Outpatient Hysteroscopy: (Green-top Guideline no. 59).

All gynaecology departments should provide a dedicated outpatient hysteroscopy service to aid care of women and people with abnormal uterine bleeding, reproductive problems, and insertion/retrieval of intrauterine devices.

[Grade A] Written information should be provided to the woman prior to their appointment. This should include details about the procedure, the benefits and risks, advice regarding pre-operative analgesia, as well as alternative options for care and contact details for the hysteroscopy unit.

[Good Practice Point] Women should be made aware of other settings and modes of anaesthesia for hysteroscopy (e. g. under general or regional anaesthesia or intravenous sedation).

[GPP] The woman should be advised that if they find the procedure too painful or distressing at any point, they must alert the clinical team who will stop the procedure immediately.

The clinical team should alert the hysteroscopist if the woman appears to be in too much pain or is experiencing a vasovagal episode and therefore unable to voice the concerns so that the procedure can be stopped.

[GPP] Women should be advised to take standard doses of oral non-steroidal anti-inflammatory agents (NSAIDs) one hour before their scheduled appointment. Vaginoscopy should be the standard technique for outpatient hysteroscopy unless the use of a vaginal speculum is required (e. g.

for administering local cervical anaesthesia or dilating the cervix).

[Grade A] When performing operative hysteroscopy, the smallest diameter hysteroscope should be used, with consideration given to the use of hysteroscopes with expandable outer working channels because they are associated with less pain.

[Grade B] Mechanical hysteroscopic tissue removal systems should be preferred over miniature bipolar electrodes to remove endometrial polyps. [Grade A] Local anaesthesia should not be routinely administered prior to outpatient hysteroscopy where a vaginoscopic approach is used.

It should be considered where use of a vaginal speculum is planned e. g. for cervical dilatation if anticipated, due to either cervical stenosis and/or the utilisation of larger-diameter hysteroscopes (≥5mm outer diameter).

[Grade A] Saline should be instilled at the lowest possible pressure to achieve a satisfactory view. [Grade A] Conscious sedation should not be routinely used in outpatient hysteroscopic procedures. [Grade B].