• 1.

  a) T b) F c) F d) T e) F

Type I submucosal fibroids indeed have more than 50% of their volume protruding into the uterine cavity. Resection of uterine septae, type 1 or 2 submucosal fibroids, endometrial resection and correction of major Asherman’s syndrome are all classified as advanced or level 3 hysteroscopic procedures. Level 2 refers to proximal fallopian tube cannulation, removal of type 0 fibroids or large polyps and treatment of minor Asherman’s syndrome.

There is no evidence that cervical ripening is needed for diagnostic hysteroscopies but may be useful for operative hysteroscopies especially if cervical dilatation beyond 5 mm is needed (RCOG UK Best Practice in Outpatient Hysteroscopy Green-top Guideline 59, RCOG press). Jansen et al published a large Dutch national audit which looked at 11000 diagnostic and 2500 operative hysteroscopies. They reported the riskiest operative hysteroscopic procedure was adhesiolysis (complication rate – 4.5%). The morcellator is very effective for treating type 0 fibroids and the intra-cavity portion of type 1 and 2 fibroids. However due to its design it is ineffective at resecting fibroids that extend deep into the muscle.

• 2.

  a) F b) T c) T d) T e) F

Prolonged procedures certainly increase the risk of fluid absorption but there are no guidelines on the absolute operating time. Accurate measurement of the deficit rather than time taken to complete the procedure should be the focus. Hysteromats have been shown to facilitate and improve measurement of fluid deficit significantly and in so doing reduce the chances of excessive fluid absorption. Five RCTs have looked at the use of pre op GnRH analogues prior to resection. The general consensus was an overall reduction in fluid absorption which was significant in 3/5 studies. Two RCTs support the use of very dilute intracervical vasopressin just prior to dilatation as they showed a marked reduction in fluid absorbed. Fluid absorption increases as the intrauterine pressure increases.

• 3.

  a) F b) T c) F d) F e) F

The incidence is estimated to be between 0.1 to 0.2%. However, with advances in technology such as the bipolar resectoscope and morcellator devices which avoids the need to use non electrolyte (conducting) media this incidence should fall. Bipolar resectoscopes tend to produce more gas bubbles during resection which could potentially impair vision. However, the ability to use normal saline as a distension medium significantly reduces the risk of getting a fluid complication. Premenopausal woman are much more likely to develop cerebral oedema and neurological sequelae than either men or postmenopausal women. This is thought to be due to an inhibitory effect of the female sex steroid hormone on the NA+/K+ ATPase pumps which usually attempts to maintain an equilibrium between brain cells and extracellular fluid. Hyponatraemia is not a reported risk when normal saline is used as a distension medium. However, absorption of over 1litre of glycine has been shown to drop serum sodium by as much as 10mmol/L. Studies have compared the effects of local, regional and general anesthesia on fluid absorption. Conflicting results have meant no firm conclusions can be drawn.

• 4.

  a) F b) F c) F d) F e) T

When a pre-determined fluid deficit has been exceeded, the procedure should be stopped immediately. Any ongoing bleeding or hemorrhage can be managed by inserting a Foley’s catheter into the uterine cavity and inflating the balloon to act as a tamponade. This can usually be removed 6-12 hrs later. Serum sodium should be corrected slowly to prevent the risk of central pontine myelinolysis. However this is done using hypertonic (3%) saline. If the patient is asymptomatic it is reasonable to observe only and monitor electrolyte levels. However, if there have been any neurological effects or the serum sodium is less than 120mmol/L then the patient should be managed in a HDU or ICU with a multidisciplinary team. If there are signs and symptoms of fluid overload then a diuretic such as Furosemide should be given immediately and not postponed while waiting for blood results. A urinary catheter is essential to monitor urinary output

• 5.

  a) F b) T c) F d) F e) F

National datasets for surgical technologies have no denominator data to provide clear information regarding risks of complications. The surgical dictum “Primum non nocere” means first do no harm- the origin of the phrase is uncertain and it has been attributed to Hippocrates. Topical application of local anaesthetic to the ectocervix should be considered where application of a cervical tenaculum is necessary (RCOG UK Best Practice in Outpatient Hysteroscopy Green-top Guideline 59, RCOG press). MISTLETOE and the Dutch national audit (Jansen et al) data demonstrated that experienced hysteroscopic surgeons have more likelihood of complications during major hysteroscopic procedures (likely due to case selection bias- experienced hysteroscopic surgeons performing more difficult procedures). The US MAUDE database reports by Haber et al reported an estimated complication rate of <0.1%.

• 6.

  a) T b) F c) F d) T e) T

Diagnostic AH is well established in most hospitals in the UK. As per the National Heavy Menstrual Bleeding Audit results published in July 2014, 87% of units across the UK have AH services. But as per a national survey of UK gynaecologists done in 2011, only 16% offered outpatient treatment of endometrial polyps. With regards to AH in a community setting, there are very few units in the country that offer this service. Community Gynaecology is in its early developmental stages in the UK. Various studies have evaluated simulation training demonstrating improved performance in operative hysteroscopic skills. The HystSim Essure Module was evaluated in a study by Chudnoff et al that showed significant improvement in the skills to perform Essure hysteroscopic sterilization. Most consider that polyps >2 cm are generally unsuitable for outpatient resection.

• 7.

  a) T b) T c) F d) F e) F

Only type 0 and type 1 fibroids are suitable for hysteroscopic resection. There is evidence from observational studies only that fibroid resection can improve fertility outcomes. The L in PALM-COIEN stands for Leiomyoma

• 8.

  a) T b) F c) T d) T e) T

Hysteroscopic morcellators have been shown to be both more acceptable and quicker than electrical resection at removing endometrial polyps in the outpatient setting through randomised controlled studies. Saline infusion sonography is more sensitive than transvaginal ultrasound for identifying space-occupation lesions but is not as sensitive as hysteroscopy. Up to 10% of women presenting with fertility problems have endometrial polyps and it is thought that removing polyps may help improve fertility.

• 9.

  a) F b) F c) T d) T e) T

In pre-menopausal women ET is best assessed on day four to six of the menstrual cycle as this is the time when the endometrium should be at its thinnest. In pre-menopausal women the upper limit of endometrial thickness (ET) is not defined as it varies with the cycle, contraceptive methods and there is no absolute upper limit. A suggested threshold of < or = 4 mm for ET with a regular endometrial lining and no fluid within the cavity reduces the possibility of malignancy to <1% in post-menopausal women. When setting a threshold for further investigation there is always a balance between specificity and sensitivity. Reducing the ET threshold to less than currently recommended will definitely result in more false positives as the likelihood of cancer reduces with the ET. Although both cancerous and pre-cancerous endometrial disease can be identified by direct visualisation, the ‘gold-standard’ for diagnosis is still histological sampling.

• 10.

  a) F b) T c) T d) T e) F

Fibrous myometrial band are typical of intrauterine adhesions. The usual appearance of intrauterine adhesions is that of greyish-white fibrous bands (fine to dense) extending across the uterine cavity in a haphazard manner, this is frequently associated with obliteration of the uterine cavity. Endometrial cancer has innumerable appearances; with a combination of any of these features: thickened, irregular endometrium, friable cells with haemorrhagic appearances of the endometrial cavity. A cystic “bubble wrap” appearance is typical of Tamoxifen stimulation and is a benign phenomenon.

• 11.

  a) F b) F c) F d) F e) T

This can be explained by the vascular architecture of the myometrium; deeper in the myometrium the number of vessels decrease but their size in diameter increases.

• 12.

  a) T b) F c) T d) T e) F

Whilst in many developing countries laparotomy remains the most common approach to sterilisation, in developed countries nearly all interval /post-partum sterilisations are performed laparoscopically. Unipolar sterilisation was the first method of laparoscopic tubal sterilisation to achieve wide spread use. Unipolar sterilisation is associated with numerous complications including thermal bowel lesions and death. Bipolar sterilisation is safer as the current flows between the active and return electrodes of the surgical instrument. In contrast, current flows through the patient in unipolar surgery and the circuit is completed via a remote return electrode (ground plate). The Filshie clip was introduced and approved by the FDA in the United States in 1996.

• 13.

  a) T b) F c) T d) T e) T

The hysteroscopic sterilisation approach is inherently less invasive and has a lower serious complication rate compared with the laparoscopic route because it avoids the need for incisions, entry into the abdominal cavity and general anaesthesia. Using thermal electrocoagulation achieved an overall bilateral tubal occlusion rate of 83 % but pregnancies including ectopics were reported. Chemical sterilisation with quinacrine is reported to have a 1-2% failure rate although the rates of ectopic pregnancy and serious complications are less than trans-abdominal sterilisations. However, drawbacks include the need for multiple applications. The ovabloc technique never became popular because it was associated with a high failure rate and the procedure was stopped in 2009. Adiana sterilisation was withdrawn in 2012 primarily because the technology was not generating expected revenues from sales and there was a long running patent infringement with another country.

• 14.

  a) F b) F c) T d) T e) F

The length of the device is 4 cm. Occlusion of the tubal lumen is demonstrated within 4-8 weeks of placement. Patients are indeed instructed to use alternative contraception until 3 months after insertion. TVS has been introduced as the default confirmatory test in many parts of Europe because it is less invasive than an HSG and avoids ionising radiation. Whilst tubal occlusion cannot be tested, satisfactory placement at 3 months can be confirmed with HSG being restricted to complicated procedures or an abnormal TVS. Successful placement occurs in 90-95 % of cases.

• 15.

  a) T b) F c) F d) T e) T

The cumulative 9 year failure rate was analysed from follow up data from 449 women included in phase 2 and pivotal trials. Only 6.3 % of gestations were categorised as luteal phase pregnancies. 45 % of pregnancies were the result of failure to use additional contraception after the procedure. According to the MAUDE database the most frequently reported adverse event was indeed pain (47.5 %). Other adverse events include delivery catheter malfunction, perforation, pregnancy, abnormal bleeding and allergic reactions. There seems to be no relationship between the experience of the physician and device placement complications.

• 16.

  a) F b) F c) T d) T e) F

The FIGO system is a classification of the different types of fibroids from Type 0-Type 8. Submucosal fibroids are graded 0 to 2 according to the degree of intra-cavity involvement relative to the myometrium. A type 1 submucosal fibroid is one where <50% of the fibroid is intramural. An entirely intramural fibroid is described as Type 4. Published data supports the contention that SIS improves the diagnostic accuracy of TVS. SIS is widely applicable and the only contra indications are pregnancy and suspected pelvic infection. 3D and 4D images can be achieved with stable and adequate distension of the uterine cavity and this is facilitated by us of a gel contrast medium. 3D provides good reproducibility of the fibroid protrusion into the uterine cavity.

• 17.

  a) F b) F c) T d) T e) T

Traditional operative hysteroscopy has a long learning curve and is difficult to learn. The first simultaneous tissue cutting and retrieval system for use in the uterine cavity was the Truclear system. The Truclear system does not use any electrocoagulation. Haemostasis occurs by spontaneous myometrial contraction. Physiological saline solution is used for distension and irrigation minimising risks associated with fluid absorption. Using the Truclear system, polyps, small myomas and retained products of pregnancy can be removed in this way, all FDA approved.

• 18.

  a) T b) F c) T d) T e) F

Isotonic fluid overload can be treated with diuretics. Hypertonic non-conductive low viscosity fluids include 5 % Mannitol, 3-5% Sorbitol and 1.5 % glycine. Nausea and malaise are the earliest findings of fluid overload and may be seen with sodium levels less than 5 mmols per litre. This can be followed by headaches, lethargy and eventually seizures if the plasma sodium falls further. Intravasation of fluid is increased with prolonged surgery and deeper, intramural extension e.g. grade 2 fibroids. Bladder catheterisation is only indicated where significant fluid deficit and overload occurs to help monitor the condition of the patient.

• 19.

  a) T b) T c) F d) F e) F

Hysteroscopic surgical skills can be difficult to acquire without expert tuition and practice.

High volume surgeons performing more than 20 hysteroscopic myomectomies annually resect more tissue and a higher amount of tissue per time than low volume surgeons. There is no difference in complication rates between high and low volume surgeons although this may reflect the complexity and completeness of treatment. Prophylactic antibiotics are not indicated because the risk of infection after operative hysteroscopy is low. All patients should have an emergency laparoscopy and / or laparotomy to exclude intra-abdominal haemorrhage or intestinal injury when a perforation is caused by an activated instrument.

• 20.

  a) F b) F c) T d) F e) F

The joint RCOG-BSGE guideline on best practice in outpatient hysteroscopy states that staffing levels will vary according to local circumstances and types of service offered but that a complement of three supporting staff consisting of at least one registered nurse and two additional staff (nurse or healthcare assistants) allows support of the nurse assisting the surgeon and a dedicated member of staff to accompany the patient during her journey. The role of the nurse hysteroscopist is only well developed in some units in the UK. In 2001 the University of Bradford-BSGE developed an educational training programme at an advanced level for nurses. In-patient admission of patients from the ambulatory setting is a very rare occurrence. The BSGE provides no formal accreditation in ambulatory hysteroscopy. The ESGE has developed training standards for hysteroscopy but these are somewhat arbitrary.

• 21.

  a) F b) F c) F d) T e) T

Ambulatory hysteroscopy can be conducted outside the formal operating setting in a room which is appropriately sized, well equipped and properly staffed. It need not be close to a formal theatre setting and indeed could be sited within a community setting. The quality of the video camera and monitor are important to get good quality visual images. Regarding distension media generally normal saline is preferred to CO ₂ as a distension medium as it allows improved image quality, permits a quicker procedure and has the advantage of acting as a conducting medium for bipolar energy. Four randomised control trials have compared the effect of size of the outer sheath on pain and success rates; it has shown that an outer sheath diameter of less than 3.5 mm was associated with significantly less intra operative pain. There is insufficient evidence to recommend preferential use of rigid or flexible hysteroscopes for ambulatory hysteroscopy. However rigid hysteroscopes allow the use of mechanical and electro surgical devices as they can be fitted though 5-French operative channels.

• 22.

  a) F b) T c) T d) F e) T

According to the 2008 RCOG Standards in Gynaecology “outpatient operative hysteroscopy” should be available to carefully selected patients. Organisational change theory suggests that unless consensus is present across professionals there is little chance of its successful development. Research has shown for ambulatory hysteroscopy there is a significant reduction in mean pain scores associated with use of local para-cervical or direct cervical anaesthesia. However, miniaturisation of endoscopes and wider adoption of vaginoscopy increasingly avoids the need for cervical dilatation and so the routine use of local anaesthesia is contentious and further trials are needed. Amongst the different routes of local anaesthetic administration, para-cervical injection of local anaesthetic was shown to be the most effective method of reducing pain during ambulatory hysteroscopy compared with intracervical, transcervical or topical routes. The vaginoscopic approach has been shown to reduce pain significantly in randomised trials.

• 23.

  a) F b) F c) T d) T e) F

There is good evidence that hysteroscopy in the ambulatory setting is preferable for the patient as it avoids complications, allows quicker recovery time and lowers costs. Miniaturisation of high definition hysteroscopes does not compromise optical performance and allows accurate diagnosis of intrauterine pathology. Ambulatory hysteroscopy represents the gold standard diagnostic test for diagnosis of submucous fibroids and polyps. In 2014 87 % of UK hospitals offered ambulatory hysteroscopy. To date there are no large randomised studies or cohort studies which clearly support the safety and effectiveness of concomitant endometrial ablation and hysteroscopic sterilisation. However, there are several small uncontrolled series observational series demonstrating feasibility and supporting short term efficacy and safety.

• 24.

  a) F b) F c) T d) T e) T

Laser ablation is very expensive and needs a highly trained surgeon. Endometrial thinning agents (GNRH or Danazol) before hysteroscopic surgery improve operating conditions and short term post-operative outcomes. The effect of these agents on long term outcome was reduced with time. Rollerball in comparison with TCRE shows no evidence of significant differences in the complication of re-interventon at 2,5 and 10 years or in complication rates as measured (fluid deficit/perforation).

• 25.

  a) F b) F c) T d) F e) T

Rollerball ablation was studied vs. cryo and thermal balloon ablation and there was no evidence of any difference in results of either technique on all parameters measured. The duration of surgery was consistently shorter with second generation compared to first generation ablation and LA was more likely to be given. Analysis of the IBD-HMB database comparing first and second generation showed no significant difference in effectiveness when defined as satisfaction. There is no evidence that first or second generation ablation are superior to each other. However a lot of practical considerations favour the choice of second generation techniques.

• 26.

  a) T b) T c) T d) F e) T

Bipolar radiofrequency ablation is associated with higher amenorrhea rates as has been shown in published meta-analysis. Surgery is shorter with bipolar radiofrequency ablation and PMS scores are reduced, the devices work on automated systems that are less skill dependent. Bipolar radiofrequency ablation has increased amenorrhoea and satisfaction scores and women are less likely to require additional surgery and this risk of further surgery decreases with age. 80 % of women will not require any additional treatment. Data from UK hospital statistics show a significant difference increase in the overall number of in-patient ablation techniques. In addition, radiofrequency endometrial ablation is the most commonly performed technique.

• 27.

  a) T b) F c) F d) F e)

Age over 45 years appears to be a prognostic favourable for a success after endometrial ablation. A long cavity appears to be an unfavourable prognostic factor for satisfaction after ablation. The existence of submucous fibroids in the uterine cavity is also an unfavourable prognostic factor and large fibroids in the cavity (>3 cm) are a contraindication to use of most second generation ablative techniques. Pre-operative dysmenorrhoea is more frequently observed in women after failed endometrial ablation. Racial differences make no difference to the outcome once appropriate women are selected.

• 28.

  a) T b) T c) T d) F

a) Tissue removal systems (hysteroscopic morcellation) has recently been introduced allowing simultaneous mechanical tissue cutting and extraction via suction. Published trials have demonstrated its efficacy in the office setting for removal of polyps. b) Essure sterilization has become an established, effective method of transcervical, non-incisional sterilization. Other hysteroscopic permanent birth control systems are in development for use in the office setting. C) The miniaturisation of endoscopes combined with the ability to visualize digital images on a computer or integrated monitors means that large stack systems are not essential to practice modern hysteroscopy. D) Bipolar electrosurgical systems for use in physiological saline distension media have facilitated safer operative hysteroscopic surgery in both the office and operating room. Traditional monopolar systems are being replaced by bipolar technologies.

• 29.

  a) T b) F c) F d) F

a) A systematic review published in the BMJ in 2011 showed the effectiveness of such methods for administering local anaesthesia. b) Avoiding the use of a vaginal speculum and / or cervical instrumentation is associated with less pain according to a systematic review of some small randomized controlled trials. c) There is no evidence to indicate that the prevalence of vaso-vagal reactions is affected by vaginoscopy. d) The OPT trial published in the BMJ in 2015 reported 4 cases of uterine perforation in the 25ö cases of uterine polypectomy performed under general anaesthesia compared to zero in the office. Thus, office-based procedures performed in conscious women appear to be less traumatic.

• 30.

  a) T b) T c) F d) F

a) Serious endometrial disease can be diagnosed with high accuracy by hysteroscopy when performed in conjunction with directed or blind endometrial sampling. b) Diagnostic test studies have shown hysteroscopy to be more accurate than 2D ultrasound and at least equivalent to saline infusion sonography. Blind endometrial biopsy may fail to sample focal lesions. c) There is no evidence to support this contention in contemporary office hysteroscopy utilising small diameter hysteroscopes under low uterine distension pressures. Abrading the uterus with endometrial sampling devices is painful in contrast to performing hysteroscopic procedures less traumatically under vision. d) Standardised criteria for diagnosing adenomyosis at hysteroscopy are lacking. Ultrasound and MRI can diagnose adenomyosis with modest levels of precision.