1. Introduction

Hysteroscopy is a minimally invasive endoscopic procedure that allows direct visualisation of the uterine cavity, endocervical canal, and tubal ostia using a hysteroscope — a thin, lighted telescope inserted through the cervix. It is considered the gold standard for the diagnosis and treatment of intrauterine pathology.

Hysteroscopy can be classified into two broad categories: diagnostic hysteroscopy, used to visualise and assess the uterine cavity, and operative or therapeutic hysteroscopy, used to perform surgical interventions within the uterine cavity itself. The procedure has transformed the management of abnormal uterine bleeding, infertility, and a range of intrauterine structural abnormalities by permitting direct, magnified inspection of the cavity that was previously only inferable from imaging or blind instrumentation.

This review presents a structured, practice-oriented overview of diagnostic and operative hysteroscopy intended for medical students, postgraduate residents, gynaecologists, and general surgeons who wish to learn the procedure, supported by an operative video supplement demonstrating key applications in clinical practice.

2. Relevant Anatomy

A thorough understanding of the relevant anatomy is essential for safe and effective hysteroscopy. The uterine cavity is triangular, lined by endometrium, and measures approximately 6–7 cm in length. The endocervical canal is 2.5–3 cm long and connects the external os to the internal os. The cornual regions, at the junctions of the cavity with the fallopian tubes, are sites of the tubal ostia and are particularly vulnerable to perforation during instrumentation. The myometrium, the muscular wall of the uterus, is approximately 1.5–2.5 cm thick and provides the working margin within which operative resection must remain to avoid perforation.

3. Equipment and Instrumentation

3.1 The Hysteroscope

The hysteroscope is composed of a telescope, available in 0°, 12°, and 30° viewing angles; an outer sheath through which distension media and instruments pass; a working channel that allows passage of operative instruments; and a light source channel that connects to an external cold light source.

3.2 Types of Hysteroscopes

3.3 Distension Media

Normal saline (isotonic) is used with bipolar energy systems and carries no risk of dilutional hyponatraemia. Glycine 1.5%, and sorbitol or mannitol, are hypotonic media used with monopolar systems such as TCRE and rollerball ablation, and require strict fluid monitoring. CO₂ gas is used for diagnostic procedures in office settings but carries a small risk of gas embolism.

4. Indications of Hysteroscopy

4.1 Diagnostic Indications

Hysteroscopy is indicated for the evaluation of abnormal uterine bleeding, including menorrhagia, intermenstrual bleeding, and postcoital bleeding; postmenopausal bleeding, to exclude endometrial carcinoma; suspected intrauterine pathology identified on ultrasound or hysterosalpingography; endometrial polyps, submucous fibroids, and intrauterine adhesions consistent with Asherman’s syndrome; infertility work-up, to evaluate the uterine cavity prior to assisted reproductive technology; recurrent pregnancy loss, for structural evaluation of the cavity; congenital uterine anomalies such as septate or bicornuate uterus; assessment of endometrial sampling sites prior to biopsy; retained products of conception, for localisation and removal; lost or embedded intrauterine device localisation and retrieval; cervical stenosis assessment; and follow-up after operative hysteroscopy.

4.2 Operative / Therapeutic Indications

Hysteroscopy permits definitive surgical management of endometrial pathology through trans-cervical resection of the endometrium (TCRE) or endometrial ablation, endometrial polypectomy, and directed endometrial biopsy. Fibroid-related pathology is managed through trans-cervical resection of sub-endometrial or submucous fibroids (TCR-F), staged according to the FIGO classification described in Section 8, and through hysteroscopic myomectomy for infertility-associated submucous fibroids. Intrauterine adhesions are managed by lysis of adhesions for Asherman’s syndrome, using scissors, laser, or electrosurgery. Uterine septa are managed by hysteroscopic metroplasty, dividing partial or complete septa. Other operative indications include removal of an intrauterine device or foreign body, removal of retained products of conception, achieving haemostasis for uterine bleeding, resection of early endometrial cancer in non-surgical candidates, and hysteroscopic cannulation of the fallopian tubes.

5. Contraindications of Hysteroscopy

5.1 Absolute Contraindications

5.2 Relative Contraindications

6. Pre-Operative Assessment and Preparation

6.1 Patient Evaluation

Pre-operative evaluation includes a complete history covering menstrual pattern, obstetric history, prior surgeries, and bleeding disorders; general, abdominal, and pelvic bimanual examination; cervical (Pap) smear to exclude cervical pathology; endometrial biopsy where abnormal uterine bleeding is present, to exclude malignancy pre-operatively; transvaginal ultrasound to assess uterine size, fibroid type and size, endometrial thickness, and polyps; saline infusion sonography where precise delineation of intrauterine pathology is required; and pelvic MRI for large or deep fibroids, to assess intramural extent.

6.2 Laboratory Investigations

Routine pre-operative investigations include complete blood count with blood group and Rh typing; coagulation profile (PT, aPTT, INR); renal and liver function tests; serum electrolytes as a baseline for fluid monitoring; a pregnancy test to exclude intrauterine pregnancy; and cervical swabs where pelvic inflammatory disease is suspected.

6.3 Timing of Procedure

The ideal timing for hysteroscopy is the early proliferative phase, days 6–10 of the cycle, when the endometrium is thin and the cavity is well visualised. TCRE may instead be performed in the secretory phase if preceded by GnRH agonist treatment. Endometrial preparation for TCRE or ablation typically uses GnRH agonists, danazol, or progestogens for 6–12 weeks to thin the endometrium prior to surgery.

6.4 Cervical Priming

Cervical priming may be achieved with misoprostol 400 mcg, given vaginally 3–4 hours before the procedure or sublingually 1–2 hours before; with a laminaria tent for overnight cervical ripening; or, less commonly, with cervical hyaluronidase injection.

7. Operative Technique

7.1 Patient Positioning and Anaesthesia

The patient is positioned in the lithotomy position with adequate hip flexion. Anaesthesia may be general, regional (spinal or epidural), or local with sedation for diagnostic procedures. Bladder catheterisation is performed for longer procedures.

7.2 Step-by-Step Procedure

The procedure begins with consent and administration of anaesthesia, followed by bimanual examination under anaesthesia to assess uterine position and size. Antiseptic preparation and draping are performed, and a vulsellum or tenaculum is applied to the anterior lip of the cervix for traction. Graduated cervical dilatation with Hegar’s dilators is carried out as required for the chosen hysteroscope size. The hysteroscope is inserted under direct vision — never blind — and the cavity is distended with the chosen media, maintaining an intrauterine pressure of 80–100 mmHg, the minimum required to achieve adequate visualisation. Systematic inspection follows a fixed sequence: anterior wall, posterior wall, lateral walls, tubal ostia, and finally the cervical canal on withdrawal of the instrument. Operative intervention is performed as required — resection, ablation, or polypectomy — and all resected tissue is retrieved and submitted for histopathological examination. Fluid balance is carefully assessed throughout, with total inflow and outflow recorded continuously.

8. Trans-Cervical Resection of Sub-Endometrial Fibroid (TCR-F)

Hysteroscopic myomectomy for submucous fibroids is one of the most commonly performed and clinically significant operative hysteroscopic procedures, particularly relevant for women presenting with menorrhagia and infertility.

8.1 FIGO Classification of Submucous Fibroids

8.2 Surgical Technique for TCR-F

A loop resectoscope is used to shave the fibroid in sequential chips, typically with cutting current of 80–100 W and coagulation current of 60–80 W for monopolar systems. Resection proceeds systematically from distal to proximal. An oxytocin infusion may be used to contract the myometrium and extrude the intramural component into the cavity. All resected chips are retrieved for histopathology, and adequate haemostasis is confirmed before withdrawal of the instrument.

8.3 Tips for Deep Fibroids (Type 2)

Type 2 fibroids with substantial intramural extension often require a two-stage procedure, allowing an interval of approximately three months for the residual intramural component to migrate into the cavity. GnRH agonist therapy between stages reduces vascularity and fibroid volume. Intraoperative ultrasound guidance helps assess residual myometrial thickness, with greater than 8 mm considered a safe margin, and excessive deep resection should be avoided given the risk of uterine perforation.

9. Trans-Cervical Resection of Endometrium (TCRE) / Endometrial Ablation

9.1 Indications

TCRE is indicated for menorrhagia unresponsive to medical treatment, where the patient desires uterine preservation but not further fertility, where hysterectomy is contraindicated, and for dysfunctional uterine bleeding once structural pathology has been excluded.

9.2 Prerequisites (Must Be Met Before TCRE)

Malignancy must be excluded by histopathology; there must be no desire for future pregnancy, and this requires explicit pre-operative counselling; uterine cavity length should be 8 cm or less, or up to 12 cm with caution; and submucous fibroids greater than 3 cm should be treated separately before proceeding to ablation.

Operative Video Library

The principles described in this review are illustrated by the following operative video recordings, performed by the author and provided as supplementary educational material for surgeons and gynaecologists learning hysteroscopy. Click any thumbnail to view on YouTube.

Video 1 · §9TCRE — Trans-Cervical Resection of Endometrium

Video 2 · §4.1Diagnostic Hysteroscopy in the Infertility Work-up

Video 3 · §4.2Hysteroscopic Assessment Related to IUD (CuT)

9.3 Techniques of Endometrial Ablation

10. Complications of Hysteroscopy

10.1 Intra-Operative Complications

10.2 Post-Operative Complications

Post-operative complications include endometritis or pelvic infection, managed with antibiotics and drainage of any abscess; haematometra, treated by drainage; intrauterine adhesions, which post-operative oestrogen helps to prevent; failure or recurrence of symptoms, requiring re-evaluation and either repeat procedure or hysterectomy; and, in rare cases of pregnancy occurring after TCRE, a high-risk pregnancy that patients should be strongly counselled against pursuing. Cyclic pain following ablation is uncommon but may indicate haematometra.

10.3 Fluid Distension Complications — TURP-Like Syndrome

Excessive absorption of hypotonic distension media such as glycine or sorbitol causes dilutional hyponatraemia, presenting with nausea, headache, visual disturbance, confusion, seizures, pulmonary oedema, and, in severe cases, coma. Risk factors include operative duration exceeding 60 minutes, deep myometrial resection, and high intrauterine pressure. Prevention rests on strict fluid balance monitoring, limiting deficit to under 1000 ml for monopolar systems, and using normal saline with bipolar systems. Management requires immediate cessation of the procedure, intravenous furosemide 40 mg, slow saline correction, and intensive care admission.

11. Quick Reference: Hysteroscopic Procedures at a Glance

12. Learning Objectives for Academic Training

12.1 For Undergraduate Medical Students (MBBS)

Undergraduate learning objectives include defining hysteroscopy and describing the procedure; listing at least eight indications and five contraindications; understanding the basic anatomy relevant to the procedure; recognising common complications and their clinical features; and understanding when to refer a patient to a specialist.

12.2 For Postgraduate Residents (MS/MD)

Postgraduate objectives include performing diagnostic hysteroscopy under supervision; classifying intrauterine pathology such as polyps, fibroids, adhesions, and septa; interpreting hysteroscopic findings and correlating them with imaging; understanding the operative principles of TCRE, TCR-F, and polypectomy; managing intra- and post-operative complications; and counselling patients appropriately before and after the procedure.

12.3 For Senior Surgeons and Gynaecologists

Objectives at this level include performing all hysteroscopic procedures independently; managing Type 2 submucous fibroids using a staged approach; handling intraoperative emergencies including perforation, haemorrhage, and fluid overload; teaching and supervising residents in hysteroscopic skills; and remaining current on new ablation technologies and energy systems.

13. Post-Operative Care and Follow-Up

Immediate post-operative monitoring includes vital signs, fluid balance, and urine output for two to four hours. Analgesia is provided with NSAIDs, with opioids reserved for significant pain. Most procedures are managed on a day-care basis, with admission reserved for complications. Prophylactic antibiotics such as doxycycline or co-amoxiclav are given where indicated. Post-operative hormonal therapy, typically conjugated oestrogens for four to six weeks, is used following adhesiolysis, alongside an intrauterine balloon maintained for one to two weeks. Follow-up review is scheduled at six to eight weeks, with repeat saline infusion sonography or hysterosalpingography where adhesions were treated, and histopathology results are discussed at the follow-up visit.

14. Conclusion

Hysteroscopy has established itself as the gold standard for diagnosis and treatment of intrauterine pathology, offering direct visualisation and, where indicated, definitive surgical management within the same procedure. A sound understanding of relevant anatomy, careful patient selection against absolute and relative contraindications, meticulous attention to fluid balance during operative procedures, and a structured, stepwise operative technique together underpin safe practice. TCRE and TCR-F remain the two most clinically significant operative applications, and staging of submucous fibroids by the FIGO classification provides a practical framework for surgical decision-making. This review, supported by an accompanying operative video supplement, is intended as a practical teaching resource for surgeons and gynaecologists at every stage of training who wish to learn or refine their hysteroscopic practice.

Declarations

References

1. American Association of Gynecologic Laparoscopists (AAGL). AAGL Practice Report: Practice Guidelines for the Diagnosis and Management of Submucous Leiomyomas. J Minim Invasive Gynecol. 2012;19(2):152–171.
2. Royal College of Obstetricians and Gynaecologists (RCOG). Best Practice in Outpatient Hysteroscopy. Green-top Guideline No. 59. London: RCOG; 2011.
3. American College of Obstetricians and Gynecologists (ACOG). Endometrial Ablation. ACOG Practice Bulletin. Obstet Gynecol. 2007;109(5):1233–1248.
4. Munro MG, Critchley HOD, Broder MS, Fraser IS. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet. 2011;113(1):3–13.
5. Wamsteker K, Emanuel MH, de Kruif JH. Transcervical hysteroscopic resection of submucous fibroids for abnormal uterine bleeding: results regarding the degree of intramural extension. Obstet Gynecol. 1993;82(5):736–740.
6. Munro MG. Endometrial ablation. Best Pract Res Clin Obstet Gynaecol. 2018;46:120–139.
7. Bettocchi S, Ceci O, Vicino M, Marello F, Impedovo L, Selvaggi L. Diagnostic inadequacy of dilatation and curettage. Fertil Steril. 2001;75(4):803–805.
8. Jansen FW, Vredevoogd CB, van Ulzen K, Hermans J, Trimbos JB, Trimbos-Kemper TC. Complications of hysteroscopy: a prospective, multicenter study. Obstet Gynecol. 2000;96(2):266–270.