Optimising gynaecological surgical care for elite female athletes: a narrative review.

The preceding sections have explored how each phase of preoperative, intraoperative, and postoperative management can be adapted to meet the specific needs of female athletes. The following section outlines key considerations for each of the main gynaecological surgical modalities—hysteroscopic, laparoscopic, and open surgery. Beyond the general considerations already discussed in the paper, the gynaecologist performing a hysteroscopy on an elite athlete is unlikely to require specific modifications. As with all hysteroscopies, the aim to complete it in the outpatient (office) setting will improve recovery time, avoiding the need for a general anaesthetic, but the decision should ultimately be made based on patient choice after relevant counselling. 4 Careful consideration should also be given to the choice of approach. Vaginoscopic technique is preferable for hysteroscopies, as it is faster, associated with less pain, and reduces the risk of inducing a vasovagal reaction compared to the traditional method, which involves the use of a vaginal speculum and cervical instrumentation ( 82 ). Hysteroscopy resection of lesions under direct vision, rather than blind polypectomy, is preferred to reduce the risk of recurrence and need for repeat procedures ( 83 ). Hysteroscopic procedures requiring a general anaesthetic should be managed with appropriate diligence paid to the pre-, intra- and post-operative factors already described. Laparoscopy remains the standard of care for most benign and many oncological gynaecological procedures, offering reduced tissue trauma, lower infection rates, and quicker return to activity ( 84 ). However, unique anatomical and physiological considerations in athletes must inform surgical technique and access. On average, athletes have lower body mass indexes compared to the general population ( 85 ). In thin patients, the distance from the anterior abdominal wall to the retroperitoneal vascular structures can be as little as 2 cm ( 86 ). The Royal College of Obstetricians and Gynaecologists’ Green-top Guideline recommends open entry or use of Palmer's point in women with a low BMI to reduce the risk of posterior abdominal wall vascular injury ( 87 ). 5 There are methods to reduce post-laparoscopy shoulder-tip pain (STP). A specific technique for releasing the pneumoperitoneum (pulmonary recruitment manoeuvre, extended assisted ventilation or actively aspirating intra-abdominal gas) has been shown to reduce STP. Intraperitoneal fluid instillation, the use of an intraperitoneal drain and local anaesthetic applied to the peritoneal cavity (not subdiaphragmatic) are also methods supported by data from RCTs ( 88 ). Port number and placement should be carefully planned, with the use of the minimum number of trocars needed to maintain surgical safety and ergonomics. There does not seem to be an advantage in single-port laparoscopy vs. conventional laparoscopy regarding pain nor hospital stay ( 89 ). For athletes, conventional multi-port access with meticulous fascial closure should remain the standard. Attention should be given to the restoration of abdominal wall anatomy in the port sites to minimise the risk of postoperative hernias and muscle weakness. Particular attention should be paid to closure of the abdominal wall at port sites ≥10 mm, to reduce the risk of port-site herniation ( 90 ). Notably, an imbalance in muscle strength, balance, stability, or endurance, particularly between a weaker abdominal wall and a stronger hip adductor muscle group, may increase stress on the inguinal region and contribute to the development of a sports hernia ( 91 ). The risk of hernias is greater with 10 mm ports, so laparoscopy with only 5 mm ports, including for the camera, should be considered ( 92 ). The surgeon should consider standardized advice on restricting high-load exercises before fascial healing is radiologically or clinically confirmed ( 93 ). In athletes for whom abdominal aesthetics are a priority, such as those in sports with exposed midriff attire, consideration may be given to fine suture techniques or Steri-strip closure only of small laparoscopic port sites to minimise visible scarring ( 94 ). While laparoscopic approaches are preferred, there, of course, remain clinical situations where open surgery is indicated or unavoidable. If laparoscopic approaches to surgery are not acceptable and open surgery needs to be performed, techniques to reduce healing time and complications from wound healing should be considered. A mini laparotomy can be performed where appropriate. This involves a smaller incision measuring 2 to 4 cm through which an ovarian cyst, for example, can be aspirated and removed ( 95 , 96 ). A smaller incision can reduce healing time but should not be used at the expense of increasing the difficulty with access during an open surgery. Incisional hernias after laparotomy are associated with significant morbidity. Recent research on prevention of incisional hernia formation suggests that a laparotomy closure technique using a slowly absorbable monofilament suture may be effective in lowering morbidity ( 86 ).

Elite women's sport is experiencing a period of rapid growth with the number of female athletes steadily increasing over the last two decades ( 1 ). This increase is also evident in the expanding media coverage and the growing number of spectators attending women's sporting events. 1 With the growing popularity of women's sport, there will be a corresponding increase in elite athletes requiring tailored and specialised gynaecological surgical care. Despite these trends, the field of Sports Gynaecology is still in its infancy. Whilst there is a greater understanding and appreciation of the unique physiological changes and gynaecological presentations that can affect elite athletes ( 2 ), there is a paucity of guidance or literature on managing the athlete requiring gynaecological surgery ( 1 ). Alongside the physical demands of their sport, female athletes face distinct challenges related to gynaecological health that can significantly impact their well-being and performance. Gynaecological conditions such as pelvic floor disorders, endometriosis, ovarian cysts, and menstrual irregularities are prevalent among female athletes, posing both physiological and psychological hurdles to their athletic careers ( 3 ). This article aims to provide a comprehensive review of pre-, intra- and post-operative care of the elite female athlete. Moreover, we propose a clinical framework outlining how different gynaecological surgical approaches, namely hysteroscopy, laparoscopy and open surgery, can be tailored to optimise the management and surgical outcomes of this unique population emphasising the importance of multidisciplinary care. The study drew upon peer-reviewed literature, consensus statements, clinical guidelines, and expert opinion relevant to the peri-operative management of elite female athletes undergoing gynaecological surgery. Literature searches for relevant articles were conducted in PubMed, Embase, and Scopus using combinations of keywords including “elite athlete”, “female athlete”, “gynaecology”, “gynaecological surgery”, “peri-operative care”, “return to play”, and “sports medicine”. Additional relevant studies were identified through manual screening of reference lists from key articles and guidelines. A summary of the search strategy, including databases, search terms, and search dates, is provided in the Supplementary Table S1 . Studies were selected based on their relevance to the peri-operative care of female athletes and/or the optimisation of surgical outcomes, rehabilitation, and return to sport. Given the limited availability of athlete-specific evidence, the review also incorporated relevant literature from broader surgical, anaesthetic, rehabilitation, and sports medicine populations where findings were considered applicable to elite female athletes. The evidence was synthesised narratively rather than through formal systematic review methodology, and recommendations were formulated using a pragmatic assessment of the available literature.

Managing elite female athletes involves distinct challenges beyond routine gynaecological care. Intense training, nutritional constraints, and performance pressures can exacerbate underlying conditions, necessitating a nuanced understanding of their physiological, anatomical, and psychological profiles to guide effective surgical and peri-operative care. Relative Energy Deficiency in Sport (RED-S) is a multifactorial syndrome arising from an imbalance between dietary energy intake and energy expenditure, wherein insufficient energy remains for optimal physiological function ( 4 ). RED-S affects a significant proportion of high-performance athletes and can result in health consequences including menstrual dysfunction, subfertility and changes in bone mineral density. In particular, the prevalence of menstrual disorders in athletes with lower BMIs is higher than that of athletes with a BMI in the normal range ( 5 ). Pelvic floor dysfunction (PFD) is prevalent among elite female athletes, particularly those involved in high-impact or load-bearing sports ( 6 ). A 2018 systematic review and meta-analysis reported the prevalence of urinary incontinence at 36% in this population with peak prevalence reaching 76% ( 7 ). The pathophysiology of PFD in athletes is multifactorial. Contributing factors include repeated elevations in intra-abdominal pressure, and over-recruitment or fatigue of the pelvic floor. Prolonged exposure to these stressors may predispose athletes to microtrauma, neuromuscular dysfunction, or compensatory patterns that eventually manifest as symptoms ( 8 ). Pre-existing PFD should therefore be actively identified before surgery, as it may influence both early post-operative recovery and the sequencing of rehabilitation. Athletes with symptoms such as urinary incontinence, pelvic heaviness, pain, or impaired load tolerance may require early pelvic health physiotherapy input, with rehabilitation prioritising breath control, pressure management, graded pelvic floor loading, and sport-specific return-to-impact progression ( 9 ). Elite sport also entails significant psychological burden and sport-related anxiety is another important consideration ( 10 ). According to Mann et al., the three most frequently discussed injury-related topics between physician and athlete include fear of reinjury, anxiety surrounding surgery, and frustration with the pace of recovery or rehabilitation ( 11 ). These findings highlight the importance of adopting a holistic and athlete-centered approach, in which psychological well-being is addressed alongside physical health. Dergaa et al., in a recent paper, supports a multidisciplinary sports medicine model in which psychological support, athlete education, communication, monitoring and individualised recovery planning are treated as core components of safeguarding elite athlete health and performance, rather than optional adjuncts ( 12 ). A further consideration is athletic identity disruption. For elite athletes, enforced absence from training and competition may represent not only a physical limitation but also a temporary loss of role, structure, autonomy, and belonging. This is particularly relevant in the peri-operative period, when athletes may be separated from their usual coaching environment, peer group, performance routines, and competitive goals. Athletic identity disruption may therefore compound anxiety, frustration, low mood, or engagement with rehabilitation ( 13 ). A strong association has been also described between disordered eating patterns and heightened anxiety levels in female athletes, indicating a bidirectional relationship between psychological and physiological stressors ( 14 ). The peri-operative period may amplify these vulnerabilities, particularly as athletes may be separated from their familiar routines, coaching structures, and support systems during recovery. To mitigate these risks, early input from sports psychologists should be considered a standard component of peri-operative care. Endometriosis warrants particular consideration within the context of gynaecological surgery in elite female athletes, as it represents one of the most common indications for operative intervention in reproductive-aged women ( 15 ). Despite its prevalence, there is a paucity of evidence specifically evaluating the peri-operative management, recovery trajectories, and return-to-play (RTP) outcomes of elite athletes undergoing surgery for endometriosis. Consequently, many aspects of clinical decision-making are extrapolated from the broader gynaecological and surgical literature. Surgical management, most commonly through laparoscopic excision or ablation of endometriotic lesions, may present unique challenges owing to the variable extent of disease, potential involvement of pelvic organs, and the complexity of some procedures ( 16 ). Careful pre-operative planning is essential to balance symptom relief and disease control against the anticipated recovery period and potential disruption to training and competition schedules. Athletes undergoing surgery for endometriosis may require individualised rehabilitation plans, particularly following extensive pelvic dissection, bowel or urinary tract involvement, or repeat procedures ( Supplementary Table S2 ). Furthermore, the chronic and recurrent nature of the disease means that surgery should be considered as part of a broader multidisciplinary management strategy that may include hormonal therapies, pain management, nutritional support, physiotherapy, and psychological support. Given the high prevalence of endometriosis and its frequent role as an indication for surgery, clinicians caring for elite female athletes should be familiar with the peri-operative considerations and recovery challenges associated with its management.

Before embarking on surgical intervention, the gynaecologist must consider whether operative management is warranted. This process begins with a thorough history and physical examination, supported by appropriate investigations, including blood tests and diagnostic imaging. Crucially, the consultation should provide a platform for shared decision-making, allowing the athlete to express her priorities, expectations, and concerns. With athlete consent, there may be an important role for the athlete's coach/manager in the shared decision-making process to further consider contextual factors such as training and competition schedules ( 17 ). The clinician should however be mindful of the potential for conflicting interests from performance stakeholders ( 18 ). Medical and conservative therapies should ordinarily be exhausted prior to committing to surgery. These will include pharmacological treatments, physical therapy, and watchful waiting, where clinically appropriate. Ultrasound imaging plays a central role as a diagnostic tool in the field of gynaecology and its use is fundamental in the evaluation of common gynaecological symptoms such as pelvic pain and heavy menstrual bleeding ( 19 ). For the ultrasound evaluation of adnexal lesions, Assessment of Different NEoplasias in the adneXa (ADNEX) model and the International Ovarian Tumour Analysis (IOTA) two-step strategy are validated tools to help differentiate between benign and malignant lesions ( 20 ). Endometrial pathology can be assessed and described on ultrasound by using International Endometrial Tumor Analysis (IETA) terminology and the IETA-1 model can help to differentiate between benign and malignant endometrial pathologies in women both with and without abnormal uterine bleeding ( 21 ). Myometrial conditions can be evaluated and described based on ultrasound with Morphological Uterus Sonographic Assessment (MUSA) terminology ( 22 ). The different phenotypes of endometriosis can be described and evaluated on ultrasound utilising the International Deep Endometriosis Analysis (IDEA) group's approach ( 23 ). These models offer an evidence-based and systematic approach to describing imaging findings which can be interpreted by the operating gynaecologist to plan and assess the need and urgency for surgery. Overall, while established clinical and imaging frameworks remain central to surgical decision-making, the management of elite athletes requires additional consideration of sport-specific factors. The timing of surgery should be individualised and balanced against competition schedules, training periodisation, symptom burden, risk of disease progression, and the anticipated impact of postoperative recovery on athletic participation and performance. Consequently, decisions regarding operative vs. conservative management should be made within a multidisciplinary framework that incorporates both clinical and athletic objectives. Once the decision for surgery has been made, the focus should shift to pre-operative care.

The surgical management of elite female athletes presents a unique challenge that extends beyond the traditional goals of peri-operative care. While the primary objective of surgery remains the safe and effective treatment of gynaecological pathology, clinicians must simultaneously consider the athlete's performance goals, training schedules, contractual obligations, psychological wellbeing, and long-term sporting career. This review highlights the need for an individualised and multidisciplinary approach that integrates principles from gynaecology, sports medicine, anaesthesia, physiotherapy, nutrition, and psychology to optimise both clinical and performance outcomes. A recurring theme throughout this review is the substantial gap between the increasing participation of women in elite sport and the limited evidence available to guide their surgical care. Although many of the peri-operative principles discussed are supported by evidence from general surgical populations, relatively few studies have specifically evaluated elite female athletes undergoing gynaecological procedures. Consequently, much of the current guidance relies on extrapolation from broader surgical, rehabilitation, and sports medicine literature. While such extrapolation is necessary given the scarcity of athlete-specific evidence, it should not be viewed as a substitute for direct research and high quality evidence from robust prospective studies. Elite athletes differ from the general population in several important respects and these factors may influence peri-operative risk, recovery trajectories, and RTP outcomes in ways that are not adequately captured by studies conducted in non-athletic populations. The review also highlights several unresolved clinical challenges. One of the most important is the absence of procedure-specific RTP data following gynaecological surgery. Current recommendations regarding recovery timelines after hysteroscopic, laparoscopic, and open procedures are largely based on expert opinion or extrapolation from general rehabilitation principles. However, RTP decisions in elite sport carry significant consequences, and both premature return and excessive restriction may negatively affect athletic performance and career progression. Prospective studies evaluating functional recovery and sport-specific outcomes following common gynaecological procedures are therefore urgently needed. Another important gap relates to ERAS pathways. ERAS programmes have transformed peri-operative care across multiple surgical specialties and are associated with reduced complications, shorter hospital stays, and faster recovery. However, existing ERAS protocols have been developed for general patient populations and do not specifically address the physiological and performance demands of elite athletes. Future research should evaluate whether athlete-adapted ERAS pathways, incorporating sport-specific nutritional strategies, accelerated rehabilitation programmes, and performance-focused recovery metrics, can further improve outcomes in this population. Pain management represents another area requiring further investigation. Contemporary peri-operative practice increasingly favours opioid-sparing analgesic strategies because of concerns regarding side effects, delayed mobilisation, and impaired recovery. In elite athletes, these concerns are compounded by anti-doping regulations and restrictions imposed by the World Anti-Doping Agency (WADA). However, the desire to minimise opioid exposure must be balanced against the need to provide adequate postoperative analgesia. Insufficient pain control may impair rehabilitation, disrupt sleep, delay recovery, and negatively affect psychological wellbeing. The optimal balance between effective analgesia and compliance with anti-doping regulations remains uncertain and warrants further study. Several limitations of this review should be acknowledged. As a narrative review, it does not employ the formal study selection, quality assessment, and evidence synthesis methods used in systematic reviews. However, the current literature base is not sufficiently mature to support a comprehensive systematic review, as athlete-specific studies are scarce and the available evidence is heterogeneous. Consequently, strict inclusion and exclusion criteria would likely have excluded much of the clinically relevant literature and limited the practical applicability of the review. To address this challenge, evidence from related fields, including surgery, anaesthesia, rehabilitation, and sports medicine, was incorporated where appropriate and carefully interpreted within the context of elite female athletes. Nevertheless, the strength of evidence supporting individual recommendations varies considerably and should be interpreted accordingly. We also acknowledge the homogeneous use of the term “elite female athlete”, as athletes in high-impact, aesthetic, endurance, strength-based and team sports will have distinct baseline risk profiles, intra-abdominal pressure demands, pelvic floor vulnerabilities, recovery trajectories and RTP requirements. Peri-operative planning should therefore be individualised according to the athlete's sporting discipline, loading pattern, competitive calendar and performance demands. Ultimately, the increasing visibility and participation of women in elite sport demands a corresponding evolution in clinical research and peri-operative care. The framework presented in this review provides a pragmatic approach to current practice while highlighting the significant evidence gaps that remain. Future prospective studies, athlete registries, and multidisciplinary collaborations will be essential to generate high-quality evidence capable of informing athlete-specific peri-operative guidelines, rehabilitation pathways, and RTP recommendations.

Pre-operative optimisation of any patient prior to surgery is a cornerstone of the principles of enhanced recovery. 2 These principles can be modified to fit the needs of elite female athletes ( Figure 1 ). Surgical optimization flowchart. The timing of surgery is a critical factor. RTP time encompasses the time between surgery and a full return to competition-level fitness. Minor gynaecological surgery such as hysteroscopic procedures and simple laparoscopic procedures will carry a short RTP time and thus have a less detrimental impact on training and competition ( Supplementary Table S2 ). As a result, these procedures allow for greater flexibility in surgical scheduling. Conversely, major surgery which carries a longer RTP time of weeks to months will impact an athlete's ability to train and compete. Consequently, such operations demand more strategic planning and coordination with the athlete's performance goals, seasonal commitments and, potentially, contractual status. Where possible, gynaecologists should consider scheduling elective procedures with prolonged RTP times during the off-season to minimise disruption. In the interim, conservative or medical management of gynaecological conditions may be appropriate until an optimal surgical window becomes available. The menstrual cycle may represent an additional consideration when planning elective surgery in elite female athletes. Fluctuations in oestrogen and progesterone concentrations throughout the cycle have been associated with changes in pain perception, ligamentous laxity, neuromuscular control, inflammatory responses, and haemostatic function ( 24 ). Some studies in sports medicine have suggested that these physiological variations may influence injury risk, performance, and recovery, although findings remain inconsistent and the overall quality of evidence is variable ( 25 ). The follicular phase has been hypothesised to represent a potentially favourable period for surgery because of lower progesterone concentrations, more stable hormonal profiles, and theoretical advantages relating to tissue healing, pain sensitivity, and postoperative rehabilitation. Conversely, the late luteal phase may be associated with increased fluid retention, altered pain perception, and premenstrual symptoms that could negatively affect peri-operative wellbeing and early recovery. However, direct evidence linking menstrual cycle phase to gynaecological surgical outcomes, complication rates, or RTP timelines is currently lacking. Therefore, while menstrual cycle timing may be considered as part of individualised pre-operative planning when clinically feasible, it should not delay necessary treatment or take precedence over other important factors, including disease severity, surgical urgency, training schedules, and athlete preference. RTP will be adversely affected if there are any peri-operative surgical complications. Prehabilitation refers to the interventions taken prior to major surgery that can improve post-operative outcomes for the patient and spreads the emphasis of rehabilitation from a solely post-operative construct to one that begins before surgery ( 26 ). In elite athletes, however, the objectives of prehabilitation may differ from those of the general surgical population. Rather than focusing primarily on increasing baseline functional capacity, prehabilitation should aim to preserve existing physiological performance, minimise deconditioning during the peri-operative period, and optimise sport-specific factors that may influence recovery, including iron deficiency, pelvic floor dysfunction, menstrual health, and RED-S. Particular attention should be given to athletes with low energy availability, as restoration of adequate nutritional status and energy balance may be required before elective surgery to support wound healing, recovery, and RTP. Exercise prior to surgery reduces post-operative complication rate and promotes earlier restoration of functional status ( 27 ). Nutritional, psychological, and behavioural interventions are considered part of prehabilitation and addressing these has been shown to improve functional recovery ( 28 ). Input for each patient will be unique, but a routine starting point would be optimisation of any haematological or biochemical markers which can be identified through a set of routine blood tests ( 29 ). Frequent or chronic NSAID use should be specifically assessed, as elite athletes may use these agents regularly to manage training-related pain or injury. Depending on the agent, dose, timing, and patient-specific risk factors, NSAIDs may have implications for platelet function, renal perfusion under general anaesthesia, gastrointestinal risk, and peri-operative bleeding ( 30 ). Where relevant, NSAID cessation, substitution, or continuation should be individualised in discussion with the anaesthetic and surgical teams, while ensuring that alternative analgesic strategies are available to avoid poorly controlled pain during the peri-operative period. Of note, female athletes tend to experience a greater incidence of iron deficiency with low energy intake, vegetarian diets and endurance exercise proposed as contributing factors ( 31 ). There is a clear link between iron regulation and exercise and specific criteria have been previously described to classify the various stages of iron deficiency in athletes ( 32 ). Standardisation of blood collection procedures for pre-operative assessment is also essential. Factors such as the time of day, hydration status, and recent physical activity should be carefully considered, as they can significantly influence haematological parameters ( 33 ). Notably, muscle-damaging exercise, particularly eccentric activity, should be avoided ideally for 2 days prior to testing, as it can provoke elevated levels of systemic inflammation, potentially altering the blood profile obtained ( 34 ). Nutritional status is a critical determinant of surgical outcomes. The dietary practices of elite athletes differs from the general population ( 35 ). Optimising nutrition in the pre-operative period can significantly influence wound healing, immune response, muscle preservation, and overall recovery, and should therefore be considered an essential component of peri-operative planning ( 36 ). In athletes at high risk of RED-S, referral to a sports nutritionist is recommended to restore adequate energy balance prior to elective surgery ( 37 ). In the peri-operative and post-operative period, the athlete may be at risk of RED-S due to a self-imposed significant reduction in energy intake as they are not undertaking their usual training. A peri-operative discussion on the importance of adequate energy intake for recovery can mitigate this risk. Macronutrient adequacy is another fundamental aspect of pre-operative preparation. Protein intake must be sufficient to support tissue repair and preserve lean body mass during periods of reduced physical activity. Recommendations suggest that athletes consume between 1.4 and 2.0 grams of protein per kilogram of body weight per day, with an emphasis on high-quality, leucine-rich sources to stimulate muscle protein synthesis ( 38 ). Carbohydrate intake should support immune competence and metabolic resilience; while training demands may be reduced pre-operatively, carbohydrate restriction is not advised, as it may exacerbate the physiological stress of surgery ( 39 ). Dietary fats, particularly those rich in omega-3 fatty acids, contribute to cell membrane integrity and inflammation modulation, and should be included in appropriate quantities to support recovery ( 40 ). In addition, attention must also be paid to micronutrient sufficiency. Vitamin D, calcium and magnesium are essential for bone health and neuromuscular function, and low levels may impair healing and increase the risk of complications ( 41 ). Assessment of vitamin D status should be performed in athletes with limited sun exposure or known risk factors for deficiency. Female athletes are at greater risk of vitamin D deficiency relative to males, potentially related to UV blocking skin moisturiser or make up ( 42 ). Magnesium levels have been shown to be commonly deficient amongst athletes ( 43 ). Other nutrients such as vitamin C, vitamin A, and zinc are known to support immune function and tissue regeneration, and while supplementation is not routinely required in well-nourished athletes, these should be considered in those with restricted or suboptimal diets ( 44 ). Emerging evidence also highlights the potential role of immunonutrition; specialised nutritional formulations containing compounds such as arginine, omega-3 fatty acids, and nucleotides, in enhancing immune competence and reducing post-operative morbidity ( 45 ). While the data are more robust in gastrointestinal and oncological surgical populations, immunonutrition may hold promise for athletes undergoing major gynaecological procedures, though further research is needed to substantiate its use in this specific cohort ( 46 ). Venous thromboembolism (VTE) prevention warrants particular consideration in elite female athletes undergoing gynaecological surgery, especially among those using hormonal contraception. Combined hormonal contraceptives are commonly utilised by athletes for contraception, menstrual suppression, cycle manipulation around training and competition schedules, and the management of menstrual-related symptoms. However, oestrogen-containing contraceptives are associated with an increased risk of VTE through their prothrombotic effects on coagulation pathways. In the peri-operative setting, this risk may be compounded by additional factors including surgical tissue injury, inflammation, reduced mobility, dehydration, and long-distance travel, all of which are frequently encountered within elite sport. Previous literature has highlighted hormonal contraceptive use as an important contributor to hypercoagulability in female athletes and recommends careful assessment of individual thrombotic risk factors when planning treatment ( 47 ). In athletes with additional VTE risk factors, including a personal or family history of thrombosis, thrombophilia, prolonged immobilisation, major surgery, or previous VTE, consideration should be given to peri-operative risk stratification and implementation of appropriate thromboprophylaxis according to established surgical guidelines ( 47 , 48 ). Decisions regarding continuation or temporary discontinuation of combined hormonal contraception should be individualised, balancing thrombotic risk against contraceptive needs, menstrual management requirements, and the potential impact on training and competition schedules. Close collaboration between gynaecologists, anaesthetists, haematologists, sports physicians, and the athlete is recommended to optimise peri-operative safety and minimise disruption to athletic performance.

Post-operative management plays a central role in facilitating safe and effective recovery following gynaecological surgery in elite female athletes. This period must be approached with a structured, individualised, and multidisciplinary plan that accounts for the short-, medium-, and long-term phases of rehabilitation ( Figure 1 ). In the short term, the clinician should ensure the athlete has an appropriate post-operative debrief and surgical review on Day One after the procedure. This allows the athlete's questions about surgery to be answered and for the identification of any early post-operative complications. If a longer than 24 h stay in hospital is required, the use of incentive spirometry can be used as an adjunct to reduce the risk of PPCs ( 73 ). The medium to long term rehabilitation of the athlete should be tailored to their individual needs and goals, with a focus on optimising pain relief, restoring pelvic floor function, core stability, and overall musculoskeletal strength and flexibility. Enhanced recovery after surgery (ERAS) programmes have become the gold standard of care in many surgical specialties ( 74 ). A recent meta-analysis demonstrated that ERAS pathways significantly reduce length of hospital stay without increasing readmission rates or rates of ileus across benign and oncological gynaecological surgery ( 75 ). ERAS has a specific post-operative focus on early nourishment, planned mobilisation, early removal of catheters and wound drains, and regular analgesia ( 76 ). Postoperative pain management should be done in consultation with the anaesthetist. Ideally opiates should be minimised to avoid the risk of nausea, vomiting or ileus, and the clinicians should be aware of WADA regulations with regards to The Prohibited List and the potential need for TUEs. The IOC's consensus statement on pain management in elite athletes specifically highlights non-pharmacological pain management including pain education, psychosocial interventions and physiotherapy. This may include adjuncts such as transcutaneous electrical nerve stimulation (TENS) ( 77 ). The medium to long term approach to recovery will require specialists in physiotherapy, nutrition, sleep, and sports psychology. Physiotherapy input is essential to provide a personalised recovery training plan to enable safe return to training. Historically, there has been significant variation in the availability of physiotherapy for patients after gynaecological surgery and in the regimens practised by physiotherapists. However, the recent robust evidence supporting ERAS has highlighted the importance of targeted physiotherapist input after major surgery ( 78 ). More focus has been given to nutrition and sleep in recovery and performance in recent years, with evidence that sleep deprivation has a detrimental impact on healing ( 79 ). Similarly, nutrition must be maintained to minimise muscle loss and inadequate dietary protein and energy intake has been associated with loss of muscle mass in the postoperative period ( 80 ). A sports psychologist should be considered for those athletes who need further input due to the mental aspects associated with a prolonged time out from training and competing ( 81 ).

The gynaecologist should maintain a comprehensive perspective on the intra-operative management of elite athletes to ensure that all members of the surgical team are informed of modifiable aspects of care that may enhance postoperative recovery and optimise clinical outcomes. This involves discussion and liaison with the anaesthetist and the wider theatre team. The Preoperative Briefing (Team Brief) is a common time to discuss intra-operative management and any anticipated challenges, and it can be used as forum to empower all members of the surgical team managing the female athlete ( Figure 1 ) ( 49 ). Anaesthetists will require a specific approach to optimising intraoperative and postoperative anaesthesia in this subset of patients. It is necessary to have the right choice of anaesthetic technique, pain management options, understanding of specific physiologic adaptations of the athlete, and knowledge of prohibited substances ( 50 ). Extreme training induces cardiovascular, respiratory and cerebral autoregulation changes, as well as extremes of body composition and muscle mass. The most common benign ECG findings in athletes are bradycardia, isolated left ventricular hypertrophy on voltage criteria and early repolarisation and the anaesthetist should be able to identify that these are normal features in the athlete's heart ( 50 ). Whilst these are a normal physiological adaptations to rigorous training regimes, they must be acknowledged and understood to avoid unnecessary concern and or overtreatment. The anaesthetist taking care of an athlete should be prudent about administering drugs restricted by the World Anti-Doping Agency (WADA), outlined on their “Prohibited List”. This comprises performance enhancing substances and methods that are prohibited either at all times, in competition or in particular sports only. Anaesthetists treating elite athletes should be cognisant that this list is reviewed and updated annually. For example, in 2024, Tramadol was added ( 51 ). When the clinical situation requires any medication on the prohibited list of WADA, the athlete and their team should be informed, ideally in writing. Athletes can apply for “Therapeutic Use Exemptions” (TUEs) for authorisation to use prohibited substances; in emergency treatment this can be applied for in retrospect ( 52 ). Some substances are only prohibited in-competition, defined as ‘The period commencing at 23:59 on the day before a Competition in which the athlete is scheduled to participate through the end of such Competition and the Sample collection process related to such Competition ( 53 ). Careful consideration of patient positioning is important in the elite athlete. Lithotomy position is commonly used in gynaecological operating and is associated with a 1.5% risk of developing lower limb neuropathy including obturator, lateral femoral cutaneous, sciatic and peroneal nerve neuropathies ( 54 ). Prolonged positioning in lithotomy is the main risk factor for these neuropathies, and although most resolve soon after surgery, this is an undesirable outcome for the elite athlete. Minimising time in lithotomy and the use of appropriate padding can help to reduce their incidence ( 55 ). Risk of neuropathies of the lower extremity can be reduced by ensuring cushioning at the fibular neck, avoiding hip flexion >90 degrees in lithotomy, and avoiding extremes of abduction and external rotation of the hip joint ( 56 ). Neuropathy of the upper limb can be associated with laparoscopic or robotic-assisted procedures performed in the Trendelenburg and Lloyd-Davies position ( 57 ). Rises in intraocular pressure caused by Trendelenburg's position will also increase the risk of perioperative visual loss ( 58 ). These risks can be mitigated for by avoiding the use of shoulder supports and reducing intraoperative sliding using non-slip pads. Thus, the extent of tilt should be kept to a minimum and the duration of any procedure with the patient in these positions should be as short as feasibly possible ( 59 ). Appropriate patient positioning will also help to prevent pressure ulcers, skin irritation, burns, nerve damage, circulatory problems and hypothermia. Positioning injuries can affect the skin, soft tissues, joints, ligaments and bones as well as the eyes, nerves and blood vessels. The risk of pressure sores can be minimised by utilising pressure-relieving aids on operating tables ( 60 ). All members of the surgical team must maintain vigilance regarding patient positioning and other factors that may contribute to perioperative risk. The nursing team plays a pivotal role in continuously monitoring the position and movement of laparoscopic arms and trocars throughout the procedure and should be encouraged to speak up immediately if any unintended contact or pressure is identified ( 61 ). For surgeries anticipated to last longer, implementing a second surgical timeout to reassess patient positioning has been proposed as an effective strategy to mitigate positioning-related complications ( 62 ). Intraoperative hypothermia (<36.0 °C) is a common consequence of anaesthesia, which increases morbidity and potentially increases mortality. 3 Athletes often exhibit distinct physiological characteristics, including a higher surface-area-to-mass ratio and lower body fat percentage, both of which can increase heat loss in cold environments ( 63 ). As a result, certain athletes may be more susceptible to hypothermia, particularly during prolonged exposure or post-surgical recovery in cool environments. Heat loss occurs in three phases. The first phase (caused by the redistribution of heat) is responsible for the greatest fall in body temperature ( 64 ). Operations occurring under general anaesthesia have a higher risk for causing hypothermia compared to awake surgery e.g., under spinal anaesthesia. The risk of intraoperative and post operative hypothermia can be minimised by regular temperature measurements, use of warmed intravenous fluids and use of forced-air warming devices (such as a Bair Hugger) ( 65 ). Additional measures may also be employed, including the use of warmed irrigation fluids, circulating water mattresses, and carbon-fibre resistive heating systems ( 66 ). Minimising early post-operative complications is essential, as even minor delays can significantly disrupt an athlete's training schedule and competition readiness. Therefore, the anaesthetist's perioperative management must aim to limit the likelihood of such complications. Elite athletes undergoing gynaecological surgery are a high-risk group for postoperative nausea and vomiting. Both gynaecological and laparoscopic surgeries are significant risk factors ( 67 ). For this reason, the anaesthetist should mitigate potential risks (e.g., minimise the use of volatile anaesthesia, consider regional or total intravenous anaesthesia and, where possible, avoid postoperative opioids) and if the patient has at least two risk factors for postoperative nausea and vomiting, 3–4 antiemetic agents of different drug classes should be given as prophylaxis ( 68 ). Central neuraxial blockade may facilitate surgery whilst avoiding the need for, and complications associated with, general anaesthesia. Additionally, peripheral nerve blockade may contribute to a multimodal, opiate-sparing analgesic regime irrespective of anaesthetic choice. Although these nerve blocks may provide optimal anaesthesia and/or analgesia, their benefits must be balanced with the risk of neuropathy. Although uncommon (central neuraxial blockade: 0.002–0.004% risk of permanent injury ( 69 ), peripheral nerve block: 1% risk of sensorimotor disturbance at 2 weeks or 0.03% risk of symptoms at 1 year ( 70 ), even temporary sensory or motor neuropathy may significantly impact one's RTP and represent a meaningful risk to an elite athlete. Therefore, these data, the location of the nerve block and the intended benefits should be considered and discussed with the patient during the informed consent process. Suxamethonium-induced postoperative myalgia, which can be severe and limit recovery, is more common in younger patients with greater muscle mass and should therefore be avoided ( 71 ). Postoperative pulmonary complications (PPCs) are common, especially after major surgery, and are associated with significant morbidity and mortality. Although there is no universal definition for lung protective ventilation strategies, which can reduce the incidence of PPCs, breathing mechanics and respiratory function will be improved by individualising mechanical ventilation parameters. Suggested initial ventilator settings include a tidal volume of 6–8 ml/kg of predicted body weight and 5 cm H20 of positive end-expiratory pressure which should subsequently be individualized ( 72 ).