Hysteroscopy for uterine pathology

Hysteroscopic picture of endometrial pathology

Endometrial hyperplasia

Endoscopic and histological studies have shown that endometrial hyperplasia (focal and polypoid) occurs more often in women of reproductive age and in premenopause. In these age groups, endometrial hyperplasia occupies a leading place in the structure of pathological processes of the endometrium. In every third patient, endometrial hyperplasia is combined with adenomyosis. Clinical manifestations of endometrial hyperplasia can be both menorrhagia and metrorrhagia. Delays in menstruation and frequent prolonged bleeding can be equally common. Heavy bleeding leading to anemia is noted in patients with the polypoid form of endometrial hyperplasia.

The hysteroscopic picture can be different and depends on the nature of the hyperplasia (normal or polypoid), its prevalence (focal or diffuse), the presence of bleeding and its duration.

In normal hyperplasia and the absence of bloody discharge, the endometrium is thickened, forms folds of varying height, is pale pink, edematous, and a large number of gland ducts are visible (transparent dots). When the fluid flow rate into the uterine cavity changes, a wave-like movement of the endometrium is noted. If hysteroscopy is performed with prolonged bloody discharge, fringed scraps of pale pink endometrium are most often determined in the fundus of the uterus and the area of the mouths of the fallopian tubes. The rest of the endometrium is thin and pale. The described hysteroscopic picture is difficult to differentiate from the endometrium in the early proliferation phase. The final diagnosis is made by histological examination of a scraping of the mucous membrane of the uterine cavity.

In the polypoid form of hyperplasia, the uterine cavity is filled with polypoid growths of the endometrium of a pale pink color, sometimes with bubbles on the surface. Multiple endometrial synechiae are detected. The surface of the endometrium looks uneven, forms pits, cysts, grooves of a polypoid shape. Their size varies from 0.1x0.3 to 0.5x1.5 cm. As a rule, the described changes are more pronounced in the bottom of the uterus.

Polypoid hyperplasia of the endometrium, especially when performing hysteroscopy on the eve of menstruation, is difficult to differentiate from the endometrium in the late secretory phase.

As can be seen, the hysteroscopic picture in various forms of endometrial hyperplasia may resemble a normal mucous membrane in one of the phases of the menstrual cycle. In such cases, to establish a diagnosis, it is necessary to compare the nature of the hysteroscopic picture with the clinical picture of the disease and the day of the menstrual cycle.

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

Adenomatous changes in the endometrium (atypical hyperplasia and focal adenomatosis) are detected 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 changes in the ovaries and diencephalic syndrome. During histological examination of the ovaries in women in the pre- and postmenopausal period, operated on for adenomatous changes in the endometrium, hormonally active structures (thecoma, stromal hyperplasia, thecomatosis) were often found in the ovarian tissue.

Clinical manifestations of focal adenomatosis and atypical hyperplasia typically include metrorrhagia and postmenopausal bleeding.

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

Endometrial polyps are the most common pathology of the endometrium (53.6%) detected in women during the postmenopausal period. In 70% of patients, a history of 2 to 7 diagnostic curettage of the uterine cavity is noted, and histological examination of the material obtained during curettage revealed polyps or fragments of atrophic endometrium. These data indicate that during curettage performed without hysteroscopy, polyps were not completely removed, and hormonal therapy was ineffective.

Endometrial polyps may be accompanied by bloody discharge from the genital tract. In asymptomatic cases, they may be a diagnostic finding detected by ultrasound. According to the authors, 35% of patients with cervical polyps have endometrial polyps in the uterine cavity. In postmenopausal patients, a polyp originating from the fundus of the uterus is often detected in the cervical canal. Therefore, in case of cervical polyps, it is recommended to perform polypectomy under hysteroscopy.

According to the histological structure, fibrous, glandular-cystic, glandular-fibrous and adenomatous endometrial polyps are distinguished.

Fibrous polyps of the endometrium are determined in hysteroscopy as single formations of pale color, round or oval shape, often small in size (from 0.5x1 to 0.5x1.5 cm). These polyps usually have a stalk, dense structure, smooth surface, are slightly vascularized. Sometimes fibrous polyps of the endometrium reach large sizes, then during hysteroscopy a diagnostic error can be made: the surface of the polyp, tightly adjacent to the wall of the uterus, can be mistaken for an atrophic mucous membrane of the uterine cavity. Taking this into account, when examining the uterine cavity, it is necessary to consistently examine all the walls of the cavity and the internal os of the form, reaching the cervical canal of the mouth of the fallopian tubes with gradual removal of the telescope to the internal os, conduct a panoramic view of the uterine cavity and only then finally remove the hysteroscope.

When a polyp is detected, it is necessary to examine it from all sides, assess its size, location, attachment site, and stalk length. Fibrous polyps resemble submucous myomatous nodes, and it is often difficult to differentiate them.

Glandular-cystic polyps of the endometrium, unlike fibrous ones, are often larger in size (from 0.5x1 to 5x6 cm). They are defined as single formations, but several polyps can be found simultaneously. The shape of the polyps can be oblong, conical, irregular (with bridges). The surface is smooth, even, in some cases cystic formations with a thin wall and transparent contents protrude above it. The color of the polyps is pale pink, pale yellow, grayish-pink. Often the top of the polyp is dark purple or bluish-purple. Vessels in the form of a capillary network are visible on the surface of the polyp.

Adenomatous polyps of the endometrium are most often localized closer to the mouths of the fallopian tubes and are small in size (from 0.5x1 to 0.5x1.5 cm). They look duller, gray, and loose.

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

A characteristic feature of endometrial polyps is the variability of their shape when the rate of fluid or gas supply to the uterine cavity changes. The polyps flatten, increase in diameter, and when the pressure decreases, they stretch out and perform oscillatory movements.

The results of studies (more than 3000 patients) showed that endometrial polyps in postmenopause are more often single, 2 and very rarely - 3 polyps are detected. Endometrial polyps in postmenopause are always determined against the background of an atrophic mucous membrane. In reproductive age and premenopause, endometrial polyps can be visualized both against the background of endometrial hyperplasia and with a normal mucous membrane in various phases of the menstrual cycle.

The authors of the book noted virtually no discrepancies between hysteroscopy data and the results of histological diagnosis in patients with endometrial polyps.

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

Endometrial cancer is most often detected in postmenopausal patients with pathological discharge from the genital tract (bloody, watery, purulent). At this age, hysteroscopy diagnoses endometrial cancer in almost 100% of cases. In this case, papillomatous growths of a grayish or dirty gray color of various shapes with areas of hemorrhage and necrosis are determined. When the rate of fluid supply to the uterine cavity changes, the tissue easily disintegrates, is rejected, crumbles, and bleeds. Hysteroscopy allows not only to diagnose the disease, but also to conduct a targeted biopsy, determine the localization and prevalence of the process, and in some cases, to detect germination into the myometrium. The wall is typically corroded at the site of the lesion (crater), the muscle tissue is frayed, the fibers are located in different directions. In such cases, caution should be exercised, since perforation of the thin wall of the uterus with a rigid hysteroscope is possible.

Hysteroscopic criteria determining the prognosis and treatment tactics include the exact size of the uterus, involvement of the mucous membrane of the cervical canal or its stromal component, growth into the myometrium, tumor size and its localization. In the case of widespread endometrial cancer, it is inappropriate to try to remove the tumor; it is sufficient to take tissue for histological examination.

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

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Submucous uterine myoma

Submucous myomatous nodes are often single, less often - multiple. They are detected mainly in patients of reproductive age and in premenopause. 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 heavy and painful, leading to anemia. Submucous myoma often causes miscarriage, infertility, premature birth.

Hysteroscopy allows for the high accuracy of diagnosing submucous nodes even if they are small. A filling defect in the uterine cavity is usually detected by ultrasound or metrography, but hysteroscopy is necessary to determine the nature of this defect. Submucous nodes are often spherical in shape, have clear contours, are whitish in color, have a dense consistency (determined by touching with the tip of a hysteroscope), and deform the uterine cavity. Small-point or extensive hemorrhages may be visible on the surface of the node, and sometimes a network of stretched and dilated blood vessels covered with thinned endometrium is visible. When the rate of fluid supply to the uterine cavity changes, submucous myomatous nodes do not change shape and size, which is the main distinguishing feature from an endometrial polyp.

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

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

Submucous myomatous nodes are usually easy to identify. But in the presence of a large node that fills almost the entire uterine cavity, as well as with a large endometrial polyp, diagnostic errors may occur. The telescope gets between the uterine wall and the node, and the uterine cavity looks slit-like.

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

There are several classifications of submucous nodes. Based on metrography data, Donnez et al. (1993) proposed the following classification:

1. Submucous 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 (EAH) adopted the hysteroscopic classification of submucosal nodes proposed by Wamsteker and de Blok, which determines the type of nodes depending on the intramural component:

• 0. Submucosal nodes on a peduncle 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 treatment method.

Adenomyosis

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

Detection of adenomyosis by hysteroscopy requires extensive experience. Sometimes hysteroscopy data are not enough for accurate diagnosis; in these cases, they must be supported by dynamic ultrasound and metrography data. Currently, the most informative method for diagnosing adenomyosis is magnetic resonance imaging (MRI), but due to its high cost and low availability, this method is rarely used.

Hysteroscopic signs of adenomyosis vary and depend on its form and severity. The best time to detect this pathology is the 5th-6th day of the menstrual cycle. Adenomyosis may look like dark purple or black eyes, dotted or slit-shaped (blood may be released from the eyes); changes in the uterine wall in the form of ridges or nodular protrusions are possible.

According to the authors of the book, 30% of patients have a combination of adenomyosis and endometrial hyperplasia. In this case, adenomyosis can only be detected by control hysteroscopy after removal of the hyperplastic endometrium.

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

• Stage I. The relief of the walls is unchanged, endometrioid passages are determined in the form of dark-blue eyes or open, bleeding (blood is released in a trickle). The walls of the uterus are of normal density during curettage.
• Stage II. The relief of the uterine walls (usually the posterior one) is uneven, has the appearance of longitudinal or transverse ridges or frayed muscle fibers, endometrioid passages are visible. The walls of the uterus are rigid, the uterine cavity is poorly stretchable. When scraping, the walls of the uterus are denser than usual.
• Stage III. On the inner surface of the uterus, bulges of various sizes without clear contours are determined. On the surface of these bulges, endometrioid passages, open or closed, are sometimes visible. When scraping, an uneven surface of the wall, ribbing, dense walls of the uterus are felt, a characteristic creaking sound is heard.

It is important to know the characteristic signs of cervical adenomyosis - uneven relief of the uterine wall at the level of the internal os and endometrioid ducts from which blood flows in a trickle (the "blizzard" symptom).

This classification helps to determine the treatment tactics. At stage I of adenomyosis, the authors of the book consider hormonal therapy to be appropriate. At stage II, hormonal therapy is indicated at the first stage, but the lack of effect from treatment in the first 3 months serves as an indication for surgical treatment. Stage III of adenomyosis at first detection is an indication for surgery. Cervical adenomyosis is an indication for extirpation of the uterus. B. Intrauterine adhesions. Intrauterine adhesions, or synechiae, that arose after curettage of the uterine cavity were first described by Fritsch in 1854, but their clinical significance was proven by Asherman in 1948 using the example of a patient with secondary amenorrhea after traumatic childbirth. Since then, Asherman's syndrome has become the generally accepted term for intrauterine adhesions. Adhesions that partially or completely block the uterine cavity cause menstrual cycle disorders up to amenorrhea, infertility or miscarriage depending on the prevalence of the process. It has been proven that women with intrauterine adhesions are more likely to have placenta previa and accreta.

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Intrauterine adhesions

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

Currently, there are several theories of the development of intrauterine adhesions: infectious, traumatic, neuroisceral. However, the main factor is considered to be mechanical trauma to 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 are considered the most dangerous due to possible trauma to the uterine mucosa. The risk of developing intrauterine adhesions is high in patients with a "frozen" pregnancy. After curettage of the uterine cavity, they develop intrauterine adhesions more often than patients with incomplete abortions. This is associated with the fact that in response to the remaining placental tissue, fibroblasts are activated and collagen is formed before the regeneration of the endometrium. Sometimes intrauterine adhesions develop after surgical interventions on the uterus, such as conization of the cervix, myomectomy, metroplasty or diagnostic curettage of the uterine cavity. After endometritis, especially of tuberculous etiology, intrauterine adhesions may also appear, accompanied by amenorrhea. Also, one of the factors provoking the occurrence of adhesions may be the intrauterine uterine membrane.

However, with the same injuries, some women develop adhesions, while others do not. Therefore, it is believed that everything depends on the individual characteristics of the body.

Depending on the degree of uterine cavity fusion, the following symptoms of intrauterine adhesions are distinguished: hypomenstrual syndrome or amenorrhea and infertility. In case of fusion of the lower part of the uterine cavity with a normally functioning endometrium, a hematometra may develop in its upper part. Significant fusion of the uterine cavity and the lack of a normally functioning endometrium lead to difficulty in implantation of the fertilized egg.

When pregnancy occurs due to intrauterine adhesions, 1/3 of women have a spontaneous miscarriage, 1/3 have premature birth, and 1/3 have placental pathology (placenta accreta, placenta previa). Thus, women who become pregnant due to intrauterine adhesions are classified as a high-risk group with a high probability of complications during pregnancy, childbirth, and after them. If intrauterine adhesions are detected, surgical treatment is necessary.

If intrauterine adhesions are suspected, hysteroscopy should be performed first. Hysterosalpingography can have many false-positive results due to fragments of the endometrium, mucus, and curvature of the uterine cavity. After diagnostic hysteroscopy, hysterosalpingography can be performed if necessary. Ultrasound also does not provide sufficient information in the case of intrauterine adhesions. More accurate results can be obtained with ultrasound with contrast of the uterine cavity, but it cannot replace hysteroscopy.

There have been attempts to use MRI to improve the accuracy of diagnosing intrauterine adhesions, but no advantages over other methods have been identified.

So, the main method of diagnosing intrauterine adhesions is hysteroscopy. During hysteroscopy, adhesions are determined as whitish avascular strands of varying length, density and extent, located between the walls of the uterus, often reducing the volume of its cavity, and sometimes completely obliterating it.

Synechiae can also be located in the cervical canal, which leads to its overgrowth. Delicate synechiae look like pale pink strands (similar to a web), sometimes the vessels passing through them are visible.

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

In multiple transverse synechiae, partial closure of the uterine cavity occurs with the formation of multiple cavities of varying sizes in the form of depressions (openings). Sometimes they are mistaken for the mouths of the fallopian tubes.

When performing hysteroscopy if intrauterine adhesions are suspected, the uterine cavity should not be probed. It is better to use a hysteroscope with a diagnostic body. Before dilating the cervical canal, it is necessary to carefully examine the entrance to the cervical canal and determine its direction. The cervical canal should be dilated carefully, without force, in order to avoid creating a false passage or perforation of the uterus. This is especially important in secondary amenorrhea and suspected complete closure of the uterine cavity. The hysteroscope is inserted through the cervical canal under visual control with a constant supply of fluid under pressure to dilate the uterine cavity. If adhesions are detected in the cervical canal, they are gradually destroyed using hydraulic dissection, scissors or forceps. Subsequently, during diagnostic hysteroscopy, the type and extent of adhesions, the degree of uterine cavity obstruction are determined, and the area of the fallopian tube orifices is examined. If a significant part of the uterine cavity is occupied by adhesions, it is impossible to examine it thoroughly during hysteroscopy. In such cases, hysterosalpingography is necessary.

There are several classifications of intrauterine adhesions.

Based on histological structure, Sugimoto (1978) distinguishes three types of intrauterine adhesions:

1. Mild - film-like synechiae, usually consisting of basal endometrium; easily dissected with the tip of a hysteroscope.
2. The middle ones are fibromuscular, covered with endometrium, and bleed when cut.
3. Severe - connective tissue, dense adhesions, usually do not bleed when cut, difficult to cut.

According to prevalence and degree of uterine cavity involvement, March and Izrael (1981) proposed the following classification:

• Grade I. Less than 1/4 of the uterine cavity is involved, thin adhesions, the bottom and mouths of the tubes are free.
• II degree. From 1/4 to 3/4 of the uterine cavity is involved, there is no adhesion of the walls, only adhesions, the bottom and mouths of the tubes are partially closed.
• Grade III. More than 3/4 of the uterine cavity is involved.

Since 1995, the classification adopted by the European Society of Gynecologists and Endoscopists (ESH), proposed by Wamsteker and de Block (1993), has been used in Europe. This classification distinguishes 5 degrees of intrauterine adhesions based on hysterography and hysteroscopy data depending on the condition and extent of the adhesions, occlusion of the fallopian tube orifices, and the degree of endometrial damage.

• I. Thin, delicate adhesions are easily destroyed by the body of the hysteroscope, the areas of the mouths of the fallopian tubes are free.
• II. A single dense adhesion connecting separate isolated areas of the uterine cavity, the mouths of both fallopian tubes are usually visible, and cannot be destroyed by the hysteroscope body alone.
• IIa. Adhesions only in the area of the internal os, the upper parts of the uterine cavity are normal.
• III. Multiple dense adhesions connecting separate isolated areas of the uterine cavity, unilateral obliteration of the area of the mouths of the fallopian tubes.
• IV. Extensive dense adhesions with partial occlusion of the uterine cavity, the openings of both fallopian tubes are partially closed.
• Va. Extensive scarring and fibrosis of the endometrium in combination with grade I or II, with amenorrhea or obvious hypomenorrhea.
• Vb. Extensive scarring and fibrosis of the endometrium in combination with grade III or IV amenorrhea.

In the USA, in 1988, the classification of the American Infertility Association (AIA) was adopted. This classification is somewhat cumbersome, since points are calculated in three sections: the degree of involvement of the uterine cavity, the type of adhesion, and menstrual dysfunction (depending on the severity of these indicators). Then the points are calculated. Three stages are distinguished: weak (I), moderate (II), and severe (III).

Classification of intrauterine adhesions AAB

Degree of uterine cavity involvement	<1/3 - 1 point	1/3 - 2/3 - 2 points	2/3 - 4 points
Type of synechia	Tender - 1 point	Tender and dense - 2 points	Dense - 4 points
Menstrual irregularities	Norm - 0 points	Hypomenorrhea - 2 points	Amenorrhea - 4 points

Scoring is carried out separately based on hysteroscopy and hysterosalpingography data.

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

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

Septum in the uterine cavity

During embryogenesis, the uterus is formed from the Müllerian ducts. As a result of canalization and reverse absorption of the median septum (usually by the 19th-20th week of pregnancy), a single uterine cavity is formed. Under the influence of unfavorable factors in this period, complete absorption of the median septum does not occur, and a uterine anomaly is formed. Malformations of the uterus are often combined with urinary tract anomalies.

A uterine septum is found in approximately 2-3% of women in the general population.

Women with a uterine septum usually suffer from miscarriage, and less often, infertility. Possible mechanisms of the septum's influence on the course of pregnancy:

1. Insufficient volume of the uterine cavity; the septum cannot accommodate the increase in the size of the uterus during pregnancy.
2. Isthmic-cervical insufficiency, often combined with uterine septum.
3. Embryo implantation into a septum devoid of blood vessels.

The length of the septum is also of great importance. More often, pregnancy pathology occurs with a complete septum in the uterus.

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

As a rule, a uterine septum is detected either during a thorough examination of a patient with miscarriage (hysterosalpingograph), or accidentally during curettage of the uterine cavity or its manual examination after childbirth (a suspicion of a developmental anomaly arises).

At the first stage, hysterosalpingography is performed. This method allows to determine only the internal contours of the uterine cavity, while the external contours are not visible, therefore an error in determining the type of uterine defect is possible. With hysterosalpingography, it is difficult to differentiate a uterine septum from a bicornuate uterus. Siegler (1967) proposed hysterographic diagnostic criteria for various uterine malformations:

1. In the bicornuate and double uterus, the halves of the cavities have an arcuate (convex) middle wall and the angle between them is usually more than 90°.
2. With a septum in the uterine cavity, the median walls are straight and the angle between them is usually less than 90°.

In practice, even taking these criteria into account, errors in differential diagnostics of various uterine malformations are possible. The most important thing in this case is examination of the uterine surface from the abdominal cavity. For this reason, hysteroscopy does not allow for an accurate determination of the type of uterine malformation.

Ultrasound is also used for diagnostics, but its information content is also low.

The nature of the defect can be determined with maximum accuracy using MRI, but this method has not found wide application due to its high cost. The most complete information about the nature of the uterine malformation is provided by hysteroscopy, supplemented by laparoscopy. During hysteroscopy, it is necessary to determine the thickness and length of the septum.

The septum may be complete, reaching the cervical canal, or incomplete. When the hysteroscope is at the level of the internal os, two dark openings separated by a whitish stripe can be seen in the cervical canal. If the septum is thick, difficulties arise in differentiating pathology with a bicornuate uterus. If the hysteroscope with a complete septum immediately enters one of the cavities, the diagnosis may be erroneous. Therefore, it is always necessary to remember the landmarks - the mouths of the fallopian tubes. If only one mouth of the tube is visible, it is necessary to exclude a malformation of the uterus. Most often, the septum is longitudinal and has a length of 1-6 cm, but transverse septa also occur. A longitudinal septum can be determined as a triangle, the base of which is thickened and is located at the bottom of the uterus. Septa in the cervical canal are rare. It is possible to more accurately determine the type of uterine malformation, especially with a thick and complete uterine septum, by supplementing hysteroscopy with hysterosalpingography and laparoscopy.

If a uterine malformation is detected, a complete urological examination must be performed due to the frequent combination of this pathology with malformations of the urinary system.

Foreign bodies in the uterine cavity

Intrauterine contraceptive. Indications for hysteroscopy include unsuccessful attempts to remove the IUD by other methods, fragments of the contraceptive remaining in the uterine cavity after its unsuccessful removal, and suspected perforation of the uterus by the IUD. Long-term presence of the contraceptive in the uterine cavity sometimes leads to its tight attachment and even ingrowth into the thickness of the myometrium. Attempts to remove it in such situations are unsuccessful. Hysteroscopy allows you to determine the location of the IUD or its fragments and remove them specifically.

The endoscopic picture depends on the type of IUD and the time of the examination. If the IUD is in the uterine cavity for a long time, it is partially covered by adhesions and endometrial flaps. If hysteroscopy is performed due to a suspicion of remnants of IUD fragments, the examination should be performed in the early phase of proliferation, carefully examining all the walls of the uterus. If perforation of the uterus by the IUD is diagnosed, hysteroscopy is supplemented by laparoscopy.

Remains of bone fragments are usually an accidental finding in women with menstrual irregularities, long-term endometritis or secondary infertility. Careful anamnesis collection reveals previous late pregnancy terminations (13-14 weeks or more), usually complicated by prolonged bleeding. The hysteroscopic picture depends on the duration of presence of bone fragments in the uterine cavity. If the period is relatively short, dense lamellar whitish formations are visible, embedded in the uterine wall and having sharp edges. When attempting to remove them, the uterine wall begins to bleed.

If bone fragments have been in the uterine cavity for a long time (more than 5 years), they have a characteristic crystalline structure (coral-like shape) and when trying to remove them with forceps, they crumble like sand. Most often, bone fragments are located in the area of the mouths of the fallopian tubes and the bottom of the uterus.

Ligatures, usually silk or lavsan, are detected in patients with chronic endometritis and pyometra, who have a history of cesarean section or conservative myomectomy. These women complain of constant purulent discharge from the genital tract, which is not amenable to massive antibacterial therapy, and secondary infertility. During hysteroscopy, against the background of general hyperemia of the uterine mucosa in its lower third along the anterior wall (after cesarean section) or in various areas of the uterine wall (after conservative myomectomy), whitish ligatures are detected, partially coming out into the uterine cavity.

The remains of the fertilized egg or placenta are determined as a shapeless tissue of a dark purple or yellowish-whitish color with hemorrhages of varying sizes, most often located at the bottom of the uterus. Often, blood clots and mucus are found in the uterine cavity, which are easily removed with washing fluid. Precise knowledge of the localization of pathological tissue allows for its targeted removal without damaging the surrounding endometrium.

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Chronic endometritis

During hysteroscopy, it 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 easily injured, bleeds at the slightest touch, the walls of the uterus are flabby. Whitish or yellowish islets can be determined - areas of hypertrophied edematous mucous membrane of the uterus.

During macrohysteroscopy, against the background of general hyperemia, whitish gland ducts (“strawberry field”) are visible.

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

Early uterine pregnancy. The hysteroscopic picture is characterized by the presence of a juicy mucous membrane of a pale pink color, in one of the areas of which a white thickening is visible. When the degree of filling of the uterine cavity with the introduced fluid changes, fluctuations of the chorionic villi can be detected. With a detailed examination, it is possible to identify the membranes of the fetal bladder with a vascular pattern.

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

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

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