CLINICAL ACTIONS:

Hysteroscopy can be performed either in the operating room or the office.  When planning a hysteroscopic procedure, the joint ACOG/AAGL recommendations include the following

• Preoperative consultation
  • Discuss risks/ benefits/ alternatives
  • Review medical history
  • Exclude pregnancy if appropriate
• If cervical stenosis is present
  • Consider misoprostol (off label) 200-400 mcg buccal/ sublingual/ intravaginal the night before surgery
• Optimize visualization
  • Perform during follicular phase of cycle, after menses | Secretory phase may mimic polyps : Irregular menses may be scheduled at any time
  • Actively bleeding “may not undergo the procedure” due to decreased visibility
  • Pretreatment with progestins or combined OCP may further optimize visualization by thinning the endometrial lining
• Antibiotic prophylaxis not recommended
• Pain management
  • Multiple pharmacologic approaches described, but evidence insufficient to recommend any particular analgesic regimen | No regimen has been shown to be superior to placebo
    • NSAIDS | Topical anesthetic | Acetaminophen | Benzodiazepines (anti-anxiety medications) | Opiates | Intracervical and/or paracervical block
  • Non-pharmacologic
    • <5 mm diameter hysteroscopes | Flexible hysteroscopes | Vaginoscopic approach
• Cervical Ripening
  • “Insufficient evidence to recommend routine cervical ripening before diagnostic or operative hyseteroscopy”
    • Consider if risk of cervical stenosis or increased procedural pain
  • Misoprostol (off label)
    • 200–400 micrograms oral or intravaginal the night before surgery (12 hours prior to procedure)
    • Postmenopause: 25 micrograms vaginal estrogen 14 days prior to procedure plus misoprostol 12 hours prior to procedure
  • Osmotic dilators
    • Data to support use | Requires additional office visit | Must be removed if procedure is cancelled
  • Vasoconstrictors (epinephrine or vasopresessin)
    • Potential benefits: Less bleeding | Reduce fluid absorption | Improve potency of local anesthesia | Reduce force needed to dilate cervix
    • Risks (rare): Bradycardia | Hypotention or increased BP | Cardiac arrest
    • No evidence for optimal dose
    • One regimen cited in literature (see ‘Learn More – Primary Sources’ below): 20 mL dilute vasopressin solution (4U of 0.05 U/mL in 80 mL normal saline)

Location

• Office hysteroscopy
  • Diagnostic or minor operative
  • Should be considered for the treatment of endometrial polyps
• Operating room hysteroscopy
  • Use for patients with
    • Cervical stenosis
    • Medical comorbidities (e.g., cardiopulmonary disease)
    • Significant uterine pathology
    • High levels of anxiety
    • Previously failed or not tolerated office hysteroscopy

Contraindications

• Known pregnancy
• Active herpetic infection
• Genital tract infection
• Known advanced stage cervical/ uterine malignancy

Distention Medium

CO₂ gas

• Clear view of cavity and easy equipment maintenance
• Limit flow to 100 mL/min
• Maintain intrauterine pressure to <100 mm Hg
• Use hysteroscopic (not laparoscopic) insufflator

Electrolyte poor fluids

• Glycine 1.5% | Sorbitol 3% |Mannitol 5%
• Use for
  • Operative hysteroscopy
  • Monopolar devices
  • Radio-frequency energy devices
• Caution: Excessive absorption associated with
  • Hyponatremia | Decreased serum osmolality | Hyperammonemia
  • Can lead to seizures and mortality
  • Note: Mannitol 5% is iso-osmolar and while may cause hyponatremia, should not decrease serum osmolality

Electrolyte-containing fluids

• Normal saline | Lactated Ringer’s solution
• Use for
  • Diagnostic cases
  • Laser | Bipolar | Mechanical energy
• Less risk of hyponatremia/ decreased osmolality

SYNOPSIS:

Polyps, synechiae, Mullerian abnormalities, leiomyomata and retained foreign bodies can often be diagnosed and treated successfully with hysteroscopy.  Visualization of the endometrial cavity allows biopsy of abnormal areas and can optimize the diagnosis of hyperplasia or malignancy

KEY POINTS:

Complications

Vasovagal 

• Signs and symptoms
  • Hypotention | Bradycardia
  • Sweating | Pallor | Loss of conciousness |  Nausea and vomiting
• Management
  • Assess: Vitals | Airway, Breathing, Circulation
  • Place patient in Trendelenberg or raise legs
  • If bradycardia does not resolve
    • Atropine: Single dose 0.5 mg IV q3 to 5 minutes (total dose 3 mg)

Fluid Overload and Hyponatremia 

• Prevention
  • Strictly monitor both IV hydration and hysteroscopic fluid deficit
  • Electrolyte poor fluids maximal deficit: 1000 mL (in healthy individuals)
    • Consider stopping procedure at 750 mL deficit
  • Electrolyte-containing fluids maximal deficit: 2500 mL (in healthy individuals)
    • Consider stopping procedure at 2000 mL deficit
  • Consider lower thresholds for elderly, cardiovascular or renal comorbidity or when laboratory services/ acute care options are limited 
•  Management
  • Hypertonic saline solution and diuretics (e.g., furosemide)
  • Increase serum sodium levels by 1–2 mEq/L/h
  • Caution: Do not increase by more than 12 mEq/L in the first 24 hours
  • Transfer to an urgent care facility and further consultation may be required

Hemorrhage

• Management
  • Apply electrosurgical coagulation if bleeding sites identified
  • Inject vasopressin into the cervix
  • Use Foley catheter balloon tamponade or manual uterine compression
  • Surgical approach as a last resort includes
    • Laparoscopic suturing of perforation
    • Hysterectomy
    • Uterine artery embolization

Uterine Perforation

• Prevention
  • Perform careful pelvic exam prior to hysteroscopy
  • Use ultrasound guidance as needed
  • If flexible hysteroscope available, insertion may be performed prior to using dilators
• Management
  • Midline perforation is seldom morbid unless laser or electrosurgery is used
  • Lateral perforations carry risk for retroperitoneal hematomas
  • Discontinue hysteroscopy if perforation occurs
  • Consider laparoscopy to
    • Identify any bowel/ bladder injury
    • Check for hematomas

Air/CO2 Embolization

• Prevention
  • Purge and flush air from tubing prior to procedure and whenever bags are changed | Avoid repetitive instrument insertions | Limit intrauterine pressure
• Worrisome symptoms include
  • Dyspnea | Chest pain | Decreased O2 saturation | ‘mill wheel’ heart murmur | Hypotension | Cardiac arrhythmia (e.g., tachycardia/bradycardia)
• Management
  • Terminate procedure
  • Deflate uterine cavity
  • Eliminate sources of fluid and gas
  • Position in left lateral decubitus with Trendelenburg position (Durnat’s maneuver)

Learn More – Primary Sources:

ACOG Committee Opinion 800: The Use of Hysteroscopy for the Diagnosis and Treatment of Intrauterine Pathology

AAGL Practice Report: Practice Guidelines for the Management of Hysteroscopic Distending Media: (Replaces Hysteroscopic Fluid Monitoring Guidelines. J Am Assoc Gynecol Laparosc. 2000;7:167-168.)

The Effect of Dilute Vasopressin Solution on the Force Needed for Cervical Dilatation: A Randomized Controlled Trial

Mini Review: Art of Hysteroscopy

Related ObG Topics:

Perform Hysteroscopy or Endometrial Biopsy First for Uterine Bleeding?

How Well Does Sonohysterography Match Up Against the Gold Standard of Hysteroscopy?

Endometrial Polyps – Do They Always Need To Be Removed?

Is Tamoxifen a Risk Factor for Endometrial Cancer in Women with Endometrial Polyps?

Endometrial Hyperplasia – Current Nomenclature and Treatment