Indications and contraindications to hysteroscopy

Indications for diagnostic hysteroscopy:

1. Violations of the menstrual cycle in different periods of a woman's life.
2. Bloody discharge in postmenopause.
3. Suspected of the following diseases and conditions:
   • submucosal uterine fibroids;
   • adenomyosis;
   • endometrial cancer;
   • abnormalities of the uterus;
   • intrauterine synechia;
   • remnants of the fetal egg in the uterine cavity;
   • foreign body in the uterine cavity;
   • perforation of the uterine wall.
4. Clarification of the location of the intrauterine contraceptive or its fragments.
5. Infertility.
6. Unintention of pregnancy.
7. Control examination of the uterine cavity after operations on the uterus, vesical drift, chorionepithelioma.
8. Efficacy evaluation and control during hormonal therapy.
9. Complicated during the postpartum period.

The most frequent indications for diagnostic hysteroscopy are various disorders of the menstrual cycle. It is known that with conventional diagnostic scraping of the uterine mucosa without hysteroscopy, the discrepancy in the diagnosis is possible in 25% of cases. According to our data, in 30-90% of patients (depending on the nature of the pathology) during the control hysteroscopy, after scraping the mucous membrane of the uterine cavity, the remains of polyps or the altered endometrium are found. Discovered polyps are often regarded as a relapse of the disease, which leads to incorrect tactics of management of patients with hyperplastic processes of the endometrium. In addition, in the remainder of the endometrium, there may be pathological changes.

Pathologic discharge from the genital tract (bloody or purulent) in postmenopause is an absolute indication to hysteroscopy. According to our data, in 53.6% of cases, the cause of pathological discharge from the genital tract in postmenopause was polyps of the endometrium. The accuracy of the diagnosis of endometrial cancer in postmenopause is almost 100%. In this case, you can determine the localization of the process and its prevalence, which is important for choosing the tactics of patient management.

Submucosal uterine myoma. When diagnostic hysteroscopy determine the size of nodes, their location, select the method of removing nodes, assess the need for preoperative hormonal therapy.

Adenomyosis. Hysteroscopic diagnosis of adenomyosis is quite complicated and requires some experience. Frequently both false positive and false-negative conclusions. If there are doubts in the diagnosis, hysteroscopy data should be supplemented with ultrasound and metrography results. With internal endometriosis, diagnostic hysteroscopy reveals the degree of severity and prevalence of the process, which determines the tactics of the patient's management.

Infertility. Hysterosalpingography remains the primary screening method for examining patients with infertility. If there is a suspicion of a pathology of the uterus, a hysteroscopy is performed to confirm or exclude the disease. In women with infertility, both the hyperplastic processes of the endometrium and the anomalies of the development of the uterus are often detected; Possible detection of foreign bodies (bone fragments remnants after previous pregnancies, ligatures, fragments of IUD). During hysteroscopy, it is possible to perform a tube catheterization or phalloposcopy to clarify the state of the fallopian tubes.

With habitual miscarriage, hysteroscopy also helps to eliminate anomalies in the development of the uterus and foreign bodies in the uterine cavity.

Postpartum complications. With hysteroscopy, you can identify and remove not only the remains of the placental tissue, but also assess the condition of the scar on the uterus after cesarean section, and in the endometrium, wash the uterine cavity with an antiseptic solution and remove the inflammatory focus (infected part of the mucosa, blood clots, mucus).

If there is a suspicion of the remains of the fetal egg after the abortion (the remains of the placental tissue after delivery), it is very important to perform a hysteroscopy to purposely remove the pathological tissues without injuring the rest of the endometrium, which serves as a preventive measure for the formation of intrauterine synechia.

A large group of indications for diagnostic hysteroscopy are control studies to evaluate the effectiveness of the treatment (eg, operations on the uterus or hormone therapy). Thus, the detection of the hyperplastic process in the endometrium after hormone treatment allows us to diagnose the relapse of the disease and determine the further tactics of managing the patient.

Some doctors believe that the term "relapse of the proliferative process in the endometrium" can only be used if, during the previous scraping of the mucous membrane of the uterine cavity, hysteroscopy was performed and the patient received a full course of hormone therapy. Otherwise, the term "relapse" is not legal.

Control hysteroscopy (2 times a year for 3 years) is indicated in postmenopausal women with previously identified atrophy of the endometrium, accompanied by bloody discharge from the genital tract.

In 2% of patients with endometrial atrophy, accompanied by bloody discharge in postmenopause, at hysteroscopic examination after 6 months and 1,5-2 years, endometrial cancer, atypical endometrial hyperplasia and uterine tube cancer are diagnosed. In this regard, the authors of the book believe that patients with endometrial atrophy (confirmed hysteroscopy), accompanied by bloody discharge, should be attributed to the group of increased risk of cancer of internal genitalia. In this group, in the future, benign hyperplastic processes in the uterus can be detected without clinical manifestations.

In 31.8% of patients with a dynamic hysteroscopic examination in a period of 1.5 to 6 years, polyps of the endometrium and mucous membrane of the cervical canal were diagnosed.

To expand the uterine cavity, you can use both liquid and gas. However, considering that most indications may require intrauterine manipulation (diagnostic scraping, removal of submucous myomatous nodes and large polyps), it is advisable to conduct liquid hysteroscopy.

Thus, diagnostic hysteroscopy is the only highly informative method for detecting intrauterine pathology, which allows not only to determine the nature of the pathology, its localization and prevalence, but also to outline the tactics of managing the patient.

Contraindications to hysteroscopy

Contraindications to diagnostic hysteroscopy are the same as for any intrauterine intervention:

1. Infectious diseases (influenza, angina, pneumonia, pyelonephritis, etc.).
2. Acute inflammatory diseases of the genitals.
3. III-IV degree of purity of vaginal smears.
4. Severe condition in diseases of the cardiovascular system and parenchymal organs (liver, kidney).
5. Pregnancy.
6. Stenosis of the cervix.
7. A common cancer of the cervix.
8. Uterine bleeding.

Contraindications can be absolute and relative. Thus, stenosis and cervical cancer are relative contraindications, since hysteroscopy can be performed by a fibrogysteroscope without expanding the cervical canal with minimal trauma.

Uterine bleeding is considered a relative contraindication because of the low information content of the study with heavy bleeding. If necessary, studies to improve the review recommend using a hysteroscope with two channels for constant flow and outflow of fluid. At the same time, the pressure created by the liquid should be sufficient for tamponade of blood vessels and stop bleeding, as well as for washing the uterus cavity from blood clots. Sometimes, to reduce bleeding, it is sufficient to inject into the cervix or intravenously a means that reduces the myometrium.

Hysteroscopy is also undesirable during menstruation, and not so much because of the risk of dissemination of endometrial cells into the abdominal cavity, but because of lack of visibility.

It is proved that the fluid used to stretch the uterine cavity during hysteroscopy enters the abdominal cavity, bringing with it particles of the endometrium; thus, cancer can enter cancer. Numerous studies have shown that cancer cells entering the abdominal cavity during hysteroscopy do not worsen the prognosis of the course of the disease, nor does the incidence of relapse or metastasis in endometrial cancer increase. According to Roberts et al. (1960), even with the usual diagnostic curettage of the uterine cavity and bimanual examination in patients with endometrial cancer, cancer cells enter the inferior vena cava. Nevertheless, one should still try to avoid getting liquid from the uterine cavity into the abdominal cavity through passable fallopian tubes. To do this, if you suspect a cancer of the endometrium, try to create the lowest pressure in the uterine cavity, allowing an adequate examination.

Absolute contraindication to hysteroscopy - infectious diseases (especially lesions of the genital organs) due to the danger of spreading the infectious process by throwing the infectious agent into the fallopian tubes and abdominal cavity.

At the same time, the pyometra in patients in the postmenopausal period does not exclude the possibility of hysteroscopy, since according to our data, the piometers can often be caused by large polyps of the endometrium, and they should be removed under the control of the hysteroscope. Patients of this group must previously undergo a comprehensive anti-inflammatory therapy (including administration of antibiotics) and sanation of the vagina. Against the backdrop of antibacterial therapy, it is better to conduct liquid hysteroscopy with the widening of the cervical canal by Gegar dilator 11 or more (to ensure a good outflow of fluid).

Such a tactic is also necessary for hysteroscopy in patients with endometritis accompanying the remains of the fetal egg, or in the postpartum endometrium. In a liquid medium used to expand the uterine cavity, it is advisable to add antiseptics. In the postoperative period, it is necessary to continue anti-inflammatory therapy.

The coveted pregnancy is a contraindication for hysteroscopy because of the high risk of abortion. The exception is when hysteroscopy is used to perform fetoscopy.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10]