Adam Magos

2500 Outpatient diagnostic hysteroscopies

Objective To evaluate the feasibility and acceptability of outpatient diagnostic hysteroscopy. Methods The outcome of 2500 consecutive outpatient hysteroscopies was analyzed. Cervical dilation was performed when necessary and local anesthesia was not administered routinely. Endometrial biopsy and minor hysteroscopic procedures were carried out when indicated. Findings and outcome were compared according to patient characteristics. Results The most common indication for hysteroscopy was abnormal uterine bleeding (87%). Hysteroscopy was performed successfully in 96.4%, and a complete view of the uterine cavity was obtained in 88.9%. Local anesthesia was used in 29.8% and was associated with the need for cervical dilation; both local anesthetic use and cervical dilation were significantly more often required in nulligravid, nulliparous, and postmenopausal women. Intrauterine pathology was diagnosed in 48%, the highest incidence being found in those 50–60 years old (53.7%). The presence of fibroids was the most common abnormality (24.3%) but was seen in only 6.8% of women older than 60 years. Conversely, the incidence of endometrial polyps increased with age, up to 20.5% in women over 60 years. Endometrial biopsy was performed in 68% and produced adequate tissue for histologic examination in 83.7%. Endometrial hyperplasia or carcinoma was detected in 1%. One hundred sixteen women (4.6%) underwent a minor hysteroscopic procedure. Conclusion Outpatient diagnostic hysteroscopy is both feasible and acceptable in the overwhelming majority of cases, with a high detection rate for intrauterine pathology. This procedure may become as routine in the 21st century as D&C has been in the 20th.

Endometrial resection for the treatment of menorrhagia

BACKGROUND Endometrial resection is an alternative to hysterectomy in the treatment of women with menorrhagia, but it may not control the condition. We sought to evaluate the effectiveness of such resection. METHODS We followed 525 consecutive women (mean age at initial surgery, 42 years) for up to five years after endometrial resection. The women were examined 6 to 12 weeks after the operation and were then sent yearly questionnaires seeking information about their condition. The mean duration of follow-up was 31 months. Thirty-seven women (86 percent of the 43 women available for five years of follow-up) were followed for the entire period. RESULTS Endometrial resection was completed successfully in 95 percent of the women, with operative complications in 6 percent. Forty-eight women underwent subsequent resection. The yearly questionnaires indicated that 85 to 100 percent of the women (depending on the year of follow-up) had adequately controlled menorrhagia, 26 to 40 percent had amenorrhea, 71 to 80 percent reported either a lessening of menstrual pain or no pain, and 79 to 87 percent were satisfied with the results of their surgery. No further surgery was needed by 80 percent of the women, and only 9 percent underwent hysterectomy during the five years of follow-up, with 98 percent of those operations being performed in the first three postoperative years. CONCLUSIONS Endometrial resection is an effective alternative to hysterectomy in women with menorrhagia.

Treatment of the premenstrual syndrome by subcutaneous estradiol implants and cyclical oral norethisterone: placebo controlled study.

The hypothesis that the many non-specific changes normally associated with cyclical ovarian activity are the primary aetiological factors in the premenstrual syndrome was tested by suppressing ovulation with subcutaneous oestradiol implants. Sixty eight women with proved premenstrual syndrome were treated under placebo controlled conditions for up to 10 months in a longitudinal study. Active treatment was combined with cyclical oral norethisterone to produce regular withdrawal periods. Symptoms were monitored with daily menstrual distress questionnaires, visual analogue scales, and the 60 item general health questionnaire. Of the 35 women treated with placebo 33 improved, giving an initial placebo response rate of 94%. The placebo effect gradually waned, but the response to the active combination was maintained for the duration of the study. Analysis of the prospective symptom ratings showed a significant superiority of oestradiol implants over placebo after two months for all six symptom clusters in the menstrual distress questionnaire. Changes seen in the retrospective assessments were less significant but the trend was the same. Treatment with oestradiol implants and cyclical progestogen was well tolerated and appears to be both rational and effective for severe cases of the premenstrual syndrome.

Vaginal hysterectomy for the large uterus

Objective To assess the feasibility and safety of performing vaginal hysterectomy on enlarged uteri the equivalent of 14 to 20 weeks of gestation in size.

Transcervical resection of endometrium in women with menorrhagia.

As an alternative to hysterectomy 16 women with menorrhagia were treated with hysteroscopic transcervical resection of the endometrium with an unmodified urological resectoscope. Twelve patients requested total resection of the endometrial lining with the intention of producing amenorrhoea, and four chose partial resection and hypomenorrhoea. Surgery was completed successfully in 15; the remaining woman, who had an acutely retroflexed uterus, sustained a uterine perforation during insertion of the rigid hysteroscope. There were no important postoperative complications, and 13 patients were discharged from hospital the day after operation. Follow up for up to six months showed beneficial effects on the duration of menses and the subjective assessment of menstrual blood loss and pain in the treated women, six of them becoming amenorrhoeic after total resection. Hysteroscopy at three months in 13 patients showed fibrosis confined to the upper half of the uterine cavity. Endouterine biopsy specimens showed the presence of microscopic deposits of normal endometrium in 10 women. Although these results are preliminary, transcervical resection of the endometrium may have an important role in managing this common complaint.

Long term follow up of hysteroscopic myomectomy assessed by survival analysis

Objective To identify patient characteristics which affect outcome after hysteroscopic myomectomy for submucous fibroids.

Lignocaine aerosol spray in outpatient hysteroscopy: a randomized double-blind placebo-controlled trial

OBJECTIVE To assess the efficacy of lignocaine spray during outpatient hysteroscopy in reducing the need for additional anesthesia and reducing the discomfort of the procedure. DESIGN A randomized double-blind, placebo-controlled trial. SETTING An undergraduate university teaching hospital in London. PATIENT(S) One hundred twenty patients undergoing outpatient hysteroscopy. INTERVENTION(S) Application of lignocaine spray to the cervix, cervical canal, and uterine cavity during outpatient hysteroscopy. MAIN OUTCOME MEASURE(S) The need to use additional anesthesia and the pain experienced at various steps of the procedure. RESULT(S) Women treated with active spray experienced significantly less pain when the cervix was grasped with a tenaculum at the start of hysteroscopy. There were no other significant differences in the outcome of hysteroscopy between the placebo and lignocaine groups, although there was a significant reduction in the use of additional anesthesia in both groups compared with historical controls. CONCLUSION(S) Lignocaine spray has beneficial effects on cervical but not uterine sensation. Pretreatment with either lignocaine or placebo seems to reduce the need for additional intracervical anesthesia during hysteroscopy.

Randomised placebo controlled trial of mefenamic acid for premedication at outpatient hysteroscopy: a pilot study

An increasing number of diagnostic hysteroscopies are being performed in an outpatient setting. Most women tolerate the examination well, but die single commonest reason for failure is pain. We assessed the efficacy of a nonsteroidal, anti‐inflammatory analgesic as premedication before hysteroscopy in a double‐blind, placebo controlled trial. Our results showed that 500 mg mefenamic acid given one hour before hysteroscopy had no significant benefit in the discomfort experienced during the procedure but did signficantly reduce pain after hysteroscopy. A larger dose or a longer interval between premedication and hysteroscopy may possibly be associated with greater benefits.

A prospective study to evaluate oophorectomy at the time of vaginal hysterectomy

Objective To assess the feasibility and safety of vaginal removal of ovaries at the time of vaginal hysterectomy.

Comparison of carbon dioxide and normal saline for uterine distension in outpatient hysteroscopy

OBJECTIVE To evaluate patient acceptance and the clinical feasibility of carbon dioxide compared with normal saline for uterine distension in outpatient hysteroscopy. DESIGN Prospective, randomized clinical trial. SETTING Outpatient hysteroscopy clinic in a university hospital. PATIENTS One hundred fifty-seven patients undergoing outpatient hysteroscopy. INTERVENTIONS Outpatient hysteroscopy was performed with carbon dioxide or normal saline with endometrial biopsy when indicated. MAIN OUTCOME MEASURES Need for local anesthesia, cervical dilatation, view of uterine cavity, need to change from carbon dioxide to normal saline distension, procedure time, patient discomfort (lower abdominal pain, shoulder tip pain, nausea) and complications. RESULTS Carbon dioxide was used for uterine distension in 79 women and normal saline was used in 78. Cervical dilatation was required more often with carbon dioxide hysteroscopy, although there was no increased requirement for local anesthesia. Hysteroscopic vision was similar between the two media, but eight carbon dioxide cases had to be converted to liquid distension. Procedure times were significantly longer for carbon dioxide hysteroscopy as was the occurrence of bubbles during the procedure. Lower abdominal pain and shoulder tip pain were significantly worse with carbon dioxide distension. Although the incidence of nausea and vomiting was higher with the use of carbon dioxide, the differences did not achieve statistical significance. CONCLUSION The use of normal saline for uterine distension had no adverse affects on the hysteroscopic view. It provided a shorter operating time and was well accepted by patients. Because of its easy availability and low cost, normal saline is an excellent alternative to carbon dioxide in women undergoing outpatient hysteroscopy.