Placental remnants following birth are often heralded by secondary post-partum haemorrhage. Diagnosis is assisted by an ultrasound scan, with MRI indicated when the scan is inconclusive. Emergency measures are required for excessive bleeding. A conservative approach is appropriate when bleeding is not heavy. Confirmation of intra-uterine placental tissue by repeated scans ensures surgery is confined to women with a high chance of retained tissue. Traditional curettage is often replaced by hysteroscopic resection allowing direct and precise removal of placental remnants with less trauma to adjacent normal endometrium. Hysteroscopic treatment, under general anaesthetic or as an outpatient, is preferably deferred for 2–3 months after delivery to minimise complications, without compromising longer-term outcomes like fertility or subsequent pregnancy rates. Intra-uterine adhesions may occur especially following repeated blind curettage, which can compromise future fertility. Clear communication with the patient and partner is important. Further research into the management options for postdelivery placental remnants is required to ascertain best practice.

Uterine fibroids are common. They arise from the myometrium and occur in approximately 20–25% of women aged 35 years or more [1]. They may be found at any position within the myometrium from the serosal surface to lying completely within the uterine cavity in 5–10% [2].

Over the ages, clinicians have tried to decipher the mysteries of the human body by exploiting natural openings to examine the internal aspects of organs. Since as far back as Hippocrates, a variety of instruments have been employed to achieve this. The simplest form of instrument is a speculum, used to augment natural openings and allow ambient light to illuminate the inner aspect of organs for inspection by the naked eye. While this may be helpful for examining the nostrils or the vagina, for example, it is not an adequate approach for a well-concealed organ such as the uterus. Accurate endoscopic examination of the endometrial cavity, i.e. hysteroscopy, requires the transmission of light into and out of a cavity. Since the endometrial cavity is a potential space, collapsed in the natural state, a distension medium is required to expand the field of vision.

Endometrial ablation (EA) is a minimally invasive surgical intervention that aims to reduce heavy menstrual bleeding (HMB) by destroying functionally active endometrial glands within the endometrium and the superficial myometrium, including the deep basal glands. To prevent regeneration and stop menstruation this destruction should be to a depth of 5 mm. In the past, destruction of the endometrium required an operating hysteroscope. Endometrial tissue was either removed using an electrical cutting loop or destroyed by applying thermal energy to induce necrosis using an electrical ‘rollerball’ or laser fibre. These first-generation techniques have largely been superseded by second-generation techniques that comprise semi-automated global ablative systems using a variety of energy sources to thermally ablate the endometrium. These systems require less operator skill, are less likely to require general anaesthesia, are quicker to perform and offer enhanced safety with no loss in effectiveness.

The first part of this chapter has been written with the patient’s journey in mind: from the time of presentation to the general practitioner (GP) with a problem such as abnormal uterine bleeding, through referral to secondary care for investigation, including hysteroscopy if appropriate, and to treatment as indicated. We hope this approach will clarify what is involved in providing such a service. In the second half of the chapter, the equipment required for providing hysteroscopy services is described in detail, making extensive use of published standards and guidelines for gynaecology and hysteroscopy specifically.

Hysteroscopy involves both diagnostic and therapeutic procedures. Inpatient hysteroscopy is well established, but the development of outpatient services is relatively new. Audit is the process by which we assess a service against recognised standards; data collection enables us to perform an audit; clinical governance provides the framework for safe and effective patient care.

Surgical procedures using electrosurgery can be undertaken within the uterine cavity to address excessive menstrual blood loss and to enhance fertility. The insertion of specialised electrodes down hysteroscopic instruments enables the direct application of electricity to uterine tissue. The electrical energy is transformed into heat and, depending upon how this heat is focused, can be used to cut tissue and excise lesions, or cauterise and ablate tissue (Box 8.1). The larger hysteroscopic resectoscopes with outer diameters of 7 to 8.5 mm are generally, though not exclusively, used during inpatient procedures with a general anaesthetic or regional anaesthesia. The introduction of smaller electrodes (1.67 mm, or 5 Fr) has enabled therapeutic procedures to be undertaken using diagnostic hysteroscopes with an operating channel. This has supported the development of outpatient operative hysteroscopy for the removal of small intrauterine lesions.

Training allows healthcare professionals to develop skills that benefit patients, improve their care and keep them safe. It is an essential aspect of reducing or preventing harm to our patients.

Over the past two decades there has been a significant shift in surgical education away from an apprenticeship model that had existed for centuries towards the use of clinical skills and simulation training. This can be undertaken in a safe environment, allowing healthcare professionals to begin their learning and practice of skills away from patients. Proponents of the ‘new’ system point to the increased availability of simulation equipment, both low (sometimes called basic) and high fidelity (virtual reality high technology systems), in NHS hospitals and university departments throughout the UK. In addition, there is a wealth of evidence supporting simulation as an important educational tool in medicine that has the potential to significantly reduce the chances of harm to patients.

Improved hysteroscopic technology has enabled clinicians not only to perform diagnostic outpatient hysteroscopy but also to treat uterine lesions. Bipolar diathermy electrodes have reduced the risk of fluid overload, allowing the excision of larger fibroids at a single setting and thus reducing the need for abdominal operations. Novel indications for hysteroscopy have become available, such as hysteroscopic tubal occlusion. Concomitant developments in hysteroscopic equipment and ultrasound technology have influenced how these tools are used in the diagnosis and treatment of intrauterine conditions.

The uterus is the primary female reproductive organ. It is situated within the pelvis and measures approximately 8 cm in length, 4 cm in width and 5 cm in depth in the normal, non-pregnant state. Though relatively quiescent in pre-pubertal and post-menopausal years, the uterus possesses a variety of functions during a woman’s reproductive years. It responds to the production of female hormones, creating changes to allow for implantation of a fertilised egg, or menstruation when pregnancy does not occur. It is also able to rapidly expand with the development of a pregnancy and has a contractile function for labour and delivery during childbirth [1].