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This article in the Women's Health series discusses uterine perforation occurring during gynecological procedures, including prevention, identification of risk factors, recognition, management, and long-term outcomes.

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OBJECTIVE: To demonstrate techniques for successful donor-to-recipient vaginal anastomosis in uterine transplantation including illustration of a tension-free technique. DESIGN: This video uses live-action footage from surgery, detailed animations, and illustrations to review the step-by-step technique we use for vaginal anastomosis in uterine transplantation. Institutional Review Board approval was obtained for this experimental surgery. SETTING: Academic medical center. PATIENT(S): Patients undergoing uterine transplantation. INTERVENTION(S): Preparation of recipient vagina with illustration of challenges and risk secondary to dense adhesions between bladder and neo-vagina. Use of surgical techniques. Key steps include appropriate preparation of both donor and recipient vaginal tissues and a tension-free closure with horizontal mattress stitches. MAIN OUTCOME MEASURE(S): Intraoperative techniques in the clinical research trial of uterine transplantation. RESULTS: Successful vaginal anastomosis in the uterine transplantation patient. CONCLUSION(S): This video provides a step-by-step guide to vaginal anastomosis in uterine transplantation patients. Our team has applied techniques from vaginal reconstructive surgery in an attempt to reduce the occurrence of postoperative vaginal strictures, with attention to planned donor and recipient anastomosis site tissue preparation and closure of the anastomosis using a tension-free suturing technique.

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Endometriosis is a leading cause of pelvic pain and infertility. It is defined by the presence of endometrial tissue in extrauterine locations. The development of novel therapies and diagnostic tools for endometriosis has been limited due in part to challenges in studying the disease. Outside of primates, few mammals menstruate, and none develop spontaneous endometriosis. Rodent models are popular but require artificial induction of endometriosis, with many utilizing either immunocompromised mice or surgically induced disease. Recently, more attention has been given to models involving intraperitoneal injection. We present a murine model of endometriosis that integrates several features of existing endometriosis models into a novel, simplified system that relies on microscopic quantification in lieu of subjective grading. In this model, we perform hormonal stimulation of donor mice, intraperitoneal injection, systematic abdominal survey and tissue harvest, and histologic quantification that can be performed and verified at any time after necropsy. This model requires minimal resources and training; does not require expertise by lab technicians in murine survival surgery or in the identification of gross endometriotic lesions; can be used in immunocompromised, immunocompetent, and/or mutant mice; and reliably creates endometriotic lesions that are histologically consistent with human endometriotic disease.

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INTRODUCTION: Endometriosis is estimated to affect 10% of reproductive-aged women. The gold standard for treatment is surgery; however, surgery carries a significant morbidity and cost burden. There is an ongoing need for safe, effective medical therapies for endometriosis patients, both in conjunction with and independent of surgical interventions. Most conventional therapies for endometriosis work by a similar mechanism, and efficacy is variable. In recent years, there has been increased interest in the development and testing of novel pharmacotherapies for endometriosis. AREAS COVERED: This review discusses both conventional and emerging treatments for endometriosis. The authors present the application of these drugs in different presentations of endometriosis across the lifespan and discuss how emerging therapies might fit into future medical management of endometriosis. Conventional therapies include nonsteroidal anti-inflammatory drugs, combined oral contraceptives, progestins, GnRH agonists/antagonists, and aromatase inhibitors. Emerging therapies are focused on disease-specific targets such as endothelial growth factor receptors. EXPERT OPINION: The field of endometriosis therapy is moving toward modifying the immune and inflammatory milieu surrounding endometrial implants. If these drugs show efficacy in clinical trials, combining them with current medical treatment is expected to result in a profound impact on symptom and disease burden for patients who suffer from endometriosis worldwide.

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IMPORTANCE: Endometriomas are a unique and complex representation of the classic phenotypes of endometriosis. Associated symptoms, high recurrence rate, and multimodal approach represent ongoing challenges in the management of this chronic disease. OBJECTIVE: To review current literature regarding medical and surgical management of endometriomas. EVIDENCE ACQUISITION: An extensive literature search including PubMed and Cochrane Library was performed. Review was performed using the following key words: "endometrioma," "cystectomy," "chronic pain," "infertility," "IVF," "menopause," "recurrence." All pertinent articles were assessed. The references of those articles were then reviewed, and additional publications were evaluated. Eligibility of the studies was first assessed on titles and abstracts. Full articles were then reviewed for all selected studies, and decision for final inclusion was made at that time. CONCLUSIONS AND RELEVANCE: Cystectomy of ovarian endometriomas has been the first-line treatment for management for many years because it provides improved pain relief, reduces recurrence rates, and was thought to be favorable in in vitro fertilization. However, a growing body of evidence is demonstrating benefit, or at least no harm, in expectant management for asymptomatic patients with small, stable endometriomas. Medical management is often very effective and appropriate first line. When surgical intervention is appropriate, careful ovarian cyst excision with goal of ovarian tissue preservation and treatment of additional endometriosis by a trained surgeon can provide the patient the best long-term outcome and preservation of ovarian tissue and function.

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