Video Description
This video outlines the approach to the hysteroscopic management of a stenotic cervix using video from cases performed in an outpatient hysteroscopy setting.
Presented By
Affiliations
University of Ottawa, The Ottawa Hospital
See Also
Click here to watch this video on YouTube.
Summary:
- A cervix is stenotic when the passageway through the cervix, between the uterus and vagina, is excessively narrow or completely blocked. This can lead to problems like chronic pain, difficulty with menstruation, and fertility problems.
- The cause of cervical stenosis isn’t always obvious. Sometimes, it’s related to age, scarring from past procedures, or congenital differences in the cervix itself.
- Hysteroscopic management is making it easier for providers to treat cervical stenosis without invasive surgery or long recovery times. Patients can have the procedure in the clinic with or without sedation and go home the same day.
- If you’re having a hysteroscopic procedure, your doctor may recommend taking OTC pain medicines, like ibuprofen or Tylenol, before you arrive. Most patients tolerate the procedure well and recover from it quickly.
Hysteroscopic Management of a Stenotic Cervix
If you or someone you love has been diagnosed with a stenotic cervix, you might be wondering what this means. The word “stenotic” means narrow or constricted, so when your provider uses this term to describe your cervix, they’re saying that the pathway leading into your uterus is smaller than normal.
This guide will help you understand what a stenotic cervix is and why it matters. You’ll also learn how new “no-touch” hysteroscopy techniques are making it easier for providers to treat the condition safely and comfortably in the clinic without the need for surgery.
Have more questions about your reproductive health? Visit CanSAGE’s library of patient-friendly videos to get answers.
What Exactly Is a Stenotic Cervix?
The cervix is the small, narrow opening at the bottom of the uterus that connects to the vagina. Normally, it acts like a passageway between the uterus and the outside of the body (via the vagina), but in stenosis, it becomes excessively narrow or even closed off.
A stenotic cervix can make it difficult or impossible to pass menstrual blood, have an IUD placed, or become pregnant. It may also make it impossible for your provider to perform certain procedures, like uterine biopsies, intrauterine device insertions, or endometrial ablation.
Some people are born with a stenotic cervix, but it’s much more common to develop the condition with age, after giving birth, or as a complication after a surgery. People over the age of 50 who are in menopause are the most likely to develop cervical stenosis.
What Causes Cervical Stenosis?
It isn’t always clear what causes someone’s cervix to become abnormally constricted. For some patients, it stems from:
- Scarring from past procedures, such as a D&C, cone biopsy, or LEEP.
- Hormonal changes. Low estrogen levels can cause the tissues in the cervix and vagina to thin out and become more rigid.
- Chronic inflammation or infection, like Pelvic Inflammatory Disease (PID). This can lead to scar tissue or blockages in the cervical canal.
Cervical stenosis can also be congenital, meaning you were born with a cervix that’s naturally closed off or severely constricted. This is relatively rare and usually becomes obvious when someone begins menstruating.
Symptoms of a Stenotic Cervix
Cervical stenosis doesn’t cause any symptoms in most patients. In fact, most people only learn they have it during a routine procedure, like a pap smear or IUD placement. For a small number of people, stenosis can lead to symptoms like:
- Chronic pelvic pain
- Hematometra (retained blood in the uterus)
- Pyometra (a serious infection of the uterus)
- Dysmenorrhea (pain during menstruation)
- Amenorrhea (no menstruation at all)
- Spotting or bleeding between periods
- Discomfort or pain during exams
- Fertility problems
If you’re experiencing any of these symptoms, you have options. Your provider may recommend hormone therapy, surgery, or a new minimally-invasive “no-touch” technique called hysteroscopic management.
What is Hysteroscopic Management of a Stenotic Cervix?
Hysteroscopic management of a stenotic cervix is a minimally invasive surgical procedure that doesn’t require any abdominal incisions. Your provider will use a hysteroscope—a long, thin tube with a camera and light—to visualize the stricture and treat it on the spot.
This has many benefits:
- There are no external incisions.
- You can have the procedure in the clinic.
- The recovery time is very short with no hospital stay.
Your provider may use a “no-touch” approach. Instead of using a speculum or tenaculum (tools your gynecologist uses during a pap smear or IUD placement, they’ll gently open your vagina and cervix by flooding the area with a liquid (usually sterile saline).
What to Expect During the Procedure
The idea of having a cervical procedure done while you’re awake may sound uncomfortable, but most patients tolerate hysteroscopy very well. The goal is to minimize your discomfort while giving your doctor the best view of your cervix and uterus.
Before Your Procedure
You’ll typically have an appointment with your provider before your procedure. This is a good time to raise any questions or to let them know if you’re feeling anxious—they can help you strategize ways to manage these feelings in advance.
Depending on your needs, your doctor may also recommend:
- Taking oral pain medication, such as ibuprofen or acetaminophen, around two hours before you arrive.
- Taking an oral anti-anxiety medication, like lorazepam or diazepam. These medications can help manage your anxiety during the procedure.
- A paracervical block. Your provider may inject a small amount of a numbing agent into the cervix and/or the tissue surrounding it. This can help manage pain.
- Conscious or light sedation. If you are especially anxious or very sensitive to pain, conscious sedation can make the procedure easier to tolerate.
In rare cases, your doctor may recommend having the procedure in an operating room while you’re under general anesthesia. You’ll be asleep before the procedure starts.
On the Day of Your Procedure
On the day of your procedure, you’ll be asked to arrive at the clinic around 15-30 minutes before your scheduled time. This gives you time to prepare for your hysteroscopy procedure and ask any last-minute questions.
Arrival & Check-In
- You’ll arrive 15-30 minutes before your scheduled appointment.
- Staff will verify your information and help you complete any remaining forms.
- Your doctor will likely review your case once more before the procedure begins.
Getting Ready
- Someone will show you to a private changing area.
- You’ll be asked to remove clothing from the waist down.
- Once changed, you’ll come back into the procedure room.
In the Procedure Room
- You’ll lie on your back with your feet in stirrups (like a pelvic exam).
- A drape will be placed over your lower body for privacy and comfort.
- A nurse or your doctor will place an IV if you’re scheduled for medication.
- You’ll be given pain or sedation medication slowly through your IV.
- Depending on the sedation level, you may become drowsy or fall asleep.
During the Procedure
- Your doctor will gently insert the hysteroscope through your vagina.
- They’ll flood the area with a sterile saline solution to better visualize the cervix.
- Your doctor will use the camera on the hysteroscope to locate and treat the stenosis.
- Small surgical tools may be used to widen any narrowing along the cervical canal.
- You may feel mild to moderate cramping during this part of the procedure.
After Your Hysteroscopy
After your hysteroscopy, you’ll rest in the procedure room or a recovery area until it’s safe for you to go home—typically 15-30 minutes. If you had sedation or were given pain medication through your IV, a nurse will monitor your vital signs to make sure they’re stable.
Most people go home shortly after their procedure and return to normal activities later the same day. You might experience mild cramping or spotting for a day or two; this is normal and expected. Let you know about any excessive bleeding or foul odors right away.
Does Hysteroscopy Come With Risks?
Hysteroscopic management is one of the safest ways to treat a stenotic cervix, but like any surgical procedure, there are a few risks.
- Bleeding during or after the procedure.
- Pyometra, an infection of the uterus or cervix.
- Scarring or adhesions, especially if healing is disrupted by infection.
- Uterine or cervical perforation, where a tool accidentally creates a small hole.
If you were given anesthesia, you may also experience temporary dizziness, nausea, or drowsiness that lasts up to 24 hours. Your doctor will also likely recommend avoiding intercourse or tampon use for a short period of time to allow the tissues to heal.
Why is Hysteroscopy Used?
A stenotic cervix may seem like a small problem to have, but it can make it really difficult for people who are still menstruating or trying to become pregnant. It can also make routine gynecological care painful, challenging, or even downright impossible.
The main goal of hysteroscopic management is to restore access to the uterus. This can help reduce pain from menstruation and/or blocked menstrual flow and make it easier to become pregnant or have embryos placed in In-Vitro Fertilization (IVF).
For some people, a reduction in discomfort and pain during routine procedures is the biggest benefit. Treating conditions like endometrial hyperplasia, fibroids, or monitoring for cancer often requires accessing the uterus through the cervix every few months. Hysteroscopy for stenosis can make these appointments easier to tolerate.
Get Informed About Stenotic Cervix With CanSAGE
If you’re dealing with symptoms or complications related to a stenotic cervix, help is available. Advances like “no-touch” hysteroscopic management are making it easier for providers to treat this common condition in the clinic without long recovery times.
Every patient is different, so if you’re interested in whether hysteroscopic management might be right for you, talk to your gynecologist. You can also learn more about your reproductive health by exploring the resources at CanSAGE.
Video Transcript: Hysteroscopic Management of a Stenotic Cervix
The authors have no conflicts of interest to disclose. We present an approach for the surgical management of a stenotic cervix in an outpatient hysteroscopy setting, with video demonstrations.
Gynecologists require intrauterine access for a number of procedures. An outpatient hysteroscopy suite has a number of advantages over the operating theatre and typically uses hysteroscopes with a smaller operative canal than traditional instruments.
Even experienced practitioners can have difficulty with a stenotic cervix. This formidable opponent is encountered when a cervical canal is too narrow to allow the insertion of a 2.5 mm Hegar or a Pratt dilator. We present the ease of a see-and-treat approach in an outpatient hysteroscopy setting to manage a stenotic cervix.
As in all aspects of surgery, patient positioning is a key component, and stirrups should be used. Surgical lighting improves visualization. Patient discomfort can be minimized with routine oral analgesia and if required, a paracervical block or conscious sedation. Although not routinely required, applying a tenaculum to the cervix can help straighten the angle and improve surgical technique. Oftentimes, these simple steps can allow passage through what was previously described as a stenotic cervix.
Vaginoscopy is the first step to the no-touch hysteroscopy technique. It decreases the patient’s discomfort by avoiding both the speculum and tenaculum. The hysteroscope is inserted under direct visualization into the vagina, and the distension medium retracts the walls of the vagina.
By following the posterior wall, as shown here, the posterior fornix is eventually visualized. By slowly retracting the hysteroscope, the external cervical os will be seen. Cervical mucus or glands found in the transformation zone can help localization.
By advancing slowly, the distension medium dilates the cervical canal ahead, and even a tortuous path through the cervix can be navigated. Adjusting the angle of the camera prevents damage to delicate vasculature within the canal, which decreases patient discomfort and improves visualization. Careful techniques can be almost pain-free and allow excellent assessment of the uterine cavity.
A stenotic cervix can be the result of thick adhesions at the external os, internal os or throughout the length of the canal. The cause is commonly due to a sharp curettage or previous treatment for cervical dysplasia. Microscissors can be used for the revision of the cervical canal. They pass through the operative canal of the hysteroscope and can sharply dissect tissue.
For these thick adhesions at the external os, the familiar push-spread technique can be adapted to allow a safe dissection. The fibrous adhesions usually allow only a small amount of distension but enough to visualize the direction of the cervical canal, as shown here.
In the awake patient, feedback is extremely helpful, as a division of fibrous scar tissue is pain-free, whereas increased pain would suggest a division of normal cervical or uterine tissue. Progressive division of adhesions allows further distension of the cervical canal ahead and eventually access into the uterine cavity.
This technique of sharp dissection can be adapted to the division of intrauterine adhesions as well. Microscissors and micrograspers can be used to remove specimens both within the cervical canal and uterine cavity.
Another similar technique uses micrograspers to push and spread, which bluntly slices the adhesions. One advantage is that injury to normal cervical or uterine tissue is minimized, but this technique is limited to a cervix that is only partially stenosed and to adhesions that are not only fibrotic, as shown in this video here.
A stenotic cervix can be narrowed to the point that even a mini hysteroscope cannot be inserted. In these patients, aggressive, blind dilation can significantly increase their risk of uterine perforation.
The width of a cutting loop electrode is significantly smaller than a hysteroscope and can oftentimes be advanced into a stenotic canal. By removing a small amount of the cervical depth, the overall cross-sectional area of the cervical canal is increased and can permit the advancement of a larger hysteroscope. By progressively removing a small amount of cervical depth, increasing the cross-sectional area and further extending the cervical canal ahead, we can access the uterus.
These particular cases are performed in the main operating theatre. The loop excision can be performed in the outpatient setting as well. Safe excision of tissue can be performed as long as the operating instrument is kept within the visual field.
We presented here an approach to the stenotic cervix, which includes optimizing the environment, no-touch hysteroscopy and revision of the cervical canal with micro instruments or a loop electrode. These techniques can be applied in an outpatient hysteroscopy setting and also adapted for use in an operating theatre.
This video was brought to you by the Ottawa Minimally Invasive Gynaecology team.
Watch on YouTube
Click here to watch this video on YouTube.
Summary:
- A cervix is stenotic when the passageway through the cervix, between the uterus and vagina, is excessively narrow or completely blocked. This can lead to problems like chronic pain, difficulty with menstruation, and fertility problems.
- The cause of cervical stenosis isn’t always obvious. Sometimes, it’s related to age, scarring from past procedures, or congenital differences in the cervix itself.
- Hysteroscopic management is making it easier for providers to treat cervical stenosis without invasive surgery or long recovery times. Patients can have the procedure in the clinic with or without sedation and go home the same day.
- If you’re having a hysteroscopic procedure, your doctor may recommend taking OTC pain medicines, like ibuprofen or Tylenol, before you arrive. Most patients tolerate the procedure well and recover from it quickly.
Hysteroscopic Management of a Stenotic Cervix
If you or someone you love has been diagnosed with a stenotic cervix, you might be wondering what this means. The word “stenotic” means narrow or constricted, so when your provider uses this term to describe your cervix, they’re saying that the pathway leading into your uterus is smaller than normal.
This guide will help you understand what a stenotic cervix is and why it matters. You’ll also learn how new “no-touch” hysteroscopy techniques are making it easier for providers to treat the condition safely and comfortably in the clinic without the need for surgery.
Have more questions about your reproductive health? Visit CanSAGE’s library of patient-friendly videos to get answers.
What Exactly Is a Stenotic Cervix?
The cervix is the small, narrow opening at the bottom of the uterus that connects to the vagina. Normally, it acts like a passageway between the uterus and the outside of the body (via the vagina), but in stenosis, it becomes excessively narrow or even closed off.
A stenotic cervix can make it difficult or impossible to pass menstrual blood, have an IUD placed, or become pregnant. It may also make it impossible for your provider to perform certain procedures, like uterine biopsies, intrauterine device insertions, or endometrial ablation.
Some people are born with a stenotic cervix, but it’s much more common to develop the condition with age, after giving birth, or as a complication after a surgery. People over the age of 50 who are in menopause are the most likely to develop cervical stenosis.
What Causes Cervical Stenosis?
It isn’t always clear what causes someone’s cervix to become abnormally constricted. For some patients, it stems from:
- Scarring from past procedures, such as a D&C, cone biopsy, or LEEP.
- Hormonal changes. Low estrogen levels can cause the tissues in the cervix and vagina to thin out and become more rigid.
- Chronic inflammation or infection, like Pelvic Inflammatory Disease (PID). This can lead to scar tissue or blockages in the cervical canal.
Cervical stenosis can also be congenital, meaning you were born with a cervix that’s naturally closed off or severely constricted. This is relatively rare and usually becomes obvious when someone begins menstruating.
Symptoms of a Stenotic Cervix
Cervical stenosis doesn’t cause any symptoms in most patients. In fact, most people only learn they have it during a routine procedure, like a pap smear or IUD placement. For a small number of people, stenosis can lead to symptoms like:
- Chronic pelvic pain
- Hematometra (retained blood in the uterus)
- Pyometra (a serious infection of the uterus)
- Dysmenorrhea (pain during menstruation)
- Amenorrhea (no menstruation at all)
- Spotting or bleeding between periods
- Discomfort or pain during exams
- Fertility problems
If you’re experiencing any of these symptoms, you have options. Your provider may recommend hormone therapy, surgery, or a new minimally-invasive “no-touch” technique called hysteroscopic management.
What is Hysteroscopic Management of a Stenotic Cervix?
Hysteroscopic management of a stenotic cervix is a minimally invasive surgical procedure that doesn’t require any abdominal incisions. Your provider will use a hysteroscope—a long, thin tube with a camera and light—to visualize the stricture and treat it on the spot.
This has many benefits:
- There are no external incisions.
- You can have the procedure in the clinic.
- The recovery time is very short with no hospital stay.
Your provider may use a “no-touch” approach. Instead of using a speculum or tenaculum (tools your gynecologist uses during a pap smear or IUD placement, they’ll gently open your vagina and cervix by flooding the area with a liquid (usually sterile saline).
What to Expect During the Procedure
The idea of having a cervical procedure done while you’re awake may sound uncomfortable, but most patients tolerate hysteroscopy very well. The goal is to minimize your discomfort while giving your doctor the best view of your cervix and uterus.
Before Your Procedure
You’ll typically have an appointment with your provider before your procedure. This is a good time to raise any questions or to let them know if you’re feeling anxious—they can help you strategize ways to manage these feelings in advance.
Depending on your needs, your doctor may also recommend:
- Taking oral pain medication, such as ibuprofen or acetaminophen, around two hours before you arrive.
- Taking an oral anti-anxiety medication, like lorazepam or diazepam. These medications can help manage your anxiety during the procedure.
- A paracervical block. Your provider may inject a small amount of a numbing agent into the cervix and/or the tissue surrounding it. This can help manage pain.
- Conscious or light sedation. If you are especially anxious or very sensitive to pain, conscious sedation can make the procedure easier to tolerate.
In rare cases, your doctor may recommend having the procedure in an operating room while you’re under general anesthesia. You’ll be asleep before the procedure starts.
On the Day of Your Procedure
On the day of your procedure, you’ll be asked to arrive at the clinic around 15-30 minutes before your scheduled time. This gives you time to prepare for your hysteroscopy procedure and ask any last-minute questions.
Arrival & Check-In
- You’ll arrive 15-30 minutes before your scheduled appointment.
- Staff will verify your information and help you complete any remaining forms.
- Your doctor will likely review your case once more before the procedure begins.
Getting Ready
- Someone will show you to a private changing area.
- You’ll be asked to remove clothing from the waist down.
- Once changed, you’ll come back into the procedure room.
In the Procedure Room
- You’ll lie on your back with your feet in stirrups (like a pelvic exam).
- A drape will be placed over your lower body for privacy and comfort.
- A nurse or your doctor will place an IV if you’re scheduled for medication.
- You’ll be given pain or sedation medication slowly through your IV.
- Depending on the sedation level, you may become drowsy or fall asleep.
During the Procedure
- Your doctor will gently insert the hysteroscope through your vagina.
- They’ll flood the area with a sterile saline solution to better visualize the cervix.
- Your doctor will use the camera on the hysteroscope to locate and treat the stenosis.
- Small surgical tools may be used to widen any narrowing along the cervical canal.
- You may feel mild to moderate cramping during this part of the procedure.
After Your Hysteroscopy
After your hysteroscopy, you’ll rest in the procedure room or a recovery area until it’s safe for you to go home—typically 15-30 minutes. If you had sedation or were given pain medication through your IV, a nurse will monitor your vital signs to make sure they’re stable.
Most people go home shortly after their procedure and return to normal activities later the same day. You might experience mild cramping or spotting for a day or two; this is normal and expected. Let you know about any excessive bleeding or foul odors right away.
Does Hysteroscopy Come With Risks?
Hysteroscopic management is one of the safest ways to treat a stenotic cervix, but like any surgical procedure, there are a few risks.
- Bleeding during or after the procedure.
- Pyometra, an infection of the uterus or cervix.
- Scarring or adhesions, especially if healing is disrupted by infection.
- Uterine or cervical perforation, where a tool accidentally creates a small hole.
If you were given anesthesia, you may also experience temporary dizziness, nausea, or drowsiness that lasts up to 24 hours. Your doctor will also likely recommend avoiding intercourse or tampon use for a short period of time to allow the tissues to heal.
Why is Hysteroscopy Used?
A stenotic cervix may seem like a small problem to have, but it can make it really difficult for people who are still menstruating or trying to become pregnant. It can also make routine gynecological care painful, challenging, or even downright impossible.
The main goal of hysteroscopic management is to restore access to the uterus. This can help reduce pain from menstruation and/or blocked menstrual flow and make it easier to become pregnant or have embryos placed in In-Vitro Fertilization (IVF).
For some people, a reduction in discomfort and pain during routine procedures is the biggest benefit. Treating conditions like endometrial hyperplasia, fibroids, or monitoring for cancer often requires accessing the uterus through the cervix every few months. Hysteroscopy for stenosis can make these appointments easier to tolerate.
Get Informed About Stenotic Cervix With CanSAGE
If you’re dealing with symptoms or complications related to a stenotic cervix, help is available. Advances like “no-touch” hysteroscopic management are making it easier for providers to treat this common condition in the clinic without long recovery times.
Every patient is different, so if you’re interested in whether hysteroscopic management might be right for you, talk to your gynecologist. You can also learn more about your reproductive health by exploring the resources at CanSAGE.
Video Transcript: Hysteroscopic Management of a Stenotic Cervix
The authors have no conflicts of interest to disclose. We present an approach for the surgical management of a stenotic cervix in an outpatient hysteroscopy setting, with video demonstrations.
Gynecologists require intrauterine access for a number of procedures. An outpatient hysteroscopy suite has a number of advantages over the operating theatre and typically uses hysteroscopes with a smaller operative canal than traditional instruments.
Even experienced practitioners can have difficulty with a stenotic cervix. This formidable opponent is encountered when a cervical canal is too narrow to allow the insertion of a 2.5 mm Hegar or a Pratt dilator. We present the ease of a see-and-treat approach in an outpatient hysteroscopy setting to manage a stenotic cervix.
As in all aspects of surgery, patient positioning is a key component, and stirrups should be used. Surgical lighting improves visualization. Patient discomfort can be minimized with routine oral analgesia and if required, a paracervical block or conscious sedation. Although not routinely required, applying a tenaculum to the cervix can help straighten the angle and improve surgical technique. Oftentimes, these simple steps can allow passage through what was previously described as a stenotic cervix.
Vaginoscopy is the first step to the no-touch hysteroscopy technique. It decreases the patient’s discomfort by avoiding both the speculum and tenaculum. The hysteroscope is inserted under direct visualization into the vagina, and the distension medium retracts the walls of the vagina.
By following the posterior wall, as shown here, the posterior fornix is eventually visualized. By slowly retracting the hysteroscope, the external cervical os will be seen. Cervical mucus or glands found in the transformation zone can help localization.
By advancing slowly, the distension medium dilates the cervical canal ahead, and even a tortuous path through the cervix can be navigated. Adjusting the angle of the camera prevents damage to delicate vasculature within the canal, which decreases patient discomfort and improves visualization. Careful techniques can be almost pain-free and allow excellent assessment of the uterine cavity.
A stenotic cervix can be the result of thick adhesions at the external os, internal os or throughout the length of the canal. The cause is commonly due to a sharp curettage or previous treatment for cervical dysplasia. Microscissors can be used for the revision of the cervical canal. They pass through the operative canal of the hysteroscope and can sharply dissect tissue.
For these thick adhesions at the external os, the familiar push-spread technique can be adapted to allow a safe dissection. The fibrous adhesions usually allow only a small amount of distension but enough to visualize the direction of the cervical canal, as shown here.
In the awake patient, feedback is extremely helpful, as a division of fibrous scar tissue is pain-free, whereas increased pain would suggest a division of normal cervical or uterine tissue. Progressive division of adhesions allows further distension of the cervical canal ahead and eventually access into the uterine cavity.
This technique of sharp dissection can be adapted to the division of intrauterine adhesions as well. Microscissors and micrograspers can be used to remove specimens both within the cervical canal and uterine cavity.
Another similar technique uses micrograspers to push and spread, which bluntly slices the adhesions. One advantage is that injury to normal cervical or uterine tissue is minimized, but this technique is limited to a cervix that is only partially stenosed and to adhesions that are not only fibrotic, as shown in this video here.
A stenotic cervix can be narrowed to the point that even a mini hysteroscope cannot be inserted. In these patients, aggressive, blind dilation can significantly increase their risk of uterine perforation.
The width of a cutting loop electrode is significantly smaller than a hysteroscope and can oftentimes be advanced into a stenotic canal. By removing a small amount of the cervical depth, the overall cross-sectional area of the cervical canal is increased and can permit the advancement of a larger hysteroscope. By progressively removing a small amount of cervical depth, increasing the cross-sectional area and further extending the cervical canal ahead, we can access the uterus.
These particular cases are performed in the main operating theatre. The loop excision can be performed in the outpatient setting as well. Safe excision of tissue can be performed as long as the operating instrument is kept within the visual field.
We presented here an approach to the stenotic cervix, which includes optimizing the environment, no-touch hysteroscopy and revision of the cervical canal with micro instruments or a loop electrode. These techniques can be applied in an outpatient hysteroscopy setting and also adapted for use in an operating theatre.
This video was brought to you by the Ottawa Minimally Invasive Gynaecology team.