Hysteroscopy - Part 2

September 19, 2006
OBGYN.net Staff

OBGYN.net Conference CoverageFrom the 5th Meeting of the European Society of Gynecologic Endoscopy Stockholm Sweden June, 1999

Roberta Speyer: "Could you make it a little easier for me to understand what would be wrong with me such that I would know to have this procedure, and would it help me to avoid a bigger problem? If I go to the doctor and I'm having abnormal bleeding during the month, they call it 'dysfunctional uterine bleeding,' and in the United States they call it 'abnormal uterine bleeding.' So this would be like having your period maybe several times during the month instead of once, correct?"

Professor Linderman: "Yes."

Roberta Speyer: "And I don't like this, so I go to my gynecologist. Is this when they should suggest doing a hysteroscopy?"

Professor Van Belle: "I think it's very important. One of the most frequent reasons or indications for hysteroscopy is abnormal bleeding. The importance of this examination is that it shows the difference between bleeding that is due to, let's say, a polyp, fibroid, or any other problem, and which is due to the function of the ovaries. The treatment is totally different if you have a problem with ovaries that are not functioning correctly. If you have bleeding as a result of that problem, you have to have medical treatment. You have to take some pills, some hormones. For instance, if you have a polyp or a fibroid, those pills won't help at all. So to determine the difference between those diseases, you have to do a hysteroscopy. There's no other technique that permits you to see inside and have the correct diagnosis. Even more important is that if you, as a patient, consult your doctor, and you do it in a correct way and assume that there is some abnormal bleeding. With this technique we are able to visualize some disturbances in the growth of the tissue on the inside of the uterus which could become a cancer afterward. So if you are reacting correctly on your side, and that means consulting your physician as soon as you notice something abnormal, I think that your doctor should react correctly and should suggest a hysteroscopy as the first choice, as I mentioned."

Roberta Speyer: "So how would this help with the diagnosis of possible cancer? What type of cancer would that be? Uterine cancer? What type of cancer are we talking about?"

Professor Linderman: "We're talking about uterine cavity cancer. This is different than cancer of the cervix, which is the part of the uterus which goes into the vagina."

Professor Van Belle: "Perhaps we could make it more clear with this model, which shows the female organs starting with the bladder. This is the vagina, and there you have the rectum. So we are talking about this organ. We are talking about the uterus, which has a part that's inside the vagina that we call the cervix. And we're talking about this, the cervix. That's the place where your physician takes a Pap smear every year or every two years."

Roberta Speyer: "Is that the type of cancer?"

Professor Van Belle: "That's not the type of cancer that we are talking about. We are talking about inside of the uterus."

Roberta Speyer: "The way that I would be alerted that something is wrong would be through this abnormal bleeding?"

Professor Van Belle: "Yes, abnormal bleeding."

Roberta Speyer: "Which could be, and would more likely be, due to fibroids, polyps, or something not so dangerous."

Professor Van Belle: "That's exactly why we wait."

Roberta Speyer: "So what age group would most likely be at risk for this cancer?"

Professor Van Belle: "The cancer of the inside of the uterus is actually more likely in older women-let's say sixty years or older, or after menopause when the menstrual bleeding has stopped."

Roberta Speyer: "So they would be more at risk for it to be that problem. Maybe you could show us with that scope what you really do. It's really very small isn't it? Is this a life-size model of the uterus, or are women smaller?"

Professor Van Belle: "It also depends on whether a woman has had children, and more would make it larger. But seeing the diameter of this scope, you can imagine that it's perfectly possible to introduce it without any problem inside the vagina and then inside the cervical canal. We don't have to go all the way up to here because, as you said before, it has a panoramic view if you just go from the inside-but more than this, which is about 3 to 4 cm, actually-and you just stay there. There's one very important thing about this instrument and that is that you are looking at a 30-degree angle. So that means that we don't have to make movements which are painful."

Roberta Speyer: "Is that what this one is for, if you do want to move it around?"

Professor Van Belle: "Yes. Once again, with this you just turn it around, and in this way you are looking all around in the cavity, so you don't make any lateral movements which would be painful. That would cause pain, but the simple fact is you just introduce this instrument inside the canal, look at it, and then turn it around with the scope."

Roberta Speyer: "And then I'm looking with you?"

Professor Van Belle: "You are seeing the same thing, and you, as a woman, would recognize those problems as well as I do."

Roberta Speyer: "They're very obvious?"

Professor Van Belle: "They're obvious, just looking inside."

Roberta Speyer: "Do you do a biopsy or something at that point, if you see something? What would you see that would make you think it might be cancerous?

Professor Linderman: "Yes. The content tissue is clearly very recognizable. It's different from a normal, non-pathologic tissue. So you can target this biopsy from this local area, and then you bring it to the pathologist. He'll make a microscopic examination and will be able to say, 'this is a cancer,' 'this is the beginning of a cancer,' or 'this is a normal tissue, a normal hyperplasia.' The advantage for this method is that I can recognize and find out in the very, very early stages the beginning of a carcinoma. The earlier I detect the pathology, if it's a malignancy, the better it is to treat it and the success of the result is then a perfect 100%. Otherwise, if it's later on, you won't have such a good chance to be put back into good health again. That is the problem, and the advantage is a very big advantage. It's the best one, compared to ultrasound. With ultrasound, you can never say, 'this is the beginning of the cancer,' 'this is a cancer,' or 'I will take a target biopsy.' It's not possible. The same can be said about a x-ray examination. It's not possible to say it might be a cancer. You cannot see it. It's a benign tissue."

Roberta Speyer: "So this is the only…?"

Professor Linderman: "The only one, yes

Roberta Speyer: "So this usually happens to older women. Many women who use OBGYN.net are taking care of their older mothers. They're the ones that help with their healthcare. I took care of my mother before she passed on, and I helped get her to the doctor and give that kind of support. As women, is it important for us who are helping our older mothers with their healthcare to ask them if they're having problems with bleeding, and if there is something going on, to make sure we get them to have a hysteroscopy? Wouldn't that be good advice for women in their forties with mothers who are in their seventies?"

Professor Van Belle: "I think you should, because this generation doesn't often go to the doctor, or at least that's the trend in our countries."

Roberta Speyer: "No, my mother would never go to the doctor."

Professor Van Belle: "They had their deliveries at home, and that's the way it happens, so if they're having some bleeding they tend to not go to their physician. I think that the younger generation should advise them to not only have an examination with a physician, but also have the necessary examinations. The same goes for people who are having difficulty having a baby, for instance."

Roberta Speyer: "Does hysteroscopy help people with that problem?"

Professor Van Belle: "Hysteroscopy is certainly the first examination, or one of the first examinations, that should be done."

Roberta Speyer: "Why would you do that?"

Professor Van Belle: "There can be problems on the inside of the uterus. We talked about the tissue that is shed each month, and it can become a cancerous. If there are problems in the development of the tissue on the inside of the uterus, there could be a pregnancy, but it would not have the right components. On the inside of the uterus, the pregnancy should find the perfect tissue which can support it for nine months."

Roberta Speyer: "So you would be able to see if that wasn't the case? Is there anything that you can do about that?"

Professor Van Belle: "We can most certainly do something by helping these women with drugs. There is another example, too. Some people have a uterus that is not normally shaped, and this results in them getting pregnant but then losing it."

Roberta Speyer: "We've had quite a few women write to us about a bicornate uterus or a double uterus. Would it be this?"

Professor Van Belle: "This is a place where hysteroscopy can most certainly help."

Roberta Speyer: "What is that?"

Professor Van Belle: "The uterus is actually formed out of two channels while coming together and merge, and you get one cavity, and that's all. This doesn't always happen perfectly, so there are some situations when both of those channels stay separated."

Roberta Speyer: "So this would happen while this woman was an infant, forming herself. So she wouldn't know it?"

Professor Van Belle: "She would not know it because she has menstrual bleeding just like every other woman. She would not know it up until the point where she's getting pregnant and loses each and every pregnancy."

Roberta Speyer: "So what do you do? Can you fix it?"

Professor Van Belle: "When you have a double uterus, you don't do anything at all. We just wait for a problem. But if you have a septum on the inside of the uterus composed of the harder tissue that doesn't support the pregnancy for nine months, we just cut it away under hysteroscopy. Before these techniques, these women were operated on. They opened up the uterus, then stitched it together again."

Roberta Speyer: "And it's not opened and sewn up, now?"

Professor Van Belle: "That's not necessary anymore, and this is good because if you have a pregnancy inside of the uterus, you have a tremendously big scar."

Roberta Speyer: "You have a weakness."

Professor Van Belle: "You have a weakness, and you have a spot where things can go wrong during labor. So that is one of the most interesting points of hysteroscopy. We can do the most because these women lose every pregnancy up to the moment where we do a one-day clinic visit and just slit the thing away, and then they get pregnant and keep their pregnancy."

Roberta Speyer: "That must be very rewarding for you, as physicians, to help people, not do such invasive procedures, and to be able to do it on a much simpler level. You're very lucky that you work so much in your career to perfect these techniques. Women around the world, and I would say for all of us women, we thank you for this."

Professor Linderman: "You're welcome, and we love you."

Roberta Speyer: "I'm convinced, now. I'm actually going to go have a hysteroscopy. I don't need one, but I'm doing it anyway. [laughter] Thank you very much for sharing this with us. But really, this is a wonderful procedure, and I do encourage women... if you have a situation with bleeding, if you have a problem, you go to a physician. If they do not suggest hysteroscopy, go find a physician who will do that because this is a wonderful procedure. It can really save your life, and it can certainly make the procedure a lot more comfortable for yourself. Thank you very much."