Minihysteroscopy for examination and management of pathologic lesions of virginal reproductive tracts: can we preserve the hymen intact?

Abstract

Dear Editors, Hysteroscopy has been widely used for uterine cavity examination and management. Although the possibility of hymen preservation is high, virgins are highly resistant to this procedure [1]. This may be due to a belief that the procedure causes disruption of virginity and worries associated with their future partners. Case 1 was a 31-year-old virgin complaining of abnormal vaginal bleeding for months despite of medical treatment. Hysteroscopic examination was indicated, but she initially hesitated. After extensive counseling about the beneWts and limitations of both conventional hysteroscopy and minihysteroscopy, she chose a minihysteroscopy with 4-mm continuous-Xow outer sheath, 5Fr operating channel and 2-mm 0°-telescope (Karl Storz, Tuttlingen, Germany) rather than a 8-mm hysteroscopy. The procedure was conducted under intravenous sedation without use of speculum, tenaculum and cervical dilators. An operative assistant was assigned to hold the hysteroscope in place to make sure the downward pressure was not excessive and for paying attention to safety of the hymen. Additionally, avoidance of wide movements during manipulation was necessary. Vagina and cervical canal were normal; one 8-mm endometrial hyperplastic polyp was found at the posterior wall of the uterine cavity and removed by a Xexible biopsy forceps piecemeal through the channel. Case 2 was a 43-year-old virgin complaining of a vulvar mass for a long time, but she was too embarrassed to visit a gynecologist. Physical examination revealed a 6-cm erosive tumor protruding from the vagina (Fig. 1a). On minihysteroscopy, the uterine cervix was normal and the tumor growing from the left lateral vaginal wall 4 cm behind the introitus (Fig. 1b) was extracted cautiously by smallest Pean forceps. The hymen integrity was preserved (Fig. 1c), and a benign polyp was diagnosed pathologically. Operation duration for both patients was less than 20 min, and both were uneventful. Their symptoms were relieved thereafter, and they were satisWed with the procedure and outcome. Informed consent was obtained from Case 2 for use of the pictures. Hymen integrity is an important representation of virginity in some countries even though it is not absolutely related to virginity. When a reproductive tract examination or transvaginal operation must be arranged for a virgin, the operator faces a challenge and may hesitate to utilize hysteroscopy, which can result in a delayed diagnosis or improper treatment. The most common indication for hysteroscopy was abnormal vaginal bleeding, experienced by 52.5% of 40 virginal patients [1, 2]. The acceptance rate for surgery, however, was only 78% [1]. Hymen integrity was preserved in all reported cases without major complications. Our Wndings concurred with their results. So far, only a few reports have discussed the protection of hymen integrity in hysteroscopy [1, 2], and the physical and psychological impacts of this surgery in virgins are not conclusive. Although hysteroscopy can improve diagnosis and thereby improve quality of life, virgins may decline this procedure. Patients with delayed diagnosis and management in some uncommon but serious situations, such as endometrial malignancy, are life-threatening. This is an important issue that gynecologists encounter, but which has seldom been discussed. In the two cases described above, minihysteroscopy was able to fulWll their physical and psychological needs after endometrial polypectomy or vaginal tumor removal. M.-L. Cheong (&) Department of Obstetrics and Gynecology, Cathay General Hospital, #280, Sect. 4, Jen-Ai Road, Taipei 106, Taiwan e-mail: joymlcheong@gmail.com