Vaginoscopy in Practice

The main difference for this team lay in the length of the procedure. Hysteroscopy and biopsy times were significantly shorter (more than 25% faster) with the vaginoscopic technique—a difference that Dr. Sharma and his colleagues said is important for patients who are anxious about the procedure (BJOG 2005;112:963–7).

In the other randomized study, in contrast, Dr. O. Garbin and his colleagues in France found that patients had significantly less pain with the vaginoscopic approach. Their randomization of 200 patients to conventional and 200 patients to vaginoscopic hysteroscopy—with no use of either anesthesia or premedication in either group—showed no differences in the quality, success, or duration of the exam but significant differences in patients' ratings of pain on a visual analog scale. Two cases of vasovagal syncope occurred in the group with traditional hysteroscopy.

Cervical passage was easier overall with vaginoscopic hysteroscopy, Dr. Garbin and his team reported, though the differences were not significant (Hum. Reprod. 2006;21:2996–3000). All of their procedures were performed using rigid single-flow hysteroscopes with an external sheath diameter of 3.5 mm.

The two randomized studies were quite different, and it's possible that Dr. Sharma's study lacked sufficient power. Certainly, it was more complicated with its use of two different hysteroscopes and the frequent use of anesthesia. Interestingly, Dr. Garbin and his colleagues addressed the issue of pelvic infection and pointed out that their procedures began with disinfection—something that was not mentioned in either Dr. Bettocchi's or Dr. Sharma's reports but is a practice that we do routinely.

All told, what I've taken away from the literature thus far is that the vaginoscopic approach to hysteroscopy is superior in terms of patient tolerance and can be quicker—without any impairment in cervical passage or visual quality.

In Practice

I first prep the vagina and the cervix with a small-diameter swab dipped in Betadine (povidone-iodine), or an alternative if the patient has an allergy to iodine. I use normal saline as a distention medium, so each patient is positioned on an under-buttocks drape to catch fluid. A 1,000-cc normal saline bag inserted in a pressure bag is hung on a tall IV pole with standard IV tubing.

I tell patients in preprocedure counseling that the use of saline and distention of the uterine walls usually causes some cramping but that ibuprofen or Celebrex (celecoxib) can minimize this cramping. I show them the diameter of the hysteroscope, which often helps alleviate any anxiety. In rare cases, if a patient is very anxious and worried about her tolerance for the procedure, or if the procedure is expected to be unusually long, I will prescribe Valium (diazepam). Usually such patients are young and have never experienced a gynecologic procedure before. In practice, however, I have almost never needed to use any local anesthetic.

I do premedicate patients—especially nulliparous patients and postmenopausal patients with stenotic cervices—with Cytotec (misoprostol) to facilitate an easier entry of the hysteroscope into the cervix.

I use a 3-mm single-flow rigid hysteroscope for diagnostic purposes and can quickly add the operative sheath, making the hysteroscope a 5-mm operative rigid hysteroscope, when I need to perform a minor procedure. If I anticipate performing a procedure, I will directly enter with the 5-mm hysteroscope. I prefer using the Bettocchi hysteroscope system (Karl Storz Endoscopy-America Inc.) because of its oblong shape that, when rotated horizontally with the light cord, easily slips into the slit-shaped external cervical os.

Rigid hysteroscopes have a camera lens angle of 0–30 degrees. I most often use scopes with a 30-degree angle to optimize visualization with minimal manipulation. With this angle, the hysteroscope can be brought to the midline of the uterine cavity and simply rotated about 90 degrees to the left or right with the light cord without much movement of the hysteroscope to visualize the cornu.

In contrast, visualizing the cornu with a 0-degree scope would require manipulation of the entire hysteroscope, potentially increasing patient discomfort. A 12-degree scope offers similar advantages to the 30-degree scope, and either one can be chosen based on physician familiarity and preference.

After placing the hysteroscope into the lower vagina, I guide it into the posterior fornix of the vagina so that I know I'm at the end of the vaginal canal. Then, I slowly pull back while observing anteriorly and visualizing the external cervical os. I then introduce the hysteroscope through the cervical os, and based on an understanding of the anatomy and the scope's angled view, I guide the hysteroscope through the endocervical canal and into the uterus. If I am not getting good distention of the vaginal walls, I will gently pinch the labia together to minimize fluid leakage.