All gynaecology units should provide a dedicated outpatient hysteroscopy service to
aid management of women with abnormal uterine bleeding. There are clinical and
economic benefits associated with this type of service.
Outpatient hysteroscopy should be conducted outside of the formal operating theatre
setting in an appropriately sized, equipped and staffed treatment room with adjoining,
private changing facilities and toilet.
Outpatient hysteroscopy should be performed in an appropriately sized and fully
equipped treatment room. This may be a dedicated hysteroscopy suite or a multipurpose
facility.
The healthcare professional should have the necessary skills and expertise to carry
out hysteroscopy.
There should be a nurse chaperone regardless of the gender of the clinician.
Written patient information should be provided before the appointment and consent
for the procedure should be taken.
Analgesia
Routine use of opiate analgesia before outpatient hysteroscopy should be avoided as
it may cause adverse effects.
Women without contraindications should be advised to consider taking standard
doses of non-steroidal anti-inflammatory agents (NSAIDs) around 1 hour before their
scheduled outpatient hysteroscopy appointment with the aimof reducing pain in the
immediate postoperative period.
Cervical preparation
Routine cervical preparation before outpatient hysteroscopy should not be used in
the absence of any evidence of benefit in terms of reduction of pain, rates of failure
or uterine trauma.
Type of hysteroscope
Miniature hysteroscopes (2.7mm with a 3–3.5mm sheath) should be used for diagnostic
outpatient hysteroscopy as they significantly reduce the discomfort experienced
by the woman.

There is insufficient evidence to recommend 0° or fore-oblique optical lenses (i.e.
12°, 25° or 30° off-set lenses) for routine outpatient hysteroscopy. Choice of hysteroscope
should be left to the discretion of the operator.
Flexible hysteroscopes are associated with less pain during outpatient hysteroscopy
compared with rigid hysteroscopes. However, rigid hysteroscopesmay provide better
images, fewer failed procedures, quicker examination time and reduced cost. Thus,
there is insufficient evidence to recommend preferential use of rigid or flexible
hysteroscopes for diagnostic outpatient procedures. Choice of hysteroscope should
be left to the discretion of the operator.
Distension medium
For routine outpatient hysteroscopy, the choice of distension medium between
carbon dioxide and normal saline should be left to the discretion of the operator as
neither is superior in reducing pain, although uterine distension with normal saline
appears to reduce the incidence of vasovagal episodes.
Uterine distension with normal saline allows improved image quality and allows
outpatient diagnostic hysteroscopy to be completed more quickly compared with
carbon dioxide.
Operative outpatient hysteroscopy, using bipolar electrosurgery, requires the use of
normal saline to act as both the distension and conducting medium.
Local anaesthesia and cervical dilatation
Blind cervical dilatation to facilitate insertion of the miniature outpatient hysteroscope
is unnecessary in the majority of procedures. Routine cervical dilatation is
associated with pain, vasovagal reactions and uterine trauma and should be avoided.
Cervical dilatation generally requires administration of local cervical anaesthesia.
Standard protocols regarding the type,maximumdosage and route of administration
of anaesthesia should be developed and implemented to help both recognise and
prevent rare but potentially serious adverse effects resulting from systemic vascular
absorption.
Instillation of local anaesthetic into the cervical canal does not reduce pain during
diagnostic outpatient hysteroscopy but may reduce the incidence of vasovagal
reactions.
Topical application of local anaesthetic to the ectocervix should be considered where
application of a cervical tenaculum is necessary.
Application of local anaesthetic into or around the cervix is associated with a reduction
of the pain experienced during outpatient diagnostic hysteroscopy. However, it
is unclear how clinically significant this reduction in pain is. Consideration should
be given to the routine administration of intracervical or paracervical local
anaesthetic, particularly in postmenopausal women.

Miniaturisation of hysteroscopes and increasing use of the vaginoscopic technique
may diminish any advantage of intracervical or paracervical anaesthesia. Routine
administration of intracervical or paracervical local anaesthetic should be used where
larger diameter hysteroscopes are being employed (outer diameter greater than
5mm) and where the need for cervical dilatation is anticipated (e.g. cervical stenosis).
Routine administration of intracervical or paracervical local anaesthetic is not
indicated to reduce the incidence of vasovagal reactions.

Vaginoscopy
Vaginoscopy reduces pain during diagnostic rigid outpatient hysteroscopy.
Vaginoscopy should be the standard technique for outpatient hysteroscopy, especially
where successful insertion of a vaginal speculum is anticipated to be difficult and
where blind endometrial biopsy is not required.