{"paper_id":"916d4c67-adb5-44df-931e-89cdc2b428bb","body_text":"communications medicine Article\nA Nature Portfolio journal\nhttps://doi.org/10.1038/s43856-026-01907-w\nGlobal inequities and fragmentation in\nguidelines for endometriosis: a\nscoping review\nCheck for updates\nA list of authors and their affiliations appears at the end of the paper\nAbstract\nBackground Despite the availability of endometriosis care guidelines from multiple\ngovernmental and professional organisations, their global applicability and\nrecommendations have been insuf ficiently examined. This scoping review examines\nendometriosis guidelines worldwide, evaluating their availability, target audiences and\npopulations, methodologies, and clinical recommendations, building on a previous review of\nregion-specific endometriosis care guidance.\nMethods We searched PubMed, EMBASE, and Scopus from inception through October\n2025 without language, publication date, or geographic location restrictions. Additional grey\nliterature searches were conducted through March 2026. Eligible guidelines addressed\nindividuals with suspected or con firmed endometriosis of any age, including adolescent-\nspecific guidance and recommendations incorporating adenomyosis.\nResultsA total of 47 guidelines were included, comprising 28 English-language and 19 non-\nEnglish-language guidelines from multiple regions. The findings reveal marked regional\ninequities: most guidelines originate from high-income settings, particularly in Europe (15/\n47, 32%), with substantial gaps in Africa (2%) and the Eastern Mediterranean (4%). Variation\nin inclusivity and methodological rigour was observed, including underrepresentation of\nadolescents (77%), individuals with lived experience (30%), and gender-diverse people\n(19%), as well as inconsistent approaches to grading evidence. There was also limited\nconsideration of primary care physicians (49%), who play a key role in early diagnosis and\nmanagement. Gaps in alignment across guidelines on key diagnostic and therapeutic\npathways include recommendations on histological con firmation, biomarker use,\naromatase inhibitors, repeat surgery, fertility care, non-medical interventions, and self-care\ninterventions.\nConclusions These findings highlight the need for a global normative guideline, greater\nstandardisation in guideline development methods, context-speci fic guidance that\nincorporates the needs and rights of end-users, and coordinated efforts to strengthen\nequitable, evidence-based care.\nEndometriosis is a chronic inflammatory condition affecting approximately\n10% of people of female sex of reproductive age (~190 million) worldwide1.\nIt is characterised by the presence of endometrium-like tissue outside the\nuterus and is commonly associated with chronic, often severe pelvic pain,\nabnormal uterine bleeding, infertility, fatigue, bowel symptoms, and mental\nhealth conditions, which can substantially impair quality of life\n2–4.D e s p i t e\nthis substantial burden on the health and well-being of affected individuals,\nendometriosis has not been adequately prioritised in global health policy,\nand no globally applicable care guidance exists5,6.\nAdvances in diagnostic approaches and increasing awareness, driven\nby targeted national policies, care guidance, and patient advocacy, exist, but\nprolonged diagnostic delays persist across healthcare systems and continue\ne-mail: d.gete@uq.edu.au; g.mishra@uq.edu.au\nPlain language summary\nEndometriosis is a chronic inflammatory\ncondition characterised by the presence of\nendometrium-like tissue outside the uterus.\nDespite numerous endometriosis care\nguidelines from various organisations, their\nglobal applicability and recommendations\nremain insufficiently examined. We reviewed\n47 endometriosis guidelines from different\ncountries and regions, including 19 published\nin languages other than English. Most guide-\nlines originated in high-income settings, par-\nticularly in Europe, while major gaps remained\nin Africa and the Eastern Mediterranean.\nAdolescents, people with lived experience,\ngender-diverse people, and primary care\nphysicians were not consistently included in\nguideline development. Recommendations\nalso varied by diagnosis, treatment, fertility\ncare, and non-medical management. These\nfindings highlight the need for high-quality,\nstandardised, and inclusive guidance that\naccounts for diverse populations and health-\ncare settings, ensuring equitable, evidence-\nbased endometriosis care globally.\nCommunications Medicine |           (2026) 6:495 1\n1234567890():,;\n1234567890():,;\n\nto challenge effective management7,8. Delays in diagnosis of 12 years or\nmore, driven by non-speci fic clinical presentations, symptom normal-\nisation, lack of non-invasive diagnostics and limited access to specialised\ncare9–11, have been reduced to 6 years in some high-income settings 12,13.\nHowever, diagnostic delays remain a contentious issue, and even the more\nrecent data are considerably longer than the one-year-or-less target\nrecommended by the United Kingdom A ll Party Parliamentary Enquiry\ninto endometriosis by 2030\n14. These delays contribute to higher hospitali-\nsation rates and increased healthcare use and costs for pain management,\nparticularly in settings with limited access to timely diagnosis and multi-\ndisciplinary care\n15,16. The health, well-being, and economic burden asso-\nciated with endometriosis across the life course are likely underestimated, as\nexisting cost data are limited and largely derived from high-income\ncountries\n17. However, the scale of the problem is significant: non-cancerous\ngynecological conditions collectively account for over 5% of global years lost\nto disability (YLDs), with endometriosis the leading individual contributor\n(0.51%), accounting for nearly half the combined burden of HIV, tuber-\nculosis, and malaria (1.08%)\n18.\nNormative guidelines, developed through systematic evidence review\nand appraisal of bene fits and harms, are essential for standardising care,\nsupporting evidence-based decision-making, and reducing unwarranted\nvariation in clinical practice, non- medical and self-care interventions 19.\nAlthough many governmental and professional bodies have issued guide-\nl i n e sf o re n d o m e t r i o s i sc a r eo v e rt h ep a s tt w od e c a d e s ,t h e i rg l o b a la p p l i c -\nability, the strength of their approaches, and their recommendations have\nbeen insufficiently examined.\nThis scoping review expands on prior work, including a review of the\nnational availability of endometriosis care guidance\n6 and three reviews of\ndiagnostic and management recommendations from a limited set of\nEnglish-language guidelines from high-income countries\n20–22.I ts y s t e m -\natically maps and compares endometriosis guidelines across all WHO\nregions. It also evaluates methodological approaches, target populations and\naudiences, and clinical recommendations to identify key gaps and inform\nthe future development of globally applicable normative guidance. The\nguidelines reveal marked regional inequities and variation in inclusivity,\nmethodological rigour, and recommendations, highlighting the need for\nmore standardised and equitable global guidance.\nMethods\nSearch strategy\nWe conducted a scoping review of the published literature up to October\n2025 using PubMed, EMBASE, and Scopus (Supplementary Table 1).\nThe search was limited to human guidelines and used combinations of\ntitle, abstract, keyword, and subject heading terms in PubMed (MeSH),\nEMBASE (Emtree), and Scopus: ( “Endometriosis” OR “Adenomyosis”)\nAND ( “Practice Guideline ” OR “Guideline” OR “Clinical Practice\nGuideline” OR “Practice Bulletin” OR “Green-top” OR “Living Guide-\nline” OR “Position Statement” OR “Consensus”). Additional guidelines,\nparticularly those in non-English publications, were identi fied through\ngrey literature sources and manual hand-searching, including the\nGuidelines International Network, Google Scholar, and websites of\nprofessional societies and government health agencies, up to March 2026.\nGrey literature searches combined “endometriosis” with country names\nand guideline-related terms to identify national endometriosis guidance\nnot captured in bibliographic databases. No restrictions were applied on\nlanguage, date of publication, or source location. We performed searches\nin English and the primary languages of each country, with non-English\ndocuments screened using Google Translate and, where possible,\nchecked by co-authors and others fluent in those languages. The review\nfollowed the Joanna Briggs Institute methodology for scoping review\n23,\nand was reported in accordance with the Preferred Reporting Items for\nSystematic Reviews and Meta-Analyses extension for Scoping Reviews\n(PRISMA-ScR) checklist (Supplementary Table 2)\n24. The review protocol\nwas registered with the Open Science Framework ( https://doi.org/10.\n17605/OSF.IO/ZE64P).\nSelection criteria\nTitles and abstracts of identified records were independently screened by\nDGG and GDM, followed by a full-te xt review of eligible documents.\nGuidelines were included if they addressed individuals with suspected or\nconfirmed endometriosis (of any age), including adolescent-specificg u i -\ndance or recommendations integrating adenomyosis. Eligible documents\ncomprised clinical guidelines, consensus statements, recommendations, or\ncare pathways developed in international, national, or regional contexts. We\nincluded clinical practice guidelines and consensus documents issued or\nendorsed by national governments, government–professional society col-\nlaborations, national professional societies, multinational or regional pro-\nfessional societies, and international professional societies or expert\nconsensus groups. Documents were excluded if they were outdated (i.e.,\nsuperseded by a more recent edition), commentaries, narrative reviews,\nsummaries without detailed recomme ndations, or committee opinions.\nWhen multiple guidelines were identified for a country, the most recent,\nauthoritative, and comprehensive source was selected; if both professional\nsociety and government guidelines were available, both were recorded.\nData extraction\nData extraction was independently performed by two reviewers (DGG and\nLWR), with any discrepancies resolved through discussion. Non-English\ndocuments (n = 19; e.g., Spanish, Portuguese, Chinese, and others) were\ntranslated using Google Translate, and the extracted data were subsequently\nreviewed and, where applicable, veri fied by multilingual collaborators.\nInformation was collected from each eligible document across three cate-\ngories: Guideline characteristics (issuing body and year, country or region,\ntitle, document type, scope,first and last edition, language, and originality);\nmethodological characteristics (target population, target audience, metho-\ndology used, and evidence grading system); and recommendation domains\n(diagnosis, imaging, surgical management, medical treatment, fertility, and\nnon-pharmacological care). Adaptation was de fined as a guideline that\nexplicitly used one or more existing clinical practice guidelines as a primary\nsource and modified or contextualised their recommendations for local use.\nThese included documents stating that they were “adapted from,”“ based\non,” or “derived from” a named guideline, or that followed a formal adap-\ntation framework.\nData synthesis and analysis\nData were synthesised using a descrip tive approach, including narrative\nsummaries, frequency tables, and t hematic mapping. Comparisons were\nmade across regions, scopes, and methodological characteristics to highlight\nsimilarities and variations among gu idelines. Clinical recommendations\nwere categorised into the prede fined domains, and each guideline was\nassessed for the presence or absence of recommendations within these\ndomains. Results were presented in summary tables (characteristics of\nincluded guidelines, methodology, and recommendations covered) and\nvisualised throughfigures, including a world map of endometriosis guide-\nlines. This review used Microsoft Excel 365 for data synthesis and visuali-\nsation, including Figs.3 and 4. The world map and heatmaps were generated\nin R (version 4.5.0) using theggplot2 package.\nResults\nA total of 5347 records were identi fied from PubMed ( n = 974), Embase\n(n = 2365), and Scopus (n = 2008). After removing 2105 duplicates, 3242\nrecords were screened, and 91 full-text documents were assessed for\neligibility (Fig. 1). Seventy documents were excluded as newer editions\nhad superseded them or were commentaries, narrative reviews, sum-\nmaries without detailed recommendations, or committee opinions.\nTwenty-one documents were included from database searches, and 26\nfrom grey literature and hand searching, yielding 47 final guidelines (28\nin English and 19 in non-English languages across multiple regions,\nincluding Spanish, Portuguese, Chinese, Thai, Russian, and others). Of\nthe 47 documents, 12 were national governmental, 6 were\ngovernment–professional society collaborative, 20 were national\nhttps://doi.org/10.1038/s43856-026-01907-w Article\nCommunications Medicine |           (2026) 6:495 2\n\nprofessional society, 6 were multinational or regional professional\nsociety, and 3 were international professional society.\nGuidelines characteristics\nA total of 38 national guidelines were identified, all published between July\n2010 and March 2026 (Supplementary Data 1). Countries in the European\nRegion had the greatest proportion of national guidelines ( n = 16),\ncomprising 13 clinical practice guidelines (CPGs) and 3 related documents\n(2 consensus and 1 clinical care pathway). Of these, 11 were original, and 5\nwere adaptations of existing guideli nes. Eight countries in the Americas\npublished 10 guidelines– 5 original CPGs and 1 consensus statement from\nNorth America, and 4 CPGs from South America (3 original, 1 adapted).\nSeven countries in the Western Pacific Region published original national-\nlevel guidelines (5 CPGs and 2 consensus). The South-East Asia Region\npublished 2 original CPGs, and one country in the African Region published\nan adapted CPG. In the Eastern Medit erranean Region, 2 countries pub-\nlished guidelines: one was an original CPG, and the other was an adapted,\nformulary-focused clinical guidance document. In addition, 9 international\nor regional guidelines, all original publications, were identified, including 2\nCPGs and 7 consensus statements. Overall, 39 guidelines were original\ndevelopments, while 8 were adaptations, most commonly drawing on the\nEuropean Society of Human Reproduction and Embryology (ESHRE), the\nNational Institute for Health and Care Excellence (NICE), or the American\nCollege of Obstetricians and Gynaecologists (ACOG).\nFigure 2 shows the global distribution of national guidelines for\nendometriosis. Most guidelines werepublished in Europe, followed by the\nWestern Pacific region, with limited coveragei nA f r i c a ,L a t i nA m e r i c a ,a n d\nthe Middle East. Most were original CPGs, with fewer related documents,\nsuch as consensus statements. Several non-English guidelines and adapta-\ntions of existing recommendations were also identified, primarily in Europe\nand South America. Overall, substantial geographic gaps in guideline\navailability were evident, particul arly across Africa and the Eastern\nMediterranean.\nMethodological characteristics\nAcross the 47 endometriosis guidelin es, all targeted reproductive-aged\npatients, and 77% also included adolescents (Fig.3, Supplementary Data 2).\nMost (83%) addressed speci fic clinical subgroups, such as pregnancy-\nassociated disease or menopausal status; however, only a minority (19%)\nexplicitly acknowledged gender-diverse individuals. All guidelines were\ndirected at gynaecologists or fertility specialists, and 85% recommended a\nmultidisciplinary team (MDT) approach. In contrast, fewer than half (49%)\nexplicitly included primary care clini cians, such as general practitioners\n(GPs). Evidence of patient and public involvement (PPI) was reported in\nonly 30% of endometriosis guidelines (n = 14).\nMethodological approaches varied across the guidelines (Fig.4,S u p -\nplementary Data 3). Among original guidelines (n = 39), 82% used a hybrid\nmodel combining evidence review (sys tematic or narrative) with expert\nconsensus, while 8% conducted a systematic or evidence-based review\nFig. 2 | Global distribution of national guidelines for endometriosis.\nRecords identified through the database search (n = 5347)\n- PubMed (n = 974)\n- Embase (n = 2365)\n- Scopus (n = 2008)   \nDuplicates (n = 2105)\nRecords after duplicates removed \n(n = 3242)\nFull text accessed for eligibility \n(n = 91)\nExcluded based on title and \nabstract screening (n = 3151)\nGuidelines included from the \ndatabase search (n = 21)\nExcluded (n= 70) with reasons:\n- Outdated (n= 33)\n- Only summaries/ no detail (n= 18)\n- Narrative review/ commentaries (n= 10)\n- Committee opinions (n= 9)\nGrey literature and \nhand searching (n = 26)\nFinal Guidelines Included (n = 47)\n(English= 28 and non-English= 19)\n- National governmental (n = 12)\n- National professional society (n = 20)\n- Government–professional society collaborative (n = 6)\n- Multinational or regional professional society (n = 6)\n- International professional society (n = 3)\nFig. 1 | PRISMA-ScR flow diagram showing the identification, screening, eligibility,\nand inclusion of guidelines.\nhttps://doi.org/10.1038/s43856-026-01907-w Article\nCommunications Medicine |           (2026) 6:495 3\n\nalone, and 10% relied solely on expert consensus without reporting a sup-\nporting evidence review. Regarding evidence grading, 26% of the original\nguidelines applied the Grading of Recommendations Assessment, Devel-\nopment and Evaluation (GRADE) framework to assess evidence quality and\nthe strength of recommendations\n25. A further 44% used national or orga-\nnisational grading systems (i.e., frameworks developed by countries or\nprofessional bodies, including ad apted or alternative approaches to\nGRADE), whereas 31% issued ungraded or consensus-based recommen-\ndations without formal appraisal of the underlying evidence. Among\nadapted guidelines (n = 8), 63% reported conducting a literature review\ncombined with consensus processes to contextualise recommendations, and\n50% applied national-level grading systems.\nClinical domain recommendation\nMost guidelines covered a broad range of clinical domains, including\ndiagnosis (91%), medicalmanagement (85%), surgical management (83%),\nfertility care (81%), and non-pharmacological interventions (74%). A\nminority had more limited scopes: t he Saudi Arabian Council of Health\nInsurance (CHI)\n26 focused only on the medical management of endome-\ntriosis; the United States’ Society of Radiologists in Ultrasound (SRU)27 and\nthe European Society of Urogenital Radiology (ESUR) 28 consensus on\nroutine pelvic imaging for endometriosis; the Asia Paci ficI n i t i a t i v eo n\nReproduction (ASPIRE)29 consensus provided a detailed evaluation of the\nstructure of care in endometriosis and criteria for networks of expertise; the\nAsia-Pacific Endometriosis Expert Panel (APEX) 30 addressed diagnosis,\nimaging, and care pathways; and the Australasian Certi ficate of Repro-\nductive Endocrinology and Infertility Consensus Expert Panel on Trial\nEvidence (ACCEPT)\n31 focused on the management of endometriosis-\nassociated infertility.\nMost guidelines (>77%) addressed core diagnostic domains, including\nclinical assessment, pelvic examination, empirical therapy, avoidance of\nroutine first-line laparoscopy, and referral to specialist care (Fig.5). How-\never, variation was observed in recomme ndations regarding histological\nconfirmation and the diagnostic value of biomarkers such as cancer antigen\n125 (CA-125), particularly among European and North American\nguidelines.\nFig. 4 | Methodology and evidence grading among\nthe original guidelines ( n = 39).\nFig. 3 | Target population and intended users of\nincluded guidelines ( n = 47).\nhttps://doi.org/10.1038/s43856-026-01907-w Article\nCommunications Medicine |           (2026) 6:495 4\n\nTransvaginal ultrasound (TVUS) was consistently recommended as\nthe first-line imaging modality, with magnetic resonance imaging (MRI)\nreserved for suspected deep endome triosis (DE) or severe disease when\nadvanced ultrasound was not feasible in almost all guidelines (94%), except\nACCEPT, CHI, and the Brazilian Ministry of Health (MoH) guideline\n(Fig. 6). Inconsistencies were evident in guidance on specialist imaging and\nin explicit recognition that imaging alone cannot exclude endometriosis,\nespecially among national gui delines from the Western Paci fic, North\nAmerica, and Europe.\nMost guidelines (>70%) – particularly those from Europe, South\nAmerica, and the Western Pacific – largely converged on recommending\nlaparoscopy when medical therapy fails, cystectomy for endometrioma,\nsymptom- or fertility-based surgical indications, and referral to expert\nsurgeons or MDTs (Fig.7). However, inconsistencies remained, particularly\nregarding repeat surgery and the preference for excision over ablation.\nMost guidelines (>77%) converged on recommending non-steroidal\nanti-inflammatory drugs (NSAIDs) for pain relief and hormonal therapy as\nfirst-line management, primarily combined oral contraceptive pills\n(COCPs) and progestins. Gonadotropin-releasing hormone (GnRH) ana-\nlogues with add-back therapy were also commonly recommended (79%) as\nsecond-line options for patients with persistent symptoms or intolerance to\nfirst-line treatment (Fig.8). Some variation was noted in recommendations\nfor post-surgical hormonal treatment, with the use of the levonorgestrel-\nreleasing intrauterine system (LNG-IUS) addressed less consistently. A\nlimited number of guidelines (45%) recommend aromatase inhibitors for\nrefractory disease.\nMost European and South-East Asian guidelines showed strong con-\nvergence in fertility-related recommendations, particularly in endorsing\nAssisted Reproductive Technology/I n Vitro Fertilisation (ART/IVF),\nreserving surgery mainly for moderate-to-severe disease, considering\novarian reserve in decision-making, and promoting individualised fertility\nplanning or MDT referral (Fig.9). In contrast, greater regional variation was\nobserved in recommendations on early f ertility referral, avoiding routine\nsurgery before ART, and providing fertility counselling, particularly among\nguidelines from North America, parts of Europe, and the Western Pacific\nregion.\nPatient education (40%) and psychological support (30%) were the\nmost frequently recommended non-pharmacological interventions across\nthe included guidelines (Fig. 10). Some guidelines acknowledged the\npotential therapeutic value of pelvicfloor physiotherapy (19%), modifiable\nbehavioural measures (e.g., dietary or physical activity changes; 36%), and\ncomplementary therapies (e.g., acupuncture, yoga, traditional Chinese\nmedicine; 26%) but did not issue specific recommendations due to insuf-\nficient evidence\n32–36. Notably, there was variation in the inclusion of com-\nplementary and behavioural therapies, with some guidelines mentioning\nthese interventions briefly and others not addressing them at all.\nGiven that many patients with endometriosis also have adenomyosis,\nrecommendations on adenomyosis appeared in 10 endometriosis guidelines\n(21%), although it was not a primary focus. However, because adenomyosis\nis a distinct condition, some guideli nes, such as ESHRE, did not include\nrecommendations for it.\nDiscussion\nThis review identi fied 38 national guidelines, mostly from high-income\ncountries in Europe and the Western Pacific. Substantial gaps– particularly\nin Africa, Latin America, and the Eastern Mediterranean– highlight frag-\nmentation and inconsistency in national endometriosis care guidance.\nSeveral national guidelines were adaptations of pre-existing frameworks,\nFig. 5 | Diagnosis recommendations across endometriosis guidelines by WHO region and issuing body ( n = 47).\nhttps://doi.org/10.1038/s43856-026-01907-w Article\nCommunications Medicine |           (2026) 6:495 5\n\nmost commonly drawing on guidance from ESHRE, NICE, or ACOG. Of\nthe 9 regional or multinational guidelines identified, most were consensus\nstatements led by Asia–Pacific or multinational expert groups, while only 2\nwere full CPGs from Europe, underscoring the limited availability of\nglobally applicable guidance for the diagnosis and management of\nendometriosis.\nThis review provides a multilingual analysis of 47 guidelines across all\nWHO regions, documenting domain-specific clinical content, methodolo-\ngical variation, and global inequitiesthat have not been previously described.\nA scoping review of the national availability of endometriosis care guidance\nreported that ~18% of WHO-recognised Member States have govern-\nmental, professional society, or collaborative government–society guide-\nlines, while many rely on informal advocacy or social media sources\n6.\nAnother review summarised diagnostic and management recommenda-\ntions from 3 major international guidelines (ESHRE, RANZCOG, and\nNICE) but did not evaluate wider global variations20. Earlier work reviewed 7\npredominantly high-income, English-language guidelines published before\n2016\n21, while another review compared treatment recommendations from 8\nguidelines using standardised, evidence-graded tables22. However, these\nprevious reviews did not evaluate guidelines across all WHO regions.\nAll included guidelines addressed reproductive-aged individuals, but\nonly 77% considered adolescents, despite the known early onset of symp-\ntoms and diagnostic delays beginning in adolescence\n37. 83% of guidelines\nalso addressed key clinical subgroups, such as pregnancy and menopause,\nbut only a small number (19%) explicitly acknowledged gender-diverse\nindividuals, highlighting persistent gaps in inclusivity. 70% of guidelines did\nnot include the needs, preferences, and priorities of people with lived\nexperience, particularly those from underserved communities. Systematic\nreviews have demonstrated that gender-diverse individuals who experience\nendometriosis often face even further delayed diagnosis and inadequate care\ndue to cis-normative assumptions and the absence of inclusive clinical\nguidance\n38,39. All guidelines included gynaecol o g i s t sa sak e yc l i n i c a lc a r e\nprovider, and most endorsed multidisciplinary care; however, fewer than\nhalf explicitly addressed primary care clinicians, despite their pivotal role in\nearly symptom recognition and referral, as highlighted by recent evidence\nemphasising the central importance of first-contact management\npathways\n20,40.\nPPI was reported inconsistently across endometriosis guidelines, with\nonly 30% of the most recent guidelines (e.g., RANZCOG, NICE, ESHRE,\nHSE/NWIHP, AWMF/DGGG, ASPIRE, APEX, and WES) documenting\npatient participation in their devel opment. This highlights the need for\ngreater integration of patient perspectives to strengthen patient-centred care\nand shared decision-making.\nMethodological heterogeneity was evident across guidelines. Although\nhybrid evidence–consensus models predominated in the original guidelines,\ngrading frameworks were applied inconsistently, with roughly one-quarter\nof guidelines using the GRADE approach (e.g., RANZCOG, KSE, and\nESHRE). This inconsistency reflects broader concerns about variability in\ntransparency and rigour in guideline development\n41. In addition, several\ncountries adopted existing guidelin es rather than undertaking original\ndevelopment, most commonly using literature review combined with\nconsensus processes to contextualise recommendations. Collectively, this\nvariation highlights limited standardisation in the strength and clarity of\nrecommendations, reducing their clinical applicability and comparability\nacross health systems.\nThe variation in how adenomyosis is addressed across guidelines\nappears to re flect differences in guideline scope rather than disagree-\nment about its clinical importance. Although adenomyosis frequently\nFig. 6 | Imaging recommendations across endometriosis guidelines by WHO region and issuing body ( n = 47).\nhttps://doi.org/10.1038/s43856-026-01907-w Article\nCommunications Medicine |           (2026) 6:495 6\n\ncoexists with endometriosis and shares clinical features, it is increas-\ningly recognised as a distinct condition with different diagnostic and\nmanagement considerations. Accordingly, most guidelines limit their\nrecommendations to endometriosis, whereas a minority, including the\nRANZCOG\n33,T E A S42,a n dP T G O43 guidelines, incorporate adeno-\nmyosis to better re flect the overlap between these conditions observed\nin clinical practice.\nOver 77% of guidelines endorse a symptom-based diagnostic\napproach, discourage diagnostic laparoscopy as a first-line investigation,\nsupport empiric medical therapy, and outline referral pathways to specialist\ncare for timely diagnosis. TVUS is commonly recommended as the initial\nimaging modality, with MRI reserved for suspected deep or severe disease\nwhen advanced ultrasound is unavailable; however, these distinctions are\noften difficult to establish from clinical presentation alone. Overall, these\nrecommendations promote earlier, less invasive clinical pathways rather\nthan routine surgical con firmation\n20. Such approaches are intended to\nminimise diagnostic delay, facilitateearlier symptom relief, and reduce the\nrisk of disease progression 44. Despite this broad convergence, incon-\nsistencies were observed in recom m e n d a t i o n so nh i s t o l o g i c a lc o nfirmation\nand the use of biomarkers such as CA-125. Most guidelines note uncertainty\nin the evidence supporting the use of biomarkers for the diagnosis of\nendometriosis, given their low sensitivity and specificity, which limits their\nability to reliably confirm or exclude the disease\n32,33,45. Consequently, bio-\nmarkers are not recommended as standalone diagnostic tests for endome-\ntriosis. In contrast, histological con firmation remains important when\nlesions are identi fied. For instance, ESHRE, NICE, and RANZCOG\nrecommend that lesions suspected at laparoscopy be confirmed histologi-\ncally, while recognising that negative histology does not definitively exclude\nendometriosis32–34.\nSome inconsistencies were observed in surgical recommendations,\nparticularly regarding repeat ovarian surgery and the management of\novarian endometriomas, with excision often prioritised over ablation. Evi-\ndence suggests that repeat ovariansurgery may reduce ovarian reserve\n46,a n d\nthat ablation may be associated with higher recurrence rates than cyst\nexcision; however, high-quality c omparative data remain limited 47.F o r\nexample, SASREG48, CENETEC49,P T G O43,a n dF O G S I50 state that both\nexcision and ablation are effective formanaging pain and infertility, while\nsome American and Western Pacific guidelines do not specify a preferred\ntechnique. Although several American and European guidelines also do not\nexplicitly address hysterectomy, most recommend it only for patients with\npersistent symptoms who no longer wishto conceive, emphasising that all\nvisible disease should be excised at the time of surgery and recognising that\nhysterectomy does not constitute a definitive cure for endometriosis32–34.\nMedical management of endometriosis showed strong convergence\nacross most guidelines, with COCPs and progestins recommended as the\npreferredfirst-line hormonal therapy and GnRH analogues with add-back\ntherapy advised as second-line options when initial treatment fails– con-\nsistent with high-quality evidence. NSAIDs or other analgesics are sug-\ngested, either alone or in combination with hormonal therapy, to alleviate\nendometriosis-related pain, although this remains a weak recommendation\ndue to limited supporting evidence\n32,33. Most guidelines do not specifically\naddress prescription opioids 32,34,35; however, the RANZCOG guideline\nrecommends that, if indicated, opioids be restricted to acute pain, prescribed\nat the lowest effective dose for the shortest possible duration, and not used\nroutinely for chronic endometriosis-associated pain33. The LNG-IUS is also\nwidely recommended for pain control, particularly when long-term, loca-\nlised hormonal suppression is appropriate, although some guidelines did\nnot explicitly include it 34,51,52. For individuals with persistent symptoms\nFig. 7 | Surgical recommendations across endometriosis guidelines by WHO region and issuing body ( n = 47).\nhttps://doi.org/10.1038/s43856-026-01907-w Article\nCommunications Medicine |           (2026) 6:495 7\n\ndespite standard medical or surgical treatment, only a minority of guidelines\n(45%) recommend aromatase inhibitors (e.g. letrozole, anastrozole) –\nusually in combination with other hormonal agents– reflecting the limited\nevidence base. Their use may be off-label for endometriosis, and differences\nin regulatory approval across jurisdictions may partly explain variation in\nrecommendations. Several guidelines also recommend postoperative hor-\nmonal therapy for individuals who are not planning immediate pregnancy\nto reduce disease recurrence and pain; however, supporting evidence for this\npractice remains heterogeneous and limited53,54.\nMost guidelines (>65%) advise offering ART/IVF for endometriosis-\nrelated infertility, incorporating ovarian reserve assessment when planning\ntreatment, and adopting an individualised approach to fertility planning or\nMDT involvement. Despite this, notable variation persists across regions,\nparticularly in guidance on early referral to fertility services, although early\nspecialist referral is recommended fo r individuals with endometriosis-\nassociated infertility20. Inconsistencies were also identified in recommen-\ndations advising against routine sur gery before ART. While surgery for\novarian endometriomas may reduce ovarian reserve, evidence for benefit\nbefore ART remains uncertain55. In addition, available evidence for the use\nof hormonal therapies, such as oral contraceptives or GnRH analogues,\nbefore ART to improve live birth outcomes, remains limited46,56.\nThe majority of guidelines advise clinicians to discuss non-medical stra-\ntegies to support quality of life and psychological well-being in endometriosis\npatients, with HAS/CNGOF\n57,M I N S A L / S O C H O G58,M o H–New Zealand59,\nand ASPIRE29, explicitly supporting the use of psychological support, patient\neducation, and complementary therapies like acupuncture and yoga. Other\nguidelines, including ESHRE32,R A N Z C O G33,N I C E34,H S E35,a n dK S E36 –\nprovide general support for this approach, but refrain from recommending\ninterventions such as acupuncture, physiotherapy, exercise, diet, self-care or\nother complementary therapies due to insufficient evidence.\nThe ASPIRE consensus\n29 evaluated, through rigorous consensus\nmethodology, how endometriosis careshould be structured (although other\nguidelines allude to this), and what criteria should de fine a network of\nexpertise for managing endometriosis in the Asia Pacific.\nThis scoping review maps the availability of endometriosis\nguidelines across all WHO regions a nd systematically characterises\nmethodological variation and inco nsistencies in clinical recommen-\ndations. Although we used a rigor ous search strategy, the limited\navailability of non-English guidelin es in electronic databases required\nreliance on grey literature sources and Google Translate, which may\nnot have captured all relevant documents or search terms. Non-\nEnglish documents were also translated using Google Translate for\ndata extraction and, where possible, reviewed by multilingual colla-\nborators; however, machine translation may have introduced minor\ninaccuracies or loss of contextual nuance\n60. Although methodological\ncharacteristics were examined in det ail, formal quality appraisal (e.g.,\nAGREE II) was not undertaken; thus, findings re flect the presence\nand content of recommendations rather than their rigour or overall\nquality. The use of a “presence versus absence ” coding framework\nmay have oversimpli fied recommendations, as items coded as present\ncan vary in detail and strength. When multiple guidelines were\navailable within a country, the most recent and comprehensive\nsource was selected; this approach might have introduced selection\nbias by excluding subspecialty or complementary guidelines that\nprovide more detailed recommendations. This review maps guideline\navailability and content but does no t assess implementation, equi-\ntable uptake, or patient outcomes; guideline availability is not a proxy\nfor quality of care. Variation in the inclusion of adenomyosis likely\nreflects differences in guideline scope and evolving clinical recogni-\ntion rather than omission or lack of importance. Direct comparison\nFig. 8 | Medical recommendations across endometriosis guidelines by WHO region and issuing body ( n = 47).\nhttps://doi.org/10.1038/s43856-026-01907-w Article\nCommunications Medicine |           (2026) 6:495 8\n\nof guidelines may be limited by differences in healthcare systems,\nresource availability, and implement a t i o nc o n t e x t sa c r o s sc o u n t r i e s ,\nparticularly between high- and low-income settings.\nThe marked variation in guideline development methods and\nrecommendations identified in this review, together with the under-\nrepresentation of Africa and the Eastern Mediterranean Region, supports\nthe value of a global normative guideline. Such a framework could promote\nmethodological consistency, broader regional representation, and equitable\nrecommendations, while allowing ad aptation to diverse health system\ncontexts and resource settings.\nThe absence of national or region al endometriosis guidelines may\ncontribute to inconsistent clinical practice, delayed diagnosis, fragmented\nreferral pathways, and inequitable access to evidence-based care, particu-\nlarly in resource-limited settings. In these contexts, clinicians often rely on\ninternational recommendations or ind ividual clinical experience, which\nmay not align with local healthcare infrastructure or resource availability. A\nglobal guideline adaptable to local contexts could establish minimum\nstandards of care, strengthen training and referral pathways, and help\nreduce inequities in endometriosis care across diverse health systems\n61,62.\nThe findings of this scoping review may guide future efforts by identifying\nregions with limited guideline coverage, highlighting variations in recom-\nmendations, and informing prioriti es for guideline development and\nimplementation. Greater collaboration among international professional\nbodies, regional organisations, policymakers, and patient representatives\nmay support the development of harmonised, contextually appropriate\nguidance across diverse healthcare settings63,64.\nUnderserved populations, including Indigenous peoples, gender-\ndiverse individuals, people living with disabilities, and those in rural and\nremote areas, may face additional barriers to timely endometriosis diagnosis\nand care due to geographic, cultural, and socioeconomic factors. These\npopulations are often underrepresented in endometriosis research and\nguideline development, which may limit the extent to which recommen-\ndations reflect their needs, preferences, and experiences\n65,66. Greater inclu-\nsion of these perspectives is essential t o support equitable, inclusive, and\npatient-centred care.\nConclusion\nThis review demonstrates substantial regional variation in the availability,\nmethodologies, and recommendations of endometriosis guidelines world-\nwide. These findings highlight the need for greater harmonisation of\nguideline development and implementation, while ensuring recommen-\ndations remain responsive to regional healthcare contexts and population\nneeds. Expanding guideline development in underrepresented regions,\nparticularly in the WHO African and Eastern Mediterranean regions, and\nbroadening target audiences to include primary care and adolescent health\nproviders could improve access to timely diagnosis and management.\nImproved collaboration between international professional bodies and\nrelevant organisations could help reduce inconsistencies in guidance,\nstrengthen education and training, support timely updates to recommen-\ndations, and enhance patient support. Further research is needed to better\nunderstand the causes and disease mechanisms, including robust evidence\nconfirming the effectiveness of aromatase inhibitors and self-care inter-\nventions for managing symptoms of suspected or confirmed endometriosis.\nAdditional research is also needed to advance non-invasive diagnostics,\ndevelop non-hormonal, precision-based treatments, and establish more\neffective clinical pathways to expedite earlier diagnosis and enable perso-\nnalised care. A high-quality, standardised, inclusive, and global guideline is\nessential to address these gaps and im prove the quality, accessibility,\nFig. 9 | Fertility recommendations across endometriosis guidelines by WHO region and issuing body ( n = 47).\nhttps://doi.org/10.1038/s43856-026-01907-w Article\nCommunications Medicine |           (2026) 6:495 9\n\naffordability, and availability of care for individuals living with endome-\ntriosis worldwide.\nData availability\nThe data supporting thefindings of this study are available within the article\nand its supplementary information files. Additional details are available\nfrom the corresponding author upon reasonable request.\nReceived: 11 May 2026; Accepted: 31 August 2026;\nReferences\n1. World Health Organisation. Endometriosis. https://www.who.int/\nnews-room/fact-sheets/detail/endometriosis (2023).\n2. Zondervan, K. T., Becker, C. M. & Missmer, S. A. Endometriosis. N.\nEngl. J. 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J e f f r e y ,S . ,A s h t o n ,L . ,F e r f o l j a ,T .&A r m o u r ,M .T r a n s g e n d e ra n dg e n d e r\ndiverse people with endometriosis: A perspective on affirming\ngynaecological care.Women’s. Health20, 17455057241251974 (2024).\n66. Timkova, V., Mikula, P., Katreniakova, Z., Howick, J. & Nagyova, I.\nAssessing healthcare needs in endometriosis: A scoping review.\nPsychol. Health 41, 635–673 (2026).\nAcknowledgements\nWe thank Jennifer J. K. Rasanathan, consultant, World Health Organization\nfor reviewing an early draft of the manuscript. The study is supported by the\nMedical Research Future Fund (MRF1199785). G.D.M. is the Australian\nNational Health and Medical Research Council Leadership Fellow\n(GNT2009577). The funding body has no role in the design, analysis, or\npreparation of the manuscript. The named authors alone are responsible for\nthe views expressed in this publication and do not necessarily represent the\ndecisions or the policies of the World Health Organization.\nAuthor contributions\nD.G.G. contributed to conceptualisation, data curation, methodology,\nformal analysis, software, visualisation, and writing– original draft. G.D.M.\nand M.N. contributed to conceptualisation, methodology, supervision, and\nwriting – review and editing. L.W.R. contributed to the translation of non-\nEnglish documents, data extraction, and manuscript revision. D.E., J.A.,\nK.T.Z., L.C.G., L.R., M.L., H.S., G.D.A., E.W., F.K., S.M., A.G.S., S.A., I.F.,\nK.K., M.K., J.W.M., E.O.M., E.O., A.S., E.S., P.J.Y., N.P.J., S.A.M., and A.H.\ncontributed to methodology, interpretation offindings within their respective\nareas of expertise, and critical revision of the manuscript. All authors read\nand approved the final manuscript.\nCompeting interests\nG.D.M. reports serving in unpaid roles as President-elect of the World\nEndometriosis Society (WES) and Member of the Scientific and Technical\nAdvisory Group for the Human Reproduction Programme at the World\nHealth Organisation (WHO). D.E. reports serving in unpaid roles as an Early\nCareer Ambassador for the WES and a member of the Gynecology Clinical\nPractice Guideline Committee of the Society of Obstetricians and Gynae-\ncologists of Canada. J.A. reports consultancy, medical advisory board, and\nspeaker fees from Hologic, Organon, Gedeon Richter, Pharmacosmos, and\nZiwig; unpaid leadership roles as Chair of the Australian Endometriosis\nClinical Guideline, Medical Director of the Ainsworth Endometriosis\nResearch Institute, and member of the Australian Government Endome-\ntriosis Advisory Group; former roles as Chair of the AAGL Practice Com-\nmittee, President of the Australian Gynaecological Endoscopy and Surgery\nSociety, and member of the FIGO Menstrual Disorders Group; and is a\ncompetitive Australian Government MRFF/NHMRC grant holder. K.T.Z.\nreports receiving institutional research funding from Aspira Ltd, Bayer AG,\nExeltis Ltd, Proteomics Inc, and Roche Diagnostics Ltd; institutional con-\nsultancy fees from Apikal Ltd, Hirundo Biosciences, Hoffmann-La Roche\nLtd, Rathlin Therapeutics, and ZEG Berlin; and serving in an unpaid role as a\nBoard Member of the World Endometriosis Research Foundation (WERF).\nL.C.G. reports unpaid roles as Past President and Board Member of the\nInternational Federation of Fertility Societies and Board Member of the\nWERF. L.R. reports consultancy, medical advisory board, and speaker fees\nfrom Besins Healthcare, Merck, Organon, and Gedeon Richter; Board\nDirector of the Grevillea Foundation, and former roles as President of the\nWES and President of the Fertility Society of Australia and New Zealand; and\nis a competitive Australian Government MRFF/NHMRC grant holder. G.D.A.\nreports unpaid roles as President of the WERF and Chair of the International\nCommittee for Monitoring Assisted Reproductive Technologies (ICMART).\nML reports research and institutional support from the Australian MRFF,\nPfizer, AbbVie, CanSAGE, CIHR, Hamilton Health Sciences, and Hyivy;\nconsulting fees from AbbVie, Hologic, Chugai, Gesynta, Roche Diagnostics,\nAfynia, and Pfizer; honoraria for lectures, presentations, speakers bureaus,\nmanuscript writing, or educational events from AIUM, GE Healthcare, Bayer,\nand AbbVie; unpaid leadership roles with the WES Early Career Board,\nISUOG Next Generation, and the Gynecologic Ultrasound Society; and\naffiliations with Imagendo, SUGO– Specialised Ultrasound in Gynecology &\nObstetrics, and Endometriosis360. A.G.S. reports receiving honoraria and\ntravel support for industry-sponsored presentations from Bayer Philippines\nand Abbott Ltd and serving in unpaid board and committee roles with the\nAsian Society of Endometriosis and Adenomyosis, the WES, the Interna-\ntional Federation for Pediatric and Adolescent Gynecology, and the Asian\nInitiative for Reproduction (ASPIRE). J.W.M. reports serving in unpaid roles\nas a Board Member of the WES, Member of the Special Interest Group on\nEndometriosis of the European Society for Gynaecological Endoscopy, and\nPast President and Board Member of the Special Interest Group Endome-\ntriosis, the Netherlands. PJY reports receiving travel funding from the WES,\nthe Society for Endometriosis and Uterine Disorders, and the European\nEndometriosis League, and serving in unpaid roles as a Board Member of the\nWES and Member of EndoAct. I.F. reports serving as Chief ScientificO fficer\nof Nura Health and Co-founder of Sur180 Therapeutics, and in unpaid roles\nas a Board Member of the WES, Board Member of the Fundación Puertor-\nriqueña de Pacientes con Endometriosis (ENDOPR), and Member of the\nWHO Endometriosis Expert Group. S.A. reports serving in unpaid roles as a\nBoard Member of the WES and Executive Board Member of the American\nhttps://doi.org/10.1038/s43856-026-01907-w Article\nCommunications Medicine |           (2026) 6:495 12\n\nAssociation of Gynecologic Laparoscopists (AAGL) Complex Benign\nGynecology Fellowship Board of Directors. E.W. reports serving in unpaid\nroles as Founder of the Endometriosis Foundation of Kenya and Co-Chair of\nthe World Endometriosis Organisations. AH reports grant funding from the\nEU, UKRI, NIHR, CSO, Wellbeing of Women, and Roche Diagnostics; con-\nsulting fees from Roche Diagnostics, Absci, Gesynta, and Theramex; lecture\nfees from Gedeon Richter and Theramex; published UK patent applications\nfor a diagnostic biomarker for endometriosis and a predictor of gabapentin\ntreatment response; and unpaid roles as President of the WES, Co-Editor-in-\nChief of Reproduction and Fertility, Trustee and Medical Advisor to Endo-\nmetriosis UK, and Specialty Advisor to the Scottish Government’sC h i e f\nMedical Officer for Obstetrics and Gynaecology. All other authors declare no\ncompeting interests.\nAdditional information\nSupplementary informationThe online version contains\nsupplementary material available at\nhttps://doi.org/10.1038/s43856-026-01907-w\n.\nCorrespondenceand requests for materials should be addressed to\nDereje G. Gete or Gita D. Mishra.\nPeer review information Communications Medicinethanks Babu\nKaravadra and the other, anonymous, reviewer(s) for their contribution to the\npeer review of this work. A peer review file is available.\nReprints and permissions informationis available at\nhttp://www.nature.com/reprints\nPublisher’s note Springer Nature remains neutral with regard to\njurisdictional claims in published maps and institutional affiliations.\nOpen Access This article is licensed under a Creative Commons\nAttribution-NonCommercial-NoDerivatives 4.0 International License,\nwhich permits any non-commercial use, sharing, distribution and\nreproduction in any medium or format, as long as you give appropriate\ncredit to the original author(s) and the source, provide a link to the Creative\nCommons licence, and indicate if you modi fied the licensed material. You\ndo not have permission under this licence to share adapted material\nderived from this article or parts of it. The images or other third party\nmaterial in this article are included in the article ’s Creative Commons\nlicence, unless indicated otherwise in a credit line to the material. If material\nis not included in the article’s Creative Commons licence and your intended\nuse is not permitted by statutory regulation or exceeds the permitted use,\nyou will need to obtain permission directly from the copyright holder. To\nview a copy of this licence, visit http://creativecommons.org/licenses/by-\nnc-nd/4.0/.\n© The Author(s) 2026\nDereje G. Gete 1 ,D e v o nE v a n s2, Jason Abbott3,4, Leticia W. Ribeiro1, Krina T. Zondervan 5, Linda C. Giudice6,\nLuk Rombauts7, Mathew Leonardi8, Hemantha Senanayake9,G .D a v i dA d a m s o n10, Elsie Wandera11,12, Femke Jansen12,13,\nSally Motlock1, Angela G. Sison-Aguilar14, Sawsan As-Sanie15, Idhaliz Flores16,K a o r iK o g a17,M a r i n aK v a s k o f f18,\nJacques WM Maas19, Ezekiel Onyonka Mecha20,E n g i nO r a l21, Adrienn Salamon22, Ertan Saridogan23,P a u lJ .Y o n g24,\nNeil P. Johnson25,26, Stacey A. Missmer15,27,30, Andrew Horne 28,30, Manjulaa Narasimhan 29,30 &G i t aD .M i s h r a1,30\n1Australian Women and Girls’ Health Research Centre, School of Public Health, The University of Queensland, Brisbane, QLD, Australia.2Department of Obstetrics,\nGynecology, and Reproductive Sciences, University of Manitoba, Winnipeg, MB, Canada.3Discipline of Women’s Health, School of Clinical Medicine, The University of\nNew South Wales, Sydney, NSW, Australia.4National Endometriosis Clinical and Scientific Trials (NECST) Network, UNSW, Sydney, NSW, Australia.5Oxford Endo-\nmetriosis CaRe Centre, Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, UK.6University of California San Francisco, San\nFrancisco, CA, USA.7Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia.8Department of Obstetrics and Gynecology, McMaster\nUniversity, Hamilton, ON, Canada.9Department of Obstetrics and Gynaecology, University of Colombo, Colombo, Sri Lanka.10Department of Obstetrics and Gyne-\ncology, Stanford University School of Medicine, Stanford, CA, USA.11Endometriosis Foundation of Kenya, Nairobi, Kenya.12World Endometriosis Organisation,\nEdinburgh, UK.13Endometriose Stichting, Sittard, The Netherlands.14University of the Philippines Manila College of Medicine, Manila, Philippines.15Department of\nObstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA.16Department of Basic Sciences, Ponce Health Sciences University, Ponce, Puerto Rico.\n17Department of Obstetrics and Gynecology, Reproductive Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan.18Université Paris-Saclay, UVSQ,\nInserm, CESP, Villejuif, France.19Department of Obstetrics and Gynaecology, Maastricht University Medical Centre and Grow, research institute for oncology and\nreproduction, Maastricht, The Netherlands.20Senior Lecturer, Department of Biochemistry, University of Nairobi, Nairobi, Kenya.21Department of Clinical Sciences,\nObstetrics and Gynaecology, Umeå University, Umeå, Sweden.22Chair of the Board of Trustees at the Women’s Health Foundation, Budapest, Hungary.23University\nCollege London, Elizabeth Garrett Anderson Institute for Women’s Health and University College London Hospital, Women’s Health Division, London, UK.24Department\nof Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada.25Flinders University, Adelaide, SA, Australia.26University of Auckland and\nAuckland Gynaecology Group, Auckland, New Zealand.27Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.28Centre for\nReproductive Health, Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, UK.29Department of Sexual, Reproductive, Maternal, Child, Adolescent\nHealth and Ageing (LHR), World Health Organization, Geneva, Switzerland.30These authors jointly supervised this work: Stacey A. Missmer, Andrew Horne, Manjulaa\nNarasimhan, Gita D. Mishra. e-mail: d.gete@uq.edu.au; g.mishra@uq.edu.au\nhttps://doi.org/10.1038/s43856-026-01907-w Article\nCommunications Medicine |           (2026) 6:495 13","source_license":"CC0","license_restricted":false}