Hysteroscopy

Hysteroscopy in plain language

A hysteroscope is a slim telescope, a few millimetres wide, that is passed through the vagina and the cervix into the cavity of the womb. Fluid gently opens the cavity, and the camera shows the lining clearly on a screen. Fine instruments can be passed through the hysteroscope to treat what is found, so the problem can often be diagnosed and treated in a single procedure. Because the hysteroscope enters through the cervix, no incisions are made on the abdomen.

I have carried out hysteroscopic surgery for around 20 years, and I now do more than 150 hysteroscopic procedures a year on average (about these figures).

Who it may help

I may recommend a hysteroscopy if you have:

• heavy or irregular periods, bleeding between periods, or bleeding after the menopause
• a scan showing a polyp, a fibroid bulging into the cavity, or a thickened lining
• light or absent periods after surgery inside the womb, which may mean Asherman’s syndrome
• spotting after periods since a caesarean, which may be due to a caesarean scar niche
• recurrent miscarriage or failed embryo transfers where a problem inside the womb is suspected
• a lost or displaced coil

What I can treat by hysteroscopy

• Polyps: soft overgrowths of the lining, which can cause irregular bleeding and may affect fertility. In one trial, women with a polyp who were chosen at random to have it removed before insemination treatment (IUI, in which prepared sperm is placed in the womb) were about twice as likely to become pregnant as those who had only a look inside ^[2].
• Fibroids that bulge into the cavity (submucosal fibroids), which can cause heavy bleeding and affect fertility.
• A uterine septum: a wall of tissue present from birth that divides the cavity.
• Adhesions (scar tissue), as in Asherman’s syndrome, divided with ultrasound guidance when they are dense.
• A caesarean scar niche, where the lower edge of the pouch is trimmed (resection) so that it drains better, which reduces spotting.
• Retained pregnancy tissue, removed selectively under direct vision.

Outpatient or day case

Many hysteroscopies can be carried out as an outpatient procedure, in a clinic room, with you awake. Short procedures, such as removing a small polyp, can often be done at the same time. More extensive procedures, such as removing a fibroid, dividing dense adhesions or removing a septum, are usually carried out as a day case in an operating theatre, and you go home the same day.

If a polyp is found on a scan, even by chance, I usually advise removing it, and a small polyp can often be removed during an outpatient hysteroscopy. We go through the options together before deciding. The Royal College of Obstetricians and Gynaecologists advises that women are told about the other settings and kinds of anaesthetic, and given written information beforehand that includes advice on pain relief, and that is how I practise ^[1].

Your choice of pain relief

Many women feel only period-like cramps, but some find it painful, occasionally severely, so you should feel in control of your pain relief. Depending on where you are seen, I offer:

• Inhaled pain relief at the CRP Clinic. You breathe it through a small hand-held inhaler and control it yourself. It starts to work within a few breaths and wears off quickly once you stop, so most women feel back to normal soon after the procedure. I introduced inhaled pain relief for outpatient gynaecology at Epsom Hospital, in my NHS practice, and I have used it since.
• Sedation at the hospitals where I operate (where I see patients), given through a small needle in the back of the hand. It leaves you relaxed and drowsy, but you are not fully asleep, and you may remember parts of the procedure.
• General anaesthetic at the hospitals, so that you are asleep throughout. This is usually recommended for longer or more complex procedures.

A local anaesthetic into or around the cervix can be added to any of these, and a nurse is present throughout; a companion is usually welcome. We agree the right choice for you beforehand, and during an outpatient procedure you can ask to stop at any time. After sedation or a general anaesthetic, a responsible adult needs to take you home and stay with you overnight.

What the day is like

You will receive written information about your procedure and how to prepare well beforehand. If you are having sedation or a general anaesthetic, you will be asked not to eat for several hours before.

On arrival, a nurse will check your details and I will see you to go through the procedure again and answer any questions before you sign the consent form. The procedure itself usually takes between five minutes and an hour, depending on what is needed. Afterwards you will rest until you feel ready, and I will explain what I found before you go home. If samples are sent to the laboratory, I will let you know the results and what they mean.

Risks

Hysteroscopy is commonly performed, and serious complications are uncommon.

The main risks are pain during the procedure, infection, bleeding and, uncommonly, a small hole in the wall of the womb (perforation), which usually heals on its own but occasionally needs a laparoscopy (keyhole surgery through small cuts in the abdomen) to check for injury to nearby organs. Occasionally a procedure cannot be completed and needs to be repeated. My written information includes advice on washing before the procedure, to help prevent infection.

Recovery

Period-like cramps and light bleeding or a watery discharge for a few days are normal. Simple painkillers usually help. Most women return to work the next day after a short procedure, or within two or three days after a longer one. Until the bleeding has settled, use sanitary towels rather than tampons and avoid sex and swimming, to reduce the risk of infection.

If you have heavy bleeding, a smelly discharge, a fever or pain that is getting worse rather than better, contact the hospital or clinic where you had the procedure, using the number in your discharge information, or NHS 111. In an emergency, call 999. My practice manager, Helen, can help with non-urgent questions. You will receive written instructions about what to look out for before you leave, and my letter with the findings follows.