How to Overcome a Resistant Cervix for Hystero Scopy and Endometrial Biopsy

Home , Cervical canal, Dilation and curettage, Endometrial biopsy, Tenaculum

Joan M.G. Crane, MD, MSc How to overcome a resistant Dr. Crane is Associate Professor of Obstetrics and Gynecology at Memorial cervix for hystero scopy and University, St. John’s, Newfoundland. The author reports no fi nancial endometrial biopsy relationships relevant to this article.` A cervix that impedes access to the uterus can lead to severe pain, cervical laceration, and other ills

CASE Difﬁ culty inserting a catheter In this article, I describe ways to suggests an unyielding cervix overcome the challenging cervix for hysteroscopic procedures and endometrial ® Dowdenbiopsy (TABLES Health 1 and 2, pages Media 38 and 40). A.W. is a 38-year-old nulliparous woman who seeks treatment for persistent irregular vaginal bleeding. Her physician attemptsCopyright an endome-For personalHysteroscopy use failureonly rate: trial biopsy in the offi ce but is unable to pass the 3.4% to 4.2% catheter through the internal cervical os. She Hysteroscopy is, of course, common schedules offi ce hysteroscopy as follow-up. in gynecologic practice, its indications What steps can the ObGyn take to re- extending across a range of investiga- IN THIS ARTICLE duce the diffi culty of the procedure, particu- tions and treatments—for menstrual larly insertion of the hysteroscope through disorders, postmenopausal bleeding, ❙ Mechanical dilation the cervical canal? infertility, and recurrent pregnancy is one antidote loss.1,7 Flexible hysteroscopes range in to cervical stenosis uccessful hysteroscopy requires diameter from 2.7 to 5 mm; rigid hys- Page 43 a cervical canal suffi ciently di- teroscopes, from 1 to 5 mm; and opera- ❙ S lated to allow passage of the tive hysteroscopes can be as large as 8 How to prime hysteroscope. And because of inevita- to 10 mm.2,7 the cervix for ble variation in anatomy—and even in A systematic review of diagnos- hysteroscopy models of hysteroscopes, which range tic hysteroscopy in more than 26,000 Page 43 in diameter from 2.7 to 10 mm—pas- women reported a failure rate of 4.2% sage is not always easily accomplished. for ambulatory hysteroscopy and 3.4% ❙ Ultrasonography Many of the complications related to for inpatient procedures.4 Failed ambu- may help guide hysteroscopy, including cervical tears, latory procedures were mainly attribut- dilation creation of a false passage, uterine per- ed to technical problems, including: Page 44 foration, vasovagal reaction, pain, and • cervical stenosis inability to complete the procedure, are • anatomic and structural caused by inadequate cervical dilation abnormalities and an inability to insert the hystero- • pain and intolerance.4 scope.1–6 One study noted that almost Ideally, hysteroscopy is performed half of complications were related to with minimal or no cervical dilation,7 cervical entry.6 but this may not always be possible. CONTINUED www.obgmanagement.com November 2007 • OBG MANAGEMENT 37

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TABLE 1 information on pregnancies, dilation and 10 actions that can ease curettage, cervical procedures such as entry to the cervix for hysteroscopy cryotherapy, and any other procedures that may increase the risk of cervical ste- ACTION COMMENTS nosis, or diffi culty dilating the cervix. Take a careful history and perform Identify risk factors for cervical Is stenosis present? Stenosis is most a rigorous physical exam stenosis and assess cervical/uterine position common in nulliparous and postmenopausal women and in those who have Administer an oral nonsteroidal Helps to reduce discomfort, undergone cervical procedures such as anti-inﬂ ammatory drug 60 minutes especially postprocedure pain before the procedure cryotherapy. Stenosis increases the risk of laceration and uterine perforation. Provide an anxiolytic or conscious Consider this option for women Consider a mechanical dilator. When cer- sedation, or both who are very anxious or unlikely to vical dilation is diffi cult, a series of small tolerate pain, especially for operative procedures Hagar or lacrimal duct dilators may be helpful (FIGURE, page 43). Use a tenaculum Consider if the uterus is not in the axial position

Use Hagar dilators or a lacrimal May be helpful if mechanical dilation Pain can be mild— duct probe is necessary or it can thwart your work

Proceed under ultrasonographic Consider transabdominal imaging to Although many women tolerate place- guidance help guide cervical dilation in diffi cult ment of a small hysteroscope without cases, e.g., when the patient has a analgesia or anesthesia, pain and vasova- history of uterine perforation gal reaction sometimes occur. Indeed, the Opt for a smaller hysteroscope A smaller scope will require less level of pain experienced by the patient is cervical dilation a major determinant of the overall suc- cess of the procedure.3,8–10 Pain can occur Administer a paracervical block Consider this option if cervical dilation is expected to be diffi cult, when a tenaculum is used to grasp the especially in women at risk of anterior cervix, as well as during cervi- signifi cant pain. Be alert for cal dilation, injection of local anesthetic, complications such as bleeding, or insertion of the hysteroscope. In some discomfort at the time of injection, and intravascular injection leading cases, a smaller scope may be all that is 11 to bradycardia and hypotension needed to solve the problem.

Administer a topical cervical May be appropriate when Analgesia may not always anesthetic a tenaculum is used be necessary Give misoprostol to prime Consider giving 400 μg of intravaginal Some researchers have studied offi ce hys- the cervix misoprostol 9 to 12 hours preopera- teroscopy without analgesia or anesthe- tively in premenopausal women, par- sia, fi nding a high level of acceptance.12,13 ticularly nulliparous women and those undergoing operative hysteroscopy Others have found a signifi cant percent- age of women requesting anesthesia or analgesia (16.5%)10 or requiring local Things to consider before embarking anesthesia (28.8%).8 Close attention to cervical and uterine Preoperative NSAIDs may sufﬁ ce. Use anatomy is critical because insertion of of oral nonsteroidal anti-infl ammatory the hysteroscope can be the most diffi cult drugs (NSAIDs) 1 hour before offi ce aspect of the procedure. A bimanual ex- hysteroscopy may reduce intraopera- amination is imperative to assess uterine tive and postoperative pain.7 Nagele and size and position. It also is useful to sound colleagues8 compared use of mefenamic the uterus to determine its depth. acid 1 hour before the procedure with An accurate medical, gynecologic, and placebo in 95 women undergoing outpa- obstetric history is essential, including tient diagnostic hysteroscopy. Mefenamic

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TABLE 2 injection of the paracervical block, as well 6 ways to prepare the cervix as bradycardia and hypotension possibly for endometrial biopsy secondary to intravascular injection.17

ACTION COMMENTS Other methods are inconsistent Take a careful history and perform Identify risk factors for cervical Intracervical injection. Some research- a thorough physical examination stenosis and assess uterine position ers have recommended injection of local Administer an oral nonsteroidal Helps to reduce discomfort, anesthetic into the cervix.13 One study anti-inﬂ ammatory drug 60 minutes especially postprocedure pain found no benefi t—in fact, the injection prior to biopsy appeared to be the most painful part of 18 Use a tenaculum May be helpful if the uterus/cervix the procedure. A case series suggested is not in the axial position that injection of local anesthetic may be effective, but the series lacked a placebo Apply a topical cervical anesthetic May help alleviate discomfort 13 associated with use of a tenaculum or control arm. Topical intrauterine anesthetic has been Use Hagar dilators or lacrimal Provide mechanical dilation investigated after administration through duct probes the channel of the hysteroscope or by a Use the smallest biopsy Reduces degree of cervical dilation catheter passed through the cervix into catheter possible necessary the uterine cavity.13 Findings have been mixed, with some researchers demon- strating reduced pain19,20 and others acid reduced pain at 30 and 60 minutes showing no relief.21 after—but not during—the procedure. Topical cervical anesthesia. Some hys- Other studies have found that pain is re- teroscopists have recommended appli- duced when an oral NSAID is taken 1 to cation of anesthetic cream, gel, or spray 2 hours before insertion of an intrauterine directly to the cervix immediately before device and before suction curettage.14,15 the procedure.13,22 The results have been Other perioperative medications mixed, with some studies noting decreased FAST TRACK may help reduce discomfort and patient pain overall,13 one fi nding decreased pain Mefenamic acid anxiety, including anxiolytics, such as only during tenaculum placement,22 and lorazepam, analgesics, and conscious others fi nding no signifi cant reduction in reduced pain at sedation.3 pain any time during the procedure.13,23,24 30 and 60 minutes A review concluded that topical cervical after—but not Paracervical block may be lignocaine spray may reduce the discom- during—diagnostic appropriate when pain is very likely fort of tenaculum placement.13 hysteroscopy A number of investigators have evaluated use of paracervical anesthesia during out- Topical anesthesia may patient hysteroscopy.9,13,16,17 They injected minimize vasovagal reaction lignocaine or mepivacaine using a 21- or In one study, 1.1% of women undergo- 22-gauge needle at 3, 5, 7, and 9 o’clock ing offi ce hysteroscopy experienced a va- or 4 and 8 o’clock paracervically.13 One sovagal reaction, caused by stimulation study found paracervical block to be ef- of the parasympathetic nervous system fective in reducing the pain of tenaculum with cervical manipulation and passage placement and insertion of the hystero- of the scope through the internal os of scope.17 However, some studies suggested the cervix.25 The reaction led to hypo- a reduction of pain in postmenopausal tension and bradycardia. Several studies women only.9 These women may be more have suggested that a local anesthetic can likely to have cervical stenosis. reduce this complication.19,20 Paracervical block does pose a risk Cicinelli and associates found that of complications. Studies have reported topical local anesthesia reduced the inci- bleeding in some women16 and pain with dence of vasovagal reaction from 32.5% CONTINUED

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FIGURE in the control arm to 5%.20 They suggest that a local anesthetic be considered in Mechanical dilation is one antidote selected women, such as postmenopausal to cervical stenosis patients, who are at increased risk of vasovagal attack. In contrast, Lau and associates17 found an increased rate of bradycardia and hypotension with paracervical lignocaine (31% versus 10%), but it may have been caused by inadvertent intravascular injection.17 Researchers have also suggested that the use of smaller hysteroscopes may reduce the incidence of vasovagal reactions.26

How to prime the cervix for hysteroscopy The use of vaginal misoprostol, a prosta-

glandin E1 analogue, 9 to 12 hours before hysteroscopy may help increase prepro- In challenging cases, such as cervical stenosis, mechanical dilation with a series of Hagar or lacrimal duct dilators may facilitate entry into the cervix. cedural cervical dilation in premenopausal women, especially in nulliparas and women undergoing operative hys- dilation, compared with 71.7% in the teroscopy. Misoprostol, used to prevent control group, and 2% of premenopausal and treat NSAID-induced gastric ulcers, women given misoprostol suffered cervi- is gaining favor as a cervical ripening cal laceration, compared with 11% in the agent. We performed a meta-analysis to control group. Among postmenopausal FAST TRACK assess its effectiveness in dilating the cer- women and those receiving a GnRH ago- Misoprostol lacked vix and reducing the need for mechanical nist, misoprostol lacked clear benefi t and dilation.5 was associated with side effects such as clear beneﬁ t among We identifi ed 10 studies that met nausea, diarrhea, abdominal cramping, postmenopausal inclusion criteria; fi ve of them included and fever. women and those premenopausal women, four included For every premenopausal woman receiving a GnRH postmenopausal women or women re- who received misoprostol before hyster- agonist ceiving a gonadotropin-releasing hor- oscopy, one woman avoided the need for mone (GnRH) agonist, and one study in- further cervical dilation. For every 12 pre- cluded both groups.5 A variety of dosing menopausal women receiving misopros- protocols were used, with dosages rang- tol, one cervical laceration was avoided. ing from 100 μg to 1,000 μg of intravag- The ideal dosing regimen could not inal or oral misoprostol 4 to 24 hours be determined because of variations preoperatively (most studies evaluated in protocols. Nor was it clear whether the vaginal route). misoprostol had any benefi t among post- We found that misoprostol signifi - menopausal women or those receiving a cantly reduced the need for further cer- GnRH agonist. vical dilation, and was associated with a Most studies of misoprostol for cer- lower rate of cervical laceration. How- vical ripening have involved intravaginal

Flewell ever, this was true only for the premeno- administration, with dosages of 200 μg Rob

2007 women given misoprostol needed further teroscopy showing the greatest benefi t. CONTINUED

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Ultrasonography the uterine cavity. Another rare complica- may help guide dilation tion is uterine perforation.29 Transabdominal ultrasonography has As with hysteroscopy, many of these been used to guide dilation in diffi cult complications are related to diffi culty dilation and curettage procedures, and is entering the uterine cavity through the especially useful in women with a history cervix. of uterine perforation.27 It may be helpful in cases involving diffi cult cervical dila- Prerequisites include thorough tion during hysteroscopy or endometrial assessment of the uterus biopsy. As with hysteroscopy, an accurate and de- Steady the cervix. A tenaculum is not al- tailed history is necessary to identify risk ways required, but its use on the anterior factors for a diffi cult procedure. Assess lip of the cervix may help steady the cer- uterine size and position with a bimanual vix and provide countertraction during examination. Although a tenaculum is insertion of the hysteroscope through the often unnecessary, its placement on the cervical canal, especially if the cervix is anterior lip of the cervix may help steady not in an axial position.7 the cervix and allow the catheter to pass through the cervical canal into the uter- CASE Resolved! ine cavity, especially if the uterus is not in the axial position.28,29 Again, it is useful Because she is nulliparous and may benefi t to sound the uterine cavity to ascertain its from cervical priming, the patient is given 400 depth. This may be done with the biopsy μg of intravaginal misoprostol 12 hours before catheter. hysteroscopy, as well as an oral NSAID 1 hour before the procedure. A bimanual examination Cervical dilation may be necessary reveals a sharply anteverted uterus, so a topi- Even when women with cervical steno- cal cervical anesthetic spray is applied to the sis were excluded in one study, it was anterior cervix, and a tenaculum is placed to diffi cult to pass the Pipelle endometrial FAST TRACK help straighten the uterine position. The hys- biopsy through the cervix in 41.7% of Almost 50% of teroscope passes easily through the cervical women.30 canal, making further dilation unnecessary. If the sampling device does not pass women experience The procedure is completed without diffi culty easily through the cervix, use a tenacu- moderate or severe and is well tolerated by the patient. lum and a lacrimal duct probe or small pain during Hagar dilators to dilate the cervix.28 endo metrial biopsy Difﬁ cult entry can also Pain may again be an issue hamper endometrial biopsy Almost 50% of women experience mod- Every ObGyn has used endometrial bi- erate or severe pain during endometrial opsy to assess abnormal uterine bleeding, biopsy.32 Many clinicians recommend postmenopausal bleeding, infertility, or giving an oral NSAID 60 minutes before recurrent pregnancy loss, or to monitor the procedure to decrease discomfort. women on hormone replacement ther- One study found that the use of naproxen apy28,29—so its advantages over dilation sodium before Vabra curettage reduced and curettage should come as no surprise. the severity of pain at 30 and 60 minutes They include the ability to perform it in an after the procedure, but did not alleviate offi ce setting, usually with minimal cervi- discomfort arising during the biopsy it- cal dilation, often without anesthesia, and self.14 Another study suggested the com- at less expense.28 Complications include bination of naproxen sodium and intra- cramping and pain,29–32 vasovagal reac- uterine lidocaine (5 mL of 2% lidocaine) tion,29 bleeding,29 and inability to pass the to reduce discomfort associated with the biopsy catheter through the cervix into procedure.30

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444_OBGM11074_OBGM1107 44 10/22/07 8:34:09 AM Use of anesthesia is controversial References A study by Lau and colleagues17 found 1. Bradley LD. Complications in hysteroscopy: pre- vention, treatment and legal risk. Curr Opin Obstet paracervical lignocaine to be ineffective Gynecol. 2002;14:409–415. at reducing pain during hysteroscopy 2. American College of Obstetricians and Gynecolo- and endometrial biopsy, but the drug did gists. ACOG technology assessment in obstetrics increase the risk of bradycardia and hy- and gynecology, number 4, August 2005: hysteroscopy. Obstet Gynecol. 2005;106:439–442. potension. Another study demonstrated a 3. Vilos GA, Abu-Rafea B. New developments in am- decrease in procedure-related discomfort bulatory hysteroscopic surgery. Best Pract Res Clin in postmenopausal women who were Obstet Gynaecol. 2005;19:727–742. given 2 mL of 2% intrauterine mepi- 4. Clark TJ, Voit D, Gupta JK, Hyde C, Song F, Khan KS. Accuracy of hysteroscopy in the diagnosis of 20 vacaine. These fi ndings are similar to endometrial cancer and hyperplasia: a systematic those of Zupi and associates.19 quantitative review. JAMA. 2002;288:1610–1621. 5. Crane JM, Healey S. Use of misoprostol before hysteroscopy: a systematic review. J Obstet Gyn- Consider the tool aecol Can. 2006;28:373–379. Discomfort may be related to the size of 6. Jansen FW, Vredevoogd CB, van Ulzen K, Hermans the biopsy catheter. Pain scores appear to J, Trimbos JB, Trimbos-Kemper TC. Complications of hysteroscopy: a prospective, multicenter study. be signifi cantly lower with the Pipelle bi- Obstet Gynecol. 2000;96:266–270. opsy catheter than with the larger Novak 7. Guido R, Stovall D. Hysteroscopy Version 14.3. Up- biopsy curette.32 ToDate [cited February 15, 2007]; Available from: www.uptodate.com. 8. Nagele F, Lockwood G, Magos AL. Randomised Vasovagal reaction usually placebo controlled trial of mefenamic acid for resolves after the procedure premedication at outpatient hysteroscopy: a pilot As with hysteroscopy, women may oc- study. Br J Obstet Gynaecol. 1997;104:842–844. 9. Cicinelli E, Didonna T, Schonauer LM, Stragapede casionally experience a vasovagal reac- S, Falco N, Pansini N. Paracervical anesthesia for tion during endometrial biopsy. This hysteroscopy and endometrial biopsy in postmenopausal women. A randomized, double-blind, place- complication usually resolves quickly bo-controlled study. J Reprod Med. 1998;43:1014– once the procedure is completed.29 Some 1018. clinicians suggest that the patient be al- 10. De Iaco P, Marabini A, Stefanetti M, Del Vecchio C, Bovicelli L. Acceptability and pain of outpatient FAST TRACK lowed to eat and drink before the proce- hysteroscopy. J Am Assoc Gynecol Laparosc. dure and be given an analgesic before it 2000;7:71–75. Pain scores appear begins.28 11. Marsh F, Jackson T, Duffy S. A case controlled study comparing 3.6 mm and 3.1 mm fl exible hys- to be signiﬁ cantly teroscopes. Gynaecol Endosc. 2002;11:393–396. lower with the Cervical priming 12. Lau WC, Ho RY, Tsang MK, Yuen PM. Patient's ac- is not a proven strategy ceptance of outpatient hysteroscopy. Gynecol Ob- Pipelle biopsy Misoprostol has been considered as a stet Invest. 1999;47:191–193. catheter than with preprocedure adjunct to endometrial 13. Hassan L, Gannon MJ. Anaesthesia and analgesia for ambulatory hysteroscopic surgery. Best Pract the larger Novak biopsy. Only one small randomized, Res Clin Obstet Gynaecol. 2005;19:681–691. biopsy curette controlled trial involving 42 women has 14. Siddle NC, Young O, Sledmere CM, Reading AE, evaluated the drug for this indication. It Whitehead MI. A controlled trial of naproxen sodium for relief of pain associated with Vabra suction cu- found no benefi t when 400 μg of miso- rettage. Br J Obstet Gynaecol. 1983;90:864–869. prostol was given orally 3 hours before 15. Edgren RA, Morton CJ. Naproxen sodium for Ob/ the procedure, as well as cramping and Gyn use, with special reference to pain states: a review. Int J Fertil. 1986;31:135–142. increased pain during the biopsy.33 This 16. Giorda G, Scarabelli C, Franceschi S, Campagnutta study had several shortcomings, includ- E. Feasibility and pain control in outpatient hyster- ing its small sample size and the inclu- oscopy in postmenopausal women: a randomized trial. Acta Obstet Gynecol Scand. 2000;79:593– sion of both pre- and postmenopausal 597. women. Further research is needed— 17. Lau WC, Lo WK, Tam WH, Yuen PM. Paracervi- separately in premenopausal and post- cal anaesthesia in outpatient hysteroscopy: a randomised double-blind placebo-controlled trial. Br J menopausal women and with adequate- Obstet Gynaecol. 1999;106:356–359. ly large samples—to assess the use of 18. Broadbent JA, Hill NC, Molnar BG, Rolfe KJ, Magos misoprostol. ■ AL. Randomized placebo controlled trial to assess

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the role of intracervical lignocaine in outpatient INSTANT POLL hysteroscopy. Br J Obstet Gynaecol. 1992;99:777– 779. RESULTS 19. Zupi E, Luciano AA, Valli E, Marconi D, Maneschi F, Romanini C. The use of topical anesthesia in diagnostic hysteroscopy and endometrial biopsy. Fertil Here’s how your peers voted Steril. 1995;63:414–416. 20. Cicinelli E, Didonna T, Ambrosi G, Schonauer LM, Fiore G, Matteo MG. Topical anaesthesia for di- Which statement best describes agnostic hysteroscopy and endometrial biopsy in postmenopausal women: a randomised placebo- how you use a uterotonic to manage controlled double-blind study. Br J Obstet Gynae- col. 1997;104:316–319. the third stage of labor? 21. Lau WC, Tam WH, Lo WK, Yuen PM. A randomised double-blind placebo-controlled trial of transcervi- cal intrauterine local anaesthesia in outpatient hys- I administer 5-10 U teroscopy. BJOG. 2000;107:610–613. of oxytocin as an 22. Davies A, Richardson RE, O’Connor H, Bas- IV bolus—routinely kett TF, Nagele F, Magos AL. Lignocaine aerosol spray in outpatient hysteroscopy: a randomized double-blind placebo-controlled trial. Fertil Steril. I administer a uterotonic 1997;67:1019–1023. only if an oxytocin solution 0% 23. Clark S, Vonau B, Macdonald R. Topical anaesthe- was used before delivery sia in out-patient hysteroscopy. Gynaecol Endosc. 1996;5:141–144. 7% 24. Wong AY, Wong K, Tang LC. Stepwise pain score I don’t administer 21% analysis of the effect of local lignocaine on outpa- a uterotonic routinely tient hysteroscopy: a randomized, double-blind, after delivery placebo-controlled trial. Fertil Steril. 2000;73:1234– 1237. 25. Bellingham FR. Outpatient hysteroscopy—prob- 72% lems. Aust N Z J Obstet Gynaecol. 1997;37:202– I administer a solution 205. of 20 U of oxytocin 26. Cicinelli E, Schonauer LM, Barba B, Tartagni M, Luisi in 1,000 mL of fl uid as D, Di Naro E. Tolerability and cardiovascular com- an IV drip—routinely plications of outpatient diagnostic minihysteros- copy compared with conventional hysteroscopy. J Am Assoc Gynecol Laparosc. 2003;10:399–402. From: May 2007 OBG MANAGEMENT FAST TRACK 27. Hunter RE, Reuter K, Kopin E. Use of ultrasonography in the diffi cult postmenopausal dilation and The underneath curettage. Obstet Gynecol. 1989;73:813–816. on the dock for a 28. Guido R, Stovall D. Endometrial sampling proce- Will you make Implanon* part dures Version 14.3. UpToDate [cited February 15, the purple situation 2007]; Available from: www.uptodate.com. whereof yourplay. practice? 29. Cooper JM, Erickson ML. Endometrial sampling techniques in the diagnosis of abnormal uterine bleeding. Obstet Gynecol Clin North Am. Yes. 2000;27:235–244. I have taken the training program 30. Dogan E, Celiloglu M, Sarihan E, Demir A. Anes- and am certifi ed to insert the device thetic effect of intrauterine lidocaine plus naproxen sodium in endometrial biopsy. Obstet Gynecol. 2004;103:347–351. 45% Yes. 31. Trolice MP, Fishburne C Jr, McGrady S. Anesthetic effi cacy of intrauterine lidocaine for endometrial I plan to be trained biopsy: a randomized double-masked trial. Obstet to insert Implanon Gynecol. 2000;95:345–347. 40% 32. Silver MM, Miles P, Rosa C. Comparison of Novak and Pipelle endometrial biopsy instruments. Obstet Gynecol. 1991;78:828–830. No. I do not plan 15% 33. Perrone JF, Caldito G, Mailhes JB, Tucker AN, Ford WR, London SN. Oral misoprostol before offi ce to be trained to endometrial biopsy. Obstet Gynecol. 2002;99:439– insert Implanon 444.

From: June 2007 OBG MANAGEMENT

* long-term progestin contraceptive

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