Menstrual Disorders, Fibroids & Polyps

“See and Treat Hysteroscopy”

SATH for post-menopausal bleeding

In the management of post-menopausal bleeding many practitioners offer one or more diagnostic tests before initiating treatment.  Specifically, women often undergo an ultrasound examination followed by a sonohysterogram (SHG).  The sonohysterogram (SHG) provides a significant amount of information regarding the presence or absence of endometrial polyps.  The SHG is often accompanied by an endometrial biopsy—both tests can be uncomfortable and occasionally painful.  Some practitioners perform the endometrial biopsy as part of a separate office visit to the SHG causing women to undergo 2 visits for “testing” before initiating treatment.

If the SHG reveals a polyp (or fibroid) the woman generally returns for a separate procedure, done in an outpatient setting, to remove the abnormality.  This is a common scenario today inasmuch as the diagnostic phase and the treatment phase of the patient’s management are separated—causing the patient to undergo at least 2 separate procedures.

sonohysterogram
Sonohysterogram View

However, these separate procedures can be combined.
This is possible for 3 reasons:

1. The advent of small diameter hysteroscopes now makes sonohysterograms unnecessary.  SHG was once considered to be less invasive than hysteroscopy because the diameter of the catheter used for SHG was once much smaller than the diameter of a hysteroscope. However, this is no longer the case.

Hysteroscopes have become smaller and smaller making them very suitable for office used—and they supply far more information (see diagnostic hysteroscopy) than SHG.

For instance, compare the appearance of an endometrial polyp on this sonohysterogram to its appearance at hysteroscopy:

hysteroscopy shows 2
Hysteroscopy View

Notice how the hysteroscopy shows that there are actually 2 of them!

2. The use of office-based intravenous sedation that allows these procedures to be safely and painlessly performed.  Because we practice in an accredited office-based surgical setting we can offer pain control for a diagnostic or operative intervention to appropriate candidates.

3. The advent of small diameter operative hysteroscopes.  With today’s small-diameter instruments and the use of intravenous sedation it is often possible to remove polyps and many fibroids at the time of the diagnostic procedure.

The fact is that we are often able to combine the diagnostic and the treatment phases of managing abnormal uterine bleeding.

Here is a common example:

ultrasoundA 58 year old mother of 4 experiences 2 days of postmenopausal bleeding.  An ultrasound examination reveals a “thickened” uterine lining (endometrium).

This is what a thickened uterine lining looks like—it’s the light grey area between the blue arrows. 

The possibilities include one or more endometrial polyps or just a symmetrically thickened lining.  The patient has consent to undergo a “see-and-treat” hysteroscopy.
At the time of her hysteroscopy she is found to have –count them—5 endometrial polyps!

5 polypsNote that there are actually 5 polyps seen here. 

Because the patient and I had already discussed this possibility she had consented to have all of the polyps and her uterine lining removed—to prevent the recurrence of her polyps.

Summary

polyps“See-and-Treat-Hysteroscopy” is not a universal treatment for all causes of postmenopausal bleeding.  However it is an option for many women who are properly informed and who are appropriate candidates for this approach to both diagnosis and management.

mult endometrial polypsThe wonderful advantage of SATH is that at the end of the procedure issues such as polyps have been addressed—they’ve been visualized, identified, removed and (hopefully) prevented from recurring.

Here’s what a specimen looks like when we’re done.