OBG Management: What techniques do you use to minimize or eliminate patient discomfort during hysteroscopy?
Dr. Bradley: I think first is always be patient-centric. Let patients be prepared for the procedure. We have reading materials; our nurses explain the procedure. In the office, I try to prepare the patient for success. I let her know what is going on. A friend, family member can be with her. We have a nurse that understands the procedure; she explains it well. We have a type of bed that allows the patients’ legs to rest more comfortably in the stirrups—a leg rest kind of stirrup. We use a heating pad. Some patients like to hear music. Some patients like to have aromatherapy. We are quick and efficient, and typically just talk to the patient throughout the procedure. Although some patients don’t like this explanatory, “talkative” approach—they say, “Dr. Bradley, just do the procedure. I don’t want to know you are touching the cervix. I don’t want to know that you’re prepping. Just do it.”
But I like what we called it when I was growing up: vocal-local (talk to your patient and explain as you proceed). It’s like local anesthesia. For these procedures in the office you usually do not have to use numbing medicine or a paracervical block. Look at the patient’s age, number of years in menopause, whether or not she has delivered vaginally, and what her cervix looks like. Does she have a sexually transmitted infection or pelvic inflammatory disease? Sometimes we will use misoprostol, my personal preference is oral, but there are data to suggest that vaginal can be of help.4 We suggest Motrin, Tylenol an hour or 2 before, and we always want patients to not come in on an empty stomach. There is also the option of primrose oil, a supplement, that patients buy at the drug store in the vitamin section. It’s used for cervical softening. It is taken orally.5-7
If they want, patients can watch a video—similar to watching childbirth videos when I used to deliver babies. At some point we started putting mirrors where women could see their efforts of pushing a baby out, as it might give them more willpower to push harder. Some people don’t want to look. But the majority of women will do well in this setting. I do have a small number of women that just say, “I can’t do this in the office,” and so in those cases, they can go to the operating room. But the main idea is, even in an operating room, you are not just doing a D&C. You are still going to look inside with a hysteroscope and have a great panoramic view of what is going on, and remove a lesion with an instrument while you watch. Not a process of looking with the hysteroscope, scraping with a curettage, and thinking that you are complete. Targeted removal of focal lesions under continuous visualization is the goal.
OBG Management: Can you describe the goals of the consensus document on ending blind sampling co-created by the European Society of Gynecologic Endoscopy, AAGL, and the Global Community on Hysteroscopy?
Dr. Bradley: Our goal for this year is to get a systematic review and guidelines paper written that speaks to what we have just talked about. We want to have as many articles about why blind sampling is not beneficial, with too many misses, and now we have new technology available. We want to speak to physicians to solve the conundrum of bleeding, with equivocal ultrasounds, equivocal saline infusion, sonograms, equivocal MRIs—be able to take a look. Let’s come up to speed like our other colleagues in other specialties that “look.” A systematic review guideline document will provide the evidence that blind D&C is fraught with problems and how often we miss disease and its inherent risk.
We need to, by itself, for most of our patients, abandon D&C because we have too many missed diagnoses. As doctors we have to be lifelong learners. There was no robot back in the day. We were not able to do laparoscopic hysterectomies, there were no MRIs. I remember in our city, there was one CT scan. We just did not have a lot of technology. The half-life of medical knowledge used to be decades—you graduated in the ‘60s, you could be a great gynecologist for the next 30 years because there was not that much going on. When I finished in the mid to late ‘80s, there was no hysteroscopy training. But I have come to see its value, the science behind it.
So what I say to doctors is, “We learn so many new things, we shouldn’t get stuck in just saying, ‘I didn’t do this when I was in training.’” And if your thought is, “Oh, in my practice, I don’t have that many cases,” you still need to be able to know who in your community can be a resource to your patients. As Maya Angelou says, “When you know better, you should do better.” And that’s where I am now—to be a lifelong learner, and just do it.
Lastly, patient influence is very important. If patients ask, “How are you going to do the procedure?” it’s a driver for change. By utilizing hysteroscopy in the evaluation of the intrauterine cavity, we have the opportunity to change the face of evaluation and treatment for abnormal uterine bleeding.●
When to schedule hysteroscopy procedures and how to prepare the endometrium
To maximize visualization and procedure ease, schedule office hysteroscopy shortly after menstruation for reproductive-age women with regular menstrual cycles, which corresponds to timing of the thinnest endometrial lining.1 By contrast, the luteal phase of the menstrual cycle may be associated with the presence of secretory endometrium, which may mimic endometrial polyps or obscure intrauterine pathology, including FIGO type 1 and 2 submucous leiomyomas.
The following patients can have their procedures scheduled at any time, as they do not regularly cycle:
- those receiving continuous hormonal contraception
- women taking menopausal hormonal therapy
- women on progestin therapy (including those using intrauterine devices).
For patients with irregular cycles, timing is crucial as the topography of the endometrium can be variable. To increase successful visualization and diagnostic accuracy, a short course of combined hormonal contraceptives2 or progestin therapy3,4 can be considered for 10-14 days, followed by a withdrawal menses, and immediate procedure scheduling after bleeding subsides, as this will produce a thin endometrium. This approach may be especially beneficial for operative procedures such as polypectomy in order to promote complete specimen extraction.
Pharmacologic endometrial preparation also is an option and has been associated with decreased procedure time and improved patient and clinician satisfaction during operative hysteroscopy.2,3 We discourage the use of hormonal pre-treatment for diagnostic hysteroscopy alone, as this may alter endometrial histology and provide misleading results. Overall, data related to pharmacologic endometrial preparation are limited to small studies with varying treatment protocols, and an optimal regimen has yet to be determined.
References
1. The use of hysteroscopy for the diagnosis and treatment of intrauterine pathology: ACOG Committee Opinion, number 800. Obstet Gynecol. 2020;135:e138-e148. doi:10.1097/AOG.0000000000003712.
2. Cicinelli E, Pinto V, Quattromini P, et al. Endometrial preparation with estradiol plus dienogest (Qlaira) for office hysteroscopic polypectomy: randomized pilot study. J Minim Invasive Gynecol. 2012;19:356-359. doi:10.1016/j.jmig.2011.12.020.
3. Laganà AS, Vitale SG, Muscia V, et al. Endometrial preparation with dienogest before hysteroscopic surgery: a systematic review. Arch Gynecol Obstet. 2017;295:661-667. doi:10.1007/s00404-016-4244-1.
4. Ciebiera M, Zgliczyńska M, Zgliczyński S, et al. Oral desogestrel as endometrial preparation before operative hysteroscopy: a systematic review. Gynecol Obstet Invest. 2021;86:209-217. doi:10.1159/000514584.