Indications for diagnostic hysteroscopy
• Evaluation of abnormal uterine bleeding: abnormal uterine bleeding account for 20% of referrals to gynaecologists and 25% of gynaecological procedures in premenstrual women (12).
Abnormal uterine bleeding can be subdivided into premenopausal problems, postmenopausal problems, and unscheduled bleeding on hormone replacement therapy or tamoxifen. When combined with pelvic ultrasound scanning and endometrial biopsy, outpatient hysteroscopy is invaluable in the investigation of abnormal uterine bleeding.• Diagnosis of focal intrauterine lesions (e.g. polyps and fibroids): structural lesions responsible for abnormal bleeding are often at their peak during the perimenopausal period; these include focal lesions such as endometrial polyps and submucosal fibroids. Endometrial cancer is rare between the age of 40 years and its incidence rises steeply between the ages of 45 and 55 (13, 14). Between 5% and 10% of all women with postmenopausal bleeding will have endometrial cancer (15).
• Investigation and infertility: the main indication for hysteroscopy is the investigation of infertility is in clarifying intrauterine pathology when an abnormal scan result is obtained, for example, endometrial polyps, submucous fibroids, intrauterine adhesions, or septa.
• Investigation of recurrent miscarriage: congenital abnormalities are associated with infertility, there is a high rate of spontaneous miscarriage and preterm labour when these structural abnormalities exist (16, 17). Hysteroscopy is not useful in diagnosing cervical incompetence but can identify cervical adhesions, atresia, and polyps. Cervical incompetence can, however, be suspected when the uterus fails to distend with loss of fluid coming through the cervix.
• Location and retrieval of a lost intrauterine contraceptive device (IUD): a pelvic ultrasound scan will locate the IUD and confirm its presence inside the cavity; if there is any doubt, a plain abdominal X-ray should be ordered. Outpatient hysteroscopy is invaluable in the removal of the IUD; a hysteroscope with an operative channel is used with a grasping forceps inserted into the uterus and either the thread or the IUD itself is grasped with the forceps and the hysteroscope is withdrawn with the IUD.
• Prior to ablation of the endometrium: endometrial ablation is designed to treat abnormal uterine bleeding in women with no intrauterine pathology. Preablation hysteroscopy is useful to exclude any unexpected pathology and to rule out endometrial cancer.
• Assessment for hysteroscopic sterilization: hysteroscopic sterilization is performed in the outpatient setting and aims to reduce the risks from general anaesthetic, has a shorter recovery time, and aims to be cost-effective; a newer method that aims to achieve this is the Essure system, details of this will be discussed later (15).