Hysteroscopy is a minimally invasive approach to view and treat pathologies within the uterine cavity, tubal ostia and cervical canal in both premenopausal and postmenopausal patients. Polyps, leiomyomas, intrauterine synechia, hyperplasia, malignancy, foreign bodies, retained products of conception and congenital uterine anomalies can both be diagnosed and treated by hysteroscopy.
Keywords: Diagnostic hysteroscopy; Operative hysteroscopy; Complications of hysteroscopy
Diagnostic and operative hysteroscopes can vary from traditionally available rigid diagnostic (3mm) and operative (5mm) hysteroscopes to more complex state-of-the-art modern equipment including flexible fibrescopes, miniaturised semi-rigid/rigid diagnostic hysteroscopes and rigid operative (3.8-5mm) hysteroscopes. Flexible hysteroscopes range in diameter from 2.7-5mm and the flexiple tip deflects in two directions ranging from 100 degrees to 180 degrees. Rigid telescopes are available in different angles of vision ranging from 0 to 30 degrees. Most diagnostic scopes are 30 °C allowing a thorough inspection of uterine walls, cornual recesses and tubal ostia with minimal movement of the shaft. Their external diameters vary from 1.2mm to 4mm. The single flow sheath of the rigid hysteroscope is used in combination with a 4- to 5mm outer sheath to create
a continuous flow system and permit the passage of semirigid
instruments such as scissors, graspers and biopsy forceps for endometrial biopsy, tubal cannulation, or intrauterine surgery.
Operative hysteroscopes are used to remove endocervical or endometrial lesions or to perform an endometrial ablation/resection. Operative hysteroscopes typically range from 8mm to 10mm in diameter and contain a retractable hand piece wherein electrosurgical tips, laser devices, or mechanical instruments may be attached. Currently, there are three types of operative hysteroscopes: Operative sheath with instruments inserted through channels or fixed to the sheath, electrosurgical resectoscope and hysteroscopic morcellator .
Different types of energy have been used for operative hysteroscopy including laser, unipolar or bipolar energies. Laser is rarely used in modern hysteroscopic procedures. The most commonly used energy for hysteroscopic surgery is unipolar energy. To avoid dispersion of the electrical current, a low-viscosity distending medium such as 1.5% glycine is needed. Compared to normal saline, its use is associated with a high risk of fluid overload. Accordingly, a versatile bipolar electrosurgery system was developed allowing operative hysteroscopy using normal saline as a distending medium. As the electrical current is confined, it is safer than a unipolar device. This bipolar device can be used for cutting, coagulation or tissue vaporization including treatment of large endometrial polyps and submucosal myomas under 2cm.
Various novel methods of producing global endometrial ablation and smaller hysteroscopic morcellator devices are appearing and undergoing evaluation for safety and effectiveness . They all have short treatment times, with acceptable pain profiles when used without general anaesthesia and require little,
if any, cervical dilatation, suggesting that they may be appropriate
for use in outpatient settings. Hysteroscopic morcellation
appears efficient at removing prominent submucosal fibroids,
but as safety and effectiveness have yet to be firmly established,
procedures should be carefully audited for complications and
treatment outcome .
Hysteroscopy enables visualisation of the uterine cavity
and allows the diagnosis and surgical treatment of intrauterine
pathology. To achieve this, the uterine cavity needs to be
distended by a medium which could either be fluid or carbon
Carbon dioxide (CO2), a colorless gas, is used in outpatient
settings for diagnostic purposes only as bleeding during
operative procedures obscures visibility. The advantages of its
use include the ease of cleaning and maintaining equipment and
a clear view of the cavity in the absence of active bleeding or
bubbles. Most gynecologists have abandoned the use of CO2 gas.
The mixture of CO2 gas and fluid such as blood produces bubbles
that impair visualization. In addition, it carries the risk of air
Fluid media are used for operative procedures, as they allow
continuous irrigation giving a clear picture and enable use of both
mechanical and electrosurgical instruments. Many distending
media have been used for hysteroscopy. Generally, normal saline
is preferred to carbon dioxide as a distension medium as it allows
improved image quality, permits quicker procedure, reduces the
vasovagal episodes and has an added advantage of acting as a
conducting medium for the use of bipolar energy for operative
hysteroscopy. Normal saline bags of 1- and 3-l volumes should
be stocked. It is better to use warmed saline (room temperature).
Delivery of the distension medium can be safely and
effectively achieved using: simple gravity, pressure bags or
automated delivery systems. It is practical to use pressure bags
with a squeeze bulb to achieve adequate uterine distension (80-
120mmHg) with normal saline during routine hysteroscopy.
Automated pressure delivery system is recommended in order
to maintain a constant intrauterine pressure and a clear view
intraoperatively as well as accurate fluid deficit surveillance
which is advantageous for prolonged cases such as endometrial
resection or hysteroscopic myomectomy.
Fluid distending media can be classified into two main types:
electrolyte-rich (conducting) media, for example, normal saline;
and electrolyte-poor (nonconducting) media. However, it is now
possible to use electrolyte media with bipolar electrosurgical
systems. It also is important to understand which media are
Electrolyte-Poor fluids include glycine, 1.5% (osmolality 200
mOsmol/kg -hypo-osmolar); sorbitol, 3% (hypo-osmolar); and
mannitol, 5% (which is iso-osmolar to plasma; 285 mOsmol/kg).
Glycine 1.5% is one of the most commonly used nonconducting
media. Devices that use monopolar energy such as the traditional
resectoscope must only be used with nonconducting media to
prevent potential injury to the patient. They are compatible with
radio-frequency energy, which cuts, desiccates, and fulgurates
intrauterine tissue. Excessive absorption of hypo-osmolar fluids
can cause hyponatremia, hyperammonemia, and decreased
serum osmolality, with the potential for seizures, cerebral
edema, and death. Some clinicians have recommended mannitol,
5%, which is iso-osmolar and acts as its own diuretic. It may
cause hyponatremia, but not decreased serum osmolality.
The use of a hyperosmolar solution of 32% dextran 70 has
been abandoned. Its use even in low volumes has been associated
with vascular overload and subsequent heart failure, pulmonary
oedema and anaphylaxis. Further, it tends to caramelize quickly
on instruments leading to damage.
Normal saline solution and lactated Ringer’s solution
are readily available and are isotonic. These solutions can be
used during diagnostic hysteroscopy and in operative cases
where mechanical, laser, or bipolar energy is used. The risk
of hyponatremia and decreased serum osmolality is low but
careful attention should be paid to fluid input and output, with
particular attention to the fluid deficit as pulmonary edema and
congestive heart failure can still occur.
Most light sources are either Tungsten or cold xenon (175
watt). Either type of lamp provides adequate illumination
for operative procedures, photography, and videotaping for
hysteroscopy. Xenon lamps are more expensive than halogen
ones. Illumination is primarily a function of the power of the
light and the light transmission properties of the light head, but
it is also influenced by the size and tissue propertises of the light
head. Light heads are either Fibre optic or Liquid. The light cables
are rather fragile, and they should be handled with extreme care
to avoid damage to the optical fibres.
Patient preparation should start from the patient’s
first presentation. Patient and physician should discuss
the hysteroscopic procedure, its risks and benefits. In
premenopausal women with regular menstrual cycles, the
optimal timing for hysteroscopic procedures is during the early
proliferative stage (menstrual days 4-10), when the endometrial
lining is the thinnest. Some women with unpredictable menses
can be scheduled at any time for operative hysteroscopy. Cervical
softening with 400 to 800μg of synthetic E1 prostaglandin (i.e., misoprostol) administered vaginally 12 hours before the
procedure is not routinely recommended.
A systematic review and meta‐analysis of randomized
controlled trials on the effectiveness of cervical ripening with
misoprostol administration before hysteroscopy showed
that misoprostol had a significant effect on cervical ripening
before hysteroscopy, except in the postmenopausal population
but adverse effects were significantly more common with
misoprostol than with placebo (risk difference 0.07, 95% CI
0.01-0.12) . It is associated with increased side effects (e.g.,
abdominal pain, nausea, diarrhea, fever, and vaginal bleeding),
no significant difference in rates of cervical laceration and false
tract formation and the risk of overdilation of the cervix for the
small diameter office hysteroscopes.
Office hysteroscopy is used for either diagnostic or minor
operative procedures including abnormal uterine bleding,
submucous fibroids, endometrial polyps and intrauterine
synchecia, removal of uterine septum. Office hysteroscopy is
safe, with a low incidence of serious complications and failure
rate. Performing the procedure in the office with no speculum,
tenaculum, or anesthesia will enable the patient comfort so
that the patient can return to normal activities at the earliest.
Major barriers to successful office hysteroscopy include pain,
cervical stenosis, and poor visualization of the cervix. Therefore,
preoperative patient selection and counseling are very important.
Poor candidates for office hysteroscopy include patients who
have cervical stenosis, high levels of anxiety, comorbidities,
limited mobility, or significant uterine pathology requiring
operative procedures. Minimal distention pressure for adequate
visualization will reduce patient discomfort. Performing any
procedure requiring >3L of fluid unless a weighted monitoring
system is available is not recommended.
Equipment generally needed to perform hysteroscopic
procedures in the office includes a hysteroscope with an outer
sheath of less than 5mm in outer diameter, distending media
and infusion system, operative instrumentation, and a light
source. Although it is possible for the surgeon to look directly
into the eyepiece, cameras and video monitoring systems make it
possible to obtain photographs and video and enable the patient
to see images.
Operative hysteroscopy incorporates the use of mechanical,
electrosurgical, or laser instruments to treat intracavitary
pathologies such as removal of endometrial polyps, submucous
fibroids, septa and adhesions or to perform targeted biopsy or an
endometrial ablation/resection. Resectoscopes typically consist
of a 7 to 9mm sheath. The hysteroscopic morcellator consists of
a rotary blade that cuts lesions; tissue is then aspirated through
the morcellator. The smaller hysteroscopic morcellators are used
for endometrial polypectomy in an outpatient setting whereas
larger hysteroscopic morcellators can remove prominent
Complications from hysteroscopy are rare, but some are
potentially life threatening. Hysteroscopic procedures are
associated with a low number of adverse events with an incidence,
reported from Germany of 0.24% of 21,676 cases . The most
common perioperative complications associated with operative
hysteroscopy were uterine perforation (0.12%), resection of
fibroids had the highest risk of uterine perforation (0.15%),
fluid-overload syndrome occurred in 0.06%. The incidence of
intra-operative hemorrhage in operative hysteroscopy ranged
between 0.03 and 0.1%. In the absence of uterine perforation,
heavy intra-operative bleeding occurred in 0.03% of the patients,
in 83.3% cases during endometrial ablation. The incidence
of intra-operative hemorrhage during endometrial ablation
was 0.1%, Endomyometritis was documented in 0.01% of
Hemorrhage may occur during hysteroscopic resection of
the endometrium, leiomyomas, uterine septa, or synechiae and
from cervical lacerations or uterine perforation. It may originate
from endometrium, myometrium or from damage to surroding
vessels. Delayed hemorrhage may be seen among patients with
endometritis weeks after surgery. Bleeding from a specific
site within the uterine cavity, with no suspicion of uterine
perforation, can be controlled with electrosurgical coagulation
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 30mL of water. Alternative strategies, such as injection of
vasopressin into the cervical stroma or uterine compression
can be attempted. In extreme cases, laparoscopic suturing of a
perforation, hysterectomy, or uterine artery embolization may
Complications related to distending media vary according to
the patient population and the media used. Systemic absorption
of distension media can occur either by intravasation or
extravasation. The most common mechanism of absorption is
intravasation whereby fluid enters the systemic circulation when
blood vessels and venous sinuses within the myometrium are
opened. Extravasation of fluid refers to the entry of distension
media into the peritoneal cavity where it is then reabsorbed.
This may occur through passage of the fluid through either the
fallopian tubes or an unrecognized perforation.
Fluid absorption is affected by size and number of the
lesions removed (Large or deep resections for type 1/2 fibroids
or transcervical resection of endometrium), the depth of
myometrial resection, the number of myometrial sinuses opened, the intrauterine pressure, and the duration of procedure .
The best way to limit excess fluid intravasation is to monitor
the fluid deficit closely and frequently throughout the procedure.
Calculation of the absorbed media should take place in a closed
and preferably automated system. If automated system is not
available, the volume should be measured and deficit should be
calculated every 5 to 10 minures.
The Practice Guidelines of the American Association for
Gynecologic Laparoscopists (AAGL) recommend a maximum
fluid deficit of 1000mL of low-viscosity medium for healthy
patients. The patient should be carefully evaluated and the
procedure should be terminated expeditiously. For elderly
patients and others with co-morbid conditions, a maximum
fluid deficit of 750mL is advised. The maximum fluid deficit for
normal saline is unclear, but 2500mL has been advocated .
Guidelines for fluid monitoring and the limits of fluid excess
have been published and adapted by the American College of
Obstetricians and Gynecologists’ Committee on Gynecologic
Practice as follows .
a) Intravenous hydration of patients undergoing
hysteroscopy should be closely monitored preoperatively and
intraoperatively. Hysteroscopic fluid absorption should be
closely monitored intraoperatively
b) Lower fluid deficit thresholds should be considered
for elderly patients, patients with comorbid conditions, patients
with cardiovascular or renal compromise, and when procedures
take place in an outpatient setting with limited acute care and
c) In healthy patients, the maximum fluid deficit is
1,000mL for hypotonic solutions, 2,500mL for isotonic solutions,
and 500mL for high-viscosity solutions. However, if fluid 1,000mL
of a hypotonic solution, 2,000mL of an electrolyte solution, or
300mL of a high-viscosity solution, consideration should be
given to stop further infusion and conclude the procedure.
Electrolytes should be assessed, administration of diuretics
considered, and further diagnostic and therapeutic intervention
begun as indicated.
d) In an outpatient setting with limited acute care
and laboratory services, consideration should be given to
discontinuing procedures at a lower fluid deficit threshold than
e) An automated fluid monitoring system facilitates early
recognition of excessive deficit in real-time totals.
f) An individual should be designated to frequently
measure intake and outflow and report the deficit to the
Uterine perforation is the most common complication of
hysteroscopy. In a retrospective study of 5474 hysteroscopies,
uterine perforation occurred in 15 cases (0.27%), however,
although the perforation rate was 0.06% for cases of diagnostic
hysteroscopy, it was 1% for those procedures categorized as
“operative hysteroscopy” .
Before performing hysteroscopy, the clinician should perform
a pelvic examination to determine uterine position. Ultrasound
guidance may be useful in difficult cases. Midline uterine
perforation rarely leads to significant morbidity unless a laser
or electrosurgical device is used. Lateral uterine perforations
can lead to the development of a retroperitoneal hematoma,
and cervical perforations can result in significant immediate or
delayed bleeding. Laparoscopy may be useful to determine the
extent of damage, including the existence of bowel injury or
Embolism (air or carbon dioxide) can occur with any
hysteroscopic technique and can cause cardiovascular collapse
or pulmonary edema. Clinically significant gas embolism
appears to occur frequently in patients undergoing operative
hysteroscopy. Preventive strategies include flushing air from
tubing and making sure that the procedure is stopped and tubing
is purged of air when bags are changed. To minimize the risk of
gas embolization, the flow of CO2 should be limited to 100mL/
min with intrauterine pressure less than 100mm Hg and used
with a hysteroscopic insufflator. Insufflators designed for use in
laparoscopy must not be used for hysteroscopy.
Hysteroscopy is considered the gold standard for the
evaluation and restoring of intracavitary problems in recent
years with advanced experience of physicians, smaller diameter
hysteroscopes, and common use of office-based procedures. It is
minimally invasive and can be used with a high degree of safety.
Knowledge of potential risks relating to distending media and
intraoperative complications will enhance its safety.