The current approach to treating endometriosis is often inadequate or intolerable for many patients. Until more effective therapies are available, we should aim to maximize the effectiveness of our current options. Optimization may be possible by reducing nocebo effects, which are the negative therapeutic effects not directly caused by a treatment. Awareness of these effects, how they arise, and the factors influencing them, is invaluable if we aim to limit their magnitude. The unique nature of endometriosis diagnosis and management is especially prone to nocebo effects due to multiple factors, including diagnostic delays, feelings of invalidation, social transmission of expectations, and persistent symptoms despite numerous treatments. This commentary discusses the origins of these effects in people with endometriosis, methods of limiting nocebo effects, and future research directions.

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Objectives To assess transfusion practices at a Canadian tertiary care center before and after a hospital‐wide blood management educational campaign based on the Choosing Wisely toolkit. Background Red blood cell (RBC) transfusions are an essential intervention in obstetrics and gynaec ology (O&G). However, with limited guidelines outlining the appropriate use of RBC transfusions, clinicians routinely transfuse based on haemoglobin values and habits. Methods/Materials We conducted a retrospective chart review of all patients who received a RBC transfusion while admitted under an O&G provider in two 12‐month periods—before and after the intervention. The campaign consisted of Grand Rounds, formal and informal teaching, and posters placed within the hospital. We judged appropriateness from a set of criteria guided by the status of ongoing bleeding, pre‐transfusion haemoglobin, and the number of units ordered simultaneously. Results Transfusion appropriateness was poor in pre‐ and post‐intervention periods (46% vs. 51%, p = 0.59). The overall rate of RBC transfusion was reduced from 1.8% to 1.2% (83/4610 vs. 55/4618, p = 0.02) after the intervention. There was a 52% reduction in the total number of RBC units of transfused (229 vs. 111, p < 0.001), a 33% reduction in the number of patients transfused (83 vs. 55, p = 0.016), and fewer multiple‐unit transfusions without reassessment (39 vs. 13, p = 0.005). Conclusion RBC transfusion appropriateness remained low after a hospital‐wide educational campaign. However, there was a marked decrease in overall transfusion use, reflecting the adoption of more restrictive transfusion practices. The low rate of transfusion appropriateness represents an opportunity for further improvement.

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