The role of hysteroscopy during COVID-19 outbreak: Safeguarding lives and saving resources.

COVID‐19 was declared a pandemic by the World Health Organization (WHO) during its 51st situation report on March 11, 2020. One purpose of the report was to advise restructuring of healthcare services by limiting them to urgent or emergent cases in order to reduce pressure on the intensive care units (ICU) of hospitals treating COVID‐19‐positive patients. The availability of ICU during a pandemic is essential. For this reason, it is mandatory to limit non‐essential surgical interventions in order to allocate resources where they are urgently needed.

Hysteroscopy is the gold standard technique for the diagnosis and treatment of intrauterine pathologies. While hysteroscopic surgeries performed in the operating room with general anesthesia will only need a single ventilator (anesthesia machine), performing office hysteroscopy does not require the use of ventilators and should not have an impact on a hospital’s ICU capacity. However, hysteroscopy is considered an elective surgery, with only a few conditions that require it to be performed as an emergency. For this reason, during this pandemic, hysteroscopy should only be carried out in selected cases. Understanding which pathology should be considered an emergency, and therefore treated immediately, is challenging and an objective decision‐making process is not easy to elucidate. Currently, the use of hysteroscopy for the treatment of potentially malignant conditions, which must be promptly diagnosed, and other conditions that are hazardous for patients has been considered a feasible and safe approach, recognizing the current role of hysteroscopy in an emergency setting.

Heavy vaginal bleeding is a frequent gynecologic pathology that can occasionally become life‐threatening. The FIGO (International Federation of Gynecology and Obstetrics) Committee on Menstrual Disorders developed the PALM‐COEIN classification system of abnormal uterine bleeding (AUB) in non‐pregnant women. Structural disorders are present in 52%–94% of cases in women complaining of heavy vaginal bleeding. Surgical management of AUB is a very effective treatment. Frequently, resecting focal intrauterine lesions will result in the immediate cessation of blood loss. However, not every condition listed in the PALM‐COEIN classification is considered an emergency and it should be clear which ones require immediate attention. If the presence of structural pathology is not identified during the clinical evaluation or after performing a pelvic ultrasound, AUB is likely caused by a functional pathology and should be treated medically. In such cases, hysteroscopy might be postponed without having any negative impact on the patient. ,

The presence of structural pathology will often require surgical intervention. The correlation between AUB and the presence of submucosal fibroids is well known. Removing submucosal fibroids by enucleation immediately stops the bleeding, thus avoiding future anemia and the potential need for blood transfusion. In such cases, performing a hysteroscopic myomectomy is considered an emergency intervention and should never be delayed. Hysteroscopic myomectomies have no impact on hospital ICU capacity.

Endometrial polyps are also a frequent cause of heavy vaginal bleeding. Hysteroscopic polypectomy in the office setting, as an emergency surgery, is a feasible solution in selected cases. The presence of small polyps in women of reproductive age should not concern clinicians and their resection could safely be postponed until after the pandemic. On the contrary, for women presenting with postmenopausal bleeding, or those with abnormal endometrial ultrasound imaging findings, resection of the lesion and subsequent histopathological evaluation is required due to the elevated risk of pre‐malignant or malignant conditions.

The editorial team of the International Journal of Gynecological Cancer have compiled evidence‐based data based on established guidelines and considerations for the management of patients with gynecological cancers during the COVID‐19 pandemic, which state that hormonal treatment should be considered for patients with low‐risk category G1 endometrial cancer tumors. Other guidelines state that delaying treatment for up to 2 months in these cases might be a reasonable option.

For any of the other conditions listed in the PALM‐COEIN classification, hysteroscopic procedures could be postponed until the pandemic period is over.

Cervical or cesarean section scar ectopic pregnancies are life‐threatening conditions that should be carefully managed, especially during this pandemic. Regarding caesarean section scar ectopic pregnancies, when diagnosed and treated during the early, asymptomatic phase, the frequency of complications is minimal. Among surgical treatment options for this condition, hysteroscopy, which is considered an emergency in this case, should not be delayed. During this intervention the trophoblastic tissue of the cesarean section scar pregnancy is removed under direct visualization using loop resection.

Regarding cervical or isthmic pregnancy, prior administration of systemic and/or local methotrexate or potassium chloride should be considered before performing the hysteroscopic procedure. Using mechanical instruments or bipolar electrodes, it is feasible to detach the gestational sac from the surrounding endometrium without any additional risk.

Another possible gynecologic emergency that could present during the pandemic is retained products of conception (RPOC). Hysteroscopy is the treatment of choice for RPOC as it is an effective way to stop the bleeding immediately, thus preventing possible anemia. For this reason, performing hysteroscopy for RPOC is essential and should not be delayed.

The COVID‐19 pandemic is causing harmful consequences not only to those who become infected with the virus. Remodeling the healthcare system is mandatory in order to prevent further overload of ICU capacity. Performing hysteroscopy only for acute (e.g. heavy vaginal bleeding, ectopic pregnancies) or potentially harmful (e.g. RPOC or uterine malignancies) pathologies while avoiding unnecessary intervention will save resources in two ways: saving lives, while allocating resources to other critical situations generated by the COVID‐19 pandemic.

AUTHOR CONTRIBUTIONS

SGV and PT conceived and wrote the manuscript; JC and GR critically revised the manuscript; ZF, ZK, GB, and RL gave support in literature search; PT supervised the project.

CONFLICTS OF INTEREST

The authors have no conflicts of interest.