Hysteroscopy

Hysteroscopy is direct visualisation of the uterine cavity using a telescope passed through the cervix. The cavity is distended with fluid or gas so that the endometrium can be seen.

It is diagnostic when used to examine the cavity, and operative when used to treat, for example to remove a polyp or a submucosal fibroid. Office hysteroscopy uses a narrow instrument and may need only local analgesia.

Usage. It is used for abnormal uterine bleeding, intrauterine pathology, the assessment of infertility, retained products, and intrauterine adhesions.

Indications. Abnormal uterine bleeding, postmenopausal bleeding, endometrial thickening on ultrasound, suspected polyp or fibroid, infertility assessment, retained products of conception, and suspected intrauterine adhesions.

Preparation and technique. Pregnancy is excluded before the procedure. The cervix may be dilated or prepared, and analgesia is given. The cavity is distended with saline, which is the most common medium, or with carbon dioxide where a gas medium is preferred. Pressure is controlled, and fluid balance is monitored in longer procedures.

Contraindications and precautions. Pregnancy, active pelvic infection, and cervical stenosis that prevents passage of the instrument. Relative cautions include severe cardiac disease, recent uterine perforation, and bleeding that obscures the view.

Interpretation.

• Endometrial polyps appear as focal, well defined lesions projecting into the cavity.
• Submucosal fibroids are classified by their relationship to the myometrium and the cavity.
• Intrauterine adhesions appear as bands or areas of reduced cavity volume, and they are relevant to infertility and pregnancy loss.
• Endometrial hyperplasia and malignancy are identified by mucosal thickening, irregularity and abnormal vascularity, and are confirmed with targeted biopsy.

Causes of an uninterpretable view. Blood in the cavity, inadequate distension, and cervical obstruction.

Critical values and findings needing immediate action.

• Uterine perforation requires immediate assessment, since intra-abdominal injury can occur.
• Fluid overload in saline hysteroscopy presents with hyponatraemia, hypotension and confusion, and needs immediate management.
• Air embolism with gas hysteroscopy is rare but requires immediate management.

Limitations and artefacts. Blood, debris and inadequate distension obscure the view. Fluid absorption during long procedures is a recognised risk. Perforation is more likely with cervical stenosis, a retroverted uterus and previous uterine surgery.

Follow up tests. Histology of biopsy specimens, repeat endometrial sampling where the appearance is equivocal, and pelvic ultrasound to assess fibroids or residual pathology.

Complications. Vasovagal reactions, infection, bleeding, uterine perforation and fluid overload.

Special groups. Postmenopausal women with bleeding are assessed with particular care, since malignancy is more likely. Adolescents are examined only where the indication is clear. Pregnancy excludes diagnostic hysteroscopy.