Role of Hysteroscopy in Evaluating Chronic Pelvic Pain

Abstract & Commentary

By Frank W. Ling, MD, Clinical Professor, Department of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville, is Associate Editor for OB/GYN Clinical Alert.

Dr. Ling reports no financial relationship to this field of study.

Synopsis: A review article whose objective is to "… provide a survey of various gynecological conditions …" that might be amenable to diagnosis by hysteroscopy.

Source: di Spezio Sardo AD, et al. Role of hysteroscopy in evaluating chronic pelvic pain. Fertil Steril 2008;90:1191-1196.

The authors present a series of gynecological conditions that are effectively diagnosed by hysteroscopy, including adenomyosis, chronic endometritis, Mullerian anomalies, retained fetal bones, endocervical ossification, and intrauterine abnormalities. In addition, they note that hysteroscopy can be a major part of the treatment for these conditions. They conclude that, because it can be safely performed in an office setting, hysteroscopy may be indicated as a first-level tool in diagnosing and treating chronic pelvic pain.

Commentary

"This is a GREAT article! It really gave me some good insights." "This is a terrible paper. I can't believe it got published … in Fertility and Sterility no less!" Like so many articles in our peer-reviewed literature, the clinician has to wade through this one with one eye on what is being written, and the other on common-sense clinical practice. This group of Italian authors has accomplished what it set out to do: review the literature on several conditions that can possibly be diagnosed with hysteroscopy. Unfortunately, even though they do put things in perspective with the disclaimer, "Although some clinicians already use hysteroscopy in the evaluation of chronic pelvic pain, other investigators refute its usefulness," I walked away from the paper with the impression that the unstated goal of writing the paper was getting more people to perform hysteroscopy on more patients. Why would I take such a clinical view of the article? It's because they later bemoan the fact that "… unfortunately most gynecologists still are unable to take advantage of the many potentialities of this technique or do not perform hysteroscopic procedures in the office setting." Thus, I interpret the authors' intent may be a bit less than totally objective.

Do I believe hysteroscopy is an appropriate part of the evaluation of chronic pelvic pain? The answer is an emphatic "absolutely," but in selected cases. The concern I have when reading articles such as this one is that folks will now do hysteroscopy on every patient with chronic pelvic pain. The physical examination is almost left out of the article entirely because each of the articles that is cited focused more on the technique of hysteroscopy and its applicability than on the individual patient. As clinicians, you and I are just the opposite: We are and should be more concerned about the patient and her pain than on whether a particular procedure can be used. In fact, the article appropriately points out the potential role of other procedures such as ultrasound, MRI, and the "gold standard" for pelvic pain evaluation, laparoscopy. So much for technology. It's almost like the authors have an operation looking for some indications. In reality, they have a very good diagnostic tool that can be effectively used appropriately, but in selected cases. What about the physical examination and how does that fit into the picture?

To be honest, I believe that the role of hysteroscopy in the evaluation of chronic pelvic pain should be driven more by the physical examination than by anything else. More than history or imaging, the pelvic examination is the one modality that can actually locate the source of pain. Just as importantly, the physical examination can rule out a source of pain. The bimanual examination can potentially recreate the location as well as the nature of the pain. Even if the abdominal wall is too thick to truly palpate the uterus between the two hands, at least manipulation of the cervix with the vaginal fingers can provide a suggestion that the uterus is the source of the pain. If the uterus is nontender and there is no cervical motion tenderness, I would submit that the likelihood of hysteroscopy being a useful procedure is minute. Do I have data to that effect? Unfortunately, only my experience says this. There are no published papers that I am aware of that focus on the pelvic examination exclusively. This makes sense clinically and intuitively. A comparable clinical example is in considering the diagnosis of interstitial cystitis. If the bladder is nontender, it is unlikely that interstitial cystitis is the cause of pain and cystoscopy is unlikely to be helpful.

The authors are accurate in assessing the role of hysteroscopy in diagnosing the various conditions. They tell us that there is no consensus of its role in the diagnosis of adenomyosis. The same is true regarding chronic endometritis. The other conditions may be associated with pain, but ultrasound rather than hysteroscopy would be a logical first test in the evaluation. The bibliography is also telling. Of the 62 cited articles, only one links the terms "hysteroscopy" and "chronic pelvic pain," and its conclusions actually address the role of hysteroscopy when used in combination with laparoscopy.

So did I waste the readers' time reviewing this topic? I hope not. I hope I stimulated the clinician to do what makes sense logically: See if the uterus seems to be a potential source of pain. If so, then hysteroscopy will be used appropriately to assess the endometrial cavity as a source of pain. If the uterus is nontender, then other sites can be investigated. We and our patients should remain masters of the various technological advances available to us, not slaves to them. It's time to get off my soapbox now.