Hysteroscopy is the modern technique of viewing and operating in the endometrial cavity from a transcervical approach (Through the cervix) where a telescope with light is introduced through the cervix to view the uterine cavity. The normal basic hysteroscope is a long, narrow telescope that is connected to a light source to help visualize the area. Hysteroscopy is a minimally invasive intervention that serves for diagnostic as well as therapeutic management of various intrauterine and endocervical problems. Diagnostic and operative hysteroscopy have become standards in gynecologic practice because of their safety and efficacy.

What are the types of Hysteroscopy?

• Diagnostic Hysteroscopy – A telescope is introduced through the cervix and the uterine cavity to inspect the inside of the uterus for any pathological or abnormal lesions.

• Operative Hysteroscopy – A telescope is introduced through the cervix into the uterine cavity for surgical repair according to the pathology or abnormality which is noticed on diagnostic Hysteroscopy

Indications for Hysteroscopic surgery

Diagnosis and surgical treatment of Uterine (Cavity) pathologies that may need hysteroscopy are:

• Abnormal uterine bleeding (AUB): It is a condition with excessive menstrual flow, bleeding in between periods, bleeding after menopause (PMB), suspected malignancy, or premalignant lesions. D&C is almost replaced by hysteroscopy in the management of AUB as direct visualization and diagnosis of intrauterine abnormalities, and simultaneous treatment can be done.

• Endometrial Polyps and Fibroids inside the uterine cavity also called Submucous myoma: Endometrial polyps and fibroids are known to cause irregular vaginal bleeding. 20% of women older than 35 years have fibroids which is the most common solid pelvic tumour. Submucosal fibroids which cause Menorrhagia( excessive bleeding) is the most common indication for surgical intervention. Other indications include infertility, dysmenorrhea, and pelvic pain. Diagnostic hysteroscopy is effective up to 88% in identifying polyps and submucosal fibroids in the uterine cavity.

• Müllerian anomalies: Müllerian anomalies are approximately found in 1-2% of all women, 4% of infertile women, and 10-15% of patients with recurrent miscarriages. These anomalies range from didelphys(a uterine malformation where there are a pair of uterus, cervices and vagina) to müllerian agenesis(congenital malformation of missing uterus and underdevelopment of related organs).

• Congenital Uterine Malformations (Intrauterine Septum): 35% of structural uterine anomalies is the septate uterus that is associated with the highest incidence of reproductive failure.

• Infertility: Hysteroscopy is equivalent to hysterosalpingography for evaluating the uterine cavity and is usually not a part of a routine infertility workup, as it increases accuracy in diagnosing the cause of intrauterine filling defects, as In unexplained infertility, hysteroscopy can be performed simultaneously with laparoscopy to evaluate the uterine cavity and cervix.

• Intrauterine adhesions(Ashermans syndrome): Amenorrhea or infertility is often due to intrauterine adhesions (IUA), The prevalence rate of intrauterine adhesions in the general population is 1.5%, up to 30% increase following 3 or more spontaneous abortions treated with dilation and curettage

• Sterilization: Hysteroscopic Sterilization (Prevention of pregnancy) Irreversible tubal sterilization can be accomplished transcervical.

• Proximal tubal obstruction: Hysteroscopic Tubal cannulation for a block in the Fallopian tube is often suggested in cases where there is the failure of contrast to enter the fallopian tube on HSG

• To remove Misplaced / Embedded Intrauterine devices: Hysteroscopy can be applied to remove Misplaced / Embedded Intrauterine devices under direct visualization after sonography-guided retrieval fails.

• In Recurrent pregnancy loss

• In the evacuation of Retained bits of conception

• For Endometrial ablation as treatment of AUB

Advantages of Hysteroscopy

Advantages of Hysteroscopy over Conventional Dilatation and Curettage (D & C): The advantages over a D&C are tissue samples of specific areas of the uterus can be taken by the doctor and view any fibroids, polyps, or structural abnormalities that can be missed on D & C.

Hysteroscopic surgery for patients with Infertility: Infertility due to pathologies in the uterine cavity like Submucous Fibroids, Intrauterine Septum, Polyps, Intrauterine adhesions, T- shaped uterus can be managed by Hysteroscopic surgery.

The advantages of Hysteroscopy are:

• Avoidance of Laparotomy / Incision over the abdomen

• Daycare surgery – Shorter hospital stay

• Ease of the procedure

• Less operative time

• Reduced blood loss during surgery

• Reduced post-operative pain and faster recovery

• Significant improvement in pregnancy rates

• Avoidance of Caesarian section following pregnancy

Contraindications for Hysteroscopy

Hysteroscopy is avoided normally in patients with the following findings:

• Active cervical or uterine infection

• A large uterine cavity, that is longer than 10 cm long (clinically the same as a 12-wk pregnant uterus) (However, this number is variable and sometimes depends on the patient’s habits.)

• Severe medical conditions precluding surgery

• Pregnancy

Concerns and contraindications for hysteroscopy depend upon the procedure planned. For endometrial ablation, considerations include a desire for future fertility, atypical endometrial hyperplasia or endometrial carcinoma, and undiagnosed abnormal bleeding.

Evaluations that are done before Hysteroscopic surgery

A thorough evaluation of your health condition is made by the consultant with necessary investigations .likeLab investigations, imaging studies, and diagnostic study

• CBC: A complete blood count in the reference range ensures adequate oxygenation to all vital and healing tissues and a good immune response.

• Blood typing and screening: The risk of haemorrhage in some surgical hysteroscopic procedures increases the efficiency of access to replacement blood products if needed.

• Electrolyte determinations: Electrolytes should be tested preoperatively as patients with medical disorders can predispose them to metabolic abnormalities if they are on diuretics. Determination of pregnancy status by testing the HCG (Human Chorionic Gonadotrophin) is mandatory in any woman of reproductive age.

• Cervical cultures: A preoperative test for chlamydia and gonorrhoea. cultures and a wet smear for bacterial vaginosis and trichomoniasis are recommended if the patient is reporting a vaginal discharge.

• Pap smear: A normal finding on a pap smear is required as any trauma to the cervix can alter the appearance of any abnormalities.

• Hysterosalpingogram: May be done for evaluating the uterine cavity and for the patency of fallopian tubes.

• CT scanning or MRI: These imaging studies are usually not needed unless the findings on hysterosalpingography do not give a clear picture.

• Endometrial biopsies: Perimenopausal/menopausal women and in women older than 35 years endometrial biopsies are advised if they have irregular bleeding (eg, heavy menses, irregular spotting, prolonged menses) and in women with absent menses with a minimum of 6 months of unopposed estrogen and Physician opinion for fitness of surgery is taken. The patient is explained about the problem she is facing and the need for the surgery. The benefits and drawbacks of the procedure are explained. The patient is given all the required information to be followed before getting admitted for the procedure.

Hysteroscopic surgery procedure

After admission to the hospital, shifting to the operation theatre is done after giving a few medications. The patient is administered general anaesthesia and the necessary position is given, draping is done after the preparation of the parts under aseptic condition. Routinely cervical dilatation is not performed. Hysteroscope is connected to a Camera, light cable, and Saline tubing (for distension of uterine cavity). Hysteroscope is introduced through the cervix to enter the uterine cavity. The openings of the tube (Ostia) are visualized. The inner lining of the uterine cavity is thoroughly assessed to look for Unhealthy endometrium, adhesions, polyps, Fibroid. The telescope is withdrawn slowly to see the cervical canal. Endometrial biopsy is taken with a hysteroscope depending on the case and sent for necessary evaluation. The vagina is toileted with antiseptics. The patient is placed during a sleeping position before she recovers from anaesthesia. She is observed in the OT / recovery room till she is fully conscious and fit to stay in the room. In the recovery room, the patient is given drips for 4 hours together with analgesics. Sips of water are given after 4 hours then liquids are given. A soft diet is started once she tolerates liquids well. Mobilization out of bed is done once the patient is recovered from anaesthesia.

Discharge from the hospital post-operative check-up after Hysteroscopy surgery

The patient is fit for discharge only after she is tolerating liquids well and has passed urine on her own. At discharge, all the required information about diet, medications, ambulation, bathing, return to work and other daily activities are explained. All the signs/symptoms which can require an early return to the hospital are explained.

At the time of discharge, the patient has instructed the date for follow-up (usually 5-7 days). An additional line of treatment will be decided based on biopsy reports in certain cases.

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