HYSTEROSCOPY
Therapeutic Hysteroscopy
In therapeutic hysteroscopy procedures, anesthesia is usually administered. After dilating the cervix, the uterine cavity is entered using an instrument called a resectoscope. The procedure is most commonly performed under general anesthesia.
The resectoscope is the same instrument used by urologists for prostate resection. With this device, intrauterine septa can be incised (septum incision), and large polyps and fibroids can be removed.
In addition, intrauterine adhesions can be released. Hysteroscopy can also be used to treat women who experience excessive uterine bleeding and do not wish to have children in the future, by removing the lining of the uterus (endometrium). This procedure is known as endometrial ablation.
Although hysteroscopy can be performed using scissors or laser, today electrosurgical energy is used in the vast majority of cases.
Office Hysteroscopy
Office hysteroscopy refers to a hysteroscopy procedure performed in an outpatient office setting without the need for general anesthesia. In this approach, very thin hysteroscopic instruments are used, allowing entry into the uterine cavity without cervical dilation.
Although office hysteroscopy was initially used primarily for diagnostic purposes, in recent years it has increasingly been used for the treatment of various intrauterine abnormalities.
Indications for Office Hysteroscopy
Office hysteroscopy is commonly used for:
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Evaluation of abnormal uterine bleeding
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Assessment of infertility
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Treatment of intrauterine adhesions
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Removal of small fibroids and polyps
Congenital uterine septa (intrauterine walls or partitions present from birth) can also be incised using office hysteroscopy. In addition, office hysteroscopy may be used to remove intrauterine devices (IUDs) when the retrieval strings are not visible.
How the Procedure Is Performed
During office hysteroscopy, the patient may first receive mild intravenous sedation. The hysteroscope is then gently introduced into the uterine cavity without the use of a speculum, without grasping the cervix, and without cervical dilation.
As the hysteroscope is inserted, a mild cramping sensation may be experienced. Once inside the uterus, sterile fluid is infused to gently expand the uterine cavity, allowing detailed visualization of the uterine lining on a video monitor.
Role in Abnormal Uterine Bleeding
Office hysteroscopy is a highly valuable diagnostic tool for both premenopausal and postmenopausal abnormal uterine bleeding. Intrauterine conditions such as polyps, fibroids, or tumors can be clearly visualized during the procedure.
Some of these abnormalities can be treated during office hysteroscopy, while others may require hysteroscopy under anesthesia or a more extensive surgical intervention.
Role in Infertility Evaluation
Hysteroscopy plays an important role in the evaluation of infertility. Space-occupying lesions or intrauterine adhesions may contribute to infertility, and a significant proportion of these conditions can be treated hysteroscopically.
Before in vitro fertilization (IVF) treatment—especially in women who have not undergone prior uterine imaging—it is important to confirm that the uterine cavity is anatomically normal. Hysteroscopy allows direct assessment of the uterine cavity for this purpose.
Importance in Recurrent IVF Failure
The role of hysteroscopy becomes even more significant in couples with previous unsuccessful IVF attempts. Some studies have shown that in women with two or more prior failed IVF cycles, intrauterine abnormalities may be detected in up to approximately 50% of cases during hysteroscopic evaluation.
The most commonly identified findings include endometritis, polyps, intrauterine adhesions, and shallow uterine septa. Identification and appropriate management of these conditions may help optimize uterine conditions prior to subsequent IVF treatments.
When Is Hysteroscopy Performed During the Menstrual Cycle?
Ideally, hysteroscopy is performed shortly after the end of menstrual bleeding. During this phase, the uterine lining (endometrium) is thin, allowing intrauterine abnormalities to be visualized more clearly.
In women who do not menstruate, or when hysteroscopy is performed for the treatment of intrauterine adhesions, the procedure can be carried out at any time, depending on clinical circumstances.
Why Is Hysteroscopy Performed?
Hysteroscopy is used to identify the causes of abnormal uterine bleeding. Abnormal uterine bleeding refers to menstrual periods that are heavier than normal, or that last longer or shorter than usual. Bleeding occurring outside the regular menstrual cycle is also considered abnormal uterine bleeding.
Hysteroscopy is considered the gold standard for the diagnosis and treatment of intrauterine adhesions caused by previous infections or surgical procedures.
It is also used in the evaluation and management of recurrent pregnancy loss and recurrent IVF failure, particularly to identify and treat intrauterine lesions that may otherwise go undetected.
Additional Indications
Hysteroscopy is one of the most effective surgical methods for correcting congenital uterine anomalies, such as a uterine septum or dysmorphic uterus.
It is often the preferred first-line approach, depending on size and location, for the removal of submucosal fibroids that extend into the uterine cavity.
Hysteroscopy is also commonly used to remove retained placental tissue following curettage, miscarriage, or childbirth.
In addition, it is an ideal method for removing intrauterine devices (IUDs) when the retrieval strings are not visible within the cervix.
What Should I Do Before Hysteroscopy?
If hysteroscopy is planned under general anesthesia, a fasting period of at least 6 hours (no food or drink) is required prior to the procedure.
For office hysteroscopy, a shorter fasting period is usually sufficient.
Will There Be Pain or Bleeding After Hysteroscopy?
Pain after hysteroscopy is generally minimal or absent.
Bleeding, if present, is usually light and spotting in nature and resolves within a short period of time.
What Are the Possible Complications of Hysteroscopy?
Possible procedure-related complications include:
These complications are relatively uncommon, occurring in approximately 1% of cases. In experienced hands, the diagnosis and management of complications are generally straightforward.
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Uterine perforation (which may require laparoscopic evaluation and repair)
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Bleeding (occasionally requiring placement of an intrauterine catheter)
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Cervical laceration (which can be repaired with suturing)
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Intrauterine adhesion formation, particularly after removal of large fibroids located near the lower uterine segment
Post-hysteroscopy ultrasonographic image of a patient with complete vaginal and uterine septum
HYSTEROSCOPY DICTIONARY
Medical Terms
Adhesion:
Bands of connective (scar) tissue that may form between the front and back surfaces of the uterus.
Biopsy:
A minor surgical procedure performed to remove a very small sample of tissue for examination.
Cervix:
The lower part of the uterus that opens into the vagina.
Fallopian Tubes:
The two tubes (right and left) that connect the ovaries to the uterus.
General Anesthesia:
The use of medications that put the patient into a controlled state of unconsciousness to prevent pain during a procedure.
Intrauterine Device (IUD):
A T-shaped plastic medical device placed inside the uterus for contraception.
Local Anesthesia:
The administration of medication to numb a specific area of the body in order to reduce pain.
Miscarriage (Abortion):
Loss of a pregnancy in the early stages.
Speculum:
A medical instrument used to gently open the vagina to allow visualization during examination.
Uterus (Womb):
A muscular organ in which a baby develops during pregnancy.
Hysteroscopy Gallery
Pre-hysteroscopy ultrasonographic image of a patient with complete vaginal and uterine septum
HYSTEROSCOPY
BEFORE / AFTER