Background The aetiology and pathogenesis of endometriosis are still under investigation. There is evidence that there is a complex bidirectional interaction between endometriosis and the microbiome.Objective To systematically review the available literature on the endometriosis-microbiome interaction, with the aim of guiding future inquiries in this emerging area of endometriosis research.Search strategy MEDLINE, Embase, Scopus and Web of Science were searched through May 2019. A manual search of reference lists of relevant studies was also performed.Selection criteria Published and unpublished literature in any language describing a comparison of the microbiome state in mammalian hosts with and without endometriosis.Data collection and analysis Identified studies were screened and assessed independently by two authors. Data were extracted and compiled in a qualitative synthesis of the evidence.Main results Endometriosis appears to be associated with an increased presence of Proteobacteria, Enterobacteriaceae, Streptococcus spp. and Escherichia coli across various microbiome sites. The phylum Firmicutes and the genus Gardnerella also appear to have an association; however, this remains unclear.Conclusions The complex bidirectional relationship between the microbiome and endometriosis has begun to be characterised by the studies highlighted in this systematic review. Laboratory and clinical studies demonstrate that there are indeed differences in the microbiome composition of hosts with and without endometriosis.

The care of patients with endometriosis has been complicated by the coronavirus disease 2019 (COVID-19) pandemic. Medical and allied healthcare appointments and surgeries are being temporarily postponed. Mandatory self-isolation has created new obstacles for individuals with endometriosis seeking pain relief and improvement in their quality of life. Anxieties may be heightened by concerns over whether endometriosis may be an underlying condition that could predispose to severe COVID-19 infection and what constitutes an appropriate indication for presentation for urgent treatment in the epidemic. Furthermore, the restrictions imposed due to COVID-19 can impose negative psychological effects, which patients with endometriosis may be more prone to already. In combination with medical therapies, or as an alternative, we encourage patients to consider self-management strategies to combat endometriosis symptoms during the COVID-19 pandemic. These self-management strategies are divided into problem-focused and emotion-focused strategies, with the former aiming to change the environment to alleviate pain, and the latter address the psychology of living with endometriosis. We put forward this guidance, which is based on evidence and expert opinion, for healthcare providers to utilize during their consultations with patients via telephone or video. Patients may also independently use this article as an educational resource. The strategies discussed are not exclusively restricted to consideration during the COVID-19 pandemic. Most have been researched before this period of time and all will continue to be a part of the biopsychological approach to endometriosis long after COVID-19 restrictions are lifted.

We believe the uterosacral ligaments (USLs) are an essential key to resolving the dilemma of diagnosing endometriosis non-invasively. This editorial will utilise laparoscopic and ultrasonographic figures and videos, along with written descriptive techniques, to educate clinicians, sonographers, sonologists and radiologists on normal and abnormal USLs to improve knowledge and skill in scanning patients with possible endometriosis.

The uterosacral ligaments (USL) have been reported to be the most common site of deep endometriosis (DE) in the pelvis 1 . A nodule within the USL may infiltrate the parametrium, increasing the complexity of surgical resection, and larger nodules (≥ 17 mm) noted on transvaginal ultrasound (TVS) should raise suspicion of ureteral involvement 2 . Nodules may also invade the torus uterinus, which is the thickening between the insertion of the USL behind the posterior cervix. The diagnostic test accuracy of TVS for USL DE is only moderate, with sensitivity and specificity of 67% and 86%, respectively 3 , which may be related to the absence of a standardized technique for its assessment. We present a method that allows easier identification of normal and abnormal USL and classification of USL DE nodules.The proposed method for TVS assessment of USL is summarized in Videoclip S1 and consists of the following steps.1. Insert the TVS probe into the posterior vaginal fornix behind the cervix and uterus. 2. Decrease the penetration depth of field and position the focal point nearest to the probe. 3. Angle the probe toward the rectum in the midsagittal position ( Figure S1). Visualize the hypoechoic posterior vaginal fornix nearest to the probe; adjacent is the hyperechoic pouch of Douglas peritoneum. Follow this hyperechoic line closely in the next step. 4. To evaluate the right USL, simultaneously sweep the ultrasound beam to the patient's right ( Figure S1) and rotate clockwise (usually not more than 45 • ); the hyperechoic line (peritoneum) should begin to thicken. The USL should be evaluated at the thickest point of the hyperechoic line. For the left USL, follow the same procedure, but instead rotating the probe counterclockwise. 5. If a hypoechoic lesion is seen within the hyperechoic USL ( Figures S2 and S3), measure it in three orthogonal planes ( Figure S4). 6. Evaluate the portion of the nodule that is within the borders of the USL and characterize the lesion according to the proposed USL DE classification system (Table 1, Figures 1 and 2), in line with the leiomyoma subclassification of submucosal leiomyomas 4 . 7. Evaluation of the ureters should always be performed ( Figure S5). A ureter of ≥ 6 mm in diameter should be considered as dilated. The kidneys should be assessed for hydronephrosis 5 .We believe that the proposed USL DE classification system (Table 1) provides a simple and standardized approach to describe such lesions, which may assist sonographers and surgeons in predicting ureteral involvement and/or the need for ureterolysis. Corresponding surgical images of USL DE with parametrial involvement are shown in Figure S6. Of course, evaluation of the USL DE classification system for its utility in diagnosis and/or preoperative planning is required before clinical implementation is considered.

Objectives To review the accuracy of different imaging modalities for the detection of rectosigmoid deep endometriosis (DE) in women with clinical suspicion of endometriosis, and to determine the optimal modality. Methods A search was conducted using PubMed, MEDLINE, Scopus, EMBASE and Google Scholar to identify studies using imaging to evaluate women with suspected DE, published from inception to May 2020. Studies were considered eligible if they were prospective and used any imaging modality to assess preoperatively for the presence of DE in the rectum/rectosigmoid, which was then correlated with the surgical diagnosis as the reference standard. Eligibility was restricted to studies including at least 10 affected and 10 unaffected women. The QUADAS‐2 tool was used to assess the quality of the included studies. Mixed‐effects diagnostic meta‐analysis was used to determine the overall pooled sensitivity and specificity of each imaging modality for rectal/rectosigmoid DE, which were used to calculate the likelihood ratio of a positive (LR+) and negative (LR–) test and diagnostic odds ratio (DOR). Results Of the 1979 records identified, 30 studies (3374 women) were included in the analysis. The overall pooled sensitivity and specificity, LR+, LR– and DOR for the detection of rectal/rectosigmoid DE using transvaginal sonography (TVS) were, respectively, 89% (95% CI, 83–92%), 97% (95% CI, 95–98%), 30.8 (95% CI, 17.6–54.1), 0.12 (95% CI, 0.08–0.17) and 264 (95% CI, 113–614). For magnetic resonance imaging (MRI), the respective values were 86% (95% CI, 79–91%), 96% (95% CI, 94–97%), 21.0 (95% CI, 13.4–33.1), 0.15 (95% CI, 0.09–0.23) and 144 (95% CI, 70–297). For computed tomography, the respective values were 93% (95% CI, 84–97%), 95% (95% CI, 81–99%), 20.3 (95% CI, 4.3–94.9), 0.07 (95% CI, 0.03–0.19) and 280 (95% CI, 28–2826). For rectal endoscopic sonography (RES), the respective values were 92% (95% CI, 87–95%), 98% (95% CI, 96–99%), 37.1 (95% CI, 21.1–65.4), 0.08 (95% CI, 0.05–0.14) and 455 (95% CI, 196–1054). There was significant heterogeneity and the studies were considered methodologically poor according to the QUADAS‐2 tool. Conclusions The sensitivity of TVS for the detection of rectal/rectosigmoid DE seems to be slightly better than that of MRI, although RES was superior to both. The specificity of both TVS and MRI was excellent. As TVS is simpler, faster and more readily available than the other methods, we believe that it should be the first‐line diagnostic tool for women with suspected DE. © 2020 International Society of Ultrasound in Obstetrics and Gynecology

Pre-exposure prophylaxis (PrEP) is a promising strategy whereby HIV-uninfected people could take antiretroviral (ARV) medications to reduce their risk of HIV acquisition. Reports suggest that unsupervised PrEP use has been occurring in gay communities of USA cities before human safety and efficacy data became available. We administered a 20-item questionnaire to men undergoing HIV testing at Hassle Free Clinic, a sexual health clinic in the gay village of Toronto. Questionnaire items enquired about demographics, sexual partners, substance use and awareness of, usage of and willingness to use PrEP. Logistic regression was used to identify characteristics associated with PrEP-related outcomes. Of 256 participants, 11.7% were aware of PrEP, with more men who have sex with men (MSM) aware (14.1%) than non-MSM (4.9%). No participants reported PrEP usage. Willingness to consider PrEP use was high and associated with high-risk activities, suggesting opportunities for PrEP use in the future.

Objectives First, to investigate the accuracy of transvaginal sonography (TVS) for presurgical evaluation of the distance between the most caudal part of the endometriotic lesion and the anal verge (lesion‐to‐anal‐verge distance (LAVD)) in women with rectosigmoid deep endometriosis (DE), compared with intraoperative measurement (IOM). Second, to assess the agreement between anastomosis height and LAVD measured using TVS. Methods This was a prospective observational multicenter study of symptomatic women who were scheduled for surgical treatment of rectosigmoid DE, by either discoid or segmental resection, between April 2017 and September 2019. Presurgical TVS was performed to evaluate the LAVD in two ways, depending on the level of the lesion. Method 1: for lesions at the level of the rectovaginal septum (RVS), the caudal part of the lesion was identified on TVS and an index finger was placed on the TVS probe at the level of the anal verge. The probe was withdrawn and the distance from the tip of the TVS probe down to the index finger was measured using a ruler, representing the LAVD. Method 2: for lesions above the RVS, the distance between the caudal part of the lesion and the lower lip of the posterior cervix was measured in a frozen image (LAVD‐1), and the distance between the lower lip of the posterior cervix and the anal verge (LAVD‐2) was measured using Method 1. These two measurements (LAVD‐1 and LAVD‐2) were added together and the result represented the total LAVD. During surgery, a rectal probe was used to perform IOM of LAVD, which was considered as the gold standard test. Agreement between LAVD measured using TVS and the IOM was assessed using Bland–Altman analysis. The intraclass correlation coefficient (ICC) for absolute agreement and Spearman's correlation coefficient were also calculated. Systematic and proportional bias were tested for significance using the paired t‐test. Similar analysis was performed to assess agreement between LAVD measured using TVS and anastomosis height. Results A total of 147 consecutive women were considered eligible for inclusion. Fourteen women were excluded initially. Thirty‐four discoid resections and 102 segmental resections were performed; both procedures were performed in three women. Two more women were excluded from the final analysis because the measurements represented extreme outliers. The mean LAVD measured using TVS was 114.8 ± 36.5 mm and the mean IOM was 116.9 ± 42.3 mm. There was no statistically significant difference between LAVD measured using TVS and IOM (mean difference, –2.12 mm (95% CI, –6.33 to 2.05 mm); P = 0.32). Bland–Altman analysis showed that there was good agreement between the two methods. The ICC was 0.81 (95% CI, 0.74–0.86) and Spearman's correlation coefficient was 0.68 (95% CI, 0.56–0.77). The mean difference between LAVD measured using TVS and anastomosis height was statistically, but not clinically, significant (mean difference, 10.25 mm (95% CI, 5.94–14.32 mm); P = 0.0005), and the ICC was 0.78 (95% CI, 0.66–0.85). Conclus...

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