I. Indications
1. abnormal uterine bleeding (AUB): including abnormal bleeding during the reproductive period, perimenopause and postmenopause.
2.Abnormal intrauterine sonographic findings: including ultrasound, HSG, CT, MRI, hysterosonography, color ultrasound Doppler ultrasound, etc.
3, Infertility: to detect lesions that interfere with the implantation and/or development of the pregnant egg, to assess the anatomical condition of the reproductive organs for normalcy and to check the patency of the fallopian tubes.
4.Physiological or specific changes caused by hormonal treatments such as triamcinolone or HRT: hysteroscopy is needed for evaluation.
5. abnormal uterine cavity seen on aspiration cytology or abnormal endometrial pathology seen on histological examination.
6. Secondary dysmenorrhea: often caused by intrauterine abnormalities such as submucosal fibroids, endometrial polyps or uterine adhesions, for which hysteroscopy should be the preferred method of examination.
7.After complex uterine operation: performed 6 to 8 weeks after surgery in order to detect and separate early slender, film-like adhesions.
8.Staging of endometrial cancer: observe whether there is invasion of the mucosal surface of the cervical canal.
9.Uterine fibroids: when choosing the surgical method for multiple fibroids, hysteroscopy should be performed to determine whether there are submucosal fibroids.
10.Check the intrauterine device: Observe whether the position of the device is normal and whether there is embedded.
11.Abnormal vaginal discharge: endometrial cancer is sometimes diagnosed with abnormal vaginal discharge.
Contraindications
1.Absolute contraindication: None.
2. Relative contraindications: Some scholars believe that the following are not contraindications, but matters that need to be noted when doing hysteroscopy
1) Massive uterine bleeding: In case of massive bleeding, the field of view of hysteroscopy is completely obscured by blood, which makes it difficult to detect lesions and increases bleeding.
2) Pregnancy: It may cause miscarriage.
3) Chronic pelvic inflammatory disease: there is a possibility of spreading the inflammation.
Three, hysteroscopy ultrasound combined examination method
1.Fill the bladder moderately until the fundus of the uterus can be revealed.
2.Before the start of hysteroscopy, two-dimensional ultrasound is done to explore the uterine position, size, uterine wall thickness, uterine cavity line position, mucosal thickness, whether there is depression at the bottom of the uterus, whether there is deformity of the uterine body, whether there is fibroid, the number, position and size of fibroid and adnexal condition.
3.The hysteroscope is placed in the direction of the uterine cavity under the guidance of ultrasound. While the hysteroscope is examining the uterine cavity, the ultrasound probe is used to make a transverse and longitudinal sweep above the pubic symphysis, using the intrauterine dilated fluid and the mirror body as a reference for all-round observation. In patent fallopian tubes, images of water passing from the fallopian tube or overflowing from the umbilical end can sometimes be seen. When the mirror is retracted, the sonographic changes before and after dilatation and the infiltration of dilatation fluid into the uterine wall are noted.
Normal uterine cavity morphology as seen by hysteroscopy
4. Abnormalities seen in combined hysteroscopic ultrasound examination
1. Intrauterine lesions
①Uterine malformation: After the uterine cavity is fully expanded by the expansion fluid, the ultrasound image can show whether the contour of the bottom of the uterus is depressed, whether the uterine cavity at the bottom of the uterus has a longitudinal septum and its length, width, thickness, etc. The highly resolved ultrasound instrument can also show the muscle layer within the longitudinal septum, which accurately suggests the diagnosis of uterine longitudinal septum.
②Uterine cavity blood accumulation: hysteroscopy can only detect uterine cavity adhesions, but cannot see the situation in the uterine cavity above the level of adhesions, and joint examination can simultaneously observe the site, scope and single or multiple rooms of intrauterine blood accumulation above them due to adhesions.
③ Intrauterine foreign body: such as intrauterine device completely embedded in the uterine wall or covered by the endometrium, the combined examination can pinpoint the location. If the residue of the uterine ring
2.Uterine wall and ectopic lesions
①Interstitial fibroids: the combined examination will combine the morphological changes in the uterus seen by hysteroscopy with ultrasound to suggest the location, size and degree of internal protrusion of interstitial fibroids, so as to pinpoint interstitial fibroids of the internal protrusion type.
②Uterine adenomyosis: during the combined examination, if the ectopic gland of uterine adenomyosis opens in the uterine cavity, the dilated fluid may enter the uterine wall, which is shown as a heterogeneous cloudy strong echogenicity at the lesion site on the sonogram.
(iii) Subplasmalemmal myoma and adnexal mass: their relationship with the uterus and uterine cavity can be clearly observed.
V. Evaluation of combined hysteroscopic ultrasound diagnosis
1, hysteroscopy is suitable for diagnosing endometrial lesions and occupying lesions that exist only in the uterine cavity, but when the occupying lesion is large and fills the uterine cavity, single hysteroscopy often has difficulty in examining the whole uterine cavity or is not comprehensive enough, which may lead to missed diagnosis or mistaking the fibroid for the uterine wall, and cannot understand the relationship between intrauterine lesions and the uterine wall, and hysteroscopy cannot detect interstitial fibroids, subplasmalemma, adenomyosis and adnexal masses. Ultrasound is an effective method for non-invasive diagnosis of gynecological disorders and has been widely used in clinical practice for many years. However, single ultrasound examination may miss tiny intrauterine and endometrial lesions, make it difficult to clarify the relationship between uterine lesions and uterine cavity, and cannot clearly suggest the diagnosis of uterine abnormalities such as uterine adhesions, uterine cavity stenosis, thin endometrium, and uterine longitudinal septum, etc. Furthermore, ultrasound examination is an indirect diagnosis, not a definite diagnosis. The combined examination makes up for the shortcomings and limitations of the two single examinations, makes the two examinations complementary, expands the indications for the combined examination, and is a valuable new method for rapid, accurate, timely and comprehensive diagnosis of gynecological disorders. The combined examination is significantly better than single hysteroscopy or B ultrasonography.
2. The intervention of ultrasound has a guiding effect on the placement of hysteroscope, which helps to prevent uterine perforation and reduce the blind area of hysteroscopic view. To diagnose the accumulation of blood in the uterine cavity due to uterine adhesions, hysteroscopy can only observe the presence or absence of uterine adhesions, while the uterine cavity above the level of uterine adhesions cannot be seen. Combined examination can simultaneously observe the site, extent, single room, and multiple rooms of the uterine cavity due to accumulation of blood due to adhesions, and suggest the extent of evacuation when accumulation of blood is excluded. The hysteroscopic examination forms a reference between the dilated fluid and the uterine wall, which clearly shows the relationship between the uterine cavity lesion and the uterine wall, indicates the depth of invasion of the uterine cavity lesion into the uterine wall, localizes foreign bodies embedded in the uterine wall, classifies interstitial fibroids, and is important for the selection of indications for hysteroscopic surgery. Compared with the hysterosonography (SHSG, also known as water ultrasound, SIS), which was introduced after 1993, SHSG is an indirect examination and does not have the effect of hysteroscopy in directly showing the state of the uterine cavity, and even if it suggests uterine cavity lesions, hysteroscopic confirmation is needed, so the diagnostic effect of the combined examination is still better than SHSG.
In rare cases, the combined diagnosis still has shortcomings, such as uterine involution, where the clinical diagnosis of submucosal myoma myoma prolapse, hysteroscopy cannot find the ectocervix of the uterus in the combined examination, and ultrasound cannot suggest the cervix, and finally the diagnosis of uterine involution is confirmed by laparoscopy. Bicornuate uterus is also divided into completely bicornuate and incomplete bicornuate uterus. Incomplete bicornuate uterus can be corrected by hysteroscopic surgery, while complete bicornuate uterus needs to be corrected under laparoscopy, and the classification of bicornuate uterus also needs to be determined by laparoscopy.