Mar-Apr 2016 | vol. 2 | issue 2 www.hysteroscopy.

info

INSIDE THIS ISSUE

T he main capacity of hysteroscopy is the diagnosis of intrauterine diseases,
however, there is a growing potential therapeutic approach. This is demonstrated
since the first description of the method, when Pantaleoni in 1869 introduced a tube
12 mm in diameter into the uterine cavity of a woman of 60 years, with uterine
bleeding and endometrial polyps detected. At the same act, he made cauterization
with silver nitrate for hemostasis.

Currently, hysteroscopy evolved with video system expanding the vision; smaller WELCOME 1
diameter instrumental and operative channel and through liquid distension. although,
the biggest development was in relation to the technical procedure, because growing
professional experience, with courses and training, promoting technical improvement
and increasing the number of professionals with similar technical quality, brings the
concept of see and treat.

Today, hysteroscopy expanded the diagnostic possibility in cases of abnormal

uterine bleeding, allowing the cleaning of the uterine cavity with fluid distension
medium. The dynamic hysteroscopy, changing the intrauterine pressure, allows to
lower pressures making possible the suspicion of intramural disorders such as
fibroids "weighing" in cavity and adenomyosis, as well as the assessment of the
uterine cavity distension capacity in cases of uterine malformations. HYSTEROSCOPY 2
PICTURES
The direct biopsy technique, which is taken under viewing the most significant
lesion area and can be repeated several times in the same procedure as well as the
possibility of endometrial biopsy, to drag the open forcep and withdrawing only
seizing materials the cloth. Interview of the month 3

The surgical technique was expanded, walking through using resectoscope with Highlights articles 6
energy, mono or bipolar, or the use of grasping and scissors, allowing you to access
the base of the lesion for its complete withdrawal. Step by Step 7

What's your diagnosis? 10

Large development also occurred in the treatment of diseases at the time of
diagnosis, see and treat, as it can perform, polypectomy, Myomectomies, lysis of Resident`s corner 11
adhesions, septoplasty and removal of foreign bodies at the time of diagnosis. Thus,
hysteroscopy reached a great brand, it has low cost because it Devices 14
is an outpatient procedure, with great diagnostic capacity and
enormous potential for treatment in the same act, this all Hysteroscopy Basic 15
combined with easy extension of this knowledge with courses,
training and adequate scientific information as the Brief review 21
Hysteroscopy Newsletter.
Ricardo Lasmar
1
 www.hysteroscopy.info Mar-Apr 2016 | vol. 2 | issue 2

TEAM COODINATOR

PICTURES
SPAIN
L. Alonso HYSTEROSCOPY
EDITORIAL COMMITTEE
SPAIN
E. Cayuela
L. Nieto
ITALY
G. Gubbini
A. S. Laganà
USA
J. Carugno
L. Bradley
MEXICO
J. Alanis-Fuentes
PORTUGAL
J. Metello
ARGENTINA
A. M. Gonzalez
VENEZUELA
J. Jimenez
Detailed aspect of the The appearance of tree
plica palmatae branches is called
SCIENTIFIC "arbor vitae"
COMMITTEE
A. Tinelli (ITA)
A. Úbeda (Spa)
The name cervix derives from the Latin word “Cervic” meaning "neck". It represents the
A. Arias (Ven)
lower portion of the uterus and communicates the uterine cavity with the vagina. It has a
M. Rodrigo (Spa) cylindrical shape with a length of about 3 cm and a diameter of about 2 cm. The uterine
A. Di Spiezio Sardo (Ita) cervix has an opening to the vagina called the “external os” (EO). In the area of division
E. de la Blanca (Spa) between the cervix and uterine body lies a fibromuscular area called the “internal os”
A. Favilli (Ita) (IO). The area located between EO and IO is called the “endocervical canal”, which has
M. Bigozzi (Arg) a fusiform shape and an oval cross section, the endocervial canal has a diameter ranging
S. Haimovich (Spa) between 3 and 10 millimiters.
R. Lasmar (Bra) The epithelium of the cervix in its intravaginal portion corresponds to squamous
A. Garcia (USA) epithelium. It changes to columnar epithelium in the endocervical canal. The area of
N. Malhotra (Ind) transition between the two epithelia corresponds to the squamocolumnar junction also
J. Dotto (Arg) known as the transformation zone. The arrangement of the epithelium at the level of the
I. Alkatout (Ger) cervical canal is made of longitudinal ridges along the canal, this is called "plica
R. Manchanda (Ind) palmatae". On top of the longitudinales ridges there are also oblique branches that give it
M. Medvediev (Ukr) the appearance of tree branches that is also called "arbor vitae".

All rights reserved.

The responsibility of the signed If you are interested in sharing your cases or have a hysteroscopy image that you
contributions is primarily of the consider unique and want to share, send it to hysteronews@gmail.com
authors and does not necessarily
reflect the views of the editorial
or scientific committees.

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Mar-Apr 2016 | vol. 2 | issue 2 www.hysteroscopy.info

INTERVIEW WITH...
Dr. Rudi Campo is one of the international recognized
hysteroscopic surgeons with a major experience in hysteroscopic
uterine, reconstructive surgery and hysteroscopic trans
endometrial myometrial exploration. He is one of the founders of
The European Academy of Gynaecological Surgery
What is the role of hysteroscopy in modern reproductive techniques?
Modern technology has brought diagnostic hysteroscopy as a mainstay of
modern gynaecological practice. The ambulatory visualization of the uterine
cavity has obvious major benefits for the patient and the diagnostic
algorithms but it has not been generally implemented by the physicians for
also obvious drawbacks like painful, difficult to get good visualization and Rudi Campo
difficult to organize. Director of +he European Academy
The main reason that hysteroscopy is not routinely implemented in the of Gynaecological Surgery.
exploration of the infertile patient is because it is not as easy as transvaginal Leuven Institute for Fertility and
ultrasound which claims to provide sufficient information. It is easy to Embryology.
insert a transvaginal ultrasound probe but not always easy to perform and Leuven. Belgium
interpret the scan correctly. In Hysteroscopy it is difficult to insert the
hysteroscope but once the cavity is visualized without bleeding or trauma it
is very easy to make the diagnosis. What is even more important is that in
more than 1/4th of the uterine cavities with a normal diagnosis at
ultrasound, abnormalities are visualized.
Today with the new small optical systems, saline as distention medium and
the vaginal minimal invasive approach, diagnostic hysteroscopy has finally
become a safe, easy and well tolerated procedure which can be performed
as a routine procedure in every infertile patient preferentially in a one stop
session with a transvaginal ultrasound.
The new Trophy hysteroscope has been proven to be extremely well
tolerated as no complication or access failure occurred in the prospective
randomized multicenter Trophy study who recently is accepted for
publication in the Lancet. This book presents all uterine,
The Trophy hysteroscope has some very interesting functions to enlarge the cervical and vaginal anomalies in a
diagnostic fase with minimal invasive procedures like visual biopsy, systematic way and the new
ESHRE/ESGE classification system
removal of polyp, removal of endometrial adhaesions, performing a global
utilised for their categorization. In
D&C with the Trophy curette or an ultrasound guided endomyometrial full addition, their embryogenesis and
thickness sampling with the spirotome applied through the Trophy sheet. etiology are summarized. The
Modern reproductive medicine should use HSC and transvaginal 2 and 3 D diagnostic work-up of women with
ultrasound as routine one stop examination to validate the uterus on its female genital malformations is
reproductive capacity. To be able to confirm this statement with solid reviewed in an evidence-based
scientific evidence the hysteroscopy community has a lot of work. fashion and taking into account the
We need to standardize the examination, the one stop uterine diagnosis ! availability of new non-invasive
We need to define and classify the findings with a universal accepted diagnostic methods. The treatment
classification. strategy and the therapeutic
The research of endometrial cavity abnormalities on the reproductive alternatives to restore health and
reproductive problems associated with
performance should be a single center and not a multi-center study to avoid
their presence are critically reviewed.
inter observer variations.

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Is hysteroscopy essential prior to any IVF?

The Trophy study has demonstrated that diagnostic hysteroscopy, before in vitro fertilization treatment in women
with normal ultrasound of the uterine cavity and a history of two to four failed in vitro fertilization treatment
cycles, does not improve the live birth rate.
A possible explanation for this finding could be that the Trophy hysteroscope is not scratching the endometrium.
All other studies do have this concomitant effect. Even more important is the finding in this study that in young
women with normal ultrasound of the uterine cavity, hysteroscopy detected abnormalities in 26 % of the cases.
Most of the findings were not acted upon and therefore further research would be required to investigate the role
of hysteroscopy in detection of unsuspected uterine pathology and the effectiveness of correction both surgical as
medical of such pathology on IVF outcome.
Personal not yet published results on the correction of 100 dysmorphic uteri prior to IVF shows remarkable
results with a bay take home rate over 60 % and no late abortions or fatal premature deliveries. Those data
indicates that the subtle cavity deformations like the T-shaped uterus (U1a) could be of higher importance than
expected until now and correction prior to IVF could be necessary.
Other remark to be made is that if subtle lesions are the tip of the iceberg then the local removal of a polypoid
change or a hypervascularisation can not have any effect on the disease. It seems important that hysteroscopy is
used under ultrasound guidance to explore the subendometrial myometrium to study, treat or to provide valuable
information for drug treatment prior to start the IVF procedure.

“Ultrasound guides hysteroscopy beyond the frontiers.”

You are a reference in adenomyosis. It is usually underdiagnosed?

Adenomyosis is the heterotopic presence of endometrial glands and stroma within the myometrium and has
traditionally been diagnosed by the pathologist in hysterectomy specimens. However, the recent development of
high quality non-invasive techniques such as transvaginal sonography (TVS), magnetic resonance imaging (MRI)
and office mini hysteroscopy with the Trophy hysteroscope has renewed the interest in the diagnosing and
treatment of adenomyosis.
The use of MRI can be considered as a turning point in the appreciation not only of adenomyosis as a disorder of
the female reproductive tract. MRI has demonstrated that we can differentiate the corpus of the uterus in 3
important functional areas, the endometrium, the Junctional zone myometrium (JZ) and the outer myometrium.
Especially the JZ myometrium should receive our close attention in the exploration and treatment of the infertile
patient. But as MRI can not be implemented as a screening tool we need to reflect on the value of the integrated
Ultrasound – hysteroscopic approach to diagnose and treat adenomyosis.
Diagnostic hysteroscopy does not provide pathognomonic signs for adenomyosis, some evidences suggest that
subtle laesions like irregular endometrium with endometrial defects, altered vascularisation and cystic
haemorrhagic changes are possibly associated with adenomyosis. In addition to the direct visualization of the
uterine cavity, the approach with the Trophy hysteroscope offers the possibility to obtain immediate endometrial /
myometrial tissue sampling under concomitant ultrasound control.
Transvaginal Ultrasound being the golden standard for global uterine screening is of great importance for
diagnosis of myometrial disorders and uterine congenital malformations whereas hysteroscopy remains the golden
standard for the evaluation of the endometrium and cervical canal. The major challenge is the combined approach
in the diagnosis and treatment of uterine disorders possibly interfering with reproductive performance.
Ultrasound guides hysteroscopy beyond the frontiers.
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You have develop some new devices for hysteroscopy, can you tell us some words about them?
The new TROPHY hysteroscope is specially designed to counteract the above mentioned drawbacks providing
the physician most innovative possibilities resulting in an all in one diagnostic procedure and the highest standard
patient comfort..
This new hysteroscope is a compact 30° rigid 2.9 mm scope with a special designed instrument tip for atraumatic
passage through the cervical canal. An innovative feature is that it can be loaded with accessory sheeths in an
active and passive position providing the possibility of enlarging the visual procedure with endometrial sampling
or surgical actions for anatomopathological examination of the endo and myometrium without removing the
instrument.
The examination is started with the compact 2,9 mm atraumatic rigid optic and the accessory sheet in passive
position is not interfering with the diagnostic visualisation. In case of pathology although the accessory sheet is
pushed forward providing a continuous- flow and the possibility to perform surgical action with semiflexible 5 Fr.
Instrument.
Moreover one can remove the hysteroscope and use the accessory sheet to introduce the Trophy D&C suction
curette or the Endo-myometrial sampler. Apo from endometrium and myometrium is possible without the need of
a speculum, even minor interventions like polyp or myoma resection are possible in a one stop procedure.
For office use the compatibility of this instrument with a biodegradable high level disinfection agent like
TRISTEL FUSE® offers the possibility to reuse the instrument within a few minutes and makes the procedure
accessible for every office gynecologist, ambulatory unit or IVF-center.
Trophy hysteroscopy opens a new dimension in the exploration of the uterine cavity accessible for every
gyneacologist.

How important are courses and training "hands on" in hysteroscopy?

Hysteroscopy courses with training on inanimate animal models are the ideal stepping stone from the first phase
of theoretical and practical skills acquirement to the clinical training on patients.
Getting familiar with the instruments and the physical features of the complex devices used in modern
hysteroscopy is essential for delivering good work in the operation theatre. The use of animal models provides
the course participant with the essential tactile experience of real-life procedures.
The structure of the courses that the European Academy of Gynaecological Surgery (EAGS) organizes since 25
years is very logic and starts the first day with basic hysteroscopic psychomotor skill training and simulation of
the most simple (diagnostic) procedures, building up to the mechanical and bipolar operative hysteroscopy with
small instruments on day 2 and ending with resectoscopy on the last day.
Through the combination of theoretical teaching, hands-on training and live demonstrations every participant
benefits from this type of courses and is prepared to progressively engage in clinical diagnostic and operative
hysteroscopy. The maximal number of twelve participants and the individual tutoring by experienced
hysteroscopists guarantee for an intensive, high-quality course.
In order to give everybody the opportunity to attend these courses we organize them on different European
locations. Our central Office in Leuven, Belgium has welcomed participants from all over Europe and Africa, the
EAGS Nicosia Branch in Cyprus is the perfect access for people from the Middle East and for candidates from
Eastern Europe it is easy to take the course in the EAGS Maribor Branch in Slovenia, the center of Eastern
Europe.
All information can be found on the EAGS website (www.europeanacademy.org)
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HIGHLIGHT ARTICLES
Published on different medias
Using narrow-band imaging with conventional hysteroscopy increases the detection of
chronic endometritis in abnormal uterine bleeding and postmenopausal bleeding.
Ozturk M, Ulubay M, Alanbay I, Keskin U, Karasahin E, Yenen MC.
J Obstet Gynaecol Res. 2016 Jan;42(1):67-71

AIM: A preliminary study was designed to evaluate whether a narrow-band imaging (NBI) endoscopic light source could
detect chronic endometritis that was not identifiable with a white light hysteroscope.
MATERIAL AND METHODS: A total of 86 patients with endometrial pathology (71 abnormal uterine bleeding and 15
postmenopausal bleeding) were examined by NBI endoscopy and white light hysteroscopy between February 2010 and
February 2011. The surgeon initially observed the uterine cavity using white light hysteroscopy and made a diagnostic
impression, which was recorded. Subsequently, after pressing a button on the telescope, NBI was used to reevaluate the
endometrial mucosa.
RESULTS: The median age of the patients was 40 years (range: 30-60 years). Endometritis was diagnosed histologically.
Six cases of abnormal uterine bleeding (6/71, 8.4%, 95% confidence interval [CI] 0.03-0.17) and one case of
postmenopausal bleeding (1/15, 6%, 95%CI 0.01-0.29) were only diagnosed with chronic endometritis by NBI (7/86, 8.1%,
95%CI 0.04-0.15).
CONCLUSION: Capillary patterns of the endometrium can be observed by NBI and this method can be used to assess
chronic endometritis.

Hysteroscopic Patterns in Women on Treatment with Ulipristal Acetate 5 Mg/Day: A

Preliminary Study.
Bettocchi S, Baranowski WE, Doniec J, Ceci O, Resta L, Fascilla FD, Mitola PC, Tinelli R, Cicinelli E.
J Minim Invasive Gynecol. 2016 Jan 19 [Epub ahead of print]

DESIGN: Preliminary study.

SETTING: OB-GYN and Gynecology Oncology Clinic, Military Medical Institute, Ministry of Defense, Warsaw, Poland
and Obstetrics and Gynecology Department University of Bari, Italy.
PATIENT(S): Seventy-four premenopausal patients complaining of AUB due to uterine myoma/s and on treatment with
UPA 5 mg/day for at least 30 days.
INTERVENTATION(S): Women received TVS and then office hysteroscopy, and visually guided eye-guided endometrial
biopsies. Video hysteroscopies were recorded in digital format. Pictures were evaluated by two authors off-line and
compared to histologic results.
MAIN OUTCOME MEASURE(S): Hysteroscopic aspects and classification of PRM-associated endometrial changes
(PAECs).
RESULT(S): The most common hysteroscopic finding was the combination of: a) flat subtle epithelium with small
glandular openings; b) large isolated or confluent cysts in the stroma giving the surface an floating aspect at fluid distention
and c) well evident subendometrial vascular network with a "chicken wire" vascular pattern (44.6%). This finding
accounted for 82% of cases with endometrial thickness > 10 mm at TVS. Histology confirmed a combination of epithelial
secretory (vacuoles) and hypotrophic effects (small and dilated glands), while at stromal level the combination of cysts,
dense stroma and vascular wall thickening. At 3 months follow-up echographic, hysteroscopic and histological endometrial
patterns were normal in all patients.
CONCLUSION(S): In most women on UPA and with thickened endometrium at TVS the hysteroscopy showed benign and
characteristics aspects related to the ambivalent effects of UPA on progesterone receptor. These alterations took place just
after one month of treatment but disappeared within 3 months after stopping treatment.

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The HOME-DU technique (Hysteroscopic

Outpatient Metroplasty To Expand
p
Ste Dysmorphic Uteri)
By

t ep
S Professore universitario presso Università degli Studi di Napoli "Federico II"
Attilio Di Spiezio Sardo

The clinical relevance of congenital anomalies of the uterus in causing infertility and pregnancy loss is
undeniable, as they are known to interfere with normal implantation and placentation. Aattentions have been
recently focused on the anatomical integrity of the uterine cavity, as a prerequisite for a receptive endometrium,
and particularly on those Müllerian anomalies named T-shaped and tubular-shaped (“infantilis”) uterus.

In 2013, the European Society of Human Reproduction and Embryology and the European Society for
Gynaecological Endoscopy working group of experts (CONgenital UTerine Anomalies - CONUTA group)
developed a new classification system of female genital tract anomalies, based on clinical approach, with the aim
of overcome the limitations of the AFS classification (that does not specify the diagnostic criteria for
classification).

In this new classification system, Class I incorporates all cases having an uterus with normal outline but with an
abnormal lateral wall shape of the uterine cavity (named “dysmorphic uteri”): T-shaped uterus (Ia) is characterized
by a correlation of two-thirds uterine corpus and one-third cervix while uterus infantilis (Ib) by an inverse
correlation of one-third uterine body and two- thirds cervix.

The importance of these anomalies relies on the fact that they are associated with poor reproductive
performance when untreated, as altered volume and shape of the uterine cavity are likely to contribute to a hostile
environment both for the implantation and continuation of the pregnancy.
An accurate evaluation of these anomalies should be carried out by combining data obtained by office
hysteroscopy and three-dimensional transvaginal ultrasound (3D-TVS). The standard surgical treatment of these
uteri involves the use of a hooked loop which is meticulously guided by the surgeon placing parallel longitudinal
incisions along the main axis of the uterine cavity, in order to decrease the centripetal force of muscle fibers and of
any fibromuscular rings that contribute to stenosis, and to promote a consecutive increase in the volume of the
uterine cavity.

Recently, our group has developed a new outpatient minimally invasive technique yielding an increase in
volume and an improved morphology of both T-shaped and tubular uterine cavities (Hysteroscopic Outpatient
Metroplasty To Expand Dysmorphic Uteri: the HOME-DU technique). The technique, performed under conscious
sedation, involves that two incisions of 3–4 mm in depth are made with a 5-Fr bipolar electrode along the lateral
walls of the uterine cavity in the isthmic region, followed by additional incisions placed on the anterior and
posterior walls of the fundal region up to the isthmus (Fig.1). The operation ends with the application of an anti-
adhesive gel. Preliminary data on a cohort of 30 infertile patients (i.e. primary infertility, > 2 early abortions or
severe preterm delivery) showed a significant increase in the volume of the uterine cavity, with a substantial
improvement in uterine morphology. Moreover, at mean follow-up of 15 months, clinical pregnancy rate was 57%
and term delivery rate 65%.

These positive preliminary data have been confirmed in a larger cohort of patients (64 patients) where together
with a clinical pregnancy rate of 55% and a term delivery rate of 69% we could also identify another interesting
data: a spontaneous conception rate of nearly 70% (unsubmitted data). These latter data have represented the

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www.hysteroscopy.info Mar-Apr 2016 | vol. 2 | issue 2

prerequisite for a study conducted in our Department where some markers of endometrial receptivity (i.e. HOXA10,
HOXA11 and LIF) will be investigated before and after HOME-DU technique.

In conclusion, all these findings would support the safety and efficacy of this novel minimally invasive technique
for expanding the volume and improving morphology of the uterine cavity of dysmorphic uteri, thus offering new
approaches in improving reproductive outcomes, without any significant obstetrical complications, which could be
beneficial particularly for infertile patients and patients with history of repeated spontaneous abortions.

FIG 1 The HOME-DU technique (Hysteroscopic Outpatient Metroplasty To Expand Dysmorphic Uteri). An incision of 3–4
mm in depth is made in redundant fibromuscular tissue using a straight bipolar electrode(KARL STORZ, Germany) at the
isthmic area of the right lateral wall(A–C). Incision in the isthmic area of the contralateral lateral wall (D–F). Additional
incisions are then made on the anterior and posterior walls, extending from the fundal region up to the isthmus.

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Mar-Apr 2016 | vol. 2 | issue 2 www.hysteroscopy.info

DID YOU KNOW...?

The diagnosis of chronic endometritis is based on the existence of
plasma cells in the endometrial stroma. Sometimes an infiltration
of the endometrium by lymphocytes and eosinophils can be found.

A loss in the uterine distension or the view of the peritoneal content

indicate an uterine perforation

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www.hysteroscopy.info Mar-Apr 2016 | vol. 2 | issue 2

Hysteroscopy Newsletter

WHAT'S YOUR Office and operative

hysteroscopy
Bernard Blanc

DIAGNOSIS? 2008; 265 pages

This book is about a new surgical

Sometimes, when performing hysteroscopy, it is
important to pay attention to every corner of the
uterus, as Vasari stated «cerca trova», «he who
seeks finds»
Answer to the previous issue:
Hysteroscopic view of a gestational sac
procedure, surgical hysteroscopy, for
out-patients. It is both a diagnostic
approach and a surgical procedure.
As a simple and non-aggresive
technique, it is a "patient-friendly"
procedure with a little surgical
trauma as it avoids hysterectomy or
laparotomy procedures thus
preserving the genital tract. It is the
leading procedure in the treatment of
uterine bleeding. It has also proved
to be an essential investigation
technique of in the assessment of
infertility.
This book is the result of surgical
practice and teaching experience in
the field of hysteroscopic
procedures.

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Mar-Apr 2016 | vol. 2 | issue 2 www.hysteroscopy.info

Resident's CORNER
Hysteroscopy and curettage as an alternative treatment of late postpartum hemorrhage
A. Boguñá, N. Barbany, A. Úbeda.

CASE

40-years old female with known thrombophilia (Factor V Leiden), who was referred to our center due to
secondary infertility. Her medical history included: a first trimester spontaneous abortion of pregnancy achieved
by assisted reproduction and an ectopic pregnancy after spontaneous pregnancy that required surgery.

After assisted fertility with Cryotransfer patient conceive a normal singleton pregnancy. She undergoes induction
of labor at 40.2 weeks with cesarean section due to failed induction. She had an uneventful cesarean section and
postpartum recovery. She presented to postpartum visit (forty-two days postpartum) referring heavy vaginal
bleeding. Pelvic ultrasound describes a uterine cavity occupied by numerous heterogeneous content and the
Doppler images show high vascularization consistent with retained fragments of placenta and blood clots (Figure
1).

Hysteroscopic removal of retained products of conception is performed with the findings of uterine cavity with
retained products that prevents proper display and uterine distention (Figure 2). Suddenly, uterine atony with
heavy bleeding occurs, which resolved after sharp blind curettage and administration of uterotonics. Pelvic
ultrasound performed 15 days after the procedure reveals absence of retained products. (Figure 3).

Hysteroscopy Newsletter Hysteroscopy Newsletter

Figure 1. Postpartum ultrasound. Figure 2. Hysteroscopic view of retained products of

conception in the posterior uterine wall.

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www.hysteroscopy.info Mar-Apr 2016 | vol. 2 | issue 2

DISCUSSION

Late postpartum hemorrhage due to retained products of conception is a not infrequent obstetrical complication.
(1,2) The use of Doppler ultrasound is essential for accurate diagnosis (3, 4) and surgical removal is often
required. Classically uterine curettage is performed, either sharp or by mechanical suction (4). This is a dangerous
intervention because postpartum uterus is extremely friable and the risk of uterine perforation is high. Therefore,
an alternative treatment is hysteroscopy, allowing a direct view of the cavity, providing both diagnosis and
treatment in one intervention, preventing uterine adhesions formation, preserving fertility, reducing hospital stay
and postoperative complications (5, 6, 7, 8, 9). However, it is suggested that hysteroscopy is not useful if: there is
heavy bleeding, vaginal delivery is recent and / or the size of retained placental fragments are larger than 4 cm.

However, in the reviewed literature there is no consensus about the indications for surgical postpartum
hysteroscopy (10, 11, 12). There is controversy in regards to the use of hysteroscopy in removal of retained
products larger than 4 cm, amount of postpartum bleeding and time after delivery for performing hysteroscopy. In
the presence of retained products of less than 4 cm size and no active bleeding hysteroscopy is an excellent
therapeutic approach. (Figure 4).

REFERENCES
1-Sheiner E, Sarid L, Levy A, et al. Obstetric risk factors and outcome of pregnancies complicated with early postpartum haemorrhage: a population-based study. J Matern Fetall Neonatal Med 2005; 18:149.
2-Dossou M, Debost-Legrand A, Déchelotte P, et al. Severe secondary postpartum haemorrhage: a historical cohort. Birth 2015; 42-149.
3-Mulic-Lutvica A, Axelsson O. Ultrasound finding of an echogenic mass in woman with secondary postpartum hemorrhage is associated with retained placental tissue. Ultrasound Obstet Gynecol 2006; 28:312.
4-Hoveyda F, MacKenzie IZ. Secondary postpartum haemorrhage: incidence, morbidity and current management. BJOG 2001; 108:927.
5-Ishai Levin, MD, Benny Almog, MD, et al. Clinical and sonographic findings in suspected retained trophoblast after pregnancy do not predict the disorder. Journal of minimally invasive gynecology, Vol 17, No 1, Jan/Feb 2010.
6-Daniel T. Rein, MD, Torsten Schmidt, MD, et al. Hysteroscopic management of residual trophoblastic tissue is superior to ultrasound-guided curettage. Journal of minimally invasive gynecology. Vol 18, No 6, NovDec 2011.
7-Tjalina W.O. Hamerlynck, MD, et al. An alternative approach for removal of placental remnants: Hysteroscopic morcellation. Journal of minimally invasive gynecology. Vol 20, No 6 Novembre/December 2013.
8-Michelle Nisolle, Katty Delbecque. Hysteroscopic resection of abnormally invasive placenta residuals. Acta Obstetricia et Gynecologica Scandinavica. 92 (2013) 451-456.
9-Guillaume Legendre, MD, Felicia Joinau Zoulovits, MD, et al. Conservative management of placenta accreta: Hysteroscopic resection of retained tissues. Journal of minimally invasive gynecology. Vol 21, No 5, SepT/Oct 2014.
10-Moshe D. Fejgin, Tal Y. Shvit MD, et al. IMAJ. Vol 16, August 2014.
11-Shaamash AH, Ahmed AG, et al. Routine postpartum ultrasonography in the prediction of puerperal uterine complications. Int J Gynaecol Obstet 2007; 98 (2): 93-9.
12-Cohen SB, Kalter-Ferber A, et al. Hysteroscopy may be the method of choice for management of residual trophoblastic tissue. J Am Assoc Gynecol Laparoscc 2001; 8 (2):199-202.

Hysteroscopy Newsletter Hysteroscopy Newsletter

Figure 3. Ultrasound after completed hysteroscopic Figure 4. Hysteroscopic view after excision of retained
procedure. products of conception.

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Mar-Apr 2016 | vol. 2 | issue 2
CongresS INTERNATIONAL
Society of Reproductive
Investigation 63 Annual
meeting
Montreal, Canada |Mar 16-19|2016
44th AAGL Global Congress
of Minimally Invasive
Gynecology
Dubai,EAU |Mar 27-29|2016
The 20th Ain Shams Obstetrics
and Gynecology International
Conference (ASOGIC).
Cairo, Egypt |May 25-26 |2016
ISGE 25th Annual Congress &
4th Croatian Congress on MIGS
Opatija, Croatia |May 25-28 |2016
12th AAGL International
Congress on Minimally
Invasive Gynecology
Mumbai, India |Jun 2-5 |2016
ESHRE 32nd Annual Meeting
Helsinki, Finland |Jul 3-6 |2016
www.hysteroscopy.info
The 23rd World Congress on
Controversies in Obstetrics,
Gynecology & Infertility
Melbourne, Australia |Mar 21-23|2016
14th ESC Congress / 2nd
Global ESC Conference
Basel, Switzerland |May 4-7|2016
10º Congreso Nacional de
endoscopia
Ibiza, Spain | May 26-27| 2016
4th International Congress of
Gynaecology and Obstetrics
Barcelona,Spain |May 28-30|2016
RCOG world congress 2016
Birmingham, UK |Jun 20-22|2016
ESGE 25th Annual Congress
Brussels, Belgium |Oct 2-5 |2016
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 www.hysteroscopy.info Mar-Apr 2016 | vol. 2 | issue 2

HYSTEROSCOPY

DEVICES
H PIPELLE
Until now, the only way to take an endometrial biopsy after "no touch" hysteroscopy (vaginoscopic hysteroscopy) was to use a
speculum to visualise the cervix, and often a tenaculum to facilitate insertion of the biopsy instrument. In collaboration with
Laboratoire C.C.D. (France), Dr. Magos has developed a modified version of the Pipelle de Cornier® for use at NTH, so that
there is no need to instrument the vagina.
The new H Pipelle® is long enough to be passed through the diagnostic sheath of the hysteroscope once the optic has been
removed at the end of the hysterosocopy. The ability to obtain an endometrial biopsy without needing to instrument the vagina
increases patient comfort. Owing to its length, a high suction pressure is produced and a greater volume of material is aspirated
ensuring that sufficient endometrium is collected at the first attempt even after hysteroscopy using a liquid distension medium.
http://www.gynendo.com/pipelle.htm

An audit of using the H Pipelle for endometrial sampling at outpatient hysteroscopy and literature
review comparison with the Pipelle de Cornier.
Dacco' MD, Moustafa M, Papoutsis D, Georgantzis D, Halmos G, Magos A.
Eur J Obstet Gynecol Reprod Biol. 2012 Dec;165(2):299-301

Objective: The main objective of this study is to analyse the efficiency of the H Pipelle endometrial sampler at ‘‘no touch’’
(vaginoscopic) diagnostic hysteroscopy in terms of biopsy adequacy for histological diagnosis.

Study design: Retrospective descriptive study of 200 premenopausal women including comparison with previously published data
on traditional biopsy instruments. Results: Biopsy was adequate in 82% of cases overall, rising to 87% in those without submucous
fibroids or polyps. Comparison with published data on other biopsy instruments shows that the H Pipelle is at least as efficient.

In conclusion, this study confirms the efficiency of the H Pipelle in obtaining an adequate endometrial biopsy following
hysteroscopy in premenopausal women. As the H Pipelle allows women to avoid the need for a vaginal speculum and tenaculum
following a ‘‘no touch’’ (vaginoscopic) hysteroscopy, we believe it should become the standard biopsy instrument in this setting.

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HYSTEROSCOPY

S IC
BA
In office diagnostic hysteroscopy for beginners
L. Nieto. H. U. Reina Sofía. Córdoba. Spain

The main goal during in office diagnostic hysteroscopy is to obtain a smooth access the uterine cavity, making a
full assessment, in a way that the patient can tolerate the procedure with minimal discomfort. Here we will
describe common everyday situations and provide some tips to improve your skills.

What is the best tolerated uterine access technique?

To access the uterine cavity by “vaginoscopy” without the use of a speculum allows not only to decrease the
stimulation of the cervix, but also to perform a visual inspection of its entirely. We place the tip of the
hysteroscope at the external os opening the outflow slowly distending the walls of the cervical canal adapting to
its larger diameter.
To explain the procedure to the patient using simple words and informing her what she is going to perceive is
essential to reduce anxiety and fear improving patient’s tolerance to the procedure.

Tips to reduce discomfort at the beginning of the hysteroscopy and decreasing vasovagal symptoms.
One of the main causes of pain during diagnostic hysteroscopy is cervical stimulation during uterine cavity
access. It is very important to match the diameter of the hysteroscope to the diameter the cervical canal, which is
achieved with smooth turns of 30 to 90° to introduce the hysteroscope with the least possible resistance. This
requires knowledge of the diameters of the sheath and the angle of the lens of the hysteroscope that is being used.
Another key point to decrease vasovagal symptoms is to avoid lateral movements of the hysteroscope at the
cervical canal; ideally, the use an angled lens allows improved lateral visualization that is key for adequate
diagnostic hysteroscopy. Only by making gentle 90° turns we can assess all the uterine walls with minimal
cervical stimulation.
Rapid uterine relaxation is another the cause of pain. It is advisable not to use high intrauterine pressure, reducing
the in-flow of distention media at the beginning of the procedure. If the distention media enter the cavity too fast
(high pressure), or if we have to release adhesions to enter the cavity it will cause pain. It is desirable to distend
the cavity gradually. This is achieved by regulating in-flow of distention media.

Stenotic cervix and intrauterine adhesions

Sometimes it can be difficult to introduce the tip of the hysteroscope in a pin-point cervical os, requiring to
increase the diameter of the cervical os. This can be done with scissors and/or forceps to allow passage of the
hysteroscope.
Similarly, it is sometimes necessary to release intrauterine adhesions to gain access to the cavity. Sometimes it is
hard to determine the direction of cervical canal. What we do in these cases is to obtain a closer look with the
hysteroscope to identify passage of a small amount of distention media. If the canal is not clearly seen, we
carefully use the tip of a grasper to lead the way forward, avoiding excessive pressure preventing uterine
perforation.

Uterus with marked anteflexion

When in presence of a marked anteflexed uterus, we find it difficult to access cavity with a rigid hysteroscope. A
simple way to correct this angle and access cavity is to have an assistant apply light suprapubic pressure to
improve the angle of the uterus and cervical canal facilitating the insertion of the hysteroscope.

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Hysteroscopy Newsletter Hysteroscopy Newsletter Hysteroscopy Newsletter

Access to the cavity

Before we begin to evaluate the cavity, we must always ask ourselves, where the tip of the hysteroscope is? That
is achieved by slightly withdrawing the hysteroscope to get an overall view. The best point of reference in the
uterine cavity is visualization of the tubal ostium, especially in cases where the uterine cavity has abnormal shape
or access has been difficult.

I am inside the cavity but can’t see well...

The accumulation of uterine secretions or blood may hinder the view preventing an adequate diagnostic
hysteroscopy. The easiest way to “wash” the uterine cavity is to place the tip of the hysteroscope at the fundus and
to open the outflow to allow the content to exit the uterine cavity progressively improving vision.

Systematically analyze the cavity

Evaluating the uterine shape and size is an important part of diagnostic hysteroscopy. It is important to be
systematic in the assessment, especially in cases where we find intracavitary pathology. We must be rigorous in
assessing the endometrium, as behind a polyp or fibroids can hide endometrial pathology. Therefore, before
performing any procedure, such as taking biopsy or resect a polyp or fibroid, it is recommended to assess the
entire endometrium.

How to properly take a biopsy and perform tissue extraction?

Taking an adequate biopsy prevent the need of multiple insertions of the hysteroscope causing unnecessary
discomfort to the patient. The biopsy grasper must move en bloc along with the hysteroscope, without working at
excessive distance from the tip of the hysteroscope, not to loose strength or definition when performing a direct
biopsy. To get more biopsy tissue and avoid loosing the specimen when removing the hysteroscope through the
cervical canal, when taking the biopsy do not obtain a pinch of tissue but place the specimen inside the open
biopsy clamp and advance the clamp into the tissue as you close its jaws, ensuring a greater amount of tissue
within the clamp.

If I want to take multiple biopsies?

Sometimes it is necessary to take several biopsies of the most representative areas and take them in an orderly
manner can facilitate our work, especially if it is friable tissues that bleed easily. It is advisable to analyze well all
areas to be biopsied before and to initially take the biopsies that are closer to the uterine fundus or are difficult to
access, so that potential bleeding will not stop us from performing all the required biopsies.

Once the hysteroscopy is completed, how to document the findings?

It is very important to document the findings of hysteroscopy describing the details as thoroughly as possible, we
also describe the route taken with the hysteroscope to enter the cavity since having this information will be very
valuable for future reference in case of assisted fertility procedures or simply placing an IUD in the future.

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Mar-Apr 2016 | vol. 2 | issue 2 www.hysteroscopy.info

Hysteroscopy Conundrums
Cervical stenosis

What do you do when you are faced with a stenotic cervix?

Do you use cervical priming with misoprostol prior to hysteroscopy?
mecanical dilators?
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We should separate the problem into external and internal os. The internal os rarely causes problems. I have
never used misoprostol and have always been able to dilate to accommodate a 9 mm resectoscope in over 25
years of practice. If number 3 goes in, the rest will also enter. It’s a matter of patience. At times, when the
cervical tissue is friable, I use 2 stitches to avoid lacerations at 12 and 6 o’clock. I assume, we are talking
about postmenopausal patients with severe atrophy. That is a real challenge! At times, the cervix is impossible
to identify having to perform a LEEP to identify the muscular fibers. If still unable to identify the cervix,
consider the use of laparoscopy after performing multiple false passages to determine the direction of the
uterine body. It is a controversial topic, but we have to differentiate a difficult hysteroscopy from an unskilled
hysteroscopist. You have to dilate many cervices to gain the needed experience. Experience is everything. I
believe the learning curve of cervical dilation is stepper than hysteroscopy itself. Warm regards from
Argentina!

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I find easier to dilate after giving misoprostol a couple of hours prior to hysteroscopy, especially in the
presence of atrophy. If there is no contraindications, we give vaginal estrogen for one month before the
procedure. I agree with Roberto regarding cervical dilation has a steep learning curve.
Look for us: hysteroscopy group in Linked In

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Mar-Apr 2016 | vol. 2 | issue 2 www.hysteroscopy.info

TIPS and TRICKS... 4U

Some things just can’t be learned from books. Some things can only be learned through experience.
In this section the best hysteroscopists will share their tricks with you.
In hysteroscopic surgery, endometrial priming is key to the success of the intervention. Performing
hysteroscopy in secretory phase of the menstrual cycle can significantly affect vision, making difficult
the intervention and prolonging the operating time. Generally, we prefer to perform hysteroscopic
interventions in early proliferative phase, during the first few days after menses. In cases in which is not
possible, we inhibit endometrial growth with oral contraceptives.

However, in patients who require endometrial assessment for fertility treatments, it is better performed
during the secretory phase, without endometrial preparation, since the administration of hormonal
therapy may affect the normal endometrial development.
Endometrial quality assessment in regards to the timing of the menstrual cycle, determined by the
presence of endometrial glandular grooves and openings reported by Sakumoto-Masamoto, classifies
the endometrium as good or bad, for embryo implantation. The endometrium is classified as good for
implantation if the endometrial glands presents openings ring type (ring-Type) with maximum
glandular secretion, and classified as bad for implantation if it has punctate endometrial glands.

Hysteroscopic appearance of the mid-secretory endometrium: relationship to early

phase pregnancy outcome after implantation.
Masamoto H, Nakama K, Kanazawa K.
Hum Reprod. 2000 Oct;15(10):2112-8.

A total of 172 patients who underwent hysteroscopic assessment of the endometrium and then became
pregnant, was analysed retrospectively to explore the relationship between endoscopic findings and
early phase pregnancy outcome after implantation. Histological examination of the endometrium and
assay of serum progesterone and oestrogen were carried out simultaneously with hysteroscopy. Of 172
patients, 12 were excluded. Of the remaining 160 patients, 62 (38.8%) were classified endoscopically as
having 'good' mid-secretory endometrium and 98 (61.3%) as 'poor', between one and four cycles prior
to the conception cycle. There were no clinical differences between these two groups, except that the
frequency of patients with a history of early abortion was significantly higher in the 'poor' group
(25.5%) than in the 'good' group (8.1%) (P < 0.05). Of 160 pregnancies, 118 persisted successfully to
live birth, but 42 ended in early pregnancy loss. The incidence of early abortion was significantly
higher in the 'poor' group (33.7%) than in the 'good' group (14.5%) (P < 0.05). Significant differences
were observed between the two groups for histological dating of the endometrium (P < 0.05) but not for
serum progesterone and oestradiol concentrations or progesterone:oestradiol ratio. In conclusion, our
data suggest that the hysteroscopic appearance of the mid-secretory endometrium at this stage of the
menstrual cycle is a better prognostic factor for pregnancy outcome than hormonal data.
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Projects
HYSTERO

Epidemiological evaluation of intrauterine adhesions (IUAs) after hysteroscopic surgery

Dear colleagues, I am pleased to inform you that the study on the prevalence of Coordinator:
Intrauterine Adhesions after hysteroscopic myomectomy had begun. It will be the first Dr. S. Haimovich
multi-center study launched from this platform. After the success of this event has
become clear that it will not be the last. Design:
We have recruited 16 centers in 10 countries on 3 different continents. If all the sites Dr. A. S. Laganá
get the minimum number of cases, we are expecting to collect over 300 cases. The
design has been thought to minimize potential bias, with a standardized surgical Aim of the study:
technique and homogeneous protocol. To evaluate the
Recruitment of cases begins in March 2016 for a total of six months. We estimate to prevalence of
have the data analyzed and a paper ready for publication before the end of this year. intrauterine adhesions
This is the first multicenter study to determine the actual prevalence of post (IUAs) after
hysteroscopic myomectomy intrauterine adhesions. hysteroscopic surgery.
The high response demonstrates the great interest and passion for hysteroscopy. We
feel that we are at a turning point in this endoscopic technique. It will be taking an
Outcomes
increasingly prominent role and no longer the "ugly friend" of laparoscopy in
gynecologic endoscopic surgery. The high number of readers of this Newsletter, the The risk of IUAs after
large number of partners, the increasing new technology in the development of new hysteroscopic surgery
instruments and our recently launched study are based on this feeling. will be evaluated
I would like to express many thanks to all site coordinators, especially Dr Luis Alonso according to the
and Dr Antonio Simone Laganá for their hard work and contribution in this ambitious different analyzed
project. variables (age, BMI,
parity, use of medical
therapy for endometrial
S. Haimovich preparation and type of
endouterine disease).

Medtube video of the

month:

How to remove an IUD

ring type

Dr. E. Cayuela
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Brief Review
Unicornuate Uterus
L. Alonso. Centro Gutenberg. Spain

The Mullerian ducts develop during the 7th week of gestation undergoing a series of structural changes, fusion,
channeling and resorption that concludes at 20th week of gestation. Failure in any of these phases will result in
congenital anomalies of the female genital tract. In the presence of unicornuate uterus, a fault occurred in the
process of Mullerian ducts development, which can be complete or partial, while the other channel has normal
development.

The incidence of this disease in the general population is difficult to establish. According to Elijah unicornuate
uterus is the least frequent uterine anomaly representing 5% of all uterine malformations that translates in one in
4020 women.

The AFS classification divides the anomalies into four types:

Type A: with rudimentary horn
A1: Horn with endometrial cavity (functioning)
A1a: Rudimentary horn functioning communicating (10%)
A1b: Rudimentary horn nonfunctioning communicating (22%)
A2: Horn without endometrial cavity (nonfunctioning) (33%)
Type B: Without rudimentary horn (35%)

The main obstetrical problem for patients with unicornuate uterus lies more in maintaining the pregnancy (early
pregnancy loss) more than achieving conception (infertility).

Unicornuate uterus is associated with obstetric complications such as ectopic pregnancy (2.7%), spontaneous
abortion in the first trimester (24.3%), early pregnancy loss in the second trimester (9.7%) and preterm delivery
(20.1%).

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Hysteroscopy Newsletter Hysteroscopy Newsletter Hysteroscopy Newsletter

Type A2: No Cavity Rudimentary horn pregnancy Hysteroscopic view

During pregnancy, patients with unicornuate uterus should be monitored due to risk of premature rupture of
membranes and preterm birth secondary to cervical incompetence. They must undergo periodic cervical
ultrasound evaluation for surveillance cervical shortening. In some cases placement of a cervical cerclage is
indicated. Another obstetrical complication frequently seen in patients with unicornuate uterus is fetal
malpresentation.

In women with uterus unicornuate type A1a, where there is a rudimentary uterus with a communicating
endometrial cavity, there is the possibility that pregnancy implants in the rudimentary uterus. If the pregnancy
progresses, growth of the rudimentary horn could result in uterine rupture in as high as 80-90% of cases which
represent a life threatening event.

Congenital uterine anomalies are associated to urologic anomalies in about 40% of patients, being contralateral
renal agenesis the most common reported in 16% of cases. Other malformations include ectopic kidney and
pyelocalyceal duplicity.

The presence of the ovary in an ectopic location is also present in 42% of cases of unicornuate uterus. This
occurs as a result of the lack of descent of the gonad into the pelvis. This ovarian migration occurs in the third
month of conception, in which the ovaries migrate down from a position near the kidney to its final location.
Ovarian ectopic location is difficult to diagnose, in which case MRI has proven to be the best imaging modality.

The diagnosis of this type of congenital uterine anomaly is usually incidental unless there is a functional non-
communicating rudimentary horn (with endometrial cavity). In this case, the patients usually present with
dysmenorrhea, which will increase from menarche, due to growing hematometra in the rudimentary horn.

There is no recommended surgical approach for the treatment unicornuate uterus. There has been some case
reports describing hysteroscopic endometrial cavity dilation, but this approach is considered experimental. The
treatment of a communicating-functioning rudimentary uterus is surgically excision as soon as it is diagnosed, to
prevent dysmenorrhea and the possibility of pregnancy in such rudimentary horn. We proceed in the same way
also in cases of non-communicating functioning cavity to treat dysmenorrhea and associated hematometra.

Unicornuate uterus, especially in nulligravid patients, the cavity has a tubular aspect in which only one of the
tubal ostium is present. The myometrium is frequently weak and distributed in concentric rings.

In the presence unicornuate uterus, it is essential to rule out the presence of an additional rudimentary uterus to
rule out other malformations such as bicornuate-bicollis uterus. It is also important to look for possible functional
communications usually located at the istmus on the contralateral uterine wall from the visualized tubal ostium.

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Hysteroscopy Newsletter
is an opened forum to
all professionals who
want to contribute with
their knowledge and
even share their doubts
with a word-wide
gynecological
community
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HYSTEROSCOPY
Editorial teaM
The hysteroscope is the gynecologist's stethoscope. How can we practice gynecology
without it?
Like the stethoscope that has many uses including auscultation of heart sounds,
listening to intestinal bowel sounds, hearing the roar of arteries and veins, and when
coupled with a sphygmomanometer to measure blood pressure--our hysteroscope
serves many purposes to evaluate uterine health.
Your hysteroscope will help you understand the conundrum of postmenopausal
bleeding, abnormal bleeding, or complete the infertility evaluation. Your hysteroscope
will help in the evaluation of persistent leukorrhea. Locating a misplaced IUD or
foreign object is simplified if you look with your hysteroscope. Do you need to know
how the endometrial cavity heals after a surgical procedure? Just look with your
hysteroscope. Hysteroscopy is also helpful to further evaluate the endometrial cavity
when ultrasound or MRI images provide equivocal results.
Keep your hysteroscope handy in your office at all times and ready to use. Don't have
one? Then advocate that your office or hospital purchase one. The investment in
purchasing a hysteroscope is financially prudent. It pays itself off quickly. Haven't been
trained? Take a course. Get a mentor. Enroll in a preceptor program. Learn with a
simulator. Hysteroscopy is much easier to learn than robotic surgery.
It's been two centuries since hysteroscopy was invented. Our hysteroscopes are
smaller, sleeker, flexible, affordable, and have excellent optics. Some are even
disposable. Camera and video attachments allow us to capture images for the medical
record. It's time to add hysteroscopy, your stethoscope, to your procedural
armamentarium.
Just do it !!
Linda D. Bradley MD
Professor of Surgery. Vice Chair Obstetrics and Gynecology
Director of the Center for Menstrual Disorders and Hysteroscopic Services
Cleveland Clinic. Cleveland , Ohio USA
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