What is hysteroscopy?
The hysteroscope is a medical instrument used to visualise the inside of the uterus. It involves the insertion of a telescope with a camera, which can be of varying sizes depending on the purpose of the hysteroscopy – thinner, just visualisation, then it is called diagnostic hysteroscopy, or to treat a condition, in this case the instrument has a larger diameter and is called operative hysteroscopy.
What conditions can it be used for?
Hysteroscopy is a commonly used investigation in the Department of Assisted Human Reproduction and In Vitro Fertilisation for patients with infertility. It plays an essential role in the treatment of synechiae, septations, conformation abnormalities of the uterine cavity, excision of intracavitary formations such as polyps or fibroids, but it is also extremely useful in oncology for endometrial biopsies or endometrial ablations. Young breast cancer patients with estrogen receptors present will undergo hormonal treatment for 5 to 10 years. Tamoxifen has as an adverse reaction the thickening of the endometrium, the formation of endouterine polyps and later endometrial cancer may even occur. Patients on Tamoxifen require close ultrasound monitoring of the endometrium, even every 3-4 months to detect in time when a change occurs. Hysteroscopy is essential in these cases, because it differentiates between endometrial thickening, or the presence of a polyp and also resolves the problem with a minimally invasive procedure after which the patient goes home the same day.
When can it be performed under sedation?
Only diagnostic procedures are usually performed without sedation, for operative procedures sedation is required because of discomfort for the patient. If a long hysteroscopy follows it can even be performed under spinal anaesthesia.
How is it performed?
Depending on the diameter of the hysteroscope it may or may not be necessary to dilate the cervix anteriorly. It is penetrated through the cervical canal (through the cervix) into the uterine cavity, the cavity is emptied with fluid (the choice of fluid depends on the type of hysteroscopy, whether it requires the use of electrosurgery or not) and with the help of various instruments, under permanent visual control, we perform the surgery.
What are its complications?
Complications can occur at different stages:
-cervical dilatation – creation of a false pathway and perforation
-during the hysteroscopy itself: when excising large fibroids that reach close to the uterine surface, perforation may occur or if the operation lasts a long time, complications may arise from the intravasation of the fluid used. The uterine synechiae can be very difficult and in general perforation remains the most common complication.
Complications are however very rare, rarer than in the case of uterine curettage, due to the fact that everything takes place under visual control, but if they occur, they are usually treated conservatively.
How do we prepare for hysteroscopy and how long does it take?
Preparation may require medication beforehand to facilitate dilation of the cervix, but on the day of surgery it is recommended that the patient does not consume fluids or food if sedation is required.
You are a specialist in gynecological oncology and are part of the Medicover Endometriosis Centre team. In the literature we find cases of endometriosis undergoing malignant transformation. What can you tell us about this?
Endometriosis is a fairly common disease, but fortunately there are rare cases where endometriosis is associated with malignancy and this is the case with endometriotic ovarian cysts. I have encountered two cases so far, and the confirmation came after histopathological results on paraffin. All tissues that are removed during surgery should be sent to pathology for microscopic examination. The good part, if there is such a thing in oncology, was related to the good prognosis of both cases.
How do you see endometriosis as a woman, but also as a doctor who participates in endometriosis operations?
I find it dreadful as a disease and extremely difficult in terms of complexity of surgery. It affects young women of childbearing age who have extremely painful menstrual periods, or heavy menstrual flow, pain during sexual intercourse, problems with defecation or urination and the list goes on. These symptoms can be debilitating, so that patients with endometriosis can become unable to carry out normal activities. Surgical interventions are laborious and must necessarily be performed by surgeons with experience in endometriosis, because an incomplete intervention guarantees a quick relapse.
What should a young woman who has severe menstrual pain know?
Some women have significant menstrual pain all their lives, without necessarily being related to endometriosis, but if it worsens or is associated with other symptoms, they should seek a gynaecological consultation with a doctor specialising in diagnosing endometriosis.
However, all women should have an annual gynaecological and breast check-up, because screening saves lives in oncology.