Hysteroscopy is an outpatient procedure that is performed to evaluate and/or treat uterine cavity pathology. Depending on the indication for the surgery, hysteroscopy can be performed in the office with local anesthesia and pain medications or in the hospital with local, regional or general anesthesia. The best time to perform the surgery is on Day 6-12 of the menstrual cycle with Day 1 being the first day of menses or at anytime if the woman is on birth control medication.
A thin telescope (hysteroscope), ranging from 3-10mm, is attached to a light source and video camera and inserted through the vagina and cervix into the uterine cavity while instilling fluid to distend the cavity. This allows the surgeon to visualize a magnified view of the uterine cavity on a television monitor. At this point, the surgeon can inspect the entire uterine cavity and treat or biopsy any pathology. Below, is a description of the various surgeries that can be performed via the hysteroscope.
A diagnostic hysteroscopy may be recommended to evaluate a previous abnormal imaging study or to rule out any disease, such as in an infertility work-up. If any irregular masses or lesions are observed, these can be biopsied and sent to pathology to evaluate the tissue.
Uterine fibroids within the cavity are classified as submucosal fibroids. A Type 0 submucosal fibroid grows completely within the uterine cavity. When the fibroid grows in the cavity as well as the uterine muscle but less than 50% of the fibroid is in the muscle, the fibroid is categorized as a Type 1 fibroid. A Type 2 fibroid is similar to a Type 1 except that greater than 50% of the fibroid grows into the uterine muscle. All three types can be removed through the hysteroscope, however, the more the fibroid grows into the uterine muscle the harder it is to completely resect the fibroid. Based on the fibroid size, location and type, a laparoscopic removal may be recommended.
Uterine or endometrial polyps are usually benign overgrowths of the uterine cavity lining, also known as the endometirum. The most common symptom polyps cause is irregular vaginal bleeding. These can easily be removed with the hysteroscope.
Uterine septums are a congenital defect of the uterus that commonly can cause recurrent miscarriages. These defects can be cut safely through the hysteroscope and treated so that the uterine cavity retains a normal shape. A balloon catheter is placed into the uterine cavity for about 5 days after the septum is resected. Patients are also placed on hormones for 30-60 days to help rebuild the uterine cavity.
Scar tissue is a natural phenomenon of the healing process. Some women who have undergone an intrauterine procedure, such as a D&C (curettage of the uterine cavity), myomectomy, or miscarriage, may develop scar tissue formation within the cavity causing partial or complete obliteration of the cavity. This is referred to as Asherman’s Syndrome. Women may present with lighter than usual or no menses after an intrauterine procedure. This can be a cause of infertility. Hysteroscopy is performed to cut the scar tissue and normalize the uterine cavity as best as possible. A balloon catheter may be placed into the uterine cavity temporarily and the patient placed on hormones for 30-60 days to help rebuild a normal uterine cavity after the procedure.
Hysteroscopic Tubal Cannulation
Women undergoing an infertility work-up may be found to have their fallopian tube(s) occluded. While utilizing hysteroscopy, the opening to the fallopian tubes (tubal ostia) may be visualized within the uterine cavity. A small catheter can be placed through the tubal ostia into the fallopian tube to establish tubal patency. Either a concurrent laparoscopy or a postoperative hysterosalpingogram may be performed to evaluate tubal patency.
Hysteroscopic Endometrial Ablation
Women with bothersome irregular vaginal bleeding who have failed medical therapy and have completed childbearing, may be offered an endometrial ablation. This is a procedure performed with the hysteroscope that utilizes energy or hot water to resect or destroy the uterine cavity lining or endometrium. About 40% of women have lighter menses, another 40% have complete cessation of their menses and 20% have no change in their symptoms.
For women who have completed childbearing and wish to obtain permanent sterilization, hysteroscopy tubal occlusion is available. While visualizing the opening of the fallopian tubes within the uterine cavity with hysteroscopy, small occlusion devices are placed into the fallopian tubes. Over a 3 month period, tissue grows into the occlusion devices to permanently occlude the fallopian tubes, causing sterilization. During this three month period, alternative birth control must be used to prevent unwanted pregnancy. To confirm that both tubes are occluded successfully, a radiologic procedure called hysterosalpingogram must be performed after 3 months from the procedure.
What is my recovery from a Hysteroscopic procedure?
The most common complaint is uterine cramping from a hysteroscopic procedure that can be controlled with pain medications. Patients go home the same day and usually resume normal activity within 48 hours. The only restriction with hysteroscopic procedures is to avoid anything within the vagina for at least two weeks. Should any patient develop sudden heavy vaginal bleeding, foul discharge, continuous pain or fever, she should contact her physician immediately.
What are the complications that can occur with Hysteroscopy?
Infection – Unless a woman has a history of pelvic infections, antibiotics are rarely recommended. Hysteroscopy is performed in a sterile environment to help prevent the development of an infection.
Bleeding – Usually to help control uterine cavity bleeding, the uterus naturally contracts to constrict the intrauterine blood vessels. If for some reason there is a vessel that does not stop bleeding, a patient may experience heavy vaginal bleeding. To prevent this from happening, usually the vessels can be visualized and cauterized if electrical energy is being used during the procedure. Another option is to place a balloon catheter into the uterine cavity and distend it with fluid to place pressure on the vessel(s) to stop the bleeding. The catheter may be left in from anywhere of one hour to overnight.
Uterine Perforation – With the guidance of the hysteroscope with a video camera attached, most of the procedure is performed under direct visualization which minimizes the risk of perforating the uterus. However, if the cervix needs to be dilated to allow the hysteroscope to fit or if the procedure you are undergoing includes some type of resection, there is a small risk of perforating the uterus. If this occurs, a diagnostic laparoscopy (thin telescope with a video camera and light source introduced into the abdomen) may have to be performed to assure no injury in the abdominal cavity, especially when the perforation occurs while using an energy source. Uterine perforations usually heal spontaneously and no other treatment is necessary. However, the hysteroscopic procedure may have to be aborted due to the perforation.
Fluid Absorption – The uterine cavity walls are typically collapsed. To visualize the uterine cavity, fluid is instilled through the hysteroscope to distend the cavity. The body has a natural tendency to absorb some of this fluid. If high levels of the fluid are absorbed, most commonly nausea and vomiting are experienced. More serious complications can occur at extreme levels of absorption, but these are prevented by using a fluid monitoring system while performing the procedure. If a hysteroscopic procedure is not completed by the time a high level of fluid absorption is reached, the procedure may be aborted and a second procedure may have to be rescheduled at a later time.
Cervical Trauma – The hysteroscope has to be introduced through the cervix to enter the uterine cavity. If the size of the hysteroscope is larger than the opening of the cervix, the cervix may have to be dilated. To ease the dilation and cause minimal cervical trauma, a medication called misoprostol may be prescribed prior to the surgery. This medication is taken the night before and the morning of the surgery to help soften the cervix, which allows dilation to be less traumatic.