Diagnostic hysteroscopy to evaluate the cause of abnormal uterine bleeding

CONTEMPORARY MANAGEMENT OF ABNORMAL UTERINE BLEEDING

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DIAGNOSTIC HYSTEROSCOPY TO EVALUATE THE CAUSE OF ABNORMAL UTERINE BLEEDING Scott P. Serden, MD

The introduction and development of intrauterine endoscopy has allowed the clinician to evaluate an area of the body that was previously only accessible by the procedure of blind dilation and curettage (D&C). Multiple authors have shown hysteroscopy to be superior to D&C, yet its use has yet to be appreciated adequately- 19 The ability to make an accurate diagnosis and the advent of operative hysteroscopic procedures to treat various pathologic conditions have been critical in reducing the number of unnecessary hysterectomies. Use of hysteroscopy has been most common in the evaluation of abnormal uterine bleeding." In the author's experience, approximately 60% of office-based hysteroscopy is performed to evaluate abnormal bleeding, but it also has been used to evaluate infertility, recurrent pregnancy loss, uterine anomalies, and suspected Asherman's syndrome. The improvement in optics, video systems, safe and effective distention media, and reduced telescope size has led to increased acceptance of hysteroscopy by both physicians and patients when symptoms require direct intrauterine examination. INDICATIONS FOR HYSTEROSCOPY

Abnormal uterine bleeding is the primary indicator for hysteroscopic evaluation . Other indications are listed in Table 1. Multiple studies have shown that hysteroscopy is superior to blind D&C in diagnosing uterine pathology (Table 2). Other indications include evaluation of mullerian abnormalities, including septa, intrauterine adhesions, and foreign bodies, and evaluation and treatment of proximal tubal occlusion with balloon tuboplasty" 11

From the University of California, Los Angeles, Los Angeles, California

OBSTETRICS AND GYNECOLOGY CLINICS OF NORTH AMERICA VOI.UME 27 • NUMBER 2 • JUNE 2000

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Table 1. INDICATIONS FOR HYSTEROSCOPY

Abnormal uterine bleeding Infertility Recurrent pregnancy loss Miscellaneous

60% 15% 20% 5%

INSTRUMENTATION

Improvement in instrumentation has occurred to the point that clarity of the hysteroscopic image with modern illumination allows the clinician to visualize adequately and accurately the inside of the endometrial cavity. Powerful xenon light generators allow excellent illumination even in a small and darkened space. When coupled with light cords with high fiberoptic quality, visualization is excellent. Magnification using video monitor systems allows for viewing by both the physician and patient, which allows for photodoeumentation. Additionally it reduces patient anxiety during the course of the procedure. Hysteroscopes vary in diameter from 3 to 10 mm. The smaller diameter scopes allow for viewing only; whereas the larger ones allow operative procedures that may be limited only by what the patient tolerates in the office setting. Rigid hysteroscopes, which are used most frequently, have viewing angles that vary from 0° to 30°. The 30° scope is used for most diagnostic purposes. This is because rotation of the hysteroscope around its axis allows a panoramic view of the lateral aspects of the uterus as well as the anterior and posterior endometrial surfaces. Modern rod/lens hysteroscopes have a beveled end that corresponds to the angle of viewing but also aids in instrument insertion into the uterine cavity.20 Flexible hysteroscopes have enjoyed popularity among fertility specialists because their 120° to 160° flexion angles allow easy access to the cornual regions of the uterus. This can be useful in tubal canalization and falloposcopy but has the disadvantage of a lower quality image because of the fiberoptic bundles that carry both the light and image. Conformation to the natural curve of the cervical canal and uterus may reduce discomfort during the insertion process, but the image of this scope is significantly different from the rigid hysteroscopes. This gives a gridlike picture that has poorer resolution and a shallower depth of field than the rigid rod-lens systems, thus limiting its use under some circumstances. The last group of scopes that enjoys limited use includes the contact hysteroscopes. These scopes use a light collector in the hand piece and have limited depth of field but need no distention media. They are useful for locating foreign bodies such as lost intrauterine devices but have been replaced mostly by modern panoramic hysteroscopes.

Table 2. FALSE-NEGATIVE RATES FOR DILATION AND CURETTAGE (D&C)

Investigator

False-Negative Rate

Brooks and Serderr' Gimpleson' Grimes?

60% 17.5% 10% 11%

Loffer-"

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DISTENTION MEDIA Carbon Dioxide

Multiple systems have been developed for distention of the uterine cavity. A traditional method has been a carbon dioxide distention system with hysteroflator equipment that operates at a low pressure «100 mm Hg) and low flow «100 cc/min). This allows for excellent visualization and safety even if carbon dioxide is absorbed into the patient's vascular system. One of the disadvantages of this type of system is that carbon dioxide at higher pressures can pass to the peritoneal cavity through patent fallopian tubes and result in referred shoulder pain secondary to diaphragmatic irritation. Carbon dioxide has limited use in patients who are actively bleeding at the time of the procedure.

Fluid Systems

Because practitioners do not always have the luxury of performing diagnostic and operative procedures in the absence of bleeding, fluid systems have been developed (Fig. 1). These systems consist of a fluid source, usually saline, that is gravity fed into a continuous flow endoscope. The outflow port of the hysteroscope is connected to a collection bag that is designed to allow for fluid collection with minimal spillage onto the floor. In the office, fluid systems have many advantages but also some disadvantages. The pain associated with carbon dioxide is virtually eliminated with a saline distention system because of the physiologic interaction between the endometrium and the saline solution. In addition, because the cervix occasionally must be dilated at the onset of the procedure, the endocervical bleeding that often interferes with visualization can be eliminated when using liquid in place of gas for distention. The only disadvantage to this type of system is that in contrast to the operating room, management of fluids in the office setting is not as convenient. Special closed collection systems have been developed to allow low-viscosity fluids to be used safely and properly.

TECHNIQUE OF OFFICE HYSTEROSCOPY Timing of Procedure

Although it is not always possible to schedule an office procedure at the best time in the menstrual cycle, ideally the best time to perform hysteroscopic evaluation is just after the conclusion of the menstrual cycle during the early proliferative phase. This allows for the best visualization of the endometrial surface and any intrauterine pathologic condition. Performing the procedure during the luteal phase of the cycle reveals a much thicker endometrium with an undulating appearance that may lead to a misdiagnosis of polyps or hyperplasia. In addition, the fluffy nature of the premenstrual endometrium may obstruct the outflow ports of the continuous flow endoscopes, thus negating their advantage. Surface vascularity is also minimal during the early follicular phase of the cycle so that the chance for troublesome bleeding is less.

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Figure 1. Continuous flow diagnostic hysteroscope and set-up. (Courtesy of Circon ACMI , Santa Barbara, CA.)

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Anesthesia and Analgesia

In order to maintain patient comfort during the procedure a number of techniques are used. The patient is instructed to take a nonsteroidal analgesic approximately 1 hour before the procedure and is requested not to eat a large meal preoperatively. Although most patients tolerate placement of a small hysteroscope with minimal anesthesia, cramping, pain, and an occasional vasovagal reaction are not uncommon. Placement of a paracervical block not only helps control pain during the procedure but also provides for vasoconstriction and pain relief after the hysteroscopic evaluation. The technique involves injecting a combination of 20 mL of 1% lidocaine or carbocaine mixed with 5 units of vasopressin. This affects vasoconstriction of the endocervical vessels and provides a long-lasting block that provides pain relief for a considerable period of time after the procedure. Approximately 5 mL of the solution are injected at the three and nine o'clock position just under the mucosa at the vaginal-cervical junction. An additional 10 mL are placed at the six o'clock position between the uterosacral ligament attachment to the posterior cervix (Fig. 2). If one uses carbon dioxide as a distention media, instillation of 10 mL of 1% lidocaine into the uterine cavity significantly reduces the pain from the interaction of the gas with the endometrium. Technique for Hysteroscopic Procedure

Insertion of the hysteroscope can be the most difficult part of the procedure, especially if one does not pay attention to the anatomy of the cervix and uterine cavity." Because most uteri are either anteflexed or retroflexed, knowledge of this position can aid in insertion of the hysteroscope. Most hysteroscopes have a bevel that is angled corresponding to the viewing angle of the scope (Fig. 3). Because most diagnostic hysteroscopes have a 30° offset angle of viewing, the bevel of the lens can be used to help guide the endoscope through the cervix into the uterine cavity (Fig. 4). When the uterus is anteflexed, the scope is held in its normal viewing position and the bevel helps the scope be deflected up

5mL

X

X 5mL X 10mL

Figure 2. The paracervical block technique.

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81""'---°--------,.

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Figure 3. The hysteroscope's bevel is angled corresponding to the viewing angle of the scope.

into th e endometrial cavity. When the uteru s is retroverted or retroflexed, the scope is inverted from its normal viewing position and the bevel aids in insertion. Once the scope is inserted through the external os, it is advanced and w ithdrawn slightly to allow direct visualization of the internal as, which appears as a dark circle. The area that represents the internal cervical os should be at the 12 0' clock position at the edge of the field of vision wh en the scope is upright and at the 6 o'clock position when the scope is inverted (Fig. 5). If the cervical canal is centered on the video screen, the scope is oriented improp erly off the proper axis of the cervical canal opposed to what appears on the screen. If one uses carbon dioxide as a distention medium, it is important not to sound or dilate the cervix before inserting the telescope so that bleeding does not obscure visualization. If one uses saline or some other fluid medium, then this is not as critical. Careful technique lessens disturbance of the endocervical canal and endometrium and allows better and more precise visualization. Once the hysteroscope is in the endometrial cavity, the fundus should be inspected first. The scope is rotated 90° to each side to see the ostia, then the rest of the endometrial cavity is visu alized as the scope is w ithdrawn into the lower uterine segment and cervix. The entire examination should take no longer than a few minutes. COMPLICATIONS

Although rare, complications have bee n described during the performance of diagnostic hysteroscopy." These are usually minor but may necessitate cessa-

,et) ;q~

e--o A

0 B

U

•

8

~

Figure 4. The bevel of the lens helps guide the endoscope inside. A. The scope is held in its normal viewing position when the uterus is anteflexed. 8, The scope is Inverted when the uterus is retroverted or retroflexed.

DIAGNOSTIC HYSTEROSCOPY TO EVALUATE ABNORMAL UTERINE BLEEDING

A

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B

Figure 5. When the scope is upright (A), the internal os appears in the 12 o'clock position. When the scope is inverted (8), the os appears in the 6 o'clock position .

tion of the procedure. It is important for the practitioner to be knowledgeable regarding potential complications in order to provide proper informed consent and manage complications when they occur.

Perforation

Uterine perforation is an uncommon but not unknown complication of diagnostic hysteroscopy. This occurs most commonl y in patients with cervical steno sis and those who requ ire cervical dilation in order to insert the telescope . It rarely occurs when insertion is done under direct vision, but if dilators are used before insertion, a false passage can be created and m ay not be seen completely until the scope passes into the peritoneal cavity. A false passage can be recognized by obse rving the crisscrossing fibers of the myometrium when adv ancing the scope. Certain landmarks should be visualized when one is in the endometrial cavity, induding the tubal ostia. Failure to recognize these structures should make one suspect that they are in a false passage or at risk for perforation. In addition, sudden loss of distention may signify a perforation. Should perforation occur, the surgeon must inform the patient of this occurrence and what symptoms to look for that may represent postperforation complications. These symptoms include fever, increasing pain, and any sign of intraperitoneal bleeding. Laparoscopic evaluation should be undertaken in any situation in which a significant complication or damage to abdominal viscera is suspected.

Infection

Infection after hysteroscopic evalua tion, espe cially using fluid distention systems, is rare . The incidence of this is probably no greater than after endometrial biopsy. In situations in which concern over contamination of the operative site is suspect, placement of the pa tient on a sh ort course of antibio tics is recommended.

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DISTENTION MEDIA COMPLICATIONS

Fluid Media

It is unlikely that using a physiologic solution such as saline or lactated Ringer's is associated with the same fluid complications as with a hypotonic solution such as sorbitol or glycine. The average amount of fluid used during diagnostic hysteroscopy is less than 250 mL, and even direct venous infusion of this amount has adverse effects in any patient. Gaseous Media

Use of gaseous media has been associated with complications, but diagnostic systems are specifically designed to avoid these. Avoiding steep Trendelenburg position in the office setting avoids the negative pressure in the venous system that may occur when the procedure is performed in the operating room. Proper positioning avoids the potential for negative pressure that can draw carbon dioxide or room air into the patient's vascular system. This situation has been associated with severe complications or even death in cases in which gas embolism has occurred. Diagnostic hysteroscopy insufflators have been designed to provide excellent visualization and distention but with a large margin of safety. These low flow and low pressure systems are specifically designed for diagnostic hysteroscopic procedures and have been associated with low complication rates." This is in direct contrast to the laparoscopic systems that allow flow rates up to 10 L / min compared to the maximum flow rates of 100 mL / min in hysteroscopic insufflators. The only significant problem with the use of carbon dioxide is pain from the interaction of the gas with the endometrium and poor visualization in the presence of bleeding, which is more a limitation than a complication. POSTOPERATIVE CARE

Minimal postoperative care is necessary for patients who undergo diagnostic hysteroscopy. Postoperative spotting can be expected for a few days but this rarely lasts long. Pain and cramping are usually minimal and can be controlled easily with over-the-counter medications. Any severe pain that occurs after this time should be evaluated because it may represent either infection or another complication related to the procedure. OTHER TECHNIQUES FOR INTRAUTERINE DIAGNOSIS

Other authors have described additional minimally invasive means to aid with the diagnosis of gynecologic problems.vv 6,9,12-16,18 These techniques include transvaginal ultrasound and instillation of saline or other fluid during the ultrasound procedure (sonohysterography). It is this author's opinion that diagnostic hysteroscopy offers many advantages over other screening methods, including transvaginal ultrasound with or without saline infusion. It allows the operator to know exactly what pathologic condition one is dealing with before treatment so as to decide on most effective therapy and the best venue to treat it. Many practitioners feel comfortable with operative endoscopic procedures in

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their office and once a diagnosis is made, therapy often can be undertaken immediately. SUMMARY

Diagnostic hysteroscopy has become an important and valuable tool for the gynecologist in the evaluation of many conditions previously evaluated with blind and inaccurate techniques. The safety, ease of proficiency; and ability to see and diagnose in an office setting have taken much of the guesswork out of office diagnosis. This modality brings the evaluation of many pathologic conditions, including the cause for abnormal uterine bleeding, infertility, and recurrent pregnancy loss, back into a relaxed office environment. References 1. Bernard JP, Lecruru F, Darles C, et al: Saline contrast sonohysterography as firstline investigation for women with uterine bleeding. Ultrasound Obstet Gynecol 10:121-125, 1997 2. Brooks PJ, Serden 5P: Hysteroscopic findings after unsuccessful dilation and curettage for abnormal uterine bleeding. Am J Obstet Gynecol 158:1354-1357, 1988 3. Corson 5L, Hoffman JJ: Cardiopulmonary effects of direct venous carbon dioxide insufflation. J Reprod Med 33:440, 1988 4. Fedele L, Bianchi S, Dorta M, et al: Transvaginal ultrasonography versus hysteroscopy in the diagnosis of uterine submucous myomas. 77:745-748, 1991 5. Gimpleson RJ, Rappold HO: A comparative study between panoramic hysteroscopy with directed biopsies and dilation and curettage. Am J Obstet GynecoI 158:489-492, 1988 6. Goldstein SR: Use of ultrasonohysterography for triage of perimenopausal patients with unexplained uterine bleeding. Am J Obstet Gynecol 170:565-570, 1994 7. Grimes DA: Diagnostic dilation and curettage: A reappraisal. Am J Obstet Gynecol 142:1-6, 1982 8. Hamilton JA, Larson AJ, Lower AM, et al: Routine use of saline hysterosonography in 500 consecutive unselective, infertile women. Hum Reprod 13:2463-2473, 1998 9. Indman PO: Abnormal uterine bleeding: Accuracy of vaginal probe ultrasound in predicting abnormal hysteroscopic findings. J Reprod Med 40:545-548,1995 10. Isaacson KB: Complications of hysteroscopy. Obstet Gynecol Clin North Am 26:3951, 1999 11. La Sala GB, Montanari R, Dessanti L, et al: The role of diagnostic hysteroscopy and endometrial biopsy assisted reproductive technologies. Fertil Steril 70:378-380, 1998 lla. Loffer FD: Does hysteroscopy improve upon the sensitivity of dilation and curettage in the diagnosis of endometrial hyperplasia or carcinoma? Gynecologic Oncology 73(1):171, 1999 12. Mortakis AE, Mavrelos K: Transvaginal ultrasonography and hysteroscopy in the diagnosis of endometrial abnormalities. J Am Assoc Gynecol Laparosc 4:449-452,1997 13. O'Connell Lp, Fries MH, Zeringue E, et al: Triage of abnormal postmenopausal bleeding: A comparison of endometrial biopsy and transvaginal sonohysterography versus fractional curettage with hysteroscopy. Am J Obstet GynecoI178:956-961, 1998 14. Pal L, Lapensee L, Toth TL, et al: Comparison of office hysteroscopy, transvaginal ultrasonography and endometrial biopsy in evaluation of abnormal uterine bleeding. Journal of the Society of Laparoendoscopic Surgeons 1:125-130, 1997 15. Saidi MH, Sadler RK, Theis VD, et al: Comparison of sonography, sonohysterography, and hysteroscopy for evaluation of abnormal uterine bleeding. J Ultrasound Med 16:587-591, 1997 16. Schwarzler P, Concin H, Bosch H, et al: An evaluation of sonohysterography and

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diagnostic hysteroscopy for the assessment of intrauterine pathology. Ultrasound in Obstetrics and Gynecology 11:337-342, 1998 17. Torrejon R, Fernandez-Alba jJ, Carnicer I, et al: The value of hysteroscopic exploration for abnormal uterine bleeding. J Am Assoc Gynecol Laparosc 4:453-456, 1997 18. Towbin NA, Gvazida 1M,March CM: Office hysteroscopy versus transvaginal ultrasonography in the evaluation of excessive uterine bleeding. Am J Obstet Gynecol 174:1678-1682, 1996 19. Valli E, Zupi E, Marconi D, et al: Outpatient diagnostic hysteroscopy. J Am Assoc Gynecol Laparosc 5:397-402, 1998 20. Weiser F, Kurz C, Wenzl R, et al: Atraumatic cervical passage at outpatient hysteroscopy. Ferti! Steril 69:549-551, 1998 21. Widrich 1; Bradley LO, Mitchinson AR, et al: Comparison of saline infusion sonogra-

phy with office hysteroscopy for the evaluation of the endometrium. Am Gynecol 174:1327-1334, 1996

J Obstet

Addressreprint requests to Scott P. Serden, MD University of California, Los Angeles 8631 W Third Street Suite SlOE Los Angeles, CA 90048