Residency · Residency · Obstetrics Gynecology
Hysteroscopy: Diagnostic and Operative Techniques
Introduction
Hysteroscopy provides direct visualization of the uterine cavity and is the gold standard for diagnosing and treating intrauterine pathology. Diagnostic hysteroscopy can be performed as an office procedure without anesthesia, while operative hysteroscopy addresses conditions such as submucosal fibroids, endometrial polyps, intrauterine adhesions, and uterine septa. Understanding instrumentation, distension media, and complication management is essential for safe and effective hysteroscopic surgery.
Indications
Diagnostic hysteroscopy is indicated for evaluation of abnormal uterine bleeding when imaging suggests intrauterine pathology, postmenopausal bleeding (where direct visualization and targeted biopsy are superior to blind sampling for focal lesions), infertility evaluation, recurrent pregnancy loss, abnormal imaging findings, and localization of lost IUD strings. Operative hysteroscopy is performed for polypectomy, myomectomy of submucosal fibroids (FIGO types 0, 1, and selected type 2), septum resection, adhesiolysis in Asherman syndrome, endometrial ablation, foreign body removal, and targeted biopsy of suspicious lesions.
Instrumentation
Hysteroscopes
Diagnostic hysteroscopes measure 2.9-4 mm in outer diameter with rigid rod-lens systems (0 or 30-degree lens) and continuous flow sheaths. Operative hysteroscopes are larger (7-9 mm) with working channels for instruments, and resectoscopes (9-10 mm) accommodate monopolar or bipolar loop electrodes. Flexible hysteroscopes (3.5-5 mm) with tip deflection are useful for office procedures, and mini-hysteroscopes (2.0-3.5 mm) enable the vaginoscopic approach without speculum or tenaculum.
Operative Instruments
Mechanical instruments (grasping forceps, scissors, biopsy forceps) pass through working channels for polypectomy and targeted biopsy. Electrosurgical loops (monopolar or bipolar) enable resection of fibroids and septa. Tissue removal systems (MyoSure, Truclear) combine mechanical cutting with continuous suction for rapid removal with reduced operative time.
<image>Labeled illustrations of hysteroscopic instrumentation including a diagnostic hysteroscope with continuous-flow sheath, an operative resectoscope with bipolar loop electrode, and a hysteroscopic tissue removal system (morcellator), with cross-sectional views showing the working channel, inflow/outflow ports, and electrode configurations</image>
Distension Media
Isotonic Solutions (Electrolyte-Containing)
Normal saline is the preferred medium for diagnostic hysteroscopy and operative procedures using bipolar electrosurgery or mechanical instruments. It carries minimal risk of hyponatremia and has a safer fluid balance profile. The maximum allowable deficit is 2,500 mL in healthy patients and 1,500 mL in patients with comorbidities.
Hypotonic Solutions (Electrolyte-Free)
Electrolyte-free solutions are required for monopolar electrosurgery because current conduction through electrolyte-containing solutions would preclude monopolar use. Options include 1.5% glycine (most common, metabolized to ammonia and glycolic acid), 3% sorbitol, and 5% mannitol. The maximum allowable deficit is 1,000 mL for hypotonic solutions (750 mL in elderly or patients with cardiac/renal disease). Strict monitoring of fluid balance is essential.
Fluid Management
Continuous monitoring with automated fluid management systems is preferred. Fluid deficit is calculated as total volume infused minus total volume recovered. The procedure must stop when the deficit approaches threshold limits, with serum electrolytes assessed if significant deficit occurs. Intrauterine pressure should be maintained below mean arterial pressure (target 70-100 mmHg) to reduce intravasation risk.
| Medium | Type | Compatible Energy | Max Deficit (Healthy) | Max Deficit (Comorbid) | Risk |
|---|---|---|---|---|---|
| Normal saline | Isotonic | Bipolar, mechanical | 2,500 mL | 1,500 mL | Volume overload |
| 1.5% Glycine | Hypotonic | Monopolar | 1,000 mL | 750 mL | Hyponatremia, ammonia toxicity |
| 3% Sorbitol | Hypotonic | Monopolar | 1,000 mL | 750 mL | Hyponatremia |
| 5% Mannitol | Hypotonic | Monopolar | 1,000 mL | 750 mL | Hyponatremia, osmotic diuresis |
Diagnostic Hysteroscopy: Office Procedure
Vaginoscopic (No-Touch) Technique
The hysteroscope is introduced directly into the vaginal canal under saline distension without speculum or tenaculum, navigating through the cervical canal with gentle pressure and rotation. This approach improves patient comfort, reduces the need for anesthesia, and is successful in more than 95% of cases. Pain management includes NSAIDs 30-60 minutes prior and paracervical block if an operative procedure is anticipated.
Systematic Evaluation
The cervical canal is evaluated during entry. The uterine cavity is inspected systematically -- anterior, posterior, lateral walls, and fundus. Bilateral tubal ostia are identified. The endometrium is assessed for thickness, vascularity, and focal lesions. Any suspicious area receives targeted biopsy.
Operative Procedures
Hysteroscopic Polypectomy
Polyps are grasped at the base and twisted/avulsed, or removed with a resectoscope loop or tissue removal system. All tissue must be submitted for pathology because polyps harbor premalignant or malignant changes in 0.5-3% of premenopausal and up to 5% of postmenopausal women. Small polyps (less than 2 cm) can be removed in the office setting.
Hysteroscopic Myomectomy
FIGO type 0 (pedunculated, entirely intracavitary) and type 1 (more than 50% intracavitary) fibroids are amenable to complete hysteroscopic resection in a single procedure. Type 2 fibroids (more than 50% intramural) may require staged resection with higher risk of incomplete removal and fluid absorption; preoperative GnRH agonist or ulipristal can reduce fibroid volume and vascularity. The technique involves sequential shaving with a bipolar resectoscope loop or rapid removal with a hysteroscopic morcellator. Maximum fibroid size for single-stage resection is generally 4-5 cm.
Hysteroscopic Septum Resection
A uterine septum associated with recurrent pregnancy loss or infertility is incised from inferior margin to the level of the tubal ostia using scissors, resectoscope, or needle electrode. Concurrent laparoscopy or ultrasound guidance monitors the external uterine contour to prevent perforation. The endpoint is a symmetrical cavity with visible bilateral tubal ostia and a concave fundal contour. Postoperative estrogen promotes re-epithelialization.
Adhesiolysis (Asherman Syndrome)
Intrauterine adhesions are lysed with hysteroscopic scissors under direct vision, avoiding electrosurgery when possible to minimize thermal injury. Dissection begins at identifiable landmarks (tubal ostia) and works toward obliterated areas. Post-procedure measures to prevent adhesion reformation include intrauterine balloon stents, estrogen therapy for 30-60 days, and follow-up hysteroscopy at 4-8 weeks. Menstrual function is restored in 70-90% of cases, with pregnancy rates of 25-70% depending on severity.
<image>Hysteroscopic views showing common intrauterine pathology: an endometrial polyp on a stalk arising from the posterior wall, a submucosal fibroid (FIGO Type 0) with smooth surface protruding into the cavity, and a uterine septum dividing the cavity with visible bilateral tubal ostia, each with accompanying anatomical diagrams</image>
Endometrial Ablation
Endometrial ablation is indicated for heavy menstrual bleeding in women who have completed childbearing and decline or are not candidates for hysterectomy. Prerequisites include endometrial biopsy to exclude hyperplasia or malignancy and reliable post-procedure contraception. First-generation techniques (resectoscopic roller-ball or loop ablation) require operator skill, while second-generation global devices (NovaSure, ThermaChoice, Her Option) are simpler with comparable efficacy. Amenorrhea rates are 30-50%, patient satisfaction is 85-95%, and 10-20% will eventually require hysterectomy. Pregnancy after ablation is contraindicated due to high risk of placenta accreta.
Complications
Uterine perforation (0.5-1.5%) is the most common complication. Passive instrument perforation can be observed, but electrosurgical or resectoscope perforation requires laparoscopy to exclude bowel or vascular injury. Fluid overload with hyponatremia from intravasation presents with nausea, confusion, pulmonary edema, and seizures, treated with furosemide, fluid restriction, and hypertonic saline if symptomatic. Hemorrhage from vascular myometrium during myomectomy is managed with balloon tamponade, vasopressin, or electrocautery. Infection (endometritis) occurs in less than 1%.
Clinical Pearls
Office hysteroscopy with the vaginoscopic technique improves patient comfort and should be the default approach for diagnostic procedures. Normal saline with bipolar or mechanical instruments should be used whenever possible to avoid the risks of hypotonic fluid-related hyponatremia. Fluid deficit must be monitored continuously, with the procedure stopped when approaching the maximum allowable deficit (1,000 mL for hypotonic, 2,500 mL for isotonic media). All removed tissue should be submitted for pathology, particularly polyps in postmenopausal women. Hysteroscopic myomectomy is the standard of care for symptomatic submucosal fibroids (FIGO types 0 and 1), with preoperative classification guiding surgical planning.
References
- AAGL Practice Report. Practice guidelines for the management of hysteroscopic distending media. J Minim Invasive Gynecol. 2013;20(2):137-148.
- ACOG Technology Assessment No. 13. Hysteroscopy. Obstet Gynecol. 2011;117(6):1486-1491.
- Munro MG, Storz K, Abbott JA, et al. AAGL practice report: practice guidelines for the management of hysteroscopic distending media. J Minim Invasive Gynecol. 2013;20(2):137-148.
- Emanuel MH. Hysteroscopy and the treatment of uterine fibroids. Best Pract Res Clin Obstet Gynaecol. 2015;29(7):920-929.
