Hysteroscopy without Anesthesia: Review of Recent Literature

doi:10.1016/j.jmig.2010.07.003

Journal of Minimally Invasive Gynecology

Volume 17, Issue 6, November–December 2010, Pages 703-708

https://doi.org/10.1016/j.jmig.2010.07.003 Get rights and content

Abstract

The need for anesthesia or analgesia for performing hysteroscopy is still matter of debate. Many factors explain the lack of agreement about anesthesia in hysteroscopy depending on the instrumentation, technique employed, need of performing surgical procedure, operator skill and patients' characteristics. Diagnostic minihysteroscopy (3.5 mm or less in size) is less painful and easier to perform than hysteroscopy performed with instruments sized around 5 mm. Thanks to miniaturized instruments, office hysteroscopy allows a growing number of women to be treated in an office setting avoiding the operating room. The main limitation to its widespread use is pain and low patient tolerance. Intrauterine surgical procedures involving only the endometrial mucosa (biopsies, adhesiolisis, cervical and endometrial polyectomies) are not painful. For endometrial polypectomy size of polyps (<2.2m) and duration of the procedure (more than 15 min) are limiting factors. Most literature suggests that office hysteroscopy in experienced hands is a well-tolerated technique and requires the use of analgesics only in selected patients like women with previous caesarean section, history of chronic pelvic pain, anxiety and in menopause.

Section snippets

Materials and Methods

A search of the PubMed database from 199 to the present was performed using the keywords “Anesthesia, “Hysteroscopy”, and “Pain.” Seventy-nine articles about both diagnostic and operative hysteroscopy were retrieved.

First, the causes of pain in simple exploration (diagnostic hysteroscopy) were examined; however, it must be remembered that the same factors influence pain perception and need for anesthesia in operative procedures.

Operative Hysteroscopy

Operative hysteroscopes sized 5 mm or smaller equipped with a 5F operative canal have enabled many surgical procedures to be performed in an office setting, with local or no anesthesia 32, 33, 34. The realization of 5F forceps, and especially of a bipolar coaxial electrode (Gynecare VersaPoint; Ethicon Inc., Somerville, NJ), has enabled the therapeutic possibility of office hysteroscopy, and currently many intrauterine diseases may be treated immediately after diagnosis, that is, using the

Conclusions

In a growing number of women, hysteroscopic procedures can be successfully performed in an office setting without any anesthesia. Diagnostic minihysteroscopy using 3.5-mm instruments is less painful and easier to perform than hysteroscopy performed using 5-cm instruments. However, severe pain and adverse effects may occur rarely even with mini-instruments. Women with a history of cesarean section, chronic pelvic pain, or anxiety, or are menopausal should be considered at risk of pain

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Cited by (84)

Guideline No. 447: Diagnosis and Management of Endometrial Polyps
2024, Journal of Obstetrics and Gynaecology Canada
The primary objective of this clinical practice guideline is to provide gynaecologists with an algorithm and evidence to guide the diagnosis and management of endometrial polyps.
All patients with symptomatic or asymptomatic endometrial polyps.
Options for management of endometrial polyps include expectant, medical, and surgical management. These will depend on symptoms, risks for malignancy, and patient choice.
Outcomes include resolution of symptoms, histopathological diagnosis, and complete removal of the polyp.
The implementation of this guideline aims to benefit patients with symptomatic or asymptomatic endometrial polyps and provide physicians with an evidence-based approach toward diagnosis and management (including expectant, medical, and surgical management) of polyps.
The following search terms were entered into PubMed/Medline and Cochrane: endometrial polyps, polyps, endometrial thickening, abnormal uterine bleeding, postmenopausal bleeding, endometrial hyperplasia, endometrial cancer, hormonal therapy, female infertility. All articles were included in the literature search up to 2021 and the following study types were included: randomized controlled trials, meta-analyses, systematic reviews, observational studies, and case reports. Additional publications were identified from the bibliographies of these articles. Only English-language articles were reviewed.
The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).
Gynaecologists, family physicians, registered nurses, nurse practitioners, medical students, and residents and fellows.
Uterine polyps are common and can cause abnormal bleeding, infertility, or bleeding after menopause. If patients don’t experience symptoms, treatment is often not necessary. Polyps can be treated with medication but often a surgery will be necessary.
- 1.
  Endometrial polyps are a common diagnosis in both pre- and postmenopausal patients (high).
- 2.
  Patients with endometrial polyps may present with abnormal uterine bleeding, postmenopausal bleeding, infertility, or may be asymptomatic (high).
- 3.
  Transvaginal ultrasound is associated with a wide range of accuracy in diagnosing endometrial polyps; however, it remains a good first-line investigation because of safety, availability, and patient acceptance (high).
- 4.
  In situations where the diagnosis of polyp on transvaginal ultrasound remains in question, consideration of saline-infused sonohysterography or 3D ultrasound, if available, can be considered as alternative diagnostic imaging techniques (moderate).
- 5.
  Hysterosalpingography, CT scanning, and MRI are not useful in the diagnosis of endometrial polyps (high).
- 6.
  Hysteroscopy with guided biopsy remains the gold standard for diagnosis of endometrial polyps (high).
- 7.
  Patients at highest risk for premalignant or malignant endometrial polyps are older (≥60y), postmenopausal, symptomatic with postmenopausal bleeding, and take tamoxifen (high).
- 8.
  Patients at intermediate risk of premalignant or malignant endometrial polyps are postmenopausal with no symptoms or premenopausal with abnormal uterine bleeding (moderate).
- 9.
  Polyp size alone has not consistently been associated with an increased risk of malignancy (low).
- 10.
  There are limited data to guide the management of patients with atypical or malignant pathology diagnosed within an endometrial polyp and normal or atrophic endometrium (low).
- 11.
  Hysteroscopic polypectomy is the most effective option for both diagnosis and treatment. The goals of hysteroscopy are three-fold: 1) complete resection, 2) minimize recurrence, and 3) obtain a pathology specimen (high).
- 12.
  Hysteroscopic polypectomy can be achieved using a variety of techniques and instruments, and it can be performed in different settings. Choice of polypectomy technique should consider the following: patient factors, local access to instruments and operating room time, setting, fluid management, cost, and surgeon preference (low).
- 13.
  Risks related to hysteroscopic polypectomy are estimated to occur in less than 3% of cases and should be discussed with the patient (high).
- 14.
  Endometrial polyps of any size treated with hysteroscopic polypectomy appear to improve pregnancy outcomes among those who conceive naturally or with intrauterine insemination (high).
- 15.
  Management of a newly diagnosed polyp during in vitro fertilization stimulation is influenced by patient prognosis, number of freezable embryos, laboratory-specific frozen embryo success rates, and accessibility of hysteroscopy (moderate).
- 16.
  There appears to be an association between endometrial polyps and recurrent pregnancy loss, but to date, data supporting polypectomy to reduce the risk of subsequent pregnancy loss is lacking (low).
- 1.
  Transvaginal ultrasound should be used as initial investigation in patients suspected to have endometrial polyps (strong, high).
- 2.
  Patients who present with features suspicious for endometrial polyps and who would benefit from subsequent polypectomy should be directed toward hysteroscopy, with a plan for operative management should a polyp be diagnosed (strong, moderate).
- 3.
  Blind sampling to diagnose endometrial polyps via endometrial biopsy or dilation and curettage should not be performed (strong, high).
- 4.
  Patients with endometrial polyps who are older (≥60 y), menopausal, have symptoms of postmenopausal bleeding, or are taking tamoxifen should be referred to a gynaecologist for further investigation and consideration of polyp resection (strong, high).
- 5.
  Referral to a gynaecologist can be considered in premenopausal patients who are symptomatic or attempting to conceive. (conditional, moderate).
- 6.
  A gynaecologic oncologist should be involved in managing the care of patients with premalignant or malignant lesions confined to an endometrial polyp, particularly in cases of uterine preservation (strong, low).
- 7.
  Expectant management can be considered for asymptomatic patients and those with a low risk of malignancy (conditional, moderate).
- 8.
  Polypectomy should be performed via direct hysteroscopic visualization, as this approach decreases the risk of complications, incomplete removal, and recurrence (strong, high).
- 9.
  Bipolar energy should be used preferentially over monopolar energy, as it reduces the risk of electrosurgical burns and fluid overload. Tissue removal systems also reduce the risk of fluid overload and avoid the risk of electrosurgical burns altogether but have functional and cost limitations (strong, high).
- 10.
  Patients diagnosed with an endometrial polyp should be offered hysteroscopic resection to improve their fertility potential if they are experiencing infertility, regardless of polyp size (strong, high).
- 11.
  When a new endometrial polyp is diagnosed during in vitro fertilization stimulation, the following options should be discussed with the patient: 1) cycle cancellation, 2) freeze-all, and 3) transfer. There is no evidence to support need to cancel the cycle (conditional, low).
Directive clinique n<sup>o</sup> 447 : Diagnostic et prise en charge des polypes endométriaux
2024, Journal of Obstetrics and Gynaecology Canada
L’objectif principal de la présente directive clinique est de fournir aux gynécologues un algorithme et des données probantes pour guider le diagnostic et la prise en charge des polypes endométriaux.
Toutes les patientes présentant des polypes endométriaux symptomatiques ou asymptomatiques.
Les options de prise en charge des polypes endométriaux sont l’expectative ou la prise en charge médicamenteuse ou chirurgicale. Le choix repose sur les symptômes, le risque de malignité et les préférences de la patiente.
Les résultats sont la résolution des symptômes, le diagnostic histopathologique et l’ablation complète du polype.
La mise en œuvre de la présente directive vise à bénéficier aux patientes ayant des polypes endométriaux symptomatiques ou asymptomatiques et à fournir aux médecins une approche fondée sur des données probantes pour le diagnostic et la prise en charge des polypes, à savoir l’expectative et la prise en charge médicamenteuse ou chirurgicale.
Des recherches ont été effectuées dans PubMed-Medline et Cochrane en utilisant les termes suivants : endometrial polyps, polyps, endometrial thickening, abnormal uterine bleeding, postmenopausal bleeding, endometrial hyperplasia, endometrial cancer, hormonal therapy et female infertility. La littérature prise en compte a été publiée jusqu’en 2021 et se compose des types d’études suivants : essais cliniques randomisés, méta-analyses, revues systématiques, études observationnelles et études de cas. D’autres publications pertinentes ont été sélectionnées à partir des notices bibliographiques de ces articles. Seuls les articles en anglais ont été examinés.
Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations, Assessment, Development, and Evaluation). Voir l’annexe A (tableau A1 pour les définitions et tableau A2 pour l’interprétation des recommandations fortes et faibles).
Gynécologues, médecins de famille, infirmières autorisées, infirmières praticiennes, étudiants en médecine, résidents et moniteurs cliniques (fellows).
Les polypes utérins sont fréquents et peuvent causer des saignements anormaux, l’infertilité et des saignements postménopausiques. Quoique la chirurgie soit souvent nécessaire, le traitement peut se faire par médicaments, mais n’est pas essentiel en l’absence de symptômes.
- 1.
  Les polypes endométriaux sont couramment diagnostiqués chez les patientes ménopausée et non ménopausée (élevée).
- 2.
  Les polypes endométriaux peuvent être asymptomatiques ou se manifester par des saignements utérins anormaux, des saignements postménopausiques ou l’infertilité (élevée).
- 3.
  L’échographie endovaginale est associée à une précision variable dans le diagnostic des polypes endométriaux; cependant, elle reste un bon examen de première intention en raison de son innocuité, de sa disponibilité et de son niveau d’acceptation par les patientes (élevée).
- 4.
  Dans les situations où le diagnostic de polype à l’échographie endovaginale reste incertain, l’hystérosonographie avec instillation de solution saline ou l’échographie 3D, si disponible, sont des solutions d’imagerie diagnostique envisageables (moyenne).
- 5.
  L’hystérosalpingographie, la tomodensitométrie et l’imagerie par résonance magnétique ne sont pas utiles pour le diagnostic des polypes endométriaux (élevée).
- 6.
  L’hystéroscopie avec biopsie guidée reste la méthode de référence pour le diagnostic des polypes endométriaux (élevée).
- 7.
  Les patientes âgées (≥ 60 ans), ménopausées, symptomatiques avec des saignements postménopausiques ou prenant du tamoxifène présentent un risque élevé de polypes endométriaux précancéreux ou malins (élevée).
- 8.
  Les patientes ménopausées asymptomatiques ou non ménopausées avec des saignements utérins anormaux présentent un risque intermédiaire de polypes endométriaux précancéreux ou malins (moyenne).
- 9.
  La taille des polypes à elle seule n’est pas systématiquement associée à un risque accru de malignité (faible).
- 10.
  Les données sont limitées pour guider la prise en charge des patientes présentant une pathologie maligne ou atypique diagnostiquée dans un polype endométrial et un endomètre normal ou atrophique (faible).
- 11.
  La polypectomie par hystéroscopie est l’option la plus efficace pour le diagnostic et le traitement. Les objectifs de l’hystéroscopie sont triples : 1) résection complète, 2) réduction du risque de récidive et 3) prélèvement pour examen histologique (élevée).
- 12.
  La polypectomie hystéroscopique peut être réalisée à l’aide d’une variété de techniques et d’instruments et dans différents milieux. Le choix de la technique de polypectomie doit tenir compte des éléments suivants : facteurs liés à la patiente, accès local aux instruments et au temps de salle d’opération, milieu, gestion des liquides, coûts et préférence du chirurgien (faible).
- 13.
  On estime les risques de complication liée à la polypectomie hystéroscopique à moins de 3 %, risques dont il faut discuter avec la patiente au préalable (élevée).
- 14.
  Quelle que soit la taille des polypes endométriaux, le traitement par polypectomie hystéroscopique semble améliorer les résultats de grossesse en cas de conception spontanée ou par insémination intra-utérine (élevée).
- 15.
  La prise en charge d’un polype nouvellement diagnostiqué en cours de stimulation ovarienne se fait en fonction du pronostic de la patiente, du nombre d’embryons congelables, du taux de réussite du laboratoire pour le transfert d’embryon congelé et de l’accessibilité à l’hystéroscopie (moyenne).
- 16.
  Bien qu’il semble y avoir un lien entre les polypes endométriaux et les fausses couches à répétition, les données actuelles sont insuffisantes pour déterminer si la polypectomie réduit le risque de fausses couches ultérieures (faible).
- 1.
  L’échographie endovaginale doit être l’examen de première intention en cas de soupçons de polypes endométriaux (forte, élevée).
- 2.
  En cas de soupçons de polypes endométriaux chez une patiente qui bénéficierait d’une polypectomie ultérieure, il y a lieu de l’orienter vers l’hystéroscopie avec un plan de prise en charge chirurgicale si un polype est diagnostiqué (forte, moyenne).
- 3.
  Le prélèvement à l’aveugle par biopsie de l’endomètre ou dilatation-curetage n’est pas recommandé pour le diagnostic des polypes endométriaux (forte, élevée).
- 4.
  En présence de polypes endométriaux, il y a lieu d’orienter les patientes âgées (≥ 60 ans), ménopausées, éprouvant des saignements postménopausiques ou prenant du tamoxifène vers un gynécologue pour subir des examens supplémentaires et envisager la résection des polypes (forte, élevée).
- 5.
  Les patientes non ménopausées qui sont symptomatiques ou qui tentent de concevoir peuvent être orientées vers un gynécologue (conditionnelle, moyenne).
- 6.
  Il y a lieu d’impliquer un gynécologue-oncologue dans la prise en charge en présence de lésions précancéreuses ou malignes confinées à un polype endométrial, en particulier en cas de préservation de l’utérus (forte, faible).
- 7.
  L’expectative est envisageable pour les patientes asymptomatiques ou à faible risque de malignité (conditionnelle, moyenne).
- 8.
  La polypectomie doit se faire sous visualisation hystéroscopique directe, car elle réduit le risque de complications, de résection incomplète et de récidive (forte, élevée).
- 9.
  L’énergie bipolaire est à utiliser de préférence à l’énergie monopolaire, car elle réduit le risque de brûlure électrochirurgicale et de surcharge liquidienne. Les systèmes de morcellement hystéroscopique réduisent aussi le risque de surcharge liquidienne et évitent totalement le risque de brûlure électrochirurgicale, mais ils ont des limites fonctionnelles et financières (forte, élevée).
- 10.
  Il convient de proposer la résection hystéroscopique des polypes diagnostiqués, quelle qu’en soit la taille, afin d’améliorer les probabilités de grossesse chez les patientes atteintes d’infertilité (forte, élevée).
- 11.
  Lorsqu’un nouveau polype endométrial est diagnostiqué en cours de stimulation ovarienne, les options suivantes doivent être abordées avec la patiente : 1) annulation du cycle, 2) congélation embryonnaire totale et 3) transfert d’embryon. Rien n’indique qu’il soit nécessaire d’annuler le cycle (conditionnelle, faible).
Office Hysteroscopy: Setting up Your Practice for Success
2022, Obstetrics and Gynecology Clinics of North America
Citation Excerpt :
One randomized control trial showed lower pain levels with a 3.5 mm hysteroscope compared with either a 5 mm hysteroscope or a 5 mm hysteroscope with paracervical block.24 Factors associated with higher levels of perceived pain include cervical stenosis, postmenopausal status, anxiety, and chronic pelvic pain.24 Premedication with nonsteroidal anti-inflammatory drugs (NSAIDs) or opioids, such as tramadol or oxycodone, can also reduce discomfort.
Addition of Lidocaine to the Distension Medium in Hysteroscopy Decreases Pain during the Procedure–A Randomized Double-blind, Placebo-controlled Trial
2021, Journal of Minimally Invasive Gynecology
To evaluate the effect of adding a local anesthetic to the distension medium in office diagnostic hysteroscopy using the vaginoscopic approach on pain during the procedure. Secondary aims included documenting side effects, patient satisfaction, and the time needed to complete the procedure.
Randomized double-blind placebo-controlled study.
University-affiliated hospital; office hysteroscopy clinic.
Total of 100 patients who underwent office hysteroscopies divided in half with 50 in the intervention group and 50 in the control group.
Ten mL of lidocaine 2% added to 1000 mL of saline solution that was used as the distension medium for hysteroscopy in the study group vs 1000 mL of saline alone in the control group.
A significant difference was found in the increment of pain as measured by visual analog scale after the hysteroscopy between the 2 groups. Patients receiving lidocaine had an average rise of 1.9 in the visual analog scale score after the procedure compared with 2.9 in the control group (p = .033). There was also a nonsignificant trend for shorter duration of hysteroscopy in the intervention group compared with the control group (180.1 vs 222.1 seconds, p = .08). Patients’ satisfaction was high in both groups (98% for the study group and 92% for the control group). Success rates were also similar between the 2 groups at approximately 95%. No side effects were recorded in either group.
The addition of local anesthetic to the distension medium in office hysteroscopy produces significant reduction in pain during the procedure without adding time to the procedure and without side effects.
The Invisible External Cervical Os. Tips and Tricks to Overcome this Challenge during In-Office Hysteroscopy
2021, Journal of Minimally Invasive Gynecology
Hysteroscopy is considered the gold standard technique for the diagnosis and management of intrauterine pathology allowing to “see and treat” patients in 1 session if desired 1, 2, 3. Pain and the inability to enter the uterine cavity are the most common limitations of hysteroscopy, especially when performed in an office setting 4, 5, 6, 7. Cervical stenosis is a common hysteroscopic finding frequently encountered in postmenopausal women, especially in patients with a history of cervical procedures such as cone biopsy [8]. It represents a challenge even for the most expert hysteroscopist. Overcoming the stenosis of the external cervical os is technically more demanding than facing the obliteration of the internal os. The aim of this video article is to illustrate the use of simple techniques that allow the hysteroscopist to safely identify the location of the external cervical os and to overcome the difficulties in entering the uterine cavity during in-office hysteroscopy in patients with severe cervical stenosis including those with complete obliteration of the external cervical os. These techniques are easy to adopt and can be used in different clinical situations in which the hysteroscopic evaluation of the uterine cavity is needed in women with severe cervical stenosis.
A series of videos of challenging cases with severe cervical stenosis with complete obliteration of the external cervical os are presented that demonstrate maneuvers to properly identify and enter the cervical canal, unfolding key aspects of the procedure. Tips and tricks to facilitate the adoption of these useful maneuvers into clinical practice are highlighted.
In-office diagnostic hysteroscopy was performed using a 5-mm rigid continuous flow operative hysteroscope. Patients were placed in a dorsal lithotomy position. The vaginoscopy “no touch” technique was used [9]. No anesthesia or sedation was administered to any of the patients. Normal saline was used as distention media.
Taking advantage of the magnification provided by the hysteroscope, the location of the external cervical os was determined. In cases in which the external cervical os was not clearly recognized, the cervix was gently probed with the use of the uterine palpator, grasper, or scissors (Fig. 1). Recognition of the landmarks of the cervical canal provides reassurance of the adequate identification of the external cervical os and facilitates the use of the correct plane of dissection that leads into the uterine cavity (Fig. 2). Additional maneuvers that are useful to navigate the endocervical canal to overcome stenosis of the internal cervical os are also illustrated.
The combination of a delicate technique and operator experience aids in overcoming the challenge of cervical stenosis in an office setting. Adopting the presented tips and tricks to enter the uterine cavity in the presence of severe cervical stenosis will reduce the rate of failed hysteroscopic procedures, decreasing the need to take patients to the operating room and the use of general anesthesia.
Pain management for in-office hysteroscopy. A practical decalogue for the operator
2021, Journal of Gynecology Obstetrics and Human Reproduction
Hysteroscopy is known to be the gold standard for evaluation of intrauterine pathologies, pre-menopausal and post-menopausal abnormal uterine bleeding and, in addition to this, it is a crucial examination in the infertility work-up. In-office operative hysteroscopy incorporates the outstanding possibility of seeing and treating an intracavitary pathology in the same examination, eliminating all the risk related to anesthesia and reducing procedure-related costs. By now, performing operative procedures in the office setting is recognized as feasible and safe. Over the last 20 years, many efforts have been made to implement the in-office operative approach worldwide. However, for some women, in-office hysteroscopy is still considered a painful experience, with reported discomfort at different steps of the hysteroscopic procedures. Moreover, uneventful and tedious sensations might be increased by a high level of anxiety for such examination. For this reason, despite the feasibility of the in-office approach, many clinicians are still afraid of provoking pain during the procedure and rather not to perform surgical procedures in the office, postponing the removal of the pathology in the operating room. To date, there is no consensus concerning pain management for in-office hysteroscopy and different approaches, pharmacological and non-pharmacological aids, as well as several procedural tips and tricks are utilized. Our purpose is to provide a feasible practical decalogue for the operator, to supply adequate management of pain during in-office hysteroscopic procedures, performing challenging operations, shrinking discomfort, aiming to upgrade both women’s and operator’s satisfaction.

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Review ArticleHysteroscopy without Anesthesia: Review of Recent Literature

Abstract

Section snippets

Materials and Methods

Operative Hysteroscopy

Conclusions

J Am Assoc Gynecol Laparosc

Obstet Gynecol Clin North Am

Fertil Steril

J Minim Invasive Gynecol

Fertil Steril

Fertil Steril

Fertil Steril

J Minim Invasive Gynecol

Eur J Obstet Gynecol Reprod Biol

J Am Assoc Gynecol Laparosc

J Am Assoc Gynecol Laparosc

J Minim Invasive Gynecol

Obstet Gynecol Clin North Am

J Minim Invasive Gynecol

Obstet Gynecol

J Minin Invasive Gynecol

J Gynecol Obstet Biol Reprod (Paris)

J Am Assoc Gynecol Laparosc

J Am Assoc Gynecol Laparosc

J Am Assoc Gynecol Laparosc

J Minim Invasive Gynecol

Eur J Obstet Gynecol Reprod Biol

Review Article
Hysteroscopy without Anesthesia: Review of Recent Literature