Hysteroscopy

Hysteroscopy is a way to look inside the uterus. A hysteroscope - a thin, telescope-like instrument that is inserted into the uterus through the vagina and cervix - may help a doctor diagnose or treat a uterine problem.

Hysteroscopy is minor surgery that may be done in a doctor's office or operating room with local, regional, or general anesthesia. In some cases, little or no anesthesia is needed. The procedure poses little risk for most women.

A Woman's Reproductive System
The uterus is a muscular organ located in the pelvis. It is broad at the top and narrow at the bottom. At each side of the upper part, a fallopian tube leads outward toward an ovary. The ovaries contain many eggs, or ova, and normally release one during each menstrual cycle. The tubes carry a fertilized egg from the ovaries to the uterus. The lower end of the uterus, called the cervix, is a narrow channel with a small opening. It opens into the vagina.

Uses of Hysteroscopy

Diagnostic Hysteroscopy
Hysteroscopy can be used to diagnose some abnormalities in the uterus. It can also be used to confirm the results of other tests, such as hysterosalpingography (HSG).

The hysteroscope is sometimes used with other instruments or techniques. For example, it may be done before dilation and curettage (D&C) or at the same time as laparoscopy. In a D&C, the cervix is widened (dilation) and part of the lining of the uterus is removed (curettage). In laparoscopy, a slender, telescope-like instrument is inserted into the abdomen through a tiny incision (cut) made through or just below the navel.

Some of the conditions for which hysteroscopy is used are described below:

Abnormal Uterine Bleeding
A woman has this condition if she has heavier or longer periods than usual, bleeds between periods, or has any bleeding after her periods have stopped at menopause. Hysteroscopy may help the doctor find the causes of abnormal bleeding that other methods have not detected. It may be used to take a biopsy (a small sample of tissue).

Infertility
A couple may not be able to achieve pregnancy for a number of reasons. Sometimes the cause of female infertility is related to a defect in the shape or size of the uterus. One example of this is a septate uterus (a thin sheet of tissue divides the inside of the uterus into two sections). These problems may not show up with the tests that are done first, but may be found with hysteroscopy.

Repeated Miscarriages
Some women, although able to get pregnant, repeatedly lose the fetus to miscarriage - the loss of a pregnancy before 20 weeks. Hysteroscopy can be used with other tests to help discover the causes of miscarriage.

Adhesions
Bands of scar tissue, or adhesions, can sometimes form inside the uterus. This is called Asherman syndrome. These adhesions may cause infertility and changes in menstrual flow.

Abnormal Growths
Sometimes benign growths, such as polyps and fibroids, can be diagnosed with the hysteroscope. Hysteroscopy might help a doctor to biopsy a suspicious growth in the uterus to find out whether it may be cancerous or may become cancerous.

Displaced IUDs
An intrauterine device (IUD) is a small plastic device inserted in the uterus to prevent pregnancy. In some cases, it moves out of its proper position inside the uterus and becomes embedded in the uterine wall or surrounding tissue. Sometimes hysteroscopy can be used to locate an IUD.

Operative Hysteroscopy

When hysteroscopy is used to diagnose certain conditions, it may be used to correct them as well. For example, uterine adhesions, septums, or fibroids often can be removed through the hysteroscope. Sometimes hysteroscopy can be used instead of open abdominal surgery. Often it will be done in an operating room with general anesthesia.

Endometrial ablation is a procedure in which the lining of the uterus is destroyed in order to treat some causes of heavy bleeding. After this is done, a woman can no longer have children. For this procedure, the hysteroscope is sometimes used with other instruments, such as a laser or a resectoscope. The resectoscope is a specially designed telescope with a wire loop, a rollerball, or a roller cylinder tip at the end. Using electric current, any of these tips can be used to destroy the uterine lining. Endometrial ablation operations are usually performed in an outpatient setting.

What to Expect

Before Surgery
When possible, hysteroscopy is scheduled during the first week or so after a menstrual period. This allows a better view of the inside of the uterus.

If you are having a hysteroscopy in a hospital, you may be asked not to eat or drink for a certain time beforehand. Some routine lab tests may be performed. You will be asked to empty your bladder, and then your vaginal area will be cleansed with an antiseptic.

Anesthesia
Hysteroscopy may be performed with local, regional, or general anesthesia. The type used depends on a number of factors, including whether other procedures are being done at the same time. Whether surgery is done in your doctor's office or in the hospital may affect the kind of anesthetic used. You will want to discuss all of the options with your doctor.

Before the procedure, your doctor may prescribe a drug to help you relax before the anesthetic is injected. When a local anesthetic is used, it is injected around the cervix to numb it. You will remain awake during the procedure and may feel some cramping.

With regional anesthesia, a drug will be injected to block the nerves that receive sensation from the pelvic region. You will be awake but will not feel any discomfort. The anesthetic will be given through a needle or tube in your lower back. This is called a spinal or epidural.

With general anesthesia, you breathe a mixture of gases through a mask. You will not be conscious during the surgery. After the anesthetic takes effect, a tube may be put down your throat to help you breathe.

The Procedure
Before a hysterectomy, the opening of your cervix may need to be dilated, or made wider, with special instruments. The hysteroscope is then inserted through the vagina and cervix and into the uterus. A liquid or gas is usually released through the hysteroscope to expand the uterus so that the inside can be seen better. A light shone through the instrument allows the doctor to view the inside of the uterus and the openings of the fallopian tubes into the uterine cavity. If surgery is to be done, small instruments will be inserted through the hysteroscope.

For more complicated procedures, a laparoscope may be used at the same time to view the outside of the uterus. In this case, a gas such as carbon dioxide or nitrous oxide is allowed to flow into the abdomen. The gas expands the abdomen, creating a space inside by raising the wall of the abdomen and moving it away from the internal organs. This makes the organs easier to see. Most of this gas is removed at the end of the procedure. This procedure is not done in the office.

Recovery
If local anesthesia was used, you will be able to go home in a relatively short time. If regional or general anesthesia was used, you may need to be watched for some time before you go home. You may feel a pain in your shoulders if laparoscopy was done with hysteroscopy, or if gas was used during hysteroscopy to inflate the uterus. This discomfort usually passes quickly as the gas is absorbed. You may feel faint or sick or you may have slight vaginal bleeding and cramps for a day or two. Get in touch with your doctor if:

• You have a fever
• You have severe abdominal pain
• You have heavy vaginal bleeding or discharge

Finally...
Hysteroscopy is a relatively safe procedure. Problems such as injury to the cervix or the uterus, infection, heavy bleeding or side effects of the anesthesia occur in less than 1% of cases.

Because hysteroscopy allows your doctor to see the inside of the uterus, it may permit an accurate diagnosis of some medical problems. It can often be performed without the use of general anesthesia. The procedure and recovery time are usually brief.

Information provided by the American College of Obstetricians and Gynecologists