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Hysteroscopy

hysteroscopy

Hysteroscopy

 

Ambulatory hysteroscopy diagnosis center

Dr Jean-Philippe Estrade - Dr Brice Gurriet

+33-(0)4-91-16-79-04

6, Rue Rocca-13008 Marseille-France

 

This exam enables to explore the uterine cavity by going through the natural tracks, meaning the vagina and the cervix. The hysteroscope is an instrument made up of a mini camera, a source of light, an irrigation system and if needed, an operative canal to proceed with the medical acts.

 

I) Diagnostic hysteroscopy

 

Technique

You will usually do it as an outpatient, meaning without being hospitalized. The procedure does not require any anesthesia or fasting, and can be done outside of an operating room.  The patient is installed on a gynecological table, a quick and thorough vaginal disinfection is done, then a speculum is inserted and a clamp fixed on the cervix. A 2.5 to 3mm diametric hysteroscope is inserted inside the cervix canal.  This last procedure can be avoided by doing a vaginoscopy, meaning the uteroscope is directly introduced into the vagina without a speculum or clamp, then into the cervix. Stretching the tissue is ensured by using a physiological salt solution (the use of gas was abandoned many years ago).

The gynecologist visualizes the images on a screen and explores the cervical canal, the uterine cavity and the root of the fallopian tubes (tubular ostium). The exam only lasts for a couple of minutes and is generally well tolerated. The patient usually experiences slight uterine spasms similar to those felt during menstruation.  It is possible to do superficial biopsies of the mucous during the exam, or to remove an IUD using a little clamp introduced in the hysteroscope. If a medical act is deemed necessary after the exam, an operative hysteroscopy will be scheduled. If a medical act is known as being unavoidable before the exam (ultrasound-revealed disorder, heavy bleeding), it is sometimes preferable to perform a diagnostic and operative hysteroscopy, at the same time, to spare the patient from repeated medical acts.

 

Indications

A hysteroscopy can be recommended for the following conditions:

  • Unexplained uterine bleeding (metrorrhagia), especially in menopausal women.  In this case, a diagnostic hysteroscopy is almost always indicated.
  • Assessment of infertility or repeated miscarriages, to explore a congenital or acquired anomaly of the uterus.
  • Assessment of a uterine malformation
  • Exploration of an intra-uterine image discovered through imaging (ultrasound, MRI..).

 

Visible anomalies with a hysteroscopy

Different anomalies can be visualized, as follows:

  • Uterine fibromas, benign tumors of the uterus. Only fibromas developing in the uterine cavity are visible: they cause bleeding, pelvic pains, even infertility.
  • Endometrial polyps which are uterine mucous excrescences causing bleeding.
  • Synechiae or intra-uterine adhesions. The internal walls of the uterus cling together, as a result to an aggressive intervention on the mucous membrane (curettage, infection, surgical act, radiotherapy..). They are asymptomatic or cause a reduced or complete stop of menstrual cycles (amenorrhea).
  • Adenomiosis, corresponding to the migration of the mucous cells into the uterine muscle (myometer) and usually inducing metrorrhagia.
  • Uterine malformations: wall, uterus bicornis (see the anatomical anomalies of the uterus chapter).
  • Atrophy or hypertrophy of the endometrium. Both situations cause bleeding and can be physiological (post menopause atrophy), pathological (endometrial hyperplasia, cancer of the endometrium) or secondary to hormonal treatments.
  • Endometrium cancer, almost exclusively in menopausal women.

 

II) Operative Hysteroscopy

 

Technique

It requires a general anesthesia or loco-regional anesthesia in an operating room: the patient must be fasting. An ambulatory hospitalization is usually sufficient. The hysteroscope used is generally bigger, 5 to 9 mm in diameter as it includes instruments, (however with today’s technology operative hysteroscopes are smaller). The patient is lying down on the gynecologist chair, and a vaginal antisepsis is done.  A speculum is inserted and a clamp on the cervix. Usually, dilating the cervix is necessary.

The irrigation liquid can either be a physiological salt solution or glycocoll, depending on the materiel used.

 

Indications

Any condition requiring an intra-uterine act, such as :

  • Removal of polyps or fibromas
  • Endometrectomy, meaning the complete removal of the endometrium, especially in case of persistent metrorrhagia after medical treatments failed in peri or post menopausal women
  • Thermo coagulation of the endometrium. It is an alternative to endometrectomy and consists of coagulating the uterine mucous membrane through heating with a specific material.  A biopsy of the endometrium must always be done during or after this act.
  • Uterine wall section.
  • Synechial cure.
  • Tubular sterilization, nowadays possible using this technique, without requiring any incision or anesthesia. An implant device is introduced and placed in each fallopian tube through hysteroscopy (Essure method ®). Within 3 months, the inflammatory reaction will have completely and definitively obstructed the fallopian tubes.

 

III) Complications

 

They are extremely rare with a diagnostic hysteroscopy and seldomly occur with operative hysteroscopy. Nevertheless, hysteroscopies remain surgical acts and complications are possible and can include :

  • Failure, when the hysteroscope cannot be introduced in the cervix, in particular because of a stenosis of the external cervical hole.  This can be observed in menopausal women, especially if she never gave birth or if she suffered from a cervix trauma (conization, hysteroscopy, late termination of pregnancy…).
  • « False route »: a break-in of the mucous membrane and uterine muscle during the dilatation, whereby the irrigation will cause the formation of a false cavity.  It is sometimes possible to correctly re-route, but often, the hysteroscopy must be interrupted and delayed. Causes are the same as for failures of the act.
  • Uterine perforation occurs when the hysteroscopy goes through the uterine wall.  In most cases, a preventive antibiotics treatment and hospitalization for observation suffice. On exceptional basis, a nearby organ can be damaged (bladder, uterine artery, rectum, small intestine) and surgery (coelioscopy or laparoscopy) can be in performed to assess the lesions and eventually repair them.
  • A wound in the cervix can occur due to the cervical dilatation and/or pulling.  This is usually noticed and immediatelyrepaired.
  • Haemorrhage is a rare complication.
  • Glycocoll intoxication should no longer be a risk if all good practice rules are repsected by the medical team: verifying ins and outs, limitating the injected volume to 9 liter, limitating the operation time to an hour.

 

Delayed complications can also occur:

  • Postoperative infections are very rare, much more than in any other intra-uterine surgical act.
  • A synechia can occur after an operative hysteroscopy, especially if the act is invasive (voluminous or multiple fibromas, synechial cure..).
  • Incompetent cervix, causing miscarriages, has become extremely rare since the miniaturization of the instruments used.

This exhaustive list can scare patients, but one must keep in mind that a hysteroscopy is a frequent medical act with rare complications. The procedure is simple is the vast majority of cases.

 

IV) Postoperative consequences

 

They usually are simple and short. Most of the time, the patient is released after one day in the hospital and can immediately resume eating. Light bleeding can occur during a few days, together with small uterine spasms but usually no medical treatment is neither prescribed nor necessary upon being discharged from the hospital.

If the patient underwent an endomectrectomy or thermo coagulation, some light liquid discharge can be experienced for an average of 15 days, depending on the oedema.  The medical instructions are related to the dilatation of the cervix, therefore the patient must avoid bathing, sexual intercourse and tampons for a week.

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Vaginal rejuvenation in London : Hysteroscopy