Diagnostic Hysteroscopy

Diagnostic hysteroscopy is a minimally invasive, second-level gynecological procedure that allows direct visualization of the uterine cavity and cervical canal. Performed at Ars Medica in the heart of North Rome, this technique enables the diagnosis of endouterine and endocervical conditions, applicable to both premenopausal and postmenopausal women.

How is hysteroscopy performed?

The examination is carried out using a slender optical instrument connected to a camera. This optical instrument is inserted into the uterine cavity via the cervical canal. The normally virtual uterine cavity is expanded using a liquid or gas distension medium. In recent years, the preference has shifted towards using liquid distension due to its superior diagnostic capability and better patient tolerance compared to gas distension.

Indications for Diagnostic Hysteroscopy:

• Abnormal uterine bleeding pre- and post-menopause
• Suspected uterine polyps (endometrial or cervical) or fibroids (intramural, submucosal, endocavitary)
• Infertility, sterility, and recurrent miscarriage
• Evaluation of the uterine cavity before assisted reproduction techniques
• Monitoring endometrial hyperplasia
• Ultrasound-diagnosed endometrial thickening pre- and post-menopause
• Suspected uterine malformations
• Suspected uterine synechiae
• Abnormal Pap smears (ASCUS, AGUS, AGC); hysteroscopy is combined with endocervicoscopy in these cases
• Lost IUD (spiral with untraceable strings)
• Suspected adenomyosis
• Isthmocele (dilation of the cesarean scar)
• Post-operative follow-up after operative hysteroscopy

The examination should ideally be performed in the absence of bleeding, except for minimal spotting.

Timing and Procedure:

For premenopausal women, the procedure is ideally performed immediately after menstruation, between the 5th and 13th day of the cycle, when the endometrium is thin. This timing allows for optimal visualization of any endometrial or uterine wall abnormalities. In menopausal women, without menstrual cycles, the exam can be performed at any time.

Duration and Tolerance:

The procedure typically lasts a few minutes and is usually well-tolerated by patients. Most patients report cramp-like pain similar to menstrual cramps. If a biopsy is needed, it may cause slightly more intense cramping but lasts only a few seconds.

The cervical canal is accessed via vaginoscopy (without a speculum), which significantly reduces patient discomfort and improves exam tolerance. In some cases, due to specific anatomical situations (such as stenosis or re-epithelialization of the external uterine os or cervical canal stenosis or synechiae), the exam may be too uncomfortable, and sedation might be recommended.

Possible Side Effects and Complications:

The procedure may stimulate vagal innervation of the uterus, potentially causing a vagal reaction with hypotension, bradycardia, and neurovegetative symptoms (pallor, cold sweat, nausea). Although more common with longer or more challenging exams, this side effect can occur even with simpler procedures. Serious complications are extremely rare but may include pelvic infection or uterine perforation.

Before the exam, fasting and anesthesia are generally not required, and usually, no pharmacological preparation is necessary. In some cases (e.g., severe endometriosis, abdominal-pelvic adhesion syndromes, previous pelvic infections, presence of a hydrosalpinx), the exam may be contraindicated or require pre- and post-exam antibiotic therapy.

Absolute Contraindications:

• Active or very recent vaginal or pelvic inflammation
• Current pregnancy
• Diagnosed cervical cancer

Direct visualization of the cervical canal and uterine cavity allows for immediate diagnosis of major endouterine pathologies. If a biopsy is performed, results must be awaited.