Advantages of vaginohisteroscopy

Vaginohysteroscopy does not have a statistically significant difference compared to intraoperative hysteroscopy in terms of efficacy, sensitivity, and specificity in the detection of intrauterine lesions⁹. It omits the risks of anesthesia, reduces recovery times, provides greater convenience and profitability for patients, and reduces work permits^8,9. This has led to the current trend towards performing most hysteroscopic procedures in the office.

Vaginohysteroscopy and ultrasound

Ultrasound is very effective in evaluating intramural and extramural uterine disease, such as type III-VII fibroids and ovarian pathologies. It also has good sensitivity and specificity in the diagnosis of endometrial pathologies and, if supplemented with saline infusion, the sensitivity and specificity increase from 89% and 56% to 91.8% and 60%, respectively. Despite these results, vaginohysteroscopy remains the gold standard with sensitivity and specificity of 97.3% and 92%, respectively¹⁰. It allows the identification of endometrial pathologies such as sub-mucosal fibromas and small polyps located in the isthmic and cornual cervix¹¹, as well as the uterine synechiae that are difficult to identify by ultrasound. Its higher sensitivity and specificity differentiate it from the rest of the less invasive indirect imaging methods, such as transvaginal ultrasound, hysterosalpingography (HSG) and hysterosonography. Vaginohysteroscopy allows direct vision and resolution or taking targeted biopsies of pathologies¹².

Vaginohysteroscopy in gynecology

The utility of vaginohysteroscopy in the gynecological area is evident in the study and treatment of bleeding in menopausal patients, dysfunctional bleeding, confirmation of ultrasound images that suggest endocavitary pathology such as fibroids, polyps, endometrial thickening and other, with the possibility of correction of these in up to 70% of cases in a single procedure, "see and treat principle" ¹³ (Figure 3). Based on this, the United Kingdom’s National Institute of Health and Clinical Excellence, NICE, has promoted a radical paradigm shift in the diagnosis of abnormal genital bleeding (HMB), reflected in its NG88 guideline ¹⁴ published in late 2018. Indicate vaginohysteroscopy in women with HMB if their history suggests submucosal fibroids, polyps or endometrial pathology, displacing ultrasound as a first-line procedure in the diagnosis of these pathologies. This change is based on the fact that vaginohysteroscopy provides more precise diagnoses and treatments, making it a more profitable tool for health policy. Another utility is the extraction of intrauterine devices whose threads are not evident through the external cervical os. This significantly reduces the risk of uterine perforation or rotation of the same by blind maneuvers.

Figure 3 longitudinal section of the uterus. (a) at the fundus of the endometrial cavity, there is a slight increase in echogenicity. (b) a vaginohysteroscopy is performed, showing uterine synechia in the left horn. (c) excision of the same with blunt tip scissors. (d) the normal endometrial cavity can be seen after treatment 

Vaginohysteroscopy in infertulity

The uterus plays a fundamental role in human reproduction. Pathologies such as polyps, endometritis, intrauterine synechiae, isthmocele, leiomyoma, Müllerian anomalies, among others, can compromise implantation and placentation, producing a negative impact on fertility. These pathologies can be found among 40-50% of infertile women and constitute 6-11% of the causes of infertility¹⁵. Hence the importance of ensuring a suitable uterine cavity to achieve a healthy child at home. As a valuable tool, hysteroscopy has been gaining importance over the years, which is expressed in the phrase of Dr. Linda Bradley “the hysteroscope should be considered the stethoscope for the uterus”^16).

At present, the role of hysteroscopy in the treatment of endometrial pathologies is not in dispute, regarding its usefulness in improving reproductive results in relation to ultrasound or saline infusion ultrasound. Despite the number of publications confirming its importance, there are two recent trials, inSIGHT¹⁷ and TROPHY¹⁸, that have not shown benefit with the use of hysteroscopy. However, these studies had several limitations that may affect their generalizability. The fact is that robust and high-quality randomized clinical trials are needed before hysteroscopy can be considered a first-line procedure in all infertile women¹⁹. However, we cannot ignore the advantages of examining most endometrial cavity under direct vision and the possibility of taking biopsies or solving most endometrial pathologies in the same surgical act, factors that speed up time and reduce costs in the processes of fertility.

Hysteroscopy in obstetrics

Hysteroscopy also has its place in obstetrics. Hysteroembryoscopy is performed in pregnant women with embryos without cardiac activity, allowing to obtain selective samples of embryonic tissue under direct vision, reducing the risk of contamination by maternal cells²⁰. A more precise view of the external morphology of the embryo is obtained and diagnoses of morphological alterations can be made or diagnostic suspicions confirmed (Figure 4), which are extremely difficult due to do when tissue is destroyed by manual vacuum aspiration or uterine curettage.

Figure 4 ultrasound of a 17.3 mm embryo without cardiac activity. (a) image suggestive of alteration in the cephalic pole. (b) vaginohysteroscopy shows a bicephalic embryo, confirming the suspicion by ultrasound. 

Means of distension

As the endometrial cavity is a virtual concavity, it requires a means of distension that allows the separation of the uterine walls for its hysteroscopic evaluation. These media can be gaseous, such as carbon dioxide (CO2), electrolyte-free solutions, such as glycine, sorbitol and mannitol, or electrolyte solutions, such as sodium chloride. The choice of the means of distension will depend on the type of energy used. Thus, when using monopolar energy, one of the electrolyte-free solutions is used; if mechanical, bipolar or laser energy is applied, electrolytic solutions are used²², noting that the latter have proven to be the most comfortable and safest means of distension²³ by reducing the risk of hyponatremia and vasovagal episodes¹² and allow a greater differential between the volume of distention medium entering and leaving the endometrial cavity; this can reach 2 500 mL in patients under 50 years of age without other pathologies⁸, resulting into longer operative time and resolution capacity.

Factors committing the success of vaginohysteroscopy

Although officinal hysteroscopy is a relatively simple procedure and very well tolerated by patients, between 5 and 15% may present pain of moderate to strong intensity, and around 5% will present a failed access to the uterine cavity, being the main causes cervical stenosis or pain (6). This can lead to the fact that, despite its great advantages, there is a group of patients and gynecologists who are not convinced by vaginohysteroscopy in an outpatient setting.

To try to identify this group of patients who have a higher risk of pain and failed hysteroscopies, it is very important to make an adequate selection and identify risk factors, such as cervical stenosis, menopause, poor visualization of the cervix, absence of vaginal delivery, as well as reinforcing the elements that serve as pain protectors, such as the experience of the operator, surgical time and the diameter and type of equipment used ²⁴. Another important element is to reduce the anxiety of the patient with an adequate explanation of the method before its performance, about the procedure, its advantages, disadvantages, scope and limitations. Based on complete information, you can make a conscious decision whether to have vaginohysteroscopy without or with anesthesia, along with a pleasant environment and constant communication of the hysteroscopist and the patient during the procedure⁶. These are factors that can contribute to the success of the procedure.

Vaginohisteroscopy in times of covid 19

This year 2020, due to the situation caused by COVID-19, there have been important changes in medical practice. Although information on this virus is still under study, there is evidence of possible viral shedding during minimally invasive gynecological procedures, due to the presence of the virus in the blood, feces and aerosolization of the virus, especially when using smoke generating devices¹² and in procedures that require intubation that generate aerosol (AGP). One of the advantages of vaginohysteroscopy is that it is not aerosol-generating and that it allows the option of using mechanical energy, such as scissors and graspers, so the risk of transmission is theoretically low or negligible. These characteristics make vaginohysteroscopy an excellent alternative for the treatment of most endometrial pathologies in this era of COVID-19.

A few months ago the consensus statement of the Global Congress of Hysteroscopy²⁵ was published, in which related recommendations are offered, such as performing adequate triage of the patient, considering requesting the preoperative COVID-19 test -in our case, it is requested per protocol to all patients the days before the procedure in the office-, limit hysteroscopic procedures to those patients in whom their delay could lead to adverse clinical results, minimize the number of people participating in the procedure, favor the use of instruments that do not produce surgical smoke -such as scissors, forceps and tissue recovery systems, as well as the respective decontamination measures after each procedureand the use of appropriate personal protective equipment.