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BackTable / OBGYN / Podcast / Transcript #34
Podcast Transcript: Advanced Hysteroscopy
with Dr. Linda Bradley
In this episode, hosts Dr. Mark Hoffman and Dr. Amy Park invite Dr. Linda Bradley to discuss advanced hysteroscopy. Linda is a professor of OB/GYN and Reproductive Biology at Cleveland Clinic as well as the Director of Center for Menstrual Disorders, Fibroids, and Hysteroscopic Services. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) The Evolution of Hysteroscopy
(2) Hysteroscopy Target Conditions & Common Issues
(3) Hysteroscopy Patient Preparation
(4) Hysteroscopy Expert Procedural Advice
(5) The Responsibility of Subspeciality Practitioners
(6) Accessing Hysteroscopy Training & Trainee Case Management Guidelines
(7) Hysteroscopic Fibroid Removal
(8) Post Hysteroscopy Care
(9) The Future of Hysteroscopy
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[Dr. Mark Hoffman]
Hello, everyone, and welcome to The BackTable OBGYN Podcast, your source for all things obstetrics and gynecology. You can find all previous episodes of our podcast on Spotify, Apple Podcasts, and on backtable.com. Welcome back to another episode of Backtable OBGYN. This is your host, Mark Hoffman, and I've got with me again, our host, Amy Park. We have a very special guest today, someone who I'm a huge fan of and someone you know as well. We have Dr. Linda Bradley. Linda, how are you?
[Dr. Linda Bradley]
I'm great.
[Dr. Mark Hoffman]
We're excited to have you here, and welcome to the show. Dr. Bradley is a professor of obstetrics and gynecology and reproductive biology at Cleveland Clinic. She is the director of the Center for Menstrual Disorders, Fibroids, and the Hysteroscopic Services. Did I get those right?
[Dr. Linda Bradley]
You got it perfectly.
[Dr. Mark Hoffman]
Wonderful. For everyone who is involved in any society or in gynecology in general knows, she is an internationally-recognized expert, an innovator in advanced office in operative hysteroscopy. It's my absolute pleasure to have you on here to pick your brain so all of our listeners can learn about all the amazing things you do, so thanks again for coming on and welcome to the show.
[Dr. Linda Bradley]
Thanks for asking me.
(1) The Evolution of Hysteroscopy
[Dr. Mark Hoffman]
All right, so like we do for most episodes, we like to ask our guests to tell us a little bit about themselves. Tell us about your practice.
[Dr. Linda Bradley]
Well, my practice for the last several decades has been at the Cleveland Clinic. During my residency, there was no hysteroscopy. It was three D&Cs. You strike out, you get a hysterectomy. I feel like I'm always a lifelong learner. There was no fellowship back in the day. There weren't mentors to teach me. I happened to go to an AAGL meeting with some of the more eminent physicians at the time.
There are three of them that I have a lot of respect for. That really opened my eyes to what's inside the uterus. The half-life of medicine is only a couple of years, probably months now. Being out of training and residency and even working for a couple of years, I was like, "This is incredible. The beauty of the uterus, the endocervix, the tubal ostia. I need to know about this."
Watching others through the AAGL, I was able to follow up and call some of the speakers on Jay Cooper, Frank Loffer, Paul Inman. I could just name many of the greats. They were so kind, didn't know me from Jane, and really talked me through a lot. I think, for me, a picture speaks a thousand words. I'm always someone who tries to be a very early adopter for certain procedures, certain medications. Basically, to answer the question more succinctly, it's just, I went, I saw, and said, "I must do," and got started.
[Dr. Mark Hoffman]
It's hard to imagine. Whenever I think about incorporating a new technology or new procedure into my office these days, it's not easy to get your hospital to buy anything. Thinking back a few years ago, when you were doing something that just sounds like not very many people were doing. Was it a challenge where you were to bring these things in? Did people think you were doing something crazy that you shouldn't be doing? Were people excited about it?
[Dr. Linda Bradley]
I think working at the Cleveland Clinic, which is over 100 years old, and we're most known for innovation, innovation, innovation. When I came to the clinic and said, "I think this is something that we should be doing," they were all for it. I have not practiced obstetrics since I've been at the clinic. This really was a new domain, a new technology. I was really very lucky that I was interested and pursued this.
I think at the Cleveland Clinic, I'm not saying other hospitals aren't for that, but just getting started, the excellent outcomes, the minimal number of complications, the brevity of doing procedures in the office, and then subsequently in the operating room. I think good outcomes breed more patients, breed the ability to get more instruments. I'm speaking specifically right now, office-based procedures that then carry you on, meaning diagnostic procedures that then allow you to do surgery.
I do on the average right now, 10 to 12 operative hysteroscopies a week. This is all I do. I don't do Pap tests. If someone needs it that's going to have a hysteroscopy, I'll do it. I don't prescribe birth control pills. I don't do OB. I don't do chronic pain. I don't do urogyn. Literally, all of my patients have bleeding problems, follow-up, fibroids, polyps, retained products of conception, bleeding of unknown origin.
Today, I did nine office hysteroscopies. Tomorrow, I'll do eight. My practice is only at the Cleveland Clinic. It's probably one of the few places. Even a cardiothoracic surgeon doesn't do every valve in the heart or stents or aneurysm. We are heavily focused on people's passion, expertise. I'm happy to say I've done over 10,000 office hysteroscopies that then give you the surgical procedures over the last many decades.
It's an easy place to work, especially in the subspecialty division. You don't have to do everything, but you have to be busy. You have to be productive and you have to write, lecture, be involved with committees. The clinic, in my mind and in my era, really allowed me to grow as much as I wanted to grow and to learn and to continue to learn for others. Amy was not at the clinic at the time, but our older CEO who's retired had every physician at the clinic doing what's called an innovation trip.
If you were a surgeon to go work with the best surgeon and what you want to do, if you're a pediatrician to go work with the best pediatrician. Even if it's a generalist, how do you do the best history, the physical exam? If you're a psychiatrist, everybody got a week off, paid for. It was an expectation, a high expectation that you go. You come back and you bring back something that you've learned.
[Dr. Mark Hoffman]
That's incredible.
[Dr. Linda Bradley]
It's a visionary institution run by physicians more so in the old days. For me, I take all those opportunities. We have a tremendous travel policy. I use every day that I'm given to go, to learn, to do. I think when you know better, you start doing better. That's been my pleasure of working at the clinic is to extend, especially in the area of hysteroscopy, something that a lot of people sadly aren't that interested even in 2023. Hysteroscopy is minimally invasive surgery,It is not a D&C. I think it's not sexy and it's a shame that folks do not use the technology, the tools that help women so much.
[Dr. Mark Hoffman]
I'm a fan and that's why I had you on here. I was thrilled to get to chat with you at meetings whenever I see you. I want to take an innovation trip and spend a week with Linda Bradley, honestly, if I could have one week. I've talked to you about this, right? There's things that you're doing that I don't think very many or maybe anyone in the world is doing, at least not that I know of.
[Dr. Linda Bradley]
Oh, gosh. Oh, I'm not going to accept that. I think there are lots of my colleagues who are gifted, interested, passionate, crazy about hysteroscopy. I'm not going to say I'm all that, but I think there are a lot of people who share my passion.
[Dr. Amy Park]
That's so cool, Linda, that you were able to develop this interest and niche and were allowed to pursue it. I'm just curious. I wanted to delve into the historical context because it sounds like it was really blind curettage and then the addition of the hysteroscope and then the flexible hysteroscope and the operative hysteroscope. Can you just tell us how you see the arc of hysteroscopy historically? Now, even since I trained a while ago, we have the advent of TruClear and MyoSure. When I was a resident, bipolar cautery for the resectoscope had come out. What are your thoughts? How do you see it having evolved over time?
[Dr. Linda Bradley]
Well, I'm really proud to say that, last year, I was asked by Jason from the Green Journal to write an expert opinion on the topic of office hysteroscopy. It was published in the September '22 edition. Within it was the article we entitled. It's something like implementing office hysteroscopy. It has 30 videos that folks can click on, about 30 images of different things that you can see.
What I realized and what I put in my last paragraph of the article and I've been saying for a long time and I said, "Somebody's going to pick up this little saying that I say," but I say that my hysteroscope is my stethoscope, okay? My husband's an internist. One day, I'm just looking at him with his stethoscope. We're talking about patients and your stethoscope. You can listen to carotid bruits. You can listen to lung sounds, listen to bowel sounds, listen for murmurs, determine if you have LAS and things like that.
When I think about the stethoscope, it's used for many things besides just heart-related things. My hysteroscope is my stethoscope. It's not always about bleeding. It could be retained products of conception. It could be evaluating women to see if they have Asherman's. It could be evaluating, why is the endometrium thick on a regular transvaginal ultrasound or the ultrasound shows that the endometrium is ill-defined, not seen in its entirety equivocal?
All bleeding from even puberty, you can use your hysteroscope as a vaginoscopy. Lots of little girls. Again, now, we have pediatric gynecology, but I used to be called for bleeding. We would take the flexible scope because you don't dilate. Lots of little kids have marbles, pens, pennies in the vagina. We're seeing that in elderly women now, foreign bodies. They're leaving odor, dementia, Alzheimer's, so not all bleeding is from the uterus. Probably once a year, I pick up one or two cases of vaginal cancer for bleeding.
You can look, do a vaginoscopy, and look for induration. All the bleeding from to say what I call the three blood phases of a woman's life from puberty to the reproductive years to the menopausal years, the hysteroscope lets you look directly inside the endocervix, which is not well seen with ultrasound, the endometrium. Sometimes there are small lesions near the tubal ostia. You can look, "How did you do? What's your thumbprint or footprint that you left after surgery?"
When I did a very difficult operative hysteroscopy, I took out a patient, 28 intracavitary fibroids in a woman who wanted a baby. You better be sure I'm going to look and see a few weeks later how that uterus is healing. I'm happy to say for her, unnamed person, she just had a baby, okay? I like to look at my efforts for some things after surgery. We look at all the bleeding issues, foreign bodies, broken IUDs. From China back in the old days, they would put in this ring IUD.
[Dr. Mark Hoffman]
The steel rings.
[Dr. Linda Bradley]
Yes. Without a screen, took those out. Women that are 80 years old, they happen to fall and break their hip. They get a CAT scan. Oh, my God, there's an IUD, a Lippes loop. I used to have a little drawer with all of them, I wish I hadn't thrown them away, but I did. I've seen a cerclage inside the uterus. There's a lot of different things that you can see. You can follow it up for hyperplasia.
We're using the levonorgestrel IUD instead of doing blind sampling. You can look. You can do directed biopsies. You can do targeted biopsies. I'm just saying, it is a shame. I'm quite embarrassed that, in 2023, when we look for bleeding disorders in women or reproductive menstrual dysfunction, that use of a blind technology, whether it's a Pipelle or, God forbid, a blind D&C, which we call "dead and cremated," that we as a society or gynecologists for bleeding that we do not look.
I say the same old thing that everyone says. If you have hematuria, you're going to do a cysto. You're having rectal bleeding. You're going to get a sigmoidoscopy or colonoscopy. If you're vomiting up blood, hemoptysis, you're going to get an endoscopy. There's no other specialty in which a scope is not used for certain things. I personally think it is a disservice, tremendous disservice to women to say that, "Oh, your Pipelle biopsy is negative."
What does negative mean? I tell the residents, it only helps you if your Pipelle gives you cancer or atypical hyperplasia because what we know from great studies with blind technology is that we miss focal lesions. We miss fibroids. One of our residents just published. It was her abstract poster, then publication, "Oh, about 2,000 patients. Everybody was bleeding, whatever age or whatever, with a biopsy in the office," but they either had a saline infusion sonogram or hysteroscopy.
If the SIS showed a polyp or fibroid, even when the biopsy was negative, we took them to the OR. The gold standard is your fibroid or your polyp. When you looked at close to 600, 800 women, of those who had fibroids that I resected or that a doctor resected, how many times do you think the Pipelle picked up? She's bleeding, bleeding. We did the Pipelle first often during the visit and then they would have the SIS or hysteroscopy.
Then you take them to the surgery because of a focal finding being seen. Focal could be a 3 or 5-centimeter intracavitary fibroid or huge polyp. I looked at a lady yesterday, a 5-centimeter postmenopausal bleeding for three years. Office biopsy, negative, okay? I go inside, a huge polyp. We'll find out what her path is. Getting back to our study. In your own experience, how often on your own Pipelle biopsies in your career have you picked up a fibroid for pathology? Any of you?
[Dr. Mark Hoffman]
Never.
[Dr. Linda Bradley]
Of course not, unless it's degenerating. Our study showed that zero out of all the hundreds of fibroids that were there when they had their "pre-op office biopsy." If you stop at that, then the patient, when they don't get the right diagnosis, they don't even get the privilege of having a minor procedure. My six patients yesterday, I've called them all. Nobody goes home with anything but Motrin. They're feeling well. "Did you do any procedures?" Minimal bleeding. They can go back to work in two days. They could drive today. They can have sex in a week.
You're not getting them on narcotics. There's just so many uses for hysteroscopy and allowing us to say, in a menopausal woman, we look inside. 70% of bleeding in menopause is from atrophy. If you look inside, I jokingly say that the endometrium looks bald-headed. There is nothing there. If I give you a comb or a brush and you have no hair, there is no hair there. It is negative because there is no endometrium. It'll say inactive or it'll say atrophic or it'll just say no endometrium. When I then get my pathology back, I can say she's bleeding from atrophy.
[Dr. Amy Park]
I know one of my partners in DC, Jim Robinson, used to do the Asherman's and sometimes even some septum resections in the office, but definitely the Asherman's. I was surprised about that, but being able to do the septum resections hysteroscopically is huge. It's so much less morbid than doing a whole abdominal approach or whatever.
[Dr. Linda Bradley]
Correct.
(2) Hysteroscopy Target Conditions & Common Issues
[Dr. Mark Hoffman]
My next question. You obviously have done this before, but you answered our next question of what conditions can be treated with hysteroscopy. It sounds like basically everything.
[Dr. Linda Bradley]
Well, I wouldn't say that. I'd like to first say, there's two roles to hysteroscopy. One is diagnostic and the other is therapeutic. When you do surgery, it is a minimally invasive surgery. When I went to one of the hospitals that I was first working only out of the main campus, the Cleveland Clinic, and then the city has grown. The Cleveland Clinic bought eight other community hospitals. Many of us were told, "It's getting so busy at the main campus. You need to move these outpatient types of procedures out."
I go to another smaller hospital to be unnamed. There were a group of doctors from another hospital that used to practice there that were gynecologists. I just asked. I said, "Oh, do you have hysteroscopy and the D&C equipment?" They said, "Oh, yes, all of our doctors do hysteroscopy and D&C." Something said, "Can you open a tray? Show me what it is." What those physicians did was basically put a hysteroscope in.
They didn't have a resectoscope. There wasn't maybe a tissue morcellator, but there were resectoscopes. They looked. They then took out the D&C, the curette, and scraped the heck out of the uterus and called it a day. That is not hysteroscopic surgery, okay? My definition of hysteroscopic surgery is an uninterrupted visualization and removal of pathology that's there. Uninterrupted. You look. I never, ever, ever put a curette in a woman's uterus anymore, ever, okay?
It would have been so rare. Why do it? Because you can see, nothing's blind. I know I haven't perped. I know I haven't missed a lesion. Especially for fibroids, the type 0s, yes, 1s and 2s, I know I have all of it taken out. I think that's important. It's very interesting. I haven't told this story, but that physician, the anesthesiologist, is now retired. I'm a little feisty sometimes. He says to me in the OR with a med student and a resident and a fellow and the nurses, "The patient's asleep."
He puts his hands on his chest and says to me, "Young lady, I've never seen anybody take this long to do a hysteroscopy D&C." I kept my cool. Patient awakened and I said, "Dr. So-and-so, I want to speak with you. Do you have an office on this floor?" I went into his office, I closed his door, and I said, "Don't you ever speak to me in this fashion around my colleagues and peers and students. If you have something to say, please talk to me privately. We're both adults."
I said, "I don't play peekaboo hysteroscopy. I am not putting a scope in, then taking it out, scraping around, maybe not even looking again." I said, "I'm doing surgery," and blah, blah, blah. I also said to him, "I don't ever want you to touch a patient of mine. I don't want to work with you and I don't want you to be assigned to any of my cases." I just started at this hospital that is Cleveland Clinic, but it was so rude and unprofessional.
I didn't do the kind of surgery that those other doctors at the other hospital do. I think that's where it could take a long time. I would have residents speak to me, "Oh, so-and-so could have done a vag hyst," and I said, "Yes, but no one's going to get into a ureter, not going to have to hystens. You're not going to need antibiotics. You're not going to need narcotics. They can have sex in a week." For small or large intracavitary pathology, the rest of the uterus and adnexa are fine. There's no other reason to take out the uterus. Tell me why I shouldn't spend an hour if it takes me that long that the patient goes, wakes up, goes to the recovery room an hour and a half, goes home, and is doing things in short order.
(3) Hysteroscopy Patient Preparation
[Dr. Amy Park]
Circling back to the office hysteroscopy, one of the big things that people are talking about now is regarding cervical manipulation like IUD placement and pain control. Do you often do a paracervical block and what's your philosophy on that? Then also regarding the financial incentives, I know now office hysteroscopy gives a lot of RVUs and then transitioning that OR diagnostic hysteroscopy to the office. You live through that transition. I'm just curious about what your philosophy is on the pain and the tricks that you do for the office.
[Dr. Linda Bradley]
I think preparation, preparation, preparation, and patients being informed of what they're going to do. Now, there's different hysteroscopes. Each of us is going to like what we like for diagnosis. It's like if you're a golfer, you have your clubs that you like. If you are a skier, you have your skis that you like. If you bowl, they could have three 10-pound, 15-pound balls, but there's something that you like.
My workhorse and my office for diagnosis is a flexible hysteroscope. It is 3.2 millimeters. There are names of other disposable hysteroscopes that I've tried, but I think in my hands, these skis work for me. This bowling ball works for me. Yes, there are others and everybody should try. The flexible scope, usually, it's 3.2 millimeters. You don't have to dilate the patient. I used to put a tenaculum on and sound everybody. I don't do any of that. I have my patients to eat before coming.
If we know that they're coming, we have them take an NSAID if they're allowed to or Tylenol. The nurses prep them. We tell them that it's brief. It's usually very comfortable. I do have a paper early on for a visual analog. Most of the patients have very low pain scores and so do other physicians. At one point, I was also very proud to have been one of the first physicians to do hysteroscopic sterilization in the country with Essure. Of course, that's gone now.
I went to Mexico to train women that were having hysterectomies. Immediately, we put the devices in. They had the hysterectomies, made sure we were doing it properly, and then it came back to the US. At the Cleveland Clinic, I was a part of that clinical trial that was ultimately FDA-approved. We started doing those in the office. I'm being very honest. I can tell you what protocols are. I haven't put a paracervical block in probably 20 years.
I don't use them. If they're young, multiple leaps, cones, all C-sections, I have them use Cytotec or misoprostol by mouth, 400 micrograms the night before, or if they're menopausal. I think I can talk with you about pain regimens. The risk of a vagal-vagal is so low. It's just very, very low. I think there are doctors that use larger scopes, that use rigid scopes, that may need to do the paracervical with the 0.25% Marcaine with the deep paracervical blocks.
You're asking me my opinion for the things that I've done even when I started to do Essure and the hysteroscopic sterilization in the office. They ate before coming. We might give Toradol the night before, 12 hours. I might say take 600 of Motrin two or three times a day the day before to help with the prostaglandin release and all of that. That's just me. There are others who give Valium. There's others that have a driver that use a Marcaine spray.
There's all kinds of things that are used. Sometimes, if you ask me, putting in these paracervical blocks, some people use epi, and then they get the racing heart. Sometimes just all this other stuff we do, to me, creates more of an issue. I don't do paracervical block tray. I don't have one. "Where does she keep her medicine?" We don't have it. Now, what we are going to be doing, and I can publicly say this because we just had a meeting on Monday, we're going to be trialing several newer devices that will allow us to do larger polyps.
I would never personally do a myoma in the office. I would not, personally for me, retained products in the office because of absorption and bleeding. There may be some things like the polyps, which are very common, or things like that in the office. These devices might be a little bit larger, but I've also read and talked to physicians that are using them, the preparation, eating, and NSAID.
I don't give Valium. I don't give Demerol or an opioid to the patients. We do the pelvic, trauma-informed care kind of thing. I'm not going to force any of this on someone who's had incest, domestic violence, sexual violence. As easy as it might seem for some patients, it's better to be done in the operating room. We have to listen to our patients and be very patient-centric.
(4) Hysteroscopy Expert Procedural Advice
[Dr. Mark Hoffman]
My experience in the office has been anything from a rigid hysteroscope or a flexible hysteroscope as well as some of the disposable devices. I have to say, in fellowship, they had a few of the flexible, I guess, similar 3.2-millimeter flexible scopes. I got to where you could drive and not touch the walls. It seemed to me that if you could avoid the walls of the cervix, if you could avoid the walls of the uterus, there really wasn't much in the way of pain.
You get some pain from some cramping, from filling the uterus with saline. For diagnostic purposes, if you could drive that scope without bumping stop, we all know when you get in there. I almost never dilate in the operating room. You just put the scope in. You see the tract, right? You see the landing strip where people have dilated every single time. If you could avoid the walls, you can avoid pain. Is that your experience as well?
[Dr. Linda Bradley]
Yes, I tell my residents or ask my residents. Now, they know all my questions, right? When you go in, what are you going to see? You should be looking for the black hole. White is not right, okay? You need to go like you said. That just means that black hole is where you need to be. If you're seeing white, you're touching the cervix. You're touching something. Back up, pivot, whatever you're going to do to find that. Even under anesthesia, because if you are seeing white, the next thing under anesthesia, patient's not going to say it hurts. You've perfed. The answer to the question is look for the black hole and then guide yourself. I totally agree with you, Mark.
[Dr. Mark Hoffman]
I've tried to get this where I am. It's tough because we don't have access to sterile supply in our clinic. Those reusable scopes, the flexible ones are a little tougher to get. We've been able to get the disposables. They're a little bit bigger. Because you don't have the control, because you can't move the angle of the scope and avoid the wall, that's everything to me.
(5) The Responsibility of Subspeciality Practitioners
[Dr. Mark Hoffman]:
If they can come up with a scope that is articulated and disposable, then I think you've made a significant advance for office hysteroscopy in terms of access, because that's the biggest thing. My main question was for you with diagnostics. As you mentioned, my hysteroscope is my stethoscope. When patients come to see you and they're complaining of bleeding, what percentage of them get hysteroscopies? Is it 100%? Is it every patient that comes to you the same way that I'll do a pelvic exam just to take a look at the cervix?
[Dr. Linda Bradley]
Well, like any practice, the benefit of being a super subspecialist is that all the other stuff has been ruled out in general, right? Basically, everybody's had a blind sampling. Everybody's been on Provera, five different birth control pills.
[Dr. Mark Hoffman]
They've had ultrasounds.
[Dr. Linda Bradley]
Yes, but regular ultrasounds are worthless. They need an SIS. If you don't have a hysteroscope, you need to do an SIS. For me, people have already come. It's just like being a generalist and a woman comes with a bag of ointment and she's had bulbar itchy. You say to her, "Ms. Jones, have you had a biopsy?" "No. In 20 years, I've just been using all these creams and ointments." You take a biopsy and you find a lichen sclerosus.
You look like you're pretty smart. You're not that smart, but we just have done something different. For me, a failure of medical response to how you think that patient's going to be, those patients will have a hysteroscope because I'm not going to go back and give them another trial of Aygestin, Provera, Megace, birth control pills, whatever people use. It's a little hard, Mark, for me to say, "Do I ever get new patients?" The answer is yes.
Women are more than some of their body parts. You get the history. You do a pelvic exam if a patient has a uterus 25-week size and bleeding all the time. Yes, we do need to know what's going on, but then there may be other reasons for the normal-sized uterus with whatever her bleeding story is. A recent Italian study says, if you happen to find out that a patient's CBC with their hemoglobin is seven or eight or below, 70% of the time, you're going to find intracavitary pathology.
We're just talking about polyps and fibroids. The patient has post-coital bleeding. If I'm seeing her for that, the first thing I'm going to do, I'm not ordering an SIS for that. I'm going to look, see, "Does she have an ectropion, cervical eversion, or an endocervical myoma? Today, in fact, I just scheduled someone, a nurse today, who's had two "cervical polyps" removed. She's had another patient, three years of bleeding. You could see the little kidney-shaped polyp. What do we learn from some literature?
One out of six women with the cervical polyp have an endometrial polyp. She had two or three other endometrial polyps. I'm not going to twist that off in the office today, but I'm going to go and I'm going to get those other three polyps that were inside and then take off the cervical. I think it is hard for me to have an algorithm driven like when I use a scope, but there are some definite reasons why I would always use a scope. There are reasons that I might use some other technology. You see what I'm saying?
I think the important thing is this storytelling and letting women tell you their stories so you can really listen to what their bleeding is like, what's been tried, what's worked, what's not worked. We have so many stories where women are not listened to and especially for women of color. It's for everybody, but especially for women of color, the issues of bleeding. We underestimate the poor quality of life. The number of physicians that they see, just like endometriosis.
I am on a paper with Elizabeth Stewart and others from the Mayo Clinic where we looked at about 1,000 women. This is with fibroids. We're not speaking specifically about hysteroscopy if I can divert my attention from that for a second. The average patient, like endometriosis, they're almost like hand in hand, three to five years, three to five different physicians. You'd say to a patient, "Tell me. How many providers have you seen?"
If they've seen three, four, or five, the buck stops with you to work up their bleeding in a decidedly different way with technology that works in your hands. It should not be another regurgitation of the same medicines again. It doesn't make us look very smart. Sometimes it's just the story. It just doesn't sound normal for just a normal period, a regular predictable period that a woman's had for all these years.
Now, she's hemorrhaging for seven days, can't work, socially embarrassed, doesn't go out, misses her kid's stuff, normal uterus, nothing on the cervix. You better look in her uterus. That's not an anovulatory cycle. People can have that sort of anovulatory cycle and it coexists with a polyp or a fibroid. I did the cases yesterday, a 49-year-old. Someone did a "D&C" a while ago, disordered proliferative endometrium. She's bleeding all the time. It was a blind D&C. I looked in there yesterday. Polyp and an endocervical myoma.
I'd already predicted that from the office workup, but I took her to surgery to resect out or remove these lesions. I think look at the patient. Listen to her story. I tell my patients. I said, "I don't save anybody's life. I'm not a cancer doctor, but I can improve the quality of your life." Look at your patients, asking them, "How do your periods affect your life?" I'll have people say, "Oh, her hemoglobin is 11 or 12." The lady is bleeding, wearing diapers, pads, and special underwear now for periods.
I was asked to do an article for somebody or interview for someone in Europe because Europeans are more flexible with time off and things like this. Some would say, "Well, I think women with heavy periods, can you speak to why they need to be off of work?" I'm like, "No, they don't need to be off of work. They need to have a hysteroscopy or an SIS to look at why they're bleeding." There's just that bit of humanism of medicine and the doctrine of medicine. Listening to patients, to me, is so important.
(6) Accessing Hysteroscopy Training & Trainee Case Management Guidelines
[Dr. Amy Park]
Linda, well, let me just ask you. I think you've eloquently described why people should be getting hysteroscopes and why we should be offering them. Can you just give insight into how you would advise trainees to gain the skills?
[Dr. Linda Bradley]
Be curious, listen. This first hysteroscope was done, I think, 154 years ago. It's just, how can you practice blindly?
[Dr. Amy Park]
How about the technical skills? Are there simulations? Are there ways to practice? Do you have to do a fellowship? Is this something we can pick up with time? How do you get better at this blind? You have to do some cervical dilation for operative hysteroscopy. How do you get familiar with managing fluid deficits and all the things? There's a lot that goes into it. It's not like when they're easy, they're easy. When they're hard, they're hard. That's how surgery is. How do you approach that? I'm curious about your thoughts too, Mark, because we're all involved in trainees. They're getting less and less time to learn.
[Dr. Linda Bradley]
You have answered it. Like I said, for myself, I just looked and said, "Oh, my God. I have to learn this." I had my first slide for almost every lecture. It's a picture of a hysteroscope. It's all red and we call it the Japanese flag sign. First 50 cases, all I saw was blood. I knew Jay Cooper, Adamyan, Phil Brooks, Dr. Loffer. I saw their pictures. I was like, "I am going to keep learning this."
Again, my training was self-instruction because we did not have anybody in Cleveland, residency for where I was at the other hospital, or at the Cleveland Clinic doing this. I just said, "This is not a big space to navigate." Now, if you asked me to do a sacrospinous fixation by myself, I'd be like, "Oh, my God." I think, now, you answered the question. One is simulation. Number two, we're going to both push our societies that we're active in. This year's AAGL meeting in November at Nashville, postgraduate courses.
You have your simulators. Again, you hope that you can start with someone that's doing something so that the blind is not leading the blind. I think how I did this decades ago would probably be more frowned upon. That's how it happened. I would say now, hopefully, there is a champion at someone's institution, residency, or fellowship that they can try to spend more time in. The Cleveland Clinic, we have a tracking program where the residents may spend more time in a certain area.
I do think the coursework, just going to lectures, looking at what's possible is beneficial. You're right. We're not talking today about fluid management. There are particulars, things to do, know Trendelenburg, the different fluid management systems. There's a whole cottage industry around being safe. I don't know what trainees-- if they're allowed to go to other places to observe. Basically, nowadays, it's finding a mentor. Then it's like an apprenticeship, watching, learning, and then doing.
[Dr. Mark Hoffman]
I agree with what you're saying. I also think that we have more opportunities in training than we realize. I think one of the things I noticed specifically with hysteroscopy, I was always fascinated by it. I loved it. They're my favorite cases. I think when you do a really tough hysteroscopic case and you just walk away and there's no incision to close, they go home and like ibuprofen and Tylenol.
You just feel like you've done something really special for them. I think people think of hysteroscopic cases as though that's an intern case or a second-year case because hysterectomies and majors are really what I need to be doing in my upper levels. I think these are cases that can be really challenging. These are cases in which there is a definite skill to hysteroscopy. There's absolutely a skill, just sometimes on the difficult case to get in.
I see all the time where I'll be with a resident. They'll start the case and they grab a dilator. I'm like, "Whoa, stop. Get that away." They'll take the giant operative scope. I say, "There's a diagnostic scope right there. Put it together. You know how to use it." They're still having trouble. "There's an outer sheath. Take the outer sheath off. Just take off the outflow. You've got a tiny, little scope. Walk right in."
They go, "Oh, wait. We didn't have to put a clamp on. We didn't dilate." All of a sudden, you walk in there and the cavity goes posteriorly. You go, "Oh, wait, it's a good thing we looked because you would have perforated anteriorly while you were dilating." This idea that you're going to dilate blindly because I can't get my scope in, it is an art like all of surgery. There is a nuance. There is a skill set that I think we have too low an expectation for advanced hysteroscopy.
We have too low an idea about what it can be. I think that one of the reasons why I was trying to find you at meetings is because I want to know how I can do more. I think about the operative hysteroscopy that I want to talk about in just a second. It's just as simple as the diagnostic part of it. Just getting there sometimes on the tough hysteroscopes where I can see where someone would perforate where the disaster happens. You got to see it ahead of time and know how to prevent that.
I do think challenging our chiefs to really continue with hysteroscopy for four years, not just, "Oh, this is a junior-level case." I think that's something that is important. Hysteroscopic myomectomy has, I think, five different variables all happening at once, right? You've got the camera rotation. You've got the rotation of the actual device, which is above the camera. Below, you've got the instrument rotation. You've got the instrument in and out, plus you've got a pedal. There's four to five or six different things moving at once.
You've got to keep your horizon. It's not a straightforward procedure. It sounds like, "Oh, camera, cutting device, simple." There is absolutely a skill. That's just for a MyoSure. The resectoscope is a whole other thing. It takes doing a lot of these like any skill. My feeling is you have to understand how valuable it is, but also understand what the potential is to know how hard to work to get there and not settle for a low bar, not settle for, "Oh, I can throw a scope at it. That's no big deal."
[Dr. Linda Bradley]
People used to ask me, do I do vagis? The answer would be yes, but I did the easiest ones. You couldn't be overweight. You couldn't have had a C-section. You had to have a baby. I just did and I'm embarrassed as a gynecologist to say that I would make a referral, like yesterday was a very interesting day. This patient had two C-sections. I met her in the office because there was postmenopausal bleeding again, but it took two hours for me to get her cervix dilated. I know I can do it, I got frustrated, but she has gone two to three years of bleeding. We can't get in. It's so tucked up and underneath her. Probably the uterus was stuck to her abdominal wall. Yes, that was not an easy case. Once we got in, it was easy, but the whole challenge for a topic expert is getting into that cervix and several people had taken her to the OR and couldn't get in.
Then I also, the way our practice is, I'm considered a consultant. People fly all over the country, have had two procedures, have had a uterine perf and complete resection, and they've just got something that needs to come out. I'm always feeling like, I've got to do this and I will just work until I get in. Sometimes it just doesn't work, but luckily it's not that often.
Yes, I agree. This is a skill you'd have to keep doing the easy cases because sometimes easy is a little bit harder than a moderate heart and then a super heart. I would tell anybody who's just starting, you shouldn't start with someone that you're getting referred. If you're finishing fellowship and training, you haven't done that much work with somebody.
(7) Hysteroscopic Fibroid Removal
[Dr. Mark Hoffman]
You were talking earlier about blind D&Cs, you're like, "No more of those," you say. What are you using now? If you're going to do an endometrial sampling in the operating room, you're not doing a cure, what are you using and how are you evaluating endometrial pathology and how are you treating endometrial pathology in the operating room?
[Dr. Linda Bradley]
That's a good question. Almost all of my patients have already had a diagnostic hysteroscopy or an SIS in the office. By tradition, they always, always have, say, a pipelle in the office. When I bring them to the OR, like yesterday, the hysteroscope that you use, the tissue retrieval system, I use tissue retrieval systems for soft things, polyps, retained products. Fibroids, I only use the bipolar resectoscope. That's just me. You're speaking with me. There are people who love the tissue retrieval systems for fibroids. I do not think that they get into, always getting the entire fibroid out. I think there are very few type 0s. There are many more type 1 and type 2 fibroids, which I think personally with the tissue retrieval system is hard to remove.
What I do, like the lady's yesterday, I take out the polyp, the bigger thing, that 3-centimeter polyp, take that out with my tissue retrieval system. They take the sock out. I finish it. They put another sock in. Then I do what I call an uninterrupted, visually directed endometrial curettage with my tissue retrieval system. You have to sometimes let your uterine pressure down so that the uterine wall falls right into your space and that you haven't also artificially pushed the fibroid, a sessile fibroid flat that you missed something.
I usually do two separate specimens. There was a case a couple of months ago I looked in. It was a clear fibroid, an older woman, a clear polyp, and then near her lower uterine segment, something "just didn't look right." It looked more friable. I took three separate specimens. Once you get the fibroid out, keep your scope inside, put your foot on the pedal, and suck out all that fluid so that your tubing has 250 cc's of saline. You don't want to contaminate it. I take out that, put another sock in. Now, polyp near the tuberosity on the left. Take that out, run my fluids, and still my scope is in.
Then the last I saw this area, it just didn't "look right." I tell my patients my eyes are not a microscope. What I need to know is that this is not atrophy. It turns out the cancer was in the lower uterine segment "polypoid vascular," the yellow plaques that you might see. The fibroid and the polyp could have just been present in a passenger and not the problem. The problem for that lady was the cancer in the lower uterine segment. You can take as many biopsies as you want, just make sure that you keep that scope in, put your foot on the pedal, run that so you get out pushing that clear fluid back into the trap, i.e. the sock. Then the nurse just changes and she labels it, whatever it is. That's how.
Yes, I don't put a curette in and that's my trick question of my residents. We do the procedure and then I'll say, "Well, what do we need to do next?" They look back at the table, "Oh, you need to do a curettage." I say, "Well, tell me why. Tell me more." You have just visually gone all the way around. What more are you going to get with your curette, except a perf, okay? There's just no reason.
[Dr. Mark Hoffman]
You're not mowing the lawn here with the device. You're not just sampling or are you?
[Dr. Linda Bradley]:
I do. No, I do a full anterior wall, posterior wall. Yes
.
You cannot get every millimeter but like yesterday, how the tubal ostia can be very concave. You get up in that little area. I've picked up cancers. It's not in your biopsy or curettage would never get up. Some people have a very deep-looking tubal ostia. You know what I'm saying? That's why endometrial ablations don't work because it doesn't get up there and burn all that endometrium as it's going out to the tubes. Then they get hematometra. Then they get retrograde bleeding. Then they get swollen bloody tubes, they get endometriosis, and they have cyclical pain.
No, I do a visually directed and I told the residents in my op notes, "Don't you ever put D&C on my patients, okay?" The way that we do this, it is labeled exam under anesthesia, dilation of cervix, hysteroscopically directed endometrial polypectomy, and hysteroscopically directed visual endometrial curettage. If I retire one day, people want to go back and look at what I've done, I never ever, almost ever use a curette. They can just take that off my table.
[Dr. Mark Hoffman]
You're doing directed biopsies and what else are you doing?
[Dr. Linda Bradley]:
When we do, we're trying to push this through now for retained products of conception. Why are you sucking the whole uterus? Suction curette for retained products, what business do we give to the reproductive endocrinologist? Asherman's, most Asherman's are caused by what? Retained products, doing a "D&C suction" of a missed abortion after postpartum. Well, postpartum hemorrhages are different, but you have a woman that's delivered, six, eight weeks later she's still bleeding. She's been on two or three birth control pills. You better look in there. It could be the smallest little piece of retained products. They bleed just like polyps. These things don't have to be that big.
[Dr. Mark Hoffman]
Are you using a hysteroscopic morcellator for that tissue?
[Dr. Linda Bradley]
Yes, absolutely, the retrieval system. Yes, for my retained products, I don't do OB. I haven't done it in decades, but I see a number of patients with retained products, yes, that were referred in.
[Dr. Mark Hoffman]
Let's talk about fibroids. The thing that I'm most curious about. You said you took 20 plus fibroids out of someone hysteroscopically, and I need to see this. I need to understand how that happens. Are you getting MRIs on these patients and seeing where they all are? How do you work them up? How do you address, how do you decide what fibroids to take? How do you know how far to go? You're going from below, right? You don't have the visualization of the outside, the serosa, of your depth. How do you deal with these tough cases?
[Dr. Linda Bradley]
Usually, if you're doing SIS or if they have a lot of fibroids, you can't distend the cavity, and they're bleeding. I do an MRI. Again, start with easy. Sometimes the uterus just doesn't distend. You might have an MRI, but with this issue, I think the uterus remodels itself during your surgery. All of my patients with fibroids, preoperatively, they all get oral misoprostol the night before. Helps with cervical dilation and makes the uterus contract. Sometimes you think that the patient has one fibroid or two, sometimes that uterus has contracted and more things have pushed in. I do a lot of variability in my intrauterine pressure, pressure's up, pressure's down. It leads to a massage of the uterus. Sometimes these intramural fibroids will pluck themselves into the cavity.
What do I do? I want to know the patient's fertility wishes because if they want children, after the surgery, I put in an intrauterine Foley catheter. Sometimes we can fill it up. It depends on how much goes in, anywhere from 10 to 30 cc's of sterile water. They stay on that. They have oral estrogen for a month. Usually, it's esterase, 1 milligram twice a day. I see them 14 days, 16 days after surgery, but they deflate their catheter two days before. Then I'm looking inside the uterine cavity.
What am I looking for? I want to make sure these walls are not agglutinated or stuck. You will always see an eschar but you know that you don't see the fibroids anymore. Then I let them finish the total of 30 days. It's not healed at that point. The intrauterine Foley is out. They then take a full 30 days of their estrogen. Then after all the estrogen is gone, in fact, I only send them home with esterase, 1 milligram BID. I send 60 tablets. I will see them in two weeks.
Then I say to them, "Okay, it looks like it's healing well." You can still see the eschar. At day, when that bottle is empty, then it's just Aygestin for 14 days by mouth. You were to take this every day, even if you start bleeding. Don't call me. I don't want all these calls. Just take your pills. Then when you finish your Aygestin, you will normally have a withdrawal bleed within 2 to 14 days. Then that's now at about four weeks, five weeks after surgery, and I look again. By then, in my own experience, the endometrium is healed. You don't see the eschar almost, you don't see Asherman's scar tissue. That's how I handle it.
[Dr. Mark Hoffman]
You look twice. Myomectomy, intrauterine Foley catheter, 10 to 30 cc's?
[Dr. Linda Bradley]
Yes. Whatever the uterus fills up with, okay.
(8) Post Hysteroscopy Care
[Dr. Mark Hoffman]
After the myomectomy, intrauterine catheter and filling up the uterus: the oral esterase, a milligram twice a day for two weeks follows? Then Aygestin for how long?
[Dr. Linda Bradley]
A month. They go with 60 capsules. 14 days, so two weeks of that. Then they get the withdrawal bleed.
[Dr. Mark Hoffman]
Then look a third time?
[Dr. Linda Bradley]
No, second time, just second. First is looking at two weeks because they're on estrogen only. Then the bottle's out. Ma'am, take your Aygestin for two weeks. When you finish that last pill within two days to two weeks, you're going to bleed. Then you call my office. Tell me when you start your period because then we're going to schedule you the following week so that way, everything is re-epithelialized. You've given them estrogen. Really, you don't even see your footprint where you left it.
[Dr. Mark Hoffman]
You're rebuilding it in a sense with the estrogen, is that the idea?
[Dr. Linda Bradley]
Yes. Many people don't do that. I've been doing this for so long. I wish I had done some kind of study. Again, many things that we do in medicine, we don't always have all the answers, but you have to do something. Now, if she's 49 and doesn't want kids, I don't do all of this. She's ambivalent. I'm going to do this. I can almost tell you, I don't see scar tissue.
The other thing that I think I do differently than REIs do, they put in 5 cc's only for the little balloon. Everybody says, "Oh, my God, she's going to be in so much pain." We teach them in the post-op area, they go home with a syringe, how to deflate it. If you have a little bit of crapping, let out no more than 2 to 3 cc's at a time. We tell them how many cc's we put in to start with. Then they self-manage this. If you get below, it's rare that they are deflating a lot. A normal uterus holds about 8 to 10 cc's so if they get below a certain amount, that's what happens.
I tell them, "Don't call me if the balloon falls out," and it's not their fault. Just keep taking your estrogen and come in two weeks because we do not see that, it's rare. I'm going to say 5% of the time. The uterus is a muscle and it just comes out. No, I don't like a lot of phone calls, okay? I give all these instructions and we come back in and then we just take a look and go from there. I think putting more fluid in the balloon.
There's something, like some catheter I tried that looks like a square. I don't want to bad mouth any company, but I almost couldn't get the darn thing out. I don't forget what it was called. I tried it once. It wasn't that big. It looks like a little pillow or something. I just use an old-fashioned Foley and sterile water. You don't want to put saline because saline can crystallize and then it won't deflate. That's important to Foley. Then they have a leg bag, a little tiny leg bag so they can work, they can shower. We teach them, it's going to drain a little bit, it's not hemorrhaging, but how to change that. That's our little protocol.
(9) The Future of Hysteroscopy
[Dr. Amy Park]
I wanted to just ask a sort of big question, which is where do you see the future of hysteroscopy going? I've seen a lot of innovation around the edges, bipolar hysteroscopic morcellation techniques.
[Dr. Mark Hoffman]
RF ablation.
[Dr. Amy Park]
Yes, RF ablation. Are we going to see something AI-generated?
[Dr. Linda Bradley]
I think the two interesting things that over the years I've been hearing or asked about, I don't know what happened to the company, but, and I'm sure other doctors that are listening may know about or have been asked, but one of the things that we're doing now, if you want a tubal ligation, what are we doing? Whether it's a C-section, you're doing salpingectomies, right? If you're doing an interval tubal, you're doing salpingectomies. Why? Because we believe that, or some believe, that ovarian cancer starts in the fallopian tube. I have personally been asked by an unnamed company to consider looking through the fallopian tube. Now, I don't know what that looks like. I guess if I did a hundred of them, I might see something. The idea that some companies are developing these small micro hysteroscopes or something that you can feed into it.
[Dr. Amy Park]
Oh, it's like a ureteroscope, basically.
[Dr. Linda Bradley]
Probably, yes. The other thing, I'm so upset that Essure was taken off the market. I think that the last hurrah for hysteroscopy, right now, if we could, in the office, again, safely, with high efficacy, is to do sterile tubal blockage for pregnancy prevention. In this era that we're all living in, with the amount of obesity and overweight that we see and the number of people with multiple abdominal surgeries, sometimes the quick, like you said, Mark, all the tubal ligation is so simple, but sometimes there's bad anatomy in there and injuries.
I think if we could conquer the fallopian tube consistently for sterilization as an office-based procedure, much like vasectomy. When I was doing Essures, patients would get up and go back to work and activities, and all that. They didn't have to take a day off. I hope that a company will really develop the right protocols, the right instrument, in order for this to happen, and I think if we can get trained for that. The AI part, perhaps a pattern recognition for hyperplasia, malignancy, the current RF things that we're doing is trans-cervical myomectomies, but that's really for intramural fibroids. It's not for the cavity.
You know what I'm saying? That's the Sonata procedure. Then the laparoscopic approach, the RF energy, is an Acessa procedure. I think for any program that, and which I'm happy to say we started, I started with the interventional radiologists in the early 90s as a collaborative practice. In fact, Amy Parks, we have a paper when she was a fellow on uterine fibroid embolization. That is a darn great procedure. The biggest side effect, and we're talking about 5 to 15% of patients, is that they could have intramural fibroids, but as the uterus contracts and gets smaller, these fibroids migrate into the intracavitary space, or you could potentially have a necrotic leiomyoma.
Programs that institutions that want to have a truly collaborative practice with an interventional radiologist, you need to have someone that's expert in hysteroscopy for those small cases where the fibroids could be two months to two years or longer where they prolapse and they end up with leukorrhea, they're dead, they're trying to slough off. I think that that's really important.
The other role for hysteroscopy is these big myomas that expel just naturally, these big vaginal myomectomies. In fact, we have just this month, our last fellow just published in Fertility and Sterility for this, I think it's this edition, a video that we did, this huge myoma. It was big. I have another one that was, so somebody said, "Do you want forceps?" It was 15 centimeters that I did a vaginal myomectomy on. You could pat yourself on the back, "Oh, my God, we got this out." You better close that uterus tight, put your hysteroscope in, and look again because there can be other intracavitary fibroids that then you pull out your resectoscope for.
I just think the sky's the limit for looking for leukorrhea, very common things that you can see, cancer, polyps. My mentor always said to speak about her case in her 70s, gynecologist, no bleeding but thought she had urinary incontinence. People think they have chronic BV. I'm thinking, I'm blocking the woman that's at Michigan. That's a big vulvar expert. She's asked for a couple of my slides.
Hope, yes, she's very good. People are like, "Linda, how do you get all these cases?" I said, "Listen to your patients. They keep coming in with discharge, you better look in that uterus. They don't always have to bleed." Like my mentor, huge mixed Mullerian sarcoma, never bled a minute, but she just thought, oh, she's older and she's just wet all the time. No. God willing, she's still here. She's one of my, at the Cleveland Clinic, as my personal sponsor back in the day. I just think about, oh, my God, I could have just written her off and said, go see your old guy. Was it weird? Just the way she described this leakage. That is another use for hysteroscopy.
My first book chapter that I did, whoever this reviewer is, "I've never heard of using a hysteroscope for leukorrhea." I feel like saying, "Well, you better start learning about it because it's very helpful." I said, "Please don't change this because that is an indication for using your scope." I think, Amy, the sky's the limit and we just need to be empowered organizations to purchase office-based procedures.
What's happening to gynecologists, even at the Cleveland Clinic, what is the complaint? We don't have enough block time, right? Can't add new doctors. Even our colleges are complaining about not enough block time. Why are we taking women to the OR for diagnostic purposes when you can just do a diagnostic in the office, right? Now, patients that are afraid, the trauma patients, yes, I will take them. Early on, my residents would say to me, "How come all your cases always have something in the uterus?" They go screw up with somebody else. Well, they're not doing diagnostic procedures in the office and you have a normal uterus. Those are the cases. Then you just put a Mirena in or you put them on birth control or something.
You can really be reassured about things. Another thing is all these women that come in with, "Oh, my IUD fell out once, twice, or three times." If you're thinking of using an IUD for contraception and for heavy bleeding, please look in that uterus before you put a thousand-dollar device in since it's not securely in there, malposition falls out. It also gives the patient by looking, they'll say, "Oh, I was told I could never have another IUD." Well, you could look at- I have so many pictures like a bow and arrow where somebody's forcefully put the Mirena or other devices and it's piercing through a big myoma. Of course, they're not going to get relief from their bleeding. You see what I'm saying?
I'm getting ready to do surgery in a couple of weeks and a woman that someone put an IUD in, Mirena, has been bleeding for one year, 20 to 30 days out of a month. You ask, Mark, well, what do people think? It's like, it was a no-brainer to me to say and she switched doctors in the city. Patient comes, I said, "I'm going to put a hysteroscope in. Your bleeding isn't better.” Big old fibroid, doing her surgery, I think, next week. Think beyond what the average doc is doing, okay? There is no downside. The risk of infection is low in the office, the risk of perforation, the risk of not being able to do it is so low. Why not look when there's something equivocal?
[Dr. Mark Hoffman]
I think we started with that. I think we can end with that. I think that's a great way to think about how to do better for our patients, to evaluate and treat uterine pathology with a hysteroscope. Dr. Linda Bradley, it's been an absolute pleasure having you on. It's always fun talking to you. I always learn so much, and I think our listeners are going to have to get out a pen and piece of paper and take notes from today's show. We're grateful that you were able to join us. Amy, it's always a pleasure getting to do this with you. Linda, thank you again for doing it, and we appreciate you coming on BackTable OBGYN.
Podcast Contributors
Dr. Linda Bradley
Dr. Linda Bradley is a professor of obstetrics, gynecology and reproductive biology with Cleveland Clinic in Ohio.
Dr. Amy Park
Dr. Amy Park is the Section Head of Female Pelvic Medicine & Reconstructive Surgery at the Cleveland Clinic, and a co-host of the BackTable OBGYN Podcast.
Dr. Mark Hoffman
Dr. Mark Hoffman is a minimally invasive gynecologic surgeon at the University of Kentucky.
Cite This Podcast
BackTable, LLC (Producer). (2023, September 21). Ep. 34 – Advanced Hysteroscopy [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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