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Is the Art of Hysteroscopy in jeopardy? A wake-up call

Nash S. Moawad MD, MS , Jose Carugno MD ,

PII: S1553-4650(24)00003-7
DOI: https://doi.org/10.1016/j.jmig.2024.02.006
Reference: JMIG 5183

To appear in: The Journal of Minimally Invasive Gynecology

Received date: 4 February 2024

Please cite this article as: Nash S. Moawad MD, MS , Jose Carugno MD , Linda D. Bradley MD , Is
the Art of Hysteroscopy in jeopardy? A wake-up call, The Journal of Minimally Invasive Gynecology
(2024), doi: https://doi.org/10.1016/j.jmig.2024.02.006

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© 2024 Published by Elsevier Inc. on behalf of AAGL.

Is the Art of Hysteroscopy in jeopardy? A wake-up call

Nash S. Moawad MD, MS1, Jose Carugno MD2, Linda D. Bradley MD3

1. Professor & Chief, Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology,

University of Florida College of Medicine, Gainesville, FL

2. Director, Minimally Invasive Gynecology Division, Department of Obstetrics and Gynecology, University of Miami

Miller School of Medicine, Miami, FL

3. Professor, Department of Obstetrics, Gynecology, and Reproductive Biology, Cleveland Clinic, Cleveland, OH;

Medical Director, The American Association of Gynecologic Laparoscopists (AAGL)

Corresponding Author:

Nash S. Moawad, MD, MS, FACOG, FACS

Professor & Chief

Division of Minimally Invasive Gynecologic Surgery

Department of Obstetrics and Gynecology

University of Florida College of Medicine

Gainesville, FL

[email protected]
Conflict of Interest Statement:

Nash S. Moawad, MD, MS

Consultant:

Medtronic, Inc

Integra Life Sciences, Inc

Jose Carugno, MD

No conflicts of interest to disclose.

Linda D. Bradley, MD

Royalties for book/book chapters:

Hysteroscopy has gained an important role in modern gynecology. It is the gold standard for

diagnosing and managing intrauterine pathology. Despite the tremendous diagnostic and

therapeutic capabilities of hysteroscopy, it remains widely underutilized. The first blind intra-

uterine procedures are attributed to Recamier in the 1840s (1). Despite the rocketing

technological advances in all aspects of life and particularly the medical field, techniques such

as blind endometrial biopsy, Dilation & Curettage, and the blind use of a polyp forceps inside the

uterine cavity are still pervasive in today’s gynecologic practice, without any incremental

improvements since the 1800s. There seems to be resistance to the mindset that visualizing

pathology and endometrial sampling or extraction of intra-uterine pathology under direct

visualization are far superior to blindly attempting to achieve the same. Blind intra-uterine

procedures are fraught with drawbacks, as summarized by Lewis in 1993, “Diagnostically

inaccurate and therapeutically useless”(2), in addition to the increased risks of intra-uterine

adhesions, uterine perforations, persistent symptoms, and need for reoperation. Although

hysteroscopy was introduced as early as 1869 by Pantaleoni (3), it remains severely

underutilized by - gynecologists; and residents and fellows training in office hysteroscopy is

dismal, with only 26.3% of residents reporting receiving adequate training in office

hysteroscopy. Of the fourth-year residents, only 14.5% reported feeling comfortable performing

hysteroscopic procedures independently (4).

unmasking the current underuse of in-office hysteroscopy in the academic setting in the United

States (5).

Aiming to identify the 3 top barriers to performing hysteroscopy by AAGL-accredited FMIGS

faculty and fellows and to recognize opportunities for education on hysteroscopy, the authors

surveyed FMIGS fellowships program directors (n=60), associate directors (n=92), and fellows

(n=158) inquiring about current hysteroscopic practice in their fellowship programs. They

obtained a 30% response rate for the online survey. It is sad to learn that only 2/3 of the

responders perform in-office hysteroscopy, with an astonishing 73% performing 5 procedures or

less per month, and only 5 participants in the survey reported performing more than 15 in-

office hysteroscopic procedures/month. Fifty-six percent of the participants expressed interest

in further education on hysteroscopy. The article takes note that the requirement of a minimal

number of office hysteroscopies during fellowship was dropped for fellows graduating in 2020,

due to the majority of FMIGS programs not having adequate office hysteroscopy volume for

their trainees to meet this requirement.

The survey was well-designed and obtained an average response rate for a 15-minute-long

survey without monetary compensation; however, a few points deserve consideration. As

acknowledged by the authors, the survey was made available on the same day that an entire

class of fellows (2024) started the fellowship. Their answers should be interpreted with caution.

Moreover, since the survey was anonymous, it was impossible to identify the participants'
fellowship program. It is known that there is significant variation among the various MIGS

fellowship programs, with some being more infertility-reproductive surgery oriented (more

likely to incorporate in-office hysteroscopy training) while others may be focused on

laparoscopic, robot-assisted, or vaginal procedures. Lastly, office hysteroscopy was not clearly

defined in the survey.

Despite the low survey response, the data is sobering, informative, and illuminating. For many

programs, hysteroscopy case volumes are low with the potential of graduating fellows with

limited proficiency in the performance of office hysteroscopy. While not discussed, office

hysteroscopy provides a gateway to offer minimally invasive surgical solutions, notably,

operative hysteroscopy, as essential options for the most conservative management of women

with intrauterine pathology.

With granular detail, the authors list potential reasons for the low numbers of office

hysteroscopy in FMIGS training. These include concerns about pain management, financial

concerns (equipment and sterilization), and staff training.

Each of these reported barriers has been studied, with evidence-based solutions offered (6-8).

These commonly perceived and cited barriers can be overcome with hysteroscopy champions;

surgeons motivated to debunk these myths. In the absence of consensus on the ideal pain

management, each fellowship should tailor pain protocols that work for their institution, with a

particular focus on utilizing the principles of trauma-informed care and “Primum non nocere”.
Fellowship programs need hysteroscopy champions that keep up to date with new evidence

and the rapidly evolving technology, with many devices now miniaturized, often disposable,

and provide excellent visualization and versatile tools. In addition, the vaginoscopic approach in

expert hands has improved acceptance and tolerability of the procedure. Hysteroscopy

champions must also be cognizant of regional and national reimbursement models and create

business plans that can demonstrate return on investment to department chairs and health

systems administrators (6-8).

It’s important to deploy a multi-pronged approach to improving training in intra-uterine surgery

in OB GYN residencies and fellowships, such as simulation, workshops, proctoring, and

mentoring. Low procedure numbers should not trigger removing office hysteroscopy as a

requirement in advanced MIGS training. Postgraduate training is the most critical time for

acquiring these skills.

We strongly urge all OB GYN physicians, and particularly MIGS surgeons, to fully adopt

hysteroscopy for the comprehensive management of women with AUB, intra-uterine pathology,

and infertility, and not settle for blind procedures, or unnecessary extirpative solutions.
References

1. Munde PF. Minor Surgical Gynecology: A Manual of Uterine Diagnosis and the Lesser

Technicalities of gynaecological practice. London: Sampson Low, Marston, Searle and

Rivington, 1880.

2. Lewis BV. Diagnostic dilatation and curettage in young women. BMJ. 1993 Jan

23;306(6872):225-6. doi: 10.1136/bmj.306.6872.225. PMID: 8443518; PMCID:

PMC1676760.

3. Pantaleoni DC. On endoscopic examination of the cavity of the womb. Med Press Crinic.

1869;8:26.

4. Michel L, Chudnoff S. Gynecology Resident Experience with Office Hysteroscopy Training.

JSLS. 2023 Apr-Jun;27(2):e2023.00009. doi: 10.4293/JSLS.2023.00009. PMID: 37522105;

PMCID: PMC10371772.

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James K. Robinson III, MD, MS, FACOG. Barriers to Office Hysteroscopy in Fellowship

Education and Practice. JMIG 2024 January.

DOI:https://doi.org/10.1016/j.jmig.2024.01.003

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hysteroscopy for abnormal uterine bleeding. JSLS. 2014 Jul-Sep;18(3):e2014.00393. doi:

10.4293/JSLS.2014.00393. PMID: 25392645; PMCID: PMC4154435.

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8. Buzzaccarini G, Alonso Pacheco L, Vitagliano A, Haimovich S, Chiantera V, Török P, Vitale

SG, Laganà AS, Carugno J. Pain Management during Office Hysteroscopy: An Evidence-

Based Approach. Medicina (Kaunas). 2022 Aug 20;58(8):1132. doi:

10.3390/medicina58081132. PMID: 36013599; PMCID: PMC9416725.

Nash S. Moawad