Hysteroscopy, performed as an outpatient procedure, is widely used for identifying uterine cavity lesions. It is a useful test for confirming the diagnosis of uterine cavity lesions through direct visualization, mainly in women with abnormal uterine bleeding. Hysteroscopy can be performed in an outpatient setting rather than in an operating room setting, which simplifies treatment, reduces the burden of costs, improves preoperative counseling, and avoids unnecessary procedures and exposure to anesthesia. Recently, with the development of endoscopic equipment and technology, simple endometrial lesion removal along with tissue biopsy has become possible with office hysteroscopy, and which can be performed in various situations to improve patient satisfaction and make a definite diagnosis [1].

In these guidelines, we aimed to provide clinicians with up-to-date evidence-based information to help them practice efficient hysteroscopy by increasing access to office hysteroscopy.

Office hysteroscopy is most commonly performed in patients with abnormal uterine bleeding. While ultrasound can assess the endometrium, it may fail to diagnose polyps or fibroids in the uterine cavity in approximately one in six cases. Thus, hysteroscopy may be performed if imaging findings are abnormal or equivocal. Additionally, if a thickened endometrium is discovered incidentally on ultrasound, especially in patients taking tamoxifen, hysteroscopy can help visualize and diagnose uncertain intrauterine lesions. It can also be used in cases of persistent discharge after endometrial ablation, removal of foreign bodies or retained intrauterine devices, abnormal hysterosalpingography, suspected intrauterine adhesions, habitual miscarriage, Müllerian anomalies, and uterine septum evaluation [2-5].

Office hysteroscopy enables the evaluation of the vagina, cervix, and uterine cavity, which helps in selecting appropriate surgical equipment and estimating surgical time. Simple procedures, such as endometrial sampling, lysis of intrauterine adhesions, and removal of endometrial/endocervical polyps, small leiomyomas, retained products of conception, and intrauterine devices, can be accomplished, potentially avoiding unnecessary surgery [3].

For a successful office hysteroscopy, it is crucial to set appropriate expectations for the procedure, including potential discomfort, expected duration, and goals [3]. This information will help in making decisions regarding anesthesia or pain management for patients. There should be a sufficient preprocedure explanation regarding the discomfort level and duration of office hysteroscopy, and efforts should be made to minimize the patient’s pain in the shortest time possible. In addition, verbal reassurance of the patient during the procedure is necessary. The key aspects to be assessed in the patient history include obstetric history, medical conditions, history of sexual abuse, presence of chronic pain, and previous cervical procedures [3,4]. To rule out pregnancy, a urine pregnancy test should be conducted, or hysteroscopy should be performed immediately after menstruation. If there is an active pelvic inflammatory disease or active genital infection, such as herpes, hysteroscopy should be postponed until after treatment.

In outpatient settings, hysteroscopy may fail in cases of cervical stenosis, poor visualization, or inability to tolerate pain. Therefore, patients with cervical stenosis, those who cannot assume the required position, severely ill patients requiring intensive monitoring, and those unable to endure the procedure under local anesthesia should be excluded [3,4].

The basic equipment includes a hysteroscope, a distension media injection system, and sterilization equipment, with additional items, such as cameras and monitors, used as needed. The hysteroscope should be thoroughly cleaned, disinfected, and sterilized before each use. Hysteroscopes come in various sizes (3-10 mm diameter), lens angles (0-70°), and lengths (160-302 mm). They can be rigid or semirigid/flexible. Rigid hysteroscopes have an outer sheath with channels for the endoscope, distension media, and surgical instruments. Instruments include biopsy tools, forceps, and scissors. The quality of the surgical field depends on the quality of the endoscope and camera, with larger diameters generally providing better image quality. The endoscope can be used directly through the ocular lens or with a camera and monitor to share views with the patient and other medical staff. The light source is typically either halogen or xenon, with halogen being the more economical option.

Performing hysteroscopy when the endometrium is thin can shorten the procedure time and reduce media absorption, making the procedure easier. The best time to perform hysteroscopy in premenopausal women with regular menstrual cycles is during the follicular phase after menstruation. It is confirmed that the patient is not pregnant before the procedure. Performing hysteroscopy during the luteal phase may lead to the misinterpretation of normal endometrial thickening as a pathology. For women with irregular cycles, the procedure can be performed at any time; however, heavy bleeding may compromise the visibility. Preprocedural medication with progestins or combined oral contraceptives may thin the endometrium and improve visualization [13,14]. Studies have suggested that short-term use of oral contraceptives before hysteroscopy can enhance visualization and procedural satisfaction. Previous reports have indicated that even a short course of oral contraceptives before surgery can improve visualization during hysteroscopy and increase surgical satisfaction. One study found that when combined oral contraceptives were started during the early follicular phase, endometrial thickness remained at an average of 4.1 mm by the 18th day of treatment. Another report described a regimen where, to maximize the effect of the Qlaira (Bayer, Pimble, Austrailia) contraceptive pill, patients took a medication containing dienogest 3 mg and estradiol 2 mg starting from the 8th day (day 1-7 of the medication, avoiding estradiol 2 mg and dienogest 2 mg) [15]. This study showed that the endometrial lining was more atrophied, regular, and pale in the group taking Qlaira (Bayer) than in those not on the pill, with higher satisfaction reported by both the physician and the patients in the contraceptive group. There are reports indicating that when dienogest was administered for approximately 2 weeks before hysteroscopic surgery, endometrial thickness decreased from 7 mm before treatment to 3.9 mm after treatment. Therefore, administering dienogest for approximately 2 weeks before surgery is considered beneficial for improving visualization during the procedure [16]. Administering gonadotropin-releasing hormone (GnRH) agonist nafarelin nasal spray 200 μg every 12 hours, before submucosal myomectomy, can thin the endometrium, reduce intraoperative bleeding, and improve visualization during the procedure [17]. However, because of the potential side effects of the medication, it is not recommended for all patients. Nonetheless, administering GnRH agonists to women with severe anemia before surgery can help increase hemoglobin levels and improve preoperative preparation.

There is conflicting or insufficient evidence regarding routine cervical preparation or ripening prior to diagnostic or operative hysteroscopy [21-23]. However, each has shown promising effects [21,22]. For patients expected to have cervical stenosis or severe pain, cervical preparation should be considered, and the potential benefits of a drug must be weighed against the increased risk of side effects [23]. One option that has been widely evaluated regarding dosage, route of administration, and effects is prostaglandins, such as misoprostol [24]. For hysteroscopy in the operating room or the office setting, misoprostol has been investigated at various dosages, most frequently 200-400 μg, alone or with vaginal estrogen, and at different administration routes, including sublingual, oral, or vaginal. Compared to a placebo, misoprostol administration has demonstrated improved ease of cervical dilatation or a decreased need for dilatation, resulting in easy cervical entry, decreased pain, and decreased procedure times [25-30]. Another option is the use of osmotic dilators such as laminaria, which have been compared to misoprostol. Osmotic dilators also have improved difficulties regarding mechanical cervical dilation with similar side effects, but depending on the case, additional hospital visits for osmotic dilator insertion prior to hysteroscopy may be the reason for discarding these options [23,31].

A few studies have investigated local cervical injections of vasoconstricting agents such as vasopressin or epinephrine to decrease blood loss and fluid absorption, increase anesthetic effects, and prevent local anesthetic systemic complications [32]. Because of the potential for rare but serious cardiovascular events, including bradycardia, hypotension, hypertension, and heart attack, vasoconstricting agents should be administered with caution, especially in an office setting [33,34].

Selecting an appropriate distension medium for hysteroscopy involves considering visibility, avoiding damage related to the cautery, cost, and safety. The ideal medium should be non-toxic, non-allergenic, non-hemolytic, and quickly removed from the body. To assess the entire uterine cavity, it is essential to use a distension medium that expands it adequately. However, it is important to apply minimal pressure to avoid excessive distension of the uterus, which can cause pain [10].

Vaginoscopy is a technique in which a hysteroscope is inserted to observe the vagina, cervix, and uterine cavity without using a vaginal speculum or cervical tenaculum [1]. Small-diameter (less than or equal to 3.5 mm) rigid or flexible hysteroscopes are suitable instruments for vaginoscopic procedures [18]. By tilting the table backward, expansion of the vaginal canal through the use of normal saline enables simultaneous visualization of the cervix and vagina; then, the scope proceeds through the cervical canal and enters the uterine cavity [10]. Fluid leakage from the vagina can be reduced by manually compressing the labial tissue to narrow the vaginal introitus [1]. As this technique is feasible without cervical preparation, it can be useful for examining children or nulliparous patients without concerns of hymen injury.

Vaginoscopy should be the standard technique for outpatient diagnostic hysteroscopy and may be the preferred method, especially in cases where inserting a vaginal speculum is expected to be challenging [10,18]. Its feasibility was reported to range from 83% to 98%, and no significant difference was found in the number of failed procedures when compared with traditional hysteroscopy [1,18,35,46-49].

Vaginoscopy alleviates pain during diagnostic rigid outpatient hysteroscopy [10,35,38,47,50]. According to a randomized study, when compared with conventional hysteroscopy, with respect to median visual analogue scale (VAS) score, the vaginoscopy showed a significant reduction in procedural pain, and with a VAS score of 0.5 (P<0.0001) with similar efficacy [48]. Clinicians performing office hysteroscopy should consider the vaginoscopic technique because it makes office hysteroscopy quicker and less painful and reduces the likelihood of inducing a vasovagal reaction [51].

Hysteroscopy is considered a safe, minimally invasive procedure. However, several complications have been reported. Most complications of hysteroscopy are rare and if they do occur, are seldom life threatening, particularly in diagnostic procedures.

If the technology is available, endometrial polyps can be treated using office hysteroscopy. Office hysteroscopic polypectomy is safe, well tolerated, and more cost-effective than traditional inpatient hysteroscopic polypectomy [64]. In a multicenter randomized trial, outpatient polypectomy was found to be noninferior to inpatient polypectomy for the treatment of abnormal uterine bleeding, with similar treatment effects maintained at 12 and 24 months [65]. A multicenter prospective observational trial found that office hysteroscopic polypectomy may be associated with a higher risk of failure or incomplete polyp removal. In contrast, inpatient hysteroscopic polypectomy may be associated with a greater risk of complications [66].

These clinical guidelines provide necessary information for clinicians performing office hysteroscopy aiming for evidence-based and effective diagnosis and treatment. Continuous research and feedback will help refine these guidelines as the use of office hysteroscopy evolves.