Pocket Guides for Gynaecologists Editors: Thomas Ro¨mer, Andreas D. Ebert
Thomas Ro¨mer
Diagnostic Hysteroscopy A practical guide 2nd Edition
DE GRUYTER
Professor Dr. med. Thomas Ro¨mer Evangelisches Krankenhaus Ko¨ln-Weyertal gGmbH Weyertal 76 50931 Ko¨ln
[email protected] Translated by Dr. Christina Ro¨mer, Cologne. This book has 134 figures and 6 tables. ISBN 978-3-11-022497-9 Library of Congress Cataloging-in-Publication Data Ro¨mer, T. (Thomas) [Hysteroskopischer Wegweiser fu¨r Gyna¨kologen. English] Diagnostic hysteroscopy : a practical guide / Thomas Roemer. - - 2nd ed. p. ; cm. - - (Pocket guides for gynaecologists) ISBN 978-3-11-022497-9 (alk. paper) 1. Hysterocopy- -Handbooks, manuals, etc. I. Title. II. Series: Pocket guides for gynaecologists. [DNLM: 1. Infertility, Female- -diagnosis- -Handbooks. 2. Hysteroscopy- Handbooks. 3. Menstruation Disturbances- -diagnosis- -Handbooks. WP 39 R763h 2010a] RG304.5.H97R6613 2010 618.10 407545- -dc22 2010003282 Bibliographic information published by the Deutsche Nationalbibliothek The Deutsche Nationalbibliothek lists this publication in the Deutsche Nationalbibliografie; detailed bibliographic data are available in the Internet at http://dnb.d-nb.de. # 2010 Walter de Gruyter GmbH & Co. KG, Berlin/New York. The publisher, together with the authors and editors, has taken great pains to ensure that all information presented in this work (programs, applications, amounts, dosages, etc.) reflects the standard of knowledge at the time of publication. Despite careful manuscript preparation and proof correction, errors can nevertheless occur. Authors, editors and publisher disclaim all responsibility and for any errors or omissions or liability for the results obtained from use of the information, or parts thereof, contained in this work. The citation of registered names, trade names, trade marks, etc. in this work does not imply, even in the absence of a specific statement, that such names are exempt from laws and regulations protecting trade marks etc. and therefore free for general use. Printed in Germany. Typesetting, printing and binding: Druckhaus “Thomas Mu¨ntzer”, Bad Langensalza.
Preface to the 2nd edition
The hysteroscopic diagnostics and therapy have become a main focus in the clinical and research activities at the Department of Obstetrics and Gynaecology at the University of Greifswald at the beginning of the 1990s, and hundreds of gynaecologists have been trained in hysteroscopy during the traditional Days of Hysteroscopy in Greifswald. As a consequence we decided to pass on this extensive experience and published a Hysteroscopic Guide for Gynaecologists together with Professor Straube in 1996. With this book the idea of Gynaecological Pocket Guides, which shall represent in a short, concise and pictorial way the main areas of our speciality, was born. After more than ten years hysteroscopy has further developed, which led to this 2nd edition containing the latest aspects of diagnostic hysteroscopy and its practical applications. The 2nd edition shall contribute to the further enhancement of diagnostic hysteroscopy in the practices and in hospitals. I would like to thank everyone who supported me in completing the book. I thank Ms. Timm for typing the manuscript, and Ms. Dr. Kowalski and Ms. Dobler from Walter de Gruyter publishing house for their excellent advice and for having responded to all my comments and requests. Cologne, February 2010
Prof. Dr. med. Thomas Ro¨mer
Contents
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Indications for diagnostic hysteroscopy . . . . . . . . . . . . . . . Instrumentation and distending medium . . . . . . . . . . . . . . Examination procedure and techniques . . . . . . . . . . . . . . . Distinctive features of hysteroscopy in the gynaecologist’s practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hysteroscopy in the diagnostics of sterility and infertility Hysteroscopy with bleeding disorders . . . . . . . . . . . . . . . . Hysteroscopy with sonographically suspect endometrial findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hysteroscopy and lost IUD/IUS. . . . . . . . . . . . . . . . . . . . . . Special cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . List of abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1 2 3 4 22 34 36 66 118 133 140 145 149 150
1. Introduction
In the last two decades hysteroscopy has been established as a method for the diagnostics and therapy of intrauterine diseases. The scope of indications has permanently increased so that today this method belongs to the standard practices in gynaecology. With the development of thin lenses hysteroscopy is not only feasible in hospitals but for many indications also in the gynaecological practice without anaesthesia. For that reason aspects of the diagnostic hysteroscopy for outpatient treatment are especially considered. For the diagnostics of sterility and bleeding disorders hysteroscopy constitutes only one form of treatment. Therefore in the case studies of this 2nd edition of the Hysteroscopic Guide this method is placed in line with anamnesis, sonography, histology and therapy. The present guide sets out to offer to the gynaecologist a companion for the practical use of hysteroscopy.
2. History
The first hysteroscopy was reported by PANTALEONI in the English journal The Medical Press in 1869. The Frankfurt physician BOZZINI, who in 1804 developed the so-called light conductor, already then talked of the possibility of hysteroscopy. In the next century there were many attempts to establish hysteroscopy as a method for gynaecological diagnostics. Its decisive impetus hysteroscopy owes to LINDEMANN, who succeeded in the 1970s in improving CO2-hysteroscopy as a method. With the possibility of therapeutic hysteroscopies and as a result of numerous technical improvements this method has now found its well-deserved application. Over the last decades the scope of applications of hysteroscopy, especially for the diagnostics of bleeding disorders, has increased by the use of fluid distending media. Thin lenses and sophisticated optical systems facilitate a high picture quality. The development of compact systems for the use in the practices (Telepack) is going to further enhance this method.
3. Indications for diagnostic hysteroscopy
1. bleeding disorders 2. diagnostics and staging of endometrial cancer 3. diagnostic assessment of sonographically suspect endometrial findings 4. sterility/infertility 5. control after intrauterine operations (intrauterine adhesiolyses, septum dissections, curettages following an abortion, curettages post partum or in childbed) 6. control after medical therapy of endometrial hyperplasias 7. lost IUD/IUS
4. Instrumentation and distending medium
1. Compulsory –– hysteroscope (30$ lenses), when indicated with continuous flow sheath –– distending medium –– light source –– (self-holding) specula 2. Optional –– video documentation –– grasping forceps –– probe/Hegar’s dilatators –– small curette for endometrial biopsy Attention: Diagnostic hysteroscopy can be best performed with 30$ lenses.
Instrumentation and distending medium
5
Small curette for target curettage or endometrial biopsy for outpatient diagnostic hysteroscopy. Self-holding specula (available in various sizes).
Attention: Extraction of histological material is possible with this curette without further cervix dilatation. Attention: Self-holding specula are especially recommended for outpatient hysteroscopy because a fixation of the cervix with grasping forceps may be dispensed with in most of the cases.
6
Instrumentation and distending medium
Diagnostic hysteroscope (2 mm-30$ -lenses), with a 2.8-mm-diagnostic sheath and a 3.6-mm-flow sheath with the possibility of continuous flow.
Attention: The continuous flow sheath is especially suited for fresh bleeding ex utero or coagula in utero for the clearing irrigation of the cavum uteri. Attention: A flushing effect may also be reached when the cervix is dilated further (Hegar 8), so that the outflow may be reached via the dilated cervical canal.
Instrumentation and distending medium
7
Bettocchi-hysteroscope with working sheath for semi-rigid instruments (biopsy forceps, grasping forceps, microscissors) and continuous flow sheath, lenses 2 mm, outer diameter: 4.2 mm.
Attention: The small-size instruments are only suited for the biopsy of focal lesions, cutting off of small polyps, IUD-extraction and cutting of intrauterine adhesions grade 1 and 2.
8
Instrumentation and distending medium
Semi-rigid instruments for the Bettocchi-hysteroscope 1. 2. 3. 4. 5. 6.
biopsy- and grasping forceps biopsy spoon forceps punch blunt scissors sharp scissors myoma-fixation instrument
Attention: For the insertion of the working sheath the non-anaesthetized patient may be given a local anaesthetic if necessary. Attention: The tissue gained from biopsy may often be very small, so that a small curette may be used.
Instrumentation and distending medium
9
Diagnostic standard hysteroscope, 4 mm-30$ -lenses and 5.1 mm outer diameter (without continuous flow sheath).
Attention: With patients suffering from cervical stenosis minihysteroscopy is primarily used.
10
Instrumentation and distending medium
Xenon light source with up to 300 W.
Attention: A high-performance light sources enhances diagnostic reliability.
Instrumentation and distending medium
11
HAMOU- microhysteroflator for CO2-hysteroscopy
Left: Digital CO2-pressure indication (mmHg) Right: Digital CO2-flow indication (ml/min).
Attention: The pressure in CO2-insufflators is limited to 200 mmHg. Attention: CO2-insufflators for laparoscopy (Laparomat) must not be used for hysteroscopy.
12
Instrumentation and distending medium
Pressure-cuff for diagnostic hysteroscopy with a fluid distending medium for 1-l-fluid (usually isotonic saline solution). Pressure on the cuff is in most of the cases adjusted to 150 mmHg (up to at most 200 mmHg).
Attention: With a more difficult passage through the cervical canal a short-term increase in pressure is recommended because it facilitates the opening of the cervical canal and the following passage.
Instrumentation and distending medium
13
Videocamera Image 1 (digital 3-chip-camera) with pendular head and Image 1 (standard head) with control gear.
Advantage: The pendular camera remains centred even when moved, which facilitates orientation.
14
Instrumentation and distending medium
Telepack-system with connected camera head (Telekam) and light cable.
Advantages of the Telepack-system: –– mobile use –– space-saving –– multi-functional (light source, screen, camera, documentation – all in one device) –– allows for video and photo documentation –– cost-effective (low costs)
Instrumentation and distending medium
15
Table 1: Comparison of CO2 -hysteroscopy and hysteroscopy with a fluid distending medium
1. picture 2. technical complexity 3. usage 4. risk of dissemination (infection, tumour cells) 5. diagnostics of bleeding disorders 6. diagnostics of sterility
CO2-hysteroscopy
hysteroscopy with fluid medium
very clear higher some experience necessary very low
clear low easy
limited (with current bleeding) very good
very good
slightly higher
good
Attention: Especially for the diagnostics of bleeding disorders hysteroscopy with a fluid distending medium should be preferred. Attention: One advantage of the hysteroscopy with a fluid distending medium is that a follow-up control of the cavity after mechanical removal of polyps or dilatation/curettage is possible.
16
Hysteroscopic finding
Hysteroscopic finding: Passage of the cervical canal with CO2-hysteroscopy. Further forward movement towards the gas bubbles.
Hysteroscopic finding
17
Hysteroscopic finding: Passage of the cervical canal with hysteroscopy with a fluid medium. Clear view of the cervical canal with further forward movement of the hysteroscope towards the cavity.
18
Hysteroscopic finding
Hysteroscopic finding after the setting up of the hysteroscope on the external os of the cervical canal.
Attention: Through the supply of the distending medium the cervical canal unfolds and the passage with the hysteroscope becomes possible.
Hysteroscopic finding
19
Hysteroscopic finding (CO2 as distending medium): Regular cavity with atrophic endometrium.
Panoramic hysteroscopy: Fundus, posterior wall and tubal cornua clearly visible on both sides. Disadvantage: Gas bubbles obstruct the assessment of the posterior wall of the cavity.
20
Regular cavity with cervical stenosis
52-year-old patient 1. Clinical diagnosis 2. Anamnesis 3. Sonography
cervical stenosis cervical stenosis, cytological swab not possible endometrium thickness: 6 mm
4. Hysteroscopy
regular cavity after dilatation of the cervix
5. Therapy
dilatation of the cervix, dilatation/ curettage
6. Histology
atrophic endometrium, cervix without findings
Hysteroscopic finding
21
Hysteroscopic finding: Regular cavity with normal endometrium. Hysteroscopy with a fluid distending medium makes assessment difficult by air bubbles on the anterior wall.
Attention: Air bubbles in the cavity can be avoided by paying attention to an empty input tube for the fluid distending medium during hysteroscopy.
5. Examination procedure and techniques
Examination procedure for the diagnostic hysteroscopy –– palpation/sonography –– vaginal disinfection –– adjustment of specula –– (grasping forceps) –– setting up of hysteroscope (Attention: There must be no air in the input tube!) –– monitored passage through the cervical canal –– panoramic hysteroscopy –– assessment of the fundus and the tubal ostia –– assessment of the cavity walls –– assessment of the cervical canal when removing the hysteroscope –– biopsy (eye-directed/target biopsy) or dilatation/curettage Attention: For hysteroscopy the tubal ostia are the major points of orientation (landmarks) in the uterine cavity. Technique Lesions of the endometrium are to be avoided. Therefore mind the following principle: Attention: The hysteroscope is always the first instrument in the cervical canal. Attention: Probing of the uterine cavity and dilatation of the cervical canal with Hegar’s dilators should, if possible, only be performed after a hysteroscopic inspection of the original cavity. Exception: cervical stenosis
Examination procedure and techniques
23
Problematic situations in diagnostic hysteroscopy 1. nullipara 2. craurosis fornicis 3. state after conisation solution: –– use of a thinner hysteroscope (2-mm-hysteroscope) –– local application of prostaglandins disadvantages of the local application of prostaglandins: –– side effects (gastrointestinal) –– bleedings may obstruct vision –– danger of via falsa because of softening-up of the whole cervix –– additional costs Attention: The local application of prostaglandins is only necessary in rare cases. With a cervical stenosis the use of minihysteroscopes is the prime choice.
24
Examination procedure and techniques
Hysteroscopic finding: With further forward movement of the hysteroscope a cervical stenosis becomes visible. In this case passage is only possible after dilatation up to Hegar 5.
Attention: Cervical stenosis (mostly on the ostium cervicis internum) can be hysteroscopically exactly verified and thus be directly dilated.
Regular cavity (minihysteroscopy, cervical stenosis)
25
26
Examination procedure and techniques
52-year-old patient 1. Clinical diagnosis 2. Anamnesis 3. Sonography
cervical stenosis, lower abdominal pain cervical stenosis, cytological swab not possible, occasional abdominal pain endometrium thickness: 3 mm (secretory congestion, mucous cervix)
4. Hysteroscopy
mucous cervix cervical stenosis regular cavity, ostia free
5. Therapy
dilatation of the cervix, dilatation/ curettage atrophic endometrium, cervix without findings
6. Histology
Optimal time for examination 1. in sterile and infertile patients – immediately post menstruationem 2. in perimenopausal patients – with bleeding disorders possibly post menstruationem 3. in postmenopausal patients – as soon as possible after the bleeding Local anaesthesia Indication 1. cervical stenosis 2. craurosis fornicis 3. nullipara 4. necessity of use of a 7-mm-hysteroscope with working sheath
Examination procedure and techniques
27
Local anaesthesia Paracervical block
depot in the subvaginal epithelium for grasping forceps 5 ml of a local anaesthetic paracervically
Attention: Before injection always aspiration to avoid intravascular injection. Attention: Wait for the effect of local anaesthesia (3–5 minutes) before beginning with hysteroscopy or further manipulations. Attention: With the development of thin hysteroscopes local anaesthesia with outpatient hysteroscopies has become necessary only in rare cases. (Patients may suffer from more pain from the injection than from the passage of the cervical canal with the minihysteroscope.)
28
Examination procedure and techniques
Permitted movements of the hysteroscope with a patient without anaesthesia 1. forward and backward movement 2. rotation with use of 30$ -angle lenses
Examination procedure and techniques
29
Attention: With the help of these two movements 95 % of all uterine cavities can be completely assessed.
30
Examination procedure and techniques
correct
forbidden
Attention: Avoid horizontal and vertical movements of the hysteroscope because that may be painful for the patient without anaesthesia.
Documentation of the findings
31
Description of a hysteroscopic finding: 1. cervix: width, state of the mucous membrane, pathology (e.g. cervical polyp) 2. corpus: size (length, width, symmetry) ( endometrium thickness (test with sheath of hysteroscope) endometrium sliding test ( vascularisation ( free-running vessels) ( local change (polyp, hyperplasia) ( myomas (submucous/intramural) – grade scale ( ostia open/obstructed (landmarks of hysteroscopy) Attention: Especially with pathological changes hysteroscopic findings should be precisely described. Attention: Myomas, uterine malformations and intrauterine adhesions should be classified according to the standard grades of ESGE.
32
Regulary cavity – documentation
Regular cavity – documentation
33
36-year-old patient 1. Clinical diagnosis 2. Anamnesis 3. Sonography
recurrent menorrhagias and dysmenorrheas for two years increasing menorrhagias and dysmenorrheas, for one year patient has wanted child/ren endometrium thickness (post menstruationem): 8 mm
4. Hysteroscopy
regular cavity and cervix, ostia free
5. Therapy
endometrium biopsy, laparoscopy: resection of the endometriosis bilateral chromopertubation: positive proliferative endometrium
6. Histology
Attention: The photo documentation should consist of at least three pictures (both ostia, panoramic view of the cavity). With pathological findings a systematic documentation and corresponding description of the findings are necessary.
6. Distinctive features of hysteroscopy in the gynaecologist’s practice
The performance of hysteroscopy without anaesthesia in a gynaecologist’s practice has to fulfil certain requirements with regard to: ( the patient ( the examiner ( the equipment The examination procedure is similar to the one described on page 22. Distinctive features 1. use of self-holding specula 2. no grasping with the forceps 3. use of as thin as possible hysteroscopes 4. mostly use of endometrium biopsy 5. patient can watch the findings on the monitor screen The outpatient hysteroscopy has many advantages: 1. For the patient ( no anaesthesia ( outpatient treatment (in the practice) ( direct information about medical findings 2. For the gynaecologist ( direct treatment of the patient ( additional offer ( relatively low costs
Distinctive features of hysteroscopy in the gynaecologist’s
35
Requirements for the outpatient hysteroscopy without anaesthesia 1. –– –– –– –– 2. –– –– –– 3. –– –– ––
Patient no cervical stenosis no extensive intracavitary findings no extreme anteflexion or retroflexion of the uterus co-operative Examiner sufficient experience in hysteroscopy sonographic and clinical check of the indication trained staff for the assistance Equipment Telepack system thin lenses (2 to 3.6 mm) vaginal sonography available
Attention: With sonographically verified intracavitary findings (polyp, myoma) minihysteroscopy should be used only after careful consideration to avoid double interventions.
7. Hysteroscopy in the diagnostics of sterility and infertility
Indications for diagnostic hysteroscopy in the diagnostics of sterility 1. 2. 3. 4.
primary sterility secondary sterility infertility (habitual abortions) post-abortion-hysteroscopy Diagnostic hysteroscopy in patients with desire of pregnancy about 8 to 12 weeks after abortion curettage for the early diagnostics of intrauterine causes of abortions and adhesions 5. control hysteroscopy after septum dissections or intrauterine adhesiolyses Attention: For the diagnostics of any sterility and infertility hysteroscopy is a standard method and therefore essential.
Hysteroscopy in the diagnostics of sterility and infertility
37
HSG versus hysteroscopy in the diagnostics of sterility Table 2: HSG versus hysteroscopy HSG–findings
hysteroscopy
( round defect of contrast medium
( polyp ( myoma ( air bubbles (hysteroscopically normal findings)
( median, clean defect of contrast medium
( uterus septus –– uterus bicornis
( blurred defect of contrast medium
( intrauterine adhesions
Attention: Intrauterine adhesions of smaller grades of extent cannot be safely detected by hysterosalpingography.
Attention: Hysterosalpingography lost its importance by the increasing use of endoscopic diagnostic methods (hysteroscopy, laparoscopy).
38
Hysteroscopy in the diagnostics of sterility and infertility
Hysterosalpingography with patient suffering from habitual abortions Diagnosis: uterus septus/bicornis – diagnostic assessment by hysteroscopy and laparoscopy. Final diagnosis: uterus subseptus.
Sonography versus hysteroscopy in the diagnostics of sterility ( Sonographically, intrauterine adhesions can be presumed only in a third of the cases. Sonographically diagnosed endometrial defects are a sign of more severe adhesions (ESGE grade extent III and IV) (see page 58). ( Slight uterus malformations (septum smaller than 2 cm) are often missed by sonography (in about 30 % of the cases). Attention: Sonography for the detection of uterus malformations should be performed immediately before menstruation (thicker endometrium). Then in most of the cases two endometrial areas can be visualized.
Hysteroscopy in the diagnostics of sterility and infertility
39
Sonographic picture of a uterus septus in the 2nd half of the menstrual cycle (2 endometrial areas).
Sonographic suspicion of endometrial defects with intrauterine adhesions grade extent 4.
40
Regular cavity with primary sterility
Regular cavity with primary sterility
41-year-old patient 1. Clinical diagnosis 2. Anamnesis 3. Sonography
primary sterility for 3 years desire to have child/ren, ovarian cyst on the left endometrium thickness: 6 mm (7th day of menstrual cycle)
4. Hysteroscopy
regular cavity without pathological changes, tubal ostia free bilaterally
5. Therapy
laparoscopy (extirpation of the ovarian cysts), chromopertubation (bilaterally positive) none
6. Histology
41
42
Regular cavity with secondary sterility
40-year-old patient 1. Clinical diagnosis 2. Anamnesis
3. Sonography
secondary sterility for 5 years one delivery 12 years ago, now new partner, for 4 years desire to have a child (spermiogram and hormonal status without pathological findings) endometrium thickness: 6 mm (6th day of menstrual cycle)
4. Hysteroscopy
regular cavity, tubal ostia bilaterally free
5. Therapy
laparoscopic resection of the endometriosis, chromopertubation (bilaterally positive) none
6. Histology
Corpus polyp with a patient wanting a child
43
39-year-old patient 1. Clinical diagnosis 2. Anamnesis
3. Sonography
desire to have a child, myoma on the posterior wall known isthmic myoma on the posterior wall, growing, for 2 years desire to have a child 4-cm isthmic, subserous-intramural myoma on the posterior wall, endometrium thickness: 8 mm (8th day of menstrual cycle)
4. Hysteroscopy
small corpus polyp in the left tubal cornua, otherwise regular cavity, tubal ostia free bilaterally
5. Therapy
target curettage with removal of the polyp, laparoscopic myoma enucleation and resection of the endometriosis, chromopertubation (bilaterally positive) glandular corpus polyp
6. Histology
44
Submucous myoma grade extent 2
32-year-old patient 1. Clinical diagnosis 2. Anamnesis 3. Sonography
submucous- intramural myoma grade extent 2 desire to have a child for 2 years, fundal myoma that continues to grow, bleeding disorders 3.5-cm submucous-intramural myoma, endometrium thickness: 6 mm
4. Hysteroscopy
submucous-intramural myoma in the left fundal area, left tubal ostium not visible
5. Therapy 6. Histology
transcervical myoma resection parts of a leiomyoma (40 g)
Attention: Submucous myomas are rarely the cause of sterility (obstruction of the tubal ostium), but a frequent cause of infertility (higher incidence of abortions by nidation problems and lack of space). Classification of myomas (see table 4, p. 74)
Uterus septus
45
29-year-old patient 1. Clinical diagnosis 2. Anamnesis
3. Sonography
uterus malformation the uterus malformation was discovered by an externally performed laparoscopy but not clearly specified. Now again diagnostic assessment before planned IVF (tubal factor) 2 endometrium areas
4. Hysteroscopy
uterus septus extending up to the internal os of the uterus (5 cm)
5. Therapy
( laparoscopy: fundal area of the uterus smooth and wide ( transcervical septum dissection and IUD insertion
Attention: Before any intervention of assisted reproduction (especially IVF/ICSI) a hysteroscopic examination of the uterine cavity should be performed. Otherwise, uterus malformations and submucous myomas can cause an abortion after successful embryo transfer.
46
Uterus septus
18-year-old patient 1. Clinical diagnosis 2. Anamnesis 3. Sonography
uterus septus recurrent hypermenorrheas and dysmenorrheas, suspected endometriosis 2 endometrium areas, suspected uterus malformation
4. Hysteroscopy
uterus septus (small septum of a length of 5 cm extending up to the internal os of the uterus)
5. Therapy
( laparoscopy: fundal area of the uterus smooth and wide; resection of the endometriosis Douglas ( transcervical septum dissection and IUD insertion
Attention: For the differential diagnosis of uterus malformations a laparoscopy is compulsory.
Residual septum after septum dissection
47
18-year-old patient 1. Clinical diagnosis 2. Anamnesis 3. Sonography
residual septum after septum dissection 3 months ago septum dissection with complete septum and IUD insertion cavity without findings, IUD in place
4. Hysteroscopy
1.5 cm residual septum, median
5. Therapy
extraction of the IUD, transcervical dissection of the septum residuals
Attention: With complete septa a control hysteroscopy for the diagnostics and therapy of possible septum residuals or intrauterine adhesions is recommended.
48
Uterus subseptus
Uterus subseptus
49
28-year-old patient 1. Clinical diagnosis 2. Anamnesis 3. Sonography
habitual abortions with uterus subseptus 3 abortions (8th/10th/11th week of pregnancy) 2 endometrial areas
4. Hysteroscopy
broad-based complete septum (3 cm)
5. Therapy
( hysteroscopic septum dissection and IUD insertion ( laparoscopy: wide uterine fundus without raphe none
6. Histology
Attention: With habitual abortions the search for uterus malformations (mostly uterus subseptus) is part of the standard diagnostic procedure.
50
Uterus subseptus
35-year-old patient 1. Clinical diagnosis 2. Anamnesis
3. Sonography
uterus subseptus abortion curettage 8 weeks ago, median resistance noticeable recommendation: diagnostic assessment by means of hysteroscopy and laparoscopy dysmenorrhea (suspected endometriosis) 2- cave-phenomenon (2 endometrial areas)
4. Hysteroscopy
complete septum (3 cm)
5. Therapy
laparoscopy (uterine fundus smooth), resection of the endometriosis and of the myoma, transcervical septum dissection
Attention: There is a high coincidence between uterus malformations and endometriosis (about 60 %).
Uterus septus
51
52
Uterus septus
29-year-old patient 1. Clinical diagnosis 2. Anamnesis
3. Sonography
uterus septus sonographic suspicion of uterus malformation with dysmenorrhea and desire for a child 2 endometrial areas
4. Hysteroscopy
complete septum extending up to the internal os of the uterus (4.5 cm)
5. Therapy
( laparoscopy (uterine fundus smooth and wide), resection of the endometriosis ( transcervical septum dissection and IUD insertion
Attention: Uterus malformations are frequently associated with dysmenorrhea.
Uterus unicornis
53
54
Uterus unicornis
29-year-old patient 1. Clinical diagnosis 2. Anamnesis 3. Sonography
uterus unicornis desire for a child for 2 years, during childhood nephrectomy on the right uterus displaced to the left side, endometrium thickness: 6 mm (post menstruationem)
4. Hysteroscopy
small cavity, narrowed to the left, only one tubal ostium, circular structure of the cavity
5. Therapy
laparoscopy: uterus unicornis on the left without rudimentary cornual horn on the right, resection of the endometriosis Douglas, chromopertubation on the left positive
Attention: The uterus unicornis is a very rare malformation and often combined with a malformation of the urinary tract.
Uterus unicornis
55
56
Uterus unicornis
65-year-old patient 1. Clinical diagnosis 2. Anamnesis
3. Sonography
uterus unicornis serometra gaining in size, cystic ovarian tumour on the right, 3 regular spontaneous deliveries serometra 10 mm, endometrium 2 mm
4. Hysteroscopy
small cavity with only one ostium, circular structures, suspicion of uterus unicornis
5. Therapy
dilatation/curettage after dilatation of the cervix laparoscopy: uterus unicornis on the right without rudimentary cornua on the left ! bilateral adnexectomy and resection of the left rudimentary cornua ( atrophic endometrium ( rudimentary uterine cornua without remains of endometrium ( serous adenocyst in the right ovary
6. Histology
Attention: Even an obstetric anamnesis without pathological findings does not exclude the existence of uterus malformations.
Uterus arcuatus
57
57-year-old patient 1. Clinical diagnosis 2. Anamnesis 3. Sonography
Pap III, bleeding disorders Pap III (twice), histological examination of the cavity is recommended endometrium thickness: 6 mm
4. Hysteroscopy
uterus arcuatus, regular cervix, otherwise regular cavity
5. Therapy 6. Histology
dilatation/curettage ( atrophic endometrium ( regular cervical mucosa
Attention: The uterus arcuatus is a physiological variation within the normal range without relevance for sterility and infertility.
58
ESGE classification of intrauterine adhesions
Table 3: Intrauterine adhesions – classification of the European Society of Gynaecological Endoscopy (ESGE) grade I:
thin, filmy adhesions ( easily ruptured by sheath of the hysteroscope ( regular cornual areas
grade II:
singular firm adhesions ( in different areas of the cavity ( connect uterine walls, but both tubal ostia are visible ( cannot be ruptured by sheath of the hysteroscope
grade II A:
occluding adhesions only in the area of the internal cervical os, upper uterine cavity is regular
grade III:
multiple firm adhesions ( in several areas ( unilateral obliteration of the cornual area
grade III A:
extensive scarring of the uterine cavity with amenorrhea or pronounced hypomenorrhea
grade III B:
combination of III and III A
grade IV:
extensive firm adhesions with agglutination of the uterine walls – both tubal ostia are occluded
Attention: A classification according to the grade extent is primarily necessary because of its therapeutic and prognostic consequences.
Intrauterine adhesions grade 1
59
60
Intrauterine adhesions grade 1
48-year-old patient 1. Clinical diagnosis 2. Anamnesis
3. Sonography
recurrent hypermenorrhea several operations because of endometriosis, 3 years ago hysteroscopy and dilatation/curettage with regular findings endometrium thickness: 10 mm
4. Hysteroscopy
intrauterine adhesions grade 1 (ruptured by sheath of hysteroscope)
5. Therapy 6. Histology
dilatation/curettage proliferative endometrium
Attention: Intrauterine adhesions of grade 1 are mostly incidental findings without clinical importance.
Intrauterine adhesions grade 2 (after septum dissection)
61
29-year-old patient 1. Clinical diagnosis 2. Anamnesis
3. Sonography
intrauterine adhesions grade 2 3 months ago hysteroscopic dissection of the septum because of primary sterility with IUD-insertion for prevention of adhesions IUD in –situ, otherwise: regular
4. Hysteroscopy
intrauterine adhesions grade 2 (located median)
5. Therapy
intrauterine adhesiolysis
Attention: After extensive intrauterine operations there is an increased incidence of adhesions.
62
Intrauterine adhesions grade 2
39-year-old patient 1. Clinical diagnosis 2. Anamnesis
3. Sonography
intrauterine adhesions grade 2 hysteroscopic myoma resection (external) 2.5 years ago, then secondary amenorrhea with regular hormonal status; 12 months ago intrauterine adhesiolysis with adhesions of grade 4 with simultaneous IUD-insertion, control hysteroscopy – normal. Now again secondary amenorrhea endometrium very small
4. Hysteroscopy
adhesions IUA grade 2 in the right fundal area, left tubal cornual area IUA grade 1, proliferative endometrium on the posterior wall
5. Therapy
repeated intrauterine adhesiolysis
Attention: Due to large defects of the endometrium extensive hysteroscopic myoma resections can also result in intrauterine adhesions. There is an increased risk with multiple (especially oppositely located) myomas.
Intrauterine adhesions grade 3
63
29-year-old patient 1. Clinical diagnosis 2. Anamnesis
3. Sonography
intrauterine adhesions grade 3 hysteroscopic myoma resection (performed externally) 3 years ago, now planned IVF because of tubal and andrologic causes of sterility, hypomenorrhea endometrium only partly visible
4. Hysteroscopy
whole left half of the cavity obliterated by adhesions, right ostium visible (intrauterine adhesions grade 3)
5. Therapy
operative hysteroscopy, intrauterine electrosurgical adhesiolysis and IUD-insertion
Attention: Secondary amenorrhea or hypomenorrheas after intrauterine interventions are an important indicator of possible intrauterine adhesions.
64
Intrauterine adhesions grade 3
37-year-old patient 1. Clinical diagnosis
3. Sonography
secondary amenorrhea with intrauterine adhesions 3 years ago postoperative curettage because of placental residuals, after that secondary amenorrhea, regular hormonal status endometrium only partly visible
4. Hysteroscopy
median-located solid adhesion (IUA grade 3)
5. Therapy
intrauterine adhesiolysis, IUD-insertion and estrogen medication
2 Anamnesis
Attention: Curettages post-partum and in childbed very often result in intrauterine adhesions.
Check-up after intrauterine adhesiolysis
65
34-year-old patient 1. Clinical diagnosis 2. Anamnesis
3. Sonography
intrauterine adhesions grade 3 1 year ago intrauterine adhesiolysis with IUD-insertion and estrogen medication because of intrauterine adhesions grade 4, afterwards regular bleeding, IUD-extraction 6 months ago endometrium only partly visible
4. Hysteroscopy
median adhesion obliterates right tubal ostium, left tubal ostium is visible
5. Therapy 6. Recommendation
intrauterine adhesiolysis repeated estrogen medication for 3 months, then pregnancy should be considered as soon as possible
Attention: With intrauterine adhesions grade 3 and 4 there is a high risk of relapses and often several surgical interventions are necessary.
8. Hysteroscopy with bleeding disorders
Indications for diagnostic hysteroscopy with bleeding disorders 1. 2. 3. 4. 5. 6. 7. 8.
hypermenorrhea, menorrhagia metrorrhagia recurrent additional bleedings postmenopausal bleedings bleeding disorders under oral contraception bleeding disorders under hormone replacement therapy bleeding disorders under Tamoxifen bleeding disorders with inserted IUD/IUS
Hysteroscopy with bleeding disorders
67
Hysteroscopic finding: With bleeding disorders the typical first hysteroscopic view which gets clearer after influx of the distending medium. If not, check or increase the influx of the distending medium.
Attention: With more serious bleeding a continuous flow hysteroscopic sheath should be used or the cervix should be further dilated. Potential sources of unclear view: 1. lack of flow 2. lack of pressure on the cuff 3. bend in the inflow sheath 4. closed flow-tap on hysteroscope 5. instruments are not correctly assembled 6. empty infusion 7. lenses are blurred by coagula 8. defective lenses or light source
68
Hysteroscopy with bleeding disorders
Sonography versus hysteroscopy in the diagnostics of bleeding disorders A differential diagnosis of polyps and myomas is sonographically not possible with certainty. A localization of the myoma (intramural or submucous) is not possible by sonography with precision. Hyperplastic endometrial structures diagnosed by sonography in postmenopausal women are hysteroscopically in 30 to 50 % of the cases corpus polyps. The clinical diagnosis and vaginal sonography provide the background to a hysteroscopic-histological diagnostic assessment.
Sonographic picture of an intracavitary structure (submucous myoma).
Regular cavity postmenopause
69
59-year-old patient 1. Clinical diagnosis 2. Anamnesis 3. Sonography
postmenopausal bleeding 3 years ago menopause, for 2 months spottings twice, dilatation/curettage 5 years ago endometrium thickness: 7 mm
4. Hysteroscopy
regular cavity and cervix, small adhesions in the fundal area
5. Therapy 6. Histology
dilatation/curettage atrophic endometrium
Attention: Smooth adhesions in the fundal area are often the result of previous abrasions but do not have clinical importance.
70
Cervical polyp
Cervical polyp
71
41-year-old patient 1. Clinical diagnosis 2. Anamnesis
3. Sonography
cervical polyp, cervical stenosis sonographically thickened cervix, outpatient minihysteroscopy not possible without anaesthesia thickened cervix with a structure of 10 mm
4. Hysteroscopy
cervical stenosis, cervical polyp on the posterior wall, hyperplastic cervical mucosa, small insulated corpus polyp
5. Therapy 6. Histology
dilatation/curettage cervical and corpus polyps
Attention: During hysteroscopy cervical changes should be paid attention to (especially when retracting the hysteroscope).
72
Cervical polyp
Cervical polyp
73
60-year-old patient 1. Clinical diagnosis 2. Anamnesis 3. Sonography
Pap III, suspected corpus changes Pap III, diagnostic assessment of the cavity recommended endometrium thickness: 8 mm
4. Hysteroscopy
small cervical polyp on the right, focal endometrial hyperplasia on the anterior wall
5. Therapy
dilatation/curettage with control hysteroscopy cervical polyp, secretive endometrium
6. Histology
Attention: Cervical and endometrial changes often occur simultaneously.
74
ESGE-classification of submucous myomas
Attention: Submucous myomas should be classified according to the grade scale of the ESGE because of resulting therapeutic consequences. Table 4: ESGE-classification of submucous myomas grade
description
0 1
only intracavitary parts of the myoma predominantly intracavitary parts of the myoma (intramural part <50 %) predominantly intramural parts of the myoma (intramural part >50 %)
2
Submucous myoma grade 0
75
46-year-old patient 1. Clinical diagnosis 2. Anamnesis
3. Sonography
recurrent hypermenorrheas and dysmenorrheas hypermenorrheas and dysmenorrheas for 2 years, now secondary anaemia (Hb 7.8g/ dl) intrauterine echo-dense structures 3.0 ' 2.8 cm (presumption diagnosis: submucous myoma)
4. Hysteroscopy
submucous myoma on the posterior wall, diameter of about 3 cm
5. Therapy 6. Histology
transcervical myoma resection 20 g of leiomyoma
Attention: Apart from the classification according to grades the approximate size of the myomas should be described, too.
76
Submucous myoma grade 0
52-year-old patient 1. Clinical diagnosis 2. Anamnesis
3. Sonography
uterus myomatosus with bleeding disorders, recurrent Pap III D, cystocele II$ uterus myomatosus for 5 years, now growing, and bleeding disorders, 3 times Pap III D during the last 12 months ! vaginal hysterectomy with colporraphia planned multiple intramural and submucous myomas
4. Hysteroscopy
submucous myoma grade 0, diameter of about 4 cm
5. Therapy
vaginal hysterectomy with morcellement sine adnexa with anterior colporraphia multiple leiomyomas (weight of the uterus: 320 g)
6. Histology
Submucous myoma grade 1
77
45-year-old patient 1. Clinical diagnosis 2. Anamnesis
3. Sonography
permanent bleedings with uterus myomatosus uterus myomatosus for 5 years, now growth of multiple submucous and intramural myomas 5 intramural myomas, one of them with submucous part
4. Hysteroscopy
large submucous myoma on the left lateral wall with intramural part (about 20 %)
5. Therapy 6. Histology
laparoscopic supracervical hysterectomy uterus myomatosus (420 g)
Attention: With submucous myomas further myomas (intramural, subserous) should be searched for by sonography.
78
Submucous myoma grade 1
55-year-old patient 1. Clinical diagnosis 2. Anamnesis
3. Sonography
postmenopausal bleeding postmenopausal bleeding (menopause 3 years ago), occasionally lower abdominal pain intracavitary echo-dense structure 3.8 ' 3.2 cm, presumption diagnosis: polyp, myoma
4. Hysteroscopy
vascular myoma with a diameter of 4cm, extending from the right posterior lateral wall (with distinctive vessels on the surface)
5. Therapy 6. Histology
hysteroscopic myoma resection parts of leiomyoma (32 g)
Attention: A differentiation between fibrosed polyp and submucous myoma is sonographically as well as hysteroscopically not possible with certainty.
Submucous myoma grade 1
79
48-year-old patient 1. Clinical diagnosis 2. Anamnesis
3. Sonography
uterus myomatosus uterus myomatosus known for some years, growing, 1 and 2 years ago myoma embolisation, afterwards again growth and increasing discomfort/pain ! planned LASH submucous-intramural myoma on the posterior wall, size: 4.5 cm, endometrium thickness: 5mm
4. Hysteroscopy
submucous-intramural myoma on the posterior wall, size: 5 cm, apart from that regular endometrium
5. Therapy 6. Histology
LASH sine adnexa uterus myomatosus (460 g)
Attention: Recurrent myomas requiring therapy can develop even after myoma embolisation.
80
Submucous myoma grade 2
41-year-old patient 1. Clinical diagnosis 2. Anamnesis
3. Sonography
uterus myomatosus with discomfort/pain and bleeding disorders for 3 years increasing abdominal pain and bleeding disorders with growing uterus myomatosus, previously 2 caesarean sections multiple myomas, one large transmural myoma on the anterior wall
4. Hysteroscopy
submucous-intramural myoma grade 2 on the anterior wall (occupying more than half of the cavity)
5. Therapy 6. Histology
LASH multiple leiomyomas
Attention: With myomas of grade 2 the further therapy (organ-preserving versus hysterectomy) should be planned with special care.
Residual myoma after uterus perfomation
81
40-year-old patient 1. Clinical diagnosis 2. Anamnesis 3. Sonography
residual myoma after perforation during myoma resection 4 months ago myoma resection (external) with perforation submucous-intramural myoma parts near the isthmus, 1.7 ' 2.0 cm
4. Hysteroscopy
myoma on the lateral wall grade 2, submucous-intramural myoma parts (60 % intramural)
5. Therapy 6. Histology
transcervical myoma resection leiomyoma (15 g)
82
Uterus subseptus and intramural myoma on the posterior wall
Uterus subseptus and intramural myoma on the posterior wall
83
52-year-old patient 1. Clinical diagnosis 2. Anamnesis 3. Sonography
postmenopausal bleeding postmenopausal bleeding, nullipara endometrium thickness: 5 mm intrauterine structure 2.0 ' 1.2 echo-dense (¼ septum)
4. Hysteroscopy
uterus subseptus, about 3.5 cm small septum, right cavity half smaller than left cavity half, intramural myoma on the posterior wall (grade 2) in the left cavity
5. Therapy
dilatation/curettage (corpus curettage from both cavity halves) atrophic endometrium
6. Histology
Attention: Uterus malformations and myomas can also occur together. Under these circumstances the sonographic diagnostics is often difficult.
84
Endometrial hyperplasia, endometrium sliding test
Endometrial hyperplasia, endometrium sliding test
85
40-year-old patient 1. Clinical diagnosis 2. Anamnesis 3. Sonography
recurrent hypermenorrheas for 3 years increasing hypermenorrheas, progestagen therapy without success endometrium thickness: 10 mm (post menstruationem)
4. Hysteroscopy
hyperplastic endometrium (see sliding test posterior wall)
5. Therapy
endometrial resection during the same operation proliferative endometrium
6. Histology
Attention: When sliding the hysteroscope forward the difference in the level of the endometrium may be seen (endometrium sliding test).
86
Endometrium sliding test
Endometrium sliding test endometrium myometrium hysteroscope
difference in level endometrium thicknes
By sliding the hysteroscopic sheath in the hyperplastic endometrium a difference in level between endometrium and myometrium can be shown. This allows for a better assessment of the extent of the hyperplasia. Attention: With high intrauterine pressure and evenly distributed endometrial hyperplasia the endometrium is often wrongly classified as atrophic or flat without the endometrium sliding test.
Endometrial hyperplasia, perimenopause, endometrium sliding test
87
88
Endometrial hyperplasia, perimenopause, endometrium sliding test
46-year-old patient 1. Clinical diagnosis 2. Anamnesis 3. Sonography
bleeding after secondary amenorrhea for 9 months recurrent metrorrhagias, progestagen therapy without success endometrium thickness: 12 mm
4. Hysteroscopy
endometrial hyperplasia (especially anterior wall) (see sliding test)
5. Therapy 6. Histology
dilatation/curettage glandular-cystic hyperplasia
Endometrial hyperplasia, endometrium sliding test
89
90
Endometrial hyperplasia, endometrium sliding test
34-year-old patient 1. Clinical diagnosis 2. Anamnesis
3. Sonography
recurrent hypermenorrhea and dysmenorrhea for 2 years recurrent hypermenorrhea, dysmenorrhea, 1 year ago hysteroscopy and curettage, corpus polyp endometrium thickness: 10 mm (post menstruationem), suspicion of adenomyosis
4. Hysteroscopy
endometrial hyperplasia (see sliding test posterior wall)
5. Therapy 6. Histology 7. Recommendation
dilatation/curettage polypoid endometrium levonorgestrel-IUS or LASH
Polypoid endometrium
91
44-year-old patient 1. Clinical diagnosis 2. Anamnesis 3. Sonography
uterus myomatosus with bleeding disorders uterus myomatosus multiple intramural myomas, endometrium thickness: 8mm (post menstruationem)
4. Hysteroscopy
polypoid endometrium posterior wall
5. Therapy 6. Histology
LASH multiple leiomyomas, proliferative endometrium
Attention: Before a LASH with its necessary morcellation of the corpus uteri a diagnostic hysteroscopy should always be performed to exclude premalignant or malignant changes.
92
Endometrial hyperplasia
38-year-old patient 1. Clinical diagnosis 2. Anamnesis
3. Sonography
hyper- and dysmenorrhea for 2 years increasing hyper- and dysmenorrhea (high consumption of analgesics during menstruation) hyperplastic uterus (suspicion of adenomyosis), endometrium thickness: 10 mm (9th day of the menstrual cycle)
4. Hysteroscopy
focal endometrial hyperplasia posterior wall, apart from that regular cavity
5. Therapy
dilatation/curettage, laparoscopy (resection of the endometriosis), later LASH (adenomyosis confirmed) glandular-cystic hyperplasia
6. Histology
Attention: Because of the estrogen-induced etiology adenomyosis uteri and endometrial hyperplasia often occur together.
Endometral hyperplasia
93
52-year-old patient 1. Clinical diagnosis 2. Anamnesis
3. Sonography
permanent bleedings permanent bleeding for 13 days, before that already for 1 year metrorrhagias, known uterus myomatosus endometrium thickness: 13 mm, multiple intramural myomas (up to a size of 3 cm)
4. Hysteroscopy
hyperplastic endometrium with multiple small, bulging out myomas
5. Therapy
dilatation/curettage, later vaginal hysterectomy with colporraphia hyperplastic endometrium
6. Histology
94
Focal endometrial hyperplasia in the postmenopause
67-year-old patient 1. Clinical diagnosis 2. Anamnesis
3. Sonography
postmenopausal bleeding 2 dilatations/curettages because of recurrent postmenopausal bleedings (2 and 6 years ago) endometrium thickness: 8 mm
4. Hysteroscopy
small focal hyperplasia, apart from that regular cavity
5. Therapy
dilatation/curettage, vaginal hysterectomy (at the request of the patient because of recurrent bleeding disorders) focal polypoid endometrium with initial formation of polyps
6. Histology
Attention: Most of the endometrial hyperplasias occur focally, demanding a targeted histological examination (target curettage).
Adenomatous hyperplasia
95
61-year-old patient 1. Clinical diagnosis 2. Anamnesis 3. Sonography
corpus polyp (sonographic suspicion) at check-up sonographically suspicious endometrium endometrium thickness: 10 mm, definable intrauterine structure 15 ' 11 mm (suspicion of a corpus polyp)
4. Hysteroscopy
large corpus polyp posterior wall, apart from that regular endometrium
5. Therapy
dilatation/curettage and removal of the polyp with grasping forceps, control hysteroscopy: without pathological findings later vaginal hysterectomy with adnexa ( corpus polyp with parts of an atypical adenomatous hyperplasia ( uterus and ovaries without pathological findings, no further parts of hyperplasia
6. Histology
Attention: About 7 % of sonographically and hysteroscopically normal corpus polyps in the postmenopause show premalignant or malignant changes.
96
Corpus polyps
Corpus polyps 1. Corpus polyps constitute one the most frequent causes of bleedings (especially in the perimenopause). 2. With a dilatation/curettage without hysteroscopy polyps are often not or incompletely removed. 3. Hysteroscopy makes the diagnostics of polyps possible, and the complete removal can be checked during the intervention (control hysteroscopy). 4. With the complete removal of the polyps (by target curettage, grasping forceps or resection) most of the bleeding disorders are successfully treated. 5. The removed polyps must be carefully examined by histology.
Corpus polyps
97
Sonographic finding with strong suspicion of a corpus polyp (confirmed by hysteroscopy).
98
Corpus polyp
45-year-old patient 1. Clinical diagnosis 2. Anamnesis
3. Sonography
bleeding disorders with uterus myomatosus 1 year ago hysteroscopy and dilatation/ curettage histology: simple adenomatous hyperplasia endometrium thickness: 12 mm (8th day of menstrual cycle), 3 intramural myomas
4. Hysteroscopy
large corpus polyp without pathological findings
5. Therapy
curettage and removal of the polyp with grasping forceps after intraoperative histology – LASH fibroglandular polyp without malignancy uterus myomatosus
6. Histology
Corpus polyp
99
85-year-old patient 1. Clinical diagnosis 2. Anamnesis 3. Sonography
postmenopausal bleeding postmenopausal bleeding (menopause 32 years ago) endometrium thickness: 18 mm
4. Hysteroscopy
large fibrosed corpus polyp posterior wall
5. Therapy
dilatation/curettage and removal of the polyp with grasping forceps, control hysteroscopy: empty cavity fibrosed glandular-cystic corpus polyp
6. Histology
100
Uterus arcuatus, corpus polyp
65-year-old patient 1. Clinical diagnosis 2. Anamnesis 3. Sonography
recurrent postmenopausal bleeding 1 year ago hysteroscopy and curettage without pathological findings endometrium thickness: 8 mm
4. Hysteroscopy
small corpus polyp right lateral wall uterus arcuatus
5. Therapy
resection of the polyp and of the endometrium corpus polyp, apart from that atrophic endometrium
6. Histology
Corpus polyp, perimenopause
101
45-year-old patient 1. Clinical diagnosis 2. Anamnesis 3. Sonography
recurrent permanent bleedings metrorrhagias for 2–3 years, progestagen therapy only temporarily successful endometrium thickness: 12 mm post menstruationem
4. Hysteroscopy
large corpus polyp right lateral wall
5. Therapy
dilatation/curettage and resection of the polyp with the grasping forceps fibroglandular corpus polyp
6. Histology
102
Corpus polyp, postmenopause
61-year-old patient 1. Clinical diagnosis 2. Anamnesis
3. Sonography
recurrent postmenopausal bleeding 1 year ago hysteroscopy and curettage with removal of the polyp, now again recurrent postmenopausal bleeding with known uterus myomatosus 15 ' 13 mm intrauterine structure (suspicion of corpus polyp)
4. Hysteroscopy
large corpus polyp extending from the fundal area
5. Therapy 6. Histology
LASH corpus polyp, multiple leiomyomas
Corpus polyp, postmenopause
103
77-year-old patient 1. Clinical diagnosis 2. Anamnesis 3. Sonography
corpus polyp sonographically suspect endometrium endometrium thickness: 17 mm
4. Hysteroscopy
corpus polyp posterior wall endometrium without pathological findings
5. Therapy
dilatation/curettage, resection of the polyp with grasping forceps, control hysteroscopy: cavity without findings fibroglandular corpus polyp, atrophic endometrium
6. Histology
104
Corpus polyp after dilatation/curettage
Corpus polyp after dilatation/curettage
105
80-year-old patient 1. Clinical diagnosis 2. Anamnesis 3. Sonography
corpus polyp sonographically suspect findings endometrium thickness: 15 mm
4. Hysteroscopy
cystic corpus polyp posterior wall
5. Therapy
dilatation/curettage, resection of the polyp with grasping forceps, control hysteroscopy: empty cavity (see picture 2)
Attention: After the removal of the polyp an intraoperative control hysteroscopy should always be performed.
106
Corpus carcinoma
Corpus carcinoma 1. The incidence of corpus carcinomas rises in line with the increasing age of the patients. 2. With estrogen-dependent carcinomas sonography (endometrium thickness >9 mm) is in most of the cases the method of diagnostics, whereas with de novo-carcinomas clinical signs (bleeding) constitute the only initial symptom. 3. Especially with corpus carcinomas hysteroscopy should be extended to the cervix, too, to correct a too high staging (extension to the cervix – stage 2) with the dilatation/curettage. 4. The potential transmission of tumour cells by hysteroscopy has been disproved by some studies, especially since in most of the cases a simultaneous operative therapy of the corpus carcinoma is performed.
Sonographic picture of a thickened endometrium with strong suspicion of a corpus carcinoma (confirmed by hysteroscopy and histology).
Corpus carcinoma
107
108
Corpus carcinoma
81-year-old patient 1. Clinical diagnosis 2. Anamnesis 3. Sonography
postmenopausal bleeding for 10 days postmenopausal bleeding endometrium thickness: 23 mm
4. Hysteroscopy
a lot of polypoid, suspect endometrium in the whole cavity (with free-running vessels)
5. Therapy 6. Histology
dilatation/curettage corpus carcinoma G2/G3 (mixed Mullerian tumour) ! abdominal hysterectomy with bilateral adnexectomy, pelvic and para-aortal lymphonodectomy Final histology: Ib G3 N0 (0/42)
Attention: Insulated free-running vessels are a sign of a corpus carcinoma.
Corpus carcinoma
109
68-year-old patient 1. Clinical diagnosis
3. Sonography
suspect histological preliminary findings (polyp with atypias) 9 months ago hysteroscopy and curettage external diagnosis: polyp with atypias now: referral to hysterectomy endometrium thickness: 8 mm
4. Hysteroscopy
necrotic, suspect, vascular endometrium
5. Therapy 6. Histology
dilatation/curettage intraoperative histology: corpus carcinoma G2 , operation finished 2nd session: LAVH with adnexectomy and pelvic and para-aortal lymphonodectomy Final histology: corpus carcinoma, Ib G2 N0 (0/38)
2. Anamnesis
Attention: Histological findings with atypias should be operated on as fast as possible to avoid progression.
110
Corpus carcinoma
65-year-old patient 1. Clinical diagnosis 2. Anamnesis 3. Sonography
postmenopausal bleeding obesity, for 5 years no check-up, no hormone replacement therapy endometrium thickness: 21 mm
4. Hysteroscopy
hyperplastic, partially necrotic endometrium with free-running vessels in the whole cavity, suspected corpus carcinoma
5. Therapy
dilatation/curettage hysterectomy with adnexa and pelvic and para-aortal lymphonodectomy, afterloading corpus carcinoma Ib G2 Final diagnosis: T1b N0 (0/48) M0 G2
6. Histology
Attention: Large necrotic endometrial parts are also a sign of a corpus carcinoma.
Bleeding disorders during use of oral contraceptives
111
Procedure for bleeding disorders during use of oral contraceptives anamnesis gynaecological examination vaginal sonography
polyp, myoma
without pathological findings
hysteroscopy (if necessary, resection of the polyp or myoma)
hormonal therapy – change of drug – estrogen or progestagen substitution (for 6 months at most) persistent bleeding
myoma, polyp
outpatient minihysteroscopy
without pathological findings again hormonal therapy, if necessary alternative contraceptive methods
112
Bleeding disorders under hormone replacement therapy
Bleeding disorders under hormone replacement therapy 1. Bleeding disorders under hormone replacement therapy must be adequately diagnosed but do not require more invasive diagnostics than bleeding disorders without HRT because the histological findings do not show any differences. 2. The invasive diagnostics of bleeding disorders under HRT reduces the subsequent compliance. 3. Minihysteroscopy without anaesthesia in the practice is especially suited for the diagnostics of bleeding disorders under HRT because the rate of compliance for HRT remains unaffected. Table 5: Compliance with bleeding disorders under hormone replacement therapy depending on the diagnostic procedure hysteroscopy minihysteroscopy þ curettage þ biopsy with anaesthesia without anaesthesia patients (n) subsequent compliance (n) continuation of HRT ( %)
156 97 62
52 49 94
Bleeding disorders under HRT, corpus polyps
113
114
Bleeding disorders under HRT, corpus polyps
62-year-old patient 1. Clinical diagnosis 2. Anamnesis
3. Sonography
sonographically suspect endometrium under HRT for 4 years continuous-combined HRT (Activelle!), no bleeding, no discomfort/ pain endometrium thickness: 13 mm (3 months ago: 8 mm)
4. Hysteroscopy
2 corpus polyps anterior and posterior wall
5. Therapy
dilatation/curettage and control hysteroscopy: empty cavity glandular corpus polyps
6. Histology
Corpus polyps, bleeding disorders under HRT
115
62-year-old patient 1. Clinical diagnosis 2. Anamnesis 3. Sonography
permanent bleedings under HRT for 2 years bleeding disorders under Activelle!, now permanent bleedings endometrium thickness: 14 mm
4. Hysteroscopy
large corpus polyp extending from the right lateral wall
5. Therapy
dilatation/curettage, extraction of the polyp with polyp forceps, control hysteroscopy: without findings glandular- cystic corpus polyp
6. Histology
116
Focal endometrial hyperplasia with bleeding disorders under HRT
60-year-old patient 1. Clinical diagnosis 2. Anamnesis 3. Sonography
recurrent bleeding disorders under HRT for 3 years HRT with Climodien!, for 3 months acyclic breakthrough bleedings endometrium thickness: 4 mm
4. Hysteroscopy
slightly proliferative endometrium on the anterior wall
5. Therapy 6. Histology
dilatation/curettage polypoid endometrium
Adenomatous hyperplasia, bleeding disorders
117
66-year-old patient 1. Clinical diagnosis 2. Anamnesis
3. Sonography
bleeding disorders under HRT for 3 years bleeding disorders under Gynodian Depot! and Uterogest, suspected ovarian fibroma on the right, known uterus myomatosus endometrium thickness: 10 mm
4. Hysteroscopy
extended polypoid structures, posterior wall with 2 insulated small polyps
5. Therapy
dilatation/curettage laparoscopy: uterus myomatosus, both adnexa without findings simple adenomatous hyperplasia without atypias ! LAVH with bilateral adnexectomy
6. Histology
9. Hysteroscopy with sonographically suspect endometrial findings
Indications 1. Thickened endometrium in postmenopause (>9 mm) (see table 6) 2. Endometrial hyperplasia in the perimenopause with negative progestagen test (see page 119) 3. Intrauterine finding (polyp, myoma) with discomfort/pain, or gaining in size 4. serometra with discomfort/pain, or gaining in size 5. sonographically suspect endometrium under HRT (see table 6) 6. sonographically suspect endometrium under Tamoxifen Tab. 6: Recommendations for the diagnostics of asymptomatic women with and without HRT (according to Roemer, Rabe, Duda, Foth 2004), Guidelines of the German Society of Gynaecology and Obstetrics double endometrium thicknes
cyclical HRTa)
continuouscombined HRT
no HRT
hysteroscopichistological examination
"13 mmb)
"9 mm
"9 mm
check-up after 2 to 3 months
9–12 mm
5–8 mm
5–8 mm
without consequence
"8 mm
"4 mm
"4 mm
a) b)
measurement after hormonally induced bleeding at least in 2 menstrual cycles
Sonographic endometrial hyperplasia
119
Sonographically supported progestagen test thickened endometrium (e.g. 12 mm) 2 mg Norethisteronacetate for 12 days bleeding control sonograpy after bleeding endometrium thickness < 5 mm
endometrium thickness > 5 mm
no further treatment necessary (if necessary, progestagen prophylaxis)
hysteroscopy and histology for diagnostic assessment
Attention: If the endometrium thickness is not adequately reduced after progestagen medication, further diagnostic assessment is necessary to exclude an endometrium carcinoma (most frequent cause: corpus polyp, endometrial hyperplasia resistant to therapy).
120
Sonographic endometrial hyperplasia
Sonographic picture of endometrial hyperplasia.
Corpus polyp, postmenopause
121
79-year-old patient 1. Clinical diagnosis 2. Anamnesis 3. Sonography
sonographically suspect endometrium postmenopause menopause 25 years ago, no HRT endometrium thickness: 14 mm
4. Hysteroscopy
2 plain fibrosed corpus polyps posterior wall
5. Therapy
dilatation/curettage and endometrium biopsy, posterior wall; control hysteroscopy: without pathological findings fibrosed corpus polyps
6. Histology
122
Corpus polyp, postmenopause
Corpus polyp, postmenopause
123
75-year-old patient 1. Clinical diagnosis 2. Anamnesis
3. Sonography
corpus polyp, no bleedings loss of weight, MRI: suspicion of cervical changes cytology: without pathological findings endometrium thickness: 18 mm
4. Hysteroscopy
cervix without pathological findings, large corpus polyp posterior wall
5. Therapy
dilatation/curettage and removal of polyp with grasping forceps glandular corpus polyp
6. Histology
124
Corpus polyp with adenomatous hyperplasia
85-year-old patient 1. Clinical diagnosis 2. Anamnesis
3. Sonography
sonographically suspect endometrium in postmenopause menopause 30 years ago, now large, intracavitary findings well visualisable by sonography, no bleedings, no discomfort endometrium thickness: 20 mm, echodense, vascular intracavitary structure
4. Hysteroscopy
large corpus polyp occupying the whole cavity, partially with necrotic changes
5. Therapy
attempt to remove polyp by grasping forceps (only partially successful) ! hysteroscopic resection of the polyp corpus polyps with parts of an atypical adenomatous hyperplasia ! vaginal hysterectomy (without morcellement) histology: no further parts of hyperplasia
6. Histology
Corpus polyp, postmenopause
125
126
Corpus polyp, postmenopause
75-year-old patient 1. Clinical diagnosis 2. Anamnesis
3. Sonography
sonographically suspect endometrium in postmenopause no bleeding, no discomfort/pain, 2 years ago hysteroscopy and dilatation/curettage of corpus polyps endometrium thickness: 10 mm (growing during the last 6 months)
4. Hysteroscopy
corpus polyps posterior wall
5. Therapy
dilatation/curettage with intraoperative control hysteroscopy without pathological findings (see second picture) fibroglandular polyps without malignancy
6. Histology
Corpus polyp, postmenopause
127
80-year-old patient 1. Clinical diagnosis 2. Anamnesis 3. Sonography
sonographically suspect endometrium no bleeding, no discomfort/pain endometrium thickness: 18 mm
4. Hysteroscopy
2 well vascularised corpus polyps in the fundal area
5. Therapy
dilatation/curettage and extraction of the polyp with polyp forceps, intraoperative control hysteroscopy: empty cavity glandular-cystic corpus polyps without malignancy
6. Histology
128
Suspect corpus polyp, postmenopause
83-year-old patient 1. Clinical diagnosis 2. Anamnesis 3. Sonography
corpus polyp sonographically suspect findings during check-up, no bleedings, no discomfort endometrium thickness: 18 mm
4. Hysteroscopy
suspect corpus polyp (soft and crumbly)
5. Therapy
dilatation/curettage and removal of the polyp fibroglandular corpus polyps without malignancy
6. Histology
Corpus carcinoma
129
69-year-old patient 1. Clinical diagnosis 2. Anamnesis 3. Sonography
sonographically suspect endometrium menopause 15 years ago endometrium thickness: 6 mm intracavitary structure 1.2 ' 1.0 cm (suspicion of corpus polyp)
4. Hysteroscopy
insulated hyperplastic vascular area right lateral wall
5. Therapy
dilatation/curettage longitudinal laparotomy, hysterectomy with bilateral adnexectomy, pelvic and para-aortal lymphonodectomy adenosquamous carcinoma G2 final histology: corpus carcinoma Ib G2 N0 (0/38)
6. Histology
130
Endometrium and Tamoxifen
Endometrium and Tamoxifen 1. Endometrial hyperplasias under Tamoxifen develop dependent on the dosage and the duration of medication. 2. Bleeding disorders under Tamoxifen require an intensive diagnostic assessment. 3. Endometrial hyperplasias under Tamoxifen do not respond to a progestagen therapy (reason: stromal hyperplasia). 4. With asymptomatic patients undergoing Tamoxifen therapy an annual sonographic check-up of the endometrium is recommended. 5. When the endometrium shows a tendency to grow (endometrium thickness >12 mm) a diagnostic assessment is necessary. 6. Since by a simple dilatation/curettage endometrium for histological examination may often not be extracted, a segmental endometrial resection (by resectoscope) must be performed, if necessary.
Sonographic picture of an endometrial hyperplasia under Tamoxifen therapy.
Endometrial hyperplasia under Tamoxifen
131
132
Endometrial hyperplasia under Tamoxifen
83-year-old patient 1. Clinical diagnosis 2. Anamnesis 3. Sonography
endometrial hyperplasia under Tamoxifen 2 years ago receptor-positive breast cancer, since then Tamoxifen 20 mg/d endometrium thickness: 15 mm
4. Hysteroscopy
polypoid endometrium posterior wall, cervical stenosis with one adhesion
5. Therapy 6. Histology
dilatation/curettage proliferative endometrium
10. Hysteroscopy and lost IUD/IUS
1. Lost IUD is one of the classic indications for a hysteroscopy. 2. At first the intrauterine evidence of the IUD/IUS should be provided by sonography. 3. The most frequent indication results from the tearing off of the IUD- thread when trying to extract the IUD. 4. The IUD can be extracted after the hysteroscopic evidence of the IUD and by using a small grasping forceps. Alternatively, a grasping forceps may be introduced through the working sheath and the IUD/IUS can then be extracted with the removal of the whole instrument.
134
Lost IUD
35-year-old patient 1. Clinical diagnosis 2. Anamnesis 3. Sonography
lost IUD for 8 years IUD in situ, with extraction threads were torn off IUD correctly placed in the uterine cavity
4. Hysteroscopy
IUD (type DANA) correctly placed in the uterine cavity
5. Therapy
extraction by hysteroscope with grasping forceps, which is introduced through the working sheath
Dislocated IUD
135
38-year-old patient 1. Clinical diagnosis
3. Sonography
planned exchange of IUD during laparoscopy for 3 years copper-IUD, now suspected dislocation IUD dislocated
4. Hysteroscopy
dislocated copper-IUD
5. Therapy
IUD extraction and insertion of a new one none
2. Anamnesis
6. Histology
136
Bleeding disorders with IUD in situ
43-year-old patient 1. Clinical diagnosis 2. Anamnesis 3. Sonography
bleeding disorders with IUD in situ (multiload) for 3 years IUD in situ, for 6 months recurrent spottings and hypermenorrheas IUD dislocated endometrium thickness: 10 mm
4. Hysteroscopy
IUD transversely located in the uterine cavity, limited contraceptive safety
5. Therapy 6. Histology
IUD extraction and dilatation/curettage proliferative endometrium
Attention: An assessment of the endometrium with bleeding disorders in IUD-patients should always be performed before IUD-removal because otherwise artificial endometrial lesions could confine diagnostics.
Bleeding disorders with IUS in situ (MIRENA)
137
42-year-old patient 1. Clinical diagnosis 2. Anamnesis
3. Sonography
permanent bleedings under MIRENA for 6 months MIRENA, recurrent permanent bleedings, progestagen therapy without success MIRENA transversely located in the uterine cavity, endometrium thickness: 8 mm
4. Hysteroscopy
MIRENA transversely located in the uterine cavity, endometrial hyperplasia posterior wall
5. Therapy 6. Histology 7. Recommendation
IUS extraction and dilatation/curettage proliferative endometrium resection of the endometrium after finished family planning
138
Bleeding disorders with dislocated IUS (MIRENA)
Bleeding disorders with dislocated IUS (MIRENA)
139
52-year-old patient 1. Clinical diagnosis 2. Anamnesis
3. Sonography
bleeding disorders with MIRENA in situ and large uterus (probe length ¼ 13.0 cm) for 6 months recurrent permanent bleedings with MIRENA in situ with adipose patient uterus clearly hyperplastic without insulated myomas uterus hyperplasia, MIRENA in the large cavity clearly dislocated
4. Hysteroscopy
MIRENA transversely located in the uterine cavity, endometrial hyperplasia
5. Therapy
extraction of MIRENA dilatation/curettage new insertion of MIRENA with hysteroscopic view (at urgent request of the patient, who refuses a further operative therapy; oral progestagens are contraindicated) simple hyperplasia
6. Histology
11. Special cases
Placental residuals 1. After some time placental residuals can become necrotic or calcify. 2. With placental disorders (placenta accreta or increta) the removal without exact localisation can be difficult. 3. In these cases hysteroscopic diagnostics and the targeted removal (if necessary, even operatively) is the treatment of choice. 4. With very large solid residuals several sessions may be necessary. Adhesions after IUS Intrauterine adhesions after IUS are extremely rare and can only be explained by local inflammation of the endometrium. Endometritis Bleeding disorders are only rarely caused by endometritis, which is in most of the cases an incidental finding.
Placental residuals after missed abortion
141
33-year-old patient 1. Clinical diagnosis 2. Anamnesis
3. Sonography
sonographically suspect placental residuals and persistent hCG-levels missed abortion 13th week of pregnancy abortion curettage, after that sonographically suspected placental residuals 3 times hysteroscopy and dilatation/curettage with postoperatively persistent sonographic findings (performed externally), followed by 3 cycles of Methotrexate-therapy (because of increased hCG-levels) clearly visible, partially calcified placental residual of 2.0 ' 2.0 cm
4. Hysteroscopy
left tubal cornua and lateral wall partially calcified and necrotic placental residual
5. Therapy
operative hysteroscopy: resection of the placental residuals necrotic placental residuals, no malignancy
6. Histology
142
Placental residuals
24-year-old patient 1. Clinical diagnosis 2. Anamnesis
3. Sonography
placental residuals with placenta accreta spontaneous delivery 3 months ago, followed by a persistent large solid intracavitary finding, recurrent bleedings, 3 times dilatations/curettages without success (performed externally) solid intracavitary vascularised finding, size: 70 ' 60 mm, occupying the entire cavity
4. Hysteroscopy
large, partially necrotic placental residuals occupying the entire cavity
5. Therapy
resection of the placenta by bipolar hysteroscopy in two sessions necrotic placental residuals (240 g)
6. Histology
Intrauterine adhesions grade 3 after MIRENA
143
35-year-old patient 1. Clinical diagnosis 2. Anamnesis
3. Sonography
secondary amenorrhea after extraction of MIRENA 9 months ago for 5 years MIRENA as method of contraception, after extraction secondary amenorrhea, hormonal status: without pathological findings, no induction of bleedings possible in spite of estrogen substitution, suspicion of intrauterine adhesions no endometrium visible
4. Hysteroscopy
intrauterine adhesions grade 3, right lateral wall
5. Therapy
intrauterine adhesiolysis
144
Endometritis
Endometritis
1. Indication
postmenopausal bleeding
2. Hysteroscopy
entire cavity reddened, endometrium touch-sensitive and bleeds easily (see posterior wall)
3. Diagnosis
endometritis
Attention: If the entire cavity is reddened, there is a strong suspicion of endometritis.
12. Complications
1. 2. 3. 4. 5. 6.
endometritis/adnexitis 0.01 % dysregulation of circulation 3 to 5 % (without anaesthesia) via falsa (cervical canal) 2 % uterus perforation 0.1 % embolism (singular cases) dissemination of tumour cells
Attention: With all safety aspects considered the total rate of complications is lower than 1 per mill. Attention: A dissemination of tumour cells is excluded by CO2-hysteroscopy. Attention: A dissemination of tumour cells by hysteroscopy with a fluid distending medium is very unlikely.
146
Via falsa
43-year-old patient 1. Clinical diagnosis 2. Anamnesis 3. Sonography
recurrent hypermenorrhea and dysmenorrhea for 3 years increasing hyper- and dysmenorrhea, finished family planning suspicion of adenomyosis (hyperplastic myometrium) endometrium thickness: 8 mm (post menstruationem)
4. Hysteroscopy
via falsa on the posterior wall with cervical stenosis, after withdrawal of the hysteroscope the right direction becomes visible at 11 o’clock
5. Therapy 6. Histology
LASH adenomyosis uteri
Perforation
147
84-year-old patient 1. Clinical diagnosis 2. Anamnesis 3. Sonography
postmenopausal bleeding for 1 month increased vaginal bleeding, menopause 30 years ago endometrium thickness: 14 mm
4. Hysteroscopy
with craurosis cautious dilatation with the smallest Hegar’s dilatators ( insertion of the hysteroscope ( perforation of the posterior wall followed by bleeding
5. Therapy 6. Histology
vaginal hysterectomy cervical myoma, corpus polyp
148
Intrauterine adhesions grade 3 (perforation)
38-year-old patient 1. Clinical diagnosis 2. Anamnesis
3. Sonography
secondary uterine amenorrhea spontaneous delivery 9 months ago with curettage post partum because of placental residuals (positive), after that secondary amenorrhea endometrium only partially visible, no hematometra
4. Hysteroscopy
cervical stenosis intrauterine adhesions grade 3 (right half of the cavity completely obstructed) slight perforation of the fundus
5. Therapy
dilatation of the cervix termination of the operation antibiotic prophylaxis ! hysteroscopic adhesiolysis 4 months after healing up of the perforation – without problems none
6. Histology
13. Summary
Advantages of diagnostic hysteroscopy ( ( ( ( ( (
simple method which can be performed as outpatient treatment direct visualisation of the uterine cavity exact localisation of pathological intrauterine findings direct biopsy high correspondence with histological findings in the diagnostics of sterility far more effective than sonography and hysterosalpingography ( with abnormal uterine bleedings the hysteroscopy fills a diagnostic gap between vaginal sonography and dilatation/curettage ( early information of the patient Today, the diagnostic hysteroscopy is a standard method in gynaecology.
14. List of abbreviations
ESGE hCG HRT ICSI IUA IUD IUS IVF LASH LAVH MRI
European Society of Gynaecological Endoscopy human Choriongonadotropin hormone replacement therapy intracytoplasmic sperm injection intrauterine adhesions intrauterine device intrauterine system in-vitro fertilisation laparoscopic supracervical hysterectomy laparoscopically assisted vaginal hysterectomy magnet resonance imaging
Thomas Römer
OPERATIVE HYSTEROSCOPY A Practical Guide 2nd ed. approx. viii, 150 pages. Paperback. ISBN 978-3-11-022499-3 Series: Pocket Guides for Gynaecologists To be published March 2010 eBook: ISBN 978-3-11-022500-6
Operative hysteroscopy represents an important extension of operative gynecology. The benefits of this endoscopic technique, however, are balanced by its high demands on the operator. It requires excellent knowledge of safety issues and possible complications. This book acts as guide and resource for the practical acquisition of this technique. This new edition is distinguished by the large number of improved color illustrations and incorporation of the newest scientific findings. • 2nd revised edition • guide and resource for the practical acquisition of operative hysteroscopy
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Founded by Erich Z. Saling Editor-in-Chief: Joachim W. Dudenhausen Publication frequency: bi-monthly (6 issues per year). Approx. 500 pages per volume. ISSN 0300-5577 ISSN (Internet) 1619-3997; CODEN JPEMAO 2008 INCREASED IMPACT FACTOR: 1.234 FIVE-YEAR IMPACT FACTOR: 1.315
Journal of Perinatal Medicine is a truly international forum covering the entire field of perinatal medicine. It is an essential news source for all obstetricians, neonatologists, perinatologists and allied health professionals who wish to keep abreast of the latest developments in perinatal and related research. All de Gruyter journals are hosted on Reference Global, de Gruyter’s integrated platform. Please visit www.reference-global.com for more information and free TOC alerts. Electronic sample copy at www.degruyter.com/jpm
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