Transcutaneous Nerve Stimulation for Pain Relief During Office Hysteroscopy: A Randomized Controlled Trial

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The article by Lisón et al1 describes an extremely interesting approach to pain relief during an important office procedure. I am concerned, however, that 28% (39/138) of these procedures were for postmenopausal endometrial thickening greater than 5 mm. I have spent much of my career trying to educate gynecologists about the appropriate use of transvaginal ultrasound. There is abundant evidence that, in postmenopausal patients with bleeding, when the endometrial thickness is 4 mm or less, histologic sampling to prove lack of endometrial carcinoma is no longer necessary.2 This abundant literature comes from patients with postmenopausal bleeding. The incidence of a thick endometrial echo in postmenopausal patients without bleeding, mostly due to inactive polyps, is as high as 13%.3 The incidence of malignancy in such asymptomatic polyps is less than 1 in 1,000.4 Even if an incidental finding of endometrial carcinoma occurs before bleeding, the prognosis and survival is not improved over those patients who present with bleeding, as long as the therapy is undertaken within 8 weeks of the bleeding episode.5
I applaud the work of the authors of this excellent study for a creative way to achieve pain relief for office hysteroscopy, but I hope that in the future they appreciate that patients with thick endometrial echo absent bleeding do not need intervention.

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