Medications to Hold Before Hysteroscopy
For diagnostic hysteroscopy, continue all antiplatelet agents (aspirin, clopidogrel) and anticoagulants without interruption, as this is a low-risk procedure with minimal bleeding risk. For operative hysteroscopy with tissue resection, apply high-risk endoscopic procedure protocols.
Risk Stratification
Diagnostic hysteroscopy is classified as a low-risk procedure similar to diagnostic endoscopy with biopsies, requiring no medication adjustments 1. Operative hysteroscopy with significant tissue resection (e.g., myomectomy, endometrial ablation) should be managed as a high-risk procedure 1.
Management by Medication Class
Antiplatelet Agents - Low Risk (Diagnostic Hysteroscopy)
Continue all antiplatelet therapy without interruption:
- Aspirin monotherapy: Continue without dose adjustment 1
- Clopidogrel monotherapy: Continue without interruption 1
- Dual antiplatelet therapy (aspirin + clopidogrel): Continue both agents 1
Antiplatelet Agents - High Risk (Operative Hysteroscopy)
For patients at low thrombotic risk:
- Discontinue clopidogrel 5 days before the procedure 1
- Continue aspirin throughout the perioperative period if on dual antiplatelet therapy 1
- Resume clopidogrel 1-2 days postoperatively if hemostasis is adequate 2
For patients at high thrombotic risk (drug-eluting stent <12 months, bare metal stent <1 month, acute coronary syndrome <6 months, prosthetic mitral valve):
- Continue aspirin 1
- Consult cardiology immediately before making any decision about stopping clopidogrel 3, 2
- The risk of stent thrombosis can occur within 7 days of stopping antiplatelet therapy 3
Anticoagulants - Low Risk (Diagnostic Hysteroscopy)
Warfarin:
- Continue warfarin with INR verification within therapeutic range during the week prior to procedure 1
- Ensure INR does not exceed therapeutic range 1
Direct Oral Anticoagulants (DOACs):
- Omit only the morning dose on the day of the procedure 1
- For dabigatran with CrCl 30-50 mL/min, take last dose 72 hours before procedure 1
Anticoagulants - High Risk (Operative Hysteroscopy)
For patients at low thrombotic risk:
Warfarin:
- Stop warfarin 5 days before the procedure 1
- Verify INR <1.5 prior to procedure 1
- No bridging with LMWH needed for low thrombotic risk 1
DOACs:
- Take last dose >48 hours before the procedure 1
- For dabigatran with reduced renal function (CrCl 30-50 mL/min), extend to 72 hours 1
For patients at high thrombotic risk:
Warfarin:
- Stop warfarin 5 days before procedure 1
- Start LMWH bridging 2 days after stopping warfarin 1
- Verify INR <1.5 before procedure 1
- Restart warfarin evening of procedure 1
NSAIDs
NSAIDs do not require discontinuation for either diagnostic or operative hysteroscopy, though they increase bleeding risk when combined with antiplatelet agents 4, 5. Avoid chronic ibuprofen use in patients on aspirin, as ibuprofen blocks aspirin's antiplatelet effect 5.
Critical Pitfalls to Avoid
- Never stop both aspirin and clopidogrel simultaneously in patients on dual antiplatelet therapy, as this dramatically increases stent thrombosis risk with median time to thrombosis as short as 7 days 3
- Do not bridge with heparin when stopping clopidogrel alone - bridging is not indicated for antiplatelet agents 2
- Do not hold clopidogrel longer than 5-7 days, as each additional day off therapy increases cardiovascular event risk 3
- Avoid omeprazole and esomeprazole in patients on clopidogrel, as these CYP2C19 inhibitors reduce clopidogrel's antiplatelet effect 4, 5
Supporting Evidence from Urologic Procedures
Ureteroscopy data supports the safety of continuing antiplatelet therapy for low-risk endoscopic procedures. Studies show no increased bleeding complications when continuing aspirin, clopidogrel, or warfarin during ureteroscopy 6, 7. The bleeding-related complication rate was 1.9% regardless of antiplatelet continuation 6.