Hysteroscopy - Part 1

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Roberta Speyer: "Hello, this is Roberta Speyer. I'm the Publisher of OBGYN.net, and I'm here at the European Society of Gynecologic Endoscopy meeting in Stockholm. I'm speaking to Professor Linderman and Dr. Van Belle, and we're talking about hysteroscopy. As a woman, why would I need hysteroscopy, and why would I not want to go to the hospital to have this procedure done?"

Professor Van Belle: "Basically, at one time in their lives about 80% of all women will have a problem concerning the inside of the uterus. That means that almost each and every woman, at a certain point, actually has a problem on the inside of the uterus. Up to now, people are trying to diagnose and see those problems with things like ultrasound, which is actually very good, but it only gives an indication. The simplest way to know about a problem in the uterine route is to look inside the uterus."

Roberta Speyer: "How do you do that?"

Professor Van Belle: "Because of the studies over the last couple of years we've had people like Professor Linderman who, with his studies, gave us the possibility to develop this very simple technique. When evaluating this area, it's better to have one eye inside of the uterus, rather than a whole bunch of instruments. These were his words, and I say they were legendary words. So, thanks to the development of the industry, we came to have very small, tiny instruments that permit us to actually go through the natural canal from which the blood is flowing during the menstrual period. We go inside, we only look where we're going, and we're not forcing anything. So that is the reason why we are able to do this examination during a normal consultation on an outpatient basis, and no form of anesthesia is required."

Roberta Speyer: "Is it painful?"

Professor Van Belle: "It's not painful if the technique is done the right way, using direct sight to see where you're going, and going through a natural canal. When I say 'tiny instruments,' I'm talking about the size that every normal canal permits-about 3 mm-to introduce this instrument under direct view. We have learned in the last couple of years that the size of the instrument is actually the most important factor."

Roberta Speyer: "Is that small?"

Professor Van Belle: "They are very small. So once again, thanks to highly technical developments we are now able to look right inside the uterus and do this procedure done in a few seconds, actually."

Roberta Speyer: "Can I see?"

Professor Van Belle: "You can have all of them. The difference between…"

Roberta Speyer: "This one seems to be firm and this one is flexible. What is the difference?"

Professor Van Belle: "The difference is we start by using this flexible instrument with the idea that we have to adjust ourselves to this natural canal. But then again, with this instrument, where you actually have a panoramic view, it is no problem whatsoever to introduce it into the uterus and to have your examination done. They both have their advantages and their disadvantages."

Roberta Speyer: "These are almost like a camera. This says Olympus-that company makes cameras don't they? This is like an optic... it's making everything bigger. I'm looking at my hand and I'm seeing my whole hand."

Professor Van Belle: "That's it. You have a panoramic view. That is the reason why this examination is so simple. You just put the scope inside, and then in a few seconds you can see the whole interior wall."

Roberta Speyer: "How do you light it up? Is there a light source?"

Professor Linderman: "Yes, of course. The light source is outside with the cable. It comes into this channel and gives off light, but it doesn't heat up like a light bulb."

Roberta Speyer: "Good idea."

Professor Linderman: "Yes, a good idea. It's called a 'cold light.'"

Roberta Speyer: "Yes. So it's an optic coming through when it's removed from the person's body. Do you have to do anything to dilate the cervix to get the scope in?"

Professor Van Belle: "That's not a problem we have to deal with in hysteroscopy. The organ that we're interested in is actually an organ that has a thick muscle wall and a very tiny interior part, or a very tiny cavity. So we have to open it up, and it can be done with CO2 gas or fluids. Actually, if more and more fluids are used, you get good distention of the cavity. Regarding CO2 distention, I think Profess Linderman can tell us a lot because he did some very important work in the late 1960's on the forms of this medium of distention. Could you tell us about it?"

Professor Linderman: "Yes. The advantage of CO2 is it's a dry medium and opposite to the fluid media of the other one. If I use CO2, the image that I get from the optic is sharp where the air is."

Roberta Speyer: "It's like what I'm looking through right now, the same kind of image."

Professor Linderman: "So when I have the correct image of the structure of the tissue, this uterine cavity, I can see pathologies such as polyps, myomas, and other diseases that are very important to recognize. In many cases, women with arterial bleeding are suffering from these factors."

Roberta Speyer: "I know a lot of our viewers have problems with fibroid tumors. Would this be a way to visualize if they had fibroids?"

Professor Van Belle: "Not only to visualize them, but also to see which part of those fibroids are inside the uterus, and in another stage, even treatment could be done in this way. You don't have to do a hysterectomy, and you don't have to stay for a week in the hospital, if the problem is inside the uterus. It's not the case for all problems, and it should only be…"

Roberta Speyer: "If you're going to do surgery, do you use CO2 gas or do you use the fluid as the medium?"

Professor Linderman: "Both are possible, but it's better to use the fluid because during surgery, if the inner wall of the uterus starts to bleed, you won't have a good view because of the bleeding. With fluid, you can wash away the blood then you have a clear image and can see what you need to do for this woman-change your instrument, or choose another kind of instrument, and find something to remove the fibroid."

Roberta Speyer: "Now if you were doing that-removing fibroids-would I still have no anesthesia, or would there be some form of anesthesia administered locally?"

Professor Van Belle: "For the treatment, some kind of anesthesia is necessary, but again, it can be done in one clinical day."

Roberta Speyer: "Rather than staying in a hospital."

Professor Van Belle: "Rather than staying for four or five days and having a major scar, or even having multiple scars."

Roberta Speyer: "Or having a hysterectomy?"

Professor Van Belle: "Yes, or having a hysterectomy. We are convinced that you should not take the organ out, but you should take out the problem."

Roberta Speyer: "This has changed in my country, the United States. A few years back it seemed that every woman, once she passed menopause, was having a hysterectomy. Now, a lot of our women viewers at OBGYN.net write in that it's very important to them not to lose their organs. There are other things to consider, especially if the ovaries are taken out. Whether they're not yet at menopause or they are going into menopause, it's an issue."

Professor Van Belle: "You could also discuss the psychological and emotional aspects, but even from a medical point of view, clearly there's no necessity to take out an organ if you can treat it and leave it where it is. Both go together-we agree that the uterus is actually very important for a woman to, essentially, be a woman. So that's the reason why all these techniques have been developed, and it's a shame that it's not used more."

Roberta Speyer: "Why isn't it used more?"

Professor Van Belle: "Some of the problems that Professor Linderman mentioned before involve difficulties with development, but there's also a problem with medical education. In medical school you learn how to take out the uterus, but you don't learn these things. So that's the reason why we are trying to develop more and more of these techniques and have them accepted, more and more, by all gynecologists."

Roberta Speyer: "You have developed a CD-ROM. I think Olympus supported that development, and it's dedicated to Professor Linderman. We're going to have an excerpt from that on OBGYN.net and it will be available right next to this interview, if viewers want to click on it and look at it. I think the part that is on OBGYN.net, which is only a small excerpt, would be interesting to women in particular because it shows more in-depth information about this procedure."

Professor Van Belle: "There are images on fibroid resection that we just mentioned. I forgot to mention that another reason why everyone does not use these techniques is that it takes a lot of investment from gynecologists, too."

Roberta Speyer: "In instrumentation, or in skill?"

Professor Van Belle: "In instrumentation, in school, and in education. Another problem is that the reimbursement is small, so you are not pushed to develop these techniques and you don't have any real motivation. But I think the investment should be made in order to give women the treatment they deserve and not over treat minor problems."

Roberta Speyer: "Then, as a woman, if I go to see a doctor, when would I maybe want to find out if my physician is good and capable of performing an office-based hysteroscopy procedure? What would be the red flag that tells me I should say, 'wait, maybe I want to see another doctor,' 'maybe this doctor isn't doing it because he or she doesn't know how,' or 'I want to get a second opinion from a hysteroscopist?' How can I, as a patient and as a woman, be more proactive in making sure that I'm having the opportunity to have this procedure?"

Professor Van Belle: "The red flag should be any gynecologist who detects some kind of problem that could be on the inside of the uterus and does not propose a hysteroscopy."

Roberta Speyer: "So what would he or she propose instead?"

Professor Van Belle: "Ultrasound. Don't you think? Or many other techniques, many of which are really very good techniques and should go together with a hysteroscopy. But we can often figure out a problem inside the uterus which would never be completed if the hysteroscopy was done first."

Roberta Speyer: "So that should be the first move that you suggest."

Professor Van Belle: "It should be the first examination."

Roberta Speyer: "I should ask, 'are you going to do a hysteroscopy?' and if they say, 'no, I was planning to...,' I should be thinking, 'go and find a doctor who will do a hysteroscopy.' If you do it and I am awake and I'm not anesthetized, can I watch or see any of what is going on?"

Professor Van Belle: "You most certainly can look during the examination."

Roberta Speyer: "Is it on a media screen?"

Professor Van Belle: "It's on a media screen. It's a small camera that is attached to the head of this scope. So the patient herself can look and then see what the problem is and can even discuss possibilities to treat that in an endoscopic way or discuss other operations, if they are necessary."