Hysteroscopy

Definition

Hysteroscopy enables a physician to look through the vagina and neck of the uterus (cervix) to inspect the cavity of the uterus with an instrument called a hysteroscope. Hysteroscopy is used as both a diagnostic and a treatment tool.

Purpose

Diagnostic hysteroscopy can be used to help determine the cause of infertility, dysfunctional uterine bleeding, and repeated miscarriages. It can also help locate polyps and fibroids, as well as intrauterine devices (IUDs).

The procedure is also used to investigate and treat gynecological conditions, often done instead of or in addition to performing a dilation and curettage (D&C). A D&C is a surgical procedure that expands the cervical canal (dilation) so that the lining of the uterus can be scraped (curettage). A D&C can be used to take a sample of the lining of the uterus for analysis. However, hysteroscopy has advantages over a D&C because the doctor can take tissue samples of specific areas and view any fibroids, polyps, or structural abnormalities. In addition, small fibroids and polyps may be removed via the hysteroscope (in combination with other instruments that are inserted through canals in the hysteroscope), thus avoiding more invasive and complicated open surgery. This approach is also used to remove IUDs that have become embedded in the wall of the uterus.

Demographics

There is no research available to indicate that hysteroscopy is performed more or less frequently on any subset of the female population.

Description

The hysteroscope is an extremely thin telescope-like instrument that looks like a lighted tube. The modern hysteroscope is so thin that it can fit through the cervix with only minimal or no dilation.

Before inserting the hysteroscope, the doctor administers an anesthetic. Once it has taken effect, the doctor dilates the cervix slightly, and then inserts the hysteroscope through the cervix to reveal the inside of the uterus. Ordinarily, the walls of the uterus are touching each other. In order to get a better view, the uterus may be inflated with carbon dioxide gas or fluid. Hysteroscopy takes approximately 30 minutes.

Treatment involving the use of hysteroscopy is usually performed as a short-stay hospital procedure with regional or general anesthesia. Tiny surgical instruments may be inserted through the hysteroscope to remove polyps or fibroids. A small sample of tissue lining the uterus is often removed for examination, especially if the patient has experienced any abnormal bleeding.

Diagnosis/Preparation

If the procedure is performed under general anesthesia, the patient should have nothing to eat or drink after midnight the night before the procedure. Routine lab tests may be ordered if the procedure is performed in a hospital. Occasionally, a mild sedative is administered to help the patient relax. The patient is asked to empty her bladder. She is then placed in position (usually in a special chair that tilts back) and the vagina is cleansed. Usually, a local anesthetic is administered around the cervix, although a regional anesthetic that blocks nerves connected to the pelvic region or a general anesthetic may be required for some patients.

Aftercare

It is normal to experience light bleeding for one to two days after surgical hysteroscopy. Mild cramping or pain is common after operative hysteroscopy, but usually diminishes within eight hours. If carbon dioxide gas was used, the resulting discomfort usually subsides within 24 hours.

Risks

Diagnostic hysteroscopy rarely causes complications. The primary risk is infection. Prolonged bleeding may follow a surgical hysteroscopy to remove a growth. Another complication is perforation of the uterus, bowel, or bladder, caused by over-forceful advancement of the hysteroscope. An infrequent but dangerous complication is increased fluid absorption from the uterus into the bloodstream. Keeping track of the amount of fluid used during the procedure can minimize this complication. Surgery under general anesthesia poses the additional risks typically associated with this type of anesthesia.

The procedure is not performed on women with acute pelvic inflammatory disease (PID) due to the potential of exacerbating the condition. Hysteroscopy should be scheduled after menstrual bleeding has ended and before ovulation to avoid a potential interruption of a new pregnancy.

Patients should notify their health care provider if, after the hysteroscopy, they develop any of the following symptoms:

• abnormal discharge
• heavy bleeding
• fever over 101°F (38.3°C)
• severe lower abdominal pain

Normal results

Normal hysteroscopy reveals a healthy uterus with no fibroids or other growths. Abnormal results include uterine fibroids, polyps, or a septum (an extra fold of tissue down the center of the uterus). Sometimes, precancerous or malignant growths are discovered.

Morbidity and mortality rates

The rate of complications during diagnostic hysteroscopy is very low, about 0.01%. Surgical hysteroscopy is associated with a higher number of complications. Perforation of the uterus occurs in 0.8% of procedures and excess bleeding in 1.2–3.5% of cases. Death as a result of hysteroscopy occurs at a rate of 2.4 per 100,000 procedures performed.

Alternatives

A laparoscope (an instrument with a video camera inserted through the abdominal wall) may be used to visualize the outside of the uterus or perform a surgical procedure on the pelvic organs. Laparoscopy and hysteroscopy are sometimes performed simultaneously to maximize their diagnostic capabilities.

Resources

BOOKS

Pagana, Kathleen D., and Timothy J. Pagana. Diagnostic Testing and Nursing Implications. 5th edition. St. Louis: Mosby, 1999.

PERIODICALS

Murdoch, J. A., and T. J. Gan. "Anesthesia for Hysteroscopy." Anesthesiology Clinics of North America 19, no. 1 (March 2001): 125–40.

Neuwirth, R. S. "Special Article: Hysteroscopy and Gynecology: Past, Present, and Future." Journal of American Association of Gynecology Laparoscopy 8, no. 2 (May 2001): 193–8.

ORGANIZATIONS

American College of Obstetricians and Gynecologists. 409 12th St., S.W., P.O. Box 96920, Washington, DC 20090-6920. http://www.acog.org/ .

OTHER

Gordon, A. G. "Complications of Hysteroscopy." Practical Training and Research in Gynecologic Endoscopy. February 17, 2003 [cited March 13, 2003]. <http://www.gfmer.ch/Books/Endoscopy_book/Ch24_Complications_hyst r.html> .

Maggie Boleyn, RN,BSN
Stephanie Dionne Sherk

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

The test is usually performed by a gynecologist, a medical doctor who specializes in the areas of women's general health, pregnancy, labor and childbirth, and prenatal testing. Nursing staff assists with providing education, positioning the patient, and specimen collection. Diagnostic hysteroscopy is performed in either a doctor's office or hospital. Uterine size and potential diagnosis and complexity of treatment determine the setting.

QUESTIONS TO ASK THE DOCTOR

• Why is hysteroscopy recommended in my case?
• Will a surgical procedure be performed?
• How long will the procedure take?
• Where will the procedure be performed?