Obstet Gynecol Sci.  2025 May;68(3):175-185. 10.5468/ogs.24234.

Clinical practice in office hysteroscopy

• Jeong N
• Cho A
• Koo YJ
• Ahn JW
• Park H
• Lee ES
• Yi SW
• Joo WD
• Lee SH
• Lee JK
• Lee SR
• Hysteroscopy Committee of The Korean Society of Gynecologic Endoscopy (KSGE)

• KMID: 2567915
• DOI: http://doi.org/10.5468/ogs.24234

Abstract

Hysteroscopy is particularly valuable for the diagnosis of uterine cavity abnormalities through direct visualization. The development of office hysteroscopy has expanded the range of diagnostic and surgical procedures available. These detailed guidelines include patient counseling and the selection and setting of office hysteroscopy, including room, equipment, and medical staff. Analgesia or local anesthesia is often required in selective office hysteroscopy cases. Cervical dilation and preparation using medical or mechanical methods are required for most diagnostic hysteroscopic procedures. Methods for optimizing visualization and choosing suitable distension media are important for a successful office hysteroscopy. It is crucial to adhere to guidelines to prevent complications, such as vasovagal syncope, cervical trauma, uterine perforation, fluid overload, and embolism. Vaginoscopy can be a good alternative option for alleviating pain, especially in cases where the insertion of a vaginal speculum is expected to be challenging.

Keyword

Hysteroscopy; Cervix; Uterine perforation; Media

Reference

References

1. The use of hysteroscopy for the diagnosis and treatment of intrauterine pathology: ACOG committee opinion, number 800. Obstet Gynecol. 2020; 135:e138–48.

2. Isaacson K. Office hysteroscopy: a valuable but under-utilized technique. Curr Opin Obstet Gynecol. 2002; 14:381–5.

3. Salazar CA, Isaacson KB. Office operative hysteroscopy: an update. J Minim Invasive Gynecol. 2018; 25:199–208.

4. Orlando MS, Bradley LD. Implementation of office hysteroscopy for the evaluation and treatment of intrauterine pathology. Obstet Gynecol. 2022; 140:499–513.

5. Chiofalo B, Palmara V, Vilos GA, Pacheco LA, Lasmar RB, Shawki O, et al. Reproductive outcomes of infertile women undergoing “see and treat” office hysteroscopy: a retrospective observational study. Minim Invasive Ther Allied Technol. 2021; 30:147–53.

6. Campo R, Molinas CR, Rombauts L, Mestdagh G, Lauwers M, Braekmans P, et al. Prospective multicentre randomized controlled trial to evaluate factors influencing the success rate of office diagnostic hysteroscopy. Hum Reprod. 2005; 20:258–63.

7. De Angelis C, Santoro G, Re ME, Nofroni I. Office hysteroscopy and compliance: mini-hysteroscopy versus traditional hysteroscopy in a randomized trial. Hum Reprod. 2003; 18:2441–5.

8. Giorda G, Scarabelli C, Franceschi S, Campagnutta E. Feasibility and pain control in outpatient hysteroscopy in postmenopausal women: a randomized trial. Acta Obstet Gynecol Scand. 2000; 79:593–7.

9. Rullo S, Sorrenti G, Marziali M, Ermini B, Sesti F, Piccione E. Office hysteroscopy: comparison of 2.7- and 4-mm hysteroscopes for acceptability, feasibility and diagnostic accuracy. J Reprod Med. 2005; 50:45–8.

10. De Silva PM, Smith PP, Cooper NAM, Clark TJ. Outpatient hysteroscopy: (green-top guideline no. 59). BJOG. 2024; 131:e86–110.

11. Baxter AJ, Beck B, Phillips K. A randomized prospective trial of rigid and flexible hysteroscopy in an outpatient setting. Gynaecol Endosc. 2002; 11:357–64.

12. Unfried G, Wieser F, Albrecht A, Kaider A, Nagele F. Flexible versus rigid endoscopes for outpatient hysteroscopy: a prospective randomized clinical trial. Hum Reprod. 2001; 16:168–71.

13. Grow DR, Iromloo K. Oral contraceptives maintain a very thin endometrium before operative hysteroscopy. Fertil Steril. 2006; 85:204–7.

14. Ciebiera M, Zgliczyńska M, Zgliczyński S, Sierant A, Laganà AS, Alonso Pacheco L, et al. Oral desogestrel as endometrial preparation before operative hysteroscopy: a systematic review. Gynecol Obstet Invest. 2021; 86:209–17.

15. Cicinelli E, Pinto V, Quattromini P, Fucci MR, Lepera A, Mitola PC, et al. Endometrial preparation with estradiol plus dienogest (Qlaira) for office hysteroscopic polypectomy: randomized pilot study. J Minim Invasive Gynecol. 2012; 19:356–9.

16. Kodama M, Onoue M, Otsuka H, Yada-Hashimoto N, Saeki N, Kodama T, et al. Efficacy of dienogest in thinning the endometrium before hysteroscopic surgery. J Minim Invasive Gynecol. 2013; 20:790–5.

17. Rai VS, Gillmer MD, Gray W. Is endometrial pretreatment of value in improving the outcome of transcervical resection of the endometrium? Hum Reprod. 2000; 15:1989–92.

18. Deffieux X, Gauthier T, Menager N, Legendre G, Agostini A, Pierre F. Hysteroscopy: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians. Eur J Obstet Gynecol Reprod Biol. 2014; 178:114–22.

19. Florio P, Puzzutiello R, Filippeschi M, D’Onofrio P, Mereu L, Morelli R, et al. Low-dose spinal anesthesia with hyperbaric bupivacaine with intrathecal fentanyl for operative hysteroscopy: a case series study. J Minim Invasive Gynecol. 2012; 19:107–12.

20. Majholm B, Bartholdy J, Clausen HV, Virkus RA, Engbæk J, Møller AM. Comparison between local anaesthesia with remifentanil and total intravenous anaesthesia for operative hysteroscopic procedures in day surgery. Br J Anaesth. 2012; 108:245–53.

21. Hua Y, Zhang W, Hu X, Yang A, Zhu X. The use of misoprostol for cervical priming prior to hysteroscopy: a systematic review and analysis. Drug Des Devel Ther. 2016; 10:2789–801.

22. Polyzos NP, Zavos A, Valachis A, Dragamestianos C, Blockeel C, Stoop D, et al. Misoprostol prior to hysteroscopy in premenopausal and post-menopausal women. A systematic review and meta-analysis. Hum Reprod Update. 2012; 18:393–404.

23. Gkrozou F, Koliopoulos G, Vrekoussis T, Valasoulis G, Lavasidis L, Navrozoglou I, et al. A systematic review and meta-analysis of randomized studies comparing misoprostol versus placebo for cervical ripening prior to hysteroscopy. Eur J Obstet Gynecol Reprod Biol. 2011; 158:17–23.

24. Al-Fozan H, Firwana B, Al Kadri H, Hassan S, Tulandi T. Preoperative ripening of the cervix before operative hysteroscopy. Cochrane Database Syst Rev. 2015; 2015:CD005998.

25. Bastu E, Celik C, Nehir A, Dogan M, Yuksel B, Ergun B. Cervical priming before diagnostic operative hysteroscopy in infertile women: a randomized, double-blind, controlled comparison of 2 vaginal misoprostol doses. Int Surg. 2013; 98:140–4.

26. El-Mazny A, Abou-Salem N. A double-blind randomized controlled trial of vaginal misoprostol for cervical priming before outpatient hysteroscopy. Fertil Steril. 2011; 96:962–5.

27. Issat T, Beta J, Nowicka MA, Maciejewski T, Jakimiuk AJ. A randomized, single blind, placebo-controlled trial for the pain reduction during the outpatient hysteroscopy after ketoprofen or intravaginal misoprostol. J Minim Invasive Gynecol. 2014; 21:921–7.

28. Casadei L, Piccolo E, Manicuti C, Cardinale S, Collamarini M, Piccione E. Role of vaginal estradiol pretreatment combined with vaginal misoprostol for cervical ripening before operative hysteroscopy in postmenopausal women. Obstet Gynecol Sci. 2016; 59:220–6.

29. Oppegaard KS, Lieng M, Berg A, Istre O, Qvigstad E, Nesheim BI. A combination of misoprostol and estradiol for preoperative cervical ripening in postmenopausal women: a randomised controlled trial. BJOG. 2010; 117:53–61.

30. Nada AM, Elzayat AR, Awad MH, Metwally AA, Taher AM, Ogila AI, et al. Cervical priming by vaginal or oral misoprostol before operative hysteroscopy: a double-blind, randomized controlled trial. J Minim Invasive Gynecol. 2016; 23:1107–12.

31. Lin YH, Hwang JL, Seow KM, Huang LW, Chen HJ, Hsieh BC. Laminaria tent vs misoprostol for cervical priming before hysteroscopy: randomized study. J Minim Invasive Gynecol. 2009; 16:708–12.

32. Phillips DR, Nathanson HG, Milim SJ, Haselkorn JS, Khapra A, Ross PL. The effect of dilute vasopressin solution on blood loss during operative hysteroscopy: a randomized controlled trial. Obstet Gynecol. 1996; 88:761–6.

33. Nezhat F, Admon D, Nezhat CH, Dicorpo JE, Nezhat C. Life-threatening hypotension after vasopressin injection during operative laparoscopy, followed by uneventful repeat laparoscopy. J Am Assoc Gynecol Laparosc. 1994; 2:83–6.

34. Hobo R, Netsu S, Koyasu Y, Tsutsumi O. Bradycardia and cardiac arrest caused by intramyometrial injection of vasopressin during a laparoscopically assisted myomectomy. Obstet Gynecol. 2009; 113:484–6.

35. Sharma M, Taylor A, di Spiezio Sardo A, Buck L, Mastrogamvrakis G, Kosmas I, et al. Outpatient hysteroscopy: traditional versus the ‘no-touch’ technique. BJOG. 2005; 112:963–7.

36. Cooper NA, Smith P, Khan KS, Clark TJ. A systematic review of the effect of the distension medium on pain during outpatient hysteroscopy. Fertil Steril. 2011; 95:264–71.

37. Brusco GF, Arena S, Angelini A. Use of carbon dioxide versus normal saline for diagnostic hysteroscopy. Fertil Steril. 2003; 79:993–7.

38. Litta P, Bonora M, Pozzan C, Merlin F, Sacco G, Fracas M, et al. Carbon dioxide versus normal saline in outpatient hysteroscopy. Hum Reprod. 2003; 18:2446–9.

39. Nagele F, Bournas N, O’Connor H, Broadbent M, Richardson R, Magos A. Comparison of carbon dioxide and normal saline for uterine distension in outpatient hysteroscopy. Fertil Steril. 1996; 65:305–9.

40. American College of Obstetricians and Gynecologists. ACOG technology assessment in obstetrics and gynecology, number 4, August 2005: hysteroscopy. Obstet Gynecol. 2005; 106:439–42.

41. Loffer FD, Bradley LD, Brill AI, Brooks PG, Cooper JM. Hysteroscopic fluid monitoring guidelines. The ad hoc committee on hysteroscopic training guidelines of the American Association of Gynecologic Laparoscopists. J Am Assoc Gynecol Laparosc. 2000; 7:167–8.

42. Hahn RG. Fluid absorption in endoscopic surgery. Br J Anaesth. 2006; 96:8–20.

43. Phillips AJ. Peritonitis from sorbitol distending medium after hysteroscopy. Obstet Gynecol. 2003; 102:1148–9.

44. Groenman FA, Peters LW, Rademaker BM, Bakkum EA. Embolism of air and gas in hysteroscopic procedures: pathophysiology and implication for daily practice. J Minim Invasive Gynecol. 2008; 15:241–7.

45. Shankar M, Davidson A, Taub N, Habiba M. Randomised comparison of distension media for outpatient hysteroscopy. BJOG. 2004; 111:57–62.

46. Ngu SF, Cheung VY, Pun TC. Randomized study of vaginoscopy and H pipelle vs traditional hysteroscopy and standard Pipelle. J Minim Invasive Gynecol. 2012; 19:206–11.

47. Sagiv R, Sadan O, Boaz M, Dishi M, Schechter E, Golan A. A new approach to office hysteroscopy compared with traditional hysteroscopy: a randomized controlled trial. Obstet Gynecol. 2006; 108:387–92.

48. Garbin O, Kutnahorsky R, Göllner JL, Vayssiere C. Vaginoscopic versus conventional approaches to outpatient diagnostic hysteroscopy: a two-centre randomized prospective study. Hum Reprod. 2006; 21:2996–3000.

49. Cooper NA, Smith P, Khan KS, Clark TJ. Vaginoscopic approach to outpatient hysteroscopy: a systematic review of the effect on pain. BJOG. 2010; 117:532–9.

50. Almeida ZMMCD, Pontes R, Costa HDLFF. Evaluation of pain in diagnostic hysteroscopy by vaginoscopy using normal saline at body temperature as distension medium: a randomized controlled trial. Rev Bras Ginecol Obstet. 2008; 30:25–30.

51. De Silva PM, Carnegy A, Smith PP, Clark TJ. Vaginoscopy for office hysteroscopy: a systematic review & meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2020; 252:278–85.

52. Bakour SH, Jones SE, O’Donovan P. Ambulatory hysteroscopy: evidence-based guide to diagnosis and therapy. Best Pract Res Clin Obstet Gynaecol. 2006; 20:953–75.

53. Rodriguez S, Haimovich S, Vitale SG, Alonso L, Carugno J. Vasovagal syncope during office hysteroscopy-A frequently overlooked unpleasant complication. Medicina (Kaunas). 2022; 58:1626.

54. Bettocchi S, Selvaggi L. A vaginoscopic approach to reduce the pain of office hysteroscopy. J Am Assoc Gynecol Laparosc. 1997; 4:255–8.

55. Aydeniz B, Gruber IV, Schauf B, Kurek R, Meyer A, Wallwiener D. A multicenter survey of complications associated with 21,676 operative hysteroscopies. Eur J Obstet Gynecol Reprod Biol. 2002; 104:160–4.

56. Royal College of Obstetricians and Gynaecologists. Best practice in outpatient hysteroscopy [Internet]. London: Royal College of Obstetricians and Gynaecologists;c2011. [cited 2011 Mar]. Available from: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.rcog.org.uk/media/5llizces/gtg59hysteroscopy.pdf.

57. Agostini A, Cravello L, Bretelle F, Shojai R, Roger V, Blanc B. Risk of uterine perforation during hysteroscopic surgery. J Am Assoc Gynecol Laparosc. 2002; 9:264–7.

58. Istre O. Managing bleeding, fluid absorption and uterine perforation at hysteroscopy. Best Pract Res Clin Obstet Gynaecol. 2009; 23:619–29.

59. Hameed N, Suresh Kumar S. Glycine-induced hypoosmolar hyponatremia and hyperammonemia: a case report of operative hysteroscopy intravascular absorption (OHIA) syndrome. Cureus. 2024; 16:e70176.

60. Aas-Eng MK, Langebrekke A, Hudelist G. Complications in operative hysteroscopy - is prevention possible? Acta Obstet Gynecol Scand. 2017; 96:1399–403.

61. Luthra N, Grewal A. Air embolism following hysteroscopy. J Anaesthesiol Clin Pharmacol. 2019; 35:416–7.

62. Storm BS, Andreasen S, Hovland A, Nielsen EW. Gas embolism during hysteroscopic surgery?: three cases and a literature review. A A Case Rep. 2017; 9:140–3.

63. Verma A, Singh MP. Venous gas embolism in operative hysteroscopy: a devastating complication in a relatively simple surgery. J Anaesthesiol Clin Pharmacol. 2018; 34:103–6.

64. Diwakar L, Roberts TE, Cooper NA, Middleton L, Jowett S, Daniels J, et al. An economic evaluation of outpatient versus inpatient polyp treatment for abnormal uterine bleeding. BJOG. 2016; 123:625–31.

65. Cooper NA, Clark TJ, Middleton L, Diwakar L, Smith P, Denny E, et al. Outpatient versus inpatient uterine polyp treatment for abnormal uterine bleeding: randomised controlled non-inferiority study. BMJ. 2015; 350:h1398.

66. Luerti M, Vitagliano A, Di Spiezio Sardo A, Angioni S, Garuti G, De Angelis C. Effectiveness of hysteroscopic techniques for endometrial polyp removal: the Italian multicenter Trial. J Minim Invasive Gynecol. 2019; 26:1169–76.