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Guest Editorial MAY 2007

Office Hysteroscopy: The Time Has Come

Stephen Grochmal, MD

First performed in 1807 by Bozzini,1 hysteroscopy is one of the oldest endoscopic procedures described in the medical literature. Few gynecologists actually perform office hysteroscopy today, though.2 However, in the last few years, the popularity of office hysteroscopy has been increasing. This is partly due to recent technical advances that have enhanced both the safety and cost-effectiveness of this procedure for intrauterine diagnosis and treatment.3 Improvements in uterine distension methods and smaller-diameter hysteroscopes have increased patient comfort and shortened the overall procedure time. These developments have made it possible for hysteroscopy to move from the traditional hospital setting into the physician’s office. In fact, recent studies suggest that there is no clear advantage to performing hysteroscopic procedures in the hospital,4 and that outpatient (office) hysteroscopy provides distinct advantages over inpatient hysteroscopy under general anesthesia.5 These benefits include enhanced time/cost effectiveness, reduced anesthetic risks, and greater patient satisfaction.

Diagnostic hysteroscopy offers an extremely reliable means of evaluating the uterine cavity, with accurate detection of intrauterine pathology.6,7 Together with endometrial biopsy, hysteroscopy is considered by many to be the primary method to investigate abnormal uterine bleeding and other intrauterine conditions.8-10 Office hysteroscopy is safe, has a low complication rate (less than 1%), and causes minimal patient discomfort.4,11,12 Furthermore, patients actually prefer the office over the hospital environment.13 When compared with other office-based procedures, patients have ranked the discomfort (if any) from office hysteroscopy as only 8% worse than that from a Papanicolaou smear, 3% worse than vaginal ultrasonography, and only 6% worse than having blood drawn.14 In fact, the majority of patients surveyed indicated they would recommend office hysteroscopy to a friend.

Another compelling benefit of office hysteroscopy is that this procedure is appropriate for treatment as well as diagnosis.15 For example, tubal sterilization using microinserts (Essure) has greatly expedited the evolution of minimally invasive hysteroscopic procedures, demonstrating excellent device-placement rates, high patient satisfaction when performed in-office, and even the assignment of specific procedure codes giving preference to in-office performance.16-19 In addition to tubal sterilization, there are a multitude of office-based operative hysteroscopic procedures that maximize patient convenience and autonomy, including removal of polyps or retained intrauterine devices, excision of small submucous/pedunculated fibroids, complete or partial endometrial ablation, and infertility evaluation.

In conjunction with affordable equipment costs, reasonable reimbursement for office-based procedures, and patient preference, office hysteroscopy is a real practice builder and should become an integral part of the gynecologist’s armamentarium. More advances in technology will soon be available such as a hysteroscope with a disposable, flexible operating sheath and reusable handle that displays a video image on a small, “iPod”-like monitor; a small-diameter, flexible, high-definition hysteroscope; and even a completely disposable, complementary metal-oxide-semiconductor sensor hysteroscope. Such developments represent a quantum leap for this office-based procedure by eliminating unnecessary downtime for sterilization, providing outstanding visualization and image quality at reduced cost, decreasing procedure time, and significantly improving patient comfort.

With all this, the future of office hysteroscopy looks brilliant. The benefits to both patient and physician are significant. So, why not make office hysteroscopy de rigueur in your practice?

Stephen Grochmal, MD
Associate Clinical Professor, Obstetrics and Gynecology (Adjunct Faculty), Howard University College of Medicine, Washington, DC; and Private Practitioner, Minimally Invasive Gynecologic Surgery, Ridgewood, NJ.

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References

1. Shah J. Endoscopy through the ages. BJU Int. 2002;89:645-652.
2. Rogerson L, Duffy S. A national survey of outpatient hysteroscopy. Gynecol Endosc. 2001;10: 343-347.
3. Lethaby A, Shepperd S, Cooke I, Farquhar C. Endometrial resection and ablation versus hysterectomy for heavy menstrual bleeding. Cochrane Database Syst Rev. 2000; (2):CD000329.
4. Nichols M, Carter JF, Fylstra DL, Childers M; Essure Systems US Post-Approval Study Group. A comparative study of hysteroscopic sterilization performed in-office versus a hospital operating room. J Minim Invasive Gynecol. 2006;13(5):447450.
5. Sagiv R, Sadan O, Boaz M, Dishi M, Schechter E, Golan A. A new approach to office hysteroscopy compared with traditional hysteroscopy: a randomized controlled trial. Obstet Gynecol. 2006;108(2): 387-392.
6. Towbin NA, Gviazda IM, March CM. Office hysteroscopy versus transvaginal ultrasonography in the evaluation of patients with excessive uterine bleeding. Am J Obstet Gynecol. 1996;174(6):1678-1682.
7. Gimpelson RJ, Rappold HO. A comparative study between panoramic hysteroscopy with directed biopsies and dilatation and curettage. A review of 276 cases. Am J Obstet Gynecol. 1988;158(3 pt 1):489-492.
8. Fraser IS. Personal techniques and results for outpatient diagnostic hysteroscopy. Gynaecol Endosc. 1993;2:29-44.
9. de Jong P, Doel F, Falconer A. Outpatient diagnostic hysteroscopy. Br J Obstet Gynecol. 1990;97(4): 299-303.
10. Nagele F, OÍConnor H, Davies A, Badawy A, Mohamed H, Magos A. 2500 Outpatient diagnostic hysteroscopies. Obstet Gynecol. 1996;88(1):87-92.
11. Itzkowic DJ, Laverty CR. Office hysteroscopy and curettage?a safediagnostic procedure. Aust N Z J Obstet Gynaecol. 1990;30(2): 150-153.
12. Bettocchi S. In-office hysteroscopy is feasible. WomenÍs Health Law Weekly. 2004;5(30):1-3.
13. Garratt DC, Grochmal SA. A survey of patient response to office surgery. J Am Assoc Gynecol Laparosc. 1996;3(4 suppl):S14.
14. Grochmal SA, Chandakas S, Garratt DC, Sherry S. Tolerability of office hysteroscopy: A patient survey. Abstract accepted for oral presentation at: Society of Laparoendoscopic Surgeons, 16th Annual Meeting and Endoscopy Expo; September 2007; San Francisco, Calif.
15. Hysteroscopy. ACOG Technology Assessment in Obstetrics and Gynecology. Obstet Gynecol. 2005;106:439-442.
16. Kerin JF, Carignan CS, Cher D. The safety and effectiveness of a new hysteroscopic method for permanent birth control: results of the first Essure pbc clinical study. Aust N Z J Obstet Gynaecol. 2001;41(4): 364-370.
17. Kerin JF, Cooper JM, Price T, et al. Hysteroscopic sterilization using a micro-insert device: results of a multicentre Phase II study. Hum Reprod. 2003;18(6): 1223-1230.
18. Cooper JM, Carignan CS, Cher D, Kerin JF: Selective Tubal Occlusion Procedure 2000 Investigators Group. Microinsert nonincisional hysteroscopic sterilization. Obstet Gynecol. 2003;102(1):59-67.
19. Kerin JF, Munday DN, Ritossa MG, Pesce A, Rosen D. Essure hysteroscopic sterilization: results based on utilizing a new coil catheter delivery system. J Am Assoc Gynecol Laparosc. 2004;11(3): 388-393.

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