Ambulatory Hysteroscopy Evidence-based Guide to Diagnosis and Therapy

8

Best Practice & Research Clinical Obstetrics and GynaecologyVol. 20, No. 6, pp. 953e975, 2006

doi:10.1016/j.bpobgyn.2006.06.004available online at http://www.sciencedirect.com

Ambulatory hysteroscopy: evidence-based

guide to diagnosis and therapy

Shagaf H. Bakour* MD, MRCOG

Consultant and Honorary Senior Lecturer in Obstetrics and Gynaecology

City Hospital, Birmingham, UK

Sian E. Jones MB, BCh, FRCOG

Consultant Gynaecologist

Bradford Royal Infirmary, Bradford, UK

Peter O’Donovan MD, Bch, BAO, FRCS (Eng), FRCOG

Consultant Obstetrician & Gynaecologist

Bradford Royal Infirmary, Bradford, UK

Healthcare providers are facing increasing demands for improvement in quality of life for pa-tients. Improvements in service provision for women are being ensured by the introductionof minimally invasive technologies into all spheres of gynaecologic practice. Ambulatory hystero-scopy (direct endoscopic visualization of the endometrial cavity) is an extremely exciting andrapidly advancing field of gynaecologic practice. It advanced dramatically during the 1990s, shift-ing the focus in healthcare away from inpatient diagnosis and treatment. Hysteroscopy is usedextensively in the evaluation of common gynaecological problems that were previously evaluatedwith blind and inaccurate techniques (e.g. premenopausal menstrual disorders, infertility andpostmenopausal bleeding). It allows direct visualization of the uterine cavity and the opportunityfor targeted biopsy, safe removal of endometrial polyps, and treatment of submucous fibroids,septa and adhesions. Ambulatory hysteroscopy is safe, with a low incidence of serious compli-cations; it has a small failure rate. There is a general consensus that hysteroscopy is the currentgold standard for evaluating intrauterine pathology, including submucous myomas, polyps, hyper-plasia and cancer. Hysteroscopy in the ambulatory setting appears to have an accuracy andpatient acceptability equivalent to inpatient hysteroscopy under general anaesthetic.

The primary goal of this chapter is to provide a high-quality, evidence-based text onambulatory diagnostic and operative hysteroscopy. The chapter includes in-depth analysis of

* Corresponding author. Address: City Hospital, Birmingham, UK. Tel.: þ44 121 554 3801x4377; Fax: þ44

121 507 5467.

E-mail address: [email protected] (S.H. Bakour).

1521-6934/$ - see front matter ª 2006 Published by Elsevier Ltd.

mailto:[email protected]

954 S. H. Bakour et al

the indications for outpatient hysteroscopy, its contraindications, the accuracy of diagnostichysteroscopy, relevant risk management issues and, training and teaching.

Keywords: advanced hysteroscopy training; ambulatory; diagnostic test accuracy; nurse hys-teroscopy; one-stop clinic; outpatient diagnostic and operative hysteroscopy; risk management.

INTRODUCTION

Historical background

Pantaleoni performed the first ambulatory diagnostic and operative hysteroscopy in1869; he used a Desmoreaux cystoscope to diagnose and treat a haemorrhagic uterinegrowth with silver nitrate. The greatest subsequent improvements in distension mediatook place in the early 1970s, and in 1979 Hamou revolutionized the field of hystero-scopy with improved visual optics and fine-diameter instruments (<4-mm hystero-scopes). The ability to examine conscious patients in the outpatient clinic furtherpopularized hysteroscopy in the 1980s and 1990s.

The need for outpatient hysteroscopy

It is estimated that about a quarter of all women will complain of abnormal uterinebleeding (pre- or postmenopausal) at some time.1 Abnormal uterine bleeding canhave a profound effect on a woman’s life; she can suffer socially, physically, psycho-logically and psychosexually. The aim of investigation is to exclude endometrial can-cer, hyperplasia and benign lesions. Until recently, diagnosis and treatment involvedlengthy multiple visits in both primary and secondary care, which meant a hugeamount of disruption to the patient’s life, long waiting times and a high rate of majorsurgery.

Questions and Literature Sources

Questions� Population: women with abnormal uterine bleeding� Interventions: ambulatory diagnostic and operative hysteroscopy (coil retrieval,

polypectomy, removal of submucous myoma, endometrial ablation, andsterilization)� Outcomes: feasibility, acceptability, success rate, effectiveness of therapeutic

interventions with the impact on quality of women’s life, and accuracy of thetest against gold standards

Literature sources� Electronic databases: relevant articles were identified through searches of the

Cochrane Library, Best Evidence, MEDLINE, and EMBASE (1970e2005)� Manual search: of bibliographies of known primary and review articles,

personal files of articles available from the authors and contact with expertsand manufacturers

Ambulatory hysteroscopy 955

Today, women with abnormal uterine bleeding can be assessed in a dedicated (one-stop) clinic and will receive prompt diagnosis and treatment. Waiting times are re-duced as women are seen in one visit, which includes a consultation, ultrasoundscan (if appropriate), outpatient hysteroscopy and endometrial sampling leading toan individualized management plan. One-stop clinics are usually staffed by a gynaecol-ogist, although nurse specialists are now taking on this role.

Since the 1990s, new hysteroscopes with a final diameter of <5 mm have enableddiagnostic and operative hysteroscopy to be performed in the outpatient setting, with-out cervical dilatation and consequently without anaesthesia or analgesia. The adventof small mechanical instruments and bipolar electrosurgical technology enables hys-teroscopic procedures to be performed in a ‘see and treat’ fashion in an ambulatorysetting.

Advantages of a one-stop hysteroscopy clinic

An ideal one-stop clinic is an outpatient, ambulatory, rapid-access, see-and-treat clinic.Recent randomized trials have shown that this approach is efficient and results in in-creased patient satisfaction.2e4 Patients benefit from more rapid diagnosis and treatmentand a speedier return to normal functioning and work; safety is improved because bipolarelectrosurgery and mechanical instruments are safer than monopolar electrosurgery.Hospitals and clinicians welcome the opportunity to increase day-case rates and protectelective activity from erosion due to rising medical emergency admissions; the opportu-nity to run ‘double’ clinic sessions with a nurse specialist is a further advantage.

Ambulatory hysteroscopy

The flexible hysteroscope was developed to overcome difficulties in viewing the cor-nual areas and in entering acutely anteverted and retroverted uterus. Flexible hystero-scopy has been shown to be associated with less pain than rigid hysteroscopy.5

Rigid telescopes are available in different angles of vision ranging from 0 to 30 de-grees, the former being the most popular for ambulatory hysteroscopy. Their externaldiameters vary from 1.2 mm to 4 mm. The telescope is inserted into an examinationsheath of 3e5 mm diameter.

Versascope and Versapoint

This innovation is very useful in ambulatory operative hysteroscopy. It can be usedwith physiological saline as a distension medium, thus reducing the chance of fluidoverload when compared with the use of hypotonic non-ionic media like glycine, sor-bitol or mannitol when monopolar electrosurgery is used. Lateral thermal spread isless likely. Three electrode configurations are available: spring, twizzle and ball elec-trodes in addition to the Versapoint bipolar loop electrode.

AMBULATORY HYSTEROSCOPIC NEW TECHNIQUE

Consent: before performing hysteroscopy, seeking patient’s consent, either verbally orin writing, is an ethical obligation.

Vaginoscopy: is an approach (without the use of speculum or tenaculum) that caneliminate patient discomfort related to the traditional approach. Vaginoscopy is easy


to perform, incurs no additional cost and is ideal for ambulatory hysteroscopy inpatients who might otherwise require general anaesthesia just because they cannottolerate a vaginal speculum (e.g. virgins and older women with somewhat stenoticvaginas). If the vaginoscopic approach is used, the vaginal fornix, ectocervix, cervicalcanal and uterine cavity can all be explored. During examination of the ectocervix,low magnification provides an excellent view of the cervix, a step that should neverbe missed.

Hysteroscopy

As a general principle, the hysteroscope should always be the first instrument to beinserted in the cervical canal. Histological specimens can be obtained either at thetime of hysteroscopy (directed/target) or using a blind endometrial suction samplingdevice (e.g. Pipelle). Research has demonstrated that such sampling has a high degreeof accuracy for diagnosis of endometrial cancer and hyperplasia.6

The failure rate for an ambulatory hysteroscopy varies between 2 and 8% in theliterature (around 4%)4,7, which is not inferior to that of an inpatient procedure(3%). The failure rate of hysteroscopy in postmenopausal women is no higher than inpremenopausal women.7

PAIN CONTROL IN OUTPATIENT HYSTEROSCOPY

The aim of ambulatory hysteroscopy is to provide an effective investigation with min-imal discomfort for the patient.

Anatomic considerations

The inferior hypogastric nerve plexus lies just lateral to the uterus and vagina in theuterosacral/cardinal ligament complex. This plexus contains sympathetic pelvicsplanchnic nerves from the thoracolumbar trunk and parasympathetics from the cra-niosacral trunk. It has three portions: (1) the vesical anterior plexus; (2) the uterova-ginal plexus (also known as Frankenhauser’s plexus); and (3) the middle rectal plexus.

Frankenhauser’s plexus appears to innervate the lower part of the uterine body,the cervix and the upper vagina. It lies on the dorsomedial surface of the uterinevessels. The uterine vessels, within the cardinal ligaments, enter the cervix at the 3and 9 o’clock positions. An additional set of nerves is contained in the uterosacralcomplex; these nerves insert at the 4 and 8 o’clock positions on the posterior aspectof the uterus. It is not clear whether the afferent pain fibres from the uterine body runin Frankenhauser’s plexus or whether they are included in the neurovascular bundle ofthe infundibulopelvic ligament.

Why hysteroscopy causes pain and discomfort

Distension of the uterine cavity causes discomfort and pain. The lower the distensionpressure in the uterus, the less the discomfort: a minimum of 30 mmHg is needed toseparate the uterine walls. In the outpatient setting the pressure should be kept to thisminimum. A prospective, randomized controlled trial (RCT) comparing carbon diox-ide and normal saline for uterine distension in outpatient hysteroscopy found signifi-cantly less abdominal pain and less shoulder tip pain with saline.8 Irrespective of the


distension medium used, pelvic discomfort is worse in nulliparous women than in mul-tiparous women.7 The size of the hysteroscope and sheath has an impact on pain andsuccess rates. Diameters of <3.5 mm are well tolerated in the outpatient setting. Theaddition of endometrial biopsy to hysteroscopy increases pain.9 Menopause has noeffect on the procedure being painful.7 Proper counselling before the procedure andtalking to the patient during the procedure can improve tolerability. A well-trainedhealthcare assistant (HCA) is ideal for this role.

Anaesthetic techniques for outpatient hysteroscopic procedures

It is important to remember that the majority of outpatient diagnostic hysteroscopiesdo not need any anaesthesia or analgesia; this is required only if there is a need toovercome cervical stenosis, i.e. to dilate the cervix or during some outpatient opera-tive hysteroscopic procedures. Polyps can be removed, or fibroids treated, with min-imal pain using bipolar energy, snares or mechanical instruments without the need todilate the cervix. The available anaesthetic techniques for outpatient hysteroscopicprocedures include topical lidocaine or Instillagel, intrauterine lidocaine, the traditionalparacervical block, and the deep paracervical block.

Paracervical blocks

The traditional paracervical block involves injecting of 1e2 mL local anaesthetic solu-tion (prilocaine, Citanest R) superficially into the tenaculum site at 12 o’clock. Thenthe cervix is gently grasped. Injections of 1e2 mL are used superficially to create blebsaround the cervicovaginal mucosa; a total of 10 mL is used to create a ring around thecervix. A further 10 mL is injected deep into the lower uterine segment where theuterosacral ligaments attach (4-quadrant block). By pulling the cervix forward, onecan see ‘tenting’ at the ligament attachment. The paracervical block involves injectingdeeply between 2 and 3 o’clock and between 4 and 5 o’clock on one side and thenbetween 9 and 10 o’clock and between 7 and 8 o’clock on the other. Aspiration beforeinjecting is essential. Less experienced clinicians often do not use deep paracervicalblock. Instead the injecting anaesthetic is placed at the cervicovaginal reflection.

Analgesia for hysteroscopy

Analgesia, in the form of paracetamol or a non-steroidal anti-inflammatory, can beused for ambulatory hysteroscopic operations. 100 mg of diclofenac sodium supposi-tory 1 hour before the procedure has demonstrated high efficacy.10 This is particularlypopular in ambulatory settings because of the simplicity of administration and low in-cidence of side-effects. Simple analgesics such as paracetamol orally 0.5e1 g every 4e6hours to a maximum of 4 g daily might be added for analgesia post-hysteroscopy.

INDICATIONS AND CONTRAINDICATIONS FOR AMBULATORYHYSTEROSCOPY

Indications for ambulatory hysteroscopy

� Evaluation of abnormal uterine bleeding.� Diagnosis and treatment of focal intrauterine lesions, e.g. polyps, fibroids.


� Investigation of infertility.� Diagnosis and treatment of intrauterine adhesions.� Diagnosis and treatment of uterine septa.� Investigation of recurrent miscarriage.� Location and retrieval of a lost intrauterine contraceptive device (IUD).� Ablation of the endometrium.� Hysteroscopic sterilization.

Abnormal uterine bleeding

Abnormal uterine bleeding accounts for more than 20% of referrals to the gynaecolo-gist and for 25% of gynaecologic procedures in premenstrual women.11 Abnormal uter-ine bleeding can be subdivided into premenopausal bleeding problems, postmenopausalbleeding and unscheduled bleeding on hormone replacement therapy or tamoxifen.

When combined with pelvic transvaginal ultrasound and endometrial biopsy, outpa-tient hysteroscopy is invaluable in the investigation of abnormal uterine bleeding. Be-fore considering hysteroscopy in all women of childbearing age, it is important to ruleout pregnancy and pregnancy-related bleeding conditions; bleeding from use of hor-monal preparations (oral contraception, contraceptive implants and injections); bleed-ing from complications of the use of intrauterine contraceptive devices; bleedingdiathesis, e.g. von Willebrand disease and bleeding from infective causes, e.g. cervicitis,endometritis.

Structural lesions responsible for abnormal uterine bleeding are often at their peakduring the perimenopausal period; these include focal lesions (like endometrial polypsand submucous fibroids) and diffuse lesions (like adenomyosis, endometrial hyperplasiaand cancer). Endometrial carcinoma is rare before the age of 40 years and its incidencerises steeply between ages 45 and 55.12,13 Between 5 and 10% of all women with post-menopausal bleeding will have endometrial cancer.14

Endometrial hyperplasia and cancer

Endometrial hyperplasia is deemed a precursor of endometrial cancer. The depth ofmucosa is evaluated by simple pressure of the tip of the endoscope. In comparisonwith the normal smooth, thin, endometrium without vascularization, features of in-creased endometrial thickness, abnormal vascularization and polypoid formationsare considered the hysteroscopic features of hyperplasia (severe glandular with orwithout atypia). Mamillations and cerebroid irregularities associated with irregular pol-ylobular, friable excrescences with necrosis or bleeding are considered diagnostic hys-teroscopic features of malignancy.15

Differential diagnosis in postmenopausal bleeding

Postmenopausal women should be seen within 2 weeks of referral:

� Endometrial pathology:� endometrial cancer� hyperplasia: simple, complex, or atypical� polyps� fibroids


� Atrophic endometrium: frequent diagnosis� Hormonal effect: proliferative or secretory endometrium, particularly in users of

hormone replacement therapy� Cervical, vaginal or vulval pathology� Extragenital tract source, per rectal bleeding or haematuria.

Blind dilatation and curettage samples only 60% of the endometrium16; most focallesions (polyps and fibroids) that will be obvious at hysteroscopy are missed by dilata-tion and curettage.17 The sensitivity and specificity of Pipelle endometrial sampling forendometrial cancer are 99.6% and 91%, respectively.18 For women with postmeno-pausal bleeding, the best balance of sensitivity versus specificity is obtained at endo-metrial thickness measurement of 5 mm, 92% and 81%, respectively.16,19

Infertility

The main indication for hysteroscopy in the investigation of infertility is in clarifying intra-uterine pathology when an abnormal hysterosalpingography result is obtained, e.g. endo-metrial polyps, submucous fibroids, intrauterine adhesions (Synechiae) or uterine septa.

Endometrial polyps

Around 10% of women presenting with infertility have endometrial polyps.20 Therehas been some suggestion that women with polyps have a higher rate of miscarriagebut there is no evidence of lower pregnancy rates in this group. The value of routinehysteroscopic removal of these polyps is unknown.

Fibroids

Fibroids have rarely been shown to be a direct cause of infertility but might affect fertilityindirectly. Some studies indicate high success rates in both pregnancy and live birthsfollowing removal of fibroids in women with otherwise unexplained infertility.21,22

Type 0 and type 1 submucous fibroids that distort the uterine cavity are well placedfor hysteroscopic diagnosis and removal. Most authors recommend removal of fibroidsno more than 2 cm in diameter in the outpatient setting.

Intrauterine synechiae (Ashermann’s syndrome)

This is usually the result of intraoperative or postoperative complications during uter-ine evacuation, termination of pregnancy or hysteroscopic surgery. It can also becaused by uterine infections. Ashermann’s syndrome has been found in 13% of womenundergoing routine infertility investigations.23 Typical symptoms are menstrual irregu-larities, amenorrhea and miscarriage. Outpatient hysteroscopy is ideal for the detec-tion of intrauterine adhesions.

Recurrent miscarriage

Congenital anomalies of the uterus

Congenital anomalies associated with infertility include uterine didelphis, unicornuate/bicornuate uterus and septate uterus. There is a high rate of spontaneous miscarriage


and of preterm labour (between 25% and 47%) when these structural anomaliesexist.24,25

Hysteroscopy is not useful in diagnosing cervical incompetence, but it can identifycervical adhesions, atresia and polyps. Cervical incompetence should be suspectedwhen, on withdrawal of the hysteroscope, the sphincter-like action of the internalos disappears. The surgeon should also suspect cervical incompetence when theuterus fails to distend with the loss of the fluid coming back through the cervix.

INDICATIONS FOR AMBULATORY OPERATIVE HYSTEROSCOPY

Improvements in the design and the manufacturing of smaller-diameter hysteroscopeshave made it possible to carry out operative hysteroscopy in the outpatient settingwithout the need for cervical dilatation or anaesthesia in most cases. Other advancesinclude the use of bipolar energy rather than monopolar energy, thus making it pos-sible to use normal saline rather than non-ionic distention media (glycine, sorbitolor mannitol).These advances have made ambulatory operative hysteroscopy a safe,cost-effective procedure.

Targeted biopsy

Suspicious or abnormal-looking focal lesions in the endometrium are best biopsiedusing a grasping forceps passed down the operating channel.

Endocervical and endometrial polypectomy

Polyps on the ectocervix can be removed by avulsion if they are pedunculated or usinga LLETZ loop if they are sessile. This is best done after the hysteroscopy is completedto prevent any bleeding obscuring vision. Polyps in the endocervical canal are removedusing the technique described below for endometrial polyps.

Endometrial polyps are formed by proliferation and hypertrophy of the basal layerof the endometrium, with varying risk of malignancy.26 At hysteroscopy they aresmooth and soft, indenting easily on contact, and often have very little vascularization.They are either sessile or pedunculated. They can be removed by using scissors orgraspers, the bipolar electrodes (the twizzle or the spring electrode). The disadvan-tage of this method is that there is no histology. Most experts would recommendthat polyps of <3 cm in diameter can be removed this way. This can be achieved inless than 15 minutes and will be tolerated by most women.

Treatment of submucous fibroids

When seen at hysteroscopy, submucous fibroids show a superficial vascularizationthrough a thin endometrium, as well as the whitish aspect of the myoma tissue.They feel firm and cannot be indented easily with the hysteroscope. Most expertswould recommend that only type 0 and type 1 submucous fibroids, of <2 cm in dia-meter, are treated in the outpatient setting. They can be treated using mechanicalinstruments, i.e. scissors or ablated using the bipolar spring electrode.


Division of intrauterine adhesions

Adhesions are classified as mild, moderate or severe. Mild adhesions are filmy, thin andusually of recent occurrence. Moderate adhesions are fibromuscular, thick and mightbleed on division. Severe adhesions are usually composed of connective tissue only,without endometrial covering, and are unlikely to bleed. Division of the moderateand severe forms often requires general anaesthesia and concomitant laparoscopy.In the outpatient, setting a scissors or twizzle electrode is used for division under hys-teroscopic vision. Around 90% of patients have normal menstruation following treat-ment and 60e70% pregnancy rates follow, depending on the severity beforetreatment.27

Division of uterine septa

Approximately 25% of women with a septate uterus have recurrent pregnancy loss.24

The septa are poorly vascularized, making them ideal for hysteroscopic division. Hys-teroscopic division with scissors suffices for the thin septum, whereas thicker andbroader septa might require a cutting electrode (e.g. twizzle) or the use of a resecto-scope under general or regional anaesthesia. Every effort should be made to ensurea thick covering of myometrium at the uterine fundus (transvaginal scan). If this isnot certain then the division is best carried out under laparoscopic control.

Hysteroscopic division offers high success rates; successful pregnancy rates of85e90% have been quoted in some series.28,29 Generally, patients are advised to delaypregnancy for at least 4e6weeks.

Removal of a lost intrauterine contraceptive device

A pelvic ultrasound scan will locate the IUD and confirm its presence inside the cavity.If there is doubt, a plain abdominal X-ray should be ordered. Outpatient hysteroscopyis invaluable in the removal of the IUD from the uterus. A hysteroscope with an op-erative channel is used with a grasping forceps inserted into the uterus and either thethread or the IUD itself is grasped with the forceps and the hysteroscope is withdrawntogether with the IUD.

Outpatient hysteroscopic sterilization: Essure��

Hysteroscopic sterilization performed in an outpatient setting aims to reduce the risksfrom a general anaesthesia, has a shorter recovery period and aims to be cost effec-tive. A new method that aims to achieve this is the Essure� permanent contraceptivesystem, developed by Conceptus, Inc. The Essure� system consists of the Essuremicroinsert, a disposable delivery system and a disposable split introducer. A standardhysteroscope with a 5 French working channel, continuous flow and a 12- to 30-degree angled lens are used when sterilizing with inserting Essure�.

The Essure microinsert consists of a stainless steel inner coil, a nitinol, super-elasticouter coil and polyethylene (PET) fibres. The microinsert is 4 cm in length and 0.8 mmin diameter. When released, the outer coil expands to 1.5 to 2.0 mm to anchor themicroinsert in the varied diameters and shapes of any fallopian tube. The microinsertremains anchored in the fallopian tube, placed across the uterotubal junction. The di-ameter of the microinsert is larger trailing into the uterus than within the tubal lumen.


This difference in the diameters is intended to prevent migration toward the perito-neal cavity. The PET fibre mesh and the microinsert act as scaffolding into whichfibrous tissue grows, anchoring the microinsert within the fallopian tube and occludingthe tube, resulting in sterilization.

In early studies30,31, bilateral tubal occlusion was demonstrated in 96% of cases and6-month follow-up confirmed bilateral occlusion in all patients. Essure� is 99.80%effective in preventing pregnancy after 3 years of follow-up. It can be performed in15e25 minutes and has a high patient satisfaction rating. Bilateral placement rateoccurs in 86% (first attempt) and 90% (with second attempt).32

An alternative method of contraception must be used for 3 months after theprocedure.

Outpatient endometrial ablation

Endometrial ablation is designed to treat abnormal uterine bleeding in women with nointrauterine pathology. Those ablative devices more suited for the outpatient setting arethe second-generation, so-called global endometrial ablation devices. The energy sour-ces used include hot water, microwave, radio frequency, laser and cryoablation. Theseprocedures can be done in an outpatient setting using local anaesthetic. The balloon de-vices (Thermachoice and Cavaterm), microwave endometrial ablation, Hydro ThermAblator and Novasure have all been approved by the National Institute for ClinicalExcellence (NICE) and in the future NICE will undoubtedly approve the other devices.

Balloon devices

There are two balloons in clinical use. These use a combination of heating and pres-sure to achieve endometrial destruction. Cavity size is also limited to between 4 and10 cm. They cause pain by uterine distension during treatment under local anaesthetic.Most authors suggest a non-steroidal anti-inflammatory drug before treatment andrescue analgesia if needed (nitrous oxide or paracervical block). Neither requires en-dometrial priming.

The Thermachoice UBT System has an external diameter of 4.5 mm, so rarelyneeds cervical dilatation prior to insertion. The device is inserted into the uterusand expanded to pressures of between 160 and 180 mmHg using sterile dextrose5%. A microprocessor controls heating to 87 �C. Once the treatment temperatureis reached, the treatment time is 8 minutes; the whole procedure usually takes 15minutes. One-year patient satisfaction rates are 85%, with 15e3% amenorrhoearates.33

Cavaterm is a similar device to Thermachoice UBT System but the silicone balloonis inflated to 180e200 mmHg with a treatment temperature of 75 �C for 15 minutes.The device has an external diameter of 8 mm so requires cervical dilatation before in-sertion. Cavaterm is not used frequently in the outpatient setting.

Microwave endometrial ablation

The microwave endometrial ablation device uses a software-controlled unit with mi-crowave energy at a fixed frequency of 9.2 GHz; the operating power is 42 W. Themicrowave energy is delivered by an 8-mm-diameter probe, which heats the tissueto 80e90 �C. This gives reliable tissue destruction to a depth of 4e5 mm. It is per-formed under local anaesthetic but the cervix needs dilating to Hegar 9 before


insertion so 4-quadrant cervical block is recommended. However, there is no uterinedistension and the treatment time is short: 3 minutes in a normal-sized cavity. The suc-cess rate at 1 year is 87% and amenorrhoea rates of 33e53% have been reported.33,34

The microwave endometrial ablation device is the only device initially licensed for usein patients with submucous fibroids up to 3 cm in diameter or a uterine cavity depth ofup to 14 cm. Women who have had lower segment caesarean section can be treatedproviding the scar thickness measured by transvaginal sonography (TVS) is >8 mm.Endometrial priming is recommended.

Hydro ThermAblator

The Hydro ThermAblator system occludes the cervix and destroys the endome-trium by circulating low pressure (50e55 mmHg) heated saline under vision inthe uterine cavity. The insulated, disposable sheath is 7.8 mm in diameter and fitsover most commercially available 3-mm hysteroscopes. The cervix needs dilatationto Hegar 8 to allow insertion of the device. The uterine cavity should measure<12 cm but cavities with fibroids can be treated. It takes 3 minutes to heat thesaline to treatment temperature of 90 �C. The treatment time is then 10 minutesfollowed by a cooling period of a further 1 minute before the device can be with-drawn. The heated saline thus bathes the endometrial cavity with the cervix sealed.Because of the low pressures used (lower than the 60 mmHg opening pressure ofthe tubal ostia) fluid spillage into the peritoneal cavity does not occur. It has beenperformed under local anaesthesia using paracervical block but the proceduretime of 15 minutes makes treatment in the outpatient setting less appealing tothe patient. One-year success rate is 94% with reported amenorrhoea rates of40e60%.33,35 Endometrial priming is recommended.

NovaSure

NovaSure is a disposable impedance-controlled device. No endometrial priming isneeded. It uses bipolar energy delivered through a gold-plated mesh mounted ona flexible frame, which conforms to the shape of the uterine cavity. The device is6.9 mm in diameter and so requires cervical dilatation. Regular cavities between 6and 11 cm can be treated with this device. Cavity integrity is checked using a smallamount of CO2. The device vaporizes the endometrium, regardless of thickness, us-ing bipolar energy. As tissue destruction continues, the resistance to flow of currentincreases until tissue impedance reaches 50 ohms. Treatment time is calculated bythe generator based on tissue impedance. When impedance reaches 50 ohms ortreatment time reaches 2 minutes, treatment is complete. Procedure time hasbeen reported at 5 minutes. There is no uterine distension. The amenorrhoearate at one year is 43% and success rate of 90%.36

Contraindications to ambulatory hysteroscopy

Absolute contraindications

� Cervical cancer: hysteroscopy should not be performed in the presence of cervicalcarcinoma (in situ or invasive) because of the danger of opening blood or lymphaticvessels and causing systemic dissemination of malignant cells.� Heavy uterine bleeding: hysteroscopy should be avoided during menstruation,

because of a theoretical risk of dissemination of endometriosis and mainly because


the view is usually unsatisfactory. Moderate uterine bleeding does not preventadequate visualization of the endometrial cavity.� Pelvic inflammatory disease: because of the danger of causing extended ascending

infection and peritonitis.

Relative contraindications

� Pregnancy: generally considered a contraindication to hysteroscopy but it might benecessary to perform hysteroscopy to remove an IUD or to diagnose retained prod-ucts of conception when there has been persistent postabortal bleeding, althoughultrasound has replaced endoscopy in many such cases. The myometrium in the graviduterus is much more distensible than in the non-pregnant organ. Uterine distensionwith gas can cause the uterus to distend like a balloon, which can result in retroplacen-tal bleeding or a massive gas embolus. It is important, therefore, that hysteroscopy inpregnancy is performed only by an expert surgeon and that the gas flow is restrictedto 20 mI/minute. It is also important to remember that the optic nerve of the fetuscan be damaged by the hysteroscope light after the tenth week of pregnancy.� Recent uterine perforation: the risk of repeat uterine perforation is considerably

greater in such patients as the healing process might have left a weak scar.� Cervical stenosis: the risk of uterine perforation is considerably greater in such

patients. The role of experienced operator can not be more reinforced.� Cardiorespiratory disease.� Uncooperative patient: although this can be overcome using the vaginoscopic

technique.

COMPLICATIONS OF DIAGNOSTIC/OPERATIVE AMBULATORYHYSTEROSCOPY

Ambulatory hysteroscopy is a safe procedure. Most complications of hysteroscopy arerare and, if they do occur, are seldom life-threatening, particularly in diagnostic proce-dures. A recent Royal College of Obstetricians and Gynaecologists’ guideline for gain-ing consent for diagnostic hysteroscopy under general anaesthetic quoted a figure aslow as 8/1000 for uterine perforation37; the figure is much lower for ambulatory pro-cedures. A large systematic review7 of studies of over 25,000 women reported onlyeight (3/10,000) cases of potentially serious complications (a pelvic infection, uterineperforations4, a bladder perforation, and precipitation of a hypocalcaemic crisis/anginalepisode). Operative hysteroscopic procedures are more risky, with uterine perfora-tion being the most common complication. Among other hysteroscopic procedures,resection of fibroids and uterine septa have significantly higher rates of complications(4e7 times more operative complications than polypectomy)38, mainly due to fluid in-travasation. Ambulatory operative procedures tend to be short in duration and, as thepatient is awake and responsive to painful stimuli, the chances are that fluid intravasa-tion problems are unlikely and difficult procedures will be abandoned early due topatient intolerability minimizing risk of complications.

Complications of hysteroscopy in the ambulatory setting

In a large observational clinical study in Italy39, 501 women were treated for benignintrauterine pathologies using an outpatient hysteroscopic procedure, without


analgesia or anaesthesia. A Versapoint 5 French bipolar electrode was used to treatendometrial polyps ranging between 0.5 and 4.5 cm, as well as submucosal and par-tially intramural myomas between 0.6 and 2.0 cm. No failures or major complications(i.e. severe pain, vagal reflex, intravasation, uterine perforation, bleeding) occurredduring the procedures. Generally, most complications are related to the surgeons’experience and the type of procedure.

Intraoperative complications

Vasovagal reflex

This commonly occurs when dilating the cervix or passing the hysteroscope. The prev-alence of vagal reaction (1 in 300 cases) depends on the ability of the endoscopist andon the diameter of the scope.

Cervical trauma

Operative ambulatory procedures can often be performed without the need to dilatethe cervix, especially with the Versascope and particularly if the vaginoscopic tech-nique described by Bettocchi et al is used.40 However, operative hysteroscopy mightrequire cervical dilatation. Trauma can be dealt with using pressure, silver nitrate orsutures. It is best to avoid overdilating the cervix because this can result in leakageof the distending media through the cervix and around the hysteroscope. Always in-troduce the hysteroscope under direct vision.

Uterine perforation

Uterine perforation is a rare event. In a large systematic review7 of studies of over25,000 women, only four (1/6000) cases of uterine perforation occurred. Even for in-patient operative procedures, the incidence is low. The uterus might be perforated bya dilator, the hysteroscope or an energy source. Management will depend on the size,site of the perforation and whether there is risk of injury to another organ. Perfora-tion occurs more frequently at the level of the fundus without significant bleeding. Sim-ple perforation rarely causes any further damage and can be treated conservatively byadmission, observation and appropriate broad-spectrum antibiotics. Laparoscopymight be considered to exclude bleeding. Complex perforation might be made withmechanical or an energy source and therefore can be associated with thermal injuryto adjacent structures including bowel or large vessels. However, energy sourcesused in the outpatient setting are usually bipolar energy (Versapoint), or heat (Ther-machoice), which offer reduction of energy spread through the tissue during the pro-cedure and hence high levels of safety.

Haemorrhage

Intra- or postoperative bleeding can be caused by:

� the tenaculum (only used if dilating cervix)� uterine perforation� the procedure.


Management will depend on the site, severity and cause of the bleeding. Intrauter-ine bleeding occurring during the procedure should be immediately obvious and canusually be controlled by spot electrocoagulation. If coagulation fails to control thebleeding, the procedure might have to be abandoned and tamponade performed byinserting a Foley catheter and distending the balloon. The catheter should be left in situfor 4e6 hours, after which the bleeding nearly always stops.

Delayed complications of ambulatory hysteroscopy

Infection

An incidence of 2/1000 of infection has been reported in over 4000 diagnostic hyster-oscopies. Acute pelvic inflammatory disease following hysteroscopic surgery is rare.The diagnosis is made from the classic symptoms and signs, and treatment shouldbe by appropriate antibiotics following culture of vaginal swabs and blood.

Vaginal discharge

Vaginal discharge is common after any ablative procedure and can sometimes be pro-longed (2e3 weeks), although it is usually self-limiting. Patients should alert theirhealthcare provider if the vaginal discharge becomes offensive or if she developspyrexia, heavy bleeding or severe lower abdominal pain.

Adhesion formation

Intrauterine adhesions are common, especially after myomectomy when two fibroidsare situated on opposing uterine walls. In this case, the myomectomy is better per-formed in stages to prevent adhesion formation. An intrauterine device and 2 monthsadministration of oestrogen and progestogen therapy (in the form of combined oralcontraceptives) can help prevent adhesion formation following resection, adhesiolysisor division of a septum.

Box 1 summarizes how complications can be avoided.

Box 1. How can we avoid complications?

Preoperative factors to consider� Complexity of procedure� Size of uterus� The role of misoprostol when expecting a difficult dilatation� Overall health status and co-morbidity� Operator’s experience

Preoperative optional imaging studiesThese have a role as a diagnostic aid providing additional information about thecavity that can be useful during surgery:

� Hysterosalpingogram� Sonohysterogram


ACCURACY OF DIAGNOSTIC AMBULATORY HYSTEROSCOPY

When the uterine cavity is adequately visualized, hysteroscopy is highly accurate andthereby clinically useful in the diagnosis of endometrial cancer. The diagnostic accuracyof hysteroscopy for endometrial cancer is such that the likelihood ratios (LRs) are 62and 0.15 for positive and negative results, respectively. The pre-test probabilityincreases with a positive result (Figure 1) and decreases with a negative result(Figure 2).41,42

The diagnostic accuracy of hysteroscopy in endometrial cancer and hyperplasia ismore modest, so that it cannot be ruled in or excluded with a high level of certainty.For endometrial cancer and hyperplasia, the pooled LRs are 10 and 0.24 for positiveand negative hysteroscopy results, respectively. The probability changes are not as pro-found with these LR values. This relatively inferior performance of hysteroscopy in de-tecting endometrial disease in comparison to its performance in detecting endometrialcancer is probably because features of hyperplasia are not clearly distinct. For diagno-sis of benign submucous fibroids and endometrial polyps, hysteroscopy has quite a highdegree of accuracy (Figure 3).26,41,42

Performance of hysteroscopy as a test does not appear to be altered by meno-pausal status. Compared to the inpatient setting, outpatient hysteroscopy has a margin-ally higher failure rate but appears to have a trend towards improved diagnosticperformance. There is a tendency towards improved diagnostic accuracy for out-patient hysteroscopy for both endometrial cancer and disease compared with inpa-tient procedures.7

Comparison with ultrasound and endometrial biopsy

A comparison of accuracy of these tests is provided in Figure 3. Although endometrialbiopsy is accurate and a relatively inexpensive test for identifying endometrial malig-nancy and premalignancy, it is a poor test for diagnosing benign endometrial abnormal-ities such as atrophy, polyps and submucosal fibroids, which are far more commoncauses of bleeding. Transvaginal ultrasonography techniques have better accuracy inthe identification of benign conditions than endometrial biopsy. In comparison, hys-teroscopy can detect small polyp or submucous fibroids that have been missed byendometrial biopsy. Hysteroscopy is considered the gold standard for the accuratedetection of these intrauterine pathologies for its superiority in directly visualizingthese lesions.7,41

� Transvaginal ultrasound� Computerized tomography or magnetic resonance imaging

Intraoperatively� Keeping operating times to a minimum� Keeping fluid pressure as low as possible because of fluid absorption if it

exceeds venous pressure� Meticulous fluid balance: the procedure must be abandoned if the deficit rises

to 750e1000 mL


Using a 5-mm threshold to define abnormal endometrial thickening generally, it can beconcluded that transvaginal ultrasound can accurately identify postmenopausal womenwith vaginal bleeding who are highly unlikely to have significant endometrial diseaseso that endometrial sampling or even hysteroscopy might be unnecessary.14,16,19

The role of sonohysterography or saline infusion sonography is developing. It in-volves instillation of 5e15 mL of normal saline into the uterine cavity for better detec-tion of endometrial polyps and submucous fibroids.

Role of outpatient endometrial biopsy

Outpatient endometrial biopsy has modest accuracy in diagnosing endometrialhyperplasia.6,18 The sensitivity and specificity of Pipelle endometrial sampling for endo-metrial cancer is high, at 99.6% and 91%, respectively.18 The sample adequacy rateranges from 90 to 95% in the premenopausal group.43,44 For postmenopausal patients,

Generating post-test probabilities for a positive test

Posttest probabilitywith negative test

90

Pretest probability ofendometrial cancer

without testing13

Likelihoodratio = 62

Nomogram adapted from N Engl J Med 1975;293:257.

Post-test probabilities of endometrial cancer according to riskgroups based on age

Age group Pre-test probability* Post-test probability+< 50 years 0.5

.1

.1

.2

.2

.5

.5

1

1

2

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202030

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Pretest probability

Likelihood Ratio

Posttest probability

2451--60 years 1.0 39> 60 years 13.0 90* Obtained from population based data+ Computed using the following formula:Posttest probability = Likelihood ratio Pre-test probability

[1 Pre-test probability (1 Likelihood ratio)]

1000

500200100502010521

.5

.2

.1

.05

.02

.01

.005

.002

.001

Figure 1. Change from pre-test to post-test probabilities using likelihood ratios. The impact of abnormal

hysteroscopy findings (positive hysteroscopy) on the likelihood of endometrial cancer among postmeno-

pausal women with vaginal bleeding. (With permission of Royal Society of Medicine Press.)


the adequacy rate is significantly lower probably because of the atrophic endometrium.Outpatient endometrial sampling has a procedure failure rate and a tissue-yield failurerate of approximately 10%.16 It should be noted that yield failures are not unexpectedin women with atrophic endometrium, whereas failure to obtain tissue would be lesslikely if cancer was present. The false-negative rate for endometrial carcinoma is lowand endometrial biopsy is therefore accurate in excluding endometrial carcinoma. Ingeneral, additional assessment of the endometrial cavity should be undertaken, espe-cially if symptoms persist or intrauterine structural abnormalities are suspected.

Role of transvaginal sonography

Patients referred to the one-stop outpatient hysteroscopy clinic with abnormal uterinebleeding might also have a transvaginal ultrasound scan. In postmenopausal women,thickening of the endometrium (>4 mm) might indicate the presence of pathology.19

Generating post-test probabilities for a negative test

Posttest probabilitywith negative test

2

Pretest probability ofendometrial cancer

without testing13

Likelihoodratio = 0.15

Post-test probabilities of endometrial cancer according to riskgroups based on age

Age group Pre-test probability* Post-test probability+< 50 years 0.5 051--60 years 1.0> 60 years 13.0 2* Obtained from population based data+ Computed using the following formula:Post-test probability = Likelihood ratio Pre-test probability

[1 Pre-test probability (1 Likelihood ratio)]

Nomogram adapted from N Engl J Med 1975;293:257.

0

.1

.1

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Posttest probability

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.02

.01

.005

.002

.001

Figure 2. The impact of normal hysteroscopy findings (negative hysteroscopy) on the likelihood of endome-

trial cancer among postmenopausal women with vaginal bleeding. (With permission of Royal Society of

Medicine Press.)


In general, the thicker the endometrium, the greater the likelihood of importantpathology (endometrial cancer) being present. Transvaginal ultrasonography can reli-ably assess thickness and morphology of the endometrium and can thus identifya group of women who have a thin endometrium and are therefore unlikely to havesignificant endometrial disease. This group might not require any further investigationunless there is a recurrence of bleeding.16 Those patients with thickened endometriumrequire further investigations in the form of hysteroscopy and endometrial sampling. Inpremenopausal women with abnormal uterine bleeding, the endometrium undergoescyclic changes in response to ovarian steroid hormone stimulation. Hence, the thick-ness of the endometrium varies and it becomes difficult to establish guidelines as towhat should be considered ‘normal’ thickness.

Saline-enhanced transvaginal ultrasonography for endometrial texture and marginanalysis can be used to help improve diagnostic accuracy. Other ultrasonographic tech-niques, such as transvaginal Doppler ultrasonography and three-dimensional ultra-sonography, are being introduced gradually for improving discrimination betweenanomalies (e.g. polyps versus fibroids). There is not enough evidence to support theirintroduction into routine clinical practice at present.

Test combinations

There remains an ongoing debate about the choice between ultrasound, endometrialbiopsy and hysteroscopy in the management of women presenting with abnormal uter-ine bleeding. Some have recommended test combinations, e.g. pelvic ultrasound scan

Positive Test

0.1 1 10

Tests for endometrial cancer

Likelihood ratio (LR)

Likelihood ratio

Positive test

Tests

Negative Test

Useless Test Useful Test

Tests for endometrial cancer plus hyperplasia

Tests for submucous fibroid

Tests for endometrial polypHysteroscopyTransvaginal ultrasoundSaline infusion sonography

HysteroscopyTransvaginal ultrasoundSaline infusion sonography

HysteroscopyTransvaginal ultrasound at 5mm cutoffMiniature endometrial biopsy (hyperplasia only)

HysteroscopyTransvaginal ultrasound at 5mm cutoffMiniature endometrial biopsy

Negative test

Figure 3. Comparison of accuracy of hysteroscopy with other modalities for diagnosis of malignant, prema-

lignant and benign condition among women with abnormal uterine bleeding. (With permission of Royal

Society of Medicine Press.)


and/or outpatient hysteroscopy.45 Ultrasonography is considered less invasive thanhysteroscopy and it is accurate at ruling-out endometrial cancer and hyperplasia inpostmenopausal women. Ambulatory hysteroscopy is accurate at ruling-in endome-trial cancer and hyperplasia. Thus a transvaginal ultrasound scan might be employedas an initial test followed by hysteroscopy in women with abnormal uterine bleedingwho have a positive result on ultrasound scanning. Endometrial sampling could alsobe considered as an initial test for excluding malignancy.

RISK MANAGEMENT FOR AMBULATORY HYSTEROSCOPY

Patient safety

Patient safety is at the very core of risk management; it is the first and foremost do-main of healthcare. Whereas historical data from incident reporting is very useful,a more proactive approach is essential if ‘hidden’ or unidentified risks are to be iden-tified. For an ambulatory hysteroscopy service, a regular risk assessment will enablethe identification of risks. A framework for performing risk assessment might involvemapping a patient’s ‘journey’ through the hysteroscopy service, assessing the followingareas for clinical and non-clinical risks:

� environment: equipment, medicines use, infection control� staffing: number, training� patient assessment: availability of medical records, documentation� patient treatment: guidelines and consent� discharge/follow-up arrangements.

When the procedure is broken down in this way, it is clear that errors or mistakescan happen at any stage. Specific areas for risk management in ambulatory hystero-scopy include: documentation, consent and adequate training before performingnew procedures.

For an ambulatory hysteroscopy service to achieve the above objectives it cannotoperate in isolation from other areas of health provision, e.g. clinic administration, gy-naecological pathology, and primary care. Interfaces between these areas representpotential barriers to patient safety.

TRAINING IN AMBULATORY HYSTEROSCOPY

Formal hysteroscopy training programmes and accreditation are rapidly expandingamong gynaecologists. In general, a distinction has to be made between two typesof training programme:

� Diagnostic hysteroscopy training programme: can be undertaken by any interestedprofessional: a nurse, a GP or a gynaecologist. The training focuses mainly onhysteroscopy as a diagnostic procedure for women with abnormal uterine bleeding.� Advanced hysteroscopic surgery training programme: should be particularly

directed at gynaecologists, either in training or qualified specialists, interested inproviding treatment.


Whatever the training programme, trainees should progress through a structurededucational system with appropriate supervision, formal instruction and critical assess-ment and evaluation under the supervision of preceptors.

SUMMARY

The aim of investigations of abnormal uterine bleeding is to diagnose endometrial can-cer, hyperplasia and benign pathology. Ambulatory hysteroscopy in a one-stop clinic isefficient, has an accuracy higher than inpatient hysteroscopy and results in increasedpatient satisfaction as a result of the rapid alleviation of anxiety, faster recovery andless time away from work and home. The key merit of this one-stop approach is toincrease the activity through an outpatient setting by giving women the option of treat-ment at the time of diagnosis, i.e. ‘see and treat’.

Vaginoscopy can be used to eliminate patient discomfort related to the traditional ap-proach. Improvements in the last decade in the design and the manufacture of smaller-diameter hysteroscopes (<5 mm) have made it possible to perform operative hystero-scopy in the outpatient setting without the need for cervical dilatation or anaethesia inmost cases. Other advances include the use of bipolar as opposed to monopolar energy,thus making it possible to use normal saline rather than non-ionic distention media.

Most experts would recommend that only type 0 and type 1 submucous fibroids of<2 cm in diameter, and polyps <3 cm, should be treated in the outpatient setting.

Most of the complications of ambulatory hysteroscopy are rare and are seldomlife-threatening. The possibility of uterine perforation is very small but should beborne in mind. Hysteroscopy is highly accurate and therefore clinically useful in thediagnosis of endometrial cancer. However, the diagnostic accuracy of hysteroscopyin endometrial hyperplasia is more modest. For polyps and submucous fibroids, hys-teroscopy is considered the gold standard. Performance of hysteroscopy as a testdoes not appear to be altered by menopausal status. The relative roles of ultrasound,endometrial biopsy and hysteroscopy and their combinations for diagnosis of pathol-ogy remain a topic of debate.

Practice points

� Knowledge of the room set-up and available instruments is crucial for success-ful outpatient hysteroscopy.� The hysteroscope should always be the first instrument to be inserted into the

cervical canal; dilatation of cervix is not necessary in a majority of cases.� A panoramic view of the endometrial cavity allows an assessment for abnor-

malities. Assessment of the cervical canal on removal of the hysteroscopecaptures cervical pathology.� Endometrial carcinoma is rare before the age of 40 years and its incidence rises

steeply between 45 and 55 years. Between 5 and 10% of all women with post-menopausal bleeding will have endometrial cancer.� Blind dilatation and curettage samples only 60% of the endometrium; most

focal lesions (polyps and fibroids) that are obvious at hysteroscopy are missedby dilatation and curettage.� Essure� is a new system that tries to achieve permanent contraception via

outpatient hysteroscopic sterilization.


ACKNOWLEDGMENTS

No work can ever be completed without the support of many individuals. The authorswould like to thank families and friends who supported the project of writing thisbook. We are particularly grateful to the following colleagues for their contributionsoutlined below:

� Professor Khalid Khan, Professor of Obstetrics-Gynaecology and Clinical Epidemi-ology Honorary Consultant Obstetrician-Gynaecologist Birmingham Women’s Hos-pital, Birmingham, UK

� The second-generation ablative devices most suited for the outpatient settingusing local anaesthetic are: Thermachoice and Cavaterm, microwave endo-metrial ablation, Hydro ThermAblator and Novasure.� Outpatient hysteroscopy has a marginally higher failure rate than hysteroscopy

in the inpatient setting.� There is a tendency towards improved diagnostic accuracy with outpatient

hysteroscopy over inpatient procedures.� The diagnostic hysteroscopy training programme can be undertaken by any

interested professional: a nurse, a general practitioner or a gynaecologist.� Advanced hysteroscopic surgery training is aimed at gynaecologists e either

residents in training or qualified specialists. It should be delivered under thesupervision of a preceptor to inculcate operative skills in an ambulatory setting.

Research agenda

� Future development of subspecialization: it has been suggested that the wayforward is to develop advanced hysteroscopic surgery as a recognizedsubspecialization.� To date, there is no official accreditation of such a subspecialization in hystero-

scopy but many individual clinicians have achieved the levels of excellence out-lined below through personal interest and training:� To improve knowledge, practice, teaching and research in the subspecialty.� To promote the concentration of very specialized expertise, special

facilities and clinical material that will be of considerable benefit to somepatients.

� To establish a close understanding and working relationship with otherdisciplines involved in this subspecialty.

� To encourage coordinated management of relevant clinical servicesthroughout a region.

� To accept a major regional responsibility for higher training, research andaudit in the subspecialty.

� To improve the recruitment of highly talented trainees into the recognizedsubspecialty.


� Mr Linga Dwrakanath MRCOG, Consultant/Honorary Senior Lecturer in Obstetri-cian and Gynaecologist, City Hospital, Birmingham, UK� Mr Alaa El-Gobashy M.B.Ch.B, MSc, MD, MRCOG, Specialist Registrar, Bradford

Royal Infirmary, UK� Mr Joseph Ogah MB BS, MRCOG, Specialist Registrar, Bradford Royal Infirmary, UK� Dr Janet Wright BSc MB BS, MRCOG, Consultant Obstetrician and Gynaecologist

and Risk Management Lead, Bradford Royal Infirmary, UK

We would like also to thank the following companies for providing the book withrelevant images:

� Boston Scientific� GynaCare� Karl Storz� Microsulis

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Ambulatory Hysteroscopy Evidence-based Guide to Diagnosis and Therapy

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