Evidence - Hysteroscopy, fractional curettage

The indications for hysteroscopy with fractional curettage encompass a wide range of gynecological complaints and diagnostic needs. Additional instruments may need to be used, such as grasping forceps or electric loops. Here are the main indications:

Abnormal uterine bleeding (premenopausal or postmenopausal):

• Irregular, heavy, or persistent bleeding that does not respond to medical treatments.
• Bleeding that occurs after menopause and needs to be investigated.

Endometrial pathologies:

• Endometrial hyperplasia: Thickening of the endometrium that requires targeted biopsy or therapeutic removal.
• Endometrial polyps: Presence of polyps that thicken the endometrium and need to be removed.
• Adenomyosis: Superficial forms where the uterine wall shows changes that are visible and treatable with hysteroscopy.

Uterine fibroids:

• Submucosal and intramural fibroids that cause bleeding or other symptoms and can be removed hysteroscopically.

Intrauterine adhesions (Asherman's syndrome):

• Treatment of adhesions within the uterine cavity that lead to fertility problems or menstrual disorders.

Abnormal findings on imaging:

• Clarification of suspicious or unclear findings on ultrasound or MRI that may indicate a pathology.

Chronic excessive vaginal discharge (leukorrhea):

• Diagnosis and treatment of chronic vaginal discharge that does not respond to other therapies.

Anatomical anomalies of the uterus (e.g., Müllerian anomalies):

• Clarification and, if necessary, treatment of congenital malformations such as uterine septum.

Retained products of conception:

• Removal of placental remnants or other pregnancy tissues after miscarriage or childbirth.

Cervical lesions:

• Examination and, if necessary, removal of pathological changes in the cervical canal.

Complications related to intrauterine contraceptives:

• Removal of embedded or displaced intrauterine devices (IUD) or other foreign bodies.

Preoperative planning and postoperative follow-up:

• Use of hysteroscopy for planning further surgical interventions or for checking the success of a previous operation.

Reference: 

1. Orlando MS, Bradley LD. Implementation of Office Hysteroscopy for the Evaluation and Treatment of Intrauterine Pathology. Obstet Gynecol 2022; 140:499.
2. Weinberg S, Pansky M, Burshtein I, et al. A Pilot Study of Guided Conservative Hysteroscopic Evacuation of Early Miscarriage. J Minim Invasive Gynecol 2021; 28:1860.
3. Munro MG, Critchley HO, Broder MS, et al. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet 2011; 113:3.

Living intrauterine pregnancy:

• A hysteroscopy should not be performed in the presence of an intact pregnancy, as the procedure carries the risk of miscarriage.

Pyometra:

• An accumulation of pus in the uterus (pyometra) is an absolute contraindication, as manipulation can increase the risk of severe infection and sepsis.

Active pelvic infection:

• This includes any acute infection in the pelvic area, including genital herpes infections. Performing a hysteroscopy in the presence of such an infection can lead to the spread of the infection and cause serious complications.

Known cervical carcinoma:

• In patients with diagnosed cervical carcinoma, hysteroscopy should be avoided as it carries the risk of tumor dissemination and may alter treatment planning.

Relative contraindications:

Medical comorbidities:

• Severe comorbidities such as coronary artery disease or bleeding disorders (bleeding diatheses) can increase the risk of a hysteroscopic procedure. However, due to its minimally invasive nature, hysteroscopy is rarely absolutely contraindicated. An individual risk-benefit assessment is required.

Excessive uterine bleeding:

• Heavy bleeding can significantly limit visibility during hysteroscopy, but it is not an absolute contraindication. It can, however, pose a challenge and may require special precautions.

Reference:

1. Orlando MS, Bradley LD. Implementation of Office Hysteroscopy for the Evaluation and Treatment of Intrauterine Pathology. Obstet Gynecol 2022; 140:499.
2. Price TM, Harris JB. Fulminant hepatic failure due to herpes simplex after hysteroscopy. Obstet Gynecol 2001; 98:954.
3. Shalev J, Levi T, Orvieto R, et al. Emergency hysteroscopic treatment of acute severe uterine bleeding. J Obstet Gynaecol 2004; 24:152.

Reasons for Hysteroscopy Failure:

• Pain, cervical stenosis, and poor visibility are common reasons for procedure termination in practice.
• Advanced operative hysteroscopy may be discontinued due to excessive fluid absorption or uterine perforation.
• Overall failure rate: 3.6% in over 26,000 procedures, similar in outpatient and inpatient settings as well as in pre- and postmenopausal women.

Cervical Stenosis:

• Preparation: Cervical ripening with misoprostol and small instruments can reduce the risk of procedure termination.
• Postmenopausal Women: Two to four weeks of vaginal estrogen therapy before the procedure may help soften the cervix, although its effectiveness is not clearly proven.
• Alternative: A flexible hysteroscope may be better introduced in cases of difficult cervical dilation.

Uterine Malposition:

• Extreme Retro- or Anteversion: May be congenital or caused by pelvic adhesions, complicating the introduction of the hysteroscope.
• Correction: Traction on the anterior cervical lip with a tenaculum can straighten the uterine axis.
• Risk of Uterine Perforation: Use of transabdominal ultrasound to guide the hysteroscope is recommended.

Difficulties in Uterine Distension:

• Possible Causes: Obstructions in the uterine cavity (e.g., synechiae, tumors) or an improperly positioned channel.

Bleeding:

• Impaired Visibility: Bleeding can impair visibility either directly or by forming gas bubbles (when using carbon dioxide for distension).
• Solution: Switching to a fluid medium, using a continuous flow hysteroscope, or employing a tissue removal system to eliminate endometrial debris and clots.

Reference:

1. Clark TJ, Voit D, Gupta JK, et al. Accuracy of hysteroscopy in the diagnosis of endometrial cancer and hyperplasia: a systematic quantitative review. JAMA 2002; 288:1610.

Uterine Perforation:

• Most common complication in operative hysteroscopy (0.8–1.6%). Often occurs during mechanical cervical dilation or hysteroscope insertion.
• Management: Immediate removal of all instruments, assessment of the patient's hemodynamic status, possibly laparoscopic examination to assess the injury.

Excessive Fluid Absorption (Fluid Overload):

• Can occur with the use of fluid media for uterine distension, especially during prolonged procedures.
• Management: Monitoring fluid balance, early detection and termination of the procedure, treatment of resulting electrolyte disturbances.

Less Common Complications:

Bladder or Bowel Injuries:

• Very rare, but can occur with uterine perforation or improper use of electrical devices.
• Management: Recognition and repair of the injury, often through laparoscopic or open surgery.

Cervical Lacerations:

• Especially in patients with cervical stenosis.
• Management: Larger or bleeding lacerations require surgical suturing.

Air or Carbon Dioxide Embolism:

• Can occur with the use of gases for uterine distension, potentially leading to cardiovascular collapse.
• Management: Immediate measures to treat the embolism, often through cardiopulmonary resuscitation.

Intraoperative Bleeding:

• Bleeding can occur at the cervix, due to uterine perforation, or at surgical sites.
• Management: Control through electrosurgical methods or placement of a Foley catheter in the uterine cavity.

Infection Risk:

• Endometritis and Urinary Tract Infections:
  • Rare after hysteroscopy, with an incidence of 0.1–0.9%.
  • Management: Postoperative antibiotic administration if infection is suspected.

Other Possible Complications:

• Dissemination of Tumor Cells:
  • Risk of spreading malignant cells in the presence of endometrial cancer.
  • Management: Evaluation and possible avoidance of hysteroscopy if malignancy is suspected.Uterine Perforation:
  • Most common complication in operative hysteroscopy (0.8–1.6%). Often occurs during mechanical cervical dilation or hysteroscope insertion.
  • Management: Immediate removal of all instruments, assessment of the patient's hemodynamic status, possibly laparoscopic examination to assess the injury.

Excessive Fluid Absorption (Fluid Overload):

• Can occur with the use of fluid media for uterine distension, especially during prolonged procedures.
• Management: Monitoring fluid balance, early detection and termination of the procedure, treatment of resulting electrolyte disturbances.

Less Common Complications:

Bladder or Bowel Injuries:

• Very rare, but can occur with uterine perforation or improper use of electrical devices.
• Management: Recognition and repair of the injury, often through laparoscopic or open surgery.

Cervical Lacerations:

• Especially in patients with cervical stenosis.
• Management: Larger or bleeding lacerations require surgical suturing.

Air or Carbon Dioxide Embolism:

• Can occur with the use of gases for uterine distension, potentially leading to cardiovascular collapse.
• Management: Immediate measures to treat the embolism, often through cardiopulmonary resuscitation.

Intraoperative Bleeding:

• Bleeding can occur at the cervix, due to uterine perforation, or at surgical sites.
• Management: Control through electrosurgical methods or placement of a Foley catheter in the uterine cavity.

Infection Risk:

• Endometritis and Urinary Tract Infections:
  • Rare after hysteroscopy, with an incidence of 0.1–0.9%.
  • Management: Postoperative antibiotic administration if infection is suspected.

Other Possible Complications:

• Dissemination of Tumor Cells:
  • Possible risk of spreading malignant cells in the presence of endometrial cancer.

Reference: 

1. Aydeniz B, Gruber IV, Schauf B, et al. A multicenter survey of complications associated with 21,676 operative hysteroscopies. Eur J Obstet Gynecol Reprod Biol 2002; 104:160.
2. Jansen FW, Vredevoogd CB, van Ulzen K, et al. Complications of hysteroscopy: a prospective, multicenter study. Obstet Gynecol 2000; 96:266.
3. Shveiky D, Rojansky N, Revel A, et al. Complications of hysteroscopic surgery: "Beyond the learning curve". J Minim Invasive Gynecol 2007; 14:218.
4. Dyrbye BA, Overdijk LE, van Kesteren PJ, et al. Gas embolism during hysteroscopic surgery using bipolar or monopolar diathermia: a randomized controlled trial. Am J Obstet Gynecol 2012; 207:271.e1.
5. Serden SP, Brooks PG. Treatment of abnormal uterine bleeding with the gynecologic resectoscope. J Reprod Med 1991; 36:697.