Hysteroscopy: The Basics, feat. Andrey Dolinko, MD

/

Today we’re joined for a first part of a two-part talk on hysteroscopy with special guest, Dr. Andrey Dolinko! Andrey was our co-resident at Brown and is currently a second-year fellow in reproductive endocrinology and infertility at the University of Pennsylvania.

What is hysteroscopy?

  • Ancient Greek hustérā, “the womb” & Skopéō - to see 

  • History (Rudic-Biljic-Erski et al 2019)

    • First developed in mid-19th century

      • Pantaleoni performed hysteroscopy on a 60yo woman to diagnose an endometrial polyp and treated it with silver nitrate. Used cystoscope developed by Desormeaux that used series of concave mirrors and light source

    • Early 20th century

      • Carbon dioxide used as first distention medium in 1925

      • 1926 - two-channel hysteroscopy (introduction and suction of distention media)

      • 1927 - operative channel introduced

      • 1928 - irrigation system

      • 1930s - fixed optic systems and fluid delivery systems

    • Second half of 20th century

      • Fiberoptic cable added to hysteroscope in 1965 (cold xenon light)

      • Operative hysteroscopy and use of different distention media takes off in 1970s

      • Videoendoscopy started in 1982

      • 1996 - Bettocchi office hysteroscope

      • 1990s - resectoscopes, first monopolar and then bipolar

    • 21st century

      • Morcellators - i.e., MyoSure

How does hysteroscopy work?

  • Contraindications

    • Pregnancy

    • Cervicitis

    • Active PID

    • Comorbidities that may be exacerbated by intravascular volume expansion

  • Timing

    • Reproductive-aged women: proliferative phase CD5-12, ideally not during active bleeding

    • Exclude pregnancy!

    • Post-menopausal-aged women: any time

  • Positioning

    • Dorsal lithotomy position

    • Avoid steep trendelenburg because risk of air embolism

      • Causes negative pressure in pelvic veins

  • Patient prep

    • Vaginal prep w/4% chlorhexidine gluconate soap or providone-iodine

  • Antibiotics

    • not indicated

  • Anesthesia (ranges)

    • None

    • Can do PO/IM/IV NSAIDs, benzos

    • Paracervical blocks

    • Regional anesthesia

    • IV sedation

    • General LMA

    • GETA

  • Vaginal instruments

    • Speculums and retractors

    • Tenaculum

    • Dilators

    • Curettes

  • Hysteroscope

    • Hysteroscope components

      • Scope

        • Eyepiece

        • Barrell

        • Objective lens

          • 0 to 70 degrees (typically 0 or 30)

      • Inner sheath w/inflow

      • Outer sheath w/outflow for operative scopes

      • Light source

        • Most-commonly Xenon or LED these days

      • Camera-head and video monitor

    • Diagnostic

      • Flexible

      • Rigid

    • Operative

      • Rigid operative scope

      • Scopes to be used with hysteroscopic tissue removal systems

      • Resectoscopes

    • Distention media

      • Fluid choice

        • Historical

          • Gas - CO2

          • High-viscosity 32% Dextra (Hyscon)

        • Current

          • Low viscosity

            • Electrolyte-rich

              • Saline

              • LR (rarely)

            • Electrolyte-poor

              • 5% Mannitol

              • 3% Sorbitol

              • 1.5% Glycine

      • Fluid deficit

        • A reflection of potnetial systemic fluid absorption

          • Surgical disruption of endometrium and myometrium provides direct access to sinus/vessels

            • If intrauterine pressure greater than vascular pressure → intravasation -> a fluid bolus!

        • Where else may the fluid be going?

          • Out the tubes

          • Out the vagina

          • Onto the floor

    • Fluid management systems help to determine deficit

      • Simple

        • Gravity

        • Pressure bag

      • Automated systems

        • Can set fluid deficits for automatic calculation

        • Uterine pressure setting

Abnormal Uterine Bleeding: The Basics

/

Today we talk through the varied etiologies and a basic workup for a common GYN complaint: abnormal uterine bleeding. ACOG PB 128 makes for good companion reading for women of reproductive age.

The terminology of AUB has changed quite a bit, and you may still hear older terms being used. “Dysfunctional uterine bleeding” or DUB has fallen out of favor, as have terms such as metrorrhagia or menorrhagia, yielding instead to simpler terminology such as prolonged menstrual bleeding and heavy menstrual bleeding, respectively. The terms such as oligomenorrhea (bleeding cycles > 35 days apart) and polymenorrhea (cycles < 21 days apart) are also in use to some degree.

Heavy bleeding is difficult to discern, but for research purposes has been described as >80cc blood loss per cycle. In clinical practice, this is obviously impractical, so we rely on subjective descriptions of heavy bleeding to guide care.

The biggest takeaways from this episode include the PALM-COIEN classification of bleeding by FIGO, as well as the common culprits of bleeding by age group. Remember also the criteria for working up for disorders of coagulation, which we’ve put here (though contained in the practice bulletin).

Stay tuned for future episodes about the treatments of these various etiologies, or check out our friends at The OBG Project for excellent summaries of guidelines and new literature!

ACOG PB 128

ACOG PB 128

ACOG PB 128