Hysteroscopy allows the examination, by means of an optical instrument called Hysteroscope, of the Cervical Canal and the Uterine Cavity (inside of the uterus), wherein menstrual bleeding regenerates and fetus implantation takes place.
The Hysteroscope includes optical fibers 2-4 mm in diameter for Diagnostic Hysteroscopy, and 8-10 mm for Operative Hysteroscopy.
Insertion of the Diagnostic Hysteroscope into the uterine cavity does not require the dilation of the Cervical Canal, with the exception of post menopause women. The uterine cavity is naturally expanded at 4 mm in women at their fertility stage in life.
Insertion of an Operative Hysteroscope requires dilation of the uterine walls utilizing dilators of increasing diameter, up to 10 mm. The dilation process will cause pain and therefore requires anesthesia. There are medications that aid in the dilation process and are administered before the surgery.
The uterine walls (front and back) are collapsed onto one another and must be dilated, in order to enable a clear view, by means of a physiological serum or CO2 gas when performing Diagnostic Hysteroscopies.
This examination allows the possibility to discover sources of Metrorrhagia (unexpected bleeding) or sources of Menorrhagia (strong or long menstrual bleeding); enables viewing the uterine cavity when attempting to resolve issues of infertility, repeated abortions or abnormalities in the uterine structure as observed by means of an ultrasound examination or a uterine x-ray.
This procedure is performed in the clinic, by natural means, without anesthesia and in rare cases with local anesthesia.
The procedure is optimally performed after menstruation, to enable unobstructed view (due to the absence of menstrual bleeding), and prior to ovulation when the uterine walls are naturally dilated and the endometrium is clear and transparent, allowing for an easier insertion of the hysteroscope and a perfect visualization.
We will refrain from performing this examination soon after ovulation so as not to abort the possible beginning of a young pregnancy.
Women in menopause or under oestro-progestative treatment need not adhere to these instructions.
Hysteroscopy – The Procedure:
- After some questions relevant to the procedure, the doctor will examine the woman in order to confirm the positioning of the uterus (anterior or posterior), and will set the Speculum in place.
- The Hysteroscope is introduced through the natural opening of the cervix, very gently up into the uterus. Sometimes this is accompanied by discomfort or contractions as during menstruation, which may continue for some hours after the procedure.
- The observation and interpretation of findings is immediate and will be given to the woman in detailed report after the procedure is completed.
- Sometimes it is necessary to take a sample of the endometrium or of the abnormal finding by means of special instruments for this purpose. Though this may be uncomfortable, it is painless. This procedure will cause bleeding for 3-4 days and sometimes longer. According to the Halacha, the bleeding comes from the uterus. Yet, some adjudicators will consider it "bleeding from an injury" and will not necessarily disqualify it.
Medically speaking, as long as there is bleeding, intercourse is forbidden, as it may increase the risk of infection.
- When CO2 (gas) is used to enlarge the cavity, the woman may feel discomfort around the shoulders after the procedure. The gynecologist may look for the "shoulder discomfort sign" as proof passage through the fallopian tube is or has been opened.
Diagnostic Hysteroscopy Reveals:
- Polyps, protuberance of the endometrium or of the cervical canal.
- Sub-endometrium myomas in the uterus or in the cervical canal.
- Abnormal thicknesses, local or of the entire endometrium (hypoplasia, pre- carcinogenic or carcinogenic findings of the endometrium).
- Thinness of the endometrium (Hypertrophy or Atrophy).
- Intra-uterine adherences.
- Defects of the cavity (partition, bifurcate uterus, etc…).
- The exact positioning of an Intra-Uterine Device (IUD) within the uterine cavity, thus aiding in its extraction (in case the strings have gone up).
Innovative use for Diagnostic Hysteroscopy:
Sterilization by obstruction of the Fallopian Tubes: A new technique by which miniature coils are introduced through the opening of the tubes, under Hysteroscopy. The wall of the Fallopian Tube reacts by permanently sealing the tube after 3 months of contact with the coil. For this reason, contraceptives must be used for 3 months after the coils have been placed.
A surgical intervention performed through the natural openings of the woman, which allows treatment of abnormalities within the uterine cavity. After the Speculum is set in place, the Hysteroscope is inserted with the surgical instruments necessary to treat the pathology.
When performing Operative Hysteroscopy it is necessary to:
- Use general or epidural anesthesia.
- Dilate the cervix by means of special instruments. Use of medication (prostaglandins) before the procedure may help in inducing dilation.
- Use physiological serum by intra-uterine splashing to enable a proper view of the cavity during the procedure.
- Continuously check the pressure within the cavity by means of special instruments, in order to perform the procedure under the best view conditions and prevent drainage of the fluid.
Operative Hysteroscopy, reasons for its use:
- Polypectomy (Polyp excision from the endometrium or canal).
- Extraction of placenta residues or pregnancy residues after a miscarriage.
- Myomectomy (excision of sub-endometrium myomas – beneath the endometrium).
- Release of uterine partition in a deformed uterus.
- Release of adhesions.
- Endometrial Ablation (removal of the entire endometrium – lining of the uterus). In case of continuous bleeding, which does not respond to progestative-hormonal treatment and which is derived from hormonal complications and/or from benign pathologies of the endometrium.
In order to perform these procedures, the Gynecologist makes use of several different techniques. Among these:
- Cutting by means of conventional surgical instruments (Hysteroscopic scissors and holders).
- Cutting by means of electrical instruments (Resector).
Recommendations and Precautions before the Intervention:
The Operative Hysteroscopy is a usually short procedure, 15-30 minutes, which is preformed under daily hospitalization.
The woman is summoned half an hour prior to the operation and is usually discharged 2 hours after the operation.
The woman should fast for 6 hours prior to the operation.
It is recommended to bring the reports of the diagnostic hysteroscopy, the US or the uterus X-Ray in her possession.
If the woman is over 40 years of age, the anesthesiologist requires and EKG.
Recommendations and Precautions after the Intervention:
Even when the woman usually feels well after the procedure, we will not allow her to drive and an escort is required.
Rest is recommended for the day following the intervention, even if the woman feels she may return to her regular activities.
Until bleeding stops, abstinence is recommended. We also recommend refraining from using tampons.
A doctor or Gynecologist should be consulted immediately if any of the following conditions should occur:
- Bleeding stronger than a heavy menstrual period.
- Rectal temperature above 38°C.
- Low stomach ache.
- Lower limb or breast pain, or unusual breathing difficulties.
Diagnostic Hysteroscopy as well as Operative Hysteroscopy have enabled more accurate diagnoses, as well as minimal and easy treatments for pathologies, which not long ago required extensive and sometimes damaging surgery.
Thanks to these procedures, Diagnostic Curettages are no longer performed and the number of Hysterectomies has diminished.
The Hysteroscopy procedure has caused a quiet revolution in the Gynecologists daily patterns of work and continues to improve the quality of life of many women.
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