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Hysteroscopy is a minimally invasive procedure, widely used to diagnose and treat different conditions inside the uterus. Its name is derived from the Greek words hystero (womb) and scopia (viewing, investigation). The first operation of this kind was performed at the end of the 19th century. Today, both the tools and the techniques have improved and are more gentle than ever.
Hysteroscopy is a procedure in which a gynaecologist inserts a thin instrument called a hysteroscope through the vagina to view the cervix and the inside of the uterus. It is most often used to find and treat the cause of abnormal bleeding or infertility. Although uterine curettage (‘cleaning’) is still sometimes used to diagnose and treat certain conditions, in many countries it has been largely replaced by hysteroscopy. This method is applicable to women of all ages. It is particularly recommended for women planning a future pregnancy. Of course, there are situations where uterine curettage is preferable, but these cases are becoming less and less common overall.
For a diagnostic hysteroscopy, very thin instruments (up to 5 mm wide) are used. These usually do not require much dilation of the cervix before being inserted into the uterus. Today, diagnostic hysteroscopes can also include a small working channel, which allows minor conditions to be treated during the same procedure.
This type of hysteroscopy can be performed under short-term anaesthesia, but in many cases, it is now performed as an outpatient procedure without the need for anaesthesia. The manipulation is performed during the gynaecological examination, and the patient can go home immediately afterwards. This makes it possible to take a biopsy of any growth and to treat small septa, polyps, or nodules during the same procedure. Evidence shows that patient satisfaction with this procedure is very high.
Diagnostic hysteroscopy can also be done under short-term anaesthesia, either at the patient’s request or when a more complex condition, such as adhesions, is suspected, since these cases carry a higher risk of complications.
Diagnostic hysteroscopy is recommended when a biopsy is needed for an unclear growth, to remove a displaced intrauterine device (spiral), or when ultrasound results are unclear and the shape of the uterine cavity needs to be examined more closely. Hysteroscopy can also be combined with uterine curettage (‘cleaning’), which has been shown to provide the highest diagnostic accuracy, especially when checking for malignant disease.
An important advantage of diagnostic hysteroscopy is that it allows the doctor to see directly inside the uterus, which reduces the risk of instruments being placed incorrectly – for example, in women with cervical narrowing or adhesions.
While the diagnostic hysteroscope can be used to treat small conditions, larger instruments are needed to remove bigger growths or lesions. Operative hysteroscopy is most commonly performed under short-acting anaesthesia to ensure patient comfort during cervical dilation. Operative hysteroscopy is based on the precise visualisation of the mass and its excision using electricity. This method can be used to treat larger conditions such as big polyps, submucosal fibroids, or uterine septa. It is also used to remove retained tissue after childbirth, treat caesarean scar defects, remove a displaced intrauterine device (spiral), and manage other major problems inside the uterus. Today, smaller operative hysteroscopes are available, making the procedure gentler and usually avoiding the need for significant cervical dilation.
Risks – less than 1% of procedures performed, and much lower than for uterine curettage
Hysteroscopy is performed with the patient lying on her back with her legs raised. The surgical area is cleaned with an antiseptic (antimicrobial) solution and covered with sterile drapes. Operative hysteroscopy starts with cervical dilation, after which the hysteroscope is inserted into the uterine cavity. Today, saline is most often used to gently expand the uterine cavity, allowing the doctor to clearly see the entire area and detect any problems.
During a diagnostic hysteroscopy, the hysteroscope is advanced through the cervical canal into the uterine cavity under continuous saline infusion to achieve distension. In this case, saline ensures slow and gentle dilation. After surgery, the instrument is removed. As the uterus contracts, the fluid is drained during the procedure, so it will not leak out later during recovery.
The operation can take from a few minutes to an hour. Outpatient hysteroscopy usually lasts no longer than 20 minutes, while operative hysteroscopy is limited to about an hour to reduce the risk of fluid build-up in the body.
It is best to schedule a hysteroscopy during the first phase of the menstrual cycle. This allows the doctor to see the uterine cavity clearly and detect any problems more easily. The clearest view is usually possible right after menstruation, when the lining of the uterus is at its thinnest. Proper planning of the potential surgery gives a better guarantee that the pathology will be completely cured.
Hysteroscopy can only be planned long in advance with the correct medical preparation. It is not advisable to perform a diagnostic or operative hysteroscopy a few days before menstruation, because the endometrium is thick and, if the pathology is small, such as a simple polyp, it is almost impossible to distinguish it from the growing mucosa.
Hysteroscopy is a more accurate and modern method of examination and treatment, with a significantly lower risk of complications. However, uterine curettage has its own specific indications, such as in cases of very heavy bleeding that needs to be stopped.
After virtually any hysteroscopic surgery, the patient can return home on the same day. The recommendations after surgery depend on the type of hysteroscopy performed and should therefore be discussed individually with your doctor. The most common symptoms after surgery are a pulling pain in the lower abdomen, which may last for a few days, and a light bloody or smearing discharge from the genital tract, which may continue for a few weeks after the removal of larger growths.
