Office Hysteroscopy: Treating Intrauterine Pathology and Avoiding the Operating Room.

Background and Objectives: Office hysteroscopy is a versatile minimally invasive procedure. However, there are limited data reporting long-term follow-up of patients undergoing these procedures. The objectives of this study were to evaluate the rate of additional procedures performed in 1 and 3 years following office hysteroscopy, and to evaluate how frequently full assessment of the uterine cavity could be performed.

This was a single-center retrospective cross-sectional analysis of all office hysteroscopies that were performed between July 2015 and December 2021. Chart review was performed to extract patient demographic data, medical history, office hysteroscopy procedural data, pathology results, and any subsequent gynecological surgery.

Only 13% of patients required further gynecologic intervention in the operating room (OR) within 1 year and 16% required further intervention in the OR within 3 years. A total of 82.7% of polyps and 90% of retained foreign bodies, were successfully removed in the office. A total of 93.4% had an adequate diagnostic office hysteroscopy with full evaluation of intrauterine cavity.

This study supports that office hysteroscopy is an effective approach that helps patients avoid the OR with the ability to perform an excellent diagnostic procedure and to treat common pathology. While patients with more advanced pathology may end up in the OR, office hysteroscopy can aid in planning the appropriate approach and procedure to be performed for more complex cases. Most our patients did not need an OR procedure in the 3 years following office hysteroscopy.

IUD, Office-based hysteroscopy, Operating room, Polyps

Hysteroscopy is a versatile minimally invasive procedure that can be used for both diagnostic and therapeutic purposes. Historically, hysteroscopies were performed in the operating room (OR). However, with the advent of smaller-diameter hysteroscopes, there has been a shift to office procedures. This allows for the convenience of being able to “see and treat” pathology while avoiding the logistics and expense of an extra healthcare encounter and the risks of anesthesia.1 In order to successfully perform office-based hysteroscopy, patient comfort must be taken into consideration. This may limit the diameter of the hysteroscope, the operative instruments available and the size of pathology treated. Inadequate office hysteroscopies which are not diagnostic and office hysteroscopies with incomplete removal of pathology and persistent symptoms may ultimately require further intervention in the OR. Inappropriate patient selection for office hysteroscopy can lead to a waste of resources and unnecessary patient discomfort. Conversely, if hysteroscopies that could be adequately performed in the office are performed in the OR, there will be increased cost to the healthcare system, patient inconvenience, and added risk from anesthesia.2 The diagnostic accuracy and tolerability of office hysteroscopy is well documented. There is evidence that outpatient hysteroscopic polypectomy without anesthesia is associated with a higher risk of residual endometrial polyp compared to hysteroscopic polypectomy performed in the OR.3 However, there are limited data reporting long-term follow-up of patients undergoing these procedures. The aim of this study is to evaluate the rate of additional gynecologic procedures within 1 and 3 years after office hysteroscopy and the rate of adequate hysteroscopic evaluation of the uterine cavity.

We conducted a single-center retrospective cross-sectional analysis of all office-based hysteroscopies that were performed between July 2015 and December 2021. Eligible patients were identified using CPT codes for office hysteroscopy (58555, 58558, 58559, 58560, 58561, and 58562) during the specified time frame. The primary outcome was the rate of additional gynecologic procedures at 1 year. Our secondary outcomes included the rate of adequate hysteroscopy, defined as the ability to visualize bilateral tubal ostia and all 4 quadrants of the uterine cavity, and the rate of additional gynecologic procedures at 3 years. Summary and descriptive statistics were used to describe demographic information, clinical history, indication for hysteroscopy, and operative findings. Bivariate analysis was used to compare adequate office hysteroscopy versus inadequate office hysteroscopy, and additional gynecologic procedures at 1 year versus no additional gynecologic procedures at 1 year. Logistic regression analysis was used to determine factors associated with adequate office hysteroscopy and additional gynecologic procedures at 1 year. Institutional Review Board (IRB) approval was obtained through our institution and patient consent was waived, given the retrospective nature of the study. All hysteroscopies were performed by minimally invasive gynecologic surgeons. The hysteroscopies were generally performed by vaginoscopy without the use of a speculum or a tenaculum, without cervical dilatation in most cases, and without paracervical block or any anesthesia. When a vaginoscopic entry failed or upon joint decision making, traditional hysteroscopic entry was chosen with a speculum and a tenaculum, with or without a paracervical block. Cervical dilation with dilators or an os finder was used at the discretion of provider to dilate to allow placement of the 5 mm hysteroscope. A 3-L bag with a pressure cuff was utilized and adjusted by the physician to obtain adequate distention. Pressures were not monitored with a fluid management system and procedures were terminated if fluid deficit exceeded 1500 cc by manual calculation. A 5-mm rigid 30-degree hysteroscope, with a round outer contour, and a 5 French working channel was used for all procedures. Graspers, scissors and a tenaculum were used at the discretion of the physician and no electrosurgical instruments or mechanical morcellators were used. All patients had the opportunity to visualize the procedure simultaneously with the provider. Reasons for subsequent gynecological procedures were categorized into “recurring symptoms,” “incomplete removal,” “complete evaluation but follow-up needed,” or “unrelated.” Clinical interpretation of the chart review was relied upon to select 1 of these categories. “Recurring symptoms” was defined as the recurrence of the original symptoms that prompted a repeat evaluation. “Incomplete removal” was defined as an adequate hysteroscopy but inability to remove the pathology. “Complete evaluation but follow-up needed” was defined as an adequate hysteroscopy with full evaluation but requiring subsequent surgery. Often these cases were due to diagnosis of endometrial cancer or fibroids requiring a subsequent surgery under anesthesia. “Unrelated” was defined as an adequate office hysteroscopy that had a surgery in the 3-year follow-up period that was completely unrelated to the initial procedure such as a patient who may have had an office hysteroscopy for removal of a retained intrauterine device (IUD) but had a subsequent urogynecological procedure (Table 6). Table 6. | N (%) | | |---|---| | Additional procedure within 1 year | 77 (14.9) | | OR | 66 (85.7) | | Office | 11 (14.3) | | Additional procedure within 3 years | 123 (23.8) | | OR | 82 (66.7) | | Office | 41 (33.3) | | Reasons for Additional Procedure | N (%) | |---|---| | Recurring symptoms | 49 (40%) | | Incomplete removal | 44 (36%) | | Complete evaluation but follow-up needed | 18 (15%) | | Unrelated | 12 (10%) |

A total of 515 diagnostic and operative office hysteroscopies were performed between July 2015 to December 2021. All office hysteroscopies were performed by trained minimally invasive gynecologists, with the more senior physicians performing a larger portion of cases. The average age of the population was 54 years old, 43.9% of which were premenopausal and 66% with a history of vaginal delivery (Table 1). Postmenopausal bleeding was the most common indication (46.6%), followed by abnormal uterine bleeding (25.3%) and retained foreign body (13.2%) (Table 1). Endometrial polyps were identified in 50% of hysteroscopies, most often in the evaluation of abnormal uterine bleeding and postmenopausal bleeding (Table 1). In patients with operative findings of either polyp or polypoid endometrium, ten cases of uterine cancer was found (8.9%). Most of the hysteroscopies were adequate (93.4%) (Table 5). There were 83 patients with at least 1 cesarean delivery and no vaginal birth. Of this group, 94% (N = 78) had adequate hysteroscopies. Success rates for postmenopausal women were not statistically different than for premenopausal women (Table 4). Table 1. | Variable | N (%) | |---|---| | Age (Mean +/− SD) | 54.36 (14.47) | | BMI (Mean) [Range] | 33.41 [17.2, 73.5] | | Premenopausal (%) | 222 (43.9) | | Nulliparous (%) | 92 (18.2) | | Ever had vaginal delivery (%) | 334 (66.0) | | Prior OR hysteroscopy (%) | 9 (1.8) | | Prior office hysteroscopy (%) | 30 (5.9) | | Indication for office hysteroscopy | | | PMB | 236 (46.6) | | AUB | 128 (25.3) | | Retained foreign body | 128 (25.3) | | Thickened endometrium | 57 (11.3) | | Infertility | 22 (4.3) | | Inadequate or failed previous biopsy | 16 (3.2) | | Pelvic pain | 12 (2.4) | | Intrauterine adhesion | 7 (1.4) | | Other | 8 (1.6) | | Operative findings | | | Polyp | 255 (50.4) | | Fibroids | 85 (16.8) | | Atrophic endometrium | 80 (15.8) | | Polypoid endometrium | 48 (9.5) | | Synechia | 27 (5.3) | | Adenomyosis | 6 (1.2) | | Septum | 2 (0.4) | | Foreign body | 62 (12.3) | | Arcuate uterus | 11 (2.2) | | Normal endometrium | 51 (10.1) | Table 5. | N (%) | | |---|---| | Total number of hysteroscopy | 515 (100) | | Adequate hysteroscopy | 469 (93.4) | | Reasons for inadequate hysteroscopy | | | Unable to visualize the Cavity | 14 (2.7) | | Cervical Stenosis | 13 (2.5) | | Pain | 10 (1.9) | | Other | 9 (1.7) | | Rate of Complete Evaluation and Removal When Operative Findings | % | |---|---| | Polyp | 82.7 | | Retained Foreign Body | 90.0 | Table 4. | Complete Removal | Not Complete Removal | % Success | | |---|---|---|---| | Premenopause | 116 | 37 | 75.8 | | Postmenopause | 189 | 52 | 78.4 | | Fisher P-value | P = .62 | Success defined as complete removal. Data excluded those with no pathology or no planned pathology removal. Complete polyp removal was successful in 82.7% of attempts. Retained foreign body had an even higher success rate of 90.0%, comprised mostly of removal of displaced IUD’s and retained IUD fragments (Table 5). A total of 77 (14.9%) of patients required repeat procedures within 1 year: 11 had another office hysteroscopy and 66 had a procedure in an OR setting (Table 6). A further breakdown of the OR procedures includes: 39 operative hysteroscopies, 21 hysterectomies, 5 endometrial ablations, 1 cesarean scar revision. Approximately 8% of the entire cohort ultimately required OR hysteroscopy subsequent to the office hysteroscopy within 1 year. A total of 123 (23.8%) of initial office hysteroscopies required repeat procedures within 3 years: 41 had another office hysteroscopy and 82 had a procedure in an OR setting (Table 6). A further breakdown of the OR procedures includes 45 operative hysteroscopies, 31 hysterectomies, 5 endometrial ablations, and 1 cesarean scar revision. The result of bivariate analysis shows that the procedure was more likely to be adequate if a polyp or a fibroid was found or if the pathology was completely removed. A subsequent procedure was less likely if the pathology was completely removed or if they had an adequate hysteroscopy (Table 2). Table 2. | Variable | Adequate Office Hysteroscopy (474) | Inadequate Office Hysteroscopy (34) | P-Value | |---|---|---|---| | History of anxiety, yes (37) | 34 (7%) | 3 (9%) | .458 | | Chief complaint, inadequate or failed previous biopsy, yes (16) | 15 (3%) | 1 (3%) | .709 | | Postmenopausal, yes (288) | 267 (56%) | 20 (59%) | .777 | | Prior LEEP/CKC, yes (14) | 12 (2.5%) | 2 (6%) | .239 | | Pathology completely removed, yes (310) | 299 (63%) | 6 (18%) | <.001 | | Misoprostol used, yes (69) | 65 (14%) | 4 (12%) | .498 | | Office operative finding, Polyp (257) | 250 (53%) | 6 (18%) | <.001 | | Office operative finding, Fibroid (85) | 84 (18%) | 1 (3%) | .026 | | Office operative finding, Foreign Object (63) | 55 (12%) | 5 (15%) | .373 | | Variable | Additional Procedure at 1 year (78) | No Additional Procedure at 1 year (434) | P-Value | |---|---|---|---| | History of anxiety, yes (37) | 5 (6%) | 32 (7%) | .762 | | Chief complaint, inadequate or failed previous biopsy, yes (16) | 1 (1%) | 15 (3.5%) | .271 | | Postmenopausal, yes (288) | 42 (54%) | 246 (57%) | .642 | | Prior LEEP/CKC, yes (14) | 3 (4%) | 11 (2.5%) | .362 | | Pathology completely removed, yes (310) | 22 (28%) | 287 (66%) | <.001 | | Misoprostol used, yes (69) | 11 (14%) | 58 (13%) | .860 | | Adequate office hysteroscopy, yes (474) | 64 (83%) | 410 (95%) | <.001 | | Office operative finding, Polyp (257) | 38 (49%) | 219 (51%) | .777 | | Office operative finding, Fibroid (85) | 21 (27%) | 64 (15%) | .008 | | Office operative finding, Foreign Object (63) | 5 (6%) | 58 (13%) | .085 | Logistic regression shows that an office hysteroscopy showing a fibroid was associated with requiring an additional procedure at 1 year with adjusted OR of 2.121 (1.189–3.784). An adequate hysteroscopy was associated with lower odds of repeat procedure at 1 year with adjusted OR of 0.248 (0.116–0.530) and pathology completely removed was associated with lower odds of repeat procedure in 1 year with adjusted OR of 0.095 (0.052–0.0175) (Table 3). Table 3. | Variable | uOR (95% CI) | P-Value | aOR (95% CI) | P-Value | |---|---|---|---|---| | History of anxiety, yes | 0.798 (0.232–2.746) | .721 | 0.920 (0.261–3.245) | .897 | | Chief complaint, inadequate or failed previous biopsy, yes | 1.078 (0.138–8.418) | .943 | 1.009 (0.126–8.101) | .993 | | Postmenopausal, yes | 0.903 (0.445–1.830) | .777 | 0.919 (0.281–3.006) | .888 | | Prior LEEP/CKC, yes | 0.416 (0.089–1.937) | .264 | 0.347 (0.070–1.711) | .194 | | Pathology completely removed, yes | 15.167 (5.899–38.993) | <.001 | 17.849 (6.433–49.524) | <.001 | | Misoprostol used, yes | 1.192 (0.407–3.494) | .749 | 1.785 (0.521–6.109) | .356 | | Office operative finding, Polyp | 5.208 (2.118−12.810) | <.001 | 8.767 (3.181–24.162) | <.001 | | Office operative finding, Fibroid | 7.108 (0.959–52.696) | .055 | 7.598 (1.019–56.675) | .048 | | Office operative finding, Foreign Object | 0.761 (0.283–2.049) | .589 | 0.663 (0.223–1.973) | .460 | | Variable | uOR (95% CI) | P-Value | aOR (95% CI) | P-Value | |---|---|---|---|---| | History of anxiety, yes | 0.860 (0.325–2.281) | .763 | 0.879 (0.326–2.366) | .798 | | Chief complaint, inadequate or failed previous biopsy, yes | 0.363 (0.047–2.787) | .330 | 0.426 (0.054–3.335) | .416 | | Postmenopausal, yes | 0.892 (0.550–1.447) | .642 | 0.923 (0.415–2.052) | .844 | | Prior LEEP/CKC, yes | 1.538 (0.419–5.644) | .516 | 1.408 (0.373–5.315) | .614 | | Pathology completely removed, yes | 0.092 (0.050–0.167) | <.001 | 0.095 (0.052–0.175) | <.001 | | Misoprostol used, yes | 1.064 (0.531–2.133) | .860 | 1.151 (0.565–2.344) | .699 | | Adequate office hysteroscopy, yes | 0.252 (0.120–0.529) | <.001 | 0.248 (0.116–0.530) | <.001 | | Office operative finding, Polyp | 0.933 (0.576–1.511) | .777 | 0.955 (0.558–1.637) | .868 | | Office operative finding, Fibroid | 2.130 (1.209–3.752) | .009 | 2.121 (1.189–3.784) | .011 | | Office operative finding, Foreign Object | 0.444 (0.172–1.145) | .093 | 0.392 (0.145–1.058) | .065 | Adjusted analysis for age, BMI, parity, and mode of delivery. Within 3 years, “recurrent symptoms” accounted for the highest percentage of repeat procedures (40%), most often postmenopausal bleeding. “Incomplete removal” accounted for 36% of the repeat procedures, “complete evaluation but follow-up needed” accounted for 15% and “unrelated” accounted for 10% (Table 5).

Office hysteroscopy is an effective, minimally invasive method for evaluation and treatment of intrauterine pathology. Over 93% of patients in our cohort had an adequate hysteroscopy which is consistent with previously reported success rates of office hysteroscopy.4,5 Bivariate analysis showed that those with adequate office hysteroscopy were less likely to have a repeat procedure within 1 year and that repeat procedure was less likely for those patients whose pathology was completed removed. This seems intuitive but does highlight the importance of adequate visualization of the uterine cavity in completely treating the pathology. For most patients, office hysteroscopy is an excellent method for treatment of intrauterine pathology. Even when the pathology cannot be totally removed, it serves as an important diagnostic tool to guide the appropriate next step in management. While approximately 13% of our patients did require another procedure in the OR in the first year, only 5.7% of patients needed these due to an incomplete removal of pathology. Office-based platforms integrating smaller diameter mechanical morcellators could expand the pathology treated in the office setting and decrease the incidence of incomplete procedures. In order to increase access to long-acting reversible contraception, our institution routinely offers postplacental IUDs due to limited adherence to postpartum visits. However, postplacental IUDs have a high rate of malpositioning and difficulty of removal. A small prospective observation study showed 30% of IUD were malpositioned and 75% were not visible on examination at 6 months postpartum in postcesarean section IUD insertions.6 A total of 13.5% of our office hysteroscopies were due to the inability to remove the IUD in a general clinic setting. Office hysteroscopy offers a highly effective method to remove IUDs with missing strings, embedded IUDs, retained fragments, or to reposition a low-lying IUD. It is notable that the highest body mass index (BMI) evaluated with office hysteroscopy was 73.5. For patients with morbidly high BMI, vaginoscopy can allow for easier identification and navigation of the cervix than the traditional approach using a speculum and tenaculum. A randomized control trial comparing the vaginoscopy to traditional hysteroscopy shows that vaginoscopy was associated lower failure rate and less pain.7 Appropriate patient selection is important for successful office hysteroscopy. Patient characteristics and pathology should be considered. Although one could suspect that postmenopausal patients may have lower rate of adequate hysteroscopy due to stenotic cervix or vaginal atrophy, the result shows no statistical difference in adequate hysteroscopy between premenopausal and postmenopausal patients. The logistic regression shows higher odds ratio of repeat procedure if a fibroid was found. Therefore, fibroids may be better treated in the OR. Alternatively, one could consider a technique described by Bettocchi et al of staged hysteroscopic method whereby the endometrial mucosa covering the submucosal myoma is incised during an office hysteroscope with subsequent finding of more prominently intracavitary fibroid for easier removal.8 To our knowledge, this is the only report looking at long-term follow-up and reintervention rates following office hysteroscopy. While this was a retrospective study it does reassure us that the large majority can successfully tolerate this procedure and obtain an accurate diagnosis. At 1 year, more than 85% of patients did not require further intervention after initial hysteroscopy. A key strength of this study is its large sample size, extended inclusion period, and use of multivariable logistic regression to identify independent predictors of reintervention. These features enhance both the statistical power and the clinical applicability of our findings. The main limitation of the study is that we could only capture subsequent interventions that happened within our health system. It is possible that some patients may have had additional intervention at a different institution. As such, our results should be interpreted in the context of this potential loss to follow-up. However, given that our institution serves as a primary referral center for this patient population, we believe most follow-up care was captured. The study is also a single institutional study. Although there are multiple providers who perform office hysteroscopies, 57% of the hysteroscopies were performed by one provider and therefore may limit the generalizability of the finding. While these results may represent outcomes achievable in experienced hands, broader adoption of office hysteroscopy may require consideration of training, experience, and case selection. In conclusion, this study supports office-based hysteroscopy allows excellent diagnostic and operative effectiveness and can help many avoid the OR. We can inform patients that while approximately 13% of patients may require further interventions in the OR within 1 years, 87% will avoid the OR with its added cost and risk. While patients with more advanced pathology may require the OR, office hysteroscopy can aid in planning the appropriate approach and procedure to be performed. Footnotes Conflict of interests: none. Disclosure: none. Funding sources: none. Contributor Information Sun Woo Kim, Obstetrics and Gynecology, Thomas Jefferson University. Philadelphia, Pennsylvania, USA. (Dr. Kim). Ali Antoine, Obstetrics and Gynecology, Cleaveland Clinic, Cleaveland, Ohio, USA. (Dr. Antoine). Lauren Cosgriff, Obstetrics and Gynecology, Medstar Health, Baltimore, Maryland, USA. (Dr. Cosgriff). Clarissa Diniz, Obstetrics and Gynecology, Mayo Clinic, Phoenix, Arizona, USA. (Dr. Diniz). Kari Plewniak, Obstetrics & Gynecology and Women’s Health, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA. (Drs. Plewniak and Levie). Mark Levie, Obstetrics & Gynecology and Women’s Health, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA. (Drs. Plewniak and Levie).

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