Hysteroscopy is the inspection of the

uterine cavity The uterine cavity is the inside of the uterus The uterus (from Latin ''uterus'', : uteri or uteruses) or womb () is the hollow organ, organ in the reproductive system of most female mammals, including humans, that accommodates the embryonic d ...

endoscopy An endoscopy is a procedure used in medicine to look inside the body. The endoscopy procedure uses an endoscope to examine the interior of a hollow organ or cavity of the body. Unlike many other medical imaging techniques, endoscopes are insert ...

with access through the

cervix The cervix (: cervices) or cervix uteri is a dynamic fibromuscular sexual organ of the female reproductive system that connects the vagina with the uterine cavity. The human female cervix has been documented anatomically since at least the time ...

. It allows for the diagnosis of intrauterine pathology and serves as a method for surgical intervention (operative hysteroscopy).

Hysteroscope

A hysteroscope is an endoscope that carries optical and light channels or fibers. It is introduced in a sheath that provides an inflow and outflow channel for insufflation of the uterine cavity. In addition, an operative channel may be present to introduce scissors, graspers or biopsy instruments. A hysteroscopic resectoscope is similar to a transurethral resectoscope and allows entry of an electric loop to shave off tissue, for instance to eliminate a fibroid. A ''contact hysteroscope'' is a hysteroscope that does not use distention media.

Procedure

Hysteroscopy has been carried out in hospitals, surgical centers and doctors' offices. It is best carried out when the endometrium is relatively thin, that is after a menstruation. Both diagnostic and simple operative hysteroscopy can be carried out in an office or clinic setting on suitably selected patients. Local anesthesia can be used.

Analgesic An analgesic drug, also called simply an analgesic, antalgic, pain reliever, or painkiller, is any member of the group of drugs used for pain management. Analgesics are conceptually distinct from anesthetics, which temporarily reduce, and in s ...

s are not always necessary. A paracervical block may be achieved using a

lidocaine Lidocaine, also known as lignocaine and sold under the brand name Xylocaine among others, is a local anesthetic of the amino amide type. It is also used to treat ventricular tachycardia and ventricular fibrillation. When used for local anae ...

injection in the upper part of the cervix. Hysteroscopic intervention can also be done under general

anesthesia Anesthesia (American English) or anaesthesia (British English) is a state of controlled, temporary loss of sensation or awareness that is induced for medical or veterinary purposes. It may include some or all of analgesia (relief from or prev ...

(endotracheal or laryngeal mask) or monitored anesthesia care (MAC). Prophylactic antibiotics are not necessary. The patient is in a lithotomy position during the procedure.

Cervical dilation

The diameter of the modern hysteroscope is generally small enough to conveniently pass the

directly. For a proportion of women

cervical dilation Cervical dilation (or cervical dilatation) is the opening of the cervix, the entrance to the uterus, during childbirth, miscarriage, induced abortion, or gynecological surgery. Cervical dilation may occur naturally, or may be induced surgically ...

may need to be performed prior to insertion. Cervical dilation can be performed by temporarily stretching the cervix with a series of ''dilators'' of increasing diameter.

Misoprostol Misoprostol is a synthetic prostaglandin medication used to prevent and treat stomach and duodenal ulcers, induce labor, cause an abortion, and treat postpartum bleeding due to poor contraction of the uterus. It is taken by mouth when used ...

prior to hysteroscopy for cervical dilation appears to facilitate an easier and uncomplicated procedure only in premenopausal women.

Insertion and inspection

The hysteroscope with its sheath is inserted transvaginally guided into the uterine cavity, the cavity insufflated, and an inspection is performed.

Insufflation media

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, the patient's condition, and the physician's preference. 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 dependent on the quality of the high-resolution video images in front of the surgeon's eyes, CO₂ gas is not commonly used as the distention medium. Electrolytic solutions include normal saline and

lactated Ringer's solution Ringer's lactate solution (RL), also known as sodium lactate solution, Lactated Ringer's (LR), and Hartmann's solution, is a mixture of sodium chloride, sodium lactate, potassium chloride, and calcium chloride in water. It is used for replaci ...

. 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 conduct 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 Hyponatremia or hyponatraemia is a low concentration of sodium in the Serum (blood), blood. It is generally defined as a sodium concentration of less than 135 mmol/L (135 mEq/L), with severe hyponatremia being below 120 mEq/L. Symp ...

. These solutions include

glucose Glucose is a sugar with the Chemical formula#Molecular formula, molecular formula , which is often abbreviated as Glc. It is overall the most abundant monosaccharide, a subcategory of carbohydrates. It is mainly made by plants and most algae d ...

glycine Glycine (symbol Gly or G; ) is an amino acid that has a single hydrogen atom as its side chain. It is the simplest stable amino acid. Glycine is one of the proteinogenic amino acids. It is encoded by all the codons starting with GG (G ...

dextran Dextran is a complex branched glucan (polysaccharide derived from the condensation of glucose), originally derived from wine. IUPAC defines dextrans as "Branched poly-α-d-glucosides of microbial origin having glycosidic bonds predominantly C-1 ...

(Hyskon),

mannitol Mannitol is a type of sugar alcohol used as a sweetener and medication. It is used as a low calorie sweetener as it is poorly absorbed by the intestines. As a medication, it is used to decrease pressure in the eyes, as in glaucoma, and to l ...

sorbitol Sorbitol (), less commonly known as glucitol (), is a sugar alcohol with a sweet taste which the human body metabolizes slowly. It can be obtained by reduction of glucose, which changes the converted aldehyde group (−CHO) to a primary alco ...

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 Fructose malabsorption, formerly named dietary fructose intolerance (DFI), is a digestive disorder in which absorption of fructose is impaired by deficient fructose carriers in the small intestine's enterocytes. This results in an increased conce ...

. 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 Mannitol is a type of sugar alcohol used as a sweetener and medication. It is used as a low calorie sweetener as it is poorly absorbed by the intestines. As a medication, it is used to decrease pressure in the eyes, as in glaucoma, and to l ...

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

. When fluids are used to distend the cavity, care should be taken to record its use (inflow and outflow) to prevent fluid overload and intoxication of the patient.

Interventional procedures

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. Hysteroscopy has also been used to apply the Nd:YAG laser treatment to the inside of the uterus. Methods of tissue removal now include electrocautery bipolar loop resection, and morcellation.

Indications

Hysteroscopy is useful in a number of uterine conditions: *

Asherman's syndrome Asherman's syndrome (AS) is an acquired uterine condition that occurs when scar tissue (adhesions) forms inside the uterus and/or the cervix. It is characterized by variable scarring inside the uterine cavity, where in many cases the front and bac ...

(i.e. 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 laparoscopy or other methods to reduce the risk of perforation during the procedure. * Endometrial polyp. Polypectomy. *

Abnormal uterine bleeding Abnormal uterine bleeding is vaginal bleeding from the uterus that is abnormally frequent, lasts excessively long, is heavier than normal, or is irregular. The term "dysfunctional uterine bleeding" was used when no underlying cause was presen ...

Adenomyosis Adenomyosis is a medical condition characterized by the growth of cells that proliferate on the inside of the uterus (endometrium) atypically located among the cells of the uterine wall (myometrium), as a result, thickening of the uterus occurs. ...

Endometrial ablation Endometrial ablation is a surgical procedure that is used to remove ( ablate) or destroy the endometrial lining of the uterus. The goal of the procedure is to decrease the amount of blood loss during menstruation (periods). Endometrial ablation i ...

(Some newer systems specifically developed for endometrial ablation such as the Novasure do not require hysteroscopy) * Myomectomy for

uterine fibroid Uterine fibroids, also known as uterine leiomyomas, fibromyoma or fibroids, are benign smooth muscle tumors of the uterus, part of the female reproductive system. Most people with fibroids have no symptoms while others may have painful or h ...

s. * Congenital

uterine malformation A uterine malformation is a type of female genital malformation resulting from an abnormal development of the Müllerian duct(s) during embryogenesis. Symptoms range from amenorrhea, infertility, recurrent pregnancy loss, and pain, to normal f ...

s (also known as Müllerian malformations). * Evacuation of retained products of conception in selected cases. * Removal of embedded IUDs. The use of hysteroscopy in

endometrial cancer Endometrial cancer is a cancer that arises from the endometrium (the epithelium, lining of the uterus or womb). It is the result of the abnormal growth of cells (biology), cells that can invade or spread to other parts of the body. The first s ...

is not established as there is concern that cancer cells could be spread into the peritoneal cavity. 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

. Hysteroscopy allows access to the

uterotubal junction The uterotubal junction is the connection between the endometrial cavity of the uterus and the fallopian tube (uterine tube) at the proximal tubal opening, the beginning of the intramural part of the fallopian tube. Histologically, the endometrial ...

for entry into the

fallopian tube The fallopian tubes, also known as uterine tubes, oviducts or salpinges (: salpinx), are paired tubular sex organs in the human female body that stretch from the Ovary, ovaries to the uterus. The fallopian tubes are part of the female reproduct ...

; this is useful for tubal occlusion procedures for sterilization and for falloposcopy.

Complications

A possible problem is

uterine perforation Uterine perforation is a potential complication of any intrauterine procedure. It may be associated with injury to surrounding blood vessels or viscera such as the bladder or intestine. If not diagnosed at the time of the procedure it can occasi ...

when either the hysteroscope itself or one of its operative instruments breaches the wall of the uterus. This can lead to bleeding and damage to other organs. If other organs such as bowel are injured during a perforation, the resulting

peritonitis Peritonitis is inflammation of the localized or generalized peritoneum, the lining of the inner wall of the abdomen and covering of the abdominal organs. Symptoms may include severe pain, swelling of the abdomen, fever, or weight loss. One pa ...

can be fatal. Furthermore, cervical laceration, intrauterine infection (especially in prolonged procedures), electrical and laser injuries, and complications caused by the distention media can be encountered. The use of insufflation (also called ''distending'') media can lead to serious and even fatal complications due to embolism or fluid overload with electrolyte imbalances. Particularly the electrolyte-free insufflation media increase the risk of fluid overload with electrolyte imbalances, particularly

heart failure Heart failure (HF), also known as congestive heart failure (CHF), is a syndrome caused by an impairment in the heart's ability to Cardiac cycle, fill with and pump blood. Although symptoms vary based on which side of the heart is affected, HF ...

as well as

pulmonary The lungs are the primary organs of the respiratory system in many animals, including humans. In mammals and most other tetrapods, two lungs are located near the backbone on either side of the heart. Their function in the respiratory syste ...

and

cerebral edema Cerebral edema is excess accumulation of fluid ( edema) in the intracellular or extracellular spaces of the brain. This typically causes impaired nerve function, increased pressure within the skull, and can eventually lead to direct compres ...

. The main factors contributing to fluid overload in hysteroscopy are: *

Hydrostatic pressure Hydrostatics is the branch of fluid mechanics that studies fluids at hydrostatic equilibrium and "the pressure in a fluid or exerted by a fluid on an immersed body". The word "hydrostatics" is sometimes used to refer specifically to water and o ...

of the insufflation media * Amount of exposed

blood vessel Blood vessels are the tubular structures of a circulatory system that transport blood throughout many Animal, animals’ bodies. Blood vessels transport blood cells, nutrients, and oxygen to most of the Tissue (biology), tissues of a Body (bi ...

s, such as being increased in

endometrial ablation Endometrial ablation is a surgical procedure that is used to remove ( ablate) or destroy the endometrial lining of the uterus. The goal of the procedure is to decrease the amount of blood loss during menstruation (periods). Endometrial ablation i ...

and myomectomy. * Duration of the hysteroscopy procedure. Women in fertile age are at increased risk of resultant hyponatremic encephalopathy, likely because of increased level of

estrogen Estrogen (also spelled oestrogen in British English; see spelling differences) is a category of sex hormone responsible for the development and regulation of the female reproductive system and secondary sex characteristics. There are three ...

s. The overall complication rate for diagnostic and operative hysteroscopy was 2% with serious complications occurring in less than 1% of cases using older methods. Morcellation has fewer complications than electrocautery, less than 0.1%.

Severe pain

The former English Member of Parliament, Lyn Brown (West Ham, Labour), has spoken eleven times in the House of Commons on behalf of the Campaign Against Painful Hysteroscopy and constituents who have been coerced into completing unbearably painful outpatient hysteroscopies without anaesthesia. Lyn Brown cites numerous instances of women throughout England being held down by nurses in order to complete an ambulatory hysteroscopy and thus avoid the expense of safely monitored sedation or general anaesthetic.Hansard : 19 December 2013
and �

/ref> A petition to grant NHS patients full information about the risks of severe outpatient hysteroscopy pain, and the upfront choice of local anaesthetic, sedation, epidural or general anaesthetic was launched in summer 2018. 'End barbaric NHS hysteroscopies with inadequate pain-relief'. It asks the Secretary of State for Health to ensure that: # All NHS hysteroscopists have advanced training in pain medicine. # All hysteroscopy patients receive full written information before the procedure, listing the risks and benefits and explaining that local anaesthetic may be painful and ineffective against the severe pain of cervical dilation, womb distension and biopsy. # All hysteroscopy services are adequately funded so that BEFORE their procedures patients may choose no anaesthesia/ local anaesthesia/ safely monitored conscious sedation/ epidural/ general anaesthetic. # The Best Practice Tariff financial incentive, which rewards NHS Trusts who perform a high percentage of hysteroscopies in outpatients without a trained anaesthetist, is abolished.

References

External links

American Congress of Obstetricians and Gynecologists, ACOG education pamphlet {{Authority control Diagnostic obstetrics and gynaecology Endoscopy Female genital procedures