Hysteroscopy is a procedure that allows a physician to look through the vagina and neck of the uterus (cervix) to inspect the cavity of the uterus. A telescope-like instrument called a hysteroscope is used. Hysteroscopy is used as both a diagnostic and a treatment tool.
Description
Diagnostic hysteroscopy is performed in either a doctor's office or hospital. Before inserting the hysteroscope, the doctor injects a local anesthetic around the cervix. Once it has taken effect, the doctor dilates the cervix and then inserts a narrow lighted tube (the hysteroscope) through the cervix to reveal the inside of the uterus. Ordinarily, the walls of the uterus are touching each other. In order to get a better view, the uterus is inflated with carbon dioxide gas or fluid. Hysteroscopy takes about 30 minutes, and can cost anywhere from $750 to $4,000 depending on the extent of the procedure.
Treatment involving the use of hysteroscopy is usually performed as a day surgical procedure with regional or general anesthesia. Tiny surgical instruments are inserted through the hysteroscope, and are used to remove polyps or fibroids. A small sample of tissue lining the uterus is often removed for examination, especially if there is any abnormal bleeding.
Who Performs the Procedure and Where Is It Performed?
The test is usually performed by a gynecologist, a medical doctor who specializes in the areas of women's general health, pregnancy, labor and childbirth, and prenatal testing. Nursing staff assists with providing education, positioning the patient, and specimen collection. Diagnostic hysteroscopy is performed in either a doctor's office or hospital. Uterine size and potential diagnosis and complexity of treatment determine the setting.
Questions to Ask the Doctor
Why is hysteroscopy recommended in my case?
Will a surgical procedure be performed?
How long will the procedure take?
Where will the procedure be performed?
Definition
Hysteroscopy enables a physician to look through the vagina and neck of the uterus (cervix) to inspect the cavity of the uterus with an instrument called a hysteroscope. Hysteroscopy is used as both a diagnostic and a treatment tool.
Purpose
Diagnostic hysteroscopy can be used to help determine the cause of infertility, dysfunctional uterine bleeding, and repeated miscarriages. It can also help locate polyps and fibroids, as well as intrauterine devices (IUDs).
The procedure is also used to investigate and treat gynecological conditions, often done instead of or in addition to performing a dilation and curettage (D&C). A D&C is a surgical procedure that expands the cervical canal (dilation) so that the lining of the uterus can be scraped (curettage). A D&C can be used to take a sample of the lining of the uterus for analysis. However, hysteroscopy has advantages over a D&C because the doctor can take tissue samples of specific areas and view any fibroids, polyps, or structural abnormalities. In addition, small fibroids and polyps may be removed via the hysteroscope (in combination with other instruments that are inserted through canals in the hysteroscope), thus avoiding more invasive and complicated open surgery. This approach is also used to remove IUDs that have become embedded in the wall of the uterus.
Demographics
There is no research available to indicate that hysteroscopy is performed more or less frequently on any subset of the female population.
Description
The hysteroscope is an extremely thin telescope-like instrument that looks like a lighted tube. The modern hysteroscope is so thin that it can fit through the cervix with only minimal or no dilation.
Before inserting the hysteroscope, the doctor administers an anesthetic. Once it has taken effect, the doctor dilates the cervix slightly, and then inserts the hysteroscope through the cervix to reveal the inside of the uterus. Ordinarily, the walls of the uterus are touching each other. In order to get a better view, the uterus may be inflated with carbon dioxide gas or fluid. Hysteroscopy takes approximately 30 minutes.
Treatment involving the use of hysteroscopy is usually performed as a short-stay hospital procedure with regional or general anesthesia. Tiny surgical instruments may be inserted through the hysteroscope to remove polyps or fibroids. A small sample of tissue lining the uterus is often removed for examination, especially if the patient has experienced any abnormal bleeding.
Diagnosis/Preparation
If the procedure is performed under general anesthesia, the patient should have nothing to eat or drink after midnight the night before the procedure. Routine lab tests may be ordered if the procedure is performed in a hospital. Occasionally, a mild sedative is administered to help the patient relax. The patient is asked to empty her bladder. She is then placed in position (usually in a special chair that tilts back) and the vagina is cleansed. Usually, a local anesthetic is administered around the cervix, although a regional anesthetic that blocks nerves connected to the pelvic region or a general anesthetic may be required for some patients.
Aftercare
It is normal to experience light bleeding for one to two days after surgical hysteroscopy. Mild cramping or pain is common after operative hysteroscopy, but usually diminishes within eight hours. If carbon dioxide gas was used, the resulting discomfort usually subsides within 24 hours.
Risks
Diagnostic hysteroscopy rarely causes complications. The primary risk is infection. Prolonged bleeding may follow a surgical hysteroscopy to remove a growth. Another complication is perforation of the uterus, bowel, or bladder, caused by over-forceful advancement of the hysteroscope. An infrequent but dangerous complication is increased fluid absorption from the uterus into the bloodstream. Keeping track of the amount of fluid used during the procedure can minimize this complication. Surgery under general anesthesia poses the additional risks typically associated with this type of anesthesia.
The procedure is not performed on women with acute pelvic inflammatory disease (PID) due to the potential of exacerbating the condition. Hysteroscopy should be scheduled after menstrual bleeding has ended and before ovulation to avoid a potential interruption of a new pregnancy.
Patients should notify their health care provider if, after the hysteroscopy, they develop any of the following symptoms:
Normal hysteroscopy reveals a healthy uterus with no fibroids or other growths. Abnormal results include uterine fibroids, polyps, or a septum (an extra fold of tissue down the center of the uterus). Sometimes, precancerous or malignant growths are discovered.
Morbidity and Mortality Rates
The rate of complications during diagnostic hysteroscopy is very low, about 0.01%. Surgical hysteroscopy is associated with a higher number of complications. Perforation of the uterus occurs in 0.8% of procedures and excess bleeding in 1.2–3.5% of cases. Death as a result of hysteroscopy occurs at a rate of 2.4 per 100,000 procedures performed.
Alternatives
A laparoscope (an instrument with a video camera inserted through the abdominal wall) may be used to visualize the outside of the uterus or perform a surgical procedure on the pelvic organs. Laparoscopy and hysteroscopy are sometimes performed simultaneously to maximize their diagnostic capabilities.
Resources
Books
Pagana, Kathleen D., and Timothy J. Pagana. Diagnostic Testing and Nursing Implications. 5th edition. St. Louis: Mosby, 1999.
Periodicals
Murdoch, J. A., and T. J. Gan. "Anesthesia for Hysteroscopy." Anesthesiology Clinics of North America 19, no. 1 (March 2001): 125–40.
Neuwirth, R. S. "Special Article: Hysteroscopy and Gynecology: Past, Present, and Future." Journal of American Association of Gynecology Laparoscopy 8, no. 2 (May 2001): 193–8.
Organizations
American College of Obstetricians and Gynecologists. 409 12th St., S.W., P.O. Box 96920, Washington, DC 20090-6920. http://www.acog.org/.
Hysteroscopy is the inspection of the uterine cavity by endoscopy. It allows for the diagnosis of intrauterine pathology and serves as a method for surgical intervention (operative hysteroscopy).
The hysteroscope is an optical instrument connected to a video unit with a fiber optic light source, and to the channels for delivery and removal of a distention medium. The uterine cavity is a potential cavity and needs to be distended to allow for inspection. Thus during hysteroscopy either fluids or CO2 gas is introduced to expand the cavity. The choice is dependent on the procedure and the patient’s condition. Fluids can be used for both diagnostic and operative procedures. However, CO2 gas does not allow the clearing of blood and endometrial debris during the procedure, which could make the imaging visualization difficult. Gas embolism may also arise as a complication. Since the success of the procedure is totally depending on the quality of the high-resolution video images in front of surgeon's eyes, CO2 gas is not commonly used as the distention medium. Electrolytic solutions include normal saline and lactated Ringer’s. Current recommendation is to use the electrolytic fluids in diagnostic cases, and in operative cases in which mechanical, laser, or bipolar energy is used. Since they are conducting electricity, these fluids should not be used with monopolar electrosurgical devices. Non-electrolytic fluids eliminate problems with electrical conductivity, but can increase the risk of hyponatremia. These solutions include glucose, glycine, dextran (Hyskon), mannitol, sorbitol and a mannitol/sorbital mixture (Purisol). Water was once used routinely, however, problems with water intoxication and hemolysis discontinued its use by 1990. Each of these distention fluids is associated with unique physiological changes that should be considered when selecting a distention fluid. Glucose is contraindicated in patients with glucose intolerance. Sorbitol metabolizes to fructose in the liver and is contraindicated if a patient has fructose malabsorption. High-viscous Dextran also has potential complications which can be physiological and mechanical. It may crystallize on instruments and obstruct the valves and channels. Coagulation abnormalities and adult respiratory distress syndrome (ARDS) have been reported. Glycine metabolizes into ammonia and can cross the blood brain barrier, causing agitation, vomiting and coma. Mannitol 5% should be used instead of glycine or sorbitol when using monopolar electrosurgical devices. Mannitol 5% has a diuretic effect and can also cause hypotension and circulatory collapse. The mannitol/sorbitol mixture (Purisol) should be avoided in patients with fructose malabsorption.
A hysteroscope is in fact a modification of the traditional resectoscope, which is used for transurethral resection of the prostate. It has a double-channeled sheath allowing for continuous flow of fluid or gas media into the uterus through the larger channel, while allowing for less outflow through the smaller channel. This results in the distention of the uterine cavity. With modern optical technologies, hysteroscopes are getting smaller in diameter yet able to provide larger and brighter images for surgeons' convenience.
After cervical dilation, the hysteroscope is guided into the uterine cavity and an inspection is performed. If abnormalities are found, an operative hysteroscope with a channel to allow specialized instruments to enter the cavity is used to perform the surgery. Typical procedures include endometrial ablation, submucosal fibroid resection, and endometrial polypectomy. Typically hysteroscopic intervention is done under general endotracheal anesthesia or Monitored Anesthesia Care (MAC), but a short diagnostic procedure can be performed in a gynecologist's office with just a paracervical block using the Lidocaine injection in the upper part of the cervix.
Indications
Hysteroscopy is useful in a number of uterine conditions:
Asherman's syndrome (ie. intrauterine adhesions). Hysteroscopic adhesiolysis is the technique of lysing adhesions in the uterus using either microscissors (recommended) or thermal energy modalities. Hysteroscopy can be used in conjunction with laparascopy or other methods to reduce the risk of perforation during the procedure.
Hysteroscopy has the benefit of allowing direct visualization of the uterus, thereby avoiding or reducing iatrogenic trauma to delicate reproductive tissue which may result in Asherman's syndrome.
Complications
A common problem is the uterine perforation when the instrument breaches the wall of the uterus. This can lead to bleeding and damage to other organs. A life-threatening condition is the bowel perforation by the instruments after the uterine perforation, resulting in acute peritonitis which can be fatal. Furthermore, cervical laceration, intrauterine infection (especially in prolonged procedures), electrical and laser injuries, and complications caused by the distention media described above are also not uncommon. The overall complication rate for diagnostic and operative hysteroscopy is 2% with serious complications occurring in less than 1% of cases.
Variations
A contact hysteroscope is a hysteroscope that does not use distention media. A resectoscope is a variation of a hysteroscope that contains an electric loop to resect a submucous leiomyoma.
