by drseckin.com | Posted on June 4, 2020
by Tamer Seckin, MD - Endometriosis Excision Surgeon &
Founder of Seckin Endometriosis Center (SEC)
At Seckin Endometriosis Center (SEC), our specialist surgeons use hysteroscopy to inspect the uterine cavity. Instead of using the old-fashioned blind procedure of Dilatation and Curettage (also commonly known as D&C), hysteroscopy is a minimally invasive visual approach for the diagnosis and treatment of common gynecologic problems, such as abnormal uterine bleeding, uterine abnormalities to treat fibrosis, polyps, adenomyosis, endometrial hyperplasia, and heavy menstruation with clots. Hysteroscopic evaluation of the uterine cavity is the gold standard in the investigation of miscarriages, early pregnancy loss, and evaluation for infertility.
Endometriosis surgery should always start with an evaluation of the endometrial cavity by hysteroscopy. Dilatation curettage, also known as D&C, is a touch-and-feel blind procedure. This procedure has been largely replaced by hysteroscopy as the current standard of accepted practice
A hysteroscope is a thin telescope that is inserted into the uterus via the natural orifice (vagina through the cervix) to visualize the endometrial cavity, as well as the tubal stia, endocervical canal, cervix, and vagina. The name of the procedure performed with a hysteroscope is called hysteroscopy.
Patients may need local anesthesia when a hysteroscope is performed in the office setting. Procedures requiring only diagnostic evaluation of the cavity, and minor procedures of endometrial biopsy and polyp removal, should not require a hospital setting. However, an operative hysteroscopy for the shaving of fibroids (as with Myosure and intrauterine septum resection) requires general anesthesia. These procedures are best performed by specialist hysteroscopic surgeons due to potential unintended consequences.
What are the indications?
What is the role of hysteroscopy during endometriosis surgery?
According to the Sampson theory (which researchers believe to be the most common theory for endometriosis), the cells causing endometriosis lesions are the cells coming from the endometrial cavity (1). Knowledge of the endometrial cavity is therefore essential. Endometriosis patients tend to bleed more than other women, and most women with endometriosis have cavitary abnormalities including endometrial polyps, uterine structural abnormalities, and Mullerian anomalies. According to our unpublished data, out of 941 patients who had endometriosis surgery with us and also had a hysteroscopy, 645 (68%) patients had any kind of uterine abnormality including uterine structure abnormalities such as cornual funneling, midline prominence, arcuate uterus, fibroids, septum, etc, and 38% of these abnormalities were arcuate uteruses (2,3).
While uterine anomalies often have been associated with infertility and recurrent pregnancy loss, they also can have an effect on the development of endometriosis. The arcuate uterus is a rare uterine anomaly and the prevalence is 2.1%-8.9% in low risk and also recurrent pregnancy loss group (4). According to our results, the incidence increases by having endometriosis. Patients with endometriosis are more likely to have an internal shape called arcuate uterus compared to the general population. Hysteroscopy procedure is an essential part of planned endometriosis surgery.
Office hysteroscopy is applied in the physician’s office and its narrow and thin camera allows easy access to the endometrial cavity. Ambulatory settings are ideal for patients, as they are time-saving compared with operating room procedures, and should be used whenever feasible. But an office hysteroscopy may fail because of pain, cervical stenosis, and poor visualization.
An operative hysteroscopy is applied in the operation room. It requires anesthesia because of the need for cervical dilatation and the timelapse of the procedure. Most cases that require uterine intervention will be solved by operative hysteroscopy. These include:
Most patients experience postoperative cramping or light bleeding and some complaints of vaginal discomfort which will be mostly eased in 15 minutes. Paracetamol or nonsteroidal anti-inflammatory drugs (like Advil or Tylenol, Brufen) are usually adequate for postoperative pain control, if necessary.
Patients can resume their daily activities within 24 hours. SEC sees patients for a follow-up visit 7-10 days postoperatively to assess for further complications and review results.
Complications from hysteroscopy are rare but could be serious if not managed by an experienced doctor
Uterine abnormalities may prevent implantation of the embryo to the endometrial cavity. All abnormalities should be evaluated for a patient who desires fertility. The uterine anomalies that are most often observed during hysteroscopy that may prevent implantation are adhesions, septa, polyps, cavitary fibroids, anomalies of the cervical canal, and lesions of the tubal cornual channels. According to literature, most of the patients with cavitary lesions profit from hysteroscopic treatments, and almost 65% achieve pregnancy (5).
Most patients experience postoperative cramping or light bleeding and some complaints of vaginal discomfort.
It is a one-day surgery. You will start feeling better just after the procedure and could get back to your daily routine the day after.
If you are having heavy periods and are at risk of having uterine malignancies, you need to have an endometrial sampling. After evaluating the endometrial cavity to visualize the reason for abnormal bleeding with hysteroscopy, a curettage (D&C) of the endometrial cavity is usually made and the sampling is sent to the pathology department for histologic diagnosis.
Office hysteroscopy does not require anesthetics but if you need to have an operative hysteroscopy for your lesions you will need sedation because of the need for cervical dilatation and the timelapse of the procedure.
Your hormonal system will be working perfectly after the hysteroscopy but if you have also had endometrial sampling your menstruation might be delayed because the endometrial lining that peels off due to menstruation every month would be collected for sampling on your hysteroscopy procedure.
Complications from hysteroscopy are rare but could be serious if not managed by experienced doctors (uterine injury, infection, hemorragia, and excessive fluid absorption caused by the uterine distention media)
The most common way to detect endometrial cancer is with D&C but if your cancer is presented on a uterine polyp a hysteroscopy is the perfect way to see and resect it.
The best time to perform hysteroscopy is immediately after the period, or in the early follicular phase. The increased endometrial thickness would impair visualization other times during the cycle. Office hysteroscopy should always be performed at the early follicular phase to obtain optimal visualization. Diagnostic hysteroscopy may be combined with laparoscopy and therefore performed in the luteal phase of the menstrual cycle, but care must be taken to avoid abrading the endometrium during the procedure, causing unnecessary trauma.
Our best approach is the “see and treat” technique in an advanced operative room with general anesthesia unless the patient prefers otherwise.
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Dr.Seckin is so much more than a surgeon. His passion for helping endometriosis sufferers and determination to improve the quality of life in all of his patients is undeniable. I remember when my gynecologist first told me I needed a laparoscopy. Her exact words were "I can do the surgery, but if you were MY daughter- I'd send you to him." From the first day I met him he took the time to explain endometriosis to me since I knew…
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