Hysteroscopy

Hysteroscopy is a procedure that uses a tube-like telescope (hysteroscope) to visualize the inside of the uterus cavity. It is also a technique that allows the performance of various surgical interventions in the uterine cavity.

Therefore, hysteroscopy can be diagnostic (when limited only to the visualization of the uterine cavity) and operative (when it performs various interventions inside the uterine cavity).

The hysteroscope is a very thin instrument (3-5 mm in diameter). It passes through the vagina and cervix into the interior of the uterine cavity. The hysteroscope has a camera inside it, which enables the acquisition of real-time images of the uterine cavity. In this way, the gynecologist can identify various abnormalities.

In addition to the camera, the hysteroscope also has other channels through which the gynecologist can pass other instruments to perform the appropriate intervention.

Why is hysteroscopy used?

In the following cases, hysteroscopy is necessary as it can find the cause of various abnormalities (diagnostic hysteroscopy):

• Abnormal uterine bleeding
• Menstruations with increased flow and/or duration
• Bleeding between menstruations
• Bleeding in menopause
• Bleeding during hormone replacement therapy
• Unexplained or recurrent miscarriages
• Unsuccessful in vitro fertilizations.

In other cases, hysteroscopy can be used to treat different uterine problems / abnormalities (operative hysteroscopy):

• Removal of endometrial polyps (the layer that lines the uterine cavity)
• Removal of submucosal myomas (under the layer that lines the uterine cavity) and intracavitary myomas (that develop inside the cavity).
• Removal of various adhesions (areas where the uterine walls are stuck together).
• Localization and removal of a lost or embedded intrauterine device (mechanical contraceptive).
• Correction of congenital uterine abnormalities such as uterine septum (wall / curtain dividing the uterine cavity in the middle) or small uterine cavity (so-called small uterus).

Operative hysteroscopy can also be used in other situations:

• As a phase preceding in vitro fertilization with the aim of increasing the chances of success of the latter.
• Permanent tubal sterilization.

What happens before hysteroscopy?

Usually, hysteroscopy is preceded by transvaginal ultrasound. This aims to determine the diagnosis as accurately as possible.

Before hysteroscopy, as before any kind of surgical procedure, there should be a process of informing the patient about the need for hysteroscopy, its effects (positive and side effects) and its alternatives. Only after the patient's informed consent can the procedure be carried out.

What happens during hysteroscopy?

Hysteroscopy can be performed under general anesthesia or local anesthesia. In the first case, the patient is asleep, while in the second case, she is awake. During hysteroscopy with local anesthesia, the patient may also watch the progress of the procedure on a monitor if she wishes.

Of course, even during hysteroscopy under local anesthesia, the patient does not feel pain.

Initially, the speculum is inserted into the vagina through which the gynecologist visualizes the cervix. After this, he passes the hysteroscope through the cervix into the interior of the uterine cavity.

Through the camera at its tip, and through the maneuvers of the gynecologist, the hysteroscope can visualize the uterine cavity at any point of it. During the procedure, fluids can be passed through the channels of the hysteroscope into the interior of the cavity to expand it. This will improve visualization and the gynecologist's maneuvering.

• During the procedure, pieces from the endometrium (the layer that lines the uterine cavity) can be taken for examination under a microscope (biopsy). This would explain the cause of many abnormal uterine bleedings.
• If submucosal / intracavitary polyps or myomas are present, then operative hysteroscopy lasts a bit longer. All removed parts (polyps, myomas) are sent for biopsy.
• Submucosal polyps and myomas in some cases can cause abnormal uterine bleeding.
• In the case of congenital abnormalities such as uterine septum (curtains dividing the cavity into 2 parts) these are fully corrected, turning the uterine cavity into a single cavity.
• In the case of a small cavity, it is enlarged by cutting laterally and on the ceiling of the cavity; in this way, the cavity is enlarged and becomes more suitable for hosting a pregnancy.
• In the case where hysteroscopy precedes in vitro fertilization, then through the hysteroscope, some lesions (grooves) are made on the inner walls of the uterus which increase the chances of pregnancy.
• If various adhesions (synechiae) are present, they will all be eliminated until the cavity is freed.

After the completion of the procedure, which usually lasts 5-30 minutes, the hysteroscope is withdrawn from the uterine cavity.

What should the patient expect after hysteroscopy?

The post-operative period is very easy for patients.

Are there side effects of hysteroscopy?

The most common side effects are pain and minimal bleeding which were mentioned above. Very rarely, perforation or infection may occur. To minimize these complications (even though very rare) as much as possible, the patient should inform the doctor/hospital if she has:

• Fever
• Pain of increasing intensity
• Vaginal discharge with an unpleasant smell and always increasing in flow
• Increased bleeding