Hysteroscopy

Overview

Endoscopic examination of the uterine cavity via the cervix is known as hysteroscopy. It is used to diagnose intrauterine disease and as a surgical intervention approach (operative hysteroscopy).

A hysteroscopy can be used to investigate gynaecological symptoms or problems (for example, heavy periods, unusual vaginal bleeding, postmenopausal bleeding, pelvic pain, repeated miscarriages, or difficulty getting pregnant), diagnose conditions (for example, fibroids and polyps), and treat conditions and problems (for example, removing fibroids, polyps, displaced intrauterine devices (IUDs), and intrauterine adhesions).

Uterine perforation occurs when either the hysteroscope or one of its operating devices breaks the uterine wall. This can result in bleeding and organ damage. Peritonitis can be fatal if other organs, such as the bowel, are affected during a perforation. Cervical laceration, intrauterine infection (particularly during long procedures), electrical and laser damage, and problems induced by the distention media are also possible.

The use of insufflation (also known as distending) media can result in significant, even fatal complications from embolism or fluid overload with electrolyte abnormalities. Electrolyte-free insufflation medium, in particular, raise the risk of fluid overload with electrolyte imbalances, including hyponatremia, heart failure, and pulmonary and cerebral edema. 

Anatomy and physiology of woman reproductive system

1. External genitalia: These anatomical structures are apparent on inspection and do not require a speculum. The mons pubis, clitoris, urethral meatus, vaginal vestibule, labia majora and minora, vaginal opening, hymen, perineum, and anus are among them. The vulva is the standard term for the exterior female genitalia.
2. Vagina: The muscular canal connecting the vulva and the cervix. It is a flexible passageway with varying length and width. It serves as a source of sexual pleasure as well as a pathway for fetal delivery. It also regulates the transport of sperm and blood during menstruation.
3. Cervix: The passage from the vaginal to the uterine cavity. It's normally about 2-3 cm long. The cervix features a central aperture termed the cervical canal, which is flanked anteriorly and posteriorly by the external os and the internal os, respectively. The width of the canal varies throughout a woman's life, with delivery causing the canal to dilate to roughly 10cm.
4. Uterus corpus: The uterus is located in the middle of the pelvis, between the bladder and the rectum. It is normally positioned anteverted and anteflexed. The position of the cervix relative to the vagina is referred to as version, while the position of the fundus relative to the cervix is referred to as flexion. The fallopian tubes link to the uterine corpus bilaterally at the fundus, with tubal ostia visible during hysteroscopy.

Types of Hysteroscopy

• Diagnostic hysteroscopy:

Diagnostic hysteroscopy is performed to diagnose uterine abnormalities. Diagnostic hysteroscopy is frequently used to confirm the outcomes of other examinations like hysterosalpingography (HSG). The uterus and fallopian tubes are examined with an X-ray dye test called HSG. Diagnostic hysteroscopy is frequently performed in an office environment.

Furthermore, hysteroscopy can be performed in conjunction with other procedures such as laparoscopy or prior to operations like as dilation and curettage (D&C). Your doctor will put an endoscope (a thin tube connected with a fiber optic camera) into your belly to inspect the outside of your uterus, ovaries, and fallopian tubes during laparoscopy. The endoscope is implanted through a small incision near or beneath your navel.

• Operative hysteroscopy:

The purpose of operative hysteroscopy is to correct an aberrant condition discovered after a diagnostic hysteroscopy. If an aberrant condition is discovered during the diagnostic hysteroscopy, an operative hysteroscopy can be performed concurrently, eliminating the need for a second surgery. Small instruments intended to fix the problem are put through the hysteroscope during operative hysteroscopy.

Uses of Hysteroscopy

 Hysteroscopy is useful in a number of uterine conditions:

1. Asherman's syndrome (i.e. intrauterine adhesions): The technique of lysing adhesions in the uterus using either microscissors (preferred) or thermal energy modalities is known as hysteroscopic adhesiolysis. To lessen the danger of perforation during the surgery, hysteroscopy might be done in conjunction with laparoscopy or other procedures.
2. Endometrial polyp. 
3. Abnormal uterine bleeding.
4. Adenomyosis.
5. Endometrial ablation
6. Myomectomy for uterine fibroids.
7. Congenital uterine malformations (also known as Mullerian malformations).
8. Evacuation of retained products of conception in selected cases.
9. Removal of embedded IUDs.

The use of hysteroscopy in endometrial cancer is not established as there is concern that cancer cells could be spread into the peritoneal cavity.

Hysteroscopy has the benefit of allowing direct visualization of the uterus, thereby avoiding or reducing iatrogenic trauma to delicate reproductive tissue which may result in Asherman's syndrome.

Hysteroscopy allows access to the utero-tubal junction for entry into the Fallopian tube; this is useful for tubal occlusion procedures for sterilization and for falloposcopy.

When Hysteroscopy is contraindicated?

There are few absolute contraindications to hysteroscopy. Active pelvic infection, prodromal or active genital herpes, and proven cervical or endometrial malignancy are among them. Hysteroscopy is a relative contraindication in the presence of moderate vaginal bleeding. However, extensive irrigation can provide adequate visualization for the surgery. Pregnancy is also a contraindication to hysteroscopy, unless it is needed to remove a retained IUD or products of conception. 

How you're prepared for Hysteroscopy?

Preparation for hysteroscopy includes preoperative screening and testing tailored to the patient's specific needs. If there are comorbid disorders that increase operation morbidity, further testing for preoperative clearance should be performed. In postmenopausal women, hysteroscopy can be performed at any time. 

Premenopausal women should be aware that undergoing hysteroscopy during the secretory phase of the menstrual cycle may result in an overdiagnosis of endometrial polyps since the endometrium may seem polypoid at this time. The use of misoprostol for pre-procedural cervical dilatation is not universally approved and is not commonly practiced.

Hysteroscopy does not necessitate the use of prophylactic antibiotics. Before doing a hysteroscopy, every patient should have a full history and physical. In addition, all premenopausal women should get a preoperative pregnancy test. In-office hysteroscopy has been found to reduce intraoperative pain by taking 800 mg of ibuprofen two hours before the operation. Prior to any surgical operation, informed consent, including a discussion of risks, benefits, and alternatives, should always be sought. performed. 

What happens during Hysteroscopy?

Hysteroscopy has been performed in hospitals, surgical centers, and doctors' offices. It is best performed after a menstruation, when the endometrium is somewhat thin. On well selected patients, diagnostic and uncomplicated surgical hysteroscopy can be performed in an office or clinic environment. Local anesthesia is an option.

Analgesics are not usually required. A paracervical block can be achieved by injecting Lidocaine into the upper section of the cervix. General anesthesia (endotracheal or laryngeal mask) or Monitored Anesthesia Care can also be used for hysteroscopic intervention (MAC). During the procedure, the patient is in a lithotomy position.

1. Cervical dilation:

The contemporary hysteroscope has a tiny enough diameter to pass directly into the cervix. Cervical dilatation may be required for a portion of women prior to insertion. Cervical dilation can be accomplished by temporarily extending the cervix with an increasing diameter set of dilators. Misoprostol prior to hysteroscopy for cervical dilatation appears to make the surgery easier and less complex only in premenopausal women.

2. Insertion and inspection:

The hysteroscope with its sheath is inserted transvaginally guided into the uterine cavity, the cavity insufflated, and an inspection is performed.  

3. Insufflation Media:

The uterine cavity is a prospective cavity that must be distended in order to be inspected. As a result, during hysteroscopy, fluids or CO2 gas are introduced to widen the cavity. The technique, the patient's condition, and the physician's preference all influence the decision.

Fluids can be used for both diagnostic and surgical purposes. However, the CO2 gas does not allow for the removal of blood and endometrial debris during the process, which may make imaging visualization difficult. As a complication, gas embolism may occur. CO2 gas is not widely employed as a distention medium since the effectiveness of the procedure is entirely contingent on the clarity of the high-resolution video images in front of the surgeon's eyes.

Normal saline and lactated Ringer's solution are two electrolytic solutions. The current advice is to employ electrolytic fluids in diagnostic and surgical instances involving mechanical, laser, or bipolar energy. These fluids should not be utilized with monopolar electrosurgical equipment because they conduct electricity. Non-electrolytic fluids minimize electrical conductivity issues, but they also increase the risk of hyponatremia. Among these are glucose, glycine, dextran (Hyskon), mannitol, sorbitol, and a mannitol/sorbital mixture (Purisol).

High-viscous Dextran can potentially cause physiological and mechanical issues. It has the potential to solidify on instruments, obstructing valves and channels. Adult respiratory distress syndrome (ARDS) and coagulation problems have been documented. Glycine metabolizes to ammonia, which can pass the blood-brain barrier and cause agitation, vomiting, and coma. When employing monopolar electrosurgical equipment, mannitol 5% should be used instead of glycine or sorbitol. Mannitol 5% has a diuretic effect and can lead to hypotension and circulatory collapse. In patients with fructose malabsorption, the mannitol/sorbitol combo (Purisol) should be avoided.

When fluids are used to distend the cavity, care should be taken to record its use (inflow and outflow) to prevent fluid overload and intoxication of the patient.

4. Interventional procedures:

If abnormalities are discovered, surgery is performed using an operating hysteroscope with a conduit to allow specialist equipment to enter the cavity. Endometrial ablation, submucosal fibroid excision, and endometrial polypectomy are common procedures. The Nd:YAG laser treatment has also been applied to the inside of the uterus via hysteroscopy. Tissue removal techniques currently include electrocautery bipolar loop resection and morcellation.

Is Hysteroscopy risky?

A hysteroscopy is normally highly safe, but there is a minor possibility of problems, as with any surgery. Women who get treatment during a hysteroscopy are at a higher risk.

Some of the main risks associated with a hysteroscopy are:

1. Uterine Perforation:

Uterine perforation is the most commonly reported complication of both diagnostic and surgical hysteroscopy. Perforation can happen at any time throughout the procedure, although it is more prevalent when the resection extends into the uterine myometrium. Uterine perforation, which occurs in around 1% of instances, can be treated conservatively or surgically, depending on the patient's condition.

If the perforation was caused by blunt dissection, the hemodynamic state should be evaluated first with a low suspicion for vascular injury. There is no need for laparoscopy or exploratory laparotomy if the patient is hemodynamically stable and there is a low suspicion of arterial or visceral injury. Prolonged postoperative same-day recovery is advised, along with rigorous pain, bleeding, and fever precautions and intensive clinical monitoring.

With deep dissection into the myometrium and intersection with a perforating artery, bleeding without uterine perforation may occur. This consequence is more common after hysteroscopy and removal of type I and type II subserosal fibroids. Hemorrhage can be controlled via electrocautery, uterotonics such as oxytocin, or the implantation of a foley balloon catheter into the uterus to tamponade bleeding.

2. Fluid Overload:

The complications associated with the distension medium used in hysteroscopy warrant a full examination. The fluid deficit is meticulously computed intraoperatively to quantify the amount of fluid absorbed into the patient's circulation. The potential of hyponatremia and subsequent cerebral edema is especially concerning, especially when electrolyte-free hypotonic solutions are utilized. Cerebral edema can cause nausea and vomiting, dizziness, shortness of breath, and headache.

The mechanism of fluid absorption is related to the amount of intrauterine pressure generated by hysteroscopic fluid management devices as well as venous absorption of distending medium.

Hysteroscopy should be avoided in healthy women if the fluid deficit reaches 2500mL when using isotonic distention media and 1000mL when using hypotonic media. In women with comorbidities that impair hemodynamic stability, such as cardiac or pulmonary problems, the surgeon should consider terminating the procedure with a fluid deficit of 1000mL and 750mL of an isotonic and hypotonic solution, respectively.

3. Embolism:

If carbon dioxide is utilized as the distending media during hysteroscopy, it can cause embolism. This complication can be fatal if it develops owing to the risk of heart collapse and death. With the use of carbon dioxide, investigations demonstrate a wide range of air embolism rates ranging from 10% to 50%. If this complication is suspected, the anesthesia staff should notify the surgeon promptly, and the procedure should be stopped.

Durant's position (patient in left lateral decubitus and Trendelenberg) may help to move air away from the right ventricular outflow pathway. If a cardiac arrest occurs, cardiac catheterization may be performed to remove the embolized air from the circulatory system.

This iatrogenic complication of hysteroscopy may be prevented by using fluid distending media, priming equipment by releasing air from tubing and avoiding excessive instrumentation, which may introduce air into the genital tract.

What are the benefits of Hysteroscopy?

Compared with other, more invasive procedures, hysteroscopy may provide the following advantages:

• Shorter hospital stay.
• Shorter recovery time.
• Less pain medication needed after surgery.
• Avoidance of hysterectomy.
• Possible avoidance of "open" abdominal surgery.

Will I have to stay in the hospital overnight after hysteroscopy?

Hysteroscopy is considered minor surgery and does not usually necessitate an overnight stay in the hospital. An overnight stay may be required in some cases, such as if your doctor is concerned about your reaction to anesthesia. 

What happens after your hysteroscopy and go back home?

• Return to work:

This will be determined by the sort of anesthesia you had and your occupation. Please consult with your doctor or nurse before leaving the house. Every patient reacts differently to anaesthesia, and there is no hard and fast rule for when you can return to work.

The majority of women believe they may resume normal activities, including work, the day after undergoing a hysteroscopy. If they had an outpatient hysteroscopy, some women return to work later that day. You might want to take a few days off to recover, especially if you've had treatment like fibroid removal or endometrial ablation.

• Having sexual intercourse:

To help prevent an infection in the uterus or vagina, it is not recommended to have sexual intercourse for at least seven days after the surgery.

• Use of tampons again:

Tampons should not be used throughout your next period. This will aid in the prevention of an infection. Tampons can be used again after your next period.

• Follow-up appointments:

You might need a follow-up appointment in the outpatient clinic. Your doctor will inform you of this before you go home and an appointment will be posted to you.

When to get medical advice?

Contact your GP or your gynecologist if you notice any of the following:

• persistent bleeding from the vagina that becomes heavier than a normal period and is bright red.
• severe pain in the lower part of your abdomen.
• a high temperature (38oC or above).
• an offensive (bad) smelling vaginal discharge.
• increasing nausea and vomiting.
• pain or burning on passing urine or the need to pass urine frequently (this may indicate a urinary tract infection).

Conclusion

A hysteroscopy is a procedure that looks inside the uterus (womb). It is performed with the help of a hysteroscope, a narrow telescope that is introduced through the cervix (womb entrance) into the uterus. The hysteroscope is attached to a light and camera that feeds images to a monitor, allowing your gynaecologist to see within the uterus.

Abnormal bleeding, fibroids, polyps, and problems getting pregnant are all common reasons for a hysteroscopy. If you do not understand why you are undergoing this procedure, please consult your doctor.

A hysteroscopy is generally safe, but as with any surgery, there is a tiny chance of problems, which is increased if the procedure is used to perform a surgical therapy rather than simply to perform an assessment (diagnostic hysteroscopy). Among the most serious dangers are:

• accidental damage to the uterus where a perforation (hole) is made in the wall. This is not common, but may require treatment with antibiotics in hospital, or in rare cases, another operation such as laparoscopy laparotomy to repair the uterus or organs such as the bowel.
• accidental damage to the cervix .
• infection – this can cause a vaginal discharge, fever and heavy bleeding. It is usually treated with a short course of antibiotics from your doctor.
• excessive bleeding during or after surgery – this can be treated with medication or another procedure; very rarely it may be necessary to remove the womb (hysterectomy).