In addition to these evidence-based recommendations, the guideline developer also identifies points of best clinical practice in the original guideline document.
Classification of evidence levels (1++ to 4) and grades of recommendations (A-D) are defined at the end of the "Major Recommendations" field.
What Is the Ideal Setting for Performing Hysteroscopy?
A - 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.
Do Analgesics Given Before Diagnostic Hysteroscopy Reduce the Pain Felt by Women during the Procedure?
B - Routine use of opiate analgesia before outpatient hysteroscopy should be avoided as it may cause adverse effects.
B - 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 aim of reducing pain in the immediate postoperative period.
Does Cervical Preparation Reduce Uterine Trauma, Failure to Access the Uterine Cavity or Pain Associated with Outpatient Hysteroscopy?
A - 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
What Size and Angle of Hysteroscope Should Be Used in the Outpatient Setting?
A - Miniature hysteroscopes (2.7 mm with a 3–3.5 mm sheath) should be used for diagnostic outpatient hysteroscopy as they significantly reduce the discomfort experienced by the woman.
Should Rigid or Flexible Hysteroscopes Be Used Routinely in the Outpatient Setting?
B - Flexible hysteroscopes are associated with less pain during outpatient hysteroscopy compared with rigid hysteroscopes. However, rigid hysteroscopes may 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.
Operative outpatient hysteroscopy using miniature mechanical and electrosurgical equipment is becoming more established. These technologies generally require the use of rigid hysteroscopies. Units offering both hysteroscopic diagnosis and treatment in the outpatient setting should consider the versatility of respective hysteroscopes and relative resource implications when planning the composition of endoscopic equipment.
Which Uterine Distension Medium Should Be Used During Outpatient Hysteroscopy?
A - 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.
A - Uterine distension with normal saline allows improved image quality and allows outpatient diagnostic hysteroscopy to be completed more quickly compared with carbon dioxide.
Local Anaesthesia and Cervical Dilatation
Should Routine Dilatation of the Cervical Canal Be Used Before Insertion of the Hysteroscope in an Outpatient Setting?
C - 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.
Should Topical Local Anaesthetic Be Administered before Outpatient Hysteroscopy?
A - Instillation of local anaesthetic into the cervical canal does not reduce pain during diagnostic outpatient hysteroscopy but may reduce the incidence of vasovagal reactions.
A - Topical application of local anaesthetic to the ectocervix should be considered where application of a cervical tenaculum is necessary.
Should Injectable Local Anaesthetic Be Administered to the Cervix and/or Paracervix before Outpatient Hysteroscopy?
A - 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.
A - Routine administration of intracervical or paracervical local anaesthetic is not indicated to reduce the incidence of vasovagal reactions.
Should Conscious Sedation Be Used to Reduce Pain Associated with Outpatient Hysteroscopic Procedures?
A - Conscious sedation should not be routinely used in outpatient hysteroscopic procedures as it confers no advantage in terms of pain control and the woman's satisfaction over local anaesthesia.
Does a Vaginoscopic Approach to Outpatient Hysteroscopy Reduce Pain and Increase the Feasibility of the Procedure?
A - Vaginoscopy reduces pain during diagnostic rigid outpatient hysteroscopy.
Grades of Recommendations
A - At least one meta-analysis, systematic review or randomised controlled trial rated as 1++, and directly applicable to the target population; or
A systematic review of randomised controlled trials or a body of evidence consisting principally of studies rated as 1+, directly applicable to the target population and demonstrating overall consistency of results
B - A body of evidence including studies rated as 2++ directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C - A body of evidence including studies rated as 2+ directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D - Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Good Practice Point - Recommended best practice based on the clinical experience of the guideline development group
Classification of Evidence Levels
1++ High-quality meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a very low risk of bias
1+ Well-conducted meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a low risk of bias
1– Meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a high risk of bias
2++ High-quality systematic reviews of case–control or cohort studies or high-quality case–control or cohort studies with a very low risk of confounding, bias, or chance and a high probability that the relationship is causal
2+ Well-conducted case–control or cohort studies with a low risk of confounding, bias, or chance and a moderate probability that the relationship is causal
2– Case–control or cohort studies with a high risk of confounding, bias, or chance and a significant risk that the relationship is not causal
3 Non-analytical studies, e.g., case reports, case series
4 Expert opinion