| Hysteroscopy | |
|---|---|
 Anatomic depiction of a modern hysteroscopic procedure | |
| ICD-9-CM | 68.12 |
| MeSH | D015907 |
| OPS-301 code | 1-672 |
Hysteroscopy is the inspection of the uterine cavity by endoscopy with access through the cervix. It allows for the diagnosis of intrauterine pathology and serves as a method for surgical intervention (operative hysteroscopy).
A hysteroscope is an endoscope that carries optical and light channels or fibers. It is introduced in a sheath that provides an inflow and outflow channel for insufflation of the uterine cavity. In addition, an operative channel may be present to introduce scissors, graspers or biopsy instruments. [1] A hysteroscopic resectoscope is similar to a transurethral resectoscope and allows entry of an electric loop to shave off tissue, for instance to eliminate a fibroid. [1] [2] A contact hysteroscope is a hysteroscope that does not use distention media.
Hysteroscopy has been carried out in hospitals, surgical centers and doctors' offices. It is best carried out when the endometrium is relatively thin, that is after a menstruation. Both diagnostic and simple operative hysteroscopy can be carried out in an office or clinic setting on suitably selected patients. Local anesthesia can be used. Analgesics are not always necessary. A paracervical block may be achieved using a lidocaine injection in the upper part of the cervix. Hysteroscopic intervention can also be done under general anesthesia (endotracheal or laryngeal mask) or monitored anesthesia care (MAC). Prophylactic antibiotics are not necessary. The patient is in a lithotomy position during the procedure. [3]
The diameter of the modern hysteroscope is generally small enough to conveniently pass the cervix directly. For a proportion of women cervical dilation may need to be performed prior to insertion. Cervical dilation can be performed by temporarily stretching the cervix with a series of dilators of increasing diameter. [4] Misoprostol prior to hysteroscopy for cervical dilation appears to facilitate an easier and uncomplicated procedure only in premenopausal women. [5]
The hysteroscope with its sheath is inserted transvaginally guided into the uterine cavity, the cavity insufflated, and an inspection is performed.[ citation needed ]
The uterine cavity is a potential cavity and needs to be distended to allow for inspection. Thus, during hysteroscopy, either fluids or CO2 gas is introduced to expand the cavity. The choice is dependent on the procedure, the patient's condition, and the physician's preference. Fluids can be used for both diagnostic and operative procedures. However, CO2 gas does not allow the clearing of blood and endometrial debris during the procedure, which could make the imaging visualization difficult. Gas embolism may also arise as a complication. Since the success of the procedure is totally dependent on the quality of the high-resolution video images in front of the surgeon's eyes, CO2 gas is not commonly used as the distention medium.[ citation needed ]
Electrolytic solutions include normal saline and lactated Ringer's solution. Current recommendation is to use the electrolytic fluids in diagnostic cases, and in operative cases in which mechanical, laser, or bipolar energy is used. Since they conduct electricity, these fluids should not be used with monopolar electrosurgical devices. Non-electrolytic fluids eliminate problems with electrical conductivity, but can increase the risk of hyponatremia. These solutions include glucose, glycine, dextran (Hyskon), mannitol, sorbitol and a mannitol/sorbital mixture (Purisol). Water was once used routinely, however, problems with water intoxication and hemolysis discontinued its use by 1990. Each of these distention fluids is associated with unique physiological changes that should be considered when selecting a distention fluid. Glucose is contraindicated in patients with glucose intolerance. Sorbitol metabolizes to fructose in the liver and is contraindicated if a patient has fructose malabsorption.[ citation needed ]
High-viscous Dextran also has potential complications which can be physiological and mechanical. It may crystallize on instruments and obstruct the valves and channels. Coagulation abnormalities and adult respiratory distress syndrome (ARDS) have been reported. Glycine metabolizes into ammonia and can cross the blood brain barrier, causing agitation, vomiting and coma. Mannitol 5% should be used instead of glycine or sorbitol when using monopolar electrosurgical devices. Mannitol 5% has a diuretic effect and can also cause hypotension and circulatory collapse. The mannitol/sorbitol mixture (Purisol) should be avoided in patients with fructose malabsorption.
When fluids are used to distend the cavity, care should be taken to record its use (inflow and outflow) to prevent fluid overload and intoxication of the patient. [6]
If abnormalities are found, an operative hysteroscope with a channel to allow specialized instruments to enter the cavity is used to perform the surgery. Typical procedures include endometrial ablation, submucosal fibroid resection, and endometrial polypectomy. Hysteroscopy has also been used to apply the Nd:YAG laser treatment to the inside of the uterus. [7] Methods of tissue removal now include electrocautery bipolar loop resection, and morcellation. [8]
Hysteroscopy is useful in a number of uterine conditions:
The use of hysteroscopy in endometrial cancer is not established as there is concern that cancer cells could be spread into the peritoneal cavity. [12]
Hysteroscopy has the benefit of allowing direct visualization of the uterus, thereby avoiding or reducing iatrogenic trauma to delicate reproductive tissue which may result in Asherman's syndrome.
Hysteroscopy allows access to the uterotubal junction for entry into the fallopian tube; this is useful for tubal occlusion procedures for sterilization and for falloposcopy.
A possible problem is uterine perforation when either the hysteroscope itself or one of its operative instruments breaches the wall of the uterus. This can lead to bleeding and damage to other organs. If other organs such as bowel are injured during a perforation, the resulting peritonitis can be fatal. Furthermore, cervical laceration, intrauterine infection (especially in prolonged procedures), electrical and laser injuries, and complications caused by the distention media can be encountered.[ citation needed ]
The use of insufflation (also called distending) media can lead to serious and even fatal complications due to embolism or fluid overload with electrolyte imbalances. [1] [6] Particularly the electrolyte-free insufflation media increase the risk of fluid overload with electrolyte imbalances, particularly hyponatremia, heart failure as well as pulmonary and cerebral edema. The main factors contributing to fluid overload in hysteroscopy are: [13]
Women in fertile age are at increased risk of resultant hyponatremic encephalopathy, likely because of increased level of estrogens. [13]
The overall complication rate for diagnostic and operative hysteroscopy was 2% with serious complications occurring in less than 1% of cases using older methods. [1] Morcellation has fewer complications than electrocautery, less than 0.1%. [14] [15]
The English Member of Parliament, Lyn Brown (West Ham, Labour), has spoken twice in the House of Commons on behalf of constituents who have been coerced into completing unbearably painful outpatient hysteroscopies without anaesthesia. Lyn Brown cites numerous instances of women throughout England being held down by nurses in order to complete an ambulatory hysteroscopy and thus avoid the expense of safely monitored sedation or general anaesthetic. [16] A petition to grant NHS patients full information about the risks of severe outpatient hysteroscopy pain, and the upfront choice of local anaesthetic, sedation, epidural or general anaesthetic was launched in summer 2018. 'End barbaric NHS hysteroscopies with inadequate pain-relief'. It asks the Secretary of State for Health to ensure that:
Dilationand curettage (D&C) refers to the dilation of the cervix and surgical removal of part of the lining of the uterus or contents of the uterus by scraping and scooping (curettage). It is a gynecologic procedure used for diagnostic and therapeutic purposes, and is the most commonly used method for first-trimester miscarriage or abortion.
Heavy menstrual bleeding (HMB), previously known as menorrhagia or hematomunia, is a menstrual period with excessively heavy flow. It is a type of abnormal uterine bleeding (AUB).
Asherman's syndrome (AS) is an acquired uterine condition that occurs when scar tissue (adhesions) forms inside the uterus and/or the cervix. It is characterized by variable scarring inside the uterine cavity, where in many cases the front and back walls of the uterus stick to one another. AS can be the cause of menstrual disturbances, infertility, and placental abnormalities. Although the first case of intrauterine adhesion was published in 1894 by Heinrich Fritsch, it was only after 54 years that a full description of Asherman syndrome was carried out by Joseph Asherman. A number of other terms have been used to describe the condition and related conditions including: uterine/cervical atresia, traumatic uterine atrophy, sclerotic endometrium, and endometrial sclerosis.
Adenomyosis is a medical condition characterized by the growth of cells that proliferate on the inside of the uterus (endometrium) atypically located among the cells of the uterine wall (myometrium), as a result, thickening of the uterus occurs. As well as being misplaced in patients with this condition, endometrial tissue is completely functional. The tissue thickens, sheds and bleeds during every menstrual cycle.
Vaginal bleeding is any expulsion of blood from the vagina. This bleeding may originate from the uterus, vaginal wall, or cervix. Generally, it is either part of a normal menstrual cycle or is caused by hormonal or other problems of the reproductive system, such as abnormal uterine bleeding.
Falloposcopy is the inspection of the fallopian tubes through a micro- endoscope. The falloposcope is inserted into the tube through its opening in the uterus at the proximal tubal opening via the uterotubal junction; technically it could also be inserted at the time of abdominal surgery or laparoscopy via the distal fimbriated end.
Gynecologic ultrasonography or gynecologic sonography refers to the application of medical ultrasonography to the female pelvic organs as well as the bladder, the adnexa, and the recto-uterine pouch. The procedure may lead to other medically relevant findings in the pelvis.This technique is useful to detect myomas or mullerian malformations.
Cervical dilation is the opening of the cervix, the entrance to the uterus, during childbirth, miscarriage, induced abortion, or gynecological surgery. Cervical dilation may occur naturally, or may be induced surgically or medically.
A uterine malformation is a type of female genital malformation resulting from an abnormal development of the Müllerian duct(s) during embryogenesis. Symptoms range from amenorrhea, infertility, recurrent pregnancy loss, and pain, to normal functioning depending on the nature of the defect.
An endometrial polyp or uterine polyp is a mass in the inner lining of the uterus. They may have a large flat base (sessile) or be attached to the uterus by an elongated pedicle (pedunculated). Pedunculated polyps are more common than sessile ones. They range in size from a few millimeters to several centimeters. If pedunculated, they can protrude through the cervix into the vagina. Small blood vessels may be present, particularly in large polyps.
Myomectomy, sometimes also called fibroidectomy, refers to the surgical removal of uterine leiomyomas, also known as fibroids. In contrast to a hysterectomy, the uterus remains preserved and the woman retains her reproductive potential. It still may impact hormonal regulation and the menstrual cycle.
Vacuum or suction aspiration is a procedure that uses a vacuum source to remove an embryo or fetus through the cervix. The procedure is performed to induce abortion, as a treatment for incomplete spontaneous abortion or retained fetal and placental tissue, or to obtain a sample of uterine lining. It is generally safe, and serious complications rarely occur.
Endometrial ablation is a surgical procedure that is used to remove (ablate) or destroy the endometrial lining of the uterus. The goal of the procedure is to decrease the amount of blood loss during menstrual periods. Endometrial ablation is most often employed in people with excessive menstrual bleeding, who do not wish to undergo a hysterectomy, following unsuccessful medical therapy.
The arcuate uterus is a form of a uterine anomaly or variation where the uterine cavity displays a concave contour towards the fundus. Normally the uterine cavity is straight or convex towards the fundus on anterior-posterior imaging, but in the arcuate uterus the myometrium of the fundus dips into the cavity and may form a small septation. The distinction between an arcuate uterus and a septate uterus is not standardized.
A uterine septum is a congenital uterine malformation where the uterine cavity is partitioned by a longitudinal septum; the outside of the uterus has a normal typical shape. The wedge-like partition may involve only the superior part of the cavity resulting in an incomplete septum or a subseptate uterus, or less frequently the total length of the cavity and the cervix resulting in a double cervix. The septation may also continue caudally into the vagina resulting in a "double vagina".
Tubal reversal, also called tubal sterilization reversal, tubal ligation reversal, or microsurgical tubal reanastomosis, is a surgical procedure that can restore fertility to women after a tubal ligation. By rejoining the separated segments of the fallopian tube, tubal reversal can give women the chance to become pregnant again. In some cases, however, the separated segments cannot actually be reattached to each other. In some cases the remaining segment of tube needs to be re-implanted into the uterus. In other cases, when the end of the tube has been removed, a procedure called a neofimbrioplasty must be performed to recreate a functional end of the tube which can then act like the missing fimbria and retrieve the egg that has been released during ovulation.
The endometrial biopsy is a medical procedure that involves taking a tissue sample of the lining of the uterus. The tissue subsequently undergoes a histologic evaluation which aids the physician in forming a diagnosis.
Hematometra is a medical condition involving collection or retention of blood in the uterus. It is most commonly caused by an imperforate hymen or a transverse vaginal septum.
An intrauterine device (IUD), also known as intrauterine contraceptive device or coil, is a small, often T-shaped birth control device that is inserted into the uterus to prevent pregnancy. IUDs are one form of long-acting reversible birth control (LARC). One study found that female family planning providers choose LARC methods more often (41.7%) than the general public (12.1%). Among birth control methods, IUDs, along with other contraceptive implants, result in the greatest satisfaction among users.
Hysterosalpingography (HSG), also known as uterosalpingography, is a radiologic procedure to investigate the shape of the uterine cavity and the shape and patency of the fallopian tubes. It is a special x-ray procedure using dye to look at the womb (uterus) and fallopian tubes. In this procedure, a radio-opaque material is injected into the cervical canal, and radiographs are taken. A normal result shows the filling of the uterine cavity and the bilateral filling of the fallopian tube with the injection material. To demonstrate tubal patency, spillage of the material into the peritoneal cavity needs to be observed. Hysterosalpingography has vital role in treatment of infertility, especially in the case of fallopian tube blockage.
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