Evidence-based practice

Best practice in outpatient hysteroscopy

The joint guideline from the Royal College of Obstetricians and Gynaecologists and the British Society for Gynaecological Endoscopy (59) recommends the following:

Service provision

• All gynaecology units should provide a dedicated outpatient hysteroscopy service to aid management of women with abnormal uterine bleeding.

• Outpatient hysteroscopy should be outside of the formal oper­ating theatre setting in an appropriately sized, equipped, and staffed treatment room with adjoining private changing facilities and toilet.

• The healthcare professional should have the necessary skills and expertise to carry out hysteroscopy.

• There should be a nurse chaperone regardless of the gender of the clinician.

• Written patient information should be provided before the ap­pointment and consent for the procedure should be undertaken.

Analgesia

• Routine use of opiate analgesia before outpatient hysteroscopy should be avoided as it may cause adverse effects.

• Women without contraindications should be advised to consider taking standard doses of non-steroidal anti-inflammatory agents around 1 hour before the scheduled outpatient hysteroscopy ap­pointment with the aim of reducing pain in the immediate post­operative period.

Cervical preparation

• Routine cervical preparation before outpatient hysteroscopy should not be used in the absence of any evidence of benefit in terms of reduction of pain, rates of failure, or uterine trauma.

Types of hysteroscope

• Miniature hysteroscopes (2.7 mm with a 3- 3.5 mm sheath) should be used for diagnostic outpatient hysteroscopy as they signifi­cantly reduce the discomfort experienced by the woman.

• Flexible hysteroscopes are associated with less pain during out­patient hysteroscopy compared with rigid hysteroscopes; how­ever, rigid hysteroscopes may provide better images, fewer failed procedures, quicker examination time, and reduced cost.

Distention medium

• For routine outpatient hysteroscopy, the choice of distention me­dium between carbon dioxide and normal saline should be left to the discretion of the operator as neither is superior in reducing pain although uterine distention with normal saline appears to re­duce the incidence of vasovagal episodes.

• Uterine distention with normal saline allows improved image quality and allows outpatient diagnostic hysteroscopy to be com­pleted more quickly compared with carbon dioxide.

Local anaesthesia and cervical dilatation

• Instillation of local anaesthetic into the cervical canal does not re­duce pain during diagnostic outpatient hysteroscopy but may re­duce the incidence of vasovagal reactions.

• Topical application of local anaesthetic to the ectocervix should be considered where application of a cervical tenaculum is necessary.

• Application of local anaesthetic into or around the cervix is asso­ciated with a reduction of the pain experienced during outpatient diagnostic hysteroscopy. However, it is unclear how clinically sig­nificant this reduction in pain is. Consideration should be given to the routine administration of intra- or paracervical local anaes­thetic, particularly in postmenopausal women.

• Routine administration of intra- or paracervical local anaesthetic is not indicated to reduce the incidence of vasovagal reactions.

Conscious sedation

• Conscious sedation should not be routinely used in out­patient hysteroscopic procedures as it confers no advantage in terms of pain control and the woman's satisfaction over local anaesthetic.

Vaginoscopy

• Vaginoscopy reduced pain during diagnostic rigid hysteroscopy.