Hysteroscopy is a minimally invasive gynecological procedure used to examine the inside of the uterus. It involves the careful insertion of a thin, lighted tube, known as a hysteroscope, through the vagina and cervix. This allows a healthcare provider to directly visualize the uterine cavity.
What Hysteroscopy Involves
Hysteroscopy typically takes place in an outpatient setting, such as a doctor’s office or a specialized clinic. Before the procedure, patients may be asked to empty their bladder and change into a gown. They are then positioned on an examination table, lying on their back with feet in stirrups.
A speculum may be used to hold the vagina open, similar to a Pap test. The hysteroscope is then inserted through the cervix and into the uterus. A liquid solution (e.g., sterile saline) or gas (e.g., carbon dioxide) is introduced to expand the uterine cavity. This clears blood or mucus, providing a clearer view of the uterine lining and fallopian tube openings. The procedure typically lasts 5 to 15 minutes, but may take longer if tissue sampling is performed.
Identifying Endometrial Changes
During a hysteroscopy, the clinician meticulously inspects the endometrial lining for visual abnormalities. Various conditions present with distinct appearances. Endometrial polyps appear as protrusions into the uterine cavity, consisting of solid, dense tissue. Submucosal fibroids, benign muscle growths, also appear as whitish, solid tissue protruding into the cavity, sometimes causing an undulating uterine wall.
Endometrial hyperplasia, a condition where the uterine lining becomes excessively thick, can appear as increased endometrial thickness, dyshomogeneous regeneration, or increased vascularization. Other signs include cystic dilatation, polypoid formations, or white, friable areas with reduced or absent vascularity. While suggestive of hyperplasia, these visual cues are not definitive for a cancer diagnosis.
For endometrial cancer concerns, the clinician looks for suspicious visual characteristics. These include irregular, polylobate excrescences that appear friable, partly necrotic, or hemorrhagic. Irregular and anarchic vascular patterns are also indicators. A clear dividing line is often observed between suspected cancerous tissue and normal endometrium. It is important to note that these visual findings are indicative and prompt further investigation, but do not confirm a cancer diagnosis.
The Definitive Role of Biopsy
Hysteroscopy visualizes the uterine cavity and identifies suspicious areas, but visual identification alone is not sufficient for a definitive cancer diagnosis. If abnormal areas are seen during the hysteroscopic examination, a biopsy is typically taken immediately. This targeted biopsy is essential as it allows for precise collection of tissue from the suspicious region, unlike blind biopsies which may miss focal lesions.
Tissue samples are sent to a pathology laboratory for microscopic examination by a pathologist. Microscopic analysis definitively diagnoses endometrial cancer (typically adenocarcinoma) or identifies conditions like atypical hyperplasia, a cancer precursor. Hysteroscopy with targeted biopsy has high accuracy for diagnosing endometrial cancer and atypical hyperplasia, making it a preferred method over blind sampling techniques like Dilation and Curettage (D&C). This targeted approach improves diagnostic yield and guides clinical decisions.
Complete Diagnostic Picture
Hysteroscopy with targeted biopsy is a diagnostic tool for evaluating the uterine cavity, but has limitations. It may not detect all forms of endometrial cancer, especially early-stage or microscopic diseases not visually apparent. Hysteroscopy findings are integrated with other diagnostic methods for a comprehensive picture.
Before hysteroscopy, transvaginal ultrasound assesses endometrial thickness and identifies structural abnormalities. While Dilation and Curettage (D&C) was a common endometrial sampling method, hysteroscopy with targeted biopsy has largely replaced it due to its ability to visualize and sample focal lesions. Combining hysteroscopy’s visual information, precise tissue diagnosis from targeted biopsies, and other imaging results allows for a complete diagnostic assessment. This comprehensive understanding guides treatment decisions.