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Hysteroscopy

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of hysteroscopy are prepared by our editorial team based on guidelines from the American College of Obstetricians and Gynecologists (ACOG 2025,2023,2018,2013), the Royal College of Obstetricians and Gynaecologists (RCOG 2024,2016), the Society of Obstetricians and Gynaecologists of Canada (SOGC 2024,2021,2018,2015), the European Society of Anaesthesiology and Intensive Care (ESAIC 2023), the ...
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Diagnostic procedures

Diagnostic indications, infertility: as per SOGC 2024 guidelines, consider performing hysteroscopy for the evaluation of uterine cavity in patients with unexplained infertility.
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  • Diagnostic indications, abnormal uterine bleeding

  • Diagnostic indications, uterine fibroids

  • Diagnostic indications, endometrial hyperplasia

  • Diagnostic indications, endometrial polyps

  • Diagnostic indications, endometrial cancer

  • Diagnostic indications, intrauterine adhesions

Medical management

Cervical ripening
As per AAGL/ACOG 2020 guidelines:
Insufficient evidence to recommend routine cervical ripening before diagnostic or operative hysteroscopy. Consider performing cervical ripening in patients at high risk of cervical stenosis or increased pain with the surgical procedure.
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Consider administering intravaginal misoprostol 400 mcg 4 hours before office hysteroscopy to reduce pain during and after the procedure. Consider administering vaginal estrogen 25 mcg 14 days before the procedure, along with vaginal misoprostol 400-1,000 mcg 12 hours before the procedure, to ease cervical dilation and reduce pain in postmenopausal patients.
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  • Antibiotic prophylaxis

  • Prophylactic tranexamic acid

Therapeutic procedures

Therapeutic indications, endometrial polyps
As per SOGC 2024 guidelines:
Offer hysteroscopic polypectomy in patients attempting unassisted conception, ovulation induction, or mild ovarian stimulation to improve reproductive outcomes.
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Offer hysteroscopic polypectomy in patients planning intrauterine insemination to improve fertility outcomes.
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  • Therapeutic indications, uterine fibroids

  • Therapeutic indications, uterine septum

  • Therapeutic indications, intrauterine adhesions

  • Therapeutic indications, Müllerian anomalies

  • Therapeutic indications, ectopic pregnancy

  • Setting of procedure

  • Timing of procedure

  • Procedural technique

Perioperative care

Analgesia and anesthesia: as per ACOG 2025 guidelines, administer local injected anesthesia during diagnostic and operative hysteroscopy and endometrial ablation. Consider administering misoprostol to reduce intraprocedural pain, recognizing that its use is associated with a high incidence of preprocedural adverse effects, such as abdominal pain and gastrointestinal symptoms.
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Patient education

Preprocedural counseling
As per RCOG 2024 guidelines:
Provide written information to all patients before appointment, including details about the procedure, the benefits and risks, advice regarding preoperative analgesia, alternative options for care, and contact details for the hysteroscopy unit.
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Provide patients information on other settings and modes of anesthesia for hysteroscopy, such as under general or regional anesthesia or IV sedation.
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Quality improvement

Hospital requirements: as per RCOG 2024 guidelines, ensure that all gynecology departments provide a dedicated outpatient hysteroscopy service to aid care of patients with abnormal uterine bleeding, reproductive issues, and insertion/retrieval of intrauterine devices.
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