S. Tara Scope is a healthy 29-year-old nulliparous patient who presents to your gynecology clinic for an initial patient visit due to recent onset of mid-cycle spotting. She is engaged to be married and hoping to conceive within the next year. She has always had regular menstrual cycles and is currently on cycle day 7. As a busy professional, it is difficult for her to miss work and she is seeking a health care provider that can diagnose and possibly treat her condition during her initial visit.
After reviewing her medical history, you determine that Ms. Scope has an unremarkable past medical history, is on no medications, and has very regular cycles. Her body mass index is 21 and the remainder of her gynecologic exam is normal. The next appropriate step is for her to have a vaginal ultrasound, which shows an endometrial echo of 1.5 cm, which is unusual for cycle day 7. Her myometrium and her ovary scan are normal. The Doppler flow suggests the presence of an intrauterine polyp (Figure 1). After consent is obtained, a vaginoscopic polpectomy is performed in less than 10 minutes. The patient rests for 5 additional minutes to allow her cramping to subside and then returns to work for the remainder of the afternoon.
Office hysteroscopy (OH) remains a valuable but underutilized tool in evaluation and treatment of abnormal uterine bleeding.1 Fostering a clinic environment in which patients have access to a “one-stop shopping” experience has benefits for both them and the gynecologist,2-5 as well as the medical system.6,7 In our minimally invasive gynecologic surgery (MIGS) clinic with only two providers, we perform approximately 15 OHs each week while we see our normal patient schedule. Despite being the gold standard for evaluation of endometrial pathology,8-11 it has been estimated that fewer than 1 in 5 gynecologists routinely perform OH.1 In this article, we will walk through how to set up a clinic practice that allows for a same-day “see and treat” approach with OH.
Who benefits from diagnostic and procedural OH?
Many patients can benefit from use of OH (Table 1). Abnormal uterine bleeding (AUB) accounts for roughly one-third of annual gynecological office visits for premenopausal women and 70% of annual visits for perimenopasal or menopausal women.12 Women with AUB who are ovulatory most often suffer from intrauterine pathology such as polyps, myomata, and adenomyosis, which can easily be diagnosed and often treated with OH. In particular, patients with myomata benefit from OH. It is important to know if the myoma is a Type 0, I, II or III before going to the operating room for removal and only OH will give the same view as the operative resectoscope. In postmenopausal women with recurrent bleeding, an endometrial echo less than 5 mm, and a normal endometrial biopsy, OH is valuable for detecting and treating focal lesions. Blind endometrial biopsies and curettages can miss over 30% of focal endometrial lesions, including endometrial cancer.13,14
Because intrauterine devices have recently become more commonplace for contraception and to control heavy painful menses, we are losing more strings. OH is a simple, quick tool for retrieving these devices.15 In addition, OH is helpful as part of an infertility workup. Twenty percent to 45% of women with infertility have intrauterine pathology, including small polyps, uterine septa, adhesions, adenomyosis, and myomata.16,17 In summary, OH can be used to diagnose and treat a variety of pathologies (Figure 2). Busy gynecologic practices are very likely to have an adequate volume of patients who will benefit from the addition of OH.