The hysteroscope is an endoluminal endoscope, adapted from the urological cystoscope that can be used to aid diagnosis or to direct the performance of a variety of intrauterine procedures. Hysteroscopic lysis of intrauterine adhesions was first described in 1973 (147). The technique of endoscopically guided electrosurgical resection was adapted from urology to gynecology for the removal of uterine leiomyomas (148). Hysteroscopic division of uterine septa was originally developed using a mechanical technique with specially designed scissors (149). Hysteroscopic destruction of the endometrium, generally termed endometrial ablation (EA), was originally reported using Nd:YAG laser vaporization, but subsequent innovators used the urological resectoscope to ablate the endometrium using electrosurgical coagulation, resection, or vaporization (150–152). Hysteroscopically guided thermal ablation with heated ﬂuid was described, as the only endoscopically guided technique for nonresectoscopic EA. Developments in the design of endoscopes resulted in smaller-diameter instruments that retain the ability to provide a high-quality image and facilitate the use of hysteroscopy in an office or procedure room setting.
Diagnostic Hysteroscopy The goal for evaluation of the uterine cavity is to obtain either a sample of the endometrium, usually for the detection of hyperplasia or neoplasia, or to identify structural abnormalities, typically a uterine septum or focal lesions, such as adhesions, polyps, or myomas. Blind endometrial sampling is the diagnostic mainstay for the detection of endometrial hyperplasia, whereas transvaginal ultrasonography, hysterography, MRI and hysteroscopy are options for the detection and characterization of structural anomalies. Hysteroscopic examination is superior to hysterography for evaluation of the endometrial cavity, but the diagnostic accuracy of transvaginal ultrasonography is comparable, when intrauterine saline or gel is used as a contrast medium, a procedure called sonohysterography or saline infusion sonography (SIS) (153–156). MRI and ultrasound-based techniques have the advantage of allowing evaluation of the myometrium, whereas office-based hysteroscopy allows simultaneous removal of small polyps and even some myomas. Diagnostic hysteroscopy provides information not obtained by blind endometrial sampling, such as detection of endometrial polyps or submucous leiomyomas (157–163). Malignant or hyperplastic polyps or other localized lesions can be identified with hysteroscopy and removed via directed biopsy (160). Blind curettage remains an effective approach for the identification of global endometrial histopathology (157,162,164). Following are potential indications for diagnostic hysteroscopy: 1.
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3. Recurrent spontaneous abortion