Office (Awake) Hysteroscopy: Do We Really Need General Anaesthesia?
Since its introduction in 1869, hysteroscopy has become the gold standard for managing intrauterine pathology, making it the most common gynaecological surgery in Australia[1]. Traditionally, this procedure requires general anaesthesia (GA) due to its invasive and painful nature. However, advancements in medical technology and new surgical techniques now allow for hysteroscopy to be performed safely in an outpatient setting, enabling patients to remain awake and alert with minimal discomfort. This procedure is offered at Royal North Shore Hospital. Advantages of Office Hysteroscopy Over Traditional Hysteroscopy The primary benefit of office hysteroscopy (OH) is the avoidance of GA. While the risks associated with GA are rare, they can include aspiration, respiratory complications, allergic reactions, and damage to the throat or mouth. Recovery from GA typically takes 2-3 days, with potential for drowsiness, nausea, and cognitive deficits. In contrast, the risks of OH are minimal, with the main complication being vasovagal syncope from cervical stimulation. The chance of uterine perforation and cervical trauma is significantly reduced since patients can communicate when significant pain is experienced[2],[3]. Non-medical considerations favouring OH include avoiding extended time off work, carer’s leave, and driving restrictions, making it particularly advantageous for those balancing work, studies, or family commitments. Financially, OH benefits both the patient and the Australian healthcare system, eliminating day surgery admissions and anaesthetist fees[4]. The success rate of OH exceeds 95 per cent with equivalent accuracy of results. It maintains high levels of patient satisfaction, with 95 per centof women preferring to undergo OH again and 97 per cent recommending it to others4,[5]. The Patient Experience Performed in a comfortable office environment, OH reduces the anxiety often associated with surgery and hospital visits. Local anaesthetic is occasionally used if needed, but always without sedation, allowing patients to remain in control during the 15-30 minute procedure. OH is interactive; patients can choose to watch and engage in real-time discussions about their diagnosis and treatment. While mild cramps may occur, the
procedure is well-tolerated. The average pain score is just three out of 10. Indications and Suitability for Office Hysteroscopy All routine indications for hysteroscopy still apply: abnormal bleeding (heavy or irregular periods, post- menopausal bleeding), intra-uterine pathology identified via ultrasound, and fertility concerns (miscarriages, unexplained infertility). Few patients are unsuitable for OH. The development of narrow diameter hysteroscopes eliminates the need for speculums and cervical dilators, broadening access for all patients, regardless of age, nulliparity, virginity, menopause, or BMI. The use of hysteroscopic shavers means we are also not limited by number, size or type of intra-uterine pathology. However, cervical stenosis may increase failure rates, and patients with cardiovascular issues should have resuscitation equipment on standby due to the risk of cervical shock. Ultimately, patient preference is key; the only truly unsuitable candidate is one who opts for GA. Office hysteroscopy is already the standard of care in countries like the UK and USA. Australia has been slower to adopt these techniques, but Australian women have indicated their preference as they seek greater control and involvement in their healthcare decisions. Referral Pathways A pelvic ultrasound is beneficial and can aid in counselling, but it is not mandatory. Patients can be referred directly to the outpatient hysteroscopy clinic at Royal North Shore Hospital through Women’s Health Ambulatory Care. [1] Marlow JL. Media and delivery systems. Obstet Gynecol Clin North Am. 1995 Sep;22(3):409-22. [2] Bennett A, Lepage C, Thavorn K, et al. Effectiveness of outpatient versus operating room hysteroscopy for the diagnosis and treatment of uterine conditions: a systematic review and meta-analysis. J Obstet Gynaecol Can 2019;41:930–41 [3] Luerti M, Vitagliano A, Di Spiezio Sardo A, Angioni S, Garuti G, De Angelis C. Effectiveness of hysteroscopic techniques for endometrial polyp removal: The Italian Multicenter Trial. Italian School of Minimally Invasive Gynecological Surgery Hysteroscopists Group. J Minim Invasive Gynecol 2019;26:1169–76 [4] Nanayakkara P, Xiao J, Aref-Adib M, Ades A. Increasing the adoption of ambulatory hysteroscopy in Australia–cost Comparisons and patient satisfaction. J Obstet Gynaecol 2021; 1-5:509–513 [5] Kremer C, Duffy S, Moroney M. Patient satisfaction with outpatient hysteroscopy versus day case hysteroscopy: randomised controlled trial. BMJ 2000;320:279–82
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GPLink | January 2025
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