top of page

BackTable / OBGYN / Article

In-Office Hysteroscopy Surgery: Tools, Techniques & Post-Op Care

Author Melissa Malena covers In-Office Hysteroscopy Surgery: Tools, Techniques & Post-Op Care on BackTable OBGYN

Melissa Malena • Jan 14, 2024 • 135 hits

Hysteroscopic surgery is pivotal in the management of many gynecologic conditions. In-office hysteroscopy procedures have become more commonplace as tools and protocols have advanced. Still, hysteroscopy surgery requires special considerations to maximize patient comfort, minimize complications, and ensure healthy endometrial recovery afterwards.

Gynecologist Dr. Linda Bradley provides her approach to in-office hysteroscopy procedures, detailing scope selection in different clinical scenarios, pain management methods, navigation techniques, and hysteroscopy post op care. This article features excerpts from the BackTable OBGYN Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.

The BackTable OBGYN Brief

• Instead of traditional paracervical blocks, in-office hysteroscopy procedures implement a non-invasive pain management strategy using NSAIDs or Tylenol before the procedure. This method has high effectiveness in reducing pain without significant side effects and minimizing vasovagal complications.

• Using visual cues of “dark” and “light” areas, which indicate the position and location of the cervix, careful manipulation of both rigid and flexible scopes through visual cues is required to avoid uterine trauma and perforation.

• Dr. Bradley’s advanced hysteroscopy techniques include variable manipulation of uterine pressure for improved visualization in endometrial curettage and bipolar resectoscopes for primary and secondary fibroids.

• Following hysteroscopic fibroid removal, a month of estrogen therapy is recommended for supporting uterine healing and reduction of scar tissue formation.

In-Office Hysteroscopy Surgery: Tools, Techniques & Post-Op Care

Table of Contents

(1) Hysteroscopy Tool Selection & Pain Management in the Office Setting

(2) Advanced Hysteroscopy Techniques to Minimize Pain & Complications

(3) Resection & Retrieval with Hysteroscopy

(4) Hysteroscopy Post Op Care Recommendations

Hysteroscopy Tool Selection & Pain Management in the Office Setting

For in-office hysteroscopy, Dr. Bradley emphasizes the importance of preparation and patient education for successful procedures. Flexible hysteroscopes are the gold standard, with unparalleled efficiency in diagnosis without the need for cervical dilation or tenaculum application. Tool selection must be personalized to each patient. Dr. Bradley's approach eschews traditional pain management methods like paracervical blocks with a preference for pre-procedure NSAIDs or Tylenol, coupled with thorough patient preparation, to manage pain. This technique, aimed at minimizing discomfort, records low pain scores and reduces the risk of vasovagal responses.

[Dr. Amy Park]
Circling back to the office hysteroscopy, one of the big things that people are talking about now is regarding cervical manipulation like IUD placement and pain control. Do you often do a paracervical block and what's your philosophy on that? Then also regarding the financial incentives, I know now office hysteroscopy gives a lot of RVUs and then transitioning that OR diagnostic hysteroscopy to the office. You live through that transition. I'm just curious about what your philosophy is on the pain and the tricks that you do for the office.

[Dr. Linda Bradley]
I think preparation, preparation, preparation, and patients being informed of what they're going to do. Now, there's different hysteroscopes. Each of us is going to like what we like for diagnosis. It's like if you're a golfer, you have your clubs that you like. If you are a skier, you have your skis that you like. If you bowl, they could have three 10-pound, 15-pound balls, but there's something that you like.

My workhorse in my office for diagnosis is a flexible hysteroscope. It is 3.2 millimeters. There are names of other disposable hysteroscopes that I've tried, but I think in my hands, these skis work for me. This bowling ball works for me. Yes, there are others and everybody should try. The flexible scope, usually, it's 3.2 millimeters. You don't have to dilate the patient. I used to put a tenaculum on and sound everybody. I don't do any of that. I have my patients to eat before coming.

If we know that they're coming, we have them take an NSAID if they're allowed to or Tylenol. The nurses prep them. We tell them that it's brief. It's usually very comfortable. I do have a paper early on for a visual analog. Most of the patients have very low pain scores and so do other physicians. At one point, I was also very proud to have been one of the first physicians to do hysteroscopic sterilization in the country with Essure. Of course, that's gone now.

I went to Mexico to train women that were having hysterectomies. Immediately, we put the devices in. They had the hysterectomies, made sure we were doing it properly, and then it came back to the US. At the Cleveland Clinic, I was a part of that clinical trial that was ultimately FDA-approved. We started doing those in the office. I'm being very honest. I can tell you what protocols are. I haven't put a paracervical block in probably 20 years.

I don't use them. If they're young, multiple leaps, cones, all C-sections, I have them use Cytotec or misoprostol by mouth, 400 micrograms the night before, or if they're menopausal. I think I can talk with you about pain regimens. The risk of a vagal-vagal is so low. It's just very, very low. I think there are doctors that use larger scopes, that use rigid scopes, that may need to do the paracervical with the 0.25% Marcaine with the deep paracervical blocks.

You're asking me my opinion for the things that I've done even when I started to do Essure and the hysteroscopic sterilization in the office. They ate before coming. We might give Toradol the night before, 12 hours. I might say take 600 of Motrin two or three times a day the day before to help with the prostaglandin release and all of that. That's just me. There are others who give Valium. There's others that have a driver that use a Marcaine spray.

There's all kinds of things that are used. Sometimes, if you ask me, putting in these paracervical blocks, some people use epi, and then they get the racing heart. Sometimes just all this other stuff we do, to me, creates more of an issue. I don't do paracervical block tray. I don't have one. "Where does she keep her medicine?" We don't have it. Now, what we are going to be doing, and I can publicly say this because we just had a meeting on Monday, we're going to be trialing several newer devices that will allow us to do larger polyps.

I would never personally do a myoma in the office. I would not, personally for me, retained products in the office because of absorption and bleeding. There may be some things like the polyps, which are very common, or things like that in the office. These devices might be a little bit larger, but I've also read and talked to physicians that are using them, the preparation, eating, and NSAID.

I don't give Valium. I don't give Demerol or an opioid to the patients. We do the pelvic, trauma-informed care kind of thing. I'm not going to force any of this on someone who's had incest, domestic violence, sexual violence. As easy as it might seem for some patients, it's better to be done in the operating room. We have to listen to our patients and be very patient-centric.

Listen to the Full Podcast

Advanced Hysteroscopy with Dr. Linda Bradley on the BackTable OBGYN Podcast)
Ep 34 Advanced Hysteroscopy with Dr. Linda Bradley
00:00 / 01:04

Earn CME

Reflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs. Follow the button below to claim your credits on CMEfy.

BackTable CMEfy button

Stay Up To Date

Follow:

Subscribe:

Sign Up:

Advanced Hysteroscopy Techniques to Minimize Pain & Complications

Avoiding contact of both rigid and flexible with the walls of the cervix and uterus during hysteroscopy significantly reduces patient pain. The ability to navigate the scope without causing trauma to the uterine walls is pivotal. This is especially true when filling the uterus with saline, which can cause cramping. Dr. Bradley advises looking for the 'black hole' and avoiding 'white' areas, which indicate contact with the cervix, to prevent perforation. This guidance is crucial for training residents and ensuring patient safety. The adaptation to using disposable scopes, which are slightly larger and offer less maneuverability, highlights the need for skill and adaptability in different clinical settings. The inability to move the angle of the scope as freely requires additional precision and care during the procedure.

[Dr. Mark Hoffman]
My experience in the office has been anything from a rigid hysteroscope or a flexible hysteroscope as well as some of the disposable devices. I have to say, in fellowship, they had a few of the flexible, I guess, similar 3.2-millimeter flexible scopes. I got to where you could drive and not touch the walls. It seemed to me that if you could avoid the walls of the cervix, if you could avoid the walls of the uterus, there really wasn't much in the way of pain.

You get some pain from some cramping, from filling the uterus with saline. For diagnostic purposes, if you could drive that scope without bumping stop, we all know when you get in there. I almost never dilate in the operating room. You just put the scope in. You see the tract, right? You see the landing strip where people have dilated every single time. If you could avoid the walls, you can avoid pain. Is that your experience as well?

[Dr. Linda Bradley]
Yes, I tell my residents or ask my residents. Now, they know all my questions, right? When you go in, what are you going to see? You should be looking for the black hole. White is not right, okay? You need to go like you said. That just means that black hole is where you need to be. If you're seeing white, you're touching the cervix. You're touching something. Back up, pivot, whatever you're going to do to find that. Even under anesthesia, because if you are seeing white, the next thing under anesthesia, patient's not going to say it hurts. You've perfed. The answer to the question is look for the black hole and then guide yourself. I totally agree with you, Mark.

[Dr. Mark Hoffman]
I've tried to get this where I am. It's tough because we don't have access to sterile supply in our clinic. Those reusable scopes, the flexible ones are a little tougher to get. We've been able to get the disposables. They're a little bit bigger. Because you don't have the control, because you can't move the angle of the scope and avoid the wall, that's everything to me.

Resection & Retrieval with Hysteroscopy

Dr. Bradley routinely conducts a diagnostic hysteroscopy or SIS before operating room procedures, often using a pipelle for sampling in the office. For polyps and retained products, tissue retrieval systems can be used, but bipolar resectoscopes for fibroids are preferred, due to their effectiveness in complete removal, especially for types 1 and 2 fibroids. Dr. Bradley practices a unique method of uninterrupted, visually directed endometrial curettage with a tissue retrieval system, emphasizing the importance of adjusting uterine pressure for optimal visibility and completeness of the procedure.

Handling and labeling multiple specimens separately during procedures to avoid contamination and ensure accurate diagnosis is crucial. For retained products, Dr. Bradley uses hysteroscopic morcellators and advocates against suction curettage to minimize the risk of Asherman's syndrome. In cases of fibroids, the patient's fertility wishes are documented and considered. Intrauterine Foley catheters are used postoperatively to prevent adhesion formation, adjusting intrauterine pressure during surgery to aid in the removal of intramural fibroids. After fibroid removal, estrogen therapy is prescribed and the healing process is monitored with follow-up hysteroscopies to ensure no adhesions or scar tissue formation.

[Dr. Mark Hoffman]
You were talking earlier about blind D&Cs, you're like, "No more of those," you say. What are you using now? If you're going to do an endometrial sampling in the operating room, you're not doing a cure, what are you using and how are you evaluating endometrial pathology and how are you treating endometrial pathology in the operating room?

[Dr. Linda Bradley]
That's a good question. Almost all of my patients have already had a diagnostic hysteroscopy or an SIS in the office. By tradition, they always, always have, say, a pipelle in the office. When I bring them to the OR, like yesterday, the hysteroscope that you use, the tissue retrieval system, I use tissue retrieval systems for soft things, polyps, retained products. Fibroids, I only use the bipolar resectoscope. That's just me. You're speaking with me. There are people who love the tissue retrieval systems for fibroids. I do not think that they get into, always getting the entire fibroid out. I think there are very few type 0s. There are many more type 1 and type 2 fibroids, which I think personally with the tissue retrieval system is hard to remove.

What I do, like the lady's yesterday, I take out the polyp, the bigger thing, that 3-centimeter polyp, take that out with my tissue retrieval system. They take the sock out. I finish it. They put another sock in. Then I do what I call an uninterrupted, visually directed endometrial curettage with my tissue retrieval system. You have to sometimes let your uterine pressure down so that the uterine wall falls right into your space and that you haven't also artificially pushed the fibroid, a sessile fibroid flat that you missed something.

I usually do two separate specimens. There was a case a couple of months ago I looked in. It was a clear fibroid, an older woman, a clear polyp, and then near her lower uterine segment, something "just didn't look right." It looked more friable. I took three separate specimens. Once you get the fibroid out, keep your scope inside, put your foot on the pedal, and suck out all that fluid so that your tubing has 250 cc's of saline. You don't want to contaminate it. I take out that, put another sock in. Now, polyp near the tuberosity on the left. Take that out, run my fluids, and still my scope is in.

Then the last I saw this area, it just didn't "look right." I tell my patients my eyes are not a microscope. What I need to know is that this is not atrophy. It turns out the cancer was in the lower uterine segment "polypoid vascular," the yellow plaques that you might see. The fibroid and the polyp could have just been present in a passenger and not the problem. The problem for that lady was the cancer in the lower uterine segment. You can take as many biopsies as you want, just make sure that you keep that scope in, put your foot on the pedal, run that so you get out pushing that clear fluid back into the trap, i.e. the sock. Then the nurse just changes and she labels it, whatever it is. That's how.

Yes, I don't put a curette in and that's my trick question of my residents. We do the procedure and then I'll say, "Well, what do we need to do next?" They look back at the table, "Oh, you need to do a curettage." I say, "Well, tell me why. Tell me more." You have just visually gone all the way around. What more are you going to get with your curette, except a perf, okay? There's just no reason.

[Dr. Mark Hoffman]
You're not mowing the lawn here with the device. You're not just sampling or are you?

[Dr. Linda Bradley]:
I do. No, I do a full anterior wall, posterior wall. Yes
.
You cannot get every millimeter but like yesterday, how the tubal ostia can be very concave. You get up in that little area. I've picked up cancers. It's not in your biopsy or curettage would never get up. Some people have a very deep-looking tubal ostia. You know what I'm saying? That's why endometrial ablations don't work because it doesn't get up there and burn all that endometrium as it's going out to the tubes. Then they get hematometra. Then they get retrograde bleeding. Then they get swollen bloody tubes, they get endometriosis, and they have cyclical pain.

No, I do a visually directed and I told the residents in my op notes, "Don't you ever put D&C on my patients, okay?" The way that we do this, it is labeled exam under anesthesia, dilation of cervix, hysteroscopically directed endometrial polypectomy, and hysteroscopically directed visual endometrial curettage. If I retire one day, people want to go back and look at what I've done, I never ever, almost ever use a curette. They can just take that off my table.

[Dr. Mark Hoffman]
You're doing directed biopsies and what else are you doing?

[Dr. Linda Bradley]:
When we do, we're trying to push this through now for retained products of conception. Why are you sucking the whole uterus? Suction curette for retained products, what business do we give to the reproductive endocrinologist? Asherman's, most Asherman's are caused by what? Retained products, doing a "D&C suction" of a missed abortion after postpartum. Well, postpartum hemorrhages are different, but you have a woman that's delivered, six, eight weeks later she's still bleeding. She's been on two or three birth control pills. You better look in there. It could be the smallest little piece of retained products. They bleed just like polyps. These things don't have to be that big.

[Dr. Mark Hoffman]
Are you using a hysteroscopic morcellator for that tissue?

[Dr. Linda Bradley]
Yes, absolutely, the retrieval system. Yes, for my retained products, I don't do OB. I haven't done it in decades, but I see a number of patients with retained products, yes, that were referred in.

[Dr. Mark Hoffman]
Let's talk about fibroids. The thing that I'm most curious about. You said you took 20 plus fibroids out of someone hysteroscopically, and I need to see this. I need to understand how that happens. Are you getting MRIs on these patients and seeing where they all are? How do you work them up? How do you address, how do you decide what fibroids to take? How do you know how far to go? You're going from below, right? You don't have the visualization of the outside, the serosa, of your depth. How do you deal with these tough cases?

[Dr. Linda Bradley]
Usually, if you're doing SIS or if they have a lot of fibroids, you can't distend the cavity, and they're bleeding. I do an MRI. Again, start with easy. Sometimes the uterus just doesn't distend. You might have an MRI, but with this issue, I think the uterus remodels itself during your surgery. All of my patients with fibroids, preoperatively, they all get oral misoprostol the night before. Helps with cervical dilation and makes the uterus contract. Sometimes you think that the patient has one fibroid or two, sometimes that uterus has contracted and more things have pushed in. I do a lot of variability in my intrauterine pressure, pressure's up, pressure's down. It leads to a massage of the uterus. Sometimes these intramural fibroids will pluck themselves into the cavity.

What do I do? I want to know the patient's fertility wishes because if they want children, after the surgery, I put in an intrauterine Foley catheter. Sometimes we can fill it up. It depends on how much goes in, anywhere from 10 to 30 cc's of sterile water. They stay on that. They have oral estrogen for a month. Usually, it's esterase, 1 milligram twice a day. I see them 14 days, 16 days after surgery, but they deflate their catheter two days before. Then I'm looking inside the uterine cavity.

What am I looking for? I want to make sure these walls are not agglutinated or stuck. You will always see an eschar but you know that you don't see the fibroids anymore. Then I let them finish the total of 30 days. It's not healed at that point. The intrauterine Foley is out. They then take a full 30 days of their estrogen. Then after all the estrogen is gone, in fact, I only send them home with esterase, 1 milligram BID. I send 60 tablets. I will see them in two weeks.

Then I say to them, "Okay, it looks like it's healing well." You can still see the eschar. At day, when that bottle is empty, then it's just Aygestin for 14 days by mouth. You were to take this every day, even if you start bleeding. Don't call me. I don't want all these calls. Just take your pills. Then when you finish your Aygestin, you will normally have a withdrawal bleed within 2 to 14 days. Then that's now at about four weeks, five weeks after surgery, and I look again. By then, in my own experience, the endometrium is healed. You don't see the eschar almost, you don't see Asherman's scar tissue. That's how I handle it.

[Dr. Mark Hoffman]
You look twice. Myomectomy, intrauterine Foley catheter, 10 to 30 cc's?

[Dr. Linda Bradley]
Yes. Whatever the uterus fills up with, okay.

Hysteroscopy Post Op Care Recommendations

Postoperative oral esterase (1 mg twice daily) for two weeks is prescribed, followed by Aygestin for another two weeks to facilitate endometrial healing and induce a withdrawal bleed. An intrauterine Foley catheter is utilized postoperatively, filled with 8 to 10 cc's of sterile water, to prevent adhesions and support the uterus in healing. Educating patients on self-managing the Foley catheter is important, including how to deflate it slightly in case of cramping and handling minor bleeding. Dr. Bradley recommends using a traditional Foley catheter with sterile water over more complex devices, citing ease of use and effectiveness, and ensuring that saline is not used to avoid crystallization issues. The use of estrogen therapy is central to this approach, aimed at rebuilding the endometrium and reducing the risk of scar tissue formation.

[Dr. Mark Hoffman]
After the myomectomy, intrauterine catheter and filling up the uterus: the oral esterase, a milligram twice a day for two weeks follows? Then Aygestin for how long?

[Dr. Linda Bradley]
A month. They go with 60 capsules. 14 days, so two weeks of that. Then they get the withdrawal bleed.

[Dr. Mark Hoffman]
Then look a third time?

[Dr. Linda Bradley]
No, second time, just second. First is looking at two weeks because they're on estrogen only. Then the bottle's out. Ma'am, take your Aygestin for two weeks. When you finish that last pill within two days to two weeks, you're going to bleed. Then you call my office. Tell me when you start your period because then we're going to schedule you the following week so that way, everything is re-epithelialized. You've given them estrogen. Really, you don't even see your footprint where you left it.

[Dr. Mark Hoffman]
You're rebuilding it in a sense with the estrogen, is that the idea?

[Dr. Linda Bradley]
Yes. Many people don't do that. I've been doing this for so long. I wish I had done some kind of study. Again, many things that we do in medicine, we don't always have all the answers, but you have to do something. Now, if she's 49 and doesn't want kids, I don't do all of this. She's ambivalent. I'm going to do this. I can almost tell you, I don't see scar tissue.
The other thing that I think I do differently than REIs do, they put in 5 cc's only for the little balloon. Everybody says, "Oh, my God, she's going to be in so much pain." We teach them in the post-op area, they go home with a syringe, how to deflate it. If you have a little bit of crapping, let out no more than 2 to 3 cc's at a time. We tell them how many cc's we put in to start with. Then they self-manage this. If you get below, it's rare that they are deflating a lot. A normal uterus holds about 8 to 10 cc's so if they get below a certain amount, that's what happens.

I tell them, "Don't call me if the balloon falls out," and it's not their fault. Just keep taking your estrogen and come in two weeks because we do not see that, it's rare. I'm going to say 5% of the time. The uterus is a muscle and it just comes out. No, I don't like a lot of phone calls, okay? I give all these instructions and we come back in and then we just take a look and go from there. I think putting more fluid in the balloon.

There's something, like some catheter I tried that looks like a square. I don't want to bad mouth any company, but I almost couldn't get the darn thing out. I don't forget what it was called. I tried it once. It wasn't that big. It looks like a little pillow or something. I just use an old-fashioned Foley and sterile water. You don't want to put saline because saline can crystallize and then it won't deflate. That's important to Foley. Then they have a leg bag, a little tiny leg bag so they can work, they can shower. We teach them, it's going to drain a little bit, it's not hemorrhaging, but how to change that. That's our little protocol.

Podcast Contributors

Dr. Linda Bradley discusses Advanced Hysteroscopy on the BackTable 34 Podcast

Dr. Linda Bradley

Dr. Linda Bradley is a professor of obstetrics, gynecology and reproductive biology with Cleveland Clinic in Ohio.

Dr. Amy Park discusses Advanced Hysteroscopy on the BackTable 34 Podcast

Dr. Amy Park

Dr. Amy Park is the Section Head of Female Pelvic Medicine & Reconstructive Surgery at the Cleveland Clinic, and a co-host of the BackTable OBGYN Podcast.

Dr. Mark Hoffman discusses Advanced Hysteroscopy on the BackTable 34 Podcast

Dr. Mark Hoffman

Dr. Mark Hoffman is a minimally invasive gynecologic surgeon at the University of Kentucky.

Cite This Podcast

BackTable, LLC (Producer). (2023, September 21). Ep. 34 – Advanced Hysteroscopy [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

backtable-earn-free-cme.jpg
backtable-plus-vi-cta.jpg

Podcasts

Advanced Hysteroscopy with Dr. Linda Bradley on the BackTable OBGYN Podcast)
Navigating Adenomyosis: From Misconceptions to Innovative Solutions with Dr. Keith Isaacson on the BackTable OBGYN Podcast)
Decoding Isthmocele: Causes and Considerations with Dr. Chuck Miller on the BackTable OBGYN Podcast)
Sustainable Global Healthcare Missions with Dr. Princess Urbina on the BackTable OBGYN Podcast)

Articles

Defining Success in Hysteroscopy Procedures

Defining Success in Hysteroscopy Procedures

The Evolution of Hysteroscopy: Past, Present & Future

The Evolution of Hysteroscopy: Past, Present & Future

Topics

Get in touch!

We want to hear from you. Let us know if you’re interested in partnering with BackTable as a Podcast guest, a sponsor, or as a member of the BackTable Team.

Select which show(s) you would like to subscribe to:

Thanks! Message sent.

bottom of page