Office Hysteroscopy is a leading endoscopic tool in cases of abnormal uterine bleeding, sonographic evidence of submucous myomas and endometrial polyps, as well as, in detecting subfertility-associated underlying endometrial pathology [1, 2, 3]. Advancements with regards to hysteroscopic equipment led to the establishment of hysteroscopy as a Gold Standard technique when assessing endometrial pathologies. According to the literature, hysteroscopy demonstrated an overall sensitivity of 98% [4], when compared with histological results. On the contrary, scientific evidence showed that dilatation and curettage (D&C) offers a moderate sensitivity of 65% [5]. Nowadays the traditional method requiring general anaesthesia is largely abandoned, since technological developments led to finer hysteroscopes with high resolution imaging allowing accurate assessment of the uterine cavity. These novel hysteroscopes can better visualise the uterine cavity by utilizing light properties [6]. With regards to the distension medium, normal saline is widely used and compared to CO${}_2$, it offers optimal results during this procedure [7, 8]. Furthermore, vaginoscopic approach as an alternative entry technique results in a more comfortable overall patient experience in an outpatient setting, without requiring cervical preparation prior to the procedure nor any kind of pharmaceutical analgesia [9, 10, 11, 12, 13]. These features increase the feasibility and acceptability of office hysteroscopy, allowing both diagnostic and, in selected cases operative interventions [14, 15, 16, 17].

Italians were the first to introduce the technique in 1997 [18], and over the past twenty years, office hysteroscopy has emerged as a gold standard technique in detecting endometrial and endocervical pathology over traditional methods. Vaginoscopic hysteroscopy is a simple technique which requires a short learning curve [10]. The hysteroscope is introduced slowly along the posterior vaginal wall and as the vagina distends, advancement of the hysteroscope until the visualization of external cervical os follows. In order to locate the cervix, which at times poses the greatest obstacle of the technique, literature suggests initially introduction of the hysteroscope to the posterior vaginal wall, known as cul-de-sac, and slow withdrawal of the equipment until the external cervical os is identified [19]. Vaginoscopic hysteroscopy requires rigid hysteroscopes, since it is very likely to experience difficulties when using flexible equipment [20, 21].

Moreover, the outdated concept of ‘diagnostic hysteroscopy’ has changed to ‘office hysteroscopy’, in which ‘see and treat’ of any pathological findings at the time of the procedure can be achieved, where applicable [22]. Hysteroscopic approach seems to be more efficient than that of sonography regarding the detection of endometrial pathology as it permits direct visualisation of the endocervix and the endometrial cavity [23]. Recent advancements resulted in reduced diameters of hysteroscopes and allowed the use of different types of electrosurgery offering the option for the majority of the procedures to be performed in an outpatient/office setting. Compared to “outpatient” hysteroscopy which may suggest the use of some type of analgesia, the term “office” hysteroscopy suggests vocal-local analgesia [24, 25]. Combined with a vaginoscopic approach when introducing the hysteroscope, patients can be diagnosed and treated in one visit with high levels of acceptance due to minimal discomfort or pain experienced during the procedure [12].

In this study, data from 2675 patients who underwent office hysteroscopy, in the past 20 years, was extracted in order to detect the feasibility of the method, as well as, determine the role of office hysteroscopy in various pathological intrauterine conditions and its relevance to available published international scientific evidence. In addition, the patient’s acceptance and overall experience were also studied.

To our best of knowledge, this is the first retrospective study presenting data from a large population on office hysteroscopy in Greece to date and one of the largest internationally. The procedure was efficient and safe. All women were discharged after the intervention with no complications. No analgesia or anesthesia was needed. This retrospective study of 2765 cases of vaginoscopic office hysteroscopy demonstrates high feasibility of the technique.

The failure rate of the technique was approximately 1%, in line with the international literature [15, 31]. However, many studies indicate great discrepancies with regards to failure rates spanning from 0.5% to more than 50% [32]. Hysteroscopy remains an operator-dependent technique. Thus, decreased rates of failure correspond with the experience and personal style of each hysteroscopist [33]. The level of expertise of the members of our endoscopic unit was already advanced and this possibly explains our results regarding the reported minimal failure rate of office hysteroscopy. There have been studies suggesting that the failure rate of the technique is estimated at approximately 5% of cases when employing vaginoscopic approach [20]. It seems that apart from the dimensions of the hysteroscopes, the distension medium also plays an assistive role at increasing the feasibility of the technique. With regards to distension medium, normal saline found to be superior of CO${}_2$ as distension medium [34]. This medium offers a more efficient entrance through the cervical canal and by extent, a smoother overall experience by women undergoing office hysteroscopy [8, 35, 36]. In terms of selecting the appropriate distension medium, Pellicano et al. [36], favoured normal saline over CO${}_2$ offering better experience for patients with less discomfort and pain [37, 38]. Additionally, Cicinelli et al. [39, 40], when comparing dimensions of equipment, concluded that smaller hysteroscopes are accompanied with lower failure rates and higher levels of acceptance by patients.

Vaginoscopic hysteroscopy is feasible, simple and well tolerated technique that can be safely performed in an outpatient/office setting [9, 14]. Vaginoscopic approach offers benefits for both specialists and patients [41]. The absence of speculum or tenaculum results in less pain, discomfort and stress experienced by patients as it is noted in our study [42]. Moreover, analgesic premedication is not indicated when performing office hysteroscopy through vaginoscopy [43, 44]. Also, a higher degree of free movements and manoeuvres from the perspective of the operator and less equipment in use simplify the procedure as experienced by the specialist [45]. Limitations of this approach are vulvar, vaginal or endometrial infection, in case of which, the procedure ought to be postponed and treatment of the underlying disease should be initiated [46].

Management of anxiety experienced by patients prior to the procedure cannot be overemphasized. As reported also in published evidence, patients that receive clear information before proceeding with an intervention are more likely to report less anxiety and stress [47]. Our findings are in keeping with this trend, since patients who had the chance to familiarise themselves with the procedure in the form of written information leaflets, felt more supported and prepared experiencing at the same time less pain. Anxiety is a common experience for many patients undergoing medical procedures such as office hysteroscopy [48]. The impact of anxiety on the procedure is well documented, with studies showing that high levels of anxiety can lead to increased pain perception, higher rates of complications, and reduced satisfaction with the procedure [49]. In addition, anxiety can also have long-lasting effects, with some patients reporting ongoing fear and avoidance of medical procedures in the future. Therefore, it is important for healthcare providers to take steps to minimize anxiety and provide support to patients undergoing office hysteroscopy, in order to ensure the best possible outcomes and patient experience [50]. This may include providing information and education about the procedure which can help to alleviate fears and uncertainties about the procedure.

On a systematic review by Cooper et al. [45], vaginoscopic approach demonstrated less pain and better overall experience by patients compared to the traditional technique. In fact, vaginoscopic approach is ideal in specific groups, such as patients with restricted movement due to an orthopaedic condition of lower extremities, or women with no history of penetrative sexual intercourse, nulliparous patients or women suffering from atrophy, in which vaginal contact often results in further distress and contributes to negative experience [45, 51]. In our study, the overall satisfaction rates were almost perfect, however mild pain sensation during the procedure was still reported. It is worth mentioning that patients who received additional written information about the procedure, were more likely to experience less pain than those who did not. It is likely that written information helped patients to understand better the procedure, minimizing at the same time stress and anxiety in advance.

In 1996, Nagele et al. [52], reported large-series scientific evidence regarding outpatient diagnostic hysteroscopies. Bettocchi et al. [26] was one of the first researchers to present the concept of office hysteroscopy combining diagnostic and operative hysteroscopy in an outpatient setting without the use of analgesia or anesthesia, establishing the concept of office hysteroscopy. Later on, almost a decade ago, Di Spiezio et al. [53] provided more information on the subject, when data arising from 5000 office hysteroscopies was published. Taken into consideration our relatively small country, it seems that our data could potentially be used as a solid representative of Greek population in terms of epidemiologic data regarding endometrial and endocervical pathologies that could significantly add up to the existing European and International scientific evidence.

The main hysteroscopic indication in our sample was AUB, but as expected the respective hysteroscopic findings were dependent on reproductive/menopausal status of the patients [53]. For women of reproductive age subfertility issues were a common hysteroscopic indication, while in menopausal women, increased endometrial thickness after sonographic evaluation indicated the need for further hysteroscopic assessment. Our findings are in keeping with the existing international scientific evidence [54, 55]. Hysteroscopy has an important role in women with postmenopausal bleeding (PMB) and decreased endometrial thickness, since identifying different endometrial pathologies under direct vision is achieved in real time [56]. In addition, hysteroscopy offers biopsies or excision of endometrial lesions under direct vision, allowing accurate diagnosis.

The efficacy of the technique is well demonstrated by offering high sensitivity and specificity in four major endometrial pathologies as a metanalysis by Gkrozou et al. [57] indicates. In case of normal endometrium, although sensitivity of the technique is not quite high, irreversibly high negative predictive value shows that in the presence of normal hysteroscopic traits, endometrial pathology should be excluded [58]. In the available literature, there are endometrial features that do not correspond to any traditional category of endometrial pathology [59]. Our study shows that in cases where the hysteroscopist fails to identify specific endometrial pathology, endometrial biopsy facilitates the diagnosis, especially in cases where suspicious endometrial patterns are recognized.

Strength of this study is mainly the large number of cases attending a single Endoscopic unit, as well as patient’s feedback addressing their overall satisfaction and pain perception by this method. This is the largest retrospective study of vaginoscopic office hysteroscopy in Greece to date. Unfortunately, no learning curve data could be obtained by this study, since only highly experienced hysteroscopists performed all hysteroscopies. However, the international literature suggests that initial adaptation of the approach tallies temporary with an increase in the duration of the procedure. More specifically, Bettocchi et al. [18] concluded that after the initial ten cases of vaginoscopic hysteroscopy, the duration of the technique is similar to the traditional method. To conclude, vaginoscopic approach technique is known as a non-traumatic technique, which is safe, efficient and improves the overall patients’ experience [60]. Our study has confirmed the importance of this technique in the everyday clinical practice. The main limitation of this study is the retrospective data analysis which could potentially increase the risk of bias. The hysteroscopists performing all hysteroscopies over the years were quite experienced and our data cannot provide information regarding hysteroscopic dexterity since no recordings on the development of their skills was retrieved. Hysteroscopy remains a subjective technique and its efficacy depends on the experience of the operator.

This retrospective study presents large data regarding vaginoscopic office hysteroscopy in a busy public endoscopic unit in Ioannina, Greece. Our findings are in keeping with current scientific evidence and provide substantial data with regards to epidemiology.

Vaginoscopic office hysteroscopy offers great diagnostic accuracy in patients with hyperplasia, endometrial cancer, fibroids, and endometrial polyps. The technique is proven to be simple, safe, and feasible.

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

OT—first authorship, extraction and drafting of the manuscript, data collection, performed procedures; FG edited and revised manuscript initial draft of the manuscript, performed procedure; IN, TV, AD, NI contributed to the interpretation of the data of this project, reviewed this project critically for important intellectual content, revised the final form of this manuscript and edited discussion; VS collected the questionnaires, edited patient experience assessment; APB collected histologic reports, edited histologic findings on the initial data; MP supervised and conceived the project, performed procedures; ED, GN, AT performed statistical analysis of the data collected. All authors read and approved the final version of this manuscript. All authors contributed to editorial changes in the manuscript. All authors have participated sufficiently in the work and agreed to be accountable for all aspects of the work.

All subjects gave their informed consent for inclusion before they participated in the study. The study was conducted in accordance with the Declaration of Helsinki. For this study Institutional Review Board Approval was obtained by the University Hospital of Ioannina (IRB number 207/15-03-2020).

The authors of this manuscript would like to thank Mr. Michael Thompson for editing the final form of this manuscript as a native English speaker. His contribution is much appreciated.

This research received no external funding.

The authors declare no conflict of interest.