Diagnostic Hysteroscopy
Linda D. Bradley
General Principles
Definition
Hysteroscopy is a minimally invasive transcervical procedure to provide panoramic visualization of the vagina, endocervix, endometrial cavity, and tubal ostia.
Hysteroscopy can be performed for diagnostic or therapeutic indications.
Diagnostic hysteroscopy with small-caliber hysteroscopes ideally can be performed in the office. However, diagnostic hysteroscopy can also be performed in an ambulatory surgical center or operating theatre.
Anatomic Considerations
Hysteroscopy is generally well tolerated in an office setting.
Anatomic findings that may impact the ability to perform diagnostic office hysteroscopy include:
Overweight and obese patient may have difficulty in keeping their legs comfortable in stirrups.
Knee braces may be better suited for obese patients or those with limited lower extremity mobility.
Limited lower extremity mobility may impair comfortable positioning for the patient.
Vaginal length may be greater in obese women. A rigid hysteroscope may not be long enough to reach the cervix. A flexible hysteroscope may be a more suitable option for obese patients due to its longer working length.
Cervical stenosis may limit the ability to insert the hysteroscope comfortably in an office setting.
Increased risk of cervical stenosis noted in:
Menopausal women (medically induced or natural)
Patients with a prior LEEP or cone biopsy
Nulliparous patients
Prior C/section
Excessive menstrual bleeding may obscure visualization during hysteroscopy:
A fluid management distention system is not required for brief diagnostic procedures. Therefore, visualization may be hampered without the ability to vary the intrauterine pressure.
The inability to vary the intrauterine pressure significantly debris, clots, and heavy bleeding can obscure findings.
Uterine distention is more difficult in patients with an enlarged uterus greater than 14 to 18 gestational weeks on bimanual examination.
Imaging and Other Diagnostics
Diagnostic hysteroscopy is often performed to evaluate:
Abnormal uterine bleeding
Postmenopausal bleeding
To clarify equivocal ultrasound or MRI results
Postoperative evaluation
Müllerian anomalies
Several diagnostic studies including endometrial biopsy and medical therapy for abnormal bleeding may precede hysteroscopy.
When medical therapy for abnormal bleeding fails, it is possible that the patient has a focal lesion including an endometrial polyp, intracavitary fibroid, endometrial hyperplasia, or endometrial malignancy.
If multiple medical or hormonal treatments do not resolve bleeding abnormalities, then hysteroscopy should be considered.
Diagnostic hysteroscopy should be considered in patients who have had a levonorgestrel intrauterine device placed for heavy menses (without an endometrial evaluation) and whose IUD expels. It is possible that an intracavitary lesion is the culprit for the expulsion. Before replacing another IUD, a quick hysteroscopy can confirm intracavitary anatomy.
Transvaginal ultrasound imaging is helpful in evaluating the endometrium in reproductive-aged patients and menopausal patients.
TVUS imaging may miss one-sixth of intracavitary lesions in reproductive-aged patients with abnormal uterine bleeding.
If hysteroscopy is not routinely available, ideally SIS would be recommended because it has greater sensitivity in evaluating the endometrial cavity compared to TVUS.
If SIS is not available, then patients with a normal endometrial echo on TVUS and who continue to have abnormal bleeding would benefit from hysteroscopy.
Menopausal patients with persistent bleeding despite a negative endometrial biopsy and thin endometrium echo (4 mm or less) should be scheduled for office hysteroscopy if SIS is not available.
A thin endometrial echo of less than 4 mm in a menopausal patient is unlikely to be associated with an endometrial malignancy. However, endometrial polyps conform to the endometrial cavity, creating a false negative result.
Patients presenting with a hematometria also benefit from diagnostic hysteroscopy after drainage of the hematometria.
If SIS findings are equivocal, hysteroscopy can be helpful in evaluating the endometrium.
MRI of the pelvis with and without contrast is sensitive in detecting intracavitary fibroids. However, endometrial and endocervical polyps are not detected as well with MRI. Therefore, patients who have abnormal bleeding which cannot be explained with MRI would benefit from hysteroscopy.
Preoperative Planning
A urine pregnancy test is required on the day of the procedure for all reproductive-aged patients.
Diagnostic hysteroscopy ideally should be scheduled in the proliferative phase in ovulatory patients. The endometrium is thin during the early proliferative phase and leads to a decrease in false positive results.
Reproductive-aged patients who bleed incessantly with a pattern of bleeding consistent with an anovulatory cycle may benefit from an endometrial biopsy and short course of progesterone therapy to halt the bleeding. Once progesterone therapy is stopped, the patient will have a withdrawal bleed. At the conclusion of the withdrawal bleeding diagnostic hysteroscopy can be scheduled. Improved visualization occurs with this strategy.
Menopausal patients can be scheduled for diagnostic hysteroscopy at any time.
Cervical cultures for sexually transmitted disease are not routinely required. However, patients queried on a case-by-case basis to determine if needed.
There are no specific laboratory tests necessary for an office hysteroscopy (except pregnancy testing). It is likely that routine labs including a CBC with platelets and TSH would be ordered as a part of the evaluation of abnormal uterine bleeding. However, it is not needed for scheduling hysteroscopy.
Follow required surgical laboratory protocols if the diagnostic procedure is performed in the ambulatory care center or operating room.
Surgical Management
Indications for office hysteroscopy:
Abnormal perimenopausal and postmenopausal bleeding
Evaluation of thickened endometrium on TVUS
Equivocal endometrial findings noted with MRI, SIS, or TVUS
Failure to respond to medical therapy
Infertility evaluation
Postoperative evaluation of the endometrial cavity following surgical procedures such as myomectomy, dilation and curettage, or an intrauterine procedure
Retained products of conception
Location of foreign bodies (IUD, suture, migration of cerclage)
Leukorrhea
Evaluation of the endometrium following uterine fibroid embolization
Sterilization
Endocervical lesions
Endometrial polyps
Evaluation of the endometrium in women on Tamoxifen therapy
Submucosal fibroids
Müllerian anomalies (e.g., uterine septum)
Evaluation of C/section scars
Following uterine perforation to determine if the perforation has healed
Location of hysteroscopic inserts to determine if migration or expulsion into the uterine cavity has occurred.
Contraindications
Viable pregnancy
Cervical cancer
Known uterine cancer
Active pelvic inflammatory disease
Acute endometritis
Untreated sexually transmitted disease
Patient apprehension for office-based procedure
Excessive vaginal bleeding and clotting that would likely preclude an adequate view of endometrium
