What are the most common indications for hysteroscopy?

Most Common Indications for Hysteroscopy

The most common indications for hysteroscopy include abnormal uterine bleeding, infertility evaluation, recurrent pregnancy loss, and evaluation of suspected intrauterine pathology. Hysteroscopy serves as both a diagnostic and therapeutic tool that allows direct visualization of the uterine cavity with high accuracy.

Primary Indications

1. Abnormal Uterine Bleeding (AUB)

• Most frequent indication for hysteroscopy
• Particularly valuable when:
  • Initial transvaginal ultrasound (TVUS) shows focal endometrial abnormalities 1
  • Endometrial biopsy is negative but symptoms persist 1
  • Previous diagnostic methods (like endometrial biopsy) have been inconclusive 1

2. Infertility Evaluation

• Used to identify potential intrauterine causes of infertility:
  • Intrauterine adhesions (Asherman syndrome)
  • Endometrial polyps
  • Submucosal fibroids
  • Uterine septum or other congenital anomalies 1
• Particularly indicated when other imaging modalities suggest abnormalities or when unexplained infertility persists 2

3. Recurrent Pregnancy Loss

• Evaluation for:
  • Uterine anomalies (septate uterus being most common)
  • Intrauterine adhesions
  • Submucosal fibroids
  • Endometrial polyps 3
• Studies show uterine anomalies are present in up to 54.5% of patients with recurrent miscarriages 3

4. Suspected Intrauterine Pathology

• Further evaluation when other imaging modalities suggest:
  • Endometrial polyps
  • Submucosal fibroids
  • Endometrial hyperplasia
  • Endometrial cancer 4

Advantages of Hysteroscopy

• Superior diagnostic accuracy: Detects focal lesions that may be missed by blind procedures like dilation and curettage 4
• Direct visualization: Allows targeted biopsy of suspicious areas
• Therapeutic capability: Can simultaneously diagnose and treat pathology (polypectomy, myomectomy, adhesiolysis, septum resection) 2
• Office-based procedure: Many diagnostic hysteroscopies can be performed in an outpatient setting 5

Diagnostic Algorithm for Hysteroscopy Use

1. For Abnormal Uterine Bleeding:

   • Initial evaluation with TVUS
   • If TVUS shows focal abnormality → Proceed to hysteroscopy
   • If TVUS shows diffuse thickening → Consider endometrial biopsy first
   • If endometrial biopsy is negative but symptoms persist → Proceed to hysteroscopy 1

2. For Infertility Evaluation:

   • After basic infertility workup
   • If other imaging (TVUS, sonohysterography, HSG) suggests intrauterine pathology → Proceed to hysteroscopy
   • Consider as part of evaluation in unexplained infertility 1

3. For Recurrent Pregnancy Loss:

   • After excluding other causes (genetic, hormonal, immunological)
   • Direct hysteroscopic evaluation to identify and potentially treat uterine anomalies 3

Clinical Pearls and Pitfalls

• Complementary use: Hysteroscopy is most effective when used in conjunction with other diagnostic modalities rather than as a standalone first-line test
• Timing considerations: Best performed in the early proliferative phase of the menstrual cycle for optimal visualization
• Diagnostic limitations: While excellent for cavity assessment, cannot evaluate the myometrium or external uterine contour
• False negatives with other methods: Office endometrial biopsies have a false-negative rate of about 10%, highlighting the value of direct visualization with hysteroscopy when symptoms persist 1

Hysteroscopy has evolved from a purely diagnostic tool to an essential minimally invasive approach that allows for both diagnosis and treatment of intrauterine pathology, making it an indispensable procedure in modern gynecological practice.