Chapter 17 Diagnostic Hysteroscopy
GENERAL PRINCIPLES
Definition
■ Hysteroscopy is a minimally invasive transcervical procedure to provide panoramic visualization of the vagina, endocervix, endometrial cavity, and tubal ostia.
■ Hysteroscopy can be performed for diagnostic or therapeutic indications.
■ Diagnostic hysteroscopy with small-caliber hysteroscopes ideally can be performed in the office. However, diagnostic hysteroscopy can also be performed in an ambulatory surgical center or operating theatre.
Anatomic Considerations
■ Hysteroscopy is generally well tolerated in an office setting.
■ Anatomic findings that may impact the ability to perform diagnostic office hysteroscopy include:
■ Overweight and obese patient may have difficulty in keeping their legs comfortable in stirrups.
■ Knee braces may be better suited for obese patients or those with limited lower extremity mobility.
■ Limited lower extremity mobility may impair comfortable positioning for the patient.
■ Vaginal length may be greater in obese women. A rigid hysteroscope may not be long enough to reach the cervix. A flexible hysteroscope may be a more suitable option for obese patients due to its longer working length.
■ Cervical stenosis may limit the ability to insert the hysteroscope comfortably in an office setting.
■ Increased risk of cervical stenosis noted in:
■ Menopausal women (medically induced or natural)
■ Patients with a prior LEEP or cone biopsy
■ Nulliparous patients
■ Prior C/section
■ Excessive menstrual bleeding may obscure visualization during hysteroscopy:
■ A fluid management distention system is not required for brief diagnostic procedures. Therefore, visualization may be hampered without the ability to vary the intrauterine pressure.
■ The inability to vary the intrauterine pressure significantly debris, clots, and heavy bleeding can obscure findings.
■ Uterine distention is more difficult in patients with an enlarged uterus greater than 14 to 18 gestational weeks on bimanual examination.
IMAGING AND OTHER DIAGNOSTICS
■ Diagnostic hysteroscopy is often performed to evaluate:
■ Abnormal uterine bleeding
■ Postmenopausal bleeding
■ To clarify equivocal ultrasound or MRI results
■ Postoperative evaluation
■ Müllerian anomalies
■ Several diagnostic studies including endometrial biopsy and medical therapy for abnormal bleeding may precede hysteroscopy.
■ When medical therapy for abnormal bleeding fails, it is possible that the patient has a focal lesion including an endometrial polyp, intracavitary fibroid, endometrial hyperplasia, or endometrial malignancy.
■ If multiple medical or hormonal treatments do not resolve bleeding abnormalities, then hysteroscopy should be considered.
■ Diagnostic hysteroscopy should be considered in patients who have had a levonorgestrel intrauterine device placed for heavy menses (without an endometrial evaluation) and whose IUD expels. It is possible that an intracavitary lesion is the culprit for the expulsion. Before replacing another IUD, a quick hysteroscopy can confirm intracavitary anatomy.
■ Transvaginal ultrasound imaging is helpful in evaluating the endometrium in reproductive-aged patients and menopausal patients.
■ TVUS imaging may miss one-sixth of intracavitary lesions in reproductive-aged patients with abnormal uterine bleeding.
■ If hysteroscopy is not routinely available, ideally SIS would be recommended because it has greater sensitivity in evaluating the endometrial cavity compared to TVUS.
■ If SIS is not available, then patients with a normal endometrial echo on TVUS and who continue to have abnormal bleeding would benefit from hysteroscopy.
■ Menopausal patients with persistent bleeding despite a negative endometrial biopsy and thin endometrium echo (4 mm or less) should be scheduled for office hysteroscopy if SIS is not available.
■ A thin endometrial echo of less than 4 mm in a menopausal patient is unlikely to be associated with an endometrial malignancy. However, endometrial polyps conform to the endometrial cavity, creating a false negative result.
■ Patients presenting with a hematometria also benefit from diagnostic hysteroscopy after drainage of the hematometria.
■ If SIS findings are equivocal, hysteroscopy can be helpful in evaluating the endometrium.
■ MRI of the pelvis with and without contrast is sensitive in detecting intracavitary fibroids. However, endometrial and endocervical polyps are not detected as well with MRI. Therefore, patients who have abnormal bleeding which cannot be explained with MRI would benefit from hysteroscopy.
PREOPERATIVE PLANNING
■ A urine pregnancy test is required on the day of the procedure for all reproductive-aged patients.
■ Diagnostic hysteroscopy ideally should be scheduled in the proliferative phase in ovulatory patients. The endometrium is thin during the early proliferative phase and leads to a decrease in false positive results.
■ Reproductive-aged patients who bleed incessantly with a pattern of bleeding consistent with an anovulatory cycle may benefit from an endometrial biopsy and short course of progesterone therapy to halt the bleeding. Once progesterone therapy is stopped, the patient will have a withdrawal bleed. At the conclusion of the withdrawal bleeding diagnostic hysteroscopy can be scheduled. Improved visualization occurs with this strategy.
■ Menopausal patients can be scheduled for diagnostic hysteroscopy at any time.
■ Cervical cultures for sexually transmitted disease are not routinely required. However, patients queried on a case-by-case basis to determine if needed.
■ There are no specific laboratory tests necessary for an office hysteroscopy (except pregnancy testing). It is likely that routine labs including a CBC with platelets and TSH would be ordered as a part of the evaluation of abnormal uterine bleeding. However, it is not needed for scheduling hysteroscopy.
■ Follow required surgical laboratory protocols if the diagnostic procedure is performed in the ambulatory care center or operating room.
SURGICAL MANAGEMENT
■ Indications for office hysteroscopy:
■ Abnormal perimenopausal and postmenopausal bleeding
■ Evaluation of thickened endometrium on TVUS
■ Equivocal endometrial findings noted with MRI, SIS, or TVUS
■ Failure to respond to medical therapy
■ Infertility evaluation
■ Postoperative evaluation of the endometrial cavity following surgical procedures such as myomectomy, dilation and curettage, or an intrauterine procedure
■ Retained products of conception
■ Location of foreign bodies (IUD, suture, migration of cerclage)
■ Leukorrhea
■ Evaluation of the endometrium following uterine fibroid embolization
■ Sterilization
■ Endocervical lesions
■ Endometrial polyps
■ Evaluation of the endometrium in women on Tamoxifen therapy
■ Submucosal fibroids
■ Müllerian anomalies (e.g., uterine septum)
■ Evaluation of C/section scars
■ Following uterine perforation to determine if the perforation has healed
■ Location of hysteroscopic inserts to determine if migration or expulsion into the uterine cavity has occurred.
■ Contraindications
■ Viable pregnancy
■ Cervical cancer
■ Known uterine cancer
■ Active pelvic inflammatory disease
■ Acute endometritis
■ Untreated sexually transmitted disease
■ Patient apprehension for office-based procedure
■ Excessive vaginal bleeding and clotting that would likely preclude an adequate view of endometrium
Positioning
■ The patient is supine with legs placed in stirrups
■ The arms can rest at her side or across the abdomen
■ Her buttock should be placed at the end of the table
Approach
■ Hysteroscopy can be performed in the office without anesthesia.
■ Hysteroscopy can be performed in an ambulatory surgical center when an
office procedure is not available or patient preference.
■ Hysteroscopy can be performed in a standard operating theatre for:
■ High-risk patients who cannot tolerate an office setting
■ Excessive bleeding
■ Hemodynamically unstable patients
■ Unable to tolerate a vaginal procedure in the officeProcedures and Techniques (Video 17.1)
Time out
■ Identify patient and proposed procedure.
■ Confirm negative pregnancy test in reproductive-aged patients.
■ Confirm that the patient has no history of an active herpes infection.
■ Determine the last menstrual period.
■ Ideally, in reproductive-aged patients diagnostic hysteroscopy should be
performed in the early proliferative phase.
■ Describe the procedure to the patient and answer questions if needed. Perform a bimanual examination and inspect cervix
■ The patient is prone on the examination table with legs in stirrups.
■ The buttock should be at the end of the table.
■ Place an absorbable pad under the patient to absorb fluids. It is helpful to have a small tray attached to the table to collect any overflow of fluid.
■ Provide a heating pad and place on the abdomen.
■ An electrical table is helpful to vary the height and to be able to place the patient in Trendelenburg position if a vasovagal reaction occurs.
■ Determine uterine size, position, exclude cervical motion tenderness.
■ Visualize cervix and exclude mucopurulent discharge.
Vaginoscopy
■ Vaginoscopy is an emerging technique to introduce the hysteroscope into the cervix without use of a speculum. This may decrease pain and discomfort for some select patients.
■ A vaginal speculum and cervical tenaculum are not used.
■ The hysteroscope is placed in the lower vagina and the distention medium fills the vagina. Vaginal distension does not provoke pain. The hysteroscope is advanced to the posterior fornix, then retracted a little, to direct the hysteroscope to the external uterine orifice.
■ Once the cervix is visualized, the hysteroscope is advanced into the endocervical canal and then the uterine cavity.
Traditional introduction of the hysteroscope
■ The open-sided speculum is placed in the vagina and the cervix cleansed with an antiseptic solution.
■ If the ectocervix appears patulous, the hysteroscope can be inserted under direct visualization without dilation or placement of a single-tooth tenaculum.
■ If the cervix is stenotic:
■ Grasp the cervix with an atraumatic single-tooth tenaculum.
■ An os dilator can gently probe the endocervix.
■ Attached the light cord, camera, distention media, hysteroscopic tubing to the hysteroscope.
■ White balance the camera.
■ Flush the IV tubing with the sterile saline solution or CO2.
Distention media options for diagnostic hysteroscopy
■ Saline or lactated ringers can be used for diagnostic hysteroscope.
■ With small-caliber hysteroscopes, a fluid pump system is not needed because the procedures are very brief lasting usually less than 5 minutes.
■ Sterile IV tubing can be attached to the hysteroscope and the fluid administered manually with sterile 60-mL syringes.
■ Hysteroscopic CO2 administered via a hysteroscopic insufflator.
■ The flow rate with a hysteroscopic insufflator is less than 100 mL/min.
■ Never use a laparoscopic insufflator. Insert the hysteroscope under direct visualization
■ Introduce the hysteroscope into the endocervix and slowly advance the hysteroscope (Tech Fig. 17.1).
Tech Figure 17.1. Introduce the hysteroscope.
Inspect the endocervix and endometrial cavity
■ Take a circumferential inspection of the endocervix.
■ Identify all endometrial landmarks including panoramic view from lower uterine
segment, tubal ostia, fundus, endometrial cavity, and endocervix (Tech Figs.
17.2 to 17.4).
■ Describe all lesions noted, size, and location (Tech Figs. 17.5 to 17.13).
■ Deflate the uterine cavity intermittently during the procedure.
■ If there is active bleeding, then saline can be infused and bloody fluid aspirated.
■ Discard the bloody fluid in the tubing and reinfuse with fresh saline.
■ Take a final inspection of the endometrial cavity and endocervical cavity as the
hysteroscope is removed.
■ Document all findings in the electronic medical record.
Tech Figure 17.2. Endometrial landmarks: panoramic view.
Tech Figure 17.3. Endometrial landmarks: tubal ostia.
Tech Figure 17.4. Endometrial landmarks: endocervix.
Tech Figure 17.5. Intracavitary fibroid.
Tech Figure 17.6. Hemorrhagic polyp through endocervix.\
Tech Figure 17.7. Healing endometrium status postfibroid resection.
Tech Figure 17.8. Fundal adhesions.
Tech Figure 17.9. Panoramic view from lower uterine segment of normal anatomy.
Tech Figure 17.10. Polyp close-up demonstrating vessels.
Tech Figure 17.11. Endocervical adhesion.
Tech Figure 17.12. Intrauterine Mirena IUD.
Tech Figure 17.13. Panoramic view of tubal ostia bilaterally.PEARLS AND PITFALLS
Schedule in early proliferative phase for patients with ovulatory menses.
Scheduling during the secretory phase is associated with more false positive findings and possible early pregnancy.
Consider hysteroscopy when abnormal bleeding persists despite a trial of medical therapy and negative endometrial biopsy.
Missing an intracavitary lesion.
Evaluate the patient in the office if she presents with postprocedural pain, fever, or discharge.
Phone triage may miss evidence of early pelvic infection.
Educate your office staff on the benefits of office hysteroscopy, safety, and outcomes.
A misinformed office staff will convey unrealistic expectations and fear to the patient.
Have an emergency cart available and practice mock emergency drills.
Pandemonium if nursing staff and physicians do not know basic steps for resuscitation.
POSTOPERATIVE CARE
■ The patient may drive home if narcotics were not used.
■ Most patients have mild cramping for a few hours after the procedure.
■ Vaginal spotting or vaginal drainage may last several days.
■ Nonsteroidal anti-inflammatory drugs or acetaminophen can be prescribed for the first 24 hours after the procedure.
■ Patient may resume all activities except that she should avoid coitus for 48 to 72 hours.
■ Patient may shower or take a tub bath.
■ Instructed to contact office if persistent pain, increased bleeding, fever, or foul smelling discharge.
■ Arrange for follow-up to discuss findings, endometrial biopsy, or response to medical therapy.
■ If the patient calls with pain, fever, and persistent bleeding, she should be seen in the office for pelvic examination and further testing as clinically indicated.
OUTCOMES
■ Diagnostic hysteroscopy is helpful in evaluation of the endocervix, endometrial cavity, and tubal ostia.■ Diagnostic hysteroscopy facilitates the triage of patients who need operative hysteroscopy.
■ The length of surgery, type of operative hysteroscopic equipment needed, operative hysteroscopic fluid selected, surgical risks and complications can be anticipated by preoperative evaluation with diagnostic hysteroscopy.
■ Ideally, diagnostic hysteroscopy should be performed in the office setting as it decreases the costs by triaging patients who need an operative hysteroscopic procedure.
■ Patients tolerate office hysteroscopy very well with small-caliber hysteroscopes currently available.
COMPLICATIONS
■ A multicenter study of 13,600 procedures involving 82 hospitals noted a low complication rate of 0.13%
■ Uterine perforation
■ Pelvic infection
■ Cervical laceration
■ Hemorrhage
■ Excessive fluid absorption
■ Air or carbon dioxide embolism
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