European Journal of Obstetrics & Gynecology and Reproductive Biology 178 (2014) 114–122

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European Journal of Obstetrics & Gynecology and

Reproductive Biology
journal homepage: www.elsevier.com/locate/ejogrb

Hysteroscopy: guidelines for clinical practice from the French College

of Gynaecologists and Obstetricians
Xavier Deffieux a, *, Tristan Gauthier b , Nicolas Menager c, Guillaume Legendre d ,
Aubert Agostini c , Fabrice Pierre e
a
Service de Gynécologie Obstétrique, Clamart, France
b
Service de Gynécologie Obstétrique, Limoges, France
c
Service de Gynécologie Obstétrique, Marseille, France
d
Service de Gynécologie Obstétrique, Le Kremlin Bicêtre, France
e
Service de Gynécologie Obstétrique, Poitiers, France

A R T I C L E I N F O A B S T R A C T

Article history: The objective of this study was to provide guidelines for clinical practice from the French College of
Received 7 February 2014 Obstetrics and Gynecology (CNGOF), based on the best evidence available, concerning hysteroscopy.
Received in revised form 18 April 2014 Vaginoscopy should be the standard technique for diagnostic hysteroscopy (Grade A) using a miniature
Accepted 22 April 2014
(3.5 mm sheath) (Grade A) rigid hysteroscope (Grade C), using normal saline solution distension
medium (Grade C), without any anaesthesia (conscious sedation should not be routinely used), without
Keywords: cervical preparation (Grade B), without vaginal disinfection and without antibiotic prophylaxy (Grade B).
Hysteroscopy
Misoprostol (Grade A), vaginal oestrogens (Grade C), or GnRH agonist routine administration is not
Vaginoscopy
Office hysteroscopy
recommended before operative hysteroscopy. Before performing hysteroscopy, it is important to purge
Outpatient hysteroscopy the air out of the system (Grade A). The uterine cavity distention pressure should be maintained below
Operative hysteroscopy the mean arterial pressure and below 120 mm Hg. The maximum fluid deficit of 2000 ml is suggested
Distension media when using normal saline solution and 1000 ml is suggested when using hypotonic solution. When
uterine perforation is recognized during operative hysteroscopy using monopolar or bipolar loop, the
procedure should be stopped and a laparoscopy should be performed in order to eliminate a bowel injury.
Diagnostic or operative hysteroscopy is allowed when an endometrial cancer is suspected (Grade B).
Implementation of this guideline should decrease the prevalence of complications related to
hysteroscopy.
ã 2014 Elsevier Ireland Ltd. All rights reserved.

Introduction operative hysteroscopy is estimated to lie between 0.06% and 0.02%

Main indications of hysteroscopy are abnormal menstrual
bleeding, infertility and removal of polyps, myomas, trophoblastic
retention, endometrial hyperplasia and intrauterine device. Abso-
lute contraindications are pregnancy and current pelvic infection.
The prevalence of complications in diagnostic hysteroscopy is
estimated to lie between 1.2% and 3.8% in the case of procedural
failures, between 0.19% and 0.97% for vasovagal reactions, 0.13% for
perforations, <0.01% for infections, and <0.06% for symptomatic
gas embolisms (LE2) [1–7]. The prevalence of complications in
for absorption of an excessive amount of this irrigation fluid
(intravascular absorption syndrome = TURP syndrome), between
0.12% and 1.6% for uterine perforations, 0.02% for visceral injuries
(urinary or digestive), 0.03% for haemorrhages of >500 ml and/or
requiring transfusion, between 0.01% and 1.9% for cases of
endometritis, and <0.06% for symptomatic gas embolisms (LE2)
[2,8–18]. Whereas various societies have published recommenda-
tions concerning diagnostic and/or operative hysteroscopy [19–
21], the present paper presents the recommendations drafted by
the French College of Gynaecologists and Obstetricians (CNGOF).

Materials and methods

* Corresponding author at: Service de Gynécologie Obstétrique et Médecine de la
Reproduction Hôpital Antoine Béclère, 157 rue de la Porte de Trivaux, F-92140,
Clamart, France. Tel.: +33 145374487/663497513; fax: +33 145374963. This study is based on an exhaustive review of the literature
E-mail address: xavier.deffieux@abc.aphp.fr (X. Deffieux). related to meta-analyses, randomized trials, controlled studies and

http://dx.doi.org/10.1016/j.ejogrb.2014.04.026
0301-2115/ ã 2014 Elsevier Ireland Ltd. All rights reserved.
 X. Deffieux et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 178 (2014) 114–122
large non-controlled studies, published on the subject up until
2013, December.
French and English-language articles from Medline, PubMed,
EMBASE and the Cochrane Database were searched, using
keywords (MeSH and no MeSH) (hysteroscopy; vaginoscopy;
office hysteroscopy; outpatient hysteroscopy; operative hysteros-
copy; distension media; haemorrhage; infection; perforation;
complication; intrauterine adhesions; synechiae; misoprostol;
GnRH agonist; anaesthesia; lidocaine; outpatient hysteroscopy;
operative hysteroscopy; polyp; myoma; fibroid; oestrogens;
mifepriston; distension media; distension fluid; flexible hysteros-
copy; distending media; uterine perforation; mefenamic acid;
premedication; gas embolism; leuprolide acetate; hysteroscopic;
adverse event; complication; intravasation; turp syndrome; see
and treat; oral contraceptive; hyaluronic acid gel; pain; hystero-
scope; minihysteroscopy; endometrial cancer; peritoneal dissem-
ination; myomectomy; bipolar; monopolar; haemorrhage;
vasovagal syndrome; fluid management.).
The expert editors summarized the literature for each of the
questions addressed, and the recommendations were established
by a “working group” (5 experts), following which these
recommendations were proofread and amended by a group of
expert proofreaders. Each recommendation for practice was
allocated a grade which not only depends on the level of evidence
(LE1: very powerful randomised comparative trials, meta-analysis
of randomised comparative trials; LE2: not very powerful
randomised trials, well-run non-randomised comparative studies,
cohort studies; LE3: case-control studies; LE4: non-randomized
comparative studies with large biases, retrospective studies,
transversal studies, series of cases), but also on the feasibility
and ethical factors [22,23]. Grade A represents the scientifically
established evidence; grade B represents a scientific presumption;
grade C is based on a low level of evidence, generally founded on
LE3 or LE4. In the absence of any conclusive scientific evidence,
some practices have nevertheless been recommended on the basis
of agreement between all the members of the working group
(“expert opinion”).
Results
Diagnostic hysteroscopy
Timing within the menstrual cycle
In published series (LE4) [6,24], the beginning of the follicular
phase (after menstrual bleeding), or any moment during the cycle
which avoids menstrual bleeding [1,25,26], is preferred. However,
it is important to rule out pregnancy if you decide to perform
hysteroscopy during luteal phase.
Misoprostol
In post-menopausal women, there is no benefit to be found in
using misoprostol, in terms of the need for dilation or the
prevalence of complications (LE1), and misoprostol is known to be
associated with an increased prevalence of side effects (abdominal
cramps, diarrhoea, nausea, bleeding and fever) (LE1) [27]. There is
no data evaluating the usefulness of misoprostol prior to a
vaginoscopy. In non-menopausal women, randomised trials have
produced conflicting results in terms of pain (little or no reduction
in pain following the administration of misoprostol) and above all a
high prevalence of side effects and cancellation as a result of
bleeding (RR 3.09; 95% CI 2–5, p = 0.0006) following the use of
misoprostol (LE2) [29–32].
Oestrogens and misoprostol
In post-menopausal patients previously treated with oestro-
gens, the (oral) administration of misoprostol is associated with
115
improved, although moderate (1 mm), spontaneous cervical
dilation, when compared with a placebo, with no difference in
terms of complications (LE2) [33,34].
Mifepristone
A randomised trial has shown that the administration of
mifepristone prior to a diagnostic HSC is not associated with
improved cervical dilation, when compared with a placebo (LE2)
[35].
Temperature of the distension media
A randomised trial (vaginoscopy using saline) did not reveal any
difference in terms of pain, satisfaction or length of procedure, for
distension media temperatures lying between 28  C and 37.5  C
(LE4) [36].
Flexible or rigid hysteroscopy
Flexible hysteroscopy appears to provide a moderate clinical
benefit in terms of pain (LE2) and the reduction of vasovagal
reactions (LE3), at the price of a more lengthy procedure (LE2),
poorer visualisation (LE2) and a higher failure rate (LE3) [37–39].
There is no data comparing flexible hysteroscopy and vaginoscopy.
Gas (CO2) or saline distension
Randomised trials have not shown any difference in terms of
visibility and pelvic pain (LE1), although a significant reduction in
scapular pain and vasovagal reactions, as well as a slight reduction
in length of procedure were observed with saline (LE2) [40–50].
Pressure of the distension media (gas and saline)
No study has compared visualisation, pain, excessive absorp-
tion, nor the rate of gas embolism as a function of the pressure of
the distension medium. In most published studies, the pressure
used with saline is not specified, or it is simply stated that the
saline pouch is attached to a stand at a height of 1.2 m (120 cm
H2O = 80 mm Hg); in other series, the pressure lies between 100
and 150 cm H2O (LE4) [44,50].
In most diagnostic HSC series using gas, the insufflation
pressure is monitored and limited to 100 mm Hg (LE4)
[40,43,44,50].
It is not recommended to monitor the instillation pressure in
the case of a diagnostic hysteroscopy using saline (expert
agreement). If a gas is used for distension, it is recommended to
monitor the pressure, and the insufflation pressure must remain
below 100 mm Hg (Grade C).
Analgesic and anaesthetic technique
Hypnosis. A non-randomised study observed that hypnosis did
not appear to be associated with any decrease in pain during
hysteroscopic tubal sterilization (LE4) [51].
General anaesthesia. More than 95% of hysteroscopies can be
carried out without general anaesthesia, without the use of
neuroleptanalgesia or conscious sedation, and without spinal/
epidural anaesthesia (LE3) [1,4,28–37].
It is recommended to carry out diagnostic hysteroscopies
without general anaesthesia (nor neuroleptanalgesia, nor con-
scious sedation), nor with regional anaesthesia (expert agree-
ment). In the case of failure or significant pain without anaesthesia,
the use of local, regional or general anaesthesia can be discussed
(Grade C).
Non-steroidal anti-inflammatory drugs. Randomised trials, dealing
mainly with procedures making use of a 5 mm diameter rigid
hysteroscope, led to conflicting results concerning pain [53–55].
116 X. Deffieux et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 178 (2014) 114–122
Buprenorphine. One trial showed that the sublingual
administration of buprenorphine did not lead to a decrease in
pain (LE2) [52]. In the group treated with buprenorphine, side
effects were observed in 38% of cases (nausea, vomiting,
drowsiness), as compared to 0% with a placebo (p < 0.0001)
(LE2) [52].
Phloroglucinol. There is no comparative study dealing with the
use of phloroglucinol.
Intravenous tramadol. One trial has shown that the injection of
intravenous tramadol prior to a diagnostic hysteroscopy decreased
pain following completion of the procedure (LE3) [56].
Nevertheless, the results of this weakly significant trial should
be verified, since the average level of pain observed in the placebo
group was very high in comparison with that which is normally
observed. No trial has evaluated tramadol taken orally.
Analgesia achieved by application (of a lidocaine/lignocaine gel or
spray) to the cervix or the cervical canal. The conflicting results of
various studies do not appear to reveal any advantage in applying
lidocaine or lignocaine in the form of a spray or a gel, prior to a
diagnostic hysteroscopy [57–63]. Only the trial reported by Soriano
et al., dealing with flexible hysteroscopies, appeared to indicate an
advantage (LE2) [59]. Meta-analyses are not in favour of the use of
this type of topically applied local anaesthesia (LE2) [57–63].
Transcervical intrauterine instillation of lidocaine/mepivacaine/
lignocaine. Randomised trials show that transcervical
instillation does not decrease the pain associated with
hysteroscopy (LE1) [43,61,64–68]. Transcervical instillation of
local anaesthetic can lead to reduce vasovagal episodes [61].
Intracervical injection and paracervical block (lidocaine/mepivacaine/
lignocaine). Analgesia by means of intracervical injection or
paracervical block using bupivacaine, mepivacaine or lidocaine,
decreases pain during the hysteroscopy (LE1) [61,69–71].
Nevertheless, the pain experienced during the administration of
paracervical block is greater than that of the hysteroscopy (LE3)
[72]. Conflicting results are found concerning the failure rate of this
procedure (LE2) [59,60,66,68,71–75].
The use of an intracervical anaesthetic injection or a para-
cervical block is not recommended as the first-line treatment for a
diagnostic HSC (Grade C).
Hysteroscope diameter. Randomised trials have shown that the
use of a 3.5 mm diameter hysteroscope was associated with a
significant decrease in pain and a decrease in the number of failed
procedures, when compared to a 5 mm hysteroscope (LE1)
[44,74,76,77].
Vaginoscopy. Vaginoscopy, the feasibility of which lies between
83% and 98% (LE2) [78–85], is associated with a significant
decrease in pain, when compared with a “conventional”
hysteroscopy (rigid 3.5 mm diameter hysteroscope, speculum
and Pozzi forceps) (LE1), with comparable failure rates (LE1)
[78–85].
The recommended first-line technique for a diagnostic hyster-
oscopy is that of vaginoscopy (Grade A) using a rigid hysteroscope
(Grade C), having a diameter less than or equal to 3.5 mm (Grade
A), associated with saline distension (Grade C) at room tempera-
ture (expert agreement), with no anaesthetic and no drug
preparation (neither misoprostol, nor oestrogens, nor mifepris-
tone, nor non-steroidal anti-inflammatory drugs, nor buprenor-
phine, nor tramadol) (Grade B), at the beginning of the follicular
phase (after menstrual bleeding) (expert agreement). The
recommendations for diagnostic hysteroscopy are applicable for
inpatient or outpatient procedures.
Operative hysteroscopy
Prevention of the risk of cervical tears, uterine perforation and failure
Misoprostol
The prescription of misoprostol (oral or vaginal), prior to
operative hysteroscopy, is associated with improved spontaneous
cervical dilation in non-menopausal women, but with no decrease
in complications prevalence and an increase in adverse events
(diarrhoea, nausea, vomiting, abdominal cramps, fever, bleeding)
(LE1) [27,86,87].
It is not recommended to prescribe misoprostol (oral or vaginal)
prior to an operative HSC (Grade A).
Laminaria
Two randomised trials have compared the use of laminaria and
misoprostol prior to an operative HSC, but produced conflicting
results [88,89]. The introduction of laminaria is not recommended
prior to an operative hysteroscopy (expert agreement).
Oestrogens
A randomised trial comparing a pre-operative treatment using
oestrogens and misoprostol, versus misoprostol alone, did not
show any improvement in dilation (LE2), nor any decrease in the
prevalence of uterine perforations (LE3) [33].
It is not recommended to administer vaginal oestrogens prior to
an operative HSC (Grade C).
GnRH agonists, danazol, progestins and progestin–oestrogen
combinations
The prescription (1–3 months prior to an operative hysterosco-
py) of GnRH agonsists, danazol, progestins or oral progestin–
oestrogen combinations, is accompanied by a decrease in thickness
of the endometrium, a shorter operating time (statistically
significant, but less than 3 min) and improved satisfaction for
the surgeons, although this does not decrease the prevalence of
complications (LE1) [90–95].
The prescription of GnRH agonists, danazol, progestins or
progestin–oestrogen combinations is not systematically recom-
mended prior to an operative HSC (Grade B).
Ultrasound and laparoscopic guidance
A series comparing ultrasound guidance with laparoscopic
guidance and with the absence of any guidance, did not observe
any significant decrease in the rate of perforation in the guidance
group (LE4) [96].
Prevention of the risk of synechiae
Intrauterine device (IUD and Foley catheter)
A randomised trial did not reveal any difference in the
prevalence of synechiae between four groups: control group,
group with an IUD only, group with hormone therapy only, and
group with hormone therapy and an IUD) (LE3) [97].
A non-randomised comparative study has shown that the
insertion of a Foley catheter at the end of an intervention did not
decrease the risk of synechiae (LE3) [98].
The insertion of an intrauterine device (IUD) or a Foley catheter
at the end of an intervention is not recommended (Grade C).
Anti-adherence gel
The application of a hyaluronic acid-based gel or a sodium
carboxymethyl cellulose gel and polyethylene oxide appears to
 X. Deffieux et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 178 (2014) 114–122
reduce the prevalence of intrauterine synechiae (LE2) [99–104].
However, there is currently no data making it possible to
determine whether this has any clinical impact (reoperation rate
for synechiae removal, risk of amenorrhea or hypomenorrhea,
future fertility). The high cost of these gels should also be
considered.
Overall, it is not recommended to make systematic use of a
hyaluronic acid-based gel or a sodium carboxymethyl cellulose gel
and polyethylene oxide, following an operative hysteroscopy
(expert agreement).
Oestrogens and danazol
Trials have shown that the administration of oestrogens (LE3)
[97] or danazol (LE3) [105] did not reduce the risk of post-operative
synechiae.
Antibiotherapy
There is no comparative data concerning the usefulness of a
per- or post-operative antibiotherapy for the prevention of
synechiae.
Bipolar versus monopolar energies
There is no comparative data having evaluated the rate of
synechiae or fertility following the resection of fibroids/polyps
using a monopolar or bipolar energy instrument.
Control hysteroscopy
Most published series report the use of an early HSC in order to
diagnose and remove synechiae during the same hysteroscopy
(LE4) [106,107].
In patients for whom the early diagnosis and treatment of
synechiae is desired, it is recommended to carry out a control
diagnostic HSC approximately 4 weeks following the operative
HSC (expert agreement).
Prevention and treatment of haemorrhage
Haemorrhage complications are rare (<1%) (LE3) [108,109]. A
randomised trial using a placebo for comparison did not show
any preventive effect resulting from the use of oxytocine (LE3)
[110]. Concerning the pre-operative administration of GnRH
analogues prior to the hysteroscopic resection of fibroids, the
outcomes of various trials are contradictory in terms of the
duration of the operation, and there is no data concerning
bleeding during the procedure [111–114]. Treatment using
GnRH agonists for a period of 2 months may reduce the
volume of type 0 or 1 fibroids prior to an operative HSC (LE2).
The impact of this reduced volume on the outcome of the
intervention (feasibility, ease and length of operation, bleeding)
has not been established (there are conflicting results in the
literature). Pre-operative treatment using GnRH agonists prior
to hysteroscopic fibroid resection should be discussed, when-
ever a reduction in fibroid volume could simplify the
hysteroscopic intervention (expert agreement).
In therapeutic terms, in the case of haemorrhage during an
intervention, the various options described in the literature have
not been evaluated: electrocoagulation at the source of bleeding,
tranexamic acid, ocytocin, use of an inflated balloon (Foley
catheter) (LE4) [19,109,115].
In the case of significant bleeding during an operative
hysteroscopy, the following forms of treatment (in addition to
intensive care measures) could be evaluated: electrocoagulation at
the source of bleeding, intrauterine inflated balloon (expert
agreement). In extreme cases, embolization, or even hysterectomy,
should be envisaged (expert agreement).
117
In addition to the aforementioned measures, any pre-existing
anaemia should be corrected in order to limit the risk of
transfusion.
Prevention of absorption difficulties
The prevalence of difficulties in the absorption of distension
liquid during operative hysteroscopy lies between 0.06% and
0.2% (LE2) [2,7–17,116]. There are two types of distension
solution: hypo-osmolar non-ionic solutions (1.5% glycine)
needed for monopolar instruments, and electrolytic solutions
(saline or ringer’s lactate), which can be used with bipolar
instruments. The risks associated with strong absorption are
an acute pulmonary oedema and a cerebral oedema, and in the
case of the use of a non-ionic hypo-osmolar solution, the risk
of hyponatremia, hyperammonemia, and hypo-osmolality.
Type of distension liquid and instrument (bipolar or monopolar)
A randomised trial has shown that a bipolar instrument
hysteroscopy, associated with saline, significantly reduces any fall
in natremia (p = 0.01) and in the volume of absorbed distension
liquid (p = 0.001) (LE2) [117]. Nevertheless, in this study no clinical
impact was described, and the rate of nausea was similar in both
groups.
In a recent retrospective, comparative study, a similar rate of
complications was found in 1318 bipolar and 524 monopolar
hysteroscopies (LE4) [118].
Intravenous ocytocin
A randomised trial with a placebo has shown that the
intravenous injection of ocytocin was associated with a significant
reduction in the absorption of glycine and the loss of sodium in the
ocytocin group, but that no case of clinical complication had
occurred (LE2) [110].
GnRH agonists
Five randomised trials concerning the preoperative use of GnRH
analogues have shown that this treatment was associated with a
significant decrease in the absorption of liquid distending media,
but with no clinical impact (LE1) [90,113,114].
Type of anaesthesia
Randomised trials comparing different modes of anaesthesia
have revealed conflicting results, with no difference in terms of
complications (LE2) [119,120].
Danazol and progestins
There is no randomised trial with a placebo evaluating the
impact of these treatments on the risk of absorption during an
operative hysteroscopy.
Intrauterine pressure
The intrauterine pressure is estimated on the basis of the
irrigation pressure at the pump. There is no comparative study
evaluating the impact of intrauterine pressure and the risk of
absorption. In most published series, the intrauterine pressure is
monitored and maintained below 100 or 120 mm Hg (LE4)
[113,119–124].
Other settings of the irrigation/aspiration system (flow rate,
aspiration pressure) can play a role in the risk of absorption;
however, there is no clinical study having accurately evaluated the
impact of these settings on the risk of complications.
It should be noted that each irrigation system is sold with a
user’s manual, in which the manufacturer indicates the
standard pre-adjusted settings.
118 X. Deffieux et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 178 (2014) 114–122
Monitoring the volume of liquid distending media (inflow/outflow
comparison)
A comparative before-and-after study dealing with more than
400 procedures has shown that the use of an alarm system,
triggered at a pre-set absorption threshold, was associated with a
decrease (of the order of 65 ml) in the absorption of liquid
distending media, although no clinical impact was demonstrated
(LE4) [123].
Fluid deficit (difference between inflow and outflow)
Most authors stop a procedure when the glycine deficit exceeds
1 l (LE4) [19,21,118,119]. One study has shown that nausea and X-
ray indications of a cerebral oedema remained constant in the case
of a fluid deficit exceeding 1 l (LE4) [125].
Cases of pulmonary oedema complicating an operative
hysteroscopy using saline were reported for deficits greater than
2.5 l [118].
Some authors recommend a particularly high level of vigilance
for women having a cardiac or renal insufficiency [19,21], but also
in non-menopausal women who could be at greater risk of
neurological after-effects in the case of a hyponatremic encepha-
lopathy (LE4) [126].
In operative hysteroscopy, whatever type of distension liquid is
used, it is recommended to keep the intrauterine pressure as low as
possible, ideally below the mean arterial pressure, at 120 mm Hg
(expert agreement). It is recommended to use a system with an
automatic pump controlling the intrauterine pressure (expert
agreement). The need to stop the procedure must be discussed
whenever the fluid deficit exceeds 2 l of saline or 1 l of glycine,
whatever the distension medium used (expert agreement). This
can be monitored by an operating room assistant, or an automated
monitoring device equipped with pre-set alarms.
Duration of the procedure
There is no established threshold for the duration of a
procedure, beyond which a risk of complications could arise.
Course of action when excessive absorption (>1 l) is diagnosed
The means described in the case of such an event are stopping
the procedure, intravenous diuretics, hydric restriction, or even
intravenous hypertonic saline serum. There is no comparative
study dealing with this topic. When fluid deficit exceeds, the
Table 1
Hysteroscopy: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians.
Diagnostic hysteroscopy
Pre-operatively No vaginal disinfection (Grade B)
No bacterial vaginal sampling prior to a hysteroscopy (expert
agreement)
No antibiotic prophylaxy (Grade B)
Allowed when an endometrial cancer is suspected (Grade B)
Intra-operatively Vaginoscopy (Grade A)
3.5 mm sheath (Grade A) rigid hysteroscope (Grade C)
Normal saline solution distension medium (Grade C)
No anaesthesia (Grade B)
Purge the air out of the system before performing hysteroscopy
(Grade A)
Uterine cavity distention pressure < mean arterial pressure and
below 120 mm Hg (expert agreement)
course of action should involve the anaesthetist, since delayed
action can be associated with high morbidity for the patient.
Anaesthesia and analgesia
No study has evaluated the impact of phloroglucinol, non-
steroidal anti-inflammatories, misoprostol, hypnosis, intrauterine
anaesthesia or the temperature of the liquid distending media, on
pain following operative hysteroscopy.
Regional anaesthesia and simple sedation are options, which
can be envisaged as an alternative to general anaesthesia (LE4)
[127,128] (Grade C). The absence of anaesthesia or analgesia and
local anaesthesia can be envisaged for simple operative procedures
carried out using a hysteroscope with a diameter 5 mm (LE4)
[129–131] (Grade C).
Prevention of the risk of infection
Antibioprophylaxis
The prevalence of infections following a hysteroscopy is low,
whether a diagnostic (<1/500) or an operative (1%) hysteroscopy
be used (LE2) [116,132–135]. Antibioprophylaxis does not reduce
the risk of infection (LE2) [132,133,136].
Antibioprophylaxis is not recommended prior to, during, or
following a diagnostic or operative HSC (Grade B).
Vaginal sampling prior to hysteroscopy
Most series do not report on the use of vaginal sampling prior
to a diagnostic or operative HSC (LE4) [116,135–137,155]. In a
series during which bacteriological samples were systematically
taken, the presence of chlamydia was revealed in <1% of cases
(LE4) [136].
It is not recommended to carry out bacterial vaginal sampling
prior to a hysteroscopy (expert agreement). The usefulness of
bacteriological vaginal sampling may be discussed in the case of
signs or recognised risk factors for a pelvic infection (antecedents
of a sexually transmitted infection, intrauterine device already in
inserted, post-partum and post-abortion, multiple sexual part-
ners) (expert agreement). A hysteroscopy should not be carried out
in the case of any doubt concerning the presence of a pelvic
infection (expert agreement). In the case of an infection revealed
by vaginal sampling, it is recommended to treat the patient by
Operative hysteroscopy
It is recommended to carry out vaginal disinfection using an
antiseptic solution prior to an operative hysteroscopy (expert
agreement)
No misoprostol (Grade A)
No vaginal oestrogens (Grade C)
No bacterial vaginal sampling prior to a hysteroscopy (expert
agreement)
No antibiotic prophylaxy (Grade B)
Allowed when an endometrial cancer is suspected (Grade B)
Purge the air out of the system before performing hysteroscopy
(Grade A)
Maximum fluid deficit :
 2000 ml when using normal saline solution
 1000 ml when using hypotonic solution (expert agreement)
When uterine perforation is recognized during operative
hysteroscopy using monopolar or bipolar loop, the procedure
should be stopped and a laparoscopy should be performed in
order to eliminate a bowel injury (expert agreement)
 X. Deffieux et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 178 (2014) 114–122
means of antibiotherapy, prior to any intervention (expert
agreement).
Vaginal disinfection
The details of any disinfection practice are rarely provided;
occasionally, it mentions in the absence of washing [135], of simple
washing using a dressing soaked in saline [46] or a non-iodine
disinfectant [138], or of the use of povidone iodine [132]. The only
comparative study of povidone iodine and paediatric shampoo did
not reveal any difference in terms of infection (LE3) [139].
Moreover, a cohort of 1028 vaginoscopies, made with no vaginal
disinfection, nor a prior vaginal douche, did not reveal any case of
infection (LE2) [135].
Most studies report antiseptic vaginal disinfection prior to an
operative hysteroscopy (LE4) [1,4,13,37,38,116,133,135,136,140].
Overall, it is not recommended to carry out vaginal disinfection
prior to a diagnostic hysteroscopy (expert agreement). It is
recommended to carry out vaginal disinfection using an antiseptic
solution prior to an operative hysteroscopy (expert agreement).
Prevention of the risk of a gas embolism
The presence of large bubbles is increased in the case of a
bipolar instrument and >1000 ml of distending media (LE2) [141].
Nevertheless, no correlation has been established between the
number of bubbles, their size, and the risk of a symptomatic gas
embolism. A before-and-after study dealing with more than 5000
diagnostic hysteroscopies observed that purging of the air in the
CO2 insufflation system made it possible to significantly reduce the
risk of a symptomatic gas embolism (LE3) [10]. The other
preventive measures (use of Y-shaped tubing, switching off the
pump systems during pouch changing, inflow/outflow deficit
monitoring, non-Trendelenburg position, low intrauterine pres-
sure, occlusion of the cervix throughout the procedure, prevention
of go-and-return displacements) have not been evaluated in a
comparative study.
It is recommended to purge the tubing prior to any
hysteroscopy (Grade A).
What should be done in the case of perforation
The risk of uterine rupture following a hysteroscopy appears to
be very low (LE4) [142–147].
In the case of uterine perforation during the use of an activated
energy electrode, it is recommended to stop the procedure and to
intervene using laparoscopy (expert agreement). Suturing of the
uterine perforation is to be discussed. Any uterine perforation must
be recorded in the operation report (expert agreement).
Conclusion
The application of these recommendations (summarized in
Table 1) should allow the best available knowledge concerning
diagnostic hysteroscopy and hysteroscopic surgery to be dissemi-
nated, in order to minimize its risks and consequences.
Conflicts of interest
Working group: At the time of the preparation and editing of
these recommendations, the expert editors (NM, GL, TG), the
president (FP), the other members of the working group (AA) and
the methodologist (XD) declare that they have not been, and are
not, consulted by any manufacturing firms involved in hysteros-
copy. They also declare that they do not hold any patents relating to
hysteroscopic equipment available on the market. They also
declare that they do not own shares in these companies and do
119
not receive compensation or remuneration from them. They
declare having previously benefited from the payment by
companies involved in hysteroscopy (Storzã, Olympusã, Gyne-
care-Ethiconã (Johnson & Johnsonã), Hologicã, Conceptusã) of
registration fees and travel costs (for no consideration), for the
purposes of national and/or international conferences (for no
consideration).
Reading group: At the time of the preparation and editing of
these recommendations, the proofreaders (AC, LC, RdT, EF, PF, OG,
AG, MH, OJ, BR et JR) declare that they have not been, and are not,
consulted by any manufacturing firm involved in hysteroscopy.
They also declare that they do not hold any patents relating to
hysteroscopic equipment available on the market. They also
declare that they do not own shares in these companies and do
not receive compensation or remuneration from them. They
declare having previously benefited from the payment by
companies involved in hysteroscopy of registration fees and travel
costs (for no consideration), for the purposes of national and/or
international conferences. HF declares to be a consultant for
Hologicã and Gynecare-Ethiconã companies; VV declares to
organize surgical demonstration sessions for the Conceptusã
company; ED declares to be a consultant for Genzymeã company;
OG, BG, JL et CT declare not to have any conflict of interest with any
companies involved in hysteroscopy.
Acknowledgements
We wish to thank those who proofread these recommendations.
Their pertinent remarks have led to the enrichment of this study:
Aurélia Chauveaud (Paris), Ludovic Cravello (Marseille), Emile Daraï
(Paris), Renaud de Tayrac (Nîmes), Erika Faivre (Clamart), Hervé
Fernandez (Le Kremlin Bicêtre), Philippe Ferry (La Rochelle), Olivier
Garbin (Strasbourg), Amélie Gervaise (Gatineau, Canada), Olivier
Graesslin (Reims), Béatrice Guigues (Caen), Martine Herry (Paris),
Olivier Jourdain (Bordeaux), Jean Levêque (Rennes), Benoit Rabi-
schong (Clermont Ferrand), Joël Renaudie (Limoges), Cyril Touboul
(Créteil), Vincent Villefranque (Pontoise).
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