adult women. A 52-year-old woman, 6 years after menopause, was evaluated for progressive enlargement of a uterine leiomyoma and postmenopausal spotting. Transvaginal ultrasonography and pelvic magnetic resonance imaging demonstrated multiple uterine leiomyomas but no adnexal mass or endometrioma. During total laparoscopic hysterectomy with bilateral salpingo-oophorectomy, dense adhesions between the sigmoid colon and posterior cul-de-sac were unexpectedly encountered. Histopathologic examination of the adhesion-related tissue revealed neither endometriosis nor significant inflammatory change. Microscopic examination of the ovary identified a 1.9 mm, sharply circumscribed nodule composed of clear, vacuolated zona fasciculata-like cells and compact eosinophilic zona reticularis-like cells. The lesional cells showed diffuse Melan-A immunoreactivity and focal-to-patchy inhibin-α positivity, supporting adrenocortical differentiation. The findings established a diagnosis of ovarian EACT. This case emphasizes that microscopic ovarian adrenal rests may be radiologically occult and should be distinguished from ovarian steroidogenic neoplasms by integrating clinical, morphologic, and immunohistochemical findings.

Ovarian fibromas are uncommon benign sex cord-stromal tumors that frequently present as unilateral solid masses and may mimic ovarian malignancy, particularly in postmenopausal women.Preoperative diagnosis remains challenging because imaging findings and tumor markers often overlap with those of other adnexal lesions.We present the case of an ovarian fibroma initially misdiagnosed as an endometrioma, illustrating the limitations of preoperative assessment.We report the case of a 60-year-old postmenopausal woman with an incidentally detected right adnexal mass initially interpreted as an endometrioma on transvaginal ultrasound and computed tomography (CT).The patient subsequently underwent laparoscopic resection, and histopathological examination confirmed the diagnosis of ovarian fibroma.Ovarian fibromas may mimic other adnexal masses, making preoperative diagnosis challenging.Imaging studies and serum tumor markers have limited specificity and may be insufficient to reliably distinguish these tumors from other ovarian lesions.In postmenopausal women, persistent solid adnexal masses generally warrant surgical exploration regardless of ancillary findings.Therefore, definitive diagnosis of ovarian fibroma relies on histopathological examination.Ovarian fibroma remains an important differential diagnosis of solid adnexal masses in postmenopausal women.The limitations of preoperative assessment reinforce the role of surgical excision, while histopathological examination remains the gold standard for definitive diagnosis.

Endometriosis and adenomyosis are characterized by the presence of endometrial-like tissue outside its normal anatomical location and are associated with pain, infertility, and other clinical manifestations. Although they share pathogenic features, including inflammation, hormonal responses, immune dysregulation, and fibrosis, their clinical and histopathological phenotypes are highly heterogeneous. This review integrates tissue mechanics and mechanobiology with inflammation, hormonal signaling, oxidative stress, angiogenesis, and neurogenesis to propose a microenvironment-dependent framework for understanding lesion formation, maintenance, and progression. Direct measurements of tissue stiffness, including elastography, have been reported, but standardized comparisons among lesion types remain limited. Existing evidence suggests that tissue stiffening may affect cellular proliferation, invasion, fibrosis, and tissue remodeling through mechanotransduction pathways such as integrin signaling. However, much of this evidence derives from in vitro studies, experimental models, or other fibrotic diseases, and direct causal relationships in human endometriosis and adenomyosis remain insufficiently established. Conversely, chronic inflammation, recurrent bleeding, and ECM accumulation may contribute to both tissue stiffening and fibrosis, indicating reciprocal interactions between mechanical and biological processes. Thus, lesion phenotypes may reflect interactions among lesion origin, cell-intrinsic properties, and the local microenvironment. Mechanobiology may complement established inflammatory, hormonal, immune, and fibrotic concepts and provide hypotheses for understanding lesion heterogeneity and progression. Longitudinal, lesion-level studies integrating mechanical and biological parameters are needed to test these hypotheses.

Pelvic pain may persist despite guideline-concordant endometriosis care. Evidence for primary motor cortex repetitive transcranial magnetic stimulation (M1-rTMS) in this population is limited. We assessed daily pain and activity interference, treatment delivery and safety after clinically indicated M1-rTMS. A prospective, single-centre observational cohort enrolled women with confirmed endometriosis and chronic pelvic pain. Ten left M1-rTMS sessions were scheduled over two weeks (10 Hz, 80% resting motor threshold, 1500 pulses/session). Daily diaries recorded pelvic pain and activity interference during pre-treatment, treatment, and post-treatment days 1–28 and week 8. Changes were estimated using linear mixed-effects models. Forty-two participants were enrolled and 40 initiated treatment; analyses included 37 for pain and 35 for interference. Model-based marginal mean pain decreased from 5.69 to 4.69 (change, −1.00; 95% CI, −1.46 to −0.55; p < 0.001), and interference from 6.03 to 4.63 (change, −1.39; 95% CI, −1.84 to −0.95; p < 0.001). Both remained below pre-treatment at week 8. Ten of 34 evaluable participants achieved ≥30% pain reduction and three achieved ≥50%. Of the 400 planned sessions, 386 were delivered; a total of 33/40 participants attended all ten and 38/40 at least eight. Twenty-eight participants reported 47 treatment-emergent adverse events; one was severe, none was serious, and all were resolved. M1-rTMS was feasible to deliver with high protocol fidelity and acceptable tolerability. Modest reductions in pain and activity interference were observed, although clinically important pain relief occurred in a minority; without a sham, usual-care, or untreated comparator, these changes cannot be attributed causally to rTMS. Controlled trials are required to determine efficacy and optimal dosing.

We report a case of a 55-year-old female who presented to the emergency department with symptoms of appendicitis.Imaging demonstrated appendiceal mucocele and possible early appendicitis.She underwent a laparoscopic appendectomy and subsequent histopathology demonstrated irregular fibrosis of the appendiceal wall as a result of endosalpingiosis with secondary mucocele formation.In this report, we present an exceedingly rare case of endosalpingiosis causing an appendicitis mimic.Although endosalpingiosis is typically considered a benign incidental finding, appendiceal involvement can mimic acute appendicitis, as in this case, and may be associated with an increased risk of gynecologic malignancy.The patient was followed up with the gynecological team due to this malignancy risk and is planned for laparoscopic oophorectomy, with the final histopathology diagnosis being appendiceal endosalpingiosis with secondary mucocele.

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Endosalpingiosis (ES) is a benign, nonneoplastic condition of the Müllerian system characterized by the ectopic implantation of fallopian tube-like ciliated columnar epithelium. Unlike endometriosis, ES lacks endometrial stroma and therefore does not produce the characteristic hemorrhagic episodes or extensive inflammatory responses associated with endometriosis. Although ES is primarily identified in the visceral pelvic peritoneum, extrapelvic manifestations are exceedingly rare, with pulmonary and pleural localization, accounting for ∼0.1% of reports. This report describes the clinical presentation of thoracic ES in a 40-year-old woman who presented with catamenial spontaneous primary pneumothorax. Despite a remote surgical history for ovarian endometriosis 10 years earlier, the patient had a prolonged period of clinical latency and no evidence of current pelvic recurrence. Videothoracoscopic surgery revealed a 5-mm apical pulmonary nodule and diffusely calcified pleural plaques. Histopathology and immunohistochemistry are remain gold-standard diagnostic methods for differentiating ES from thoracic endometriosis syndrome or malignancy. The diagnosis was confirmed by epithelial immunoreactivity for Müllerian transcription factors (PAX8 and WT1), keratin 7, and estrogen/progesterone receptors, together with the absence of cluster of differentiation 10 expression, which argued against endometrial stroma, and calretinin negativity, which argued against mesothelial origin. The pathophysiology of thoracic ES may resemble that of pulmonary endometriosis, involving transdiaphragmatic or vascular migration of Müllerian cells. For symptomatic presentations, surgical excision combined with long-term suppressive hormonal therapy is recommended to reduce epithelial proliferation. Given that the emerging literature suggests a possible link between ES and gynecological malignancies, rigorous long-term postoperative surveillance remains essential.