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Bangladesh Guideline: Hysteroscopy & Office Hysteroscopy

Table of Contents

(Adapted from RCOG, ESGE, AAGL recommendations with local context)

1. Scope & Purpose

  • Standardize safe practice of diagnostic and operative hysteroscopy in Bangladesh.
  • Promote office hysteroscopy as a minimal-access, anesthesia-sparing, patient-friendly technique.
  • Reduce unnecessary dilatation & curettage (D&C), improve infertility evaluation, and provide cost-effective care.

2. Indications

Diagnostic Hysteroscopy

  • Abnormal uterine bleeding (AUB)
  • Postmenopausal bleeding
  • Infertility/subfertility (cavity & tubal ostia assessment)
  • Suspected intrauterine pathology on ultrasound (polyp, fibroid, adhesions, septum)
  • Recurrent miscarriage (uterine anomalies)
  • Lost IUCD / foreign body

Operative Hysteroscopy

  • Polypectomy
  • Submucous fibroid resection (type 0–I)
  • Adhesiolysis (Asherman’s syndrome)
  • Septum resection
  • IUCD/foreign body removal
  • Endometrial ablation (selected cases; not routine in Bangladesh yet)

Office Hysteroscopy

  • Diagnostic evaluation for AUB, infertility, miscarriage
  • Directed endometrial biopsy
  • Small polyp removal (<1–2 cm)
  • IUCD removal
  • Cavity check after adhesiolysis/septum surgery

3. Contraindications

  • Active pelvic infection
  • Heavy bleeding at procedure time (poor visualization)
  • Suspected pregnancy
  • Known gynecological malignancy (perform diagnostic hysteroscopy cautiously for biopsy)

4. Pre-Procedure Requirements

  • History & exam: Exclude pregnancy/infection
  • Imaging: TVS or SIS for mapping pathology
  • Counseling & consent: Explain risks (pain, infection, perforation, bleeding, rare fluid overload); use Bangla consent forms for accessibility
  • Antibiotics: Not routine unless infection risk
  • Cervical prep: Misoprostol (200 mcg orally/vaginally) in nulliparous or stenosed cervix

5. Technique (Office Hysteroscopy)

  • Setting: Outpatient room with aseptic facilities
  • Equipment:
    • Rigid hysteroscope 2.9–3.5 mm with 5 Fr channel, 30° optics
    • Saline distension medium (safe, cheap, widely available)
    • Infusion pump/pressure bag
    • Graspers, scissors, bipolar electrodes for minor work
  • Anesthesia: None in most cases; NSAID or paracervical block if needed
  • Technique:
    • Vaginoscopic “no-touch” approach improves comfort
    • Continuous-flow saline distension
    • Systematic cavity exam: cervix → cavity → endometrium → tubal ostia
    • Minor procedures (biopsy, polyp removal) under direct vision

6. Safety & Complications

  • Possible complications: Uterine perforation, infection, fluid overload (rare with saline), bleeding, vasovagal attack
  • Prevention:
    • Small-diameter scopes
    • Low-pressure distension (50–80 mmHg)
    • Stop if vision lost or cavity not distending
    • Monitor input/output if large fluid volumes used
  • Management:
    • Suspected perforation → stop, monitor, admit if major, surgical repair if bleeding/visceral injury
    • Infection → antibiotics
    • Fluid overload → diuretics & electrolyte correction

7. Post-Procedure Care

  • Most office cases discharged in 30–60 minutes
  • Mild pain/spotting is common
  • Warning signs: fever, heavy bleeding, severe abdominal pain
  • Pathology samples must be documented

8. Systems & Implementation (Bangladesh Context)

  • Promote office hysteroscopy to reduce D&C and anesthesia risks
  • Training: Simulation + supervised procedures before independent practice
  • Facilities: Each district hospital should have one hysteroscope and saline system
  • Cost-effectiveness: Reusable scopes & bipolar energy are sustainable
  • Awareness: Educate patients/physicians that office hysteroscopy is safer & more informative than blind D&C

9. Documentation & Audit

  • Record indication, findings (draw cavity map/images), procedures, complications
  • Audit outcomes: success rate, complication rate, patient satisfaction, reduction of D&C

References

  1. RCOG Green-top Guideline No. 59 — Best practice in outpatient hysteroscopy
  2. ESGE/ESMO Position statements on office hysteroscopy (2015–2021 updates)
  3. AAGL Practice Report: Practice guidelines for the management of hysteroscopic procedures
  4. Kriplani A, Agarwal N, et al. “Office hysteroscopy in low-resource settings: experience and adaptations.” Int J Gynecol Obstet

Compiled By:

Dr. Reshma Sharmin


Contributors :

  1. Prof Fawzia Hossain
  2. Dr Maruf Siddique
  3. Dr Tanzeem Sabina Chowdhury
  4. Dr Sumaiya Binte Asif
  5. Dr Taslima Akter
  6. Dr Maniza Khan
  7. Dr Amena Fardous
  8. Dr Tanjila Karim
  9. Dr Runa Akhter Dola
  10. Dr Polly Ahmed