Hysteroscopy

Dr. Reed and Dr. Klimczak talk all about hysteroscopy. They talk about what a hysteroscopy is, who needs one, and how it can help you get and stay pregnant. They talk about polyps, scar tissue (adhesions), and chronic endometritis (inflammation of the lining of the uterus).

Transcript

0:06

Hi, I am Dr. Beverly Reed. And I'm Dr. Amber k Cluck. And we are two peaks in a pod. Hi everybody. Welcome back. Let's talk about one of my favorite things, which is. historoscopy. That is true. You do love historoscopy. I do. I feel like you do too. We both do. Um, okay, so let's kind of share with everybody what is a historoscopy and then we'll kind of talk all about it. So do you want to tell us what hystereoscopy is? Yeah. So a hystereoscopy is a minimally invasive procedure where we take a small camera inside a scope and we insert it through the cervix up into the uterus. So we can actually look inside the uterus and then we can remove any pathology that we might see there, or just, really better understand what might be going on. Absolutely. And I think one of the first things when it comes to hysteroscopy is who needs a hysteroscopy? Um, although I love this procedure, most people probably don't need one, but sometimes there will be certain clues or hints either in the patient's history or the patient's testing that I have done that will kind of lead me towards that direction. So For example, let's say I'm doing an ultrasound. Let's say we do a 3d ultrasound and we notice that the shape of the uterus appears to be abnormal. Sometimes that can happen when women have what's called a septum. It's almost like a divider in, um, in the uterine cavity, and that can contribute to recurrent miscarriage. So that is one example on just a regular ultrasound where we can So, what are some other things that you might see in history or on testing that would lead you to recommend hystereoscopy for somebody? Yeah, probably the hystereoscopies for, are small little growths. It's called polyps. So polyps are basically where the inside lining of your uterus just has a little mutation and it grows like crazy and you have this little growth and it can affect your fertility. And so we actually go in with a hysteroscopy and we remove them. You could have one polyp, you could have lots of polyps. And so it's a nice way after we are suspicious that they might be there to confirm they're there and then remove them at the same time. So I would say polyps are really common, similar to polyps. Fibroids. Um, you know, especially depending on where the fibroid is and how big it is, if it isn't on the inside of your uterus and we want to try and remove it from the inside, then we use a hystereoscopy to try and remove it. Um, so those are probably my most common reasons. Yeah, absolutely. And here's the hard thing too, though. Sometimes when we're doing an ultrasound, some of these things may not be apparent on just our regular ultrasound. So y'all know, if you follow me, one of my favorite tests is actually an SIS, a saline infusion sonogram. This is a test where we put saline inside of the lining to try to open that lining up and look inside to see, are there any polyps, is there scar tissue, are there fibrins that can be hiding in that lining? And that can often be a problem. prompt us then to say, okay, our next step would be to do a hystereoscopy, where instead of just seeing it on an ultrasound, we can actually see everything with our eyes to really be able to look and assess. And although SIS is one of my favorite tests, one of the limitations is that you can't always see inflammation on this test. So certainly if somebody has a lot of inflammation, sometimes I can see what's called micro polyps. These just tiny little bumps all throughout the saline infusion sonogram. But one of the biggest signs of inflammation is actually color. And that's the hard thing with ultrasound. It's all just black and white and gray, right? So I can't see patches of color on an ultrasound. Whereas when I'm doing a hysteroscopy, I'm putting a camera in, usually the inside of the uterus should look smooth and just pale pink. But I know if I see any bright red spots or anything like that, that leads me to go assess that area and say, Hey, could these be little patches of inflammation that maybe we just could not see on either a routine ultrasound or an SIX. Yeah, I will say the other downside that I've recently just had an encounter with, with saline infusion sonograms, and you guys know this, like when you really hear us talk about a sonogram, right? A sonogram is just us using sound waves to try and visualize what's going on, so it's certainly not perfect. And sometimes we can have things that are artifact or maybe not even real, or we think we see something on this alien infusion sonogram, but we're just not quite sure. So we actually end up doing like a diagnostic histroscopy to try and diagnose what is actually present there. So I've, I've certainly had a few alien infusion sonograms, most recently I had a patient, it was kind of funny when I called her, I was like, listen, I asked some of my other colleagues and we saw this. still don't know what's inside your uterus. So we just, we have to do a hysterectomy sometimes to better figure out what the saline sonogram is trying to show us that we can't quite delineate it. Yeah. Like when we fill up with saline, we expect to only see the saline and nothing else inside the uterus. And if we do see something in there, then we say, gosh, we need to really make sure it's not anything concerning. But what are some of the artifacts you can, artifacts you can see in there? Well, for example, sometimes even though we schedule this period when you're not supposed to be on your period or you're bleeding, sometimes you could have a little blood clot or something like in the, like that in the uterus. And a little blood clot is not anything concerning, but it can certainly look just like a polyp or anything else, um, on the ultrasound. Or sometimes as women, too, we have that fertile discharge our body makes and you could just have maybe a clump of discharge inside the uterus or something that makes it look like there's something there. So I think that's a good point. When we're doing a hysteroscopy, our first step is really just look and see what's it look like in there. There may be that you don't need to do anything, but then at least you can feel good that hey, We've appropriately screened and really looked at the site of implantation to make sure it looks really good as well. Yeah, and sometimes just actually doing the saline sonogram can introduce a little bit of an issue because we do use a small little catheter to actually get the saline or the salty water inside. And sometimes that catheter can maybe just slough off a little bit of your lining and then make it look like something's there. So, So it's really important that whoever's doing your saline infusion sonogram really uses what we call dynamic imaging. Try to move it around and push more saline in, and you can really try and delineate whether something is. Is truly pathology or online. Yeah, absolutely. Absolutely. But I always say, when in doubt, just do a hysteroscopy. You're never gonna be wrong to take a look inside and, and see what it looks like. Mm-Hmm, So, um, I think it is important when you're doing a hysteroscopy, you wanna make sure you get the timing of the hysteroscopy right. So, um, you know, as women, most of us have a menstrual cycle about every 28 to 30 days. So when we're scheduling the hysterectomy, we want to make sure we're not doing it when you're on your period, because imagine if we're putting a camera in and all we see is red blood everywhere, that's not going to be helpful. for you. So it is important when we're doing hysterectomy that we're scheduling it at a time when we know you're not on your period. Yes, which is sometimes not able to be done. So we can also put you on a birth control pill. We've talked about doing holds before using just regular birth control pills. Sometimes we start that and do it that way as well. Yes, absolutely. Okay, so let's say we are doing a hysteroscopy. I do think it's important to kind of point out all the different ways somebody might do hysteroscopy. So I kind of like our way the best. Maybe we can start with that, which is that we put you to sleep for hysteroscopy. But admittedly, some people will do hysteroscopy with you completely awake. And, um, the logic there is they probably want to do it for convenience for you. That way you don't have to have someone, you know, um, start an ID on you. You don't have to have someone, um, bring you and drive you home and everything. So I can definitely understand the convenience part of it, but I think how we've always talked about before, we just are, Just, it's so important to us. It's just pain control for our patients. We hate for our patients to feel uncomfortable, um, or anything like that. So we usually like to have our patients have an IV started and be put completely asleep so that we can really feel comfortable getting a full assessment without having to worry about causing pain for the patient as well. Yeah, I've never had a patient ask to do it. I mean, I, I do. I, so, and, so, and we have the capability to do it. We can do it awake. Um, and so I, I have had some people, uh, request to do it awake. And sometimes it's for financial, um, reasons, which makes me sad because of course, I don't want that to be a limitation for anybody. Um, but for some people, they say, look, I'd rather just, you know, You know, do it away and not have to take anesthesia to put me to sleep and, and that's okay. And you know what? There may be some people who are better candidates for it than others. A lot of it may depend on how open your cervix is. Maybe for some women that is not as, as uncomfortable as for others. Um, so I think it's always a case by case situation, but I think for the vast majority of ours, we, we'd like to just make sure we're offering good anesthesia for that. Yes. And I think if you're considering getting one in the office, you should clarify with your doctor. What sort of pain control is going to be used for you? And if you know, you have a low threshold for pain, you might want to consider some other options, because for example, if I knew I was going to have it done, I would say absolutely not. I would. Yes, I would never want one. Yeah. You may have to do one on me one day. I really don't know. Knock me out. Give me all the good stuff. But yeah, and I will say too, Part of it usually depends on what all you're going to be doing with the hystereoscopy. If it is only a diagnostic hystereoscopy, there are really tiny skinny little hysteroscopes that you can use that are probably very doable, not as uncomfortable. But most of the time when we're doing this, we're expecting not only to do a diagnostic hystereoscopy, meaning we look to see what it looks inside, but we also want to treat any abnormalities that we see. And in order to treat, you usually need a wider hysteroscope so that your instruments can fit through the scope to do the work that needs to be done. Absolutely. Yes. Okay. So let's say we start our hysteroscopy. We look inside and let's say we see some pulse. What would you do now? So typically we try and remove the polyps. There's a couple of different things that we can use to remove it. We can just use a little grasper and go in and actually pluck the polyps off. Or we can use what's called a morselator, which is just like an electronic kind of shaver that shaves the polyps off. down and removes them. Um, after we remove your polyps, we send them off to pathology, which is basically just a specialist that looks at the tissue and tells us, yes, this is the nine or, you know, tries to describe just what the polyps look like to help better classify them. Yes, absolutely. And then if we see some other abnormalities, we may just have other strategies. So remember how I brought up that divider in the uterus before called a septum. So for a septum, we can usually just take scissors and we just snip. the fiber span that is dividing the, um, uterus into the two separate sections so that we just snip through. And then if you have fibroids, we can also remove those, but fibroids are very rubbery and it's just a harder, um, kind of material. And so for those, sometimes it does just require maybe a larger, um, instrument. And sometimes we even have to do what's called A C D. stage procedure where you go ahead and start trying to remove a fibroid, but sometimes it's so big that you actually end up having to stop and then just come back later to remove the rest of it. Um, so that's usually for people that have very large fibroids that that would need to be done for that. Yeah. And it's probably an important question for you as a patient to advocate for yourself. Do you think you're going to be able to do this surgery in one pass? Is there a chance that I might have to come back in a couple of weeks and have a, have second go at it because that's important to know. I think in advance it certainly is helpful. Um, and so, and when we're doing these surgeries, we want to make sure that the patients really understand, okay, whatever is there, we're going to try and remove it going into it. So that a lot of times when we're doing a diagnostic hysteroscopy, we don't know exactly what we're going to see. but you want to make sure that your surgeon knows, yes, whatever you see, just try and remove all through there. Yeah. Yeah. And then, um, so let's say we go in there and everything looks pretty normal. Um, I still actually like to do, what's called a global sampling of the endometrial tissues. So the endometrial tissue is the lining of the uterus. It's kind of like this fluffy area that an embryo would implant on. But sometimes we can look with our eyes and it may look totally normal, but what if there's something going on on a microscopic level that could be affecting your fertility? And so what I do is I sample that area, but here's a very Important point for me, which is that probably the older way of doing things or, or maybe even what some, maybe non specialists do these days is they sample that lining by scraping it off. And when fertility doctors hear the word scrape, we cringe. We do not like any kind of scraping of the lining of the uterus. Imagine if you're You can increase the chance for somebody to build up scar tissue, which could then negatively impact the fertility. And so when I'm doing the global sampling instead, I like to use a little device and Dr. K was kind of describing it earlier. I almost kind of think of it as a little vacuum because it's, it's, um, it's hooked up to suction and it just kind of sucks that top layer off. It is called a soft tissue mini. so gentle, it's not even capable of going too deep. It's not even capable of damaging any of that deeper layer of the lining. And so when you're just kind of sucking off that top layer, I think it's perfect because then I'm getting a good global sampling to give to the pathologist. And then usually I'm asking them to run some scans. special stains to look for inflammation or any other cause for what could be going on. Yeah, I think that's another tool that you can really arm yourself with. You might be a young woman in your 20s, maybe you're not even thinking about your fertility right now, but you know, you have to get a hysterectomy, maybe you've had some abnormal uterine bleeding, you know, you have polyps, you have to get a hysterectomy. I think you should really advocate and make sure that your doctor knows, Hey, I want to have children in the future. You know, it is. This surgery going to affect that and that way they can be really thoughtful about how they are taking care of your lining. We are very ginger. We are really, really gentle with the lining. Not only can it cause adhesions like Dr. Reid is talking about, it can also, if we get too deep, sometimes the lining just doesn't grow back. You don't get this nice, thick, fluffy lining later that would be able to receive the embryo and grow a nice healthy baby. Yeah. So we are very, very careful about that. But a lot of times when gynecologists are doing surgeries for other things, they're, you know, they're just focusing on getting out pathology. I mean, they're really fantastic surgeons. Most people will be totally fine. Yeah. You know, it's the rare person who maybe your lining just gets more affected and is more sensitive to that type of procedure. Yeah. Yeah. And then I did just want to touch on, um, a diagnosis called chronic endometritis. And that is kind of what I've been alluding to when I'm talking about inflammation that we see sometimes. So chronic, uh, endometritis, this just means that it's kind of just this skin, state of inflammation. We don't know exactly why people get it, but it does have to do with the flora and the uterine capi for the bacterial flora. We know we should have plenty of good bacteria there, but sometimes some of the bad bacteria can kind of overtake the area, but it's not like an acute infection where you would have like a high fever or pus coming out or anything like that. You wouldn't have any symptoms. It's just more this, this low line inflammation. And here's the thing, right? I have seen it is so important for fertility and miscarriage, and you can't see it on a regular ultrasound. You sometimes can't even see it on SIS, but there's two ways to diagnose it. The first is on hysteroscopy. The second is when you remove the specimen and the pathologist can see it using a special state stain called CD138. On hysteroscopy, signs that you can look for are something called strawberry sign, where part of the endometrium, the lining, just looks kind of red with little dots, um, throughout, so that can be a sign, or what we call petechial hemorrhages, these are kind of little red spots, um, throughout, and so that's why it is so important when we're doing the diagnostic part, we're looking to see are there any patches that we need to make sure that we're sampling and that we're getting. But aside from that, what I have found out over the years with chronic endometritis is I do think sometimes it's undertreated. So what I mean by that is let's say somebody got the diagnosis, not through hysteroscopy. Let's say they just had a little endometrial biopsy in the clinic. They just took a little sample. They said, you have chronic endometritis. They treat it with antibiotics, and then they test you and you still have it, okay? And so, I have an analogy for this that I came up with that makes a lot of sense to me. So, imagine a pool that has leaves at the bottom, and it's all green like a pond because it's been neglected, okay? This is kind of what I would describe as chronic endometriosis. Side uterus! No, but we're gonna make it good, okay? So, let's say we only shocked the pool. We put the chemicals in, right? Okay. Is the pool going to be okay? Well, no, because there's leaves all in the bottom, right? It's not going to look great yet. Or let's say we took the leaves out, but we didn't shock the pool. Is it going to be okay? No, it's going to be green water and it's going to be gross and everything, right? But if you remove the leaves and shock the pool, that's how you get that crystal clean, beautiful pool. Again, that's how I think about the uterus. Okay. In a mild case of chronic endometritis. Potentially just giving antibiotics may be fine, but if you've got a severe case, you need to use hysteroscopy to remove all the inflammation, and you need to give antibiotics to get it back to where it should be. Yeah. No, I love it. I definitely agree. I think chronic endometritis is a really interesting pathology. Um, I think it's something that a lot of people are out there studying. Um, I know my co fellow Nola and she, and I helped her with this a lot. We did a lot of research about, um, how we diagnose chronic endometritis and what, what is it really? Are we overdiagnosing it? We don't know. And so something interesting that happens with chronic endometritis is your uterus recruits These immune cells called plasma cells and they get present, they're present there in high numbers and they're markers and we know that the immune system and fertility are very much interrelated and you want to have a certain amount of immune cells but you don't want to have too many so it's another sign of your immune system's kind of on overdrive and this is just area where we're lacking, you know, we just don't really know why are they there in the first place? Why, why are some people, because probably what's happening with most people is they get there and they do their job, but they're removed. You know, they clean up this inflammation, everything's better again, but why was some people, does the inflammation remain and then you can still sit there very similar kind of to injury. endometriosis, you know, out in the cavity. It's just this dysfunctional immune system. Um, and yeah, you know, or why do certain people have recurrent chronic endometriosis? You know, yes, it can be treated and there's lots of studies where people treat it and then they check again in six weeks and they do an endometrial opsy to make sure it's gone. But then people can get it again the next year, you know, so why does it keep happening for certain women? Um, we don't really know. You know, I think it is a really interesting diagnosis and, you know, Time that I think clinically it comes into play is when women have secondary infertility. Not a lot of people talk about secondary infertility, but You know, you had one child or two children, you're trying for another baby, and you try and try and try, and I think that often people don't always look for chronic endometritis, but it can certainly be an explanation for that. Absolutely, especially too, this kind of comes up with the what came first, the chicken or the egg. Chronic endometritis can cause a miscarriage, but miscarriage can also cause chronic endometritis. So sometimes you don't know which came first, but whenever I hear somebody, just like you said, they said, I had a baby before, no problem. Now I'm really struggling. It is definitely something that is towards the top of my list to evaluate and look for. Um, but the good news is once we get the uterus all cleaned out, whether it's polyps, fibroids, a septum, chronic endometritis, Really, you can get right back to it and, and try to get pregnant. And in that case, it's just so, it's almost a great thing because what we found was actionable and will make such a big difference. So that's one of my favorite things is just such a simple, easy surgery can really just change somebody's life for them. Yeah. Recovery from a hysterectomy is really pretty easy. Of course, you have to take the day off of work. They're going to have the surgery. But a lot of people by the next day, you're feeling pretty good. I mean, it depends on what your job is and how difficult it is, whether you can go back to work the next day. Yeah, that's a nice thing. It's a quick recovery. It doesn't put you out for six weeks or anything like that. Um, and really it's fairly low risk, you know, like most surgeries we do. Especially for considering doing this in the office, like the risks are very low, right? Bleeding is pretty minimal, infection is very rare, okay? And then damage to surrounding structures, we're mainly operating inside the uterus. It's rare that we can perforate or go all the way through the uterus with a scope. So the risks are really pretty minimal for this type of surgery. Yes, absolutely. So it ends up just being such a high yield thing to really get us answers and to give you treatment and to give you better chances. Okay, should we wrap it up? Alright, have a good one. Alright, thanks guys. Have a good day. Bye.