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Comment and Controversy

More tips for overcoming a resistant cervix

March 2008 · Vol. 20, No. 03
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“How to overcome a resistant cervix for hysteroscopy and endometrial biopsy,” by Joan M.G. Crane, MD, MSc (November)

I want to thank Dr. Joan Crane for her helpful article offering tips on dealing with a stenotic cervix. One suggestion I would like to add is to use a narrow loop electrode from the loop electrosurgical excision procedure (LEEP) to remove the stenotic portion of the external os. I tried this soon after LEEP devices became available and it worked well, allowing endometrial biopsy. Since then, I’ve seen at least one article describing this technique.

One other trick I’ve read about is to simply make a small incision or two to widen the os.

Jerome Sinsky, MD
Escondido, Calif

Dr. Crane responds: Use caution in women who may become pregnant

I thank Dr. Sinsky for his interest in my article. His suggestion to use LEEP to re-move the stenotic portion of the external os may be useful in some cases. However, I would suggest caution when considering its use in premenopausal women, particularly those who have not completed childbearing. Research has suggested that the LEEP procedure may increase the risk of preterm delivery. Although the LEEP would be shallow when used to overcome a stenotic or resistant cervix for hysteroscopy or endometrial biopsy, the potential for complications still exists.

As for the use of a shallow LEEP to remove a small portion of the external os, this strategy would be of benefit only if the stenosis is limited to the external os, as in some women who have undergone cryotherapy. However, cervical stenosis may exist throughout the cervical canal as well as at the internal os; in this situation, shallow LEEP may be of little benefit.

I would also suggest caution before making small incisions to widen the os when the patient has not completed childbearing, as this technique may increase the risk of cervical incompetence if the incisions are too deep. There is also a potential for bleeding.

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