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HYSTEROSCOPY

TOPICS
INTRODUCTION

A hysteroscopy is a telescope that is


inserted into the uterus via the vaina and
cervi! to visuali"e the endo#etrial cavity$
as %ell as the tu&al ostia$ endocervical
canal$ cervi!$ and vaina
INDICATIONS

A&nor#al pre#enopausal or post#enopausal uterine &leedin

Endo#etrial thic'enin or polyps

Su&#ucosal$ and so#e intra#ural$ (i&roids

Intrauterine adhesions

)*llerian ano#alies +e$ uterine septu#,

Retained intrauterine contraceptives or other (orein &odies

Retained products o( conception

Desire (or sterili"ation

Endocervical lesions

Hysteroscopy cannot assess #yo#etrial


disease$ tu&al patholoy$ or the e!ternal
uterine contour-

Additional procedures +e$ laparoscopy or


hysterosalpinoraphy, are necessary-
CONTRAINDICATIONS

.ia&le intrauterine prenancy

Active pelvic in(ection +includin enital


herpes in(ection -

cervical or uterine cancer


CONTRAINDICATIONS

E!cessive uterine &leedin #ay li#it


visuali"ation durin hysteroscopy$ &ut it is not a
contraindication

)edical co#or&idities +e$ coronary heart


disease$ &leedin diathesis, are also potential
contraindications -

Ho%ever$ since this is a #ini#ally invasive


procedure$ it is rarely contraindicated in (e%
%o#en
INSTRU)ENTATION

The riid hysteroscope includes an outer


sheath %hich surrounds channels (or the
telescope$ in(lo% and out(lo%$ and
operative instru#ents-

Additional e/uip#ent is needed (or in(usin


and #onitorin uterine distendin #edia-

There are #any di((erent si"es and type o(


hysteroscope-

So#e are &etter suited (or dianostic


versus operative procedures$ or (or
outpatient rather than operatin roo#
procedures
Outer dia#eter and %or'in lenth

The total outer dia#eter +OD, o( a hysteroscope


re(ers to the dia#eter o( the sheath$ a #etal tu&e
%hich houses the telescope and instru#ents- Sheath
ODs rane (ro# 0-1 to 12 ##-
S#aller OD hysteroscope cause less pain and
decrease the need (or #echanical dilation-

Even reducin the sheath si"e (ro# 3 to 0-0 ## can


i#prove patient co#(ort

insertin a hysteroscope %ith 43 ## OD %ill re/uire


#echanical cervical dilation5

#ost patients %ill e!perience disco#(ort and %ill


re/uire analesia +e$ paracervical&loc'$nonsteroidal
aents,-

In addition$ analesia is typically re/uired (or


operative procedures-

Dianostic procedures per(or#ed %ith s#aller OD


sheaths can usually &e per(or#ed %ithout dilation and
in the o((ice-

6oth dianostic and operative sheaths are (itted %ith stopcoc's


or ports (or the instillation o( distendin #edia- To clear &lood
and thus i#prove visuali"ation o( the uterine cavity$ so#e
operative sheaths have dual ports that provide continuous
la#inar (lo% o( distendin #edia- In addition$ so#e operative
sheaths aspirate pieces o( tissue (ro# the uterine cavity +ie$ to
re#ove de&ris or retrieve speci#ens (or patholoic evaluation,-
This allo%s re#oval o( lare de&ris %hile #aintainin cervical
dilation
Selected dianostic hysteroscopes per#it tareted &iopsies and retrieval o(
(orein &odies$ as %ell as li#ited intrauterine surery +re#oval o( (il#y adhesions
or s#all endo#etrial polyps,-
Si#ple operative sheaths use the distendin #edia channel (or the insertion o(
instru#ents- Althouh this #ethod is easy and allo%s one to use a s#all7
dia#eter sheath$ lea's o( #edia are co##on-
Advanced operative sheaths #ay have three channels8 t%o (or operative
instru#ents and one (or instillin distendin #edia-
Other operative sheaths contain per#anently attached operative tools$ such as
&iopsy instru#ents$ (orceps$ or scissors
9or'in lenth

The %or'in lenth o( a hysteroscope


#easures (ro# the eyepiece to the distal
tip$ and rane (ro# 1:2 to 02; ##-

A loner %or'in ele#ent per#its the


hysteroscopist to &e (urther a%ay (ro# the
vaina
Riid versus (le!i&le

)ost hysteroscopes are riid$ &ut narro% cali&er


scopes +<3 ##, #ay also &e se#i7riid or (le!i&le-
Riid hysteroscopes cause #ore intraoperative pain$
&ut o((er &etter optical /uality and are less costly-

=le!i&le hysteroscopy is especially use(ul (or dianostic


or operative procedures in %o#en %ith an irreularly
shaped uterus$ as the distal tip can &e de(lected up%ard
or do%n%ard +e$ (or tu&al cannulation or lysis o(
adhesions near the tu&al ostia
OPTICS
DISTENDIN> )EDIA

A uterine distendin #ediu# is used to allo% a lo&al


vie% o( the endo#etrial cavity-

Car&on dio!ide and lo% viscosity (luids are the #ost


(re/uently used distendin #edia-

Each #ediu# has advantaes and disadvantaes$


includin speci(ic sa(ety concerns-
Contact hysteroscopy

Contact hysteroscopy is another #ethod$


&ut it is rarely per(or#ed- Since no
distendin #ediu# is used$ only tissue in
direct contact %ith the scope can &e
vie%ed -
CHARACTERISTICS O= DISTENDIN>
)EDIA
Allo%s clear visuali"ation

Nonconductive +to avoid electrocautery7related in?ury,

Ine!pensive

Since distendin #edia are a&sor&ed$ a #ediu# should also


&e8

Nonto!ic

Hypoallerenic

Non7he#olytic

Isoos#olar

Rapidly cleared (ro# the &ody


=luid #edia

@o%7viscosity (luids are used (or uterine distension


durin hysteroscopy-

Hih7viscosity (luids +ie$ 0; percent de!tran A2


BHys'onCD, have little role in #odern hysteroscopy
&ecause they are associated %ith increased ris' o(
co#plications +e$ electrolyte i#&alance$
anaphyla!is$ and disse#inated intravascular
coaulation, and can ruin e!pensive hysteroscopic
e/uip#ent B;$0D-
=luid #edia

=luid distendin #edia #ay &e either electrolyte


+e$ nor#al saline$ lactated RinerEs, or
electrolyte7poor +e$ lycine$ sor&itol$ #annitol,-

The choice o( (luid type depends upon %hether


a dianostic or operative procedure is planned
and on the sureonEs choice o( e/uip#ent +ie$
#onopolar or &ipolar enery source,-

Each type o( (luid can result in co#plications i(


not used properly
Electrolyte
There are t%o types o( lo%7viscosity distendin #edia8 those that
contain electrolytes and those that do not-
The electrolyte7containin #edia include nor#al saline and lactated
RinerEs solution and cannot &e used %ith #onopolar
electrocautery &ecause they conduct electric current +&ut can &e
used %ith #echanical$ laser$ or &ipolar enery,-
The electrolyte7poor solutions are 3 percent de!trose$ 1-3 percent
lycine$ 0 percent sor&itol and 3 percent #annitol$ and are used
%ith #onopolar enery syste#s-
Electrolyte

The electrolyte (luids used (or hysteroscopy are


isoos#olar +isotonic,$ and thus do not distur&
the os#olar &alance &et%een intracellular and
e!tracellular (luid- 9hile the ris's o( (luid
a&sorption are associated #ainly %ith
electrolyte7poor (luids$ intravasation o( lare
volu#es o( electrolyte (luid can also lead to (luid
overload +e$ pul#onary ede#a
Electrolyte7poor
The electrolyte7poor (luids that are used #ost co##only (or hysteroscopy are8 1-3 percent
lycine$ 0 percent sor&itol$ 3 percent #annitol-
Each has di((erent properties and is #eta&oli"ed &y a di((erent #echanis# +ta&le 1,- The
physioloy o( these (luids is discussed in detail separately- +See FHyponatre#ia
(ollo%in transurethral resection or hysteroscopyF-,
All the electrolyte7poor (luids used in hysteroscopy can lead to hyponatre#ia i( a lare
volu#e is a&sor&ed- )annitol di((ers (ro# the others &ecause it is isoos#olar$ &ut is not
co##only used &ecause it is not availa&le in the 0 @ &as typically used (or hysteroscopy
In(lo% and #onitorin
In(lo% and #onitorin are controlled &y the hysteroscope and the (luid
in(lo% syste#-
The sureon should &e (re/uently updated reardin the (luid de(icit$
particularly %hen the de(icit approaches 322 #@- +9e pre(er a
hysteroscope that has a dual outer sheath or dual port syste# %ith an
out(lo% port that can &e directly connected to a vacuu# collectin
syste#- This ives an accurate assess#ent o( the (luid de(icit$ as less
#edia is lost in the drapes$ to%els$ or on the operatin roo# (loor-
Use o( an auto#ated (luid pu#p and #onitorin syste# is advocated
&y &oth the A#erican Collee o( O&stetricians and >ynecoloists and
the A#erican Association o( >ynecoloic @aparoscopists B3$:D-
Auto#ated syste#s have the (ollo%in advantaes over #anual set7
ups8
Continually #easure (luid de(icit and provide auto#ated alerts
)easure and titrate intrauterine (luid pressure

)ost auto#ated hysteroscopic pu#p syste#s allo% you to set


the desired intrauterine pressure #anually$ and the syste# %ill
then ad?ust the (lo% o( (luid to #aintain this pressure- In addition$
auto#ated pu#p syste#s should &e set to ive audi&le alerts at
each ;32 #@ o( additional (luid de(icit-

Titratin intrauterine pressure is i#portant to #anae &leedin$


(acilitate (ull resection o( endo#etrial lesions$ and decrease
F(alse7neativeF vie%s o( the endo#etrial cavity that #ay occur
%ith hiher or constant endo#etrial pressure-
Pressure

@o%est pressure should &e use that allo%s opti#al


visuali"ation-

typically$ intrauterine pressure ranes (ro# A2 to G2 ##H-

Hiher pressures +up to 122 ##H, #ay &e re/uired (or


patients %ith intrauterine &leedin$ &lood clots$ or other
de&ris5 a uterine %all that is less co#pliant5 or a uterus that
is lare andHor has intra#ural (i&roids-

A hiher intrauterine pressure #ay result in


increased a&sorption or e!travasation o( the
distendin #ediu#-

Thus$ i( a hiher pressure is used$ the (luid


de(icit should &e #onitored closely$ the
procedure should &e per(or#ed as /uic'ly as
possi&le$ and the pressure should &e lo%ered
i( the hiher pressure is no loner needed-
9here auto#ated syste#s are not availa&le$ a #anual techni/ue is used- =luid is in(used usin the (orce o( ravity +ie$ elevatin the
(luid &a, or &y placin the (luid &a in a lare &lood pressure cu(( and in(latin the cu((- =luid input and output are recorded #anually-
A surical sta(( #e#&er should &e desinated to (re/uently #easure the input and output and report the de(icit to the sureon- To
record (luid input #anually$ the volu#e o( (luid in each &a #ust &e 'no%n- So#e sureons #a'e calculations &ased on the co##on
assertion that (luid &as are enerally over(illed &y 12 percent or #ore +e$ a 1222 #@ &a o( nor#al saline is considered to have
1122 #@ or #ore,5 this leads to an overesti#ate o( the (luid de(icit- Ho%ever$ a study o( &as o( nor#al saline$ lycine$ and sor&itol
(ound that the averae over(ill %as only 0 to : percent o( the &a volu#e BAD +see E=luid overloadE &elo%,-
To avoid hypother#ia durin loner procedures +ie$ operative versus dianostic hysteroscopy,$ (luid distendin #edia should &e
%ar#ed to roo# te#perature at a #ini#u#5 hypother#ia #ay potentiate the ris' o( acide#ia and cardiac arrhyth#ias BGD-
>aseous #edia I Car&on dio!ide is the only aseous #ediu# used in hysteroscopy5
it is used solely (or dianostic hysteroscopy- It provides a clear (ield o( vie%$ is rapidly
a&sor&ed$ and has a lon history o( sa(ety in tu&al patency testin BJD5 it is also %idely
availa&le and #a'es cleanin o( instru#ents easy- Ho%ever$ it is &est suited (or
dianostic rather than operative hysteroscopy$ since as &u&&les (or# in association
%ith intrauterine &leedin and i#pair visuali"ation B12D-
Car&on dio!ide #ust &e insu((lated %ith a special instru#ent 'no%n as a
hysteroinsu((lator +see EPrevention o( as e#&olis#E &elo%,-
E((ects on operative visuali"ation

The anle o( vie% and #ani(ication vary %ith the


re(ractory inde! o( the distendin #ediu#-

>aseous #edia +e$ car&on dio!ide, allo%


perception o( the #a!i#al anle o( vie%$ %hile
li/uid #edia reduce the anle o( vie%

Use o( aseous #edia is usually li#ited to


dianostic procedures$ since as &u&&le #ay
inter(ere %ith visuali"ation
CO)P@ICATIONS AND AD.ERSE E==ECTS

=luid overload I rare$ occurrin in 2-2: to


2-; percent o( operative hysteroscopy
proceduresD-

Co#plications related to distendin #edia


vary accordin to the patient and the
#ediu# used-

A patientEs a&ility to adapt to (luid overload


varies %ith ae and co#or&id conditions-

A&sorption o( lare volu#es o( electrolyte7poor (luid #ay result


in 8

.olu#e overload K acute deco#pensated heart (ailure$


pul#onary ede#a$ dilutional ane#ia
Electrolyte or other plas#a i#&alance K hyponatre#ia$
hypoos#olality$ hypera##one#ia$ hyperlyce#ia$ acidosis

Neuroloic se/uelae K slurred speech$ visual distur&ances$


hyperso#nia$ con(usion$ sei"ures$ co#a

Durin hysteroscopy$ a&sorption is


increased %hen venous sinuses are
e!posed +e$ durin #yo#ecto#y,-

#ini#al (luid e!travasates throuh the


=allopian tu&es5 history o( prior sterili"ation
does not alter total a&sorptionD-

Hyponatre#ia is a particular ris' %ith


electrolyte7poor (luids
Prevention o( (luid overload

Use isoos#olar$ electrolyte (luids %henever


possi&le

)onitor (luid de(icit closely and halt the


procedure and evaluate (or (luid7related
co#plications at a&sorption thresholds

)aintain intrauterine (luid pressure at or A2


to G2 ##H-

@i#it surical ti#e to <1 hour


Dianosis and #anae#ent o( (luid
overload
I Serious co#plications o( electrolyte7poor (luid overload have
&een reported at a (luid de(icit o( 322 to 1222 #@ and are #ore
li'ely to occur in patients %ith co#or&idities +e$ heart disease,-
Thus$ dependin upon the type o( (luid used and the health status
o( the patient$ %hen the (luid de(icit reaches 322 #@$ the surical
tea# should pause and assess patient status- A(ter esti#atin the
a#ount o( ti#e necessary to co#plete the procedure$ the tea#
should either e!pedite the co#pletion o( the procedure or ter#inate
the procedure-

=or nonconductive$ electrolyte7poor (luids$


the procedure should &e ter#inated %hen
1222 #@ has &een a&sor&ed and the
patient evaluated (or hyponatre#ia-
=or nonconductive$ electrolyte7poor (luids$ the procedure should &e ter#inated
%hen 1222 #@ has &een a&sor&ed and the patient evaluated (or hyponatre#ia-
+See FHyponatre#ia
(ollo%in transurethral resection or hysteroscopyF$ section on EPreventionE-,
=or electrolyte7containin #edia$ the criteria (or ter#inatin a procedure are8
;322 #@ (or youner patients %ith no co#or&idities5 so#e data suest that
(luid intravasation o( 41222 #@ is associated %ith an increased ris' o( as
e#&olis# B;3D- +See E>as e#&olis#E &elo%-,
=or other patients$ the threshold #ust &e individuali"ed accordin to
cardiovascular status or other co#or&idities
Prevention o( as e#&olis# I

Leep the patient in (lat or reverse Trendelen&ur position

Avoid use o( nitrous o!ide (or anesthesia +this #ay enlare air
&u&&les,

Pure air (ro# all tu&in prior to insertion into the uterus

)aintain intrauterine pressure at <122 ##H

@i#it re#oval and re7introduction o( the hysteroscope +this #ay


(orce air or as into the uterus,

Re#ove intrauterine as &u&&les +ideally %ith a continuous


out(lo% syste#,
@i#itin the distension (luid de(icit #ay also &e associated %ith a decrease in the ris' o( as
e#&olis#$ reardless o( the type o( (luid or type o( electrosurical instru#ent- This %as illustrated
in a rando#i"ed trial +n M 32, that (ound that use o( either #onopolar and &ipolar electrosurery
(or operative hysteroscopy resulted in evidence o( intracardiac as &u&&les in nearly all patients$
althouh no patients re/uired treat#ent B;3D- A su&set analysis (ound that the li'elihood o( as
e#&olis# %as sini(icantly hiher %ith a (luid de(icit o( 41222 #@ co#pared %ith <1222 #@-
Car&on dio!ide #ust &e insu((lated %ith a special instru#ent 'no%n as a hysteroinsu((lator- The
laparoscopic insu((lator delivers 1 @H#in or #ore o( (lo% and should NEVER &e used (or
hysteroscopy$ as a as e#&olis# #ay occur-
Hysteroinsu((lators can &e set to reach a taret intrauterine pressure o( less than 122 ##H or to
deliver a constant rate o( (lo% o( less than 122 #@H#in B3$:$;G$;J
Dianosis and #anae#ent o( as
e#&olis#
Dyspnea is the #ost co##on sy#pto#5 other sins and sy#pto#s are listed
in the ta&le +ta&le ;,- A (all in a patientEs end7tidal car&on dio!ide pressure #ay
raise intraoperative suspicion o( as e#&olis#$ &ut #ay also &e present in
other conditions B;GD-
I( as e#&olis# is suspected$ the procedure should &e ter#inated
i##ediately$ the uterus de(lated$ and sources o( (luid or as re#oved B;GD-
Supportive care +e$ the use o( #echanical ventilation$ vasopressors$ volu#e
resuscitation as indicated, is the cornerstone o( #anae#ent$ &ut active
#easures #ay also &e help(ul- +See FAir e#&olis#F-,
Choosin a hysteroscope
Instru#entation choices (or hysteroscopy #ust &e tailored to the
procedure and operative settin-
Dianostic hysteroscopy$ particularly in the outpatient settin$ relies
upon a s#all outer dia#eter +OD, to #ini#i"e &oth the need (or
cervical dilation and patient disco#(ort-
=or #inor procedures per(or#ed in the outpatient settin andHor under
local anesthetic$ it also #a'es sense to &alance OD and optical
/uality- Ho%ever$ in eneral$ a larer OD %ill &e re/uired to
acco##odate operative instru#ents co#pared %ith dianostic
hysteroscopy-
Advanced operative procedures re/uire an operative hysteroscope
%ith one or t%o channels (or instru#ents and also a hih /uality
telescope-
In(or#ed consent

9o#en should &e counseled a&out alternative dianostic or


treat#ent approaches$ and in(or#ed consent reardin e!pected
treat#ent success and possi&le co#plications-

Patients should &e in(or#ed o( possi&le need to a&andon or


pre#aturely stop a procedure due to (luid overload-

Also$ since uterine per(oration is a possi&le co#plication$


patients should consent to a possi&le laparoscopy or laparoto#y
i( it &eco#es necessary to rule out visceral or vascular in?ury-
Evaluation
A #edical history is ta'en$ includin8 detailed /uestions
reardin sy#pto#s that relate to the indication (or the
procedure5 o&stetrical and surical history5 and #edical
co#or&idities$ #edications$ and alleries-
A co#plete pelvic and eneral physical e!a#ination is
per(or#ed$ %ith particular attention to the si"e and #o&ility o(
the uterus and the patency o( the cervi!-
Prenancy testin is per(or#ed5 cervical cultures are
appropriate i( cervicitis is suspected
Ti#in and endo#etrial preparation

=or pre#enopausal %o#en %ith reular


#enstrual cycles$ the proli(erative phase is
&est (or visuali"ation o( the uterine cavity-

Durin the secretory phase$ the thic'


endo#etriu# can #i#ic endo#etrial
polyps and lead to inaccurate dianoses-

Also$ durin #enstruation$ &lood #ay


inter(ere %ith visuali"ation-

In reproductive ae %o#en %ith irreular &leedin$ the


ideal ti#e (or the procedure is unpredicta&le-

patients should &e counseled that a procedure #ay &e


atte#pted$ &ut #ay need to &e rescheduled i( o&scurin
&lood #a'es it i#possi&le to evaluate the uterine cavity-

O(ten$ surery is still (easi&le$ &ecause (luid pu#ps


(acilitate visuali"ation &y rapidly clearin de&ris and
&lood
Another approach is phar#acoloic thinnin o( the endo#etriu#- Thinnin aents should &e used only %hen the sureon plans
operative hysteroscopic resection o( a leio#yo#a or endo#etrial a&lation- Thinnin aents should not &e used %hen dianostic
hysteroscopy alone is planned$ as these hor#ones #ay in(luence the histoloy o( the endo#etriu#- The #ost co##only used
aents are estroen7proestin contraceptives or proestins alone +e$ oral #edro!yproesterone acetate 12 # daily on cycle
days 13 to ;:, B13D- >onadotropin releasin hor#one aonists and dana"ol are also e((ective$ &ut are used in(re/uently due to
adverse e((ects B1:71JD- All o( these aents re/uire at least t%o #onths o( therapy to e((ectively thin the endo#etriu#- Rei#ens
that re/uire a shorter duration o( therapy have &een proposed +e$ desoestrel and ralo!i(ene, B;2D-
=or post#enopausal %o#en$ hysteroscopy #ay &e per(or#ed at any ti#e-
Cervical preparation and dilation

Narro% cali&er hysteroscopes +N3 ##,


typically do not re/uire cervical dilation$
particularly in pre#enopausal %o#en-

I( possi&le$ #echanical cervical dilation


should &e avoided since it can &e pain(ul-
=or patients %ho do re/uire cervical dilation$ cervical preparation %ith a
prostalandin +e$ #isoprostol, #ay &e su((icient on its o%n or can (acilitate
#echanical dilation-
B;1D- )isoprostol %as associated %ith a reduced need (or (urther cervical
dilation a lo%er rate o( cervical laceration,$ and reater cervical dilation$ &ut a
hiher rate o( side e((ects +vainal &leedin$ cra#pin$ (ever,-
=or every (our %o#en %ho received #isoprostol prior to hysteroscopy$ one
%o#an avoided the need (or (urther cervical dilation- =or every 1; %o#en
receivin #isoprostol$ one cervical laceration %as avoided-

The vainal route (or #isoprostol #ay &e


#ore e((ective than oral-

Post7treat#ent dilation %as reater +A


versus : ##, and procedure duration %as
reduced +G versus 13,sini(icantly in the
vainal ad#inistration roup-

opti#al #isoprostol dose has not &een


esta&lished$ &ut usually ;22 to O22 #c-
In post#enopausal %o#en$ rando#i"ed trial data have not consistently de#onstrated that preoperative #isoprostol decreases the
need (or #echanical cervical dilation B;07;AD- Pretreat#ent %ith vainal estroen (or t%o %ee's &e(ore surery #ay au#ent the
cervical dilation caused &y #isoprostol B;OD- A rando#i"ed trial o( :A post#enopausal %o#en underoin hysteroscopy %ere treated
(or t%o %ee's %ith vainal estradiol +;3 #c daily, and then received either vainal #isoprostol +1222 #c, or place&o on the niht
&e(ore surery BJD- Cervical dilation %as sini(icantly increased in the %o#en treated %ith #isoprostol versus place&o- )isoprostol
also decreases intraoperative pain B;0$;OD- 9e have (ound #isoprostol to &e use(ul in this population in our clinical practice-
>iven these data$ %e as' patients to sel(7ad#inister oral or vainal #isoprostol +;22 to O22 #c, the niht &e(ore the procedure-
Another option (or cervical dilation prior to hysteroscopy is os#otic dilation +e$ la#inaria,- +See
FOvervie% o( prenancy ter#inationF$ section on EOs#otic dilatorsE-,
Prophylactic anti&iotics

Anti&iotics are not routinely ad#inistered


durin hysteroscopy (or prevention o(
surical site in(ection or endocarditis since
posthysteroscopy in(ection occurs in less
than 1 percent o( %o#en-
Sterile preparation

Povidone iodine solution is typically used


(or sterile vainal preparation- Ho%ever$
there are (e% studies evaluatin the e((ect
o( vainal preparation on the ris' o(
surical site in(ection prevention-
Anesthesia

Anesthesia #ay &e needed to i#prove patient


co#(ort durin hysteroscopy-

Parts o( the procedure that are potentially


pain(ul include place#ent o( a tenaculu# on
the cervi!$ dilation o( the cervi!$ insertion o(
the hysteroscope$ uterine distension$ and
uterine &iopsy5

so#e %o#en (ind uterine &iopsy to &e the


#ost pain(ul part o( the procedure-
The a&ility to per(or# hysteroscopy usin no anesthetic or local anesthesia allo%s
use o( outpatient settins and speeds recovery- )ost dianostic and &rie( or #inor
operative procedures can &e per(or#ed %ithout anesthetic or %ith a local
anesthetic- Reional or eneral anesthesia is reserved (or patients %ho cannot
tolerate a procedure under local anesthesia$ e!tensive operative procedures$ or
patients %ith co#or&idities that necessitate intensive #onitorin B02D-
)anain pain or disco#(ort enco#passes not ?ust analesia$ &ut also patient
counselin and selection o( the type o( procedure and instru#ents +see
EApproach to outpatient
Pre7procedure nonsteroidal antiin(la##atory drus reduce postoperative$ &ut not intraoperative$ pain$ as sho%n in rando#i"ed trials B01700D- There(ore$ %e do not
pre#edicate %ith these drus- So#e sureons pretreat selected patients %ith an!iolytics$ &ut there are no data assessin this approach-
@ocal anesthesia (or hysteroscopy can &e ad#inistered topically +cervical or intrauterine BtranscervicalD, or &y in?ection +intracervical$ paracervical$ or uterosacral,- 9e pre(er
paracervical &loc' or$ in selected cases$ no anesthetic +e$ dianostic hysteroscopy %ith a <O ## dia#eter hysteroscope,- In a literature revie%$ patients underoin an
outpatient hysteroscopy %ho received a paracervical &loc' (ound the procedure to &e #ore accepta&le than other types o( analesia B1;D- The percent o( %o#en %ho said
they %ould pre(er eneral anesthesia (or a (uture procedure %ere8 paracervical +; percent,$ uterosacral +0 percent,$ intracervical +1; percent,$ no anesthetic +1A to OG
percent,5 there %ere no data (or topical cervical or intrauterine ad#inistration- In addition$ #ost rando#i"ed trials o( paracervical &loc' have sho%n a decrease in pain$ %hile
results (ro# trials o( other techni/ues have &een inconsistent B0O7O0
One (actor in decidin %hether to use a paracervical &loc' versus no anesthetic is the pain o( the in?ection5 so#e %o#en (ind the in?ection o( the
anesthetic aent #ore pain(ul than the procedure itsel( B;J$03D- Use o( a paracervical &loc' decreases pain co#pared %ith an in?ection o( place&o BOO$O3
D- Ho%ever$ no di((erence in pain %as (ound in one trial that co#pared paracervical %ith uterosacral in?ection BO:D$ and results (ro# rando#i"ed trials
co#parin paracervical &loc' to no anesthetic have &een inconsistent B;J$OAD- Choice o( aent and techni/ue (or paracervical &loc' are discussed in
detail separately- +See FPudendal and paracervical &loc'F$ section on EParacervical &loc' +>ynecoloic,E-,
=or procedures that re/uire additional pain control$ a local aent can &e co#&ined %ith intravenous conscious sedation or other aents can &e used in
either the outpatient or operatin roo# settin5 intravenous tra#adol also appears to &e e((ective (or reducin procedure7related pain BOGD-
So#e sureons advocate usin no anesthetic BOJ$32D- Also$ (actors other than anesthetic #ay in(luence a patientEs a&ility to tolerate a procedure %ithout
anesthesia- As an e!a#ple$ one trial (ound that %hen a 3 ## hysteroscope %as used$ %o#en had less pain %ith a paracervical &loc' than %ithout
anesthetic B;JD- Ho%ever$ %o#en %ho under%ent the procedure %ith a 0-3 ## hysteroscope and no anesthetic had sini(icantly less pain than either 3
## roup- A #ulti7#odal approach to opti#al pain #anae#ent (or outpatient hysteroscopy is discussed a&ove +see
EApproach to outpatient hysteroscopyE a&ove,-
As noted a&ove$ eneral or reional anesthesia #ay &e re/uired (or so#e patients or procedures
procedure

=oley urethral catheter is not necessary


unless intensive #onitorin o( urine output is
necessary +e$ proloned procedure$
e!cessive (luid a&sorption$ or need to diuresis
patient,-

Althouh a video #onitor is not re/uisite$ it


reatly &ene(its the sureon$ trainees$ and
scru& and nursin personnel throuhout the
case-
Entry and cervical dilation
patient in dorsal lithoto#y position$ place#ent o( speculu#$ use o( tenaculu# or
#echanical dilation as needed,-
The cervi! should not &e dilated &eyond the si"e o( the hysteroscope$
A re#ova&le o&turator +rod %ithin the sheath, is especially help(ul (or introduction o( the
sheath into the uterine cavity %hen entry is di((icult- Ho%ever$ it is enerally advisa&le to
introduce the hysteroscope under direct visuali"ation to &e a&le to naviate throuh the
cervical canal-
Once the hysteroscope has &een inserted$ it is help(ul to re#ove the speculu#5 usin a
&ivalve speculu# +open on one side, #a'es this possi&le- Insert the hysteroscope throuh
the cervical os under direct endoscopic vision and re#ove the speculu#-
So#e e!perts advocate an alternative approach to the classic initial entry +particularly (or
dianostic procedures, techni/ue$ the vainoscopic techni/ue$ %hich avoids the use o( a
speculu# or tenaculu#
techni/ue I The vainoscopic
techni/ue I The vainoscopic$ or Fno touch$F techni/ue is per(or#ed %ithout a speculu# or tenaculu# and %ithout anesthesia BOGD- 9o#en
%ith cervical stenosis are not candidates (or this approach- A #eta7analysis o( si! rando#i"ed trials (ound that use o( the vainoscopic versus
traditional techni/ue %as associated %ith a sini(icant decrease in operative pain B31D- =ailed procedures %ere in(re/uent (or &oth techni/ues-
So#e$ &ut not all$ rando#i"ed trials have (ound that operative ti#e %as shorter (or the vainoscopic techni/ue B3;733D-
To per(or# the vainoscopic techni/ue$ per(or# a &i#anual pelvic e!a#ination %ith the patient in the dorsal lithoto#y position- Prepare the
vainal introitus %ith saline or povidone iodine B3:D- 9ithout usin a speculu#$ introduce a riid or se#i7riid$ narro% cali&er +<O ##,
hysteroscope into the vainal introitus- In(use nor#al saline at a pressure o( 132 ##H B3AD- Close the la&ia #inora #anually i( needed to
contain the distendin #ediu#- .isuali"e the cervi! and direct the hysteroscope throuh the cervical canal into the uterine cavity
Evaluatin the endocervi!

The endocervi! can &e easily inspected


durin insertion o( the hysteroscope-

Any lesions that %arrant (urther evaluation


can &e visuali"ed &y %ithdra%in the
hysteroscope to the lesion site
Evaluatin the uterine cavity
Once the hysteroscope is %ithin the endo#etrial cavity$ the uterine cavity
is distended$inspected$ includin the tu&al ostia and any patholoy-
It is o(ten help(ul to ta'e photoraphs (or docu#entation and
co##unication %ith the patient-
9hether usin a aseous or (luid #ediu#$ a(ter initial uterine distension$
de(late the endo#etrial cavity- This %ill prevent Fneative hysteroscopic
vie%F +ie$ (lattenin o( lesions &y the pressure o( distension$ there&y
#a'in the# di((icult to see,-
Evaluatin the uterine cavity

In eneral$ 1 to 0 percent o( &enin or #alinant endo#etrial


lesions are #issed on hysteroscopy B3GD-

To avoid #issin uterine patholoy$ endo#etrial sa#plin


+hysteroscopic &iopsies or &lind sa#plin, should &e
per(or#ed in patients %ith lo&al endo#etrial patholoy or %ith
persistent &leedin and no hysteroscopic (indins-

9o#en %ith (ocal patholoy should undero hysteroscopically


directed re#oval o( lesions
)anae#ent o( distendin #edia

One o( the #ost i#portant (actors in


per(or#in operative hysteroscopy is
#aintenance o( a clear operative (ield-

=or (luid #edia$ this is #ost sa(ely


acco#plished %ith a continuous (lo%
hysteroscope and (luid pu#p-
.asovaal reactions

.asovaal syncope +also called neurocardioenic syncope, is


usually$ associated %ith a di""iness$ nausea$ &radycardia$ pallor
or diaphoresis-

stop the procedure$

placin the patient in supine position %ith her les raised or in


the Trendelen&ur position$

ad#inisterin intravenous (luid-

atropine +2-3 to 1 # I. every (ive #inutes$ not to e!ceed a


total o( 0 # or 2-2O #H', or

Fs#ellin saltsF +ie$ aro#atic a##onia spirit,-


OPERATI.E CHA@@EN>ES

There are several reasons (or hysteroscopic (ailure-

in the o((ice settin$

pain$

cervical stenosis$

and poor visuali"ation

- In addition$ operative hysteroscopy #ay need to


&e halted due to e!cessive (luid a&sorption or
uterine per(oration
=AI@URE RATE

the overall rate o( (ailure %as 0-: percent$


and %as si#ilar in a#&ulatory and
hospitali"ed patients and pre7 and
post#enopausal %o#en B3J
Cervical stenosis
Pre7procedure cervical ripenin and s#all dia#eter instru#ents can reduce the (re/uency o(
procedure (ailure due to cervical stenosis-
In post#enopausal %o#en %ith cervical stenosis$ one option is to treat %ith t%o to (our %ee's or
#ore o( vainal estroen prior to the procedure to so(ten the cervi! and there&y (acilitate the action o(
#isoprostol$ althouh the e((icacy o( this approach has not &een proven
9hen dilation o( the cervi! is di((icult$ a (le!i&le hysteroscope #ay &e passed #ore easily than a riid
dilator or sound- Also$ the direct vie% helps to naviate the canal-
=or %o#en %ho (ail these #easures$ intracervical in?ection o( dilute vasopressin +O units per G2 #@
nor#al saline, has &een reported to (acilitate cervical dilation B:2D- Althouh enerally %ell tolerated$
vasopressin in?ection #ust &e per(or#ed %ith caution +&y aspiratin and con(ir#in the a&sence o(
&lood in the syrine prior to each in?ection,$ since intravascular in?ection or a&sorption has &een
associated %ith pro(ound hypertension$ &radycardia$ and intraoperative #ortality B:1D-
I( a s#all dilator cannot &e easily inserted$ hysteroscopy can &e per(or#ed under ultrasound uidance
to con(ir# correct passae o( the dilator into the endo#etrial cavity and #a'e sure a (alse passae is
not created-
Uterine #alposition

E!tre#e uterine retroversion or anteversion #ay &e


conenital or #ay &e due to pelvic adhesions$#ay li#it
the a&ility to introduce the hysteroscope-

Traction %ith a tenaculu# on the anterior lip o( the cervi!


%ill o(ten straihten the uterine a!is-

Also$ use o( a (le!i&le hysteroscope #ay &e help(ul-

#alposition #ay increase the ris' o( uterine per(oration-

9hen the uterus is severely anulated$ the tu&al ostia


#ust &e visuali"ed to con(ir# that the entire uterine
cavity has &een evaluated
Di((icult uterine distention

Once the cervi! has &een dilated$ it is


unusual to have di((iculty instillin a
distention #ediu#-

I( this di((iculty is encountered$ it is li'ely


that there is an o&struction in the uterine
cavity +e$ synechiae$ #alinancy,-
O&scurin &lood
6leedin can i#pair visuali"ation either directly or$ i( car&on dio!ide is used
(or distension$ &leedin #ay cause as &u&&les to (or#-
The as &u&&les can &e cleared &y s%itchin to a (luid #ediu#-
=or (luid #edia procedures$ use o( a continuous (lo% hysteroscope allo%s
lavae o( the endo#etrial cavity- 9hen lavae is not possi&le$ then dilation
and curettae can &e per(or#ed to re#ove endo#etrial de&ris and clots-
Repeatin the hysteroscopic procedure %ith a continuous (lo% hysteroscope
can then &e success(ul-
POSTOPERATI.E CARE

postoperative cra#pin or liht &leedin


and so#e co#plain o( vainal disco#(ort-

Car&on dio!ide distension can cause


re(erred shoulder pain$ &ut this typically
resolves %ithin 13 #inutes
Post op analesia

Aceta#inophen or nonsteroidal antiin(la##atory drus


are usually ade/uate (or postoperative pain control$ i(
necessary-

The patient #ay resu#e #ost nor#al activities %ithin ;O


hours and should (ollo% standard postoperative
instructions (or ynecoloic procedures-,

a (ollo%7up visit ;P0%ee's postoperatively to assess (or


(urther co#plications and revie% patholoy results
CO)P@ICATIONS

enerally sa(e procedure $ co#plication


are rare$ &ut so#e are potentially li(e
threatenin-

Qoverall co#plication rate o( 2-;; percent -

The #ost co##on co#plication %as

1 per(oration o( the uterus +2-1; percent,$

; (luid overload +2-2: percent,$

0 intraoperative he#orrhae +2-20


percent,$

O &ladder or &o%el in?ury +2-2; percent,$


and 3 endo#yo#etritis +2-21 percent

The #ost co##on co#plication o( &oth types o( hysteroscopy %as uterine per(oration +2-10 (or dianostic5 2-A: percent
(or operative,5 1G o( 00 per(orations occurred durin entry +#easurin the si"e o( the uterus %ith the sound instru#ent$
dilation pro&le#s$ per(oration &y hysteroscope,- =luid overload occurred in operative +2-2; percent,$ &ut not dianostic$
procedures- The operative procedure %ith the hihest (re/uency o( co#plications %as intrauterine adhesiolysis +O-3
percent co#plication rate,5 all o( the other procedures had co#plication rates less than 1 percent-
QIn a syste#atic revie% o( over ;:$222 %o#en %ho under%ent dianostic hysteroscopy$ co#plication rates %ere reported
&y only ;J percent o( studies$ totalin JO10 procedures B3JD- A#on these procedures$ there %ere only eiht
co#plications8 (our uterine per(orations$ one pelvic in(ection$ one &ladder per(oration$ and t%o #edical co#plications
Uterine per(oration

#ost co##on co#plication o(


hysteroscopy-

Incidence 2-G to 1-:R o( operative


procedures

- Chance is less durin dianostic


hysteroscopy +e$ 2-1 versus 1-2 percent
%ith operative hysteroscopyD-
uterine per(oration
occur durin #echanical cervical dilation or insertion o( the hysteroscope-
Such a per(oration #ay &e reconi"ed %hen an instru#ent passes &eyond depth
o( the uterine (undus$ %hen there is sudden loss o( visuali"ation$ %hen o#entu# or
&o%el or peritoneal structures can &e visuali"ed at the uterine (undus$ or %hen
there is a sudden increase in the (luid de(icit-
I( a uterine per(oration occurs$ all instru#ents should &e re#oved (ro# the uterus
and the he#odyna#ic status o( the patient should &e assessed- A detailed
discussion o( the #anae#ent o( uterine per(oration can &e (ound separately-
Urinary tract or &o%el in?ury

I 6o%el or &ladder in?ury are rare$ &ut


#ay occur in association %ith uterine
per(oration or as a result o( use o(
electrical current- )anae#ent o( these
in?uries is discussed in detail else%here- +
Cervical laceration

Cervical lacerations can occur$


particularly in %o#en %ith cervical
stenosis-

@acerations that are lare or are &leedin


re/uire sutures
E!cessive (luid a&sorption

E#&olis# I E#&olis# +air or car&on


dio!ide, can occur %ith any hysteroscopic
techni/ue and can cause cardiovascular
collapse-
He#orrhae
Potential sources o( intraoperative &leedin include operative
sites$ uterine per(oration$ and cervical laceration-
6leedin (ro# cervical lacerations that is reconi"ed at surery
can &e controlled usin electrocautery or sutures-

6leedin (ro# a speci(ic site %ithin the uterine cavity$ %ith no


suspicion o( uterine per(oration$ can &e controlled %ith
electrosurery is #ost cases-
9o#en %ith di((use &leedin should &e evaluated (or
coaulopathy-
He#orrhae

I( coaulation testin is nor#al and di((use


&leedin continues$ it can &e treated &y
placin a =oley catheter in the uterine
cavity and then distendin the &ul& %ith 13
to 02 #@ o( %ater
In(ection

in(ection a(ter operative hysteroscopy is


lo%- postoperative incidences o( 2-1 to 2-J
R (or endo#etritis

2-: percent (or urinary tract in(ections

Disse#ination o( tu#or I on
ERis' o( tu#or disse#inationE

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