What is Hysteroscopy?

Hysteroscopy is a minor surgical procedure utilizing a thin fiberoptic tube or hysteroscope to see the inside of the uterus (endometrial cavity). Hysteroscopy allows the doctor to diagnose and treat a variety of uterine abnormalities which may cause infertility, recurrent miscarriages, abnormal bleeding and pain.

How is Hysteroscopy done? (click here to watch the video)

Hysteroscopy is an outpatient procedure which can be performed in the operating room of a hospital, surgical center or at a doctor’s office. Before the surgery, you will be given a hospital gown and asked to empty your bladder. You will be given medicine to help you relax and then local or general anesthesia depending on the type of hysteroscopy (diagnostic or operative) planned for you.

The hysteroscopy is performed with you lying on your back while your feet are supported by footrests (stirrups).

A speculum will be inserted into the vagina so your doctor can see the cervix. The vagina is cleaned with a special antiseptic solution and the hysteroscope is gently inserted through the cervix and advanced into the uterus. A liquid will be injected through the hysteroscope into your uterus to help your doctor see the uterine cavity clearly. A camera attached to the hysteroscope will project a magnified view of the uterine cavity on a video monitor. Your doctor will be able to see if there is any abnormality in the uterine cavity and to look at the opening of the tubes. The hysteroscopy takes only 10-15 minutes to complete unless other procedures are planned to remove fibroids, polyps , uterine adhesions  or unblock your tubes.

Preparing for Hysteroscopy

• Hysteroscopy is best performed during the first week after your period (day 5-12 of cycle).
• If you are scheduled to have a fibroid  removed, you may be treated with Lupron for several weeks before surgery, to shrink the size of the fibroid 
• Tell the doctor if you are or might be pregnant, if you are allergic to any medicines or if you take blood-thinning medications, such as aspirin or Coumadin.  
• Talk with your doctor about the risks of hysteroscopy. Have the doctor explain how the procedure is performed and what the results will mean.
• You will be asked to sign a consent form giving the doctor permission to perform the surgery.
• You should not eat or drink after midnight the day before your scheduled surgery. 

Hysteroscopy – operating room view

The “normal” Hysteroscopy

The uterine cavity has smooth walls and is free of fibroids, scar tissue, congenital malformation or polyps.

When to consider hysteroscopy?

Indications for hysteroscopic surgery include:   

• Uterine Polyps
• Uterine Fibroids
• Uterine scar tissue
• Tubal Blockage
• Congenital Uterine Abnormalities

Uterine Polyps

Polyps can grow within the uterine cavity, where they may interfere with embryo implantation and cause infertility or abnormal bleeding. They can be diagnosed by HSG (tubal x-rays), ultrasound or MRI. A special cutting tool called the resectoscope is often used to remove the polyps.

Uterine Fibroids

When growing within the uterine cavity, fibroids  can cause infertility, recurrent miscarriage, abnormal bleeding and severe menstrual cramps. Such fibroids are called intracavitary or submucosal. Their presence can be confirmed by Saline Infusion Sonography  (SIS), MRI, and HSG or by direct visualization with a hysteroscope.
The fibroids can be resected with a specialized cutting loop or resectoscope, which is inserted through the hysteroscope. The instrument cuts the fibroid into little pieces so that they can be easily removed from the uterine cavity.

Asherman’s Syndrome  - uterine scar tissue (adhesions)

Scar tissue within the uterine cavity may occur after D&C, uterine surgery or as a result of an infection. The scar tissue has poor blood supply and is hostile to embryo implantation, and can cause infertility. When severe uterine scarring is present (Asherman's syndrome), it may cause a woman to stop having periods altogether.

During surgery, long scissors, inserted through the hysteroscope operating channel, are used to cut through the scar tissue.  After surgery, a small balloon may be inserted into the uterine cavity to prevent the walls of the uterus from getting stuck to each other all over again. Estrogen therapy may also be utilized in severe cases to speed up the healing of the uterine lining.

Tubal Blockage

The tube is sometimes blocked at its narrowest part, at the point where it is closest to the uterus. This is called Proximal Tubal Occlusion or PTO.  This blockage is most often caused by thin scar tissue or a mucus "plug". Using the hysteroscope, the opening of the tube is visualized and a thin soft catheter is guided into the tube, clearing away the mucus plug. This procedure is often combined with laparoscopy to evaluate the other side of the tube (the one closer to the ovary) and to make sure the tube is open.

Uterine Septum

A uterine septum  is a congenital malformation of the uterus. The uterine cavity is divided by an elongated fibrous tissue or septum (blue arrow). It lacks adequate blood supply, and is hostile to implantation of the fertilized egg. This abnormality can cause recurrent pregnancy loss, infertility and various obstetrical complications. To repair the uterus, scissors are introduced through the hysteroscope to cut the septum along the dotted line, unifying the divided uterus into a single cavity.

How safe is Hysteroscopy?

Hysteroscopy is a very safe procedure. The most common complications are:

• Uterine bleeding, occurring in 3% of patients.
• Puncture of the cervix or uterus by the hysteroscope occurs in less than 1% of patients.
• In rare cases, puncture of the bowel or bladder can occur.  If this happen surgical repair of the complication will be necessary.
• During hysteroscopy, fluid is injected to distend the uterus. This helps the surgeon see the lining of the uterus more clearly. In very rare cases, excess fluid can be absorbed by your system, lowering the sodium level. Low sodium level requires treatment to prevent more serious complications.
• There is a small risk of complications from anesthesia.
• Infection can occur, but it is an uncommon complication of hysteroscopy.   

Recovering from Hysteroscopy

• You will be taken to a recovery room immediately after surgery. The Recovery Room nurses will care for and observe you for 1 to 3 hours or until the anesthesia wear off.
• Cramping can occur after surgery and you may be given appropriate medication to help you feel better.
• When you are ready for discharge, you will be given a paper with care instructions and who to call if there is any problem. 
• It is normal to have a bloody discharge for a few days after your surgery.
• You should use sanitary napkins rather than tampons and avoid sexual intercourse or strenuous physical exercise for two weeks after surgery.
• You may resume normal activities within 24 hours after surgery. 

When to call your doctor

You should contact your doctor if you develop any of the following after your hysteroscopy:

• Heavy bleeding
• Fever or chills
• Severe abdominal pain
• Problem urinating 
• Shortness of breath