Outpatient hysteroscopy

An OPH is a procedure that involves examining the inside of your uterus (womb). This is done by passing a thin telescope-like device, called a hysteroscope, that is fitted with a small camera through the neck of your womb (cervix). The healthcare professional doing the procedure can then see whether there are any problems inside your uterus that may need further investigation or treatment.

[Image] A hysteroscope being used to examine the cervix:

[Image] A polyp inside the uterus which may be removed during hysteroscopy:

It may be possible for a minor procedure to be done at the same visit, such as:

• Endometrial biopsy – taking a sample from the lining of the uterus. This can be done through the hysteroscope or after inserting a speculum and passing a thin tube through the cervix. You may experience severe period-like pain during this procedure, but the pain should not last long.
• Polyp removal – a polyp inside the uterus is a skin tag that looks like a small grape, sometimes on a stalk. Polyps are formed as a result of overgrowth of the lining of the uterus.
• Small fibroid removal – fibroids are knots in the muscle of the uterus that are non-cancerous (benign). They can sometimes bulge like a polyp into the lining of your uterus and your healthcare professional may advise removal to help with your symptoms.
• Insertion of a hormone-releasing intrauterine device (for example, Mirena®).
• Removal of a coil from the uterus when the threads are not visible. 

You may have been referred for OPH for one of the following reasons:

• bleeding after the menopause (postmenopausal bleeding)
• very heavy periods
• bleeding between periods
• irregular bleeding while on hormonal treatment
• removal of a coil when the threads are not visible at the cervix
• fertility concerns
• following a miscarriage
• to investigate something seen inside the uterus on an ultrasound scan, such as an endometrial polyp or fibroid.

The purpose of your appointment is to find the cause of your problem and plan or undertake treatment if needed.

Your healthcare professional will discuss your options and whether OPH is right for you. 

You should eat and drink normally. You do not need to fast before your appointment.

It is recommended that you take pain relief (400mg of ibuprofen or 1 gram of paracetamol or whatever pain relief you find useful for period pain) at least 1 hour before your appointment.

Bring a list of any medications that you are taking with you.

You may wish to have a friend or family member accompanying you. 

The procedure must not be performed if there is any chance that you are pregnant. To avoid this possibility, it is important to use contraception or avoid sex between your last period and your appointment. You may be offered a urine pregnancy test on arrival at your appointment. 

It is best to keep the appointment. Sometimes it can be difficult to do the test if you are bleeding heavily. If you have any concerns, please ring and speak to your healthcare professional. 

There may be other things to consider when deciding whether OPH is the right choice for you, such as:

• if you faint during your periods because of pain
• if you have experienced severe pain during a previous vaginal examination
• if you have experienced difficult or painful cervical smears
• if you have had any previous traumatic experience that might make the procedure difficult for you
• if you do not wish to have this examination when awake.

You may choose to have your hysteroscopy with either a general or spinal anaesthetic. This will be done in an operating theatre, usually as a daycase procedure. You can discuss this option with your healthcare professional. The risks and complications are lower when hysteroscopy is done as an outpatient procedure rather than under anaesthesia.

You may choose not to have a hysteroscopy at all, though this may make it more difficult for your healthcare professional to find the cause of your symptoms and to offer the right treatment for you. They may then recommend a scan and a biopsy to find out more information and/or may ask you to come back if your symptoms continue. 

On arrival

You will meet your healthcare professional who will discuss the procedure and ask for your consent. Please take this opportunity to ask any questions you may have.

There will be two or three healthcare professionals in the room and one of them will support you throughout the procedure. They will help you to get positioned in a special chair and will keep you as covered as possible.

The procedure

A hysteroscope is passed through the cervix to give a clear view of the inside of your uterus. No cuts are needed. Fluid (saline solution) is used to help see the inner lining of your uterus and you will feel wet as the fluid trickles back out.

If no problems are found, the actual procedure will only take about 10–15 minutes. Sometimes, a biopsy (small sample) from the lining of your uterus may be taken and sent to the laboratory for examination. The biopsy can be painful, but the pain should not last long.

If a fibroid or polyp is found, it can sometimes be removed at the same time by using additional instruments. You may be offered a local anaesthetic to make you more comfortable, particularly if a wider hysteroscope is to be used. Tell your healthcare professional if the procedure is becoming painful.

During the OPH, your healthcare professional will look inside your uterus on a screen and you can also watch the screen if you choose to. Photographs of the findings inside your uterus are often taken and kept in your healthcare notes. 

• Pain during or after OPH is usually mild and similar to period pain. Simple pain relief medications can help. On occasion, women may experience severe pain.
• Feeling or being sick or fainting can affect a small number of women. However, these symptoms usually settle quickly. Let your healthcare professional know if you are feeling unwell during or straight after the procedure.
• Bleeding is usually very mild and is lighter than a period, settling within a few days. It is recommended that you use sanitary towels, not tampons. If the bleeding does not settle and gets worse, contact your healthcare professional or nearest emergency department.
• Infection is uncommon (1 in 400 women). It may appear as a smelly discharge, fever or severe pain in the tummy. If you develop any of these symptoms, contact your healthcare professional urgently.
• Failed/unsuccessful OPH occurs if it is not possible to pass the hysteroscope inside your uterus. Usually this happens when the cervix is tightly ‘closed’ or scarred. If this happens, your healthcare professional will discuss alternative options with you.
• Damage to the wall of the uterus (uterine perforation) – rarely, a small hole is accidentally made in the wall of the uterus. This could also cause damage to nearby tissues. This happens in fewer than 1 in 1000 diagnostic hysteroscopy procedures, but is slightly more common if someone has a polyp or fibroid removed at the same time. It may mean that you have to stay in hospital overnight. Usually, nothing more needs to be done, but you may need a further operation to repair the hole. 

For most women, OPH is quick and safe, and is carried out with little pain or discomfort. OPH is often done without inserting a speculum, by using a thin telescope (called vaginoscopic OPH) as this is more comfortable.

However, everyone’s experience of pain is different and some women will find the procedure very painful. If it is too painful for you, let your healthcare professional know as the procedure can be stopped at any time if you wish.

Your healthcare professional may offer a local anaesthetic injection into your cervix. This will require using a speculum to see your cervix and your healthcare professional will discuss this with you.

Some hospitals may offer nitrous oxide (Entonox or ‘gas and air’) to help with your pain. In this situation, you may be advised to wait a bit longer in the hospital for recovery before you can drive.

If you feel anxious about the procedure, you should talk to your healthcare professional before your appointment. 

The actual procedure may only take 10–15 minutes. However, the total visit may take up to 1-2 hours including consultation, having the procedure and recovery. If polyps or small fibroids are removed at the same time, this may take a bit longer.

You can rest in the outpatient clinic’s recovery area for as long as you need (usually about 20 minutes). 

You may get some period-like pain for 1–2 days. You may also have some spotting or fresh (bright red) bleeding that may last up to 1 week. These symptoms usually settle very quickly. Most women feel able to go back to their normal activities on the same day.

You can shower as normal.

Normal physical activity and sex can be resumed when any bleeding and discomfort has settled.

If needed, you can take pain relief such as 400 mg of ibuprofen every 8 hours or 1 gram of paracetamol every 4 hours, or your usual period pain tablets.

If your pain is not controlled with the above medication, you should contact your healthcare professional or nearest emergency department.

What happens next?

If no problems are found, you may not need any follow-up appointments. If a biopsy has been taken, you will be contacted with the results as soon as they become available. Your healthcare professional will discuss any further treatment with you. 

The nature of gynaecological and obstetric care means that intimate examinations are often necessary. We understand that for some people, particularly those who may have anxiety or who have experienced trauma, physical or sexual abuse, such examinations can be very difficult. If you feel uncomfortable, anxious or distressed at any time before, during, or after an examination, please let your healthcare professionals know. If you find this difficult to talk about, you may communicate your feelings in writing. Your healthcare professionals are there to help and they can offer alternative options and support for you. Remember that you can always ask them to stop at any time and that you are entitled to ask for a chaperone to be present. You can also bring a friend or relative if you wish.