The main goal during in office diagnostic hysteroscopy is to obtain a smooth access the uterine cavity, making a full assessment, in a way that the patient can tolerate the procedure with minimal discomfort. Here we will describe common everyday situations and provide some tips to improve your skills.
What is the best tolerated uterine access technique?
To access the uterine cavity by “vaginoscopy” without the use of a speculum allows not only to decrease the stimulation of the cervix, but also to perform a visual inspection of its entirely. We place the tip of the hysteroscope at the external os opening the outflow slowly distending the walls of the cervical canal adapting to its larger diameter.
To explain the procedure to the patient using simple words and informing her what she is going to perceive is essential to reduce anxiety and fear improving patient’s tolerance to the procedure.
Tips to reduce discomfort at the beginning of the hysteroscopy and decreasing vasovagal symptoms.
One of the main causes of pain during diagnostic hysteroscopy is cervical stimulation during uterine cavity access. It is very important to match the diameter of the hysteroscope to the diameter the cervical canal, which is achieved with smooth turns of 30 to 90° to introduce the hysteroscope with the least possible resistance. This requires knowledge of the diameters of the sheath and the angle of the lens of the hysteroscope that is being used.
Another key point to decrease vasovagal symptoms is to avoid lateral movements of the hysteroscope at the cervical canal; ideally, the use an angled lens allows improved lateral visualization that is key for adequate diagnostic hysteroscopy. Only by making gentle 90° turns we can assess all the uterine walls with minimal cervical stimulation.
Rapid uterine relaxation is another the cause of pain. It is advisable not to use high intrauterine pressure, reducing the in-flow of distention media at the beginning of the procedure. If the distention media enter the cavity too fast (high pressure), or if we have to release adhesions to enter the cavity it will cause pain. It is desirable to distend the cavity gradually. This is achieved by regulating in-flow of distention media.
Stenotic cervix and intrauterine adhesions
Sometimes it can be difficult to introduce the tip of the hysteroscope in a pin-point cervical os, requiring to increase the diameter of the cervical os. This can be done with scissors and/or forceps to allow passage of the hysteroscope.
Similarly, it is sometimes necessary to release intrauterine adhesions to gain access to the cavity. Sometimes it is hard to determine the direction of cervical canal. What we do in these cases is to obtain a closer look with the hysteroscope to identify passage of a small amount of distention media. If the canal is not clearly seen, we carefully use the tip of a grasper to lead the way forward, avoiding excessive pressure preventing uterine perforation.
Uterus with marked anteflexion
When in presence of a marked anteflexed uterus, we find it difficult to access cavity with a rigid hysteroscope. A simple way to correct this angle and access cavity is to have an assistant apply light suprapubic pressure to improve the angle of the uterus and cervical canal facilitating the insertion of the hysteroscope.
Access to the cavity
Before we begin to evaluate the cavity, we must always ask ourselves, where the tip of the hysteroscope is? That is achieved by slightly withdrawing the hysteroscope to get an overall view. The best point of reference in the uterine cavity is visualization of the tubal ostium, especially in cases where the uterine cavity has abnormal shape or access has been difficult.
I am inside the cavity but can’t see well…
The accumulation of uterine secretions or blood may hinder the view preventing an adequate diagnostic hysteroscopy. The easiest way to “wash” the uterine cavity is to place the tip of the hysteroscope at the fundus and to open the outflow to allow the content to exit the uterine cavity progressively improving vision.
Systematically analyze the cavity
Evaluating the uterine shape and size is an important part of diagnostic hysteroscopy. It is really important to be systematic in the assessment,especially in cases where we find intracavitary pathology. We must be rigorous in assessing the endometrium, as behind a polyp or fibroids can hide endometrial pathology. Therefore, before performing any procedure, such as taking biopsy or resect a polyp or fibroid, it is recommended to assess the entire endometrium.
How to properly take a biopsy and perform tissue extraction?
Taking an adequate biopsy prevent the need of multiple insertions of the hysteroscope causing unnecessary discomfort to the patient. The biopsy grasper must move en bloc along with the hysteroscope, without working at excessive distance from the tip of the hysteroscope, not to loose strength or definition when performing a direct biopsy. To get more biopsy tissue and avoid loosing the specimen when removing the hysteroscope through the cervical canal, when taking the biopsy do not obtain a pinch of tissue but place the specimen inside the open biopsy clamp and advance the clamp into the tissue as you close its jaws, ensuring a greater amount of tissue within the clamp.
If I want to take multiple biopsies?
Sometimes it is necessary to take several biopsies of the most representative areas and take them in an orderly manner can facilitate our work, especially if it is friable tissues that bleed easily. It is advisable to analyze well all areas to be biopsied before and to initially take the biopsies that are closer to the uterine fundus or are difficult to access, so that potential bleeding will not stop us from performing all the required biopsies.
Once the hysteroscopy is completed, how to document the findings?
It is very important to document the findings of hysteroscopy describing the details as thoroughly as possible, we also describe the route taken with the hysteroscope to enter the cavity since having this information will be very valuable for future reference in case of assisted fertility procedures or simply placing an IUD in the future.