A Powerful Value of Hysteroscopy.

Both ultrasound (especially transvaginal ultrasound) and hysteroscopy are convenient and effective tools to evaluate the physiology and/or pathology of the uterine cavity.[1] Conventionally, an application of transvaginal ultrasound is much more acceptable in the majority of obstetricians and gynecologists because it is often considered as the simplest, low cost, least invasive, and easily acceptable tool. In addition, transvaginal ultrasound has been shown to have good accuracy for the detection of endometrial pathology; furthermore, of the most importance, transvaginal ultrasound can be advocated as a routine modality of choice for gynecological diagnosis.[2] The power of ultrasound is not only limited to the diagnostic role but also it is also applied as assistance of treatment.[34] There are many and various kinds of diseases could be successfully managed and treated by ultrasound-guidance. For example, cesarean scar ectopic pregnancy, one of the most complicated abnormal pregnancies, can be managed by ultrasound-guided curettage because it is relatively simple and inexpensive compared to the hysteroscopy approach.[5]

Compared to hysteroscopy, ultrasound seemed to be a winner. However, it does not always be. In the April–June issue of the Gynecology and Minimally Invasive Therapy, Asto and Habana published a very interesting report to claim the value of the hysteroscopy. The authors found that there were many patients with the intrauterine device, which could not be successfully removed by ultrasound-guidance.[6] By contrast, with the assistance of hysteroscopy, these difficulties could be easily overcome. Although the authors still recommended that ultrasound-guided removal of the intrauterine device should be done as the first-line management in patients with no visible strings, and suggested that the above-mentioned procedures can be done during menstruation period in premenopausal women and after cervical ripening in menopausal women. The use of hysteroscopy for removing intrauterine device can be delayed to cases with an attempt by ultrasound but failure. The current study is worthy of discussion.

First, hysteroscopy is often considered as a much more invasive and costly tool than ultrasound is.[1] However, it is believed to be a more effective method for the diagnosis of endometrial disorders. Regarding cesarean scar ectopic pregnancy, hysteroscopy provides a clear view for us, making it easy to identify the range of affected tissues, and clean the pregnancy tissue,[5] compared to ultrasound does. Hysteroscopy might be recommended as a first-line treatment modality for patients with a cesarean scar ectopic pregnancy, although the different opinions are raised.[78]

Second, as shown by the authors, the authors revealed two sets of hysteroscope in their studies, and one is a diagnostic hysteroscope, and the other is an operative hysteroscope.[6] More than half of patients (10/19) were successful in the use of a diagnostic hysteroscope,[6] suggesting that this less invasive office hysteroscope can be used initially. In fact, the benefits of the office hysteroscope have been reported recently.[2910] Cheng et al. used a flexible hysteroscope with Lin's biopsy grasper to deal with endometrial lesions successfully.[9] The main advantage of Cheng's study is that the patients did not receive any analgesics or anesthesia treatment, suggesting that advanced development of hysteroscope might achieve the least invasive goal in the future.

In conclusion, there might be no doubt of the benefits of hysteroscopy in the use of current and routine clinical practice, especially to evaluate the intrauterine lesion. With much more experiences about the hysteroscopic procedure, I am looking forward to seeing more studies to address this topic.

Conflicts of interest

There are no conflicts of interest.