Hysteroscopy

Hysteroscopy is the use of a very small scope by a gynecologist, either in the office or in an outpatient surgery setting to visualize the interior of the uterus. The reasons for doing hysteroscopy usually revolve around some sort of abnormal uterine bleeding. Hysteroscopy will determine if the uterine lining is abnormally thick or thin, or has a structural abnormality such as a polyp or fibroid. Hysteroscopy allows removal of those abnormalities. Its main indication today is to treat women who are having bothersome bleeding and who no longer desire childbearing. This procedure is called an endometrial ablation. In doing an ablation the goal is to hopefully stop the periods. Success is defined as completely stopping the periods. However when you look at satisfaction rates with the ablation procedure, 90-95% of women are satisfied, even if their bleeding hasn’t completely stopped, but has dramatically decreased.

There are several types of procedures. The gold standard has been rollerball ablation where there is a small stainless steel ball with electrical current running through it that burns away the uterine lining. This uterine lining may be thick, it may be thin, or it may be irregular. So the rollerball ablation removes all of that lining. Patients may have some spotting. The more successful the procedure, the less chance there is going to be any bleeding. Other procedures that have come along are NovaSure, which is using a radiofrequency device inside the uterus. Energy is used for about a minute and a half to burn that lining. This is very successful and works well. There is cramping during the procedure but has been very successful in doctor’s offices. There is also heated saline that can be put in the uterus. There can also be cryotherapy which is a freezing of the uterine lining. Each of these procedures are usually successful in decreasing the bleeding to some degree, however the success rate, meaning completely stopping periods is usually much lower.

There are also complications that can occur. If gynecologists are just looking in the uterus to get a diagnosis they are usually using some saline and so there is not usually too many problems with that. However, there can be what we call a perforation; that means that the scope is put through the back or side of the uterus. To prevent that most doctors are able to do an ultrasound before to evaluate the position of the uterus so they kind of have an idea if it is tilted back or tilted forward. Also when the procedure is done, if a treatment is going to be done such as an ablation, there is a solution that is used that is really concentrated solution that allows electrical current to be used. However, this solution, if the uterus were to be perforated, can leak into the abdominal cavity and can change the electrolytes to the point where that can be quite severe. There have been reported deaths from that, but today with the equipment we have to monitor the fluids going in and out that is really unlikely.

One thing to keep in mind is that an ablation is primarily indicated for ladies who are having bleeding - heavy bleeding, prolonged bleeding, unpredictable bleeding, bleeding that doesn’t stop with medical treatment. However, it is not really indicated for people who have pain. Ladies that have pain can still have that pain after an ablation procedure, so I would caution ladies that if you have a large pain component with your bleeding I would probably consider something other than an ablation to alleviate that.