Indications and contraindications for hysteroscopy

Indications for diagnostic hysteroscopy:

1. Menstrual cycle disorders at different periods of a woman’s life.
2. Bloody discharge in postmenopause.
3. Suspected of the following diseases and conditions:
   • submucous uterine myoma;
   • adenomyosis;
   • endometrial cancer;
   • developmental abnormalities of the uterus;
   • intrauterine adhesions;
   • remnants of the fertilized 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 device or its fragments.
5. Infertility.
6. Miscarriage.
7. Control examination of the uterine cavity after operations on the uterus, hydatidiform mole, chorioepithelioma.
8. Evaluation of effectiveness and monitoring during hormonal therapy.
9. Complicated postpartum period.

The most frequent indications for diagnostic hysteroscopy are various menstrual cycle disorders. It is known that with routine diagnostic curettage of the uterine mucosa without hysteroscopy, a discrepancy in diagnosis is possible in 25% of cases. According to our data, in 30-90% of patients (depending on the nature of the pathology) during control hysteroscopy performed after curettage of the uterine mucosa, remnants of polyps or altered endometrium are detected. The detected polyps are often regarded as a relapse of the disease, which leads to incorrect tactics for managing patients with endometrial hyperplastic processes. In addition, pathological changes may be present in the remaining part of the endometrium.

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

Submucous uterine myoma. During diagnostic hysteroscopy, the size of the nodes and their location are determined, the method of node removal is selected, and the need for preoperative hormonal therapy is assessed.

Adenomyosis. Hysteroscopic diagnostics of adenomyosis is quite complicated and requires certain experience. Both false-positive and false-negative findings are common. If there are doubts about the diagnosis, hysteroscopy data should be supplemented by ultrasound and metrography results. In case of internal endometriosis, diagnostic hysteroscopy reveals the degree of severity and prevalence of the process, which determines the tactics of patient management.

Infertility. Hysterosalpingography remains the primary screening method for examining patients with infertility. If there is a suspicion of uterine pathology, hysteroscopy is performed to confirm or exclude the disease. In women with infertility, both hyperplastic processes of the endometrium and uterine developmental anomalies are often detected; foreign bodies (remains of bone fragments from previous pregnancies, ligatures, fragments of the intrauterine device) may be detected. During hysteroscopy, tubal catheterization or falloposcopy may be performed to clarify the condition of the fallopian tubes.

In case of habitual miscarriage, hysteroscopy also allows to exclude developmental anomalies of the uterus and foreign bodies in the uterine cavity.

Postpartum complications. Hysteroscopy can reveal and remove not only the remnants of placental tissue, but also assess the condition of the uterine scar after a cesarean section, and in the case of endometritis, wash the uterine cavity with an antiseptic solution and remove the inflammatory focus (infected part of the mucous membrane, blood clots, mucus).

If there is a suspicion of remnants of the fertilized egg after an abortion (remnants of placental tissue after childbirth), it is very important to perform a hysteroscopy in order to specifically remove pathological tissue without damaging the rest of the endometrium, which serves as a preventive measure for the formation of intrauterine adhesions.

A large group of indications for diagnostic hysteroscopy are control studies to assess the effectiveness of the treatment performed (for example, uterine surgery or hormonal therapy). Thus, detection of a hyperplastic process in the endometrium after hormonal treatment allows diagnosing a relapse of the disease and determining further tactics for managing the patient.

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

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

In 2% of patients with endometrial atrophy accompanied by bloody discharge in postmenopause, endometrial cancer, atypical endometrial hyperplasia and fallopian tube cancer are diagnosed during hysteroscopic examination after 6 months and 1.5-2 years. In this regard, the authors of the book believe that patients with endometrial atrophy (confirmed by hysteroscopy) accompanied by bloody discharge should be classified as a high-risk group for developing cancer of the internal genitalia. In this group, benign hyperplastic processes in the uterus without clinical manifestations may also be detected later.

In 31.8% of patients, polyps of the endometrium and cervical canal mucosa were diagnosed during dynamic hysteroscopic examination over a period of 1.5 to 6 years.

Both liquid and gas can be used to expand the uterine cavity. However, given that most indications may require intrauterine manipulations (diagnostic curettage, removal of submucous myomatous nodes and large polyps), it is advisable to perform liquid hysteroscopy.

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

Contraindications to hysteroscopy

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

1. Infectious diseases (flu, tonsillitis, pneumonia, pyelonephritis, etc.).
2. Acute inflammatory diseases of the genital organs.
3. III-IV degree of purity of vaginal smears.
4. Severe condition in diseases of the cardiovascular system and parenchymal organs (liver, kidneys).
5. Pregnancy.
6. Cervical stenosis.
7. Advanced cervical cancer.
8. Uterine bleeding.

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

Uterine bleeding is considered a relative contraindication due to the low informativeness of the study in case of heavy bleeding. If the study is necessary to improve the overview, it is recommended to use a hysteroscope with two channels for constant fluid inflow and outflow. In this case, the pressure created by the fluid should be sufficient to tamponade the vessels and stop bleeding, as well as to wash the uterine cavity from blood clots. Sometimes, to reduce bleeding, it is enough to introduce a myometrium-contracting agent into the cervix or intravenously.

It is also undesirable to perform hysteroscopy during menstruation, not so much because of the risk of dissemination of endometrial cells into the abdominal cavity, but because of insufficient visibility.

It has been proven that the fluid used to stretch the uterine cavity during hysteroscopy enters the abdominal cavity, bringing with it particles of the endometrium; thus, in the case of an oncological disease, cancer cells can enter there. Numerous studies have shown that cancer cells entering the abdominal cavity during hysteroscopy do not worsen the prognosis of the disease, and the frequency of relapses or metastases in endometrial cancer does not increase. According to Roberts et al. (1960), even with routine 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 fluid from the uterine cavity entering the abdominal cavity through the passable fallopian tubes. To do this, if endometrial cancer is suspected, they try to create the least pressure in the uterine cavity, allowing for an adequate examination.

An absolute contraindication to hysteroscopy is infectious diseases (especially damage to the genitals) due to the risk of spreading the infectious process by introducing an infectious agent into the fallopian tubes and abdominal cavity.

At the same time, pyometra in patients in the postmenopausal period does not exclude hysteroscopy, since, according to our data, the cause of pyometra development can often be large endometrial polyps, and they should be removed under the control of a hysteroscope. Patients in this group must first undergo complex anti-inflammatory therapy (including antibiotics) and vaginal sanitation. Against the background of antibacterial therapy, it is better to perform liquid hysteroscopy with dilation of the cervical canal with a Hegar dilator No. 11 or more (to ensure good fluid outflow).

Similar tactics are also necessary when performing hysteroscopy on patients with endometritis accompanying the remains of the ovum, or with postpartum endometritis. It is advisable to add antiseptics to the liquid medium used to expand the uterine cavity. In the postoperative period, it is necessary to continue anti-inflammatory therapy.

A desired pregnancy is a contraindication for hysteroscopy due to the high risk of miscarriage. The exception is when hysteroscopy is used to perform fetoscopy.

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