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Hysteroscopy involves inserting a rigid or flexible hysteroscope through the cervical canal into the uterus and then using distending media to allow for complete visualization of the endometrial cavity, allowing for minimally invasive diagnosis and surgical management of endocervical and intrauterine pathology. Hysteroscopy is considered the gold standard technique for evaluating and managing intrauterine pathology. Indications for hysteroscopy are numerous, including abnormal uterine bleeding, infertility, removal of intrauterine foreign bodies, and congenital müllerian anomalies. This course explores this commonly performed procedure, including the current indications, established guidelines on disstention mediums, and complications associated with hysteroscopy. This activity for healthcare professionals is designed to enhance the learner's competence in identifying the indications for hysteroscopy, performing the procedure with proper technique, and implementing an appropriate interprofessional approach when managing this condition. Objectives: Identify the indications for hysteroscopy. Apply recommended technique to perform hysteroscopy. Implement appropriate management of complications associated with hysteroscopy. Apply interprofessional team strategies to improve care coordination and outcomes in patients undergoing hysteroscopy. Access free multiple choice questions on this topic.

Historical Evolution of Hysteroscopy Hysteroscopy was first performed on a patient in 1869 by Pantaleoni, who, using a cystoscope developed by Desormeaux, discovered and treated an endometrial polyp in a 60-year-old patient who presented with postmenopausal bleeding.[1] In the 20th century, hysteroscopy using distending media was developed, first using carbon dioxide in 1925. In-office hysteroscopy was introduced into clinical practice in the early 1980s with the improvement of distension media options and operative techniques. Today, with the development of bipolar energy, various instruments, safe and effective distending media, optics, and smaller scope sizes, hysteroscopy is the preferred technique for managing intrauterine pathology. The utilization of in-office hysteroscopy depends not only on appropriate patient selection but also on the availability of equipment and resources. The preferred entry technique is vaginoscopy due to the reduction of intraprocedural and postprocedural pain. The efficacy of the vaginoscopic approach is comparable to the traditional entry approach.[2] Hysteroscopy Overview Hysteroscopy involves inserting a rigid or flexible hysteroscope through the cervical canal into the uterus and then using distending media to allow for complete visualization of the endometrial cavity. The type of distending media is selected based on the type of energy that will be used. Electrolyte-rich distention media may not be used if monopolar energy is used due to the risk of conducting electricity outside the operative field. Because of the potential for fluid overload and resulting complications, a fluid deficit with an upper limit of 1000 mL is recommended when using the hypotonic solution as the distending media. A fluid deficit upper limit of 2500 mL is recommended when using the isotonic solution as the distending media. This limit does not apply to older adults or patients who have comorbidities. A fluid deficit cutoff of 750 mL for hypotonic solutions and 1500 mL for isotonic solutions is recommended in this population.[3] This is due to the potential for complications resulting from fluid overload. Normal saline has been found to provide better visualization and is associated with less postoperative pain than carbon dioxide.[4] Normal saline also allows for the utilization of bipolar electrocautery since it is isotonic.

A fluid deficit upper limit of 2500 mL is recommended when using the isotonic solution as the distending media. This limit does not apply to older adults or patients who have comorbidities. A fluid deficit cutoff of 750 mL for hypotonic solutions and 1500 mL for isotonic solutions is recommended in this population.[3] This is due to the potential for complications resulting from fluid overload. Normal saline has been found to provide better visualization and is associated with less postoperative pain than carbon dioxide.[4] Normal saline also allows for the utilization of bipolar electrocautery since it is isotonic. The type of hysteroscope is selected based on operative needs. The 3 parts of the scope are the eyepiece, the barrel, and the objective lens. Scope viewing angles range from 0 to 70 degrees, with a decreased angle giving a more panoramic view. An operative hysteroscope is needed for surgical intervention. Options include a resectoscope, a hysteroscopic tissue retrieval system, or the addition of an operative sheath.[5] With the invention of smaller hysteroscopes with reduced diameters and more technically advanced operating systems, in-office hysteroscopy has become a widely accepted method for diagnosing and treating intrauterine pathology. For women with abnormal uterine bleeding (AUB), hysteroscopy has been introduced as a viable or even superior alternative to hysterectomy in some cases.[6] Hysteroscopy has also been validated as a diagnostic tool for infertility workups.[7] Moreover, this procedure has been shown to be safe and effective for the removal of retained products of conception and foreign bodies.[8][9][10] A new concept gaining popularity is the “see-and-treat” strategy, in which the patient is diagnosed during office hysteroscopy with an intrauterine organic pathology, eg, endometrial polyps or thickened endometrium. This identified pathology can then be treated hysteroscopically during the same visit. The see-and-treat strategy has all the same indications, and more, compared to traditional hysteroscopy, including thickened endometrium, endometrial pathology, retained products of conception, and retained foreign bodies. Polypectomy is the most common hysteroscopic procedure worldwide and can be easily transitioned to be performed through the see-and-treat method.[11][12]

Overall, hysteroscopy is regarded as a safe, minimally invasive procedure.[36] However, the procedure is associated with several complications that clinicians should learn to recognize and manage promptly. Uterine Perforation The most common reported complication of both diagnostic and operative hysteroscopy is uterine perforation.[37] Perforation can occur at any point during the procedure but is more common with resection extending into the uterine myometrium.[38] Encountered in about 1% of cases, uterine perforation may be managed conservatively or operatively, depending on patient status. Hemodynamic status should first be assessed with low suspicion for vascular injury if perforation was caused by blunt dissection. If the patient is hemodynamically stable and there is low suspicion of vascular or visceral damage, laparoscopy or exploratory laparotomy is unneeded. Prolonged postoperative same-day recovery is recommended with strict pain, bleeding, and fever precautions and close clinical follow-up.[39] Bleeding alone without uterine perforation may be encountered with deep dissection into the myometrium and intersection with a perforating vessel. This complication is more common with operative hysteroscopy and the removal of type I and type II subserosal fibroids. Bleeding may be managed with electrocautery, uterotonics such as oxytocin, or foley balloon catheter placement to be left inside the uterus to tamponade bleeding.[39] Fluid Overload Complications associated with distension media used in hysteroscopy deserve detailed discussion. The fluid deficit is carefully calculated intraoperatively to quantify the amount of fluid the patient is absorbing into their circulation. Of particular concern is the risk of hyponatremia and resulting cerebral edema, especially when electrolyte-free hypotonic solutions are used. Cerebral edema may manifest with symptoms of nausea and or vomiting, dizziness, shortness of breath, or headache. The mechanism of fluid absorption has to do with the amount of intrauterine pressure created by hysteroscopic fluid management systems and the venous absorption of distending media.[36] Some institutions recognize this as operative hysteroscopy intravascular absorption syndrome (OHIA).

Complications associated with distension media used in hysteroscopy deserve detailed discussion. The fluid deficit is carefully calculated intraoperatively to quantify the amount of fluid the patient is absorbing into their circulation. Of particular concern is the risk of hyponatremia and resulting cerebral edema, especially when electrolyte-free hypotonic solutions are used. Cerebral edema may manifest with symptoms of nausea and or vomiting, dizziness, shortness of breath, or headache. The mechanism of fluid absorption has to do with the amount of intrauterine pressure created by hysteroscopic fluid management systems and the venous absorption of distending media.[36] Some institutions recognize this as operative hysteroscopy intravascular absorption syndrome (OHIA). Electrolyte-rich isotonic fluid, eg, normal saline, may be used with bipolar systems. As such, bipolar systems have less risk of fluid overload syndromes. In healthy women, hysteroscopy should be aborted if the fluid deficit exceeds 2500 mL when isotonic distention media is used and 1000 mL with hypotonic media. In women with comorbidities (eg, cardiac or pulmonary conditions) that compromise hemodynamic stability, the surgeon should consider termination of the procedure with a fluid deficit of 1000 mL and 750 mL of an isotonic and hypotonic solution, respectively. Avoidance of OHIA can be achieved by closely monitoring fluid status. Patients at risk for OHIA may be identified beforehand by assessing estimated procedure time, risk for incomplete resection of intrauterine pathology, and the existence of comorbidities. Air Embolism

Electrolyte-rich isotonic fluid, eg, normal saline, may be used with bipolar systems. As such, bipolar systems have less risk of fluid overload syndromes. In healthy women, hysteroscopy should be aborted if the fluid deficit exceeds 2500 mL when isotonic distention media is used and 1000 mL with hypotonic media. In women with comorbidities (eg, cardiac or pulmonary conditions) that compromise hemodynamic stability, the surgeon should consider termination of the procedure with a fluid deficit of 1000 mL and 750 mL of an isotonic and hypotonic solution, respectively. Avoidance of OHIA can be achieved by closely monitoring fluid status. Patients at risk for OHIA may be identified beforehand by assessing estimated procedure time, risk for incomplete resection of intrauterine pathology, and the existence of comorbidities. Air Embolism Hysteroscopy can result in carbon dioxide embolism if used as the distending media. This complication can be catastrophic if it occurs due to the potential for cardiac failure, leading to death. Limited studies show a wide-ranging air embolism rate from 10% to 50% with the use of carbon dioxide.[40] If this complication is suspected, the anesthesia team should immediately advise the surgeon, and the procedure should be terminated. Durant’s position (ie, patient placement in left lateral decubitus and Trendelenberg) may assist in air migration away from the right ventricular outflow tract. If cardiac arrest occurs, cardiac catheterization may be performed to relieve the embolized air from the cardiovascular system. This iatrogenic complication of hysteroscopy may be prevented by using fluid-distending media and priming equipment by releasing air from tubing and avoiding excessive instrumentation, which may introduce air into the genital tract. Vasovagal Syncope While the risk of a vasovagal syncope reaction is low, ranging from 0.21% to 1.85% of patients undergoing in-office hysteroscopy, this is an unpleasant adverse effect to undergo as the patient or treat as the clinician. Sometimes overlooked because of its short-lived and benign nature, vasovagal syncope occurs with exposure to pain, emotional stress, or in medical settings. Most patients develop an “aura” before either fully or partially experiencing syncope, with this "aura" consisting of some combination of lightheadedness, paleness, palpitations, sweating, and blurred vision.

While the risk of a vasovagal syncope reaction is low, ranging from 0.21% to 1.85% of patients undergoing in-office hysteroscopy, this is an unpleasant adverse effect to undergo as the patient or treat as the clinician. Sometimes overlooked because of its short-lived and benign nature, vasovagal syncope occurs with exposure to pain, emotional stress, or in medical settings. Most patients develop an “aura” before either fully or partially experiencing syncope, with this "aura" consisting of some combination of lightheadedness, paleness, palpitations, sweating, and blurred vision. Risk factors for vasovagal syncope include young age, female gender, low body mass index, Caucasian race, and family history. If this complication occurs during an in-office hysteroscopy, the procedure should be halted for appropriate patient evaluation. This evaluation should assess the ABCs (airway, breathing, and circulation). For treatment, the patient may be placed in the Trendelenburg position and the intrauterine pressure decreased by closing the inflow or removing the hysteroscopic device. If bradycardia, hypotension, or patient symptoms persist, the patient should be referred to the emergency department for further evaluation and observation.[41]

If a hysteroscopy is performed in the ambulatory or inpatient operating room setting, more personnel must be included in the interprofessional healthcare team. Technicians and representatives should confirm that all equipment functions properly before the patient enters the operating room. Scrub technicians are essential in prepreparing equipment so delays and malfunctions may be limited. The final patient assessment before surgery should always be prompted by the circulator or other operating room staff and include a pelvic examination. Effective communication is paramount at every stage, beginning with team briefings and culminating in a formal time-out to confirm procedural details. Anesthesia should direct patient positioning to avoid dislodging endotracheal tubes, lines, and other monitoring systems. Throughout the procedure, appropriate attention to surgical undertakings is needed from the scrub tech and circulator to maintain adequate lighting, fluid balance, and distending media pressure. Equipment adjustments, such as those for display monitors or electrocautery instruments, may also be needed. At the procedure's end, all fluids in, fluids out, blood loss, and urine output are documented and announced by the circulator nurse. Anesthesia must continue to monitor hemodynamic and respiratory statuses after extubation or weaning from sedation. However, it is essential to remember that all healthcare team members are responsible for working together to ensure the patient's safety. Seamless communication and collaboration across all stages of hysteroscopy—preoperative, intraoperative, and postoperative—enhance patient-centered care and team efficiency. Nursing staff must remain well-informed about patient status to ensure a cohesive and safe surgical experience. In-office hysteroscopy does not need to consist of more than 2 to 3 personnel. The surgeon may be semi-self-sufficient, and a scrub tech is not required. However, the clinician must understand and review the equipment thoroughly. In academic centers, in-office hysteroscopy offers more involvement for residents and medical students, as personnel is reduced, but assistance may be needed to ensure smooth operation in the awake patient. Patient comfort and assurance are of utmost importance. The right demeanor in an in-office hysteroscopy team can ease anxiety and improve outcomes.