What is hysteroscopy?

Hysteroscopy is the direct visualization of the uterine cavity and the cervical canal through a telescope-like instrument called the hysteroscope. The hysteroscope is provided with a light source and a camera for viewing on a TV screen (by the doctor and patient). The hysteroscope is designed to allow flow of fluid or air to distend the uterine cavity, which actually is a collapsed space or a narrow slit. Generally fluid is used as the distending medium. Visualisation of the uterine cavity will note the presence of any masses (polyps), bands (adhesions), and uterine deformities (septum) and nature of the uterine lining or endometrium. The opening of the fallopian tubes (ostia) into the uterine cavity is also visualized. Hysteroscopy can serve as an aid to diagnosis as well as treatment for certain conditions. The former is termed as a diagnostic hysteroscopy, while the latter is referred to an an operative hysteroscopy.  

What are the indications for a hysteroscopy?

They include:

• Infertility
• Abnormal uterine bleeding
• Abnormal hysterosalpingography findings

Around 60% of uterine abnormalities may be missed on a hysterosalpingography; hence hysteroscopy has an important place.Infertility related to uterine cavity abnormality has been estimated as an etiologic factor in 10-15% of the couples.

When is it performed?

Hysteroscopy is an outpatient or day-care procedure performed between the 7^th & 10^th day of the menstrual cycle (after cessation of the menstrual bleeding). Prior to undertaking the test it is important to ensure that the patient is in good health by a clinical examination and certain laboratory investigations such as routine blood and urine tests. In the presence of any significant medical disorder, the relevant tests are performed to assess the patient’s suitability for the procedure. Diagnostic hysteroscopy is usually performed soon after menstruation because the uterine cavity is more easily evaluated and there is no risk of interrupting pregnancy.

Procedure:

• The procedure can be performed under intravenous sedation and/or local anesthesia. For the latter a small amount of anesthetic solution is injected into the cervix to numb it. In very apprehensive patients or when there is a likelihood of the procedure proceeding to a therapuetic one, general anesthesia may be used.
• The woman reports on the morning of the procedure on an empty stomach after an overnight fast.
• The patient is placed on the examination table in a specific yet comfortable position.
• A pelvic or a vaginal examination is done to assess the position and size of the uterus. A thin instrument called the uterine sound is passed into the uterine cavity.
• The mouth of the uterus i.e. the cervix is visualized by gently placing a light instrument called the speculum, in the vagina. The anterior lip of the cervix is held by a special forceps.
• If the hysteroscope is of a diameter that cannot be passed through a normal i..e. undilated cervix then the latter is dilated by means of instruments called dilators, used in a graded manner. In selected patients the cervical dilatation can be achieved by means of a drug given orally or vaginally, a few hours prior to the procedure. Small diameter hysteroscopes may be passed into the cervix without dilatation.
• The hysteroscope is inserted a little beyond the internal cervical opening into the uterine cavity. A liquid medium is used to distend the uterine cavity. The solution also clears blood and mucus away, and enables the doctor to directly view the uterine cavity.
• The uterine cavity is visualized completely in its length and breadth, along with the tubal ostia.
• The procedure is short and lasts between 2-7 minutes.
• At the end  the woman is given an analgesic to relieve any discomfort or pain that may result

 

After-care

• In the absence of general anesthesia or any complications the woman can leave after 1-2 hours.
• Antibiotics are given to prevent infection and analgesics are prescribed to relieve pain if any.
• She may have mild cramping pain in the abdomen for a few hours after the procedure.
• Avoid sexual intercourse for 48 hours or until spotting has stopped
• The woman may resume work the next day.
• She may experience uterine bleeding (mild to moderate) for a few days after the procedure.
• Patients who experience heavy bleeding, fever greater than 101°F, foul smelling vaginal discharge, chills or severe and persistent abdominal pain are advised to report immediately to the clinic.  .

Complications

Complications of diagnostic hysteroscopy are rare and seldom life-threatening.  

• Perforation of the uterus (a hole punctured in the uterus) is the most common complication, but the hole usually heals on its own, without requiring additional surgery
• Cervical trauma
• Infection
• Rarely fluid embolism - if the flow of the distending medium into the uterine cavity is not to specifications.

Contraindications

• Heavy uterine bleeding as the presence of blood may obscure the view. There is a likelihood of fluid embolism as the blood vessels are open.
• Active pelvic infection
• Cancer of the cervix or uterus

Operative hysteroscopy involves placing accessory instruments such as scissors, biopsy forceps, electosurgical or laser instruments, through channels in the hysteroscope. Operative procedures generally are day-care procedures performed under general anesthesia. The accessory instruments are used to correct any abnormality found during diagnostic hysteroscopy. Treatment may be performed at the same sitting as a diagnostic hysteroscopy or at a later date.