Embracing Hysteroscopy

With an estimated 90 percent of hysterectomies performed for non-life-threatening indications, including uterine fibroids and uterine bleeding, Cleveland Clinic gynecologist Linda D. Bradley, MD, Director of the Fibroid and Menstrual Disorders Center and Director of Hysteroscopic Services, is an outlier.

To effectively reduce the need for hysterectomies, Dr. Bradley champions the use of hysteroscopy for the evaluation of patients with abnormal menstrual periods, infertility, recurrent miscarriage, retained products of conception, endometrial polyps, intrauterine fibroids, abnormal bleeding and, in some cases, abnormal Pap results. Over time, she has convinced her colleagues in the Ob/Gyn & Women’s Health Institute to carry the hysteroscopy banner and is now urging others to do the same.

Scopes in many practices

“Urologists use cystoscopes to investigate urinary tract bleeding with hematuria. Pulmonologists use bronchoscopes on patients who are coughing up blood. An orthopod will use an arthroscope to look inside a painful knee. Yet gynecologists have not fully embraced hysteroscopes like other specialties have for symptomatic problems,” says Dr. Bradley, who is also institute Vice Chair.

“My hysteroscope is my stethoscope!” she adds.

Hysteroscopy offers multiple benefits for physicians and patients alike.

“Hysteroscopy can be a comfortable, office-based, economically wise technique for taking a look that offers the best use of time and resources. It enables me to evaluate endometrial health and then plan the appropriate surgical procedure or make a referral,” she says.

Hysteroscopic image of two submucosal fibroids. A 46-year-old woman presented with incessant vaginal bleeding. After undergoing a brief outpatient hysteroscopic myomectomy, her menstrual cycles returned to normal.

Typical hysteroscopy cases

Dr. Bradley generally performs six to 10 office hysteroscopies per week. Typical patients may include:

• A 45-year-old woman with irregular, but heavy bleeding. If no polyps, submucosal fibroids or endometrial hyperplasia are found, the patient could be treated medically.
• A patient with heavy menstrual bleeding. If a fibroid or fibroids are seen, the size, number and location will help determine what technology will be needed for surgery and estimate surgical duration.
• A 48-year-old with abnormal bleeding. Biopsies can miss cancerous lesions involving less than 5 to 25 percent of the uterine cavity; hysteroscopy will detect even small lesions.
• A patient who miscarried and continues to bleed after a D&C. Even small placental remnants can cause bleeding for weeks or months. “I have found placental remnants in a 70-year-old,” Dr. Bradley notes.
• An asymptomatic 30-year-old who cannot get pregnant. An asymptomatic fibroid or endometrial polyp may be filling the uterus and preventing pregnancy.

Dr. Bradley also advocates using operative hysteroscopy to remove submucosal and endometrial polyps. “Operative hysteroscopic myomectomy provides excellent outcomes, has low risk of complications and preserves fertility,” she says.

A thorough review of the procedure coauthored by Dr. Bradley was published in Clinical Obstetrics and Gynecology.

“There are so many reasons to make hysteroscopy part of your armamentarium,” she says.