eMedicine Specialties > Obstetrics and Gynecology > Gynecologic Surgery
Hysteroscopy: Treatment
Updated: Jul 16, 2006
Treatment
Preoperative Details
Appropriate surgical management always begins with accurate history taking, physical examination, and careful workup of the suspected problem. In preparation for hysteroscopic procedures, the following considerations may be useful.
Antibiotic prophylaxis
For hysteroscopy, prophylactic antibiotics are not indicated unless the patient has clinically significant valvular disease or a history of tubal occlusion due to pelvic inflammatory disease.
Cervical stenosis
In patients with known cervical stenosis or tortuous cervical canals, preoperative vaginal or oral misoprostol, or intraoperative vasopressin 1% administered paracervically may be used to assist in cervical dilation.
Endometrial preparation for ablation
Before ablation procedures are performed, the administration of a GnRH agonist in the luteal phase of the previous menstrual cycle in ovulating women improves visibility and provides a smooth, pale, hypovascular surface 3-4 weeks later (after the patient has her menses). These changes make the procedure easier to perform and improve its success rate.
For those who do not want a GnRH agonist, the simultaneous use of a GnRH antagonist with progesterone at any point in the menstrual cycle theoretically creates a similar surface after the patient has her menses, but it has fewer adverse effects and allows greater scheduling flexibility than does other method.
One antagonist, ganirelix acetate (Antagon) (Organon, Inc, Oss, the Netherlands), is available packaged with gonadotropins for use in infertility therapy. However, cetrorelix, (Cetrotide; Serono, Inc, Rockland, Mass) is available packaged alone. This author has successfully used a single 3-mg dose of cetrorelix administered subcutaneously every 4 days along with medroxyprogesterone acetate (Provera) 10 mg taken orally for 5 days. Unlike the agonist, the action of the antagonist is immediate, suppressing follicle-stimulating hormone (FSH) and luteinizing hormone (LH) without any of the flare effect commonly observed with the agonist. The ablation procedure is then typically performed after the patient completes her menses, which usually begins 2-3 days after she takes the last progesterone tablet. A study is being conducted at the author's institution to compare the agonist and antagonist protocol.
Finally, suction curettage done before e ablation creates a comparable surface. However, it appears to be most effective in the late luteal phase or during menstruation, when the endometrium is loosely attached. In this author's experience, the medical approaches are superior.
Fibroids
For large submucosal fibroids, the use of a GnRH agonist decreases uterine volume by approximately 30%. It may decrease blood loss and allow for an easier and more complete resection, though some data suggest that the change in tissue quality may make the procedure technically more difficult than before, negating other benefits.
Large uterus
During ultrasonography or sonohysterogram, measurements of the uterine dimensions are helpful. In particular, a uterus longer than 10 cm makes the case difficult because of the length of the hysteroscope (typically 35 cm) because it must traverse the length of the uterus, cervix, and vagina while maintaining a position outside the introitus with enough distance to attach the camera and manipulate the fluid inflow-outflow valves and the surgical instruments. Also, maintaining intrauterine pressures with large cavities is more difficult than with small cavities.
Intraoperative Details
Anesthesia
The type of anesthesia used depends on the procedure, the patient's level of anxiety, and the anesthesiologist's expertise. Simple diagnostic procedures can be completed without anesthesia, with a paracervical block alone, or with mild sedation. For extensive procedures or for patients with a low pain tolerance, general or regional anesthesia is indicated. If electrosurgery is to be performed, sufficient anesthesia must be given to ensure that the patient does not move with uterine stimulation because of the risk of uterine perforation and intraperitoneal injury.
The patient is placed in the dorsal lithotomy position and prepared and draped in a sterile manner. Unless a laparoscopy is also planned, the patient's thighs should be positioned at a 90° angle to the pelvis to create enough space for the surgeon to manipulate the hysteroscope. The patient's perineum should be just past the edge of the table, with the coccyx and sacrum well supported on the flat surface of the table. The patient's legs should be secured in the leg stirrups to avoid any abrupt movements, which can cause nerve or muscle injury to the patient or potential injury to the surgeon. The surgeon should be seated with the operative field and hysteroscope at the level of the his or her abdomen. If it is positioned higher, the surgeon's shoulders become fatigued, and, if it is positioned lower, the instrument is hard to maneuver and is likely to become contaminated.
Attempts to reduce blood loss and fluid deficits are reported (and ultimately tried by this author). Use of cold (ie, 5°C) distention medium causes vasoconstriction and reduces blood loss and distention fluid deficits. However, the patient's core body temperature substantially decreases and may interfere with the anesthesia process. Vasopressin in dilute solution (ie, 1%) can be injected paracervically to help constrict the cervical and lower uterine branches of the uterine artery and its collaterals, reducing blood loss and fluid deficits.
- Bladder catheterization: At the discretion of the surgeon, the bladder may need to be emptied with a straight, red rubber catheter by using sterile technique.
- Examination under anesthesia: Bimanual examination should always be performed before the endocervix and uterus are dilated and entered. This examination aids the surgeon in assessing angles and preventing perforation.
- Cervical dilation: The cervix is manually dilated with metal dilators to the same diameter as the outer diameter of the outer sheath of the hysteroscope setup. A single-tooth tenaculum is placed on the anterior lip of the cervix while dilating to help straighten the cervix and uterus. Take care to avoid creating a false cervical passage that could make it difficult to continue with the surgery. If the surgeon is unsure of the path of the cervical canal, lacrimal duct probes or flexible uterine sounds should be used to determine the correct angle. Ultrasonographic guidance for dilation may be helpful in severe cases.
- Visualization of the uterine cavity: After the cervix is dilated, the hysteroscope is inserted into the endocervical canal and advanced into the uterine cavity (with the distention medium flowing) under direct visualization to limit the risk of perforation. The tenaculum on the cervix is left in place to help in manipulating the uterus, and the vaginal speculum is removed to increase maneuverability of the hysteroscope. If the cervix was dilated too much and if fluid is leaking extensively, a purse-string suture can be placed around the cervix using 0-Vicryl to limit this leakage. The suture should be removed at the end of the procedure.
Procedure are individually described below with regard to the type and width of the hysteroscope, the type of medium, and the use of surgical instrumentation and energy sources, depending on the indications and desired outcomes.
- Diagnostic hysteroscopy: A small 5- or 7-mm hysteroscope can be used with isotonic sodium chloride distention medium. A 30° scope is preferable to clearly visualize the tubal ostia. The ability to introduce small surgical instruments through an operating channel is optimal. Office procedures can be performed with 2.5- to 3- mm flexible or rigid hysteroscopes that are attached to isotonic sodium chloride solution in a bag or 30-mL syringe. Some new models have a small operating channel through which a thin-wired biopsy forceps can be placed. This channel is enough to sample suspected areas or to remove small polyps.
- Endometrial ablation with the roller-ball or roller-barrel method
- The cervix must typically be dilated to 7-9 mm depending on the resectoscope used. An Iglesias grip mechanism on the resectoscope is preferred because it maintains the electrode within the shaft at rest. A 12° scope is suggested because it provides a panoramic view of the uterine cavity. A coagulation mode of 50-100 watts is used.
- A roller barrel provides improves the uniformity of contact with the endometrium compared with the roller ball, but it may inadequately ablate the cornua and fundus. A 2-mm rollerball is more effective than a 4-mm ball because it has more current density for a given power level. The ball or barrel is extended and allowed to passively return toward the sheath at a rate of 1.0-1.5 mm/s. In clinical use, the proper amount of power is being used if the crater that is formed is 25% of the volume of the electrode and if the borders of the crater are carbonized. On occasion, the roller ball or barrel may become coated with tissue, and it may have to be removed and cleaned with a sterile gauze.
- If the endometrium is not thinned, resection may be preferred.The uterine cornua and tubal angles are ablated first because of their difficulty. Starting at the 9-o'clock position, the lateral and anterior walls are ablated next because blood, debris, and bubbles rise, making later ablation attempts in these areas more difficult. The posterior wall then is ablated by continuing in a clockwise fashion. Do not continue to ablate over areas that have already been ablated because of the risk of uterine perforation.
- Endometrial ablation, resection method: As with the other procedures, the cervix is typically dilated to 7 or 9 mm, depending on the size of resectoscope. A blended current of 70-100 watts is preferred. A 5- or 7-mm loop electrode is used and extended. The electrode is allowed to return passively at 1.0- 1.5 mm/s. A methodical approach should be used, with plan to uniformly continue around the cavity. Do not resect the same place twice. The angles of the tubal ostia are difficult to ablate with the loop electrode, so a small rollerball is preferable. Also, the corpus and isthmus may be thin; therefore, a rollerball is preferable in this area as well. The correct wattage is being used if the loop easily penetrates the tissue without tearing it. The strips of resected tissue require removal intermittently with polyp forceps. All tissue is sent to the pathologist for histologic evaluation.
- Resection of submucosal fibroids
- Several instruments may be used for hysteroscopic myomectomy. They include the resectoscope (by far the most common), scissors, and the laser. New techniques, including hysteroscopic morcellation, are being developed. Resection of a completely intramural fibroid poses the risk of intravasation of media due to prolonged procedure time (Vercellini, 1999). Some gynecologists inject vasopressin into the cervical stroma before the procedure to decrease blood loss and surgical time (Tulandi, 1999).
- Similar to resection of the endometrium, the rectoscopic method results resection of only the fibroid rather than the surface layer of endometrium. Take care when resecting a fibroid to limit the resection to only the fibroid without resecting the adjoining endometrial tissue, especially in women desiring to conceive. The fibroid can be resected to the level of only the endometrium. After some is removed, the intramural portion of fibroid may begin to invert into the endometrial cavity. Surgeons should apply their skill and experience to estimate how many passes they will continue to resect to avoid uterine perforation. The loop can often be used to separate the fibroid from the pseudocapsule, facilitating its removal and helping to identify normal myometrium and endometrium to avoid coagulation, especially in young women desiring to conceive.
- For resection of a submucosal fibroid, high cutting power is required. Using the cutting mode at 80-100 watts provides clean cuts through the fibroid and facilitates a rapid technique. Power settings lower than this do not allow for easy resection and only delay completion of the procedure, with resulting fluid deficits.
- Transection and resection of the uterine septum
- Three methods for performing this procedure are discussed. A 12° scope is preferred with this procedure. If extensive lysis is indicated, laparoscopy can be used as an aid to decrease the risk of perforation by visualizing the illuminated cavity intra-abdominally (March, 1992).
- The first method involves the use of resectoscope, a straight, 5-mm-loop electrode, and a blended current of 70-100 watts. The septum is transected until small areas of bleeding are observed; these indicate that myometrium is reached. Do not allow the intrauterine fluid pressure to become higher than the patient's mean arterial pressure because this may prevent these bleeders from being observed easily.
- In the second method, a 5- to 7-mm operative hysteroscope and small scissors are used to transect the septum until the important, small bleeding areas are observed. The intrauterine pressure helps in expanding the septum as it is cut.
- With the third method, an operative hysteroscope and vaporizing electrode (ie, VersaPoint system) is used with 0.9% sodium chloride solution. By vaporizing the septum distally toward the fundus, it is completely removed rather than just transected.
- Resection of uterine septum can be performed with scissors, a laser, or the resectoscope. When the septum is narrower than 3 cm at the fundus, incising it from distal to cephalic may allow the fibroelastic band to retract; this usually results in minimal bleeding. A broad septum requires a different approach. The first step is a lateral, alternating technique of side-to-side resection up to 0.5 cm from the fundus. Then, the remainder is removed from cornua to cornua to avoid damage to this area and to decrease bleeding. Laparoscopy or transabdominal ultrasonography may be useful to evaluate the external uterus during resection. In ultrasonography is used, the bladder should be left full to best visualize the uterus. Incising or resecting a cervical septum is not recommended because it can result in cervical incompetence (March, 1992).
- IUD removal: By using a 5- to 7-mm hysteroscope and a 12° scope, the IUD is grasped with a toothed grasper. The IUD is pulled toward the hysteroscope sheath. Pulling the IUD through the operating channel of the hysteroscope is impossible. Instead, the grasper is held closed, and both hysteroscope and the IUD are pulled out together.
- Proximal tubal cannulation: A 5- to 7-mm hysteroscope is used with a 30° scope. The occluded tubal ostia is cannulated approximately 1-2 cm with a flexible tubal catheter, and indigo carmine is injected through the cannula and observed for its spillage through the fimbriated end by the surgical assistant performing laparoscopy. If no patency is documented, the assistant straightens the fallopian tube as the hysteroscopic surgeon slides a guide wire with a soft, flexible tip through the initial catheter and into the isthmic area of the fallopian tube. The wire is then withdrawn and patency is evaluated again.
Postoperative Details
General post-hysteroscopy care
Patients typically report cramping after the procedure. A single dose of ketorolac tromethamine (Toradol) reduces postoperative discomfort. Opioid derivatives can be added, if needed, for severe pain. Peritoneal discomfort may occur if a substantial amount of the distention media entered the abdominal cavity by way of the fallopian tubes. This discomfort generally subsides within 24 hours.
Most patients can go home within 1-2 hours. They require nonsteroidal anti-inflammatory drugs (NSAIDs) for 24-48 hours. Patients may have some light-to-heavy spotting for a few days to a couple of weeks, depending on the procedure performed.
Intrauterine adhesiolysis
Postoperative stenting to prevent repeat adhesion formation with a silicone stent or an IUD has been suggested, but copper IUDs may induce an excessive inflammatory reaction and the Progestasert IUD (Alza Pharmaceuticals, Vacaville, Calif [discontinued in 2001]) may be too small to achieve adequate results (March, 1992).
Cook Women's Health (Spencer, Ind) makes a triangular balloon catheter that may improve separation of the uterine walls at the cornua during the healing phase (personal communication).
A Foley catheter placed into the uterine cavity with estrogen supplementation (conjugated estrogen 5 mg for 25 d with medroxyprogesterone 10 mg for the last 5 d) also has been used for stenting the cavity (Schenk, 1999). The purpose of the estrogen is to limit the amount of postoperative bleeding due to vasoconstriction of small blood vessels and to rapidly rejuvenate the endometrial lining, which is less prone to form adhesions than a persistently raw, cut surface. If any sort of intrauterine stent is used, antibiotic prophylaxis should be considered for the duration of the stent placement (March, 1992). Oral doxycycline 100 mg twice daily is typically used.
The use of nonsteroidal medications helps with uterine cramping and reduces adhesion formation in other pelvic procedures. Follow-up hysterosalpingography or diagnostic hysteroscopy after withdrawal bleeding is recommended. Some authors report normal findings on 90% of follow-up hysterosalpingography studies (March, 1992).
Resection of fibroids
If a fibroid resection is performed, inform the patient that she may pass small pieces of tissue, which may cause cramping. Removal of extensive adhesions or fibroids raises the possibility of adhesion formation in the uterine cavity. Many surgeons advocate the use of high-dose estrogen to encourage endometrial growth over any denuded areas. Conjugated estrogen 2.5-5 mg daily or estradiol 2 mg twice daily for 25 days, followed by progesterone for days is typically sufficient.
To prevent the juxtaposition of the inner uterine walls during the initial phase of the healing process, placement of an intrauterine catheter is recommended. Many types have been used, including the Malecot and Foley catheters. The author prefers to use a pediatric Foley catheter with the balloon filled with 15-20 mL of sterile water because it has the added benefit of providing tamponade to any areas that may be bleeding. The exterior end of the catheter is capped, and the patient is placed given doxycycline 100 mg twice daily until the catheter is removed 7 days later. The patient is instructed on how to remove the catheter (ie, cut the catheter with scissors and pull it out).
One area of uncertainty pertains to hysteroscopic resection of large submucosal fibroids, especially those with extensive myometrial involvement. When fibroids are removed through a laparotomy and a large defect is repaired, the patient is counseled not to labor when she is pregnant. Intuition suggests that patients who have large defects after a hysteroscopic procedure should be counseled similarly.
Follow-up
Follow-up in 2-4 weeks is recommended to evaluate the patient and to probe the cervix (when ablation was performed) to break up any scar tissue that may have developed near the internal os. For simple diagnostic hysteroscopy, no postoperative visit is usually necessary.
After resection of fibroids or polyps or transection of a septum, sonohysterography should be performed to confirm a normal uterine cavity. If adhesions were removed, diagnostic hysteroscopy in the office or operating room is likely to be most sensitive.
For excellent patient education resources, visit eMedicine's Pregnancy and Reproduction Center and Women's Health Center. Also, see eMedicine's patient education articles Miscarriage, Vaginal Bleeding, Amenorrhea, Fibroids, and Female Sexual Problems.
Complications
The most common complications after hysteroscopy are bleeding and uterine trauma. An accepted rate for all complications during surgical hysteroscopy is 3.8%.
Mechanical complications
Perforation and cervical trauma are 2 of the most common complications of hysteroscopy, with uterine perforation rates of approximately 0.7-0.8% (Jansen, 2000). Risk factors for perforation include cervical stenosis, severe uterine anteflexion or retroflexion, infection, myomas of lower uterine segments, and synechiae (Loffer, 1995). Most cervical traumas and uterine perforations occur during dilation of the cervix.
Cervical lacerations can occur from tearing of the single-toothed tenaculum from the cervix. Some authors suggest using a relatively atraumatic instrument, such as a double-toothed tenaculum or a ringed forceps, to prevent this complication. Using medical or mechanical preoperative cervical dilators may help to decrease resistance during dilation. In addition, ultrasonographic guidance may help to direct dilating maneuvers. Use of the small-diameter and flexible hysteroscopes can ultimately limit the need for excessive dilation and thereby limit one of the most dangerous portions of the procedure.
Uterine perforations can occur during operative maneuvers as well. Care should be taken during procedures in the cornua because this is the thinnest portion of the myometrium. In general, a small midline or fundal injury with a blunt instrument does not have clinically significant sequelae if bleeding is minimal, but large rents or those caused by sharp or electrosurgical instruments may result in a need for diagnostic laparoscopy to completely evaluate the patient for bleeding or visceral injury. Lateral perforations involve risk of injury to vessels and should be further inspected with diagnostic laparoscopy or interventional radiology and/or angiography.
Whenever electrical or laser injury to the bowel or bladder is suspected, laparoscopy or laparotomy is required for complete evaluation. The risk of peritonitis, sepsis, and death are most often associated with unrecognized and untreated thermal injuries to the viscera. Some of these thermal visceral injuries occur without apparent perforation of the uterus. For procedures in which electrical or laser energy is used, the surgical tip should be kept in direct view to avoid thermal injury.
Media-related complications
The risk of gas embolism is the primary complication associated with the use of CO2 as the distention medium. Because of its solubility in plasma, CO2 has a wide margin of safety. Trendelenburg positioning, cervical trauma, and overdilation of the cervix should be avoided to help prevent embolus formation. Intrauterine pressures should be maintained below 100 mm Hg, with maximal flow rates less than 100 mL/min (Morrison, 1999).
When gas embolism occurs, results can be devastating, and circulatory collapse can occur. If an embolus is suspected because of a change in a patient's vital signs (eg, hypotension, tachycardia, tachypnea, desaturation, decreased end-tidal CO2 value), the hysteroscope should be removed, the patient positioned on her left side, and an IV bolus of isotonic sodium chloride solution should be delivered as a first-line treatment. In addition, attempted percutaneous aspiration of an embolus is reported (Cooper, 2000). Further evaluation with echocardiography and possible cardiopulmonary resuscitation may be indicated.
The risk of absorption of media is minimal under normal operative conditions. Risk factors for clinically significant intravasation of fluid include prolonged operative procedures, the use of large volumes of low-viscosity media, or the resection of fibroids or myometrial trauma that results in open uterine venous channels or unidentified perforations (Jansen, 2000). Intravasation can occur when the intrauterine pressure is greater than the patient's mean arterial pressure (Morrison, 1999).
Fluid overload is rare with electrolyte-containing fluids. When excessive intravasation occurs, isotonic fluid overload occurs. This is relatively easy to treat. However, these fluids are uncommonly used in operative procedures.
On the contrary, nonelectrolyte, hypotonic media, which are nonconductive, are most often used for the prolonged, complicated electrosurgical procedures. These media have relatively serious adverse effect profiles (see Media above). When large volumes of these solutions are absorbed, subsequent hyponatremia, hypervolemia, hypotension, pulmonary edema, cerebral edema, and cardiovascular collapse can occur. Absorption (or deficit) of nonelectrolyte solutions must be closely monitored throughout operative hysteroscopy.
For every liter of hypotonic media absorbed, the patient's serum sodium decreases by 10 mEq/L. If the patient's sodium level is less than 120 mEq/L, she is at increased risk for having devastating complications. Hyponatremia can occur rapidly, resulting in generalized cerebral edema, seizures, and even death. In general, if a deficit of serum sodium that is greater than 1500 mL or if the sodium level is less than 125 mEq/L, the procedure should be terminated. Some suggest that of all nonelectrolyte media, 5% mannitol has the safest adverse-effect profile because it can maintain a patient's osmolality despite hyponatremia, improving neurologic outcomes (Cooper, 2000).
If the patient's sodium osmolality is less than 125 mOsm, forced diuresis with furosemide (Lasix) 40 mg IV, fluid restriction, and administration of 3% sodium chloride at a rate to correct hyponatremia by 1.5-2.0 mOsm/L/h is required. To limit any cerebral effects, do not correct the osmolality to more than 135 mOsm. Frequent assessments of the patient's sodium levels every 30 minutes may be appropriate to follow up this titration.
Dextran 70 can cause clinically significant overload in long surgical procedures; maximal absorption should not exceed 500 mL. This type of overload does not respond to diuretic treatment because the kidneys poorly excrete Dextran 70. Therefore, plasmapheresis may be required (Borten, 1983; Cooper, 2000). Pulmonary edema and diffuse intravascular coagulation are other adverse effects associated with the use of Dextran 70. The proposed mechanisms are fluid overload, toxic effects of Dextran 70 on the pulmonary capillaries, and/or probable anticoagulant effects (Jedeikin, 1990; Loffer, 1995; Cooper, 2000).
Anaphylaxis is another complication of Dextran 70, with frequencies of 1 case per 1500-300,000 patients (Borten, 1983; Jedeikin, 1990; Cooper, 2000). Treatment of anaphylaxis includes diphenhydramine, epinephrine, steroids, and possible fluid and ventilatory support.
Bleeding
Bleeding during or after surgery is the second most common complication of hysteroscopy (0.25% of all cases). Myomectomy is the procedure with the highest complication rate (2-3%) (Cooper, 2000). Data suggest improvements in blood loss and preprocedural hematocrit levels when patients are pretreated with GnRH agonists or oral contraceptives. Distention media themselves may yield enough pressure to cause hemostasis during a procedure. In addition, the coagulating effects of surgical instruments can aid in controlling bleeding during surgery.
If bleeding persists after surgery, a 30-mL Foley catheter balloon filled with 15-30 mL of fluid can be inserted into the cavity. This balloon can easily be removed 24 hours later. Antibiotic prophylaxis should be given if a foreign body is placed in the uterus. Vasopressin and misoprostol are alternate medications that can help with vasoconstriction and uterine contractions. As a last resort, embolization of the uterine artery or hysterectomy is an option for definitive management.
Infection
Infection is an uncommon complication of hysteroscopy. Even with Dextran 70, which is a polymerized sucrose, infection is rare in a patient who is preoperatively screened. If a patient has a preoperative infection or a significant history of pelvic inflammatory disease, treatment before surgery is recommended, but prophylactic antibiotics do not reduce the risk of infection after surgery (Loffer, 1995; Cooper, 2000; Gimpelson, 2000). If indicated, antibiotics should be used to prevent subacute bacterial endocarditis. Cystitis and endometritis are the most common infections associated with hysteroscopic procedures, and these should be treated in a standard fashion.
More on Hysteroscopy |
| Overview: Hysteroscopy |
| Workup: Hysteroscopy |
 Treatment: Hysteroscopy |
| Follow-up: Hysteroscopy |
| References |
| « Previous Page | Next Page » |
References
ACOG. Hysteroscopy. ACOG Technical Bulletin Number 191-April 1994. Int J Gynaecol Obstet. May 1994;45(2):175-80. [Medline].
Bacsko G. Uterine surgery by operative hysteroscopy. Eur J Obstet Gynecol Reprod Biol. Feb 1997;71(2):219-22. [Medline].
Balmaceda JP, Ciuffardi I. Hysteroscopy and assisted reproductive technology. Obstet Gynecol Clin North Am. Sep 1995;22(3):507-18. [Medline].
Blanc B. Benign expansive lesions: fibroids, polyps, and endometrial pathology--treatment by hysteroscopic resector. Eur J Obstet Gynecol Reprod Biol. Mar 1996;65(1):99.
Borten M, Seibert CP, Taymor ML. Recurrent anaphylactic reaction to intraperitoneal dextran 75 used for prevention of postsurgical adhesions. Obstet Gynecol. Jun 1983;61(6):755-7. [Medline].
Bradley LD, Pasqualotto EB, Price LL. Hysteroscopic management of endometrial polyps. Obstet Gynecol. Apr 2000;95(4 Suppl 1):S23.
Brill AI. Energy systems for operative hysteroscopy. Obstet Gynecol Clin North Am. Jun 2000;27(2):317-26. [Medline].
Campo S, Campo V, Gambadauro P. Short-term and long-term results of resectoscopic myomectomy with and without pretreatment with GnRH analogs in premenopausal women. Acta Obstet Gynecol Scand. Aug 2005;84(8):756-60.
Cooper JM, Brady RM. Intraoperative and early postoperative complications of operative hysteroscopy. Obstet Gynecol Clin North Am. Jun 2000;27(2):347-66. [Medline].
Cooper JM, Brady RM. Late complications of operative hysteroscopy. Obstet Gynecol Clin North Am. Jun 2000;27(2):367-74. [Medline].
Cooper JM, Brady RM. Hysteroscopy in the management of abnormal uterine bleeding. Obstet Gynecol Clin North Am. Mar 1999;26(1):217-36. [Medline].
Corfman RS. Indications for hysteroscopy. Obstet Gynecol Clin North Am. Mar 1988;15(1):41-9. [Medline].
Daniell JF, Kurtz BR, Ke RW. Hysteroscopic endometrial ablation using the rollerball electrode. Obstet Gynecol. Sep 1992;80(3 Pt 1):329-32. [Medline].
DeCherney AH, Diamond MP, Lavy G, Polan ML. Endometrial ablation for intractable uterine bleeding: hysteroscopic resection. Obstet Gynecol. Oct 1987;70(4):668-70. [Medline].
Emanuel MH, Wamsteker K, Hart AA, et al. Long-term results of hysteroscopic myomectomy for abnormal uterine bleeding. Obstet Gynecol. May 1999;93(5 Pt 1):743-8. [Medline].
Gimpelson RJ. Hysteroscopic treatment of the patient with intracavitary pathology (myomectomy/polypectomy). Obstet Gynecol Clin North Am. Jun 2000;27(2):327-37, vii. [Medline].
Goldrath MH. Hysteroscopic endometrial ablation. Obstet Gynecol Clin North Am. Sep 1995;22(3):559-72. [Medline].
Indman PD. Instrumentation and distention media for the hysteroscopic treatment of abnormal uterine bleeding. Obstet Gynecol Clin North Am. Jun 2000;27(2):305-15, vi. [Medline].
Isaacson K. New developments in operative hysteroscopy. Obstet Gynecol Clin North Am. Jun 2000;27(2):375-83. [Medline].
Jansen FW, Vredevoogd CB, van Ulzen K. Complications of hysteroscopy: a prospective, multicenter study. Obstet Gynecol. Aug 2000;96(2):266-70. [Medline].
Jedeikin R, Olsfanger D, Kessler I. Disseminated intravascular coagulopathy and adult respiratory distress syndrome: life-threatening complications of hysteroscopy. Am J Obstet Gynecol. Jan 1990;162(1):44-5. [Medline].
Loffer FD, Bradley LD, Brill AI, et al. Hysteroscopic fluid monitoring guidelines. The ad hoc committee on hysteroscopic training guidelines of the American Association of Gynecologic Laparoscopists. J Am Assoc Gynecol Laparosc. Feb 2000;7(1):167-8. [Medline].
Loffer FD, Bradley LD, Brill AI, et al. Hysteroscopic training guidelines. The ad hoc committee on hysteroscopic training guidelines of the American Association of Gynecologic Laparoscopists. J Am Assoc Gynecol Laparosc. Feb 2000;7(1):165. [Medline].
Loffer FD. Contraindications and complications of hysteroscopy. Obstet Gynecol Clin North Am. Sep 1995;22(3):445-55. [Medline].
Luciano AA. Power sources. Obstet Gynecol Clin North Am. Sep 1995;22(3):423-43. [Medline].
March CM. Hysteroscopy. J Reprod Med. Apr 1992;37(4):293-311; discussion 311-2. [Medline].
Marlow JL. Media and delivery systems. Obstet Gynecol Clin North Am. Sep 1995;22(3):409-22. [Medline].
Morrison DM. Management of hysteroscopic surgery complications. AORN J. Jan 1999;69(1):194-7, 199-209; quiz 210, 213-5, 21. [Medline].
Neuwirth RS, Duran AA, Singer A, et al. The endometrial ablator: a new instrument. Obstet Gynecol. May 1994;83(5 Pt 1):792-6. [Medline].
Onbargi LC, Hayden R, Valle RF. Effects of power and electrical current density variations in an in vitro endometrial ablation model. Obstet Gynecol. Dec 1993;82(6):912-8. [Medline].
Propst AM, Liberman RF, Harlow BL, Ginsberg ES. Complications of hysteroscopic surgery: predicting patients at risk. Obstet Gynecol. Oct 2000;96(4):517-20. [Medline].
Schenk LM, Coddington CC 3rd. Laparoscopy and hysteroscopy. Obstet Gynecol Clin North Am. Mar 1999;26(1):1-22, v. [Medline].
Serden SP. Diagnostic hysteroscopy to evaluate the cause of abnormal uterine bleeding. Obstet Gynecol Clin North Am. Jun 2000;27(2):277-86. [Medline].
Shapiro BS. Instrumentation in hysteroscopy. Obstet Gynecol Clin North Am. Mar 1988;15(1):13-21. [Medline].
Shokeir TA. Hysteroscopic management in submucous fibroids to improve fertility. Arch Gynecol Obstet. 2005;Nov; 273(1):50-4.
Singer A, Almanza R, Gutierrez A, et al. Preliminary clinical experience with a thermal balloon endometrial ablation method to treat menorrhagia. Obstet Gynecol. May 1994;83(5 Pt 1):732-4. [Medline].
Surrey ES, Minjarez DA, Stevens JM, Schoolcraft WB. Effect of myomectomy on the outcome of assisted reproductive technologies. Fertil Steril. May 2005;83(5):1473-9.
Tulandi T, al-Took S. Endoscopic myomectomy. Laparoscopy and hysteroscopy. Obstet Gynecol Clin North Am. Mar 1999;26(1):135-48, viii. [Medline].
Vancaillie TG. Electrocoagulation of the endometrium with the ball-end resectoscope. Obstet Gynecol. Sep 1989;74(3 Pt 1):425-7. [Medline].
Vercellini P, Zaina B, Yaylayan L, et al. Hysteroscopic myomectomy: long-term effects on menstrual pattern and fertility. Obstet Gynecol. Sep 1999;94(3):341-7. [Medline].
Vulgaropulos SP, Haley LC, Hulka JF. Intrauterine pressure and fluid absorption during continuous flow hysteroscopy. Am J Obstet Gynecol. Aug 1992;167(2):386-90; discussion 390-1. [Medline].
Further Reading
Keywords
hysteroscope, rigid hysteroscope, contact hysteroscope, microcolpohysteroscope, flexible hysteroscope, electrosurgery, myomectomy, resectoscope, proximal tubal obstruction, removal of IUD, intrauterine device, müllerian anomalies, infertility evaluation, abnormal uterine bleeding, AUB, endometrial ablation
