A 42-year-old woman underwent a bilateral uterine artery embolization (UAE) in October 2022 for management of menorrhagia and bulk symptoms caused by multiple large intramural and subserosal fibroids. Her symptoms persisted, and three years later, she underwent a robotic myomectomy for definitive uterine-sparing management. Intraoperatively, the fibroids were necrotic and consistent with prior UAE. A single-tooth tenaculum was used to grasp the fibroid, and upon release, embolic beads spilled out from the grasp sites. The beads were suctioned from the peritoneal cavity, and the patient recovered well and achieved symptom improvement.

Background and Clinical Significance: Placental site trophoblastic tumour (PSTT) is a malignant tumour of the implantation site intermediate trophoblasts. It has historically been described using terms such as atypical chorioepithelioma, atypical choriocarcinoma, syncytioma, and chorioepitheliosis. It belongs to one of the heterogeneous spectrums of gestational trophoblastic disease. It accounts for about 0.25 to 5% of all gestational trophoblastic neoplasia. The typical clinical presentation is alternating menorrhagia and amenorrhea, mildly elevated β-hCG, and radiological findings of a uterine mass. Case Presentation: A 32-year-old woman presented with a history of intermittent menorrhagia and amenorrhea, with a persistent mildly raised β-hCG level. Ultrasonography showed a hypoechoic lesion on the right side of the posterior wall of the uterus. She was diagnosed with a missed miscarriage, and an evacuation of the products of conception was performed. Histologically, the tissue fragments comprised cords and sheets of atypical intermediate trophoblast cells, with characteristic features of myometrial smooth muscle infiltration, vascular invasion, and vascular wall replaced by the neoplastic cells. Immunohistochemically, these cells are positive for β-hCG and GATA3, while negative for P63. Conclusions: PSTT is a rare form of gestational trophoblastic neoplasia. Early recognition of PSTT is essential because its clinical presentation may mimic benign pregnancy-related conditions, and diagnosis relies heavily on histopathological and immunohistochemical evaluation.

Background: Smooth muscle tumors of uncertain malignant potential (STUMPs) are rare uterine neoplasms occupying the diagnostic continuum between benign leiomyoma and overtly malignant leiomyosarcoma. Their preoperative identification remains beyond the capability of current imaging modalities, and the diagnosis is almost invariably established through postoperative histopathological examination. The natural history of STUMP is highly variable, with recurrence rates ranging from approximately 7-27% and a documented potential for malignant transformation, underscoring the need for accurate pathological classification and long-term surveillance. Case Presentation: A 40-year-old woman with a history of hypertension presented with a 5-month history of progressive lower abdominal distension, urinary frequency, and menorrhagia. Transabdominal ultrasonography identified a large uterine fundal mass measuring approximately 10.89 × 8.96 cm. Preoperative laboratory findings demonstrated microcytic anemia. She underwent laparo-endoscopic single-site supracervical hysterectomy with bilateral salpingectomy. Histopathological examination revealed spindle cells with bland to mildly atypical nuclei, a mitotic count of <10/10 high-power fields, and focal necrosis, consistent with a diagnosis of STUMP. The patient remained free of recurrence over a 2-year follow-up period. Conclusions: This case illustrates the diagnostic challenge posed by STUMP in the preoperative setting and highlights the critical importance of thorough histopathological evaluation of all uterine smooth muscle tumor specimens. Minimally invasive hysterectomy with in-bag morcellation represents a feasible surgical approach, and long-term oncological surveillance is warranted given the risk of late recurrence and malignant transformation. Clinicians should maintain a heightened index of suspicion for borderline smooth muscle tumors when evaluating large or symptomatic uterine masses in premenopausal women.

Uterine leiomyomas are common benign tumors, whereas "giant" leiomyomas occupying most of the abdominal cavity are now uncommon and can pose diagnostic and operative challenges. We present the case of a 45-year-old woman with progressive abdominal distension and long-standing menorrhagia. Computed tomography demonstrated a massive uterine fundal mass consistent with a giant subserosal leiomyoma and a separate right adnexal cystic lesion. The patient underwent elective midline laparotomy and total abdominal hysterectomy with bilateral salpingo-oophorectomy. The ovarian cyst was removed intact without capsular rupture, and peritoneal washings were obtained. Estimated blood loss was 80 mL. Postoperative recovery followed an enhanced recovery after surgery (ERAS) pathway, enabling discharge on postoperative day four. Final histopathology confirmed a giant subserosal leiomyoma measuring 44 × 38 × 30 cm and revealed an occult clear cell carcinoma confined to the ovarian cyst (FIGO stage IA), with negative peritoneal cytology. Completion staging surgery and adjuvant-treatment discussion were recommended at a multidisciplinary tumor board; however, the patient declined further extensive surgery and was referred to medical oncology for adjuvant management and close surveillance. This case highlights the complexity of removal in giant uterine tumors, careful handling of adnexal cysts to avoid intraoperative rupture, and the feasibility of ERAS-based recovery.

Heavy menstrual bleeding (HMB) is a common gynecological disorder increasingly recognized as a complex systemic condition involving dysregulated interactions between the immune system and the endometrium. Beyond traditional uterine-centered explanations, growing evidence highlights the importance of immune-endometrial crosstalk in regulating menstruation, vascular integrity, inflammation, tissue breakdown, and endometrial repair. This narrative review examines the role of monocyte and macrophage dysregulation in the pathophysiology of HMB and explores the broader interorgan dynamics contributing to disease progression. Monocytes and macrophages are central regulators of endometrial remodeling, angiogenesis, extracellular matrix turnover, and hemostasis throughout the menstrual cycle. Dysregulated recruitment, polarization, and activation of these immune cells contribute to excessive inflammatory signaling, impaired vascular stability, delayed tissue repair, and abnormal menstrual blood loss. Key inflammatory mediators implicated include tumor necrosis factor-alpha, interleukin-6, CCL2, vascular endothelial growth factor, prostaglandins, matrix metalloproteinases, and NF-κB-associated pathways. The review further highlights systemic interactions involving the bone marrow, liver, vascular endothelium, endocrine system, and gut-immune axis, emphasizing HMB as a multisystem inflammatory disorder. Emerging evidence suggests that inflammatory biomarkers, immune profiling, and molecular characterization may improve disease stratification and support precision medicine approaches. Understanding HMB through the framework of immune-endometrial crosstalk provides new opportunities for biomarker development, targeted immunomodulatory therapies, and individualized patient management aimed at improving reproductive and overall health outcomes.

This study aimed to systematically evaluate the quality of widely accessible, English language, patient-facing resources on heavy menstrual bleeding (HMB), identifying strengths, gaps, and opportunities for improvement. Resources were obtained from (1) a systematic Google Trends-informed Google search and (2) submissions from subject matter experts. Eligible resources were independently reviewed and scored using validated tools for credibility (QUEST), aesthetics (modified Abbott's scale), and readability. To evaluate clinical utility, resources were graded using a tool designed by international experts for comprehensiveness and accuracy across six domains. Inter-rater reliability was assessed with the intraclass correlation coefficient (ICC) and Cohen's kappa. Of 353 resources identified, 63 met the inclusion criteria. Mean QUEST score (maximum = 28) was 18.7 ± 5.1, with 4/63 (6%) resources meeting all credibility criteria. Mean aesthetics score (maximum = 7) was 5.3 ± 1.1, with only 15/63 (24%) resources with graphics. Most resources (40/63, 64%) were written at a grade 10-12 reading level. Mean comprehensiveness score (maximum = 6) was 4.6 ± 0.8, with gaps most often observed in advice on when to seek emergency care and information about iron deficiency. Mean accuracy score (maximum = 12) was 8.0 ± 2.3, with only 3/63 (13%) resources containing completely accurate content. There was moderate-to-substantial agreement across reviewers (ICC = 0.60-65 for aesthetics credibility; κ = 0.38-49 for accuracy comprehensiveness). In conclusion, most online resources accessed by patients are moderately credible, difficult to read, and underutilize figures. Content gaps exist mainly related to education on safety and iron deficiency. Very few resources are entirely accurate. We recommend targeted revisions to patient education resources to better inform and empower patients experiencing HMB.

Menstrual health is a key indicator of adolescent health and should be evaluated at routine visits using a patient-centered approach. It is important to understand normal menstrual patterns in order to better recognize when a presentation may be abnormal or concerning. Clinicians may frequently encounter challenges, particularly when caring for adolescents with disabilities. In this article, we review typical menstrual development and evaluation and management of abnormal uterine bleeding including amenorrhea, dysmenorrhea, and heavy menstrual bleeding. We also highlight special considerations for adolescents who are differently abled.

This case report describes a rare presentation of primary periumbilical endometriosis, also known as Villar's nodule, highlighting the diagnostic difficulties and the importance of maintaining clinical suspicion. A 37‑year‑old woman presented with a one‑year history of cyclical periumbilical pain along with severe menorrhagia and dysmenorrhea. Initial ultrasonography suggested an umbilical hernia, but subsequent imaging, including repeat ultrasound and contrast‑enhanced MRI, revealed subcutaneous periumbilical nodules without evidence of intraperitoneal extension or associated pelvic endometriosis. An incidental intramural uterine fibroid was also noted. The patient underwent surgical excision of the periumbilical nodules along with myomectomy. Histopathological examination confirmed the diagnosis of endometriosis. Her postoperative recovery was uncomplicated, and she remained asymptomatic at the six‑month follow‑up. This case underscores the need to consider primary periumbilical endometriosis in women presenting with cyclical umbilical pain and demonstrates that early diagnosis and complete surgical excision can lead to favorable clinical outcomes.

Estetrol/drospirenone (E4/DRSP) is a combined oral contraceptive noted for its minimal hemostatic impact compared to ethinyl estradiol-based preparations. However, real-world thrombotic risk data in patients with significant comorbidities remain limited. A woman in her early 40s with adenomyosis and menorrhagia was prescribed E4/DRSP. Six weeks later, she developed acute left upper extremity weakness; imaging confirmed superior sagittal sinus thrombosis. She had severe iron deficiency anemia (hemoglobin 6.4 g/dL). Multiple overlapping risk factors-including severe iron deficiency anemia with reactive thrombocytosis, adenomyosis, obesity, hypertension, and age over 40-likely contributed synergistically, and the independent contribution of E4/DRSP cannot be determined. She was treated with anticoagulation and transitioned to relugolix for adenomyosis management. Although E4/DRSP has a favorable coagulation profile, thrombotic risk persists in women with adenomyosis and severe anemia. Pre-prescription assessment including correction of anemia and consideration of estrogen-free alternatives is warranted.