Hysteroscopy Fellowship Programme — The Medicity

Hysteroscopy Fellowship Programme

A comprehensive clinical reference for fellowship-level gynaecology training. Covers basic principles through advanced operative procedures — designed for rapid review at the point of care.

Modules 1–5 Module 1: Principles Module 2: Anatomy Module 3: Equipment Module 4: Media Module 5: Patient Selection

MOD 1

Introduction & Fundamentals

1.1 — Basic Principles & Definition

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Hysteroscopy is the direct endoscopic visualisation of the uterine cavity and endocervical canal using a hysteroscope and a distension medium, allowing both diagnosis and treatment of intrauterine pathology.

🔍 Visualise

Direct, real-time view of uterine cavity, endometrium, and tubal ostia without blind manipulation.

🎯 Diagnose

Identify and characterise polyps, fibroids, septa, adhesions, and endometrial abnormalities with highest accuracy.

✂️ Treat

Remove pathology in the same sitting — polypectomy, myomectomy, adhesiolysis, ablation (see-and-treat).

📋 Sample

Targeted biopsy under direct vision — superior to blind Pipelle for focal lesions (10× surface area sampled).

Feature	🔭 Diagnostic	✂️ Operative
Purpose	Inspection & biopsy only	Diagnosis + simultaneous treatment
Scope size	2.7–4 mm (mini/standard)	5–9 mm operative / resectoscope
Sheath	Diagnostic single-flow	Continuous-flow operative
Medium	Normal saline or CO₂ (office)	Saline (bipolar) / Glycine (monopolar)
Anaesthesia	None / NSAID / paracervical block	GA / spinal / IV sedation
Setting	Office / outpatient / day-care	OT (day-care or inpatient)
Duration	5–15 minutes	20–90+ minutes
Indications	AUB, PMB, infertility workup, lost IUCD	Polyps, fibroids, septum, adhesions, ablation

❌ Traditional / Blind Procedures

Blind D&C — high miss rate for focal lesions
Laparotomy — large incision, long recovery
No direct visualisation — guesswork
Cannot sample specific area
Higher perforation risk without guidance
Significant post-op pain & hospital stay
GA always required
Adhesion formation more common
High recurrence — incomplete resection

✅ Hysteroscopy Advantages

Direct visualisation — real-time, magnified
Targeted biopsy — sample exact lesion
See & treat in same session
Day-care — no admission needed
Minimal anaesthesia (office: NSAIDs only)
Precise resection confirmed on-screen
Faster recovery (1–3 days diagnostic)
Lower morbidity vs laparotomy
Repeatable for surveillance or staged procedures

1.2 — History of Hysteroscopy

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1869 — Pantaleoni: first uterine endoscopy using a cystoscope

Early 20th century — Limitations of optical systems; poor distension media

1970s — Edström & Fernström: CO₂ distension medium introduced

1980s — Neuwirth, DeCherney: operative resectoscopy developed

1990s — Bipolar energy, better optics, miniaturisation; flexible scopes

2000s–present — Vaginoscopy, morcellators (MyoSure, TruClear), global ablation (NovaSure, MEA), HD/4K imaging

1.3 — Indications

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Diagnostic — Abnormal Uterine Bleeding (AUB)

Heavy menstrual bleeding unresponsive to medical therapy
Intermenstrual / post-coital bleeding
Irregular cycles with structural cause suspected

Post-menopausal Bleeding (PMB)

Any PMB must be investigated — exclude endometrial carcinoma
Thickened endometrium on TVS (>4 mm)
Inadequate or failed outpatient biopsy

Infertility & Recurrent Pregnancy Loss

Pre-IVF cavity assessment (ESHRE recommends before embryo transfer)
Unexplained infertility — exclude intrauterine pathology
Recurrent miscarriage (≥2 losses) — detect septa, adhesions

Operative Indications

Submucosal fibroids: FIGO Type 0, 1, 2
Endometrial polyps (symptomatic or post-menopausal)
Uterine septum / Müllerian anomalies
Intrauterine adhesions (Asherman's syndrome)
Endometrial ablation (HMB, completed family)
Lost IUCD, RPOC, tubal cannulation

1.4 — Contraindications

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ABSOLUTE — Do Not Proceed Active PID / pelvic infection · Confirmed/suspected pregnancy (mandatory beta-hCG pre-op) · Recent uterine perforation (wait ≥6–8 weeks) · Invasive cervical cancer · Inability to distend cavity

⚠️

RELATIVE — Proceed with Caution Heavy active bleeding · Previous pelvic irradiation · Severe cardiac/renal disease · Coagulopathy (correct INR <1.5, platelets >80k first) · Cervical stenosis (misoprostol 400 mcg vaginally 6–12h before) · Anticoagulant therapy (bridging plan required)

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Clinical Pearl: For every relative contraindication — document your risk-benefit discussion and obtain specific informed consent addressing that additional risk.

MOD 2

Anatomy & Physiology

2.1 — Uterine Anatomy & Dimensions

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Total uterine length
7–8 cm
Slightly larger in multiparous women
Cavity length
6–7 cm
From internal os to fundus; triangular
Cavity width (fundus)
~4 cm
Widest at fundal level between ostia
Endometrial thickness
3–16 mm
<4 mm post-menopausal (investigate if ≥4 mm + PMB)

Uterine Layers (Inner → Outer)

Endometrium — functional (shed) + basal (permanent) layers; directly visualised at hysteroscopy; glandular openings visible as pits
Myometrium — 1.5–2.5 cm; inner circular, middle oblique, outer longitudinal fibres; uterine artery branches penetrate here
Perimetrium — visceral peritoneum; absent anteriorly below peritoneal reflection; perforation may breach peritoneum

Vascular Supply — Surgical Relevance

Aorta → Common iliac → Internal iliac → Uterine artery
Uterine artery crosses ureter at base of broad ligament ('water under the bridge')
Arcuate → Radial → Spiral arteries (hormone-sensitive)
Lateral perforation risks ureteral injury (1–2 cm lateral to cervix)

Nerve Supply (Key for LA)

Sympathetic: T10–L1; superior hypogastric plexus
Pain fibres: T11–T12 → referred lower abdomen/back
Cervix/vagina: S2–S4 — paracervical block targets these nerves
Parasympathetic: S2–S4 (pelvic splanchnics)

Proximity — Bowel & Bladder

Bladder directly anterior → anterior perforation → bladder injury
Sigmoid colon posterolateral → posterior/fundal perforation → bowel
Bowel visible through scope = STOP immediately; laparotomy
Delayed bowel injury: fever + peritonism 24–72 h post-op

2.2 — Endometrial Cycle — Hysteroscopic Appearances & Optimal Timing

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Phase	Days	Hysteroscopic Appearance	Timing for Scope
Proliferative	Day 6–14	Thin, pale pink, translucent; glandular openings visible; clear view; tubal ostia clearly seen	✅ IDEAL — Days 6–10
Secretory	Day 15–28	Thick, velvety, oedematous; polypoid folds; may obscure small lesions	⚠ Suboptimal — diagnostic only
Menstrual	Day 1–5	Blood, clots, debris; fragmented tissue; poor visualisation; increased infection risk	❌ Avoid unless urgent
Atrophic (post-menopausal)	—	Very thin, pale/white; blood vessels visible; petechiae; cervical stenosis common	⚠ Misoprostol + mini-scope

⏱️

Optimal timing: Days 6–10 of cycle — early proliferative phase. Endometrium is thin (2–6 mm), pale pink, translucent. Best for detecting small polyps, thin septa, and subtle adhesions.

2.3 — Cervical Anatomy & Tubal Ostia

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Endocervical Canal

2–3 cm long; spindle-shaped; lined by columnar epithelium
Cervical crypts (Nabothian glands) — mucus secreting; antimicrobial barrier
Internal os: functional sphincter — site of resistance during dilation; false passage risk
Softened by misoprostol / GnRH analogue pre-treatment
Stenosis common post-menopausal and after LLETZ

Tubal Ostia — Normal & Variants

Oval/round opening, ~1–2 mm diameter at cornual angles
Surrounded by raised endometrial ridge (cornual prominence)
Symmetrical — both ostia visible in same plane; appear slightly darker
Proximal tubal block on HSG → confirm at hysteroscopy (spasm is common false positive)
Hysteroscopic tubal cannulation: 5 Fr catheter; ~85% success for proximal block

MOD 3

Equipment & Instrumentation

3.1 — Hysteroscope Types

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Rigid Diagnostic

2.7 mm — Mini/office; fits un-dilated cervix; vaginoscopic technique compatible
4 mm — Standard diagnostic; wider field of view; requires slight dilatation (Hegar 5)
Viewing angles: 0° (most common), 12°, 25°, 30°
Superior image quality; gold standard in OT setting

Rigid Operative

5 mm — 5 Fr working channel; polypectomy, directed biopsy
7 mm — Standard operative; 7 Fr channel; most outpatient procedures; Versapoint compatible
9 mm — Resectoscope outer sheath; continuous-flow; myomectomy, ablation, septoplasty
Requires cervical dilatation for operative sizes

Flexible Hysteroscopes

Tip deflection 90°–130° — ideal for severe anteflexion/retroflexion
Diameter 3.5–5 mm; better tolerated without anaesthesia
Working channel: 2 Fr (limited operative capability)
Lower image resolution; fragile fibre optics; more expensive maintenance

Mini / Vaginoscopic

Diameter 1.9–3.5 mm outer sheath — ultra-slim
No speculum / tenaculum needed — no-touch technique
Minimal pain (VAS 2–3/10 vs 5–6/10 for rigid under LA)
Ideal: nulliparous, post-menopausal, anxious patients
Failure rate ~5–10%; convert to OT if cervix undilatable

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Vaginoscopic (No-Touch) Technique: Scope introduced directly via vaginal walls under vision. Saline distends vagina → os identified → scope advances into canal without speculum or tenaculum. Significantly less pain and vasovagal risk. Preferred in nulliparous and post-menopausal women.

3.2 — Sheaths & Flow Systems

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Feature	Single Flow	Continuous Flow
In-flow	Via scope sheath	Dedicated inner sheath
Out-flow	None — fluid exits around scope	Dedicated outer sheath channel
Cavity pressure	Variable — may rise unpredictably	Controlled; maintained at set pressure
Visibility	Decreases with debris/blood	Constant — debris continuously flushed
Best for	Diagnostic & minor operative	All resectoscopic & complex operative
Fluid deficit tracking	More difficult	Easier — inflow/outflow measured precisely

3.3 — Energy Systems — Monopolar vs Bipolar vs Mechanical

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Feature	⚡ Monopolar	🔋 Bipolar	🔧 Mechanical
Circuit	Active electrode → patient → return pad	Between two tips on instrument only	Rotating blade — no current
Distension medium	Hypotonic ONLY (glycine, sorbitol)	Isotonic saline ✅	Isotonic saline ✅
Fluid deficit limit	1,000–1,500 mL ⚠	2,500 mL	2,500 mL
Thermal spread	Up to 2–3 mm lateral	Less; safer near ostia	None — no heat generated
Return pad	Mandatory on thigh	Not needed	Not needed
Hyponatraemia risk	HIGH (TURP syndrome)	Low (isotonic medium)	Low
Histology preservation	Thermal artefact	Less artefact	Fully preserved

✅

Modern standard: Bipolar + saline for all operative hysteroscopy. Monopolar use is declining. Mechanical morcellators (MyoSure, TruClear) have no thermal risk and preserve histology — preferred for polyps and Type 0/1 fibroids.

Resectoscope Electrode Types

Cutting loop — semicircular wire; resect/shave fibroids, polyps, endometrium
Rollerball — spherical tip; coagulates endometrium (ablation, haemostasis)
Roller-cylinder — wider surface; faster ablation of large areas
Needle electrode — precise cuts (metroplasty, adhesiolysis); minimal lateral spread
Vaporising bar — combines cutting + coagulation in one pass

Versapoint Bipolar Electrodes (5 Fr)

Twizzle — cutting; for stalk transection and precise division
Spring — vaporisation; for broader tissue destruction
Ball — haemostasis; spot coagulation of bleeding vessels
Office-compatible — fits through 5 Fr operative sheath
Saline distension only; no return pad needed

3.4 — Ancillary Instruments & Sterilisation

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Graspers & Scissors

Alligator graspers — retrieve IUCD, polyp fragments, specimen
Cup/punch biopsy forceps (5 Fr) — directed endometrial biopsy
Semi-rigid scissors — metroplasty (preferred cold technique; no thermal damage)
Flexible scissors — use with flexible scope; adhesiolysis

Morcellators (MyoSure / TruClear)

Rotating/oscillating blade cuts and aspirates simultaneously
No thermal energy — histology fully preserved
MyoSure Reach: articulating tip for cornual polyps
TruClear 8.0 Elite: 8 mm — for larger myomas (Type 0/1)
Disposable blades — single patient use only

Balloon Catheters

Foley (8–12 Fr, 10 mL balloon) — post-adhesiolysis cavity stent (5–7 days)
Cook balloon — purpose-built intrauterine post-adhesiolysis
SOS Bakri balloon — for significant post-hysteroscopic haemorrhage
Remove under direct vision or clinic review at 5–7 days

Sterilisation — Key Rules

OPA (Ortho-phthalaldehyde): 12 min for HLD; less toxic than glutaraldehyde
Glutaraldehyde 2% (Cidex): 20 min HLD; 3–4 h for sterility
Most rigid scopes NOT autoclave-compatible — check manufacturer guidance
Log all disinfection cycles: scope ID, solution, date/time, staff name
Troubleshooting foggy image: warm scope in warm saline before insertion

MOD 4

Distension Media

4.1 — Media Types — Quick Reference

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Medium	Type	Energy Compatible	Osmolality	Deficit Limit	Key Risk
Normal Saline 0.9%	Isotonic	Bipolar / Diagnostic	308 mOsm/kg	2,500 mL	Volume overload only
Lactated Ringer's	Near-isotonic	Bipolar / Diagnostic	273 mOsm/kg	2,500 mL	Volume overload
Glycine 1.5%	Hypotonic	Monopolar ONLY	200 mOsm/kg	1,000 mL	Hyponatraemia + ammonia toxicity
Sorbitol 3%	Hypotonic	Monopolar ONLY	165 mOsm/kg	1,000 mL	Hyponatraemia + lactic acidosis
Sorbitol-Mannitol	Hypotonic	Monopolar ONLY	178 mOsm/kg	1,000 mL	Hyponatraemia (mannitol reduces severity)
CO₂ Gas	Gas	Diagnostic ONLY	N/A	100 mL/min max flow	Gas embolism if flow >100 mL/min

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Normal saline + bipolar is the modern standard. Hypotonic media (glycine, sorbitol) should only be used with monopolar resectoscopes and their use is progressively declining as bipolar systems become universal.

4.2 — Intrauterine Pressure Targets & Fluid Deficit Limits

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Intrauterine Pressure	Status	Effect
<40 mmHg	Too Low	Cavity collapses; walls appose; poor visualisation
40–70 mmHg	Suboptimal	Borderline; cavity may partially open
70–120 mmHg	✅ TARGET	Optimal distension; clear view; tubal ostia visible
>120 mmHg	DANGER	Increased intravasation; rapid deficit accumulation
>150 mmHg	CRITICAL	Risk of perforation from hydraulic pressure

Deficit Formula

Fluid Deficit = Fluid IN − Fluid OUT

Out-flow = suction canister + floor suction + drapes + irrigation bags returned. Record every 15 minutes during operative procedures.

Isotonic (Saline) Thresholds

1,000 mL — Inform surgeon + anaesthetist
1,500 mL — Alert; assess necessity to continue
2,500 mL — STOP procedure immediately
High-risk (cardiac/renal): limit 1,000 mL

Hypotonic Media Thresholds

750 mL — Inform surgeon + anaesthetist
1,000 mL — STOP; send urgent U&E
High-risk patients: limit 750 mL
Check Na⁺, K⁺ urgently if limit exceeded

Team Responsibilities

Scrub Nurse — Count all bags; measure canister every 15 min; record on whiteboard visible to team
Anaesthetist — Monitor haemodynamics; watch for hyponatraemia signs; check electrolytes if limit exceeded
Surgeon — Set alarm thresholds pre-op; expedite procedure; decide continue/stop at warning

4.3 — Distension Media Complications

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TURP Syndrome (Hypotonic Media Only) Dilutional hyponatraemia + volume overload + glycine → ammonia (encephalopathy) / sorbitol → lactic acidosis. Incidence: 0.5–2% with hypotonic media. Classic signs: confusion, visual disturbance, headache, bradycardia, hypertension then hypotension, pulmonary oedema. Management: STOP → ICU → hypertonic saline 3% → furosemide → check ammonia level.

Complication	Mechanism	Signs	Management
Fluid Overload	Absorbed fluid ↑ intravascular volume → cardiac strain	Hypertension → hypotension; SpO₂↓; pulmonary oedema; peripheral oedema	Stop; sit upright; furosemide 40 mg IV; O₂; monitor urine output
Dilutional Hyponatraemia	Na⁺ <135 mEq/L; severe <120 mEq/L	Nausea, headache (mild); seizures, coma (severe)	Mild: fluid restriction + furosemide. Severe Na⁺ <120: 3% NaCl at max 1–2 mEq/L/h; ICU
Pulmonary Oedema	Left heart failure from overload; non-cardiogenic oncotic shift	Dyspnoea; pink frothy sputum; SpO₂↓; bilateral crackles; bat-wing on CXR	Sit upright; high-flow O₂; furosemide 40–80 mg IV; CPAP; ICU
Gas Embolism	CO₂ or air enters open uterine veins	Sudden cardiovascular collapse; mill-wheel murmur; ETCO₂ drops suddenly	STOP; Durant's manoeuvre (left lateral Trendelenburg); 100% O₂; CPR; central aspiration

MOD 5

Patient Selection & Pre-operative Workup

5.1 — Operative Indications — FIGO Fibroid Classification

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FIGO Type	Location	Intracavitary %	Approach	Risk
Type 0	100% intracavitary; pedunculated	100%	Single session; full resection expected	Low
Type 1	>50% intracavitary; sessile	>50%	Usually single session; staged if >4 cm; GnRH pre-Rx	Moderate
Type 2	<50% intracavitary; mostly intramural	<50%	Usually staged; GnRH mandatory; high deficit risk	High

Endometrial Polyps — Key Rules

All symptomatic polyps: AUB, IMB, infertility — remove and send histology
Asymptomatic <1 cm in premenopausal: may regress; watchful waiting acceptable
Post-menopausal polyps: ALWAYS remove — up to 5% malignancy risk
Histology mandatory for every polyp — rule out atypical hyperplasia / adenocarcinoma
Ensure complete stalk excision to prevent recurrence

Endometrial Ablation — Checklist

HMB in women who have completed their family
Failed medical management
Mandatory exclusion: desire for future pregnancy; endometrial hyperplasia/cancer
Pre-treatment: GnRH analogue or progestogen to thin endometrium
Gen 1 (resectoscopic): TCRE, rollerball; Gen 2: NovaSure, Thermachoice, MEA
Success: 90% amenorrhoea or reduced bleeding

5.2 — Pre-operative Assessment

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Assessment Area	Key Points
Menstrual history	Cycle length, duration, flow volume, IMB/PCB, LMP
Obstetric history	Parity, miscarriages/RPL, previous uterine surgery (CS, myomectomy, D&C)
Medical history	Diabetes, hypertension, cardiac/renal disease, bleeding disorders, anticoagulants
TVS (first line)	ET measurement, fibroid mapping (size, FIGO type, serosal relationship), anomalies
Post-menopausal ET	Investigate if ≥4–5 mm; biopsy if >10 mm; action threshold 4 mm in symptomatic
3D TVS	Superior to 2D for uterine anomalies (septum vs. arcuate vs. bicornuate)
SIS (saline infusion sonography)	Distinguishes polyp (mobile, echogenic) from fibroid (sessile, shadowing)
MRI pelvis	Complex fibroids (Type 2); Müllerian anomalies; adenomyosis; myometrial invasion
Pregnancy test	Mandatory beta-hCG before EVERY procedure — absolute contraindication if positive
STI screen	Chlamydia/gonorrhoea swab — treat and confirm clear before listing

5.3 — Relative Contraindications — Risk-Benefit & Management

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Cervical Stenosis

Risk: false passage or perforation with forced dilatation
Priming: misoprostol 400 mcg vaginally 6–12 h pre-op (especially post-menopausal)
Gentle graduated dilatation with Hegar dilators
Guide wire technique if very stenotic
Ultrasound-guided dilatation for difficult cases
Convert to GA if office priming fails — EUA with laparoscopic standby

Anticoagulant Therapy

Warfarin: target INR <1.5 for operative; therapeutic acceptable for diagnostic
DOACs: hold 24–48 h pre-op; restart 24 h post-op when haemostasis confirmed
Aspirin: continue — bleeding risk minimal, stopping increases cardiovascular risk
Haematology involvement if complex bridging required
Bipolar + saline preferred for all anticoagulated patients

Active Uterine Bleeding

Obscures view — procedure technically difficult
Temporise with tranexamic acid, iron, or GnRH pre-treatment
Defer and reschedule once bleeding settled
Emergency exception (RPOC, vascular polyp): proceed in OT with anaesthetic backup

Severe Medical Comorbidities

Cardiac disease: bipolar + saline mandatory; lower fluid limits; anaesthesia risk assessment
Coagulopathy: correct INR <1.5; platelets >80,000 before operative hysteroscopy
Renal impairment: lower deficit limits; careful fluid monitoring
MDT approach: cardiology, haematology, anaesthesia involvement pre-operatively

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Documentation principle: For every relative contraindication — document your risk-benefit discussion in the notes and obtain specific informed consent addressing that additional risk.