Premise
The execution of a hysteroscopy is always preceded by a very precise preparation, to which each patient must strictly adhere, for the success of the entire procedure.
This article is dedicated to the aforementioned topics (execution of hysteroscopy and preparation for the latter), with the addition of information regarding the instrumentation used, the possible side effects of the procedure in question and the post-procedural phase.
Obviously, there is also a brief review of what hysteroscopy is.
What is hysteroscopy?
Hysteroscopy is the procedure by which a doctor - generally a gynecologist - observes and analyzes from inside the cavity of the uterus (or uterine cavity ), the cervical canal and the endometrium (mucous membrane of the uterus).
Returning to the list of gynecological exams, hysteroscopy can have diagnostic ( diagnostic hysteroscopy ) or therapeutic ( hysteroscopic or operative ) purposes.
Diagnostic hysteroscopy is used in the search for pathologies of the uterus (eg uterine fibroids, uterine polyps, intrauterine adhesions, etc.), in the collection of an endometrial sample to be biopsied and to identify the causes of certain abnormalities and symptoms (eg: presence of menstrual irregularities, unusual loss of blood from the vagina, chronic pelvic pain, presence of menstruation after menopause, infertility, etc.).
Operative hysteroscopy, on the other hand, is a useful resource, mainly for: the treatment of the aforementioned polyps and uterine fibroids, the correction of the aforementioned intrauterine adhesions, the removal of post-abortive or postpartum placental residues, and the realization of so-called tubal sterilization or tubal closure (a form of permanent contraception).
Whether diagnostic or operational, hysteroscopy is a procedure generally performed in an outpatient or day surgery setting ; therefore, except in special cases, the patient is never admitted to hospital.
Hysteroscope: the instrument for hysteroscopy
The indispensable tool for performing hysteroscopy is the so-called hysteroscope .
During hysteroscopy practices, the gynecologist uses the hysteroscope as an exploratory probe of the uterus, after having introduced it inside the uterine cavity, through the vaginal opening and the passage along the vagina and cervix.
It should be pointed out, however, that the hysteroscope is also useful in exploring the components of the female reproductive system that crosses before reaching the uterus, ie the aforementioned vagina and cervix .
There are two types of hysteroscopes: a hysteroscope with a diameter of 4-5 millimeters, specifically indicated for diagnostic hysteroscopy procedures, and a hysteroscope with a diameter of 7-8 millimeters, whose use is reserved exclusively for operative hysteroscopy procedures.
Preparation
A few weeks before any hysteroscopy procedure (regardless of its diagnostic or therapeutic value), the prospective patient must undergo:
- A careful gynecological examination, with the trusted specialist;
- An accurate medical history ;
- A cervico-vaginal swab ;
- A transvaginal ultrasound .
Sometimes, these diagnostic tests may also need to add blood tests, in order to verify the presence or absence of any coagulation disorders, and a pregnancy test, to have a proof of not being pregnant (NB: pregnancy is a contraindication to hysteroscopy).
Readers are reminded that, in addition to pregnancy, they represent a contraindication to hysteroscopy: cervical cancer, endometrial carcinoma, endometritis, pelvic peritonitis, acute vaginitis, acute cervicitis and metritis.
On the day of the procedure
On the day of the procedure, it is advisable for the patient to wear comfortable and practical clothes, because then she will have to take them off in favor of a hospital gown specially prepared for her by the medical staff.
Then, after changing clothes and just before hysteroscopy begins, an assistant of the doctor who will carry out the procedure or this same doctor will present the patient with a short questionnaire, which contains questions related to any allergies present (for example, nickel allergy, latex allergy, allergy to anesthetic drugs, etc.), any past surgical procedures, any ongoing chronic conditions and, finally, any particular drugs taken at that time.
For the success of hysteroscopy and to avoid complications, it is very important that the patient accurately answers the aforementioned questionnaire.
If anesthesia is provided, how does the preparation vary?
Hysteroscopy may require anesthesia .
When this happens, anesthesia is local, for procedures with diagnostic purposes, while it is general, for procedures with therapeutic purposes.
Local anesthesia does not require special preparations.
The general anesthesia, instead, requires the observance of a complete fast for at least 8 hours (therefore, if for example the procedure is fixed for the morning, the last meal must be the dinner of the evening before the hysteroscopy). Failure to comply with the full fast involves the cancellation of the entire gynecological examination, even if all other circumstances exist to execute it.
If general anesthesia is provided, it is advisable for the patient to ask a relative or trusted friend to take her home at the end of the procedure, and to take care of her in the first hours after her return.
All this is necessary because the general anesthesia momentarily slows down the reflexes, induces a temporary confusional state, prevents for a few hours the right concentration when driving a vehicle, etc.
For menstruating women, what is the best time to perform hysteroscopy?
For menstruating women, the best time to perform a hysteroscopy is in the first seven days following menstruation . In fact, the execution of the procedure in this period of the menstrual cycle allows gynecologists a better and more detailed view of the uterus and its internal cavities.
Instrumentation preparation
While waiting for the patient to be ready for hysteroscopy and to respond to the planned questionnaire, the medical staff prepares all the instruments necessary for the procedure.
This equipment includes: speculum (vaginal valve), pliers, dilators, cannulas, insufflator, video camera system, sterile gauze, fiber optic cable, CO2 conductor cable, hysteroscope etc.
execution
Once the patient has worn the hospital gown, a nurse of the medical staff invites her to sit on a special bed, equipped with leg supports, and makes her assume the so-called gynecological position, with a favorable inclination to the introduction of various tools necessary for the procedure.
As soon as the patient is in position and feels at ease, the gynecologist intervenes, who, thanks to the speculum, opens the vagina and gently introduces the hysteroscope, in order to lead him into the uterine cavity.
To easily conduct the hysteroscope inside the uterus, it is essential to stretch the walls of the uterine cervix, cervical canal and uterine cavity; the distension of these sections of the female reproductive system can take place in two ways: through the insufflation of air rich in carbon dioxide (a more common practice during diagnostic hysteroscopy) or by injecting a liquid substance, called " distension liquid " "(Most frequent mode during operative hysteroscopy).
The gynecologist uses the hysteroscope both to achieve the insufflation of air and to perform the injection of the distension liquid; the latter, in fact, is hollow internally precisely to allow the passage of gases, liquids or thin surgical instruments, which could be used during the hysteroscopy procedure.
The distension (or dilation) of the uterus is important not only to allow the conduction of the hysteroscope, but also to allow a better analysis of its internal anatomy.
In this phase of the procedure, careful monitoring by the entire medical staff of intrauterine pressure is important, which must remain at a value between 60 and 70 mmHg. The maintenance of these pressure values, in fact, avoids the over-distension of the walls constituting the uterine cavity and prevents the diffusion fluid from spreading through the abdomen through the fallopian tubes.
When the hysteroscope is finally in the uterus and the latter has expanded sufficiently, visual exploration of the uterine cavity, endometrium and cervical canal begins. Remember that what resumes the hysteroscope, through its camera and with the help of the light source, can be seen by the gynecologist on the appropriate external monitor.
If the hysteroscopy has operational purposes or is used for a subsequent biopsy, it is at this time of the procedure that the treatments against the pathology encountered (first case) or the endometrium sample collection operations (second case) take place.
Once the gynecologist has finished the exploration and any therapeutic interventions, he gently extracts the hysteroscope; the extraction operation of the hysteroscope is important and is also part of hysteroscopy: in fact, it serves to evaluate the integrity of the uterine isthmus, ie the point of passage between the internal cavity of the uterus and the cervical canal.
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Where is anesthesia placed, when scheduled?
In the aforementioned description of the various procedural steps that characterize hysteroscopy, any local or general anesthesia is placed after the patient is settled, but before the speculum and hysteroscope are inserted.
Once administered, the anesthetics go into action within minutes.
It should be remembered that, unlike with the practice of local anesthesia, the use of general anesthesia involves the patient falling asleep, sleep that lasts until the end of the procedure (when the administration of anesthetics ends).
When anesthesia is provided, another professional figure is added to the medical staff composed by the gynecologist and his nurses: the anesthesiologist . The anesthesiologist is a doctor who specializes in anesthesia and resuscitation practices.
What feelings does the patient feel during the procedure?
Without the practice of anesthesia, the patient may experience slight discomfort / pain during the introduction of the hysteroscope into the vagina and cervical canal.
However, this sensation lasts very little, as, shortly after the hysteroscope is inserted, the gynecologist dilates the cervix and uterus (NB: the dilation serves to widen the passage space for the hysteroscope).
Duration of hysteroscopy
In general, diagnostic hysteroscopy lasts 10-15 minutes ; operating hysteroscopy, on the other hand, takes longer, around 30-60 minutes .
The purpose of the procedure affects the duration of operative hysteroscopy: for simpler treatments, the intervention times are clearly shorter than for more complex treatments.
When is the return home expected?
After a diagnostic hysteroscopy, the patient can return home immediately, even if she has received local anesthesia.
On the contrary, after an operative hysteroscopy, the patient can return home only at the end of a series of medical tests, which evaluate the success of the procedure and its response to general anesthesia (eg: monitoring of vital functions is provided etc.). In general, this series of medical tests requires from 2 to 4 hours, a period in which the woman who has supported the procedure can count on all the comforts of the case.
Risks and Complications
Hysteroscopy is a safe procedure for most women. In fact, it is very rare that it can lead to adverse effects or, worse still, to complications.
Adverse effects
Due to adverse effects of a diagnostic-operative procedure, the doctors intend to deal with minor and temporary problems.
The possible adverse effects of hysteroscopy include:
- Mild vaginal bleeding . Result of injuries caused by the passage of the hysteroscope, along the cervix and cervical canal, this adverse effect can last from a few days to even a little over a week;
- Abdominal pain and cramps . Often, the painful sensation is controllable with an analgesic, such as paracetamol or ibuprofen (an NSAID);
- Feeling tired and / or unwell ;
- Pain reflected in the shoulder, resulting from the use of gas rich in carbon dioxide.
Complications
For complications of a diagnostic-operative procedure, the doctors mean problems of a certain clinical relevance, which can take place during or after the aforementioned procedure.
On the occasion of a hysteroscopy, the risk of complications is less than 1%, therefore a real rarity; however, it should be pointed out that this risk varies according to the type of hysteroscopy: diagnostic hysteroscopy, in fact, is less risky than operative hysteroscopy, which is actually a surgical intervention.
The potential complications of diagnostic hysteroscopy procedures include:
- Uterine perforation ;
- Bladder perforation ;
- The development of an infection at the pelvic level (metritis).
As regards the possible complications of operative hysteroscopy, these consist of:
- The aforementioned uterine perforation, bladder perforation and metritis;
- Vast vaginal bleeding, resulting from a severe laceration of the uterine blood vessels;
- Endometritis, or inflammation of the endometrium;
- Peritonitis, ie inflammation of the peritoneum;
- Severe allergic reaction (anaphylactic shock) to anesthetics;
- Edema in the uterine area;
- Embolism gas (is connected to the practice of general anesthesia);
- Trauma to the cervix caused by the hysteroscope.
Curiosity: how common are the complications of diagnostic hysteroscopy?
According to a study by the Royal College of Obstetrics and Gynecology, only 8 patients undergoing diagnostic hysteroscopy per 1, 000 would be subject to uterine perforation and only 3 patients per 10, 000 would experience utero-bladder perforation and a pelvic infection.
How to recognize any complications?
The symptoms that characterize the complications of hysteroscopy include:
- Intense and protracted abdominal pain, which is not attenuated with the most common analgesics;
- Fever above 38 ° C;
- Large and recurrent vaginal bleeding;
- Loss of dark and smelly liquid from the vagina.
Recovery
Recovery from diagnostic hysteroscopy is quite rapid, so that the patient can return to her working activities (if they are not heavy) already the day after the procedure.
Recovery from an operative hysteroscopy, on the other hand, is slightly more complex than in the previous case, and could take a few days to rest, before returning to normal daily activities.
What can a woman do after a hysteroscopy?
After a hysteroscopy, the patient can safely eat and drink as usual, and take a shower.
If you have been subjected to general anesthesia and feel a slight confusion, your doctor may tell you to eat small and light meals for at least 24 hours.
What can't a woman do after a hysteroscopy?
For women who have sustained a hysteroscopy, gynecologists recommend abstention from sexual activity for about 7 days or, in the presence of vaginal bleeding, until the end of the latter. This is a precautionary measure to prevent infections.
Results
- Diagnostic hysteroscopy. If the procedure shows a serious condition, the gynecologist immediately informs the patient of the above and explains the possible treatments.
If nothing significant emerges from the procedure, the results are available after a few days.
In the event that diagnostic hysteroscopy serves to collect a sample of endometrium to be biopsied, the results of the latter will be ready within 10-14 days.
- Operative hysteroscopy. It is a procedure that, without being particularly invasive, allows different pathologies to be treated satisfactorily.
Thanks to this and the fact that it does not require hospitalization, operative hysteroscopy is an increasingly popular therapeutic solution.
