One-stop outpatient hysteroscopy clinic

Who is the leaflet for? What is its aim?

You have been given this leaflet as your gynaecologist has recommended you attend the hysteroscopy clinic at the Rosie hospital (clinic 21 or clinic 25 – on daphne ward). The aim of the leaflet is to explain the procedure, its benefits and risks, the aftercare you may require and how you will obtain any results following the procedure.

Key points

Outpatient hysteroscopy (OPH) is a procedure carried out in the outpatient clinic that involves examination of the inside of your uterus (womb) with a thin telescope.

• The actual procedure itself usually takes 5 to 10 minutes but it can take longer to set up the equipment especially if you are having any additional procedures.
• You may feel pain or discomfort during OPH. We recommend you take pain relief one to two hours before the appointment but if it is too painful, it is important to let your healthcare professional (doctor or specialist nurse) and the nursing staff know so the procedure can be stopped immediately.
• Alternatively, you may choose to have the hysteroscopy under general anaesthetic. This will then be arranged to take place in an operating theatre, usually as a day-case procedure.
• Possible risks with hysteroscopy include pain, feeling faint or nauseous, bleeding, infection and rarely uterine perforation (damage to the wall of the uterus). The risk of uterine perforation is lower during OPH than during hysteroscopy under general anaesthesia.

Why have you been advised to undergo outpatient hysteroscopy?

There are many reasons why you may be referred for outpatient hysteroscopy. You may have been experiencing:

• bleeding after the menopause (postmenopausal bleeding) bleeding between periods (intermenstrual bleeding)
• irregular bleeding while on hormonal treatment or HRT (Hormonal Replacement Therapy)
• require removal of a coil when the threads are not visible at the cervix
• fertility concerns
• following a miscarriage
• investigation for something seen inside the uterus on an ultrasound scan, such as an endometrial polyp or fibroid.

Your healthcare professional will discuss your options and whether OPH is right for you at the visit if you have not been seen previously. The purpose of your hysteroscopy appointment is to find the cause of your problem and plan or indeed undertake treatment if needed.

What is outpatient hysteroscopy (OPH)?

OPH is a procedure that involves examining the inside of your uterus. This is done by gently passing a thin fibre optic telescope-like device with a small camera, called a hysteroscope, through the cervix (neck of the uterus and into the uterus itself.

It may be possible for a minor procedure to be done at the same visit, such as:

• Endometrial biopsy – taking a sample from the lining of the uterus (endometrium). This is done through the hysteroscope or by passing a thin tube through the cervix once the hysteroscope is removed.
• Polyp removal – a polyp is formed as a result of overgrowth of the lining of the uterus and often looks like a small grape, sometimes on a stalk.
• Small fibroid removal – fibroids are knots in the muscle of the uterus that are non-cancerous (benign). They can sometimes bulge, like a polyp, into the cavity of your uterus.
• Insertion of a hormone-releasing intrauterine device (for example, Mirena®). This is an effective treatment for heavy menstrual bleeding (periods), is a contraceptive and may also be a component of HRT.
• Removal of a coil / Mirena® from the uterus when the threads are not visible and imaging confirms the device is within the uterine cavity.

Medication

Please bring all of your medicines (including inhalers, injections, creams, eye drops or patches, herbal medicines), or a current repeat prescription from your GP.

Please tell the staff about all of the medicines you use and your allergy status.

What should I do before my appointment?

You do not need to fast before your appointment, indeed we recommend you have a light breakfast / lunch before you attend as this reduces the risk of your feeling faint.

We recommend that you take some simple, over the counter pain relief such as ibuprofen, providing you are not allergic and can tolerate it, approximately an hour before your appointment. If you are unable to tolerate ibuprofen take paracetamol as an alternative.

You will be free to go home as soon as we all agree you are well. You may wish to have a friend or relative accompanying you for support.

Do I need to use contraception?

The procedure must not be performed if there is any chance that you are pregnant. To avoid this possibility, it is important to use contraception or avoid sexual intercourse between your last period and your appointment. You will usually be offered a urine pregnancy test on arrival at your appointment. If you have had unprotected intercourse since your last period, please contact the department to reschedule your appointment.

Can I still have an outpatient hysteroscopy if I’m bleeding?

It is best to keep the appointment but sometimes it can be difficult to do the procedure if you are bleeding heavily. This can be assessed by the clinician at the time of your appointment. If you have any concerns, please call the given telephone numbers below.

What happens during outpatient hysteroscopy?

On arrival

You will meet the healthcare professional performing the procedure who will discuss the procedure and ask for your consent. Please take this opportunity to ask any questions you may have.

You will be given the opportunity to empty your bladder.

You will be asked to go behind a curtain and undress below the waist and cover yourself with a modesty sheet.

There will be two or three healthcare professionals in the procedure room and one of them will support you throughout the procedure. You will then be asked to sit on a couch, which is specifically designed for gynaecological procedures and will have stirrups to support your legs and a ‘cut out’ seat. You will be asked to place your legs in the stirrups, unless you have any mobility issues that the nursing staff will discuss with you. If you are unable to weight bear and use a hoist at home, it is still possible to have the procedure, however, we would prefer you let us know in advance so we are prepared and do not delay your appointment. If you have your own sling, please being this in with you.

The procedure

During the procedure there will be a nurse by your side.

Initially the setting up of the equipment and manoeuvring the couch into the correct position will take a few minutes. If no problems are found, the actual procedure will only take about 5 to 10 minutes.

A hysteroscope (3mm width) is passed through the cervix to give a clear view of the inside of your uterus. Sometimes this will also involve passing a speculum, like when having a smear test. You will also be able to view these same images during the examination if you wish. Fluid is inserted into the hysteroscope to help visualised the uterine cavity. Consequently, you may feel a little wet but do not be concerned this is only saline solution.

As mentioned a biopsy (small sample) from the lining of your endometrium may be taken and sent to the laboratory for examination. The biopsy can be painful, but the pain should not last long.

At this point a Mirena® device can be placed into the uterus, if this has been agreed.

Alternatively if a fibroid or polyp is found, it can sometimes be removed at the same time by using additional techniques. The instrument to remove fibroids and polyps is called a MyoSure®. This device is inserted through a somewhat wider hysteroscope (6 - 7mm width) so we will then administer a local anaesthetic to the cervix.

Your practitioner passes the MyoSure® through the hysteroscope and it works by shaving away the polyp or fibroid into tiny pieces which are suctioned out through a small open window and removed. It does so with minimal discomfort and without damaging the lining of the uterus more generally.

On completion of the procedure both the hysteroscope and the MyoSure® will be removed. Nothing is left in your body after the procedure.

Photographs of the findings inside your uterus are often taken and scanned into your healthcare notes. As a leading teaching hospital we take great pride in our research and staff training. We ask for your permission to use images and recordings for your diagnosis and treatment; they will form part of your medical record. We also ask for your permission to use these images for audit and in training medical and other healthcare staff and UK medical students; you do not have to agree and if you prefer not to, this will not affect the care and treatment we provide. We will ask for your separate written permission to use any images or recordings in publications or research.

Will outpatient hysteroscopy hurt?

For most women, OPH is quick and safe, and is carried out with little pain or discomfort. OPH is often done without inserting a speculum, by using a thin telescope (called vaginoscopic OPH) as this is more comfortable.

However, everyone’s experience of pain is different and some women will find the procedure very painful. If it is too painful for you, let the team know as the procedure can be stopped at any time if you wish.

The healthcare professional may offer a local anaesthetic injection into your cervix. This will require using a speculum to see your cervix.

If you feel anxious about the procedure, you can contact us in advance although you will also have an opportunity to discuss this with your healthcare professional before the test is performed.

How long does the visit take?

Initially the setting up of the equipment and manoeuvring the couch into the correct position will take a few minutes. The actual procedure may only take 5-10 minutes. However, it is best to allow up to 30 minutes including a consultation, having the procedure and recovery and if polyps or small fibroids are removed at the same time, this may take a bit longer.

You can rest in the outpatient clinic’s recovery area for as long as you need (usually about 20 minutes).

What happens afterwards and how will I feel?

After the procedure you will be given time to recover and, when you feel ready, get dressed behind the curtain. There are wipes, and washing facilities (if required). We ask that you bring in your own panty liner/sanitary towel as you will have some spotting after the procedure. A nurse will advise you of what to expect afterwards (see below).

If you are driving yourself we will ask you to sit in our reception area or the Rosie café for at least 30 minutes before setting off.

At home

• Most women feel able to go back to their normal day-to-day activities on the same day but we suggest that you avoid any more strenuous physical activity until any bleeding has stopped.
• You may have some spotting or fresh (bright red) bleeding that may last up to one week. Please do not use tampons and avoid intercourse until the spotting/blood loss has stopped; this reduces the risk of possible infection. We recommend you do not swim or take long soaks in a bath. Though you can shower as normal.
• You may get some period-like pain for one to two days. You may need to take simple, over the counter pain relief, such as 400mg ibuprofen every eight hours or (500mg to 1g) paracetamol every four hours (for under 50kg patient, the dose of paracetamol is safer to start with 500mg), or your usual period pain tablets (no more than the recommended dose). If you are unable to tolerate either of these please discuss with the nurse who talks to you after the procedure.
• If you are worried for any reason following your appointment, telephone the reproductive medicine specialist nurse on 01223 808 240 (Tuesday-Friday 08:00-17:00) Outside of these hours please contact the emergency gynaecology unit on 01223 217 636 (Monday - Friday; 08:00 - 20:00 and weekends; 08:30 - 14:00) or Daphne inpatient gynaecology ward on 01223 257 206 (at any time). In an emergency please attend the emergency department.

Results

If no problems are found, you may agree with your healthcare professional that no follow-up appointments are needed.

If a biopsy has been taken, we generally have the results available to us in approximately 14 days however this can take up to 2 months and we will write to you shortly after.

Benefits

• Likelihood of reducing heavy or irregular bleeding caused by a polyp / fibroid is about 80% The recurrence rate of polyp/fibroid is less than 10% after 2 years
• An outpatient hysteroscopy does not involve a general or regional anaesthetic and the associated risks. You will be fully awake during the procedure and most women find this preferable.
• You only need to be in hospital for the duration of your appointment.
• You do not need to starve prior to the procedure and indeed should eat and drink as normal.
• An outpatient MyoSure® is intended to reduce the risk of traumatic injury to the uterus and risks associated with general anaesthetic.

Risks

Overall complication risk is 2 in 100 (Uncommon)

• Minor risks involved with the procedure:
  • Pain during or after OPH is usually mild and similar to period pain; if you are unable to tolerate this, the procedure can be halted immediately. Simple pain relief medications can help. Rarely, women may experience severe pain
  • Bleeding is usually very mild and is lighter than a period, settling within a few days.
  • Nausea, vomiting or fainting can affect a small number of women. However, these symptoms usually settle quickly. Do let the staff know if you are feeling unwell during or straight after the procedure.
• Failed / unsuccessful OPH occurs (1 in 20 women, common) if it is not possible to pass the hysteroscope inside your uterus. This may happen if the cervix is tightly ‘closed’ or scarred or if the procedure is too painful for you to tolerate. If this is the case, your healthcare practitioner will discuss the option of scheduling the procedure under a general or spinal anaesthetic.

More serious risks (however, these risks are extremely rare):

• Infection is uncommon (1 in 400 women). It may appear as a smelly discharge, fever or severe pain in the tummy. If you develop any of these symptoms, contact us urgently.
• Damage to the wall of the uterus (uterine perforation) – rarely, a small hole is accidentally made in the wall of the uterus. This could also cause damage to nearby tissues. This happens in less than 1 in 1000 diagnostic hysteroscopy procedures but is slightly more common if someone has a polyp or fibroid removed at the same time. It may mean that you have to stay in hospital overnight for observation. Usually, nothing more needs to be done; rarely you may need a further operation to repair the hole.
• Fluid overload (2 in 1000, uncommon). Serious overload requiring intensive therapy (65 in 10000, rare). Uncomplicated overload (1 in 1000, uncommon)

Are there alternatives to having an outpatient hysteroscopy?

There may be other things to consider when deciding whether OPH is the right choice for you, such as:

• if you faint during your periods because of pain
• if you have experienced severe pain during a previous vaginal examination
• if you have experienced difficult or painful cervical smears
• if you have had any previous traumatic experience that might make the procedure difficult for you or simply if you do not wish to have this examination when awake.

Alternatively you may choose to have your hysteroscopy under either a general or spinal anaesthetic. This will then be arranged to take place in an operating theatre, usually as a day-case procedure. If that is the case please contact the hospital on the above contact numbers. The risks and complications are lower when hysteroscopy is done as an outpatient procedure rather than under anaesthesia

You may choose not to have a hysteroscopy; however, this may make it difficult to find the cause of your symptoms and to offer the right treatment for you. We may alternatively recommend a scan to find out more information and/or may ask you to come back if your symptoms continue.

Your consultant would be able to discuss the implications of not having the procedure with you.

Shared decision making

You are often asked to make choices about tests that are offered or treatments that are available and you may have many questions to ask. You may find it helpful to write a list of questions that you would like addressed and bring that to the appointment.

There are three key questions to address when asked to make choices about healthcare:

• What are my options?
• What are the advantages and disadvantages of each option?
• How do I get the support and advice to help me make a decision that is right for me?

About intimate examinations

The nature of gynaecological care means that intimate examinations are often necessary.

We understand that for some people, particularly those who may have anxiety or who have experienced trauma, physical or sexual abuse, such examinations can be very difficult. If you feel uncomfortable, anxious or distressed at any time before, during, or after an examination, please let your healthcare professionals know. If you find this difficult to talk about, you may communicate your feelings in writing. Your healthcare professionals are there to help and they can offer alternative options and support for you. Remember that you can always ask them to stop at any time. You will have a member of staff as a chaperone to support you. You can also bring a friend or relative if you wish.

Contacts

Reproductive medicine specialist nurse

01223 808240

Tuesday, Wednesday, Thursday and Friday; 08.00 – 17:00

Clinic 24 (emergency gynaecology unit / early pregnancy unit)

01223 217636

Monday to Friday; 08.00 – 20.00

Weekends; 08.30 – 14.00, Closed Bank holidays

Daphne Ward (inpatient gynaecology ward)

01223 257206

At all other times

Further information

NHS information on hysteroscopy, 2018. What-happens: Hysteroscopy (opens in a new tab). [Accessed 07 June 2019]

References and sources of evidence

This leaflet is almost wholly based on based on the patient information leaflet:

Royal College of Obstetricians and Gynaecologists/ British Society of Gynaecological Endoscopy, 2018. Information for you: Outpatient hysteroscopy. (opens in a new tab)

Further sources of evidence

National Institute for Health and care excellence (NICE); 2015. Interventional procedure guidance IPG522 Hysteroscopic morcellation of uterine leiomyomas (fibroids) (opens in a new tab). [Accessed 07 June 2019]

National Institute for Health and Care Excellence (NICE) guideline NG88, 2018. Heavy Menstrual Bleeding: Assessment and Management. (opens in a new tab) [Accessed 07 June 2019]

Hologic (2015) MyoSure®: Fibroid removal simplified. Life uninterrupted. (opens in a new tab)

Hologic MyoSure®: Tissue Removal Suite (opens in a new tab)

Privacy and dignity

We aim to ensure that privacy and dignity are maintained at all times. There are private changing areas and toilet facilities within the hysteroscopy procedure suite.