Pantaleoni first performed hysteroscopy in 1869, but it was not until the early 1970s that hysteroscopy became part of the gynecologist's armamentarium. The need for visual appraisal of the endocervix and endometrial cavity and technical advances in instrumentation increased the awareness of, and interest in, the advantages of hysteroscopic sterilization techniques. During this time, it was widely documented that hysteroscopic sterilization techniques generally were done in office settings. However, diagnostic hysteroscopy was usually done along with dilatation and curettage (D&C) in the operating room. It was this "marriage" of performing diagnostic hysteroscopy with the D&C that obscured the ease and value of office hysteroscopy.Challenges to the D&C Procedure
Until recently most gynecologists have relied on the D&C as both a therapeutic and diagnostic tool for abnormal uterine bleeding. This was despite the fact that there has been no published evidence indicating any therapeutic value gained from the procedure. Indeed, numerous articles have reported on the inaccuracies of this blind procedure, suggesting that D&C is not the best method for diagnosing endometrial pathology. The primary advantage of the D&C procedure is the ability to obtain a large tissue specimen for pathology. In contrast, hysteroscopy not only allows for providing tissue, but permits the gynecologist to choose selected areas for directed biopsy and identify polyps and submucous fibroids. The latter are routinely missed by blind procedures such as a D&C. However, in patients where an endometrial carcinoma or an ovulatory disorder may be the basis of bleeding, an endometrial biopsy (a procedure similar to a D&C) should always be considered prior to hysteroscopy. In these cases a positive diagnosis is meaningful. An endometrial biopsy, combined with a sonohysterogram, approaches the diagnostic accuracy of hysteroscopy and is frequently used in offices that are not able to perform hysteroscopy.
Diagnostic Hysteroscopy — Indications
The primary purpose of office hysteroscopy is to evaluate patients with abnormal uterine bleeding resistant to medical management or to perform a panoramic visualization of the uterine cavity. In addition, filling defects identified by ultrasound or hysterosalpingography can be confirmed or mapped by hysteroscopic visualization. Routine hysteroscopy in infertility cases has little benefit. Both pre- and postmenopausal patients are easily evaluated. A two-year review of my practice showed that 85% of all diagnostic hysteroscopies were accomplished in the office. The majority of the other 15% required concomitant laparoscopy, which was performed in a surgical setting. Only a few patients could not be done in the office, because they were too difficult to examine or were postmenopausal with a stenotic vagina.