“Hysteroscopy!” – with Dr. Lis Shlansky
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Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast design to export topics on women’s health at all stages of life. I’m your host Dr. Nathan Fox, an OB/GYN and Maternal Fetal Medicine Specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. Dr. Lis Shlansky, welcome back to “Healthful Woman.” Great to see you.
Dr. Shlansky: Nice to see you too, Nate.
Dr. Fox: So we’re gonna talk today about hysteroscopy. So, Lis, explain to our listeners just at a very broad level what is hysteroscopy?
Dr. Shlansky: Hysteroscopy is basically looking inside the uterus with a small camera so that we can see any, well, for a multitude of reasons.
Dr. Fox: What was done before hysteroscopy?
Dr. Shlansky: Before hysteroscopy, actually, I’m not sure I know because when I first started doing this, there was hysteroscopy.
Dr. Fox: It’s been around for a while. It’s one of the earliest what we call minimally invasive or non-invasive based on how you sort of, you know, look at the invasive nature of this procedure that we have. But, you know, the idea is that it’s either getting you better information to look inside the uterus, because you can actually see like almost with your own eyes of what’s going on and potentially, maybe, avoid procedures where you have to, you know, put other instruments in the uterus blindly to try to remove things, or even on a bigger scale maybe do something, like, hysterectomy which would be a more of invasive operation obviously.
Dr. Shlansky: The best explanation is that we use this to both sometimes diagnose, so it’s a way of visually inspecting the inside of the lining of the uterus. But not only can you inspect the inside of the uterus, but you can also take a look at the cervix. So the cervix is the gateway between the vagina and the uterus, and that’s what opens in childbirth, but it allows you to look all the way from what you can’t see in a regular exam room to the inside of the cervix to the inside of the uterus. And you can also see the opening to the tubes as well so you can see where sperm actually go. And obviously you can’t look out the tubes, but you can get a good idea of something’s normal or abnormal.The other part of hysteroscopy is it allows you that if you see something that’s abnormal that you can biopsy at. In the office, we can do endometrial biopsies which are biopsies of the lining of the uterus, but they’re usually blind. And hysteroscopy allows you to look and figure out where that abnormal area is visually inspected and then actually do a biopsy of that area if you’re worried about one particular place.
Dr. Fox: Right, which is really good for two reasons. Because, number one, if you’re doing blind biopsy, which means it doesn’t mean that the doctor’s eyes are closed, it just means that when we put, whether it’s a tube or anything inside uterus, we can’t see exactly where it’s going. You know, it’s in the uterus, but not what part. So number one, you might miss what you’re trying to biopsy. So if the issue is not global inside the uterus, you could biopsy a part of uterus it’s normal and not biopsy the part that’s abnormal. That’s number one.
Number two, the other issue is when you’re going into to look inside uterus, you can actually see if there is a reason to biopsy at all because there’s different things. For example, sometimes a biopsy just means getting a sample tissue to sent to a pathologist to look for. Sometimes it’s very focal, what we call lesions, like, a polyp or something that’s inside it. You don’t need to biopsy, you just remove it. And so you would actually to see it in order to know that hysteroscopy usually the best way to do that.
Dr. Shlansky: Correct.
Dr. Fox: Now there are other ways to, in terms of diagnosis, to look inside a uterus, I mean, we use ultrasound just as it is. There are sometimes ultrasound where you put water inside uterus, a saline infusion, a sonohysterogram which is a fancy word for ultrasound. There is MRIs. There’s other modalities. But this is really considered the gold standard in terms of seeing what’s going inside the uterus because you look at it literally as if you’re inside.
Dr. Shlansky: Yes. So traditionally this was done through surgery. In the very beginning, the only way that you could do it was to take somebody to the operating room. There were few exceptions to that, but for the most part, putting a little camera that is thinner than actually a pen or pencil up into the uterus so that you can actually take a look inside. There are office hysteroscopies, so meaning, looking inside the uterus that you can actually do in the office. And now there are even some cool little tubes that actually allow you to look as well and put little instruments in and do it in the office. So there’s lots of different options for how to do this.
Dr. Fox: Yeah. The main difference is really just the technology, because the thing that makes the hysteroscopy painful is really the size of the scope, right, because if it is bigger, meaning, wider or thicker, the cervix being dilated to allow that to pass is painful they have you to go through. So if, the thinner the scope, the easier it is to do this in the office without any anesthesia. So now, you know, they range the bigger scopes are about 10 millimeters which is probably, you know, the size of a typical index finger give or take, and now they’re down to like 3 millimeters which is really, really small.
Dr. Shlansky: Yeah. They’re very cool.
Dr. Fox: Yeah. And similar to other instruments we use in the office for other procedures.
Dr. Shlansky: Yes.
Dr. Fox: So who might need a hysteroscopy? Like, who is it that potentially would be getting one?
Dr. Shlansky: Well, obviously we don’t just do this on everybody. So people need to present with a problem and the problem could be abnormal bleeding, the problem could be on ultrasound somebody’s found something that looks abnormal and they may have no problem but an issue potentially with pregnancy or getting pregnant or loosing pregnancies. There can be problems after delivery where people maybe have bleeding that’s abnormal and on ultrasound, we suspect that there’s maybe some tissue left behind so there’s lots of different reasons. In the group of people who have abnormal bleeding, there can be little polyps. So it’s like a little skin tag that’s inside the uterus and that might make people bleed abnormally. There can also be fibroids which are benign growths off the muscle, and that presses on the cavity and can make people bleed abnormally. So there’s a lot of different reasons for why people may end up with a hysteroscopy.
Dr. Fox: The procedure is done the same way pretty much for whatever reason it’s being done and there is a lot of people who might end up getting a hysteroscopy, but from such varied reasons. So for example, you could have someone where it’s a very real concern, you know, there’s abnormal bleeding and a woman is postmenopausal, and your concern maybe there something cancerous or precancerous and so you really have to look in and get an assessment, and get a biopsy. And that’s, you know, we’re doing it for a reason that’s, you know, really important. And it could be ranging to someone who they did an ultrasound and they saw something and not sure what it is. No one suspects it’s dangerous, but, you know, we don’t like things growing in places they shouldn’t be. And so maybe let’s take a look or maybe like you said it’s causing her just some annoyance that her period is a regular and it’s a very straightforward procedure if you find a polyp remove it. A lot of women ends up getting hysteroscopy if they see fertility specialists because the fertility specialists are very particular about the lining of the uterus. If they’re going to put an embryo in there, they like it to be pristine. So they wanna make sure that it’s looks fine, there is no polyps, there is no old scar tissue inside so a lot of women end up getting it for that reason. Sometimes it’s, you know, a part of evaluation, again, just because of a follow up from an ultrasound and that’s just on the diagnostic side, just to see what’s going on. And I think one of the really, which is great, and I think it’s again it’s a safe, we’ll talk about it, it’s a safe procedure, it’s not a painful procedure, there’s no like recovery or anything. But what’s really cool is this idea that you can do things with the hysteroscope. And that’s, like, you’re not just looking but you’re really operating in a sense but also with the same low risk, low pain, you know, no time off from work. And, I guess, the main one really is for fibroids and for polyps and sometimes uterine septums, right? So explain what happens in that situation, like, how is it different when you’re operating with the hysteroscope? What are we doing inside there?
Dr. Shlansky: Well, there’s a difference. So first off, hysteroscopy as hyster is uterus, and oscopy is looking with the camera. And so when people do a D&C, they can, D is for dilation, C is curettage. So it basically means opening the cervix so that you can get instruments in there. Hysteroscopy means looking inside. So the hysteroscopy can be what we call diagnostic hysteroscopy, which means just looking. The other choices are that you can do what’s called an operative hysteroscopy, and operative hysteroscopy means that you’re operating inside the uterus, from our perspective two very different approaches. One, uses a very thin camera that you mentioned before which is usually anywhere from 2 to 4 millimeters. Which is pretty small. Remember that a centimeter is smaller than an inch, it’s about half an inch, and 4 millimeters is a half of a centimeter so it’s really very small. The diagnostic hysteroscopy allows you to look inside. The operative hysteroscope comes in different sizes. The smallest one is about 7 millimeters. Those are pretty cool, because, again, you need less dilation. The old school ones from way back when were like 12 millimeters or 1.2 centimeters so it’s about half an inch in diameter. But they have a probe in there that you can watch as that’s coming out, and it allows you to remove parts or pieces of tissue, and so you’re doing that under direct visualization.
Dr. Fox: So the camera goes in as I got a long telescope sort of speak, goes in so you’re looking at the uterus, and then from outside, there is little, like, channels where you can sneak through it what a wire and at the end of that wire might be a scissors, might be a grasper, might be something to cauterize, might be something to squirt water, whatever it might be. So you can insert instruments through this instrument and so when you’re looking at the camera, you can sort of see what you’re doing. And then the operator has, you know, the handles of these instruments are all outside so whether it’s scissors, you know, if you’re closing your hand or if it’s a grasper, you’re grasping, and then you can pull things out through there. And so, you know, for polyp or for biopsy you can see under direct visualization what you’re grabbing. Sometimes, you know, someone with less pain maybe you’ll do the diagnostic hysteroscope, take a look, say, “All right. I see what’s there,” take it out, and then put it, then do like, it’s like a blind sampling but not really, because you know what you’re going for and what you have to get. That’s another option as well.
Dr. Shlansky: So the operative hysteroscope you can use to remove polyps that are large and you can also remove fibroids. So usually we try to if there’s a fibroid that’s poking into the cavity, you can actually see how much of it poked into the cavity so beforehand, you actually know what you’re removing so that you don’t remove too much of it and thin the wall out. So that’s called an operative hysteroscopy, and you can remove polyps with that, you can remove fibroids with that. If there’s possibly tissue that’s left behind from a pregnancy or scar tissue, you can remove that as well. So that’s a pretty cool procedure. And the huge advantage to all of these procedures is there’s very little pain the next day. Aside from wearing off anesthesia for 24 hours, people go right back to their daily life. So it’s a very nice procedure for people that are bleeding heavily because of a lesion or something poking into the uterus in the cavity.
Dr. Fox: And one of the really cool things is in addition to it being easier recovery from the operation itself, and I think one of the big differences is maybe with fibroids, right? So with fibroids, let’s see, I see a fibroid on ultrasound, and I don’t know it’s a 3 centimeter fibroid and half of it is in the bulk of the uterine wall, and the other half is poking into the cavity. And it’s causing her problems whatever that might be. Whether it’s your fertility issue or whether it’s issue with heavy periods, but it’s causing her issues and she wants it to get taken care of. Traditionally, if you were gonna operate, you’d have to make a big incision through her belly, make a big incision in the uterus, pull out the fibroid, and then close up the uterus and close up her belly. Now, it’s safe and should be okay, but that’s general anesthesia for an hour let’s say or two, she would need…it’s the recovery is weeks to months, and when she ultimately does get pregnant if that’s what it’s for, she would need a Cesarean because you’ve cut through uterus and sewed together and that thing usually needs a Cesarean. And that’s a big deal, right, that’s, you know, one major operation to do it plus a major operation to have a baby, and all of her babies. If you do it the other way through the hysteroscopy, you go from below, you just shave it off what’s part of the cavity, and leave behind some of it on the wall. Her recovery is easier, that operation is easier, and she does not need a Cesarean for the next delivery, because you didn’t really interrupt the integrity of the uterus. And that’s a huge difference when we see women who have a history, when we they say, “I have a history of fibroid removal,” I was like, “How? Like, how did they take out the fibroid?” Because it changes everything in terms of their future, in terms of the pregnancy. And so it’s not possible for all fibroids, but in certain cases, this is an option and it’s a much lower risk and lower morbidity option.
Dr. Shlansky: Yes. But that requires planning ahead of time where people have to get the information by ultrasound so that there’s a lot of planning that goes to getting to the operating room, and then the actual doing is significantly easier. But people do, they recover in a great way, and they’re very thankful, because it fixes whatever bleeding problem they had or potentially a problem getting them pregnant or keeping them pregnant.
Dr. Fox: Let’s say someone doesn’t need a hysteroscopy, what would be the factors that would determine whether it’s something that could be done in the office versus something that would need an operating room? And again, there may be some overlap between this too but, in general, broad strokes, what would be a reason that you could do it in the office in a reason you need to do it in operating room.
Dr. Shlansky: I think, one of them is based on the patients. So patients need to be relatively comfortable with pelvic exams. There are some people who really struggle with a pelvic exam. Those would be folks that really are better served by being in the operating room. They’re just uncomfortable. You have to put up with little bit of discomfort. You can get pre-medicated in the office. It also needs to be a relatively simple problem. So people who you’re trying to remove a fibroid, that’s, and in our world, anything bigger than probably half a centimeter is something that should probably be handled in the operating room. But for the smaller stuff, where it’s just like a little focal area that looks abnormal that needs to be biopsied, or maybe a small little polyp, those are things that possibly can be handled in the office.
Dr. Fox: Right. I mean, generally the smaller scopes, you know, the 2, 3, 4 millimeters not everybody but most people will tolerate it in the office. And if you only have to do it most, like, a small biopsy or removal of something small, because again, of coursse, these channels are small, there is no room to pull out something bigger necessarily. So that’ll be okay. Any time you’re really trying to do a lot, number one, it could be more painful, and number two, we’d like to, you know, have anesthesia. And the other factor which we didn’t discuss is with the bigger procedures that you do with the hysteroscopy, you actually have to have fluid going inside the uterus. So that’s one. So explain what is that all about?
Dr. Shlansky: So for all the hysteroscopies, and actually it’s not true, because some hysteroscopies can be what’s called CO2 hysteroscopy. And when we say that, we’re talking about what it is that distends the uterus. So the uterus in it’s happy state unbothered by us, actually…
Dr. Fox: For those gynecologists, yeah.
Dr. Shlansky: Right. It’s actually a potential space, but it’s not an open cavity.
Dr. Fox: Right. It’s collapsed basically.
Dr. Shlansky: Right. So to do the hysteroscopy, you have to push the walls apart so that you can actually see. There was an old thing cut CO2 hysteroscopy where you pumped in carbon dioxide, which didn’t matter if your body absorbed it, and you could do that as an office procedure. What we typically do in the operating rooms to do hysteroscopy is we put fluid in, so all of these cameras there’s a light source but there’s also an inflow and an outflow. So fluid flows in which pushes the walls of the uterus apart so that you can actually see, and then there’s an outflow channel which allows it to come out. With a diagnostic, which means just looking hysteroscopy we don’t really keep tabs on what comes out, because we need very little amount of fluid to be able to see. But for the operative scope, we actually put a good amount of fluid in. In the old way, we used to use, it was called Hyskon, it was a fluid that was made from I think beets, it had a lot of sugar in it. So if your body absorbs that, it could actually make you relatively ill. And so now we just use saline, so just like you would get an intravenous solution, if your body absorbs it, it’s not a big deal. But there is a little bit of danger there that as you’re pushing the uterus apart, and you’re cutting something that the body can absorb too much fluid, and people can be fluid overloaded from that. And so when you’re doing the operative hysteroscopes, you have to have accounting for what goes in and what comes out, because that can be a danger to a patient.
Dr. Fox: Right. It’s like the school bus, you count everyone going in, you count everyone going out.
Dr. Shlansky: There you go.
Dr. Fox: Yeah. No, because you have to know because there’s certain amounts you have to… It’s expected and it’s okay that a woman is gonna absorb a certain amount of fluid. But after certain, you know, when you reach a certain point, you have to make sure she’s okay or you have to stop or, you know, whatever based on exact circumstances. But the point is it has to be monitored. And that’s what you said really for the more significant procedures you’re gonna do with the hysteroscope. If you’re just gonna look, there’s so much, you know, so little fluid goes in, you just go on and you’re looking you’re basically done. And in the office, it’s usually either carbon dioxide or even without you can somebody just looking, you can see sometimes even if it’s collapsed if you get a good enough look. What would a day be like for a woman who’s about to have a hysteroscopy, let’s say, in the office? You know, from the day before till that day just so she can prepare and have expectations what that would be like?
Dr. Shlansky: It should be pretty straightforward. Many times people get pre-medicated beforehand. They may get a medication that helps to soften their cervix that they can either take the night before the day off, and again it depends on what their ages, if they’re menopausal or haven’t gone through menopause yet. And so a lot of times for the office procedure, they what actually take some pain meds beforehand. And they may also take something to help them relax so that they’re a little bit more tolerant of the whole procedure.
Dr. Fox: Right. And so then they do that either at home or in the office, and they come in and then they’re on an exam table, right, and their lives are up like they’re getting a Pap smear. Correct?
Dr. Shlansky: Yes.
Dr. Fox: Yeah. And then the camera just goes in and, you know, you don’t feel cramping or they won’t and then it’s done probably like few minutes later. What kind of recovery is there from that type of procedure?
Dr. Shlansky: So recovery is pretty simple. They may have a little bit of spotting. They may have a little bit of cramping. But they should be able to do everything pretty normally the next day.
Dr. Fox: Right. And then how would it’d be different if they’re having it in the hospital?
Dr. Shlansky: I don’t think it would be significantly different.
Dr. Fox: Right. Yeah, I knew you answered the question. I mean, I guess the main difference is just in the hospital to meeting anesthesiologists so get an IV, and she’ll pretty much be asleep, you know, sort of nap during this. And she is go to sleep and wake up. But the recovery is the same. It really doesn’t seem to matter much what exactly was done, whether you just went, you know, quickly what, whether you wanted remove the polyp or fibroid. There aren’t pain fibers on the inside of the uterus, like, it doesn’t hurt for the uterus that something, you know, removed from the inside. It’s really just whether to hurt have the cervix dilated or not, and then they’re done. I think pretty much everyone goes to work the next day.
Dr. Shlansky: If you removed a significant fibroid, the area where its removed were weep. So when people have what’s called endometrial ablation when you burn the lining or freeze the lining or do whatever for an endometrial ablation, there’s a lot of discharge that people have for days later. And so the hospital procedure if a large fibroid has been removed or a large area has been removed, they’ll actually have a weepy kind of watery discharge and that’s actually totally normal, and that lasts for almost four weeks. But the folks who just had a little doodad [SP] or a little biopsy, they’ll be perfectly fine.
Dr. Fox: For our listeners, doodad is the medical term. Sorry for being so technical with you. We try to avoid that but occasionally those Latin phrases just come out, and we can’t do anything about it. If someone’s having a hysteroscopy, you’re talking about it. Obviously, we’re describing a relatively straightforward say procedure. But what would be the potential risks to doing this, meaning, you know, what could possibly happen and what should people watch out for if they’re having one or had one?
Dr. Shlansky: So in terms of risks of the procedure, there’s a big difference between having a diagnostic hysteroscopy which means that you’re just going in with a smaller camera to take a look. The risk of any complication is probably 1%. And the next few things I’m going to say total up to that 1%. An operative hysteroscopy is a little bit different. So the diagnostic hysteroscopy, the risks are basically having a problem with bleeding, which is really very rare, having a problem with infection, which is also very rare, having a complication of anesthesia, which is very rare. But in the process of trying to dilate the cervix, for some people you can make a false passageway, and that false passageway we call perforation, and that risk is also very small. So again, all four things I just mentioned total up to 1% of all diagnostic hysteroscopies. The operative hysteroscopy where you’re removing something that’s bigger or larger actually has slightly greater risks. There’s still the risk of bleeding, there’s still a risk of infection or complications of anesthesia. But we mentioned the fluid needing to go in and come out, there’s a risk of fluid overload. Because there had been some safety issues probably about 20 years ago, they ask that we stop the procedure if are fluid loss. So what went in versus what came out exceeds about a liter to one and half liters, which is like a normal bag of IV fluid that you actually have to stop at that point. So sometimes we can’t finish the procedure, because it’s a large 3-centimeter fibroid that we’re actually removing. And at that point, you have to stop the procedure for safety reasons, not because of any other reason. And it’s really just to keep people safe. So that procedure is a little bit riskier, because you’re using currents. And it is a different class of procedure. It’s more of a medium risk procedure, but again, the total risk of complication probably totals up to about 3% or 4%.
Dr. Fox: Right. It’s all low. It’s just lower if you do a diagnostic hysteroscopy. Correct. And then would there be any signs like before one had a hysteroscopy when she goes home. What do you tell her to sort of be on the lookout for, you know, in that 1%, 2%, or 3%?
Dr. Shlansky: Usually pain and bleeding just like most other things. Most people should be able to get up recover, go back to their normal life very quickly. So somebody who’s having pelvic pain and it’s not responding to Motrin assuming they are allowed to take that or Tylenol. And some people can’t take it for medical reasons. They should really get relief with just Motrin and Tylenol. That should be it.
Dr. Fox: Okay. So you think if they have pain that’s a significantly more that maybe a clue that there’s a complication.
Dr. Shlansky: Absolutely.
Dr. Fox: Not necessarily obviously, but it may be. And what about for bleeding, what should they be expecting, and what would be abnormal?
Dr. Fox: So people shouldn’t bleed like a period. So volume wise it should always be less than a period. And people could bleed up to, like, 10 days after they have a procedure. But it should be pretty light, and it might come and go. If a lot of tissues removed, there may be, like, a little bit of an odor there from it, especially, the operative hysteroscopies have a little bit of odor. But overall, they should be feeling pretty well and really back to their normal activity levels.
Dr. Fox: Fantastic. Well, I think this is a real thorough review of an important procedure. And I agree it’s really, it’s fortunate that this procedure is doable. Because a lot of information is gained, and sometimes treatments and it can avoid operations, you know, it technically is an operation it can avoid potentially bigger operations. And I do think that fortunately it’s safe and it’s, for the most part, painless. And I think it’s great. Lis, thank you so much.
Dr. Shlansky: Thank you Nate.
Dr. Fox: All right. Thank you for listening to the Healthful Woman Podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at firstname.lastname@example.org Have a great day. The information discussed in Health Woman is intended for educational uses only. It does not replace medical care from your physician. Healthful Woman is meant to expand your knowledge of women’s health and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.