We read with interest Cooper et al.’s1 systematic review and were pleased to read that a study from our Unit of ‘no-touch’ (vaginoscopic) hysteroscopy2 was included as one of the six high-quality randomised trials on which their analysis was based. We agree wholeheartedly with the conclusion that outpatient hysteroscopy should ideally be performed with minimal vaginal instrumentation.
There is one factual error, however, in this otherwise excellent overview. In their discussion of the circumstances in which a speculum may still be required, Cooper et al. state that, ‘A vaginal speculum is also required when a global endometrial biopsy is indicated’. This is factually incorrect. In 2004, we described a device which allows endometrial sampling to be performed at diagnostic hysteroscopy without additional instrumentation by the simple step of withdrawing the optic from the diagnostic sheath whilst it is still in the uterine cavity, and inserting a lengthened Pipelle sampler, the H Pipelle (‘H’ stands for hysteroscopy), into the uterus to obtain the biopsy.3 We have further shown that the use of the H Pipelle is associated with a shorter biopsy time and less patient discomfort than if a Pipelle is used following insertion of a vaginal speculum and tenaculum.4
The ethos of ‘no-touch’ hysteroscopy, a term we prefer to ‘vaginoscopic’, is to minimise vaginal instrumentation and thereby patient discomfort. It is logical to apply the same principles to biopsy the endometrium, and the H Pipelle makes this both possible and easy.