What you should know before your hysteroscopy

Hysteroscopy is a procedure done to allow the inside of the womb to be examined.

In her latest article, renowned gynaecologist Miss Lamiese Ismail offers her expert insight into this procedure, including how it is performed, the possible complications and what the recovery period entails.

What is a hysteroscopy?

Hysteroscopy is a gynaecological procedure where a very slim telescope is placed into the vagina to try to enter the cervix, and ultimately enter the womb to assess if there's any problem with the womb lining or the inside of the womb. This is typically done for women who have problems with abnormal bleeding, and can affect pre-menopausal or even post-menopausal women. It can also be performed for women who have problems conceiving and are having fertility investigations done.

How is it different from laparoscopy and colposcopy?

Colposcopy is an outpatient procedure which is very similar to a cervical smear test. The doctor will insert a speculum into the vagina, which is a device that allows them to see the vagina and the cervix, and then uses a special microscope after applying some special stains to the cervix to see if there are any abnormalities that could be cancer or pre-cancerous changes. With the colposcopy, we're not entering the cervix or the womb, but we're simply looking at the surface of the cervix, so you could probably consider colposcopy to be a little bit less invasive than a hysteroscopy.

When we compare this with laparoscopy, this requires the patient to have a general anaesthetic so they need to be fully unconscious and they won't remember or feel anything during the procedure. During this procedure, we make little cuts on the tummy typically in the belly button and a few smaller cuts lower down, to allow us to place instruments into the abdomen so that we can visualize the genital structures from above. We can then assess the outside of the womb, the fallopian tubes and the ovaries, and the areas in front and behind of those structures for gynaecological problems.

What is involved in a hysteroscopy procedure, and is it painful?

During a hysteroscopy procedure, we start by placing the patient on an examination couch and typically in stirrups. We then very gently examine the patient and place the telescope at the opening of the vagina, turning on some fluid or water which is slightly lukewarm so that it feels more comfortable. Under direct vision, we slowly advance the telescope to the level of the cervix.

Once we can visualize the cervix, we very gently negotiate through the cervix until we enter the inside of the womb. The fluid will then fill the inside of it. This will allow the doctor to see any problems happening inside the womb.

We might find that there are polyps which are little fleshy growths inside the womb, fibroids, and sometimes, we can assess pre-cancerous or cancerous changes as well whilst doing this test.

The procedure doesn't take long, probably about five minutes if we just want to go in and have a little look, but it can be painful. For most women, we would say that it is tolerable. There's a degree of discomfort that's to be expected because as the womb is filled with fluid, you'll feel a sort of crampy feeling inside your tummy very similar to having period pains. As most women will have some degree of period pain, this will not be an unfamiliar feeling, but of course, it can be unpleasant because the sensation comes on quite quickly and for a small proportion of patients it will be too painful.

We won't want to hurt our patients, so if at any point the patient feels too much pain then the patient must express this to the doctor so that we can stop the procedure.

What are the risks and complications that may happen?

Hysteroscopy is thought to be a very safe procedure. It's typically done in the outpatient setting so that means the patient is awake, but it can also be done whilst the patient is asleep so under general anaesthetic.  The risks of the procedure whether it's performed while the patient is awake or asleep are fairly similar.

The patient will experience some pain, and that could either be pain during the procedure if they're awake or afterwards if under general anaesthetic. There will be a small risk of bleeding, but usually not very much. This bleeding or discharge may go on for a few days after the procedure. There's also a small risk of infection, with the typical quoted rate of infection being about one in 400 cases. We ask patients to watch out for any signs of infection, such as increasing tummy pain after the procedure, a smelly discharge, or feeling generally unwell.

During outpatient hysteroscopy, patients can also experience what we call a vasovagal episode which is when they have a slight drop in their blood pressure and heart rate. This can make them feel faint, lightheaded or giddy. I normally say to my patients if they feel unwell in any way they should mention it to me, and we can then manage this for them. It's usually a transient feeling but of course, it can go on for a bit longer in a small cohort of patients.

We can manage this vasovagal episode relatively simply. This is also unlikely to happen if you have your hysteroscopy done under general anaesthetic.

Another slightly more serious risk of the procedure is the potential to cause an injury to the womb. The rate of this is about one in a thousand cases, so it's fairly uncommon but of course, it is quite a serious risk. If we were concerned about this sort of injury then we would typically admit the patient for a period of observation. If there's a genuine risk of a serious injury to the womb, the patient might need to have to go to the theatre to have the injury assessed and repaired through keyhole surgery.

What can be expected during recovery from a hysteroscopy?

Most women recover well from the procedure. They will experience some cramping discomfort for up to 24 hours after the procedure, and we typically recommend taking some pain relief. Paracetamol or ibuprofen should be more than sufficient to improve the discomfort associated with the procedure.

Usually, after 24 hours most women won't have any significant discomfort. They might still have a bit of bloody discharge or bleeding, which could go on for up to seven to 10 days depending on exactly what's being done during the hysteroscopy.

Most people will find that they can go back to normal life relatively quickly if they've had it in an outpatient setting. If they've had it under general anaesthesia, then there may be some additional time that would be required to recover but usually, it's not considered to be a major surgery. It's typically done on a day-case basis, which means you would come in and have a procedure done and go home on the same day.

How are results reviewed by the doctor with the patient?

Results can be reviewed between the doctor and the patient depending on preference. If biopsies or samples have been taken from the inside of the womb to investigate things like abnormal bleeding, then the doctor would typically relay that information to the patient by telephone consultation or face-to-face.

In some situations, the patient may choose to just receive the results through a letter form, which can also be arranged. This is on the assumption that the results were normal. If by any chance the results come back showing something unexpected or abnormal, then it would be more appropriate to arrange a face-to-face consultation so that the results can be more thoroughly explained and any questions that the patient may have can then be answered at that time.

Miss Lamiese Ismail is a leading gynaecologist based in Oxford, with more than 20 years of experience.

If you have any gynaecological concerns, you can book a consultation with Miss Ismail via her Top Doctors profile.