REVIEW

CURRENT
OPINION Hysteroscopy safety
Aarathi Cholkeri-Singh a,b,c and Kirsten Jill Sasaki a,b

Purpose of review
Hysteroscopy is a very common tool providing the gynecologist the ability to diagnose and treat a variety
of intrauterine disorders. This outpatient therapy has provided quick and effective relief for women
worldwide. Although simple in concept, hysteroscopy is associated with minor and major complications.
Awareness of these difficulties and methods of prevention and management is key to good surgical
outcomes. This article reviews well tolerated practices for hysteroscopy complications.
Recent findings
Although complications with both diagnostic and operative hysteroscopy are rare, they can often be
prevented with thorough preoperative evaluation and appropriate intraoperative decision making.
Understanding the patient, disorder, and surgical process can assist the surgeon in providing the best
outcome for the patient.
Summary
With appropriate training and education, gynecologists can safely incorporate hysteroscopy into their
surgical practice.
Keywords
bleeding, cervical stenosis, electrosurgery, fluid overload, gas embolism, hysteroscopy, infection,
intrauterine adhesions, nerve injury, uterine perforation

INTRODUCTION symptomatic gas embolisms [2 ,10–20]. Delayed

&&

Hysteroscopy has been in the gynecologists’ arma- complications resulting from patient positioning
mentarium since the 1970s. The use of a uterine and intrauterine scar development have also been
&&

endoscope was first described in 1869; however, its noted [21 ].

rudimentary design and lack of uterine distension
capability rendered the instrument inoperative. In
1925, Rubin incorporated CO2 to allow visualization
of the uterine cavity, and the routine use of liquid
media became prevalent in the 1980s [1].
Gynecologists now utilize hysteroscopy for
multiple indications, including diagnostic evalu-
ation of abnormal uterine bleeding and infertility.
Operative hysteroscopy is used for the treatment of
polyps, submucous fibroids, retained products of
conception, uterine septums, intrauterine adhe-
sions, tubal sterilization, and ablative therapy. Com-
plications from diagnostic hysteroscopy are low,
with ranges from 1.2 to 3.8% for procedural failures,
0.19 to 0.97% for vasovagal reactions, 0.13% for
uterine perforations, less than 0.01% for infections,
and less than 0.06% for symptomatic gas embolisms
&&
[2 ,3–9]. Complications from operative hystero-
scopy are estimated between 0.06 and 0.2% for fluid
overload, 0.12 and 1.6% for perforations, 0.02% for
adjacent organ injuries, 0.03% for blood loss more
than 500 ml and/or requiring transfusion, 0.01 and
1.9% for endometritis, and less than 0.06% for
Albeit the rates of complications are low, lack of
knowledge for prevention or proper management
can become disabling or even fatal for the patient,
ultimately. This article will review complications of
hysteroscopy and methods for safety management
and prevention.
Preoperative evaluation
Reducing surgical complications begins during pre-
operative evaluation. Not only is it essential to
understand the problem, it is equally important to
obtain a thorough patient history, perform a pelvic
a
The Advanced Gynecologic Surgery Institute, Naperville, bAdvocate
Lutheran General Hospital, Park Ridge and cUniversity of Illinois at
Chicago, Chicago, Illinois, USA
Correspondence to Aarathi Cholkeri-Singh, The Advanced Gynecologic
Surgery Institute, 120 Osler Drive, Suite 100, Naperville, IL 60540, USA.
Tel: +1 630 428 2229; fax: +1 630 428 0336;
e-mail: acholkeri@gmail.com
Curr Opin Obstet Gynecol 2016, 28:250–254
DOI:10.1097/GCO.0000000000000289

www.co-obgyn.com Volume 28  Number 4  August 2016

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.


KEY POINTS
 Complications from hysteroscopy are rare, but most
complications can be avoided with thorough
preoperative planning, careful surgical technique, and
constant vigilance in the operating room or office
setting.
 When complications do occur, it is essential to
completely evaluate the problem, which may include a
laparoscopy or laparotomy to prevent a further delayed
complication that is often more challenging to manage.
 With practice and training, the gynecologist can be
confident and comfortable performing both diagnostic
and operative hysteroscopy, as well as anticipating
and treating all potential complications.
exam, and complete any testing or imaging to pre-
pare an appropriate surgical plan. A discussion of
patient expectations is needed in case multistep
procedures are required. The preoperative prep-
aration will help to assess any precautions necessary
to take regarding patient positioning, anticipating
hysteroscopy difficulties, and requesting the appro-
priate equipment and help to be readily available
for surgery.
Some medical conditions that need to be
assessed include cardiovascular, pulmonary, and
renal compromise as these may limit procedure time
and allowable fluid deficit [22]. In addition, it is
important to determine what prior cervical and
intrauterine procedures have been performed, as it
can increase the risk of cervical stenosis and intra-
uterine scarring. Preoperative evaluation generally
includes a pelvic ultrasound and often a saline-
infused sonohysterogram to aid in operative plan-
ning as well as patient expectation. Hysteroscopy is
contraindicated in patients with a viable intrauter-
ine pregnancy, active pelvic infection including
herpes simplex virus, and known uterine or cervical
cancer (ACOG Technology assessment).
Patient positioning
Factors to consider are the patient’s limitation while
in a lithotomy position. Positioning the legs and
hips while the patient is awake can help reduce any
potential nerve injuries. Femoral nerve injuries can
occur with external rotation, hyperflexion, and
abduction at the hip. Sciatic nerve injuries can occur
from prolonged hyperflexion of the thigh and knee
extension or external hip rotation and knee flexion.
Common peroneal injuries can occur from lateral
knee compression [23–25]. Candy cane stirrups
should be avoided as control of leg positioning is
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Hysteroscopy safety Cholkeri-Singh and Sasaki
not reliable and can increase the risk of nerve injury
[24].
The same care should be taken for back injuries
that may not allow the patient to lay completely
supine on the operative table. Extra support for the
back with gel or foam padding may help alleviate
back strain as well as reduce the risk of the patient
slipping on the table if the bed is placed in
Trendelenburg position.
Cervical and intrauterine scarring
Up to 50% of hysteroscopy complications are due to
difficult access through the cervical canal [26].
Cervical stenosis and intrauterine adhesions can
increase the risk of false tracts and uterine perfor-
ation.
The use of cervical ripening agents such as
misoprostol, dinoprostone, or vaginal osmotic dila-
tors (laminaria) has been shown to reduce the need
for mechanical dilation, thus reducing the risk of
perforation and false tracking [27–30]. We routinely
instruct our patients to take 200 mg of misoprostol
orally the night before and repeat the dose in the
morning. In postmenopausal women, use of daily
vaginal 25 mg estrogen as a pretreatment may
enhance the softening effect of misoprostol
[31]. Intraoperative use of dilute vasopressin
(0.05 U/ml), injected intracervical, has also been
shown to significantly reduce the force needed to
dilate the cervix [32]. Care should be taken not
to over-dilate the cervix as leakage of distension
media fluid may lead to poor uterine distension.
Guidance with ultrasound may be helpful in
visualization of the cervical canal and endometrial
cavity when dealing with either cervical stenosis or
intrauterine adhesions.
Uterine perforation
Uterine perforation is the most common hystero-
scopic complication. Known risk factors are cervical
stenosis or scarring, uterine extreme anteversion or
retroversion, anatomical distortion from previous
surgery, fibroids or other uterine anomalies, and
endometrial or myometrial thinning [14]. It occurs
most often with uterine sounding or mechanical
cervical dilation, but uterine perforation can also
&&
occur with extensive electrosurgery [21 ]. Use of a
flexible hysteroscope or abdominal ultrasound
guidance with a full bladder may help identify the
cervical canal in difficult cases at higher risk of
&&
perforation [21 ]. Concomitant laparoscopy can
be used if ultrasound is not available or unsuccess-
ful, or when there is a high suspicion for uterine
adhesions with bowel, thus placing the bowel at a
www.co-obgyn.com 251
Minimally invasive gynecologic procedures
&&
higher risk of injury [21 ]. As perforations can also
occur with use of electrosurgery, care must be taken
to avoid a forward motion of the electrosurgical
electrode.
Uterine perforation can be diagnosed by direct
visualization of the perforation site and/or adjacent
organs, severe bleeding, or with sudden loss of intra-
uterine pressure and distension, as large amounts of
distension fluid media may be lost into the abdomi-
nal/pelvic cavity. The most common site of perfor-
ation is the uterine fundus. Lateral perforation will
increase the risk of bleeding due to the uterine
vessels.
When a fundal perforation is suspected with a
blunt instrument, the procedure must be termi-
nated immediately. If minimal bleeding is noted,
the patient can often be observed. If a fundal per-
foration occurs with use of suction, morcellation,
electrosurgery, or major bleeding is suspected, the
abdomen should be explored with laparoscopy or
laparotomy due to the risk of injury to adjacent
organs or blood vessels. If a lateral injury occurs,
the patient must undergo further evaluation with
laparoscopy or laparotomy to evaluate for vessel or
organ injury. If an anterior or posterior perforation
occurs, the bladder and/or rectum may need to be
explored, with appropriate subspecialty consul-
tation when required. Thermal injury may present,
however, as a delayed complication, up to 2 weeks
after the procedure, despite appropriate immediate
&&
measures taken [21 ].
Uterine distension media
Three types of uterine distension media are avail-
able, including CO2 gas, electrolyte, and nonelec-
trolyte fluids. CO2 is only used for diagnostic
hysteroscopy due to higher risk of embolism and
reduced visualization when bleeding occurs. It is
important to never use a CO2 insufflator designed
for laparoscopy, as the rate of flow is often too high
and there have been case reports of CO2 embolisms
&&
and death [21 ]. Electrolyte and nonelectrolyte flu-
ids are used for both diagnostic and operative hys-
teroscopy. The fluids are further categorized as
isotonic or hypotonic.
When blood vessels are transected and the intra-
uterine pressure of fluid is higher than systemic
pressure, fluid becomes absorbed. Nonelectrolyte,
hypotonic fluids, such as 3% sorbitol (Baxter Inter-
national Inc., Deerfield, Illinois, USA) or 1.5%
glycine, are used with monopolar electrosurgery.
Excessive absorption of these fluids can lead to
electrolyte changes, heart failure, and pulmonary
and cerebral edema. Isotonic, nonelectrolyte fluid,
such as 5% mannitol, also used for monopolar
252 www.co-obgyn.com
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
electrosurgery and isotonic, electrolyte-rich fluid
media, such as normal saline which is used for
bipolar electrosurgery, may not necessarily lead to
electrolyte disturbances but can lead to fluid-
overload complications.
Maintaining a balance between visualization
and an intrauterine pressure below the mean arterial
pressure is key to reducing fluid absorption. Pre-
operative use of gonadotropin-releasing hormone
agonists and intraoperative injection of vasopressin
into the cervix at 4 and 8 o’clock (8 ml of 0.05 U/ml
dilute solution) have helped reduce fluid absorption
[33–35].
It is important to continuously monitor the
fluid deficit. Multiple fluid monitoring systems
are available, and they all serve the purpose of
calculating the net fluid absorbed. These systems
are helpful because they give a real-time calculation
of fluid deficit, whereas manual calculation is time
consuming and may not provide a real-time esti-
mate of the actual deficit. AAGL practice guidelines
provide Level C evidence of maximum fluid deficits.
When using hypotonic solutions, the maximum
fluid deficit recommended is 1000 ml, and when
using isotonic fluids, the maximum recommended
deficit is 2500 ml. For elderly patients or others with
compromised cardiac and renal function, a lower
threshold of about 750 ml should be considered [36].
When excess fluid has been absorbed, the pro-
cedure must be terminated. A foley catheter can be
used to monitor the patient’s urine output, as diu-
retics are often used in cases of fluid overload. If a
nonelectrolyte media is used, it is important to
measure serum electrolytes and correct for any
abnormalities. For all cases of fluid overload, it is
important to monitor the patient for cardiac,
pulmonary, and/or cerebral changes, such as chest
pain, shortness of breath, nausea, headache, or
visual changes [37].
Electrosurgical injury
Thermal injury can occur with the use of both
monopolar and bipolar instrumentation. Organs
adjacent to the uterus, including vagina, bowel,
bladder, and blood vessels, are at risk. Proper tech-
nique is to only move the activated electrosurgical
electrode toward the hysteroscope and avoid desic-
cating the cornual areas, as these can be as thin as
&&
4 mm [21 ]. This will help to avoid inadvertent
perforation, although injuries can occur from ther-
mal injury to the bladder, bowel, and vessels with-
out obvious perforation due to prior myometrial
thinning and thermal spread. Immediate laparo-
scopy or laparotomy, with appropriate surgical con-
sultation, is necessary to assess the impact of the
Volume 28  Number 4  August 2016

complication and perform any essential procedures,
such as running the bowel or cystoscopy, to ensure
safety and reduce risk of postoperative compli-
cations.
The risks for vaginal injury include cervical over-
dilation, a proximal electrode insulation defect, and
placement of less than 2 cm of the external sheath in
the cervical canal [38].
Hysteroscopic morcellators
The first hysteroscopic morcellator, TRUCLEAR
(Smith & Nephew, Andover, Massachusetts, USA),
emerged in 2005, followed by Myosure Tissue
Removal System (Hologic Inc., Bedord, Massachu-
setts, USA) in 2009. These two systems use electro-
mechanical morcellators that function via a rotating
cutting blade. The newest product, Symphion Tissue
Removal System (Boston Scientific, Marlborough,
Massachusetts, USA), uses a rotating blade with
bipolar radiofrequency. These three instruments
enable one to resect polyps, fibroids, perform a
visual dilatation and curettage, and evacuate
retained products of conception.
A recent MAUDE database review of TRUCLEAR
and Myosure noted uterine perforation to be the
most common complication. The risk of uterine
perforation was noted to be 0.02% and bleeding
0.003% with the use of these devices. According
to the authors, life-threatening complications such
as fluid overload, uterine perforation, and bleeding
do occur with the hysteroscopic morcellators, but
less frequently than with traditional hysteroscopic
resection [39]. To date, there have been no pub-
lished complications with Symphion.
Bleeding
Bleeding during hysteroscopy can occur from
trauma within the myometrium or with a uterine
perforation. Preoperative use of gonadotropin-
releasing hormone agonists as well as intraoperative
misoprostol or intracervical vasopressin has reduced
myometrial bleeding [35]. Bleeding is sometimes
not recognized until the procedure is complete
because of the elevated intrauterine pressure used
during operative hysteroscopy, but is often recog-
nized while the patient is still in the operating room.
If an active bleeding vessel is identified during
the procedure, but visualization is compromised,
tamponade with increasing intrauterine pressure
may aid in the visualization of the vessel to allow
&&
use of electrosurgical dessication [21 ]. Alterna-
tively, if a vessel cannot be identified, or the pro-
cedure has terminated, a foley catheter can be placed
within the uterine cavity and the bulb inflated until
resistance is met to provide a tamponade effect. This
can be left in for up to 24 h. A foley leg bag is
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Hysteroscopy safety Cholkeri-Singh and Sasaki
attached to the catheter, and over time the fluid
in the foley bulb is slowly removed. If bleeding
worsens, fluid can be added to the bulb to increase
the tamponade. The catheter can be removed com-
pletely when the bleeding is acceptable or has
stopped. Alternatively, a small study of 17 women
showed effective bleeding control when the uterine
cavity was packed with an 1-in. gauze soaked in
diluted 20 U vasopressin in 30 ml of normal saline
[40]. If conservative measures fail, a uterine artery
embolization or hysterectomy may be necessary to
control persistent or severe hemorrhage [22].
Infection
Endometritis or endomyometritis is an uncom-
mon complication associated with hysteroscopy.
These infections are estimated to occur at a rate
of 0.18–1.5% [41]. The American College of Obste-
tricians and Gynecologists recommend against
routine antibiotic use, however, state that for those
women with a higher risk of infection, such as a
history of pelvic inflammatory disease or tubal dis-
order, prophylaxis therapy should be considered
[42].
Gas embolism
Air or gaseous by-products from use of monopolar
and bipolar electrosurgery may enter the venous
circulation during operative hysteroscopy. Signifi-
cant volume of emboli may result in cardiovascular
collapse, pulmonary edema, or death as they inter-
fere with gas exchange. Worrisome effects tend to
occur more frequently with air emboli which are
largely composed of nitrogen and not easily
absorbed compared with the by-products of electro-
surgery, which are CO2, carbon monoxide, and
hydrogen [43]. The most common symptoms are
dyspnea and chest pain postoperatively but a drop
in end-tidal CO2 pressure and oxygen desaturation
intraoperatively raise suspicion of an embolism.
In cases of a gas or air embolism, the procedure
should be immediately terminated and the patient
given 100% oxygen [26]. The patient should be
placed in the left lateral decubitus position with
the head tilted downward to prevent outflow
obstruction of the right ventricle and cardiopulmo-
nary collapse [22]. Aspiration of gas with a central
venous catheter by anesthesia is the next step.
As this can be a catastrophic complication,
prevention is key to reducing this risk. Several steps
that can be taken include avoiding Trendelenburg
positioning, removing all air from the tubing
and hysteroscope prior to use, limiting repetitive
introduction of the instrument into the uterine
cavity, and keeping the intrauterine pressure at less
than 100 mmHg [43,44].
www.co-obgyn.com 253
Minimally invasive gynecologic procedures
CONCLUSION
Hysteroscopy can be an extremely well tolerated and
effective tool to diagnose and treat uterine disorder.
It is often underutilized because of surgeon fear and
inadequate training. It is essential that the surgeon
understands and is ready to manage the potential
complications as they can be severe and life-threat-
ening. With proper training and education, one can
limit and prevent complications.
Acknowledgements
We would like to thank Dr Matthew Siedhoff for the
opportunity to write this article. Dr Cholkeri-Singh is on
the Speaker’s Bureau for DySIS Medical, Bayer Inc, and
Hologic Inc, a consultant for Smith&Nephew and an
Advisory Board Member for Bayer Inc and Hologic Inc.
Financial support and sponsorship
There was no financial support or sponsorship for this
work.
Conflicts of interest
There are no conflicts of interest.
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