**1. Introduction**

Hysteroscopy represents the endoscopic gynaecological examination of the endometrial cavity and denotes one of the most frequent investigations in gynaecology today, used in the diagnostic work up of abnormal uterine bleeding, postmenopausal bleeding and subfertility. The National Institute for Health and Care Excellence recommends an enhanced role of outpatient hysteroscopy in the diagnostic workup of heavy menstrual bleeding, leading to increase in the number of hysteroscopies being performed each year [1, 2]. Abnormal uterine bleeding in both the premenopausal and postmenopausal women is the commonest indication for diagnostic hysteroscopy. Similarly endometrial polyp is the most frequent preoperative indication for operative hysteroscopy followed by submucosal leiomyoma [3]. In a retrospective clinical study of 397 patients, dilatation and curettage failed to identify pathology in 62.5% cases subsequently found at hysterectomy within

2 months [4]. A large clinical observational study demonstrated that up to 3.7 cm pathology could be safely treated by office hysteroscopy without anaesthesia [5]. Paracervical block is however commonly used for operative hysteroscopy where cervical dilatation is required [6].

During hysteroscopy it is recommended to provide the patient with emotional support ("local-vocal"), by chatting to her and offering her to look at the monitor while explaining the findings to her in order to avoid feeling of exclusion. Dedicated nursing and healthcare assistant staff is crucial in ambulatory setting. It is recommended for patients to take 400 mg of ibuprofen or another NSAID approximately 1 hour before the procedure.

#### **2. Vaginoscopy**

The traditional approach to hysteroscopy is by utilising a vaginal speculum with or without manipulation of the cervix.

Vaginoscopy refers to a method where the hysteroscope is guided into the uterus without having to use the potentially painful vaginal instruments. The availability of miniature hysteroscopes has facilitated this development. A randomised controlled multicentre trial in the UK concluded that vaginoscopy is quicker to perform, less painful, and more successful than standard hysteroscopy and therefore should be regarded as the technique of choice for outpatient hysteroscopy [7, 8].

### **3. Outpatient diagnostic hysteroscopy**

#### **3.1 Abnormal uterine bleeding (AUB) in women of reproductive age group**

The hysteroscopy has been gold standard in the examination of the endometrial cavity in ladies with abnormal uterine bleeding for several years. In the UK, the national best practice recommendation is that all gynaecology departments should offer dedicated outpatient hysteroscopy facility to support the diagnosis and treatment of ladies with abnormal uterine bleeding. The advances in outpatient hysteroscopy have further powered the use of this facility, and it is not required any more to put patients through general anaesthesia for this purpose [9]. In most women, the diagnosis for abnormal uterine bleeding can be made in the outpatient clinic with one-stop approach with a host of other investigations, including blood tests, pelvic ultrasound, outpatient hysteroscopy and endometrial biopsy. The prompt diagnosis permits timely treatment, avoiding unnecessary delays and patient anxiety [10].

A large number of women presenting with AUB belong to the reproductive age group. The causative factors may be structural abnormalities such as endometrial polyps or fibroids or ovulatory dysfunction and primary disorder of endometrium as described in the PALM-COEIN classification (**Figure 1**). These abnormalities can be readily diagnosed in outpatient setting by ambulatory hysteroscopy with or without endometrial biopsy [11–13]. **Figure 2** shows office hysteroscope with different channels for diagnosis as well as removal of pathology.

#### **3.2 Perimenopausal bleeding**

For women in this age group presenting with new onset abnormal uterine bleeding, organic pathology, such as atypical hyperplasia or endometrial cancer, must be ruled out as anovulatory cycles and sinister pathology can coexist, in this cohort of women (**Figure 3**).

*Advances in Outpatient Hysteroscopy DOI: http://dx.doi.org/10.5772/intechopen.97093*

**Figure 1.**

*FIGO classification of PALM-COEIN system. Abbreviation: FIGO, International Federation of Gynaecology and Obstetrics.*

**Figure 2.** *Omni-myosure (HOLOGIC).*

Endorsed pelvic ultrasound scan as the first-line tool for identifying structural abnormalities. Hysteroscopy remains the gold standard for precise evaluation of endometrial cavity. Indications for endometrial biopsy include women ≥45 years of age, failed or ineffective treatment, persistent intermenstrual bleeding and coexistence of risk factors demonstrated in **Figure 2**.

### **3.3 Postmenopausal bleeding**

Hysteroscopy is established as the gold standard in the evaluation of AUB in postmenopausal women, eliminating the false-negative results of blind biopsy by direct visualisation of the endometrial cavity and enabling targeted biopsy if warranted [14]. It allows full visualisation of the endocervix, endometrial cavity and tubal ostia, permitting diagnosis of endometrial lesions that may be missed with blind endometrial sampling, TVS or even saline infusion sonography (SIS). Moreover, vaginoscopic technique to perform office hysteroscopy can also be employed for careful examination of possible vaginal and cervical lesion that may be responsible for abnormal uterine bleeding. This approach also reduces discomfort in women, including virgins, older women and those with moderate stenosis of the cervical os who would have required general anaesthesia otherwise.

**Figure 3.**

*Risk factors for endometrial cancer. Abbreviations: PCOS, polycystic ovarian syndrome; HNPCC, hereditary non-polyposis colorectal cancer.*

The sensitivity, specificity and high precision of hysteroscopy are well established. With miniaturisation of hysteroscopes and newer treatment techniques such as bipolar devices and hysteroscopic tissue removal systems, outpatient hysteroscopy is no longer just a diagnostic test but can offer one stop treatment to women presenting with AUB [15–17].
