Diagnostic & Operative Hysteroscopy

Medically reviewed by Dr Manan Boob, MBBS (KEM), MS ObGyn (Gold Medalist), DNB — Consultant Gynaecologist & Laparoscopic Surgeon

What it is

Hysteroscopy is a way of looking directly inside the uterus. A slim telescope — a hysteroscope — is passed through the vagina and the cervix into the uterine cavity, a little sterile fluid is run in to gently open the walls apart, and the inside of the uterus appears on a monitor, magnified and lit. Nothing is cut. There is no incision anywhere on your body.

Diagnostic hysteroscopy is the looking part: identifying a polyp, a fibroid bulging into the cavity, a band of scar tissue, an unusual patch of lining, or a wall of tissue dividing the cavity in two. Operative hysteroscopy is treating what has been found, in the same sitting, through the same route, using fine instruments passed down a working channel in the telescope.

Here is what I tell patients when I am explaining it for the first time: for a hundred years, gynaecologists treated the inside of the uterus by feel. Hysteroscopy replaced feel with sight. That is the whole idea, and almost everything good about the procedure follows from it.

Who needs it

• Heavy periods that have not responded to medication, or periods that have changed character over the past year.
• Bleeding between periods, or after intercourse.
• Any bleeding after menopause — this always needs the cavity examined, and usually a sample of the lining taken.
• A polyp or a thickened endometrium reported on ultrasound.
• A submucous fibroid — one growing into the cavity rather than within the muscle wall.
• Difficulty conceiving, particularly before starting IVF, where an unrecognised polyp or adhesion can quietly undo an expensive cycle.
• Recurrent miscarriage, where a uterine septum or intrauterine adhesions may be the reason.
• A copper-T or IUCD whose threads cannot be found, or a device that has become embedded.
• Retained tissue after a miscarriage or delivery, which can be removed under vision instead of blindly.
• Suspected Asherman’s syndrome — scarring inside the cavity, often after a previous curettage, causing scanty or absent periods.

“My ultrasound already showed a polyp. Why do I need another test?” An ultrasound tells us that something is there. It cannot tell us with certainty what it is, how it is attached, or whether it is the actual cause of your bleeding. And critically, an ultrasound cannot treat it. In practice the hysteroscopy is not really a second test — it is the treatment, with the confirmation built into the first thirty seconds of it.

How it is done

You lie in the usual examination position. The vagina and cervix are cleaned.

For a diagnostic hysteroscopy we use a very fine telescope, around 2.9 to 4 mm across — narrower than most people expect. Often the cervix needs no dilatation at all; the scope is guided in under vision, using the fluid itself to open the passage. Warm sterile saline flows in, the cavity opens up to a triangular chamber the size of a small plum, and both tubal openings, the lining and the walls come into view. This takes only a few minutes. If a sample of the lining is needed, it is taken at the same time.

For an operative hysteroscopy the cervix is dilated a little more to admit a slightly wider instrument — a resectoscope or a mechanical tissue-removal system. What happens next depends on what we find:

• Polypectomy — the polyp is cut off at its base and retrieved, rather than left in fragments.
• Hysteroscopic myomectomy (TCRE / resection) — a submucous fibroid is shaved down in slices until the cavity is smooth again.
• Septal resection — the wall of tissue dividing the cavity is divided along its length until the cavity becomes one normal chamber.
• Adhesiolysis — bands of scar tissue are cut, restoring the cavity’s shape.
• Retrieval of a lost or embedded contraceptive device.

Fluid balance is measured throughout: how much saline goes in, how much comes out. That may sound like a minor housekeeping detail, but it is one of the most important safety steps in the whole operation.

Anaesthesia, duration and hospital stay

A diagnostic hysteroscopy takes about 5 to 15 minutes. It can be done with the patient awake, with light sedation, or under a short general anaesthetic — we decide together, based on what you are comfortable with and whether we expect to treat something we find.

Operative hysteroscopy is done under general or spinal anaesthesia and takes 20 to 45 minutes, longer for a large fibroid or a densely scarred cavity, and occasionally planned as two shorter sittings rather than one long one.

Either way, this is day-care surgery for most women: admission in the morning, discharge the same evening once you are eating, walking and passing urine normally. A complex resection, significant bleeding or another medical condition may mean one night. You will not have any dressing to look after, and there are no stitches to remove.

Why hysteroscopy rather than a blind D&C

Dilatation and curettage has been performed for generations and still has occasional uses. But as a way of finding out what is wrong inside a uterus, it has a basic flaw: it is done without seeing.

A curette scrapes the lining in broad sweeps. A polyp tucked into a cornu, a small submucous fibroid, a patch of abnormal lining in one area — all of these can be missed, and the pathology report comes back reassuringly normal while the problem stays exactly where it was. Women are then told nothing is wrong, and go on bleeding.

Hysteroscopy removes that uncertainty. We see the lesion, we take it out under vision, and we confirm at the end that the cavity is clear. The removal is targeted, so healthy endometrium is left alone — which matters greatly if you are hoping to conceive. And repeated blind curettage is itself one of the commonest causes of intrauterine adhesions, the very problem hysteroscopy is often called upon to fix.

The honest counterpoint: hysteroscopy needs specific equipment and training, and if the bleeding is torrential the view can be poor, which is one situation where a curettage may still be the right immediate answer.

Recovery

Day 1. Cramping like a period, easing through the day, and light bleeding or spotting. Ordinary painkillers are enough. Most women eat normally the same evening and sleep well that night.

The first week. Spotting or a light brownish discharge for a few days to a week is expected. Use pads rather than tampons, and avoid intercourse, swimming and douching until the bleeding has stopped. Most women return to office work in one to three days. After a purely diagnostic hysteroscopy, many are back the next day.

Weeks 2 to 4. Everything back to normal — exercise, travel, intercourse, lifting. Your next period may come a little early or late, and may be heavier or lighter than usual for a cycle or two. That is not a sign that something has gone wrong.

By six weeks. After a septal resection, a large fibroid resection or adhesiolysis, we usually look inside again at this point with a short check hysteroscopy, to confirm the cavity has healed into a good shape before you try to conceive. For a simple polypectomy no repeat look is needed.

Call us straight away for fever, foul-smelling discharge, bleeding heavier than a normal period, or pain that is increasing rather than settling.

Risks and complications

• Uterine perforation — making a small hole in the wall of the uterus, most often while dilating a tight cervix. Uncommon; usually managed by simply stopping and allowing it to heal, occasionally needing a laparoscopy to check nothing else was injured.
• Fluid absorption — the distension fluid can be absorbed into the circulation during a long resection, which is why intake and output are measured minute by minute and why we stop at a set limit.
• Bleeding, at the time or in the days afterwards.
• Infection of the uterus, uncommon and treatable with antibiotics.
• Cervical injury or a false passage, more likely when the cervix is tight, as it can be after menopause or a previous caesarean.
• Intrauterine adhesions forming afterwards, particularly after extensive resection — the reason we sometimes use hormonal treatment or a temporary device to keep the walls apart while healing.
• Failure to complete the procedure because of a stenosed cervix, a poor view, or a fibroid too large to remove safely in one sitting.
• Anaesthetic risks, which the anaesthetist will go through with you separately.

Alternatives

Transvaginal ultrasound is the sensible first test and often the only one needed. It shows fibroids, endometrial thickness and ovarian cysts, but it looks at the cavity from the outside.

Saline infusion sonography (SIS) — ultrasound with a little fluid instilled into the cavity — improves the view considerably and is a reasonable alternative when the question is purely diagnostic. It still cannot treat anything.

Endometrial biopsy in the clinic with a fine sampler is quick and useful for assessing the lining in abnormal bleeding, but like a curettage it samples blindly.

Medical treatment genuinely works for many women with heavy bleeding and no structural lesion: tranexamic acid, hormonal tablets, or a hormone-releasing intrauterine device. If your cavity is normal, medication may be all you need.

Laparoscopic or open myomectomy is the route for fibroids sitting in the muscle wall rather than the cavity — our page on laparoscopic myomectomy covers that operation in detail.

Hysterectomy remains the definitive answer for a woman with completed family and persistent heavy bleeding that has not settled with anything else. Most women who come in for a hysteroscopy never need to go down that road.

If you would like the plainer, non-technical version first, we have written a simple guide to hysteroscopy for exactly that purpose, and the advanced laparoscopy and hysteroscopy department page describes the wider range of keyhole work our team does.

What it costs

Hysteroscopy is priced according to what is actually done, so the range depends on whether we are only looking or also treating:

Diagnostic hysteroscopy: ₹19,000 – ₹31,000 Hysteroscopic polypectomy: ₹27,000 – ₹46,000 Septal resection: ₹31,000 – ₹52,000 TCRE / hysteroscopic myomectomy: ₹35,000 – ₹58,000

Each figure is all-inclusive — surgeon’s fee, operation theatre, anaesthesia, room rent for a typical stay, medicines and routine investigations.

Please note: The figures above are indicative estimates for a typical case. The final cost depends on your individual condition, the complexity of the surgery, the room category you choose, how long you stay, and any complications that arise. Deluxe and super-deluxe rooms are charged higher. Emergency admissions and night or holiday surgery attract additional charges. These charges are subject to change without prior intimation. Please call us on +91-8668954915 for a written estimate for your own case before you decide anything.

Preparing for your surgery

• Bring all previous ultrasound reports, and any earlier biopsy or operation notes.
• Tell us the first day of your last period. For most indications we schedule the hysteroscopy in the week just after a period, when the lining is thin and the view is at its best.
• Do not have intercourse between your period and the procedure if there is any chance of pregnancy.
• List every medicine you take, including blood thinners — never stop those on your own.
• Mention diabetes, thyroid disease, heart or lung problems, and any previous caesarean or cervical surgery, which can make the cervix tight.
• Routine blood tests and an ECG are usually asked for before admission.
• Sometimes a tablet is given the night before to soften the cervix. Take it exactly as instructed.
• Nothing to eat for six hours and nothing to drink for two hours before surgery, unless told otherwise.
• Bring sanitary pads; expect some bleeding afterwards.
• Have someone accompany you home, since you should not drive on the day of an anaesthetic.
• Keep two to three days free from work — most women need less, but it is easier to have the time and not use it.

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If you have been bleeding heavily for months, or have been told there is “something in the uterus” and are not sure what happens next, bring your scans to the gynaecology team at Shubham Hi-Tech Hospital, Amravati. Very often the answer is a single, short, scar-free procedure — and we will tell you honestly if it is not. Call +91-8668954915, get in touch here, or see all the procedures we perform.

Disclaimer: This article is for general information only and is not a substitute for professional medical advice. Please consult a qualified doctor for guidance specific to your situation.