As Dr. James Presthus discussed, in-office hysteroscopy not only makes good economic sense, it is good patient care. The office hysteroscope is critical for thoroughly evaluating abnormal uterine bleeding (the most common indication) and for more accurately diagnosing its common causes while maintaining the valuable ability to “see and treat.” For the diagnosis of abnormal uterine bleeding, hysteroscopy is simply an essential, integral part of good patient care. Once you add the office hysteroscope to your diagnostic armamentarium, you will find it difficult to imagine practicing ambulatory gynecology without it.
Office hysteroscopy plays a much larger role beyond diagnosis, however, because it enables us to remove polyps and adhesions, to do biopsies, and to perform minor therapeutic and operative procedures—such as hysteroscopic sterilization using the Essure system and global endometrial ablation—in a setting where our patients are comfortable and relaxed.
Control of pain (or the perception that patients will not tolerate the procedure) seems to be the greatest concern of physicians who are considering adding in-office hysteroscopy to their practice. It need not be. Patients tolerate in-office hysteroscopy extremely well.
A small hysteroscope is no larger than a Pipelle endometrial suction curette. Showing the patient a picture of both instruments, side by side, is truly worth a thousand words. Add to that the reduction in anxiety thanks to familiar surroundings, the conversations with office staff who often know the patient on a first-name basis, and a visualization of the procedure, and the discomfort that would be experienced in an operating room quickly dissipates.
Diagnostic hysteroscopy with a 3-mm flexible hysteroscope, in fact, does not require any anesthesia. Nevertheless, because studies indicate that a minority of patients find distention of the uterus uncomfortable and because we take a “see and treat” approach to in-office hysteroscopy, we use a small paracervical block. This way, virtually 100% of our patients are completely comfortable, and we are ready to move on to treatment if needed.
This is exactly what we tell our patients: that the small injection of local anesthetic will help them to tolerate the procedure, especially if we find a polyp or other abnormal tissue and want to remove it on the spot rather than subject them to a second procedure at a later date.
Both the Essure procedure and global endometrial ablation—we use a thermal ablation device called the Hydro ThermAblator (HTA) system—can be performed under local anesthesia with oral premedication at home.
When you embark on in-office operative hysteroscopy, it is vital to be aware of state regulations regarding in-office surgery. Almost 20 states now have rules that differentiate procedures into level I surgery and level II surgery, depending largely on the types of anesthesia used.
The South Carolina Board of Medical Examiners, for instance, defines level I surgery as including minor procedures in which “[oral] preoperative medication and/or unsupplemented local anesthesia” is used in quantities no greater than the manufacturer's recommended dose, with “no drug-induced alteration of consciousness other than preoperative minimal [oral] anxiolysis of the patient.”
Level II office surgery includes procedures that “require the administration of minimal or moderate intravenous, intramuscular, or rectal sedation/analgesia, thus making postoperative monitoring necessary.” Offices performing level II surgery must receive certification and follow various regulations and standards aimed at ensuring patient safety. A significant amount of office-based surgery done today involves the use of parenteral narcotics and thus is considered level II surgery. The protocols we use for in-office hysteroscopy and hysteroscopic procedures, however, are all level I.
For ablation, the HTA system is ideally suited for office use under minimal or level I sedation because it operates at low pressure (50 mm Hg) and is a “no touch” technique. Many of the other nonhysteroscopic global ablation technologies have also been used in the office setting, but—in order to ensure patient comfort—they may require parenteral narcotics, which are considered moderate or level II sedation.
Instrumentation and Setup
For diagnostic hysteroscopy, I favor a 3-mm flexible hysteroscope. I also prefer using normal warmed saline as a distension medium, and I have found that hanging the saline in a 1,000-cc bag on a tall IV pole, with standard IV tubing and with a pressure cuff to maintain distention, is an ideal setup. We use the C-Fusor pressure infusor bag.
Injecting the saline with a 60-cc syringe is another option and is certainly adequate for a quick diagnostic procedure. The disadvantage to this approach, however, is the likelihood of needing to continually change syringes if polyp removal or another treatment is needed, or if the patient has a patulous cervix and transcervical fluid loss occurs.