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New Updated Video: Uterine Septum

Dear Readers,

Yes, it has been quite a while since I’ve written. I hope you all have been well and I am excited to return to the blog sphere. It’s not that I have been slacking; I have been writing extensively in other areas, but I do miss the blog so it’s good to be back.
The attached link is to a patient education piece that I produced on uterine septums, which was accepted and presented at the latest meeting of the American Society of Reproductive Medicine. I am very pleased with this final version and I hope some of you find it helpful.

Patient Education: Uterine Septum Video

More to come!

Frederick Licciardi, M.D.
Professor OGBYN
NYU Langone Medical Center

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Hysteroscopy 101

Hysteroscopy is a procedure whereby a doctor slides in a long narrow scope, about the size of a drinking straw, through the cervix and into the uterus. There are a few things at the far end of the scope. One is a light. The light is actually a few feet away, but the light rays are carried to the scope via a fiber optic cord, and then through the fiber optic strands inside the scope. At the end is also a hole. Out of the hole comes a water-like fluid that shoots out under pressure into the uterus. This distends the uterus so the doctor can look inside. A lens at the end of the scope allows the doctor to see. A camera is placed over the lens so everything inside the uterus becomes visible on a TV screen.
At times there are problems with hysteroscopies. One is getting in. To get this straw from the vagina to the uterus, one needs to go through the cervix. In most cases the cervix needs to be opened, or dilated, because the cervical canal is normally too narrow for the scope. Some patients have asked me how we dilate the cervix. It is done using metal rods of different diameters. We start with a skinny one, and then use one that is a tiny bit wider, then a little wider, until the cervix is open enough for the scope to fit in. We may need 5-10 dilators if increasing diameter to get the job done.
A woman who has had a child will have a cervical canal that is a little wider than a woman who has not. Scopes come in different diameters, so if the scope is very narrow, no or little dilation is needed. If the doctor is removing tissue at the time of a hysteroscopy, as is the case when removing a fibroid or septum, the scope needs to be wider and more dilation is necessary.
Some women have a cervix that is very difficult to dilate. This could be due to scarring as a result of previous surgery. Some women with endometriosis have scarring in their cervix. Others have a cervix that is normal diameter, however the canal may be very angled, making it very difficult for the scope to get into the uterus. All doctors have had or heard of cases where the hysteroscopy could not be performed because the cervix could not be safely dilated. I will write about other potential problems with hysteroscopies next time.

References:

  • Bosteels J, Weyers S, Puttemans P, Panayotidis C, Van Herendael B, Gomel V, Mol. BW, Mathieu C, D’Hooghe T.  The effectiveness of hysteroscopy in improving pregnancy rates in subfertile women without other gynaecological symptoms: a systematic review. Hum Reprod Update. 2010 Jan-Feb; 16(1):1-11.
  • Baggish, MS, Valle, RF, Guedj, H. Hysteroscopy: Visual perspectives of uterine anatomy, physiology, and pathology, 3rd ed. Lippincott Williams, & Wilkins 2007.

Abnormal Bleeding? Don’t have a D and C without a Hysteroscopy (and have an ultrasound first)

I just left the operating room where I was performing surgery on a patient who didn’t need it.
The woman is a 48 y.o. with a bunch of kids who had developed very heavy vaginal bleeding over the past few months. So what did her gynecologist do? He did a D&C(dilatation and curettage).
The dilation and curettage procedure is called a D&C. The D stands for dilation, which means enlarging. Curettage (the C) means scraping. Together, this procedure involves expanding or enlarging the entrance of a woman’s uterus so that a thin, sharp instrument can scrape or suction away the lining of the uterus and take tissue samples. (from e medicine). It’s similar to the procedure a woman may have for a miscarriage.
Guess what? The D and C had no effect on her bleeding and she called me for a second opinion. My questions to her were, did they do an ultrasound before the procedure and did they look inside the uterus with a scope at the time of the D and C (hysteroscopy)? The answer to both were no. I could not believe that in this day and age, things were still performed in such an archaic fashion. An ultrasound can give the doctor a better idea of what the problem really is. A D&C without a hysteroscopy is like bobbing for apples blindfolded. The hysteroscope allows us look directly inside the uterus to look for common problems such as polyps and fibroids (another blog). If we just try to scrape the lining of the uterus, polyps may get swept from side to side but not removed, and fibroids are too firm to be scrapped away. When these items are seen on hysteroscopy, instruments can be used to remove them under direct visualization, a much more accurate way of doing things. Hysterosopcy in not necessary during a D&C for miscarriage.

So this lovely woman needed me to give her a second procedure with another anesthesia. My pre-op ultrasound showed a polyp, which was seen and removed at the hysteroscopy. All went well, and this problem should be solved.
And dont forget, see post 5/17/06.

References:

  • March CM. Management of Asherman’s syndrome. Reprod Biomed Online. 2011 Jul; 23(1):63-76.
  • Tuuli MG, Shanks A, Bernhard L, Odibo AO, Macones GA, Cahill A. Uterine synechiae and pregnancy complications. Obstet Gynecol. 2012 Apr; 119(4):810-4.
  • Cooper JM, Houck RM, Rigberg HS. The incidence of intrauterine abnormalities found at hysteroscopy in patients undergoing elective hysteroscopic sterilization. J Reprod Med. 1983 Oct; 28(10):659-61.