Hysteroscopy

Anatomy and Physiology

The following anatomical structures are essential to understanding hysteroscopy and performing the proper technique:

• External genitalia: These anatomical structures are visible on inspection and do not require speculum examination. They include the mons pubis, clitoris, urethral meatus, vestibule of the vagina, labia majora and minora, vaginal opening, hymen, perineum, and anus. The external female genitalia is collectively known as the vulva. 
• Vagina: The vagina is a muscular canal that connects the vulva to the cervix. This structure is an elastic passageway that varies in length and width and functions as a source of sexual pleasure and a route for fetal delivery. The vagina also conducts the passage of sperm after intercourse and blood during menses. 
• Cervix: This structure is the opening from the vagina to the uterus, usually 2 or 3 cm in length. The cervix has a central opening called the cervical canal flanked by the external os anteriorly and the internal os posteriorly. Canal width varies throughout a female’s life, with maximal dilation to around 10 cm during childbirth. 
• Uterus corpus: The uterus lies midline within the pelvis between the bladder anteriorly and the rectum posteriorly. It usually lies in an anteverted and anteflexed position. Version refers to the position of the cervix relative to the vagina, and flexion refers to the position of the fundus relative to the cervix. The fallopian tubes connect to the uterine corpus at the fundus bilaterally, with tubal ostia able to be visualized on hysteroscopy.

Indications

The most common indications for hysteroscopy are as follows:

• Suspicion of the intracavitary lesion 
• Abnormal uterine bleeding
• Abnormal endometrial thickening 
• Postmenopausal bleeding
• Infertility 
• Mullerian congenital anomaly
• Removal of foreign bodies [13]

Whenever possible, in-office hysteroscopy is preferred. Compared to surgical inpatient hysteroscopy, in-office hysteroscopy offers many potential benefits, including patient and physician convenience, avoidance of general anesthesia, higher patient satisfaction, faster recovery, and cost-effectiveness.[14] Factors that challenge outpatient hysteroscopy feasibility include large intrauterine pathology, patient anxiety, lack of appropriate treatment setting and personnel, and physician skill and expertise.[15][14]

Contraindications

Hysteroscopy has few absolute contraindications, including active pelvic infection, prodromal or active genital herpes, and confirmed cervical or endometrial cancer. Moderate vaginal bleeding is a relative contraindication to hysteroscopy. However, adequate visualization for the procedure may be achieved with copious irrigation. Pregnancy is also a contraindication to hysteroscopy unless used in the setting of retained IUD or products of conception removal.

Medical comorbidities could be potential contraindications to hysteroscopic surgery (eg, coronary heart disease and bleeding diathesis). 

Equipment

Hysteroscopes

Several types of hysteroscopes available for diagnostic and operative purposes deserve further explanation. The 2 main types of hysteroscopes are flexible and rigid. Hysteroscopes are available at viewing angles ranging from 0 to 70 degrees. They all easily connect to fluid channels, a light source, and a video monitoring system. A continuous flow of distending media is needed for optimal visualization of the endometrial cavity. Most hysteroscopes have an operative channel that permits the passage of surgical instruments such as small hysteroscopic graspers, scissors, or a tenaculum. The following hysteroscopes are among those commonly used:

• STORZ Bettocchi integrated in-office hysteroscope: this hysteroscope has a small diameter of 4mm (Bettocchi 4) or 5 mm (Bettocchi 5) with an oval tip that permits easy passage through the cervix, which is especially important when used in an office setting with conscious patients. It features 2.1 mm (Bettocchi 4) and 2.9 mm (Bettocchi 5) 12 and 30-degree optics and a working channel for 5 French semi-rigid operative instruments. 
• STORZ Campo Trophyscope: This hysteroscope has an outer diameter of 2.9 mm, permitting even easier passage through the cervix due to the smaller scope diameter. However, with the Trophyscope, the intraoperative changeover to a continuous flow examination sheath is necessary. This sheath is 3.7 mm in diameter. It features a 30-degree scope with a working operative channel that allows for the introduction of 5 French semi-rigid instruments and bipolar electrodes.
• Olympus flexible hysteroscope: This hysteroscope has a flexible outer tip with a wide 100-degree tip angulation range that the operator may adjust. This scope is 3.1 mm in diameter. It features a wide field of view and an instrument channel. 

Other types of rigid diagnostic and operative hysteroscopes range in diameter and degree of viewing angulation. In addition, the resectoscope and mini-resectoscope offer easy manipulation of electrocautery monopolar and bipolar loop devices that can be loaded into the scope, providing an easier dissection through dense tissue.[16]

Tissue Retrieval Systems

Several types of tissue retrieval systems on the market easily fragment and extract intrauterine pathology. These devices may be referred to as mechanical hysteroscopic tissue removal systems or mHTR systems. These systems overcome the limitations of traditional resectoscopic systems and methods because they do not use electrocautery to remove the pathology, thereby eliminating the risk of electrosurgical damage to surrounding structures and energetic reactions, including:

• Truclear 8.0 system: FDA approved in 2005, this mHTR is manufactured by Medtronic, is 9.0 mm in diameter, has a 0-degree optic device, a 4.0 mm disposable cutting device, and an operator to set window closure.
• TruClear elite: FDA approved in 2008, this mHTR is manufactured by Medtronic, is 7.25 mm in diameter, has a 0-degree optic device, 4.0 and 2.9 mm disposable cutting devices, and an operator to set window closure.
• Trueclear 5C system: FDA approved in 2012, this mHTR is manufactured by Medtronic, is 5.25 mm in diameter, has a 0-degree optic device, a 2.9 mm disposable cutting device, and an operator to set window closure.
• Integrated Bigatti shaver: FDA approved in 2012, this mHTR is manufactured by Storz, is 6.3 mm in diameter, has a 6-degree optic device, a 4.5 mm reusable cutting device, and automatic window closure.
• Myosure system: FDA approved in 2009, this mHTR is manufactured by Hologic, is 7.25 mm in diameter, has a 0-degree optic device, 3.0 and 4.0 mm disposable cutting devices, and automatic window closure.
• Synphioin system: FDA approved in 2014, this mHTR is manufactured by Boston Scientific and Minerva Surgical, is 6.3 mm in diameter, has a 0-degree optic device, a 3.6 mm disposable cutting device, and automatic window closure. Unique to this device is the capability for radiofrequency bipolar plasma tissue resection.
• Omni hysteroscope: FDA approved in 2018, this mHTR is 6.0 mm in diameter, has a 0-degree optic device, a 3.0 and 4.0 mm disposable cutting device, and automatic window closure.

Based on current literature, all mHTR systems demonstrate similar specifications and capabilities. These devices have been shown to be easy for surgeons to learn how to use and are associated with fewer complications than traditional resectoscopic approaches.[17]

Distension Medium

Adequate distention of the uterus is imperative to performing a hysteroscopy. Fluid or gas (carbon dioxide) may be used. However, carbon dioxide is only used during diagnostic hysteroscopies because visibility is lost with bleeding.[3] Fluid distension media allows the irrigation of the cavity for better visualization. With operative hysteroscopy and the electrical current loops used for dissection, fluid media must be carefully chosen. Fluid-containing electrolytes must not be utilized with monopolar current due to the risk of energy dispersal to surrounding tissues. When bipolar instruments are used, electrolyte-rich fluid-distending media, such as normal saline, may be selected.[18]

Other Instruments

The traditional hysteroscopic entry technique requires a tray with instruments for cervical dilation. These instruments and materials include a metal speculum, cervical tenaculum, sound, cervical dilators, ring forceps, and raytecs. Local anesthesia, if needed, might be selected based on operator preference. Preferred options include 1% or 2% lidocaine with or without epinephrine. A long 25- or 27-gauge needle is needed for the administration of anesthetic into the cervix.[19] With vaginoscopy and the no-touch technique, instruments apart from the hysteroscope are not required.[20]

Personnel

The number of personnel needed depends on where the hysteroscopy is undertaken. Personnel in the operating room include a dedicated anesthesiologist or certified nurse anesthetist, preoperative and postoperative care nurses and techs for operating room and supply maintenance, scrub techs, and transport staff.[21] 

In the office, the number of staff needed is significantly reduced. Dedicated patient monitoring requires a staff member who is qualified to do so other than the physician. The presence of a team member with ACLS certification and capabilities is highly recommended. Another consideration for in-office hysteroscopy is equipment accessibility for treating cardiovascular emergencies and anaphylaxis. Dedicated anesthesia personnel are not needed in the office since the procedure is usually performed only with local or no anesthesia.[22]

Preparation

Preparation for hysteroscopy includes preoperative evaluation and individualized testing for patient needs. Further testing for preoperative clearance should be undertaken if comorbid conditions exist that increase operative morbidity. Hysteroscopy may be performed at any time in postmenopausal women. For premenopausal women, a consideration that performing a hysteroscopy during the secretory phase of the menstrual cycle may lead to an overdiagnosis of endometrial polyps is essential since the endometrium may appear polypoid during this time.[14] Using misoprostol for cervical dilation pre-procedure is not universally accepted and is not routinely performed.[23] 

Prophylactic antibiotics are not needed for hysteroscopy.[24] A thorough history and physical should be conducted on every patient before a hysteroscopy is performed.[25] In addition, a preoperative pregnancy test should be performed on all premenopausal women. Currently, no consensus on pain management for in-office hysteroscopy has been established. Different protocols, both pharmacologic and nonpharmacologic, have been proposed.[26] Informed consent, including a discussion of risks, benefits, and alternatives, should always be obtained before any surgical procedure.[27][28][29]

Technique or Treatment

Hysteroscopy Set-Up

First, as with any gynecologic procedure, the appropriate positioning of the patient must be ensured. The patient is positioned in the dorsal lithotomy position, taking care to avoid unnecessary pressure that may cause nerve injury. The table must be flat; Trendelenberg positioning should be avoided. The bimanual examination should always be performed before the start of any gynecologic procedure. An indwelling Foley catheter is unnecessary; however, a straight catheter may drain the bladder before starting the procedure.

Next, the hysteroscope is set up, the camera is white-balanced and focused, and the inflow tract is primed. With the vaginoscopic entry technique, the need for the traditional instruments used for entry is avoided. The clinician begins vaginoscopy by introducing the hysteroscope into the vagina. The vagina is then distended, and the cervix and external os may be located by gently advancing the scope. The posterior fornix is usually easily identified. Once the external os is located, the hysteroscope is carefully inserted and passed through the internal os into the uterine cavity.

Insertion of the Hysteroscope and Uterine Cavity Assessment

Using standardized techniques, a speculum is first inserted. The cervix is visualized and grasped anteriorly with a single-tooth tenaculum. The cervix is then dilated to the diameter of the hysteroscope being used, after which the hysteroscope is inserted. At the same time, countertraction is applied with the tenaculum to straighten the uterus. 

Once inside the uterus, the entire uterine cavity may be inspected. Any pathology can be quickly identified, and preoperative planning can be performed. The bilateral tubal ostia should be identified at the beginning of the case. 

Hysteroscopic Procedures

Further technique varies depending on the type of intrauterine pathology. Operative techniques as they apply to fibroids, polyps, adhesions, and retained intrauterine devices will be reviewed here. AUB is the most common indication for hysteroscopy with structural abnormalities such as polyps or fibroids, usually as root causes.[30]

Hysteroscopic myomectomy

Hysteroscopic myomectomy can be performed in numerous ways. Submucosa myomas are accessible by operative hysteroscopy and are divided into types 0, I, and II based on their distribution within the myometrium. Type 0 is fully intracavitary, type I is mostly intracavitary, and type II is mostly myometrial. Since type 0 fibroids are usually pedunculated, they may be resected easily depending on their size, using sharp dissection, electrocautery, or a loop dissection device.[31] Type I and Type II myoma resection often requires 2 surgical procedures to achieve full resection. The excision of only the intracavitary portion of a fibroid is not recommended due to its propensity for intracavitary regrowth. Resectoscopic progressive excision followed by interval complete excision after the fibroid spontaneously migrates into the cavity has been shown to be a successful strategy.[5] Some studies show higher success rates for total removal of intrauterine pathology with these systems, with no significant difference in complication rates. However, the tissue removal system group reported a higher fluid deficit.[30]

Pretreatment with GnRH agonists to shrink fibroids and correct anemia is not universally performed. Small studies have shown the benefits of GnRH agonist use for submucosal fibroids greater than 3 cm for a period ranging from 6 weeks to 4 months. However, this drug class causes unpleasant adverse effects, including hot flashes, decreased libido, and insomnia. One recent retrospective study found that treatment before surgery was associated with longer surgical times and increased cervical resistance. Consider shared decision-making and patient individualization before prescribing medical pretreatment.[5] 

Hysteroscopic polypectomy

Hysteroscopic polypectomy can be carried out with operative microscissors or monopolar or bipolar electrocautery. Nonhysteroscopic polypectomy, eg, with polyp forceps, has a higher recurrence rate than hysteroscopic polypectomy.[32] With mechanical tissue removal systems, data show increased rates of complete pathology resection and shorter operation times for the resectioning of polyps.[30]

Hysteroscopic resection

With hysteroscopy, the removal of a uterine septum, or, in other words, the performance of a uterine septoplasty, has become possible. Likewise, the resection of intrauterine adhesions spurred by a history of endometrial trauma is termed hysteroscopic adhesiolysis. These 2 abnormalities are associated with infertility and can be remedied with resection as long as they do not reform. A Cochrane review published in 2017 suggests limited evidence for medical or IUD treatment in operative hysteroscopy to prevent intrauterine adhesion formation.[33]

Hysteroscopic retrieval

Hysteroscopy is a safe and effective method for the retrieval of retained or embedded devices, the most common of which are intrauterine devices (IUDs). Hysteroscopy may even be used in the first trimester of pregnancy to retrieve IUDs when strings cannot be seen on the pelvic exam. Pregnancies with retained IUDs are associated with increased rates of miscarriage, preterm delivery, and chorioamnionitis. Hysteroscopic removal for a retained IUD is an emerging option for treatment, especially when ultrasound-guided removal is not feasible.[34][35]

Postoperative Management

Most patients tolerate diagnostic and operative hysteroscopy well and can be discharged from the postoperative recovery unit or office setting soon after the completion of the procedure. Vaginal spotting and discomfort are common. Recommendations for the timing of pelvic rest vary by clinician, with some saying that normal activities may resume in 24 hours, especially when the vaginoscopy “no-touch” entry technique is used. A follow-up appointment should be arranged before discharge for an anticipatory review of pathology results.

Complications

Overall, hysteroscopy is regarded as a safe, minimally invasive procedure.[36] However, the procedure is associated with several complications that clinicians should learn to recognize and manage promptly.

Uterine Perforation

The most common reported complication of both diagnostic and operative hysteroscopy is uterine perforation.[37] Perforation can occur at any point during the procedure but is more common with resection extending into the uterine myometrium.[38] Encountered in about 1% of cases, uterine perforation may be managed conservatively or operatively, depending on patient status. Hemodynamic status should first be assessed with low suspicion for vascular injury if perforation was caused by blunt dissection. If the patient is hemodynamically stable and there is low suspicion of vascular or visceral damage, laparoscopy or exploratory laparotomy is unneeded. Prolonged postoperative same-day recovery is recommended with strict pain, bleeding, and fever precautions and close clinical follow-up.[39] 

Bleeding alone without uterine perforation may be encountered with deep dissection into the myometrium and intersection with a perforating vessel. This complication is more common with operative hysteroscopy and the removal of type I and type II subserosal fibroids. Bleeding may be managed with electrocautery, uterotonics such as oxytocin, or foley balloon catheter placement to be left inside the uterus to tamponade bleeding.[39]

Fluid Overload

Complications associated with distension media used in hysteroscopy deserve detailed discussion. The fluid deficit is carefully calculated intraoperatively to quantify the amount of fluid the patient is absorbing into their circulation. Of particular concern is the risk of hyponatremia and resulting cerebral edema, especially when electrolyte-free hypotonic solutions are used. Cerebral edema may manifest with symptoms of nausea and or vomiting, dizziness, shortness of breath, or headache. The mechanism of fluid absorption has to do with the amount of intrauterine pressure created by hysteroscopic fluid management systems and the venous absorption of distending media.[36] Some institutions recognize this as operative hysteroscopy intravascular absorption syndrome (OHIA).

Electrolyte-rich isotonic fluid, eg, normal saline, may be used with bipolar systems. As such, bipolar systems have less risk of fluid overload syndromes. In healthy women, hysteroscopy should be aborted if the fluid deficit exceeds 2500 mL when isotonic distention media is used and 1000 mL with hypotonic media. In women with comorbidities (eg, cardiac or pulmonary conditions) that compromise hemodynamic stability, the surgeon should consider termination of the procedure with a fluid deficit of 1000 mL and 750 mL of an isotonic and hypotonic solution, respectively. Avoidance of OHIA can be achieved by closely monitoring fluid status. Patients at risk for OHIA may be identified beforehand by assessing estimated procedure time, risk for incomplete resection of intrauterine pathology, and the existence of comorbidities.

Air Embolism 

Hysteroscopy can result in carbon dioxide embolism if used as the distending media. This complication can be catastrophic if it occurs due to the potential for cardiac failure, leading to death. Limited studies show a wide-ranging air embolism rate from 10% to 50% with the use of carbon dioxide.[40] If this complication is suspected, the anesthesia team should immediately advise the surgeon, and the procedure should be terminated. Durant’s position (ie, patient placement in left lateral decubitus and Trendelenberg) may assist in air migration away from the right ventricular outflow tract. If cardiac arrest occurs, cardiac catheterization may be performed to relieve the embolized air from the cardiovascular system. This iatrogenic complication of hysteroscopy may be prevented by using fluid-distending media and priming equipment by releasing air from tubing and avoiding excessive instrumentation, which may introduce air into the genital tract.

Vasovagal Syncope

While the risk of a vasovagal syncope reaction is low, ranging from 0.21% to 1.85% of patients undergoing in-office hysteroscopy, this is an unpleasant adverse effect to undergo as the patient or treat as the clinician. Sometimes overlooked because of its short-lived and benign nature, vasovagal syncope occurs with exposure to pain, emotional stress, or in medical settings. Most patients develop an “aura” before either fully or partially experiencing syncope, with this "aura" consisting of some combination of lightheadedness, paleness, palpitations, sweating, and blurred vision.

Risk factors for vasovagal syncope include young age, female gender, low body mass index, Caucasian race, and family history. If this complication occurs during an in-office hysteroscopy, the procedure should be halted for appropriate patient evaluation. This evaluation should assess the ABCs (airway, breathing, and circulation). For treatment, the patient may be placed in the Trendelenburg position and the intrauterine pressure decreased by closing the inflow or removing the hysteroscopic device. If bradycardia, hypotension, or patient symptoms persist, the patient should be referred to the emergency department for further evaluation and observation.[41]

Clinical Significance

The gold standard for the diagnosis and treatment of intrauterine pathology is hysteroscopy. As such, this technique has numerous indications and benefits. Hysteroscopy can improve quality of life, treat infertility, remove foreign bodies, or diagnose malignancy. Women with abnormal uterine bleeding may experience significant improvement in symptoms post hysteroscopic resection of pathology, avoiding the need for invasive surgical procedures such as hysterectomy.[42] 

Also, compared to blind endometrial sampling, direct visualization of the entire uterine cavity and biopsy with hysteroscopy allows for targeted sampling and complete resection of uterine abnormalities such as polyps. These have the potential for malignancy, especially in postmenopausal women and women with a family history of gynecologic cancer. Further, ambulatory hysteroscopy offers appeal with the potential avoidance of general anesthesia or conscious sedation. Studies comparing in-office to operating room hysteroscopy show comparable patient acceptance and outcomes, as well as decreased cost.[43]

Enhancing Healthcare Team Outcomes

If a hysteroscopy is performed in the ambulatory or inpatient operating room setting, more personnel must be included in the interprofessional healthcare team. Technicians and representatives should confirm that all equipment functions properly before the patient enters the operating room. Scrub technicians are essential in prepreparing equipment so delays and malfunctions may be limited. The final patient assessment before surgery should always be prompted by the circulator or other operating room staff and include a pelvic examination. 

Effective communication is paramount at every stage, beginning with team briefings and culminating in a formal time-out to confirm procedural details. Anesthesia should direct patient positioning to avoid dislodging endotracheal tubes, lines, and other monitoring systems. Throughout the procedure, appropriate attention to surgical undertakings is needed from the scrub tech and circulator to maintain adequate lighting, fluid balance, and distending media pressure. Equipment adjustments, such as those for display monitors or electrocautery instruments, may also be needed. 

At the procedure's end, all fluids in, fluids out, blood loss, and urine output are documented and announced by the circulator nurse. Anesthesia must continue to monitor hemodynamic and respiratory statuses after extubation or weaning from sedation. However, it is essential to remember that all healthcare team members are responsible for working together to ensure the patient's safety. Seamless communication and collaboration across all stages of hysteroscopy—preoperative, intraoperative, and postoperative—enhance patient-centered care and team efficiency. Nursing staff must remain well-informed about patient status to ensure a cohesive and safe surgical experience. 

In-office hysteroscopy does not need to consist of more than 2 to 3 personnel. The surgeon may be semi-self-sufficient, and a scrub tech is not required. However, the clinician must understand and review the equipment thoroughly. In academic centers, in-office hysteroscopy offers more involvement for residents and medical students, as personnel is reduced, but assistance may be needed to ensure smooth operation in the awake patient. Patient comfort and assurance are of utmost importance. The right demeanor in an in-office hysteroscopy team can ease anxiety and improve outcomes.