What is a hysteroscopy?
Hysteroscopy is a procedure where the inside of the uterus is examined through a thin telescope that is inserted through the cervix without any cutting. It is usually performed as a day procedure in a hospital under a general or local anaesthetic. Hysteroscopy may be used to both diagnose and treat specific conditions of the uterine cavity. Common problems that can be treated by hysteroscopy include:
- diagnosing and treating abnormal uterine bleeding
- investigation of infertility
- the treatment of scar tissue in the uterus (Asherman’s syndrome)
- removal of fibroids or polyps
- endometrial ablation (a treatment where the uterine lining is removed due to heavy periods)
- treatment of uterine abnormalities
The decision to have a hysteroscopy should be made by you after discussion with your Alana doctor about your symptoms. If you decide on a hysteroscopy then you will be asked to sign a consent form that outlines specific risks and complications that may occur and is tailor made to your symptoms. For elective surgical procedures that include hysteroscopy, you should consider the reason for the treatment, the alternatives and only proceed with the hysteroscopy when you are satisfied that you understand all of the implications of the procedure.
Before your hysteroscopy
You will be given specific instructions on any dietary requirements before proceeding with your hysteroscopy. Generally this will mean fasting (no food or drink) prior to your procedure. If you are having a laparoscopy in conjunction with your hysteroscopy there may be additional dietary requirements. You will be advised of any additional requirements well in advance.
Medication
You should stop aspirin 14 days prior to surgery. You may continue to take medications containing paracetamol or non-steroidal anti-inflammatory medications (such as Nurofen) for pain symptoms. Other regular medications such as blood pressure medications, diabetes treatments and the oral contraceptive pill should be continued. You should contact your Alana doctor if you are unsure about which medications to stop or continue. If you are a smoker, you are also recommended to stop smoking prior to your surgery and for 6 weeks after to improve your recovery and wound healing rate.
Your hospital stay
If you are having a hysteroscopy then you will be admitted to the Prince of Wales Private Hospital or the Royal Hospital for Women and go through the following procedures:
- The administration process
- Admission to the ward
- The operating room
- Recovery
- Return to the ward
- The discharge process
The administration process involves the paperwork required by the hospital for your admission. You should ensure that you know what time you are expected to arrive for admission and give yourself some leeway to arrive on time. Once the paper work has been completed at the administration area of the hospital that you are being admitted to, you will be told where to attend for your admission to the ward.
Your admission to the ward will involve a day-stay admission if you are having a hysteroscopic procedure only or to a ward where you will stay for one or more nights if there are other procedures involved that require you to be admitted. You will be oriented to the ward and have procedures explained to you by the nursing staff of the ward. They will take your observations such as pulse, blood pressure and temperature, ask you questions regarding your past history, any allergies and medications that you take. You will be seen by the anaesthetist who will perform examinations such as listening to your chest and heart. It is important that you tell your doctor, the nursing staff and the anaesthetist any medications that you are on (including over the counter medications without prescription and herbal medications). Your consent form will be checked with you and you will have the opportunity to ask any questions regarding your procedure.
Once all of these checks have been completed you will wait until the operating room is ready for your case. You will be taken to the operating room either walking accompanied by a nurse or by a trolley. You will be checked into the operating theatres by a nurse who will confirm your details with you. Your anaesthetist will see you and put a drip in your arm and start fluids running into a vein. You may also receive medication at this time to help you relax and feel more comfortable. You will be moved into the operating room where you will be asked to move from the trolley to the operating bed. On some occasions a special board is placed under you to slide you across to the operating table. Monitoring devices for your heart and oxygen levels will be placed on you and the anaesthetic will begin with oxygen being given to you before you go to sleep.
In addition to your surgeon and your anaesthetist, there will be nursing staff to assist your surgeon and the anaesthetist. Once you are asleep, you will have your legs placed in stirrups and sterile drapes are placed over the lower part of your body. The cervix is then located using a speculum and held using a special holding clamp. The telescope is placed into the cervix and advanced whilst looking at a television screen where the image can be seen. Fluid is connected to the telescope and flows into the uterus to hold the walls apart so that the inside of the uterus can be seen. The telescope is advanced until the uterine cavity is entered and all the walls can be seen. Any problems in the uterus may be demonstrated and treated if appropriate. Special instruments may be used through the hysteroscope (the name of the telescope used in the uterine cavity) for additional surgeries that are necessary.
When your hysteroscopy has been completed and the instruments removed you will wake from the anaesthetic and be taken to the recovery room. You may not remember much of this part of your admission, since the effects of the anaesthetic are likely to be present. In the recovery room, you will continue to be monitored and have your vital signs taken by nursing staff. Once you are awake, your pain is under control and all your observations are stable, you will be returned to the ward for further observation before being discharged if you are a day-stay patient or will continue to be monitored for the length of your stay. You will usually spend between 30-60 minutes in the recovery room.
When you are back on the ward your doctor will see you and explain the results of the surgery to you. Don’t worry if you do not remember all of the details at this point, as these will be explained again at any and all of your subsequent visits. If you have specific questions regarding your surgery then you can contact Alana Healthcare for Women and we will answer your questions when possible.
When you have fully recovered, your observations are stable, your bladder is working normally, your pain is under control with oral medications and you can eat, drink and walk as normal you will be discharged home. You will be given a prescription for pain medication and instructions on post-operative care by the nursing staff. At the time of discharge you will be given a Discharge Summary – all patients receive this and you should ask the nursing staff if it is not given to you. It contains important information regarding your procedure and discharge instructions as well as phone numbers. You are likely to have some vaginal bleeding for a few days up to 2 weeks. Your period may also come at a time different than what you expect. You should use pads not tampons for the first 2 weeks after hysteroscopy and not have intercourse for the first two weeks or until you have stopped bleeding, whichever is first. You should contact Alana Healthcare for Women on the next working day to arrange a follow-up visit, if not already arranged.
At discharge, you cannot drive yourself home and will need to be picked up from the hospital where your surgery was performed. You are likely to experience cramping period like discomfort in the days after your surgery. This discomfort is usually mild and should get better over time. If there is no improvement after a few days, you should contact Alana Healthcare for Women. Simple painkillers such as paracetemol and anti inflammatory medications (e.g. Nurofen) should help with this type of pain. If you experience fever, chills or sweats, an increase in pain, vaginal discharge that is offensive or copious then you should contact your Alana doctor.
Complications of hysteroscopy
Significant complications are very uncommon at the time of hysteroscopic surgery. In fact serious complications occur in less than 1/2500 cases. That is for every 2500 hysteroscopies, there is less than one serious complication. Although complications are rare, it is important for you to be informed of what could happen, as no surgery is risk-free and even the simplest procedure can result in a complication.
Complications specific to hysteroscopic surgery include uterine perforation where a hole is made in the uterus. Usually this will have no significant consequences, although you may require an overnight stay for observation. It may also be necessary to do a laparoscopy to have a look at the outside of the uterus. Bleeding may be a consequence of this type of complication. Very rarely would you need to have a blood transfusion. If the hole was made during a surgery where there was a lesion being removed from the uterus (e.g. a fibroid or a polyp) then damage to other organs such as the bladder or bowel may result and this is a potentially serious complication. If this was to occur, it may be necessary to perform a laparotomy, which is where a large incision is made in the abdomen. Usually this will be done under the same anaesthetic. In the case of life-threatening emergencies this will be essential. A laparotomy will only be performed when it is suspected that there is a serious complication arising from the hysteroscopy. It is important to remember that your long-term safety is the most important aspect of your treatment and the necessary steps to ensure your safety is the first priority.
Since fluid is used to hold the walls of the uterus open, some of this fluid may leak into your blood stream, especially during surgeries where there are lesions being removed (such as fibroids). The problem arising from this is that absorption of too much fluid can lead to a salt imbalance, which may cause wet lungs or rarely swelling of the brain. Your Alana doctor uses specialised fluid measuring equipment to ensure that this does not occur and when the fluid level reached a certain amount, the procedure is stopped. This will occur even if the procedure is not finished, since to continue may be dangerous. If this occurs, you will be rescheduled in 1-2 months to complete the procedure. If there is any doubt as to the amount of fluid that is absorbed, then your blood salt levels will be checked and you may be given medication to get rid of excessive fluid. You will be discharged when your blood salt levels have returned to normal.
Bleeding may occur during or after your hysteroscopy but is not common. Blood transfusion is very rarely required. Other minor complications include urinary tract infections or infections of the lining of the uterus. If you experience pain or discharge that is offensive or copious then you should contact your doctor.
The most serious complications following hysteroscopy are considered to be injuries to other organs in the pelvis including the bladder (the organ that holds urine), the ureter (the tube that leads from the kidney to the bladder), the bowel and the major blood vessels. These complications are very rare. In addition, medical complications such as clots that develop in the legs or lungs, or excessive stress that is placed on the heart and lungs from the surgery can occur resulting in heart attack or stroke. The likelihood of these complications occurring will depend on the reason for your hysteroscopy, your past surgical and medical history and your age.
Specific problems can include bladder injuries, which may be treated by placing a catheter in the bladder for up to a week, but may also require additional surgery. Occasionally a large incision (called a laparotomy – see picture above) in the abdomen would have to be made to repair the bladder. If you required a bladder repair following an injury, you would have a catheter in your bladder that may stay in for up to one week. You may be able to go home with the catheter in after instruction on caring for it at home if this is your preference.
Injuries to the ureter (the tube that leads from your kidney to your bladder) may only require a stent – a small hollow tube placed through the ureter from the kidney to the bladder for about 6 weeks. These can be inserted through the bladder without an incision in the abdomen and can be removed through the bladder in a simple procedure, again without an incision in the abdomen. Sometimes the ureter must be ‘reimplanted’ in the bladder. This means that a large incision is made in the abdomen (vertical midline incision see picture), the ureter is cut and placed into the top of the bladder to drain normally. A stent would be placed as above and would need removing, usually at about 6 weeks.
This procedure would normally be performed as an outpatient. The bladder and the ureter will usually function completely normally after this procedure. You will require a special X-ray test at between 6 weeks and 3 months to make sure that the bladder and the ureter are working normally.
Injuries to the large blood vessels are the most urgent complication and require immediate attention. It is likely that a very large incision (midline vertical incision) would be made in the abdomen for immediate repair. Almost certainly there would be a blood transfusion. Your stay in hospital is likely to be much longer than anticipated. Injury to a blood vessel is a very serious and life-threatening complication.
Injuries to the bowel are a rare complication of hysteroscopy, but can be very serious. The injury to the bowel may be caused by a sharp instrument or an electrical current if the uterus is perforated or very occasionally when there is no perforation but the electrical current has passed through the uterus and into the bowel on the other side. If the injury is detected, it may be repaired by laparoscopy, though more commonly a laparotomy is required. You will be given antibiotics and you may require a colostomy. A colostomy is where a loop of bowel is brought to the skin and stitched in place with a bag is placed over this. The bowel contents will empty into the bag. This will usually be in place for three months after the surgery to allow the bowel time to heal. When the bowel is healed, the loop of bowel is closed and placed back in the abdomen. Very occasionally the colostomy may be permanent. If a bowel injury occurs during surgery and is missed, then there may be development of a serious infection in the abdomen. This will require surgery with a large incision in the abdomen and a colostomy (see above). You are likely to have a prolonged hospital stay whilst the infection is treated and may require admission to an intensive care ward. This is a very serious and life-threatening complication. The risk of bowel injury that is missed is rare with hysteroscopy, being less than 1/2500 cases. That is for every 2500 hysteroscopies performed, there will be approximately one missed bowel injury.
Once you have been discharged from hospital, signs that may alert you to a complication include an increasing amount of pain, abdominal distension or cramping, vomiting, high fever or sweats, vaginal discharge that is offensive or shortness of breath. If you have any of these symptoms then you should contact your Alana doctor or attend to the emergency department for further advice.
You should not have a hysteroscopy if you are pregnant, since there is a risk of inducing a miscarriage. You should inform your doctor if you think that you are pregnant and your surgery may be delayed. Your doctor will inform you if your surgery needs to be timed with your menstrual cycle. If you are not timed, then you do not need to worry if you have a period at the time of your scheduled surgery.