Hysteroscopic Surgery

Hysteroscopy involves the insertion of a narrow telescope (the hysteroscope) through the neck of the womb and into the womb cavity. No cuts are required. To see the walls of the womb cavity clearly, the cavity is distended, most commonly using a liquid (e.g. saline). A camera attached to the hysteroscope is used to project the image of the womb cavity on to a television monitor thereby providing a very clear picture of the womb lining.

Hysteroscopy is used to investigate:

• Heavy menstrual bleeding: Problems that cause heavy bleeding such as fibroids can been clearly seen on hysteroscopy
• Abnormal menstrual bleeding pattern: Hysteroscopy can identify problems known to cause irregular bleeding such as polyps.
• Bleeding after the menopause: Abnormalities of the womb lining, including cancer, which may cause postmenopausal bleeding can be diagnosed with hysteroscopy.
• Miscarriage and recurrent miscarriage: Fibroids, polyps and uterine septae that may cause miscarriage can be easily seen using hysteroscopy.
• Scant or absent periods: Scarring of the womb lining, for instance following a D&C, can be seen with hysteroscopy.
• Retained pregnancy products (e.g. after miscarriage): Hysteroscopy will give a clear answer regarding whether small remnants of a pregnancy have become stuck within the womb.
• Locate a lost intrauterine contraceptive device: A hysteroscopy will tell whether an intrauterine device is still located within the womb cavity if the threads of the device have become lost.

Hysteroscopy is used to treat:

• Fibroids: The submucous variety of fibroids is easily seen at the time of hysteroscopy and can be shaved away (or resected) using electrical energy. This operation is known as a Trans-Cervical Resection of Fibroid (or TCRF) and can be a very effective way of treating heavy periods. Submucous fibroids should be removed prior to IVF to improve the chances of the embryo implanting.
• Uterine septum: A uterine septum can be cut away (or resected) using hysteroscopy.
• Polyps: As for submucous fibroids, hysteroscopy can be used to shave away polyps. This is an effective treatment for some cases of irregular bleeding and bleeding after the menopause.
• Heavy periods: In women with heavy periods who have completed their family, shaving away the lining of the womb is a very effective way of reducing/stopping bleeding. This operation is called a Trans-Cervical Resection of Endometrium (or TCRE).
• Adhesions: Sometimes, the womb lining becomes scarred after operations like Dilatation & Curettage (or D&C), especially if performed to remove retained pregnancy products. Hysteroscopy can be used to break down these adhesions and improve the chance of embryo implantation and hence pregnancy.
• Lost IUDs: If the threads of an intrauterine contraceptive device (IUD) gets pulled up into the womb cavity, hysteroscopy can locate it in the womb and enable it to be removed.
• Retained pregnancy products: Sometimes pregnancy products and placental pieces remain in the womb after a miscarriage or a full-term delivery and may become very stuck to the womb lining. Hysteroscopy will allow these remnants to be separated from the lining and removed.

Because no cuts on the tummy are required during hysteroscopy, recovery is very fast. Indeed, most hysteroscopic procedures can be performed as a day-case with the patient going home on the same day as the surgery. Complete recovery takes only a couple of days.

Hysteroscopy is a very safe procedure and complications are rare. The main risks are infection and making a hole in the womb (known as a perforation). Perforations are riskiest when they occur whilst cutting energy is being used in the womb as it could then cause injury to bowel or bladder. Some hysteroscopic procedures such as fibroid resections can be associated with heavy bleeding. With prolonged hysteroscopic procedures, for instance for resecting large fibroids, large volumes of the distension fluid used during the operation may enter the blood circulation; this is called fluid overload.

Hysteroscopy for diagnosing abnormalities in the womb is a very common procedure. Hysteroscopic surgery on the other hand, for treating conditions like fibroids, is less commonly performed. Hysteroscopic operations for removing fibroids or a uterine septum require considerable training and expertise. Prof Homer trained and worked for several years in one of the UK’s leading units for hysteroscopic surgery, University College London Hospitals. He is fully accredited (CREI) in using hysteroscopy to operate on rare conditions such as the uterine septum. Prof Homer wrote one of the world’s leading papers on how to treat the uterine septum as well as a very recent comprehensive review on treating fibroids, polyps and uterine septae to reduce miscarriage risk.