Hysteroscopy is an endoscopic diagnostic and surgical technique involving examination of the uterine cavity and intrauterine manipulations using a special optical system inserted through the vagina. The procedure is informative for the diagnosis of endometriosis, uterine fibroids, endometrial hyperplasia and polyps, endometrial cancer, foreign bodies of the uterine cavity, intrauterine adhesions; finding out the causes of infertility, miscarriage, uterine bleeding. Hysteroscopy allows for endometrial biopsy, controlled SDC, removal of ingrown intrauterine spirals or fetal egg remnants. Depending on the goals pursued, it can be performed using a rigid or flexible hysteroscope.
In modern gynecology, hysteroscopy serves as a routine and, at the same time, an indispensable method of instrumental diagnosis of uterine pathology. In the course of the study, visualization of the inner surface of the uterus is achieved with the help of optical systems, which allows not only to clarify the diagnosis, but also to carry out controlled therapeutic and diagnostic manipulations and even intrauterine surgical interventions. Compared with ultrasound of the uterus, hysterosalpingoscopy or blind curettage of the endometrium, hysteroscopy has a number of undeniable advantages: it is a direct visualization of the uterine cavity, the objectivity and accuracy of the data obtained, the ability to record the results using photo and video.
Types of techniques
Taking into account the purposes of the hysteroscopy, it can be diagnostic, operational and control. With the help of a diagnostic procedure, it is possible not only to detect the presence of pathology, but also to determine its localization and prevalence, to take material directly from the pathological focus. Surgical hysteroresectoscopy is a microsurgical intervention, and in some cases it can act as a full-fledged alternative to abdominal or laparoscopic gynecological surgery. Thanks to the improvement of the technique in operative gynecology, the direction of intrauterine surgery is successfully developing. The purpose of control hysteroscopy is to evaluate the effectiveness of conservative or surgical treatment.
Various types of examination can be carried out using a rigid or flexible hysteroscope (fibrogysteroscope). Modern hysteroscopes with a working part diameter of no more than 3.7 mm allow performing diagnostic manipulation without dilating the cervical canal on an outpatient basis, which is why it is often called “office hysteroscopy”. According to the time of the procedure, there are planned and emergency, preoperative, intraoperative and postoperative hysteroscopy. Surgical resectoscopy can be performed as an independent operation or combined with laparoscopy.
Depending on the medium used to expand the uterine cavity and create a visualization space, liquid and gas hysteroscopy are distinguished. In the first case, carbon dioxide is used for these purposes; in the second, sterile low-molecular solutions (saline, glucose, glycine, Ringer solutions, etc.). In addition, taking into account the field of view, the procedure can be panoramic (general examination of the uterine cavity) and contact (examination of the endometrial surface in a limited area of 6-8 mm). Microhysteroscopy, involving the use of 60 and 150-fold magnification, allows for cellular examination of the uterine mucosa. Contact and microscopic techniques do not require preliminary expansion of the uterine cavity with the help of liquid or gas.
Due to its diagnostic capabilities, hysteroscopy serves as the “gold standard” for detecting various intrauterine pathology. The need for its implementation may arise if endometriosis, submucosal uterine fibroids, endometrial hyperplasia, uterine polyps, endometrial cancer, the presence of foreign bodies and remains of the fetal egg in the uterine cavity are suspected. If necessary, an endoscopic examination of the uterine cavity is carried out in order to clarify the location of the intrauterine device or fragments of the intrauterine contraceptive, to detect perforation of the uterine wall caused by an unsuccessful medical abortion or SDC.
Hysteroscopy is practically indispensable for detecting abnormalities of uterine development: intrauterine synechiae, intrauterine septum, doubling of the uterus, etc. The question of conducting a diagnostic procedure is raised by a gynecologist with menstrual cycle disorders in the reproductive period, postmenopausal uterine bleeding, habitual miscarriage and infertility. Microhysteroscopy in combination with colposcopy is informative in relation to the early detection of dysplasia and cervical cancer. As practice shows, the hysteroscopic diagnosis during other operations is confirmed in more than 90% of cases.
Surgical hysteroscopy is used for endometrial ablation, laser reconstruction of the uterine cavity, removal of ingrown spirals and other foreign bodies from the uterine cavity (ligatures, ossified fetal remains, fragments of IUD). Under endoscopic control, separate diagnostic curettage of the uterine mucosa can be performed, since “blind” curettage performed without visual control turns out to be ineffective and uninformative in 30-60% of cases. Hysteroresectoscopy is used to remove endometrial polyps and submucous myomatous nodes, to separate the synechiae and to remove the septa of the uterine cavity.
Control hysteroscopy can be indicated after intrauterine operations, hormone therapy, uterine artery embolization, transferred cystic drift, chorioncarcinoma, as well as with a complicated course of the postpartum period.
Diagnostic or surgical manipulation should be postponed if the patient has acute infectious diseases (ARVI, pneumonia, sore throat) or exacerbation of chronic pathology (pyelonephritis, decompensation of heart failure, diabetes mellitus, renal failure, hypertension, etc.). Scheduled hysteroscopy is not performed for colpitis, urethritis, cervicitis, endometritis and other acute inflammatory diseases of the genitals due to the high probability of the spread of the infectious process.
Relative limitations are cervical canal stenosis and cervical cancer – in these cases, preference is given to fibrogysteroscopy, which is performed with a flexible hysteroscope, without dilating the cervical canal. The identification of the III-IV degree of purity of the vagina is an indication for its preliminary sanitation.
It is recommended to refrain from carrying out the procedure during menstruation and with heavy uterine bleeding due to poor visibility and the risk of dissemination of endometrial cells through the fallopian tubes into the abdominal cavity. However, in the presence of vital indications, in order to reduce bleeding and improve vision, they resort to increasing the pressure created by the fluid, washing the uterine cavity from blood clots, injecting drugs into the cervix. Finally, pregnancy is a contraindication to hysteroscopy, except in cases when the procedure is used for invasive prenatal diagnosis.
Preparation for hysteroscopy
In order to properly assess the indications and contraindications, as well as minimize the risks of complications, it is necessary to conduct a clinical and gynecological examination of the patient. General clinical diagnostics includes evaluation of the results of a general urine and blood test, chest X-ray, ECG, biochemical blood analysis, coagulogram, basic hospital complex. Before hysteroscopy, the patient should be previously consulted by a therapist and an anesthesiologist (when planning a subcutaneous examination). Gynecological examination involves examining the patient in a chair, smear microscopy, ultrasound of the pelvic organs.
Such a preparation algorithm allows you to get the necessary information about pathological processes in the uterus already at the planning stage of hysteroscopy, choose a method of anesthesia for the procedure and plan the goals of the upcoming study. In case of detection of extragenital pathology in a patient, consultations of specialists of appropriate profiles (cardiologist, endocrinologist, nephrologist, etc.) are organized; if necessary, pathogenetic therapy is carried out aimed at compensating for the identified violations.
Immediate preparation for hysteroscopy includes setting up a cleansing enema on the eve of the procedure, shaving hair from the external genitals, conducting intimate hygiene, emptying the bladder, showing up for an empty stomach examination. Planned hysteroscopic examination in women of reproductive age is usually prescribed for 5-10 days of the menstrual cycle.
Methodology of conducting
Hysteroscopy refers to surgical manipulations, therefore it is performed in a small gynecological operating room. The patient is placed in a standard position on a gynecological chair or table. If it is necessary to expand the cervical canal and perform intrauterine surgical manipulations, intravenous anesthesia is used for anesthesia; for diagnostic examination, local paracervical anesthesia can be limited.
The external genitals of the patient are treated with 5% alcohol tincture of iodine. Before the hysteroscopy begins, a bimanual examination and probing are performed to determine the position and length of the uterine cavity. The cervix is fixed with bullet forceps, and with the help of Gegar dilators, the cervical canal is expanded. Then, under the control of vision, a hysteroscope is inserted into the uterine cavity, equipped with a flexible light guide with a light source, a channel for air or liquid supply and a video camera. The walls of the uterine cavity, the mouth of the fallopian tubes are examined sequentially, and when the hysteroscope is removed, the cervical canal is examined.
During the examination, the shape and size of the uterine cavity, the relief of the walls, the color and thickness of the endometrium are evaluated, taking into account the phase of the menstrual cycle, the condition of the uterine tube mouths; pathological inclusions and formations are detected. In case of detection of focal formations, a targeted biopsy is performed; if necessary, endometrial scraping, hysteroresectoscopic surgery. The average duration of the procedure is from 10 to 30 minutes.
In the next 1-2 days after hysteroscopy, minor pains of a pulling nature in the lower abdomen, scanty bloody discharge from the genital tract may be noted. To reduce the risk of infectious and inflammatory complications, a woman is recommended to refrain from sexual intercourse, douching, using tampons, visiting baths and saunas, taking hot baths for 1 week. To reduce the risk of an ascending infection, antibiotic therapy may be prescribed for a preventive purpose.
If the manipulation technique is followed, the correct assessment of indications and risks, complications rarely occur. Nevertheless, like any intrauterine surgical intervention, hysteroscopy can be accompanied by various undesirable consequences and, first of all, infectious complications (endometritis, salpingitis, pelvioperitonitis).
Careless and inattentive performance of various stages of hysteroscopy can lead to traumatic damage to the uterus: perforation, rupture of the cervix or fallopian tube, and damage to the vessels of the myometrium – uterine bleeding, which can occur both during surgery and in the immediate postoperative period. In case of alarming symptoms (severe abdominal pain, fever, bloody and purulent discharge from the genital tract), an immediate appeal to a gynecologist is necessary.
The lack of control over the inflow and outflow of fluid during fluid hysteroscopy can lead to overload of the vascular bed and pulmonary edema. The supply of gas into the uterine cavity at high speed under high pressure can lead to gas embolism. When performing electrosurgical and laser intrauterine manipulations, thermal damage to the pelvic organs is possible.