Hysteroscopy

Hysteroscopy is a procedure to examine the inside of the uterus. The doctor uses a thin telescope called a hysteroscope. It is passed through the cervix, as shown in the illustration.

The hysteroscope allows to inspect the lining of the uterus and the openings of the fallopian tubes, and to look for any abnormalities. This minimally invasive procedure helps to diagnose uterine problems and can be used to treat some conditions.

Diagnostic hysteroscopy

Diagnostic hysteroscopy examines the uterus for abnormalities and signs of disease. A small sample (biopsy) of the uterine lining is usually taken. The biopsy is often sent to a pathologist for examination.

I may recommend a diagnostic hysteroscopy if a test (such as pelvic ultrasound) or pelvic examination indicates a problem, or if you have abnormal uterine symptoms or signs. It may be used to investigate:

• abnormal bleeding from the uterus (such as heavy, long or scanty periods), absence of periods, adhesions in the uterus, or bleeding between periods
• uterine bleeding after menopause.
• painful or irregular periods.
• pelvic pain and discomfort .
• infertility.
• recurrent miscarriages.

Operative Hysteroscopy

Operative hystreroscopy (also called therapeutic hysteroscopy) is used to treat certain uterine problems. Tiny surgical instruments are inserted through the hysteroscope and into the uterus. Depending on the diagnosis, this proce-dure can sometimes replaie the need for major surgery. Operative hysteroscopy is most often used to:

• remove some fibroids (non-cancerous growths of the uterine muscle wall).
• remove some polyps (non-cancerous growths of the endometrial lining of the uterus).
• treat abnormally heavy menstrual flow by ablation of the endometrium.
• remove adhesions (scar tissue).
• correct some defects of the uterus, such as uterine septum (a wall of tissue that divides the inside of the uterus).
• remove an intrauterine contraceptive device (IUD).
• insert a special type of contraceptive device into the uterus.

Operative hysteroscopy in conjunction with laparoscopy

Once the hysteroscope is inserted and the inside of the uterus is visible, I may sometimes decide that a laparoscopy is necessary. Laparoscopy can assist with the diagnosis and treatment of a range of gynaecological conditions.

The aim of this article is to provide general information. Some medical terms are used that may require further explanation . I will be pleased to answer questions. It may be helpful to make a list of questions. If you have any concerns about the procedure, discuss it with me.

YOUR COMPLETE MEDICAL HISTORY

I and anaesthetist need to know your medical history. Tell us about any health problems you may have had, because some problems may interfere with the surgery, anaesthesia or recovery. This information is confidential. Tell the me if you have or have had:

• an allergy or bad reaction to antibiotics, anaesthetic drugs or any other medicines.
• prolonged bleeding or excessive bruising when injured.
• recent or current infection.
• recent or long-term illness.
• any previous surgery.

Tell me if you are, could be, or plan to become pregnant.

Give me and anaesthetist a list of ALL medicines you are taking or have recently taken, including:

• medicines prescribed by your family doctor.
• over-the-counter medicines bought without prescription.
• herbal medicines .
• long-term treatments such as blood thinners, aspirin (including that contained in cough syrups), arthritis medication or insulin.

I may ask you to stop taking some medications for a week or more before your procedure, or give you an alternative dose.

BEFORE SURGERY

Before a hysteroscopy, some patients need an X-ray examination called a hysterosalpingogram (HSG). An HSG is used o check for abnormalities of the uterus and fallopian tubes. The items is filled with a special dye that shows up on X-ray examination. The passage of dye shows, for example, if the fallopian tubes are open or blocked. An HSG and other tests help the gynaecologist with diagnosis and planning of the procedure. In some patients, an ultrasound examination may be helpful.

Your doctor may prefer to do the hysteroscopy in the first week after your period. If performed at other times of your menstrual cycle, menstrual fluid or a thickened endometrium could interfere with the view of the inside of uterus. If you have regular periods, give me estimate of when your next period is due.

The day before surgery, I may insert medicated pessary high inside the vagina to help soften or dilate the cervix. This can cause mild cramping overnight that requires pain relief.

Some women have cramp pains during a hysteroscopy. On the day of surgery, the I may give you medication help reduce any uterine cramping.

It is best to stop smoking, particularly if you are about to a surgical procedure. Otherwise, stop smoking several we before and after the procedure.

Consent form: If you need to have hysteroscopy, I will ask you to sign a consent form. Read it carefully. If you have any questions about the consent form, surgery, risks anything else, ask your gynaecologist.

ANAESTHESIA

Depending on the patient's medical history, general health and the recommended procedure, hysteroscopy may be done with the patient having general, epidural or local anaesthesia.

Some women who have had children may not need local anaethesia of the cervix.

I or anaesthetist can explain which type anaesthesia is best for you. Follow all preoperative instruction Modern anaesthetic drugs are safe with few risks. However, a few people may have a serious reaction to them. Rarely, a side effect from anaesthesia can be life threatening Ask your anaesthetist or me for more information.

DIAGNOSTIC HYSTEROSCOPY

The woman lies on her back with her I legs apart. A frame or stirrups support her feet and knees. A urinary catheter may be inserted into the urethra drain urine.

I introduce an instrument called a speculum into the vagina to keep the vaginal walls apart. This allows a clear view of the cervix. The cervical canal is gently opened (dilated) to allow passage of the hysteroscope. In some cases, the hysteroscope can be comfortably inserted without the need for cervical dilation.

The hysteroscope is passed through cervix and into the uterus. The uterus has a narrow cavity inside. Some fluid (such as saline) is passed through the hysteroscope to gently separate the walls of the uterus and allows me to view the uterine walls and shape of the uterus.

Any abnormalities can be seen, as well as the internal openings of the fallopian tubes.

Infertility evaluation:

In the evaluation of infertility, hysteroscopy can be useful because it allows a clear view of the inside of the uterus. Problems such as disease or damage to the uterus can be diagnosed and sometimes treated during the procedure.

Operative hysteroscopy is used in the treatment of blocked fallopian tubes, a known cause of female infertility. On visual inspection, the openings to the fallopian tubes may appear to be closed or collapsed. This may be due to permanent scarring or to temporary muscular spasm of the fallopian tubes.

OPERATIVE HYSTEROSCOPY

REMOVAL OF A UTERINE FIBROID

Fibroids are the most common type of non-cancerous pelvic tumour in women and can cause heavy or irregular bleeding. A hysteroscopy can remove fibroids that have grown in the cavity of the uterus but not those in the muscle wall of the uterus.

ENDOMETRIAL ABLATION

Some women with heavy bleeding and a completed family may choose to have the lining of the uterus (endometrium) destroyed. This is called endometrial ablation. Different ablation techniques can be used, including rollerball, microwave, loop resection, thermal balloon and laser, among others. Endometrial ablation destroys the endometrium, so pregnancy becomes unlikely. However, this is not a form of contraception, and sterilisation at the same time may be an option for some women.

REMOVAL OF UTERINE POLYPS

Polyps are abnormal fleshy lumps that grow in the endometrium. They often cause irregular bleeding. They are usually benign (non-cancerous) but can rarely become cancerous.

RETRIEVAL OF DISPLACED IUD

Hysteroscopy is usually recommended if an IUD has become displaced from its normal position in the cervix and uterus, and cannot be removed or found. The IUD can be removed with a grasping instrument.

REMOVAL OF UTERINE SEPTUM

Some abnormal shapes of the uterus can increase the risk of infertility and miscarriage. Some of these defects can be treated with hysteroscopy. For example, treatment of uterine septum involves removing the thin wall of tissue. However, most uterine defects can only be diagnosed or confirmed with hysteroscopy, not treated.

REMOVAL OF ADHESIONS

Adhesions are bands of scar tissue inside the uterus that can interfere with menstruation and, in severe cases, can cause menstruation to stop. Adhesions that block the openings of the fallopian tubes can cause infertility. Thin adhesions are sometimes disrupted by the fluid used to inflate the uterus. In other cases, surgical instruments are used to remove the adhesions.

RECOVERY AFTER HYSTEROSCOPY

Most women are able to go home after two to four hours; this may be longer if you had a general anaesthetia.

Arrange for a relative or friend to drive you home. If you had a general anaesthetia, do not drive for at least 24 hours and avoid making any important decisions for about two days. Do not undertake strenuous work or exercise.

Although some women feel able to return to work the next day, others take a few days off work.

You can shower as normal, but avoid baths, spas and swimming because there is a small risk of infection.

Do not use tampons as they can increase the risk of infection. Wear sanitary napkins .

Mild cramping, similar to period cramps, can be managed with over-the-counter pain-relieving medication. The cramping should. resolve during the next few days. You will be prescribed a short course of non-steroidal anti-inflammatory drugs (NSAIDs). Take them as directed.

If adhesions or fibroids were treated, you might be prescribed a short course of female hormones. This discourages the formation of scar tissue within the uterine cavity.

Blood-stained fluid may drain from the vagina following the procedure. The fluid may contain small clots or pieces of tissue.

A small amount of vaginal bleeding for a few days is normal, but it should be no more than the flow of a normal period. It should stop within 14 days.

Normal physical and sexual activity can be resumed when any bleeding and discomfort have disappeared, and you are feeling well enough.

POSSIBLE COMPLICATIONS OF HYSTEROSCOPY AND HYSTEROSCOPIC SURGERY

As with all, procedures, hysteroscopy does have risks, despite the highest standards of practice.

It is not usual for me to outline every possible side effect or rare complication of a procedure. However, it is important that you have enough information about possible complications to fully weigh up the benefits and risks of the procedure.

I cannot guarantee that your symptoms will improve following operative hysteroscopy. A successful hysteroscopy does not rule out the possibility of repeat surgery. For example, polyps and fibroids may grow back. However, most patients can expect good results.

The following possible complications are listed to inform you, not to alarm you. There may be other complications that are not listed.

Smoking, obesity and other significant medical problems can cause greater risks of complications.

General surgical risks

• Rarely, excessive bleeding may be life threatening and require a blood transfusion.
• A blood clot can develop in a deep vein of the thigh or leg, which can be life threatening if it moves to the heart or lungs. However, this is not common and can be treated.
• Risks of general anaesthesia include a chest infection, short-term nausea, a sore throat due to the breathing tube ,or cardiovascular problems such as heart attack or stroke, which are uncommon.

Specific risks of hysteroscopy

About four women out of every 100 who undergo hysteroscopy have a complication of some kind. Specific risks include:

Postoperative infection, such as infection of the bladder (cystitis) or uterine lining (endometritis); treatment with antibiotics is usually needed

Trauma to the cervix during dilatation.

Perforation of the uterus with the hysteroscope or other surgical instrument. Although uncommon, this risk is slightly greater in postmenopausal women and in women who have recently been pregnant. I may decide to postpone the hysteroscopy until the uterus has healed. A perforation usually heals quickly. Rarely, further surgery may be required to repair it.

Injury to nearby organs (such as the bladder, bowel or blood vessels) if perforation of the uterus has occurred. Laparoscopy or open surgery to repair the damage may be necessary.

Heat damage to nearby organs (such as the bladder, bowel or blood vessels) caused by electrical or laser instruments during cautery to stop bleeding, or during resection or ablation of tissue.

Heavy postoperative bleeding- Treatment may include medication to constrict the blood vessels. In severe and rare cases, a hysterectomy may be needed if the bleeding cannot be stopped.

Fluid imbalance- Hysteroscopic surgery is sometimes performed with the uterus distended with fluid. Pressure within the uterus may force fluid into the bloodstream, and cause a fluid imbalance in the body. Complications can include a build up of fluid in the brain (cerebral oedema) or lungs (pulmonary oedema). In rare cases, it can be life threatening. Treatment includes special fluids delivered through a vein or by mouth. Further observation in hospital may be needed for a few days until the problem resolves.

Gas embolism- If carbon dioxide gas is used to distend the uterus, a gas bubble may rarely enter the bloodstream. This can be life threatening but can usually be quickly treated by the anaesthetist and surgeon.

REPORT

• fever greater than 38°C or chills .
• increasing nausea and vomiting .
• increasing or persisting pain .
• bad-smelling discharge or bleeding from the vagina .
• persistent bleeding from the vagina that becomes heavier than a normal period and is bright red.
• pain or burring on passing urine or the need to pass urine frequently (this may indicate a urinary tract infection).

COSTS OF TREATMENT

I can advise you about coverage by health insurance and any out-of-pocket costs. You may want to ask for an estimate that lists the likely costs. As the actual treatment may differ from the pro-posed treatment, the final account may vary from the estimate.