For most patients, diagnostic hysteroscopy can be performed in an office or procedure room setting with minimal discomfort and at a much lower cost than in a surgical center or a traditional operating room. For some, concerns about patient comfort or a preexisting medical condition may preclude office hysteroscopy. In many patients hysteroscopy can provide more information than blind curettage, but it should be used prudently. For most patients, other diagnostic or therapeutic measures can be undertaken before, or instead of, diagnostic hysteroscopy. For example, for women in the late reproductive years who have abnormal uterine bleeding (AUB) or for those with postmenopausal bleeding, transvaginal sonography or office endometrial biopsy or curettage is typically adequate to evaluate for neoplasia and provide enough information to support an initial management strategy. In the absence of a satisfactory diagnosis or if unexplained bleeding continues without response to treatment, further investigation is appropriate, using one or a combination of ultrasound, endometrial sampling, SIS, or office hysteroscopy. For women in their earlier reproductive years who have AUB, medical or expectant management may be used initially, depending on the severity and inconvenience of the bleeding. For those who do not respond to medical treatments such as oral contraceptives, further diagnostic procedures such as transvaginal ultrasonography, SIS, or hysteroscopy with biopsy can be performed (165).
For women with infertility, hysterosalpingography is the best initial imaging step because it provides information about the patency of the oviducts. In the presence of a suspicious or identified abnormality in the endometrial cavity, hysteroscopy or sonohysterography can be performed to confirm the diagnosis, to better define the abnormality, and perhaps to direct the removal of a lesion. Some experts consider hysteroscopy or MRI mandatory for such patients because of the high occurrence of false-negative radiologic images in those with intrauterine anomalies (166). In women with previous in vitro fertilization failure, there is evidence that hysteroscopic identification and treatment of these “missed” anomalies improves pregnancy rates (167). Confirmation of patency of the oviduct is unnecessary in women who have recurrent abortions; therefore, these patients can be evaluated primarily with hysteroscopy.
Operative Hysteroscopy A number of intrauterine procedures can be performed under endoscopic direction, including adhesiolysis, sterilization, division of a uterine septum, resection of myomas and polyps, removal of retained products of conception, and endometrial destruction through Nd:YAG laser vaporization or radiofrequency resection, desiccation, or vaporization. Hysteroscopy may be used to direct the removal of foreign bodies, including imbedded intrauterine contraceptive devices (IUDs).
Foreign Body If the string of an IUD is absent, the device usually can be removed with a specially designed hook or a toothed curette (e.g., Novak). When removal is difficult or impossible, the location of the device may be confirmed by hysteroscopy, allowing removal with a grasping forceps. If the device is not seen or if only a portion is visible hysteroscopically and the remainder is imbedded in the myometrium, then individualized management is recommended, usually following appropriate imaging studies to identify the more precise location of the device.