Hysteroscopy — An Evaluation

Summary: An assessment has been made of the technique of hysteroscopy. Five per cent dextrose and 32% dextran are the most satisfactory intrauterine media to employ. The procedure is a most valuable diagnostic aid in gynaecology and promises to have a place as a method for achieving female sterilization.     

Analgesia for Office Hysteroscopy: A Systematic Review and Meta-analysis

ObjectiveTo identify the most effective analgesia for women undergoing office hysteroscopy.Data SourcesWe searched Medline, Embase, the Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library from inception until August 2019 for studies that investigated the effect of different analgesics on pain control in office hysteroscopy.Methods of Study SelectionWe included randomized controlled trials that investigated the effect of analgesics on pain experienced by women undergoing diagnostic or operative hysteroscopy in an office setting compared with the control group.Tabulation, Integration, and ResultsThe literature search returned 561 records. Twenty-two studies were selected for a systematic review, of which 16 were suitable for meta-analysis. There was a statistically significant reduction in pain during office hysteroscopy associated with preprocedural administration of nonsteroidal anti-inflammatory drugs (NSAIDs) (standardized mean difference [SMD] –0.72; 95% confidence interval [CI] –1.27 to –0.16), opioids (SMD –0.50; 95% CI –0.97 to –0.03), and antispasmodics (SMD –1.48; 95% CI –1.82 to –1.13), as well as with the use of transcutaneous electrical nerve stimulation (TENS) (SMD –0.99; 95% CI –1.67 to –0.31), compared with the control group. Moreover, similar reduction in pain was observed after office hysteroscopy: NSAIDs (SMD –0.55; 95% CI –0.97 to –0.13), opioids (SMD –0.73; 95% CI –1.07 to –0.39), antispasmodics (SMD –1.02; 95% CI –1.34 to –0.69), and TENS (SMD –0.54; 95% CI –0.95 to –0.12). Significantly reduced pain scores with oral NSAID administration during (SMD –0.87; 95% CI –1.59 to –0.15) and after (SMD –0.56; 95% CI –1.02 to –0.10) office hysteroscopy were seen in contrast to other routes. Significantly more adverse effects were reported with the use of opioids (p <.001) and antispasmodics (p <.001) when compared with the control group, in contrast to NSAIDs (p = .97) and TENS (p = .63).ConclusionWomen without contraindications should be advised to take oral NSAIDs before undergoing office hysteroscopy to reduce pain during and after the procedure. TENS should be considered as an alternative analgesic in women with contraindications to NSAIDs.     

Gentian Violet — Is It Safe?

EDITORIAL COMMENT: Yet another old friend seems to have become a potential enemy. Because of the evidence reviewed in this report, many paediatricians no longer prescribe gentian violet for infants with evidence of candidial infection of buccal mucosa or buttocks. Whether or not the gynaecologist should discontinue the practice of using a single application of gentian violet (1/2 % aqueous) at the time of diagnosis of severe thrush infection of the vagina, while the speculum remains in position, is uncertain; although immediate relief of itch and discomfort is guaranteed, a dose of a specific antifungal preparation, perhaps one of the single-dose treatments (isoconazole pessaries 2 × 300mg or clotrimazole pessaries 500mg), could be used in the same manner.     

Determining the Optimal Time Interval between Vaginal Dinoprostone Administration and Diagnostic Office Hysteroscopy in Nulliparous Women: A Randomized,Double-blind Trial

Study ObjectiveTo determine the optimal timing of vaginal dinoprostone administration before office hysteroscopy (OH) in nulliparous women.DesignRandomized, double-blind trial.SettingTertiary referral hospital.PatientsA total of 180 nulliparous women undergoing diagnostic OH.InterventionsWe randomly allocated the women to long-interval or short-interval dinoprostone groups: three mg dinoprostone was administered vaginally 12 hours before OH in the long-interval group and 3 hours before OH in the short-interval group.Measurements and Main ResultsThe primary outcome was pain during OH measured using a 100-mm visual analog scale (0 = no pain; 100 = worst pain imaginable). The secondary outcomes were ease of hysteroscope passage, patient satisfaction score, and drug-related adverse effects. The patients in the long-interval dinoprostone group had lower pain scores during OH (p <.001). Contrarily, pain scores 30 minutes after the procedure were similar in both groups (p = .1). The patient satisfaction score was higher and clinicians found hysteroscope passage through the cervical canal easier and quicker in the long-interval dinoprostone group than in the short-interval group (p <.001, p = .003, and p <.001, respectively). Side effects were comparable in both study groups.ConclusionVaginal dinoprostone administered 12 hours before OH was more effective than that administered 3 hours before OH in reducing pain during OH in nulliparous women, with easier hysteroscope insertion, shorter procedure duration, and higher patient satisfaction score.     

Vaginal Dinoprostone in Reducing Pain Perception During Diagnostic Office Hysteroscopy in Postmenopausal Women: A Randomized,Double-Blind,Placebo-Controlled Trial

Study ObjectiveTo evaluate the efficacy of vaginal dinoprostone in reducing pain perception during diagnostic office hysteroscopy (OH) in postmenopausal women.DesignRandomized, double-blind controlled trial.SettingTertiary university hospital.ParticipantsPostmenopausal patients scheduled for OH.InterventionsEligible participants were randomized in a 1:1 ratio to the dinoprostone and placebo groups. The severity of pain was assessed with a visual analog scale (VAS) ranging from 0, no pain to 10, worst pain during OH and 30 minutes after OH.Measurements and Main ResultsThe difference in the intensity of pain using the VAS score during the procedure. One hundred women (50 in each arm) were included in the study. The mean VAS score during OH was significantly lower in the dinoprostone group compared with the placebo group (3.9 ± 0.8 vs 5.6 ± 0.7; p <.001). The passage of the hysteroscope through the cervical canal was easier in the dinoprostone group (62.4 ± 9.5 vs 42.8 ± 10.8; p <.001). The 2 groups were comparable in terms of the duration of the procedure (p = .91) and the rate of adverse effects.ConclusionVaginal dinoprostone is effective in relieving pain during diagnostic OH in postmenopausal women with few adverse effects.     

Office Diagnostic and Operative Hysteroscopy Using Local Anesthesia Only: An Analysis of Patient Reported Pain and Other Procedural Outcomes

Study ObjectiveTo evaluate the effectiveness of a multimodality local anesthetic protocol for office diagnostic and operative hysteroscopy.DesignRetrospective cohort study (Canadian Task Force classification II-3).SettingAcademic community–based institution.PatientsFive hundred sixty-nine women undergoing 639 office-based diagnostic or operative hysteroscopic procedures.InterventionsMultimodality local anesthetic protocol addressing vagina, cervix, paracervical region, and endometrial cavity.Measurements and Main ResultsPrimary outcomes were numeric pain scores and rate of premature termination because of pain. Secondary outcomes included procedure pain and parity, delivery route, menopausal status, procedure type, and cost effect on procedure delivery. The overall mean (SD) pain score across 535 evaluable procedures was 3.7 (2.5). Patients undergoing operative hysteroscopy had a higher mean maximum pain score than did those who underwent diagnostic hysteroscopy only (4.1 vs 3.2; p < .001). There was no difference among women in different age groups; however, those with both cesarean section and vaginal delivery had scores higher than the mean (4.7 [0.4]; p < .001). The estimated cost savings was almost $2 million.ConclusionUsing a multimodality approach to local anesthesia, a broad spectrum of diagnostic and operative procedures can be performed successfully, comfortably, and inexpensively in the context of an office procedure room, without the need for procedural sedation.     

Transabdominal Chorion Villus Sampling: A Safe and Reliable Procedure

A complete follow-up of the first 578 patients undergoing transabdominal chorion villus sampling (TACVS) in our combined practices was undertaken to determine the pregnancy loss rate. Factors contributing to losses and the problems incurred in achieving a clinically relevant result were also examined. It was found that increasing experience led to fewer procedural difficulties but that there persisted a higher problem rate in those women with a retroverted uterus. In 98.1% of patients an adequate volume of tissue was obtained and in 95.5% a clinically relevant result was achieved. This second figure rose to 96.3% in the latter part of the study. There was a total fetal loss rate of 2%, with only 0.5% (3 patients) having a missed abortion within 4 weeks of the procedure. It is concluded that TACVS is a reliable procedure with a high level of safety.     

The Biopsy Snake Grasper Sec. VITALE: A New Tool for Office Hysteroscopy

Hysteroscopic evaluation of the endometrium with biopsy can be performed using different graspers whose terminal ends have specific features. This technical note aims to describe an innovative hysteroscopic grasper, the biopsy snake grasper sec. VITALE (Centrel S.r.l., Ponte San Nicolò, Padua, Italy), which can be used to grasp and cut at the same time. The characteristic features of this grasper are as follows: a sleeve with an opening along the whole width, a flat pointed tip with serrated edges fixed to its end by a U-shaped joint, and 2 sharp-edged jaws that completely encompass the tip when they are clenched. The biopsy snake grasper sec. VITALE, therefore, aims to be a useful innovative tool. It is a robust, easy-to-use instrument compatible with all modern hysteroscopes equipped with a 1.67-mm (5 French) working channel.     

Practical Tips for Office Hysteroscopy and Second-Generation “Global” Endometrial Ablation

Hysteroscopy and endometrial ablation using the second-generation devices are safe, generally well tolerated, and effective when performed in the medical office as opposed to the ambulatory surgery center or hospital operating room. Not only does this benefit the patient and physician in terms of convenience and cost savings, and the overall economic benefit to the health care system is great. The availability of modern hysteroscopic and video equipment, the advent of second-generation “global”endometrial ablation devices, and use of minimal sedation combined with effective local anesthesia have made office procedures possible. Several states have enacted specific regulations and requirements for office based surgery. It is incumbent on the physician to be aware of which local regulations are applicable and the level of procedure he or she is willing to perform before embarking on an office-based surgery program. The AAGL ListServ discussion forum provides members with an invaluable source of clinical opinion about patient care issues in minimally invasive gynecology. These opinions come from experts around the world representing both academic centers and clinical practice who respond to questions or issues posed by colleagues. This review discusses each of the second-generation endometrial ablation devices in detail and some of the more pertinent issues related to office hysteroscopy and global endometrial ablation that were posted on the ListServ. Rollerball and transcervical resection of the endometrium are not discussed because the overwhelming majority of these procedures are performed in the operating room and there is little potential for their becoming office procedures. Practical clinical tips based on the evidence in the literature are discussed.     

Pain and Operative Technologies Used in Office Hysteroscopy: A Systematic Review of Randomized Controlled Trials

ObjectiveTo identify technologies associated with the least operative pain in women undergoing operative office hysteroscopic procedures.Data SourcesMEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central Register of Controlled Trials were searched until January 2021 using a combination of keywords “hysteroscop*,” “endometrial ablation,” “outpatient,” “ambulatory,” “office,” and associated Medical Subject Headings.Methods of Study SelectionRandomized controlled trials evaluating the effect of hysteroscopic devices on pain experienced by women undergoing operative office hysteroscopy were included. Data were also collected regarding efficacy, procedural time, adverse events, and patient/clinician acceptability and/or satisfaction.Tabulation, Integration, and ResultsThe search returned 5347 records. Ten studies provided data for review. Two trials compared endometrial ablation using bipolar radiofrequency with thermal balloon energy, with no significant difference in pain observed (p <.05). Seven trials evaluated technologies for endometrial polypectomy, of which, 4 compared energy modalities: miniature bipolar electrode resection against resectoscopy (N = 1), morcellation (N = 2), and diode laser resection (N = 1). Two studies compared hysteroscope diameter, and one study compared methods of polyp retrieval. A significant reduction in pain was found using morcellators rather than miniature bipolar electrosurgical devices (p <.001), 22Fr rather than 26Fr resectoscopes (p <.001), and 3.5-mm fiber-optic hysteroscopes with 7Fr forceps rather than 5-mm lens-based hysteroscopes with 5Fr forceps (p <.05). One study investigating septoplasty showed significant reduction in pain when cold mini-scissors, rather than a miniature bipolar electrode, were used (p = .013). Average procedural times ranged from 5 minutes 28 seconds to 22 minutes. The incidence of adverse events was low, and data regarding efficacy and acceptability/satisfaction were limited.ConclusionPain is reduced when mechanical technologies such as morcellators and scissors are used compared with electrical devices for removing structural lesions in the office. For hysteroscopic and ablative procedures, smaller and quicker devices are less painful. Large-scale RCTs investigating patient pain and experience with modern operative devices in the office setting are urgently needed.     

Assessment of Tubal Patency: A Prospective Comparison of Diagnostic Hysteroscopy and Laparoscopic Chromopertubation

Study ObjectiveTo evaluate whether the presence of a visualizable “flow” effect in the fallopian tube ostia in hysteroscopy was predictive of tubal patency.DesignA prospective cohort study.SettingIn a prospective study, infertile women who underwent surgery because of infertility between March and November 2018 were included. The main outcome parameter was fallopian tube patency assessed by laparoscopic chromopertubation. The predictive parameter tested was the presence of hysteroscopic tube flow.PatientsSeventy-two infertile women.InterventionsCombined hysteroscopy and laparoscopy with chromopertubation.ResultsOne-hundred forty-four fallopian tubes were evaluated, with 88 (61.1%) patent tubes at laparoscopic chromopertubation. A positive hysteroscopic flow effect was recorded for 94 (65.3%) ostia and was accurate in predicting patency (p < .001), with a sensitivity of 85.3% (95% confidence interval [CI], 76.1–91.9) and a specificity of 66.1% (95% CI, 52.2–78.2). A multivariate binary regression model revealed that the presence of a hydrosalpinx (odds ratio = 8.216; 95% CI, 1.062–63.574; p = .044) and peritubal adhesions (odds ratio = 3.439; 95% CI, 1.142–10.353; p = .028) were associated with a false-normal flow result. A hazy hysteroscopic picture was found in 15 of 21 (71.4%) and 5 of 51 (9.8%) cases with and without bilateral tubal occlusion, respectively (p < .001, sensitivity = 71.4% [95% CI, 47.8–88.7], specificity = 90.2% [95% CI, 78.6–96.7]).ConclusionsThe presence of hysteroscopic tubal flow was a reliable indicator of tubal patency. A hydrosalpinx or peritubal adhesions increase the risk for a false-normal result. A hazy hysteroscopic picture suggests bilateral tubal occlusion. Using the hysteroscopic flow effect, one can provide additional information for the patient.     

Hysteroscopy for Assessing Fallopian Tubal Obstruction: A Systematic Review and Diagnostic Test Accuracy Meta-analysis

ObjectiveTo assess the diagnostic accuracy of hysteroscopy compared with that of laparoscopic chromopertubation for the detection of fallopian tubal obstruction.Data SourcesAn electronic search from inception to March 31, 2020, was performed in Medline, Scopus, EMBASE, and the Cochrane Central Register of Controlled Trials.Methods of Study SelectionThis diagnostic accuracy meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Synthesizing Evidence from Diagnostic Accuracy Tests recommendations. A combination of the following Medical Subject Headings terms and keywords was included in the search strategy: “hysteroscopy[MeSH],” “tubal obstruction,” “tubal patency,” “tubal dysfunction,” and “tubal blockage.” Quality assessment of the included studies was conducted using the Quality Assessment Tool for Diagnostic Accuracy Studies–2 (University of Bristol, Bristol, United Kingdom). Publication bias was evaluated by means of the Deek funnel plot asymmetry test. The following outcomes were analyzed: diagnostic odds ratio, area under hierarchical summary receiver operating characteristic and area under receiver operating characteristic curve, sensitivity, specificity, and positive and negative likelihood ratios.Tabulation, Integration, and ResultsSix studies comparing hysteroscopy with laparoscopic chromopertubation were included in the meta-analysis. After pooling all the studies, the diagnostic odds ratio was 43. The evaluated area under receiver operating characteristic curve was 0.93, correlating with high diagnostic accuracy for the index test. Sensitivity and specificity were 88% and 85%, respectively. In addition, the positive and negative likelihood ratios were 5.88 and 0.16, respectively.ConclusionHysteroscopic techniques are highly accurate and sensitive for detecting fallopian tubal obstruction. Interventional assessment enhances diagnostic accuracy compared with observational assessment, as does the office setting compared with the operating room. Additional studies, along with a refinement of the techniques, could facilitate the widespread use of hysteroscopic techniques for the detection of fallopian tube occlusion.     

Office Hysteroscopy. An operative gold standard technique and an important contribution to Patient Safety

According to World Health Organization (WHO), about 1 out of 10 hospitalized patients suffers an adverse event, in developed countries, being an adverse event an injury related to medical management, in contrast to complications of disease. These events cause both unnecessary suffering and huge cost to health systems. This issue is so important that WHO has defined it as a global health problem and in 2004 launched the World Alliance for Patient Safety, with the aim to coordinate, disseminate and accelerate improvements in Patient Safety. Office Hysteroscopy (OH), as an independent technique of the hospital circuit, has the ideal conditions to be qualified as the gold standard technique for the surgical treatment of intracavitary uterine pathology. It does not require the use of an operating room, hospital admission and general or locoregional anaesthesia. The appropriate surgical techniques, allied to pain control, allow OH to resolve much more than 90 % of the surgical needs of the intracavitary uterine pathology, thus being an important contribution for Patient Safety.     

Diagnostic validity of the Vabra Curettage. Compared study on 172 patients who underwent Vabra Curettage and the fractional curettage of the uterine cavity

The authors report 172 cases of patients who had to undergo a curettage of the uterine cavity and an endometrial sampling with Vabra Curettage. In 80.8% of the cases, the histologic diagnosis of the material removed with Vabra Curettage was comparable with that of the uterine curettage. In 8.7% of the sampling, the histologic diagnosis of the tissue removed with the "suction technique" was easier. In 10.5% of the cases, the diagnosis was more reliable in the samplings taken away with uterine curettage. In this last group, nevertheless, the endometrial tissue removed with Vabra curettage allowed us to exclude the presence of an adenocarcinoma or of an atypical hyperplasia. Only in 1.2% of the specimens, the Vabra Curettage did not allow us to exclude an endometrial pathology (for lack of material). On account of the increased incidence of endometrial carcinoma, the tolerability of the method proposed, its low cost, the Authors advocate a large-scale use of this method for a prevention program directed at the high-risk population for this carcinoma.     

宫腔镜检查与子宫内膜癌腹腔冲洗液细胞学相关因素的临床研究

目的:研究宫腔镜检查是否增加子宫内膜癌腹腔冲洗液细胞学的阳性率.方法:回顾性分析子宫内膜癌患者224例,其中经分段诊刮诊断184例,经宫腔镜诊断40例.比较两组腹腔冲洗液细胞学的阳性率,并同时分析组织学类型、肌层浸润深度、病灶分布、组织学分级、临床分期等与腹腔冲洗液细胞学的关系.结果:经宫腔镜检查的40例患者中,腹腔冲洗液细胞学的阳性率(25.00%)高于经诊刮诊断的184例患者的阳性率(21.74%),但两者差异无统计学意义.腹腔冲洗液细胞学阳性与组织学类型、肌层浸润深度、组织学分级无关(P＞0.05),但与病灶分布(弥漫型)、临床分期晚(Ⅱ期以上)有关(P＜0.05).经宫腔镜检查和经分段诊刮诊断的腹腔冲洗液细胞学阳性率在以上各因素下比较,差异均无统计学意义(P＞0.05).结论:宫腔镜检查并未增加子宫内膜癌患者腹腔冲洗液细胞学阳性率,经宫腔镜检查的子宫内膜癌患者同诊断性刮宫诊断者一样,腹腔冲洗液细胞学阳性率与临床分期晚、病灶分布弥漫因素有关.     

Sexual Counselling — A Dual Counselling Approach

A technique has been described which utilises a dual counselling approach to handle problems of a sexual nature. The methods used to structure counselling sessions are discussed as well as the benefits and the drawbacks of using a male and female counsellor to assist people who have some failure in their sexual lifestyle.     

A Systematic Review of the Effect of Type,Pressure, and Temperature of the Distension Medium on Pain During Office Hysteroscopy

ObjectiveTo identify the optimal distension medium type, pressure, and temperature to minimize pain during office hysteroscopy.Data SourcesMEDLINE, EMBASE, CINAHL, and CENTRAL were searched from inception to January 29, 2020.Methods of Study SelectionWe included randomized controlled trials in which women undergoing office hysteroscopy were randomized to either a distension medium type, pressure, or temperature against a suitable control, where pain was an outcome. Data regarding feasibility, visualization, complications, and satisfaction were also collected.Tabulation, Integration, and ResultsThe literature search returned 847 studies, of which 18 were included for systematic review and 17 for meta-analysis. There was no significant difference in intraprocedural pain when comparing the use of normal saline against carbon dioxide (standardized mean difference [SMD], –0.12; 95% confidence interval [CI], –0.36 to 0.13). Subgroup analysis of high-quality studies revealed a statistically significant reduction in postprocedural pain with normal saline (SMD, –0.65; 95% CI, –1.14 to –0.16). Side effects were less frequent (Peto odds ratio, 0.29; 95% CI, 0.20–0.40) and patient satisfaction was higher (SMD, 1.39; 95% CI, 0.51–2.28) with normal saline compared with carbon dioxide. Pressures of ≤40 mm Hg reduced intraprocedural pain (SMD, –0.67; 95% CI, –1.09 to –0.26) at the expense of a higher proportion of unsatisfactory views (81%–89% at ≤40 mm Hg vs 95%–99% at ≥50 mm Hg). Postprocedural pain was reduced with lower filling pressures. Warming saline did not reduce intraprocedural pain (SMD, 0.59; 95% CI, –0.14 to 1.33).ConclusionNormal saline, instilled at the lowest pressure to acquire a satisfactory view, should be used for uterine distension during office hysteroscopy to minimize pain.