Office Hysteroscopy

The first use of hysteroscopy as a diagnostic tool occurred in 1869 by Pantaleoni who used a tube with an external light source to detect “vegetations in the uterine cavity.”[1] Since that time, improvements in optics, light sources and video cameras have made office hysteroscopy an invaluable tool in the diagnosis of abnormal uterine bleeding. Additionally, the office hysteroscope has the potential for use in treatment of certain disorders of the uterine cavity.

Is There a Role for the Dilatation & Curettage?

Many gynecologists continue to rely upon the use of the D&C or endometrial biopsy as a means of assessing the uterine cavity in cases of abnormal uterine bleeding. While these techniques continue to remain proven tools, there are numerous situations that arise where the pathologic results from the D&C or endometrial biopsy are inadequate. Despite insufficient or benign pathologic findings on biopsy the patient may continue to have abnormal bleeding episodes. It is in these situations where office hysteroscopy becomes a valuable adjunct to the gynecologist's armamentarium. Hysteroscopy can be performed in an office setting so that thorough visualization of the uterine cavity is achieved, and in many cases directed tissue biopsies can be performed. Office hysteroscopy also allows the clinician to remove small polyps and even uterine leiomyomata or intrauterine devices in a timely manner.

Many clinicians note that an endometrial biopsy in conjunction with a sonohysterogram approaches the diagnostic accuracy of hysteroscopy. There is a potential dilemma with this approach. If minor pathology is noted on the sonohysterogram, this is pathology that could potentially have been removed via office hysteroscopy, sparing the patient an additional office visit or outpatient procedure. It is also important to note that numerous articles have reported that pathology can be missed by a blind procedure such as a D&C or endometrial biopsy.[2]

Indications for office hysteroscopy

This procedure provides a means of both diagnosing and potentially treating cases of persistent abnormal uterine bleeding that are unresponsive to hormonal manipulations or that persist despite findings of benign pathology on biopsy. Specific examples are the young patient with heavy unpredictable episodes of vaginal bleeding and benign proliferative endometrium on an endometrial biopsy; the removal of retained or lost IUDs; the evaluation/treatment of intrauterine filling defects noted at the time of hysterosalpingography; and evaluation of the post-menopausal patient with persistent episodes of bleeding despite unremarkable endometrial biopsies and/or negative sonohysterograms.

The use of office hysteroscopy is essential in my practice. Many of my patients undergoing this procedure are infertility patients who have filling defects noted at the time of hysterosalpingography. When filling defects are evaluated in the office, these patients are spared the expense of going to the operating room and incurring anesthesia and instrument costs and facility fees. Most of these patients will have small polyps that are easily removed at the time of office hysteroscopy. Additionally, there are a large number of breast cancer survivors in my practice who use tamoxifen and who will have episodes of bleeding. Pathology is ruled out in the vast majority of these women via a simple office hysteroscopy, sparing them the expense of going to the operating room.

Instrumentation

Office hysteroscopy is a very simple procedure that requires minimal instrumentation.

At our institution we prefer to use a 4.6 mm semi-rigid hysteroscope (CIRCON Corporation, Santa Barbara, CA) with a 7 Fr operating channel (Figure 1). This operating channel allows for placement of grasping and/or biopsy instruments for removal of IUDs and small polyps. The availability of a 5.5 mm outer sheath provides a better seal in cases of the more patulous cervical os. Visualization is provided through fiberoptics. The 5.5 mm rigid hysteroscope with a 7 Fr operating channel uses a rod lens technology that provides an even clearer picture for the gynecologist (Figure 2).

Figure 1. Micro-H™ Operative Hysteroscope (4.6 mm with 5.5 mm outer sheath, 2.3 mm working channel)

Figure 2. SlimLine™ Operative Hysteroscope (5.5 mm, 2.3 mm working channel)

The next piece of equipment is a fiberoptic light source. A CO2 insufflator that is specifically dedicated to hysteroscopy is essential. Laparoscopic insufflators are ABSOLUTELY CONTRAINDICATED because CO2 is delivered in liters per minute. Hysteroscopic insufflators are the instruments of choice, as CO2 gas is delivered at no more than 100 ml of CO2 per minute while maintaining the intrauterine pressure at values less than 200 mm Hg. The inadvertent use of laparoscopic insufflators can lead to carbon dioxide embolisms that have an extremely high mortality rate.[3]

The use of carbon dioxide is quite satisfactory because it allows for an extremely clear image. It has a very low refractive index that enables the operator to see a wide, nonmagnified view of the field. I have not found a need to use liquid distending media because the procedures are extremely short in our office. The disadvantage of carbon dioxide is that if bleeding does occur it will easily obscure the operator's field of view. A paracervical block with 1% lidocaine is also used during the course of office hysteroscopy. A single tooth tenaculum, ring forceps, betadine swabs, and 4 x 4 sponges are the only additional equipment needed.

Technique

After a thorough review of the procedure with the patient, she is taken to the procedure room. The patient is placed in the dorsal lithotomy position and examined to determine the position of the uterus. The cervix is then visualized with the help of the speculum and then cleansed with an appropriate solution such as betadine or hibiclens. The cervix is infiltrated along the anterior lip with 1% lidocaine and a tenaculum then applied. With the cervix under traction, a paracervical block using 1% lidocaine is completed. The hysteroscope is then introduced using visualization via the eyepiece or a video monitor, as is the case in our office.

With the CO2 running, a dilating wedge is obtained that allows for the resistance to gradually decrease at the internal os, so that the hysteroscope slowly slides into the uterine cavity while maintaining gentle counter-traction on the cervix. The uterine cavity is visualized in a step-wise manner. The tubal ostia is first visualized, followed by the remainder of the superior uterine cavity, lateral uterine walls, and anterior and posterior uterine walls. The lower uterine segment is also visualized.

It is important to use gentle movement throughout the uterine cavity. If the cavity is traumatized with carbon dioxide gas during the procedure it will bleed and potentially obscure visualization. If there is a significant amount of pathology present in the cavity, an endometrial biopsy or office D&C can be performed after removal of the hysteroscope to provide additional tissue for pathology. In my practice the need to perform a D&C is the exception rather than the rule. Patients tolerate multiple directed biopsies extremely well, and the specimens have been adequate for pathologic review.

The entire procedure takes approximately 10-15 minutes. Over 95% of my patients have tolerated the procedure with the paracervical block. The few patients who have failed office hysteroscopy are those with an extreme level of anxiety and who did not tolerate the pelvic examination and/or cervical manipulation.

Results

Office hysteroscopy is an extremely valuable tool in my practice. It allows patients to be thoroughly evaluated and, in some cases, treated without incurring the cost and lost work time required when undergoing an outpatient hospital procedure. In 12 years of practice I have never experienced a complication as a result of office hysteroscopy. I do not use prophylactic antibiotics since the literature has failed to demonstrate any significant infectious morbidity following this procedure. There have been no cases of uterine perforation nor have there been any complications related to anesthesia or carbon dioxide gas use.

Summary

The most frequent argument by gynecologists expressing a reluctance to perform office hysteroscopy is the difficulty in learning the technique. My recommendation for learning this procedure is to perform diagnostic hysteroscopy using CO2 at the time of every D&C performed in an operating room setting. If the physician will do this for a minimum of 10 cases, enough experience will be gained to translate this knowledge to an office setting.

I would also like to emphasize that hysteroscopy should be first learned in the context of a supervised course setting where there are both didactics and hands-on exposure. We are happy to provide such tutorials at our institution. We have monthly hands-on training sessions for our junior residents in a variety of endoscopic techniques.

References:

References

1. Pantaleoni DC. An endoscopic examination of the cavity of the womb. Med Press Circ. 1869; 8:26-27.

2. Loffer FD. Hysteroscopy with selected endometrial sampling compared with D&C for abnormal uterine bleeding: the value of a negative hysteroscopic view. Obstet Gynecol 1989; 73:16-20.

3. Lindemann JH, Mohr J. CO2 hysteroscopy: diagnosis and treatment. Am J Obstet Gynecol. 1976; 124:129-133.

Dr. Strawn is an assistant professor, residency education program coordinator, and director of the in vitro fertilization program, department of obstetrics and gynecology, at the Medical College of Wisconsin, in Milwaukee.