Ambulatory Hysteroscopy Research Articles

Outpatient hysteroscopy: Factors influencing post‐procedure acceptability in patients attending a tertiary referral centre

Ambulatory hysteroscopy is a safe, reliable and cost-effective alternative to hysteroscopy under a general anaesthetic for the diagnosis of abnormal uterine bleeding. The objective of this study was to assess which factors influenced patients' willingness to attend for future outpatient hysteroscopy. The outpatient hysteroscopy service commenced at the Mercy Hospital for Women in 2000. It provides women with the opportunity to have the cause of abnormal uterine bleeding diagnosed in an outpatient setting. A prospective audit was conducted of 283 women attending for outpatient hysteroscopy at the Mercy Hospital for Women over a period of almost five years (May 2003 through February 2008). Of the women audited, 88.7% stated that they would accept the procedure in future, whilst 11.3% would not. There was a significant difference between the two groups with respect to their median visual analogue pain scale (VAS) pain scores during the procedure (3.00 versus 6.50 P < 0.0001) with the higher score in the group who would not re-attend for the procedure. There was also a significant difference between the two groups with respect to the change in median VAS score from pain anticipated to pain experienced (0.00 versus 3.50 P = 0.0001). The rate of unsuccessful procedures was significantly higher (40.6% versus 0.8%P < 0.05) in future non-attendees as well as a higher rate of clinical vasovagal episodes (25% versus 5.2%P = 0.01) in women who stated that they would not re-attend for the procedure. Preprocedure analgesia and type of anaesthetic administered during the procedure did not seem to influence whether women would attend for outpatient hysteroscopy in future. The acceptability rate for women attending for outpatient hysteroscopy during the audit period was 88.7%. Pain was a significant determinant of procedure acceptability; however, the acceptability rate was not influenced by analgesia or type of anaesthetic administered.

Diagnostic Accuracy by the Presence of Symptoms: Ambulatory Hysteroscopy in Postmenopausal Women

Diagnostic Accuracy by the Presence of Symptoms: Ambulatory Hysteroscopy in Postmenopausal Women

Conservative management of retained trophoblastic tissue and placental polyp with diagnostic ambulatory hysteroscopy

Objective To analyse the results of our conservative management of retained trophoblastic tissue and placental polyp with diagnostic ambulatory hysteroscopy and to describe our experience and guidelines. Study design Descriptive retrospective study. Eighty-four women with suspected retained trophoblastic tissue after pregnancy underwent hysteroscopic examination and extraction of all residual tissue in the office under direct visualization of the uterine cavity, without anaesthesia or cervical dilatation. Results Hysteroscopic examination was tolerated by all but one patient. In 82 cases (97.4%), the diagnosis after hysteroscopic examination was placental polyp or retained trophoblastic tissue. This diagnosis was histologically confirmed in 79 cases (94.7%). In 43.6% (36) of the cases, complete evacuation of the uterine cavity was achieved during a single hysteroscopic examination. The only complication after hysteroscopy was one case of major vaginal bleeding requiring curettage. Conclusions Diagnostic-operative ambulatory hysteroscopy is a suitable alternative to blind curettage in the management of retained trophoblastic tissue. This technique can be performed in the office without anaesthesia and with a low rate of complications.

The Impact of Viewing a Hysteroscopy on a Screen on the Patient’s Experience: A Randomised Trial

It is becoming increasingly common to enable a woman to see her ambulatory hysteroscopy procedure on a monitor. However, there is only limited evidence on the potential impact of seeing or not seeing the procedure on patient mood, perception of pain, and patient–physician interaction. This randomized controlled trial compared the effects of seeing or not seeing the screen during an outpatient hysteroscopy procedure on patient’s experience. At two outpatient clinics, 157 women scheduled for a hysteroscopy procedure were randomized either to see the screen (n = 81) or not to see the screen (n = 76). Before and after the procedure, the patients completed questionnaires to evaluate various parameters of their experience (mood, pain perception, illness cognitions, and communication with the health professional). After the initial study, the analysis was repeated using a local anesthetic to control for the potential impact of this covariate on the experience of the patients for whom this was measured [screen on: (n = 51) and screen off (n = 54)]. The data showed that seeing the screen or not had no effect on changes in mood, perception of pain, several parameters of illness cognitions, and patient–physician communication with respect to patient involvement, affect and information giving. Women who did not see the screen, however, had greater confidence in the effectiveness of their treatment and reported that the health professional was more receptive to their views during the consultation. After adjustment for the use of a local anesthetic, anxiety was decreased more after the procedure in women who did not see the screen. The investigators conclude from these findings that viewing the procedure is not beneficial to the patient and may be detrimental to patient–physician communication.

B‐Lynch suture for massive persistent postpartum hemorrhage following stepwise uterine devascularization

To estimate the effectiveness and safety of the B-Lynch suture for severe persistent postpartum hemorrhage (PPH) following vessel ligation before considering hysterectomy and its impact on menstruation and uterine cavity. Cohort study. University-affiliated tertiary referral center. Population. Fifteen consecutive women who underwent B-Lynch suture for persistent PPH despite vessel ligation. Data were retrieved from medical files and telephone interviews. Hysterectomy, infection, hysteroscopy, future menstruations. In 13 of the 15 cases (86.7%), PPH occurred after cesarean deliveries. B-Lynch sutures controlled the hemorrhage and resulted in an avoidance of immediate hysterectomy in 12 of 15 cases (80%). The postpartum period was uneventful for 14 of 15 women (93.3%). In one case hysterectomy was required due to pyometra in an ischemic uterus. In the remaining 11 women where the uterus was preserved, ambulatory hysteroscopy was normal. No women reported any differences in menses or pain compared to that they experienced before pregnancy, or any clinical symptoms of early menopause. One woman reported a subsequent pregnancy with normal conception delay, whereas the ten remaining women had no desired pregnancy due to, in each case, the fear of PPH recurrence. B-Lynch technique appears to be an effective procedure with a relatively low morbidity to control persistent severe PPH following a failure of vessel ligation before considering hysterectomy.

Incidence of endometrial carcinoma after hysterectomy for atypical hyperplasia or FIGO stage IA carcinoma diagnosed on endometrial biopsy or endometrial resection

To evaluate the risk of finding an infiltrating endometrial carcinoma when atypical hyperplasia (AH) or FIGO stage IA carcinoma were diagnosed on endometrial biopsy by Novak curette during ambulatory hysteroscopy or on pathological analysis of endometrial ablation product during operatoring hysteroscopy. Retrospective unicentric study from 2000 to 2006 including 107 patients. Total hysterectomy with bilateral oophorectomy was performed on 95 of them. All patients had initial diagnosis of AH or FIGO stage IA carcinoma realised either by biopsy with Novak curette performed according to hysteroscopic data (52 cases), or on product of endometrial ablation (43 cases). AH and stage IA carcinoma were voluntarily studied together because of the same surgical treatment and because it is acknowledged that no complementary treatment is necessary if lesion remains intramucous. However, in presence of myometrial infiltration, the risk of lymph node infiltration exists and lymphadenectomy must be discussed. Out of the 95 hysterectomy specimens, 20 infiltrating endometrial carcinoma were diagnosed (21%). The risk of discovering an infiltrating endometrial carcinoma when diagnosis of AH or stage IA carcinoma is done by biopsy with Novak curette is 32.7% (17 out of 52 patients). Let's note that 30% of these ambulatory hysteroscopies (5 out of 17) were non suspect. When diagnosis is done on the products of endometrial ablation, infiltrating carcinoma is observed on the hysterectomy piece in 6.9% of cases (3 out of 43 patients). Presence of AH or stage IA endometrial carcinoma on endometrial biopsies or on products of endometrial ablation can be associated with infiltrating endometrial carcinoma. In presence of AH or stage IA carcinoma diagnosed on biopsy with Novak curette, the incidence of infiltrating carcinoma on hysterectomy product is sizeable (32.7%) and check-up of infiltrating endometrial carcinoma should be realised with the view to state the prognostic factors and the possible indication of lymphadenectomy. Besides, in the case of a patient presenting with post menopausal bleeding with non suspect hysteroscopy, biopsic examination is necessary.

Case report of malignant endometrial polyps

The aims of this retrospective review were to determine the frequency of malignant endometrial polyps diagnosed with ambulatory hysteroscopy in the Obstetrics/ Gynaecology Department of HDE, Lisbon, between January 2001 and December 2005 and to characterize these cases according to risk factors, sonographic and endoscopic findings tumoral histology, and tumor stage. We found seven cases of malignant endometrial polyps in a total of 1333 polyps initially diagnosed: an incidence rate of 0. 53%. These seven patients had a mean age of 68 years (55–82 years), and all were postmenopausal, with five having one risk factor each for endometrial cancer. Metrorrhagia was present in six of the seven patients (85.7%). Ultrasonography was abnormal in all seven patients, with a mean endometrial thickness of 26 mm (range: 12–44 mm). The hysteroscopy images suggested malignancy in all cases. All except one patient had a single polyp. The polyps had volumes between 1.5 and 3 cm; two were removed completely and five were biopsed. The histological subtype was: mixed endometrioid/serous papillary or clear cell (2), adenocarcinoma with squamous differentiation (2), carcinosarcoma (2), and clear cell carcinoma (1). Malignancy inside polyps is rare, but diagnostic hysteroscopy with visual guided biopsies can identify these cases in the earlier stages. The risk factors are not different from those of other endometrial carcinomas, but the histological subtype seems to point to more aggressive cancers.

Development of a thinner and more flexible type of minihysteroscope with a controlled 90-degree bendable tip for vision-guided endometrium biopsy

Study objective Evaluation of the uterine cavity is limited with rigid 5-mm hysteroscopes because of the need for cervical dilatation, reduced movements inside the uterus, and no option for vision-guided biopsy. In cooperation with PolyDiagnost GmbH, Pfaffenhofen, Germany, a new type of flexible minihysteroscope with bendable tip was developed and evaluated. Design Prospective and parallel observational interindividual evaluation of flexible minihysteroscope and standard hysteroscope for diagnostic hysteroscopy (Canadian Task Force classification II-3). Setting Obstetrics and gynecology department of a university clinic. Patients Nine women, average age 65.0 years (range 46–89 years), with indications for diagnostic hysteroscopy. Interventions After defining requirements, a novel, thinner, and more flexible minihysteroscope, 18-cm long with a 2.67-mm outer diameter, was developed with straight zero-degree scope, 70-degree vision field, and 6000-pixel resolution. Two working channels, 1.2 mm and 0.55 mm, allow suction-irrigation and introduction of a 1.0-mm biopsy forceps or cytology brush. The tip of the instrument is 90-degree stageless bendable to both sides. Diagnostic hysteroscopy was performed with flexible minihysteroscope followed by standard rigid hysteroscopy to verify results. Measurements and main results From July 2003 through March 2004, both procedures were performed in nine patients with identical visual and histologic results. No complications occurred. No cervix-dilating instruments were necessary for introduction of the flexible minihysteroscope. Visualization of the entire uterine cavity is improved with the flexible scope because a bendable tip allows better peripheral vision (e.g., of the openings of the tubes). However, movement of the tip should be performed carefully due to potential risk of uterine perforation. Conclusion This new flexible minihysteroscope is less invasive compared with standard rigid hysteroscopy, which supports performance of ambulatory hysteroscopy and makes increased movements and vision-guided biopsy inside the uterine cavity possible.

Ambulatory hysteroscopy results post-menopause: comparative study between patients with and without metrorrhagia

Our objective was to compare the results of ambulatory hysteroscopy in postmenopausal women with and without uterine bleeding. A retrospective descriptive study was carried out on 236 women who were at least 2 years into the menopause, who were not undergoing hormone treatment and who had had abnormal pelvic ultrasound results. Of these women, 150 were asymptomatic and 86 reported haemorrhage. Diagnostic and operative outpatient hysteroscopy was performed between January 2002 and December 2003. There was no difference between the two groups regarding age of patients, age of menopause and presence of at least one of the risk factors for endometrial carcinoma evaluated, although obesity was more frequent in the symptomatic group. Abnormal ultrasound results for these women corresponded in the majority of cases to intracavitary disease, and the absence of organic endometrial pathology was 9.3% vs 11.3% in each group. The more frequent pathology was benign endometrial polyps (64% in bleeding patients and 84.7% in asymptomatic ones). Endometrial carcinoma was diagnosed in 23.3% of women with metrorrhagia and in 1.3% of asymptomatic women. We diagnosed 2.6% of malignancy inside polyps. Hysteroscopy results were confirmed by histology in 90.3% of cases. See and treat in one session was achieved in 91% of benign endometrial polyps. Ambulatory hysteroscopy has high sensitivity and specificity for intracavitary pathology and high tolerability and safety. See and treat in one session can be achieved in the majority of lesions with indication for excision. These results make us advise our menopausal patients with abnormal uterine bleeding to undergo diagnostic hysteroscopy complemented with biopsy.

Pain Relief and Outpatient Hysteroscopy: A Literature Review

Our early experience in setting up an ambulatory hysteroscopy service provoked a review of the literature, due to an unacceptably high failure rate. A literature review has been undertaken to establish the accepted success rates and reasons for failure, and to assess evidence for various analgesic protocols through randomized controlled trials. The data suggest the procedure is acceptable to most patients, with a completion success rate over 90%, and the use of analgesia may enhance the success rate. Analgesic protocols studied were nonsteroidal anti-inflammatory drugs, intracervical block, paracervical block, transcervical block, and topical analgesia. Failures are due predominantly to pain, stenosis, and poor view.

Endognost hysteroscope and Russel hysteroscope: Two different concepts of flexible and rigid micro-hysteroscopes for lesser invasive ambulatory hysteroscopy

Endognost hysteroscope and Russel hysteroscope: Two different concepts of flexible and rigid micro-hysteroscopes for lesser invasive ambulatory hysteroscopy

Prevalence of Asherman's syndrome after secondary removal of placental remnants or a repeat curettage for incomplete abortion.

This prospective study assesses the prevalence of intrauterine adhesions among women undergoing secondary removal of placental remnants after delivery, or a repeat curettage for incomplete abortions, and evaluates risk factors associated with the presence of intrauterine adhesions. In 50 women, undergoing either a secondary removal of placental remnants more than 24 h after delivery, or a repeat curettage for incomplete abortions, ambulatory hysteroscopy was performed 3 months after the intervention. Intrauterine adhesions were found in 20 of the women (40%): five patients had Asherman's syndrome grade I, six had grade II, six had grade III and three had grade IV. In women with menstrual disorders a statistically significant 12-fold increased risk for Asherman's syndrome grade II-IV was found. Previous abortion as well as infection during surgery were associated with a mildly but non-significant increased risk. Based on our findings, hysteroscopy is recommended only in those patients who develop menstrual disorders, either after secondary intervention for placental remnants after delivery or after a repeat curettage.

Prevention of endometrial hyperplasia by progesterone during long-term estradiol replacement: influence of bleeding pattern and secretory changes

To determine the relative influences of induction of withdrawal bleedings secretory transformation, and reduction of mitosis in glands on prevention of endometrial hyperplasia during long-term hormonal replacement therapy. Observational expanded clinical case report. Reproductive Endocrine Department of Hospital Necker, Paris, France, and Pathology Department of Women's Hospital, Los Angeles County and University of Southern California Medical Center, Los Angeles, California. Postmenopausal women seeking treatment for symptomatic menopause. Endometrial biopsy and/or ambulatory hysteroscopy. Endometrial histology including progestational maturation patterns and glandular epithelial mitosis rates. Macroscopic endometrial appearance. The use of larger doses of E2 and P induced more marked secretory changes and more frequent withdrawal bleeding than the lower doses. There was no evidence of endometrial hyperplasia after 5 years of E2/P replacement therapy independently of bleeding pattern or progestational maturation. Consistent reduction of mitosis rates in glandular epithelium was found after 9 or more days of P administration in each cycle. Control of endometrial growth is mainly related to control of mitosis in glands by a relatively low doses of P. Induction of withdrawal bleeding and endometrial secretory transformation, which require larger doses of Progesterone, do not provide additional benefit for prevention of hyperplasia. Induction of amenorrhea with a relatively low dose of P may be offered to women seeking hormone replacement therapy with similar levels of safety.