Hysteroscopy and endometrial biopsy is a diagnostic procedure
performed to eliminate or diagnose the possibility of an
abnormality of the womb lining. It is usually performed following a complaint of abnormal vaginal bleeding.
What happens during the operation?
You are placed on an examination couch with your legs in stirrups. An instrument is placed on the neck of the womb (cervix) and the cervix canal is dilated to allow the passage of a telescope (hysteroscope) (figure 1).The cavity and the lining of the womb are inspected thoroughly using the telescope (figure 2). This process is called Hysteroscopy and requires the womb to be filled with either gas or fluid. Once the hysteroscopy has been completed, a specimen of the lining of the womb is taken. This process is called Endometrial Biopsy. Sometimes it is not possible to obtain an adequate specimen due to a thin womb lining. If this happens it is a reassuring and normal occurrence.
Figure 2. Two types of hysteroscope
What can be seen during a hysteroscopy?
When the cavity of the womb is normal, the whole of the lining of the womb can be seen. This includes normal smooth pink surfaces and the openings of the Fallopian tubes. Hysteroscopy only examines the inner cavity of the womb. It does not examine the ovaries and the Fallopian tubes nor the muscle and outside surface of the womb. As a result, hysteroscopy will not diagnose problems with the ovaries or tubes, endometriosis or some types of fibroids.
Abnormalities of the whole womb lining are sometimes diagnosed during the hysteroscopy examination and sometimes when the biopsy specimen is analysed in the laboratory. The appearances depend on the specific abnormality but are characterised by changes over the whole or large part of the womb lining. These include, endometritis (inflammation of the womb lining); hormonal changes (due to hormone in-balance or medication); atrophic changes (due to a lack of the hormone oestrogen after the menopause); and hyperplasia (abnormal thickening of the womb lining which can sometime be pre-cancerous).
Other abnormalities that can be detected by hysteroscopy include some malformations of the womb; fibroids that project into the cavity and cancers of the lining of the womb. Most womb cancers are curable if detected at an early stage which is why most gynaecologist recommend hysteroscopy when women have bleeding after the menopause.
What type of anaesthetic and hospital stay is needed?
This is very variable and depends on a number of situations. Sometimes the procedure can be performed in clinic with no anaesthetic, sometimes a general anaesthetic is required and a three day hospital stay. When it is easy to examine the cervix (neck of the womb) and the cervix gapes open slightly (sometimes as a result of childbirth), it may be possible to perform the hysteroscopy without coming into hospital and under no or just local anaethestic. A general anaesthetic is often required when vaginal examination is difficult or the neck of the womb is tightly closed. These criteria vary with different women so the decision is usually made on an individual basis.
When a general anaesthetic is required it is often possible to have the procedure performed as a day case which requires no overnight hospital stay. An overnight stay is required in women who require a general anaesthetic and do not meet the health and fitness criteria for day case surgery.
What preparation is required?
This is variable depending on how the procedure is done and you medical fitness. It is important that you understand what you are having done by reading this leaflet and speaking to your doctor. You may be asked to sign a special consent form agreeing to the operation and stating that you understand what is being performed. This always occurs if having a general anaesthetic. Other than this, some women require no preparation. Other women may need blood tests, a chest X-ray and a heart recording to assess their fitness for a general anaesthetic.
If having a general anaesthetic, it is important that you have nothing to eat or drink for six hours prior to the procedure. One of the complications of a general anaesthetic is inhalation of vomit. This is prevented by having an empty stomach at the time of the operation. This is achieved by starving for six hours. If you have not been starved your operation will be cancelled.
It is important that you understand when you are required in hospital and where you have to go. It is important for the surgeon and anaesthetist to see you just before your operation to ensure that there has been no change in your medical condition since you were last seen. When you have you procedure, other patients will be having operations on the same list. If you arrive in hospital after the start of the operation list the surgeon and anaesthetist will be unable to see you and will therefore cancel your operation. This is unavoidable, as the surgeon and anaesthetist are unable to leave the patients they are caring for in the operating theatre complex.
If you are taking any prescribed medicines (including hormone replacement or contraceptive pills) you must ensure that you understand which medicine you should take and which you should not on the day of the operation.
After the procedure and going home?
If you have a general anaesthetic you should not drive on the day of the procedure. We recommend that all women who have a hysteroscopy (even under local anaesthetic) are accompanied when they go home and do not spend the first night at home alone.
On leaving the hospital, you should ensure that you understand what medication you should be taking once discharged (including contraception) and know when you are expected for follow-up. Sometimes no follow-up appointment is required. When one is required, it is usually when the laboratory results of the specimens taken (endometrial biopsy) are back. These can take up to two weeks. Normally you will be given your follow-up appointment before going home. Sometimes it is necessary to send you your appointment through the post. Members of the medical, nursing and secretarial staff will not give results over the telephone.
You should refrain from swimming, having sex, and using tampons for three days afterwards. It is acceptable to have baths during this period. Attend the emergency department if you feel feverish or dizzy, have a smelly discharge, or have bleeding greater than the worst day of your worst ever period. If you have other concerns it is best to phone the clinic sister (020 7601 7842)between 09:00 and 17:00 on a weekday.
What are the common side effects of the procedure?
If done under local anaesthetic, some women experience a mild light headedness and a period like cramp during the procedure. Afterwards (if done under local or general anaesthetic), some women have a period like cramp. Vaginal bleeding can occur for up to seven days afterwards. However, bleeding usually lasts for less than a day and should be no greater in amount than a normal period.
Different women react to general anaesthetics in different ways. Usually only a light anaesthetic is required and most women recover without any problems. Some women have mild nausea following the first hour of recovery and others can vomit. Medicine is available to counteract these symptoms.
What are the important risks of the procedure?
There are less risks associated with hysteroscopy and endometrial currettage than most operations. It is classified as a minor procedure. As with all operations there are rare occasions when complications occur. The overall chances of these complications occurring are difficult to give exactly and can depend on individual factors. However, average estimate of the risks are given below based on information in the medical literature. If you wish to discuss your personal chances of developing complications you should discuss this with a doctor or nurse looking after you.
The procedure can cause excessive bleeding resulting in the need for a blood transfusion in about 4 of 1000 cases 1.
Infection of the womb also occurs in about 4 of 1000 cases 1. Infection can be recognised by a smelly vaginal discharge, excessive vaginal bleeding, crampy tummy pains, and a temperature. Infection is normally cured by a short course of antibiotics but occasionally, a repeat hysteroscopy is required to flush out the infection. In very rare cases when a severe infection has occurred and has gone unrecognised, scarring can occur in the pelvis resulting in infertility.
The initial part of the procedure is blind to the surgeon. In other words the surgeon cannot see the inside of the uterus in which he/she is inserting an instrument. As a result of this, it is possible that an instrument can pass through the muscle of the womb. This occurs in about 1 in 170 procedures and is called a ‘uterine perforation’ 1. In most cases of perforation there are no long term consequences. However, sometimes the bladder, bowel or blood vessels can be damaged which may result in a major abdominal operation being required through an up and down incision. The risk of this is about one in 700 for all women having a hysteroscopy 1. Very rarely, the perforation may result in the need for a hysterectomy (surgical removal of the womb) and the risk of this is about one in 1700 1.
The combination of all the above risk factors and the complications of a general anaesthetic to be explained to you by you’re your anaesthetist result in a small mortality rate of less than one in a quarter of a million. This risk may be higher if you have a chronic medical problem.
Although some of the important possible complication have been given in this section it must be remembered that the overall risks of this procedure are extremely low and must be put in prospective. The probability of death or long term harm is considerably less than the risk of dying or being permanently injured in a road accident. It should also be born in mind that the risks may be greater from the consequences of not having the procedure performed and failing to have a potentially curable illness diagnosed.
1 — Ind TEJ in Progress in Obstetrics & Gynaecology 13 Churchill Livingstone, 1998; p361.