Diagnostic Hysteroscopy & Biopsy

 In order to perform hysteroscopy, the surgeon must have clear indications for the procedure. It is also especially important to ensure that the patient has as much information as possible about their condition and the anticipated risks and benefits of any procedure.  A complete and focused history and physical exam should be performed, in order to have a complete picture of the patient’s condition. Potential contraindications to the hysteroscopic approach should be identified, including pregnancy or active pelvic infection. All previous imaging and lab testing need to be reviewed. After completing the evaluation the procedure can be scheduled. Office procedures can actually be performed the same day of the initial visit, but this decision depends on patient’s choice, the particular clinical features, available technology, office environment, local requirements and regulatory compliance. Although it is generally preferable to do the procedure when the endometrium is thin, a circumstance that facilitates a more accurate evaluation. Naturally, this occurs in postmenopausal women, or, for those ovulatory women in their reproductive years, early in the follicular phase of the cycle but within a few days of the end of the period.  For others, a thin endometrium can be created using a spectrum of medications but most commonly progestins or combined estrogen/progestin compounds. In some instances, and particularly when evaluating for malignancy, diagnostic hysteroscopy should be performed without such suppression and in an expeditious fashion. It is especially important to assure patients have the adequate information about their condition and the procedure before performing it.  

As with any procedure, patients should be provided complete and adequate information in an understandable fashion based on language, culture and educational level. Included are the reasons for the hysteroscopy, alternatives to the hysteroscopic approach, and the potential adverse effects including those related to anesthesia and the procedure, such as perforation or failure to access the endometrial cavity. The clinician must ensure that the informed consent form is read completely, and they should be provided both verbally and via written materials adequate information to ensure understanding of their condition their condition and the indications for the procedure.

For an office hysteroscopy, no preparation is needed unless medical suppression is required as discussed above. Presurgical AINEs, prophylactic antibiotics or cervical ripening medications are not routinely indicated but may be considered on a case by case basis. Preprocedure fasting is unnecessary if the procedure is performed using no or local anesthesia and medical leave beyond the day of the procedure is generally unnecessary. If performed under nor or local anesthesia the patient can expect go back to their regular activities immediately after the hysteroscopy. Pregnancy should be systematically excluded on the procedure day, and the clinician should take steps to be as sure as possible that there no evidence of an abdominal-pelvic infection.

For the surgeon and team, it is essential that there is both adequate training and surgical expertise, including complete knowledge of surgical principles and equipment. The design and elements of the procedure room have been described elsewhere, and should be be ready, not only for the procedure, but for the possibility of adverse events. There should be consideration for the provision of adequate analgesia/anesthesia if needed. Appropriate hysteroscopic and ancillary instruments and supplies must be available. The room environment should foster a sense of comfort including the room temperature, appropriate music and décor.