Gynecologic surgeons are getting good reimbursement rates for office hysteroscopy, and patients appreciate the convenience of having hysteroscopic evaluations done more quickly and comfortably in an office with which they are familiar.
As commitments to office-based surgery expand, it seems logical and important for physicians to become familiar with—and consider adopting—a less-invasive approach to hysteroscopy. The vaginoscopic technique for hysteroscopy—sometimes referred to as a no-touch approach—avoids the use of a vaginal speculum and cervical tenaculum. It is an easier and quicker procedure for the surgeon, provides equally good visualization, and most importantly is even more tolerable for patients than the traditional approach that utilizes instrumentation.
Without placing a speculum in the vagina, grasping the cervix with a tenaculum, or injecting a paracervical block, I have seen a significant decrease in discomfort among my patients. I use minimal premedication and rarely use any local anesthetic. In addition to diagnosing and evaluating the uterine cavity, I can perform minor therapeutic and operative procedures such as removing polyps, lysing adhesions, obtaining biopsies, removing lost intrauterine devices, and occluding the tubes using the Essure sterilization system.
With patients tolerating the procedure even more than they would a traditional hysteroscopy, we have the opportunity to increase the possible applications of hysteroscopy, to do more during the procedure, and to advance hysteroscopy even further as a successful in-office procedure that is part and parcel of our diagnostic and therapeutic armamentarium.
Vaginoscopy has been described in the literature as far back as the 1950s and continues to be used for diagnosing vaginal endometriosis, pelvic floor mesh erosions, vaginal fistulas, and cervical pathology, for example, as well as excising vaginal lesions or longitudinal vaginal septums. It has also been utilized in the pediatric/adolescent population for visualizing and removing foreign bodies, and for evaluating pelvic trauma, abnormal bleeding, and infection.
Dr. Stefano Bettocchi and Dr. Luigi Selvaggi in Italy were the first, however, to describe the utilization of a vaginoscopic approach to office hysteroscopy for evaluating the endocervical canal and uterine cavity in addition to the vagina and external cervical os. In a paper published in 1997 in the Journal of the American Association of Gynecologic Laparoscopists (4:255–8), they described various approaches they took to improve patient tolerance during the 1,200 diagnostic hysteroscopies they performed between 1992 and 1996.
The first 49 procedures were done using the speculum and tenaculum but without local anesthesia. The investigators saw high rates of discomfort (53%), moderate pain (25%), and severe pain (20%), as well as two cases of serious vagal reactions.
They then began using local anesthetic (mepivacaine 2%) but found that, while it helped some of the women, many of them continued to have discomfort or pain. In the next 169 cases, 69% had discomfort or mild pain, 11% had moderate pain, and 8% had severe pain resulting in suspension of the procedure (again, including two women who had vagal reactions requiring medical assistance).
Dr. Bettocchi and Dr. Selvaggi then decided to use the speculum to visualize the cervix but not place the tenaculum. They did not use any anesthesia with this group of 308 women. Their patients' pain levels started decreasing quite a bit, with 66% of these patients reporting no complaints. Cases of severe pain disappeared completely.
They then took it a step further to deal with the remaining causes of pain (32% had reported mild pain and 2% had reported moderate pain) and utilized the vaginoscopic approach. In these last 680 procedures—in unselected patients, both multiparas and nulliparas—the patients had a 96% no-discomfort rate. By not using the speculum and tenaculum to expose and grasp the cervix, the investigators nearly eliminated patient discomfort while still performing effective hysteroscopy.
Since this landmark report, several teams that have adopted a vaginoscopic approach to hysteroscopy have reported good results, and at least two teams among those I reviewed in the literature have conducted randomized prospective studies.
Dr. M. Sharma and his team in London randomized 120 women to undergo either traditional hysteroscopy or vaginoscopic hysteroscopy (60 women in each group)—with a further breakdown into the use of a 2.9-mm and a 4-mm hysteroscope. The investigators reported an overall success rate of 99%. They used the need for local anesthesia as a primary outcome measure. Although they reported lower requirements with the vaginoscopic approach using the narrower hysteroscope, they found that overall, there was no significant difference in the use of local anesthesia among the groups. There also were no statistically significant differences in pain scores between the two techniques.