‘My Hysteroscope is My Stethoscope’

Hysteroscopy offers a minimally invasive way to evaluate intrauterine pathology, yet only 15%-25% of gynecologists in the United States currently offer the procedure in their offices.

“Gynecologists have not embraced direct scoping evaluation the way other specialties have,” says Linda Bradley, MD, a gynecologic surgeon at Cleveland Clinic. “If you repeatedly had blood in your stool, a doctor would do a sigmoidoscopy or a colonoscopy. If you consistently had blood in your urine, you would get a cystoscopy. I want to open doors and get physicians to embrace office hysteroscopies.” To help achieve that goal, Dr. Bradley published an article presenting best practices for implementation of office hysteroscopy in the September 2022 issue of Obstetrics & Gynecology.

Indications and comparisons to other procedures

Indications for hysteroscopies include symptomatic abnormal uterine bleeding, unexplained infertility, recurrent miscarriages, leukorrhea and suspected retained products of conception or foreign bodies. Traditionally, other procedures have been used to assess these conditions.

The standard of care for evaluating the endometrial cavity has been blind dilation and curettage or biopsy. However, both procedures sample only a portion of the endometrium and have low sensitivity for focal lesions. Hysteroscopy allows for direct inspection and uninterrupted visualization, and it can facilitate visually directed curettage.

Similarly, transvaginal ultrasonography and saline infusion ultrasonography are often used for evaluating endometrial disorders and intracavitary masses. Hysteroscopy is a more sensitive and specific imaging modality. “If we miss a diagnosis, women continue to suffer,” says Dr. Bradley. “Office evaluation using a hysteroscope is so critical to making a diagnosis and selecting the right procedure, tools and equipment to treat patients.”

Best practices for office hysteroscopy

The advent of miniaturized, flexible hysteroscopes has made in-office visualization of the endometrial cavity, cervix and proximal tubal ostia a more viable option that can streamline care, reduce financial and logistic barriers, and prevent unnecessary procedures.

“It’s safe, easy, quick and gives you a reliable diagnosis,” says Dr. Bradley, who performs approximately 700 hysteroscopies a year. She offers several strategies for implementation of the procedure, including the following:

• Select appropriate patients. Hysteroscopy isn’t suitable for all patients. Absolute contraindications include cervical cancer, viable intrauterine pregnancy, and active reproductive tract infection, such as pelvic inflammatory disease or active or prodromal herpes infection.
• Other factors may call for extra consideration and/or trauma-informed care when hysteroscopy is indicated. These factors include comorbid medical conditions, mobility limitations, history of chronic pain or sexual abuse, and known cervical stenosis or previous cervical procedures. Previous experiences with pelvic examinations should be discussed and taken into consideration.
• Consider procedural timing. Scheduling the hysteroscopy shortly after menstruation for women with regular cycles will help maximize visualization and ease the procedure. The endometrial lining is thinnest during this early proliferative phase of the uterus.
• Prepare the cervix for patients at highest risk of cervical stenosis or pain with dilation. There are several evidence-based regimens for pre-procedure pharmacologic cervical softening.
• Counsel patients in advance on pain management strategies, which may include no medication, oral nonsedating medications, administration of local anesthetic agents and conscious sedation with oral or inhaled therapies.
• Use a video monitoring system that allows patients and other medical personnel to view the procedure, if desired.

As a vocal advocate for office hysteroscopies, Dr. Bradley borrows her final message for gynecologists from Nike: Just do it. “Learn it, do it and pass it on,” she says.

There are many ways to get trained on the procedure, including apprenticeships, participation in hands-on simulation, and through regional and national conferences.

“We need to consider our patients – the women at the end of the speculum,” says Dr. Bradley. “My hysteroscope is my stethoscope when it comes to evaluating intrauterine pathology.”