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World Journal of Laparoscopic Surgery, May-August 2008;1(2):20-22
Role of Mechanical Dilatation of Cervix
Monique Directo Javier
Diplomate of Philippines Obstetrical and Gynecological Society, Cebu, Philippines
2.7-5 mm; rigid hysteroscopes, from 1-5 mm; and operative
Hysteroscopy with sample of the tissue is the gold
hysteroscopes can be as large as 8-10 mm.2,3 The diameters of
standard in the diagnosing of abnormal uterine bleeding. Operative
the telescope prerequisite the dilatation of the cervix to 10-
hysteroscopy can then be performed as a therapeutic procedure in
11mm prior to insertion of the instrument. Ideally, hysteroscopy
patients presenting with intrauterine abnormalities. Cervical dilatation
is performed with minimal or no cervical dilation.3 But this may
poses a great challenge particularly in nulligravid, post-menopausal
not always be possible because the common complications
women and women with cervical stenosis. Difficulties encountered indilating the cervix poses threat to complications such as cervical tears,
encountered during the procedure are reported mainly to be
creation of false track, hemorrhage and uterine perforation.
related to the difficulty in entering the internal cervical os withthe telescope especially in nulliparous and postmenopausal
The aim of this study is to review the role of mechanical
women. Complications reported are cervical tears, creation of
dilatation in hysteroscopy using oral and vaginal misoprostol and
false passages, and uterine perforation.4 Prevention of cervical
injury and uterine perforation during termination of pregnancy
This study involves a retrospective analytical review and
has been demonstrated by pre-operative cervical ripening5,6
compares the role of oral and vaginal misoprostol and laminaria
and may be achieved either mechanically, such as with osmotic
application in achieving cervical ripening before hysteroscopy. Its
dilators,7 or biochemically with prostaglandins.8 Misoprostol
effects in cervical dilatation as well as the dosing, advantages and side-
is a prostaglandin E1 analogue which is commonly used in
effects were also reviewed. There were twenty articles included in this
obstetrics for induction of abortion and labor as well as
study as extracted from electronic databases Cochrane Library,
postpartum to control bleeding (Bugaho et al., 1994). Misoprostol
Medscape, Highwire Press and Google. Most of the articles assessedthe cervical diameter by the largest number of Hegar dilators that could
applied before hysteroscopy has reduced the need for cervical
be inserted into the cervix without resistance. Subjective assessments
dilatation, facilitated hysteroscopic surgery and minimized
of adverse effects and complications were recorded.
cervical complications (Preutthipan and Herabutya, 1999). Onthe other hand, laminaria tents, made from the stems of Laminaria
Methods of cervical priming before hysteroscopy lessens
japomica (brown seaweed), are attractive natural substances
the need of further cervical dilation pre-operatively, lessens the
that can cause cervical dilatation with minimal and no systemic
complications associated with the entry of the hysteroscope into thecervical os and offered acceptable side effects.
side effects. They have been shown to be effective in inducingcervical priming prior to operative hysteroscopy (Ostrzenski,
1994). The aim of this work is to review several studies of therole of cervical dilatation in hysteroscopy.
Recent advances in fiberoptics, light sources, high resolutionlenses, and endoscopic surgical instrumentation made
hysteroscopy an important diagnostic tool as well as therapeutic
There were 19 reported randomized controlled trials that
tool for patients presenting with intrauterine diseases.
evaluated the efficacy of misoprostol on cervical ripening in
Hysteroscopy permits direct visualization of the uterine cavity
gynecologic patients, after searching medical literature
thus making it the gold standard in diagnosing abnormal uterine
databases including Cochrane Library, Medscape, High wire
bleeding. Operative hysteroscopy as well has gained popularity
Press and Google. One article evaluated the efficacy of laminaria
as a minimally invasive approach to intrauterine lesions (Siegler
tents. The search terms used included “mechanical cervical
and Valle, 1988). However, a systematic review of diagnostic
dilation”, “cervical ripening” and “hysteroscopy.” References
hysteroscopy in more than 26,000 women reported a failure rate
from identified publications were manually searched and cross-
of 4.2% for ambulatory hysteroscopy and 3.4% for in-patient
referenced to identify additional relevant articles. The studies
procedures. Failed procedures were mainly attributed to
have shown different cervical responses and outcomes.9-28
technical problems, including cervical stenosis, anatomic and
Most of the studies compared the effect of misoprostol against
structural abnormalities and pain and intolerance.1 Flexible
placebo on different groups of women, such a nulliparous women
hysteroscopes used in this procedure range in diameter from
and postmenopausal women. Patients received misoprostol
Role of Mechanical Dilatation of Cervix in Hysteroscopy
either orally or vaginally. The dosages given in the studies
varied from 200 and 1000 mcg given between 2-24 hours before
1. Clark TJ, Volt D, Gupta JK, Hyde C, Song F, Khan KS.
the surgery, via oral, sublingual or vaginal route. One of the
Accuracy of hysteroscopy in the diagnosis of endometrial cancer
studies compared the effect of laminaria tents against placebo.
and hyperplasia: a systematic quantitative review. JAMA. 202;
The patients were randomly assigned into two groups. They
underwent hysteroscopic procedure with a 5-10 mm
2. American College of Obstetricians and Gynecologists. ACOG
hysteroscope during the follicular phases of their cycle. The
Technology assessment in obstetrics and gynecology, number
cervical width was assessed by the largest number of Hegar
4, August, 2005: hysteroscopy. Obstet Gynecol. 2005; 106:
dilators that could be inserted into the cervix without resistance.
Subjective assessment of the ease of the dilatation to 9 mm by
3. Guido R. Stovall D Hysteroscopy Version 14.3. Uptodate (cited
the surgeon was also recorded. Adverse effects like pre-
operative pain, mild lower abdominal pain and slight vaginal
4. Bradley LD. Complications in hysteroscopy: prevention,
treatment, and legal risk. Curr Opin Obstet Gynecol 2002; 14:409-15.
5. Grimes DA, Schulz KF, Cates WJ Jr. Prevention of uterine
perforation during curettage abortion. JAMA 1984; 251: 2108-
Recently, hysteroscopy has been used to investigate women
presenting with abnormal uterine bleeding (Nagele et al, 1996).
6. Schulz KF, Grimes DA, Cates W. Measures to prevent cervical
injury during suction curettage abortion. Lancet 1983; 1:
Hysteroscopy plus sampling the endometrial tissue increased
the sensitivity and specificity for the detection of endometrial
7. Lichtenberg ES. Complications of osmotic dilators. Obstet
pathology when compared with blind endometrial biopsy alone.
However, difficulty in cervical dilatation has been one of the
8. Blanchard K, Clark S, Winikoff B, Gaines G, Kabani G, Shannon
major causes of failure of this procedure (Scottish Hysteroscopy
C. Misoprostol for women’s health. Obstet Bynecol 2002; 99:
Audit Group, 1995). The articles reviewed showed that vaginal
misoprostol applied pre-operatively facilitates cervical priming
9. Yu D, Li T-c, Xia E, Huang X. A prospective, randomized,
and reduced the need for cervical dilation, facilitated the ease
controlled trial comparing vaginal misoprostol and osmotic dilator
of diagnostic and operative hysteroscopy and minimized cervical
in achieving cervical ripening before operative hysteroscopy.
complications. One article mentioned that both misoprostol and
Gynecological Surgery 2006; 3: 186-89.
laminaria were equally effective. Nevertheless, misoprostol is
10. Aslan G, Yuce MA, Gucer F. A comparison of vaginal and oral
routes in misoprostol administration for cervical priming before
superior over the laminaria due to easy application, cheap cost
hysteroscopy: a prospective randomized double-blind study.
and convenience and better acceptability to the patient. Both
Jinekoloji Ve Obstetrik Dergisi 2004; 18: 145-49.
oral and vaginal misoprostol showed no significant difference
11. Fung TM, Lam MH, Wong SF, Ho LC. A randomized placebo-
with respect to cervical opening, duration of dilation as well as
controlled trial of vaginal misoprostol for cervical priming before
the rate of complications. Most studies of dosing have involved
hysteroscopy in postmenopausal women. BJOG 2002; 109;
the use of vaginal misoprostol administration with dosages of
200 microgram to 400 microgram given 9-12 hours before
12. Thomas JA, Leylans N, Durand N, Windrim RC. The use of oral
hysteroscopy showing the greatest benefit. One review showed
misoprostol as a cervical ripening agent in operative
that misoprostol application is safe and effective for cervical
hysteroscopy: a double blind, placebo controlled trial. Am J
priming against placebo in premenopausal women but not in
postmenopausal women. Misoprostol is a drug used for the
13. Preutthipan S, Herabutya Y. A randomized controlled trial of
vaginal misoprostol for cervical priming before hysteroscopy.
treatment of peptic ulcer disease. The cost is cheap, self-
administration is easy and does not require hospital resources
14. Ngia SW, Chan YM, Liu KL, Ho PC. Oral misoprostol for
in application, other than information.
cervical priming in non-pregnant women. Hum Reprod 1997;12: 2373-75.
15. Preutthipan S. Herabutya Y. Vaginal misoprostol for cervical
priming before operative hysteroscopy, a randomized controlled
In conclusion, methods of cervical priming and dilation before
trial. Obstet Gynecol 2000; 96: 890-94.
hysteroscopy negate the need of further dilating the cervix at
16. Fernandez H, Alby JD, Tournox C, Chauveaud-Lambling A, de
the operation theater prior to the procedure. Among the methods
Tayrac R, Frydman R, et al. Vaginal misoprostol for cervical
offered in the market, misoprostol is highly superior in the
ripening before operative hysteroscopy in premenopausal
cervical ripening before hysteroscopy due to cheap cost, easy
women: a double-blind, placebo controlled trial with three dose
regimens. Human Reprod 2004; 19: 1618-21.
17. Darwish AM, Ahmad AM, Mohammad AM. Cervical priming
23. Bunnasathiansri S, Herabutya Y, O-Prasertsawat P. Vaginal
prior to operative hysteroscopy: a randomized comparison
misoprostol for cervical priming before dilatation and curettage
of laminaria versus misoprostol. Hum Reprod 2004; 19:
in post-menopausal women; a randomised controlled trial. J
Obstet Gynaecol Res 2004; 30: 221-25.
18. Atay V, Duru NK, Pabuccu R, Ergun A, Tokac G, Aydin BA.
24. Barcaite E, Bartusevicius A, Railaite DR, Nadisaukiene R. Vaginal
Vaginal misoprostol for cervical dilatation before operative office
misoprostol for cervical priming before hysteroscopy in
hysteroscopy. Gynael Endoscopy 1997; 6: 47-49.
perimenopausal and postmenopausal women. Int J Gynaecol
19. Ngai SW, Chan YM, Ho PC. The use of misoprostol prior to
hysteroscopy in post-menopausal women. Hum Reprod 2001;
25. Choksuchat C, Cheewadhadnaraks S, Getpook C, Wootipoom
V, Dhanavoravibul K. Misoprostol for cervical ripening in non-pregnant women: a randomized double-blind controlled trial of
20. Perrone JF, Caldito G, Mailhes JB, Tucker AN, Ford WR, London
oral versus vaginal regimens. Hum Reprod 2006; 21: 2167-70.
SN. Oral misoprostol before office endometrial biopsy. Obstet
26. Oppegaard KS, Nesheim B-I, Istre O, Qvigstad E. Comparison
of self-administered vaginal misoprostol versus placebo for
21. Thomas JA, Leynard N, Durand N, Windrim RC. The use of
cervical priming prior to operative hysteroscopy using a
oral misoprostol as a cervical ripening agent in operative
sequential trial design. BJOG 2007; 114: 769.
hysteroscopy; a double blind placebo controlled trial. Am J
27. Crane JM, Healy S. Use of misoprostol before hysteroscopy: a
systematic review. J Obstet Gynaecol Can 2006; 28: 373-79.
22. Bisharah M, Al fozan H, Tulandi T. a randomized trial of
28. Darwish AM, Ahmad AM, Mohammad AM. Cervical priming
sublingual misoprostol for cervical priming before hysteroscopy.
prior to operative hysteroscopy: a randomized comparison of
J Am Assoc Gynecol Laparosc 2003; 10: 390-91.
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