AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

Overview

Hysteroscopy is the process of viewing and operating in the endometrial cavity from a transcervical approach. The basic hysteroscope is a long, narrow telescope connected to a light source to illuminate the area to be visualized. With a patient in the lithotomy position, the cervix is visualized by placing a speculum in the vagina. The distal end of the telescope is passed into a dilated cervical canal, and, under direct visualization, the instrument is advanced into the uterine cavity. A camera is commonly attached to the proximal end of the hysteroscope to broadcast the image onto a large video screen. Other common modifications are inflow and outflow tracts included in the shaft of the telescope for fluids. Media, such as sodium chloride solution, can be pumped through a hysteroscope to distend the endometrial cavity, enabling visualization and operation in an enlarged area.

Hysteroscopy is a minimally invasive intervention that can be used to diagnose and treat many intrauterine and endocervical problems. Hysteroscopic polypectomy, myomectomy, and endometrial ablation are just a few of the commonly performed procedures. Given their safety and efficacy, diagnostic and operative hysteroscopy have become standards in gynecologic practice.

Equipment

Hysteroscopes

The telescope consists of 3 parts: the eyepiece, the barrel, and the objective lens. The focal length and angle of the distal tip of the instrument are important for visualization (as are the fiberoptics of the light source).

Angle options include 0°, 12°, 15°, 25°, 30°, and 70°. A 0° hysteroscope provides a panoramic view, whereas an angled one might improve the view of the ostia in an abnormally shaped cavity.

Hysteroscopes are available in different styles, including rigid and flexible (used most commonly in clinical settings) hysteroscopes, contact hysteroscopes, and microcolpohysteroscopes. The diameter of each instrument varies and is an important consideration. The requirement of a sheath for input-outflow of distention media increases the size of the hysteroscope.

Rigid hysteroscope

Rigid hysteroscopes are the most commonly used instruments. Their wide range of diameters allows for in-office and complex operating-room procedures. Of the narrow options (3-5 mm in diameter), the 4-mm scope offers the sharpest and clearest view. It accommodates surgical instruments but is small enough to require minimal cervical dilation. In addition, patients tolerate this instrument well with only paracervical block anesthesia.

Rigid scopes larger than 5 mm in diameter (commonly 8-10 mm) require increased cervical dilation for insertion. Therefore, they are most frequently used in the operating room with intravenous (IV) sedation or general anesthesia. Large instruments include an outer sheath to introduce and remove media and to provide ports to accommodate large and varied surgical instruments.

Flexible hysteroscope

The flexible hysteroscope is most commonly used for office hysteroscopy. It is notable for its flexibility, with a tip that deflects over a range of 120-160°. Its most appropriate use is to accommodate the irregularly shaped uterus and to navigate around intrauterine lesions. It is also used for diagnostic and operative procedures.

During insertion, the flexible contour accommodates to the cervix more easily than does a rigid scope of a similarly small diameter. The view is often described as having a ground-glass quality, which is markedly less desirable than the view obtained with rigid scopes (Corfman, 1988). New, digitally enhanced scopes improve image quality.

Light source

Each hysteroscope is attached to an internal or external light source for illumination at the distal tip. Energy sources include tungsten, metal halide, and xenon. A xenon light source with a liquid cable is considered the superior option (Shapiro, 1988; ACOG, 1994).

Surgical instruments

Surgical instruments are available in both rigid and flexible forms to be inserted through the operating channels of the scopes. Examples of surgical instruments and their uses are listed below:

• Scissors - To incise a septum, excise a polyp, or lyse synechiae
• Biopsy forceps - To perform directed biopsy for pathologic review
• Grasping instruments - To remove foreign bodies
• Roller ball, barrel, or ellipsoid - To perform endometrial ablation and/or desiccation (This instrument is used with a resectoscope.)
• Loop electrode - To resect a fibroid or polyp or endometrium (This instrument is used with a resectoscope.)
• Scalpel - To cut or coagulate tissue, with high power density at its tip (This instrument is used with a resectoscope.)

Improvements in hysteroscope design have improved the effectiveness inflow-outflow tracts and of specific operating instruments. For example, the Resection Master resectoscope (Richard Wolf Medical Instruments Corporation, Vernon Hill, Ill) incorporates a suction channel and a pump to aid in removing chips of tissue during resection. This feature improves visibility and may decrease time otherwise spent emptying the pieces from the endometrial cavity. Other instruments on the forefront include a hysteroscopic morcellator (Smith & Nephew, Inc, Andover, MA), which may reduce myomectomy and polypectomy time by morcellating and removing tissue in 1 movement under direct visualization.

Energy sources and uses

Monopolar and bipolar electricity, as well as laser energy, all have uses in hysteroscopy.

Monopolar cautery

The resectoscope is a specialized instrument with a monopolar, double-armed electrode and a trigger device for use in hypotonic, nonconductive media, such as glycine. It cuts and coagulates tissue by means of contact desiccation with resistive heating (Brill, 2000). The depth of thermal damage is based on several factors: endometrial thickness; speed, pressure, and duration of contact during motion; and power setting (Luciano, 1995; Brill, 2000).

A thin electrode can cut tissue, whereas one with a large surface area, such as a ball or barrel, is best suited for coagulation (Indman, 2000).

Bipolar cautery

The VersaPoint system (Gynecare, Inc, Somerville, NJ), uses bipolar circuitry for electrosurgery, which can be performed in isotonic conductive media. This system includes a spring tip for hemostatic vaporization of large areas, a ball tip for precise vaporization, and a twizzle tip for hemostatic resection and morcellation of tissue. There is also a cutting loop similar to traditional resectoscopy (Brill, 2000).

Laser techniques

Several fiberoptic lasers are available for gynecologic use, including potassium-titanyl-phosphate (KTP), argon, and Nd:YAG lasers. They all have different wavelengths, though the KTP and argon lasers have similar properties.

Media

The use of media is critical for panoramic inspection of the uterine cavity. The medium opens the potential space of the otherwise narrow uterine cavity. Intrauterine pressures needed to adequately view the endometrium are proportional to the muscle tone and thickness of the uterus. The refractive index of each medium affects magnification and visualization of the endometrium.

Gases

Carbon dioxide (CO₂) is rapidly absorbed and easily cleared from the body by respiration. The refractory index of CO₂ is 1.0, which allows for excellent clarity and widens the field of view at low magnification. The gas easily flows through narrow channels in small-diameter scopes, making it useful for office-based diagnostic hysteroscopy. However, this method offers no way to clear blood from the scope.

With CO₂, a hysteroscopic insufflator is required to regulate flow and limit maximal intrauterine pressure. (Note that laparoscopic insufflators are not safe.) A flow rate to 40-60 mL/min at a maximum pressure of 100 mm Hg is generally accepted as safe. Pressures and rates higher than this can result in cardiac arrhythmias and arrest (Shapiro, 1988).

Fluids

The advantage of fluid over gas is the symmetric distention of the uterus with fluid and its effective ability to flush blood, mucus, bubbles, and small tissue fragments out of the visual field. Both low-viscosity and high-viscosity fluid media can be used for distention. A pressure of 75 mm Hg is usually adequate for uterine distention; rarely is more than 100 mm Hg required, and pressures higher than this can increases the risk of intravasation of medium (Marlow, 1995).

Various delivery systems are designed to suit the many media used for uterine distention and to accurately record volumes of inflow and outflow. This recording is important because fluid can leave the uterus by means of intended efflux systems, cervical or tubal leakage, or intravasation. Preventing excess absorption of hypotonic fluids is essential for patient safety. The simplest delivery system is a syringe that most often is used with high-viscosity dextran 70. Hanging, gravity-fed containers to deliver low-viscosity fluids can be raised or compressed with a cuff; however, these can be unreliable in estimating intrauterine pressures. Pumps are available to monitor pressure and volume for low-viscosity media. Media then usually flows into the uterine cavity through an inner sheath around the hysteroscope. A perforated outer sheath is used for collection or efflux of media. This design creates laminar flow, which keeps the visual field clear (Corfman, 1988).

As noted above, new, sophisticated efflux mechanisms are being designed to improve the clearance of both blood and particulate matter from the operating space. Closed systems actively return fluid to a pump reservoir, whereas open systems allow free flow of the medium out the cervix into a collection bag for volume monitoring.

0.9% sodium chloride solution and lactated Ringer solution

Normal sodium chloride solution and lactated ringer solution are isotonic, conductive, low-viscosity fluids that can be used for diagnostic hysteroscopy and for limited operative procedures. Surgical procedures using mechanical, laser, monopolar (only with the ERA sleeve or Opera Star systems), and bipolar energy (VersaPoint system) are safe. (See Surgical instruments and Energy sources and uses above.)

Two major disadvantages associated with these solutions include (1) their miscibility with blood, which obscures visibility with bleeding, leading to the need for increased volumes to clear the operative field, and (2) their excellent conductivity, which precludes procedures that with standard monopolar electrosurgery.

5% Mannitol, 3% sorbitol, and 1.5% glycine

The hypotonic, nonconductive, low-viscosity fluids 5% mannitol, 3% sorbitol, and 1.5% glycine improve visualization when bleeding occurs. They can be used in diagnostic as well as operative hysteroscopy. (Note that 5% mannitol can be used only with monopolar operative procedures.)

All impose a risk of volume overload and hyponatremia from intravascular absorption (particularly > 2 L). Therefore, careful fluid monitoring is required during their use. When intravasation of 5% mannitol occurs, it stays in the extracellular compartment; treatment of this condition is discontinuing the procedure and administering diuretics (Marlow, 1995). Three-percent sorbitol is broken down into fructose and glucose and therefore has an added risk of hyperglycemia when absorbed in excess. Use 1.5% glycine with caution in patients with impaired hepatic function because glycine is metabolized to ammonia.

Dextran 70

The only high-viscosity medium available, dextran 70 (Hyskon; Pharmacia Laboratories, Piscataway, NJ) is a nonelectrolytic, nonconductive fluid that can be used in all types of procedures. It is immiscible with blood and minimally leaks through the cervix and tubes, allowing for excellent visibility during surgical procedures.

Like the other nonelectrolytic fluids, however, prevent absorption of more than 500 mL to avoid fluid overload. With each 100 mL of dextran 70 absorbed, the intravascular volume increases by 800 mL (Marlow, 1995; Cooper, 2000). Allergic reactions and anaphylaxis, fluid overload, disseminated intravascular coagulopathy, and destruction of instruments are adverse effects of this medium.

History of the Procedure

The development of hysteroscopy is rooted in the work of Pantaleoni, who first reported uterine endoscopy in 1869 (Marlow, 1995). However, at that time, instrumentation was elementary, and expansion of the uterine cavity was insufficient. In 1925, Rubin first used CO₂ to distend the uterus (Marlow, 1995). Around the same time, Gauss was experimenting with the use of fluids to achieve uterine expansion.

Hysteroscopy did not become popular until the 1970s, when technology afforded more practical and usable instruments than before (see Hysteroscopes above). The use of liquid distention media became routine by the 1980s, and many new hysteroscopic procedures, including endometrial ablation, were developed (Marlow, 1995). Initially used by urologists for transurethral resection of the prostate, the resectoscope was modified for hysteroscopic procedures, allowing for resection of intrauterine pathology with monopolar cautery. By the mid-1980s, hysteroscopic procedures had nearly replaced dilation and curettage (D&C) for diagnosing intrauterine pathology (Jansen, 2000).

Over the past few decades, refinements in optic and fiberoptic technology and inventions of new surgical accessories have dramatically improved visual resolution and surgical techniques in hysteroscopy. Many hysteroscopic procedures have replaced old, invasive techniques. Now, as instruments become smaller than before, office hysteroscopy is replacing operating-room procedures. One of the most recent hysteroscopic procedures approved by the US Food and Drug Administration (FDA) is female sterilization (Essure, Conceptus, Incorporated, Mountain View, Calif), which can be performed in the gynecologist's office. Novel instruments and techniques continue to emerge, and the prospects for improvement seem unlimited.

INDICATIONS

Section 3 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

Abnormal uterine bleeding

Hysteroscopy has nearly replaced standard D&C for the management of abnormal uterine bleeding (AUB), as it allows for direct visualization and diagnosis of intrauterine abnormalities, and it often offers an opportunity for simultaneous treatment (Cooper, 1999).

To diagnose the cause of AUB, a full workup to rule out endocrine or hormonal disorders, benign lesions, premalignant, or malignant pathology is required. Uterine sampling can be done by means of endometrial biopsy, D&C, or direct visualization with hysteroscopy and specific biopsy procedures. Evaluation of the uterine cavity with sonohysterography or diagnostic hysteroscopy is up to 88% effective in identifying polyps and submucosal fibroids (March, 1992; Bradley, 2000). Some consider MRI useful for evaluating intrauterine pathology, but MRI is a relatively expensive test (Gimpelson, 2000).

For patients with AUB for whom fertility is not an issue, in whom no endocrine or hormonal cause is isolated, and in whom endometrial atypia or malignancy is ruled out, endometrial ablation has become an acceptable alternative to hysterectomy. In the short term, ablation for a benign disorder results in amenorrhea in approximately 30% of patients (Daniell, 1992; Cooper, 2000; Probst, 2000). Studies show that approximately 26% of patients have spotting after ablation, 34% have a decreased flow, and 10% have no change or increased symptoms (Cooper, 2000). The same data suggested that the long-term effectiveness of endometrial ablation for menorrhagia or fibroids is 60-90%, with 90% of patients noting an overall decrease in flow and amenorrhea, which occurs in 30-50% (Schenk, 1999). Patients who are taking estrogen still require progesterone for endometrial protection from estrogen-induced endometrial changes (March, 1992).

Infertility

Hysteroscopy is not part of the routine workup for infertility, but when compared with hysterosalpingography, hysteroscopy is equivalent for evaluating the uterine cavity, and it increases accuracy in diagnosing the cause of intrauterine filling defects (Corfman, 1988). In unexplained infertility, hysteroscopy may be performed simultaneously with laparoscopy to evaluate the uterine cavity and cervix (Balmaceda, 1995). Intracavitary lesions are implicated as causes of infertility, and their removal may increase fertility. However, this possibility has not been clearly documented (Vercellini, 1999). In contrast, for patients with recurrent miscarriage and intracavitary fibroids, surgery increases rates of viable pregnancy outcomes (Vercellini, 1999).

Intrauterine adhesions

Asherman syndrome was identified in 1948 as uterine synechiae (Goldrath, 1995). These intrauterine adhesions are often associated with amenorrhea or infertility. Hysteroscopy can be used to diagnose and treat these adhesions. Benefits include visually directed lysis. Filmy adhesions are often lysed by distention alone, whereas the dense adhesions often require cutting or excision with blunt, sharp, electrocautery, or laser techniques (Shapiro, 1988).

If the patient's symptoms include abnormal bleeding, hysteroscopic treatment results in an 88-98% return to normal menstrual cycles (March, 1992; Schenk, 1999). If no other infertility issues are present, 79% of treated patients have normal pregnancies (ie, 75% of those with mild disease but only 31% with severe adhesions) (March, 1992). However, hysteroscopic treatment may increase the risk of abnormal placentation (eg, accreta, percreta, increta, previa).

Müllerian anomalies

Approximately 1-2% of all women, 4% of infertile women, and 10-15% of patients with recurrent miscarriage have müllerian anomalies. These anomalies range from didelphys to müllerian agenesis. Uterine septum and in utero diethylstilbestrol (DES) exposure are more likely to be associated with miscarriage than is uterus didelphys (March, 1992). Patients with a bicornuate uterus have a >50% live birth rate compared with those with a uterine septum, who has a <30% live birth rate (Bacsko, 1997). Patients with in utero DES exposure are likely to have a T-shaped uterus with corneal restriction bands, pretubal bulges, lower-uterine-segment dilation, and a small and irregular cavity with borders resembling adhesions (March, 1992). Hysteroscopy can be used to confirm but not always to treat these findings. Of patients undergoing hysteroscopic resection for müllerian anomalies, 20% have dysmenorrhea after surgery compared with 50% after abdominal procedures (Bacsko, 1997).

A uterine septum can be removed by means hysteroscopy. However, before surgery, a bicornuate uterus must be ruled out with MRI or sonohysterography. These studies have now replaced laparoscopy for this indication. Edstrom reported the first hysteroscopic resection of a septum (Corfman, 1988). Bret and Guillet were the first to recommend incising versus excising the septum (Bacsko, 1997). Surgical complications are fewer with the hysteroscopic approach than with other procedures, such as Jones, Strassman, or Tompkins metroplasty (Bacsko, 1997). Rates of term-pregnancy outcomes after hysteroscopic resection are equivalent to those of metroplasty for uterine septum (March, 1992). Live birth rates after treatment are as high as 80% (Schenk, 1999).

Polyps and fibroids

Endometrial polyps and fibroids are well known to cause irregular vaginal bleeding. Fibroids are the most common solid pelvic tumor in women, found in 20% of women older than 35 years (March, 1992). Menorrhagia due to symptomatic submucosal fibroids is the most common indication for surgical intervention (Vercellini, 1999).

Polyps and submucosal fibroids can be definitively diagnosed with hysteroscopy, and hysteroscopic resection is an effective treatment. Only 16% of treated patients require further surgery (ACOG, 1994). The advantages of hysteroscopic resection are numerous and include treating irregular bleeding and obtaining tissue diagnosis; for myomectomy, benefits include avoiding laparotomy, uterine incision, and hospital stays. If a fibroid is predominantly submucosal, complete resection is possible. A 2-step procedure is sometimes needed to resect a fibroid that is partially intramural or large (Gimpelson, 2000).

Recurrence of symptoms after hysteroscopic myomectomy is most common with large uteri and numerous and deep fibroids (Emanuel, 1999; Vercellini, 1999).

Some investigators report improved results and decreased adhesion rates after pretreatment with a gonadotropin-releasing hormone (GnRH) agonist or medroxyprogesterone acetate (Depo-Provera) on the day of surgery (March, 1992), while others report no benefit and possibly increased difficulty of surgery (Campo, 2005).Postoperative use of estrogen decreases adhesion formation (March, 1992; Schenk, 1999).

In patients desiring to maintain fertility, hysteroscopic myomectomy is a reasonable option (Shoiker, 2005; Surrey, 2005), and minimal cauterization should be used to decrease damage to otherwise healthy endometrium.

Proximal tubal obstruction

No controlled studies have been conducted to support the efficacy of hysteroscopic treatment of proximal tubal obstruction for infertility. Many cases may simply be due to spasm (March, 1992). This diagnosis is difficult to make. In theory, repair of proximal disease and removal of scar tissue is beneficial, and cannulation of the tubes can be performed at the same time (Schenk, 1999).

Intrauterine devices

Hysteroscopy can be applied to remove an intrauterine device (IUD) under direct visualization after sonography-guided retrieval fails (ACOG, 1994).

RELEVANT ANATOMY

Section 4 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

For any hysteroscopic procedure, the surgeon must understand the thickness of the uterine wall. This knowledge allows the surgeon to manipulate the surgery on the basis of the area of the uterus where he or she is operating. The table lists the wall thicknesses for each area of the uterus. Remember that the uterus is longer and thicker in reproductive-aged women than in postmenopausal women.

Thickness of the Uterine Wall

CONTRAINDICATIONS

Section 5 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

In generally hysteroscopy is avoided in patients with the following findings:

• Active cervical or uterine infection
• A large uterine cavity, ie, longer than 10 cm in length (clinically similar to a 12-wk pregnant uterus) (However, this number is variable and often depends on the patient's habitus.)
• Severe medical conditions precluding surgery
• Pregnancy

Concerns and contraindications for hysteroscopy depend on the procedure planned. For endometrial ablation, considerations include a desire for future fertility, atypical endometrial hyperplasia or endometrial cancer, and undiagnosed abnormal bleeding. Polypectomy and myomectomy, issues include transmural lesions, use of hypotonic media in patients with hyponatremia, use of glycine in patients with liver disease, and use of sorbitol in patients with severe diabetes. In addition, if the uterus is deeper than 12 cm, the cavity may not distend appropriately (Tulandi, 1999) If lesions larger than 2 cm, patients must be counseled about possibility of a staged procedure, increased fluid deficit, and blood loss.

WORKUP

Section 6 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

Lab Studies

• CBC: As in most surgical procedures, the CBC provides the surgeon with information the patient's baseline status and, if blood loss is encountered, with an idea of how much blood loss is acceptable. A blood count in the reference range also ensures adequate oxygenation to all vital and healing tissues and an adequate immune response.
• Blood typing and screening: With the risk of hemorrhage approaching 7-8% in some surgical hysteroscopic procedures, a sample in the blood bank increases the efficiency of access to replacement blood products if needed.
• Electrolyte determinations: In patients with medical disorders that predispose them to metabolic abnormalities (eg, diuretic use), electrolytes should be tested preoperatively. Some surgeons routinely obtain baseline levels in case a significant deficit of distention medium occurs (especially with a hyposmolar solution), whereas most obtain electrolyte levels intraoperatively or postoperatively only if a clinically significant fluid deficit occurs. The ultimate decision should be based on the type of case, the surgeon's skill, the suspected fluid absorption, and the ability to accurately ascertain fluid deficits in the operating room.
• Determination of human chorionic gonadotropin (hCG) levels: Determination of pregnancy status is mandatory in any woman of reproductive age.
• Cervical cultures: Depending on the prevalence of chlamydia and gonorrhea in the population, this may be a worthwhile preoperative test. Also, if the patient is reporting a vaginal discharge, cultures and a wet smear for bacterial vaginosis and trichomoniasis are recommended.
• Papanicolaou test (Pap smear): A normal finding on Pap smear, or at least an abnormal finding on Pap smear that has been appropriately evaluated, is required because trauma to the cervix may alter the appearance of any abnormalities.

Imaging Studies

• Hysterosalpingogram or sonohysterogram: For evaluating the uterine cavity and patency of fallopian tubes, hysterosalpingography is the superior study. However, to selectively look at the uterine cavity, sonohysterography or saline-infused sonography appears to have a better negative and predictive values than those of hysterosalpingogram for determining the location and size of fibroids and endometrial polyps and for ascertaining the presence of most uterine anomalies, including septa, bicornuate uteri, didelphic uteri, and even dense adhesions.
• CT scanning or MRI: These imaging studies are not usually needed unless the findings on sonohysterography or hysterosalpingography are inconclusive.

Diagnostic Procedures

• Endometrial biopsy is indicated in perimenopausal or menopausal women with irregular bleeding (eg, heavy menses, irregular spotting, prolonged menses) or in women with absent menses and at least 6 months of unopposed estrogen. In these women, the risk for endometrial hyperplasia or cancer is increased.
• In any woman undergoing endometrial ablation, benign endometrial tissue should be pathologically confirmed.

TREATMENT

Section 7 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

Preoperative details

Appropriate surgical management always begins with accurate history taking, physical examination, and careful workup of the suspected problem. In preparation for hysteroscopic procedures, the following considerations may be useful.

Antibiotic prophylaxis

For hysteroscopy, prophylactic antibiotics are not indicated unless the patient has clinically significant valvular disease or a history of tubal occlusion due to pelvic inflammatory disease.

Cervical stenosis

In patients with known cervical stenosis or tortuous cervical canals, preoperative vaginal or oral misoprostol, or intraoperative vasopressin 1% administered paracervically may be used to assist in cervical dilation.

Endometrial preparation for ablation

Before ablation procedures are performed, the administration of a GnRH agonist in the luteal phase of the previous menstrual cycle in ovulating women improves visibility and provides a smooth, pale, hypovascular surface 3-4 weeks later (after the patient has her menses). These changes make the procedure easier to perform and improve its success rate.

For those who do not want a GnRH agonist, the simultaneous use of a GnRH antagonist with progesterone at any point in the menstrual cycle theoretically creates a similar surface after the patient has her menses, but it has fewer adverse effects and allows greater scheduling flexibility than does other method.

One antagonist, ganirelix acetate (Antagon) (Organon, Inc, Oss, the Netherlands), is available packaged with gonadotropins for use in infertility therapy. However, cetrorelix, (Cetrotide; Serono, Inc, Rockland, Mass) is available packaged alone. This author has successfully used a single 3-mg dose of cetrorelix administered subcutaneously every 4 days along with medroxyprogesterone acetate (Provera) 10 mg taken orally for 5 days. Unlike the agonist, the action of the antagonist is immediate, suppressing follicle-stimulating hormone (FSH) and luteinizing hormone (LH) without any of the flare effect commonly observed with the agonist. The ablation procedure is then typically performed after the patient completes her menses, which usually begins 2-3 days after she takes the last progesterone tablet. A study is being conducted at the author's institution to compare the agonist and antagonist protocol.

Finally, suction curettage done before e ablation creates a comparable surface. However, it appears to be most effective in the late luteal phase or during menstruation, when the endometrium is loosely attached. In this author's experience, the medical approaches are superior.

Fibroids

For large submucosal fibroids, the use of a GnRH agonist decreases uterine volume by approximately 30%. It may decrease blood loss and allow for an easier and more complete resection, though some data suggest that the change in tissue quality may make the procedure technically more difficult than before, negating other benefits.

Large uterus

During ultrasonography or sonohysterogram, measurements of the uterine dimensions are helpful. In particular, a uterus longer than 10 cm makes the case difficult because of the length of the hysteroscope (typically 35 cm) because it must traverse the length of the uterus, cervix, and vagina while maintaining a position outside the introitus with enough distance to attach the camera and manipulate the fluid inflow-outflow valves and the surgical instruments. Also, maintaining intrauterine pressures with large cavities is more difficult than with small cavities.

Intraoperative details

Anesthesia

The type of anesthesia used depends on the procedure, the patient's level of anxiety, and the anesthesiologist's expertise. Simple diagnostic procedures can be completed without anesthesia, with a paracervical block alone, or with mild sedation. For extensive procedures or for patients with a low pain tolerance, general or regional anesthesia is indicated. If electrosurgery is to be performed, sufficient anesthesia must be given to ensure that the patient does not move with uterine stimulation because of the risk of uterine perforation and intraperitoneal injury.

Positioning

The patient is placed in the dorsal lithotomy position and prepared and draped in a sterile manner. Unless a laparoscopy is also planned, the patient's thighs should be positioned at a 90° angle to the pelvis to create enough space for the surgeon to manipulate the hysteroscope. The patient's perineum should be just past the edge of the table, with the coccyx and sacrum well supported on the flat surface of the table. The patient's legs should be secured in the leg stirrups to avoid any abrupt movements, which can cause nerve or muscle injury to the patient or potential injury to the surgeon. The surgeon should be seated with the operative field and hysteroscope at the level of the his or her abdomen. If it is positioned higher, the surgeon's shoulders become fatigued, and, if it is positioned lower, the instrument is hard to maneuver and is likely to become contaminated.

Hemostasis

Attempts to reduce blood loss and fluid deficits are reported (and ultimately tried by this author). Use of cold (ie, 5°C) distention medium causes vasoconstriction and reduces blood loss and distention fluid deficits. However, the patient's core body temperature substantially decreases and may interfere with the anesthesia process. Vasopressin in dilute solution (ie, 1%) can be injected paracervically to help constrict the cervical and lower uterine branches of the uterine artery and its collaterals, reducing blood loss and fluid deficits.

Placing the Hysteroscope

Bladder catheterization

At the discretion of the surgeon, the bladder may need to be emptied with a straight, red rubber catheter by using sterile technique.

Examination under anesthesia

Bimanual examination should always be performed before the endocervix and uterus are dilated and entered. This examination aids the surgeon in assessing angles and preventing perforation.

Cervical dilation

The cervix is manually dilated with metal dilators to the same diameter as the outer diameter of the outer sheath of the hysteroscope setup. A single-tooth tenaculum is placed on the anterior lip of the cervix while dilating to help straighten the cervix and uterus. Take care to avoid creating a false cervical passage that could make it difficult to continue with the surgery. If the surgeon is unsure of the path of the cervical canal, lacrimal duct probes or flexible uterine sounds should be used to determine the correct angle. Ultrasonographic guidance for dilation may be helpful in severe cases.

Visualization of the uterine cavity

After the cervix is dilated, the hysteroscope is inserted into the endocervical canal and advanced into the uterine cavity (with the distention medium flowing) under direct visualization to limit the risk of perforation. The tenaculum on the cervix is left in place to help in manipulating the uterus, and the vaginal speculum is removed to increase maneuverability of the hysteroscope. If the cervix was dilated too much and if fluid is leaking extensively, a purse-string suture can be placed around the cervix using 0-Vicryl to limit this leakage. The suture should be removed at the end of the procedure.

Techniques

Procedure are individually described below with regard to the type and width of the hysteroscope, the type of medium, and the use of surgical instrumentation and energy sources, depending on the indications and desired outcomes.

Diagnostic hysteroscopy

A small 5- or 7-mm hysteroscope can be used with isotonic sodium chloride distention medium. A 30° scope is preferable to clearly visualize the tubal ostia. The ability to introduce small surgical instruments through an operating channel is optimal. Office procedures can be performed with 2.5- to 3- mm flexible or rigid hysteroscopes that are attached to isotonic sodium chloride solution in a bag or 30-mL syringe. Some new models have a small operating channel through which a thin-wired biopsy forceps can be placed. This channel is enough to sample suspected areas or to remove small polyps.

Endometrial ablation with the roller-ball or roller-barrel method

The cervix must typically be dilated to 7-9 mm depending on the resectoscope used. An Iglesias grip mechanism on the resectoscope is preferred because it maintains the electrode within the shaft at rest. A 12° scope is suggested because it provides a panoramic view of the uterine cavity. A coagulation mode of 50-100 watts is used.

A roller barrel provides improves the uniformity of contact with the endometrium compared with the roller ball, but it may inadequately ablate the cornua and fundus. A 2-mm rollerball is more effective than a 4-mm ball because it has more current density for a given power level. The ball or barrel is extended and allowed to passively return toward the sheath at a rate of 1.0-1.5 mm/s. In clinical use, the proper amount of power is being used if the crater that is formed is 25% of the volume of the electrode and if the borders of the crater are carbonized. On occasion, the roller ball or barrel may become coated with tissue, and it may have to be removed and cleaned with a sterile gauze. If the endometrium is not thinned, resection may be preferred.The uterine cornua and tubal angles are ablated first because of their difficulty. Starting at the 9-o'clock position, the lateral and anterior walls are ablated next because blood, debris, and bubbles rise, making later ablation attempts in these areas more

difficult. The posterior wall then is ablated by continuing in a clockwise fashion. Do not continue to ablate over areas that have already been ablated because of the risk of uterine perforation.

Endometrial ablation, resection method

As with the other procedures, the cervix is typically dilated to 7 or 9 mm, depending on the size of resectoscope. A blended current of 70-100 watts is preferred. A 5- or 7-mm loop electrode is used and extended. The electrode is allowed to return passively at 1.0- 1.5 mm/s. A methodical approach should be used, with plan to uniformly continue around the cavity. Do not resect the same place twice. The angles of the tubal ostia are difficult to ablate with the loop electrode, so a small rollerball is preferable. Also, the corpus and isthmus may be thin; therefore, a rollerball is preferable in this area as well. The correct wattage is being used if the loop easily penetrates the tissue without tearing it. The strips of resected tissue require removal intermittently with polyp forceps. All tissue is sent to the pathologist for histologic evaluation.

Resection of submucosal fibroids

Several instruments may be used for hysteroscopic myomectomy. They include the resectoscope (by far the most common), scissors, and the laser. New techniques, including hysteroscopic morcellation, are being developed. Resection of a completely intramural fibroid poses the risk of intravasation of media due to prolonged procedure time (Vercellini, 1999). Some gynecologists inject vasopressin into the cervical stroma before the procedure to decrease blood loss and surgical time (Tulandi, 1999).

Similar to resection of the endometrium, the rectoscopic method results resection of only the fibroid rather than the surface layer of endometrium. Take care when resecting a fibroid to limit the resection to only the fibroid without resecting the adjoining endometrial tissue, especially in women desiring to conceive. The fibroid can be resected to the level of only the endometrium. After some is removed, the intramural portion of fibroid may begin to invert into the endometrial cavity. Surgeons should apply their skill and experience to estimate how many passes they will continue to resect to avoid uterine perforation. The loop can often be used to separate the fibroid from the pseudocapsule, facilitating its removal and helping to identify normal myometrium and endometrium to avoid coagulation, especially in young women desiring to conceive.

For resection of a submucosal fibroid, high cutting power is required. Using the cutting mode at 80-100 watts provides clean cuts through the fibroid and facilitates a rapid technique. Power settings lower than this do not allow for easy resection and only delay completion of the procedure, with resulting fluid deficits.

Transection and resection of the uterine septum

Three methods for performing this procedure are discussed. A 12° scope is preferred with this procedure. If extensive lysis is indicated, laparoscopy can be used as an aid to decrease the risk of perforation by visualizing the illuminated cavity intra-abdominally (March, 1992).

The first method involves the use of resectoscope, a straight, 5-mm-loop electrode, and a blended current of 70-100 watts. The septum is transected until small areas of bleeding are observed; these indicate that myometrium is reached. Do not allow the intrauterine fluid pressure to become higher than the patient's mean arterial pressure because this may prevent these bleeders from being observed easily.

In the second method, a 5- to 7-mm operative hysteroscope and small scissors are used to transect the septum until the important, small bleeding areas are observed. The intrauterine pressure helps in expanding the septum as it is cut.

With the third method, an operative hysteroscope and vaporizing electrode (ie, VersaPoint system) is used with 0.9% sodium chloride solution. By vaporizing the septum distally toward the fundus, it is completely removed rather than just transected.

Resection of uterine septum can be performed with scissors, a laser, or the resectoscope. When the septum is narrower than 3 cm at the fundus, incising it from distal to cephalic may allow the fibroelastic band to retract; this usually results in minimal bleeding. A broad septum requires a different approach. The first step is a lateral, alternating technique of side-to-side resection up to 0.5 cm from the fundus. Then, the remainder is removed from cornua to cornua to avoid damage to this area and to decrease bleeding. Laparoscopy or transabdominal ultrasonography may be useful to evaluate the external uterus during resection. In ultrasonography is used, the bladder should be left full to best visualize the uterus. Incising or resecting a cervical septum is not recommended because it can result in cervical incompetence (March, 1992).

IUD removal

By sing a 5- to 7-mm hysteroscope and a 12° scope, the IUD is grasped with a toothed grasper. The IUD is pulled toward the hysteroscope sheath. Pulling the IUD through the operating channel of the hysteroscope is impossible. Instead, the grasper is held closed, and both hysteroscope and the IUD are pulled out together.

Proximal tubal cannulation

A 5- to 7-mm hysteroscope is used with a 30° scope. The occluded tubal ostia is cannulated approximately 1-2 cm with a flexible tubal catheter, and indigo carmine is injected through the cannula and observed for its spillage through the fimbriated end by the surgical assistant performing laparoscopy. If no patency is documented, the assistant straightens the fallopian tube as the hysteroscopic surgeon slides a guide wire with a soft, flexible tip through the initial catheter and into the isthmic area of the fallopian tube. The wire is then withdrawn and patency is evaluated again.

Postoperative details

General post-hysteroscopy care

Patients typically report cramping after the procedure. A single dose of ketorolac tromethamine (Toradol) reduces postoperative discomfort. Opioid derivatives can be added, if needed, for severe pain. Peritoneal discomfort may occur if a substantial amount of the distention media entered the abdominal cavity by way of the fallopian tubes. This discomfort generally subsides within 24 hours.

Most patients can go home within 1-2 hours. They require nonsteroidal anti-inflammatory drugs (NSAIDs) for 24-48 hours. Patients may have some light-to-heavy spotting for a few days to a couple of weeks, depending on the procedure performed.

Intrauterine adhesiolysis

Postoperative stenting to prevent repeat adhesion formation with a silicone stent or an IUD has been suggested, but copper IUDs may induce an excessive inflammatory reaction and the Progestasert IUD (Alza Pharmaceuticals, Vacaville, Calif [discontinued in 2001]) may be too small to achieve adequate results (March, 1992).

Cook Women's Health (Spencer, Ind) makes a triangular balloon catheter that may improve separation of the uterine walls at the cornua during the healing phase (personal communication).

A Foley catheter placed into the uterine cavity with estrogen supplementation (conjugated estrogen 5 mg for 25 d with medroxyprogesterone 10 mg for the last 5 d) also has been used for stenting the cavity (Schenk, 1999). The purpose of the estrogen is to limit the amount of postoperative bleeding due to vasoconstriction of small blood vessels and to rapidly rejuvenate the endometrial lining, which is less prone to form adhesions than a persistently raw, cut surface. If any sort of intrauterine stent is used, antibiotic prophylaxis should be considered for the duration of the stent placement (March, 1992). Oral doxycycline 100 mg twice daily is typically used.

The use of nonsteroidal medications helps with uterine cramping and reduces adhesion formation in other pelvic procedures. Follow-up hysterosalpingography or diagnostic hysteroscopy after withdrawal bleeding is recommended. Some authors report normal findings on 90% of follow-up hysterosalpingography studies (March, 1992).

Resection of fibroids

If a fibroid resection is performed, inform the patient that she may pass small pieces of tissue, which may cause cramping. Removal of extensive adhesions or fibroids raises the possibility of adhesion formation in the uterine cavity. Many surgeons advocate the use of high-dose estrogen to encourage endometrial growth over any denuded areas. Conjugated estrogen 2.5-5 mg daily or estradiol 2 mg twice daily for 25 days, followed by progesterone for days is typically sufficient.

To prevent the juxtaposition of the inner uterine walls during the initial phase of the healing process, placement of an intrauterine catheter is recommended. Many types have been used, including the Malecot and Foley catheters. The author prefers to use a pediatric Foley catheter with the balloon filled with 15-20 mL of sterile water because it has the added benefit of providing tamponade to any areas that may be bleeding. The exterior end of the catheter is capped, and the patient is placed given doxycycline 100 mg twice daily until the catheter is removed 7 days later. The patient is instructed on how to remove the catheter (ie, cut the catheter with scissors and pull it out).

One area of uncertainty pertains to hysteroscopic resection of large submucosal fibroids, especially those with extensive myometrial involvement. When fibroids are removed through a laparotomy and a large defect is repaired, the patient is counseled not to labor when she is pregnant. Intuition suggests that patients who have large defects after a hysteroscopic procedure should be counseled similarly.

Follow-up

Follow-up in 2-4 weeks is recommended to evaluate the patient and to probe the cervix (when ablation was performed) to break up any scar tissue that may have developed near the internal os. For simple diagnostic hysteroscopy, no postoperative visit is usually necessary.

After resection of fibroids or polyps or transection of a septum, sonohysterography should be performed to confirm a normal uterine cavity. If adhesions were removed, diagnostic hysteroscopy in the office or operating room is likely to be most sensitive.

For excellent patient education resources, visit eMedicine's Pregnancy and Reproduction Center and Women's Health Center. Also, see eMedicine's patient education articles Miscarriage, Vaginal Bleeding, Amenorrhea, Fibroids, and Female Sexual Problems.

COMPLICATIONS

Section 8 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

The most common complications after hysteroscopy are bleeding and uterine trauma. An accepted rate for all complications during surgical hysteroscopy is 3.8%.

Mechanical complications

Perforation and cervical trauma are 2 of the most common complications of hysteroscopy, with uterine perforation rates of approximately 0.7-0.8% (Jansen, 2000). Risk factors for perforation include cervical stenosis, severe uterine anteflexion or retroflexion, infection, myomas of lower uterine segments, and synechiae (Loffer, 1995). Most cervical traumas and uterine perforations occur during dilation of the cervix.

Cervical lacerations can occur from tearing of the single-toothed tenaculum from the cervix. Some authors suggest using a relatively atraumatic instrument, such as a double-toothed tenaculum or a ringed forceps, to prevent this complication. Using medical or mechanical preoperative cervical dilators may help to decrease resistance during dilation. In addition, ultrasonographic guidance may help to direct dilating maneuvers. Use of the small-diameter and flexible hysteroscopes can ultimately limit the need for excessive dilation and thereby limit one of the most dangerous portions of the procedure.

Uterine perforations can occur during operative maneuvers as well. Care should be taken during procedures in the cornua because this is the thinnest portion of the myometrium. In general, a small midline or fundal injury with a blunt instrument does not have clinically significant sequelae if bleeding is minimal, but large rents or those caused by sharp or electrosurgical instruments may result in a need for diagnostic laparoscopy to completely evaluate the patient for bleeding or visceral injury. Lateral perforations involve risk of injury to vessels and should be further inspected with diagnostic laparoscopy or interventional radiology and/or angiography.

Whenever electrical or laser injury to the bowel or bladder is suspected, laparoscopy or laparotomy is required for complete evaluation. The risk of peritonitis, sepsis, and death are most often associated with unrecognized and untreated thermal injuries to the viscera. Some of these thermal visceral injuries occur without apparent perforation of the uterus. For procedures in which electrical or laser energy is used, the surgical tip should be kept in direct view to avoid thermal injury.

Media-related complications

The risk of gas embolism is the primary complication associated with the use of CO₂ as the distention medium. Because of its solubility in plasma, CO₂ has a wide margin of safety. Trendelenburg positioning, cervical trauma, and overdilation of the cervix should be avoided to help prevent embolus formation. Intrauterine pressures should be maintained below 100 mm Hg, with maximal flow rates less than 100 mL/min (Morrison, 1999).

When gas embolism occurs, results can be devastating, and circulatory collapse can occur. If an embolus is suspected because of a change in a patient's vital signs (eg, hypotension, tachycardia, tachypnea, desaturation, decreased end-tidal CO₂ value), the hysteroscope should be removed, the patient positioned on her left side, and an IV bolus of isotonic sodium chloride solution should be delivered as a first-line treatment. In addition, attempted percutaneous aspiration of an embolus is reported (Cooper, 2000). Further evaluation with echocardiography and possible cardiopulmonary resuscitation may be indicated.

The risk of absorption of media is minimal under normal operative conditions. Risk factors for clinically significant intravasation of fluid include prolonged operative procedures, the use of large volumes of low-viscosity media, or the resection of fibroids or myometrial trauma that results in open uterine venous channels or unidentified perforations (Jansen, 2000). Intravasation can occur when the intrauterine pressure is greater than the patient's mean arterial pressure (Morrison, 1999).

Fluid overload is rare with electrolyte-containing fluids. When excessive intravasation occurs, isotonic fluid overload occurs. This is relatively easy to treat. However, these fluids are uncommonly used in operative procedures.

On the contrary, nonelectrolyte, hypotonic media, which are nonconductive, are most often used for the prolonged, complicated electrosurgical procedures. These media have relatively serious adverse effect profiles (see Media above). When large volumes of these solutions are absorbed, subsequent hyponatremia, hypervolemia, hypotension, pulmonary edema, cerebral edema, and cardiovascular collapse can occur. Absorption (or deficit) of nonelectrolyte solutions must be closely monitored throughout operative hysteroscopy.

For every liter of hypotonic media absorbed, the patient's serum sodium decreases by 10 mEq/L. If the patient's sodium level is less than 120 mEq/L, she is at increased risk for having devastating complications. Hyponatremia can occur rapidly, resulting in generalized cerebral edema, seizures, and even death. In general, if a deficit of serum sodium that is greater than 1500 mL or if the sodium level is less than 125 mEq/L, the procedure should be terminated. Some suggest that of all nonelectrolyte media, 5% mannitol has the safest adverse-effect profile because it can maintain a patient's osmolality despite hyponatremia, improving neurologic outcomes (Cooper, 2000).

If the patient's sodium osmolality is less than 125 mOsm, forced diuresis with furosemide (Lasix) 40 mg IV, fluid restriction, and administration of 3% sodium chloride at a rate to correct hyponatremia by 1.5-2.0 mOsm/L/h is required. To limit any cerebral effects, do not correct the osmolality to more than 135 mOsm. Frequent assessments of the patient's sodium levels every 30 minutes may be appropriate to follow up this titration.

Dextran 70 can cause clinically significant overload in long surgical procedures; maximal absorption should not exceed 500 mL. This type of overload does not respond to diuretic treatment because the kidneys poorly excrete Dextran 70. Therefore, plasmapheresis may be required (Borten, 1983; Cooper, 2000). Pulmonary edema and diffuse intravascular coagulation are other adverse effects associated with the use of Dextran 70. The proposed mechanisms are fluid overload, toxic effects of Dextran 70 on the pulmonary capillaries, and/or probable anticoagulant effects (Jedeikin, 1990; Loffer, 1995; Cooper, 2000).

Anaphylaxis is another complication of Dextran 70, with frequencies of 1 case per 1500-300,000 patients (Borten, 1983; Jedeikin, 1990; Cooper, 2000). Treatment of anaphylaxis includes diphenhydramine, epinephrine, steroids, and possible fluid and ventilatory support.

Bleeding

Bleeding during or after surgery is the second most common complication of hysteroscopy (0.25% of all cases). Myomectomy is the procedure with the highest complication rate (2-3%) (Cooper, 2000). Data suggest improvements in blood loss and preprocedural hematocrit levels when patients are pretreated with GnRH agonists or oral contraceptives. Distention media themselves may yield enough pressure to cause hemostasis during a procedure. In addition, the coagulating effects of surgical instruments can aid in controlling bleeding during surgery.

If bleeding persists after surgery, a 30-mL Foley catheter balloon filled with 15-30 mL of fluid can be inserted into the cavity. This balloon can easily be removed 24 hours later. Antibiotic prophylaxis should be given if a foreign body is placed in the uterus. Vasopressin and misoprostol are alternate medications that can help with vasoconstriction and uterine contractions. As a last resort, embolization of the uterine artery or hysterectomy is an option for definitive management.

Infection

Infection is an uncommon complication of hysteroscopy. Even with Dextran 70, which is a polymerized sucrose, infection is rare in a patient who is preoperatively screened. If a patient has a preoperative infection or a significant history of pelvic inflammatory disease, treatment before surgery is recommended, but prophylactic antibiotics do not reduce the risk of infection after surgery (Loffer, 1995; Cooper, 2000; Gimpelson, 2000). If indicated, antibiotics should be used to prevent subacute bacterial endocarditis. Cystitis and endometritis are the most common infections associated with hysteroscopic procedures, and these should be treated in a standard fashion.

OUTCOME AND PROGNOSIS

Section 9 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

Outcomes for each type of procedure are discussed in Indications. Attempts at hysteroscopic evaluation or treatment are obviously meant to overcome the traditional problems associated with invasive procedures performed in the past that involved prolonged hospital stays, increased morbidity, and increased costs.

In addition to surgical success rates, other important considerations are the patient's long-term satisfaction, sexual function, and overall quality of life. For example, when endometrial ablation is compared with hysterectomy, endometrial ablation is most cost-effective, and patients undergoing endometrial ablation report 80-85% sexual, functional, and psychological satisfaction.

FUTURE AND CONTROVERSIES

Section 10 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

New and improved instruments are available for endometrial ablation. The thermal balloon used for menorrhagia has effects equal to those of hysteroscopic ablation, though amenorrhea is not as common with the thermal balloon than with hysteroscopic ablation (Singer, 1994). The balloon method is fast and simple to complete.

Another FDA-approved method is the direct instillation of sodium chloride solution heated to 90°C onto the endometrium at low intrauterine pressures of 50 mm Hg. Again, success rates are similar to those of the hysteroscopic approach. However, the reported rate of amenorrhea is higher than that of the thermal balloon approach, and it is nearly similar to the 40% achieved with hysteroscopic ablation. Cryoablation of the endometrium has also been used with success. The NovaSure (Cytyc Corporation, Mountain View, Calif) procedure is performed to desiccate and coagulate the endometrium and a superficial layer of myometrium by using radiofrequency energy delivered through a bipolar array. Although the size of the instrument is a limiting factor, this technique is perhaps the easiest of all. The newest procedure is microwave endometrial ablation, which offers excellent rates of amenorrhea but which requires increased dilatation of the cervix to introduce the mechanism.

Innovative and borrowed techniques are enabling many other types of hysteroscopic interventions, such as hysteroscopic sterilization, hysteroscopic morcellation, and other new and improved hysteroscopic designs. Instruments are becoming smaller than before, enabling additional in-office interventions.

As sonohysterography becomes common, as 3-dimensional sonographic software improves, and as physicians are required to apply increasingly cost-effective procedures, these new technologies may be used to perform certain operative procedures that now are performed with hysteroscopy. For example, MRI-guided ultrasonic destruction of fibroids is already in clinical trials. Patient demand for safe and minimally invasive treatments will continue to drive research and development.

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

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Article Last Updated: Jul 16, 2006