Hysteroscopy

What Is Hysteroscopy? How Does It Work and How Is It Performed?

Literally, hysteroscopy means “looking into the uterus.” During the procedure, a thin hysteroscope — typically ranging from 3 to 10 mm in diameter (varying depending on its intended use) — is gently passed through the vagina and cervix and placed into the uterine cavity. Thanks to the camera and light source at the tip of the hysteroscope, images of the interior of the uterus are transmitted to a video monitor.

Since the uterus is normally an organ whose walls touch one another, the uterine cavity is expanded (distension) during the procedure with a special sterile fluid (usually saline) or, rarely, carbon dioxide gas, in order to obtain a clear view of its interior. This allows detailed examination of the uterine walls, the lining of the uterus (endometrium), and the points where the fallopian tubes open into the uterus (tubal ostia).

Hysteroscopes may be purely diagnostic types that provide only visualization, or they may be operative (therapeutic) types equipped with channels that allow thin surgical instruments — such as scissors, graspers, biopsy forceps, or a resectoscope capable of cutting/coagulating with electrical energy — to be passed through.

Why and in Which Situations Is Hysteroscopy Performed? (Indications for Use)

Hysteroscopy is used in both the diagnosis and treatment of a wide variety of gynecological conditions:

Indications for Diagnostic Hysteroscopy:

• Determining the Cause of Abnormal Uterine Bleeding: To investigate the underlying cause (polyp, myoma/fibroid, endometrial hyperplasia, suspected cancer, etc.) of heavy, irregular, prolonged, or intermenstrual bleeding, particularly around the perimenopausal or postmenopausal period.
• Investigating the Cause of Recurrent Pregnancy Loss (Miscarriage): To detect structural problems in the uterus (uterine septum, intrauterine adhesions/synechiae, submucosal myoma, polyp) that may prevent implantation or development of the pregnancy.
• Infertility Work-up: To evaluate intrauterine factors that may prevent the embryo from implanting. It may particularly be performed before IVF treatment to confirm that the uterine cavity is normal.
• Confirming Suspicious Findings from Other Imaging Methods (Ultrasound, HSG): To establish a definitive diagnosis for suspicious findings — such as a polyp, myoma, or septum — seen on ultrasound or hysterosalpingography.
• Locating and Removing an Intrauterine Device (IUD) That Has Migrated into the Uterus or Whose Strings Are Not Visible:
• Evaluating Congenital Uterine Anomalies (Structural Malformations):

Indications for Operative Hysteroscopy (Therapeutic Use): Many problems detected during diagnostic hysteroscopy can be treated with operative hysteroscopy in the same session or in a planned second session:

• Removal of Intrauterine Polyps (Polypectomy): Excision of polyps that may cause abnormal bleeding or infertility.
• Removal of Submucosal Myomas (Myomectomy): Resection of myomas growing into the uterine cavity that cause bleeding or infertility, using a resectoscope.
• Lysis of Intrauterine Adhesions (Adhesiolysis): Cutting and releasing adhesions — usually resulting from previous curettages or infections — that can cause absence of menstruation (amenorrhea) or infertility (treatment of Asherman’s Syndrome).
• Incision of the Uterine Septum (Septum Resection): Normalizing the uterine cavity by incising a congenital uterine septum that may cause recurrent miscarriage or infertility.
• Endometrial Ablation or Resection: Destruction or removal of the uterine lining (endometrium) using electrical energy, laser, or heat, as an alternative to hysterectomy (removal of the uterus) in women who do not wish to have children and who have severe menstrual bleeding unresponsive to medical treatment.
• Removal of an IUD That Has Migrated into the Uterus or Other Foreign Bodies.
• Targeted Endometrial Biopsy: Taking a biopsy directly under vision from areas that appear suspicious.

How Is Hysteroscopy Performed? Step-by-Step Process

The hysteroscopy procedure generally includes the following steps:

1. Timing and Preparation: The procedure is generally scheduled within the first week after menstrual bleeding ends (the proliferative phase), because the uterine lining is thin during this period and the uterine cavity is more clearly visible. If operative hysteroscopy or general anesthesia is planned, you may be asked to fast (no food or drink) for a certain period beforehand (usually 6-8 hours). If deemed necessary, your doctor may recommend antibiotics or cervical-softening medication before the procedure.
2. Anesthesia: The anesthesia method is determined based on the type of hysteroscopy to be performed (diagnostic or operative), the expected duration of the procedure, the patient’s pain threshold, and preferences. Diagnostic (office) hysteroscopy generally does not require anesthesia, or local anesthesia is sufficient, whereas operative hysteroscopy is usually performed under light general anesthesia or regional anesthesia (spinal/epidural).
3. Positioning and Preparation: The patient is placed on the table in the gynecological examination position (lithotomy). The vagina and cervix are cleansed with antiseptic solutions.
4. Insertion of the Hysteroscope: After the speculum is inserted, the hysteroscope is carefully advanced through the vagina and through the cervical canal until it reaches the uterine cavity. Because operative hysteroscopes in particular are thicker, it may sometimes be necessary to gently widen the cervix with special instruments (dilation).
5. Distension of the Uterine Cavity: To obtain a clear view of the uterine interior, a continuous flow of sterile fluid (usually saline) or, rarely, gas (CO2) is delivered into the uterine cavity through the hysteroscope. The volume and pressure of the fluid used are carefully monitored throughout the procedure.
6. Examination and/or Surgery: Watching the images from the hysteroscope’s camera on the screen, the doctor systematically examines the cervical canal, the entire uterine cavity, its walls, and the points where the tubes open into the uterus (ostia). Any polyp, myoma, adhesion, septum, or other abnormal appearance is noted. If an operative procedure is planned, special surgical instruments (scissors, forceps, resectoscope, etc.) advanced through or alongside the hysteroscope are used to cut, remove, or correct the identified pathology. Excised tissue may be sent for pathological examination.
7. Completion of the Procedure: After the examination and/or surgery is completed, the hysteroscope and other instruments are carefully withdrawn. Most of the fluid in the uterus is drained.

Procedure Duration: Diagnostic hysteroscopy is generally completed in a short time, around 5-15 minutes, while operative hysteroscopy can range from 15 minutes to 1 hour or longer, depending on the procedure to be performed.

What Are the Advantages of Hysteroscopy? Why Is It Preferred?

Hysteroscopy offers many important advantages in the diagnosis and treatment of intrauterine problems:

• Direct Visualization: Enables direct, magnified viewing of the uterine interior, helping to establish the most accurate diagnosis.
• Minimally Invasive: Requires no abdominal incision or sutures.
• Diagnosis and Treatment at the Same Time: In many cases, the therapeutic procedure (polyp removal, myoma removal, etc.) can be performed in the same session as the diagnosis is made (a “see and treat” approach).
• Short Procedure Time: The diagnostic procedure, in particular, is very quick.
• Rapid Recovery: Postoperative pain is generally minimal, and patients can return to their normal lives very quickly.
• Short or No Hospital Stay: Most hysteroscopy procedures are performed on an outpatient basis, requiring no hospitalization, or only a few hours of observation.
• Low Complication Rate: The risk of complications is quite low when performed by experienced hands.
• Uterus-Preserving: Allows intrauterine problems to be resolved without removing the uterus, and can preserve or improve fertility.

What Are the Risks and Possible Complications of Hysteroscopy?

Although hysteroscopy is generally considered a very safe procedure, as with any medical intervention, certain risks and complications can rarely occur:

• Uterine Perforation: This occurs when the hysteroscope or instruments used puncture the uterine wall during the procedure (incidence below 1%). It usually heals on its own without causing problems, but it rarely carries a risk of injury to surrounding organs (bowel, bladder) and may require repair by laparoscopy or open surgery.
• Infection: The risk of developing an intrauterine or pelvic infection after the procedure is low (1-2%).
• Bleeding: Mild bleeding during or after the procedure is normal. The risk of serious bleeding is very low.
• Fluid Overload Syndrome: This is a rare but serious complication, particularly during prolonged operative hysteroscopies, resulting from excessive absorption of the fluid used to distend the uterus into the bloodstream (it can cause pulmonary edema, cerebral edema, or electrolyte imbalance). The risk is minimized through careful monitoring of fluid balance during the procedure.
• Cervical Injury or Laceration: This can rarely occur while inserting the hysteroscope, particularly in patients with a narrow cervix or a history of prior cervical surgery.
• Anesthesia-Related Risks: Risks associated with the type of anesthesia used (local, sedation, general, spinal).
• Formation of Intrauterine Adhesions: New adhesions can rarely develop, particularly after extensive operative procedures.

When performed under appropriate conditions by an experienced gynecologist, hysteroscopy is a quite safe procedure.

The Recovery Process After Hysteroscopy and What to Watch For

Recovery after hysteroscopy is generally fast and uneventful:

• Hospital Discharge: Most patients can go home a few hours after the procedure or the same day. An overnight hospital stay may be necessary if general anesthesia was administered or the procedure was lengthy.
• Pain: Mild cramping similar to menstrual pain, or groin pain, may occur after the procedure. This pain is usually easily controlled with simple painkillers (e.g., ibuprofen, paracetamol) and resolves within 1-2 days.
• Bleeding and Discharge: Light vaginal bleeding, spotting, or watery, pinkish discharge lasting from a few days to a week after the procedure is normal. A doctor should be consulted if heavy bleeding or foul-smelling discharge occurs.
• Return to Normal Activities: Patients can generally return to their normal daily activities the following day. It is recommended to avoid strenuous activities, heavy lifting, and intense exercise for a few days after the procedure.
• Sexual Intercourse, Tampon Use, Vaginal Douching: To reduce the risk of infection, unless your doctor advises otherwise, it is generally recommended to avoid sexual intercourse, tampon use, and vaginal douching until your first period or for at least 1-2 weeks.
• Follow-up: Your doctor will schedule a follow-up appointment to review the pathology results (if a tissue sample was taken) and check on your recovery.

Hysteroscopy in Ankara: The Expertise and Experience of Prof. Dr. Nuray Bozkurt

Prof. Dr. Nuray Bozkurt offers hysteroscopy — a procedure with an important role in the diagnosis and treatment of intrauterine problems — to her patients in Ankara in a modern and reliable manner:

• Comprehensive Experience: She has the necessary training and experience in both diagnostic (office or operating-room) and operative hysteroscopy (polypectomy, myomectomy, septum resection, adhesiolysis).
• Accurate Diagnosis: She uses hysteroscopy effectively to accurately diagnose intrauterine pathologies.
• Minimally Invasive Treatment: Whenever possible, she treats intrauterine problems using minimally invasive methods such as hysteroscopy, prioritizing patient comfort and rapid recovery.
• Up-to-Date Technology: She performs the procedure using modern, slim hysteroscopy equipment at the affiliated institutions where she practices in Ankara.
• Safety Focus: She performs the procedure under sterile conditions, keeping patient safety at the highest priority and taking precautions to minimize possible risks. She pays close attention to fluid management.
• Patient-Centered Approach: She informs the patient in detail before the procedure, answers all their questions, and addresses their concerns. She plans the post-procedure follow-up process and supports her patients.
• Easy Communication: She offers easily accessible communication for your questions or concerns about the process (0538 983 18 78)(0312 284 00 12).

If you have complaints such as abnormal uterine bleeding, recurrent miscarriage, or infertility, or if your doctor believes that an evaluation of the uterine cavity is needed, hysteroscopy may be a suitable option for you. To get more information about the hysteroscopy procedure performed by Prof. Dr. Nuray Bozkurt in Ankara, to assess its suitability for you, and to schedule an appointment, please contact our clinic at 0538 983 18 78.