Best Practice & Research Clinical Obstetrics and Gynaecology 29 (2015) 1139e1145

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Best Practice & Research Clinical

Obstetrics and Gynaecology
journal homepage: www.elsevier.com/locate/bpobgyn

Hysteroscopy e Multiple Choice Answers for Vol. 29, No. 7

1. a) T b) F c) F d) T e) F

Type I submucosal broids indeed have more than 50% of their volume protruding into the uterine
cavity. Resection of uterine septae, type 1 or 2 submucosal broids, endometrial resection and
correction of major Ashermans syndrome are all classied as advanced or level 3 hysteroscopic pro-
cedures. Level 2 refers to proximal fallopian tube cannulation, removal of type 0 broids or large polyps
and treatment of minor Ashermans syndrome.
There is no evidence that cervical ripening is needed for diagnostic hysteroscopies but may be
useful for operative hysteroscopies especially if cervical dilatation beyond 5 mm is needed (RCOG UK
Best Practice in Outpatient Hysteroscopy Green-top Guideline 59, RCOG press). Jansen et al published a
large Dutch national audit which looked at 11000 diagnostic and 2500 operative hysteroscopies. They
reported the riskiest operative hysteroscopic procedure was adhesiolysis (complication rate - 4.5%).
The morcellator is very effective for treating type 0 broids and the intra-cavity portion of type 1 and 2
broids. However due to its design it is ineffective at resecting broids that extend deep into the
muscle.

2. a) F b) T c) T d) T e) F

Prolonged procedures certainly increase the risk of uid absorption but there are no guidelines on
the absolute operating time. Accurate measurement of the decit rather than time taken to complete
the procedure should be the focus. Hysteromats have been shown to facilitate and improve mea-
surement of uid decit signicantly and in so doing reduce the chances of excessive uid absorption.
Five RCTs have looked at the use of pre op GnRH analogues prior to resection. The general consensus
was an overall reduction in uid absorption which was signicant in 3/5 studies. Two RCTs support the
use of very dilute intracervical vasopressin just prior to dilatation as they showed a marked reduction
in uid absorbed. Fluid absorption increases as the intrauterine pressure increases.

3. a) F b) T c) F d) F e) F

The incidence is estimated to be between 0.1 to 0.2%. However, with advances in technology such as
the bipolar resectoscope and morcellator devices which avoids the need to use non electrolyte (con-
ducting) media this incidence should fall. Bipolar resectoscopes tend to produce more gas bubbles
during resection which could potentially impair vision. However, the ability to use normal saline as a
distension medium signicantly reduces the risk of getting a uid complication. Premenopausal
woman are much more likely to develop cerebral oedema and neurological sequelae than either men
or postmenopausal women. This is thought to be due to an inhibitory effect of the female sex steroid
hormone on the NA/K ATPase pumps which usually attempts to maintain an equilibrium between
brain cells and extracellular uid. Hyponatraemia is not a reported risk when normal saline is used as a
distension medium. However, absorption of over 1litre of glycine has been shown to drop serum

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sodium by as much as 10mmol/L. Studies have compared the effects of local, regional and general
anesthesia on uid absorption. Conicting results have meant no rm conclusions can be drawn.

4. a) F b) F c) F d) F e) T

When a pre-determined uid decit has been exceeded, the procedure should be stopped imme-
diately. Any ongoing bleeding or hemorrhage can be managed by inserting a Foleys catheter into the
uterine cavity and inating the balloon to act as a tamponade. This can usually be removed 6-12 hrs
later. Serum sodium should be corrected slowly to prevent the risk of central pontine myelinolysis.
However this is done using hypertonic (3%) saline. If the patient is asymptomatic it is reasonable to
observe only and monitor electrolyte levels. However, if there have been any neurological effects or the
serum sodium is less than 120mmol/L then the patient should be managed in a HDU or ICU with a
multidisciplinary team. If there are signs and symptoms of uid overload then a diuretic such as
Furosemide should be given immediately and not postponed while waiting for blood results. A urinary
catheter is essential to monitor urinary output

5. a) F b) T c) F d) F e) F

National datasets for surgical technologies have no denominator data to provide clear information
regarding risks of complications. The surgical dictum Primum non nocere means rst do no harm-
the origin of the phrase is uncertain and it has been attributed to Hippocrates. Topical application of
local anaesthetic to the ectocervix should be considered where application of a cervical tenaculum is
necessary (RCOG UK Best Practice in Outpatient Hysteroscopy Green-top Guideline 59, RCOG press).
MISTLETOE and the Dutch national audit (Jansen et al) data demonstrated that experienced hystero-
scopic surgeons have more likelihood of complications during major hysteroscopic procedures (likely
due to case selection bias- experienced hysteroscopic surgeons performing more difcult procedures).
The US MAUDE database reports by Haber et al reported an estimated complication rate of <0.1%.

6. a) T b) F c) F d) T e) T

Diagnostic AH is well established in most hospitals in the UK. As per the National Heavy Menstrual
Bleeding Audit results published in July 2014, 87% of units across the UK have AH services. But as per a
national survey of UK gynaecologists done in 2011, only 16% offered outpatient treatment of endo-
metrial polyps. With regards to AH in a community setting, there are very few units in the country that
offer this service. Community Gynaecology is in its early developmental stages in the UK. Various
studies have evaluated simulation training demonstrating improved performance in operative hys-
teroscopic skills. The HystSim Essure Module was evaluated in a study by Chudnoff et al that showed
signicant improvement in the skills to perform Essure hysteroscopic sterilization. Most consider that
polyps >2 cm are generally unsuitable for outpatient resection.

7. a) T b) T c) F d) F e) F

Only type 0 and type 1 broids are suitable for hysteroscopic resection. There is evidence from
observational studies only that broid resection can improve fertility outcomes. The L in PALM-COIEN
stands for Leiomyoma

8. a) T b) F c) T d) T e) T

Hysteroscopic morcellators have been shown to be both more acceptable and quicker than electrical
resection at removing endometrial polyps in the outpatient setting through randomised controlled
studies. Saline infusion sonography is more sensitive than transvaginal ultrasound for identifying
space-occupation lesions but is not as sensitive as hysteroscopy. Up to 10% of women presenting with
 Appendix / Best Practice & Research Clinical Obstetrics and Gynaecology 29 (2015) 1139e1145 1141

fertility problems have endometrial polyps and it is thought that removing polyps may help improve
fertility.

9. a) F b) F c) T d) T e) T

In pre-menopausal women ET is best assessed on day four to six of the menstrual cycle as this is the
time when the endometrium should be at its thinnest. In pre-menopausal women the upper limit of
endometrial thickness (ET) is not dened as it varies with the cycle, contraceptive methods and there is
no absolute upper limit. A suggested threshold of < or 4 mm for ET with a regular endometrial lining
and no uid within the cavity reduces the possibility of malignancy to <1% in post-menopausal
women. When setting a threshold for further investigation there is always a balance between speci-
city and sensitivity. Reducing the ET threshold to less than currently recommended will denitely
result in more false positives as the likelihood of cancer reduces with the ET. Although both cancerous
and pre-cancerous endometrial disease can be identied by direct visualisation, the gold-standard for
diagnosis is still histological sampling.

10. a) F b) T c) T d) T e) F

Fibrous myometrial band are typical of intrauterine adhesions. The usual appearance of intrauterine
adhesions is that of greyish-white brous bands (ne to dense) extending across the uterine cavity in a
haphazard manner, this is frequently associated with obliteration of the uterine cavity. Endometrial
cancer has innumerable appearances; with a combination of any of these features: thickened, irregular
endometrium, friable cells with haemorrhagic appearances of the endometrial cavity. A cystic bubble
wrap appearance is typical of Tamoxifen stimulation and is a benign phenomenon.

11. a) F b) F c) F d) F e) T

This can be explained by the vascular architecture of the myometrium; deeper in the myometrium
the number of vessels decrease but their size in diameter increases.

12. a) T b) F c) T d) T e) F

Whilst in many developing countries laparotomy remains the most common approach to steri-
lisation, in developed countries nearly all interval /post-partum sterilisations are performed lapa-
roscopically. Unipolar sterilisation was the rst method of laparoscopic tubal sterilisation to achieve
wide spread use. Unipolar sterilisation is associated with numerous complications including thermal
bowel lesions and death. Bipolar sterilisation is safer as the current ows between the active and return
electrodes of the surgical instrument. In contrast, current ows through the patient in unipolar surgery
and the circuit is completed via a remote return electrode (ground plate). The Filshie clip was intro-
duced and approved by the FDA in the United States in 1996.

13. a) T b) F c) T d) T e) T

The hysteroscopic sterilisation approach is inherently less invasive and has a lower serious
complication rate compared with the laparoscopic route because it avoids the need for incisions, entry
into the abdominal cavity and general anaesthesia. Using thermal electrocoagulation achieved an
overall bilateral tubal occlusion rate of 83 % but pregnancies including ectopics were reported.
Chemical sterilisation with quinacrine is reported to have a 1-2% failure rate although the rates of
ectopic pregnancy and serious complications are less than trans-abdominal sterilisations. However,
drawbacks include the need for multiple applications. The ovabloc technique never became popular
because it was associated with a high failure rate and the procedure was stopped in 2009. Adiana
sterilisation was withdrawn in 2012 primarily because the technology was not generating expected
revenues from sales and there was a long running patent infringement with another country.
1142 Appendix / Best Practice & Research Clinical Obstetrics and Gynaecology 29 (2015) 1139e1145

14. a) F b) F c) T d) T e) F

The length of the device is 4 cm. Occlusion of the tubal lumen is demonstrated within 4-8 weeks of
placement. Patients are indeed instructed to use alternative contraception until 3 months after
insertion. TVS has been introduced as the default conrmatory test in many parts of Europe because it
is less invasive than an HSG and avoids ionising radiation. Whilst tubal occlusion cannot be tested,
satisfactory placement at 3 months can be conrmed with HSG being restricted to complicated pro-
cedures or an abnormal TVS. Successful placement occurs in 90-95 % of cases.

15. a) T b) F c) F d) T e) T

The cumulative 9 year failure rate was analysed from follow up data from 449 women included in
phase 2 and pivotal trials. Only 6.3 % of gestations were categorised as luteal phase pregnancies. 45 % of
pregnancies were the result of failure to use additional contraception after the procedure. According to
the MAUDE database the most frequently reported adverse event was indeed pain (47.5 %). Other
adverse events include delivery catheter malfunction, perforation, pregnancy, abnormal bleeding and
allergic reactions. There seems to be no relationship between the experience of the physician and
device placement complications.

16. a) F b) F c) T d) T e) F

The FIGO system is a classication of the different types of broids from Type 0-Type 8. Submucosal
broids are graded 0 to 2 according to the degree of intra-cavity involvement relative to the myo-
metrium. A type 1 submucosal broid is one where <50% of the broid is intramural. An entirely
intramural broid is described as Type 4. Published data supports the contention that SIS improves the
diagnostic accuracy of TVS. SIS is widely applicable and the only contra indications are pregnancy and
suspected pelvic infection. 3D and 4D images can be achieved with stable and adequate distension of
the uterine cavity and this is facilitated by us of a gel contrast medium. 3D provides good reproduc-
ibility of the broid protrusion into the uterine cavity.

17. a) F b) F c) T d) T e) T

Traditional operative hysteroscopy has a long learning curve and is difcult to learn. The rst
simultaneous tissue cutting and retrieval system for use in the uterine cavity was the Truclear system.
The Truclear system does not use any electrocoagulation. Haemostasis occurs by spontaneous myo-
metrial contraction. Physiological saline solution is used for distension and irrigation minimising risks
associated with uid absorption. Using the Truclear system, polyps, small myomas and retained
products of pregnancy can be removed in this way, all FDA approved.

18. a) T b) F c) T d) T e) F

Isotonic uid overload can be treated with diuretics. Hypertonic non-conductive low viscosity uids
include 5 % Mannitol, 3-5% Sorbitol and 1.5 % glycine. Nausea and malaise are the earliest ndings of
uid overload and may be seen with sodium levels less than 5 mmols per litre. This can be followed by
headaches, lethargy and eventually seizures if the plasma sodium falls further. Intravasation of uid is
increased with prolonged surgery and deeper, intramural extension e.g. grade 2 broids. Bladder
catheterisation is only indicated where signicant uid decit and overload occurs to help monitor the
condition of the patient.

19. a) T b) T c) F d) F e) F

Hysteroscopic surgical skills can be difcult to acquire without expert tuition and practice.
 Appendix / Best Practice & Research Clinical Obstetrics and Gynaecology 29 (2015) 1139e1145 1143

High volume surgeons performing more than 20 hysteroscopic myomectomies annually resect
more tissue and a higher amount of tissue per time than low volume surgeons. There is no difference in
complication rates between high and low volume surgeons although this may reect the complexity
and completeness of treatment. Prophylactic antibiotics are not indicated because the risk of infection
after operative hysteroscopy is low. All patients should have an emergency laparoscopy and / or lap-
arotomy to exclude intra-abdominal haemorrhage or intestinal injury when a perforation is caused by
an activated instrument.

20. a) F b) F c) T d) F e) F

The joint RCOG-BSGE guideline on best practice in outpatient hysteroscopy states that stafng levels
will vary according to local circumstances and types of service offered but that a complement of three
supporting staff consisting of at least one registered nurse and two additional staff (nurse or healthcare
assistants) allows support of the nurse assisting the surgeon and a dedicated member of staff to
accompany the patient during her journey. The role of the nurse hysteroscopist is only well developed
in some units in the UK. In 2001 the University of Bradford-BSGE developed an educational training
programme at an advanced level for nurses. In-patient admission of patients from the ambulatory
setting is a very rare occurrence. The BSGE provides no formal accreditation in ambulatory hysteros-
copy. The ESGE has developed training standards for hysteroscopy but these are somewhat arbitrary.

21. a) F b) F c) F d) T e) T

Ambulatory hysteroscopy can be conducted outside the formal operating setting in a room which is
appropriately sized, well equipped and properly staffed. It need not be close to a formal theatre setting
and indeed could be sited within a community setting. The quality of the video camera and monitor are
important to get good quality visual images. Regarding distension media generally normal saline is
preferred to CO2 as a distension medium as it allows improved image quality, permits a quicker pro-
cedure and has the advantage of acting as a conducting medium for bipolar energy. Four randomised
control trials have compared the effect of size of the outer sheath on pain and success rates; it has
shown that an outer sheath diameter of less than 3.5 mm was associated with signicantly less intra
operative pain. There is insufcient evidence to recommend preferential use of rigid or exible hys-
teroscopes for ambulatory hysteroscopy. However rigid hysteroscopes allow the use of mechanical and
electro surgical devices as they can be tted though 5-French operative channels.

22. a) F b) T c) T d) F e) T

According to the 2008 RCOG Standards in Gynaecology outpatient operative hysteroscopy should
be available to carefully selected patients. Organisational change theory suggests that unless consensus
is present across professionals there is little chance of its successful development. Research has shown
for ambulatory hysteroscopy there is a signicant reduction in mean pain scores associated with use of
local para-cervical or direct cervical anaesthesia. However, miniaturisation of endoscopes and wider
adoption of vaginoscopy increasingly avoids the need for cervical dilatation and so the routine use of
local anaesthesia is contentious and further trials are needed. Amongst the different routes of local
anaesthetic administration, para-cervical injection of local anaesthetic was shown to be the most
effective method of reducing pain during ambulatory hysteroscopy compared with intracervical,
transcervical or topical routes. The vaginoscopic approach has been shown to reduce pain signicantly
in randomised trials.

23. a) F b) F c) T d) T e) F

There is good evidence that hysteroscopy in the ambulatory setting is preferable for the patient as it
avoids complications, allows quicker recovery time and lowers costs. Miniaturisation of high denition
hysteroscopes does not compromise optical performance and allows accurate diagnosis of intrauterine
1144 Appendix / Best Practice & Research Clinical Obstetrics and Gynaecology 29 (2015) 1139e1145

pathology. Ambulatory hysteroscopy represents the gold standard diagnostic test for diagnosis of
submucous broids and polyps. In 2014 87 % of UK hospitals offered ambulatory hysteroscopy. To date
there are no large randomised studies or cohort studies which clearly support the safety and effec-
tiveness of concomitant endometrial ablation and hysteroscopic sterilisation. However, there are
several small uncontrolled series observational series demonstrating feasibility and supporting short
term efcacy and safety.

24. a) F b) F c) T d) T e) T

Laser ablation is very expensive and needs a highly trained surgeon. Endometrial thinning agents
(GNRH or Danazol) before hysteroscopic surgery improve operating conditions and short term post-
operative outcomes. The effect of these agents on long term outcome was reduced with time. Roller-
ball in comparison with TCRE shows no evidence of signicant differences in the complication of re-
interventon at 2,5 and 10 years or in complication rates as measured (uid decit/perforation).

25. a) F b) F c) T d) F e) T

Rollerball ablation was studied vs. cryo and thermal balloon ablation and there was no evidence of
any difference in results of either technique on all parameters measured. The duration of surgery was
consistently shorter with second generation compared to rst generation ablation and LA was more
likely to be given. Analysis of the IBD-HMB database comparing rst and second generation showed no
signicant difference in effectiveness when dened as satisfaction. There is no evidence that rst or
second generation ablation are superior to each other. However a lot of practical considerations favour
the choice of second generation techniques.

26. a) T b) T c) T d) F e) T

Bipolar radiofrequency ablation is associated with higher amenorrhea rates as has been shown in
published meta-analysis. Surgery is shorter with bipolar radiofrequency ablation and PMS scores are
reduced, the devices work on automated systems that are less skill dependent. Bipolar radiofrequency
ablation has increased amenorrhoea and satisfaction scores and women are less likely to require
additional surgery and this risk of further surgery decreases with age. 80 % of women will not require
any additional treatment. Data from UK hospital statistics show a signicant difference increase in the
overall number of in-patient ablation techniques. In addition, radiofrequency endometrial ablation is
the most commonly performed technique.

27. a) T b) F c) F d) F e)

Age over 45 years appears to be a prognostic favourable for a success after endometrial ablation. A
long cavity appears to be an unfavourable prognostic factor for satisfaction after ablation. The existence
of submucous broids in the uterine cavity is also an unfavourable prognostic factor and large broids
in the cavity (>3 cm) are a contraindication to use of most second generation ablative techniques. Pre-
operative dysmenorrhoea is more frequently observed in women after failed endometrial ablation.
Racial differences make no difference to the outcome once appropriate women are selected.

28. a) T b) T c) T d) F

a) Tissue removal systems (hysteroscopic morcellation) has recently been introduced allowing
simultaneous mechanical tissue cutting and extraction via suction. Published trials have demonstrated
its efcacy in the ofce setting for removal of polyps. b) Essure sterilization has become an established,
effective method of transcervical, non-incisional sterilization. Other hysteroscopic permanent birth
control systems are in development for use in the ofce setting. C) The miniaturisation of endoscopes
combined with the ability to visualize digital images on a computer or integrated monitors means that
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large stack systems are not essential to practice modern hysteroscopy. D) Bipolar electrosurgical sys-
tems for use in physiological saline distension media have facilitated safer operative hysteroscopic
surgery in both the ofce and operating room. Traditional monopolar systems are being replaced by
bipolar technologies.

29. a) T b) F c) F d) F

a) A systematic review published in the BMJ in 2011 showed the effectiveness of such methods for
administering local anaesthesia. b) Avoiding the use of a vaginal speculum and / or cervical instru-
mentation is associated with less pain according to a systematic review of some small randomized
controlled trials. c) There is no evidence to indicate that the prevalence of vaso-vagal reactions is
affected by vaginoscopy. d) The OPT trial published in the BMJ in 2015 reported 4 cases of uterine
perforation in the 25o cases of uterine polypectomy performed under general anaesthesia compared to
zero in the ofce. Thus, ofce-based procedures performed in conscious women appear to be less
traumatic.

30. a) T b) T c) F d) F

a) Serious endometrial disease can be diagnosed with high accuracy by hysteroscopy when per-
formed in conjunction with directed or blind endometrial sampling. b) Diagnostic test studies have
shown hysteroscopy to be more accurate than 2D ultrasound and at least equivalent to saline infusion
sonography. Blind endometrial biopsy may fail to sample focal lesions. c) There is no evidence to
support this contention in contemporary ofce hysteroscopy utilising small diameter hysteroscopes
under low uterine distension pressures. Abrading the uterus with endometrial sampling devices is
painful in contrast to performing hysteroscopic procedures less traumatically under vision. d) Stand-
ardised criteria for diagnosing adenomyosis at hysteroscopy are lacking. Ultrasound and MRI can di-
agnose adenomyosis with modest levels of precision.