James B. Presthus, MD

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Imagine your practice transformed into one that offers a full spectrum of office-based procedures. It isn't difficult to do. What it takes is a commitment to seeing it through. Making that transition easier is the wealth of medical knowledge, excellent training opportunities, and affordable state-of-the-art equipment that's out there. Not to mention appropriate third-party reimbursement along with support from experienced colleagues, professional societies, and industry. The confluence of these factors almost ensures that if you're willing to make the effort, you will be rewarded with a very satisfying and successful office-based practice.  

Why aren't more ob/gyns performing office-based hysteroscopy?

 Most ob/gyns already offer some in-office procedures such as colposcopy with biopsy, endometrial biopsy, LEEP, IUD insertions and removals, and ultrasound. We wouldn't consider routinely moving these procedures out of our offices to a hospital. Yet it's estimated that only 15% of gynecologists currently perform office hysteroscopy and fewer than 5% are offering their patients hysteroscopic sterilization and global endometrial ablation (GEA) in the office.

I already have ultrasound. Isn't that enough?

 Up until menopause, roughly 20% or more of all gynecologic visits are for abnormal uterine bleeding (AUB).

 A typical patient is often evaluated with an endometrial biopsy and then treated with hormones. An office endometrial biopsy is effective at diagnosing diffuse disease such as hyperplasia and carcinoma but will often miss a focal lesion-like endometrial polyps and fibroids. Yet these types of focal lesions are often the cause of AUB. A woman with an intrauterine defect usually won't respond to hormonal therapy so she returns to the office for further evaluation, usually an U/S. If U/S identifies an endometrial polyp or intracavitary fibroid, she's scheduled for outpatient surgery. Assuming the surgery is successful, she is now adequately treated. This scenario takes place over several months. The woman has had at least two office visits and an outpatient hospitalization. She's undergone three invasive procedures: endometrial biopsy, vaginal U/S, and surgical removal of the intrauterine pathology-a considerable investment in time, money, and frustration. 

U/S may be the workhorse of a busy ob/gyn's office, but hysteroscopy is the gold standard for evaluating AUB. Consider U/S and diagnostic office hysteroscopy as complementary, not exclusionary procedures. Hysteroscopy has been shown to have a sensitivity of 100% and a specificity of 95% in evaluating the uterine cavity.

  Transvaginal ultrasound (TVUS) and saline infusion sonography (SIS) improve the sensitivity and specificity of detecting intracavitary lesions and provide global assessment of uterine and adnexal architecture. SIS has a comparable positive predictive value for detecting intracavitary myomas and polyps. Proponents of SIS will list the cost of outpatient hysteroscopy, patient comfort, and need for anesthesia as reasons to choose SIS.

  However, office hysteroscopy is cost-effective and well tolerated.

  It also allows you to "see and treat" at the same time.

 It's the lack of office hysteroscopy equipment that causes many physicians to use only U/S and endometrial biopsy to evaluate AUB. The combination of U/S and hysteroscopy allows for the most complete investigation. 

Articles

What's holding you back? Cost? Worries about managing pain or complications? An expert debunks common excuses for not doing more office-based procedures and explains why you need both U/S and diagnostic hysteroscopy-and the rewards you can reap from taking your practice in this direction.

Author | James B. Presthus, MD

Articles

Office-based hysteroscopy: getting started now