1. HYSTEROSCOPY OVERVIEW DiagnosisTreatment

2. Contraindications to Hysteroscopy Pelvic infection Pelvic infection Cervical malignancy Cervical malignancy Pregnancy Pregnancy

3. Diagnostic Hysteroscopy Abnormal Uterine Bleeding Menorrhaghia (heavy cyclic bleeding) evaluate for fibroids, polyps Menorrhaghia (heavy cyclic bleeding) evaluate for fibroids, polyps Premenopausal irregular bleeding – usually anovulatory (first try hormonal correction) Premenopausal irregular bleeding – usually anovulatory (first try hormonal correction) Post menopausal bleeding - Post menopausal bleeding - after negative endometrial biopsy

4. Diagnostic Hysteroscopy Infertility Usually in office, local anesthesia Usually in office, local anesthesia Habitual Abortion – evaluate for Habitual Abortion – evaluate for Submucous myoma Septate uterus Prior to In Vitro Fertilization Prior to In Vitro Fertilization

5. Distending Media Saline Saline CO 2 CO 2 Hyskon (use ½ strength) Hyskon (use ½ strength) Mannitol/Sorbitol/Glycine Mannitol/Sorbitol/Glycine

6. Saline Advantages Cheap Cheap Simple to use Simple to use

7. PHOTO OF SALINE INFUSION PUMP PHOTO OF SALINE INFUSION PUMP

8. Saline Disadvantages Poor visibility if bleeding Poor visibility if bleeding Can’t use with electrocautery Can’t use with electrocautery

9. CO 2 Advantages Excellent image quality Excellent image quality Extremely safe Extremely safe Minimal discomfort Minimal discomfort No mess – ideal for office No mess – ideal for office

10. CO 2 Disadvantages Bubbles - Diagnostic only Bubbles - Diagnostic only Cost - Special insufflator = high pressure (up to 100mm Hg), low flow (ml/min, not liters/min) Cost - Special insufflator = high pressure (up to 100mm Hg), low flow (ml/min, not liters/min)

12. Hyskon (Dextran) Advantages Excellent optical qualities Excellent optical qualities Does not mix with blood Does not mix with blood No special equipment - 50 ml syringe No special equipment - 50 ml syringe Non conductive - electrocautery OK Non conductive - electrocautery OK

13. Hyskon Disadvantages Very messy Very messy Requires immediate, thorough washing & rinsing (difficult in office) Requires immediate, thorough washing & rinsing (difficult in office) Rare anaphylactic reaction Rare anaphylactic reaction

14. Sorbitol-Mannitol-Glycine Advantages Non conductive – electrocautery OK Non conductive – electrocautery OK Can use with active bleeding Can use with active bleeding

15. Sorbitol-Mannitol-Glycine Disadvantages Fluid overload – dedicated person monitor I&O every 5-10 min. Reassess at 500ml stop at 1000ml* Fluid overload – dedicated person monitor I&O every 5-10 min. Reassess at 500ml stop at 1000ml* Hyponatremia –(Na < 120 mmol/l) most common cause of death from hysteroscopy Hyponatremia –(Na < 120 mmol/l) most common cause of death from hysteroscopy Allergic reactions – fructose (rare) Allergic reactions – fructose (rare)

18. Therapeutic Hysteroscopy Infertility Infertility Abnormal Uterine Bleeding Abnormal Uterine Bleeding

19. Therapeutic Hysteroscopy Infertility Resection of Septation (scissors, cautery, laser) Resection of Septation (scissors, cautery, laser) Resection of Synichiae (Ascherman's syndrome) give post op estrogen and place IUD 4 weeks Resection of Synichiae (Ascherman's syndrome) give post op estrogen and place IUD 4 weeks

22. Therapeutic Hysteroscopy Infertility Cannulation for proximal tubal occlusion – usually done with simultaneous laparoscopy Cannulation for proximal tubal occlusion – usually done with simultaneous laparoscopy Give intravenous glucagon (1–2 mg IV) to help prevent tubal spasm Give intravenous glucagon (1–2 mg IV) to help prevent tubal spasm Laparoscope with tubal dye first, after glucagon. –problem seen at HSG may be solved Laparoscope with tubal dye first, after glucagon. –problem seen at HSG may be solved