HYSTEROSCOPY

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 Diagnostic
Hysteroscopy
Hysteroscopy is an important tool on the study of infertility,
recurrent miscarriage, or abnormal uterine bleeding.
Diagnostic hysteroscopy is used to examine the inside of the
uterus, also known as the uterine cavity, and is helpful in
diagnosing abnormal uterine conditions such as internal
fibroids, scarring, polyps, and congenital malformations. A
hysterosalpingogram (an x-ray of the uterus and fallopian
tubes) or an endometrial biopsy may be performed before or
after diagnostic hysteroscopy.
The first step of diagnostic hysteroscopy involves slightly
stretching the canal of the cervix with a series of dilatators.
Once the cervix is dilated, the hysteroscope, a narrow lighted
viewing instrument similar to but smaller than the
laparoscope, is inserted through the cervix and into the lower
end of the uterus. Carbon dioxide gas or special clear
solutions are then injected into the uterus through the
hysteroscope. This gas or solution expands the uterine cavity,
clears blood and mucus away, and enables the physician to
directly view the internal structure of the uterus.

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 Diagnostic
Hysteroscopy
Diagnostic hysteroscopy is usually
conducted on an outpatient basis
with either general or local
anesthesia. Diagnostic hysteroscopy
is usually performed soon after
menstruation because the uterine
cavity is more easily evaluated and
there is no risk of interrupting
pregnancy. 3
 Distension Media
Carbon Dioxide
For diagnostic hysteroscopy, gaseous distension media are usually
preferred. A continuous flow is necessary to replace gas lost through the
tubes, around the hysteroscope and absorbed into the uterus.
High-viscosity Fluids
Dextran 70 has a molecular weight of 70000 and is a mixture of 32%
dextran in 10% dextrose. It is a thick viscous fluid and is electrolyte free,
non-conductive and biodegradable.
Low-viscosity Fluids
5% DEXTROSE IN WATER
As this substance has no clinical advantages over 0.9% sodium chloride
solution, but has this significant additional risk of dilutional electrolyte
disturbance its use can no longer be recommended.
1.5% GLYCINE
It is optically clear and non-hemolytic and does not conduct electricity.
Excessive absorption of such an electrolyte-free solution can be associated
with hyponatremia and hemolysis.
SORBITOL
It is optically clear and is being used as an alternative to glycine.
0.9% SODIUM CHLORIDE
Normal saline is optically clear, cheap and readily available. Excess
intravasation is not associated with any major electrolyte or metabolic
disturbances and any fluid overload can be rapidly reversed with diuretic
therapy alone. 4
 Indications
Direct hysteroscopic
inspection with adequate
distention and
visualization discloses
almost every intrauterine
abnormality with high
accuracy. Additionally, it
enables exact localization
of the pathology and
determination of its
intracavitary extent.
However, for the
diagnosis of endometritis
and adenomyosis,
conclusive hysteroscopic
criteria are still lacking.

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 Abnormal Uterine Bleeding

Abnormal uterine
bleeding is the most
common complaint
of patients
consulting the
gynecologist and
provides the most
frequent indication
for hysterectomy
Figure Endometrial
polyp with atypical
vessel structure.

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 Abnormal Uterine Bleeding
For histologic
examination selective
samples of any abnormal
tissue can be obtained
by visually controlled
biopsies.
Figure Adenocarcinoma
of the endometrium with
an irregular surface with
necrosis and dilated
tortuous vessels.

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 Infertility
Hysteroscopic diagnosis and
treatment appear to have been very
important in patients with infertility
or recurrent pregnancy loss. The
method should be considered as
complementary to TVS and HSG
rather than competing with them in
these patients.
Diagnostic hysteroscopy is always
needed for intrauterine filling
defects on HSG to confirm or
exclude pathology and to determine
the nature of an abnormality and the
possibilities for transcervical
endosurgical treatment.
FigureHSG with intrauterine filling
defects caused by grade III IUAs

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 I ntrauterine A dhesions
If the filling defects are
caused by intrauterine
adhesions, for which
treatment by hysteroscopy
is the method of choice,
any other 'blind'
intrauterine procedure can
deteriorate the
possibilities for
hysteroscopic treatment
by creating a false route or
perforation and reducing
the amount of residual
normal endometrium,
which is required for
adequate regeneration
after synechiolysis.
Figure Grade III IUAs
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 Submucous M yomas
Submucous myomas
can be a reason for
infertility or pregnancy
loss. They generally
cause abnormal uterine
bleeding, but may be
asymptomatic and only
present as intracavitary
filling defects during
HSG in infertility
patients. In these cases
hysteroscopic diagnosis
will disclose the nature
and extent of the
pathology and the
possibilities for
endosurgical treatment

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 Other s
Other intrauterine disorders that may interfere with
fertility and cause bleeding abnormalities are endometrial
polyps, endometrial hyperplasia and endometritis.
Specific indications for diagnostic hysteroscopy in
infertility patients are:
Abnormal uterine bleeding.
History of complicated intrauterine procedures or uterine
surgery.
History of recurrent pregnancy loss.
Intrauterine abnormalities on TVS.
Abnormalities of the uterine cavity or intrauterine filling
defects with HSG.
Together with laparoscopy if no hysteroscopy has been
performed before.
Infertility with unknown cause.
Unsuccessful in vitro fertilization and embryo transfer
(IVF-ET) if no hysteroscopy has been performed before.

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 Other Indications
SECONDARY DYSMENORRHEA
As secondary dysmenorrhea often appears to be
due to intrauterine disorders such as submucous
myomas, endometrial polyps or IUAs,
hysteroscopic diagnosis should be performed in
these cases as first diagnostic method.

'MISSING' INTRAUTERINE CONTRACEPTIVE

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 Minor Intrauterine
Procedures
In a significant number of cases minor
intrauterine diagnostic or therapeutic
interventions can be performed during
a diagnostic procedure, for example:
Biopsies.
Polypectomy.
Synechiolysis.
Focal coagulation.

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Operative Hysteroscopy
Operative hysteroscopy can treat many of the
abnormalities found during diagnostic
hysteroscopy. Operative hysteroscopy is similar
to diagnostic hysteroscopy except that a ideal
hysteroscope is used to allow operating
instruments such as scissors, biopsy forceps,
electosurgical or laser instruments, and
graspers to be placed into the uterine cavity
through a channel in the operative
hysteroscope. Fibroids, scar tissue, and polyps
can be removed from inside the uterus.
Congenital abnormalities, such as uterine
septum, may also be corrected through the
hysteroscope.

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Operative Hysteroscopy
After surgical repair of the uterine cavity, a
Foley catheter or intrauterine device (IUD) may
be placed inside the uterus to prevent the
uterine walls from fusing together and forming
scar tissue. Antibiotic and/or hormonal
medication may also be prescribed after uterine
surgery to prevent infection and stimulate
healing of the endometrium (uterine lining).
Endometrial ablation, an operative hysteroscopy
procedure in which the endometrium is
destroyed, can be used to treat excessive
uterine bleeding when a hysterectomy is not
considered feasible.

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 Risks of Hysteroscopy
Complications of diagnostic hysteroscopy are rare and
seldom life-threatening. Perforation of the uterus is
the most common, When operative hysteroscopy is
planned, diagnostic hysteroscopy is frequently
performed at the same time to allow the physician to
see the outside as well as the inside of the uterus.
Complications occur in one or two out of every 100
operative hysteroscopy procedures, with uterine
perforation being the most common. Some
complications related to the liquids used to distend
the uterus include pulmonary edema (fluid in the
lungs), breathing difficulties, blood clotting problems,
decreased body temperature, and severe allergic
reactions. Complications related to the surgical
procedure include damage to intra-abdominal organs
and hemorrhage.

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 Conclusion
Diagnosing and correcting gynecologic
disorders once required major surgery and
many days of hospitalization. Laparoscopy and
hysteroscopy now allow physicians to diagnose
and correct many of these disorders on an
outpatient basis. Patient recovery time is
normally only two to three days, which is
significantly less than the recovery time from
major abdominal surgery. The procedures also
decrease patient discomfort. Before
undergoing laparoscopy or hysteroscopy,
patients should discuss with their physicians
any concerns about the procedures and their
risks.

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