Discussion
Decisions concerning any procedure under general anesthesia are less
easily made due to the associated comorbidities and higher risks among
women older than 70 years of age. The performance of a procedure in the
OR may also be affected by the unwillingness of the patient to undergo
general anesthesia when given the option, even at the cost of not
reaching a diagnosis.
Altogether, 194 (87.4%) patients in our cohort who were referred to
office hysteroscopy had a successful procedure. Our results showed a
success rate similar to the 74.5% success rate for office hysteroscopy
in postmenopausal women recently reported by Sauvan et
al4. Sousa et al., who used a hysteroscopic technique
similar to ours on 88 postmenopausal patients with genital bleeding,
reported similar failure rates of 17.8%5.
Endometrial sampling was generally less likely to be performed in the
office compared to the OR, but the fact that more than one-half of the
women in our cohort (58.6%) did have a biopsy taken during the office
procedure is of considerable diagnostic value for this age group. It is
important to emphasize that even incomplete procedures, which were much
more common in the office group than in the OR group, are of some value
in this age group, especially if a biopsy has been carried out. For
example, if a biopsy from a benign endometrial polyp is taken, the
patient and her physician would feel more confident about choosing a
conservative sonographic follow-up, thus avoiding a procedure under
anesthesia. With good medical practice becoming more and more tailored
to the individual needs of the patient, we should be aware of this
option for minimizing risks to the patient.
Bleeding and large or multiple findings were a leading cause of failed
or incomplete procedures in the office, while in the OR they limited the
procedure in only two cases. Bleeding in the uterine cavity limits the
operating viewing field during hysteroscopy, but this problem is
overcome in the OR by washing the uterine cavity continuously with an
irrigation flow pump using higher pressures than those used in the
office. This also serves to explain the significant difference in the
indications for which women were referred to the treatment options. More
women were referred to office procedures due to abnormal sonographic
findings, while more women with active PMB were referred to procedures
in the OR.
Our results revealed that cervical stenosis is not a contraindication
for office hysteroscopy. We managed to overcome cervical stenosis in
more than half of the patients who presented with it (32/54 cases,
59%). The techniques used in our clinic to contend with cervical
stenosis are either mechanical, including forcing pressure with the
hysteroscope or using scissors, or electrical by means of a bipolar
electrode for widening the orifice and penetrating through the fibrotic
tissue. Pretreatment with 25 mcg of vaginal estradiol in combination
with 400 mcg of vaginal misoprostol before the procedure can facilitate
passage of the hysteroscope through the cervical
canal6.
Malignancy was found in 30.9% of the patients who presented with PMB,
as well as in 7.3% of the patients who had no PMB. The pathological
results from the repeat hysteroscopy are striking. One-quarter (12/48)
of the samples retrieved from repeat hysteroscopy were abnormal. This
emphasizes the importance of pursuing a diagnosis. In selected cases of
a moderate-to-high index of suspicion, we do not favor a conservative
sonographic follow-up but rather recommend referring the patient
directly to a repeat hysteroscopy. It is noteworthy that malignancy was
detected in 6/36 (16.7%) of the patients who did not present with PMB
and who were referred to a repeat hysteroscopy.
The volume of procedures in the office increased 16 times during the
study period, and a higher percentage of malignancies was diagnosed
compared to office procedures (Figure 1B ). These trends are the
result of a newly implemented technique in our institution, and also of
a change of clinical practice of referring women to the office option as
a first-line procedure. Once the refined biopsy-taking technique was
implemented, no significant change in yield was observed during the last
three years of the study, indicating that the technique is relatively
quickly and easily learned and put into practice.
The most compelling advantage of office hysteroscopy compared to OR
hysteroscopy in this cohort is the absence of complications in the
former and the rate and severity of complications in the latter,
including ICU hospitalization, sepsis, abdominal operation, and two
mortalities related to the OR hysteroscopy procedure. A similar recent
publication on office hysteroscopy in postmenopausal women also did not
observe any complications, such as uterine infection, uterine
perforation, or genital tract hemorrhage4.
Our study has several limitations. The main limitation is that the two
sub-groups were not matched for demographic and clinical characteristics
or for indications for undergoing the procedure. Also, we did not have
information on previous procedures that may have been performed outside
our medical center. It is likely that some patients with a history of
failure of a previous trial of office procedures were directly referred
to OR hysteroscopy. While our data are primarily descriptive, they
nevertheless suggest that office hysteroscopy for women over the age of
70 is safe, feasible, and reliable. Moreover, to the best of our
knowledge, this is the first study to compare office and OR hysteroscopy
for this age group. We believe that patient selection will improve with
greater application of office hysteroscopy and as more and more
physicians become aware of its advantages as well as its limitations.
This, in turn, will lead to higher rates of successfully completed
procedures and to higher rates of accurate pathological diagnoses in the
office setting. Further prospective trials are needed in order to
confirm our findings. Such studies may help to design a tool for better
patient selection for either office or OR hysteroscopy.