Hysteroscopy for uterine pathology

Hysteroscopic picture in endometrial pathology

Endometrial hyperplasia

Through endoscopic and histological studies revealed that endometrial hyperplasia (focal and polypoid) occurs more often in women of reproductive age and in premenopause. In these age groups, endometrial hyperplasia takes a leading place in the structure of endometrial pathological processes. In every third patient, endometrial hyperplasia is combined with adenomyosis. Clinical manifestations of endometrial hyperplasia can be both menorrhagia and metrorrhagia. Equally often there can be both delays in menstruation and frequent prolonged bleeding. Abundant hemorrhages leading to anemia were noted in patients with polypoid endometrial hyperplasia.

Hysteroscopic pattern is different and depends on the nature of hyperplasia (normal or polypoid), its prevalence (focal or diffuse), the presence of bleeding and its duration.

With normal hyperplasia and absence of bloody discharge, the endometrium is thickened, forms folds of different heights, pale pink, edematous, a large number of gland ducts (transparent dots) are seen. When the rate of fluid flow changes into the uterine cavity, the undulating movement of the endometrium is noted. If the hysteroscopy is performed with prolonged bloody discharge, more often in the bottom of the uterus and the area of the uterine tubes, fringed fragments of the endometrium are pale pink. The rest of the endometrium is thin and pale. The described hysteroscopic picture is difficult to differentiate from the endometrium in the phase of early proliferation. The final diagnosis is made with a histological examination of the scraping of the mucous membrane of the uterine cavity.

In the polypoid form of hyperplasia, the uterine cavity throughout the entire process is performed by polypoid growths of the endometrium of a pale pink color, sometimes with bubbles over the surface. Identify multiple endometrial synechiae. The surface of the endometrium looks uneven, forms pits, cysts, grooves of polypoid shape. Their value varies from 0.1x0.3 to 0.5x1.5 cm. As a rule, the described changes are more pronounced in the womb day.

Polypovidnuyu hyperplasia of the endometrium, especially when carrying out hysteroscopy on the eve of menstruation, it is difficult to differentiate from the endometrium in the phase of late secretion.

As can be seen, the hysteroscopic picture with various forms of endometrial hyperplasia can resemble a normal mucosa in one of the phases of the menstrual cycle. In such cases, the nature of the hysteroscopic picture must be compared with the clinical picture of the disease and the day of the menstrual cycle in order to diagnose it.

When comparing the data of hysteroscopy with the results of histological examination of scrapes, the authors of the book found that, despite the variety of hysteroscopic picture in endometrial hyperplasia, the accuracy of diagnosis in this form of pathology is 97.1%.

Adenomatous changes in the endometrium (atypical hyperplasia and focal adenomatosis) are revealed in all age groups of women (more often in reproductive age, less often in the postmenopausal period). Most often this pathology of the endometrium is diagnosed in patients with polycystic ovarian changes and diencephalic syndrome. At a histological examination of the ovaries in women during the pre- and postmenopause, operated on for adenomatous changes in the endometrium, hormonal-active structures (such as stromal hyperplasia, tekomatosis) were often found in ovarian tissue.

Clinical manifestations of focal adenomatosis and atypical hyperplasia include, as a rule, metrorrhagia and spotting in postmenopausal women.

Atypical hyperplasia of the endometrium and focal adenomatosis do not have characteristic endoscopic criteria, and their hysteroscopic pattern resembles the usual glandular-cystic hyperplasia. In the severe form of atypical hyperplasia, glandular polypoid dull growths of a yellowish or grayish color can be seen. More often they have a colorful appearance - yellowish-grayish with a whitish coating. Usually the final diagnosis is made after a histological examination.

Endometrial polyps are the most frequent pathology of the endometrium (53.6%), which is detected in postmenopausal women. In 70% of patients in history, from 2 to 7 diagnostic curettage of the uterine cavity, and histological examination of the material obtained by scraping, found polyps or scraps of atrophic endometrium. These data indicate that when scraping without hysteroscopy, polyps were not completely removed, hormone therapy was ineffective.

Polyps of the endometrium may be accompanied by spotting from the genital tract. With asymptomatic flow, they are a diagnostic finding, identified with ultrasound. According to the authors, in 35% of patients with polyps of the cervical canal in the uterine cavity, endometrial polyps are detected. Patients in the postmenopausal period often in the cervical canal determine the polyp, coming from the bottom of the uterus. Therefore, for polyps the cervix is recommended to perform a polypectomy under the control of hysteroscopy.

The histological structure distinguishes fibrous, glandular-cystic, glandular fibrotic and adenomatous polyps of the endometrium.

Fibrous polyps of the endometrium in hysteroscopy are defined as single formations of pale color, round or oval, more often of small sizes (from 0.5x1 to 0.5x1.5 cm). These polyps usually have a leg, a dense structure, a smooth surface, are vascularized slightly. Sometimes fibrotic polyps endometrium reach a large size, then with hysteroscopy, you can admit a diagnostic error: the surface of the polyp, tightly adjacent to the wall of the uterus, take for atrophic mucosa of the uterine cavity. Considering this, when examining the uterine cavity it is necessary to consistently inspect all the walls of the cavity and internal pharynx of the form, reaching the cervical canal of the orifice of the fallopian tubes with a gradual extraction of the telescope to the internal pharynx, to carry out a panoramic view of the uterine cavity and only then finally remove the hysteroscope.

When a polyp is found, it is necessary to examine it from all sides, to assess the magnitude, location, attachment, length of the leg. Fibrous polyps resemble submucosal myomatous nodes, and often there are difficulties in their differentiation.

The glandular cystic polyps of the endometrium, unlike the fibrous ones, are more often large (from 0.5x1 to 5x6 cm). Identified in the form of single formations, but there are simultaneously several polyps. The shape of the polyps can be oblong, conical, irregular (with bridges). The surface is smooth, smooth, in some cases over it appear cystic formations with a thin wall and transparent contents. The color of polyps is pale pink, pale yellow, grayish pink. Often the tip of the polyp is dark purple or cyanotic-purple. On the surface of the polyp, vessels in the form of a capillary network are visible.

Adenomatous polyps of the endometrium are most often located closer to the ovaries of the fallopian tubes and can be of small sizes (from 0.5x1 to 0.5x1.5 cm). They look more dull, gray, friable.

Adenomatous changes can be determined in the tissue of glandular-cystic polyps; in this case, the nature of the polyp in endoscopic examination can not be determined.

A characteristic feature of endometrial polyps is the variability of their shape when the rate of fluid or gas flow into the uterine cavity changes. The polyps are then flattened, enlarged in diameter, and as the pressure decreases, they stretch out and make oscillatory movements.

The results of studies (more than 3000 patients) showed that endometrial polyps in postmenopause are more often single, less often 2 and very rarely 3 polyps. Polyps of the endometrium in postmenopause are always determined against the background of an atrophic mucosa. In the reproductive age and premenopausal, endometrial polyps can be visualized both against the background of endometrial hyperplasia and in the normal mucosa in various phases of the menstrual cycle.

Differences in the data of hysteroscopy with the results of a histological diagnosis in patients with endometrial polyps have practically not been noted by the authors of the book.

The term "endometrial polyposis" includes both polypoid endometrial hyperplasia and individual multiple endometrial polyps. The hysteroscopic picture is very similar. The diagnosis, as a rule, is established by the histologist.

Endometrial cancer is most often diagnosed in postmenopausal women with pathological vagaries from the genital tract (bloody, watery, purulent). At this age, with hysteroscopy, endometrial cancer is diagnosed in almost 100% of cases. At the same time, papillomatous growths of grayish or dirty-gray color of various forms with areas of hemorrhages and necrosis are determined. When the rate of fluid supply to the uterine cavity varies, the tissue easily disintegrates, tears away, crumbles, and bleeds. Hysteroscopy allows not only to diagnose the disease, but also to conduct a targeted biopsy, to determine the localization and prevalence of the process, and in some cases, to identify germination in the myometrium. Typical is the erosion of the wall at the site of the lesion (crater), the muscle tissue is uncovered, the fibers are located in different directions. In such cases, you should be careful, since it is possible to perforate the thin wall of the uterus with a rigid hysteroscope.

Hysteroscopic criteria determining the prognosis and treatment tactics include the exact size of the uterus, the involvement of the cervical canal or its stromal component in the mucosa process, germination into the myometrium, the size of the tumor and its localization. With the widespread cancer of the endometrium, it is not advisable to try to remove the tumor, just take the tissue for histological examination.

Hysteroscopic picture with uterine myoma, adenomyosis and other forms of intrauterine pathology

[1], [2], [3], [4]

Submucous uterine myoma

Submucous myomatous nodes are more often single, less often - multiple. They are detected mainly in patients of reproductive age and in premenopauia. Submucous myomatous nodes are rarely diagnosed in the postmenopausal period and in girls under 18 years of age. The main complaint is uterine bleeding, usually abundant and painful, leading to anemia. Often, submucous myoma becomes the cause of miscarriage, infertility, premature birth.

Hysteroscopy with high accuracy allows to diagnose submucous nodes even at small sizes. Defect filling in the uterine cavity is usually detected with ultrasound or metrography, but hysteroscopy is necessary to determine the nature of this defect. Submucosal nodes often have a spherical shape, clear contours, whitish color, dense consistency (determined when touching the tip of the hysteroscope), deform the uterine cavity. On the surface of the node, small or large hemorrhages can be seen, sometimes a network of dilated and dilated blood vessels covered with a thin endometrium is seen. When the rate of fluid supply to the uterine cavity changes, submucous myoma nodes do not change shape and size, which is the main distinguishing feature of the endometrial polyp.

Interstitial-submucous myomatous nodes with hysteroscopy are visualized as a bulging of one of the walls of the uterus. The degree of bulging depends on the size and nature of the growth of the myomatous node. The endometrium above the surface of the node is thin, pale, the outlines of the formation are clear.

According to the authors of the book, in every third patient submucosal nodes are combined with the hyperplastic process of the endometrium or adenomyosis. Double pathology should always attract close attention due to the difficulties in determining the tactics of treatment.

Submucosal myomatous nodes are usually easy to identify. But in the presence of a large node that performs almost the entire cavity of the uterus, as well as with a large endometrial polyps, there may be diagnostic errors. The telescope gets between the wall of the uterus and the node, and the uterine cavity at the same time looks slit-shaped.

When a submucosal node is detected, its size, localization, and width of the base are determined. It is important to examine it from all sides to determine the ratio of the values of intramural and submucosal components. All these indicators are important for selecting the method of node removal and assessing the need for hormonal preoperative preparation.

There are several classifications of submucous nodes. According to metrography Donnez et al. (1993) proposed the following classification:

1. Submucosal nodes, mainly located in the uterine cavity.
2. Submucosal nodes, mainly located in the wall of the uterus.
3. Multiple submucosal nodes (more than 2).

In 1995, the European Association of Hysteroscopists (EAG) adopted a hysteroscopic classification of submucous nodes, proposed by Wamsteker and de Blok, which determines the type of nodes depending on the intramural component:

• 0. Submucosal nodes on a pedicle without an intramural component.
• I. Submucous nodes on a broad base with an intramural component of less than 50%.
• II. Myomatous nodes with an intramural component of 50% or more.

Both classifications are convenient for choosing a method of treatment.

Adenomyosis

The most difficult for diagnosis type of pathology, with a large number of false positives and false negative results. In the structure of gynecological diseases, adenomyosis is the third most frequent after inflammatory diseases of the genitals and uterine myomas. Clinical manifestations of adenomyosis depend on the severity of the process and its localization. The most frequent complaint is copious and painful (in the first 1-2 days) menstruation. With the cervical form of adenomyosis, there may be contact bloody discharge along with very abundant menstrual bleeding.

The detection of adenomyosis with hysteroscopy requires a lot of experience. Sometimes for accurate diagnosis of hysteroscopy data is not enough, in these cases, they must be supported by ultrasound data in dynamics and metrography. Currently, the most informative method for diagnosis of adenomyosis is magnetic resonance imaging (MRI), but because of the high cost and low availability, this method is rarely used.

Hysteroscopic signs of adenomyosis are different and depend on its form and severity. The best time to start this pathology is the 5th-6th day of the menstrual cycle. Adenomyosis can have the form of eyes of a dark purple or black color, point or slit-shaped (blood may be released from the eyes); possibly changing the walls of the uterus in the form of ridges or knotty bulging.

According to the authors of the book, in 30% of patients a combination of adenomyosis and hyperplastic endometrium is revealed. In this case, adenomyosis can be detected only with control hysteroscopy after removal of hyperplastic endometrium.

A hysteroscopic classification of adenomyosis has also been developed. According to the degree of expression, the authors of the book distinguish three stages of adenomyosis.

• I stage. The relief of the walls is not changed, endometriotic passages are defined in the form of eye sights of dark-cyanotic color or open, bleeding (blood flowing in a trickle). The walls of the uterus when scraping out the usual density.
• II stage. The relief of the walls of the uterus (often the posterior one) is uneven, has the form of longitudinal or transverse ridges or deflected muscle fibers, and endometriotic passages are seen. The walls of the uterus are rigid, the uterine cavity is poorly stretched. When scraping the walls of the uterus is denser than usual.
• III stage. On the inner surface of the uterus, bulging of different sizes without clear contours is determined. On the surface of these bulging, endometriotic passages are sometimes visible, open or closed. When scraping, the uneven surface of the wall, the ribbing, the walls of the uterus are dense, a characteristic creak is heard.

It is important to know the characteristic signs of cervical adenomyosis - an uneven relief of the uterine wall at the level of the internal pharynx and endometriotic passages, from which a stream follows blood (a symptom of "blizzard").

This classification allows you to determine the tactics of treatment. At the first stage of adenomyosis, the authors of the book consider it appropriate hormonal therapy. At the II stage at the first stage hormonal therapy is shown, however absence of effect from treatment in the first 3 months serves as an indication for operative treatment. The third stage of adenomyosis at the first detection is the indication for the operation. Cervical adenomyosis is an indication for the extirpation of the uterus. Intrauterine synechia. For the first time, intrauterine adhesions, or synechia, arising after curettage of the uterus, were described by Fritsch in 1854, but Asherman proved their clinical significance in 1948 on the example of a patient with secondary amenorrhea after traumatic birth. Since then, the common term for intrauterine synechia has become Asherman's syndrome. Synechia, partially or completely overlapping the uterine cavity, causes menstrual irregularities until amenorrhea, infertility or miscarriage, depending on the prevalence of the process. It is proved that in women with intrauterine synechiae, placenta previa and accretion are more common.

[5], [6], [7], [8], [9]

Intrauterine synechiae

Normal endometrium consists of three layers: basal (functioning, 25% of the total thickness of the endometrium), medium (25%) and functional (50%). During the menstruation, the last two layers are rejected.

At present, there are several theories of the occurrence of intrauterine synechia: infectious, traumatic, neuroscientific. However, the main factor is the mechanical trauma of the basal layer of the endometrium in the wound phase after childbirth or abortion, infection is a secondary factor. The first 4 weeks after childbirth or termination of pregnancy is considered the most dangerous because of possible trauma to the mucous membrane of the uterus. The risk of intrauterine synechia is high in patients with "frozen" pregnancy. After scraping the uterine cavity, they develop intrauterine synechia more often than in patients with incomplete abortions. This is due to the fact that in response to the remaining placental tissue fibroblasts are activated and collagen is formed before the endometrium regeneration. Sometimes intrauterine synechia develops after surgical interventions on the uterus, such as conization of the cervix, myomectomy, metroplasty or diagnostic curettage of the uterine cavity. After endometritis, especially tubercular etiology, intrauterine synechia accompanied by amenorrhea may also appear. Also one of the provoking factors of the occurrence of synechia can be VMK.

However, with the same damage, some women develop synechia, while others do not. Therefore, they believe that everything depends on the individual characteristics of the organism.

Depending on the degree of infection of the uterine cavity, the following symptoms of intrauterine synechia are distinguished: hypomenstrual syndrome or amenorrhea and infertility. If the lower part of the uterus cavity with the normal functioning endometrium is infected, a hematometer may develop in its upper part. Significant infection of the uterine cavity and a lack of normally functioning endometrium lead to difficulty in implantation of the fetal egg.

When pregnancy occurs on the background of intrauterine synechia, a spontaneous abortion occurs in 1/3 of women, 1/3 - premature births and in 1/3 there is abnormal placenta (increment, presentation). Thus, women who become pregnant with intrauterine synechiae are referred to a high-risk group with a high probability of complications during pregnancy, during and after childbirth. In the case of intrauterine synechia, surgical treatment is necessary.

If there is a suspicion of intrauterine synechia, hysteroscopy should be performed first. When hysterosalpingography, there are many false positive results due to fragments of the endometrium, mucus, curvature of the uterine cavity. After diagnostic hysteroscopy, if necessary, hysterosalpingography can be performed. Ultrasound also does not provide enough information for intrauterine synechiae. More accurate results can be obtained with ultrasound with contrasting of the uterine cavity, but it can not replace hysteroscopy.

There have been attempts to use MRI to improve the accuracy of intrauterine synechia diagnostics, but there have been no advantages over other methods.

So, the main method of diagnosing intrauterine synechia is hysteroscopy. In hysteroscopy, synechiae is defined as whitish, avascular cords of varying length, density, and length, located between the walls of the uterus, often decreasing the volume of its cavity, and sometimes completely obliterating it.

Synechia can also be located in the cervical canal, which leads to its infection. Delicate sinhyas look like strands of pale pink color (similar to cobwebs), sometimes the vessels passing through them are visible.

Denser synechiae are defined as whitish cords, usually located along lateral walls and rarely in the center of the uterine cavity.

With multiple transverse sinhychi, a partial incision of the uterine cavity occurs, with the formation of a multitude of cavities of various sizes in the form of depressions (orifices). Sometimes they mistakenly take the mouth of the fallopian tubes.

Carrying out a hysteroscopy for suspected intrauterine synechia, one should not probe the uterine cavity. It is better to use a hysteroscope with a diagnostic casing. Before the expansion of the cervical canal, it is necessary to carefully examine the entrance to the cervical canal, determine its direction. Expand the cervical canal carefully, without effort to avoid creating a false path or perforation of the uterus. This is especially important with secondary amenorrhea and a suspected full infection of the uterine cavity. The hysteroscope is guided through the cervical canal under visual control with a constant supply of fluid under pressure to expand the uterine cavity. If cervical ducts identify synechia, they are gradually destroyed by hydraulic dissection, scissors or forceps. In the future, when diagnostic hysteroscopy determine the type and extent of synechia, the extent of infection of the uterine cavity, examine the area of the uterine tubes. If a significant part of the uterus cavity is occupied by the synechiae, it is impossible to thoroughly examine it with hysteroscopy. In such cases, hysterosalpingography is necessary.

There are several classifications of intrauterine synechia.

According to the histological structure, Sugimoto (1978) distinguishes three types of intrauterine synechia:

1. Lungs - synechiae in the form of a film, usually consisting of basal endometrium; Easily dissected by the tip of the hysteroscope.
2. The averages are fibrous-muscular, covered with endometrium, bleed during dissection.
3. Heavy - connective tissue, dense synechia, usually do not bleed when dissected, severely dissect.

In terms of prevalence and extent of involvement of the uterus cavity, March and Izrael (1981) proposed the following classification:

• I degree. Less than 1/4 of the uterine cavity is involved, thin spikes, the bottom and mouth of the tubes are free.
• II degree. Involved from 1/4 to 3/4 of the uterine cavity, there is no blocking of the walls, only the adhesions, the bottom and mouth of the tubes are partially closed.
• III degree. More than 3/4 of the uterine cavity is involved.

Since 1995, in Europe, the classification adopted by the European Association of Gynecological Endoscopists (ESH), proposed by Wamsteker and de Block (1993), is used. This classification distinguishes 5 degrees of intrauterine synechia on the basis of hysterography and hysteroscopy data, depending on the state and extent of synechia, the occlusion of the uterine tubes and the degree of endometrial damage.

• I. Thin, gentle synechia, easily destroyed by the hysteroscope body, the areas of the uterine tube mouths are free.
• II. A single dense sinchia, connecting separate isolated areas of the uterine cavity, usually seen the mouths of both fallopian tubes, can not be destroyed only by the hysteroscope body.
• IIa. Synechia only in the area of internal pharynx, the upper parts of the uterine cavity are normal.
• III. Multiple dense synechia, connecting separate isolated areas of the uterine cavity, unilateral obliteration of the uterus of the uterine tubes.
• IV. Extensive dense synechiae with partial occlusion of the uterine cavity, the mouth of both fallopian tubes are partially closed.
• Va. Extensive scarring and fibrosis of the endometrium in combination with I or II degree, with amenorrhea or apparent hypomenorrhea.
• Vb. Extensive scarring and endometrial fibrosis in combination with grade III or IV with amenorrhea.

In the USA in 1988, the classification of the American Association for Infertility (AAB) was adopted. This classification is somewhat cumbersome, since scoring is carried out in three sections: the degree of involvement of the uterine cavity, the type of synechia and the violation of menstrual function (depending on the severity of these indicators). Then the points are counted. There are three stages: weak (I), medium (II) and heavy (III).

Classification of intrauterine synechia of AAB

The degree of involvement of the uterine cavity	<1/3 - 1 point	1/3 - 2/3 - 2 points	2/3 - 4 points
Type of synagogue	Gentle - 1 point	Tender and dense - 2 points	Dense - 4 points
Violation of menstruation	Norm - 0 points	Hypomenorrhœa - 2 points	Amenorrhea - 4 points

The scores are calculated separately according to the data of hysteroscopy and hysterosalpingography.

• Stage I -1-4 points.
• Stage II - 5-8 points.
• Stage III - 9-12 points.

I and II degrees according to EAG corresponds to stage I in AAB, III degree according to EAG corresponds to II stage in AAB, IV and V degrees in EAG - III stage in AAB.

The septum in the uterus cavity

In the process of embryogenesis, the uterus is formed from mullerian ducts. As a result of canalization and reverse resorption of the median septum (usually by the 19-20th week of pregnancy) a single uterine cavity is formed. Under the influence of unfavorable factors, there is no complete resolution of the middle septum in this period, an abnormality of the uterus is formed. Malformations of the uterus are often combined with anomalies of the urinary tract.

The septum in the uterus is detected in approximately 2-3% of women in the general population.

Women with a septum in the uterus usually suffer from miscarriage, less often infertility. Possible mechanisms of the influence of the septum during pregnancy:

1. Insufficient volume of the uterine cavity; The septum can not adapt to an increase in uterine size during pregnancy.
2. Isthmiko-cervical insufficiency, often combined with a uterine septum.
3. Implantation of the embryo on the septum, deprived of blood vessels.

Of great importance is the length of the septum. More often the pathology of pregnancy occurs with a full septum in the uterus.

With a septum in the uterus, frequent symptoms are dysmenorrhea and abnormal uterine bleeding.

As a rule, the septum in the uterus is detected either by careful examination of the patient with miscarriage (hysterosalpingography), or accidentally when the uterine cavity is scraped or manually examined after delivery (there is a suspicion of an anomaly of development).

At the first stage, hysterosalpingography is performed). This method allows you to determine only the inner contours of the uterine cavity, while the outer contours are not visible, so an error in determining the type of uterine defect is possible. In hysterosalpingography, it is difficult to differentiate the septum in the uterus with a two-legged uterus. Siegler (1967) proposed hysterographic diagnostic criteria for various malformations of the uterus:

1. In the two-horned and doubled uterus, the cavity halves have an arcuate (convex) median wall and the angle between them is usually more than 90 °.
2. With the septum in the uterine cavity, the median walls are straight (straight) and the angle between them is usually less than 90 °.

In practice, even with these criteria in mind, errors in the differential diagnosis of various malformations of the uterus are possible. The greatest importance in this case is the examination of the uterine surface from the side of the abdominal cavity. For this reason, and hysteroscopy does not accurately determine the type of malformation of the uterus.

Ultrasound is also used for diagnosis, but its informativeness is also low.

With maximum accuracy, the nature of the defect can be determined with MRI, but this technique, because of its high cost, has not found wide application. The most complete information on the nature of the developmental defects of the uterus is provided by hysteroscopy, supplemented by laparoscopy. When hysteroscopy is necessary to determine the thickness and extent of the septum.

The septum can be complete, reaching the cervical canal, and incomplete. When the hysteroscope is at the level of the internal pharynx, two dark holes separated by a whitish strip can be seen in the cervical canal. If the septum is thick, difficulties arise in the differentiation of pathology with the two-legged uterus. If the hysteroscope with a full septum immediately enters one of the cavities, the diagnosis may be erroneous. Therefore, you must always remember the landmarks - the mouths of the fallopian tubes. If only one mouth of the tube is seen, it is necessary to exclude the development of the uterus. Most often the septum is longitudinal and has a length of 1-6 cm, but there are also transverse septa. The longitudinal partition can be defined as a triangle, the base of which is thickened and located in the bottom of the uterus. Rarely there are septa in the cervical canal. More precisely, the type of developmental defect in the uterus, especially with a thick and complete septum in the uterus, can be supplemented by hysteroscopy with hysterosalpingography and laparoscopy.

When revealing the defect of the development of the uterus, it is necessary to conduct a complete urological examination because of the frequent combination of this pathology with the developmental defects of the urinary system.

Foreign bodies in the uterus cavity

Intrauterine device. Indications for hysteroscopy include an unsuccessful attempt to remove IUD by other methods, fragments of the contraceptive remaining in the uterine cavity after its unsuccessful removal, and suspicion of perforation of the uterus of the IUD. Prolonged stay of the contraceptive in the uterine cavity sometimes results in its tight attachment and even ingrowth into the thickness of the myometrium. Attempts to remove it in such situations are unsuccessful. Hysteroscopy allows to determine the localization of IUDs or fragments thereof and to remove them precisely.

The endoscopic picture depends on the type of IUD and the time of the study. When the IUD is in the uterus for a long time, it is partially covered with synechia and endometrial flaps. If hysteroscopy is carried out with suspicion of remnants of IUD fragments, the examination should be carried out in the early phase of proliferation, carefully examining all the walls of the uterus. If uterine perforation is diagnosed, the hysteroscopy is supplemented with laparoscopy.

Remnants of bone fragments are usually a random finding in women with menstrual irregularities, long-term endometritis or secondary infertility. With careful collection of anamnesis, early abortions of pregnancy are detected at a long period (13-14 weeks or more), usually complicated by prolonged bleeding. Hysteroscopic picture depends on the duration of the presence of bone fragments in the uterine cavity. If the period is relatively small, dense lamellate whitish formations are seen, embedded in the uterine wall and having sharp edges. When you try to remove them, the wall of the uterus begins to bleed.

If the bone fragments were in the uterine cavity for a long time (more than 5 years), they have a characteristic crystalline structure (coral form), and when they try to remove them, the forceps disintegrate like sand. Most often, bone fragments are located in the area of the ovaries of the fallopian tubes and the bottom of the uterus.

Ligatures, usually silk or lavsan, are detected in patients with chronic endometritis and pyometra, having a history of caesarean section or conservative myomectomy. These women complain of persistent purulent discharge from the genital tract, not amenable to massive antibiotic therapy, and secondary infertility. When hysteroscopy against a background of general hyperemia of the uterine mucosa in its lower third along the anterior wall (after caesarean section) or in various parts of the uterus wall (after a conservative myomectomy), whitish ligatures are determined, partially released into the uterine cavity.

Remnants of the fetal egg or placenta are defined as a formless tissue of dark purple or yellowish-whitish color with hemorrhages of various sizes, often located on the bottom of the uterus. Often, at the same time in the uterine cavity, blood clots and mucus that are easily removed by the washing liquid are detected. Accurate knowledge of the localization of pathological tissue allows you to accurately remove it without injuring the surrounding endometrium.

[10], [11], [12]

Chronic endometritis

When hysteroscopy has specific signs, they are determined in the early phase of proliferation (preferably on the 1st day). The surface of the uterine wall is hyperemic, bright red, the wall is light-legged, bleeding at the slightest touch, the walls of the uterus flabby. Can be determined whitish or yellowish color - areas of hypertrophic edema of the uterine mucosa.

When macrohysteroscopy against the background of general hyperemia, ducts of gland of whitish color ("strawberry field") are visible.

Chronic endometritis can be diagnosed only hysteroscopically, a histological examination is necessary.

Uterine pregnancy of small term. The hysteroscopic picture is characterized by the presence of a juicy mucous membrane of a pale pink color, one of which shows a white thickening. When the degree of filling the uterine cavity with the injected fluid, it is possible to detect fluctuations in the chorionic villi. At a detailed examination it is possible to select the membranes of the fetal bladder with the vascular pattern.

Of course, hysteroscopy is not performed to detect uterine pregnancy. Data on the hysteroscopic picture were obtained during differential diagnosis between ectopic and uterine pregnancy. Desired pregnancy is a contraindication for hysteroscopy due to the high risk of its interruption.

Thus, for today hysteroscopy is a safe and highly informative method for diagnosing the pathological processes of the endometrium and intrauterine pathology. This method allows you to determine not only the nature of the pathology, but also its exact localization, prevalence, and choose the appropriate method of treatment. In some cases, diagnostic hysteroscopy can be translated into an operative one.

[13], [14], [15], [16], [17],