Reliability, feasibility, and safety of minihysteroscopy with a vaginoscopic approach: experience with 6,000 cases

The Current Situation of Anaesthesia for Hysteroscopy in Mainland China: A National Survey

Purpose: The need for anaesthesia or analgesia for performing hysteroscopy remains debatable. This study aimed to conduct an overview of the situation of anaesthesia for hysteroscopy in mainland China. Methods: Two questionnaires were separately designed for anaesthesiologists and gynaecologists and distributed to every medical institution that performed hysteroscopic procedures on patients with infertility in mainland China. Electronic questionnaires were distributed via WeChat, and data on anaesthesia regimen, monitoring parameters, procedure number, and other information were collected. Results: Reproductive technology is conducted by 536 institutions in mainland China. The survey received 491 responses from anaesthetists (91.6%) and 436 from gynaecologists (81.3%). In 2021, 552,225 hysteroscopies were conducted in 268 medical centres. The average percentage of hysteroscopy under anaesthesia is 63.8% in 2021, wherein 47.3% of institutions have an anaesthesia percentage of >75%. Propofol and opioid analgesics, such as fentanyl and sufentanil, were the most commonly used intravenous anaesthetics. All sedations were performed by anaesthesiologists. Monitoring parameters included pulse oxygen saturation (98.9%), electrocardiogram (91.6%) and noninvasive blood pressure (91.3%). An anaesthesiologist-to-operating room ratio of <1 was observed in 31.3% of medical institutions. Surprisingly, 52.4% of medical institutions performing hysteroscopy had no postanaesthesia care unit (PACU). Most institutions with PACU were equipped with independent oxygen sources, suction and monitors. Both rigid and flexible hysteroscopes (rigid hysteroscope, 45.1%; flexible hysteroscope, 4.5%; both types, 50.4%) were used, and the hysteroscopic diameter was ≤5 mm in 60.3% of medical centres. Conclusions: China performs a large number of hysteroscopies, and sedation is the most frequently used anesthesia regimen. However, issues such as inadequate emergency support devices, insufficient personnel and weak resuscitation management after anaesthesia, have been observed.

Hysteroscopic Endometrial Ablation: From Indications to Instrumentation and Techniques-A Call to Action

The development of minimally invasive techniques has led to the creation of innovative alternatives in cases where traditional methods are not applicable. In modern gynecology, hysteroscopy has become the gold standard for the evaluation and treatment of intrauterine pathology. Endometrial ablation (EA) is a procedure that uses different types of energy to destroy the endometrium and is currently used as an alternative technique in cases of heavy menstrual bleeding when medical treatment has failed and uterine preservation is desired. The aim of this review was to evaluate the feasibility, safety, and clinical outcomes of hysteroscopic EA as an alternative in patients with abnormal uterine bleeding. A detailed computerized search of the literature was performed in the main electronic databases (MEDLINE, EMBASE, Web of Science, PubMed, and Cochrane Library), from 1994 to June 2022, to evaluate the outcomes in patients with abnormal uterine bleeding (AUB) undergoing EA using hysteroscopic and non-hysteroscopic techniques. Only scientific publications in English were included. Twelve articles on the current use of endometrial ablation were included. Data on patient symptoms, tools used for EA, primary outcomes, and adverse events were recorded. EA should be considered an effective and safe approach in the management of patients with abnormal uterine bleeding caused by benign pathology, in whom medical treatment has failed or is contraindicated. Due to the lack of evidence, it would be interesting to determine whether EA would also have a role in the treatment of women with premalignant lesions, avoiding invasive surgical procedures or medical treatment in those patients for whom hysterectomy or the use of hormonal treatment is contraindicated.

Outpatient hysteroscopy is effective for uterine cavity evaluation following failed office-based endometrial biopsy

BACKGROUND

Failure to obtain an office-based endometrial biopsy for abnormal uterine bleeding is not uncommon. Although operating room-based procedures are traditionally considered the gold standard assessment tool in these circumstances, outpatient hysteroscopy is a less invasive, more cost-effective, and safer alternative. However, there is no contemporary Canadian literature on the effectiveness of an outpatient approach for this specific population.

OBJECTIVE

We aim to evaluate the effectiveness and outcomes of outpatient hysteroscopy for uterine cavity evaluation for patients who have failed an in-office endometrial biopsy attempt.

METHODS

We conducted a retrospective cohort study of all patients referred to an academic outpatient hysteroscopy unit between January 2015 and January 2018, who underwent an outpatient hysteroscopy following failed endometrial biopsy. Data were collected from electronic medical records.

RESULTS

Of the 407 consecutive patients who underwent an outpatient hysteroscopic procedure, 68 met inclusion criteria. Postmenopausal bleeding was the most common indication for initial biopsy, and most failures were attributed to cervical stenosis. Outpatient hysteroscopies were successfully completed in 96% of cases (n = 65/68). Failure resulted from either anxiety and discomfort (n = 2), or severe intrauterine adhesions (n = 1). Overall, 10% of patients subsequently required an operating room-based hysteroscopy, either to complete a myomectomy or polypectomy, or to allow general anesthesia. Outpatient hysteroscopy identified endometrial hyperplasia and cancer in 4.5% and 3% of patients, respectively.

CONCLUSION

Outpatient hysteroscopy following unsuccessful office endometrial biopsy attempts appears to be a feasible, safe, and cost-effective investigation strategy that may prevent the need for an operating room-based procedure in 90% of cases.

The diagnostic value of human epididymis protein 4 for endometrial cancer is moderate

Human epididymis protein 4 (HE4) has been used as a biomarker of endometrial cancer (EC) in clinical practice. However, there remains a lack of systemic research on the critical values of HE4 for diagnosing different clinical stages and pathological types of EC. This study investigated the accuracy of human epididymis protein 4 (HE4) in the diagnosis of EC. Patients who were hospitalized for a chief complaint of abnormal vaginal hemorrhage at Xinjiang Uyghur Autonomous Region People's Hospital between 2014 and 2019 were consecutively included. Pathological biopsy confirmed the diagnosis of EC; there were a total of 136 EC patients and 127 non-EC patients. The accuracy of HE4 in the diagnosis of EC was assessed with SPSS software. The accuracy of HE4 for diagnosing different clinical stages and pathological types of EC was also explored. The critical value of HE4 for endometrial cancer was 52.40 mmol/L, with a sensitivity of 57.35% and a specificity of 76.38%. For different stages of EC, the critical value was 36.9 mmol/L, and the sensitivity and specificity were 28% and 87.39%, respectively. For different pathological types, the critical value was 30.60 mmol/L, and the sensitivity and specificity were 93.85% and 33.33%, respectively. The diagnostic value of HE4 for EC is moderate, and the serum HE4 level cannot reflect the stage and type of EC.

A Prospective Randomized Comparative Clinical trial of Hysteroscopic Septal Resection Using Conventional Resectoscope Versus Mini-resectoscope

CONTEXT

Hysteroscopic metroplasty (HM) is the gold standard treatment for women with septate uterus with recurrent pregnancy loss. Miniresectoscope requires less cervical dilatation as compared to conventional resectoscope. Very few studies are available in the literature on use of miniresectoscope for operative purpose.

AIM OF THE STUDY

This study aimed to compare operative and postoperative outcome parameters using conventional versus mini resectoscope (MR) for hysteroscopic septal resection (HSR).

STUDY SETTINGS AND DESIGN

This was a prospective randomized controlled trial conducted in the Department of Obstetrics and Gynaecology from July 2017 to May 2019.

MATERIALS AND METHODS

Forty patients fulfilling the inclusion criteria were recruited and randomized into two groups. In Group A (20 patients), HSR was done using conventional resectoscope (CR) and in Group B (20 patients), MR was used. The various parameters recorded were cervical dilatation time, operating time, intraoperative complications, postoperative pain, and hospital stay and reproductive outcome post surgery in both groups.

RESULTS

Data analysis was carried out using SPSS IBM software version 20.0. The mean operating time was comparable but cervical dilatation time was significantly more in Group A. The duration of hospital stay was significantly less in Group B. There were no differences in adequacy of vision in both the groups but area of field was less in MR group. Four out of nine patients with infertility conceived after surgery. 65% in Group A and 70% in Group B conceived during follow up.

CONCLUSION

Our study showed that hysteroscopic metroplasty with MR, has comparable efficacy to CR in terms of good vision and septal resectability with added advantages of shorter cervical dilatation time, ease of entry of resectoscope, shorter operative time and significantly reduced postoperative morbidity in terms of less pain. However, the field of vision is less and resection time is more, hence more expertise is required. Further larger randomized trials are required.

CHRONIC ENDOMETRITIS - MODERN CONCEPTS, PRINCIPLES OF MAINTENANCE. LITERATURE REVIEW

In our review article, we assessed the etiological factors of chronic endometritis, the most frequent manifestations of clinical and endoscopic data, the effectiveness of various diagnostic procedures and existing treatment methods. However, until now, many questions of the optimal algorithm for the diagnosis and treatment of this pathology remain open and require further study. In connection with the above, a certain practical and scientific interest may be of prospective studies assessing modern diagnostic and treatment methods for ChE, their impact on the number of unsuccessful reproductive outcomes of ART programs, taking into account the personal characteristics of the reproductive system of patients.

Impact of anxiety levels on the perception of pain in patients undergoing office hysteroscopy

OBJECTIVE

This study aimed at assessing the impact of anxiety on pain perception during hysteroscopy and to highlight the possible contribution of factors related to pain perception.

MATERIALS AND METHODS

104 women with indication for office hysteroscopy fullfilled anonymous self-report questionnaires during the waiting time, before the procedure. The first self-report questionnaire included general patient information and an overall assessment of the degree of satisfaction with the information received before the procedure. The level of pre-procedural anxiety was measured through the State-Trait Anxiety Inventory STAI-Y1 (state anxiety). The perceived stress was assessed using the Perceived Stress Scale (PSS). The intensity of pain during the procedure and 20 min later was assessed with VAS score.

RESULTS

The average waiting time was of 192.33 ± 91 min. 59 patients (56.7%) performed the examination without analgesia while 45 women (43.3%) required analgesia. 28 women (27%) experienced mild pain, 34 (33%) moderate pain and 42 (40%) severe pain. The patients who performed the procedure without analgosedation had an average STAI-Y1 score of 44.81 ± 1.20, compared to women who required analgosedation (average score of 49.40 ± 1.64). The perceived level of stress was also associated with the use of analgosedation. Patients who did not request any anesthetic intervention obtained a PSS average score of 16.66 ± 0.75, compared to the subgroup with anesthesia (score of 19.76 ± 0.90).

CONCLUSIONS

Anxiety represents a key element for the success of ambulatory hysteroscopy. The management of anxiety can reduce the request for analgesia with a consequent optimization of time, costs and safety.

Reproductive outcomes of infertile women undergoing "see and treat" office hysteroscopy: a retrospective observational study

INTRODUCTION

This study aimed to assess the feasibility and efficacy of office hysteroscopy to diagnose and treat the specific uterine pathologies frequently diagnosed and thought to be associated with female infertility.

MATERIAL AND METHODS

Using office hysteroscopy, we examined the uterine cavity in women with primary or secondary infertility and evaluated the reproductive outcomes of those affected by one or more pathologies, including cervico-isthmic adhesions, intrauterine polyps and intrauterine adhesions. Additional patient characteristics considered were age and parity, uterine pathology, pain during hysteroscopy, and outcomes including spontaneous pregnancies achieved and time between treatment and pregnancy.

RESULTS

Reproductive outcomes of 200 patients affected by one or more uterine pathologies were evaluated. Cervico-isthmic adhesions were the most frequent findings in older women, with nearly 80% of them achieving pregnancy sooner than the others in our study. Spontaneous pregnancy rates following office hysteroscopy were 76%, 53% and 22% in women with cervico-isthmic adhesions, polyps (< 5 mm) and intrauterine adhesions, respectively.

CONCLUSIONS

Office hysteroscopy is a feasible and highly effective diagnostic and therapeutic procedure for cervico-isthmic and intrauterine adhesions, as well as for small polyps, allowing the resolution of female infertility related to these pathologies, without trauma and with only minimal discomfort.

Two-Step Office-Based Hysteroscopic Operation for Submucosal Myoma

Background and Objectives:

In the past, diagnostic hys- teroscopy was used to diagnose an intrauterine mass or abnormality and surgical hysteroscopy was used to treat a uterine polyp, uterine synechia, uterine septum, and submucosal myoma. The old hysteroscope had large diameters. Thus, general anesthesia was needed for inpatient management. However, due to the development of smalldiameter hysteroscopes, hysteroscopic diagnosis and surgery are now possible on an outpatient basis. Despite the development of small-diameter hysteroscopes, resection of submucosal myoma is possible only through resecto- scopic operation under general anesthesia, including type 0 uterine myoma. The objective of the present study was to determine the usefulness of secondary office operating hysteroscopy after cutting the pedicle of submucosal myoma via primary office operating hysteroscopy.

Methods:

We primarily cut the pedicle of type 0 submucosal myoma with the first rigid 5-mm operating mini- hysteroscopy in the outpatient clinic. We then expected the myoma to shrink. Two months later, we confirmed the size with use of 3-mm flexible diagnostic hysteroscopy. If the myoma was shrunk to less than one-third the original size, it was removed with the second rigid 5-mm operating mini-hysteroscopy.

Results:

In 14 of 24 patients, the myoma had shrunk to less than one-third the size. The rest was successfully removed with the second operating mini-hysteroscopy. In 5 of 24 patients, the myoma mass was not present in the uterine cavity. However, in another 5 of 24 patients, the myoma size had not changed significantly. The myomas were removed via resectoscopic operation under general anesthesia.

Conclusions:

The trial with this 2-step operation was very useful for the removal of type 0 submucosal myoma in an outpatient clinic.

A Pilot Study Comparing Hysteroscopic Adhesiolysis by Conventional Resectoscope Versus Mini-resectoscope

OBJECTIVES

To compare the feasibility and efficacy of the mini-resectoscope with the conventional resectoscope in terms of the operative, menstrual, and reproductive outcome in hysteroscopic adhesiolysis in infertile women.

METHODS

We conducted a parallel prospective randomized study at All India Institute of Medical Sciences, New Delhi. A total of 60 patients underwent hysteroscopic adhesiolysis using either conventional resectoscope (n = 30) or mini-resectoscope (n = 30). The primary outcome measures were pregnancy-related indicators. Secondary outcome measures were the operative parameters (cervical dilatation time, operation time, postoperative pain scores, fluid deficit, and preoperative and postoperative sodium levels), second-look hysteroscopy findings, and improvement in the menstrual pattern after surgery.

RESULTS

Cervical dilatation time and pain score 30 minutes after the procedure were significantly lower in the mini-resectoscope group. Out of the total 21 cases with hypomenorrhea, 12 cases (57.1%) started having normal menstrual flow postsurgery. All amenorrheic patients resumed menstruation after surgery. However, nine cases continued to have hypomenorrhea. Over long-term follow-up, 16 patients out of 60 had conceived (seven in the conventional resectoscope group and nine in the mini-resectoscope group). There were three ongoing pregnancies, three abortions, one ectopic pregnancy, and nine term pregnancies. The difference between the two groups was not statistically significant.

CONCLUSIONS

The use of mini-resectoscope for hysteroscopic adhesiolysis is associated with reduced operative morbidity. Use of the mini-resectoscope is an effective and safe alternative to the conventional system.

Use of hysteroscope for vaginoscopy or hysteroscopy in adolescents for the diagnosis and therapeutic management of gynecologic disorders: a systematic review

STUDY OBJECTIVE

The purpose of this article is to review the published literature and perform a systematic review to evaluate the effectiveness and feasibility of the use of a hysteroscope for vaginoscopy or hysteroscopy in diagnosing and establishing therapeutic management of adolescent patients with gynecologic problems.

DESIGN

A systematic review.

SETTING

PubMed, Web of science, and Scopus searches were performed for the period up to September 2013 to identify all the eligible studies. Additional relevant articles were identified using citations within these publications.

PARTICIPANTS

Female adolescents aged 10 to 18 years.

RESULTS

A total of 19 studies were included in the systematic review. We identified 19 case reports that described the application of a hysteroscope as treatment modality for some gynecologic conditions or diseases in adolescents. No original study was found matching the age of this specific population.

CONCLUSIONS

A hysteroscope is a useful substitute for vaginoscopy or hysteroscopy for the exploration of the immature genital tract and may help in the diagnosis and treatment of gynecologic disorders in adolescent patients with an intact hymen, limited vaginal access, or a narrow vagina.

Chronic endometritis due to common bacteria is prevalent in women with recurrent miscarriage as confirmed by improved pregnancy outcome after antibiotic treatment

Recurrent miscarriage (RM) is defined as 3 or more miscarriages before 20 weeks' pregnancy. In recent years, interest has been focused on chronic endometritis (CE), a subtle inflammation thought to be associated with RM. We aimed to evaluate the relationships between CE and RM. The records of 360 women with unexplained RM were retrospectively analyzed. Data from hysteroscopy, endometrial histology, endometrial culture, and polymerase chain reaction for chlamydia, performed before and after antibiotic treatment for CE, were analyzed. The occurrence of successful pregnancies within 1 year after treatment was also evaluated. Results showed that 208 (57.8%) women with RM showed CE at hysteroscopy; 190 (91.3%), positive at hysteroscopy, were also positive at histology, and 142 (68.3%) had positive cultures. Common bacteria were found in 110 (77.5%) patients. Mycoplasma and Ureaplasma were found in 36 (25.3%) patients and Chlamydia in 18 patients (12.7%). In 102 (71%) women, antibiogram-based antibiotic treatment normalized hysteroscopy, histology, and cultures (group 1); while in 40 (28.2%) patients, CE was still present at hysteroscopy (group 2). In 16 of the 66 patients positive at hysteroscopy, but not at cultures, the hysteroscopy becomes normal (group 3) after a Centers for Disease Control and Prevention-based therapy; while in 50 women, CE was still present (group 4). One year after treatment, group 1 showed a significantly higher number of pregnancies (78.4%) compared to group 2 (17.5%; P < .001) and group 4 (15.3%; P = .005). The CE is frequent in women with RM. Antibiotic treatment seems to be associated with an improved reproductive outcome.

Polipectomia endometrial histeroscópica: tratamento ambulatorial versus convencional

OBJETIVO: Comparar resultados da polipectomia histeroscópica endometrial efetuada ambulatorialmente, sem anestesia, com polipectomia histeroscópica convencional sob anestesia, em centro cirúrgico, avaliando taxa de sucesso, tempo de procedimento e complicações. Mensurar dor aferida pela paciente nos dois grupos. MÉTODOS: Estudo transversal observacional de 60 pacientes com diagnóstico histeroscópico de pólipo endometrial divididas em dois grupos: Grupo Ambulatorial, composto por pacientes submetidas à polipectomia histeroscópica ambulatorial, utilizando-se pinça endoscópica em histeroscópio operatório ambulatorial de fluxo contínuo, por meio de vaginoscopia sem anestesia, e Grupo Convencional com pacientes submetidas à polipectomia histeroscópica em centro cirúrgico, utilizando-se ressectoscópio monopolar sob anestesia. RESULTADOS: Os grupos foram similares quanto a idade, paridade, tipo de parto e presença ou não de menopausa. Ambos os grupos apresentaram 100% de eficácia na exérese dos pólipos. O tempo médio de procedimento foi de 7 minutos no Grupo Ambulatorial e 35,16 minutos no Grupo Convencional. No Grupo Ambulatorial, as pacientes após a menopausa (p=0,04) e aquelas com pólipos >1cm (p=0,01) apresentaram tempo de procedimento maior. Durante o procedimento,a média de dor referida pelas pacientes, segundo a Escala Analógica Verbal de Dor, no Grupo Ambulatorial, foi de 2,93 e, após efeito anestésico do procedimento no Grupo Convencional, foi de 1,42 pontos. Não houve complicações no Grupo Ambulatorial. No Grupo Convencional, registraram-se um caso de perfuração uterina e um de falso trajeto. CONCLUSÃO: A polipectomia histeroscópica realizada em regime ambulatorial, sem anestesia, é um procedimento bem tolerado. Quando comparada ao tratamento convencional, apresenta a mesma eficácia, porém com menor tempo gasto no procedimento e menor índice de complicações.

AlphaScope vs lens-based hysteroscope for office polypectomy without anesthesia: randomized controlled study

In this randomized controlled study, effectiveness, operative time, and acceptability of endometrial polypectomy were compared using an AlphaScope vs an office operative lens-based hysteroscope (LBH). One hundred fifty women with a diagnosis of endometrial polyp were operated on using an AlphaScope or LBH in the office setting. In 73 procedures using the AlphaScope (97.3%) and 68 using the LBH (90.7%), the polyp was successfully removed completely. In the AlphaScope group, 2 procedures were incomplete because of excessive endometrial mucosa thickness. In the LBH group, 3 procedures were incomplete because of difficulty in management of a large polyp, and 4 procedures were stopped because of patient pain and low compliance. Time to completion of the procedure and complete removal of the polyp was significantly shorter in the AlphaScope group than in the LBH group (p < .05). Similarly, the pain score at the end of the procedure was significantly lower in the AlphaScope group than in the LBH group (p < .05). The AlphaScope is an effective operative hysteroscope that increases the possibility of performing endometrial polypectomy in the office setting without anesthesia and improves the indications for and acceptability of office hysteroscopy.

Hysteroscopic placement of tubal sterilization implants: virtual reality simulator training

STUDY OBJECTIVE

To assess face and construct validity of a new virtual reality (VR) training simulator for hysteroscopic placement of tubal sterilization implants.

DESIGN

Nonrandomized, controlled trial comparing responses and performance of novices and experts on the simulator.

DESIGN CLASSIFICATION

Canadian task force II-1.

SETTING

Forty-six gynecologists were personally invited or recruited at the 33rd Conference of the French National College of Gynecologists and Obstetricians (CNGOF) from December 9 to 12, 2009, grouped as 20 experts and 26 novices. They all performed the defined sequence of virtual procedures on the simulator (case 1 for familiarization, case 4 for study assessment) and finally completed the study questionnaire.

MEASUREMENTS AND MAIN RESULTS

Responses to realism, educational potential, and general opinion were excellent, proving face validity. Significant differences between novices and experts were assessed for 7 of the 15 metrics analyzed, proving construct validity.

CONCLUSIONS

We established face and construct validity for EssureSim, an educational VR simulator for hysteroscopic tubal sterilization implant placement. The next steps are to investigate convergent and predictive validity to affirm the real capacity of transferring the skills learned on the training simulator to the patient in the operating room.

Efficacy of a polyethylene oxide-sodium carboxymethylcellulose gel in prevention of intrauterine adhesions after hysteroscopic surgery

STUDY OBJECTIVES

To assess the efficacy of a polyethylene oxide-sodium carboxymethylcellulose gel (Intercoat; Gynecare, division of Ethicon, Inc., Somerville, NJ) in preventing the development of de novo intrauterine adhesions (IUAs) after hysteroscopic surgery and to rate the patency of the internal uterine ostium at 1-month follow-up diagnostic hysteroscopy.

DESIGN

Randomized controlled study (Canadian Task Force classification I).

SETTING

University hospital.

PATIENTS

One hundred ten patients diagnosed during office hysteroscopy as having single or multiple lesions suitable for surgical treatment or resistant dysfunctional uterine bleeding requiring endometrial ablation.

INTERVENTIONS

Patients were randomized to 2 groups. Group 1 underwent hysteroscopic surgery plus intrauterine application of Intercoat gel, and group 2 underwent hysteroscopic surgery only (control group). Follow-up office hysteroscopy was performed at 1 month after surgery to assess the rate and severity of IUA formation and to rate the patency of the internal uterine ostium after the surgical intervention.

MEASUREMENTS AND MAIN RESULTS

Compared with the group 2, group 1 demonstrated a significant reduction in the incidence (6% vs 22%; p <.05) of de-novo IUAs. Application of the gel seemed to reduce the severity of IUAs, with fewer moderate and severe IUAs at follow-up in group 1 in comparison with group 2 (33% vs 92%). Furthermore, group 1 demonstrated significant improvement in the degree of patency of the internal uterine ostium (41.9% of cases) in comparison with diagnostic office hysteroscopy performed at enrollment (p <.05). In contrast, in group 2, worsening of patency of the internal uterine ostium was recorded in 18.2% of cases (p <.05).

CONCLUSIONS

Intercoat gel seems to prevent de novo formation of IUAs and to improve the patency of the internal uterine ostium at follow-up hysteroscopy. However, larger studies are needed to confirm these findings.

Hysteroscopy without anesthesia: review of recent literature

The need for anesthesia or analgesia for performing hysteroscopy is still matter of debate. Many factors explain the lack of agreement about anesthesia in hysteroscopy depending on the instrumentation, technique employed, need of performing surgical procedure, operator skill and patients' characteristics. Diagnostic minihysteroscopy (3.5 mm or less in size) is less painful and easier to perform than hysteroscopy performed with instruments sized around 5 mm. Thanks to miniaturized instruments, office hysteroscopy allows a growing number of women to be treated in an office setting avoiding the operating room. The main limitation to its widespread use is pain and low patient tolerance. Intrauterine surgical procedures involving only the endometrial mucosa (biopsies, adhesiolisis, cervical and endometrial polyectomies) are not painful. For endometrial polypectomy size of polyps (<2.2m) and duration of the procedure (more than 15 min) are limiting factors. Most literature suggests that office hysteroscopy in experienced hands is a well-tolerated technique and requires the use of analgesics only in selected patients like women with previous caesarean section, history of chronic pelvic pain, anxiety and in menopause.

Office hysteroscopy: current trends and potential applications: a critical review

Office hysteroscopy is an excellent method of identifying and treating intracavitary uterine lesions. It has become easy to learn and perform; as an aid of modern technological applications, it is safe, accurate, provides immediate results under direct visualisation, and offers the additional benefit of histological confirmation and the discomfort of patients is minimal. We applied an extended literature search to explore the special features and details of the technique itself, as it evolved since it first appeared 30 years back. Our initial goal was to examine potential changes/improvements of the modality, in terms of the instrumentation used and the technique itself, the indications of use, its incorporation in daily practice, and patients' and clinicians' acceptability.

Hysteroscopy: a technique for all? Analysis of 5,000 outpatient hysteroscopies

OBJECTIVE

1) To investigate the relationship between operator experience and the success of outpatient hysteroscopy; and 2) to determine if the introduction of normal saline and the use of narrow-caliber hysteroscopes and vaginoscopic approach are associated with a lower failure rate.

DESIGN

Retrospective study.

SETTING

Teaching-hospital based outpatient hysteroscopy clinic.

PATIENT(S)

Five thousand consecutive women undergoing outpatient hysteroscopy between October 1988 and June 2003.

INTERVENTION(S)

The hysteroscopies were carried out both by experienced operators and by trainees. Procedures were performed using 4-mm and 2.9-mm telescopes with 5-mm and 3.5-mm diagnostic sheaths, respectively. Between October 1988 and 1996, the uterine cavity was distended with CO(2) (CO(2) period), whereas normal saline was preferred after 1997 (1997-2003: saline period). Traditional technique of hysteroscope insertion and vaginoscopic approach were used depending on operator preference and experience and patient characteristics.

MAIN OUTCOME MEASURE(S)

Success, failure, and complication rates.

RESULT(S)

The hysteroscopies were successfully performed in nearly 95% of cases by 362 operators (mean 13.8 hysteroscopies per operator) with different levels of expertise. Failure and complication rates were 5.2% and 5.4%, respectively, without any significant difference between CO(2) and saline periods. Vasovagal attacks and shoulder pain were significantly higher during the CO(2) period. The success of outpatient hysteroscopy was negatively affected by postmenopausal status, nulliparity, need for cervical dilatation or local anaesthesia, traditional technique of hysteroscope insertion, and use of a 5-mm hysteroscope.

CONCLUSION(S)

A high level of expertise is not a prerequisite to performing hysteroscopy on an outpatient basis. Recent advances in technique and instrumentation facilitate this approach and might encourage greater adoption by the wider gynecology community.

Predictive factors for pain experienced at office fluid minihysteroscopy

STUDY OBJECTIVE

Fluid minihysteroscopy is in most cases a painless procedure. However, rarely, severe pain and side effects are reported. The goal of this study was to identify predictive factors of pain at minihysteroscopy.

DESIGN

Prospective study (Canadian Task Force classification II-2).

SETTING

Academic environment.

PATIENTS

Five hundred thirty-three women undergoing fluid minihysteroscopy.

INTERVENTIONS

Diagnostic fluid minihysteroscopy.

MEASUREMENTS AND MAIN RESULTS

The women were asked to score pain perception on a visual analog scale from zero (no pain) to 5 (unbearable pain). Correlation between pain at procedure and parity, previous cesarean section (PCS), menopausal status, anxiety, and chronic pelvic pain (CPP) was evaluated. Four hundred thirteen women (78%) reported no pain or discomfort (0-1 pain score, group A), while 120 (22%) experienced mild to unbearable pain (2-5 pain score, group B). Instances of PCS, CPP, anxiety, and menopause were significantly lower in group A than in group B (4% vs 82%, 0% vs 29%, 62% vs 72%, 25% vs 72%, respectively), whereas menopausal status was less frequent in group A (25.2%) than in group B (72.5%). At binary logistic regression, all the variables were independent risk factors for pain; however, when CPP was stratified for intensity, no correlation between pain at procedure and intensity of CPP was found.

CONCLUSION

Previous cesarean section, CPP, anxiety, and menopause are predictive factors for pain perception during fluid minihysteroscopy, and history of CPP even of low intensity is predictive of pain at hysteroscopy. These patients may benefit from local anesthesia.