Dealing with problems inside the uterus – Hysteroscopy Case Capsules

There was a time when people would raise their eyebrows and ask” What is hysteroscopy and what good is it ?” Today, we cannot even think of a gyne examination and a satisfactory diagnosis without Hysteroscopy. When you can see inside the uterus directly through a small telescope introduced via the cervix (mouth of the uterus), why would anyone want to do a ‘blind’ Dilatation & Curettage (D&C) today? In fact, D&Cs are outmoded procedures and have absolutely no place in gyne practice. In April 2001, this was the comment in the prestigious journal, Fertility and Sterility : ‘D&C is an inadequate diagnostic and therapeutic tool for all disorders inside the uterus: it misses 62.5% of major intrauterine disorders.’
Endoscopic evaluation of the inside of the uterus by a telescope called Hysteroscope is not just a replacement for D & C; it is much, much more than that. Not only can you diagnose the problem, you can treat it in the same sitting, same anaesthesia, same hospitalization. A few case studies can bring out the situations when Hysteroscopy is needed:

    1. A 52 year old senior gynecologist and nursing home owner of Chandigarh reported with bleeding after menopause. That her mother and sister both had hysterectomy (removal of the uterus) in the past for Uterine Cancer gave her sleepless nights. An ultrasound scan showed ‘thick’ endometrium (lining of the uterus) and she was all set for hysterectomy before she self – referred herself for Hysteroscopy. On hysteroscopic examination, the endometrium was found to be thin and atrophic with evidences of stippling so commonly seen in menopausal women on direct view of the endometrium. The diagnosis was
      Atrophic Endometritis

      – generally seen in 10 to 20% of postmenopausal women with bleeding. She certainly did not need any major surgery to remove her uterus: in fact the cause of her bleeding was not excess estrogen which can cause cancer but a lack of it and giving low dose estrogen cured her of her problem. This case also demonstrates how even ultrasound has its own limited sensitivity and resultant pitfalls. A replay of the recording of the video – hysteroscopy reassured her as nothing else would.

    2. Another postmenopausal woman, 65 years of age, wife of a retired Brigadier, had postmenopausal bleeding, and came for appointment for major surgery. Ultrasound showed, once again, a ‘thick‘ endometrium. Hysteroscopy under local anaesthesia showed a benign looking, noncancerous growth or

      at one cornua. This was snipped it off with microscopic hysteroscopic scissors under direct view and patient went home, all within 2 hours, operating time being 20 minutes. The rest of the endometrium looked thin and atrophic and the histopathology report of the polyp biopsy confirmed it’s benign nature. So a ‘thick’ endometrium on ultrasound can be anything – a foreign body, cancer, hypertrophic endometrium or a polyp. Only the hysteroscopy can tell what it is. Some gynecologists will just not give up their D&Cs even though they may struggle for hours to do this blind procedure in these elderly women who have a tight opening at the cervix. At hysteroscopy this does not cause so much of a problem because you just need to see the tiniest opening that can be entered under vision and lo and behold! You can be inside the uterus easily. The moot point is: hysterectomy is not required in such cases.

    3. This 26 year old infertile patient had a large 5 cm

      (benign tumour) in the uterine cavity preventing a pregnancy. One can, of course, open the abdomen, cut open the uterus, chop off the fibroid, and retrace your steps back, stitching every layer on the way. However it is preferable to enter the uterus from below – no incisions; to coagulate and vaporize the fibroid and come out within an hour. The patient can be sent home the same day.

    4. Same is true of most congenital abnormalities of the uterus. Opening up as above would traditionally, treat a large

      dividing the uterine cavity into two. It is much more satisfying, however, to incise the septum from below and be done with it in no time with better results as far as fertility is concerned.

    5. A 32 years old with no periods at all following a vigorous D&C 7 years ago desired a pregnancy. Investigations revealed that the uterine lining had been replaced by fibrous tissue and the uterine walls were stuck to each other. Under local anaesthesia the diagnosis of
      Asherman’s Syndrome

      was confirmed. Partly with micro scissors and partly with electrocautery knife, the adhesions were painstakingly snipped off, fibre-by-fibre and hormone therapy started. A month later the patient had her first period after several years and she conceived in the same cycle, went on to full term pregnancy with no complications. Cases like this are not rarities but come very frequently and the pattern of success is the same and immensely satisfying. Earlier, such cases always had a Caesarean Section but the placenta is NOT stuck as expected. Therefore these patients can even have a normal delivery: a perfect end to a practically hopeless case.

    6. A 17 year old unmarried girl underwent an abortion procedure under general anaesthesia. Unfortunately the plastic suction cannula broke inside the uterine cavity and couldn’t be retrieved over 2 hours by routine scrapping and attempts to pull it out. With hysteroscopy removal of such
      foreign bodies

      , including bone pieces from a previous abortion is extremely easy and is generally done under local anaesthesia. Fertility after such procedures is really excellent.

Hysteroscopy is not only excellent for postmenopausal bleeding but for all types of abnormal bleeding: for diagnosis, for directed biopsies under vision and for treatment as well. The abnormalities of the endometrium are not uniform but are more often focal and localized. This underlines the importance of visualization of the uterine cavity for all abnormalities of the lining of the uterus as well as for tumours, growths, adhesions and foreign bodies inside the uterus especially in patients who are unable to conceive.

Dr Nirja Chawla