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
10 actions that can ease entry to the cervix for hysteroscopy
|Take a careful history and perform a rigorous physical exam||Identify risk factors for cervical stenosis and assess cervical/uterine position|
|Administer an oral nonsteroidal anti-inflammatory drug 60 minutes before the procedure||Helps to reduce discomfort, especially postprocedure pain|
|Provide an anxiolytic or conscious sedation, or both||Consider this option for women who are very anxious or unlikely to tolerate pain, especially for operative procedures|
|Use a tenaculum||Consider if the uterus is not in the axial position|
|Use Hagar dilators or a lacrimal duct probe||May be helpful if mechanical dilation is necessary|
|Proceed under ultrasonographic guidance||Consider 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 hysteroscope||A smaller scope will require less cervical dilation|
|Administer a paracervical block||Consider 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 anesthetic||May be appropriate when a tenaculum is used|
|Give misoprostol to prime the cervix||Consider 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 examination||Identify risk factors for cervical stenosis and assess uterine position|
|Administer an oral nonsteroidal anti-inflammatory drug 60 minutes prior to biopsy||Helps to reduce discomfort, especially postprocedure pain|
|Use a tenaculum||May be helpful if the uterus/cervix is not in the axial position|
|Apply a topical cervical anesthetic||May help alleviate discomfort associated with use of a tenaculum|
|Use Hagar dilators or lacrimal duct probes||Provide mechanical dilation|
|Use the smallest biopsy catheter possible||Reduces 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.