Hysteroscopy

Hysteroscopy was first performed on a patient in 1869 by Pantaleoni, who, using a cystoscope developed by Desormeaux, discovered and treated an endometrial polyp in a 60-year-old patient who presented with postmenopausal bleeding. In the 20th century, hysteroscopy using distending media was developed, first using carbon dioxide in 1925. In-office hysteroscopy was introduced into clinical practice in the early 1980s with the improvement of distension media options and operative techniques. Today, with the development of bipolar energy, various instruments, safe and effective distending media, optics, and smaller scope sizes, hysteroscopy is the preferred technique for managing intrauterine pathology. The utilization of in-office hysteroscopy depends not only on appropriate patient selection but also on the availability of equipment and resources. The preferred entry technique is vaginoscopy due to the reduction of intraprocedural and postprocedural pain. The efficacy of the vaginoscopic approach is comparable to the traditional entry approach. Hysteroscopy involves inserting a rigid or flexible hysteroscope through the cervical canal into the uterus and then using distending media to allow for complete visualization of the endometrial cavity. The type of distending media is selected based on the type of energy that will be used. Electrolyte-rich distention media may not be used if monopolar energy is used due to the risk of conducting electricity outside the operative field. Because of the potential for fluid overload and resulting complications, a fluid deficit with an upper limit of 1000 mL is recommended when using the hypotonic solution as the distending media. A fluid deficit upper limit of 2500 mL is recommended when using the isotonic solution as the distending media. This limit does not apply to older adults or patients who have comorbidities. A fluid deficit cutoff of 750 mL for hypotonic solutions and 1500 mL for isotonic solutions is recommended in this population. This is due to the potential for complications resulting from fluid overload. Normal saline has been found to provide better visualization and is associated with less postoperative pain than carbon dioxide. Normal saline also allows for the utilization of bipolar electrocautery since it is isotonic.  The type of hysteroscope is selected based on operative needs. The 3 parts of the scope are the eyepiece, the barrel, and the objective lens. Scope viewing angles range from 0 to 70 degrees, with a decreased angle giving a more panoramic view. An operative hysteroscope is needed for surgical intervention. Options include a resectoscope, a hysteroscopic tissue retrieval system, or the addition of an operative sheath. With the invention of smaller hysteroscopes with reduced diameters and more technically advanced operating systems, in-office hysteroscopy has become a widely accepted method for diagnosing and treating intrauterine pathology. For women with abnormal uterine bleeding (AUB), hysteroscopy has been introduced as a viable or even superior alternative to hysterectomy in some cases. Hysteroscopy has also been validated as a diagnostic tool for infertility workups. Moreover, this procedure has been shown to be safe and effective for the removal of retained products of conception and foreign bodies. A new concept gaining popularity is the “see-and-treat” strategy, in which the patient is diagnosed during office hysteroscopy with an intrauterine organic pathology, eg, endometrial polyps or thickened endometrium. This identified pathology can then be treated hysteroscopically during the same visit. The see-and-treat strategy has all the same indications, and more, compared to traditional hysteroscopy, including thickened endometrium, endometrial pathology, retained products of conception, and retained foreign bodies. Polypectomy is the most common hysteroscopic procedure worldwide and can be easily transitioned to be performed through the see-and-treat method.