We appreciate the valuable comments by Timmermans et al. In our series the pain experienced during saline contrast sonohysterography (SCSH) was less than that during hysteroscopy or endometrial sampling1. We suggest taking pain experienced into account when defining diagnostic strategies, i.e. if at any point in a diagnostic tree two tests have a similar diagnostic value, it may be logical to choose the test that causes the least pain to the patient.

Although beyond the scope of our article, the comments of Timmermans et al. nicely illustrate that, besides the commonly quoted diagnostic accuracy, cost and procedure-related failure rates, the choice of a diagnostic strategy largely depends on the clinical setting (including the availability of ultrasound and/or office (operative) hysteroscopy, local referral policies, patients' population characteristics and clinicians' experience with the diagnostic procedures). Endometrial sampling may for instance be suitable as an initial diagnostic procedure in an extremely obese, hypertensive, postmenopausal patient in a setting without ultrasound facilities, if only malignancy is to be excluded. At the other end of the spectrum, if operative office hysteroscopy is available, diagnosis and treatment may be offered in a ‘one-stop clinic’ setting. In that case, a triage system (e.g. SCSH) might be considered in order to optimize time for the experienced operative hysteroscopist. That, in Belgium, the €27 specialist's fee for hysteroscopy is entirely reimbursed by the medical health system may be surprising to some, and illustrates the fact that the integration of costs in diagnostic algorithms may lead to different diagnostic strategies from one country to another. The patient's choice will thus largely depend on the information she receives. This information should rely on evidence-based data2, but in practice it also depends on the clinician's experience and on the setting in which she or he works.

We acknowledged in our paper that carrying out the tests in a particular order might have affected the results. In a randomized crossover study in patients on tamoxifen, comparing SCSH and office hysteroscopy, Timmerman et al.3 also showed that more patients preferred SCSH to hysteroscopy (P < 0.001). In the present study the patients were asked to compare the pain experienced during the different tests with the pain at dental care. Because we looked at intrapatient pain experience using paired tests, the type of dental care was of little importance.

Although a universally accepted strategy in the diagnosis of uterine pathology may remain a utopia, we believe that the pain experienced by patients is one of the variables that should be integrated into the design of further diagnostic algorithms.

T. Van den Bosch*, J. Verguts*, A. Daemen†, O. Gevaert†, E. Domali*, F. Claerhout*, V. Vandenbroucke*, B. De Moor†, J. Deprest*, D. Timmerman*, * Department of Obstetrics & Gynaecology, University Hospitals, 3000 Leuven, Belgium, † Electrical Engineering, ESAT-SCD, K.U.Leuven, 3000 Leuven, Belgium