Evaluación de la efectividad y satisfacción de las pacientes tras miomectomía histeroscópica en consulta / Evaluation of effectiveness and patient satisfaction of hysteroscopic myomectomy in office

OBJETIVO: Analizar la efectividad de las miomectomías histeroscópicas en consulta realizadas con minirresector y conocer si hay factores relacionados con el grado de satisfacción de las pacientes. MÉTODO: Estudio observacional, transversal y prospectivo, de mujeres sometidas a miomectomía histeroscópica en consulta durante el año 2018. Las pacientes recibieron medicación para la preparación cervical, analgesia oral y anestesia paracervical. La miomectomía se realizó con un minirresector de 5.8 mm. Se registraron el tiempo y el dolor en una escala visual analógica (EVA) durante la entrada y la resección, así como la satisfacción de las pacientes a los 3 meses con el cuestionario validado CSQ-8. RESULTADOS: El estudio incluyó 59 pacientes. El tiempo medio de entrada fue menor de 1 minuto (47,93 segundos) y el de resección fue de 13,51 minutos. El dolor referido por las pacientes en la EVA durante la entrada y la resección puntuó en torno a 3 y 4, respectivamente. Se consiguió un 74.6% de resecciones completas de los miomas y la puntuación media de satisfacción de las pacientes fue de 27.17. La resección completa del mioma se asoció con una mayor satisfacción total de las pacientes. CONCLUSIONES: La miomectomía histeroscópica en consulta llevada a cabo con un minirresector de 5.8 mm con analgesia paracervical obtiene buenos resultados clínicos, con buena satisfacción de las pacientes. Esta última se relaciona con una resección completa del mioma, sin que influyan el tiempo necesario para su exéresis ni el dolor.

OBJECTIVE: To analyze the effectiveness of hysteroscopic myomectomy in office performed with mini-resectoscope, and to know if there is any variable related with patient satisfaction. METHOD: Observational and prospective transversal study, which included all women who underwent a hysteroscopic myomectomy in office in 2018. Patients received drugs for cervical preparation and pain management, as well as paracervical block. We used the 5.8 mm mini-resectoscope. We kept record of time and AVS pain during entrance and resection, as well as patient satisfaction 3 months after the procedure using the CSQ-8. RESULTS: The study included 59 patients. Mean entrance time was less than 1 minute (47.93 seconds), while mean resection time was 13.51 minutes. AVS pain during entrance and resection was around 3 and 4, respectively. We achieved 74.6% rate of complete resection. Mean patient satisfaction rate was 27.17 points. We found that a complete myoma resection is related to higher patient satisfaction. CONCLUSIONS: Hysteroscopic myomectomy in office performed with the 5.8 mm mini-resectoscope, using cervical block, achieves good clinical results and a good patient satisfaction. Patient satisfaction is associated with a complete resection of the myoma, without any influence of pain experienced or time required.

Prevalence and intensity of pain during diagnostic hysteroscopy in women attending an infertility clinic: analysis of 489 cases.

OBJECTIVE: To investigate the prevalence and intensity of pain perception during diagnostic hysteroscopy in women and potential related factors. METHODS: A total of 489 women were investigated at an infertility clinic. Fluid diagnostic hysteroscopy was performed without analgesia or anesthesia by gynecologists with different levels of experience in operative hysteroscopy, using a 2.9mm rigid scope. The Visual Analog Scale was used to score pain intensity after vaginal speculum insertion and after hysteroscopy. Data collected included age, ethnicity, body mass index, history of infertility and endometrial surgery (curettage and/or hysteroscopy), smoking habits, and hysteroscopy diagnosis. Only the state of anxiety was assessed by the State-Trait Anxiety Inventory given to each patient before the procedure. RESULTS: Hysteroscopy median (25th to 75th) Visual Analog Scale scored 3.3 (3 to 5), and 41.7% of the women referred Visual Analog Scale score ≥4. Median (25th to 75th) State-Trait Anxiety Inventory score was 42 (38 to 45), and 58.3% of the women referred State-Trait Anxiety Inventory score >40. Hysteroscopy Visual Analog Scale score was significantly correlated to surgeon experience and to vaginal speculum insertion but not to State-Trait Anxiety Inventory score, ethnicity or abnormal hysteroscopic findings. CONCLUSION: Diagnostic hysteroscopy was mostly perceived as a mild discomfort procedure by most women. Nevertheless, in a considerable number of cases, women perceived hysteroscopy as painful. Pain perception was linked to individual pain threshold and surgeon experience, but not to pre-procedural anxiety state levels, ethnicity or abnormal hysteroscopic findings.

Short-term quality of life after myomectomy for uterine fibroids from the COMPARE-UF Fibroid Registry.

BACKGROUND: Uterine fibroids may decrease quality of life in a significant proportion of affected women. Myomectomy offers a uterine-sparing treatment option for patients with uterine fibroids that can be performed abdominally, laparoscopically (with or without robotic assistance), and hysteroscopically. Quality of life information using validated measures for different myomectomy routes, especially hysteroscopic myomectomy, is limited. OBJECTIVE: To compare women's perception of their short-term health-related quality of life measures and reported time to return to usual activities and return to work for different routes of myomectomy. MATERIALS AND METHODS: Comparing Options for Management: Patient-centered Results for Uterine Fibroids (COMPARE-UF) is a prospective nationwide fibroid registry that enrolled premenopausal women seeking treatment for uterine fibroids at 8 clinical sites. For this analysis, we included women undergoing hysteroscopic, abdominal, or laparoscopic myomectomy who completed the postprocedure questionnaire scheduled between 6 and 12 weeks after surgery. Health-related quality of life outcomes, such as pain, anxiety, and return to usual activitie, were assessed for each route. The hysteroscopic myomectomy group had large differences in demographics, fibroid number, and uterine size compared to the other groups; thus, a direct comparison of quality of life measures was performed only for abdominal and laparoscopic approaches after propensity weighting. Propensity weighting was done using 24 variables that included demographics, quality of life baseline measures, and fibroid and uterine measurements. RESULTS: A total of 1206 women from 8 COMPARE-UF sites underwent myomectomy (338 hysteroscopic, 519 laparoscopic, and 349 abdominal). All women had substantial improvement in short-term health-related quality of life and symptom severity scores, which was not different among groups. Average symptom severity scores decreased about 30 points in each group. Return to usual activities averaged 0 days (interquartile range, 0-14 days) for hysteroscopic myomectomy, 21 days (interquartile range, 14-28 days) for laparoscopic myomectomy, and 28 days (interquartile range, 14-35 days) for abdominal myomectomy. After propensity adjustment, quality of life outcomes in the laparoscopic and abdominal myomectomy groups were similar except for more anxiety in the laparoscopic myomectomy group and slightly more pain in the abdominal myomectomy group. After propensity weighting, return to usual activities favored laparoscopic compared to abdominal procedures; median time was the same at 21 days, but the highest quartile of women in the abdominal group needed an additional week of recovery (interquartile range,14.0-28.0 for laparoscopic versus 14.0-35.0 for abdominal, P < .01). Time to return to work was also longer in the abdominal arm (median, 22 days; interquartile range, 14-40 days, versus median, 42; interquartile range, 27-56). CONCLUSION: Women who underwent myomectomy had substantial improvement in health-related quality of life, regardless of route of myomectomy. After propensity weighting, abdominal myomectomy was associated with a nearly 2-week longer time to return to work than laparoscopic myomectomy.

Papel de la ansiedad preoperatoria en la percepción de dolor en pacientes sometidas a histeroscopia quirurgica en consulta / Impact of preprocedural anxiety levels on pain perception in patients undergoing office surgical hysteroscopy

OBJETIVO: Determinar si la ansiedad preoperatoria supone un factor de riesgo independiente para la percepción de dolor severo durante la realización de una histeroscopia quirúrgica ambulatoria. MATERIAL Y MÉTODOS: Estudio de cohortes en el que incluimos179 pacientes. Se ha aplicado el formulario STAI-S para valorar la ansiedad preoperatoria de las pacientes y distribuirlas en dos cohortes: Pacientes con ansiedad (STAI-S >50) y pacientes sin ansiedad (STAI-S7. Se ha calculado la asociación y el riesgo entre ambas variables mediante el Test X2 y el Riesgo Relativo (RR). Se ha utilizado el test de correlación de Pearson para valorar la correlación entre ambas variables. Se ha considerado estadísticamente significativo un valor de p<0.05. RESULTADOS: Las pacientes que percibieron dolor severo durante la entrada a la cavidad uterina (78,3% vs 29,5%; p<0,001) y durante la realización del proceso quirúrgico (78,8% vs 26,2%; p<0,001) fueron en su mayoría pacientes con ansiedad preoperatoria. El RR de las pacientes con ansiedad para percibir dolor severo es de 6,46 (IC 95%; 2,52 -16,60) durante la entrada y de 6,61 (IC 95%; 3,04 -14,38) durante la resección. Existe una correlación moderada y positiva entre las puntuaciones obtenida en la escala STAI-S y la puntuación EVA, tanto durante la entrada a la cavidad (r = 0,629; p = 0,042) como durante el proceso quirúrgico (r = 0'661; p =0'021). CONCLUSIONES: Las pacientes con ansiedad preoperatoria tienen más riesgo de percibir dolor severo durante la entrada en la cavidad uterina y durante la realización de la intervención histeroscópica.

OBJECTIVE: Determine if preprocedural anxiety is an independent risk factor for the perception of severe pain during an outpatient surgical hysteroscopy. MATERIAL AND METHODS: There were 179 patients included in this cohort study. The STAI-S questionnaire has been applied to assess the preoperative anxiety of the patients and distribute them into two cohorts: Patients with anxiety (STAI-S>50) and patients without anxiety (STAI-S 7. The association and the risk between both variables have been calculated using X2 test and relative risk (RR). Pearson's correlation test was used to assess the correlation between both variables. A p value < 0,05 has been considered statistically significant. RESULTS: Patients who perceived severe pain during access to the uterine cavity (78,3% vs 29,5%; p<0,001) and during the surgical procedure (78,8% vs 26,2%; p<0,001) were mostly patients with preoperative anxiety. The RR of patients with anxiety to perceive severe pain is 6.46 (95% CI; 2,52-16,60) during access to the uterine cavity and 6,61 (95% CI; 3,04-14,38) during resection. We have found a moderate and positive correlation between the scores obtained on the STAI-S questionnaire and VAS score during access to the uterine cavity (r=0,629; p=0,042) and during the surgical process (r=0,661; p=0,021) CONCLUSIONS: Patients with preprocedural anxiety are more at risk of perceiving severe pain during access into the uterine cavity and during the hysteroscopic intervention.

Prevalence and intensity of pain during diagnostic hysteroscopy in women attending an infertility clinic: analysis of 489 cases / Prevalência e intensidade da dor na histeroscopia diagnóstica em mulheres atendidas em uma clínica de infertilidade: análise de 489 casos

ABSTRACT Objective To investigate the prevalence and intensity of pain perception during diagnostic hysteroscopy in women and potential related factors. Methods A total of 489 women were investigated at an infertility clinic. Fluid diagnostic hysteroscopy was performed without analgesia or anesthesia by gynecologists with different levels of experience in operative hysteroscopy, using a 2.9mm rigid scope. The Visual Analog Scale was used to score pain intensity after vaginal speculum insertion and after hysteroscopy. Data collected included age, ethnicity, body mass index, history of infertility and endometrial surgery (curettage and/or hysteroscopy), smoking habits, and hysteroscopy diagnosis. Only the state of anxiety was assessed by the State-Trait Anxiety Inventory given to each patient before the procedure. Results Hysteroscopy median (25th to 75th) Visual Analog Scale scored 3.3 (3 to 5), and 41.7% of the women referred Visual Analog Scale score ≥4. Median (25th to 75th) State-Trait Anxiety Inventory score was 42 (38 to 45), and 58.3% of the women referred State-Trait Anxiety Inventory score >40. Hysteroscopy Visual Analog Scale score was significantly correlated to surgeon experience and to vaginal speculum insertion but not to State-Trait Anxiety Inventory score, ethnicity or abnormal hysteroscopic findings. Conclusion Diagnostic hysteroscopy was mostly perceived as a mild discomfort procedure by most women. Nevertheless, in a considerable number of cases, women perceived hysteroscopy as painful. Pain perception was linked to individual pain threshold and surgeon experience, but not to pre-procedural anxiety state levels, ethnicity or abnormal hysteroscopic findings.

RESUMO Objetivo Investigar a prevalência e a intensidade da percepção da dor durante a histeroscopia diagnóstica, bem como os possíveis fatores relacionados. Métodos Foram incluídas 489 mulheres submetidas à propedêutica de infertilidade. A histeroscopia diagnóstica foi realizada sem analgesia ou anestesia, por ginecologistas com níveis de experiência diferentes em histeroscopia, usando histeroscópio rígido de 2,9mm. A Escala Visual Analógica foi utilizada para avaliar a intensidade da dor após a inserção do espéculo vaginal e após a histeroscopia. Os dados coletados incluíram idade, etnia, índice de massa corporal, história de infertilidade e cirurgia endometrial (curetagem e/ou histeroscopia), tabagismo e histeroscopia diagnóstica. Avaliou-se apenas o estado de ansiedade pelo Inventário de Ansiedade Traço-Estado de cada paciente antes do procedimento. Resultados A mediana (25ºa 75º) de histeroscopia pela Escala Visual Analógica foi 3,3 (3 a 5), e 41,7% das mulheres obtiveram pontuação ≥4. A mediana (25ºa 75º) do Inventário de Ansiedade Traço-Estado foi 42 (38 a 45), e 58,3% das mulheres referiram pontuação >40. A pontuação da Escala Visual Analógica da histeroscopia apresentou correlação estatisticamente significante com a experiência do cirurgião e a inserção do espéculo vaginal, mas não a pontuação do Inventário de Ansiedade Traço-Estado, etnia ou achados histeroscópicos anormais. Conclusão A histeroscopia diagnóstica foi percebida pela maioria das mulheres como desconforto leve, mas um número considerável de pacientes classificou o procedimento como doloroso. A percepção da dor esteve ligada ao limiar individual e à experiência do cirurgião, mas não aos níveis de ansiedade pré-procedimento, à etnia e nem aos achados histeroscópicos anormais.

Vaginoscopy Against Standard Treatment: a randomised controlled trial.

OBJECTIVE: To evaluate whether vaginoscopy or standard hysteroscopy was more successful in the outpatient setting. DESIGN: Randomised controlled multicentre trial. SETTING: Outpatient hysteroscopy clinics at two UK hospitals. POPULATION: 1597 women aged 16 or older undergoing an outpatient hysteroscopy. METHODS: Women were allocated to vaginoscopy or standard hysteroscopy using third party randomisation stratified by menopausal status with no blinding of participants or clinicians. MAIN OUTCOME MEASURES: The primary outcome was 'success', a composite endpoint defined as: a complete procedure, no complications, a level of pain acceptable to the patient, and no sign of genitourinary tract infection 2 weeks after the procedure. RESULTS: Vaginoscopy was significantly more successful than standard hysteroscopy [647/726 (89%) versus 621/734 (85%), respectively; relative risk (RR) 1.05, 95% CI 1.01-1.10; P = 0.01]. The median time taken to complete vaginoscopy was 2 minutes compared with 3 minutes for standard hysteroscopy (P < 0.001). The mean pain score was 42.7 for vaginoscopy, which was significantly less than standard hysteroscopy 46.4 (P = 0.02). Operative complications occurred in five women receiving vaginoscopy and 19 women receiving standard hysteroscopy (RR 0.26, 95% CI 0.10-0.69). CONCLUSIONS: Vaginoscopy is quicker to perform, less painful, and more successful than standard hysteroscopy and therefore should be considered the technique of choice for outpatient hysteroscopy. TWEETABLE ABSTRACT: Vaginoscopy is quicker to perform, less painful, and more successful than standard hysteroscopy.

Use of music to reduce anxiety during office hysteroscopy: prospective randomized trial.

STUDY OBJECTIVE: To investigate the effects of music on anxiety and perception of pain during office hysteroscopy. DESIGN: Prospective randomized trial (Canadian Task Force classification I). SETTING: Major university medical center. INTERVENTIONS: Three hundred fifty-six patients were enrolled between July 2012 and January 2013. Hysteroscopy was performed in a dedicated ambulatory room, using vaginoscopy and without any type of anesthesia. A Bettocchi hysteroscope 5 mm in diameter was used. All procedures were performed by the same surgeon, a gynecologist with special interest in hysteroscopy. MEASUREMENTS AND MAIN RESULTS: Data collected included age, body mass index, number of vaginal deliveries, educational achievement level, and history of endometrial surgery (curettage and/or hysteroscopy). For each patient, vital parameters such as blood pressure, heart rate, and respiratory rate were recorded 15 minutes before the procedure and during hysteroscopy after traversing the cervix. Wait time before surgery and the duration of the procedure were also recorded. A completed Italian version of the state anxiety questionnaire (State-Trait Anxiety Inventory) and a visual analog scale (VAS) were administered to each patient before and after the procedure. The t test and Mann-Whitney U test was used when appropriate to compare the 2 groups. Statistical significance was accepted at p = .05. During surgery, systolic blood pressure and heart rate were significantly lower in the music group compared with the no music group. Women in the music group experienced significantly lower anxiety after hysteroscopy and less pain during the procedure, and a significant decrease in both anxiety and pain scores after hysteroscopy. Postoperative State-Trait Anxiety Inventory form Y1 and VAS scores were significantly lower in the music group. CONCLUSION: Music can be useful as a complementary method to control anxiety and reduce perception of pain. The patient is more relaxed and experiences less discomfort.

[Regret following hysteroscopic tubal sterilization]. / Regret après stérilisation tubaire hystéroscopique par technique Essure(®)

INTRODUCTION: The definitive contraception techniques are irreversible. Women opting for this type of contraception may therefore regret their decision later. Since 2002, the number of tubal sterilizations performed by the Essure(®) technique has steadily increased to more than 100,000 procedures to date. Due to the simplicity of the technique, the low operative risk and the absence of anesthesia, in most cases hysteroscopic sterilization is now the first tubal sterilization technique in France. The rate of regret after hysteroscopic tubal sterilization has never been evaluated. The purpose of this study is to evaluate the regret after hysteroscopic sterilization with Essure(®). METHODS: All patients who benefited hysteroscopic sterilization by Essure(®), in two teaching departments of obstetrics and gynecology of the same university, between June 2005 and December 2011 were included in this study. Patients with a medical indication for tubal sterilization or patients with an obturation of hydrosalpinx before in vitro fertilization were excluded. A specific questionnaire to assess patients regret was sent by post to all patients. RESULTS: During the study period, 452 hysteroscopic sterilizations were performed. Three hundred and six patients (67%) completed and returned the questionnaire. The average age of patients at the procedure was 41.4 [39.1, 43.7]. Mean follow after sterilization was 43 months [40.1, 45.9]. Seventeen of 306 patients (5.5%) expressed a sense of regret after sterilization. Seven women out of 306 (2.3%) consulted to discuss the possibility of a new pregnancy. None of these patients has finally resorted either to adopt or to medically assisted procreation. CONCLUSION: The regret after tubal sterilization by hysteroscopy is a rare event. All patients asking for a permanent contraception technique should be informed of the irreversible nature of the technique.

Control and constraint for low-income women choosing outpatient sterilization.

Little is known about Hispanics and their contraceptive choices in general, with some past studies detailing nonconsensual sterilization. This article is based on interviews with a mostly Hispanic sample of 44 women being sterilized at a public clinic in southeast Texas with the Essure device, which entails a new outpatient sterilization procedure. The women cited relationship factors, wanting to better their and their children's lives, and past reproductive histories as reasons for deciding on sterilization. They specifically chose Essure as a result of an apprehension of surgery and potential side effects from tubal ligation. Their choices, however, were limited by larger structural factors of work, family, the political economy, and the health care system. We concluded that this new sterilization technique provided more contraceptive choices for these women, yet more contraceptive decision-making autonomy and more equitable social structures are still needed.

Waiting time and pain during office hysteroscopy.

STUDY OBJECTIVE: To find a correlation between the waiting time between counseling about and performance of office hysteroscopy and the perception of pain. DESIGN: Observational study (Canadian Task Force classification II-2). SETTING: Academic environment. PATIENTS: Two hundred eighty-four women undergoing hysteroscopy. INTERVENTIONS: Diagnostic hysteroscopy with endometrial biopsy. MEASUREMENTS AND MAIN RESULTS: Before examination, patients were asked to complete 2 forms, the STAI-S (State-Trait Anxiety Inventory, State) and STAI-T (State-Trait Anxiety Inventory, Trait) anxiety scales, for evaluation of their usual anxiety state and their state of anxiety during the examination. Patients were asked to quantify on a visual analog scale the pain felt during the examination. A statistically significant positive correlation, even if weak, was demonstrated between pain and waiting time (r = 0.45; p < .01) but not with the values for the anxiety state (r = 0.06; p = .56) and anxiety trait (r = -0.05; p = .66). Pain (≥4) was significantly associated with waiting time (≥60 minutes) (odds ratio [OR], 5.21; 95% confidence interval [CI], 1.29-35.50), age (OR, 1.57; 95% CI, 0.40-5.87) and menopause (OR, 2.81; 95% CI, 1.10-7.40) but not with STAI-S level (≥34) (OR, 0.87; 95% CI, 0.26-3.12) or STAI-T level (≥34) (OR, 0.65; 95% CI, 0.19-2.32). CONCLUSION: Office hysteroscopy is associated with a level of anxiety that can affect patient tolerability of the procedure. However, factors such as reducing waiting time may have a positive effect on patient compliance, making hysteroscopy easier and thereby increasing its diagnostic and therapeutic potential.

Outpatient hysteroscopy: factors influencing post-procedure acceptability in patients attending a tertiary referral centre.

BACKGROUND: Ambulatory hysteroscopy is a safe, reliable and cost-effective alternative to hysteroscopy under a general anaesthetic for the diagnosis of abnormal uterine bleeding. AIM: The objective of this study was to assess which factors influenced patients' willingness to attend for future outpatient hysteroscopy. The outpatient hysteroscopy service commenced at the Mercy Hospital for Women in 2000. It provides women with the opportunity to have the cause of abnormal uterine bleeding diagnosed in an outpatient setting. METHODS: A prospective audit was conducted of 283 women attending for outpatient hysteroscopy at the Mercy Hospital for Women over a period of almost five years (May 2003 through February 2008). RESULTS: Of the women audited, 88.7% stated that they would accept the procedure in future, whilst 11.3% would not. There was a significant difference between the two groups with respect to their median visual analogue pain scale (VAS) pain scores during the procedure (3.00 versus 6.50 P < 0.0001) with the higher score in the group who would not re-attend for the procedure. There was also a significant difference between the two groups with respect to the change in median VAS score from pain anticipated to pain experienced (0.00 versus 3.50 P = 0.0001). The rate of unsuccessful procedures was significantly higher (40.6% versus 0.8%P < 0.05) in future non-attendees as well as a higher rate of clinical vasovagal episodes (25% versus 5.2%P = 0.01) in women who stated that they would not re-attend for the procedure. Preprocedure analgesia and type of anaesthetic administered during the procedure did not seem to influence whether women would attend for outpatient hysteroscopy in future. CONCLUSIONS: The acceptability rate for women attending for outpatient hysteroscopy during the audit period was 88.7%. Pain was a significant determinant of procedure acceptability; however, the acceptability rate was not influenced by analgesia or type of anaesthetic administered.

The impact of viewing a hysteroscopy on a screen on the patient's experience: a randomised trial.

BACKGROUND: The introduction of patient screens for outpatient procedures is becoming increasingly common. To date, the impact on the patient of viewing the screen remains unknown. OBJECTIVES: To explore how viewing the screen during a hysteroscopy procedure affects the patient's experience. SETTING: The outpatient clinics at the Royal Surrey Hospital in Guildford and the Royal Infirmary in Bradford. DESIGN: A randomised control trial. SAMPLE: Women undergoing a hysteroscopy procedure were randomly allocated to see the screen (n=81) or not to see the screen (n=76). METHODS: A quantitative study with measures taken before and after the intervention. MAIN OUTCOME MEASURES: Pain perception, mood, illness cognitions, communication. RESULTS: Seeing the screen or not had no impact on several measures of pain perception, mood, illness cognitions or communication. However, women who did not see the screen were more optimistic about the effectiveness of their treatment and felt that the health professional was more receptive to them during the consultation compared with those who saw the screen. After controlling for the use of a local anaesthetic, those who did not see the screen also reported a greater decrease in anxiety after the procedure. However, those who saw the screen described pain more positively (i.e. in terms of comfort, reassurance or encouragement) compared with those who did not see the screen. CONCLUSION: Viewing the screen does not benefit the patient and may interfere with the patient-physician interaction.

The hysteroscopic approach to sterilization.

Permanent sterilization is the most common form of contraception in the United States today. Previously, this was accomplished via the laparoscopic method. A new less invasive method has been developed, in which the Essure microinsert is inserted through a hysteroscope into the fallopian tubes. A subsequent benign inflammatory process results in tubal occlusion within 3 months of insertion. Approved since 2002, this method offers high efficacy without incisions, general anesthesia, or a prolonged recovery period.

[Essure--a novel method of sterilization].

INTRODUCTION: Essure hysteroscopic sterilization is a minimally invasive, outpatient approach to female sterilization, which avoids the possible complications of laparoscopic sterilization. This procedure has been available since 2003 in both Europe and North America. We present our experience of the first 12 cases of the procedure performed in Israel. METHODS: Women who have completed their family planning were offered to consider Essure as their permanent contraception. The procedure was performed without anesthesia by the vaginoscopic technique at the hospital's outpatient clinic. Patients completed a questionnaire and were discharged immediately following the procedure. A follow-up checkup was completed after three months including three dimensional sonography, abdominal X-ray and occasional hysterosalpingogram. RESULTS: Twelve patients participated in the pilot group at Hadassah. The average age was 40 years (34-45) and the average number of children was 5 (4-8). The average time for the procedure was under 8 minutes. Periostial adhesions required adhesiolysis prior to insertion of the device in one patient. All patients resumed their normal activity on the same day. Our patient satisfaction survey revealed that the procedure was associated with high satisfaction levels. Sonographic and radiographic studies confirmed the good placement of the device. DISCUSSION: The Essure procedure was well tolerated by patients. The limitation is probably going to be the price of Essure, as this procedure is not covered by the 'health basket' in Israel.

Patients' preferences in the evaluation of postmenopausal bleeding.

OBJECTIVE: To assess patients' preferences for diagnostic management of postmenopausal bleeding (PMB). DESIGN: A structured interview. SETTING: A teaching hospital with office hysteroscopy facilities. POPULATION: Thirty-nine women with PMB and with a completed work-up including an office hysteroscopy. METHODS: A structured interview was taken from 39 women who had had an office hysteroscopy in the diagnostic work-up for PMB. Women were informed about the probability of endometrial carcinoma versus benign disease and about advantages and disadvantages of different diagnostic strategies, i.e. expectant management after ultrasound or complete diagnostic work-up, including invasive procedures. MAIN OUTCOME MEASURES: Women were informed about the probability of endometrial carcinoma versus benign disease and about advantages and disadvantages of different diagnostic strategies, i.e., expectant management after ultrasound or complete diagnostic work-up including invasive procedures. Women were asked to make a trade-off between different options. RESULTS: Most women wanted to be 100% certain that carcinoma could be ruled out. Only 5% of the women were willing to accept more than 5% risk of false reassurance. If the risk of recurrent bleeding due to benign disease exceeded 25%, the majority of women would prefer immediate diagnosis and treatment of benign lesions. CONCLUSION: Women with PMB are prepared to undergo hysteroscopy to rule out any risk on cancer. This finding implicates that the measurement of endometrial thickness with transvaginal ultrasound as a first-line test in the assessment of PMB should be reconsidered.

Success rate and patient satisfaction with the Essure sterilisation in an outpatient setting: a prospective study of 857 women.

After 857 women with Essure system inserted for tubal obstruction as a method of sterilization in an outpatient setting, insertion is achieved in close to 99% of the women. Physician described the procedure as very difficult in 15% of the cases, mainly due to anatomical tubal anomalis or tubal spasm, and women felt highly satisfied in all cases.

Hysteroscopic sterilisation: a study of women's attitudes to a novel procedure.

Laparoscopy is the most common mode of surgery for female tubal sterilisation. Hysteroscopic sterilisation is a new method which can be performed in the outpatient setting under local anaesthetic. We carried out a prospective cohort trial to determine whether women would actually favour hysteroscopic sterilisation over laparoscopic sterilisation. Data analysis in a cohort of 96 women showed that 77% would prefer laparoscopic sterilisation over the hysteroscopic procedure (23%), despite the advantages of an outpatient setting. Age, obstetric history, employment and marital status, access to transport and previous anaesthetic did not significantly influence the choice made.