Introduction

Hysteroscopy is a minimally invasive approach for evaluating the uterine cavity using an endoscope and a distention medium. It is a valuable investigative tool for managing common gynecological problems like abnormal uterine bleeding and is considered a “gold standard” by some authorities. The birth of hysteroscopy can be traced to the early nineteenth century when Phillip Bozzini first attempted to illuminate the hollow cavities of human body by using conducted light, and Desormeaux presented a workable cytoscope. Pantoleoni performed the first hysteroscopy in 1869, using an improved version of Desormeaux endoscope. Rapidly evolving technology and newer innovations have made hysteroscopy procedure more accurate, safer, and highly effective in diagnosing and treating intrauterine pathologies that in the past may have required major surgical management.

This chapter covers the various equipment, distention media, and surgical techniques required to diagnose and treat several uterine abnormalities.

Scope of Hysteroscopy

Abnormal uterine bleeding in premenopausal and postmenopausal women is a common gynecologic problem that has traditionally been investigated with a blind dilation and curettage. The current trend is to use a combination of ultrasound, office-performed endometrial biopsy and hysteroscopy to improve diagnostic accuracy. Compared to blind dilation and curettage as well as sonography with or without saline infusion, hysteroscopy has been shown to be more reliable and accurate for evaluating endometrial pathology in women with abnormal uterine bleeding with fewer false-positive and false-negative results.

A hysteroscopic “see and treat” approach offers the advantage of a significantly lower incidence of pain, bleeding, intraoperative injuries or postoperative infection, and a rapid recovery time when compared to hysterectomy. It is cost-effective and a huge patient satisfier when performed in an office or an ambulatory care setting. Common indications for the use of hysteroscopy can be found in Box 8.1.

Introduction

Permanent female sterilization remains one of the most popular methods of birth control. It is the fifth most commonly performed procedure in the United States, following cesarean section, abortion, cholecystectomy, and coronary angioplasty. [1] It provides a safe and effective method of birth control for women who have completed childbearing. It remains a viable option for women who have contraindications to medical contraceptives. It can be performed at any time and there are multiple ways to achieve blockage of the tubes. Different approaches are available which have their own risks and benefits, and provides women with options to choose from.

Scope of the Problem

It is estimated that as much as half of all pregnancies in the United States are unintended at the time of conception.[2] Unintended pregnancies are associated with a number of adverse maternal behaviors including lack of or limited prenatal care, smoking, and drinking during the pregnancy, failure to breastfeed, and poor maternal-child bonding. The costs of caring for these unintended pregnancies are estimated to be anywhere from $11.1 billion to $11.3 billion per year. These costs include only prenatal care, labor and delivery, and infant care for a year; they do not include nonmedical care and long-term costs because they are more difficult to estimate. [3] Nor do they consider the emotional burden or the costs to the woman in terms of her personal or professional goals. This highlights the importance of safe and effective contraception. According to data from the National Survey of Family Growth, which provides data from 2011 to 2013, the most commonly used methods for contraception include the pills (25.9 percent), female sterilization (25.1 percent), the male condom (15.3 percent), and intrauterine devices/subdermal implants (11.6 percent). [4] In choosing a contraceptive option, one has to consider efficacy, safety profile, ease of use and adverse effects. For women who have completed childbearing, the option of female permanent sterilization is certainly practical and cost-effective.

Timing

Female sterilization can be performed at any time during the menstrual cycle, following a pregnancy or an abortion, or during cesarean delivery. If the procedure is not performed immediately postabortion or postpartum, the patient should be using an effective contraceptive, or the sterilization procedure should be performed during the follicular phase, to avoid the chances of a concurrent, undiagnosed pregnancy.

Introduction

The evaluation and management of abnormal uterine bleeding (AUB) has recently been focused on the specific etiology of the condition. The use of a pneumonic delineating the most common causes (PALM-COEIN see Box 3.1) has been established by the International Federation of Obstetrics and Gynecology (FIGO) and adapted by the American College of Obstetrics and Gynecology (ACOG) as the approach for these condition (1). As listed in Box 3.1, the “C” stands for coagulation disorders. Management of patients with coagulation disruption is a common encounter in the practice of obstetrics and gynecology. Multiple conditions and medications can cause defects in the coagulation pathway, leading to unpredictable and sometimes heavy uterine bleeding. The chapter reviews common causes including hereditary, genetic, acquired, and medication-related causes that are associated with a disruption of the coagulation pathway and thus lead to heavy bleeding in gynecology (Figure 3.1). Familiarity with the different pathways and elements involved in the process of coagulation as well as those that counteract it are important basic concepts to understand the etiology and management of all these conditions.

Scope of the Problem

FIGO Classification: Coagulopathies (AUB-C)

This category includes (1) those patients who have defects in the coagulation pathway as well as (2) those who have platelet disorders (either functional or in quantity) along with (3) those with chronic anticoagulation therapy. These patients present generally with abundant bleeding around menarche or close to their initiation of anticoagulation medication. Most of the patients who present early after menarche have not been diagnosed with a bleeding disorder as most have not had any surgical intervention that tested their coagulation capacity. Key items on history taking for these patients include the clues present during their interview. Family history of bleeding disorders is not uncommon. Epistaxis, gum bleeding, and taking a long time for bleeding to stop after minor cuts could be clues that increase the suspicion for these conditions.