Hysteroscopy Treatment & Management

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

According to guidelines from the American College of Obstetricians and Gynecologists (ACOG), routine cervical ripening before diagnostic or operative hysteroscopy is not warranted; however, it may be considered for patients who are at higher risk for cervical stenosis or increased pain with the procedure. ^[69]

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. Additionally, when intravaginal misoprostol is used for preoperative cervical ripening in the premenopausal women (without known cervical stenosis), it has been described to increase the ease of dilation, reduce the need for mechanical cervical dilation, and lower the rate of cervical laceration. ^{[70, 71]} However, not all studies have shown the same improvement. ^[72] The potential benefits still need further evaluation in the postmenopausal population and potential side effects (vaginal bleeding, cramping, fever, diarrhea, and nausea) must be considered for all women. The optimal dose and route of administration (vaginal or oral) remains an area of investigation.

A randomized, double-blind, placebo-controlled trial by Nakano et al that included 158 postmenopausal women who received 200 μg of misoprostol or placebo before diagnostic hysteroscopy reported no significant differences between groups in pain intensity and duration of hysteroscopy and also that additional cervical dilatation was needed in 11 women in the misoprostol group versus 9 in the placebo group. ^[73]

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 the 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.

Finally, suction curettage done before 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. There is currently no consensus on their use prior to hysteroscopic myomectomy. ^[37] Benefits of preoperative use should be weighed against their cost and side effect profile. ^[53]

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.

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.

Analgesia regimens recommended in ACOG guidelines for office-based hysteroscopy include a single agent or a combination of several agents, such as a topical anesthetic, acetaminophen, a nonsteroidal anti-inflammatory drug, a benzodiazepine, an opiate, and an intracervical or paracervical block, or both. ^[69]

Positioning

The patient is placed in the dorsal lithotomy position then 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 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.

Hemostasis

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.

Placing the hysteroscope

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

Using the standard approach, 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.

Alternatively, a vaginoscopic approach has also been defined. ^[74] Distention media is introduced into the vagina at the same pressure used for dilation of the uterine cavity (around 30-40 mm) to distend the vaginal cavity. The hysteroscope is then used to visualize the cervix and facilitate its entry into the cervical canal. The use of a speculum and tenaculum is not needed with this approach.

Techniques

Procedures 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 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.

Diagnostic mini-hysteroscopy, using a 3.5 mm single-flow diagnostic sheath (ACMI Slim-Line Hysteroscope, Southborough, Mass), has also proven to be an easy and reliable procedure with acceptable patient tolerance. ^[75]

Endometrial ablation

First-generation endometrial ablation using the roller-ball or roller-barrel method, resection method, and laser method are described below.

• 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 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 more difficult. The posterior wall is then ablated by continuing in a clockwise fashion. Do not continue to ablate over areas that have already been treated because of the risk of uterine perforation.

• The resection method: As with the other procedures, the cervix is typically dilated to the size of the 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 a 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. Depending on the system used, the strips of resected tissue may require removal intermittently with polyp forceps. All tissue is sent to the pathologist for histologic evaluation.

• The laser method

  • The neodymium-yttrium-aluminium-garnet laser (Nd:YAG laser) can also be used for ablation. Laser energy is delivered to the tissues via a fiber inserted through an operating hysteroscope. The laser energy provides a tissue penetration of 5-6 mm. Two techniques are commonly described. The dragging technique requires the laser fiber to be in constant contact with the endometrium, which ultimately results in vaporization of the tissue. ^[76]

  • Alternatively, coagulation can be induced with the blanching technique in which the fiber does not come in direct contact with the endometrium. ^[77] Both techniques require constant motion to minimize risk of perforation. Choice of distention media includes normal saline or Dextran 70.

Second-generation endometrial ablation, hydrothermal method is described as follows:

The HydroThermAblator System (Boston Scientific, Natick, Mass) is the only second generation ablation device that uses direct visualization with the hysteroscope. A single-use 3 mm hysteroscope coated with polycarbonate is inserted into the endometrial cavity. Saline is instilled at low intrauterine pressures of < 45 mm Hg and then heated to 90°C. This low pressure is used to prevent flow of heated saline through the fallopian tubes. After the treatment is complete, cool saline is used to replace the heated saline prior to removal of the device from the cavity. Endomyometrial necrosis to a depth of 2-4 mm is achieved after 10 minutes of treatment. The endometrial cavity is uniformly ablated with this method, including both cornua. ^[78]

Submucosal fibroids

Several instruments may be used for hysteroscopic myomectomy. They include the resectoscope (by far the most common), scissors, the laser, and the morcellator. Some gynecologists inject vasopressin into the cervical stroma before the procedure to decrease blood loss and surgical time. ^[68]

• Resection

  • This is similar to resection of the endometrium, but the resectoscopic method results in 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, any remaining intramural portion of the 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 while aiming to avoid uterine perforation. The loop can often be used to separate the fibroid from the pseudocapsule, often called cold-loop resection, 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.

  • Resectoscopes historically relied on monopolar currents to cut tissue and thus required the use of hypotonic electrolyte-free distention media. Strict fluid monitoring is an obvious need. Fortunately, bipolar resectoscopes are now in use. The Princess resectoscope (Richard Wolf Medical Instruments Corporation, Vernon Hills, Ill) is a 7-mm resectoscope — the smallest bipolar resectoscope currently available.

  • Obstructed visualization due to floating tissue fragments during resection can prove difficult and may necessitate catching the loose tissue with the loop electrode or poly forcep, removing the hysteroscope to grab the tissue, followed by reintroduction of the scope. To address this problem, the Bipolar Chip E-Vac System (Richard Wolf Medical Instruments Corporation, Vernon Hills, Ill) has been introduced to the market. The system uses a traditional resectoscope with an automatic chip aspirator and can be used with monopolar or bipolar current. A microprocessor controlled pump pulses at an adjustable level to aspirate chips out through an operative channel in the hysteroscope while preventing fluid losses and uterine collapse. Published reviews favorably evaluate this new system but do note that the aspiration system is prone to becoming clogged if tissue chips are too large. ^[79] This system encourages the surgeon to remove smaller tissue fragments with each pass of the resectoscope.

• Vaporization

  • Vaporization of a fibroid can also be performed through the use of a variety of different shaped electrodes. The chosen electrode is dragged along the surface of the myoma to directly vaporize the tissue. Perforation from prolonged use at one point can occur. Using this method, tissue is destroyed and thus unavailable for pathologic examination.

  • The Gynecare Versapoint Bipolar Electrosurgery System (Johnson & Johnson Gateway LLC, Piscataway, NJ) provides the opportunity to use both a vaporizing electrode and resecting loop electrode with normal saline distention media for a variety of operative needs. Vaporizing electrode options include a ball or spring electrode for rapid vaporization and desiccation and a twizzle electrode for more precision.

• Laser ablation: Fibroids less than 2 cm in diameter can also be ablated with the use of the Nd:YAG laser. The laser fiber is dragged over the surface of the fibroid until it is flat. As with its use for endometrial ablation, continual movement is required and tissue is destroyed and not available for pathology evaluation.

• Morcellation

  • Hysteroscopic morcellation may also be used for resection of submucosal fibroids, as well as, endometrial polyps. The Intra Uterine Morcellator (IUM) (prototype: Smith & Nephew Operative Hysteroscopy System, Andover, Mass) provides a nonelectrosurgical removal option. The morcellator consists of an inner rotating or reciprocating tube electronically controlled by a foot pedal and a 4.5-mm outer tube. Only a single insertion through a 9-mm rigid hysteroscope is required, followed by saline inflation of the uterus. After the fibroid or polyp is visualized, the morcellator is placed against the lesion and rotation (optimal for polyp morcellation) or reciprocation (optimal for myomas) of the inner tube cuts the lesion as controlled suction is used for continuous tissue removal and outflow. Each tube has an opening at the end of it for visualization of cutting.

  • Advantages of morcellation include the use of physiologic saline for distention and irrigation and the availability of tissue fragments for histologic analysis after morcellation. Of note, the system is not designed to be used for submucosal fibroids with greater than 50% intramural penetration. Mean operating time has been demonstrated to be shorter when compared to resectoscopy in both a retrospective comparison and a randomized controlled pilot study among residents in training. ^{[80, 81]} The latter study demonstrated a significantly reduced operating time of more than 8 minutes in comparison to conventional resectoscopy when using the IUM for polyps as well as type 0 and small (< 30 mm) type 1 submucosal myomas (17 min vs 30.9 min).

  • Interlace Medical, Inc (Framingham, Mass) has also developed a hysteroscopic morcellation system not yet commercially available. The system is used with normal saline and is being tested using 2 lens options. The rigid rod lens hysteroscope has an overall outer diameter of approximately 6.2 mm and the flexible hysteroscope has an overall diameter of < 5.5 mm. The morcellator is designed to both reciprocate and rotate simultaneously. The metal and coating used make this device sharp and decreases tissue clogging. There is a side window in the rod for visualization of cutting. The morcellator is designed to treat type 0 and type 1 submucosal fibroids and has been used successfully during user preference testing for fibroids as large as 5 cm (oral communication). In addition to successful testing under general anesthesia, procedures using this device are also reported to be acceptable to sedated patients with use of a paracervical block. The system has the potential to beperformed in the office.

Fibroids with an intramural component

In general, nonhysteroscopic myomectomy should be considered for fibroids with greater than 50% myometrial extension (type II, G2 fibroids), which are technically the most difficult resections to perform through the hysteroscope. In addition, resection of the intramural component is associated with the greatest risk of fluid intravasation and decreases the chance per procedure of achieving complete resection. ^[54] However, different techniques for hysteroscopic resection have been proposed for the experienced surgeon. Resection of a completely intramural fibroid poses the risk of intravasation of media due to prolonged procedure time. ^[39]

• Resection

  • After initial excision of the intracavitary portion of the fibroid, the intramural component will typically expel into the cavity, but the volume of the remaining intramural fibroid will subsequently increase. Thus, excising only the intracavity portion can prove futile.

  • One surgical option is complete electrosurgical excision of the fibroid, including the intramural component. This technique is associated with increased risk of perforation, bleeding, thermal damage, and fluid absorption.

  • Another suggested resection technique involves using a resectoscope to cut the capsule of the myoma away from myometrium to prevent the fibroid from sinking into the muscular layer, followed by grasping of the myoma with graspers. Rotation can then be used to pull the myoma into the intrauterine cavity. ^[82] This is accomplished under ultrasonographic guidance. Supporting data is limited, with only 2 cases reported using this technique.

• Cold loop: Alternatively, the cold loop myomectomy has been proposed. ^[38] The surgeon first excises the intracavitary portion of the fibroid and then uses a loop, not connected to an electrical source, for blunt dissection. The loop is used to mechanically create a plane between the fibroid and myometrium. Once the fibroid is detached from the myometrium, it can then be removed in pieces.

• Toto enucleation: Alternatively, in toto enucleation has been proposed. ^[83] An elliptic incision is made in the endometrial mucosa covering the fibroid until the cleavage zone of the myoma and myometrium is reached. Tissue bridges between the myoma and muscle fibers are resected with electrocautery, resulting in protrusion of the fibroid into the uterine cavity. Myomectomy can then be completed by slicing. This technique has been successful in a small series of women (41 of 44) with myomas less than 4 cm in diameter with a reported mean operating time of 27 minutes. ^[83]

• Uterine contractions: Induction of uterine contractions by facilitating rapid changes in intrauterine pressure, uterine massage, or pharmacologic agents has also been proposed as a means to encourage migration of the residual intramural fibroid into the uterine cavity.

Intrauterine adhesions

The standard treatment of intrauterine adhesions is hysteroscopic resection. The operative hysteroscope is introduced into the uterine cavity and centrally located synechiae are lysed first. Progression is then made to the margins of the cavity. Thin, filmy adhesions can often be lysed with blunt dissection, but thicker adhesions require excision or transection. This can be accomplished with scissors, vaporization with bipolar electrocautery, or fiberoptic laser. Concurrent use of laparoscopy or ultrasonography may be useful with extensive adhesive disease to reduce the risk of perforation.

Intraoperative fluoroscopic guidance during synechiolysis has also been proposed. ^{[45, 84]} With this technique, a 16-gauge, 80-mm needle or an 18-gauge, 100-mm needle is used to introduce contrast transcervically along side the hysteroscope. As contrast is injected, pockets of endometrium are identified and the needle is used to create a passageway in the surrounding adhesions. Subsequent sharp resection with the needle or hysteroscopic scissors then follows. Advantages of this technique may include early detection of false passage and capability to concurrently assess tubal patency. ^[84]

Mechanical disruption of mild intrauterine adhesions through the use of pressure lavage under ultrasonographic guidance has also been proposed. ^[85]

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. ^[14]

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. If ultrasonography is used, the bladder should be left full to best visualize the uterus.

Although the septum is usually contained within the uterine cavity, a cervical septum may be present. The cervical septum can be incised with the use of Metzenbaum scissors followed by hysteroscopic resection of the corporal portion. Historically, removal has not been recommended as it may result in bleeding and cervical incompetence. ^[14] However, recent studies have demonstrated improved outcomes after resection. Decreased operating times (36 min vs 73 min), use of less distending media and favorable reproductive outcomes have been reported with resection when compared to retention of the cervical septum. ^[86]

Transcervical tubal sterilization

With the Essure system, a 5-mm hysteroscope is used to introduce a delivery catheter that contains a 3.85 cm flexible coil called a microinsert into the proximal portion of the fallopian tube. The inserts are made of a stainless steel inner coil wound in polyethylene fibers and an outer coil of nickel titanium. After a microinsert is placed at the uterotubal junction, the delivery catheter is removed and the outer coil of the insert expands. Three to eight trailing coils of the insert should remain visible at the tubal ostia. The inner polyethylene fibers induce tissue in-growth into the insert, facilitating occlusion of the tubal lumen by 12 weeks. The procedure can be performed without any anesthesia with acceptable pain scores. ^[83] Additionally, it can be performed safely and efficiently in the office setting with great overall patient satisfaction. ^{[60, 87]} Placement in the operating room may not offer any advantage. ^[60]

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.

Operative office hysteroscopy

Small, more sophisticated instruments and improved flow systems now allow an operative therapy to be performed at the same time as initial diagnosis. Procedures performed in the office setting include targeted endometrial biopsy, polypectomy, myomectomy, adhesiolysis, metroplasty, and tubal sterilization.

The 5-mm Office Continuous Flow Operative Bettocchi Hysteroscope (Karl Storz, Tuttlingen, Germany) has encountered success in the office setting. ^[88] This system includes a 2.9-mm rod lens system with an outer diameter of 5-mm. The instrument has a sheath for irrigation and another for suction as well as a 5 F (1.6-mm) operative canal. An oval-shaped tip facilitates introduction of the scope through a similarly shaped internal cervical os. Rotation of the scope by 90 degrees during entry to align the main axis of the scope with the transverse axis of the internal cervical os is recommended. A 4-mm system with a 2-mm rod lens system is also available. A number of 5 F instruments and bipolar electrodes are available for use with either system.

A variety of procedures have been well tolerated, without any analgesia or anesthesia, when using this system with a vaginoscopic entry approach. Procedures include mechanical treatment of cervical and endometrial polyps, IUAs, and cervical anatomical impediments, as well as Versapoint treatment of endometrial polyps and submucosal and partially intramural myomas. ^{[88, 74]}

Small diameter miniresectoscopes are also available. Recently, a small, prospective, observational study using a prototype of the 5.3-mm monopolar resectoscope (Karl Storz, Tuttlingen, Germany) reported favorable results for the removal of endometrial polyps and small (< 3 cm) type 0 or 1 submucosal fibroids. ^[89]

General posthysteroscopy 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

Prevention of postoperative adhesion formation begins with minimizing endometrial and myometrial trauma during the initial hysteroscopic procedure. 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. ^[14] There is currently no data on the potential use of the levonorgestrel-releasing intrauterine device (Mirena), but a similar size concern remains.

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. ^[22] 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. ^[14] 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. ^[14] Additionally, an early second-look hysteroscopy (2-4 weeks postoperatively) may facilitate treatment of new adhesions at an earlier, more amendable stage. ^[90]

Intrauterine use of auto-cross linked hyaluronic acid gel has also been examined in prevention of intrauterine adhesions after hysteroscopic surgery. Administration of 10 mL of gel after adhesiolysis or hysteroscopic surgery for intrauterine lesions may be associated with a significant reduction in the development and severity of de-novo adhesions. ^{[91, 92]} Long-term reproductive outcomes are not yet available.

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 5 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 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. Vaginal birth is generally, but not universally, an accepted means of delivery after hysteroscopic resection of type 0 or 1 fibroids. ^[53] However, further consideration may be given if the surgery resulted in large defects or if it was complicated by uterine perforation. Intuition suggests that patients who have large defects after a hysteroscopic procedure should be counseled similarly.

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.

Follow-up HSG 3 months after placement of Essure microinserts is required to confirm proper placement and tubal occlusion. A review of 50,000 hysteroscopic Essure sterilizations identified 64 reported pregnancies. Most pregnancies, 47%, occurred in patients without appropriate follow-up. Other notable causes included misinterpretation of HSG and preprocedural pregnancy. ^[66] The physician must place emphasis on patient education and stress importance on follow-up imaging as well as additional contraception use until confirmation of occlusion is documented.

For excellent patient education resources, visit eMedicineHealth's Pregnancy Center and Women's Health Center. Also, see eMedicineHealth's patient education articles Miscarriage, Vaginal Bleeding, Amenorrhea, Uterine Fibroids, and Female Sexual Problems.

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%. ^[9] Risk factors for perforation include cervical stenosis, severe uterine anteflexion or retroflexion, infection, myomas of lower uterine segments, and synechiae. ^[93] 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. The vaginoscopic entry approach, when appropriate, eliminates the need for a tenaculum entirely.

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.

Although rare, cases of tubal perforation following Essure microinsert placement have been reported.

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. ^[94]

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. ^[8] 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. ^[9] Intravasation can occur when the intrauterine pressure is greater than the patient's mean arterial pressure. ^[94]

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 fluid deficit 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. ^[8]

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. ^{[95, 8]} 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. ^{[96, 93, 8]}

Anaphylaxis is another complication of Dextran 70, with frequencies of 1 case per 1500-300,000 patients. ^{[95, 96, 8]} 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%). ^[8] 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. ^{[93, 8, 19]} 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.

Outcomes for each type of procedure are discussed in Indications. Attempts at hysteroscopic evaluation or treatment are obviously meant to overcome the traditional problems associated with invasive procedures performed in the past that involved prolonged hospital stays, increased morbidity, and increased costs.

In addition to surgical success rates, other important considerations are the patient's long-term satisfaction, sexual function, and overall quality of life. For example, when endometrial ablation is compared with hysterectomy, endometrial ablation is most cost-effective, and patients undergoing endometrial ablation report 80-85% sexual, functional, and psychological satisfaction.

A variety of nonhysteroscopic instruments and techniques are now available for endometrial ablation. In general, these techniques are safe, effective, quick, and easy to learn.

The thermal balloon used for menorrhagia has effects equal to those of hysteroscopic ablation, though amenorrhea is not as common with the thermal balloon as with hysteroscopic ablation. ^[97] The balloon method is fast and simple to complete.

Cryoablation of the endometrium has also been used with success. The 3-dimensional bipolar ablation device NovaSure (Cytyc Corporation, Mountain View, Calif) has been welcomed into the market. The procedure is performed to desiccate and coagulate the endometrium and a superficial layer of myometrium by using radiofrequency energy delivered through a bipolar array. Although the size of the instrument is a limiting factor, this technique is perhaps the easiest of all. The microwave endometrial ablation system offers excellent rates of amenorrhea but requires increased dilatation of the cervix to introduce the mechanism.

Overall, these newer nonhysteroscopic techniques are associated with high patient satisfaction and achieve amenorrhea results similar to hysteroscopic methods. ^[98]

An area of current interest is the feasibility and safety of simultaneous nonhysteroscopic endometrial ablation and Essure tubal sterilization. Many women of reproductive age require ablation. Reproductive outcomes could be complicated should a women become pregnant after an ablation. Thus, it would seem to be a reasonable option to offer permanent sterilization at the time of endometrial ablation. Initial studies have indicated that combination therapy may safely be performed. Concomitant performance of Essure sterilization and Thermachoice endometrial ablation has been shown to be feasible as a one-step approach and Essure sterilization immediately following NovaSure global endometrial ablation has successfully been performed. ^{[99, 100]}

In addition to the innovative Essure sterilization system, a second hysteroscopic transcervical sterilization method is currently seeking FDA approval. The Adiana (Hologic, Inc, Marlborough, Mass) sterilization method combines controlled thermal damage to the endosalpinx and insertion of a nonabsorbable silicone elastomer matrix.

The Essure system was removed from the US market on December 31, 2018. As of December 31, 2019, all unused Essure units should have been returned to Bayer so that they are no longer available for implantation.  ^{[10, 11]} The Adiana system for female sterilization is no longer available in the United States. The manufacturer stopped producing and marketing the system in 2012.

Innovative and borrowed techniques are enabling many other types of hysteroscopic interventions and new and improved hysteroscopic designs. Instruments are becoming smaller than before, enabling additional in-office interventions.

As sonohysterography becomes common, as 3-dimensional sonographic software improves, and as physicians are required to apply increasingly cost-effective procedures, these new technologies may be used to perform certain operative procedures that now are performed with hysteroscopy. For example, MRI-guided ultrasonic destruction of fibroids has completed initial phase I and II trials. The trials have shown the treatment to be highly acceptable to patients, safe, and effective at 24 months of follow-up. ^[101] Patient demand for safe and minimally invasive treatments will continue to drive research and development.