Abstract Introduction: The lymph node status is of utmost importance in endometrial cancer staging. However, the therapeutic importance of systematic lymphadenectomy was not proven, thus the sentinel lymph node biopsy (SLNB) is emerging as an alternative to classic surgical staging procedure. We aimed to evaluate the feasibility of SLNB in clinical early-stage endometrial cancer, at a university-affiliated teaching hospital. Material and Methods: Retrospective, single-centre, observational analysis, including patients with clinical stage I or II endometrial cancer, submitted to minimally invasive primary surgery. Patients underwent sentinel lymph node mapping with indocyanine green dye, after cervical injection, from September 2019 to September 2022. The ultra-staging protocol was followed. The map rate, sensitivity, negative predictive value, and false negatives were calculated. Results: Fifty-six patients met the inclusion criteria. The overall and bilateral detection rate was o 96.4% and 80.3%, respectively. After SLNB, complete pelvic lymphadenectomy was performed in 33.9% of patients. Lymphatic metastases were found in 6 (10.7%) cases, all of them in sentinel lymph node sampling. Four patients, with pre-operative low-risk of recurrence, had bilateral SLNB and the histopathological evaluation revealed micrometastases. Two patients, who underwent pelvic lymphadenectomy, had macrometastases. The sensitivity and negative predictive value of SLNB were 100%, with a false negative rate of 0%. Comparative analysis between the groups with a low-risk of recurrence, that underwent SLNB alone, and intermediate/high-risk groups, that performed systematic lymphadenectomy, showed a significant difference in surgery duration, hospital stay, and complication rate (higher in the systematic lymphadenectomy group). There were no adverse effects related to the indocyanine green injection. Conclusion: SLNB is a safe procedure, with a high detection rate and sensitivity, avoiding the morbidities related to systematic lymphadenectomy. The implementation of the ultra-staging protocol is crucial to allow the diagnosis of the low-volume metastatic involvement, influencing the definitive staging of apparently low-risk patients.

Resumo Introdução: No cancro do endométrio (CE), o estadiamento cirúrgico é fundamental para estabelecer o prognóstico. Contudo, o valor terapêutico da linfadenectomia sistemática não foi demonstrado. A biópsia do gânglio sentinela (BGS) tem-se revelado como alternativa ao estadiamento cirúrgico clássico. O objetivo deste estudo foi avaliar a precisão diagnóstica da BGS em doentes com CE em estádios iniciais, num centro terciário. Materiais e Métodos: Estudo retrospetivo observacional, unicêntrico, de doentes com CE no estádio I ou II da FIGO, submetidas a cirurgia primária por laparoscopia com BGS, após injeção cervical de verde de indocianina. Realizou-se protocolo de ultraestadiamento em todos os gânglios sentinela identificados. Calcularam-se a taxa de deteção, sensibilidade, valor preditivo negativo e taxa de falsos negativos. Resultados: Incluíram-se 56 doentes. A taxa de deteção total e bilateral foi de 96,4% e 80,3%, respetivamente. Após a BGS, a linfadenectomia sistemática foi realizada em 19 (33,9%) doentes. A metastização ganglionar foi detetada em 6 (10,7%) casos, todos em gânglios sentinela. Nas quatro doentes, do grupo de baixo risco de recorrência, submetidas apenas a BGS, a invasão ganglionar foi sob a forma de micrometástases, nos 2 casos que realizaram linfadenectomia pélvica foram encontradas macrometástases. A sensibilidade e o valor preditivo negativo da BGS foi de 100%, com taxa de falsos negativos de 0%. A análise comparativa entre o grupo submetido apenas a BGS e o submetido ao estadiamento ganglionar clássico, demonstrou diferenças significativas na duração da cirurgia, dias de internamento e complicações, que foram superiores neste último. Não houve efeitos adversos associados à utilização do verde de indocianina. Conclusão: A BGS é um procedimento seguro com elevada taxa de deteção e sensibilidade, permitindo reduzir a morbilidade associada ao estadiamento clássico. O protocolo de ultrastaging é essencial para diagnosticar envolvimento metastático de baixo volume, influenciando o estadiamento definitivo de doentes com aparente baixo-risco de recorrência.

Abstract The medical treatment of uterine fibroids is a subject of growing interest, often associated to difficult decisions, especially in women who wish to preserve fertility and the uterus. The existing treatments are only used for short or limited periods, due to the evidence paucity on the benefits and risks of long-term use. New molecules are being tested showing improved efficacy in the management of uterine fibroids associated symptoms, especially in abnormal uterine bleeding and good safety profiles. The recent data which supports the new treatment options for symptomatic uterine fibroids, particularly in the control of abnormal uterine bleeding, are reviewed herein.

Resumo O tratamento médico dos miomas uterinos sintomáticos continua a ser um dos grandes desafios, existindo cada vez mais a preocupação da preservação anatómica e da fertilidade. Os tratamentos existentes são utilizados apenas por períodos curtos e limitados, devido à escassez de evidências sobre os benefícios e riscos do uso a longo prazo. Novas moléculas inovadoras têm sido investigadas, mostrando melhorias no controlo da hemorragia uterina anormal e perfis de segurança apropriados. Os dados recentes que suportam as novas opções de tratamento para miomas uterinos sintomáticos, particularmente no controlo da hemorragia uterina anormal, são aqui revistos e sistematizados.

Abstract The Essure® (Bayer) system was introduced in 2002, as a hysteroscopic sterilization technique, however, serious long-term adverse events raised concern about its use and lead to the discontinuation of the device in 2017. The authors present a report of intrauterine migration from one of the microinsert components in a woman with abnormal uterine bleeding. Transvaginal ultrasound was the key to the diagnosis, finding in the endometrial cavity a hyperechogenic structure with a coiled shape. The hysteroscopic removal of the migrated component conducted to the resolution of the clinical complaints.

Abstract Introduction: Ulipristal acetate (UPA) was introduced in clinical practice for the treatment of uterine fibroids in February 2012. During the post-marketing exposure, there were reports of liver injury and the European Medicine Agency recommended monitoring of liver enzymes for safety reasons. Objectives: The aim of this survey was to gather information about Portuguese gynaecologists’ experience with UPA regarding liver function and other complications related to UPA use. Material and methods: The study consisted of a cross-section survey among members of the Portuguese Society of Gynaecology between April and May 2018. The responders used an online platform to answer a survey that focused on safety and specific alterations in laboratory analyses of liver function considering treatment with UPA since January 2018. Results: In the period considered in this survey, 199 women were treated with UPA by the responders. Monitoring of liver function was performed in 93 women and alterations in liver function laboratory tests were reported in five cases (2.5%). In two of these cases, the past medical history was associated with liver diseases, namely alcoholic, infectious and autoimmune. The clinical course was favourable in all cases. Conclusions: Despite temporary UPA temporary suspension, this survey reinforced the need of clinical database for UPA safety monitoring, particularly regarding the possible application in selected clinical cases.

Overview and Aims: The purpose of this study was to find the best ultrasound model for preoperative discrimination between benign and malignant adnexal masses in a group of Portuguese women. Methods: Single-centre retrospective study of 123 adnexal masses. The ultrasound images were described by an experienced ultrasonographer and classified as benign or malignant, according to IOTA simple rules (SR), RMI scoring and logistic regression model L2 (LR2). Two study groups were considered according to histologic diagnosis (benign and malignant). Borderline tumours were counted as malignant. The sensitivity, specificity, positive and negative predictive values (PPV and NPV) were calculated for IOTA SR; LR2 model; RMI score and use of serum CA 125 as a secondstage test in cases of IOTA SR complemented by subjective assessment. Results: Among the 123 tumours, 81.3% were benign and 18.7% were malignant on histolopathology. When inconclusive tumors were considered malignant, the IOTA SR had a sensitivity of 95.6%, specificity of 69.9%, PPV 46.8% and NPV of 98.3%. If inconclusive tumors were classified by subjective sonographic assessment, IOTA SR had a sensitivity of 91.3% and specificity of 78.3%. The LR2 model had a sensitivity of 91.3%, specificity 77.1%, PPV 63.6% and NPV 93.06%. Conclusion: IOTA SR and IOTA LR2 models achieved the best diagnostic accuracy for differentiating between benign or malignant adnexal masses. In case of inconclusive results, subjective assessment of ultrasound findings by expert examiners should be incorporated.

The Portuguese College of Obstetrics and Gynecology has been following the evolution of the COVID 19 pandemic since its beginning and all the impact in terms of clinical activities in different areas of the Specialty. Likewise, there has been a concern about how changes in the functioning of the Departments of Obstetrics and Gynecology have been reflected in the Specific Training Internship. This matter was discussed at one of the College Board's meetings, and an opinion document was sent to the National Council of Postgraduate Studies of the Medical College of Physicians.

Overview and aims: This article addresses the diagnosis of anemia in the context of abnormal uterine bleeding and reviews the treatment options of iron deficiency anemia. This topic was worked out as a section of the Portuguese Consensus on Abnormal Uterine Bleeding, endorsed by the Portuguese Society of Gynaecology. The working group established recommendations that provide guidance to the medical society to better decision making concerning the treatment of iron deficiency anemia. We expose here evidence based guidelines consigning the diagnosis and management of this disease. Study design and Methods: A group of experts in the field performed a thorough systematic search of the publications on the treatment of iron deficiency anemia and a quality assessment of the included papers. On this basis a proposal was drawn up and later on was discussed and approved on consensus meeting with all members of the guidelines developing group reaching the final version of the recommendations. Conclusions: The present clinical practice guidelines on treatment of iron deficiency anemia may improve the diagnosis and management of this high prevalent disease.

The uterine niche presents as a recess located in the anterior uterine wall, at the site of previous hysterorrhaphy. Although obstetric complications associated with a history of cesarean delivery are well known, recognition of the niche as a surgical sequel and its association with gynecological symptoms such as abnormal uterine bleeding and pelvic pain is poorly described, compromising its identification in clinical practice. There are no validated guidelines for the diagnostic criteria of uterine niche. Treatment includes hormonal methods and surgery, namely hysteroscopic or laparoscopic isthmoplasty.

Overview: Despite the reduction in the rate of hysterectomies during the past years, it is still the second most common major surgical procedure performed among women. It has been common practice to counsel women who were planning hysterectomy, particularly in their mid-40s or older, to undergo concomitant bilateral salpingo-oophorectomy. However, this recommendation is now being replaced by consideration of ovarian conservation with bilateral salpingectomy (BS). Aims: To describe the trends regarding hysterectomies and concomitant adnexal surgery. Study Design: Single-center retrospective comparative study. Population: Women who underwent hysterectomy (2004 versus 2014). Methods: Data were analysed using STATA 13.1. Results: The overall number of hysterectomies decreased 28.5% (n=916 versus n=656). There was a change in the pattern of indications for hysterectomy: benign pathology decreased [79.4% versus 64.5% (p<0.001)] (mainly due to uterine fibroids) with a corresponding increase in hysterectomies due to urogenital prolapse [13.7% versus 23.6% p<0.001)] and malignant pathology [7.0% versus 11.9% (p<0.01)]. Regarding the surgical approach, there was a decrease in laparotomic route (80.9% versus 57.4% (p <0.001) with an increase in the vaginal [12.6% versus 28.7% (p<0.001)] and laparoscopic routes [6.6% versus 13.9% (p<0.001)]. In women with benign pathology, the rate of bilateral adnexectomy decreased from 69.4% to 53.3% (p<0.001) and the rate of BS increased from 0.9% to 16.5% (p<0.001). There was a reduction in intraoperative complications [4.3% versus 1.8% (p=0.006)], immediate postoperative complications [11.6% versus 7.0% (p=0.003)] and duration of hospitalizations [5.6±3.0 versus 4.1±2.4 days (p<0.001)]. Conclusion: The rate of hysterectomies decreased in the last decade, mainly due to the reduction in hysterectomies for uterine fibroids. We verified a significant shift towards ovarian conservation with increasingly concomitant BS. Considering ovarian carcinogenesis, the increase in prophylactic BS may have future impact on the reduction of ovarian cancer.

Overview: Endometrial cancer is a common gynecological malignancy, diagnosed at stage I in 80% of cases. In the absence of contra-indication, staging is surgical. Pelvic lymphadenectomy is not recommended in low risk endometrial cancers. Magnetic resonance imaging (MRI) is useful to predict the depth of myometrial invasion in the preoperative assessment, but intra-operative pathological exam could also be used. Aim: To analyze the concordance between final histological exam and pre-operative MRI or intra-operative pathological exam. Study Design: Cross-Sectional Study Methods: It was performed a cross-sectional study of 145 women diagnosed with endometrial carcinoma, in a tertiary clinical center, from January 2010 to December 2015. It was analyzed 60 cases, the ones submitted to MRI and extemporaneous exam. Statistical analysis was performed by STATA 13.1. Results: Sixty cases of endometrial cancers have been rated using MRI and intraoperative histological exam. The observed concordance (MRI versus final invasion) was 81%, with kappa index of 0.54 (moderate concordance). MRI has demonstrated diagnostic sensitivity of 86%, specificity of 80% (AUC:0.84). Adjusting for prevalence, MRI negative predictive value (NPV) was 95% and positive predictive value (PPV) was 55%. When compared to MRI, the extemporaneous exam demonstrates higher sensitivity and specificity (Sensitivity:91%; specificity:93%, AUC:0.92; PPV: 77%, NPV: 98%). The Kappa index was 0.79 (substantial concordance). Comparing the two diagnostic tools, the extemporaneous exam was superior (p= 0.04). Conclusion: Extemporaneous exam has demonstrated diagnostic superiority

Overview and Aims: The concept of "genitourinary syndrome of menopause" (GUSM), created in 2013, is widely used, despite the lack of studies and validation. This survey intended to evaluate the knowledge, agreement and concerns of Portuguese gynaecologists about it. Study design, population and methods: An online survey was sent to Portuguese gynaecologists (all the members of the Portuguese Society of Gynaecology, personal contacts and specific groups in social networks). Results: Out of 118 completed surveys, 66.1% belonged to specialists and 43.9% to residents. It was reported by 83.9% that they were acquainted with the GUSM, without differences between specialists and residents (85.0% vs. 83.3%, p=1.000). Most (66.7%) use "vaginal atrophy" or "atrophic vaginitis" in their daily practice; GUSM is used by 6.1% and 27.3% use both denominations. Considering "0" to be total disagreement and "10" total agreement, the justifications for the creation of this syndrome were rated as follows: "vaginitis implies infection or inflammation, which is not always the case" 8.1±2.57; "urinary signs and symptoms tend to be overlooked" 6.4±2.96; "atrophy has a negative connotation" 4.7±3.46 and "vagina is not generally a well-accepted term by women and the media" 3.4±3.41. It was considered by 37.9% that it may lead to sub-diagnosis/no diagnosis of sexual dysfunction; of vulvar pathology by 32.6% and of urinary tract pathology by 23.7%. Globally, 77.8% agree with the concept of GUSM, without differences between specialists and residents (80.0% vs. 73.5%, p=0.459); 75.4% consider that they will use it in the future (residents 57.9% vs. specialists 83.3%, p=0.053). Conclusion: Most Portuguese gynaecologists are aware of the concept of GUSM, and intend to use it the future, despite not fully agreeing with the assumptions that led to its creation.

Objetivo: Estabelecer as recomendações portuguesas relativas à indicação de realização da DXA e de iniciação de tratamento para a prevenção de fraturas de fragilidade. Métodos: Foi reunido um painel multidisciplinar, representando o leque das especialidades médicas e associações de doentes dedicadas à osteoporose, bem como especialistas nacionais neste domínio e em economia da saúde, com o objetivo de desenvolver recomendações com base na evidência científica e no consenso dos especialistas. As decisões foram suportadas por dados epidemiológicos, sócio-económicos e de qualidade de vida obtidos recentemente sobre as fraturas osteoporóticas. Resultados: Foram desenvolvidas 10 recomendações que abordam as questões de quem deve ser objeto de investigação com a DXA e quem deve ser tratado com terapêutica para prevenção de fraturas. Os limiares para a avaliação e intervenção baseiam-se na análise de custo-eficácia das intervenções em diferentes limiares da probabilidade a dez anos de fratura osteoporótica, calculados com base na versão portuguesa da FRAX® (FRAX®Port) tendo em consideração os dados epidemiológicos e económicos portugueses. Enumeram-se as limitações da FRAX® e, sempre que possível, propõem-se orientações para uma adaptação. Conclusões: Os limiares de custo-eficácia para realização de DXA e a instituição de terapêutica para a prevenção das fraturas de fragilidade são agora facultados à população portuguesa. Estes limiares são práticos, baseiam-se em dados epidemiológicos e económicos nacionais e em evidência científica e são corroborados por um painel multidisciplinar de especialistas e de instituições científicas. A implementação destas recomendações oferece perspetivas muito promissoras no que diz respeito a uma utilização mais eficaz dos recursos de saúde na prevenção das fraturas osteoporóticas em Portugal.

Objective: To establish Portuguese recommendations regarding the indications for ordering bone densitometry measurement to (DXA) and for starting treatment to prevent osteoporotic fractures. Methods: A multidisciplinary panel, representing a wide range of medical specialties and patient associations related to osteoporosis, as well as national experts in this field and in health economics, met to develop recommendations based on available evidence and expert consensus. Recently obtained data on the epidemiologic, economic and quality-of-life aspects of osteoporotic fractures in Portugal were used to support decisions. Results: Ten recommendations were developed covering the issues of indications for ordering DXA measurements and whom to treat with anti-fracture medications. Thresholds for assessment and intervention are based on the cost-effectiveness analysis of interventions at different thresholds of a ten-year probability of osteoporotic fractures, calculated with the Portuguese version of FRAX® (FRAX®Port), and taking into account Portuguese epidemiologic and economic data. Limitations of FRAX® are highlighted and guidance for appropriate adjustment is provided, when possible. Conclusions: Cost-effectiveness thresholds for DXA examination and drug intervention aiming at fragility fracture prevention are provided for the Portuguese population. These are practical, based on national epidemiological and economic data, evidence-based, and supported by a multidisciplinary panel of experts and scientific societies. Implementation of these recommendations has the possibility to assure the most effective use of health resources in the prevention of osteoporotic fractures in Portugal.

Background: The study about evaluation of the contraceptive practices in Portugal is a cross-sectional survey that evaluated women's contraceptive choices and how they get information and advice about sexuality and contraception. Methods: Women aged between 15 and 49 years completed an anonymous questionnaire with 21 questions, which included open and closed questions on information and use of contraceptive methods. The results were analyzed and compared with the results of the survey performed in 2005 by the Portuguese Gynecology Society. Results: Information about sexuality and contraception at school is acknowledged by 70% of the younger women. For this group other sources of information about contraception are friends, 46,1% and internet 45,9%. On the other side women older than 30 years get information on contraception mainly through family doctors and gynecologists. 94% of sexuality active women use contraception, this percentage is significantly higher than the one observed in 2005, 75,4%. Contraceptive pill remains as the preferred method for Portuguese women although its use decreased from 70,4% to 58% of the women between 2005 and 2015. On the other hand the preference for methods independent from the users, long-acting reversible contraception (LARCs), has significantly increased. Women still maintain a high rate of forgetfulness for the pill and considering this fact the use of emergency contraception is still low. Use of contraception is beneficial for quality of life according to 81% of women in this study. Conclusions: Portuguese women are in general well informed and get an easy access to contraceptive methods. The amount of sexually active women using contraception has increased in ten years and almost achieves 100%. Contraceptive pill is the number one choice for more than 50% of women but the use of LARCs is steadily increasing

Overview and aims: This article summarises the Portuguese endometriosis consensus elaborated in order to adapt to our population the consensus documents published in the literature. Endorsed by the Portuguese Society of Gynaecology, we established recommendations that provide guidance to our medical society to better decision making concerning the assistance of patients with endometriosis, to improve diagnosis and to optimize management. We expose here a short version of the second section of the guidelines, addressing the medical treatment of this disease. Study design and Methods: The European Society of Human Reproduction and Embryology (ESHRE) guideline for the diagnosis and treatment of endometriosis (2014) was the reference paper for these clinical recommendations in endometriosis. A group of experts in the field performed a thorough systematic search of the publications between January 2012 up to December 2014 and a quality assessment of the included papers. A consensus meeting with all members of the guidelines developing group reached the final version of the recommendations. Conclusions: The present clinical practice guidelines on endometriosis may improve the medical management in endometriosis-associated pain.