Wright is the director of the Division of Minimally Invasive Gynecologic Surgery in the Department of Obstetrics and Gynecology, Cedars-Sinai, Los Angeles, California.

Kelly N. Wright, MD

Endometriosis is a poorly understood condition in which endometrial-like–tissue implants outside the uterus. The disease affects 10% of reproductive-age women and 90% of patients with chronic pelvic pain and infertility.1 The mechanism of implantation and associated pain development is still incompletely described.1 Stage and pain do not correlate well because pelvic pain can be inflammatory and neuropathic in nature, with a component of central sensitization of the nervous system.

 Patients with pelvic pain exhibit enhanced anterior insula glutamatergic neurotransmission and connectivity with the prefrontal cortex, meaning that even with full excision of disease, pain may persist.

Although expert opinion suggests that early diagnosis of endometriosis is key, diagnostic challenges in combination with the requirement for a surgical procedure for diagnosis contribute to a significant delay in treatment. In 2008, US health care costs for endometriosis were estimated at $4000 annually per affected patient.

 Delays in surgical diagnosis are thought to contribute to this high cost because patients without answers seek further care and expensive testing. 

Endometriosis can have serious effects on patients’ quality of life and fertility, leading to lost wages and lack of productivity. The average delay in diagnosis is approximately
7 years, preventing early treatment that can reduce chronic pain and stress on mental and emotional health.

One must remember that chronic pelvic pain can be multifactorial, so a comprehensive evaluation for all causes of the disease must be undertaken, not only gynecologic causes, but also other organ systems, including musculoskeletal, gastrointestinal, genitourinary, and psychological. Infectious diseases as well as immunological diseases, in which the contribution to pain is more poorly understood, must also be considered. Many of these can be identified using a careful history and physical to identify a “source” organ and
through imaging.

Because of the range of etiologies for pelvic pain, a broader work-up should always be performed to rule out other causes. However, when endometriosis is suspected, further action should be taken. Although advances in imaging (eg, MRI and gel-contrast dynamic ultrasound) and the development of predictive algorithms might help with a clinical diagnosis of endometriosis, no current technology can predict all stages of the disease.

 Laparoscopy for endometriosis began in the 1970s and remains the gold standard for diagnosis and treatment of endometriosis.

Given that medical therapies are generally well tolerated, most national organizations recommend a trial of medical therapy to give patients a shorter time to pain relief. Studies have shown that combined hormonal contraceptives, progestins, and gonadotropin-releasing hormone agonists are very effective at reducing pain related to endometriosis.

However, the study authors recommend having a low threshold for surgical evaluation. For persistent pain despite a short course of medical therapy (3-6 months), surgical therapy and reevaluation of other causes of pelvic pain is indicated. 

Careful patient assessment, physical examination findings, and imaging can help guide surgical management. Structural abnormalities such as adenomyosis, ovarian endometriomas, and deeply infiltrating endometriosis nodules indicate advanced disease and should expedite surgical referrals.

A comprehensive discussion regarding the limitations of surgery and continuing medical therapy and multidisciplinary treatments for pain after surgery should be had with the patient as part of preoperative counseling. Further, a discussion should take place that the finding of no endometriosis on laparoscopy and biopsy can help the physician and patient focus on identifying and treating other pain generators. The vast options for the medical suppression of endometriosis and the treatment of chronic pelvic pain are outside the scope of this manuscript but are nonetheless exceedingly important in the comprehensive management of the patient.

Both excision and ablation of endometriosis as a means of surgical treatment remain debated. A Cochrane systematic review showed an unclear benefit with excision vs ablation, although studies were extremely heterogeneous.

 Another systematic review showed significantly greater improvement in dysmenorrhea, dyschezia, and chronic pelvic pain with excision compared with ablation procedures.

A recent study looking at complete peritoneal excision resulted in a high level of pain relief for patients with and without endometriosis.

 Although this study is new and not comparable with patients who did not undergo surgery, the findings may shed light on the physiologic reasons why excision of the peritoneum can result in some level of pain decrease. The authors recommend performing excision surgery, with the goal being histologic diagnosis and full excision of deeply infiltrative endometriosis.

 Because lesions appear heterogeneous or can be microscopic in nature, a true diagnosis cannot be made without a biopsy. With deeply infiltrative endometriosis, the lesions extend beyond the surface of the peritoneum and require a full excision to remove.

The location and depth of lesions impact the excisional technique and the procedures performed. Endometriotic lesions are commonly found on the uterosacral ligaments, posterior cul-de-sac, and rectovaginal septum.9 The typical appearance of an endometriosis lesion is a superficial “powder-burn” implant that can be black, dark brown, or red hemorrhagic spots. Deeply infiltrating endometriosis (DIE) invades greater than 5 mm into the surrounding organ or peritoneal surface.

 Pelvic spaces outlined after a comprehensive excision of endometriosis. Here the pararectal, paravesical, retrorectal, and rectovaginal spaces are opened to assist with removal of all disease. (Image provided by authors)

Because implants can be associated with underlying fibrosis, adhesions, and distortion of adjacent anatomy, resection must be performed with a clear understanding of anatomic structures and relevant anatomic planes, including the pararectal, paravesical, rectovaginal, retrorectal, and retropubic spaces 

The surgeon should be comfortable with retroperitoneal dissection and both blunt and sharp dissection, with and without energy sources for lesions that lie on vital structures. Note: Because of the contractile nature of endometriosis, even early-stage disease may come close to retroperitoneal structures, including the ureter 

A) Early-stage disease in the left ovarian fossa. B) The proximity to retroperitoneal structures must always be considered. Here the left ureter dives underneath the uterine artery close to the lesion being excised. (Images provided by authors)

Complete resection results in decreased pain and recurrence compared with incomplete resection of lesions. Complete resection, however, is associated with increased complication rates, so cases involving advanced disease require meticulous technique by surgeons with substantial experience in complex endometriosis

Cul-de-sac lesions are common in patients diagnosed with endometriosis, especially DIE. The cul-de-sac or the pouch of Douglas is the peritoneal cavity between the rectum and the posterior uterus. Partial obliteration of the cul-de-sac can occur when fibrotic endometriosis has fused the rectum to the posterior vagina, or complete obliteration can occur when fibrotic endometriosis obscures the plane between the cervicovaginal junction and the rectum, usually involving the uterosacral ligaments 

 An MRI shows the rectum adherent to the back of the uterus with a deeply infiltrating nodule of endometriosis. (Image provided by authors)

Surgical inspection confirms MRI findings: The rectum is stuck to the back of the uterus, and the posterior cul-de-sac is obliterated. A) Global view. B) Zoomed in. (Images provided by authors)

Careful dissection is needed to avoid damaging the rectum and ureters. Opening the pararectal spaces on both sides can help in dissection and restoration of normal anatomy. To open the pararectal space, an incision can be made either medially or laterally to the infundibulopelvic ligament. The ureter can be found most superficially at the bifurcation of the common internal iliac artery, and starting the dissection at the pelvic brim—where the anatomy is less distorted—can be beneficial. Early identification of anatomic structures and pelvic vasculature allows the surgeon to limit bleeding and complications.

A) Global anatomy has been restored. B) The rectovaginal space has been opened and the nodule of endometriosis shaved off the rectum. The rectum has been repaired with a unidirectional barbed suture. The red arrows show the sites that were previously adhered together, and the rectovaginal space is opened and identified. Note the proximity of the right ureter to the nodule that was excised. (Images provided by authors)

To resect lesions deep in the posterior cul-de-sac, the rectovaginal space can be entered at the uterosacral ligaments and generously developed below the fibrotic adhesions before attempting to divide them. The plane between the vagina and the rectum is avascular and can be separated with a combination of blunt and sharp dissection, up to the levator ani if necessary. Creating this plane allows the surgeon to identify the safest place to sharply divide the adhesions between the rectum and the cervix. Dilute vasopressin solution injected into the cervix and uterus prior to dissection can limit bleeding. Once the rectum has been carefully separated, the surgeon can focus on removing endometriotic implants from the vagina and cervix with electrosurgical devices 

Ovarian endometriomas occur in 17% to 44% of patients with endometriosis.

 When treating endometriomas, the goals are to reduce pain, exclude malignancy, improve fertility, and preserve ovarian function.

Endometriomas occur when menstrual debris builds up and becomes encapsulated within ovarian tissue. The cyst does not have an epithelial lining and is considered a pseudocyst, which can make removal more difficult. Options for treatment include drainage, ablation, cystectomy, and oophorectomy. Aspiration and fenestration with ablation are surgical options; however, because of high recurrence rates with aspiration and lower effectiveness at reducing pain and improving fertility with fenestration, excision is preferred.

For women who desire ovarian conservation, ovarian cystectomy is favored. Use of vasopressin, hemostatic agents, and suturing to achieve hemostasis results in decreased collateral damage to surrounding ovary compared with electrosurgical methods. Oophorectomy is primarily performed if patients have recurrent cysts, are postmenopausal, or there is concern for malignancy. It is important to consider that bilateral oophorectomy without hormone replacement in those younger than 50 years plays a role in increasing risks of cardiovascular disease and all-cause mortality.

Endometriosis can affect the urinary system, and the bladder is the most affected site. In 36% of cases, the endometriosis is localized only to the bladder. Lesions generally evolve from the serosal surface to the mucosa, and the trigone and the dome are the most affected areas.

Prior to surgical management, it is important to rule out vesical malignancy and identify the specific location of the lesion, including distance from the ureter. Complete resection of these lesions has been associated with decreased recurrence and significant reduction of pain.

Treatment for the gynecologist typically involves partial cystectomy with full thickness incision. For lesions near the trigone, ureteral stents should be employed. Mobilization of the retropubic space can aid in visualization of the borders of the lesion. Closure of the cystotomy depends on the size of the lesion; however, as with repair of an inadvertent bladder injury, 2-layer closure using a 3-0 delayed absorbable suture can generally be utilized.

When endometriosis involves the rectosigmoid colon, the depth of invasion should be assessed. Disease severity can vary greatly, from superficial adhesions to full-thickness disease that penetrates the mucosa. When gastrointestinal involvement is suspected, MRI, gel-contrast ultrasonography, and colonoscopy with endoscopic ultrasound can help assess colonic involvement. For severe disease—including cases with multiple bowel implants, sigmoid involvement, lesions greater than 3 cm, and lesions that involve greater than 50% of the bowel circumference, or in cases with bowel stenosis—resection with reanastomosis is beneficial.

For more superficial cases, a shaving technique or discoid resection can be performed. A shaving technique can be implemented with sharp dissection of the implant down to the level of the muscularis. The bowel can then be oversewn perpendicular to the incision to avoid constriction of the bowel lumen. Barbed suture has been shown to be safe when suturing the bowel; however, traditional delayed absorbable sutures can also be used.

 In patients with smaller nodules that involve the mucosa, discoid resection can be considered, with closure in the same fashion.

In one study comparing the shaving technique, discoid resection, and segmental resection, the shaving group had a higher rate of recurrence of dysmenorrhea and dyspareunia, with similar rates of postoperative complications.

Lesions greater than 3 cm were associated with an increased risk of requiring bowel resection.

Integrity of the bowel after a rectovaginal dissection or bowel resection should be confirmed. In a “bubble test,” air is injected retrograde into the rectum, the sigmoid is occluded at the sacral promontory, and the pelvis is filled with sterile irrigant. Observing bubbles indicates an opening that must be addressed to prevent postoperative bowel leakage into the peritoneal cavity.

Endometriosis of the abdominal wall is rare but expected to increase with rising cesarean section rates.

 In most studies, cesarean section was the inciting surgery; however, cases following laparotomy and port-site endometriosis have also been described, as well as cases in patients with no history of prior abdominal surgery. Some studies show concurrent pelvic endometriosis, whereas others describe cases with no associated pelvic lesions.

Excision of the implant with complete margins is recommended to decrease risk of recurrence. Surgery may be booked with a general surgeon for closure if a large fascial defect is anticipated. Preoperative radioisotope injection to clearly identify small lesions has been described but is not well studied.

Extrapelvic endometriosis is a rare condition, representing 8.9% of endometriotic cases. The most common sites include the gastrointestinal tract, urinary tract, and distant organs including the lung, abdominal wall, liver, gallbladder, and pancreas. Thoracic endometriosis syndrome, although rare, is the most frequent extrapelvic type of endometriosis. Catamenial pneumothorax (recurrent pneumothorax associated with menstruation) is a possible manifestation. Video-assisted thoracoscopic surgery to remove all endometriotic lesions and pleurectomy or pleurodesis are recommended
treatment strategies.

Although surgical management of endometriosis is considered the gold standard for diagnosis and treatment of the disease, it should not be considered curative of all chronic pelvic pain. Pelvic pain can be both neuropathic and inflammatory in nature, with central sensitization of the nervous system and prefrontal cortex remodeling leading to continued pain even after excision of all endometriosis.

Discouragingly, 30% of patients have chronic pain that is not responsive to surgery, and 50% develop recurrent symptoms within 5 years of treatment.5 One study found high pain recurrence rates after operative laparoscopy in patients aged 19 to 29 years, despite having no identifiable lesions on
repeat surgery.

Patients with continued pain after surgery need comprehensive multidisciplinary management for their symptoms, including continued medical suppression of menses, consultations with pelvic floor physical therapists and pain interventionalists, and referrals to other subspecialists for the other organ systems involved.

To improve diagnosis of endometriosis and preoperative planning, imaging with an experienced sonographer can identify areas of endometriotic disease through site-specific tenderness, fixed ovaries, a negative “sliding sign,” and evidence of DIE nodules in the anterior and posterior compartments.

Further, advances in MRI-acquisition protocols have improved diagnosis for DIE and enhancing lesions.

 Improved imaging can be diagnostic and also provide guidance for the surgeon in removing all the disease.

Endometriosis is a heterogeneous disease that inflicts a significant quality-of-life and cost burden on patients. Laparoscopy remains the gold standard for diagnosis and treatment. Although it is not curative for all chronic pelvic pain, laparoscopy should be a start in the approach to patients with suspicious symptoms. We recommend a comprehensive work-up for all causes of pelvic pain, and when endometriosis is suspected, preoperative planning with imaging, when applicable, and excision of all disease. When DIE is suspected, treatment should include referral to a subspecialist with experience in complex endometriosis. 

Zondervan KT, Becker CM, Missmer SA. Endometriosis. 

. 2020;382(13):1244-1256. doi:10.1056/NEJMra1810764

As-Sanie S, Kim J, Schmidt-Wilcke T, et al. Functional connectivity is associated with altered brain chemistry in women with endometriosis-associated chronic pelvic pain. 

. 2016;17(1):1-13. doi:10.1016/j.jpain.2015.09.008

Taylor HS, Adamson GD, Diamond MP, et al. An evidence-based approach to assessing surgical versus clinical diagnosis of symptomatic endometriosis. 

. 2018;142(2):131-142. doi:10.1002/ijgo.12521

Nnoaham KE, Hummelshoj L, Kennedy SH, Jenkinson C, Zondervan KT; World Endometriosis Research Foundation Women’s Health Symptom Survey Consortium. Developing symptom-based predictive models of endometriosis as a clinical screening tool: results from a multicenter study. 

. 2012;98(3):692-701.e5. doi:10.1016/j.fertnstert.2012.04.022

Practice bulletin no. 114: management of endometriosis. 

. 2010;116(1):223-236. doi:10.1097/AOG.0b013e3181e8b073

Bafort C, Beebeejaun Y, Tomassetti C, Bosteels J, Duffy JM. Laparoscopic surgery for endometriosis. 

. 2020;10(10):CD011031. doi:10.1002/14651858.CD011031.pub3

Pundir J, Omanwa K, Kovoor E, Pundir V, Lancaster G, Barton-Smith P. Laparoscopic excision versus ablation for endometriosis-associated pain: an updated systematic review and meta-analysis. 

. 2017;24(5):747-756. doi:10.1016/j.jmig.2017.04.008

Misal M, Girardo M, Wasson M. Improved pain and quality of life after complete pelvic peritonectomy. 

. 2022;226(3):S1273-S1274. doi:10.1016/j.ajog.2021.12.165

Lee HJ, Park YM, Jee BC, Kim YB, Suh CS. Various anatomic locations of surgically proven endometriosis: a single-center experience. 

. 2015;58(1):53-58. doi:10.5468/ogs.2015.58.1.53

Cao Q, Lu F, Feng WW, Ding JX, Hua KQ. Comparison of complete and incomplete excision of deep infiltrating endometriosis. 

Zanelotti A, Decherney AH. Surgery and endometriosis. 

. 2017;60(3):477-484. doi:10.1097/GRF.0000000000000291

Levy B, Barbieri R. Endometriosis: management of ovarian endometriomas. UpToDate. Accessed October 12, 2022. 

https://www.uptodate.com/contents/endometriosis-management-of-ovarian-endometriomas

Maccagnano C, Pellucchi F, Rocchini L, et al. Diagnosis and treatment of bladder endometriosis: state of the art. 

. 2012;89(3):249-258. doi:10.1159/000339519

Atlas of Pelvic Anatomy and Gynecologic Surgery

Chamsy D, King C, Lee T. The use of barbed suture for bladder and bowel repair. 

. 2015;22(4):648-652. doi:10.1016/j.jmig.2015.01.030

Afors K, Centini G, Fernandes R, et al. Segmental and discoid resection are preferential to bowel shaving for medium-term symptomatic relief in patients with bowel endometriosis. 

. 2016;23(7):1123-1129. doi:10.1016/j.jmig.2016.08.813

Carsote M, Terzea DC, Valea A, Gheorghisan-Galateanu AA. Abdominal wall endometriosis (a narrative review). 

. 2020;17(4):536-542. doi:10.7150/ijms.38679

Vitral GSF, Salgado HC, Rangel JMC. Use of radioguided surgery in abdominal wall endometriosis: an innovative approach. 

. 2018;17(3):204-206. doi:10.4103/wjnm.WJNM_47_17

Chamié LP, Ribeiro DMFR, Tiferes DA, Macedo Neto AC, Serafini PC. Atypical sites of deeply infiltrative endometriosis: clinical characteristics and imaging findings. 

. 2018;38(1):309-328. doi:10.1148/rg.2018170093

Stratton P, Berkley KJ. Chronic pelvic pain and endometriosis: translational evidence of the relationship and implications. 

. 2011;17(3):327-346. doi:10.1093/humupd/dmq050

Noventa M, Scioscia M, Schincariol M, et al. Imaging modalities for diagnosis of deep pelvic endometriosis: comparison between trans-vaginal sonography, rectal endoscopy sonography and magnetic resonance imaging. a head-to-head meta-analysis. 

. 2019;9(4):225. doi:10.3390/diagnostics9040225

Lorusso F, Scioscia M, Rubini D, et al. Magnetic resonance imaging for deep infiltrating endometriosis: current concepts, imaging technique and key findings. 

. 2021;12(1):105. doi:10.1186/s13244-021-01054-x

Articles

Laparoscopy remains the gold standard for diagnosis and treatment of the disease.

Surgical treatments for endometriosis

Hysteroscopy is a technique through which the uterine cavity can be evaluated visually to assess for structural abnormalities. The first hysteroscopy was performed by Pantaleoni in 1869, and since then emerging technologies have greatly advanced the scope of this technique.

Office hysteroscopy (OH) is a safe and effective option for diagnosis and management of intrauterine pathology.

Primary uses of OH include diagnosis of abnormal uterine bleeding and treating endometrial polyps, uterine septa, retained products of pregnancy, and adhesions.

Equipment selection should be based on the types of procedures planned for the office setting.

Appropriate patient selection is the most important component for both patient and physician comfort when starting an OH program. 

Care should be taken to attempt to reduce pain and anxiety during OH, with recommended methods including preprocedural NSAIDs, vaginoscopy, and appropriate counseling.

Improvements in hysteroscopes, optics, distension media, anesthetics, and hysteroscopic instruments have made office hysteroscopy (OH) more feasible and less painful for patients.

 Advantages to OH include avoidance of general anesthesia, patient and physician convenience, faster recovery, and cost-effectiveness.

The costs of OH vs hysteroscopy in the operating room (OR) have been reviewed for various indications. OH has been found to be cost-effective for evaluation of abnormal uterine bleeding (AUB), infertility, and triage of intracavitary pathology, ranging from negative to complex pathology.

 In one study assessing cost-effectiveness of OH over OR hysteroscopy to evaluate AUB, the cost savings was found to be $1498 per patient.

 OH has also been found to be safe and effective, with a complication rate of 0% to 1.5%.

 Study findings have revealed high success rates for diagnostic OH, with rates as high as 94.8%.

Not only has OH been shown to be effective, but it has also been found to have high patient satisfaction regarding comfort and convenience.

In one study of patients undergoing OH vs hysteroscopic polypectomy in the OR, 95% of women who underwent OH stated they would prefer OH again. Women were also found to have decreased postoperative analgesic requirements, decreased time away from home, and decreased recovery time.

Despite these advantages, OH remains underutilized. In a study by Shields et al, among 305 hysteroscopies, only about 25% were performed in the office.

 This discrepancy may be due to limited physician training, limited availability in clinics, concerns with start-up costs, and fears of patient discomfort.

This article will review current best practices for OH and provide strategies for practicing ob-gyn specialists who hope to incorporate OH into their practice.

Hysteroscopy has a wide range of diagnostic and therapeutic uses. Some of the more common uses include diagnosis and management of abnormal uterine bleeding (AUB) and postmenopausal bleeding, including polyps, submucosal fibroids, and thickened endometrium. Importantly, OH can be used to rule out structural abnormalities to prevent unnecessary trips to the operating room.

AUB accounts for 30% of all gynecologic visits to the specialist obstetrician-gynecologist.

 Diagnosis has long relied on a combination of tissue sampling and ultrasound despite their low diagnostic accuracy for intracavitary pathology. Although transvaginal ultrasound is helpful for evaluating the myometrium, its sensitivity and specificity for evaluating intracavitary pathology are only 56% and 73%, respectively.

A systematic review showed that endometrial biopsy has high accuracy when assessing for a global process, such as endometrial cancer or hyperplasia, but if cancer occupies less than 50% of the endometrial cavity surface, it is likely to be missed.12 In a meta-analysis that evaluated the accuracy of diagnostic hysteroscopy compared with guided biopsy during hysteroscopy, operative hysteroscopy, or hysterectomy, diagnostic hysteroscopy had an overall success rate of 96.6%, and abnormalities were found in 46.6% of premenopausal and postmenopausal women with AUB.

Hysteroscopy can be also used in the work-up of infertility and can aid in the diagnosis and treatment of uterine septa and Asherman syndrome. Additional uses include removal of retained intrauterine devices, targeted biopsy, diagnosis of isthmoceles, and removal of retained products of contraception.


Setting up an office hysteroscopy program

Hysteroscopes come in a variety of sizes, lens angles, and capabilities. When starting an office hysteroscopy program, consider what procedures will be performed. There are diagnostic hysteroscopes, which may offer a smaller outer diameter but lack the attachments for anything but inflow, and there are operative hysteroscopes that have a larger outer sheath but allow for the passage of instruments including scissors, graspers, tenacula, and biopsy forceps.

Consider the size of instruments used in other common gynecologic procedures. For example, a typical endometrial biopsy pipelle is 3 mm, whereas an intrauterine device insertion sheath can be 4 to 5 mm. Diagnostic and operative hysteroscopes come in sizes as small as 2.8 and 4 mm, respectively, so these sizes may offer the physician and patient further comfort.

Lenses come in different angles as well. Typically, a 30° lens goes well with a diagnostic hysteroscope, as it provides the ability to see around acute angles with little movement. A 12° lens is more compatible with an operative hysteroscope since the operative equipment can be better seen directly in front of the lens.

Lastly, some may consider a rigid, flexible, or disposable hysteroscopy system. Rigid hysteroscopes allow for vaginoscopy and more robust operative procedures to be performed. They often require a large capital investment but can be more cost-effective and less wasteful than disposable systems when used frequently.

Flexible hysteroscopes provide the user the ability to see around acute angles without touching sensitive cervical walls. 

However, flexible hysteroscopes typically have fiber-optic cables, which are expensive to maintain, and the systems are often limited to diagnostic capabilities only. Flexible scopes are often not able to perform vaginoscopy, which is the recommended technique for pain control.

Disposable hysteroscopes offer an alternative to the high up-front costs and sterilization needs of reusable hysteroscopes. However, the per-use cost can be prohibitively high, and the plastic medical waste created is an environmental problem. Most of these have a 3- to 4-mm sheath with limited ability to perform operative procedures.

When performing operative hysteroscopy, consideration must be given to the type of tools needed. Most basic office procedures can be done with scissors (polypectomy, lysis of adhesions, metroplasty) and grasper (directed biopsy, intrauterine device (IUD) removal, products of conception removal). 

The authors prefer the addition of a hysteroscopic tenaculum to allow for intact removal of large polyps by providing a more robust grip than a grasper. Although biopsy forceps can be useful for directed biopsies, a grasper can provide the same functionality while also being able to grasp retained IUDs.

Mechanical tissue extraction devices are also available, whether operated manually by hand or powered. Some of these are paired with a tabletop suction device or fluid management system. There are electrosurgical instruments available for the office as well, but the authors prefer to avoid electrosurgery in the office to reduce the risk of complications, such as injury to surrounding structures and perforation. 

Figure 1. This exam room setup shows all the necessary components for office hysteroscopy, including a bed with stirrups, video system with camera and light cord, sterilized hysteroscope on a mayo stand with infl ow coming from a pressure bag on an IV pole and outflow to gravity in a basin, and a tabletop suction for tissue extraction devices.

However, the 15 French bipolar resectoscope and 5 French bipolar twizzle can be used with a generator if the physician prefers energy for procedures like metroplasty or myomectomy.


Hysteroscopy can be done in a small area like a converted exam room (

). An exam table that rises and lowers is preferred. In addition to the hysteroscope, a visualization system is required, such as a camera, light source, and monitor, as well as the ability to capture images for the electronic health record (

Hysteroscopic images of various intrauterine pathology taken in the office. (A) Grasping a small intrauterine polyp. (B) A focal endometrial cancer missed by endometrial biopsy. (C) Uterine septum. (D) Lysis of adhesions in the lower uterine segment. (E) A retained IUD with previously avulsed strings. (F) A grasper removing an embedded IUD arm.

Inflow and outflow tubing, operative port seals, and a way to measure inflow and outflow are necessary. The authors prefer using a 1-L normal saline bag in a pressure bag for inflow, with the outflow hung to gravity into a basin or under-buttocks drape. A mayo stand or cart can be helpful for setting the equipment on. In addition, a speculum, tenaculum, dilators, and local anesthesia should be available for use if needed. Most importantly, a cleaning process is required for all reusable instruments including high-level disinfection or autoclaving in office or through a centralized sterile processing unit.

The most widely used distension medium in the office setting is normal saline because it is ubiquitously available and comes in multiple bag sizes. Most office hysteroscopy settings will not use a fluid management device, as these are large and have expensive tubing, canister costs, and waste requirements. The physician will need a way to manually calculate the fluid deficit. 

This can be performed by measuring outflow in a graded under-buttocks drape or a basin at the foot of the bed. If the hysteroscope has no outflow channel, typically the amount of inflow is so small that a true deficit does not need to be calculated. The recommended deficit limit for normal saline in healthy patients is 2500 mL; however, in elderly patients or those with comorbidities, a lower threshold may be considered.14 If the physician anticipates doing procedures in the office that could go above this limit, a fluid management device should be utilized.

Appropriate patient selection is the most important component for both patient and physician comfort when starting an office hysteroscopy program. 

A prospective cohort study showed that nulliparity, cervical pathology, and procedures over 2 minutes in length were correlated with severe pain.15 Physicians may want to start with diagnostic hysteroscopy in multiparous patients without cervical pathology to allow for building confidence to progress to operative hysteroscopy.

Anesthesia and analgesia have been well studied for office hysteroscopy. A 2020 systematic review found that nonsteroidal anti-inflammatory drugs (NSAIDs) significantly reduced observed and reported pain during and after office hysteroscopy. Opioids and antispasmodics reduced observed pain during the procedure but were associated with a higher risk of adverse effects (AEs). 

Therefore, women without contraindications should be advised to take oral NSAIDs prior to office hysteroscopy.

 Another 2020 meta-analysis of over 1300 patients showed that when data were aggregated, all anesthetics had some benefit, including topical, transcervical, intracervical, paracervical, and intracornual sites.

However, every type of anesthesia included studies that favored placebo, and several randomized, controlled trials have reported increased pain, bradycardia, and hypotension after cervical injection.

 Local anesthesia did not reduce the risk of procedural failure.

The authors choose to use vaginoscopy as the main approach for reducing pain. Vaginoscopy involves using no speculum or tenaculum and placing the camera directly into the patient’s vagina to allow for distention with saline. 

Rotation of the light cord then allows for guidance of the angled hysteroscope along the cervical canal and into the uterus. Hydrodistension of the canal promotes passage even with difficult angles or stenosis. Large studies enrolling thousands of patients over 25 years of age have found that a vaginoscopic approach has decreased pain compared with traditional hysteroscopy with a speculum with no difference in procedural success rates.

The use of hysteroscopy for the diagnosis and treatment of intrauterine pathology: ACOG Committee opinion, number 800

. Obstet Gynecol. 2020;135(3):e138-e148. doi:10.1097/AOG.0000000000003712

AAGL Advancing Minimally Invasive Gynecology Worldwide, Munro MG, Storz K, et al. AAGL practice report: practice guidelines for the management of hysteroscopic distending media:

 (replaces hysteroscopic fluid monitoring guidelines. 2000;7:167-168). J Minim Invasive Gynecol. 2013;20(2):137-148. doi:10.1016/j.jmig.2012.12.002

. Centers for Medicare & Medicaid Services. https://www.cms.gov/medicare/physician-fee-schedule/search

The authors also do not routinely use medical cervical dilation for pain control. A meta-analysis evaluating use of cervical preparations to reduce pain during outpatient hysteroscopy showed no reduction in pain in premenopausal or postmenopausal women who required cervical dilation of 5 mm or less, which is the maximum size of our operative hysteroscope.

 Preprocedural misoprostol can be associated with AEs such as cramping, fever, and diarrhea, making the patient uncomfortable before the procedure even starts.

Lastly, efforts to reduce preprocedural anxiety should be employed. Another meta-analysis found that pain experienced during hysteroscopy is worsened by preprocedural anxiety. Wait time before the procedure can increase anxiety, and music during the procedure may reduce anxiety.

It is important to counsel patients on expectations and let them know that the procedure can be stopped at any time. Patients who prefer a procedure under sedation should be accommodated in an operating room or surgery center. 

All patients should be involved in a fully informed consent process and booked when an optimal view of the endometrial cavity is achievable. Patients typically are booked immediately after cessation of menses or optimally cycle days 4 through 11.

Considerations for starting OH in the clinic include startup cost, reimbursement, coding, and setting up appropriate procedures for sterilization. 

In 2017, relative value units (RVUs) for office operative hysteroscopy (CPT code 58558) went up by 237%, whereas RVUs for OR hysteroscopy cases went down by 11%.25 These changes reflect that payers recognize the benefits of OH and are committed to facilitating and incentivizing its use. Estimates place equipment start-up costs between $15,000 and $35,000 based on whether the equipment is new or used, the number of operative trays, and the style of camera and monitor system.

 With the increased reimbursement, physicians and practices have the potential to break even with less than 50 office operative hysteroscopies.

Multiple models have been devised for hysteroscopy simulation, however, there are limited studies on clinical utility and outcomes.

 Models include animal organs, vegetables, synthetic uteri, and virtual reality. 

The American College of Obstetricians and Gynecologists (ACOG) has devised a module for hysteroscopy simulation for resident education that uses a synthetic uterine model and a vegetable model to increase skills and knowledge, including hysteroscope assembly as well as the ability to maneuver the hysteroscope and operative tools.

 Virtual models, including the HystSim (VirtaMed), have become more realistic and allow for a range of procedures, but require further validation before inclusion in standardized courses.

Hysteroscopy can be performed safely in the office and has high efficacy and patient satisfaction; however, there are still low rates of OH in the United States. Additionally, OH has been found to be cost-effective, and physician reimbursement rates have increased for OH compared with hysteroscopy in the OR. Setup should be relatively simple and requires communication with clinic staff to ensure that the patient is comfortable and that equipment can be available and sterilized. 

Considering the benefits to physicians and patients, OH should be considered a first-line option for the diagnosis and treatment of a variety of uterine pathology. 

OH can also serve to triage cases, preventing negative cases from going to the OR and ensuring that more complex pathologies can be done in the appropriate setting. 

Tarneja P, Duggal BS. Hysteroscopy: past, present and future. 

. 2002;58(4):293-294.doi:10.1016/S0377-1237(02)80079-X

Campo R, Santangelo F, Gordts S, et al. Outpatient hysteroscopy. 

The use of hysteroscopy for the diagnosis and treatment of intrauterine pathology: ACOG committee opinion, number 800. 

. 2020;135(3):e138-e148.doi:10.1097/AOG.0000000000003712

Moawad NS, Santamaria E, Johnson M, Shuster J. Cost-effectiveness of office hysteroscopy for abnormal uterine bleeding. 

. 2014;18(3):e2014.00393. doi:10.4293/JSLS.2014.00393

Kasius JC, Eijkemans RJ, Mol BW, Fauser BC, Fatemi HM, Broekmans FJ. Cost-effectiveness of hysteroscopy screening for infertile women. 

 2013;26(6):619-626. doi:10.1016/j.rbmo.2013.02.015

Shields J, Dilday E, Chang S, Kho K. Moving hysteroscopy from the office to the operating room: a comparison of clinical outcomes and resource utilization. Presented at: High Value Practice Academic Alliance National Conference; September 21-23, 2018; Baltimore, Maryland. Accessed July 5, 2021.

https://hvpaa.org/moving-hysteroscopy-from-the-office-to-the-operating-room-a-comparison-of-clinical-outcomes-and-resource-utilization/

Ghaly S, de Abreu Lourenco R, Abbott JA. Audit of endometrial biopsy at outpatient hysteroscopy. 

. 2008;48(2):202-206. doi:10.1111/j.1479-828X.2008.00834.x

Marsh FA, Rogerson LJ, Duffy SR. A randomised controlled trial comparing outpatient versus daycase endometrial polypectomy.

. 2006;113(8):896-901. doi:10.1111/j.1471-0528.2006.00967

Kremer C, Duffy S, Moroney M. Patient satisfaction with outpatient hysteroscopy versus day case hysteroscopy: randomised controlled trial. 

Committee on Practice Bulletins—Gynecology. Practice bulletin no. 128: diagnosis of abnormal uterine bleeding in reproductive-aged women. 

. 2012;120(1):197–206. doi:10.1097/AOG.0b013e318262e320

Kelekci S, Kaya E, Alan M, Alan Y, Bilge U, Mollamahmutoglu L. Comparison of transvaginal sonography, saline infusion sonography, and office hysteroscopy in reproductive-aged women with or without abnormal uterine bleeding. 

. 2005;84(3):682-686. doi:10.1016/j.fertnstert.2005.03.036

Guido RS, Kanbour-Shakir A, Rulin MC, Christopherson WA. Pipelle endometrial sampling. Sensitivity in the detection of endometrial cancer. 

Van Dongen H, de Kroon CD, Jacobi CE, Trimbos JB, Jansen FW. Diagnostic hysteroscopy in abnormal uterine bleeding: a systematic review and meta-analysis. 

. 2007;114(6):664-675. doi:10.1111/j.1471-0528.2007.01326.x

AAGL Advancing Minimally Invasive Gynecology Worldwide, Munro MG, Storz K, et al. AAGL practice report: practice guidelines for the management of hysteroscopic distending media: (replaces hysteroscopic fluid monitoring guidelines. 

. 2013;20(2):137-148. doi:10.1016/j.jmig.2012.12.002

Zayed SM, Elsetohy KA, Zayed M, Fouda UM. Factors affecting pain experienced during office hysteroscopy. 

De Silva PM, Mahmud A, Smith PP, Clark TJ. Analgesia for office hysteroscopy: a systematic review and meta-analysis. 

. 2020;27(5):1034-1047. doi:10.1016/j.jmig.2020.01.008

De Silva PM, Carnegy A, Smith PP, Clark TJ. Local anaesthesia for office hysteroscopy: a systematic review & meta-analysis. 

. 2020;252:70-81. doi:10.1016/j.ejogrb.2020.05.062

Lau WC, Lo WK, Tam WH, Yuen PM. Paracervical anaesthesia in outpatient hysteroscopy: a randomised double-blind placebo-controlled trial. 

Despite advantages to its use, the procedure remains underutilized. Two experts outline an approach for getting started. 

Kelly N. Wright, MD

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