What are the steps involved in a hysteroscopy procedure?

Hysteroscopy Procedure Steps

Hysteroscopy involves sequential steps beginning with patient positioning and speculum placement, followed by cervical visualization, hysteroscope insertion through the cervical canal, distension of the uterine cavity, systematic visualization of the endometrium and tubal ostia, and completion of any indicated operative interventions before instrument removal. 1, 2

Pre-Procedure Preparation

Patient Positioning and Setup

• Position the patient in dorsal lithotomy position on the examination table 1
• Elevate the exam table so the patient can maintain eye contact with the clinician throughout the procedure 3
• Ensure the patient has eaten and drunk beforehand to prevent vasovagal reactions 3
• Obtain informed consent and confirm the patient is not pregnant, as pregnancy is an absolute contraindication 2

Pain Management Administration

• Administer pericervical block with local anesthetic if planned (this is the first moment of discomfort, averaging 2-3 on pain scale) 4
• Consider pre-procedure NSAIDs for pain control 3
• For high-risk patients (history of chronic pelvic pain, anxiety, menopause, previous cesarean section), consider additional analgesic strategies 5

Procedural Steps

Step 1: Speculum Insertion and Cervical Visualization

• Insert the vaginal speculum to visualize the cervix 1
• Cleanse the cervix with antiseptic solution 2
• This stage typically causes minimal discomfort (lowest pain ratings) 4

Step 2: Hysteroscope Introduction

• For vaginoscopic "no-touch" approach: Insert the miniaturized hysteroscope (3.5mm or less) directly through the vagina without speculum or tenaculum, which significantly reduces pain 1, 5
• For traditional approach: Apply a cervix holder (tenaculum) if needed for cervical traction 3
• Remove the speculum and advance the hysteroscope into the vagina 4
• Visualize the external cervical os 4

Step 3: Passage Through the Cervical Canal

• This is the most painful stage of the procedure (averaging 2.47 on VAS pain scale), particularly in postmenopausal patients 4
• Gently advance the hysteroscope through the endocervical canal under direct visualization 1, 2
• Begin distension of the cavity with appropriate medium (normal saline for diagnostic procedures; glycine or sorbitol if electrosurgery is planned) 2
• Pause after this step to allow the patient to indicate readiness to continue 3

Step 4: Uterine Cavity Visualization

• Systematically examine the entire endometrial cavity including anterior, posterior, and lateral walls 6, 2
• Visualize both tubal ostia 2
• Assess for polyps, submucosal fibroids, adhesions, septa, or other pathology 6, 1
• This stage causes moderate discomfort (averaging 2.12 on pain scale) 4

Step 5: Operative Intervention (if indicated)

• For submucosal fibroids: Use electrosurgical wire loop or mechanical instruments for resection 7
• For polyps: Grasp and remove with hysteroscopic forceps or scissors 5
• For adhesions: Lyse under direct visualization 5
• For biopsies: Obtain targeted endometrial samples 5
• Procedures limited to endometrial mucosa (biopsies, polypectomy <2.2cm, adhesiolysis) are generally not painful 5

Step 6: Procedure Completion

• Withdraw the hysteroscope slowly while performing a final inspection 1
• Monitor for immediate complications including bleeding, perforation, or vasovagal reaction (occurs in 5% of cases) 7
• Total procedure time typically ranges from 5-15 minutes for diagnostic hysteroscopy 5

Critical Procedural Considerations

Equipment Selection

• Use miniaturized hysteroscopes (≤3.5mm diameter) for office procedures, as they cause significantly less pain than 5mm instruments 5
• Video monitoring allows patient engagement and reduces anxiety 1

Distension Media Management

• Monitor fluid deficit carefully during operative procedures to prevent fluid overload 7, 2
• Normal saline is preferred for diagnostic procedures and compatible with bipolar electrosurgery 2

Common Pitfalls to Avoid

• Forcing the hysteroscope through cervical stenosis: This increases perforation risk and pain; consider cervical preparation with misoprostol in high-risk patients (postmenopausal, nulliparous) 1
• Inadequate distension: Poor visualization leads to missed pathology and increased procedure time (>15 minutes increases pain) 5
• Ignoring patient distress signals: The patient controls the procedure and can pause or stop at any time 3
• Performing in inappropriate settings: High-risk cardiac patients (pulmonary arterial hypertension, Fontan circulation) require hospital-based settings with full emergency support, not office settings 7

Potential Complications

• Uterine perforation (most common serious complication) 7, 2
• Hemorrhage requiring transfusion 7
• Cervical laceration 2
• Bowel or bladder injury (rare) 7
• Fluid overload with electrolyte disturbances 7, 2