The Evolution of Hysteroscopy: Past, Present & Future

[Dr. Mark Hoffman]
All right, so like we do for most episodes, we like to ask our guests to tell us a little bit about themselves. Tell us about your practice.

[Dr. Linda Bradley]
Well, my practice for the last several decades has been at the Cleveland Clinic. During my residency, there was no hysteroscopy. It was three D&Cs. You strike out, you get a hysterectomy. I feel like I'm always a lifelong learner. There was no fellowship back in the day. There weren't mentors to teach me. I happened to go to an AAGL meeting with some of the more eminent physicians at the time.

There are three of them that I have a lot of respect for. That really opened my eyes to what's inside the uterus. The half-life of medicine is only a couple of years, probably months now. Being out of training and residency and even working for a couple of years, I was like, "This is incredible. The beauty of the uterus, the endocervix, the tubal ostia. I need to know about this."

Watching others through the AAGL, I was able to follow up and call some of the speakers on Jay Cooper, Frank Loffer, Paul Inman. I could just name many of the greats. They were so kind, didn't know me from Jane, and really talked me through a lot. I think, for me, a picture speaks a thousand words. I'm always someone who tries to be a very early adopter for certain procedures, certain medications. Basically, to answer the question more succinctly, it's just, I went, I saw, and said, "I must do," and got started.

[Dr. Mark Hoffman]
It's hard to imagine. Whenever I think about incorporating a new technology or new procedure into my office these days, it's not easy to get your hospital to buy anything. Thinking back a few years ago, when you were doing something that just sounds like not very many people were doing. Was it a challenge where you were to bring these things in? Did people think you were doing something crazy that you shouldn't be doing? Were people excited about it?

[Dr. Linda Bradley]
I think working at the Cleveland Clinic, which is over 100 years old, and we're most known for innovation, innovation, innovation. When I came to the clinic and said, "I think this is something that we should be doing," they were all for it. I have not practiced obstetrics since I've been at the clinic. This really was a new domain, a new technology. I was really very lucky that I was interested and pursued this.

I think at the Cleveland Clinic, I'm not saying other hospitals aren't for that, but just getting started, the excellent outcomes, the minimal number of complications, the brevity of doing procedures in the office, and then subsequently in the operating room. I think good outcomes breed more patients, breed the ability to get more instruments. I'm speaking specifically right now, office-based procedures that then carry you on, meaning diagnostic procedures that then allow you to do surgery.

I do on the average right now, 10 to 12 operative hysteroscopies a week. This is all I do. I don't do Pap tests. If someone needs it that's going to have a hysteroscopy, I'll do it. I don't prescribe birth control pills. I don't do OB. I don't do chronic pain. I don't do urogyn. Literally, all of my patients have bleeding problems, follow-up, fibroids, polyps, retained products of conception, bleeding of unknown origin.

Today, I did nine office hysteroscopies. Tomorrow, I'll do eight. My practice is only at the Cleveland Clinic. It's probably one of the few places. Even a cardiothoracic surgeon doesn't do every valve in the heart or stents or aneurysm. We are heavily focused on people's passion, expertise. I'm happy to say I've done over 10,000 office hysteroscopies that then give you the surgical procedures over the last many decades.

It's an easy place to work, especially in the subspecialty division. You don't have to do everything, but you have to be busy. You have to be productive and you have to write, lecture, be involved with committees. The clinic, in my mind and in my era, really allowed me to grow as much as I wanted to grow and to learn and to continue to learn for others. Amy was not at the clinic at the time, but our older CEO who's retired had every physician at the clinic doing what's called an innovation trip.

If you were a surgeon to go work with the best surgeon and what you want to do, if you're a pediatrician to go work with the best pediatrician. Even if it's a generalist, how do you do the best history, the physical exam? If you're a psychiatrist, everybody got a week off, paid for. It was an expectation, a high expectation that you go. You come back and you bring back something that you've learned.

[Dr. Mark Hoffman]
That's incredible.

[Dr. Linda Bradley]
It's a visionary institution run by physicians more so in the old days. For me, I take all those opportunities. We have a tremendous travel policy. I use every day that I'm given to go, to learn, to do. I think when you know better, you start doing better. That's been my pleasure of working at the clinic is to extend, especially in the area of hysteroscopy, something that a lot of people sadly aren't that interested even in 2023. Hysteroscopy is minimally invasive surgery,It is not a D&C. I think it's not sexy and it's a shame that folks do not use the technology, the tools that help women so much.

[Dr. Mark Hoffman]
I'm a fan and that's why I had you on here. I was thrilled to get to chat with you at meetings whenever I see you. I want to take an innovation trip and spend a week with Linda Bradley, honestly, if I could have one week. I've talked to you about this, right? There's things that you're doing that I don't think very many or maybe anyone in the world is doing, at least not that I know of.

[Dr. Linda Bradley]
Oh, gosh. Oh, I'm not going to accept that. I think there are lots of my colleagues who are gifted, interested, passionate, crazy about hysteroscopy. I'm not going to say I'm all that, but I think there are a lot of people who share my passion.

[Dr. Amy Park]
That's so cool, Linda, that you were able to develop this interest and niche and were allowed to pursue it. I'm just curious. I wanted to delve into the historical context because it sounds like it was really blind curettage and then the addition of the hysteroscope and then the flexible hysteroscope and the operative hysteroscope. Can you just tell us how you see the arc of hysteroscopy historically? Now, even since I trained a while ago, we have the advent of TruClear and MyoSure. When I was a resident, bipolar cautery for the resectoscope had come out. What are your thoughts? How do you see it having evolved over time?

[Dr. Linda Bradley]
Well, I'm really proud to say that, last year, I was asked by Jason from the Green Journal to write an expert opinion on the topic of office hysteroscopy. It was published in the September '22 edition. Within it was the article we entitled. It's something like implementing office hysteroscopy. It has 30 videos that folks can click on, about 30 images of different things that you can see.

What I realized and what I put in my last paragraph of the article and I've been saying for a long time and I said, "Somebody's going to pick up this little saying that I say," but I say that my hysteroscope is my stethoscope, okay? My husband's an internist. One day, I'm just looking at him with his stethoscope. We're talking about patients and your stethoscope. You can listen to carotid bruits. You can listen to lung sounds, listen to bowel sounds, listen for murmurs, determine if you have LAS and things like that.

When I think about the stethoscope, it's used for many things besides just heart-related things. My hysteroscope is my stethoscope. It's not always about bleeding. It could be retained products of conception. It could be evaluating women to see if they have Asherman's. It could be evaluating, why is the endometrium thick on a regular transvaginal ultrasound or the ultrasound shows that the endometrium is ill-defined, not seen in its entirety equivocal?

All bleeding from even puberty, you can use your hysteroscope as a vaginoscopy. Lots of little girls. Again, now, we have pediatric gynecology, but I used to be called for bleeding. We would take the flexible scope because you don't dilate. Lots of little kids have marbles, pens, pennies in the vagina. We're seeing that in elderly women now, foreign bodies. They're leaving odor, dementia, Alzheimer's, so not all bleeding is from the uterus. Probably once a year, I pick up one or two cases of vaginal cancer for bleeding.

You can look, do a vaginoscopy, and look for induration. All the bleeding from to say what I call the three blood phases of a woman's life from puberty to the reproductive years to the menopausal years, the hysteroscope lets you look directly inside the endocervix, which is not well seen with ultrasound, the endometrium. Sometimes there are small lesions near the tubal ostia. You can look, "How did you do? What's your thumbprint or footprint that you left after surgery?"

When I did a very difficult operative hysteroscopy, I took out a patient, 28 intracavitary fibroids in a woman who wanted a baby. You better be sure I'm going to look and see a few weeks later how that uterus is healing. I'm happy to say for her, unnamed person, she just had a baby, okay? I like to look at my efforts for some things after surgery. We look at all the bleeding issues, foreign bodies, broken IUDs. From China back in the old days, they would put in this ring IUD.

[Dr. Mark Hoffman]
The steel rings.

[Dr. Linda Bradley]
Yes. Without a screen, took those out. Women that are 80 years old, they happen to fall and break their hip. They get a CAT scan. Oh, my God, there's an IUD, a Lippes loop. I used to have a little drawer with all of them, I wish I hadn't thrown them away, but I did. I've seen a cerclage inside the uterus. There's a lot of different things that you can see. You can follow it up for hyperplasia.

We're using the levonorgestrel IUD instead of doing blind sampling. You can look. You can do directed biopsies. You can do targeted biopsies. I'm just saying, it is a shame. I'm quite embarrassed that, in 2023, when we look for bleeding disorders in women or reproductive menstrual dysfunction, that use of a blind technology, whether it's a Pipelle or, God forbid, a blind D&C, which we call "dead and cremated," that we as a society or gynecologists for bleeding that we do not look.

I say the same old thing that everyone says. If you have hematuria, you're going to do a cysto. You're having rectal bleeding. You're going to get a sigmoidoscopy or colonoscopy. If you're vomiting up blood, hemoptysis, you're going to get an endoscopy. There's no other specialty in which a scope is not used for certain things. I personally think it is a disservice, tremendous disservice to women to say that, "Oh, your Pipelle biopsy is negative."

What does negative mean? I tell the residents, it only helps you if your Pipelle gives you cancer or atypical hyperplasia because what we know from great studies with blind technology is that we miss focal lesions. We miss fibroids. One of our residents just published. It was her abstract poster, then publication, "Oh, about 2,000 patients. Everybody was bleeding, whatever age or whatever, with a biopsy in the office," but they either had a saline infusion sonogram or hysteroscopy.

If the SIS showed a polyp or fibroid, even when the biopsy was negative, we took them to the OR. The gold standard is your fibroid or your polyp. When you looked at close to 600, 800 women, of those who had fibroids that I resected or that a doctor resected, how many times do you think the Pipelle picked up? She's bleeding, bleeding. We did the Pipelle first often during the visit and then they would have the SIS or hysteroscopy.

Then you take them to the surgery because of a focal finding being seen. Focal could be a 3 or 5-centimeter intracavitary fibroid or huge polyp. I looked at a lady yesterday, a 5-centimeter postmenopausal bleeding for three years. Office biopsy, negative, okay? I go inside, a huge polyp. We'll find out what her path is. Getting back to our study. In your own experience, how often on your own Pipelle biopsies in your career have you picked up a fibroid for pathology? Any of you?

[Dr. Mark Hoffman]
Never.

[Dr. Linda Bradley]
Of course not, unless it's degenerating. Our study showed that zero out of all the hundreds of fibroids that were there when they had their "pre-op office biopsy." If you stop at that, then the patient, when they don't get the right diagnosis, they don't even get the privilege of having a minor procedure. My six patients yesterday, I've called them all. Nobody goes home with anything but Motrin. They're feeling well. "Did you do any procedures?" Minimal bleeding. They can go back to work in two days. They could drive today. They can have sex in a week.

You're not getting them on narcotics. There's just so many uses for hysteroscopy and allowing us to say, in a menopausal woman, we look inside. 70% of bleeding in menopause is from atrophy. If you look inside, I jokingly say that the endometrium looks bald-headed. There is nothing there. If I give you a comb or a brush and you have no hair, there is no hair there. It is negative because there is no endometrium. It'll say inactive or it'll say atrophic or it'll just say no endometrium. When I then get my pathology back, I can say she's bleeding from atrophy.

[Dr. Amy Park]
I know one of my partners in DC, Jim Robinson, used to do the Asherman's and sometimes even some septum resections in the office, but definitely the Asherman's. I was surprised about that, but being able to do the septum resections hysteroscopically is huge. It's so much less morbid than doing a whole abdominal approach or whatever.

[Dr. Linda Bradley]
Correct.