Hysteroscopy overview

Benha University Hospital, EGYPT

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Hysteroscopy

overview

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In 1869: Pantaleoni performed the first hysteroscopy, but it did

not achieve routine gynecologic use due to its poor optic

system.

In 1970s: improvements in optics, distension media, light system

and instruments.

In 1980s and 90s: Office hysteroscopy without anesthesia or cervical

dilatation

Today: Many hysteroscopic procedures have replaced older,

more invasive techniques.

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Hysteroscopy as described by S.Duplay and S.Clado, 1898

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The hysteroscope is a telescope

(eyepiece, barrel, and objective lens) attached to a light source.

Optical systems:

Optical systems are either rigid or flexible.

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Rigid hysteroscope

The rigid hysteroscope is available in a range of

diameters.

• 3 mm (Office hysteroscopy).

Cervical dilatation: Rarely required (paracervical

block)

• >5 mm

more specific surgical instruments through

separate ports.

• 8-10 mm

continuous flow of media.

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3 mm (Office hysteroscopy)

4.5 mm

Continuous flow

8 mm (Operative hysteroscopy) Aboubakr ElnasharAboubakr Elnashar

Flexible hysteroscope (Office hysteroscope)

•The tip is flexible (120-160 degrees).

The outer diameter: 3-3.7 mm

• Cervical dilatation: rarely required (Paracervical

analgesia)

Appropriate for the irregularly shaped uterus.

Discomfort is less than rigid office hysteroscopy

•The view (ground glass quality) less than the rigid

scopes .

•Biopsy

Tubal catheterization

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The Olympus HYF-XP flexible micro-hysteroscope

Outer diameter of 3.1 mm: No anesthesia required

1.2 mm irrigation channel: Minor therapeutic procedures (e.g.

biopsies)

Light cable

eyepiece Channel port

Flexible sheath Up/down lever

Bendable tip

Ventilation

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Objective lens

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Light Source:

• Halogen or xenon lamps.

• The power:100- 300 W.

• A fiber optic cable transmits light from the

source to the endoscope.

• A videocamera: allow colleagues and the

patient to participate and to make video

recordings and training.

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Distension media:

It is necessary to distend the uterine cavity to

obtain a panoramic view.

• Carbon dioxide.

• Low viscosity fluids: dextrose, saline, lactated

Ringer’s, glycine, sorbitol. Saline offers

advantages (shorter and less discomfort) over

Co2 instillation

• High viscosity fluids: Dextran 70 (Hyskon)

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Diagnostic Abnormal uterine

bleeding

Recurrent pregnancy loss

Unexplained infertility

Amenorrhea

Assisted conception

Abnormal HSG Chronic pelvic pain

Postoperative evaluation

Pregnancy

Operative

• Endometrial biopsy

• Removal of IUCD

• Removal of polyps

• Myomectomy

• Lysis of IU adhesions

• Resection of uterine

septum

• Endometrial ablation

• Tubal cannulation

• Tubal sterilization.

• Removal of retained

products of conception Aboubakr ElnasharAboubakr Elnashar

I.I. Abnormal uterine bleedingAbnormal uterine bleeding

Findings:

1. Endometrial hyperplasia.

2. Submucous/intramural fibroid:

(Wamsteaker et al,1993)

Type 0: pedunculated

Type 1: < 50% intramural

Type 2: > 50% intramural

3. Endometrial polyps.

4. Endometrial cancer.

5. IUCD

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15

36

38

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Hysteroscopy should replace D&C in

investigating postmenopausal bleeding

(International Society for gyn endoscopy, 1989) It is the gold standard for diagnosis

1. Erratic menstrual bleeding

2. Failed medical treatment

3. TVS suggestive of intrauterine pathology e.g.

polyp, fibroid (Grade B)

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*Curettage or biopsy may miss: Small polyp Submucous fibroid Focal hyperplasia Focal endometrial carcinoma *Transvaginal ultrasound

is accurate in excluding endometrial hyperplasia

but is often unable to distinguish submucosal

fibroids and polyps

(New Zealand Guidelines Group : 1998-2002 Level A)

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Advantages of hysteroscopy over D &C

1.The whole uterine cavity & the endocervix can

be directly visualized

2.Very small lesions such as polyps can be

identified & biopsed or removed 3.Bleeding from ruptured venules & echymoses can be

readily identified & treated

4.The sensitivity in detecting intrauterine pathology is

98% (Loffer,1989)

5.Outpatient procedure

6. Treatment modality.

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Disadvantages of hysteroscopy:

1.Cost of the apparatus

2.Lack of availability or experience

3. Hysteroscopy without biopsy is unreliable in

D.D. between pre-malignant & malignant

endometrium

(Karlssson et al, 1994).

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Cervical Polyp

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)

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II. Recurrent pregnancy loss.

Anatomic:(10%)

1. Congenital uterine malformation.

2. Submucous fibroid

3. Cervical incompetence

4. Severe IU synechiae

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HysteroscopicHysteroscopic classifications of classifications of IU adhesionsIU adhesions (March et al,(March et al,19781978))

Severe:Severe: >>33//4 4 of uterine cavity involved; of uterine cavity involved;

agglutination of walls or thick bands; agglutination of walls or thick bands; ostialostial area & area &

upper cavity occluded upper cavity occluded

Moderate:Moderate: ¼ ¼ -- ¾ of uterine cavity involved; no ¾ of uterine cavity involved; no

agglutination of walls, adhesions only; agglutination of walls, adhesions only; ostialostial

areas & upper areas & upper fundusfundus only partially occluded. only partially occluded.

Minimal:Minimal: <<11//4 4 of uterine cavity involved; thin or of uterine cavity involved; thin or

filmy adhesions; filmy adhesions; ostialostial areas & upper areas & upper fundusfundus

minimally involved or clearminimally involved or clear

. .

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63

Severe Moderate

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Classification of Mullerian anomalies (American Fertility

Society, 1988)

Class I: Hypoplastic/agenic

Class II: Unicornuate

Class III: Didelphis

Class VI: bicornuate

Class V: Septate.

Class VI: Arcuate

ClassVII: DES related.

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Septate

uterus

.

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Bicornuate

uterus

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Cervical incompetence:

It is suspected if the resistance of internal os is

< that of the cervical canal

Opening of the int. os without passing through it .

Internal os does not close after removing the

optics (Traver et al., 2000)

Dilators or balloons to determine cervical Dilators or balloons to determine cervical

resistance and/or HSG to measure the width of resistance and/or HSG to measure the width of

the cervical canal between pregnancies are the cervical canal between pregnancies are

neither sensitive nor specific. neither sensitive nor specific.

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III. Unexplained infertility

•Small endometrial polyp

•Small cervical polyp

•Adhesion at cornual cones

•Cornual polyp

•Endometrial dystrophies

(atrophy or hyperplasia) that

may affect receptivity or

implantation especially in ART.

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55 52 Cornual polyp

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IV. Amenorrhea 1. Pregnancy test.

2. TSH &PRL.

3. Progestin challenge test: (MPA 5mgX5d or P in oil 100 mg /3dX 3)

+ve: Anovulation

-ve: E + P :

-ve: outflow or uterine failure HSG, hysteroscopy,

IVP & laparoscopy. +ve: Ovarian failure or pituitary-hypothalamic dysfunction.

3. FSH:

high: Ovarian failure.

If 1ry: Karyotyping.

If 2ndry: premature menopause

Low or Normal: CT of Pituitary-hypothalamic region.

. Abnormal: pituitary disease

. Normal: hypothalamic dysfunction.

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V. Abnormal HSG

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VI. Assisted conception

1. After repeated implantation failure

Abnormalities of the endometrium & organic

IU pathologies are important causes of

failed IVF-ET cycles (Dicker,1992)

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2. Pre IVF evaluation:

Hysteroscopy is an integral part of the

pre IVF evaluation, to avoid

unnecessary & expensive treatment

failures (Shamma et al,1992; Shushan et al, 1999)

Cost-effective analysis indicates that

hysteroscopy, as a universal

screening test even before the first

IVF treatment , is well justified (La Sala et al,

1998)

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VII. Postoperative evaluation= 2nd look

hysteroscopy

•Hysteroscopic myomectomy

•Abdominal myomectomy

•Cesarean section

•Septum resection

•Asherman TT

•Endometrial ablation or resction

•Tubal reimplantation

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Findings

•De novo or recurrent IU adhesions

•Incomplete myoma resection

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VII. Pregnancy Rarely indicated

•IUD in pregnancy

•Embryoscopy

•Evaluate the disturbed pregnancy

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Absolute

. Acute pelvic infection

Relative

. Active uterine bleeding

. Pregnancy

. Recent uterine perforation

. Invasive cervical cancer

. Inability to distend the uterus

. Cervical/vaginal infection

. Medical contraindication or intolerance of

anesthesia

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Thank You Thank You

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