Advanced Hysteroscopy

The episode begins with Linda describing the utility of hysteroscopy: it is a great option to visualize the endocervix, endometrium, uterine healing after complicated surgeries, foreign bodies, broken IUDs, and hyperplasia. It should be used for uterine bleeding, retained products of conception, evaluating women for Asherman’s, and evaluating why the endometrium is thick on ultrasound. Hysteroscopy has two main roles: diagnosis and therapeutics. Hysteroscopic surgery allows for the uninterrupted visualization and removal of pathology, as opposed to other measures like D&C where the uterus is scraped blindly. It is also great for visually-directed, targeted biopsies and treating pathologies like fibroids and polyps. Linda emphasizes that it is a disservice to women to go in blind because fibroids or cancer can be missed with blind biopsies--in fact, pipelle biopsies picked up zero polyps in their study. Hysteroscopy surgery has a faster recovery, is less invasive, has less risks of bleeding or damaging other structures, and has low risk of infection.

The physicians then discuss techniques involving hysteroscopy. Linda prefers using a flexible hysteroscope that is 3.2 mm wide because dilation isn’t needed. She also explains that there isn’t a need for a paracervical block (just oral ibuprofen) as the patients have minimal pain when the walls of the uterus are appropriately avoided.

Linda focuses on the need to believe women when they are bleeding. It takes 3-5 doctors and 3-5 years for many women to get their bleeding appropriately treated instead of trying the same medicines without success. We have the technology to do something different, and hysteroscopy is the best option to look into the uterus and understand what is going on. Mark asks about the training of physicians in hysteroscopy, and Linda responds that simulators are key in addition to having courses and mentors to teach the technique properly. Finally, the doctors finish by talking about future applications of hysteroscopy.