What is hysteroscopy?
Hysteroscopy is a minimally invasive surgical procedure that can be used to diagnose and treat many intrauterine and endocervical problems. The hysteroscope is a specialised telescope which is passed through the cervix into the uterus allowing the surgeon to look inside as well as operate inside the endometrial cavity and the cervix. Diagnostic hysteroscopy is the term used when the hysteroscope is used to make or aid in making a diagnosis. Operative hysteroscopy describes a number of different procedures where the hysteroscope is central to operating within the uterus or cervix. In the past blind endometrial biopsies were the prevailing standard in assessing the endometrial cavity. This technique has not been superseded but rather. the combination of hysteroscopy with endometrial biopsy has become the prevailing standard as the hysteroscope facilitates direct visualisation of the inside of the uterus. The hysteroscope cannot be used to visualise the muscle (myometrium) of the uterus nor the outside (serosal) surface.
Indications for diagnostic hysteroscopy
- Abnormal uterine bleeding.
- Postmenopausal bleeding.
- Painful periods and pelvic pain.
- Recurrent miscarriages.
Indications for operative hysteroscopy
- Excision of adhesions, polyps, fibroids and retained intrauterine contraceptive devices.
- Endometrial resection or ablation for heavy periods.
- Tubal occlusion by insertion of a special contraceptive device to block the fallopian tubes.
Preparation for hysteroscopy
If you are having your hysteroscopy under local anaesthesia then you will be able to eat and drink normally prior to the test. If you are having a general anaesthetic there will be specific instructions on eating, drinking and which of your usual tablets you can take prior to surgery. Always confirm this with your doctor. You will be informed of what time to arrive either at your doctors surgery or at the hospital. You will be required to sign a consent form. Before insertion of the hysteroscope, the length of the uterus is assessed by inserting a uterine sound, a thin metal instrument with graded markings. The cervix is often dilated using graded dilators. This will allow for easy passage of the hysteroscope. After the diagnostic hysteroscopy has been completed, curettage of the endometrium is performed to obtain an endometrial biopsy to send for histological analysis.
About the test
The hysteroscopy can be carried out in the doctors’ office or in the operating theatre. It will be done under a general or local anaesthesia. The procedure, including obtaining biopsies takes about 15-20 mins. Additional time will be incurred if some form of treatment is undertaken. In most cases, whether awake or asleep, you will be positioned lying on your back with your knees raised and apart. Usual aseptic (clean) techniques will be used to reduce the risk of infection. If you are awake for the procedure discomfort can be reduced by the infiltration of local anaesthetic into the cervix.
Normal endometrial cavity
The surgeon will insert the hysteroscope through the cervix and into the uterus. The uterine cavity is usually collapsed and requires distension to be viewed properly. Distension is achieved either using a fluid medium or carbon dioxide gas. Fluid distension tends to give more symmetrical distension and a better view of the endometrial cavity. Once the inspection has been completed, an endometrial biopsy can be obtained. Thereafter operative hysteroscopy (polypectomy, removal of IUCD, resection of fibroid, excision septum and adhesions) can take place. Occasionally hysteroscopy cannot be carried out because of cervical stenosis or a uterine cavity obliterated by adhesions or severely distorted by fibroids.
Endometrial fibroid polyp
Small submucous fibroid
Resection of polyp
Ablation of uterine septum
Completed ablation of septum
Removal of stuck IUCD
Risks associated with hysteroscopy
- General surgical and anaesthetic risks.
- Uterine perforation.
- Injury to the cervix during instrumentation.
- Heavy bleeding.
- Injury to adjacent organs (bowel, bladder, blood vessels).
- Fluid overload during operative hysteroscopy.
- Gas embolism (when Co2 used to distend the uterus).
Recovery from hysteroscopy is usually uneventful. Notify your doctor if you:
- Feel unwell.
- Suffer ongoing nausea/vomiting.
- Develop an offensive vaginal discharge.
- Have very heavy vaginal bleeding.
- Unexpected abdominal pain.
- Have a raised temperature or signs of fever.
- Develop signs of a urinary tract infection.
- Avoid sexual intercourse, taking a bath, using tampons and swimming for two weeks after surgery. This time frame may increase if you have also had vaginal surgery. Please consult your doctor.
- In most cases you should be able to return to work and drive 24 hours after surgery. It is important that you confirm this with your doctor and your insurance company. If you operate machinery at work then take some advice about this.
- Make sure you have a followup appointment with your doctor to discuss the results of your investigations and the plans for further management if required.