Evidence - Hysteroscopy, fractional curettage

The indications for hysteroscopy with fractional curettage encompass a wide range of gynecological complaints and diagnostic needs. Additional instruments may need to be used, such as grasping forceps or electric loops. Here are the main indications:

Abnormal uterine bleeding (premenopausal or postmenopausal):

• Irregular, heavy, or persistent bleeding that does not respond to medical treatments.
• Bleeding that occurs after menopause and needs to be investigated.

Endometrial pathologies:

• Endometrial hyperplasia: Thickening of the endometrium that requires targeted biopsy or therapeutic removal.
• Endometrial polyps: Presence of polyps that thicken the endometrium and need to be removed.
• Adenomyosis: Superficial forms where the uterine wall shows changes that are visible and treatable with hysteroscopy.

Uterine fibroids:

• Submucosal and intramural fibroids that cause bleeding or other symptoms and can be removed hysteroscopically.

Intrauterine adhesions (Asherman's syndrome):

• Treatment of adhesions within the uterine cavity that lead to fertility problems or menstrual disorders.

Abnormal findings on imaging:

• Clarification of suspicious or unclear findings on ultrasound or MRI that may indicate a pathology.

Chronic excessive vaginal discharge (leukorrhea):

• Diagnosis and treatment of chronic vaginal discharge that does not respond to other therapies.

Anatomical anomalies of the uterus (e.g., Müllerian anomalies):

• Clarification and, if necessary, treatment of congenital malformations such as uterine septum.

Retained products of conception:

• Removal of placental remnants or other pregnancy tissues after miscarriage or childbirth.

Cervical lesions:

• Examination and, if necessary, removal of pathological changes in the cervical canal.

Complications related to intrauterine contraceptives:

• Removal of embedded or displaced intrauterine devices (IUD) or other foreign bodies.

Preoperative planning and postoperative follow-up:

• Use of hysteroscopy for planning further surgical interventions or for checking the success of a previous operation.

Reference: 

1. Orlando MS, Bradley LD. Implementation of Office Hysteroscopy for the Evaluation and Treatment of Intrauterine Pathology. Obstet Gynecol 2022; 140:499.
2. Weinberg S, Pansky M, Burshtein I, et al. A Pilot Study of Guided Conservative Hysteroscopic Evacuation of Early Miscarriage. J Minim Invasive Gynecol 2021; 28:1860.
3. Munro MG, Critchley HO, Broder MS, et al. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet 2011; 113:3.

Living intrauterine pregnancy:

• A hysteroscopy should not be performed in the presence of an intact pregnancy, as the procedure carries the risk of miscarriage.

Pyometra:

• An accumulation of pus in the uterus (pyometra) is an absolute contraindication, as manipulation can increase the risk of severe infection and sepsis.

Active pelvic infection:

• This includes any acute infection in the pelvic area, including genital herpes infections. Performing a hysteroscopy in the presence of such an infection can lead to the spread of the infection and cause serious complications.

Known cervical carcinoma:

• In patients with diagnosed cervical carcinoma, hysteroscopy should be avoided as it carries the risk of tumor dissemination and may alter treatment planning.

Relative contraindications:

Medical comorbidities:

• Severe comorbidities such as coronary artery disease or bleeding disorders (bleeding diatheses) can increase the risk of a hysteroscopic procedure. However, due to its minimally invasive nature, hysteroscopy is rarely absolutely contraindicated. An individual risk-benefit assessment is required.

Excessive uterine bleeding:

• Heavy bleeding can significantly limit visibility during hysteroscopy, but it is not an absolute contraindication. It can, however, pose a challenge and may require special precautions.

Reference:

1. Orlando MS, Bradley LD. Implementation of Office Hysteroscopy for the Evaluation and Treatment of Intrauterine Pathology. Obstet Gynecol 2022; 140:499.
2. Price TM, Harris JB. Fulminant hepatic failure due to herpes simplex after hysteroscopy. Obstet Gynecol 2001; 98:954.
3. Shalev J, Levi T, Orvieto R, et al. Emergency hysteroscopic treatment of acute severe uterine bleeding. J Obstet Gynaecol 2004; 24:152.