Hysteroscopy: Incision-Free Diagnosis and Treatment for Intrauterine Conditions

Hysteroscopy is a gynaecological procedure that allows the uterine cavity to be visualised directly through a thin, illuminated camera called a hysteroscope. Whereas ultrasound and hysterosalpingography (HSG) provide only indirect information about the endometrial cavity, hysteroscopy offers a real-time, high-resolution view from within. Many intrauterine conditions can therefore be both diagnosed and treated in the same session.

Advances in miniaturised optics over the past two decades have transformed hysteroscopy into a largely office-based procedure, performed with no anaesthesia or light sedation. It is today the gold standard for the evaluation of abnormal uterine bleeding, recurrent pregnancy loss, infertility and intrauterine adhesions.

Types of hysteroscopy

1. Diagnostic (office) hysteroscopy

The aim is to inspect the uterine cavity and, if indicated, to perform a targeted biopsy. Thin (2.7–3 mm) hysteroscopes are used and cervical dilation is generally not required. The procedure is completed in 5–15 minutes without anaesthesia or with light sedation, and the patient can usually return to normal activities the same day.

2. Operative hysteroscopy

Operative hysteroscopy is performed to remove an intrauterine pathology (polyp, fibroid, septum or adhesion) in the same session. Larger (8–10 mm) operative hysteroscopes or thinner "see-and-treat" systems capable of both diagnosis and treatment may be used. It is performed in an operating theatre under general or spinal anaesthesia, and typically lasts 20–60 minutes depending on the pathology.

When is hysteroscopy indicated?

Abnormal uterine bleeding

Prolonged, irregular or heavy menstrual bleeding, intermenstrual spotting and — most importantly — any bleeding after the menopause are the most common indications. Endometrial polyps, submucosal fibroids, endometrial hyperplasia and, more rarely, endometrial cancer can be distinguished through targeted biopsy.

Endometrial polyps

Endometrial polyps are benign overgrowths of the uterine lining that may cause bleeding and infertility. Hysteroscopic polypectomy is the gold standard for their complete removal and for assessing the risk of malignancy. Blind curettage can miss 30–50% of polyps; direct visualisation eliminates that risk.

Submucosal fibroids

Fibroids projecting into the uterine cavity (FIGO types 0, 1 and selected type 2) can generally be removed hysteroscopically. Hysteroscopic myomectomy is a uterus-sparing option that avoids abdominal incisions and treats heavy bleeding, infertility and recurrent pregnancy loss caused by these fibroids.

Uterine septum and congenital anomalies

A uterine septum is a fibrous-muscular partition that divides the uterine cavity and is one of the correctable causes of recurrent pregnancy loss and preterm birth. Hysteroscopic septum resection (metroplasty) significantly reduces miscarriage rates and improves live-birth outcomes.

Intrauterine adhesions (Asherman syndrome)

Adhesions inside the uterine cavity — usually after curettage, infection or surgery — can cause reduced or absent menstruation, infertility and recurrent miscarriage. Hysteroscopic adhesiolysis is the cornerstone of treatment. Post-procedure oestrogen therapy and, in selected cases, a temporary intrauterine balloon help prevent recurrence.

Infertility assessment

In couples with suspicious findings on HSG or ultrasound, in recurrent IVF failure and in recurrent pregnancy loss, hysteroscopy provides a clear view of the cavity. Silent polyps, fibroids, septa and adhesions can be identified and treated in the same session.

Displaced or embedded intrauterine device (IUD)

An IUD with missing strings or one that has become embedded in the uterine wall can be removed safely and under vision by hysteroscopy, avoiding injury from blind traction attempts.

Preparation

• Timing: In menstruating women the procedure is scheduled in the early follicular phase, just after menstruation ends (usually days 6–12 of the cycle), when the endometrium is thin and visibility is optimal.
• Pregnancy exclusion: Pregnancy is always excluded before the procedure.
• Infection screening: Any active vaginal or pelvic infection is treated beforehand.
• Analgesia: An oral analgesic (naproxen, ibuprofen) may be given before office hysteroscopy.
• Anaesthesia: Operative hysteroscopy requires 6–8 hours of fasting; anticoagulant medication is reviewed in advance.

How the procedure is performed

1. The patient is placed in the lithotomy position and the vagina is cleansed with antiseptic.
2. In office hysteroscopy the "vaginoscopic" approach is often used: the hysteroscope is introduced through the vagina and cervix without a speculum.
3. Warm saline (isotonic solution) is instilled into the cavity at low pressure to distend it and separate the walls for inspection.
4. The endometrial surface, tubal ostia and cervical canal are examined systematically, and targeted biopsies are taken from suspicious areas.
5. During operative hysteroscopy, polyps, fibroids or septa are removed with a monopolar/bipolar resectoscope, fine scissors or a morcellator. Adhesions are opened with sharp dissection.

Recovery

Mild cramping and light spotting for 1–3 days are common after diagnostic hysteroscopy. After operative hysteroscopy, spotting may last up to a week. The following advice is routinely given:

• Avoid intercourse, tampons and swimming/hot tubs for the first 1–2 weeks.
• Postpone strenuous exercise and heavy lifting for approximately one week.
• Use paracetamol or a physician-recommended NSAID for mild discomfort.
• Seek prompt medical attention for fever, foul-smelling discharge, worsening pain or heavy bleeding that soaks through a pad.

Is hysteroscopy safe? What are the risks?

Hysteroscopy is one of the safest gynaecological procedures, with an overall complication rate below 1%. As with any surgical intervention, however, the following risks should be understood:

• Uterine perforation: Puncture of the uterine wall by the hysteroscope (0.1–1%). Observation is usually sufficient; laparoscopic repair is rarely required.
• Infection: Rare (0.1–0.9%); presents with fever and foul-smelling discharge and is treated with antibiotics.
• Fluid overload: Absorption of the distension medium into the vascular system, mainly during longer operative procedures. Modern monitoring and the use of isotonic saline minimise this risk.
• Bleeding: Usually mild and self-limiting.
• Cervical injury: A small tear of the cervix; rare and usually requires no treatment.

Hysteroscopy versus D&C

Classical dilation and curettage (D&C) is a blind scraping of the uterine cavity; the surgeon cannot see the interior of the uterus, and focal lesions such as polyps or submucosal fibroids can be missed. Hysteroscopy allows the cavity to be seen directly and pathology to be removed under vision, making it both more accurate and less traumatic. In many centres, "see-and-treat" hysteroscopy has replaced diagnostic curettage.

Hysteroscopy and fertility

Numerous studies have shown that hysteroscopic correction of endometrial polyps, submucosal fibroids, a uterine septum and intrauterine adhesions improves pregnancy and live-birth rates. Office hysteroscopy before embryo transfer is used routinely in many centres following recurrent IVF failure. Attempts to conceive can generally resume after 1–2 menstrual cycles; where operative procedures involve deeper myometrial repair (for example, myomectomy), an individualised waiting period is advised.

When to see a specialist

Consultation with a gynaecologist is recommended if any of the following apply — you may benefit from hysteroscopy:

• Prolonged, irregular or heavy menstrual bleeding.
• Any bleeding or spotting after the menopause.
• Failure to conceive after one year of regular intercourse (6 months over age 35).
• Two or more consecutive pregnancy losses.
• Suspicious intrauterine findings on ultrasound or HSG.
• An IUD with missing strings or embedded in the uterine wall.

Hysteroscopy is today one of the most valuable tools in gynaecology: it both accurately diagnoses and — in the same session, without an abdominal incision — treats a wide range of intrauterine conditions, allowing patients a rapid return to daily life. Used with the right indications, it combines high success rates with a very low complication profile.