What are the steps involved in a hysteroscopy procedure?

Hysteroscopy Procedure Steps

Hysteroscopy is performed by inserting a hysteroscope transvaginally through the cervix into the uterine cavity, using distension media for visualization, and can be done in an office setting with local anesthesia or in an operating room under general anesthesia depending on the complexity of the procedure. 1, 2

Pre-Procedure Preparation

• Patient positioning and equipment setup: Position the patient in lithotomy position and prepare miniaturized hysteroscopic equipment with video monitoring capabilities 1, 3
• Cervical preparation: For patients at highest risk of cervical stenosis (particularly postmenopausal women) or anticipated pain with dilation, consider cervical preparation agents 1, 4
• Pain management: Administer pericervical local anesthetic block for office procedures, or arrange general anesthesia for complex operative cases 1, 4
• Distension media preparation: Prepare saline as the distending medium for office-based procedures 2, 3

Procedural Steps

Step 1: Vaginoscopic Approach (No-Touch Technique)

• Insert hysteroscope without speculum or tenaculum using the "no-touch" vaginoscopic approach to minimize patient discomfort 1, 3
• This stage (equipment installation) typically causes minimal pain (VAS2: lowest pain scores) 4

Step 2: Visualization of External Cervical Os

• Advance hysteroscope through vagina until external orifice of cervical canal becomes visible 4
• This stage (VAS3) causes moderate pain levels 4

Step 3: Passage Through Cervical Canal

• Navigate hysteroscope through the cervical canal into the uterine cavity 4
• This is the most painful stage of the procedure (VAS4: 2.47 ± 2.48 points), particularly in postmenopausal patients who require additional pain management strategies 4

Step 4: Uterine Cavity Evaluation and Treatment

• Systematically visualize the entire uterine cavity including anterior and posterior walls, fundus, tubal ostia, and endocervical canal 2, 3
• Perform diagnostic assessment or therapeutic intervention as indicated (biopsy, polypectomy, adhesiolysis, myomectomy) using the "see and treat" approach 2, 3
• This stage (VAS5) causes the second-highest pain level (2.12 ± 2.33 points) 4

Step 5: Hysteroscope Withdrawal

• Remove hysteroscope under direct visualization to complete the procedure 2
• Overall procedure pain (VASmax) averages 3.5 ± 2.37 on a 10-point scale 4

Specific Hysteroscopic Procedures

Hysteroscopic Myomectomy

• Insert hysteroscope and remove submucosal fibroids using electrosurgical wire loop or other instruments 5
• This approach is indicated specifically for submucosal fibroids 5

Hysteroscopic Sterilization

• Insert metal micro-insert or polymer matrix (such as Essure device) into the interstitial portion of each fallopian tube 5
• Confirm bilateral tubal occlusion with pelvic imaging three months after placement 5

Critical Pitfalls to Avoid

• Do not perform hysteroscopy in high-risk cardiac patients (PAH, Fontan circulation) in outpatient settings; these require hospital-based procedures with full emergency support 5
• Recognize that postmenopausal patients experience significantly more pain during cervical canal passage and require enhanced pain management 4
• Monitor for vasovagal reactions, which occur in 5% of patients during intrauterine device procedures 5
• Watch for complications including uterine perforation, fluid overload, bleeding requiring transfusion, and bowel or bladder injury 5