Flexible Hysteroscopy Research Articles

Laparoscopic Myomectomy: Surgical Tips and Tricks

<h3>Study Objective</h3> The objective of this video is to provide surgical and suturing tips for successful laparoscopic myomectomy of an enlarged fibroid uterus. <h3>Design</h3> Video case presentation. <h3>Setting</h3> The surgery in this video was performed in the operating room at an academic medical center. The patient was positioned in dorsal lithotomy position. Laparoscopic myomectomy and closure were completed using a 12mm umbilical port, a 12mm left lower quadrant port, a 5mm left upper quadrant port, and a 5mm right lower quadrant port. <h3>Patients or Participants</h3> The patient is a 38-yo G0 with symptomatic uterine fibroids including heavy menstrual bleeding and bulk symptoms, desiring future fertility. She had a preoperative pelvic MRI demonstrating a 15cm multifibroid uterus with 6 fibroids, the largest being a 7.5cm Type II-V fibroid at the uterine fundus. She's had a prior laparoscopic right salpingo-oophorectomy for an ovarian stromal tumor and reports that 2 small fibroids were also removed at that time. <h3>Interventions</h3> Laparoscopic enterolysis, laparoscopic myomectomy <h3>Measurements and Main Results</h3> This patient underwent an uncomplicated laparoscopic myomectomy. Total operative time was 201 minutes. Estimated blood loss was 100cc. Eight fibroids were removed, weighing 459g. The endometrial cavity was entered, and she will need a cesarean section with future deliveries. The patient was doing well at her 2-week post-operative visit with improvement in pelvic pain and bleeding. She will have an in-office flexible hysteroscopy 3 months post-op during the early proliferative phase prior to pursuing fertility goals. <h3>Conclusion</h3> Laparoscopic myomectomy of a large fibroid uterus can be successfully completed with minimal blood loss using the techniques described in this video. Closure of deep myometrial and endometrial defects can be done under good visualization utilizing ipsilateral ports for efficient suture placement and recovery.

Clinical application of Lin's biopsy grasper for intrauterine targeted biopsy and polypectomy during office hysteroscopy

ObjectiveHysteroscopy has widely been used for diagnosis of the uterine cavity; however, target biopsy has often been difficult in part to the inherent limitations of ancillary instruments. Lin's biopsy grasper was specifically designed to work in conjunction with a flexible hysteroscope to obtain intrauterine biopsy under transabdominal sonography. Herein, we share our clinical experience in the management of endometrial abnormalities with the use of Lin's biopsy grasper during office-based hysteroscopy. Materials and methodsFrom February 2006 to November 2016, the use of Lin's biopsy grasper for tissue biopsy was attempted on 126 cases. We retrospectively recorded and analyzed the patients' preoperative characteristics and biopsy outcomes to demonstrate the feasibility and efficacy of Lin's biopsy grasper. ResultsOut of the one hundred and twenty-six enrolled patients, satisfactory targeted biopsies were achieved; including high diagnostic rate (92.1%, with 116 cases confirmed histologically) and adequate tissue retrieval (77.8%, with 98 cases obtaining optimal specimen volume). All patients tolerated the procedure without analgesics or anesthesia. ConclusionDiagnostic flexible hysteroscopy combined with the use of Lin's biopsy grasper has proven to be an effective tool for intrauterine evaluation and obtaining tissue sample.

Invention of a new Lin soft outer sheath as a continuous flow system for diagnostic flexible hysteroscopy

Abstract Objectives This study aims to evaluate the efficacy of a newly developed Lin soft outer sheath that is used as a continuous flow system for outpatient flexible hysteroscopy. Materials and methods Diagnostic hysteroscopy was performed in 134 patients who presented to our center with uterine bleeding over the 25-month study period. The flexible hysteroscope was equipped with a Lin soft outer sheath. Results Hysteroscope insertion failure was observed in six cases of, i.e., an insertion failure rate of 4.5%. Out of the other 128 women, accurate diagnosis of four patients could not be made because of intrauterine blood clots, i.e., a success rate of 92.5%. No complication, except postprocedure bleeding for a few days, was encountered. Conclusion The new Lin soft outer sheath is effective as a continuous flow system for outpatient flexible hysteroscopy.

Demonstration of Laparoscopic Resection of Uterine Sacculation (Niche) With Uterine Reconstruction

Study ObjectiveTo demonstrate a technique of laparoscopic excision of uterine sacculation (niche) with uterine reconstruction. DesignNarrated video presenting a step-by-step explanation of a laparoscopic technique for excision of uterine sacculation (niche) with uterine reconstruction using a narrated video (Canadian Task Force classification III). SettingLaparoscopic excision of uterine sacculation (niche) is a fertility-sparing technique for use in a selected group of patients who do not respond to medical treatment and in whom definitive treatment via hysterectomy is not an option. InterventionsLaparoscopic excision of uterine sacculation (niche) is performed by excising the uterine defect after initial reflection of the uterovesical fold. The area of uterine defect is identified preoperatively using flexible hysteroscopy. Once the margins of the defect are identified laparoscopically, it is circumferentially excised. The uterine manipulator helps to identify the cervical canal. Reconstruction is performed using interrupted 1 Vicryl sutures using an extracorporeal technique for secure tissue apposition. An adhesion barrier is then applied around the reconstructed area. ConclusionExcision of uterine sacculation (niche) with uterine reconstruction is a conservative surgical laparoscopic technique that should be considered in a selected group of patients in whom fertility sparing is desired and after medical therapy including progestogens, combined contraceptive pills, or the Mirena coil has failed to resolve symptoms.

Removal of endometrial polyps through a small-caliber diagnostic flexible hysteroscope using a Lin polyp snare system

To evaluate the efficacy of a newly developed snare system used for hysteroscopic polypectomy in a small-caliber diagnostic flexible hysteroscope. One hundred thirty-eight women (age 26–69 years) with endometrial polyps underwent hysteroscopic polypectomy using a Lin polyp snare system in a small-caliber diagnostic flexible hysteroscope without cervical dilation, analgesia, anesthesia, or use of a tenaculum. No electric current was used during the procedure. Indications of hysteroscopic examinations for these 138 women were infertility in 56, abnormal uterine bleeding in 43, menorrhagia in 17, abnormal ultrasound findings in 20, and abnormal intrauterine pathologic or cytologic findings in 2. Sixty-nine women had a single polyp, whereas the other 69 had multiple polyps. In 11 women, the polyps were only excised without removing the specimens. In 29 women, the polyps were removed partly by a snare first and the remaining polyps by a polyp grasper. In 49 women, the polyps were transected by a snare and the specimens were removed by a polyp grasper. In the other 49 women, the polyps were transected and removed only by using a snare. Most of the women had a satisfactory specimen, but there were 28 women with small specimens and 11 women with no specimen. The pathologic findings were endometrial polyps in 100 women, endometrium in 17, endometrial hyperplasia complex in three, atypical endometrial hyperplasia complex in three, adenomyoma in two, atypical polypoid adenomyoma in one, and endometrial carcinoma in one. The painful sensation was slight and all patients could tolerate the whole procedures. No special complication other than bleeding for several days was encountered. Endometrial polyps can be removed using a Lin polyp snare system equipped in a small-caliber flexible hysteroscopy without requiring cervical dilation, anesthesia, analgesia, or a tenaculum in the office. This procedure may substitute for blind dilation and curettage for intrauterine pathologic evaluation.

Sensitivity of Flexible Hysteroscopy for Endometrial Polyps and the Role of Endometrial Biopsies

Rigid hysteroscopy is considered the gold standard for detection of endometrial polyps (EP). Sensitivity of flexible hysteroscopy (FH) is known to be lower. This study seeks sensitivity of FH for detection of EP and assesses if additional endometrial biopsy (EMB) improves its diagnostic potential.

Laparoscopic Treatment of Large Cell Neuroendocrine Carcinoma of the Endometrium

Abstract Background: This article describes the presentation, identification, and laparoscopic treatment of a large-cell neuroendocrine carcinoma arising from the endometrium. Case: A para 4, 43-year-old female was referred for treatment for menorrhagia. Clinical oncology, histopathology, and pathology departments of the hospital followed her presentation, diagnosis, and management. In addition, a literature review provided a comparison of treatment modalities in this type of tumor. Results: Ultrasound revealed a 40×32×38–mm heterogenous endometrial mass, representative of a fibroid, extending from the uterine fundus. Flexible hysteroscopy supported this diagnosis, showing a smooth, white submucosal mass, which was resected hysteroscopically. Initial histology suggested an anaplastic endometrial carcinoma. The tumor was strongly estrogen-receptor–positive and progestin-receptor–positive. Testing and treatment involved laparoscopic hysterectomy, bilateral salpingo-oophrectomy, pelvic-lymph node dissection ...

Narrow band imaging hysteroscopy: A comparative study using randomized video images

Narrow band imaging (NBI) has been used in the gastrointestinal endoscopy field as a novel endoscopic imaging technique and has contributed to improved qualitative diagnosis and detection of lesions. However, there are only a few studies of use of NBI in the gynecology field. We applied NBI in flexible hysteroscopy at our outpatient clinic and evaluated the utility of NBI hysteroscopy for diagnosis of malignant endometrial lesions by comparison of the sensitivity and specificity between white light alone and white light+NBI using hysteroscopic video images. The subjects were 65 patients with a suspected endometrial lesion in the uterine cavity. These patients underwent flexible hysteroscopy using NBI in addition to conventional white light. Video images from 65 patients were edited into two groups, white light alone (WL group) and white light+NBI (NBI group) (130 images in total). Computerized block randomization of the order was then performed. Four raters independently diagnosed the images without use of other clinical information. Using the pathological diagnosis as the gold standard, we evaluated the sensitivity and specificity of diagnosis of atypical endometrial hyperplasia (AEH) or endometrial carcinoma compared between the WL and NBI groups. The sensitivity of diagnosis of AEH or endometrial carcinoma was numerically higher in the NBI group for all raters, and the average sensitivity was significantly higher in the NBI group compared to the WL group (78.6% vs. 63.7%, P<0.001). The specificity for each rater and the average specificity were comparable between the two groups. Compared to white light hysteroscopy, NBI hysteroscopy had a higher sensitivity for diagnosis of AEH or endometrial carcinoma without loss of specificity. This suggests that NBI hysteroscopy may be more useful than white light hysteroscopy for endoscopic diagnosis of malignant endometrial lesions.

Flexible hysteroscopy with narrow band imaging (NBI) for endoscopic diagnosis of malignant endometrial lesions

Narrow band imaging (NBI) for detection of blood vessels and microstructures on the mucosal surface is used in gastrointestinal endoscopy since it can improve qualitative diagnosis and detection of lesion. However, there are no studies on flexible hysteroscopy using NBI. We performed flexible hysteroscopy with NBI for outpatients to investigate the sensitivity and specificity of endoscopic diagnosis of malignant endometrial lesions. Of patients who attended our hospital for suspected lesions in the uterine cavity between April 2009 and May 2010, 104 subjects underwent hysteroscopy with NBI, in addition to white light. Using the pathological diagnosis as the gold-standard, we evaluated the sensitivity and specificity of NBI hysteroscopy for detecting atypical endometrial hyperplasia (AEH) or carcinoma. The results were also compared with historical data (n=209) for conventional hysteroscopy using white light only in 2008. The sensitivities were 97.2% [95% confidence interval (95% CI): 90.3-99.7%] and 82.6% (95% CI: 74.4-89.0%) for NBI hysteroscopy and conventional hysteroscopy, respectively. The 95% CIs for the two methods did not overlap and the sensitivity of lesion detection was higher with NBI hysteroscopy. Specificities were comparable, 90.6% (95% CI: 75.0-98.0%) and 85.1% (95% CI: 76.3-91.6%) between the methods. NBI hysteroscopy has increased sensitivity for detection of atypical endometrial hyperplasia (AEH) or carcinoma. A comparison with historical data suggested that NBI may be useful for diagnosis of malignant endometrial lesions. As far as we are aware, this is the first evaluation of flexible hysteroscopy with NBI for diagnosis of malignant endometrial lesions.

Intrauterine Adhesions

Joseph Asherman first described intrauterine adhesions in 1948. It is commonly referred to as Asherman's syndrome and intrauterine synechiae. It is characterized by a spectrum ranging from amenorrhea to menstrual disturbance to normal menses. It is frequently associated with infertility. The true incidence is unknown. Most cases occur within close temporal proximity to a pregnancy, usually within 4 months and usually while the woman is in a hypoestrogenized state. Most cases are associated with trauma to the endometrium from surgical procedures, primarily curettage. Increasingly, cases are associated with myomectomy both abdominal and hysteroscopic, removal of septae, and any other intrauterine surgery. Pathology shows fibrous connective tissue bands with or without glandular tissue, although this may range from filmy to dense. The diagnosis is primarily by history and a high index of suspicion. Confirmatory tests are increasingly saline infusion hysterography (SIS) or hysterosalpingogram (HSG), although magnetic resonance imaging has also been used. Ultimately, hysteroscopy is employed for the final diagnosis and treatment. Hysteroscopic lysis of adhesions is the main method of treatment. Dense scar tissue and difficult entry into the cervix may require laparoscopic or ultrasound guidance. Most authors use an intrauterine stent and follow treatment with sequential estrogen and progesterone therapy. Increasingly early intervention either with repeat SIS or HSG or most recently with flexible hysteroscopy has been advocated. Treatments outcomes are difficult to assess as there are no universally agreed upon classification system. However, intrauterine pregnancies rates range from 22 to 45% and live births range from 28 to 32%. The risk of complications for those that achieve pregnancy is significant with a significant risk for placenta accreta and subsequent blood loss, transfusion, and hysterectomy. Prospective controlled studies are needed to determine the best diagnostic and treatments for intrauterine adhesions.

Early second-look flexible hysteroscopy is effective for the treatment of asherman's syndrome

Early second-look flexible hysteroscopy is effective for the treatment of asherman's syndrome

Hysteroscopic findings in women at risk of HNPCC. Results of a prospective observational study

To report the feasibility and results of diagnostic hysteroscopy in women at risk of HNPCC. Fifty-seven women with mismatch repair gene mutations (n = 11) or Amsterdam II criteria (n = 46) were followed-up prospectively from January 1999 to March 2005. Flexible hysteroscopy was performed once a year. The endometrium was sampled routinely. Of 91 attempted hysteroscopies, 10 failed. The endometrial mucosa appeared normal in 34 cases. Polyps were seen in 12 cases, atrophy in 11, hypertrophy in 10, and fibroids in 7; two hysteroscopies suspected malignancy. A micropolypoid appearance was visualized during five hysteroscopies (5/81, 6%). Of the 86 endometrial biopsy attempts, 64 were successful and showed atrophy (n = 14), proliferation (n = 12), secretion (n = 27), polyps (n = 6), simple hyperplasia without atypia (n = 3), or cancer (n = 2). Micropolypoid appearance was not associated with a specific histological pattern. Operative hysteroscopy was done in 24 cases; in two patients with apparently benign focal lesions the results showed simple hyperplasia without atypias. Five patients underwent hysterectomy (simple hyperplasia without atypias, n = 2; endometrioid adenocarcinoma, n = 2; or secretory mucosa, n = 1). This study led to diagnosis of endometrial simple hyperplasia in 6% of cases and of cancer in 3%. In patients at risk of HNPCC, hysteroscopy appears feasible to screen endometrial pathology. Two cancers have been diagnosed over 91 patient-years at risk. Hysteroscopy should be compared to sonography as a screening tool in women at risk of HNPCC.

Novel Adjunctive Treatment for Cervical Adhesion with Cross-Type Nelaton Catheter: A Preliminary Report and Literature Review

Intrauterine adhesion remains a common complication post dilatation and curettage (D&C) in reproductive females. Internal cervical orifice adhesion (ICA) is also observed incidentally after D&C. Here, we introduce a novel adjunctive management for ICA with cross-type nelaton catheter. In this study, 20 patients suffering from amenorrhea and ICA after D&C were included. All individuals underwent flexible hysteroscopy to confirm their simple ICA statuses. All women accepted the insertion of simple cross-type nelaton catheter. Two weeks post insertion, the catheter was removed and a second-look hysteroscopy was performed. Three months post catheter removal, the menstruation statuses and the efficiency of nelaton catheter in preventing ICA were evaluated. Nineteen patients had 3-month follow-up. Seventeen individuals (89.4%) had normal menstruation flow as well as the impact internal orifice of cervical canal. Only two patients (10.5%) had hypomenorrhea and fibrotic narrowing of the internal orifice of the cervix, which required resectoscopy to remove the internal cervical adhesions. All patients appeared the competence of endurance for these procedures. The novel cross-type nelaton catheter is a simple, well tolerated, and highly effective method for the management of ICA after D&C.

Flexible hysteroscopic exploration in surgical termination of pregnancy in a patient with uterine abnormality

Congenital uterine anomalies may cause various reproductive problems, including difficulty performing vaginal surgical termination of pregnancy (TOP). We report the case of a 35-year-old woman with a uterus bicornis bicollis (a double, partially fused uterus with two cervices and a vaginal septum), who was requesting termination of pregnancy following two failed attempts at vacuum aspiration. Flexible hysteroscopy, in combination with trans-abdominal ultrasound, was used to facilitate the correct passage of the dilators during a successful dilatation and evacuation (D&E) followed by insertion of intra-uterine progestogen-only contraceptive system (‘Mirena’). On review of the literature, we found no similar cases reported.

Use of Flexible Hysteroscopy in Prepubertal Aged Girls with Genital Complaints

We describe our experience with flexible hysteroscopy and concomitant manual examination to explore the immature lower genital tract of seven prepubertal girls with genital complaints. Seven early prepubertal girls aged from 1 year 3 months to 5 years 9 months presented with abnormal vaginal discharge or bleeding or occluded vaginal outlet. All these girls with different indications for vaginal inspection underwent flexible hysteroscopy under anesthesia due to the potential for lack of cooperation and psychologic impact. Intravaginal foreign bodies were found in two patients, together with their location and tissue reaction. The origins of vaginal bleeding were identified in two patients. Verification of vagina and cervix in three patients with ambiguous external genitalia showed no vertical fusion defects or congenital Müllerian duct abnormalities. The advantages of safety, convenience, and effectiveness suggest that flexible hysteroscopy under anesthesia is a good substitute for traditional vaginoscopy and may help in the diagnosis of genital complaints in selected prepubertal patients in the pediatric gynecology clinic.

Hysteroscopic Differences in the Gestational Sac in Asymptomatic Blighted Ovum and Viable Pregnancy at Early Gestation

Summary Objective To assess differences in the surface anatomy of the gestational sac and endometrium in cases of blighted ovum and viable pregnancies using flexible hysteroscopy. Methods This was an observational case-control study. Seventeen patients with asymptomatic blighted ovum at gestational ages of 8-13 weeks and 32 women with viable pregnancy at 6-12 weeks of gestation were recruited. Subjects at 8-10 weeks of gestation in both groups were matched for comparison. The gross surface anatomy of the gestational sac and the endometrium was assessed and compared between the two groups. Results In the viable pregnancy group, the gestational sac was either round (84.4%, 27/32) or ellipsoid and slightly creased (15.6%, 5/32). In the blighted ovum group, the sac appeared collapsed and wrinkled (58.8%, 10/17), small for gestational age (11.8%, 2/17), a combination of the two (17.6%, 3/17), or round and normal (11.8%, 2/17). In general, the sac in subjects with blighted ovum tended to have various degrees of loss in surface tension, collapse in shape, decrease in sac size, and dark blue color at the sac dome compared with the sac in viable pregnancies. Conclusions The anatomic alterations of the gestational sac reflect impending sac necrosis and abortion in early-stage pregnancy loss. There were no morphologic differences between the two groups in the pattern of capillary distribution on the endometrium or the implantation base.

Incomplete Uterine Perforation After Intrauterine Device Insertion: Diagnosis and Retrieval by Flexible Hysterofibroscopy in Three Very Rare Cases

Summary Objective Incomplete uterine perforation after intrauterine device (IUD) insertion has occasionally been observed. We report on three patients who underwent flexible hysteroscopy for localization and retrieval of these intramural devices. Case Reports Three Taiwanese women presented with lower abdominal pain, discomfort during defecation and frequent urination. All used a Nova-T IUD for contraception. Sonography suggested dislocation of the IUD or perforation, and pelvic examination revealed missing strings. All the women underwent flexible hysteroscopy to localize and retrieve the devices. The hysteroscopic examination indicated partial perforation or embedding of the device into the cervical or uterine wall. Retrieval was smoothly performed without cervical dilatation or anesthesia in all three women. All devices were directly retrieved using the grasping forceps of the flexible hysterofibroscope. The subsequent courses were smooth and uneventful. Conclusion Flexible hysteroscopy is a simple and useful tool for diagnosis and retrieval of intramural IUDs. The instant removal of an IUD that has incompletely perforated the uterine wall might prevent complete uterine perforation.

Sono-Guided Endometrial Biopsy: Comparison with Hysteroscopy Biopsy

Objective: To assess the feasibility, tolerance and diagnostic accuracy of endometrial biopsy (EB) during sonohysterography (SH) compared to EB after hysteroscopy (HSC) in endometrial disorders. Methods: 105 consecutive patients with irregular uterine bleeding were included prospectively in the calendar year 2001. SH and flexible HSC were performed in an office setting, subsequently and in a random order, by two different practitioners blind to the former experiment. SH-EB was performed using a 3.1-mm ultrasound-guided Bernard catheter in the uterine cavity still partly distended and with a gentle 20-ml syringe vacuum aspiration. The biopsy was directed on focal lesions or else randomly when no targets had previously been found. A Cornier Pipelle^® was used to perform EB after HSC. We investigated all patients by biopsy, independent of the endometrial thickness. HSC-EB was the gold standard. Results: For both methods, cervical catheterism was impossible in 20 patients, 75 of them successfully underwent both exams. Duration and tolerance were similar. SH was effective in the distinction between normal and pathologic cavities, as well as in the diagnosis of polyps. Endometrium appeared significantly thinner with HSC (1.8 mm) when compared to SH (2.9 mm, p < 0.05). Histological endometrial assessment failed in 30 cases of SH-EB and in 22 cases in HSC-EB (NS). There was a poor correlation of the histological results of both techniques. Hyperplasia has never been diagnosed by SH-EB, whereas 3 EB issued from HSC-EB brought up this diagnosis. Conclusion: SH-EB with our technique did not improve the diagnostic potential of SH and severe diagnosis was missed. Histological assessment should fail less when we exclude endometrial atrophy. The diameter of the catheter and the aspiration technique must be revised and the learning curve must be considered. Our technique cannot replace EB by HSC.

A randomized prospective trial of rigid and flexible hysteroscopy in an outpatient setting

ABSTRACTObjective To compare flexible and rigid hysteroscopy in an outpatient hysteroscopy clinic.Design A randomized, single‐blinded prospective study.Setting A one‐stop, outpatient hysteroscopy clinic in a district general hospital.Subjects 96 women referred to the clinic with abnormal uterine bleeding.Main outcome measures Patient pain scores, local anaesthetic usage, need for cervical dilation, quality of view, correlation of clinical and histological findings, duration of procedure, operator's assessment of the ease of the procedure.Results Data from 83 women were analysed; three declined to enter the study, one failed to complete the pain scores and nine also had an operative hysteroscopy. Immediate median pain scores were statistically lower in the flexible hysteroscopy group, 1.2 vs. 3.6 (P = 0.001). The difference persisted 30 min after the procedure (0.4 vs. 1.1, P = 0.031). Pain experienced with endometrial biopsy was similar in the two groups (2.5 vs. 3.0, P = 0.16). There were no statistical differences between the two study arms with regard to procedure duration, quality of view, need for cervical dilation, anaesthetic usage or operator assessment of the ease of the procedure. There was agreement in clinical and histological diagnoses in all cases. The operators’ assessment of patients’ pain level correlated highly with patient pain scores. There were no statistically significant differences in any end‐point between the two operators.Conclusion Flexible hysteroscopy is associated with lower levels of patient discomfort than rigid hysteroscopy. Other study variables were comparable for the two types of hysteroscopy.

A case–control study comparing 3.6‐mm and 3.1‐mm flexible hysteroscopes

ABSTRACTObjective To determine whether a 3.1‐mm diameter flexible hysteroscope causes less patient discomfort and requirement for cervical dilatation than a 3.6‐mm hysteroscope.Setting The outpatient hysteroscopy clinic of a large teaching hospital in the UK.Participants 159 women with abnormal uterine bleeding who required an outpatient hysteroscopy.Design and intervention A cohort of patients undergoing hysteroscopy with a 3.6‐mm hysteroscope was matched for age, parity and menopausal status with a cohort of patients undergoing hysteroscopy with a 3.1‐mm hysteroscope.Main outcome measures Pain scores using a 10‐cm visual analogue scale, and women's description of pain using a Likert‐scale question.Results Significantly more postmenopausal women undergoing a 3.6‐mm required dilatation of the cervical canal compared with those undergoing a 3.1‐mm hysteroscopy (P = 0.02). In both the premenopausal and postmenopausal groups significantly more women undergoing a 3.1‐mm hysteroscopy had a pain score of zero compared with those undergoing a 3.6‐mm hysteroscopy. In the postmenopausal cohort significantly fewer women in the 3.1‐mm group (31% compared with 51% in the 3.6‐mm group) had pain scores of more than three (P = 0.007). There were also significantly more postmenopausal women in the 3.1‐mm group (64% compared with 23% in the 3.6‐mm group) who described either mild pain or no pain whatsoever (P = 0.0003).Conclusion Decreasing the diameter of the device used in flexible hysteroscopy from 3.6 mm to 3.1 mm results in a significant reduction in pain and discomfort for both premenopausal and postmenopausal women and significantly reduces the requirement for cervical dilatation in postmenopausal women.