Human Reproduction Update 1999, Vol. 5, No. 1 pp.

73–81  European Society of Human Reproduction and Embryology

Office mini-hysteroscopy

R.Campo1, Y.Van Belle, L.Rombauts, I.Brosens and S.Gordts

Leuven Institute for Fertility and Embryology, Tiensevest, 168, B-3000 Leuven, Belgium

The technique of diagnostic hysteroscopy has not yet been accepted generally as an ambulatory, well-tolerated office
procedure. Especially in the infertile patient the standard hysteroscopic procedure is poorly tolerated in an office environ-
ment. Our prospective registration of 530 diagnostic office mini-hysteroscopies in infertile patients demonstrates that using
an atraumatic insertion technique, watery distention medium and the new generation of mini-hysteroscopic endoscopes,
hysteroscopy can be performed in an office set-up without any form of anaesthesia and with a high patient compliance. The
significant number of abnormal findings (28.5%), the absence of complications and the low failure rate (2.3%) indicate that
diagnostic office mini-hysteroscopy should be a first-line diagnostic procedure. Those results are compared with the
registration of 4204 consecutive conventional diagnostic hysteroscopies in a routine gynaecological population performed
between 1982 and 1989. We conclude that the mini-hysteroscopic system offers a simple, safe and efficient diagnostic
method in the office for the investigation of abnormal uterine bleeding, to evaluate the cervix and uterine cavity in the
infertile patient, for screening of endometrial changes in patients under hormone replacement therapy or anti-oestrogens
as (adjuvant) treatment and, lastly, it may be very helpful for the interpretation of uncertain findings in other diagnostic
techniques such as ultrasound, magnetic resonance imaging, blind biopsy or hysterosalpingography.

Key words: hysteroscopy/infertility/office procedure

TABLE OF CONTENTS
Introduction
History
Diagnostic mini-hysteroscopy
Patients
Conventional versus mini-hysteroscopic instrumentation
Applications of diagnostic office mini-hysteroscopy
Conclusion
References
Introduction
Endoscopic techniques for diagnosis and treatment of several
diseases have gained importance in medicine, especially over
recent years. The advantage lies in the direct optical judgement of
body cavities and frequently the possibility of surgical treatment
during the same procedure. For the patient the endoscopic access
is less traumatic than laparotomy, resulting in reduced post-oper-
ative pain and shorter hospital stay. Although laparoscopy has
been established in gynaecology for several decades, hysteros-
copy is still neglected, due to the problematic nature of its techni-
cal development. Only in the last ten years have technical and
organ-specific problems been solved. It was difficult to develop
instrumentation and techniques that could deal with the fragile
endometrium, the virtual cavity and the problems of possible
73
resorption (vascular, peritoneal) and loss (cervix, tubes) of disten-
74
sion medium.
74
For the operative hysteroscopic procedures it is now generally
76
accepted that for the treatment of intrauterine polyps, myomas,
76
uterine septa, synechiae or endometrial ablation the transcervical
77
hysteroscopic approach is preferred to the transabdominal one
80
(Goldrath et al., 1981; Hallez et al., 1987; Loffer, 1990; Hucke et
81
al., 1993; Ezeh et al., 1995). Operative hysteroscopy is a good
example of minimal invasive surgery. Nevertheless the operative
procedures call for a complex instrumentation set-up, special
training of the surgeon is required and knowledge of possible
complications and their appropriate management are mandatory
(Bailey et al., 1967; Roesch et al., 1983; Jedeikin et al., 1990;
Hucke et al., 1992; Ghimoux et al., 1996; Perlitz et al., 1996).
The technique of diagnostic hysteroscopy on the contrary has
not yet been accepted generally as an ambulatory, well-tolerated
office procedure, giving the gynaecologist reliable and important
information regarding the cervical and intrauterine situation.
With the new technical developments (video camera, mini-
hysteroscopes, photo documentation, distention medium), we be-
lieve that the requirements are fulfilled for the establishment of
office hysteroscopy in daily gynaecology practice (Figure 1).

1To whom correspondence should be addressed. Tel.: 32/16.22.43.45; Fax: 32/16.20.80.18.

74 R.Campo et al.
History
During the early history of hysteroscopy (1805–1966) the
organ-specific and technical problems had not been resolved
(Van Der Pas et al., 1983). Both diagnostic and operative
hysteroscopy were not accepted in routine gynaecological
practice; it remained a toy for some exotic gynaecologists.
It was only in 1967 that Fritz Menken made a first step
towards an atraumatic ambulatory approach using a paediatric
cystoscope to perform a hysteroscopy. The distension of the
uterine cavity was done with a high colloidal liquid, called
luviscol, and an elastic cone was used to seal the cervical
channel and prevent leakage of the liquid (Menken, 1967).
The present history of hysteroscopy is characterized by the
fact that, due to the intensive collaboration between the in-
dustry and scientifically oriented groups, the road has been
paved for standardized diagnostic and operative procedures.
In the 1970s and 1980s, however, hysteroscopy had to face
some rather unscientific approaches such as hysteroscopic
tubal sterilization and the micro-colposcopy. Those publica-
tions damaged its reputation a great deal.
In the 1970s Lindemann and Gallinat (1976) and
Lindemann et al. (1976, 1979) published their experimental
findings regarding the influence of CO2 gas during
hysteroscopy. Here, for the first time, not only the advantages
of this new method, but also the possible dangers and com-
plications of gas insufflation were analysed. Cornier et al.
(1986) and Lin et al. (1987) tried to find a new way by using a
flexible hysteroscope, a small flexible bored instrument with a
channel for instrument application, through which for
example laser wires could be applied. The use of the Nd-YAG
laser for the destruction of the endometrium in patients with
idiopathic uterine bleeding disorders, as published by
Goldrath (1981), was certainly the start for renewed interest in
this method by the public, mainly because the transcervical
approach offered a safe and valid alternative with extremely
high patient compliance in comparison to the transabdominal
approaches (Fayez, 1986). At the end of the 1980s CO2 was
replaced by watery or low viscosity solutions as a distension
medium and the introduction of a continuous flow system
enabled the surgeon to restore view in nearly every situation.
The introduction of the atraumatic technique, the new mini-
hysteroscopes and the technically superior video documenta-
tion now raises the chances that hysteroscopy, both diagnostic
and operative, may become established as a routine procedure
by every gynaecologist. The new generation of mini-endo-
scopes, both rigid and micro-fibre systems, have excellent to
acceptable optical qualities with a large image diameter, suffi-
cient brightness, good resolution and a field of view which
allows panoramic sight. These instruments are suitable for
both laparoscopy and hysteroscopy (Karabacak et al., 1997;
Risquez et al., 1997).
The history of hysteroscopy shows that it has taken a tre-
mendous amount of time to simplify the method to make
practical for everybody (Table I). The organ-specific prob-
lems such as the immediate bleeding in cases of mechanical
damage to the endometrium and the necessity to dilate the
uterine cavity with special distension media make hysteros-
copy difficult, with a rather long learning curve. Once one has
mastered the technique, hysteroscopy becomes a safe, easy
diagnostic and operative procedure with a high degree of pa-
tient compliance.
Table I. What can we learn from the history of hysteroscopy?
It was a long and difficult way for hysteroscopy to gain
acceptance because of:
Organ-specific problems
The uterine cavity is a virtual cavity
The endometrium is very fragile
Resorption (vascular, peritoneal) and loss (cervix, tubes)
of distension medium
Technique-specific problems
Instrument: diameter and optical quality (image diameter,
brightness, angle of view, field of view, resolution)
Distension medium
Video documentation
Slow learning curve
Diagnostic mini-hysteroscopy
The technique of diagnostic hysteroscopy, has changed only
in the last years into a simple, safe and very efficient method to
investigate intrauterine pathology. In our institution the atrau-
matic insertion technique has been used since 1982. To im-
prove our patient compliance and diagnostic capacities the
conventional instrumentation was changed for the mini-hys-
teroscopic instrumentation. Both procedures were prospec-
tively registered.
The atraumatic insertion technique (Table II)
The patient is installed in a gynaecological position, possibly
with the husband at her side. The gynaecologist uses sterile
gloves and, after having put together the instruments, checks
the flow of the distension medium. After disinfection of the
vagina with an aqueous solution and applying the speculum
the hysteroscope is introduced intracervically. The speculum
is removed and after opening the inflow the path of the cervi-
cal channel becomes visible. Slowly and under sight the in-
strument is moved forwards. The passage through the cervical
channel generally is the most difficult part of the total examin-
ation. On passage through the internal cervical ostium a resis-
tance frequently has to be overcome before the uterine cavity
is reached. By slowly turning the instrument along its axis the
tubal ostia are clearly visible with the 12° or 30° optic. Docu-
mentation of the form of the cavity and the aspect of the
endometrium are necessary. The cervical channel is mainly
 Office mini-hysteroscopy 75

inspected while slowly moving back the instrument. The en-

tire examination usually does not last longer than a few min-
utes and can be conducted in an outpatient setting without any
form of anaesthesia (Figure 1).

Table II. Technique of atraumatic diagnostic hysteroscopy

No cervix dilatation
No blind insertion of instruments into the uterine cavity
No use of portio tenaculum
Atraumatic and sight-controlled insertion of the hysteroscope
Use non-irritating distension medium ( ionic watery solution )
No anaesthesia or analgesia necessary

The following are not necessary for diagnostic hysteros- Figure 1. Mini-hysteroscopy is an office procedure with very mod-
copy: est instrumentation needs.
(i) Tenaculum. While patients are not anaesthetized the
portio has to be grasped only in rare cases. When a
diagnostic hysteroscopy is conducted under general
or regional anaesthesia the grasping of the portio is al-
ways necessary due to the relaxation of the pelvic
floor.
(ii) Hegar dilator. In case of cervical stenosis we recom-
mend the use of a thin-bored instrument, for instance
the semi-rigid hysteroscope 2.4 mm.
(iii) Local anaesthesia. There is no evidence whatsoever
that local anaesthesia improves patient satisfaction
and compliance during the procedure. On the contrary
the application of local anaesthesia increases the op-
erating time and the risks associated with the whole
procedure (Ezeh et al., 1995; Clark et al., 1996).
Figure 2. Instrumentation. 2.7 mm 30° mini-hysteroscope specially
designed for both hysteroscopy and transvaginal laparoscopy outer
Conventional instrumentation sheath 3.5 mm for single flow use with rigid optic and continuous
flow with fibre-optic 2.4 mm single flow semi-rigid 12° hystero-
(i) Conventional hysteroscope: Conventionally a 5 mm total scope, also designed for transvaginal hydrosalpingoscopy.
diameter single flow hysteroscope with a 30° rigid optical
system is used for diagnostic hysteroscopy.
(ii) Distension medium: Mainly inspired by the work of
Lindemann and Gallinat (1976) and Lindemann et al. (1976,
1979), CO2 gas was generally accepted as the standard disten-
tion medium for diagnostic hysteroscopy.
(iii) Hardware: As the examination is carried out under direct
visual control a high performance light source is not necessary
and conventionally diagnostic procedures are done with a
150–250 W source. For safe CO2 gas administration a pres-
sure-flow controlled hysteroflator is used. The usage of a
laparoflator for hysteroscopy is strictly forbidden, because
high flow and pressure can lead to life-threatening complica-
tions (CO2 embolism).
(iv) Documentation: Pre-designed registration form on which
the physician collects clinical findings, patient compliance
and possible complications. Figure 3. Normal uterine cavity.
76 R.Campo et al.
Mini-hysteroscopic instrumentation
(i) Mini-hysteroscopic system: The Circon ACMI mini-hys-
teroscopic system (Figure 2) is a combination of a 30° rigid,
3.5 mm outer diameter, single flow hysteroscope and a 12°
semi-rigid, 2.4 mm, single flow fibrescope. For continuous
flow purposes the telescopes are interchangeable and the 2.4
mm semi-rigid fibrescope can be inserted in the 3.5 mm outer
sheath. The surgeon can choose the instrument configuration
which he thinks will be most suitable for the situation. The
advantages of the semi-rigid fibrescopes are the smaller total
diameter, the superior brightness and the instrument life-time.
The advantages of the rigid optical system are the larger field
and angle of view and the superior resolution.
(ii) Distension medium: For ambulatory diagnostic hysteros-
copy we use a watery solutions such as Ringer’s lactate, saline
or Hartman’s solution. A pressure cuff installed between 80
and 150 mmHg delivers the necessary pressure for cavity
distension. Physiological watery solutions have the advantage
of being less irritating and painful than CO2 gas (Nagele et al.,
1996). In contrast to CO2 gas, delicate structures will not
collapse in a watery distension medium, resulting in a more
accurate diagnosis of subtle lesions.
(iii) Hardware: video camera-printer, xenon light source.
With the use of video equipment every finding can be docum-
ented and archived in an appropriate way (video documenta-
tion, videoprint, or direct archiving of images in the
computer). For optimal visualization and image quality a high
performance light source is mandatory.
(iv) Documentation: The findings are documented with four
images on a videoprint and on a pre-designed registration
form on which the physician collects clinical findings, patient
compliance and possible complications.
Patients
This diagnostic procedure is basically indicated for patients
with abnormal uterine bleeding and in the infertile patient.
Hysteroscopy also offers great assistance for the interpreta-
tion of uncertain findings from other diagnostic methods such
as ultrasound, hysterosalpingography, blind biopsy and/or
magnetic resonance imaging (MRI). Only a traumatically per-
formed mini-hysteroscopic examination can be accepted as a
screening method in the surveillance of endometrial changes
during hormone replacement treatment or, even more import-
ant, in the follow-up of anti-oestrogen (adjuvant) therapy in
patients suffering from breast cancer.
A routine vaginal examination and a vaginal ultrasono-
graphy are performed to assess the size and position of the
uterus and to exclude major uterine and adnexal pathology.
The examination is scheduled in an office environment, pref-
erentially in the follicular phase of the cycle. The aim is to
differentiate normal from abnormal cervical and/or intrauter-
ine findings. (Figure 3).
Only in infertile patients do we perform systematically
cervical swabs for microbiological examination, but as they
are taken just before the hysteroscopic examination they do
not influence the decision to give antibiotics. Antibiotics are
only given in patients with endometrial changes, such as hy-
pervascularization or strawberry-like pattern.
Contraindications to perform an office mini-hysteroscopy
are symptomatic vaginal, uterine, or adnexal infections, men-
strual bleeding, an evolutive pregnancy or severe uterine
haemorrhage.
The atraumatic insertion technique can easily be performed
in virgins without placing a speculum and without destroying
the hymen. The distension medium is warmed to 37°C and
progressively the vagina, cervix, cervical channel and uterine
cavity are explored.
To evaluate the influence of the mini-hysteroscopic instru-
mentation on patient compliance and efficacy we performed a
prospective registration of every office diagnostic hysteros-
copy in infertility patients from January 1993 until January
1995. Those results are compared with the registration of
conventional diagnostic hysteroscopies in a routine gynaeco-
logical population performed between 1982 and 1989. The
infertile patient population is characterized by a higher inci-
dence of nullipara, congenital anomalies and anxious patients
in comparison to the standard gynaecological population.
This results in a technically more difficult examination and
can thus serve as a reference population to evaluate the full
potential of the mini-hysteroscopic system. A prospective
registration of patient compliance, complications and clinical
findings was performed. Failures were defined as every situ-
ation in which no diagnosis could be established due to poor
visualization or failed access or in which the patient’s discom-
fort resulted in interruption of the procedure, drug treatment
or need for recovery after the examination.
Conventional versus mini-hysteroscopic
instrumentation
Using the conventional instrumentation we performed a total
of 4204 consecutive office diagnostic hysteroscopic pro-
cedures in a standard obstetric–gynaecology patient collec-
tive between 1982 and 1989. The results show an acceptable
compliance of the patient (Table III) in at least 3332 (79.3%)
of all examinations. In 217 patients (5.2%) the examination
was impossible mainly due to a narrow cervical channel, in-
sufficient visualization or major discomfort. Detailed analysis
of the procedure failures shows that there was a high failure
rate in nullipara and infertile patients. Seven complications
occurred: two fundal perforation, four prolonged vagal reac-
tions and one epileptic insult (Table IV). In none of those
situations hospital admission was necessary. All complica-
tions occurred in the first 1000 examinations.
Between January 1993 and January 1995, 530 infertility
patients underwent a diagnostic mini-hysteroscopy. In 518 of
 Office mini-hysteroscopy 77

530 examinations (97.7%) the examination were performed

without any problem. In 12 cases (2.3%) the examination
failed (Table V). In four cases the patients reported discom-
fort, in three cases we encountered an impenetrable internal
cervical stenosis and in five cases visualization was insuffi-
cient to establish a diagnosis. In this series of 530 mini-hyster-
oscopies no complications were encountered.

Applications of diagnostic office

mini-hysteroscopy
Diagnostic office mini-hysteroscopy aims to differentiate nor-
mal cervical and intrauterine findings from abnormal ones.
The information should be gathered in a simple, safe and
efficient way with a high patient compliance. Unnecessary Figure 4. Hypervascularization is often seen in the presence of a
hospital admissions can thus be avoided and in case of abnor- large intrauterine myoma.
mal findings the patients can be correctly informed prior to
further procedures or treatments.

Table III. Patient compliance in 4204 conventional office

hysteroscopies (1982–1989)

Patient compliance No. %

No or minor discomfort 3332 79.3
Discomfort 112 2.7
Major discomfort 82 1.9
Examination impossible 217 5.2
No documentation 461 10.9
Total 4204 100

Table IV. Complications in 4204 conventional office Figure 5. Typical strawberry-like pattern.
hysteroscopies (1982–1989)

Complications No. %
Fundal perforation 2
Prolonged vagal reaction 4
Epileptic insult 1
Infections 0
Total 7 0.16

Table V. Failures in 530 consecutive ambulatory

mini-hysteroscopies in infertility patients (1993–1995)

Failures No. %
Pain 4 0.75
Internal cervical stenosis 3 0.57
Insufficient visualization 5 0.94
Complications 0
Figure 6. Distension with saline improves the diagnostic capacity
Total 12/530 2.26 for subtle endometrial lesions.
78 R.Campo et al.

Table VI. The feasibility of office mini-hysteroscopy in infertile patients in comparision to conventional hysteroscopy in a
standard gynaecological population

Mini-hysteroscopy in Infertility Conventional hysteroscopy in Gynaecology

No. % No. %
Examination without 518 97.7 3332 79.3
difficulties
Examination with 12 2.3 411 9.7
difficulties
Insufficient 0 461 11
documentation
Total 530 100 4204 100
Complications 0 7 0.16

Table VII. Ambulatory hysteroscopy with conventional Infertility

instrumentation (1982–1989)

Indications No. %
The second important area of application of hysteroscopy is
infertility diagnosis. The aim is to detect intrauterine changes
Abnormal uterine bleeding 2969 67.9
which could interfere with implantation and/or growth of the
Pre-perimenopausal 2506 57.4
conceptus. This includes cavity deformations from congenital
Post-menopausal 463 10.6 or acquired origin such as septa, synechia, polyps or myomas.
Oligo-amenorrhoea 136 3.1 Very little is known about hysteroscopically detectable en-
Dysmenorrhoea 36 0.8 dometrial changes such as small polyps, marked and moder-
Infertility 254 5.8 ate mucosal elevations and endometrial hypervascularization
and their significance for normal nidation, implantation and
Suspicion of pathology 976 22.4
growth of the conceptus. Mini-hysteroscopy plays a key role
Clinical examination 384 8.8
in the evaluation of different treatment modalities to restore
Hysterosalpinography 79 1.8 the normal endometrial environment.
Ultrasound 200 4.6 Through combined diagnostic hysteroscopy and transvagi-
Blind biopsy 313 7.2 nal hydrolaparoscopy, perhaps together with a transcervical
Total 4371 100 dye test and a transvaginal salpingoscopy, anatomic condi-
tions of the internal genital tract can sufficiently be evaluated
in the office environment (Gordts et al., 1998 and unpublished
observations). Thus hysterosalpingography or contrast sono-
Abnormal uterine bleeding
graphy are made redundant.
Uterine bleeding disorders are the most frequent indication Dicker et al. (1992) demonstrated the value of repeated
for diagnostic hysteroscopy in a standard population. In our hysteroscopy in in-vitro fertilization (IVF)–embryo transfer
consecutive registration of 4204 office hysteroscopies be- patients in whom, without obvious reason, pregnancy did not
tween 1982 and 1989 we found that in 2969 (67.9%) cases one occur. In 110 women with normal hysteroscopic findings and
of the indications for the diagnostic procedure was the pres- three or more failed IVF–embryo transfer cycles they per-
ence of abnormal uterine bleeding (Table VII). formed a control hysteroscopy. They found in 20 cases
In our series of 4200 examinations we prevented an unnec- (18.2%) abnormal findings possibly being the cause for the
essary hospital admission in 2492 (59.3%) patients when nor- implantation failure (Dicker et al., 1992). In our own prospec-
mal cervical and intracavitary findings were diagnosed by tive registration of 530 consecutively performed office mini-
ambulatory hysteroscopy. Using fractionated curettage, hysteroscopies we found significant pathology in 151 patients
which currently is often conducted as the sole measure, in- (Table VIII).
trauterine polyps, myomas or early stages of endometrial Besides the diagnosis of major pathology like uterine septa,
carcinomas might escape diagnosis (Word et al., 1958; Valle, polyps, myoma, synechia or total cavity obliteration, mini-
1981; Brooks et al., 1988; Hucke et al., 1993). Word had hysteroscopy in the infertile patient frequently indicates the
reported already in 1958 the fallacy of simple uterine curet- presence of minimal or subtle changes of the endometrium
tage (Word et al., 1958). In the case of an endometrial carcino- such as moderate or marked mucosal elevations, which are
ma a pre-operative staging via hysteroscopy is possible with possibly a marker for inappropriate hormonal stimulation of
great accuracy (Joelsson et al., 1971; Cronje et al., 1988). the endometrium.

Table VIII. Ambulatory mini-hysteroscopy in infertility patients
Hysteroscopic findings No.
Normal 370
No diagnosis 9 1.7
Abnormal 151
Congenital disorders 70
Cavum compartmentalization (septum) 44
Uterus infantilis 16
Diethylstilboestrol uterus 7 for congenital anomalies, although it must be said that most of
Uterus unicornis 3 the anomalies are found during hysteroscopic screening and
Acquired disorders 81
Mucosal elevation (marked or moderate) 33
Hypervascularization 9
Polyp–myoma 20
Synechia 14
Necrotic tissue 4 Mini-hysteroscopic surveillance of the
Asherman 1 endometrium
Total 530
Aberration of the vascular architecture of the endometrium
is another lesion which could be important for reproductive
performance and can only be visualized by hysteroscopy.
Hypervascularization is often seen in the presence of a large
intrauterine or intramural myoma (Figure 4) but can also been
seen as a solitary finding. In our series we found nine cases of
endometrial hypervascularization defined as a significantly
increased number of vessels in the proliferative phase or a
reddish endometrium in which the white openings of the
glands produce the typical strawberry-like pattern (Figure 5).
Neither microbiology nor histology seems to have any diag-
nostic value in those cases. Only in one case could we prove
histologically the presence of a chronic endometritis. Cervical
swabs showed the presence of Gardnerella vaginalis in two
cases, Escherichia coli in one and streptococci group D infec-
tion in one other patient. We observed that in those nine cases
the hysteroscopic view normalized after 2 months of hormone
replacement treatment combined with 10 days of antibiotic
treatment. In two women with a problem of secondary infertil-
ity and where the hypervascularization was the only feature
found, pregnancy occurred spontaneously within 6 months
after the drug treatment.
Suspicion of pathology in other examination
Hysteroscopy offers great assistance for the interpretation of
uncertain findings in other examination methods such as ul-
trasound, hysterosalpingography, blind biopsy and/or MRI.
Only for vaginal sonography is there a case for performing the
examination before the mini-hysteroscopic procedure. The
Office mini-hysteroscopy 79
other examinations are more invasive or more expensive than
the hysteroscopic one.
% Sonography is very important for the diagnosis of uterine
69.8 and adnexal pathology. Prospective studies show that for the
diagnosis of congenital uterine anomalies ultrasound has a
28.5 low sensitivity but a high specificity (Nicolini et al., 1987);
but diethylstilboestrol-induced intracavitary changes such as
13.2
T-uteri are not likely to be diagnosed by ultrasound (Kipersz-
tok et al., 1996). Randolph et al. (1986) reported that contrast
sonography improves the diagnostic capacity of ultrasound
15.3 not during routine sonography. In case of a hysteroscopically
diagnosed malformation a concomitant transabdominal sono-
graphy can define the final diagnosis in most cases, otherwise
a laparoscopy must follow.
100
Drug therapy. Mini-hysteroscopy could play a role in the
surveillance of endometrial changes during hormone replace-
ment treatment or even more importantly in the surveillance
of anti-oestrogen (adjuvant) therapy in patients suffering from
breast cancer.
Tamoxifen the most widely used anti-oestrogen for adjuv-
ant breast cancer treatment, and can produce changes in the
endometrial stroma and myometrium resulting in an echo-
genic effect in vaginal ultrasound without any pathological
changes in the epithelial layer of the endometrium. This effect
makes sonography useless as a screening method for patients
under tamoxifen. Moreover it has been proven that a sonogra-
phically normal-looking endometrium is no guarantee for the
absence of polyps or atypical hyperplasia.
It has been proven that tamoxifen has a significant and
dose-related influence on the endometrium. Therefore we ad-
vise that every patient under continuous tamoxifen treatment
should receive an annual ambulatory hysteroscopy (Neven et
al., 1994, 1997; Neven and Vergote, 1998).
Correlation with histology? As mentioned before it is clear
that the direct visualization of the endometrium offers more
possibilities than the blind or indirect interpretation of the
uterine mucosa. This does not mean that hysteroscopy equals
histology. An atrophic, pale endometrium with small pete-
chiae (due to the distension of the cavity) will indeed be recog-
nized easily, even by the inexperienced hysteroscopist. The
correct diagnosis of a functional endometrium can easily be
made just by looking at the vascular pattern and the glandular
openings. Irregular, exophytic lesions featuring anarchic
vascularization will mostly be confirmed as being carcinoma-
tous.
More difficult to interpret are the moderate or marked mu-
cosal elevations. They correlate with a large variety of histo-
80 R.Campo et al.
logical diagnoses. In those cases it has been proven that the
eye-directed biopsy with histological examination is abso-
lutely necessary for establishing a diagnosis.
Technique of tissue prelevation for histological
examination.
The aim of office hysteroscopy is to differentiate the normal
from abnormal findings. In the case of uncertainty or evident
pathology the hysteroscopic procedure should always be
completed with a tissue sampling for histological analysis.
Depending on the hysteroscopic findings there are three ways
to perform the sampling.
(i) Hysteroscopy shows a generalized lesion. In the case of a
generalized lesion a representative endometrium sampling is
carried out with a 3 mm diameter hand-suction curette (pipelle
de Cornier). This procedure can easily be done at the same
time as the diagnostic hysteroscopy.
(ii) Hysteroscopy shows a localized lesion. In the case of
marked or moderated mucosal elevation, localized abnormal
vascular patterns or, in the presence of a small polyp, an eye-
directed biopsy or resection of the polyp should be performed.
The new mini-hysteroscopic instrumentation already offers
rigid optical systems with double-flow sheath and a maximal
total diameter of 5.5 mm, accessible for 7 French instrumenta-
tion. The fibre optics offer the same possibilities with an in-
strument total diameter less than 4 mm. With this
instrumentation set-up the procedure can be performed in an
office environment without major patient discomfort.
(iii) Hysteroscopy shows major pathology. For major pa-
thology such as large polyps, myomas or difficult combined
pathology where continuous flow and possibly diathermy are
required, we prefer a hospitalization with the availability of
loco-regional or general anaesthesia to establish diagnosis and
treatment in the same procedure.
Conclusion
The reduction of the total instrument diameter from 5 to 3.5 or
2.4 mm and the change of distention medium from CO2 to
watery solutions appears to increase significantly the com-
pliance of the patient. The combination of both a small bored
fibre optical system and a rigid one gives the ideal instru-
mentation set-up to deal with in nearly every challenging
situation in the office. As the samples are from two large
prospective registries and because the infertile population is
thought to be the more difficult one we like to conclude that
mini-hysteroscopy provokes less discomfort than conven-
tional hysteroscopy (Table VI). Furthermore, in the hands of
an experienced examiner, both conventional and mini-hyster-
oscopy seem to be safe procedures, which is an absolute requi-
site for introduction into daily practice.
The high patient compliance, the low failure rate and low
complication rate observed during mini-hysteroscopy enable
us to integrate hysteroscopy as a first-line diagnostic pro-
cedure in daily gynaecological practice. With the mini-hyster-
oscopic system it is easier to insert the scope in an atraumatic
way, thus preventing the artefacts and iatrogenic pathology.
This system offers in cases of uterine bleeding a continuous
flow system without enlarging the total instrument diameter.
The use of saline as a distension medium improves the
diagnostic capacity for subtle endometrial lesions (Figure 6).
In the same way the advantage of saline is seen in the trans-
vaginal hydrolaparoscopy, where it is shown that the diagnos-
tic accuracy in saline is higher than in a CO2 environment
(R.Campo et al., unpublished observations). Nagele et al.
(1996) demonstrated in their prospective study that the use of
CO2 during office hysteroscopy increased the patient discom-
fort during the examination in comparison to the use of saline
distension medium. The technique is certainly not more diffi-
cult than a contrast sonography and the information gathered
by direct visualization remains the gold standard.
The diagnostic work-up in abnormal uterine bleeding dis-
orders (AUB) is standardized by a thorough anamnesis, clini-
cal examination, a vaginal sonography and blood sampling
for evaluation of haematology, endocrinology and coagu-
lation parameters. Frequently a decision towards treatment,
expectant management or more invasive procedures such as
dilatation and curettage (D&C) is taken at this phase.
Introducing the ambulatory mini-hysteroscopy with or
without direct tissue prelevation in a first-line diagnostic
model provides both gynaecologist and patient with appropri-
ate and very valuable information regarding the possible in-
trauterine causes of AUB.
The explanation of the diagnostic findings to the patient and
her partner before surgery or medical treatment has the benefit
of obtaining fully informed consent. In addition, in case of
findings of doubtful clinical significance the evolution can be
evaluated by a repeat procedure and the effect of surgery or
drug treatment on the disease process can be more readily
controlled by a second-look procedure.
Based on data in the current literature and on our own
experience, hospital admissions for D&C can be avoided in
>50% of women who undergo (mini-)hysteroscopy for ab-
normal uterine bleeding disorders. The economic savings of
mini-hysteroscopy can therefore be very significant.
Especially in infertility diagnosis the combination of mini-
hysteroscopy, transvaginal hydrolaparoscopy with dye hy-
drotubation, and distal tubal endoscopy appears to be a very
complete and efficient first-line office diagnostic procedure
(Gordts et al., 1998 and unpublished observations). The use of
saline as distension medium increases patient compliance,
making it therefore more attractive to patients than conven-
tional hysteroscopy. The resulting increase in effectiveness
and cost-benefit along with the decreased patient morbidity
could be very significant.
With the use of video equipment every finding can be do-
cumented and archived in an appropriate way (video docu-

mentation, videoprint, or direct archiving of images in the
computer). The acceptable to perfect imaging of the mini-hys-
teroscopes, the ability to document and the high patient com-
pliance should guarantee the broad application of diagnostic
hysteroscopy in an office environment, although the tech-
nique requires training, is characterized by a slow learning
curve and in most countries lacks adequate reimbursement as
an office procedure.
Mini-hysteroscopy plays a key role in the diagnosis of ab-
normal uterine bleeding; it is a primary investigation tool in
infertility work-up; it is the ideal screening method for en-
dometrial changes in patients under hormone replacement
therapy or anti-oestrogens (adjuvant) treatment (Neven et al.,
1994) and it is very helpful in the interpretation of uncertain
findings in other diagnostic techniques such as ultrasound,
MRI, blind biopsy or hysterosalpingography. In the diagnosis
of pathology such as myoma, polyp, synechia or subtle en-
dometrial lesions, mini-hysteroscopy remains an extremely
valuable tool to help with interpreting the sonographic find-
ings or to identify the problem in the case of negative sono-
graphy. Both transvaginal sonography and mini-hysteroscopy
have their place in first-line office diagnostic procedures.
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Received on January 8, 1998; accepted on June 27, 1998