Clinical Review

How to overcome a resistant cervix for hysteroscopy and endometrial biopsy

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A cervix that impedes access to the uterus can lead to severe pain, cervical laceration, and other ills



CASE: Difficulty inserting a catheter suggests an unyielding cervix

A.W. is a 38-year-old nulliparous woman who seeks treatment for persistent irregular vaginal bleeding. Her physician attempts an endometrial biopsy in the office but is unable to pass the catheter through the internal cervical os. She schedules office hysteroscopy as follow-up.

What steps can the ObGyn take to reduce the difficulty of the procedure, particularly insertion of the hysteroscope through the cervical canal?

Successful hysteroscopy requires a cervical canal sufficiently dilated to allow passage of the hysteroscope. And because of inevitable variation in anatomy—and even in models of hysteroscopes, which range in diameter from 2.7 to 10 mm—passage is not always easily accomplished. Many of the complications related to hysteroscopy, including cervical tears, creation of a false passage, uterine perforation, vasovagal reaction, pain, and inability to complete the procedure, are caused by inadequate cervical dilation and an inability to insert the hysteroscope.1-6 One study noted that almost half of complications were related to cervical entry.6

In this article, I describe ways to overcome the challenging cervix for hysteroscopic procedures and endometrial biopsy (TABLES 1 and 2).


10 actions that can ease entry to the cervix for hysteroscopy

Take a careful history and perform a rigorous physical examIdentify risk factors for cervical stenosis and assess cervical/uterine position
Administer an oral nonsteroidal anti-inflammatory drug 60 minutes before the procedureHelps to reduce discomfort, especially postprocedure pain
Provide an anxiolytic or conscious sedation, or bothConsider this option for women who are very anxious or unlikely to tolerate pain, especially for operative procedures
Use a tenaculumConsider if the uterus is not in the axial position
Use Hagar dilators or a lacrimal duct probeMay be helpful if mechanical dilation is necessary
Proceed under ultrasonographic guidanceConsider transabdominal imaging to help guide cervical dilation in difficult cases, e.g., when the patient has a history of uterine perforation
Opt for a smaller hysteroscopeA smaller scope will require less cervical dilation
Administer a paracervical blockConsider this option if cervical dilation is expected to be difficult, especially in women at risk of significant pain. Be alert for complications such as bleeding, discomfort at the time of injection, and intravascular injection leading to bradycardia and hypotension
Administer a topical cervical anestheticMay be appropriate when a tenaculum is used
Give misoprostol to prime the cervixConsider giving 400 μg of intravaginal misoprostol 9 to 12 hours preoperatively in premenopausal women, particularly nulliparous women and those undergoing operative hysteroscopy


6 ways to prepare the cervix for endometrial biopsy

Take a careful history and perform a thorough physical examinationIdentify risk factors for cervical stenosis and assess uterine position
Administer an oral nonsteroidal anti-inflammatory drug 60 minutes prior to biopsyHelps to reduce discomfort, especially postprocedure pain
Use a tenaculumMay be helpful if the uterus/cervix is not in the axial position
Apply a topical cervical anestheticMay help alleviate discomfort associated with use of a tenaculum
Use Hagar dilators or lacrimal duct probesProvide mechanical dilation
Use the smallest biopsy catheter possibleReduces degree of cervical dilation necessary

Hysteroscopy failure rate: 3.4% to 4.2%

Hysteroscopy is, of course, common in gynecologic practice, its indications extending across a range of investigations and treatments—for menstrual disorders, postmenopausal bleeding, infertility, and recurrent pregnancy loss.1,7 Flexible hysteroscopes range in diameter from 2.7 to 5 mm; rigid hysteroscopes, from 1 to 5 mm; and operative hysteroscopes can be as large as 8 to 10 mm.2,7

A systematic review of diagnostic hysteroscopy in more than 26,000 women reported a failure rate of 4.2% for ambulatory hysteroscopy and 3.4% for inpatient procedures.4 Failed ambulatory procedures were mainly attributed to technical problems, including:

  • cervical stenosis
  • anatomic and structural abnormalities
  • pain and intolerance.4

Ideally, hysteroscopy is performed with minimal or no cervical dilation,7 but this may not always be possible.

Things to consider before embarking
Close attention to cervical and uterine anatomy
is critical because insertion of the hysteroscope can be the most difficult aspect of the procedure. A bimanual examination is imperative to assess uterine size and position. It also is useful to sound the uterus to determine its depth.

An accurate medical, gynecologic, and obstetric history is essential, including information on pregnancies, dilation and curettage, cervical procedures such as cryotherapy, and any other procedures that may increase the risk of cervical stenosis, or difficulty dilating the cervix.


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