Hysteroscopy: How To Prepare and What To Expect
Let's review just preparing for the hysteroscopy including more detail about what it is, what you should know, and the questions you should ask. Hysteroscopy is a surgical procedure. It is where a camera is placed through the cervix into the uterine cavity. The uterus is a potential space, meaning it's not open, like that triangular picture you see on your brain or if you go and google uterus image, you see this triangle. That's not really what the uterus looks like. It is collapsed amongst itself, and those endometrial layers are touching in it's day to day life. It expands like that when there's a pregnancy inside of it or anything that distends the walls, since it is a potential space. When you do hysteroscopy, what you're doing is putting that camera inside, and it is connected to what we call a fluid management system Two tubes are connected to the camera device, and one brings water in and the other allows water out. Imagine a circuit where water is going into the uterine cavity and then coming out. The reason why you have this double flow is because if you are doing operative hysteroscopy, meaning more than just looking diagnostic, you might have some blood, and you want to get that blood out of the urine cavity so you can see what is going on. Visualization of what is happening is one of the issues with hysteroscopy because if everything's dark or bloody or you can't see, you can't operate. This is why people are very picky about when they might do hysteroscopy in your cycle. By people, I mean me.
When Should You Get A Hysteroscopy Done?
So if I'm going to do hysteroscopy, I will do it in three scenarios.
1. You have amenorrhea, you are not bleeding, and I know you have a very thin uterine lining.
2. You're on birth control pills. Birth control pills are Ethinylestradiol and a progestin. This daily progestin prevents extensive growth of the uterine lining. A lot of people like the pill because they now have lighter bleeding, lose less blood, less anemia, and less cramps. I'm a bad analogy girl. You all know this. I tell patients, if I'm going to hysteroscopy and I want to take a polyp out, imagine I have a tree stump in my yard I need to remove. If the grass is all really tall and hasn't been mowed for weeks, I may not be able to remove all of the tree stump because it will be hard to see where the base of it is. However, if I go in and I have freshly mowed the grass now I can see really great, get the tree stump, and it's no longer a problem for me. So if you're on birth control pills, it's like keeping the grass mowed.
3. The other option is right after your period. So in the follicular phase, this is a very small window where after you're done bleeding, but before you have ovulated. Really it's before you get closer to ovulation when that uterine lining is really thick and fluffy, preparing for implantation because it's hard to see then. So this is that late follicular phase. It's typically days, so it's quite specific.
That is a very small window when you can do the surgery because you want to be able to see if you are actively bleeding, and it's the day of your surgery, you should let your doctor know nobody wants to put you through anesthesia and then have your surgery cancelled. So if you're actively bleeding, you should tell your team because they may change the surgery date. This is also why if they tell you to take the birth control pill, you should a take it, or have a conversation that you don't want to and ask what else can you do? I have these conversations with patients all the time. What will make me frustrated is if you say, “Sure, I'll take the pill,” and then we show up to your surgery day and you tell me, “Oh, I didn't like that, so I didn't take it.” Now I'm probably set up to operate on the wrong day, the wrong time, and I'm not going to be able to do as good of a surgery. You've taken time off work. So has your person who's driven you there, and we are just not set up for success. I want to be set up for success, and I promise all your surgeons do too, so honesty is the best policy here.
What is the prep?
You may or may not get certain instructions, so nothing by mouth after midnight is a pretty common one. This is an anesthesia requirement because we don't want you to aspirate, which can happen in general. This is not a full on crazy intense anesthesia because we're not doing abdominal surgery. One exception is if you're having concurrent laparoscopy like having surgery to see about your endometriosis, and they're also doing hysteroscopy at the beginning of it, that's a different scenario. If you're just coming in for hysteroscopy, it is a relatively mild anesthetic because you don't have to be paralyzed as extensively. You do if somebody's operating your abdominal cavity. That's a whole different ballgame. So when we are doing this, it's usually nothing to eat after midnight. We don't want you to aspirate. That's where you almost regurgitate your stomach contents like you vomit, and then you swallow it into your airway. People can get a terrible pneumonia from that. You'll get an IV, and you'll talk to anesthesia, and they'll get you prepped. You'll have to answer some questions. You should see your surgeon. There'll be a consent form to review. You may or may not have gotten a medication to prepare you for the surgery. So this could be an oral antibiotic. It could be misoprostol, which is a cervical dilation medication, and this is something I love. It can cause some cramps, so you might be instructed to take it the night before or the morning of. What it is doing is starting to ripen the cervix. It's actually used in labor to soften and open up the cervix. If we do this before hysteroscopy, it is a lot easier to get the camera in without having to dilate the cervix up, and ultimately that decreases their risks. If somebody is dilating the cervix, that's a blind part of the procedure, and there is the potential for risk, versus if I can get you to have your cervix ripened. This means it's soft, a little bit open, and I can just put my camera through. That's direct visualization, and that's my preference. If you are prescribed misoprostol, it can cause some cramping. It is important to take it. Make sure you follow the instructions. It's usually placed vaginal in this scenario, so just make sure you know what you're doing. You'll get there. You'll talk to everybody the day of the surgery, you'll get your IV, you'll roll back to the operating room.
What Happens During The Hysteroscopy?
I'm a believer that it's important to know what is happening. So if the plan is for a polyp that is typically micro instruments, so we are putting in very small little scissors and graspers, cutting the base of the polyp, pulling it out and often sending it off to pathology. If we are doing a fibroid, it is sometimes these little micro instruments, but often it can be what we call a morcellator instrument. It actually is this little instrument that goes through the camera sheet. These cameras have an operative port where you place these little, tiny instruments through, and the instrument is so small, has this very long, tiny wire that it's attached to, and then there's a handle on the end that is almost like a lever that you open and close. The actual operative part is millimeters. It's so small. So we have these tiny instruments, which we use a lot for a fibroid, you have an instrument that actually can be more attached to the camera, that can cut and suck those fibroid pieces out, and that can be very helpful. If it's a larger fibroid, for septums and scar tissue, we tend to use our micro scissors for that portion of the procedure. So all of this is contained within the hysteroscopy device. The surgery typically is going to take 20 to 50 minutes, depending on the scenario or how extensive the situation is.
Why Could The Surgery Get Stopped?
Your surgery could get stopped because one you can't see. So you might be operating and just can't see anymore, and nothing you do clears it up. So you stop and maybe have to come back for another look or look with further imaging in the office to see if we got everything. Your surgery may be stopped if you have fluid overload. This is much less common than it used to be, but in big surgeries, especially big fibroids, it's a potential thing. This is where, as you're cutting into that uterus, your uterine blood vessels absorb some of that water that you're using in the uterus, and that water gets into your vasculature. It dilutes your blood too much, and you can get water overload. So the nurses are typically measuring how much water is going in and out. Then a surgery could be stopped if you're not tolerating the anesthesia. The most common reasons are can't see, lack of visualization, or fluid overload. Those are reasons why you might leave the surgery and hear that you have a different type of follow up, whether it's a repeat surgery or something else. That's not common, I will say, 95% of the time, this goes exactly like it should.
What Can I expect Post-Op?
Remember, e are going from a not sterile place to a more sterile place. If your tubes are open, that fluid will exit your fallopian tubes and get into your peritoneal cavity. We don't want you to have an infection. You might get antibiotics the time of procedure. You might get antibiotics afterward. You will definitely have a cleaning of your vagina. Usually it's an iodine based prep, but it can be different. If you're allergic to iodine, shellfish, or shrimp, you need to talk to your team make sure they know that. I say afterward, no intercourse, no swimming, in lakes, oceans, pools or sitting in baths of water. Nothing should go in the vagina. No tampons, etc, because we have operated there, and we don't want you to get an infection. So I usually say those things for a couple weeks. Your doctor might give you different recommendations. I am notably conservative because one pelvic infection post operatively and one person is too many for me. You want to understand, what is your follow up? Are there medications to take? Are there restrictions? Are we going to re image or re look? And when do I need to contact the clinic again? So often I hear of people who go and have a surgery or a procedure of any kind, then they have no idea what to do next. I hate that. So what is my next step? That is always what you need to know. The last thing I'll say is you can be an advocate for yourself. So if you've never had imaging, whether it's saline sonogram, HSG or a hysteroscopy of your uterine cavity, and you've been trying to conceive, we don't know what we don't know. So this can be a very important part of your fertility work up.
