Clinical practice in office hysteroscopy
Article information
, Hysteroscopy Committee of The Korean Society of Gynecologic Endoscopy (KSGE)10
Abstract
Hysteroscopy is particularly valuable for the diagnosis of uterine cavity abnormalities through direct visualization. The development of office hysteroscopy has expanded the range of diagnostic and surgical procedures available. These detailed guidelines include patient counseling and the selection and setting of office hysteroscopy, including room, equipment, and medical staff. Analgesia or local anesthesia is often required in selective office hysteroscopy cases. Cervical dilation and preparation using medical or mechanical methods are required for most diagnostic hysteroscopic procedures. Methods for optimizing visualization and choosing suitable distension media are important for a successful office hysteroscopy. It is crucial to adhere to guidelines to prevent complications, such as vasovagal syncope, cervical trauma, uterine perforation, fluid overload, and embolism. Vaginoscopy can be a good alternative option for alleviating pain, especially in cases where the insertion of a vaginal speculum is expected to be challenging.
Introduction
Hysteroscopy, performed as an outpatient procedure, is widely used for identifying uterine cavity lesions. It is a useful test for confirming the diagnosis of uterine cavity lesions through direct visualization, mainly in women with abnormal uterine bleeding. Hysteroscopy can be performed in an outpatient setting rather than in an operating room setting, which simplifies treatment, reduces the burden of costs, improves preoperative counseling, and avoids unnecessary procedures and exposure to anesthesia. Recently, with the development of endoscopic equipment and technology, simple endometrial lesion removal along with tissue biopsy has become possible with office hysteroscopy, and which can be performed in various situations to improve patient satisfaction and make a definite diagnosis [1].
In these guidelines, we aimed to provide clinicians with up-to-date evidence-based information to help them practice efficient hysteroscopy by increasing access to office hysteroscopy.
Patient counseling and selection
Office hysteroscopy is most commonly performed in patients with abnormal uterine bleeding. While ultrasound can assess the endometrium, it may fail to diagnose polyps or fibroids in the uterine cavity in approximately one in six cases. Thus, hysteroscopy may be performed if imaging findings are abnormal or equivocal. Additionally, if a thickened endometrium is discovered incidentally on ultrasound, especially in patients taking tamoxifen, hysteroscopy can help visualize and diagnose uncertain intrauterine lesions. It can also be used in cases of persistent discharge after endometrial ablation, removal of foreign bodies or retained intrauterine devices, abnormal hysterosalpingography, suspected intrauterine adhesions, habitual miscarriage, Müllerian anomalies, and uterine septum evaluation [2-5].
Office hysteroscopy enables the evaluation of the vagina, cervix, and uterine cavity, which helps in selecting appropriate surgical equipment and estimating surgical time. Simple procedures, such as endometrial sampling, lysis of intrauterine adhesions, and removal of endometrial/endocervical polyps, small leiomyomas, retained products of conception, and intrauterine devices, can be accomplished, potentially avoiding unnecessary surgery [3].
For a successful office hysteroscopy, it is crucial to set appropriate expectations for the procedure, including potential discomfort, expected duration, and goals [3]. This information will help in making decisions regarding anesthesia or pain management for patients. There should be a sufficient preprocedure explanation regarding the discomfort level and duration of office hysteroscopy, and efforts should be made to minimize the patient’s pain in the shortest time possible. In addition, verbal reassurance of the patient during the procedure is necessary. The key aspects to be assessed in the patient history include obstetric history, medical conditions, history of sexual abuse, presence of chronic pain, and previous cervical procedures [3,4]. To rule out pregnancy, a urine pregnancy test should be conducted, or hysteroscopy should be performed immediately after menstruation. If there is an active pelvic inflammatory disease or active genital infection, such as herpes, hysteroscopy should be postponed until after treatment.
In outpatient settings, hysteroscopy may fail in cases of cervical stenosis, poor visualization, or inability to tolerate pain. Therefore, patients with cervical stenosis, those who cannot assume the required position, severely ill patients requiring intensive monitoring, and those unable to endure the procedure under local anesthesia should be excluded [3,4].
Setting for performing hysteroscopy
1. Room
The procedure space should prioritize patient safety and comfort. It should be private yet welcoming, separate from typical operating rooms used for general anesthesia. The room should be sufficiently large for equipment setup and medical staff movement and should include space for the patient to change and a restroom. There should be a comfortable recovery area and emergency equipment. Proper cleanliness and ventilation to filter contaminants are essential.
Equipment
The basic equipment includes a hysteroscope, a distension media injection system, and sterilization equipment, with additional items, such as cameras and monitors, used as needed. The hysteroscope should be thoroughly cleaned, disinfected, and sterilized before each use. Hysteroscopes come in various sizes (3-10 mm diameter), lens angles (0-70°), and lengths (160-302 mm). They can be rigid or semirigid/flexible. Rigid hysteroscopes have an outer sheath with channels for the endoscope, distension media, and surgical instruments. Instruments include biopsy tools, forceps, and scissors. The quality of the surgical field depends on the quality of the endoscope and camera, with larger diameters generally providing better image quality. The endoscope can be used directly through the ocular lens or with a camera and monitor to share views with the patient and other medical staff. The light source is typically either halogen or xenon, with halogen being the more economical option.
1. Size and angle of hysteroscope
The size of a hysteroscope typically refers to its outer diameter, ranging from 3-12 mm. For outpatient hysteroscopy, a 2.7 mm endoscope with a 3-3.5 mm sheath is commonly used. Smaller hysteroscopes generally cause less discomfort and require less cervical dilation. Larger hysteroscopes (5 mm or more) may necessitate cervical dilation and analgesics. Four randomized controlled trials studied the impact of hysteroscope diameter on patient pain during outpatient hysteroscopy [5-9]. These studies compared 5 mm diameter hysteroscopes with mini-hysteroscopes (3 mm or 3.3 mm, 3.5 mm). Three of the studies found that smaller-diameter hysteroscopes significantly reduced pain whereas the remaining study reported no significant difference. However, while the success rate of mini-hysteroscopes was higher than that of 5 mm hysteroscopes in two studies, the other two studies showed no significant difference. Therefore, the use of a smaller-diameter hysteroscope is recommended to minimize procedure-related pain although the success rate of mini-hysteroscopy can vary. To date, no randomized clinical trials have analyzed the effect of the hysteroscope lens angle on surgical outcomes. The 0° lenses offer a more intuitive view, thereby reducing the need for cervical dilation and potential cervical damage. However, fore-oblique lenses provide a wider field, facilitating observation of specific areas and easier instrument insertion. The choice of lens should be based on the specific case and the surgeon’s preference. It is easier for the surgeon to observe the cornual recess and tubal ostia while minimizing hysteroscope movement. Additionally, when inserting instruments such as forceps into the hysteroscope, it is easier to see the entry of these instruments, which is advantageous during operative hysteroscopy. Each type has its advantages and disadvantages, and there is insufficient evidence to recommend a specific type uniformly for all patients.
2. Flexible or rigid hysteroscopy
When setting up for outpatient hysteroscopy, consider whether to use a flexible or rigid hysteroscope based on the intended diagnostic and therapeutic ranges. Flexible hysteroscopes generally cause less pain and fewer vasovagal reactions, but may have poorer visualization and higher failure rates at a high cost [10]. There is also a lack of clear evidence regarding the type of hysteroscope that should be preferred for diagnostic outpatient hysteroscopy; therefore, the choice should be made at the discretion of the surgeon. Two randomized controlled trials compared flexible and rigid hysteroscopes in outpatient hysteroscopy [11,12]. Both studies reported that flexible hysteroscopes resulted in significantly less pain than rigid hysteroscopes. No studies have compared flexible hysteroscopy with vaginoscopy; therefore, there is insufficient evidence to make recommendations.
3. Medical staff
The medical team should be skilled and knowledgeable in hysteroscopy. At least one nurse should assist with preparation and support regardless of the procedure type. Ideally, another nurse should monitor the patient’s condition, provide reassurance, and alleviate anxiety.
Optimization of visualization
Performing hysteroscopy when the endometrium is thin can shorten the procedure time and reduce media absorption, making the procedure easier. The best time to perform hysteroscopy in premenopausal women with regular menstrual cycles is during the follicular phase after menstruation. It is confirmed that the patient is not pregnant before the procedure. Performing hysteroscopy during the luteal phase may lead to the misinterpretation of normal endometrial thickening as a pathology. For women with irregular cycles, the procedure can be performed at any time; however, heavy bleeding may compromise the visibility. Preprocedural medication with progestins or combined oral contraceptives may thin the endometrium and improve visualization [13,14]. Studies have suggested that short-term use of oral contraceptives before hysteroscopy can enhance visualization and procedural satisfaction. Previous reports have indicated that even a short course of oral contraceptives before surgery can improve visualization during hysteroscopy and increase surgical satisfaction. One study found that when combined oral contraceptives were started during the early follicular phase, endometrial thickness remained at an average of 4.1 mm by the 18th day of treatment. Another report described a regimen where, to maximize the effect of the Qlaira (Bayer, Pimble, Austrailia) contraceptive pill, patients took a medication containing dienogest 3 mg and estradiol 2 mg starting from the 8th day (day 1-7 of the medication, avoiding estradiol 2 mg and dienogest 2 mg) [15]. This study showed that the endometrial lining was more atrophied, regular, and pale in the group taking Qlaira (Bayer) than in those not on the pill, with higher satisfaction reported by both the physician and the patients in the contraceptive group. There are reports indicating that when dienogest was administered for approximately 2 weeks before hysteroscopic surgery, endometrial thickness decreased from 7 mm before treatment to 3.9 mm after treatment. Therefore, administering dienogest for approximately 2 weeks before surgery is considered beneficial for improving visualization during the procedure [16]. Administering gonadotropin-releasing hormone (GnRH) agonist nafarelin nasal spray 200 μg every 12 hours, before submucosal myomectomy, can thin the endometrium, reduce intraoperative bleeding, and improve visualization during the procedure [17]. However, because of the potential side effects of the medication, it is not recommended for all patients. Nonetheless, administering GnRH agonists to women with severe anemia before surgery can help increase hemoglobin levels and improve preoperative preparation.
Analgesia, local anesthesia, sedation
1. Analgesia
Routine use of opiate analgesia before outpatient hysteroscopy should be avoided because it may cause adverse effects. Women without contraindications should be advised to take standard doses of nonsteroidal anti-inflammatory agents approximately 1 hour before their scheduled outpatient hysteroscopy appointment to reduce pain in the immediate postoperative period [1].
2. Local anesthesia
Routine cervical dilatation is associated with pain, vasovagal reactions, and uterine trauma, and should therefore be avoided. Cervical dilatation to facilitate the insertion of an outpatient hysteroscope is unnecessary in most procedures. Cervical dilatation generally requires local cervical anesthesia. Standard protocols regarding the type, maximum dosage, and route of administration of anesthetic should be developed and implemented to help recognize and prevent rare but potentially serious adverse effects resulting from systemic vascular absorption. Instillation of a local anesthetic into the cervical canal may reduce the incidence of vasovagal reactions. However, it does not reduce the pain during diagnostic outpatient hysteroscopy. Topical application of a local anesthetic to the ectocervix should be considered when application of a cervical tenaculum is necessary. Application of a local anesthetic to or around the cervix (paracervical block with 8-11 mL of 1% lidocaine) may reduce the pain experienced during outpatient diagnostic hysteroscopy. In postmenopausal women, routine administration of intracervical or paracervical local anesthetic should be considered [1].
Increasing the use of the vaginoscopic technique and decreasing the diameter of hysteroscopes may diminish the advantages of intracervical or paracervical anesthesia. Routine administration of intracervical or paracervical local anesthetic should be used when larger-diameter hysteroscopes are being employed (outer diameter greater than 5 mm) and when the need for cervical dilatation is anticipated (e.g., cervical stenosis). The routine administration of intracervical or paracervical local anesthetic is not indicated to reduce the incidence of vasovagal reactions [1].
3. Sedation
Sedation should not be routinely used in outpatient hysteroscopic procedures as it provides no advantage in terms of pain control or patient satisfaction over local anesthesia [1].
Appropriate monitoring and staff skills are mandatory to avoid life-threatening complications if the procedures are to be performed under sedation [18]. Regional anesthesia and simple sedation are options for operative hysteroscopy and can be considered alternatives to general anesthesia [19,20].
Cervical preparation and cervical dilatation
There is conflicting or insufficient evidence regarding routine cervical preparation or ripening prior to diagnostic or operative hysteroscopy [21-23]. However, each has shown promising effects [21,22]. For patients expected to have cervical stenosis or severe pain, cervical preparation should be considered, and the potential benefits of a drug must be weighed against the increased risk of side effects [23]. One option that has been widely evaluated regarding dosage, route of administration, and effects is prostaglandins, such as misoprostol [24]. For hysteroscopy in the operating room or the office setting, misoprostol has been investigated at various dosages, most frequently 200-400 μg, alone or with vaginal estrogen, and at different administration routes, including sublingual, oral, or vaginal. Compared to a placebo, misoprostol administration has demonstrated improved ease of cervical dilatation or a decreased need for dilatation, resulting in easy cervical entry, decreased pain, and decreased procedure times [25-30]. Another option is the use of osmotic dilators such as laminaria, which have been compared to misoprostol. Osmotic dilators also have improved difficulties regarding mechanical cervical dilation with similar side effects, but depending on the case, additional hospital visits for osmotic dilator insertion prior to hysteroscopy may be the reason for discarding these options [23,31].
A few studies have investigated local cervical injections of vasoconstricting agents such as vasopressin or epinephrine to decrease blood loss and fluid absorption, increase anesthetic effects, and prevent local anesthetic systemic complications [32]. Because of the potential for rare but serious cardiovascular events, including bradycardia, hypotension, hypertension, and heart attack, vasoconstricting agents should be administered with caution, especially in an office setting [33,34].
Distension media
Selecting an appropriate distension medium for hysteroscopy involves considering visibility, avoiding damage related to the cautery, cost, and safety. The ideal medium should be non-toxic, non-allergenic, non-hemolytic, and quickly removed from the body. To assess the entire uterine cavity, it is essential to use a distension medium that expands it adequately. However, it is important to apply minimal pressure to avoid excessive distension of the uterus, which can cause pain [10].
1. Distension media and pain
A systematic review of six studies examined whether there were differences in pain induction when using saline versus carbon dioxide as the uterine distension medium [35]. The results indicated no statistically significant difference in pain levels between the use of carbon dioxide and saline as the uterine distension medium during office hysteroscopy [35]. However, isotonic saline is often preferred for its visibility and reduced incidence of vasovagal side effects compared to carbon dioxide [36].
2. Visualization
If the expansion medium sufficiently expands the uterine cavity, it is also important to consider which medium provides the highest-quality images. In four randomized controlled trials, the quality of the hysteroscopic images was compared and analyzed among different uterine expansion media. Three studies reported no statistically significant difference in image quality when comparing carbon dioxide to saline [37-39]. However, there was a higher risk of obtaining unsatisfactory hysteroscopic images when using carbon dioxide as the expansion medium. This was mainly because the visibility was obstructed by air bubbles and bleeding. Saline appears to be advantageous for removing bleeding or mucus that could obscure the hysteroscopic view while washing the uterine cavity [36].
3. Association with operative time
In outpatient hysteroscopy, where the procedure must be completed quickly without anesthesia, the use of saline, which provides clear visualization, and was associated with shorter procedure times. This finding was also statistically significant in a meta-analysis [36].
4. Selection of expansion media in surgical outpatient hysteroscopy
If using a bipolar cautery during hysteroscopic surgery, saline should be used as the uterine expansion medium [10,40]. Therefore, if both diagnostic and therapeutic procedures are anticipated, it would be more logical to use saline from the beginning to avoid having to change the expansion medium mid-procedure when using surgical instruments. Hysteroscopic cautery requires a liquid uterine expansion medium, and depending on the technique used, either saline or glycine solution can be chosen. Utilizing an automated solution pump and monitoring system can be helpful in administering the uterine expansion medium. Therefore, when performing outpatient hysteroscopy, it is important to thoroughly consider the above factors when deciding which expansion medium to use.
5. Complications or side effects of distension media and prevention
Acute noncardiogenic pulmonary edema, bronchial edema, and dilutional anemia can result from fluid overload. Hypoatremia, storage disorders, hyperammonemia, hyperglycemia, and acidosis can result from electrolyte or plasma imbalances. Neurological sequelae such as lethargy, visual disturbances, excessive sleepiness, confusion, seizures, coma, and gas embolism can result from distension media use [40-45].
To prevent fluid overload, isotonic electrolyte solutions can be used and preoperative intravenous fluids limited. In cases in which large fibroids need to be resected, the procedure should be performed after adequate anesthesia, and the solution levels should be continuously monitored during the procedure. The procedure should be discontinued when necessary. The intrauterine pressure should be approximately 70-80 mmHg, although it may sometimes be increased to 125-150 mmHg [40,41]. The procedure should be completed within 1 hour whenever possible [40]. Gas embolism is a potential complication primarily associated with surgical hysteroscopy, with dyspnea being the main symptom. Additionally, an increase in end-tidal carbon dioxide pressure may suggest the presence of gas embolism. If gas embolism is suspected, the procedure should be immediately discontinued, and the causative solvent or gas should be removed to reduce uterine cavity expansion [37,44,45].
Vaginoscopy
Vaginoscopy is a technique in which a hysteroscope is inserted to observe the vagina, cervix, and uterine cavity without using a vaginal speculum or cervical tenaculum [1]. Small-diameter (less than or equal to 3.5 mm) rigid or flexible hysteroscopes are suitable instruments for vaginoscopic procedures [18]. By tilting the table backward, expansion of the vaginal canal through the use of normal saline enables simultaneous visualization of the cervix and vagina; then, the scope proceeds through the cervical canal and enters the uterine cavity [10]. Fluid leakage from the vagina can be reduced by manually compressing the labial tissue to narrow the vaginal introitus [1]. As this technique is feasible without cervical preparation, it can be useful for examining children or nulliparous patients without concerns of hymen injury.
Vaginoscopy should be the standard technique for outpatient diagnostic hysteroscopy and may be the preferred method, especially in cases where inserting a vaginal speculum is expected to be challenging [10,18]. Its feasibility was reported to range from 83% to 98%, and no significant difference was found in the number of failed procedures when compared with traditional hysteroscopy [1,18,35,46-49].
Vaginoscopy alleviates pain during diagnostic rigid outpatient hysteroscopy [10,35,38,47,50]. According to a randomized study, when compared with conventional hysteroscopy, with respect to median visual analogue scale (VAS) score, the vaginoscopy showed a significant reduction in procedural pain, and with a VAS score of 0.5 (P<0.0001) with similar efficacy [48]. Clinicians performing office hysteroscopy should consider the vaginoscopic technique because it makes office hysteroscopy quicker and less painful and reduces the likelihood of inducing a vasovagal reaction [51].
Complications
Hysteroscopy is considered a safe, minimally invasive procedure. However, several complications have been reported. Most complications of hysteroscopy are rare and if they do occur, are seldom life threatening, particularly in diagnostic procedures.
1. Vasovagal syncope
As vasovagal syncope is the most common complication during office hysteroscopy, physicians should prepare for its management. The vasovagal reflex commonly occurs when the cervix is dilated or when the hysteroscope is passed through it. The prevalence of vagal reactions (1 in 300 cases) depends on the ability of the hysteroscopist and the lesion diameter [52]. The first step, when a patient complains of prodromal symptoms (e.g., warmth, nausea) and when vital signs show a decrease in blood pressure and/or bradycardia, is to pause the procedure and assess the airway, breathing, and circulation [53]. In this situation, the patient is placed in the Trendelenburg position for physical counter maneuver therapy to increase central blood volume and cardiac output.
2. Cervical trauma
Office hysteroscopic procedures can often be performed without cervical dilation, particularly if the vaginoscopic technique described by Bettocchi and Selvaggi [54] is used. However, surgical procedures under hysteroscopy may also require cervical dilation. It is best to avoid overdilation of the cervix because this can result in leakage of the distending media through the cervix and around the hysteroscope. Trauma can be managed using pressure, silver nitrate, or sutures, and the introduction of a hysteroscope under direct vision can be prevented.
3. Uterine perforation
Uterine perforation is a common complication of diagnostic and operative hysteroscopy [55]. The incidence of uterine perforation during diagnostic hysteroscopy under general anesthesia is considered to be as low as 8/1,000 [56]. Perforation can occur at any point during the procedure but is more common when the resection extends into the uterine myometrium [57]. If the patient is hemodynamically stable and there is low suspicion of vascular or visceral damage, laparoscopy or exploratory laparotomy is not needed [58]. Bleeding alone without uterine perforation may occur with deep dissection of the myometrium and intersection with a perforating vessel. This complication is more common with operative hysteroscopy and removal of type I and type II subserosal fibroids. Bleeding may be managed with electrocautery, uterotonics such as oxytocin, or Foley balloon catheter placement [59].
4. Fluid overload
The fluid deficit is carefully calculated intraoperatively to quantify the amount of fluid that the patient is absorbing into the circulation. Of particular concern is the risk of hyponatremia and resulting cerebral edema, especially when electrolyte-free hypotonic solutions are used. Cerebral edema may manifest with symptoms of nausea and vomiting, dizziness, shortness of breath, or headache. The mechanism of fluid absorption involves the amount of intrauterine pressure created by hysteroscopic fluid management systems and the venous absorption of distending media [60]. This disease is known as operative hysteroscopy intravascular absorption syndrome (OHIA) [59]. In women with comorbidities such as cardiac or pulmonary conditions that compromise hemodynamic stability, surgeons should consider terminating the procedure with fluid deficits of 1,000 mL or 750 mL of an isotonic or hypotonic solution, respectively. OHIA can be avoided by closely monitoring the fluid status. Patients at risk for OHIA may be identified beforehand by assessing the estimated procedure time, risk of incomplete resection of intrauterine pathology, and existence of comorbidities.
5. Embolism
Carbon dioxide embolism may occur during hysteroscopy if carbon dioxide is used as the distending medium. This complication can be catastrophic if it occurs because of the potential for cardiac failure, leading to death [61-63]. A limited number of studies have shown a wide range of air embolism rates, from 10% to 50%, with the use of carbon dioxide [60]. If this complication is suspected, the anesthesia team should immediately advise the surgeon, and the procedure should be terminated. The Durant position (patient placement in the left lateral decubitus position) and Trendelenburg position may assist in the migration of air away from the right ventricular outflow tract. If cardiac arrest occurs, cardiac catheterization may be performed to relieve the embolized air from the cardiovascular system.
6. Delayed complications
The incidence of infections was reported to be 2/1,000 in more than 4,000 diagnostic hysteroscopies [52]. Acute pelvic inflammatory disease following hysteroscopic surgery is rare. Diagnosis is based on classic signs and symptoms, and treatment should be administered using appropriate antibiotics. Vaginal discharge is a common self-limiting symptom after any ablative procedure and can be prolonged for 2 or 3 weeks. Patients should alert their healthcare providers if the vaginal discharge becomes offensive or if they develop pyrexia, heavy bleeding, or severe lower abdominal pain. Intrauterine adhesions are common, especially after myomectomy, when two fibroids are situated on opposing uterine walls. An intrauterine device and 2 months of estrogen administration and progestogen therapy, such as combined oral contraceptives, can help prevent adhesion formation [52].
Special considerations for office hysteroscopy
If the technology is available, endometrial polyps can be treated using office hysteroscopy. Office hysteroscopic polypectomy is safe, well tolerated, and more cost-effective than traditional inpatient hysteroscopic polypectomy [64]. In a multicenter randomized trial, outpatient polypectomy was found to be noninferior to inpatient polypectomy for the treatment of abnormal uterine bleeding, with similar treatment effects maintained at 12 and 24 months [65]. A multicenter prospective observational trial found that office hysteroscopic polypectomy may be associated with a higher risk of failure or incomplete polyp removal. In contrast, inpatient hysteroscopic polypectomy may be associated with a greater risk of complications [66].
Conclusion
These clinical guidelines provide necessary information for clinicians performing office hysteroscopy aiming for evidence-based and effective diagnosis and treatment. Continuous research and feedback will help refine these guidelines as the use of office hysteroscopy evolves.
Notes
Conflict of interest
The authors report no conflicts of interest.
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