Hysteroscopy in Gynecology: A Practitioner’s Perspective
Why do women facing reproductive health issues so often hear the word "hysteroscopy" from their doctors? What lies behind this term, and how necessary is the procedure really? Over years of practice, I have realized that patient awareness plays a key role in the success of treatment. Therefore, today I want to discuss in detail the method that has become the gold standard in the diagnosis and treatment of many gynecologic diseases.
Hysteroscopy is a minimally invasive endoscopic procedure that allows for the visualization of the uterine cavity using a special optical instrument called a hysteroscope. In my practice, I distinguish between two main types of this examination: diagnostic hysteroscopy, aimed at inspecting and assessing the state of the endometrium, and operative (surgical) hysteroscopy, during which therapeutic manipulations are performed. It is important to understand that these two types often complement each other; a diagnostic procedure can seamlessly transition into an operative one if a pathology requiring immediate correction is identified.
When Hysteroscopy is Necessary: Indications for the Procedure
The indications for hysteroscopy are quite diverse, and every case requires an individual approach. The most common reason for referral is abnormal uterine bleeding, including:
- Menorrhagia (heavy menstrual periods)
- Metrorrhagia (bleeding between periods)
- Postmenopausal bleeding
These symptoms may indicate endometrial polyps, submucosal fibroids, endometrial hyperplasia, or even malignant processes. Hysteroscopy allows for both the visualization of the pathology and the simultaneous performance of a biopsy or removal of the lesion.
Hysteroscopy holds a special place in reproductive medicine. When evaluating couples with infertility, I regularly identify:
- Intrauterine synechiae (adhesions) that may prevent embryo implantation.
- Endometrial polyps that disrupt endometrial receptivity.
- Congenital uterine anomalies, such as a uterine septum.
For patients with recurrent pregnancy loss, hysteroscopy helps detect submucosal fibroids deforming the uterine cavity or chronic endometritis requiring specific treatment. Additionally, the procedure is indispensable for removing intrauterine foreign bodies, such as fragments of an IUD or retained products of conception after a miscarriage.
Contraindications: When the Procedure Should Be Postponed
Despite the high safety of the method, there are situations where hysteroscopy is contraindicated:
- Absolute contraindication: Pregnancy (manipulations can lead to termination).
- Active pelvic infection: Acute endometritis, salpingitis, or cervicitis requires delay until inflammation is fully resolved.
- Verified cervical or endometrial cancer: Manipulations may contribute to the dissemination of tumor cells.
- Heavy bleeding: If visualization is impossible, hemostatic therapy must be performed first.
- Relative contraindications: Severe systemic diseases in a stage of decompensation (e.g., unmanaged diabetes or severe cardiovascular pathology).
Equipment: Tools for Precision Work
Modern hysteroscopes are high-technology optical systems providing high-resolution images. I work with both rigid and flexible hysteroscopes. Rigid scopes provide superior image quality and offer various viewing angles (0°, 12°, and 30°) for inspecting the tubal ostia and lateral walls.
| Parameter | Diagnostic | Operative |
|---|---|---|
| Purpose | Examination and diagnosis | Treatment (removal of polyps, fibroids) |
| Anesthesia | Often not required or local | Intravenous sedation / General |
| Instrument diameter | 2.9 – 5 mm | 9 – 10 mm |
The diameter varies from 2.9 to 5 mm for diagnostic procedures and up to 9–10 mm for operative interventions. To expand the uterine cavity, we use:
- Saline for diagnostic procedures.
- Glycine or Sorbitol for operative interventions using monopolar electrosurgery.
The surgical toolkit includes forceps, resection loops, and morcellators. A critical component is the insufflation and aspiration system, which maintains a constant pressure of 70–100 mmHg and monitors fluid balance to prevent fluid overload.
Patient Preparation: The Path to a Successful Procedure
Thorough preparation is the guarantee of a successful procedure. During the preoperative consultation, I collect a detailed history, including menstrual function and allergies (especially to anesthetics).
| Test | Validity period |
|---|---|
| 🩸 Complete blood count + platelets | 10–14 days |
| 🧪 Coagulation test (coagulogram) | 10–14 days |
| 🧬 HIV, syphilis, hepatitis tests | 3 months |
| 🔬 Vaginal flora smear | 10 days |
Standard tests include:
- Complete blood count (CBC) and coagulation profile.
- Biochemical blood analysis (glucose, creatinine, electrolytes).
- Infection screening (HIV, Hepatitis B/C, Syphilis).
- Blood type and Rh factor.
- Pregnancy test (mandatory on the day of the procedure).
- Vaginal and cervical swabs.
The optimal time for diagnostic hysteroscopy is the early proliferative phase (days 5–10 of the menstrual cycle), when the endometrium is thinnest, providing the best visibility.
Procedure Technique: A Detailed Breakdown
Hysteroscopy can be performed under various types of anesthesia, from local paracervical blocks for office procedures to intravenous sedation or general anesthesia for major surgery.
- Positioning: The patient is placed in the lithotomy position.
- Approach: I often use the vaginoscopic approach, inserting the scope directly through the vagina without speculums.
- Visualization: Under visual control, the scope moves through the cervical canal. Once in the cavity, the distension medium is supplied.
- Surgical Phase: If pathology is found, polyps are removed with forceps, fibroids are resected layer by layer, and synechiae are divided until normal anatomy is restored.
Practitioner’s Note: Fluid balance monitoring is critical. If the fluid deficit exceeds 1000–1500 ml, the procedure must be stopped immediately.
Postoperative Period: Recommendations and Monitoring
Most patients can go home within a few hours. Mild cramping and light spotting for 1–2 days are expected.
- No sexual intercourse for two weeks.
- Avoid tampons, douching, swimming pools, and saunas for two weeks.
- Restrict physical activity and avoid lifting over 3 kg.
A follow-up visit is usually scheduled after one week. For those planning a pregnancy, waiting one menstrual cycle is recommended to allow full endometrial recovery.
Key points after the procedure
- Sexual rest — 2 weeks.
- No tampons or baths — 2 weeks.
- Follow-up ultrasound/doctor visit — in one week.
- Pain similar to menstrual cramps — this is normal.
In summary, hysteroscopy is an indispensable tool in modern gynecology, enabling precise diagnosis and effective treatment of a wide range of intrauterine pathologies. Its high diagnostic yield combined with a low risk of complications makes it the gold standard in the management of abnormal uterine bleeding, infertility, and recurrent pregnancy loss.
