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Hysteroscopy overview
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Benha University Hospital, EGYPT
Aboubakr ElnasharAboubakr Elnashar
Hysteroscopy
overview
Aboubakr ElnasharAboubakr Elnashar
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.
Aboubakr ElnasharAboubakr Elnashar
Hysteroscopy as described by S.Duplay and S.Clado, 1898
Aboubakr ElnasharAboubakr Elnashar
Aboubakr ElnasharAboubakr Elnashar
The hysteroscope is a telescope
(eyepiece, barrel, and objective lens) attached to a light source.
Optical systems:
Optical systems are either rigid or flexible.
Aboubakr ElnasharAboubakr Elnashar
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.
Aboubakr ElnasharAboubakr Elnashar
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
Aboubakr ElnasharAboubakr Elnashar
Aboubakr ElnasharAboubakr Elnashar
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
Aboubakr ElnasharAboubakr Elnashar
Objective lens
Aboubakr ElnasharAboubakr Elnashar
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.
Aboubakr ElnasharAboubakr Elnashar
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)
Aboubakr ElnasharAboubakr Elnashar
Aboubakr ElnasharAboubakr Elnashar
Aboubakr ElnasharAboubakr Elnashar
Aboubakr ElnasharAboubakr Elnashar
Aboubakr ElnasharAboubakr Elnashar
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
Aboubakr ElnasharAboubakr Elnashar
Aboubakr ElnasharAboubakr Elnashar
Aboubakr ElnasharAboubakr Elnashar
Aboubakr ElnasharAboubakr Elnashar
15
36
38
Aboubakr ElnasharAboubakr Elnashar
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)
Aboubakr ElnasharAboubakr Elnashar
*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)
Aboubakr ElnasharAboubakr Elnashar
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.
Aboubakr ElnasharAboubakr Elnashar
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).
Aboubakr ElnasharAboubakr Elnashar
Cervical Polyp
Aboubakr ElnasharAboubakr Elnashar
)
Aboubakr ElnasharAboubakr Elnashar
Aboubakr ElnasharAboubakr Elnashar
II. Recurrent pregnancy loss.
Anatomic:(10%)
1. Congenital uterine malformation.
2. Submucous fibroid
3. Cervical incompetence
4. Severe IU synechiae
Aboubakr ElnasharAboubakr Elnashar
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
. .
Aboubakr ElnasharAboubakr Elnashar
63
Severe Moderate
Aboubakr ElnasharAboubakr Elnashar
Aboubakr ElnasharAboubakr Elnashar
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.
Aboubakr ElnasharAboubakr Elnashar
Septate
uterus
.
Aboubakr ElnasharAboubakr Elnashar
Bicornuate
uterus
Aboubakr ElnasharAboubakr Elnashar
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.
Aboubakr ElnasharAboubakr Elnashar
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.
Aboubakr ElnasharAboubakr Elnashar
55 52 Cornual polyp
Aboubakr ElnasharAboubakr Elnashar
Aboubakr ElnasharAboubakr Elnashar
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.
Aboubakr ElnasharAboubakr Elnashar
V. Abnormal HSG
Aboubakr ElnasharAboubakr Elnashar
Aboubakr ElnasharAboubakr Elnashar
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)
Aboubakr ElnasharAboubakr Elnashar
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)
Aboubakr ElnasharAboubakr Elnashar
VII. Postoperative evaluation= 2nd look
hysteroscopy
•Hysteroscopic myomectomy
•Abdominal myomectomy
•Cesarean section
•Septum resection
•Asherman TT
•Endometrial ablation or resction
•Tubal reimplantation
Aboubakr ElnasharAboubakr Elnashar
Findings
•De novo or recurrent IU adhesions
•Incomplete myoma resection
Aboubakr ElnasharAboubakr Elnashar
VII. Pregnancy Rarely indicated
•IUD in pregnancy
•Embryoscopy
•Evaluate the disturbed pregnancy
Aboubakr ElnasharAboubakr Elnashar
Aboubakr ElnasharAboubakr Elnashar
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
Aboubakr ElnasharAboubakr Elnashar
Thank You Thank You
Aboubakr Elnashar
Aboubakr ElnasharAboubakr Elnashar