Hysteroscopy

Question 1

Indications for hysteroscopy.

Answer 1

1. Abnormal uterine bleeding (previously called dysfunctional uterine bleeding or post menopausal bleeding)
2. Ultrasound demonstrating endometrial thickening or polyps
3. Submucosal and some partly intramural fibroids
4. Suspected intrauterine adhesions
5. Mullerian tract anomalies, i.e., uterine septae
6. Retained intrauterine devices or other foreign bodies
7. Investigation of retained products of conception
8. Desire for sterilisation (the Essure device may no longer be on the market at the time of
   writing)
9. Endocervical lesions
10. Cervical stenosis

Question 2

Contraindications to hysteroscopy?

Answer 2

Absolute contraindications

1. Viable intrauterine pregnancy
2. Untreated and pelvic infection in an unstable patient

Relative contraindications
1. Treated pelvic infection.
2. Previously multiple, failed attempts at hysteroscopy in a woman with ultrasound evidence of
carcinoma
3. Excessive, uncontrolled uterine bleeding in an unstable patient 4. Already diagnosed endometrial or cervical cancer
5. Current indication for emergency hysterectomy

Question 3

What are the different types of hysteroscope?

Answer 3

Diagnostic scope (3-5mm sheath)
Operative scope (7-10mm sheath)
Resectoscope (7-9mm, can using monopoly/bipolar)

Question 4

Why do we not use CO2 as a distension media?

Answer 4

Higher risk of :

• CO2 embolism
• vasovagal reactions
• high pain scores and increased LA requirement
• longer operating times
• Flattened endometrium making it easier to miss pathology

Question 5

What are the pros/cons of saline/plasmalyte distension media?

Answer 5

Pros:

• Iso-osmolar so no risk of TUR (hyponatremia)
• Cheap and readily available

Cons:

• Can conduct electricity so not safe for monopolar electrosurgical procedures
• Risk of fluid overload
• mixes really with blood which can causes cloudy of view

Question 6

What are the pros/cons of 1.5% glycine or 3% sorbitol distension media?

Answer 6

Pros:
- Does not conduct electricity so IS safe for electrosurgical procedures

Cons:
- Hypo-osmolar so high risk of TUR

Question 7

What precautions should be taken to prevents fluid overload?

Answer 7

o Active input versus output monitoring
o Limit operative time to <60 minutes
o Consider ceasing procedure if unaccounted for fluid deficit is >1000ml, and less if patient older or medically compromised.

Question 8

What is the difference in power settings for hysteroscopic surgery compared to open?

Answer 8

Power settings of 70-80w are required to deliver similar cut/coag effect as 40w at open surgery.