Office hysteroscopy and suction curettage: can we eliminate the hospital diagnostic dilatation and curettage?

The risk of diagnostic hysteroscopy in women with endometrial cancer

OBJECTIVE

We sought to evaluate whether hysteroscopy in patients with endometrial cancer had an effect on disease stage or mortality.

STUDY DESIGN

This was a retrospective cohort analysis of data linked between a registry of women diagnosed with endometrial cancer and physician billing data on hysteroscopy.

RESULTS

A 99.8% match rate was obtained. Eighty-five percent of cases had complete data on staging. Of these 1972 cases, 672 (34.1%) had undergone hysteroscopy. There was no difference in stage III disease between the hysteroscopy (7.1%) vs no hysteroscopy (6.5%) group (P = .38). There was also no difference in death rates, 13.2% vs 15.2% (P = .25), or in the proportion of women dying of female genital organ cancer, 46.1% vs 42.1% (P = .53), respectively.

CONCLUSION

Hysteroscopy is not associated with a higher rate of stage III disease or mortality. It allows for accurate diagnosis with direct visualization and biopsy, and should be considered a safe diagnostic tool.

Nd-YAG laser hysteroscopic surgery: endometrial ablation, partial endometrial ablation and myomectomy

Hysteroscopy was first reported by Pantaleoni in 1869. He used a 12 mm diameter straight tube that was inserted into the uterine cavity with a concave mirror to reflect light into the uterus. Today, there are two main types of endoscopes in use: (1) the rigid endoscopie panoramic hysteroscope and (2) the flexible hysteroscope.

The role of hysteroscopy in the current management of the cervical polyps

The current management of patients with cervical polyps may include different approaches and protocols, such as a simply removal of the polyp in most cases at an office setting, surgical dilatation and curettage, electrosurgical excision or hysteroscopic polypectomy. Exploration of the cervical canal and uterine cavity by hysteroscopy determines the exact origin of the polyp pedicle (cervical or endometrial) and if there is any concurrent endometrial pathology. The majority of cervical polyps are asymptomatic, and their incidence is increasing with age. Symptomatic cervical polyps may cause intermenstrual bleeding, postcoital bleeding, heavy menses, postmenopausal bleeding and vaginal discharge. Cervical polyps may be detected by routine gynaecological examination, colposcopy, filling defects on hysterosalpingogram, gynaecological ultrasound (abdominal, transvaginal or sonohysterography) or endometrial biopsy. The location, number, and size of cervical polyps are best determined with diagnostic hysteroscopy. In the past, simple twisting or avulsion of the polyp or blind curettage was the standard surgical treatment of choice. However, this treatment often leaves residual polyp fragments in the cervical canal. Difficulty may also occur in differentiating endocervical from endometrial lesions. In addition, up to 25% of patients who have cervical polyp, have also a coexisting endometrial polyp, so there is a need for evaluation of the endometrial cavity. It is important to note the usefulness of hysteroscopy to manage a patient with a cervical polyp, especially when she presents abnormal uterine bleeding, in order to make an accurate diagnosis and offer appropriate treatment.

Management of Heavy Menstrual Bleeding: Is Hysterectomy the Radical Mastectomy of Gynecology?

Both hysterectomy for heavy menstrual bleeding and radical mastectomy for breast cancer are steeped in the history of surgery and have recently been challenged as being too radical for the disorder at hand. Radical mastectomy has largely been replaced with local removal of the tumor with subsequent radiation and/or chemotherapy. Alternatives to hysterectomy include a number of medical interventions, most notably intrauterine progestin-releasing systems, and endometrial ablation, a procedure that has a relatively high success rate and one that is now feasible for many women in an office or procedure room setting. However, although radical mastectomy rates have dropped precipitously, hysterectomy rates, at least in the United States remain relatively stable. Determining the proportion of hysterectomies that are done for heavy menstrual bleeding is difficult, largely because of coding issues, so it is difficult to measure the impact of new medical and minimally invasive surgical procedures. Nevertheless, it seems clear that many women are not exposed to the plethora of options to hysterectomy, a fact that may reflect a number of issues that may include training, skill, and financial incentives or disincentives. Clearly, options to hysterectomy are not a panacea, but if women are empowered to select from all of the options available, the rate of hysterectomy for bleeding should decrease while maintaining, or even enhancing the patient's satisfaction with care.

The Vabra aspirator versus the Pipelle device for outpatient endometrial sampling

OBJECTIVE

To compare the effectiveness of the Vabra aspirator and the Pipelle device as an outpatient endometrial assessment tool.

METHOD

This was a randomised, prospective trial conducted for a period of one year.

RESULTS

A total of 147 patients were recruited, of which 71 were in the Vabra group and 76 were in the Pipelle arm. The procedure success rate in the Pipelle group was significantly higher than the Vabra arm (98.7 vs 88.7%, P=0.02). Adequate tissue yield was also significantly more in the Pipelle arm (73.3 vs 52.4%, P=0.02). Cost-benefit analysis revealed a higher average cost per patient in the Vabra group compared to the Pipelle arm.

CONCLUSION

This study proved that the Vabra aspirator was not as effective as the Pipelle device in obtaining endometrial tissue for histological diagnosis. Despite its higher price per unit, the Pipelle device was a more cost-effective tool for outpatient endometrial assessment.

Efficacy of intravenous tramadol treatment for reducing pain during office diagnostic hysteroscopy

OBJECTIVE

To assess whether IV tramadol before outpatient hysteroscopy could reduce procedure-related pain.

DESIGN

A randomized double-blind placebo controlled trial.

SETTING

Outpatient Hysteroscopy Centre in the Department of Obstetrics and Gynaecology of Cagliari University.

PATIENT(S)

Fifty healthy, parous, women who underwent outpatient diagnostic hysteroscopy and endometrial biopsy.

INTERVENTION(S)

Random IV infusion of tramadol or placebo before hysteroscopy and endometrial biopsy were performed.

MAIN OUTCOME MEASURE(S)

Visual analogue scale of pain was measured both immediately after and 15 minutes after the procedure. Stress hormones (ACTH, cortisol), blood pressure, and heart frequency were evaluated before, during, and 15 minutes after the procedure.

RESULT(S)

In the tramadol group, the visual analogue scale of pain was significantly lower than in the placebo group both immediately after the procedure and 15 minutes later. Basal levels of ACTH and cortisol did not differ between the groups. In both groups, the ACTH levels remained unchanged during the study, and the cortisol levels were higher 15 minutes after the procedure than before the procedure. Procedure time, heart frequency, blood pressure, and adverse effects did not differ between the groups.

CONCLUSION(S)

In parous women without uterine malformations, a treatment with tramadol before hysteroscopy and endometrial biopsy appears to be capable of reducing the pain and discomfort that are associated with this procedure.

Improved Patient Compliance using Pediatric Cystoscope during Office Hysteroscopy

STUDY OBJECTIVE

To evaluate the use of a pediatric cystoscope in office diagnostic hysteroscopy.

DESIGN

Retrospective review (Canadian Task Force classification II-2).

SETTING

Maccabi Outpatient Women's Health Center.

PATIENTS

One thousand three hundred and thirty-five women; 959 (71.8%) premenopausal and 376 (28.2%) menopausal.

INTERVENTION

Office diagnostic hysteroscopy using 2.3-mm diameter pediatric cystoscope, without premedication or anesthesia.

MEASUREMENTS AND MAIN RESULTS

Hysteroscopy was successfully completed in 1298 patients (97.3%). The main reason for failure was cervical stenosis. Menopausal status was the only statistically significant factor correlating with increased failure rate. The analysis demonstrates that for every year of age, the OR for success decreases by 0.965, and success rises by 1.29 for every delivery the woman had. In menopausal women, the OR for success decreases by 0.45. Dilatation of the cervix was required in six women (0.46%), and local anesthesia was needed in only two women. One uterine perforation was recorded, and eight women (0.006%) developed vasovagal reflex or severe abdominal cramps. Post procedural oral analgesia was needed in 108 (8%) of the women.

CONCLUSION

The combination of a very small diameter continuous flow pediatric cystoscope, together with its ability to deliver high-quality images of the uterine cavity, make this instrument an excellent option for office diagnostic hysteroscopy.

Office-based anesthesia: an overview

Office-based anesthesia, like other specific forms of anesthesia practice, has many unique attributes. Better work hours and a closer working relationship with surgeons and patients can provide the forum for a considerable amount of professional resonance. Moreover, the itinerant nature of the practice, the limited resources, and the need to innovate on the spur of the moment can make for variety and excitement. The gamut of anesthesia techniques, patient comorbidities, and surgeon expectations does not necessarily produce a facile experience, of course. But no specific anesthesia specialty or venue is devoid of challenge. While OBA is different from other types of anesthesia practice, this distinction does not necessarily make it superior or inferior. The political climate has improved, with more states acknowledging the status of OBS and OBA. This may force those OBA providers who routinely practice without regard to practical and appropriate industry standards out of business. AAAHC accreditation of an OBA practice may serve as a confidence-inspiring indication to patients that nationwide peer-reviewed standards are being met. However, everyone involved must recognize that accreditation is not a substitute for the sound application of clinical knowledge and expertise, as well as the collection and assessment of quality assurance data. It is inappropriate to view each OBS client as a minihospital. Although this may seem a simpler business model, the business and legal issues can be far more complex than those found in more traditional locales. A meld between business-person and clinician is becoming more a rule than an exception, and efforts to maintain and promote professional sovereignty will help forge continued growth of this unique form of anesthesiology practice.

High frequency of endometrial polyps in endometriosis

STUDY OBJECTIVE

To evaluate the effectiveness of hysteroscopy and the frequency of endometrial polyps in women with endometriosis.

DESIGN

Retrospective clinical study (Canadian Task Force classification II-2).

SETTING

Infertility unit at a university-affiliated hospital.

PATIENTS

One hundred eighty-three infertile women, 92 with endometriosis and 91 controls without the disease.

INTERVENTION

Laparoscopy and scoring of endometriosis according to the American Fertility Society classification, and confirmation of endometrial polyps by pathologic examination.

MEASUREMENTS AND MAIN RESULTS

There was no significant difference between groups with regard to age, mean duration of infertility, and frequency of primary or secondary infertility. Endometrial polyps were found in 43 women (46.7%) with endometriosis and in 15 controls (16.5%, p = 0.0000). Their frequency did not differ significantly according to stage of endometriosis.

CONCLUSIONS

We strongly recommend hysteroscopy if endometriosis is detected in a woman undergoing evaluation for infertility, even if hysterosalpingography and transvaginal ultrasonography do not suggest endometrial polyps.

Postmenopausal bleeding: value of imaging

Endovaginal sonography in combination with HSG is an effective screening tool in evaluating patients with postmenopausal bleeding. Endovaginal sonography is highly sensitive for detecting endometrial carcinoma and can identify patients at low risk for endometrial disease obviating the need for endometrial sampling in this subgroup of patients. In patients with abnormal findings at sonography, a detailed morphologic analysis can be used to determine which patients can undergo blind endometrial sampling successfully versus those who would benefit from hysteroscopic guidance. In patients in whom endovaginal sonography and HSG are inadequate, MRI may provide additional information on the appearance of the endometrium, particularly in patients in whom endometrial sampling is difficult (eg, patients with cervical stenosis).

Endometrial adenocarcinoma encountered at the time of hysteroscopic endometrial ablation

STUDY OBJECTIVE

To determine the diagnostic accuracy and possible role of treatment of hysteroscopic endometrial resection in women with abnormal uterine bleeding (AUB) diagnosed with endometrial adenocarcinoma.

DESIGN

Retrospective analysis (Canadian Task Force classification II-2).

SETTING

University-affiliated center.

PATIENTS

Thirteen women with AUB and eight with postmenopausal bleeding.

INTERVENTION

Preablation endometrial office biopsy and hysteroscopic evaluation.

MEASUREMENTS AND MAIN RESULTS

Preablation endometrial biopsy was inadequate, inconclusive, or difficult to obtain in these women, and endometrial cancer was found at the time of resectoscopic surgery. Total endomyometrial resection including the tubal ostia was completed in eight women (group 1) and partial resection in five (group 2). Endometrial adenocarcinoma was confirmed histologically in all patients. A small focus of cancer was found in only two women in group 1 after total resection; in one the procedure was performed 9 years earlier and in the other it was completed hastily after absorption of 800 ml of 1.5% glycine irrigation solution. In women in group 2 malignancy was highly suspected and total resection was considered unwise.

CONCLUSION

All patients were alive and well 0.5 to 9 years after hysterectomy, with no evidence of recurrent cancer.

Dysfunctional uterine bleeding: advances in diagnosis and treatment

Dysfunctional uterine bleeding occurs during the reproductive years unrelated to structural uterine abnormalities. Ovulatory dysfunctional uterine bleeding occurs secondary to defects in local endometrial hemostasis; while anovulatory dysfunctional uterine bleeding is a systemic disorder, occurring secondary to endocrinologic, neurochemical, or pharmacologic mechanisms. Evaluation of patients with abnormal uterine bleeding and identifying those with dysfunctional uterine bleeding is achieved with a combination of the following: history; physical examination; and judicious use of laboratory evaluation, endometrial sampling and uterine imaging, with sonographic techniques and/or hysteroscopy. Coagulopathies should be considered as should the notion that intramural and subserosal myomas are unlikely to contribute to AUB. High-quality evidence suggests that medical therapy is frequently successful, and newer approaches, such as local delivery of progestins via intrauterine devices, appear to be particularly promising and devoid of systemic side effects. For those intolerant of medical therapy, and/or for whom fertility is no longer desired, a number of minimally invasive surgical options for hysterectomy now exist and are collectively termed endometrial ablation. Endometrial ablation may be performed with or without hysteroscopic guidance. There is an increasing body of evidence that suggests that nonhysteroscopic endometrial ablation may be at least as effective as hysteroscopic endometrial ablation, even when the hysteroscopic procedure is performed by experts.

Anesthesia for hysteroscopy

Hysteroscopy is becoming a more widely used technique. Diagnostic hysteroscopy is replacing conventional dilatation and curettage in the diagnosis of intrauterine pathologies. Transcervical endometrial resection is often the first-line surgical treatment for dysfunctional uterine bleeding and carries less associated morbidity and morality. Overall, the technique is extremely safe, but vigilance is required particularly for intravasation of irrigation media. Complications such as gas embolus and hypo-osmolar hyponatremia require prompt treatment to reduce associated morbidity and morality. Careful monitoring of fluid deficit is paramount in avoiding the latter problem. Regional or general anesthetic techniques can be used and, in the ambulatory or office-based setting, in which these procedures are increasingly performed, the need for "street readiness" can influence the choice of the agents used.

Fast-track office-based anesthesia: a comparison of propofol versus desflurane with antiemetic prophylaxis in spontaneously breathing patients

IMPLICATIONS

Compared to propofol, maintenance of anesthesia with desflurane provided significantly better intraoperative conditions during office-based surgery. In addition, desflurane with routine antiemetic prophylaxis was associated with a faster early recovery and similar incidence of postoperative side effects.

Six thousand office diagnostic-operative hysteroscopies

OBJECTIVE

To compare CO(2) and normal saline as distention media in office diagnostic hysteroscopy.

METHODS

The outcome of more than 6000 office hysteroscopies was analyzed. We used carbon dioxide or saline as distension medium. Minor hysteroscopic techniques were performed when indicated.

RESULTS

The major indication was abnormal uterine bleeding (45%). Satisfactory hysteroscopy was achieved in 92. 4% with CO(2) and in 98.3% with saline (P<0.05). Local anesthesia was used in 54 patients (1.5%) with CO(2) and in three patients (0. 1%) with saline (P<0.001). Four hundred and two women (16.3%) underwent hysteroscopic procedures under saline hysteroscopy. Endometrial polyps were removed in 281 patients, 75 IUDs were removed, 14 fibroids were extracted, uterine septa were excised in 11 cases and mild and moderate adhesions were transected in 21 patients.

CONCLUSION

Saline office diagnostic hysteroscopy offers at least all the advantages of the CO(2) hysteroscopy, and gives the possibility to easily 'find and treat in situ' many of the lesions observed.

Office hysteroscopy

Office hysteroscopy has developed into an easy, safe, quick, and effective method of intrauterine evaluation that provides immediate results, offers the capacity of direct targeted biopsies of suspicious focal lesions, and offers the direct treatment of some intrauterine conditions. It has been facilitated by the availability of small-caliber endoscopes. Because of its simplicity and ease, the procedure is applicable as a screening method for patients with abnormal uterine bleeding or questionable hysterograms and for patients with suspected intrauterine pathology. Office hysteroscopy can be undertaken in a short period of time with minimal morbidity and inconvenience to the patient. It is important, nonetheless, to select the patients appropriately and time the examination strictly to the early follicular phase, once menstruation has ceased. When suction aspiration plastic cannulas are used for endometrial sampling, the combined procedure, hysteroscopy-suction sampling, offers an excellent method in the evaluation of patients with abnormal uterine bleeding. Transvaginal sonography with or without fluid enhancement complements the uterine evaluation, rather than replacing hysteroscopy, by outlining intramural uterine lesions such as myomas, adenomyosis, and other adnexal pathology not susceptible to hysteroscopic evaluation. Although some patients may not require analgesia or anesthesia for office hysteroscopy, the majority will benefit from a paracervical block or topical anesthesia, particularly if a suction endometrial aspiration will follow hysteroscopy or if any hysteroscopic intervention is performed, including a targeted biopsy. The success office hysteroscopy depends on the appropriate selection of the patient, the absence of contraindications, adequate instrumentation, and meticulous technique.

Use of propofol for office-based anesthesia: effect of nitrous oxide on recovery profile

STUDY OBJECTIVE

To evaluate the effect of nitrous oxide (N2O) on the recovery profile and the incidence of postoperative nausea and vomiting (PONV) after office-based surgery performed under propofol anesthesia.

DESIGN

Prospective, randomized, single-blind study.

SETTING

Office-based surgical center.

PATIENTS

69 ASA physical status I, II, and III healthy, consenting outpatients undergoing superficial surgical procedures lasting 15 to 45 minutes.

INTERVENTIONS

After a standard propofol induction (1.5 mg.kg-1 i.v.), anesthesia was initially maintained with propofol, 100 micrograms.kg-1.min-1 i.v., in combination with either air or N2O 65% in oxygen. The propofol infusion rate was subsequently varied to maintain an adequate depth of anesthesia. All patients received local anesthetic infiltration prior to the surgical incision, as well as during the operation. No prophylactic antiemetics were administered.

MEASUREMENTS AND MAIN RESULTS

Recovery times and the incidences of PONV were recorded during the first 24 hours after surgery. Early and late recovery variables were similar in the two treatment groups; however, 65% N2O produced a 19% decrease in the propofol maintenance dosage requirement. One patient (3%) experienced nausea prior to discharge in the propofol-N2O group, and two patients (6%) experienced nausea at home in the propofol alone group. None of the patients vomited or received antiemetic medication during the 24 hours postdischarge period. Ninety-seven percent of patients receiving propofol alone and all of the patients in the propofol-N2O group were "very satisfied" with their anesthetic experience.

CONCLUSIONS

In outpatients undergoing office-based surgical procedures with propofol anesthesia, administration of 65% N2O decreased the anesthetic requirement without increasing PONV. Therefore, use of a propofol-N2O combination may be a cost-effective alternative to propofol alone for office-based anesthesia.

Hysteroscopy and transvaginal ultrasonography in postmenopausal women with uterine bleeding

OBJECTIVE

To evaluate the accuracy of hysteroscopy and transvaginal ultrasonography (TU), based on a histopathological report from endometrial specimens, in diagnosing endometrial pathology in menopausal women with uterine bleeding.

METHODS

Four-hundred and nineteen postmenopausal women with uterine bleeding underwent TU, hysteroscopy and endometrial biopsy. Hysteroscopic and sonographic findings have been evaluated on the basis of the final diagnosis established by histologic examination. Sensitivity, specificity and positive predictive value of TU at an endometrial thickness cut-off point of 4 and 8 mm (double layer technique) and of panoramic hysteroscopy have been detected.

RESULTS

Normal and abnormal endometrium was found in 222 and in 197 women, respectively. TU showed sensitivity of 95.1%, specificity of 54.8% and positive predictive value of 63.7% at a cut-off limit of 4 mm. With a cut-off limit of 8 mm the corresponding figures were 83.8%, 81.3% and 79.4%. Hysteroscopy demonstrated a sensitivity of 96.5%, specificity of 93.6% and positive predictive value of 92.6%. The combination of the two diagnostic tools showed a 100% sensitivity, 94.8% specificity and 93.3% positive predictive value.

CONCLUSIONS

With cut-off limit of 4 mm, TU can be considered the first choice modality of endometrial investigation in women with postmenopausal uterine bleeding to select patients at risk to carry endometrial pathology. Hysteroscopy is a more accurate technique than TU because of better specificity and must be indicated for all patients showing an endometrial strip more than 4 mm. When an endometrial thickness below 4 mm is detected by ultrasound, hysteroscopy may be indicated on clinical background because of the possibility to miss infrequent (2.5% in our series), but relevant endometrial pathologies. Endometrial sampling should follow hysteroscopic view in all cases showing abnormal or suspicious lesions as well as in all cases with irregularly shaped endometrial lining and/or suboptimal endoscopic vision.

A prospective randomized study comparing hysteroscopy and curettage (H & C) under local anaesthesia (LA) and general anaesthesia (GA) in Chinese population

OBJECTIVE

To compare the difference in patient's acceptance of local anaesthesia (LA) and general anaesthesia (GA) hysteroscopy and curettage in Chinese population.

DESIGN

A prospective randomized study.

SUBJECTS AND METHODS

In the period September 1994 to August 1995, all Chinese women with abnormal uterine bleeding or suspected uterine anomaly who warranted hysteroscopy and uterine curettage were invited to participate in this study with informed consent. They were randomly allocated to the control (i.e. GA) and study (i.e. LA) group.

RESULTS

Overall 90% of the controls and 91% of the study group were satisfied with the procedure. The hysteroscopic diagnostic accuracy was 83%. Significantly higher percentage of patients in the study group opted for the same form of admission arrangement if given the choice.

CONCLUSION

Hysteroscopy and curettage under LA and GA are equally acceptable in the Chinese population in Hong Kong. The patient satisfaction rate is high in both groups. Hysteroscopic diagnosis is highly accurate in malignant condition (100% sensitivity and 83% specificity).

Diagnostic and therapeutic advances in gynecologic oncology: screening for gynecologic cancer

Endometrial carcinoma is associated with a good prognosis because patients tend to present with early disease. Mass screening is therefore unlikely to be of benefit. High-risk populations may benefit from screening, but no prospective studies have demonstrated a benefit in any population. The most promising modality for screening appears to be TVS, and a normal TVS may also preclude the need for further evaluation of symptomatic patients. The appropriate use of TVS in patients on tamoxifen is currently unknown. Hysteroscopy and endometrial biopsy may have a role in the evaluation of symptomatic patients but do not appear promising as screening modalities.

Endometrial cancer, cervical cancer, and the adnexal mass

Cancers of the endometrium, cervix, and ovaries account for nearly 25,000 annual deaths among women in the United States. In recent years, better understanding of the causes and risk factors associated with gynecologic malignancies has contributed to more effective screening and early diagnosis. Abnormal uterine bleeding, a palpable adnexal mass, or vague abdominal complaints in women older than 40 can be signs of cancer. Regular pelvic examination, combined with appropriate use of the Papanicolaou's smear, endometrial biopsy, transvaginal sonography, and other tests, is recommended.

Flexible outpatient hysteroscopy without anaesthesia: a safe, successful and well tolerated procedure

The objective of this study was to assess the feasibility and tolerance of diagnostic outpatient flexible hysteroscopy without anaesthesia. Records from 554 consecutive patients were analysed retrospectively. Success rate, reasons for failure, adverse reactions and level of pain were the main outcome measures. Hysteroscopy was successful in 90.5% of patients and well tolerated in 93.3%; 5.4% experienced moderate to severe pain. Inability to negotiate the cervical canal accounted for 47% of failed procedures and poor view for 42%. These results suggest that flexible outpatient hysteroscopy without anaesthesia is a successful and well tolerated procedure.

Atraumatic cervical passage at outpatient hysteroscopy

OBJECTIVE

To evaluate the efficacy of topical anesthesia routinely administered to reduce discomfort and the need for additional local anesthesia during outpatient hysteroscopy.

DESIGN

Comparative observational study.

SETTING

Outpatient hysteroscopy clinic in a University hospital.

PATIENT(S)

Three hundred patients undergoing outpatient hysteroscopy.

INTERVENTION(S)

Application of lidocaine spray both to the surface of the cervix and into the cervical canal before performing hysteroscopy.

MAIN OUTCOME MEASURE(S)

The discomfort during passage of the hysteroscope through the cervical canal, the need for additional local anesthesia, and the failure rate of outpatient hysteroscopy.

RESULT(S)

One hundred fifty consecutive patients receiving lidocaine spray before the hysteroscopy were compared to a control group of another 150 consecutive patients who underwent the examination without pretreatment. Women treated with spray experienced significantly less pain at insertion of the hysteroscope. Furthermore, the spray significantly reduced both the need for additional anesthesia and the rate of failed hysteroscopies due to intolerable pain.

CONCLUSION(S)

Topical anesthesia with lidocaine spray is a simple method to alleviate patients' discomfort during cervical passage. It is effective in reducing the need for local anesthesia and should reduce the rate of failed outpatient hysteroscopies.

Does hysteroscopy improve upon the sensitivity of dilatation and curettage in the diagnosis of endometrial hyperplasia or carcinoma?

OBJECTIVE

The objective of this study was to determine whether hysteroscopy improved upon the diagnostic sensitivity of dilatation and curettage (D+C) in the detection of endometrial hyperplasia and carcinoma.

METHODS

A retrospective chart review was conducted of all patients undergoing hysteroscopy/D+C for abnormal uterine bleeding between 1991 and 1995. Hysteroscopic impressions and D+C diagnoses were compared.

RESULTS

Three hundred seventy-three patients were included in the study. Of the 61 patients with D+C demonstrating hyperplasia, the hysteroscopic impression was hyperplasia in 32 (52%). Of the 10 patients with D+C demonstrating carcinoma, the hysteroscopic impression was hyperplasia in 8 (80%) and carcinoma in 2 (20%). Two additional cases of carcinoma were diagnosed within 6 months of hysteroscopy/D+C, and both had been missed on both hysteroscopy and D+C. Of 204 patients with a normal hysteroscopic impression, 23 (11%) had hyperplasia on D+C.

CONCLUSIONS

Hysteroscopy did not improve upon the sensitivity of D+C in the detection of endometrial hyperplasia or carcinoma.

The value of hysteroscopic exploration for abnormal uterine bleeding

STUDY OBJECTIVE

To determine sensitivity, specificity, positive predictive value, negative predictive value, and global diagnostic precision of hysteroscopic exploration in the diagnosis of endometrial hyperplasia and adenocarcinoma in women with abnormal uterine bleeding.

DESIGN

Retrospective analysis.

SETTING

University-affiliated hospital.

PATIENTS

One thousand three hundred ninety-eight patients with abnormal uterine bleeding, 57.3% premenopausal and 42.6% postmenopausal.

INTERVENTIONS

Diagnostic hysteroscopy and subsequent dilatation and curettage.

MEASUREMENTS AND MAIN RESULTS

Endometrium was classified hysteroscopically as normal, atrophic, endometrial hyperplasia, and endometrial carcinoma. Histopathologic diagnosis was performed to determine the efficacy of hysteroscopy in diagnosing endometrial hyperplasia and adenocarcinoma. For endometrial hyperplasia in premenopausal women, sensitivity was 71.8%, specificity 96.4%, and global diagnostic precision 92.5%; in postmenopausal women, respective figures were 85. 1%, 100%, and 97.3%. For diagnosing adenocarcinoma in premenopausal patients, hysteroscopy was 100% sensitive, with specificity 99.4% and global diagnostic precision 99.5%; in postmenopausal women, respective figures were 100%, 99.4%, and 99.5%.

CONCLUSIONS

In women with abnormal uterine bleeding, diagnostic hysteroscopy is a basic tool that allows precise diagnosis of endouterine lesions such as polyps and submucous myomas. It also is highly accurate for evaluating endometrial adenocarcinoma and hyperplasia.

Transvaginal ultrasonography and hysteroscopy in the diagnosis of endometrial abnormalities

STUDY OBJECTIVE

To investigate the value of transvaginal ultrasonography, aspiration biopsy, and hysteroscopy combined with curettage or directed biopsy in detecting endometrial pathology in women with abnormal uterine bleeding.

DESIGN

Prospective, nonrandomized study.

SETTING

A university-affiliated hospital.

PATIENTS

One hundred twenty-two premenopausal and 78 postmenopausal women with abnormal uterine bleeding.

INTERVENTIONS

The women underwent transvaginal ultrasonography (TVS) combined with aspiration Pipelle biopsy. They were scheduled for hysteroscopy and endometrial sampling by curettage or directed biopsy within 4 weeks.

MEASUREMENTS AND MAIN RESULTS

Ultrasonographic findings were evaluated on the basis of final diagnoses established by hysteroscopy and histologic examination. The endometrium was measured at its thickest part in the longitudinal plane. In premenopausal women, endometrial thickness was measured during the early proliferative phase of the cycle. Ultrasound examination was considered negative if single-layer thickness was less than 5 mm in the absence of endometrial projections. In all other cases it was classified as positive. For postmenopausal women the cutoff point was 4 mm (single layer). In postmenopausal women with endometrial thickness less than 4 mm, as well as in premenopausal patients with negative TVS, the combination of TVS and aspiration biopsy missed only one case of atypical hyperplasia. In premenopausal patients TVS clearly detected 73% of polyps and myomata, permitting diagnostic and surgical hysteroscopy to be performed at the same time. In postmenopausal women with endometrial thickness 4 mm or greater, aspiration biopsy failed to detect two cases of atypical hyperplasia and one of focal adenocarcinoma. Pipelle sampling was technically infeasible in a woman with endometrial cancer because of a stenotic cervix. It also missed the majority of benign lesions (polyps and myomas).

CONCLUSIONS

Transvaginal ultrasound seems to be an excellent initial diagnostic method, with high sensitivity in diagnosing endometrial abnormalities. Its combination with aspiration biopsy seems to be safe in women with a thin endometrium. Hysteroscopy is necessary in postmenopausal women with an endometrium of 4 mm or more, as well as in premenopausal patients with endometrial thickness more than 5 mm (preovulatory phase of the cycle) and in those with suspected polyps or myomas.

Lignocaine aerosol spray in outpatient hysteroscopy: a randomized double-blind placebo-controlled trial

OBJECTIVE

To assess the efficacy of lignocaine spray during outpatient hysteroscopy in reducing the need for additional anesthesia and reducing the discomfort of the procedure.

DESIGN

A randomized double-blind, placebo-controlled trial.

SETTING

An undergraduate university teaching hospital in London.

PATIENT(S)

One hundred twenty patients undergoing outpatient hysteroscopy.

INTERVENTION(S)

Application of lignocaine spray to the cervix, cervical canal, and uterine cavity during outpatient hysteroscopy.

MAIN OUTCOME MEASURE(S)

The need to use additional anesthesia and the pain experienced at various steps of the procedure.

RESULT(S)

Women treated with active spray experienced significantly less pain when the cervix was grasped with a tenaculum at the start of hysteroscopy. There were no other significant differences in the outcome of hysteroscopy between the placebo and lignocaine groups, although there was a significant reduction in the use of additional anesthesia in both groups compared with historical controls.

CONCLUSION(S)

Lignocaine spray has beneficial effects on cervical but not uterine sensation. Pretreatment with either lignocaine or placebo seems to reduce the need for additional intracervical anesthesia during hysteroscopy.

The hysteroscopic management of endometrial leiomyomatosis

Uterine myomata are frequently the cause of abnormal uterine bleeding. They may be removed successfully by hysteroscopy. As a rule, the myomata are single, although on occasion several pedunculated myomas may be present. Three women were diagnosed with extremely large numbers of submucous leiomyomata. Many of the lesions were removed by hysteroscopic resection and many were destroyed with the neodymium:yttrium-aluminum-garnet laser.

A comparison of clinical outcomes and cost of office versus hospital hysteroscopy

STUDY OBJECTIVE

To compare office hysteroscopy with suction biopsy versus the hospital procedure with respect to clinical outcomes, success rates, and cost.

DESIGN

Retrospective review of outpatient and inpatient records for all attempted office hysteroscopies with suction biopsy from September 1991 to June 1995, and all hospital diagnostic hysteroscopies with dilatation curettage from January 1993 to June 1994.

SETTING

Multispeciality office group practice and a university-affiliated private hospital.

PATIENTS

Four hundred seventy-three women who had office hysteroscopy with suction biopsy and 95 who had hospital diagnostic hysteroscopy with dilatation curettage.

INTERVENTIONS

The procedures were performed by 13 gynecologists who had no experience with office hysteroscopy.

MEASUREMENTS AND MAIN RESULTS

A cost analysis was completed by obtaining hospital and anesthesia charges for the hospital procedures and comparing them with office, instrument repair, and capital equipment costs. Gynecologists' professional fees were excluded from the analysis since they were the same in both settings. The overall failure rates to complete office and hospital hysteroscopies were 7.2% and 3.1%, respectively. Abnormal uterine bleeding was the indication in 89% of office and 96% of hospital procedures. Office hysteroscopy in these women revealed an abnormality in 40.1% of office versus 38.5% of hospital procedures. Histology revealed insufficient tissue for diagnosis in 3.4% office and 22.1% hospital procedures. The minor complication rate for office hysteroscopy was 1.9% and for hospital hysteroscopy 4.2%. There were no major complications in either group. The mean charges, excluding professional fees, for the hospital were $1799 versus $62 for office hysteroscopy.

CONCLUSIONS

Office hysteroscopy has a high success rate and a low complication rate even when performed by a group of gynecologists with limited experience in the procedure. Because of its lower cost and greater diagnostic accuracy, office hysteroscopy with suction biopsy should be the method of choice for evaluating gynecologic conditions such as abnormal bleeding.

Transvaginal sonography and hysteroscopy in women with postmenopausal bleeding

OBJECTIVE

To make a prospective comparison between endometrial thickness determined by transvaginal sonography (TVS) and hysteroscopic findings in women with postmenopausal bleeding with histologic findings obtained by dilatation and curettage (D&C).

METHODS

Eighty-one patients who had not received hormonal replacement therapy were scanned by transvaginal probe, and double-layer endometrial thickness was measured 1 day before hysterectomy and D&C.

RESULTS

The histologic diagnosis was atrophy in 12 cases, irregular proliferative changes in 21, endometrial polyps in 16 hyperplasia in 16 and endometrial carcinoma in 16. TVS detected 46 of 48 pathologic conditions, including all cases of endometrial carcinoma if the endometrial thickness (both layers) was > or = 5 mm (sensitivity 95.8%, specificity 4.5%). Hysteroscopy also detected the endometrial pathology in 46 of 48 cases but with a higher specificity (sensitivity 95.3%, specificity 93.9%).

CONCLUSION

TVS and hysteroscopy are complementary diagnostic methods and could be accurately used to discriminate normal and pathologic conditions in patients with postmenopausal bleeding.

Hysteroscopy in women with abnormal uterine bleeding on hormone replacement therapy: a comparison with postmenopausal bleeding

OBJECTIVE

To determine the role of outpatient diagnostic hysteroscopy in patients with abnormal uterine bleeding (AUB) on hormone replacement therapy (HRT) and to contrast this with a control group of women presenting with postmenopausal bleeding.

DESIGN

Comparative observational study.

SETTING

Outpatient hysteroscopy clinic in a university hospital.

PATIENTS

Three hundred ten patients undergoing outpatient hysteroscopy.

INTERVENTIONS

Outpatient diagnostic hysteroscopy with endometrial biopsy when indicated.

MAIN OUTCOME MEASURES

Hysteroscopic findings, need for cervical dilatation and local anaesthesia, correlation between hysteroscopy and histologic diagnosis.

RESULTS

There were 157 (7.1%) patients with AUB on HRT and another 153 (6.9%) with postmenopausal bleeding out of 2,203 outpatient hysteroscopies. Hysteroscopy was successful in 97% and 92% of patients, respectively, and intrauterine pathology was diagnosed in 46.7% and 39.7% of these cases. Functional endometrium was noted significantly more often with HRT and endometrial atrophy with postmenopausal bleeding. Overall, local anesthesia was used in 126 (40.6%) and shown to be associated significantly with the need for cervical dilatation. Endometrial biopsy was attempted in 125 (80%) and 119 (78%) patients in the study and control groups, but was unsuccessful significantly more often with postmenopausal bleeding (38.7%) versus 16%). There were six cases of endometrial carcinoma, all in the control group.

CONCLUSION

There is a high incidence of intrauterine abnormalities in women with menstrual symptoms while taking HRT, but the pathology differed from those with postmenopausal bleeding. As focal lesions are found commonly in such patients, their detection by diagnostic hysteroscopy should improve compliance with HRT as it would allow individualization of treatment.

Comparison of carbon dioxide and normal saline for uterine distension in outpatient hysteroscopy

OBJECTIVE

To evaluate patient acceptance and the clinical feasibility of carbon dioxide compared with normal saline for uterine distension in outpatient hysteroscopy.

DESIGN

Prospective, randomized clinical trial.

SETTING

Outpatient hysteroscopy clinic in a university hospital.

PATIENTS

One hundred fifty-seven patients undergoing outpatient hysteroscopy.

INTERVENTIONS

Outpatient hysteroscopy was performed with carbon dioxide or normal saline with endometrial biopsy when indicated.

MAIN OUTCOME MEASURES

Need for local anesthesia, cervical dilatation, view of uterine cavity, need to change from carbon dioxide to normal saline distension, procedure time, patient discomfort (lower abdominal pain, shoulder tip pain, nausea) and complications.

RESULTS

Carbon dioxide was used for uterine distension in 79 women and normal saline was used in 78. Cervical dilatation was required more often with carbon dioxide hysteroscopy, although there was no increased requirement for local anesthesia. Hysteroscopic vision was similar between the two media, but eight carbon dioxide cases had to be converted to liquid distension. Procedure times were significantly longer for carbon dioxide hysteroscopy as was the occurrence of bubbles during the procedure. Lower abdominal pain and shoulder tip pain were significantly worse with carbon dioxide distension. Although the incidence of nausea and vomiting was higher with the use of carbon dioxide, the differences did not achieve statistical significance.

CONCLUSION

The use of normal saline for uterine distension had no adverse affects on the hysteroscopic view. It provided a shorter operating time and was well accepted by patients. Because of its easy availability and low cost, normal saline is an excellent alternative to carbon dioxide in women undergoing outpatient hysteroscopy.