Wider use of office flexible hysteroscopy urged. (Only 3% of U.S. Gyns. Use It).

SCOTTSDALE, ARIZ. -- To hear Dr. Keith Isaacson talk about it, you'd think that office-based flexible hysteroscopy is far and away the best means of getting a good look at a submucous myoma.

So why are only 3% of U.S. gynecologists doing office flexible hysteroscopy?

One reason why this technology hasn't been more widely embraced is that initially only rigid hysteroscopes were available. Inserting a rigid scope in an anteflexed uterus required a paracervical block, attachment of a tenaculum, and pulling on the tenaculum to straighten the uterus, a maneuver that's quite painful for the patient, he said at an international congress on uterine fibroids sponsored by the American Association of Gynecologic Laparoscopists.

Today only about 15% of U.S. gynecologists do office hysteroscopy of any kind--rigid or flexible. "When we have something that's good technology but it causes pain, it usually doesn't go anywhere," said Dr. Isaacson, who has received payments from hysteroscope manufacturers to lecture at hysteroscopy courses.

When flexible hysteroscopes came on the scene in the early 1990s, the quality of the images they produced was quite poor. Today the quality of images produced by flexible hysteroscopes is comparable with that of rigid scopes, said Dr. Isaacson of Harvard Medical School, Boston, and Newton-Wellesley Hospital in Newton, Mass.

The flexible scope's ability to bend to the shape of the uterus avoids much of the pain associated with the procedure. One study of 387 women who underwent flexible hysreroscopy with no anesthesia and no tenaculum found that 84% rated pain during the procedure as tolerable, acceptable, or easily accepted. Another 12% described the pain as barely tolerable, and 4% found it intolerable.

Another reason for the slow growth in office flexible hysreroscopy is that it's a "disruptive technology": one that starts with poorer quality than the standard technology and improves with time but takes 5-15 years to become accepted as the instrument of choice. "It takes a while to get out of the habit of doing blind D&Cs" to evaluate the uterine cavity of a woman with a suspected submucous myoma. With better methods available, D&Cs no longer should be performed just for evaluation, he said.