Reimpresión oficial de UpToDate ® www.uptodate.com © 2020 UpToDate, Inc. y / o sus filiales. Todos los derechos reservados. Resumen de la histeroscopia Autor: Linda D Bradley, MD Editor de sección: Tommaso Falcone, MD, FRCSC, FACOG Subdirector: Kristen Eckler, MD, FACOG Todos los temas se actualizan a medida que hay nuevas pruebas disponibles y nuestro proceso de revisión por pares está completo. Revisión de literatura actualizada hasta: enero de 2020. | Última actualización de este tema: 26 de enero de 2020. INTRODUCCIÓN El desarrollo de la histeroscopia ha proporcionado un enfoque mínimamente invasivo para los problemas ginecológicos comunes, como el sangrado uterino anormal. El aumento de la capacitación del médico, los histeroscopios de menor diámetro y el mayor énfasis en los procedimientos basados en el consultorio han llevado a un uso generalizado de esta importante tecnología. Un histeroscopio es un telescopio que se inserta en el útero a través de la vagina y el cuello uterino para visualizar la cavidad endometrial, así como la ostia tubárica, el canal endocervical, el cuello uterino y la vagina. La histeroscopia se puede realizar para indicaciones diagnósticas o terapéuticas. Aquí se presenta una descripción general de la histeroscopia. La vaginoscopia se discute por separado. (Ver "Vaginoscopia" ). INDICACIONES La histeroscopia se realiza para evaluar o tratar la cavidad endometrial, la ostia tubárica o el canal endocervical en mujeres con: ● Sangrado uterino premenopáusico o posmenopáusico anormal. ● engrosamiento endometrial o pólipos ● Fibromas submucosas y algunos intramurales. ● adherencias intrauterinas ● Anomalías de Müller (p. Ej., Tabique uterino) ● Anticonceptivos intrauterinos retenidos u otros cuerpos extraños. ● Productos retenidos de la concepción. ● Deseo de esterilización. ● lesiones endocervicales Existen varios enfoques para evaluar a las mujeres con sangrado uterino anormal o lesiones intrauterinas (ecografía pélvica, ecografía de infusión salina, muestreo endometrial, histerosalpingografía). El uso de la histeroscopia para la evaluación inicial ofrece el beneficio potencial de combinar la evaluación con el tratamiento. Además, la histeroscopia evita el riesgo de falta de patología focal, como puede ocurrir con el muestreo endometrial ciego. Alternativamente, la histeroscopia se puede utilizar para evaluar o tratar las lesiones identificadas en los estudios de imágenes (por ejemplo, eco endometrial normal detectado con ultrasonido transvaginal), o para confirmar la ausencia de enfermedad cuando los síntomas persisten y las pruebas de diagnóstico iniciales son normales (por ejemplo, muestreo endometrial ciego ) El uso de la histeroscopia para hacer un seguimiento de los hallazgos anormales en las imágenes ayuda a descartar la patología ovárica o tubárica que puede contribuir al sangrado uterino anormal. Una discusión detallada de la elección entre la histeroscopia y otros métodos de evaluación endometrial se puede encontrar por separado. (Ver "Descripción general de la evaluación del endometrio para enfermedades malignas o premalignas" y "Procedimientos de muestreo endometrial" ). La histeroscopia no puede evaluar la enfermedad miometrial (p. Ej., Adenomiosis), la patología tubárica o el contorno uterino externo; por lo tanto, no es suficiente para evaluar estas estructuras anatómicas durante una evaluación de infertilidad. Se necesitan procedimientos adicionales (p. Ej., Laparoscopia o histerosalpingografía). (Consulte "Descripción general de la infertilidad" ). CONTRAINDICACIONES Las contraindicaciones para la histeroscopia son: ● Embarazo intrauterino viable. ● Infección pélvica activa (incluida la infección por herpes genital [ 1 ]) ● Cáncer cervical o uterino conocido Si bien la histeroscopia no debe realizarse en una paciente con un embarazo intrauterino viable, la histeroscopia posparto o postaborto a veces es útil para la evaluación y el tratamiento de los productos retenidos de la concepción [ 2,3 ]. El sangrado uterino excesivo puede limitar la visualización durante la histeroscopia, pero no es una contraindicación [ 4 ]. (Ver 'Desafíos operativos' a continuación). Las comorbilidades médicas (p. Ej., Enfermedad coronaria, diátesis hemorrágica) también son contraindicaciones potenciales para la cirugía histeroscópica. Sin embargo, dado que este es un procedimiento mínimamente invasivo, rara vez está contraindicado en pocas mujeres. (Ver "Resumen de los principios de consulta médica y medicina perioperatoria" .) 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 [5,6]. 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 [7]. 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). There are two main hysteroscopic optical systems: direct optical and contact. 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. Conversely, contact hysteroscopes work without a distending medium and provide only a focal view of the endometrial cavity, since only tissue in direct contact with the scope can be viewed [8]. Thus, unless the uterine cavity is explored in a slow, systematic fashion, significant pathology can be missed. This approach is rarely used. ● 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. Laser is rarely used in modern hysteroscopic procedures. The three types of operative hysteroscopes are: ● Operative sheath with instruments inserted through channels or fixed to the sheath ● Electrosurgical resectoscope ● Hysteroscopic morcellator 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 [9]. 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 [9] (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) [10]. (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, Versapoint) 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 morcellator — The hysteroscopic morcellator consists of a rotary blade that cuts lesions; tissue is then aspirated through the morcellator [11]. Morcellators, which are inserted through the working channel of hysteroscope, exist for use with 6 mm, 7 mm, and 9 mm hysteroscopes. The morcellator does not use radiofrequency electrical energy, and thus, is not able to coagulate bleeding vessels encountered during surgery [12,13]. Distending media — Hysteroscopy is performed using a distending medium to provide a global view of the endometrial cavity. 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 [14-16]. Approach to outpatient hysteroscopy — The most common reasons for failure to complete an outpatient hysteroscopy are pain, cervical stenosis, and poor visualization [14]. 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 mcg per vaginam) • 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 'Anesthesia' 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 [17-23], although two small trials reported a small reduction in intraoperative pain with pre-procedure use of tramadol [24,25]. NSAID use has been associated with reduced posthysteroscopy pain and can be used postoperatively as needed [17-19]. (See 'Postoperative care' below and "Management of acute perioperative pain", section on 'Oral NSAIDs'.) 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. 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, the proliferative phase is best for visualization of the uterine cavity. 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) [26]. Gonadotropin releasing hormone agonists and danazol are also effective, but are used infrequently due to adverse effects [27-30]. 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) [31]. 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 [32]. Not all women will require cervical dilation for hysteroscopy, namely premenopausal women undergoing hysteroscopy with a narrow caliber (<5 mm) or flexible hysteroscope. Women who benefit from cervical dilation include those having procedures with larger hysteroscopes (≥5 mm), women with a history of cervical stenosis or cervical surgery, and postmenopausal women. Cervical dilation can be done mechanically at the time of the procedure (dilators) or done preoperatively with cervical ripening agents (misoprostol or dinoprostone) or vaginal osmotic dilators (laminaria). Preoperative dilation is generally preferred because it avoids or reduces the need for mechanical dilation and the associated risks of pain, uterine perforation, and false track creation [14,33]. (See "Dilation and curettage", section on 'Procedure'.) In our practice, for women expected to need cervical dilation for hysteroscopy, we pretreat with 200 to 400 mcg of vaginal misoprostol 12 to 24 hours prior to hysteroscopy. 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) [33]. 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 metaanalysis 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). The side effects of misoprostol included mild abdominal pain, vaginal bleeding, and increased body temperature. Although prior trials of misoprostol in postmenopausal women had reported conflicting results [3438], the meta-analysis above, which only included two trials in the analysis of postmenopausal women, did demonstrate a benefit of misoprostol in this group [33]. 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 [35]. 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. 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 [35,43]. One study reported evening primrose oil (EPO) facilitated cervical ripening and dilation before operative hysteroscopy in both pre- and postmenopausal patients [44]. 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. Another option for preoperative cervical dilation is osmotic dilation (eg, laminaria). However, 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. Although 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 [33,45], 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 [33]. 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 [46]. (See 'Infection' below and "Antimicrobial prophylaxis for the prevention of bacterial endocarditis" 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'.) Anesthesia — Anesthesia may be needed to limit pain and facilitate hysteroscopy. 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 [47]. Some women find uterine biopsy to be the most painful part of the procedure [48]. Managing pain or discomfort encompasses not just medication, but also patient counseling, complimentary treatments (eg, guided visualization or listening to music [49]), and selection of the type of procedure and instruments. (See 'Approach to outpatient hysteroscopy' above.) Most women are able to undergo diagnostic hysteroscopy without anesthesia [50,51]. The benefits of not using anesthesia include no adverse medication reactions, reduced procedure time and cost, and avoidance of a pain-inducing paracervical block [48,52]. 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 [48]. For women 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. 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 [53]: ● 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 agent and technique for paracervical block are discussed in detail separately. (See "Pudendal and paracervical block", section on 'Women undergoing gynecologic procedures'.) Women undergoing operative hysteroscopy with intrauterine procedures (eg, myomectomy, uterine evacuation) typically require additional pain control beyond that provided by a paracervical block [14]. Options include intravenous medication (ie, conscious sedation) and regional or general anesthesia. Paracervical block can be combined with these other modalities, but no benefit has been demonstrated [53]. Patient selection and use of conscious sedation is reviewed separately. (See "Procedural sedation in adults outside the operating room".) 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 [54]. 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. A detailed discussion of specific operative procedures can be found separately. (See "An overview of endometrial ablation" and "Intrauterine adhesions: Clinical manifestation and diagnosis" and "Congenital uterine anomalies: Surgical repair".) 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 [55]. 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 [56]. Failed procedures were infrequent for both techniques. Some, but not all, randomized trials have found that operative time was shorter for the vaginoscopic technique [57-60]. 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 [61]. 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 [62]. 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 [63]. To avoid missing uterine pathology, endometrial sampling (hysteroscopic biopsies or blind sampling) should be performed in patients with 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 [64]. 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 [65]. 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 [66]. 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. 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). 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 dilation and curettage 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 [67]. 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 [32]. ● A multicenter study of 92 centers and over 21,000 operative hysteroscopic procedures reported a complication rate of 0.22 percent [68]. 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 [69]. 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 [64]. Among these procedures, there were only eight complications: four uterine perforations, one pelvic infection, one bladder perforation, and two medical complications. 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 [68-72]. 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) [69]. 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. 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 or hysteroscopy".) Embolism — Embolism (air or carbon dioxide) can occur with any hysteroscopic technique and can cause cardiovascular collapse [73]. 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 [74]. 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 [9]. In particular, a significant risk of bowel injury has been reported from hysteroscopic coagulation of the tubal cornua for sterilization [75]. 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 [76]. 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 [77]. 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 [68,69,78]. 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 ● 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.) ● 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.) ● During hysteroscopy, the uterus is distended with a gas or fluid medium. Each medium has benefits and risks, including fluid overload or gas embolism. (See "Hysteroscopy: Managing fluid and gas distending media".) ● 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. We suggest preoperative cervical ripening with misoprostol rather than no preoperative treatment (Grade 2B). We prescribe misoprostol 200 mcg to be 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. (See 'Cervical preparation and dilation' above.) ● Prophylactic antibiotics are not routinely administered during hysteroscopy since posthysteroscopy infection is rare. (See 'Preoperative evaluation and preparation' above.) ● Most diagnostic and brief or minor operative procedures can be performed without anesthetic or with a local anesthetic. 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Postoperative infection and surgical hysteroscopy. Fertil Steril 2002; 77:766. Topic 3278 Version 26.0 GRAPHICS Flexible hysteroscope Courtesy of William J Mann, Jr, MD. Graphic 59639 Version 1.0 Hysteroscope with different viewing angles Graphic 58867 Version 1.0 Hysteroscopic instruments (A) Scissors. (B) Grasping forceps. (C) Rigid hysteroscopic biopsy forceps. Courtesy of William J Mann, Jr, MD. Graphic 82008 Version 2.0 In-line operative hysteroscope with semirigid scissors Courtesy of William J Mann, Jr, MD. Graphic 69759 Version 1.0 Hysteroscopy: resectoscope (A) Assembled hysteroscopic resectoscope with (B) rollerbar and (C) rollerball. Courtesy of William J Mann, Jr, MD. Graphic 74123 Version 3.0 Hysteroscopy: Resectoscopic instruments (A) Rollerball. (B) Loop electrode. (C) Punctate electrode. Courtesy of William J Mann, Jr, MD. Graphic 55853 Version 4.0 Hysteroscopy: Resectoscope parts Courtesy of Linda D Bradley, MD. Graphic 69544 Version 1.0 Hysteroscopy: Resectoscope assembly 1 Courtesy of Linda D Bradley, MD. Graphic 50056 Version 2.0 Hysteroscopy: Resectoscope assembly 2 Courtesy of Linda D Bradley, MD. Graphic 62804 Version 2.0 Hysteroscopy: Resectoscope assembly 3 Courtesy of Linda D Bradley, MD. Graphic 75612 Version 2.0 Contributor Disclosures Linda D Bradley, MD Grant/Research/Clinical Trial Support: Bayer Healthcare [Uterine fibroids]. Other Financial Interest: Gynesonics [Uterine fibroids]; PCORI [Uterine fibroids registry]. Tommaso Falcone, MD, FRCSC, FACOG Nothing to disclose Kristen Eckler, MD, FACOG Nothing to disclose Las divulgaciones de los colaboradores son revisadas por conflictos de intereses por el grupo editorial. Cuando se encuentran, se abordan examinando a través de un proceso de revisión multinivel y a través de los requisitos para que se proporcionen referencias para respaldar el contenido. Se requiere el contenido de referencia apropiado de todos los autores y debe cumplir con los estándares de evidencia de UpToDate. Política de conflicto de intereses
