ﺑﺎﺯﮔﺸﺖ ﺑﻪ ﺻﻔﺤﻪ ﻗﺒﻠﯽ
خرید پکیج
تعداد آیتم قابل مشاهده باقیمانده : 3 مورد
نسخه الکترونیک
medimedia.ir

Overview of hysteroscopy

Overview of hysteroscopy
Literature review current through: Jan 2024.
This topic last updated: Feb 07, 2023.

INTRODUCTION — The development of hysteroscopy has provided a minimally invasive approach to common gynecologic problems, such as abnormal uterine bleeding. Increased clinician training, smaller diameter hysteroscopes, and increased emphasis on office-based procedures have led to a widespread use of this important technology.

A hysteroscope is a telescope that is inserted into the uterus via the vagina and cervix to visualize the endometrial cavity, as well as the tubal ostia, endocervical canal, cervix, and vagina. Hysteroscopy can be performed for diagnostic or therapeutic indications.

An overview of hysteroscopy is presented here. Vaginoscopy is discussed separately. (See "Vaginoscopy".)

In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. However, we encourage the reader to consider the specific counseling and treatment needs of transgender and gender-expansive individuals.

BENEFITS AND LIMITATIONS OF HYSTEROSCOPY — Hysteroscopy offers many benefits for patients who require evaluation of the uterine cavity. A detailed discussion of the choice between hysteroscopy and other methods of endometrial evaluation can be found separately. (See "Overview of the evaluation of the endometrium for malignant or premalignant disease" and "Endometrial sampling procedures".)

Abnormal uterine bleeding – There are several approaches to evaluating women with abnormal uterine bleeding or intrauterine lesions (pelvic sonography, saline infusion sonography, endometrial sampling, hysterosalpingography). Office hysteroscopy allows by evaluation and guides choice of subsequent treatment options. Also, hysteroscopy avoids the risk of missing focal pathology, as may occur with blind endometrial sampling or dilation and curettage.

The International Federation of Gynecology and Obstetrics (FIGO) classification system (PALM-COEIN [polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified]) adopted in 2011 integrates hysteroscopy findings into the evaluation of abnormal uterine bleeding [1]. (See "Abnormal uterine bleeding in nonpregnant reproductive-age patients: Terminology, evaluation, and approach to diagnosis".)

Lesions seen on imaging studies – Alternatively, hysteroscopy can be used to further evaluate or treat lesions identified on imaging studies (eg, abnormal endometrial echo detected with transvaginal ultrasound, saline infusion sonography, or magnetic resonance imaging [MRI]), or to confirm the absence of disease when symptoms persist and initial diagnostic tests are normal (eg, blind endometrial sampling).

Streamlined diagnosis and treatment planning – Additional benefits of office evaluation with hysteroscopy include streamlining diagnosis and treatment planning, minimizing financial and logistical barriers, and avoiding unnecessary anesthesia when hysteroscopy is normal.

Hysteroscopy cannot assess deep myometrial disease (eg, adenomyosis), tubal pathology, or the external uterine contour; thus, it is not sufficient for evaluation of these anatomic structures during an infertility evaluation. Gland-like openings may be visible during office hysteroscopy. Additional procedures (eg, laparoscopy or hysterosalpingography) are necessary. (See "Overview of infertility".)

INDICATIONS — Hysteroscopy is performed for evaluation or treatment of the endometrial cavity, tubal ostia, or endocervical canal in patients with [2,3]:

Abnormal premenopausal or postmenopausal uterine bleeding

Endometrial thickening or polyps

Submucosal, and some intramural, fibroids

Superficial adenomyosis (gland-like openings)

Intrauterine adhesions

Abnormal or equivocal findings on imaging

Chronic excessive leukorrhea

Endometrial hyperplasia (directed biopsies and/or post-treatment response)

Müllerian anomalies (eg, uterine septum)

Retained intrauterine contraceptives or other foreign bodies

Complications of pregnancy

Retained products of conception

Evaluation of cesarean delivery scar defect or isthmocele

Persistent bleeding after termination of pregnancy

Endocervical lesions

Vaginoscopy

Preoperative planning

Postoperative or postprocedure follow-up

CONTRAINDICATIONS — Contraindications to hysteroscopy are [2]:

Viable intrauterine pregnancy

Pyometria

Active pelvic infection (including genital herpes infection [4])

Known cervical cancer

While hysteroscopy should not be performed in a patient with a viable intrauterine pregnancy, postpartum or post-abortal hysteroscopy is sometimes useful for evaluation and treatment of retained products of conception [5,6].

Excessive uterine bleeding may limit visualization during hysteroscopy, but it is not a contraindication [7]. (See 'Operative challenges' below.)

Medical comorbidities (eg, coronary heart disease, bleeding diathesis) are also potential contraindications to hysteroscopic surgery. However, since this is a minimally invasive procedure, it is rarely contraindicated in few women. (See "Overview of the principles of medical consultation and perioperative medicine".)

INSTRUMENTATION — The rigid hysteroscope includes an outer sheath which surrounds channels for the telescope, distending media inflow and outflow, and operative instruments. Additional equipment is needed for infusing and monitoring uterine distending media.

There are many different sizes and type of hysteroscopes. Some are better suited for diagnostic versus operative procedures, or for outpatient rather than operating room procedures.

Hysteroscopes

Outer diameter and working length

Outer diameter – The total outer diameter (OD) of a hysteroscope refers to the diameter of the sheath, a metal tube which houses the telescope and instruments. Sheath ODs range from 3.1 to 10 mm.

Smaller OD hysteroscopes cause less pain and decrease the need for mechanical dilation. Even reducing the sheath size from 5 to 3.3 mm can improve patient comfort [8,9]. In general, inserting a hysteroscope with >5 mm OD will require mechanical cervical dilation; most patients will experience discomfort and will require analgesia (eg, paracervical block, peri-procedural nonsteroidal agents). In addition, analgesia is typically required for operative procedures. Diagnostic procedures performed with smaller OD sheaths can usually be performed without dilation and in the office.

Both diagnostic and operative sheaths are fitted with stopcocks or ports for the instillation of distending media. To clear blood and thus improve visualization of the uterine cavity, some operative sheaths have dual ports that provide continuous laminar flow of distending media. In addition, some operative sheaths aspirate pieces of tissue from the uterine cavity (ie, to remove debris or retrieve specimens for pathologic evaluation). This allows removal of large debris while maintaining cervical dilation. (See 'Distending media' below.)

Selected diagnostic hysteroscopes permit targeted biopsies and retrieval of foreign bodies, as well as limited intrauterine surgery (removal of filmy adhesions or small endometrial polyps).

Simple operative sheaths use the distending media channel for the insertion of instruments. Although this method is easy and allows one to use a small-diameter sheath, leaks of media are common.

Advanced operative sheaths may have three channels: two for operative instruments and one for instilling distending media.

Other operative sheaths contain permanently attached operative tools, such as biopsy instruments, forceps, or scissors.

Working length – The working length of a hysteroscope measures from the eyepiece to the distal tip, and can range from 160 to 302 mm. A longer working element permits the hysteroscopist to be further away from the vagina.

Rigid versus flexible — Most hysteroscopes are rigid, but narrow caliber scopes (<5 mm) may also be semi-rigid or flexible. Rigid hysteroscopes cause more intraoperative pain, but offer better optical quality and are less costly. This was illustrated in a randomized trial that assigned 144 pre- and postmenopausal women undergoing outpatient diagnostic hysteroscopy to a 3.7 mm rigid or 3.6 mm flexible hysteroscope [10]. Both groups received topical cervical anesthesia. Compared with flexible hysteroscopes, use of a rigid hysteroscope was associated with significantly more pain, but better optical quality and ease of insertion.

Flexible hysteroscopy is especially useful for diagnostic or operative procedures in women with an irregularly shaped uterus, as the distal tip can be deflected upward or downward (eg, for tubal cannulation or lysis of adhesions near the tubal ostia) (picture 1).

Optics — Quality of visualization varies among hysteroscopic telescopes. In general, the higher quality cameras have larger ODs and are more costly. Thus, narrow caliber telescopes provide adequate quality for routine diagnostic procedures, while the high quality cameras are preferable for advanced operative hysteroscopy.

The telescope consists of three parts: the eyepiece, barrel, and objective lens. The image depends upon characteristics of these components. Hysteroscopes are monocular (single eyepiece), and thus, provide little depth perception. The surgeon can look directly through the eyepiece or view the image via a video monitoring system. Use of a video monitoring system allows other operating room personnel and the patient to view the procedure and also allows still photographs and video recordings for documentation.

Viewing angles range from zero to 70 degrees (figure 1). A zero degree hysteroscope provides a panoramic view in line with the sheath. Increasing viewing angles allow the surgeon to visualize areas to the left or right of midline without shifting the telescope from side to side (eg, to view the tubal ostia or a focal lesion in an irregularly shaped cavity).

The main hysteroscopic optical system is a direct optical. The direct optical hysteroscope, derived from the cystoscope, provides the surgeon with a global view of the uterine cavity. A distending medium is used and the image is well-illuminated and has excellent contrast and resolution.

Light source – Illumination for hysteroscopy is provided by a light source connected to the hysteroscope by a fiberoptic cable. Fiberoptics allow transmission of bright light without the transmission of significant heat.

Most light sources are either halogen or xenon. Either type of lamp provides adequate illumination for operative procedures, photography, and videotaping; xenon lamps are more expensive than halogen.

Operative instrumentation — Operative hysteroscopes are used to remove endocervical or endometrial lesions (eg, submucosal myomas, endometrial polyps) or to perform an endometrial ablation/resection. Some, but not all, operative hysteroscopes use electrosurgical cutting or mechanical aspiration of tissue.

The three types of operative hysteroscopes are:

Operative sheath with instruments inserted through channels or fixed to the sheath

Electrosurgical resectoscope

Hysteroscopic tissue retrieval systems

Operative sheaths — An assortment of flexible, semirigid, and rigid instruments have been developed or adapted for hysteroscopic surgery.

Flexible and semirigid instruments range in diameter from 2 to 3 mm and are inserted through an operating channel in the sheath [11]. These instruments include scissors, grasping forceps, biopsy forceps, and punctate electrodes (picture 2A-B). Semirigid or flexible instruments may be fragile, and must be handled with care to avoid damage.

Rigid instruments may also be inserted through a channel, or may be fixed to the end of the hysteroscope. Fixed instruments are not commonly used, since they must be inserted, removed, and manipulated along with the entire hysteroscope.

Some systems have sheaths which use suction to retrieve tissue fragments without removing the hysteroscope.

Resectoscopes — Resectoscopes typically consist of a 7 to 9 mm sheath [11] (picture 3). They use radiofrequency electrical energy which may be either monopolar or bipolar. When a monopolar resectoscope is used, the patient must be grounded and a nonconducting (ie, nonelectrolyte), distending medium must be used. Bipolar resectoscopes are a newer development and can be used with electrolyte distending media (eg, saline or Ringer's lactate) [12]. (See 'Distending media' below and "Overview of electrosurgery".)

Traditionally, radiofrequency tools for the resectoscope have included the loop (tissue cutting) and rollerball (coagulation) (picture 4). Newer vaporizing electrodes (eg, VaporTrode) have been introduced that vaporize lesions and thus obviate the need to remove floating pieces of tissue. Of course, they are not appropriate for procedures in which a specimen is needed for histology.

Assembly of resectoscopes generally requires some practice and should be mastered before a surgical procedure is undertaken (picture 5A-D).

Hysteroscopic tissue retrieval system — The hysteroscopic tissue retrieval system consists of a rotary blade that cuts lesions; the cut tissue is then aspirated through the tissue retrieval apparatus [13]. Tissue retrieval systems, which are inserted through the working channel of hysteroscope, exist for use with 6 mm, 7 mm, and 9 mm hysteroscopes. Two of the currently available tissue retrieval systems do not use any electrical energy. There is one tissue retrieval system that utilizes radiofrequency electrical energy, and thus can coagulate bleeding vessels; the other systems do not [14,15].

Distending media — Hysteroscopy is performed using a distending medium to provide a global view of the endometrial cavity and to clear debris, tissue fragments, and blood within the uterine cavity [16].

The most commonly used distending media are low viscosity fluids and carbon dioxide. Carbon dioxide is used for diagnostic procedures. The management of fluid and gaseous distending media is discussed in detail separately. (See "Hysteroscopy: Managing fluid and gas distending media".)

SURGICAL PLANNING

Choosing an operative setting — Outpatient settings are increasingly common for diagnostic and some operative hysteroscopy (eg, hysteroscopic sterilization, removal of small lesions or adhesions). Ambulatory settings are acceptable to patients, time-saving, and cost-effective compared with operating room procedures, and should be used, whenever feasible [17-19].

Approach to outpatient hysteroscopy — The most common reasons for failure to complete an outpatient hysteroscopy are pain, cervical stenosis, and poor visualization [17,20]. Thus, an approach to successful outpatient hysteroscopy includes:

Patient counseling and selection

Exclude patients with cervical stenosis, limited mobility that impedes positioning, comorbidities that require intensive monitoring, or who cannot tolerate the procedure with a local anesthetic

Provide anticipatory guidance about the degree and duration of discomfort

Verbally reassure the patient during the procedure

Procedure selection and approach

Choose procedures that are brief (<30 minutes)

Perform diagnostic or minor operative procedures

Minimize intraoperative pain

Minimizing cervical dilation

Pre-treat with a prostaglandin the night before the procedure (eg, a single dose of misoprostol, 200 to 400 mcg, taken orally or inserted into the vagina)

Use a narrow caliber hysteroscope (≤4 mm)

Analgesia

Choose an anesthetic plan specific to the patient and procedure (eg, procedures that include endometrial biopsy or use a larger diameter hysteroscope are more likely to require analgesia). (See 'Pain management' below.)

We do not pre-medicate patients with nonsteroidal anti-inflammatory drugs (NSAIDs) because the data generally do not support a reduction in intraoperative pain [21-27], although two small trials reported a small reduction in intraoperative pain with pre-procedure use of tramadol [28,29]. NSAID use has been associated with reduced posthysteroscopy pain and can be used postoperatively as needed [21-23]. (See 'Postoperative care' below and "Nonopioid pharmacotherapy for acute pain in adults", section on 'Nonsteroidal anti-inflammatory drugs'.)

Choosing a hysteroscope — Instrumentation choices for hysteroscopy must be tailored to the procedure and operative setting. Diagnostic hysteroscopy, particularly in the outpatient setting, relies upon a small outer diameter (OD) to minimize both the need for cervical dilation and patient discomfort.

For minor procedures performed in the outpatient setting and/or under local anesthetic, it also makes sense to balance OD and optical quality. However, in general, a larger OD will be required to accommodate operative instruments compared with diagnostic hysteroscopy.

Advanced operative procedures require an operative hysteroscope with one or two channels for instruments and also a high quality telescope.

Choosing a distending medium — Diagnostic procedures can be performed using either carbon dioxide or normal saline. For operative procedures that use monopolar electrosurgical instruments, a nonconductive fluid (eg, glycine) is required to avoid thermal injury. Bipolar electrosurgical procedures may be performed using an isotonic fluid (eg, normal saline or lactated Ringer's), which avoids the risks of electrolyte and osmolar imbalances associated with nonconductive solutions [16].

A detailed discussion of choosing a distending medium for hysteroscopy can be found separately. (See "Hysteroscopy: Managing fluid and gas distending media", section on 'Choosing a distending medium'.)

PREOPERATIVE EVALUATION AND PREPARATION

Informed consent — Women considering hysteroscopy should be counseled about alternative diagnostic or treatment approaches, and informed consent regarding expected treatment success and possible complications. Patients should be informed of possible need to abandon or prematurely stop a procedure due to fluid overload. Also, since uterine perforation is a possible complication, patients should consent to a possible laparoscopy or laparotomy if it becomes necessary to rule out visceral or vascular injury. (See "Overview of preoperative evaluation and preparation for gynecologic surgery".)

Evaluation — A medical history is taken, including: detailed questions regarding symptoms that relate to the indication for the procedure; obstetric and surgical history; and medical comorbidities, medications, and allergies. A complete pelvic and general physical examination is performed, with particular attention to the size and mobility of the uterus and the patency of the cervix. Pregnancy testing is performed; cervical cultures are appropriate if cervicitis is suspected.

Timing and endometrial preparation — For premenopausal women with regular menstrual cycles, performing hysteroscopy during the proliferative (ie, follicular) phase is preferred for visualization of the uterine cavity [30]. During the secretory phase, the thick endometrium can mimic endometrial polyps and lead to inaccurate diagnoses. Also, during menstruation, blood may interfere with visualization.

In reproductive age women with irregular uterine bleeding, the ideal time for the procedure is unpredictable. Thus, patients should be counseled that a procedure may be attempted, but may need to be rescheduled if obscuring blood makes it impossible to evaluate the uterine cavity. Often, surgery is still feasible, because fluid pumps facilitate visualization by rapidly clearing debris and blood. (See 'Operative challenges' below.)

Another approach is pharmacologic thinning of the endometrium. Thinning agents should be used only when the surgeon plans operative hysteroscopic resection of a leiomyoma or endometrial ablation. Thinning agents should not be used when diagnostic hysteroscopy alone is planned, as these hormones may influence the histology of the endometrium. The most commonly used agents are estrogen-progestin contraceptives or progestins alone (eg, oral medroxyprogesterone acetate 10 mg daily on cycle days 15 to 26) [31]. Gonadotropin releasing hormone agonists and danazol are also effective, but are used infrequently due to adverse effects [32-35]. All of these agents require at least two months of therapy to effectively thin the endometrium. Regimens that require a shorter duration of therapy have been proposed (eg, desogestrel and raloxifene) [36].

For postmenopausal women, hysteroscopy may be performed at any time.

Cervical preparation and dilation — Adequate cervical dilation is an important step in hysteroscopy, as nearly 50 percent of hysteroscopic complications are associated with difficult passage of the hysteroscope through the cervical canal [37]. Not all patients will require cervical dilation for hysteroscopy, namely premenopausal women undergoing hysteroscopy with a narrow caliber (<5 mm) or flexible hysteroscope. Patients who benefit from cervical dilation include those having procedures with larger hysteroscopes (≥5 mm); have a history of cervical stenosis, cervical surgery, nulliparity, or prior cesarean section; and postmenopausal patients.

Timing and selection of approach – Cervical dilation can be done mechanically at the time of the procedure (dilators) or done preoperatively with either cervical ripening agents (misoprostol or dinoprostone) or vaginal osmotic dilators (laminaria).

Preference for preoperative dilation – Preoperative dilation is generally preferred to intraoperative dilation because it avoids or reduces the need for mechanical dilation and the associated risks of pain, uterine perforation, and false track creation [17,38].

Medication dilation – In our practice, we pretreat patients who are anticipated to need cervical dilation with misoprostol, 200 to 400 mcg, taken orally or inserted vaginally 24 to 48 hours prior to hysteroscopy. We prefer misoprostol to dinoprostone based on the following data:

-In a 2015 systematic review and meta-analysis of 19 trials addressing preoperative cervical ripening prior to operative hysteroscopy, pre- and postmenopausal women treated with misoprostol were much less likely to require additional mechanical dilation than women treated with placebo or no intervention (odds ratio [OR] 0.08, 95% CI 0.04-0.16) or women treated with dinoprostone (OR 0.58, 95% CI 0.34-0.98) [38]. As an illustration of this effect, if mechanical dilation would normally be needed in 80 percent of untreated women undergoing hysteroscopy, the use of misoprostol would reduce the need for mechanical dilation to between 14 and 39 percent of women based on this meta-analysis.

-The meta-analysis also reported that women receiving misoprostol pretreatment had fewer complications than those treated with placebo (OR 0.37, 95% CI 0.18-0.77) or those treated with dinoprostone (OR 0.32, 95% CI 0.12-0.83) [38]. The side effects of misoprostol included mild abdominal pain, vaginal bleeding, and increased body temperature.

The optimal misoprostol pretreatment dose, route, and timing have not been determined; most studies have used 200 to 400 mcg. While trials comparing oral versus vaginal administration of misoprostol have reported conflicting results regarding superiority, both routes of administration appear to improve pre-operative cervical dilation and ease of procedure [39-41]. In another study that compared 400 mcg of misoprostol inserted vaginally either 12 or 3 hours prior to the procedure, the women in the 12-hour group had easier insertion of the hysteroscope and reported less pain than the women in the 3-hour group [42]. Thus, we ask women to self-administer misoprostol (200 to 400 mcg) vaginally the night before the procedure. For women who cannot or prefer not to use a vaginal medication, oral dosing is a reasonable alternative.

Mechanical dilation with laminaria – Although effective, we do not use laminaria as they are typically inserted in the office on the day prior to the procedure and therefore require an additional visit for the patient. While a meta-analysis (one trial, 110 women) and a separate trial of 150 women both reported a reduced need for intraoperative cervical dilation after laminaria pretreatment compared with misoprostol pretreatment [38,43], we do not believe this difference warrants the extra time and cost of an additional office visit because the intraoperative complication rates were the same between the two groups [38].

Postmenopausal patients – Although prior trials of misoprostol in postmenopausal women had reported conflicting results [44-48], the meta-analysis above, which only included two trials in the analysis of postmenopausal women, did demonstrate a benefit of misoprostol in this group [38]. In addition, pretreatment of postmenopausal women with vaginal estrogen (25 mcg daily) for two weeks before surgery may augment the cervical dilation caused by misoprostol [45].

Adjunct treatments

Vaginal estrogen – With the addition of 25 mcg vaginal estrogen 14 days prior to hysteroscopy, along with 400 to 1000 mcg vaginal misoprostol 12 hours prior to the procedure, ease of cervical dilation and reduction in pain was significantly lower compared with misoprostol alone [45,49].

Evening primrose oil (EPO) – One study reported evening primrose oil (EPO) facilitated cervical ripening and dilation before operative hysteroscopy in both pre- and postmenopausal patients [50]. Patients without a prior vaginal delivery were randomly assigned to receive two soft gels (each 500 mg) placed into the posterior vaginal fornix six to eight hours before operative hysteroscopy. The total dilation time and the size of the first dilator used to apply force was less in women treated with EPO. It is easy to use, available, inexpensive, and had no serious sequelae, but these study results have not been replicated.

Prophylactic antibiotics — Antibiotics are not routinely administered during hysteroscopy for prevention of surgical site infection or endocarditis since posthysteroscopy infection occurs in less than 1 percent of women [51]. (See 'Infection' below and "Overview of preoperative evaluation and preparation for gynecologic surgery", section on 'Antibiotic prophylaxis'.)

Sterile preparation — Povidone iodine solution is typically used for sterile vaginal preparation. However, there are few studies evaluating the effect of vaginal preparation on the risk of surgical site infection prevention. (See "Overview of preoperative evaluation and preparation for gynecologic surgery", section on 'Vaginal preparation'.)

Pain management — Anesthesia may be needed to limit pain and facilitate hysteroscopy; selection of approach depends on patient preferences and procedure factors. Parts of the procedure that are potentially painful include placement of a tenaculum on the cervix, dilation of the cervix, insertion of the hysteroscope, uterine distension, and uterine biopsy [52]. Some women find uterine biopsy to be the most painful part of the procedure [53]. Managing pain or discomfort encompasses not just medication, but also patient counseling, complimentary treatments (eg, guided visualization or listening to music [54]), and selection of the type of procedure and instruments. (See 'Approach to outpatient hysteroscopy' above.)

While pain management is individualized based on needs of the patient and planned procedure, we generally take the following approach:

Diagnostic hysteroscopy – Most patients are able to undergo diagnostic hysteroscopy without anesthesia [55,56]. The benefits of not using anesthesia include no adverse medication reactions, reduced procedure time and cost, and avoidance of a pain-inducing paracervical block [53,57]. Not using anesthesia appears particularly appropriate for diagnostic procedures using a hysteroscope that is <4 mm in diameter. In a trial of over 350 postmenopausal women undergoing hysteroscopy, women who underwent hysteroscopy with a 3.5 mm hysteroscope and no anesthetic had significantly less pain than women who had the procedure with a 5 mm hysteroscope, even when a paracervical block was used [53]. One study of 40 participants undergoing hysteroscopy reported less pain in those using a virtual reality intervention compared with those receiving standard care [58].

Simple operative hysteroscopy – For those undergoing simple operative hysteroscopy (eg, IUD removal) or hysteroscopy with a hysteroscope 4 mm or larger, we prefer a paracervical block because it is low cost, well tolerated, and reduces some aspects of pain.

Supporting data – Although a meta-analysis of 26 studies comparing paracervical block with various interventions during cervical dilation and uterine intervention reported that no technique provided reliable pain control across all studies, sub-analysis comparing paracervical block with placebo reported that paracervical block reduced the following [59]:

-Pain with cervical dilation (standardized mean difference [SMD] -0.96, 95% CI -1.91 to -0.01, four trials, 381 women).

-Pain of uterine interventions (SMD -0.74, 95% CI -1.19 to -0.28, six trials, 696 women). Interventions included carbon dioxide insufflation, endometrial biopsy, fractional curettage, suction evacuation, or aspiration.

-Risk of severe pain (relative risk 0.16, 95% CI 0.04-0.74, two trials, 242 women).

Choice of drug and technique – Choice of agent and technique for paracervical block are discussed in detail separately. (See "Pudendal and paracervical block", section on 'Gynecologic procedures'.)

Operative hysteroscopy with intrauterine procedure – Women undergoing operative hysteroscopy with intrauterine procedures (eg, myomectomy, uterine evacuation, uterine septum resection) typically require additional pain control beyond that provided by a paracervical block [17]. Options include intravenous medication (ie, conscious sedation) and regional or general anesthesia. Paracervical block is commonly combined with these other modalities although a review of six trials comparing paracervical block with sedation reported similar outcomes for the two modalities in pain during or after the procedure, use of postoperative pain medication, adverse effects, patient satisfaction, or operator's perception of analgesia [59]. Patient selection and use of conscious sedation is reviewed separately. (See "Procedural sedation in adults in the emergency department: General considerations, preparation, monitoring, and mitigating complications".)

Regional or general anesthesia is reserved for women who cannot tolerate a procedure under local or intravenous anesthesia, such as patients who require extensive operative procedures (eg, resection of uterine septum) or who have other medical comorbidities [60]. Patients with comorbidities may require intensive monitoring in an operating room, even when local anesthesia or conscious sedation is planned.

PROCEDURE — General principles regarding performing hysteroscopy are reviewed here. The working group of the American Association of Gynecologic Laparoscopists (AAGL), The European Society for Gynaecological Endoscopy (ESGE), and the Global Community of Hysteroscopy (GCH) released a consensus statement outlining parameters to describe myriad components of hysteroscopic procedures [61].

A detailed discussion of specific operative procedures can be found separately.

(See "Overview of endometrial ablation".)

(See "Intrauterine adhesions: Treatment and prevention".)

(See "Congenital uterine anomalies: Surgical repair".)

Ancillary equipment — A Foley urethral catheter is not necessary unless intensive monitoring of urine output is necessary (eg, prolonged procedure, excessive fluid absorption, or need to diuresis patient).

Although a video monitor is not requisite, it greatly benefits the surgeon, trainees, and scrub and nursing personnel throughout the case.

Entry and cervical dilation — The initial steps for all hysteroscopic procedures are the same as for other transcervical procedures (patient in dorsal lithotomy position, placement of speculum, use of tenaculum or mechanical dilation as needed). The cervix should not be dilated beyond the size of the hysteroscope, since this may cause leakage of distending medium.

A removable obturator (rod within the sheath) is especially helpful for introduction of the sheath into the uterine cavity when entry is difficult. However, it is generally advisable to introduce the hysteroscope under direct visualization to be able to navigate through the cervical canal.

Once the hysteroscope has been inserted, it is helpful to remove the speculum; using a bivalve speculum (open on one side) makes this possible. Insert the hysteroscope through the cervical os under direct endoscopic vision and remove the speculum.

Some experts advocate an alternative approach to the classic initial entry (particularly for diagnostic procedures) technique, the vaginoscopic technique, which avoids the use of a speculum or tenaculum.

Vaginoscopic technique — The vaginoscopic, or "no touch," technique is performed without a speculum or tenaculum and without anesthesia [62]. Women with cervical stenosis are not candidates for this approach. A meta-analysis of six randomized trials found that use of the vaginoscopic versus traditional technique was associated with a significant decrease in operative pain [63]. Failed procedures were infrequent for both techniques. Some, but not all, randomized trials have found that operative time was shorter for the vaginoscopic technique [64-68].

To perform the vaginoscopic technique, perform a bimanual pelvic examination with the patient in the dorsal lithotomy position. Prepare the vaginal introitus with saline or povidone iodine [69]. Without using a speculum, introduce a rigid or semi-rigid, narrow caliber (<4 mm) hysteroscope into the vaginal introitus. Infuse normal saline at a pressure of 150 mmHg [70]. Close the labia minora manually if needed to contain the distending medium. Visualize the cervix and direct the hysteroscope through the cervical canal into the uterine cavity.

Evaluating the endocervix — The endocervix can be easily inspected during insertion of the hysteroscope. Any lesions that warrant further evaluation can be visualized by withdrawing the hysteroscope to the lesion site.

Evaluating the uterine cavity — Once the hysteroscope is within the endometrial cavity, the uterine cavity is distended. The entire cavity is inspected, including the tubal ostia and any pathology. It is often helpful to take photographs for documentation and communication with the patient.

Whether using a gaseous or fluid medium, after initial uterine distension, deflate the endometrial cavity. This will prevent "negative hysteroscopic view" (ie, flattening of lesions by the pressure of distension, thereby making them difficult to see).

In general, 1 to 3 percent of benign or malignant endometrial lesions are missed on hysteroscopy [71]. To avoid missing uterine pathology, endometrial sampling (hysteroscopic-directed biopsies instead of blind sampling) should be performed in patients with focal pathology and blind sampling when there is global endometrial pathology or with persistent bleeding and no hysteroscopic findings.

Women with focal pathology should undergo hysteroscopically directed removal of lesions. (See "Endometrial carcinoma: Epidemiology, risk factors, and prevention".)

Management of distending media — One of the most important factors in performing operative hysteroscopy is maintenance of a clear operative field. For fluid media, this is most safely accomplished with a continuous flow hysteroscope and fluid pump. A complete discussion of the choice and management of distending media can be found separately. (See "Hysteroscopy: Managing fluid and gas distending media".)

Vasovagal reactions — Vasovagal syncope (also called neurocardiogenic syncope) is usually, but not always, associated with a prodrome of dizziness, nausea, bradycardia, pallor or diaphoresis. When these symptoms occur, useful measures are: stopping the procedure, placing the patient in supine position with her legs raised or in the Trendelenburg position, and administering intravenous fluid. Some patients may require atropine (0.5 to 1 mg IV every five minutes, not to exceed a total of 3 mg or 0.04 mg/kg) or "smelling salts" (ie, aromatic ammonia spirit).

OPERATIVE CHALLENGES — There are several reasons for hysteroscopic failure. As noted above, in the office setting, pain, cervical stenosis, and poor visualization are the most common reasons for terminating a procedure. In addition, advanced operative hysteroscopy may need to be halted due to excessive fluid absorption or uterine perforation (which precludes adequate uterine distension). In a systematic review of over 26,000 procedures, the overall rate of failure was 3.6 percent, and was similar in ambulatory and hospitalized patients and pre- and postmenopausal women [72].

Cervical stenosis — Pre-procedure cervical ripening with misoprostol and small diameter instruments can reduce the frequency of procedure failure due to cervical stenosis. In postmenopausal women with cervical stenosis, one option is to treat with two to four weeks or more of vaginal estrogen prior to the procedure to soften the cervix and thereby facilitate the action of misoprostol, although the efficacy of this approach has not been proven. (See 'Cervical preparation and dilation' above.)

When dilation of the cervix is difficult, a flexible hysteroscope may be passed more easily than a rigid dilator or sound. Also, the direct view helps to navigate the canal.

For women who fail these measures, intracervical injection of dilute vasopressin (4 units per 80 mL normal saline) has been reported to facilitate cervical dilation [73]. Although generally well tolerated, vasopressin injection must be performed with caution (by aspirating and confirming the absence of blood in the syringe prior to each injection), since intravascular injection or absorption has been associated with profound hypertension, bradycardia, and intraoperative mortality [74].

If a small dilator cannot be easily inserted, hysteroscopy can be performed under ultrasound guidance to confirm correct passage of the dilator into the endometrial cavity and make sure a false passage is not created.

Uterine malposition — Extreme uterine retroversion or anteversion may be congenital or may be due to pelvic adhesions. Such malposition may limit the ability to introduce the hysteroscope. Traction with a tenaculum on the anterior lip of the cervix will often straighten the uterine axis. Also, use of a flexible hysteroscope may be helpful. Of note, malposition may increase the risk of uterine perforation. To reduce the risk of uterine perforation, transabdominal ultrasound may be used to directly visualize the hysteroscope and guide insertion into the endometrial cavity.

When the uterus is severely angulated, the tubal ostia must be visualized to confirm that the entire uterine cavity has been evaluated.

Difficult uterine distention — Once the cervix has been dilated, it is unusual to have difficulty instilling a distention medium. If this difficulty is encountered, it is likely that there is an obstruction in the uterine cavity (eg, synechiae, malignancy) or a false tract may have been created during cervical dilation or hysteroscope insertion.

Obscuring blood — Bleeding can impair visualization either directly or, if carbon dioxide is used for distension, bleeding may cause gas bubbles to form. The gas bubbles can be cleared by switching to a fluid medium.

For fluid media procedures, use of a continuous flow hysteroscope allows lavage of the endometrial cavity. When lavage is not possible, then use of a tissue retrieval system facilitates a visually directed dilation and curettage that can be performed to remove endometrial debris and clots. Repeating the hysteroscopic procedure with a continuous flow hysteroscope can then be successful. (See "Dilation and curettage".)

POSTOPERATIVE CARE — Most patients experience postoperative cramping or light bleeding and some complain of vaginal discomfort. Carbon dioxide distension can cause referred shoulder pain, but this typically resolves within 15 minutes [75]. Acetaminophen or nonsteroidal anti-inflammatory drugs are usually adequate for postoperative pain control, if necessary.

The patient may resume most normal activities within 24 hours and should follow standard postoperative instructions for gynecologic procedures. (See "Patient education: Care after gynecologic surgery (Beyond the Basics)".)

We see patients for a follow-up visit two weeks postoperatively to assess for further complications and review pathology results.

COMPLICATIONS — Complications from hysteroscopy are rare, but some are potentially life threatening [37].

A multicenter study of 92 centers and over 21,000 operative hysteroscopic procedures reported a complication rate of 0.22 percent [76]. The most common complication was perforation of the uterus (0.12 percent), followed by fluid overload (0.06 percent), intraoperative hemorrhage (0.03 percent), bladder or bowel injury (0.02 percent), and endomyometritis (0.01 percent).

Another multicenter study reported data from both diagnostic and operative procedures [77]. The study involved 82 hospitals and 13,600 procedures; the overall complication rate was 0.28 percent. Diagnostic hysteroscopy had a significantly lower complication rate than operative hysteroscopy (0.13 versus 0.95 percent).

The most common complication of both types of hysteroscopy was uterine perforation (0.13 for diagnostic; 0.76 percent for operative); 18 of 33 perforations occurred during entry (measuring the size of the uterus with the sound instrument, dilation problems, perforation by hysteroscope). Fluid overload occurred in operative (0.02 percent), but not diagnostic, procedures. The operative procedure with the highest frequency of complications was intrauterine adhesiolysis (4.5 percent complication rate); all of the other procedures had complication rates less than 1 percent.

In a systematic review of over 26,000 women who underwent diagnostic hysteroscopy, complication rates were reported by only 29 percent of studies, totaling 9413 procedures [72]. Among these procedures, there were only eight complications: four uterine perforations, one pelvic infection, one bladder perforation, and two medical complications [78].

Uterine perforation — Uterine perforation is the most common complication of hysteroscopy. In most studies, hysteroscopy is complicated by confirmed uterine perforation in 0.8 to 1.6 percent of operative procedures [76,77,79-81]. The perforation rate is less during diagnostic hysteroscopy (eg, 0.1 versus 1.0 percent with operative hysteroscopy percent in a series of 13,600 procedures) [77].

A uterine perforation can occur during mechanical cervical dilation or insertion of the hysteroscope. Such a perforation may be recognized when an instrument passes beyond depth of the uterine fundus, when there is sudden loss of visualization, when omentum or bowel or peritoneal structures can be visualized at the uterine fundus, or when there is a sudden increase in the fluid deficit.

If a uterine perforation occurs, all instruments should be removed from the uterus and the hemodynamic status of the patient should be assessed. A detailed discussion of the management of uterine perforation can be found separately. (See "Uterine perforation during gynecologic procedures".)

Urinary tract or bowel injury — Bowel or bladder injury are rare, but may occur in association with uterine perforation or as a result of use of electrical current or false tract. Management of these injuries is discussed in detail elsewhere. (See "Urinary tract injury in gynecologic surgery: Identification and management".)

Cervical laceration — Cervical lacerations can occur, particularly in women with cervical stenosis. Lacerations that are large or are bleeding require sutures.

Excessive fluid absorption — Complications related to distending media vary according to the patient population and the media used. A complete discussion of management of distending media can be found separately. (See "Hysteroscopy: Managing fluid and gas distending media" and "Hyponatremia following transurethral resection, hysteroscopy, or other procedures involving electrolyte-free irrigation".)

Embolism — Embolism (air or carbon dioxide) can occur with any hysteroscopic technique and can cause cardiovascular collapse [82]. A complete discussion of management of distending media and prevention of gas embolism can be found separately. (See "Hysteroscopy: Managing fluid and gas distending media".)

Hemorrhage — Potential sources of intraoperative bleeding include operative sites, uterine perforation, and cervical laceration.

Bleeding from cervical lacerations that is recognized at surgery can be controlled using the operative instrument or sutures.

Bleeding from a specific site within the uterine cavity, with no suspicion of uterine perforation, can be controlled with electrosurgery is most cases. Women with diffuse bleeding should be evaluated for coagulopathy.

If coagulation testing is normal and diffuse bleeding continues, it can be treated by placing a Foley catheter in the uterine cavity and then distending the bulb with 15 to 30 mL of water. In one series of 216 resectoscope procedures, four women (1.9 percent) developed postoperative uterine bleeding and were successfully treated with this procedure [83]. Postoperative bleeding (with no suspicion of uterine perforation), can also be managed with this technique.

Electrosurgical injury — Thermal effects of radiofrequency or laser energy can cause injuries to the uterine cavity, as well as bowel, urinary bladder, and large pelvic vessels [11]. In particular, a significant risk of bowel injury has been reported from hysteroscopic coagulation of the tubal cornua for sterilization [84]. One must be cautious if coagulating in the tubal recesses.

The risk of thermal injury can be minimized by always moving the electrical instrument when it is activated because the temperature of the uterine serosal surface does not rise appreciably if the instrument is not held stationary during coagulation [85]. Vaginal thermal injury may result from overdilation of the cervix or activation of current when the external sheath is less than 2 cms past the external cervical os [86]. Electrode insulation defects can also cause thermal injury.

Sepsis generally results from unrecognized thermal bowel injury; fistulae or urinary ascites can occur from an unrecognized bladder injury. Such complications require consultation with a colorectal surgeon, urologist, or infectious disease specialist.

Infection — The risk of infection after operative hysteroscopy is low. Studies of 2000 or more procedures report postoperative incidences of 0.1 to 0.9 percent incidence for endometritis and 0.6 percent for urinary tract infections [76,77,87].

Dissemination of tumor — Concerns regarding the dissemination of malignant cells during hysteroscopy are discussed separately. (See "Overview of the evaluation of the endometrium for malignant or premalignant disease", section on 'Risk of tumor dissemination'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Hysteroscopy".)

SUMMARY AND RECOMMENDATIONS

Procedure description – Hysteroscopy is a procedure in which a telescope with a camera is used to evaluate or treat pathology of the endometrial cavity, tubal ostia, or endocervical canal. (See 'Indications' above.)

Procedure location – Hysteroscopy in outpatient settings is increasingly common. Advances in instrumentation, including narrow caliber hysteroscopes, decrease patient discomfort and have facilitated use of local anesthetic and ambulatory procedures. (See 'Hysteroscopes' above.)

Preoperative preparation – Preoperative preparation includes patient education, informed consent, and consideration of cervical preparation, prophylactic antibiotics, and pain management. (See 'Preoperative evaluation and preparation' above.)

Preoperative cervical dilation – For individuals undergoing hysteroscopy, we suggest preoperative cervical ripening with misoprostol rather than no preoperative treatment (Grade 2B). Most women will need cervical dilation to undergo hysteroscopy. Preoperative cervical ripening can reduce the need for mechanical dilation at the time of hysteroscopy and its attendant risks. (See 'Cervical preparation and dilation' above.)

We prescribe misoprostol, 200 to 400 mcg, to be taken orally or inserted into the posterior vaginal fornix the night prior to the procedure. Premenopausal women undergoing hysteroscopy with a flexible or narrow (<5 mm) scope may not require dilation at all and thus not benefit from cervical ripening.

Prophylactic antibiotics – Prophylactic antibiotics are not routinely administered during hysteroscopy since posthysteroscopy infection is rare. (See 'Preoperative evaluation and preparation' above.)

Pain management – Most diagnostic and brief or minor operative procedures can be performed without anesthetic or with a local anesthetic (ie, paracervical block). Regional or general anesthesia is reserved for patients who cannot tolerate a procedure under local anesthesia, have extensive operative procedures planned, or have comorbidities that necessitate intensive monitoring. (See 'Pain management' above.)

-Paracervical block – In women undergoing hysteroscopy under local anesthetic, we suggest a paracervical block over other methods of administering local anesthesia (Grade 2B). (See 'Pain management' above.)

-Vaginoscopic technique – The vaginoscopic technique for hysteroscopy avoids the use of a speculum and tenaculum. This may decrease patient discomfort in some procedures. (See 'Vaginoscopic technique' above.)

Procedure – The initial steps for all hysteroscopic procedures are the same as for other transcervical procedures (patient in dorsal lithotomy position, placement of speculum, use of tenaculum or mechanical dilation as needed). The cervix should not be dilated beyond the size of the hysteroscope, since this may cause leakage of distending medium.

(See 'Procedure' above.)

(See "Hysteroscopy: Managing fluid and gas distending media".)

Complications – Surgical complications with hysteroscopy are infrequent. Major complications include: uterine perforation, fluid overload, and gas embolism. We encourage timely in-person evaluation of patients with persistent pain, fever, or foul-smelling discharge. (See 'Complications' above and "Hysteroscopy: Managing fluid and gas distending media".)

  1. Munro MG, Critchley HO, Broder MS, et al. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet 2011; 113:3.
  2. Orlando MS, Bradley LD. Implementation of Office Hysteroscopy for the Evaluation and Treatment of Intrauterine Pathology. Obstet Gynecol 2022; 140:499.
  3. Weinberg S, Pansky M, Burshtein I, et al. A Pilot Study of Guided Conservative Hysteroscopic Evacuation of Early Miscarriage. J Minim Invasive Gynecol 2021; 28:1860.
  4. Price TM, Harris JB. Fulminant hepatic failure due to herpes simplex after hysteroscopy. Obstet Gynecol 2001; 98:954.
  5. Hatfield JL, Brumsted JR, Cooper BC. Conservative treatment of placenta accreta. J Minim Invasive Gynecol 2006; 13:510.
  6. Hinckley MD, Milki AA. 1000 office-based hysteroscopies prior to in vitro fertilization: feasibility and findings. JSLS 2004; 8:103.
  7. Shalev J, Levi T, Orvieto R, et al. Emergency hysteroscopic treatment of acute severe uterine bleeding. J Obstet Gynaecol 2004; 24:152.
  8. Cicinelli E, Parisi C, Galantino P, et al. Reliability, feasibility, and safety of minihysteroscopy with a vaginoscopic approach: experience with 6,000 cases. Fertil Steril 2003; 80:199.
  9. De Angelis C, Santoro G, Re ME, Nofroni I. Office hysteroscopy and compliance: mini-hysteroscopy versus traditional hysteroscopy in a randomized trial. Hum Reprod 2003; 18:2441.
  10. Unfried G, Wieser F, Albrecht A, et al. Flexible versus rigid endoscopes for outpatient hysteroscopy: a prospective randomized clinical trial. Hum Reprod 2001; 16:168.
  11. Vilos GA, Brown S, Graham G, et al. Genital tract electrical burns during hysteroscopic endometrial ablation: report of 13 cases in the United States and Canada. J Am Assoc Gynecol Laparosc 2000; 7:141.
  12. Phillips DR, Milim SJ, Nathanson HG, et al. Preventing hyponatremic encephalopathy: comparison of serum sodium and osmolality during operative hysteroscopy with 5.0% mannitol and 1.5% glycine distention media. J Am Assoc Gynecol Laparosc 1997; 4:567.
  13. Vilos GA, Abu-Rafea B. New developments in ambulatory hysteroscopic surgery. Best Pract Res Clin Obstet Gynaecol 2005; 19:727.
  14. Li C, Dai Z, Gong Y, et al. A systematic review and meta-analysis of randomized controlled trials comparing hysteroscopic morcellation with resectoscopy for patients with endometrial lesions. Int J Gynaecol Obstet 2017; 136:6.
  15. Shazly SA, Laughlin-Tommaso SK, Breitkopf DM, et al. Hysteroscopic Morcellation Versus Resection for the Treatment of Uterine Cavitary Lesions: A Systematic Review and Meta-analysis. J Minim Invasive Gynecol 2016; 23:867.
  16. Abdallah KS, Gadalla MA, Breijer M, Mol BWJ. Uterine distension media for outpatient hysteroscopy. Cochrane Database Syst Rev 2021; 11:CD006604.
  17. Readman E, Maher PJ. Pain relief and outpatient hysteroscopy: a literature review. J Am Assoc Gynecol Laparosc 2004; 11:315.
  18. Marsh FA, Rogerson LJ, Duffy SR. A randomised controlled trial comparing outpatient versus daycase endometrial polypectomy. BJOG 2006; 113:896.
  19. Kremer C, Duffy S, Moroney M. Patient satisfaction with outpatient hysteroscopy versus day case hysteroscopy: randomised controlled trial. BMJ 2000; 320:279.
  20. Salazar CA, Isaacson KB. Office Operative Hysteroscopy: An Update. J Minim Invasive Gynecol 2018; 25:199.
  21. Nagele F, Lockwood G, Magos AL. Randomised placebo controlled trial of mefenamic acid for premedication at outpatient hysteroscopy: a pilot study. Br J Obstet Gynaecol 1997; 104:842.
  22. Tam WH, Yuen PM. Use of diclofenac as an analgesic in outpatient hysteroscopy: a randomized, double-blind, placebo-controlled study. Fertil Steril 2001; 76:1070.
  23. Mercorio F, De Simone R, Landi P, et al. Oral dexketoprofen for pain treatment during diagnostic hysteroscopy in postmenopausal women. Maturitas 2002; 43:277.
  24. Teran-Alonso MJ, De Santiago J, Usandizaga R, Zapardiel I. Evaluation of pain in office hysteroscopy with prior analgesic medication: a prospective randomized study. Eur J Obstet Gynecol Reprod Biol 2014; 178:123.
  25. Issat T, Beta J, Nowicka MA, et al. A randomized, single blind, placebo-controlled trial for the pain reduction during the outpatient hysteroscopy after ketoprofen or intravaginal misoprostol. J Minim Invasive Gynecol 2014; 21:921.
  26. Luscombe KS, McDonnell NJ, Muchatuta NA, et al. A randomised comparison of parecoxib versus placebo for pain management following minor day stay gynaecological surgery. Anaesth Intensive Care 2010; 38:141.
  27. Ahmad G, Saluja S, O'Flynn H, et al. Pain relief for outpatient hysteroscopy. Cochrane Database Syst Rev 2017.
  28. Hassan A, Wahba A, Haggag H. Tramadol versus Celecoxib for reducing pain associated with outpatient hysteroscopy: a randomized double-blind placebo-controlled trial. Hum Reprod 2016; 31:60.
  29. Hassan A, Haggag H. Role of oral tramadol 50 mg in reducing pain associated with outpatient hysteroscopy: A randomised double-blind placebo-controlled trial. Aust N Z J Obstet Gynaecol 2016; 56:102.
  30. The Use of Hysteroscopy for the Diagnosis and Treatment of Intrauterine Pathology: ACOG Committee Opinion, Number 800. Obstet Gynecol 2020; 135:e138.
  31. Grow DR, Iromloo K. Oral contraceptives maintain a very thin endometrium before operative hysteroscopy. Fertil Steril 2006; 85:204.
  32. Vercellini P, Perino A, Consonni R, et al. Treatment with a gonadotrophin releasing hormone agonist before endometrial resection: a multicentre, randomised controlled trial. Br J Obstet Gynaecol 1996; 103:562.
  33. Donnez J, Vilos G, Gannon MJ, et al. Goserelin acetate (Zoladex) plus endometrial ablation for dysfunctional uterine bleeding: a large randomized, double-blind study. Fertil Steril 1997; 68:29.
  34. Fedele L, Bianchi S, Gruft L, et al. Danazol versus a gonadotropin-releasing hormone agonist as preoperative preparation for hysteroscopic metroplasty. Fertil Steril 1996; 65:186.
  35. Marchini M, Fedele L, Bianchi S, et al. Endometrial patterns during therapy with danazol or gestrinone for endometriosis: structural and ultrastructural study. Hum Pathol 1992; 23:51.
  36. Cicinelli E, Pinto V, Tinelli R, et al. Rapid endometrial preparation for hysteroscopic surgery with oral desogestrel plus vaginal raloxifene: a prospective, randomized pilot study. Fertil Steril 2007; 88:698.
  37. Bradley LD. Complications in hysteroscopy: prevention, treatment and legal risk. Curr Opin Obstet Gynecol 2002; 14:409.
  38. Al-Fozan H, Firwana B, Al Kadri H, et al. Preoperative ripening of the cervix before operative hysteroscopy. Cochrane Database Syst Rev 2015; :CD005998.
  39. Batukan C, Ozgun MT, Ozcelik B, et al. Cervical ripening before operative hysteroscopy in premenopausal women: a randomized, double-blind, placebo-controlled comparison of vaginal and oral misoprostol. Fertil Steril 2008; 89:966.
  40. Nada AM, Elzayat AR, Awad MH, et al. Cervical Priming by Vaginal or Oral Misoprostol Before Operative Hysteroscopy: A Double-Blind, Randomized Controlled Trial. J Minim Invasive Gynecol 2016; 23:1107.
  41. Abdelhakim AM, Gadallah AH, Abbas AM. Efficacy and safety of oral vs vaginal misoprostol for cervical priming before hysteroscopy: A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2019; 243:111.
  42. Fouda UM, Gad Allah SH, Elshaer HS. Optimal timing of misoprostol administration in nulliparous women undergoing office hysteroscopy: a randomized double-blind placebo-controlled study. Fertil Steril 2016; 106:196.
  43. Karakus S, Akkar OB, Yildiz C, et al. Comparison of Effectiveness of Laminaria versus Vaginal Misoprostol for Cervical Preparation Before Operative Hysteroscopy in Women of Reproductive Age: A Prospective Randomized Trial. J Minim Invasive Gynecol 2016; 23:46.
  44. da Costa AR, Pinto-Neto AM, Amorim M, et al. Use of misoprostol prior to hysteroscopy in postmenopausal women: a randomized, placebo-controlled clinical trial. J Minim Invasive Gynecol 2008; 15:67.
  45. Oppegaard KS, Lieng M, Berg A, et al. A combination of misoprostol and estradiol for preoperative cervical ripening in postmenopausal women: a randomised controlled trial. BJOG 2010; 117:53.
  46. Ngai SW, Chan YM, Ho PC. The use of misoprostol prior to hysteroscopy in postmenopausal women. Hum Reprod 2001; 16:1486.
  47. Fung TM, Lam MH, Wong SF, Ho LC. A randomised placebo-controlled trial of vaginal misoprostol for cervical priming before hysteroscopy in postmenopausal women. BJOG 2002; 109:561.
  48. Barcaite E, Bartusevicius A, Railaite DR, Nadisauskiene R. Vaginal misoprostol for cervical priming before hysteroscopy in perimenopausal and postmenopausal women. Int J Gynaecol Obstet 2005; 91:141.
  49. Casadei L, Piccolo E, Manicuti C, et al. Role of vaginal estradiol pretreatment combined with vaginal misoprostol for cervical ripening before operative hysteroscopy in postmenopausal women. Obstet Gynecol Sci 2016; 59:220.
  50. Vahdat M, Tahermanesh K, Kashi AM, et al. Evening Primrose Oil Effect on the Ease of Cervical Ripening and Dilation Before Operative Hysteroscopy. Thrita 2015; 4:e29876.
  51. ACOG Practice Bulletin No. 195: Prevention of Infection After Gynecologic Procedures. Obstet Gynecol 2018; 131:e172. Reaffirmed 2022.
  52. Allen RH, Micks E, Edelman A. Pain relief for obstetric and gynecologic ambulatory procedures. Obstet Gynecol Clin North Am 2013; 40:625.
  53. Giorda G, Scarabelli C, Franceschi S, Campagnutta E. Feasibility and pain control in outpatient hysteroscopy in postmenopausal women: a randomized trial. Acta Obstet Gynecol Scand 2000; 79:593.
  54. Angioli R, De Cicco Nardone C, Plotti F, et al. Use of music to reduce anxiety during office hysteroscopy: prospective randomized trial. J Minim Invasive Gynecol 2014; 21:454.
  55. De Iaco P, Marabini A, Stefanetti M, et al. Acceptability and pain of outpatient hysteroscopy. J Am Assoc Gynecol Laparosc 2000; 7:71.
  56. Kremer C, Barik S, Duffy S. Flexible outpatient hysteroscopy without anaesthesia: a safe, successful and well tolerated procedure. Br J Obstet Gynaecol 1998; 105:672.
  57. Broadbent JA, Hill NC, Molnár BG, et al. Randomized placebo controlled trial to assess the role of intracervical lignocaine in outpatient hysteroscopy. Br J Obstet Gynaecol 1992; 99:777.
  58. Deo N, Khan KS, Mak J, et al. Virtual reality for acute pain in outpatient hysteroscopy: a randomised controlled trial. BJOG 2021; 128:87.
  59. Tangsiriwatthana T, Sangkomkamhang US, Lumbiganon P, Laopaiboon M. Paracervical local anaesthesia for cervical dilatation and uterine intervention. Cochrane Database Syst Rev 2013; :CD005056.
  60. Bettocchi S, Ceci O, Di Venere R, et al. Advanced operative office hysteroscopy without anaesthesia: analysis of 501 cases treated with a 5 Fr. bipolar electrode. Hum Reprod 2002; 17:2435.
  61. Carugno J, Grimbizis G, Franchini M, et al. International Consensus Statement for Recommended Terminology Describing Hysteroscopic Procedures. J Minim Invasive Gynecol 2022; 29:385.
  62. Floris S, Piras B, Orrù M, et al. Efficacy of intravenous tramadol treatment for reducing pain during office diagnostic hysteroscopy. Fertil Steril 2007; 87:147.
  63. Cooper NA, Smith P, Khan KS, Clark TJ. Vaginoscopic approach to outpatient hysteroscopy: a systematic review of the effect on pain. BJOG 2010; 117:532.
  64. Sagiv R, Sadan O, Boaz M, et al. A new approach to office hysteroscopy compared with traditional hysteroscopy: a randomized controlled trial. Obstet Gynecol 2006; 108:387.
  65. Guida M, Di Spiezio Sardo A, Acunzo G, et al. Vaginoscopic versus traditional office hysteroscopy: a randomized controlled study. Hum Reprod 2006; 21:3253.
  66. Garbin O, Kutnahorsky R, Göllner JL, Vayssiere C. Vaginoscopic versus conventional approaches to outpatient diagnostic hysteroscopy: a two-centre randomized prospective study. Hum Reprod 2006; 21:2996.
  67. Sharma M, Taylor A, di Spiezio Sardo A, et al. Outpatient hysteroscopy: traditional versus the 'no-touch' technique. BJOG 2005; 112:963.
  68. De Silva PM, Carnegy A, Smith PP, Clark TJ. Vaginoscopy for office hysteroscopy: A systematic review & meta-analysis. Eur J Obstet Gynecol Reprod Biol 2020; 252:278.
  69. Comparative trial of tubal insufflation, hysterosalpingography, and laparoscopy with dye hydrotubation for assessment of tubal patency. World Health Organization. Fertil Steril 1986; 46:1101.
  70. Data from Conceptus Incorporated, San Carlos, CA.
  71. Loffer FD. Hysteroscopy with selective endometrial sampling compared with D&C for abnormal uterine bleeding: the value of a negative hysteroscopic view. Obstet Gynecol 1989; 73:16.
  72. Clark TJ, Voit D, Gupta JK, et al. Accuracy of hysteroscopy in the diagnosis of endometrial cancer and hyperplasia: a systematic quantitative review. JAMA 2002; 288:1610.
  73. Phillips DR, Nathanson HG, Milim SJ, Haselkorn JS. The effect of dilute vasopressin solution on the force needed for cervical dilatation: a randomized controlled trial. Obstet Gynecol 1997; 89:507.
  74. Hobo R, Netsu S, Koyasu Y, Tsutsumi O. Bradycardia and cardiac arrest caused by intramyometrial injection of vasopressin during a laparoscopically assisted myomectomy. Obstet Gynecol 2009; 113:484.
  75. Pellicano M, Guida M, Zullo F, et al. Carbon dioxide versus normal saline as a uterine distension medium for diagnostic vaginoscopic hysteroscopy in infertile patients: a prospective, randomized, multicenter study. Fertil Steril 2003; 79:418.
  76. Aydeniz B, Gruber IV, Schauf B, et al. A multicenter survey of complications associated with 21,676 operative hysteroscopies. Eur J Obstet Gynecol Reprod Biol 2002; 104:160.
  77. Jansen FW, Vredevoogd CB, van Ulzen K, et al. Complications of hysteroscopy: a prospective, multicenter study. Obstet Gynecol 2000; 96:266.
  78. Florio P, Nappi L, Mannini L, et al. Prevalence of Infections After In-Office Hysteroscopy in Premenopausal and Postmenopausal Women. J Minim Invasive Gynecol 2019; 26:733.
  79. Shveiky D, Rojansky N, Revel A, et al. Complications of hysteroscopic surgery: "Beyond the learning curve". J Minim Invasive Gynecol 2007; 14:218.
  80. Agostini A, Cravello L, Bretelle F, et al. Risk of uterine perforation during hysteroscopic surgery. J Am Assoc Gynecol Laparosc 2002; 9:264.
  81. Hulka JF, Peterson HB, Phillips JM, Surrey MW. Operative hysteroscopy. American Association of Gynecologic Laparoscopists 1991 membership survey. J Reprod Med 1993; 38:572.
  82. Dyrbye BA, Overdijk LE, van Kesteren PJ, et al. Gas embolism during hysteroscopic surgery using bipolar or monopolar diathermia: a randomized controlled trial. Am J Obstet Gynecol 2012; 207:271.e1.
  83. Serden SP, Brooks PG. Treatment of abnormal uterine bleeding with the gynecologic resectoscope. J Reprod Med 1991; 36:697.
  84. Darabi, K, Roy, et al. Collaborative studies on hysteroscopic sterilization procedures: final report. In: Risks, Benefits, and Controversies in Fertility Control, Sciarra JJ, Zatuchni GI, Speidel JJ (Eds), Harper & Row, Hagerstown MD 1978. p.81.
  85. Duffy S, Reid PC, Sharp F. In-vivo studies of uterine electrosurgery. Br J Obstet Gynaecol 1992; 99:579.
  86. Munro MG. Mechanisms of thermal injury to the lower genital tract with radiofrequency resectoscopic surgery. J Minim Invasive Gynecol 2006; 13:36.
  87. Agostini A, Cravello L, Shojai R, et al. Postoperative infection and surgical hysteroscopy. Fertil Steril 2002; 77:766.
Topic 3278 Version 36.0

References

آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟