(Pocket Guides For Gynaecologists) Thomas Romer - Diagnostic Hysteroscopy - A Practical Guide, 2nd Edition (Pocket Guides For Gynaecologists) (2010, de Gruyter) PDF

Pocket Guides for Gynaecologists
Editors: Thomas Römer, Andreas D. Ebert

Thomas Römer
Diagnostic Hysteroscopy
A practical guide
2nd Edition
DE GRUYTER
Professor Dr. med. Thomas Römer
Evangelisches Krankenhaus
Köln-Weyertal gGmbH
Weyertal 76
50931 Köln
Thomas.Roemer@EVK-Koeln.de
Translated by Dr. Christina Römer, Cologne.

This book has 134 figures and 6 tables.
ISBN 978-3-11-022497-9
Library of Congress Cataloging-in-Publication Data

Römer, T. (Thomas)
[Hysteroskopischer Wegweiser für Gynäkologen. 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 Natio-
nalbibliografie; 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 care-
ful 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 Müntzer”, 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 Hyste-
roscopy 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 diag-
nostic hysteroscopy and its practical applications.
The 2nd edition shall contribute to the further enhancement of di-
agnostic 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 Römer

Contents
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2. History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3. Indications for diagnostic hysteroscopy . . . . . . . . . . . . . . . 3
4. Instrumentation and distending medium . . . . . . . . . . . . . . 4
5. Examination procedure and techniques . . . . . . . . . . . . . . . 22
6. Distinctive features of hysteroscopy in the gynaecologist’s
practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
7. Hysteroscopy in the diagnostics of sterility and infertility 36
8. Hysteroscopy with bleeding disorders . . . . . . . . . . . . . . . . 66
9. Hysteroscopy with sonographically suspect endometrial
findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
10. Hysteroscopy and lost IUD/IUS. . . . . . . . . . . . . . . . . . . . . . 133
11. Special cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
12. Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
13. Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
14. List of abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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 fea-
sible in hospitals but for many indications also in the gynaecolo-
gical practice without anaesthesia.
For that reason aspects of the diagnostic hysteroscopy for outpati-
ent treatment are especially considered.
For the diagnostics of sterility and bleeding disorders hysteroscopy
constitutes only one form of treatment. Therefore in the case stu-
dies 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 compa-
nion for the practical use of hysteroscopy.
2. History
The first hysteroscopy was reported by PANTALEONI in the Eng-

lish 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 hystero-
scopy 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 pic-
ture 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, curet-
tages 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-diagnos-

tic sheath and a 3.6-mm-flow sheath with the possibility of continu-
ous 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 cer-

vix is dilated further (Hegar 8), so that the outflow may be
reached via the dilated cervical canal.
Bettocchi-hysteroscope with working sheath for semi-rigid instru-

ments (biopsy forceps, grasping forceps, microscissors) and continu-
ous 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-extrac-
tion and cutting of intrauterine adhesions grade 1 and 2.
Semi-rigid instruments for the Bettocchi-hysteroscope

1. biopsy- and grasping forceps
2. biopsy spoon forceps
3. punch
4. blunt scissors
5. sharp scissors
6. myoma-fixation instrument
Attention: For the insertion of the working sheath the non-anaes-

thetized 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.
Diagnostic standard hysteroscope, 4 mm-30$ -lenses and 5.1 mm out-

er diameter (without continuous flow sheath).
Attention: With patients suffering from cervical stenosis mini-

hysteroscopy is primarily used.
Xenon light source with up to 300 W.
Attention: A high-performance light sources enhances diagnos-

tic reliability.
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.
Pressure-cuff for diagnostic hysteroscopy with a fluid distending med-

ium 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 be-
cause it facilitates the opening of the cervical canal and the
following passage.
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.
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)
Table 1: Comparison of CO2 -hysteroscopy and hysteroscopy with a

fluid distending medium
CO2-hysteroscopy hysteroscopy
with fluid
medium
1. picture very clear clear

2. technical complexity higher low
3. usage some experience easy
necessary
4. risk of dissemination very low slightly higher
(infection, tumour cells)
5. diagnostics of bleeding limited (with very good
disorders current bleeding)
6. diagnostics of sterility very good good
Attention: Especially for the diagnostics of bleeding disorders

hysteroscopy with a fluid distending medium should be pre-
ferred.
Attention: One advantage of the hysteroscopy with a fluid dis-

tending medium is that a follow-up control of the cavity after
mechanical removal of polyps or dilatation/curettage is possi-
ble.
16 Hysteroscopic finding
Hysteroscopic finding: Passage of the cervical canal with CO2-hys-

teroscopy. Further forward movement towards the gas bubbles.
Hysteroscopic finding 17
Hysteroscopic finding: Passage of the cervical canal with hystero-

scopy 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 (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 poster-
ior wall of the cavity.
20 Regular cavity with cervical stenosis
52-year-old patient
1. Clinical diagnosis cervical stenosis

2. Anamnesis cervical stenosis, cytological swab not
possible
3. Sonography 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: Regular cavity with normal endometrium.

Hysteroscopy with a fluid distending medium makes assessment diffi-
cult 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 med-
ium 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 hystero-
scope
–– 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 ne-

cessary in rare cases. With a cervical stenosis the use of mini-
hysteroscopes is the prime choice.
24 Examination procedure and techniques
Hysteroscopic finding: With further forward movement of the hystero-

scope 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 in-

ternum) can be hysteroscopically exactly verified and thus be
directly dilated.
Regular cavity (minihysteroscopy, cervical stenosis) 25
52-year-old patient
1. Clinical diagnosis cervical stenosis, lower abdominal pain

2. Anamnesis cervical stenosis, cytological swab not
possible, occasional abdominal pain
(secretory congestion, mucous cervix)
4. Hysteroscopy mucous cervix

cervical stenosis
regular cavity, ostia free
5. Therapy dilatation of the cervix, dilatation/

curettage
6. Histology atrophic endometrium, cervix without
findings
Optimal time for examination

1. in sterile and infertile patients – immediately post menstruatio-
nem
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
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 intravas-

cular injection.
Attention: Wait for the effect of local anaesthesia (3–5 min-

utes) before beginning with hysteroscopy or further manipula-
tions.
Attention: With the development of thin hysteroscopes local

anaesthesia with outpatient hysteroscopies has become neces-
sary only in rare cases.
(Patients may suffer from more pain from the injection than
from the passage of the cervical canal with the minihystero-
scope.)
Permitted movements of the hysteroscope with a patient without

anaesthesia
1. forward and backward movement
2. rotation with use of 30$ -angle lenses
Attention: With the help of these two movements 95 % of all

uterine cavities can be completely assessed.
correct
forbidden
Attention: Avoid horizontal and vertical movements of the hys-

teroscope 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 ad-

hesions 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 recurrent menorrhagias and
dysmenorrheas
2. Anamnesis for two years increasing menorrhagias and
dysmenorrheas, for one year patient has
wanted child/ren
3. Sonography endometrium thickness (post menstruatio-
nem): 8 mm
4. Hysteroscopy regular cavity and cervix, ostia free
5. Therapy endometrium biopsy, laparoscopy:
resection of the endometriosis
bilateral chromopertubation: positive
6. Histology proliferative endometrium
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 corre-
sponding description of the findings are necessary.
6. Distinctive features of hysteroscopy
in the gynaecologist’s practice
The performance of hysteroscopy without anaesthesia in a gynae-

cologist’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. Patient
–– no cervical stenosis
–– no extensive intracavitary findings
–– no extreme anteflexion or retroflexion of the uterus
–– co-operative
2. Examiner
–– sufficient experience in hysteroscopy
–– sonographic and clinical check of the indication
–– trained staff for the assistance
3. 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. primary sterility
2. secondary sterility
3. infertility (habitual abortions)
4. post-abortion-hysteroscopy
Diagnostic hysteroscopy in patients with desire of pregnancy
about 8 to 12 weeks after abortion curettage for the early di-
agnostics 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 hys-

teroscopy 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 ( uterus septus
contrast medium –– 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 in-

creasing 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 hystero-
scopy 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 ex-
tent III and IV) (see page 58).
( Slight uterus malformations (septum smaller than 2 cm) are of-
ten missed by sonography (in about 30 % of the cases).
Attention: Sonography for the detection of uterus malforma-

tions should be performed immediately before menstruation
(thicker endometrium). Then in most of the cases two endome-
trial 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 menstru-

al cycle (2 endometrial areas).
Sonographic suspicion of endometrial defects with intrauterine adhe-

sions grade extent 4.
40 Regular cavity with primary sterility
Regular cavity with primary sterility 41
41-year-old patient
1. Clinical diagnosis primary sterility
2. Anamnesis for 3 years desire to have child/ren,
ovarian cyst on the left
3. Sonography 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)
6. Histology none
42 Regular cavity with secondary sterility
40-year-old patient
1. Clinical diagnosis secondary sterility for 5 years
2. Anamnesis one delivery 12 years ago, now new part-
ner, for 4 years desire to have a child
(spermiogram and hormonal status with-
out pathological findings)
of menstrual cycle)
4. Hysteroscopy regular cavity, tubal ostia bilaterally

free
5. Therapy laparoscopic resection of the endometrio-

sis, chromopertubation (bilaterally posi-
tive)
6. Histology none
Corpus polyp with a patient wanting a child 43
39-year-old patient
1. Clinical diagnosis desire to have a child, myoma on the pos-

terior wall
2. Anamnesis known isthmic myoma on the posterior
wall, growing, for 2 years desire to have a
child
3. Sonography 4-cm isthmic, subserous-intramural myoma
on the posterior wall, endometrium thick-
ness: 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, chro-
mopertubation (bilaterally positive)
6. Histology glandular corpus polyp
44 Submucous myoma grade extent 2
32-year-old patient
1. Clinical diagnosis submucous- intramural myoma grade
extent 2
2. Anamnesis desire to have a child for 2 years, fundal
myoma that continues to grow, bleeding
disorders
3. Sonography 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 transcervical myoma resection
6. Histology parts of a leiomyoma (40 g)
Attention: Submucous myomas are rarely the cause of sterility (ob-

struction of the tubal ostium), but a frequent cause of infertility (high-
er 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 uterus malformation
2. Anamnesis the uterus malformation was discovered
by an externally performed laparoscopy
but not clearly specified. Now again diag-
nostic assessment before planned IVF
(tubal factor)
3. Sonography 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 uterus septus
2. Anamnesis recurrent hypermenorrheas and dysmenor-
rheas, suspected endometriosis
3. Sonography 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 en-
dometriosis Douglas
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 residual septum after septum dissection
2. Anamnesis 3 months ago septum dissection with
complete septum and IUD insertion
3. Sonography 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 intrau-
terine adhesions is recommended.
48 Uterus subseptus
Uterus subseptus 49
28-year-old patient
1. Clinical diagnosis habitual abortions with uterus subseptus
2. Anamnesis 3 abortions (8th/10th/11th week of preg-
nancy)
3. Sonography 2 endometrial areas
4. Hysteroscopy broad-based complete septum (3 cm)

5. Therapy ( hysteroscopic septum dissection and
IUD insertion
( laparoscopy: wide uterine fundus with-
out raphe
6. Histology none
Attention: With habitual abortions the search for uterus malfor-

mations (mostly uterus subseptus) is part of the standard diag-
nostic procedure.
50 Uterus subseptus
35-year-old patient
1. Clinical diagnosis uterus subseptus
2. Anamnesis abortion curettage 8 weeks ago, median
resistance noticeable
recommendation: diagnostic assessment by
means of hysteroscopy and laparoscopy
dysmenorrhea (suspected endometriosis)
3. Sonography 2- cave-phenomenon (2 endometrial areas)
4. Hysteroscopy complete septum (3 cm)

5. Therapy laparoscopy (uterine fundus smooth), resec-
tion of the endometriosis and of the myoma,
transcervical septum dissection
Attention: There is a high coincidence between uterus malfor-

mations and endometriosis (about 60 %).
Uterus septus 51
52 Uterus septus
29-year-old patient
1. Clinical diagnosis uterus septus
2. Anamnesis sonographic suspicion of uterus malforma-
tion with dysmenorrhea and desire for a
child
3. Sonography 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
IUD insertion
Attention: Uterus malformations are frequently associated with

dysmenorrhea.
Uterus unicornis 53
54 Uterus unicornis
29-year-old patient
1. Clinical diagnosis uterus unicornis

2. Anamnesis desire for a child for 2 years, during child-
hood nephrectomy on the right
3. Sonography uterus displaced to the left side, endome-
trium thickness: 6 mm (post menstruatio-
nem)
4. Hysteroscopy small cavity, narrowed to the left, only one
tubal ostium, circular structure of the cav-
ity
5. Therapy laparoscopy: uterus unicornis on the left
without rudimentary cornual horn on the
right, resection of the endometriosis Dou-
glas, chromopertubation on the left posi-
tive
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 uterus unicornis
2. Anamnesis serometra gaining in size, cystic ovarian
tumour on the right, 3 regular sponta-
neous deliveries
3. Sonography 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
6. Histology ( atrophic endometrium
( rudimentary uterine cornua without re-
mains of endometrium
( serous adenocyst in the right ovary
Attention: Even an obstetric anamnesis without pathological

findings does not exclude the existence of uterus malforma-
tions.
Uterus arcuatus 57
57-year-old patient
1. Clinical diagnosis Pap III, bleeding disorders
2. Anamnesis Pap III (twice), histological examination of
the cavity is recommended
4. Hysteroscopy uterus arcuatus, regular cervix, otherwise
regular cavity
5. Therapy dilatation/curettage
6. Histology ( 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 Socie-

ty 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 amenor-
rhea or pronounced hypomenorrhea
grade III B: combination of III and III A
grade IV: extensive firm adhesions with agglutination of the ute-
rine walls – both tubal ostia are occluded
Attention: A classification according to the grade extent is pri-

marily necessary because of its therapeutic and prognostic con-
sequences.
Intrauterine adhesions grade 1 59
60 Intrauterine adhesions grade 1
48-year-old patient
1. Clinical diagnosis recurrent hypermenorrhea
2. Anamnesis several operations because of endometrio-
sis, 3 years ago hysteroscopy and dilata-
tion/curettage with regular findings
4. Hysteroscopy intrauterine adhesions grade 1
(ruptured by sheath of hysteroscope)
Attention: Intrauterine adhesions of grade 1 are mostly inciden-

tal findings without clinical importance.
Intrauterine adhesions grade 2 (after septum dissection) 61
29-year-old patient
1. Clinical diagnosis intrauterine adhesions grade 2
2. Anamnesis 3 months ago hysteroscopic dissection of
the septum because of primary sterility
with IUD-insertion for prevention of adhe-
sions
3. Sonography 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 in-

creased incidence of adhesions.
39-year-old patient
2. Anamnesis hysteroscopic myoma resection (external)
2.5 years ago, then secondary amenorrhea
with regular hormonal status; 12 months
ago intrauterine adhesiolysis with adhe-
sions of grade 4 with simultaneous IUD-in-
sertion, control hysteroscopy – normal.
Now again secondary amenorrhea
3. Sonography 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 poster-
ior 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
2. Anamnesis hysteroscopic myoma resection (per-
formed externally) 3 years ago, now
planned IVF because of tubal and andro-
logic causes of sterility, hypomenorrhea
3. Sonography endometrium only partly visible
4. Hysteroscopy whole left half of the cavity obliterated
by adhesions, right ostium visible (in-
trauterine adhesions grade 3)
5. Therapy operative hysteroscopy, intrauterine elec-
trosurgical adhesiolysis and IUD-insertion
Attention: Secondary amenorrhea or hypomenorrheas after in-

trauterine interventions are an important indicator of possible
intrauterine adhesions.
37-year-old patient
1. Clinical diagnosis secondary amenorrhea with intrauterine
adhesions
2 Anamnesis 3 years ago postoperative curettage be-
cause of placental residuals, after that sec-
ondary amenorrhea, regular hormonal sta-
tus
4. Hysteroscopy median-located solid adhesion (IUA grade 3)
5. Therapy intrauterine adhesiolysis, IUD-insertion and
estrogen medication
Attention: Curettages post-partum and in childbed very often

result in intrauterine adhesions.
Check-up after intrauterine adhesiolysis 65
34-year-old patient
2. Anamnesis 1 year ago intrauterine adhesiolysis with
IUD-insertion and estrogen medication
because of intrauterine adhesions grade 4,
afterwards regular bleeding, IUD-extrac-
tion 6 months ago
4. Hysteroscopy median adhesion obliterates right tubal
ostium, left tubal ostium is visible
6. Recommendation 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. hypermenorrhea, menorrhagia
2. metrorrhagia
3. recurrent additional bleedings
4. postmenopausal bleedings
5. bleeding disorders under oral contraception
6. bleeding disorders under hormone replacement therapy
7. bleeding disorders under Tamoxifen
8. bleeding disorders with inserted IUD/IUS
Hysteroscopy with bleeding disorders 67
Hysteroscopic finding: With bleeding disorders the typical first hys-

teroscopic view which gets clearer after influx of the distending med-
ium. If not, check or increase the influx of the distending medium.
Attention: With more serious bleeding a continuous flow hys-

teroscopic 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 back-
ground 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 postmenopausal bleeding
2. Anamnesis 3 years ago menopause, for 2 months spot-
tings twice, dilatation/curettage 5 years ago
4. Hysteroscopy regular cavity and cervix, small adhesions
in the fundal area
6. Histology 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 cervical polyp, cervical stenosis
2. Anamnesis sonographically thickened cervix, outpati-
ent minihysteroscopy not possible without
anaesthesia
3. Sonography thickened cervix with a structure of 10 mm
4. Hysteroscopy cervical stenosis, cervical polyp on the
posterior wall, hyperplastic cervical mu-
cosa, small insulated corpus polyp
6. Histology 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 Pap III, suspected corpus changes
2. Anamnesis Pap III, diagnostic assessment of the cavity
recommended
4. Hysteroscopy small cervical polyp on the right, focal
endometrial hyperplasia on the anterior
wall
5. Therapy dilatation/curettage with control hystero-
scopy
6. Histology cervical polyp, secretive endometrium
Attention: Cervical and endometrial changes often occur simul-

taneously.
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 only intracavitary parts of the myoma

1 predominantly intracavitary parts of the myoma
(intramural part <50 %)
2 predominantly intramural parts of the myoma
(intramural part >50 %)
Submucous myoma grade 0 75
46-year-old patient
1. Clinical diagnosis recurrent hypermenorrheas and dysmenor-
rheas
2. Anamnesis hypermenorrheas and dysmenorrheas for
2 years, now secondary anaemia (Hb 7.8g/
dl)
3. Sonography intrauterine echo-dense structures 3.0 '
2.8 cm (presumption diagnosis: submu-
cous myoma)
4. Hysteroscopy submucous myoma on the posterior wall,
diameter of about 3 cm
6. Histology 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 uterus myomatosus with bleeding disor-
ders, recurrent Pap III D, cystocele II$
2. Anamnesis uterus myomatosus for 5 years, now grow-
ing, and bleeding disorders, 3 times Pap
III D during the last 12 months
! vaginal hysterectomy with colporraphia
planned
3. Sonography multiple intramural and submucous myo-
mas
4. Hysteroscopy submucous myoma grade 0, diameter of
about 4 cm
5. Therapy vaginal hysterectomy with morcellement
sine adnexa with anterior colporraphia
6. Histology multiple leiomyomas (weight of the
uterus: 320 g)
45-year-old patient
1. Clinical diagnosis permanent bleedings with uterus myoma-
tosus
2. Anamnesis uterus myomatosus for 5 years, now
growth of multiple submucous and intra-
mural myomas
3. Sonography 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 laparoscopic supracervical hysterectomy
6. Histology uterus myomatosus (420 g)
Attention: With submucous myomas further myomas (intra-

mural, subserous) should be searched for by sonography.
55-year-old patient
2. Anamnesis postmenopausal bleeding (menopause
3 years ago), occasionally lower abdom-
inal pain
3. Sonography intracavitary echo-dense structure 3.8 '
3.2 cm, presumption diagnosis: polyp,
myoma
4. Hysteroscopy vascular myoma with a diameter of 4cm, ex-
tending from the right posterior lateral wall
(with distinctive vessels on the surface)
5. Therapy hysteroscopic myoma resection
6. Histology parts of leiomyoma (32 g)
Attention: A differentiation between fibrosed polyp and submu-

cous myoma is sonographically as well as hysteroscopically not
possible with certainty.
48-year-old patient
1. Clinical diagnosis uterus myomatosus
2. Anamnesis uterus myomatosus known for some years,
growing, 1 and 2 years ago myoma embo-
lisation, afterwards again growth and in-
creasing discomfort/pain
! planned LASH
3. Sonography submucous-intramural myoma on the pos-
terior 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 LASH sine adnexa
6. Histology uterus myomatosus (460 g)
Attention: Recurrent myomas requiring therapy can develop

even after myoma embolisation.
41-year-old patient
1. Clinical diagnosis uterus myomatosus with discomfort/pain
and bleeding disorders
2. Anamnesis for 3 years increasing abdominal pain and
bleeding disorders with growing uterus
myomatosus, previously 2 caesarean sec-
tions
3. Sonography 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 LASH
6. Histology multiple leiomyomas
Attention: With myomas of grade 2 the further therapy (organ-pre-

serving versus hysterectomy) should be planned with special care.
Residual myoma after uterus perfomation 81
40-year-old patient
1. Clinical diagnosis residual myoma after perforation during
myoma resection
2. Anamnesis 4 months ago myoma resection (external)
with perforation
3. Sonography submucous-intramural myoma parts near
the isthmus, 1.7 ' 2.0 cm
4. Hysteroscopy myoma on the lateral wall grade 2, sub-
mucous-intramural myoma parts (60 %
intramural)
6. Histology 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
2. Anamnesis postmenopausal bleeding, nullipara
intrauterine structure 2.0 ' 1.2 echo-dense
(¼ septum)
4. Hysteroscopy uterus subseptus, about 3.5 cm small sep-
tum, 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)
6. Histology atrophic endometrium
Attention: Uterus malformations and myomas can also occur

together. Under these circumstances the sonographic diagnos-
tics is often difficult.
84 Endometrial hyperplasia, endometrium sliding test
Endometrial hyperplasia, endometrium sliding test 85
40-year-old patient
1. Clinical diagnosis recurrent hypermenorrheas
2. Anamnesis for 3 years increasing hypermenorrheas,
progestagen therapy without success
(post menstruationem)
4. Hysteroscopy hyperplastic endometrium (see sliding test
posterior wall)
5. Therapy endometrial resection during the same op-
eration
Attention: When sliding the hysteroscope forward the differ-

ence in the level of the endometrium may be seen (endome-
trium 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 endome-

trium a difference in level between endometrium and myome-
trium can be shown. This allows for a better assessment of the
extent of the hyperplasia.
Attention: With high intrauterine pressure and evenly distribu-

ted 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 bleeding after secondary amenorrhea
2. Anamnesis for 9 months recurrent metrorrhagias, pro-
gestagen therapy without success
4. Hysteroscopy endometrial hyperplasia (especially ante-
rior wall) (see sliding test)
6. Histology glandular-cystic hyperplasia
Endometrial hyperplasia, endometrium sliding test 89
90 Endometrial hyperplasia, endometrium sliding test
34-year-old patient
1. Clinical diagnosis recurrent hypermenorrhea and dysmenor-
rhea
2. Anamnesis for 2 years recurrent hypermenorrhea, dys-
menorrhea, 1 year ago hysteroscopy and
curettage, corpus polyp
3. Sonography endometrium thickness: 10 mm (post men-
struationem), suspicion of adenomyosis
4. Hysteroscopy endometrial hyperplasia (see sliding test
posterior wall)
6. Histology polypoid endometrium
7. Recommendation levonorgestrel-IUS or LASH
Polypoid endometrium 91
44-year-old patient
1. Clinical diagnosis uterus myomatosus with bleeding disorders
2. Anamnesis uterus myomatosus
3. Sonography multiple intramural myomas, endome-
trium thickness: 8mm (post menstruatio-
nem)
4. Hysteroscopy polypoid endometrium posterior wall
5. Therapy LASH
6. Histology multiple leiomyomas, proliferative endo-
metrium
Attention: Before a LASH with its necessary morcellation of the

corpus uteri a diagnostic hysteroscopy should always be per-
formed to exclude premalignant or malignant changes.
92 Endometrial hyperplasia
38-year-old patient
1. Clinical diagnosis hyper- and dysmenorrhea
2. Anamnesis for 2 years increasing hyper- and dysme-
norrhea (high consumption of analgesics
during menstruation)
3. Sonography hyperplastic uterus (suspicion of adeno-
myosis), 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 (resec-
tion of the endometriosis), later LASH
(adenomyosis confirmed)
6. Histology glandular-cystic hyperplasia
Attention: Because of the estrogen-induced etiology adeno-

myosis uteri and endometrial hyperplasia often occur together.
Endometral hyperplasia 93
52-year-old patient
1. Clinical diagnosis permanent bleedings
2. Anamnesis permanent bleeding for 13 days, before
that already for 1 year metrorrhagias,
known uterus myomatosus
3. Sonography 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 hyster-
ectomy with colporraphia
6. Histology hyperplastic endometrium
94 Focal endometrial hyperplasia in the postmenopause
67-year-old patient
2. Anamnesis 2 dilatations/curettages because of recur-
rent postmenopausal bleedings (2 and
6 years ago)
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)
6. Histology focal polypoid endometrium with initial
formation of polyps
Attention: Most of the endometrial hyperplasias occur focally,

demanding a targeted histological examination (target curet-
tage).
Adenomatous hyperplasia 95
61-year-old patient
1. Clinical diagnosis corpus polyp (sonographic suspicion)
2. Anamnesis at check-up sonographically suspicious
endometrium
3. Sonography 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 hys-
teroscopy: without pathological findings
later vaginal hysterectomy with adnexa
6. Histology ( corpus polyp with parts of an atypical
adenomatous hyperplasia
( uterus and ovaries without pathological
findings, no further parts of hyperplasia
Attention: About 7 % of sonographically and hysteroscopically

normal corpus polyps in the postmenopause show premalig-
nant 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.
Sonographic finding with strong suspicion of a corpus polyp (con-
firmed by hysteroscopy).
98 Corpus polyp
45-year-old patient
1. Clinical diagnosis bleeding disorders with uterus myomatosus
2. Anamnesis 1 year ago hysteroscopy and dilatation/
curettage
histology: simple adenomatous hyperpla-
sia
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 histol-
ogy – LASH
6. Histology fibroglandular polyp without malignancy
uterus myomatosus
Corpus polyp 99
85-year-old patient
2. Anamnesis postmenopausal bleeding
(menopause 32 years ago)
4. Hysteroscopy large fibrosed corpus polyp posterior wall
polyp with grasping forceps, control hys-
teroscopy: empty cavity
6. Histology fibrosed glandular-cystic corpus polyp
100 Uterus arcuatus, corpus polyp
65-year-old patient
1. Clinical diagnosis recurrent postmenopausal bleeding
2. Anamnesis 1 year ago hysteroscopy and curettage
without pathological findings
4. Hysteroscopy small corpus polyp right lateral wall
uterus arcuatus
5. Therapy resection of the polyp and of the endome-
trium
6. Histology corpus polyp, apart from that atrophic en-
dometrium
Corpus polyp, perimenopause 101
45-year-old patient
1. Clinical diagnosis recurrent permanent bleedings
2. Anamnesis metrorrhagias for 2–3 years, progestagen
therapy only temporarily successful
3. Sonography endometrium thickness: 12 mm post men-
struationem
4. Hysteroscopy large corpus polyp right lateral wall
5. Therapy dilatation/curettage and resection of the
polyp with the grasping forceps
6. Histology fibroglandular corpus polyp
102 Corpus polyp, postmenopause
61-year-old patient
1. Clinical diagnosis recurrent postmenopausal bleeding
2. Anamnesis 1 year ago hysteroscopy and curettage
with removal of the polyp, now again re-
current postmenopausal bleeding with
known uterus myomatosus
3. Sonography 15 ' 13 mm intrauterine structure (suspi-
cion of corpus polyp)
4. Hysteroscopy large corpus polyp extending from the
fundal area
5. Therapy LASH
6. Histology corpus polyp, multiple leiomyomas
Corpus polyp, postmenopause 103
77-year-old patient
1. Clinical diagnosis corpus polyp
2. Anamnesis sonographically suspect endometrium
4. Hysteroscopy corpus polyp posterior wall
endometrium without pathological
findings
5. Therapy dilatation/curettage, resection of the polyp
with grasping forceps, control hystero-
scopy: cavity without findings
6. Histology fibroglandular corpus polyp, atrophic en-
dometrium
104 Corpus polyp after dilatation/curettage
Corpus polyp after dilatation/curettage 105
80-year-old patient
2. Anamnesis sonographically suspect findings
4. Hysteroscopy cystic corpus polyp posterior wall
5. Therapy dilatation/curettage, resection of the polyp
with grasping forceps, control hystero-
scopy: empty cavity (see picture 2)
Attention: After the removal of the polyp an intraoperative con-

trol hysteroscopy should always be performed.
106 Corpus carcinoma
Corpus carcinoma
1. The incidence of corpus carcinomas rises in line with the in-
creasing age of the patients.
2. With estrogen-dependent carcinomas sonography (endome-
trium 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 ex-
tended to the cervix, too, to correct a too high staging (exten-
sion 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 carci-
noma is performed.
Sonographic picture of a thickened endometrium with strong suspi-

cion of a corpus carcinoma (confirmed by hysteroscopy and histol-
ogy).
Corpus carcinoma 107
81-year-old patient
2. Anamnesis for 10 days postmenopausal bleeding
4. Hysteroscopy a lot of polypoid, suspect endometrium
in the whole cavity (with free-running
vessels)
6. Histology corpus carcinoma G2/G3 (mixed Mullerian
tumour)
! abdominal hysterectomy with bilateral
adnexectomy, pelvic and para-aortal lym-
phonodectomy
Final histology: Ib G3 N0 (0/42)
Attention: Insulated free-running vessels are a sign of a corpus

carcinoma.
68-year-old patient
1. Clinical diagnosis suspect histological preliminary findings
(polyp with atypias)
2. Anamnesis 9 months ago hysteroscopy and curettage
external diagnosis: polyp with atypias
now: referral to hysterectomy
4. Hysteroscopy necrotic, suspect, vascular endometrium
6. Histology 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)
Attention: Histological findings with atypias should be oper-

ated on as fast as possible to avoid progression.
65-year-old patient
2. Anamnesis obesity, for 5 years no check-up, no hor-
mone replacement therapy
4. Hysteroscopy hyperplastic, partially necrotic endome-
trium with free-running vessels in the
whole cavity, suspected corpus carcinoma
hysterectomy with adnexa and pelvic and
para-aortal lymphonodectomy, afterloading
6. Histology corpus carcinoma Ib G2
Final diagnosis: T1b N0 (0/48) M0 G2
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, hormonal therapy

resection of the polyp – change of drug
or myoma) – 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 di-
agnostics than bleeding disorders without HRT because the
histological findings do not show any differences.
2. The invasive diagnostics of bleeding disorders under HRT re-
duces the subsequent compliance.
3. Minihysteroscopy without anaesthesia in the practice is espe-
cially suited for the diagnostics of bleeding disorders under
HRT because the rate of compliance for HRT remains unaf-
fected.
Table 5: Compliance with bleeding disorders under hormone replace-

ment therapy depending on the diagnostic procedure
hysteroscopy minihysteroscopy
þ curettage þ biopsy
with anaesthesia without anaesthesia
patients (n) 156 52

subsequent compliance (n) 97 49
continuation of HRT ( %) 62 94
Bleeding disorders under HRT, corpus polyps 113
114 Bleeding disorders under HRT, corpus polyps
62-year-old patient
1. Clinical diagnosis sonographically suspect endometrium
under HRT
2. Anamnesis for 4 years continuous-combined HRT
(Activelle!), no bleeding, no discomfort/
pain
3. Sonography endometrium thickness: 13 mm (3 months
ago: 8 mm)
4. Hysteroscopy 2 corpus polyps anterior and posterior
wall
5. Therapy dilatation/curettage and control hystero-
scopy: empty cavity
6. Histology glandular corpus polyps
Corpus polyps, bleeding disorders under HRT 115
62-year-old patient
1. Clinical diagnosis permanent bleedings under HRT
2. Anamnesis for 2 years bleeding disorders under Acti-
velle!, now permanent bleedings
4. Hysteroscopy large corpus polyp extending from the
right lateral wall
5. Therapy dilatation/curettage, extraction of the
polyp with polyp forceps, control hystero-
scopy: without findings
6. Histology glandular- cystic corpus polyp
116 Focal endometrial hyperplasia with bleeding disorders under HRT
60-year-old patient
1. Clinical diagnosis recurrent bleeding disorders under HRT
2. Anamnesis for 3 years HRT with Climodien!, for
3 months acyclic breakthrough bleedings
4. Hysteroscopy slightly proliferative endometrium on the
anterior wall
6. Histology polypoid endometrium
Adenomatous hyperplasia, bleeding disorders 117
66-year-old patient
1. Clinical diagnosis bleeding disorders under HRT
2. Anamnesis for 3 years bleeding disorders under Gy-
nodian Depot! and Uterogest, suspected
ovarian fibroma on the right, known
uterus myomatosus
4. Hysteroscopy extended polypoid structures, posterior
wall with 2 insulated small polyps
laparoscopy: uterus myomatosus, both
adnexa without findings
6. Histology simple adenomatous hyperplasia without
atypias
! LAVH with bilateral adnexectomy
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 wo-

men with and without HRT (according to Roemer, Rabe, Duda, Foth
2004), Guidelines of the German Society of Gynaecology and Obs-
tetrics
double endometrium cyclical HRTa) continuous- no HRT

thicknes combined HRT
hysteroscopic- "13 mmb) "9 mm "9 mm

histological
examination
check-up after 9–12 mm 5–8 mm 5–8 mm
2 to 3 months
without consequence "8 mm "4 mm "4 mm
a)
measurement after hormonally induced bleeding
b)
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 hysteroscopy and histology for

(if necessary, progestagen diagnostic assessment
prophylaxis)
Attention: If the endometrium thickness is not adequately re-

duced after progestagen medication, further diagnostic assess-
ment 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.

79-year-old patient
postmenopause
2. Anamnesis menopause 25 years ago, no HRT
4. Hysteroscopy 2 plain fibrosed corpus polyps posterior
wall
5. Therapy dilatation/curettage and endometrium
biopsy, posterior wall; control hystero-
scopy: without pathological findings
6. Histology fibrosed corpus polyps
75-year-old patient
1. Clinical diagnosis corpus polyp, no bleedings
2. Anamnesis loss of weight,
MRI: suspicion of cervical changes
cytology: without pathological findings
4. Hysteroscopy cervix without pathological findings,
large corpus polyp posterior wall
5. Therapy dilatation/curettage and removal of polyp
with grasping forceps
6. Histology glandular corpus polyp
124 Corpus polyp with adenomatous hyperplasia
85-year-old patient
1. Clinical diagnosis sonographically suspect endometrium in
postmenopause
2. Anamnesis menopause 30 years ago, now large, in-
tracavitary findings well visualisable by
sonography, no bleedings, no discomfort
3. Sonography endometrium thickness: 20 mm, echo-
dense, vascular intracavitary structure
4. Hysteroscopy large corpus polyp occupying the whole
cavity, partially with necrotic changes
5. Therapy attempt to remove polyp by grasping for-
ceps (only partially successful)
! hysteroscopic resection of the polyp
6. Histology corpus polyps with parts of an atypical
adenomatous hyperplasia
! vaginal hysterectomy (without morcel-
lement)
histology: no further parts of hyperplasia
75-year-old patient
1. Clinical diagnosis sonographically suspect endometrium in
postmenopause
2. Anamnesis no bleeding, no discomfort/pain, 2 years
ago hysteroscopy and dilatation/curettage
of corpus polyps
3. Sonography 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)
6. Histology fibroglandular polyps without malignancy
80-year-old patient
2. Anamnesis no bleeding, no discomfort/pain
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
6. Histology glandular-cystic corpus polyps without
malignancy
128 Suspect corpus polyp, postmenopause
83-year-old patient
2. Anamnesis sonographically suspect findings during
check-up, no bleedings, no discomfort
4. Hysteroscopy suspect corpus polyp (soft and crumbly)
polyp
6. Histology fibroglandular corpus polyps without ma-
lignancy
69-year-old patient
2. Anamnesis menopause 15 years ago
intracavitary structure 1.2 ' 1.0 cm
(suspicion of corpus polyp)
4. Hysteroscopy insulated hyperplastic vascular area right
lateral wall
longitudinal laparotomy, hysterectomy
with bilateral adnexectomy, pelvic and
para-aortal lymphonodectomy
6. Histology adenosquamous carcinoma G2
final histology: corpus carcinoma Ib G2
N0 (0/38)
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 diag-
nostic 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 recom-
mended.
5. When the endometrium shows a tendency to grow (endome-
trium thickness >12 mm) a diagnostic assessment is necessary.
6. Since by a simple dilatation/curettage endometrium for histolo-
gical examination may often not be extracted, a segmental en-
dometrial 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 endometrial hyperplasia under Tamoxifen
2. Anamnesis 2 years ago receptor-positive breast can-
cer, since then Tamoxifen 20 mg/d
4. Hysteroscopy polypoid endometrium posterior wall,
cervical stenosis with one adhesion
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 re-
moval of the whole instrument.
134 Lost IUD
35-year-old patient
1. Clinical diagnosis lost IUD
2. Anamnesis for 8 years IUD in situ, with extraction
threads were torn off
3. Sonography 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 planned exchange of IUD during laparo-
scopy
2. Anamnesis for 3 years copper-IUD, now suspected
dislocation
3. Sonography IUD dislocated
4. Hysteroscopy dislocated copper-IUD
5. Therapy IUD extraction and insertion of a new
one
6. Histology none
136 Bleeding disorders with IUD in situ
43-year-old patient
1. Clinical diagnosis bleeding disorders with IUD in situ
(multiload)
2. Anamnesis for 3 years IUD in situ, for 6 months
recurrent spottings and hypermenorrheas
3. Sonography IUD dislocated
endometrium thickness: 10 mm
4. Hysteroscopy IUD transversely located in the uterine
cavity, limited contraceptive safety
5. Therapy IUD extraction and dilatation/curettage
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 permanent bleedings under MIRENA
2. Anamnesis for 6 months MIRENA, recurrent perma-
nent bleedings, progestagen therapy with-
out success
3. Sonography MIRENA transversely located in the uter-
ine cavity, endometrium thickness: 8 mm
4. Hysteroscopy MIRENA transversely located in the uter-
ine cavity, endometrial hyperplasia pos-
terior wall
5. Therapy IUS extraction and dilatation/curettage
7. Recommendation resection of the endometrium after fin-
ished family planning
138 Bleeding disorders with dislocated IUS (MIRENA)
Bleeding disorders with dislocated IUS (MIRENA) 139
52-year-old patient
1. Clinical diagnosis bleeding disorders with MIRENA in situ
and large uterus (probe length ¼ 13.0 cm)
2. Anamnesis for 6 months recurrent permanent bleed-
ings with MIRENA in situ with adipose
patient
uterus clearly hyperplastic without insu-
lated myomas
3. Sonography uterus hyperplasia, MIRENA in the large
cavity clearly dislocated
4. Hysteroscopy MIRENA transversely located in the uter-
ine cavity, endometrial hyperplasia
5. Therapy extraction of MIRENA
dilatation/curettage
new insertion of MIRENA with hystero-
scopic view (at urgent request of the
patient, who refuses a further operative
therapy; oral progestagens are contraindi-
cated)
6. Histology simple hyperplasia
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 re-
moval without exact localisation can be difficult.
3. In these cases hysteroscopic diagnostics and the targeted re-
moval (if necessary, even operatively) is the treatment of choice.
4. With very large solid residuals several sessions may be neces-
sary.
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 sonographically suspect placental resi-
duals and persistent hCG-levels
2. Anamnesis missed abortion 13th week of pregnancy
abortion curettage, after that sonographi-
cally suspected placental residuals
3 times hysteroscopy and dilatation/curet-
tage with postoperatively persistent sono-
graphic findings (performed externally),
followed by 3 cycles of Methotrexate-ther-
apy (because of increased hCG-levels)
3. Sonography 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
6. Histology necrotic placental residuals, no malignancy
142 Placental residuals
24-year-old patient
1. Clinical diagnosis placental residuals with placenta accreta
2. Anamnesis spontaneous delivery 3 months ago, fol-
lowed by a persistent large solid intracavi-
tary finding, recurrent bleedings, 3 times
dilatations/curettages without success
(performed externally)
3. Sonography 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 hys-
teroscopy in two sessions
6. Histology necrotic placental residuals (240 g)
Intrauterine adhesions grade 3 after MIRENA 143
35-year-old patient
1. Clinical diagnosis secondary amenorrhea after extraction of
MIRENA 9 months ago
2. Anamnesis for 5 years MIRENA as method of contra-
ception, after extraction secondary ame-
norrhea,
hormonal status: without pathological
findings, no induction of bleedings possi-
ble in spite of estrogen substitution,
suspicion of intrauterine adhesions
3. Sonography no endometrium visible
4. Hysteroscopy intrauterine adhesions grade 3, right lateral
wall
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 sus-

picion of endometritis.
12. Complications
1. endometritis/adnexitis 0.01 %
2. dysregulation of circulation 3 to 5 % (without anaesthesia)
3. via falsa (cervical canal) 2 %
4. uterus perforation 0.1 %
5. embolism (singular cases)
6. 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 recurrent hypermenorrhea and dysmenor-
rhea
2. Anamnesis for 3 years increasing hyper- and dysme-
norrhea, finished family planning
3. Sonography suspicion of adenomyosis
(hyperplastic myometrium)
endometrium thickness: 8 mm (post men-
struationem)
4. Hysteroscopy via falsa on the posterior wall with cervi-
cal stenosis, after withdrawal of the hys-
teroscope the right direction becomes
visible at 11 o’clock
5. Therapy LASH
6. Histology adenomyosis uteri
Perforation 147
84-year-old patient
2. Anamnesis for 1 month increased vaginal bleeding,
menopause 30 years ago
4. Hysteroscopy with craurosis cautious dilatation with
the smallest Hegar’s dilatators
( insertion of the hysteroscope
( perforation of the posterior wall fol-
lowed by bleeding
5. Therapy vaginal hysterectomy
6. Histology cervical myoma, corpus polyp
148 Intrauterine adhesions grade 3 (perforation)
38-year-old patient
1. Clinical diagnosis secondary uterine amenorrhea
2. Anamnesis spontaneous delivery 9 months ago with
curettage post partum because of placen-
tal residuals (positive), after that secondary
amenorrhea
3. Sonography endometrium only partially visible, no he-
matometra
4. Hysteroscopy cervical stenosis
intrauterine adhesions grade 3
(right half of the cavity completely ob-
structed)
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 – with-
out problems
6. Histology none
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 sonogra-
phy and hysterosalpingography
( with abnormal uterine bleedings the hysteroscopy fills a diag-
nostic 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 European Society of Gynaecological Endoscopy

hCG human Choriongonadotropin
HRT hormone replacement therapy
ICSI intracytoplasmic sperm injection
IUA intrauterine adhesions
IUD intrauterine device
IUS intrauterine system
IVF in-vitro fertilisation
LASH laparoscopic supracervical hysterectomy
LAVH laparoscopically assisted vaginal hysterectomy
MRI 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
www.degruyter.com
JOURNAL OF
PERINATAL
MEDICINE
Official journal of the World
Association of Perinatal
Medicine (WAPM)
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 profession-
als 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
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Pocket Guides for Gynaecologists

Editors: Thomas Römer, Andreas D. Ebert

Translated by Dr. Christina Römer, Cologne.

Library of Congress Cataloging-in-Publication Data

Bibliographic information published by the Deutsche Nationalbibliothek

The hysteroscopic diagnostics and therapy have become a main

Cologne, February 2010 Prof. Dr. med. Thomas Römer

In the last two decades hysteroscopy has been established as a

The first hysteroscopy was reported by PANTALEONI in the Eng-

Attention: Diagnostic hysteroscopy can be best performed with

Small curette for target curettage or endometrial biopsy for outpatient

Attention: Extraction of histological material is possible with

Attention: Self-holding specula are especially recommended

Diagnostic hysteroscope (2 mm-30$ -lenses), with a 2.8-mm-diagnos-

Attention: The continuous flow sheath is especially suited for

Attention: A flushing effect may also be reached when the cer-

Bettocchi-hysteroscope with working sheath for semi-rigid instru-

Attention: The small-size instruments are only suited for the

Semi-rigid instruments for the Bettocchi-hysteroscope

Attention: For the insertion of the working sheath the non-anaes-

Attention: The tissue gained from biopsy may often be very

Diagnostic standard hysteroscope, 4 mm-30$ -lenses and 5.1 mm out-

Attention: With patients suffering from cervical stenosis mini-

Xenon light source with up to 300 W.

Attention: A high-performance light sources enhances diagnos-

HAMOU- microhysteroflator for CO2-hysteroscopy

Attention: The pressure in CO2-insufflators is limited to

Attention: CO2-insufflators for laparoscopy (Laparomat) must

Pressure-cuff for diagnostic hysteroscopy with a fluid distending med-

Attention: With a more difficult passage through the cervical

Videocamera Image 1 (digital 3-chip-camera) with pendular head

Advantage: The pendular camera remains centred even when

Telepack-system with connected camera head (Telekam) and light

Advantages of the Telepack-system:

Table 1: Comparison of CO2 -hysteroscopy and hysteroscopy with a

1. picture very clear clear

Attention: Especially for the diagnostics of bleeding disorders

Attention: One advantage of the hysteroscopy with a fluid dis-

Hysteroscopic finding: Passage of the cervical canal with CO2-hys-

Hysteroscopic finding: Passage of the cervical canal with hystero-

Hysteroscopic finding after the setting up of the hysteroscope on the

Attention: Through the supply of the distending medium the

Hysteroscopic finding (CO2 as distending medium): Regular cavity

1. Clinical diagnosis cervical stenosis

Hysteroscopic finding: Regular cavity with normal endometrium.

Attention: Air bubbles in the cavity can be avoided by paying

Examination procedure for the diagnostic hysteroscopy

Attention: The hysteroscope is always the first instrument in the

Attention: Probing of the uterine cavity and dilatation of the

Problematic situations in diagnostic hysteroscopy

Attention: The local application of prostaglandins is only ne-

Hysteroscopic finding: With further forward movement of the hystero-

Attention: Cervical stenosis (mostly on the ostium cervicis in-

1. Clinical diagnosis cervical stenosis, lower abdominal pain

4. Hysteroscopy mucous cervix

5. Therapy dilatation of the cervix, dilatation/

Optimal time for examination

depot in the subvaginal epithelium for grasping forceps

Attention: Before injection always aspiration to avoid intravas-

Attention: Wait for the effect of local anaesthesia (3–5 min-

Attention: With the development of thin hysteroscopes local

Permitted movements of the hysteroscope with a patient without

Attention: With the help of these two movements 95 % of all