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Diagnostic Procedures in Gynecology

Diagnostic procedures in gynecology are useful in identifying the presence of disease, determining the progression of disease, and monitoring the response of the organs to treatment. The major diagnostic procedures include speculum examinations, sonography (ultrasound), colposcopy, cervical biopsy and endocervical curettage, loop electrosurgical excision procedures, vulvar biopsy, endometrial biopsy, hysteroscopy, and hysterosalpingography (HSG). All of these procedures can be performed in the office setting or in a radiology suite, though in certain situations they are performed in the OR if more sedation or increased monitoring is required.

Last updated: Oct 20, 2022

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Overview

The female reproductive organs are split into the lower and upper genital tracts.

Lower genital tract

  • Includes:
    • Cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy
    • Vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy
    • Vulva Vulva The vulva is the external genitalia of the female and includes the mons pubis, labia majora, labia minora, clitoris, vestibule, vestibular bulb, and greater vestibular glands. Vagina, Vulva, and Pelvic Floor: Anatomy
  • Types of procedures used to assess the lower tract:
    • Speculum exam
    • Colposcopy Colposcopy The examination, therapy or surgery of the cervix and vagina by means of a specially designed endoscope introduced vaginally. Cervical Cancer Screening
    • Cervical biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma
    • Endocervical curettage Curettage A scraping, usually of the interior of a cavity or tract, for removal of new growth or other abnormal tissue, or to obtain material for tissue diagnosis. It is performed with a curet (curette), a spoon-shaped instrument designed for that purpose. Benign Bone Tumors
    • Loop electrosurgical excision procedure
    • Vulvar biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma

Upper genital tract

  • Includes:
    • Uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy
    • Fallopian tubes Fallopian tubes The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The fallopian tubes receive an ovum after ovulation and help move it and/or a fertilized embryo toward the uterus via ciliated cells lining the tubes and peristaltic movements of its smooth muscle. Uterus, Cervix, and Fallopian Tubes: Anatomy
    • Ovaries Ovaries Ovaries are the paired gonads of the female reproductive system that contain haploid gametes known as oocytes. The ovaries are located intraperitoneally in the pelvis, just posterior to the broad ligament, and are connected to the pelvic sidewall and to the uterus by ligaments. These organs function to secrete hormones (estrogen and progesterone) and to produce the female germ cells (oocytes). Ovaries: Anatomy
  • Types of procedures used to assess the upper tract:
Gross anatomy of the female reproductive system

Gross anatomy of the female reproductive system

Image by Lecturio.

Speculum Examination

Description

A speculum is a plastic or metal device used to mechanically open the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy, allowing visualization and examination of the vaginal wall and ectocervix.

Vaginal speculum

A vaginal speculum

Image: “vaginal speculum” by Saltanat. License: Public Domain

Indications

  • Most gynecologic symptoms, including:
    • Vaginal bleeding
    • Abnormal uterine bleeding Abnormal Uterine Bleeding Abnormal uterine bleeding is the medical term for abnormalities in the frequency, volume, duration, and regularity of the menstrual cycle. Abnormal uterine bleeding is classified using the acronym PALM-COEIN, with PALM representing the structural causes and COEIN indicating the non-structural causes. Abnormal Uterine Bleeding (e.g., oligomenorrhea Oligomenorrhea Polycystic Ovarian Syndrome, amenorrhea Amenorrhea Absence of menstruation. Congenital Malformations of the Female Reproductive System, heavy menstrual bleeding Heavy menstrual bleeding Excessive menstrual blood loss (objectively defined as > 80 mL blood loss/cycle). Can be based on heavy flow, as determined by the patient Abnormal Uterine Bleeding)
    • Pelvic pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways
    • Abnormal discharge
    • Vaginal itching
    • Pelvic organ prolapse Pelvic Organ Prolapse Pelvic organ prolapse (POP) is a general term that refers to herniation of 1 or more pelvic organs (e.g., bladder, uterus, rectum) into the vaginal canal, and potentially all the way through the introitus. Weakness and insufficiency of the pelvic floor may result in POP. Pelvic Organ Prolapse
    • Mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast
    • Pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care symptoms:
      • Loss of fluid
      • Concerns for preterm labor Preterm labor Preterm labor refers to regular uterine contractions leading to cervical change prior to 37 weeks of gestation; preterm birth refers to birth prior to 37 weeks of gestation. Preterm birth may be spontaneous due to preterm labor, preterm prelabor rupture of membranes (PPROM), or cervical insufficiency. Preterm Labor and Birth
      • Bleeding
  • As part of a routine wellness examination:
    • To obtain samples for cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer screening Screening Preoperative Care (e.g., a Pap smear Pap smear Cytological preparation of cells collected from a mucosal surface and stained with Papanicolaou stain. Cervical Cancer Screening)
    • Clinical utility when woman is asymptomatic and does not need cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer screening Screening Preoperative Care is controversial → joint decision-making between woman and clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship is recommended
  • To gain access to the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy for other procedures
  • Note: A desire to initiate contraception without any other concerns does not require a speculum exam.

Contraindications Contraindications A condition or factor associated with a recipient that makes the use of a drug, procedure, or physical agent improper or inadvisable. Contraindications may be absolute (life threatening) or relative (higher risk of complications in which benefits may outweigh risks). Noninvasive Ventilation

  • Preadolescent girls (if needed to evaluate for abuse or for other procedures → general anesthesia Anesthesia A state characterized by loss of feeling or sensation. This depression of nerve function is usually the result of pharmacologic action and is induced to allow performance of surgery or other painful procedures. Anesthesiology: History and Basic Concepts)
  • Severe immunosuppression: ↑ risk of bacterial translocation with speculum exams

Procedure

Placing the speculum:

  • Make sure you have all swabs, collection containers, and tools within reach prior to starting.
  • Wash your hands and wear gloves:
    • Tip: Avoid touching other items that are not part of the procedure once your hands are gloved (e.g., foot Foot The foot is the terminal portion of the lower limb, whose primary function is to bear weight and facilitate locomotion. The foot comprises 26 bones, including the tarsal bones, metatarsal bones, and phalanges. The bones of the foot form longitudinal and transverse arches and are supported by various muscles, ligaments, and tendons. Foot: Anatomy stirrups, supply drawer, etc ETC The electron transport chain (ETC) sends electrons through a series of proteins, which generate an electrochemical proton gradient that produces energy in the form of adenosine triphosphate (ATP). Electron Transport Chain (ETC).)
    • Unlikely to cause true harm, but your hands will touch the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy → don’t touch something “unclean” right before you do so
  • Select a speculum of appropriate size and shape.
  • Familiarize yourself with the speculum prior to the exam.
  • Lubricate the speculum with warm water or a water-soluble lubricant (some lubricants may interfere with sampling for cervical cytology Cervical cytology A procedure in which ectocervical and endocervical cells are collected to evaluate the transformation zone (area at risk for cervical cancer). Cervical Cancer Screening and should be avoided).
  • Let the woman know that you are about to insert the speculum.
    • Tip: Gently touch the back of your hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy to the woman’s inner thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh: Anatomy to let her adjust to the temperature/touch of your hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy before touching the labia.
  • Manually spread the labia.
  • Introduce the speculum holding it at a downward angle, then slide it inward while applying gentle downward pressure along the posterior vaginal wall
  • Once the speculum is fully inserted, open it slowly and carefully.
    • Tip: Be careful not to open the blades prematurely.
      • This is very uncomfortable.
      • Typically, the fornix Fornix Vagina, Vulva, and Pelvic Floor: Anatomy of the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy (upper portion around the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy) is able to comfortably tolerate much larger diameters than the introitus.
  • Rotate and adjust the speculum until it cups the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy and brings it into full view.
  • If there’s difficulty finding the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy, partially withdraw and try again.
    • Tip: Try to find the “smooth” surface of the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy hidden within the vaginal rugal folds → once found, use the speculum to “catch” the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy between the speculum blades
    • Note: The cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy is often pointed directly downward.
      • May need to direct the tip of the speculum more posteriorly, then sweep upward while opening to catch the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy
      • The bottom blade is longer than the top blade for this reason.
    • Less commonly, the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy points more upward (can be seen with retroverted/retroflexed uteri).
  • Position the light until you can visualize the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy well.
  • Maintain the open position of the speculum by tightening the thumbscrew on a metal speculum, or “clicking” it into place with a plastic speculum.

Inspection Inspection Dermatologic Examination of the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy:

On examination, note:

  • The characteristics of the surface
  • Whether the external os External os Uterus, Cervix, and Fallopian Tubes: Anatomy appears:
    • Parous (has had a vaginal delivery): larger, horizontal opening
    • Nulliparous (has not had a vaginal delivery): tight circular opening
  • Bleeding
  • Discharge (volume, color, consistency Consistency Dermatologic Examination, and odor)
    • Take a sample with a cotton swab if present
  • Visible lesions:
    • Ulcerations
    • Nodules or masses
    • Describing lesions: 
      • Envision the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy as a clock face, and describe the location of the lesion as a time.
      • E.g., a lesion in the middle of the upper cervical lip would be described as being at “12:00”

Obtain specimens for cervical cytology Cervical cytology A procedure in which ectocervical and endocervical cells are collected to evaluate the transformation zone (area at risk for cervical cancer). Cervical Cancer Screening:

  • Obtain 1 specimen from the endocervix Endocervix Uterus, Cervix, and Fallopian Tubes: Anatomy by:
  • Obtain 1 specimen from from the ectocervix by:
    • Rubbing a spatula across the entire surface of the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy
    • Placing 1 side of the spatula in the os, then rotating the spatula around like the hands on a clock
  • You can also get a combination specimen with the cervical brush (“broom”) instead:
    • Place the central, taller portion in the os.
    • Spin the brush around several times.
  • For best results:
    • The woman should not be menstruating. Note that this is not a contraindication; however, too much blood may make the sample uninterpretable.
    • Avoid intercourse, douches, or vaginal suppositories Suppositories Medicated dosage forms that are designed to be inserted into the rectal, vaginal, or urethral orifice of the body for absorption. Generally, the active ingredients are packaged in dosage forms containing fatty bases such as cocoa butter, hydrogenated oil, or glycerogelatin that are solid at room temperature but melt or dissolve at body temperature. Large Bowel Obstruction for 24–48 hours before the examination. 

Inspect the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy:

  • Unscrew the thumbscrew and open the speculum slightly further to release Release Release of a virus from the host cell following virus assembly and maturation. Egress can occur by host cell lysis, exocytosis, or budding through the plasma membrane. Virology the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy.
  • Withdraw the speculum slowly while observing the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy.
  • Maintain a slightly open position of the speculum as you withdraw it, carefully observing the mucosa as you do so, noting:
    • Color
    • Any inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation
    • Discharge (volume, color, consistency Consistency Dermatologic Examination, and odor)
    • Ulcers
    • Masses
  • Close the speculum fully before it emerges from the introitus.

Colposcopy, Cervical Biopsy, and Endocervical Curettage (ECC)

Description

  • Colposcopy Colposcopy The examination, therapy or surgery of the cervix and vagina by means of a specially designed endoscope introduced vaginally. Cervical Cancer Screening:
    • A colposcope (magnifying device) is used to provide an illuminated, magnified view of the ectocervix, vaginal wall, and vulva Vulva The vulva is the external genitalia of the female and includes the mons pubis, labia majora, labia minora, clitoris, vestibule, vestibular bulb, and greater vestibular glands. Vagina, Vulva, and Pelvic Floor: Anatomy.
    • Can be used for both diagnosis and treatment of identified lesions
  • Cervical biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma: A tissue sample from the ectocervix and/or transformation Transformation Change brought about to an organism’s genetic composition by unidirectional transfer (transfection; transduction, genetic; conjugation, genetic, etc.) and incorporation of foreign DNA into prokaryotic or eukaryotic cells by recombination of part or all of that DNA into the cell’s genome. Bacteriology zone is taken of any abnormal areas identified on colposcopy Colposcopy The examination, therapy or surgery of the cervix and vagina by means of a specially designed endoscope introduced vaginally. Cervical Cancer Screening.
  • Endocervical curettage Curettage A scraping, usually of the interior of a cavity or tract, for removal of new growth or other abnormal tissue, or to obtain material for tissue diagnosis. It is performed with a curet (curette), a spoon-shaped instrument designed for that purpose. Benign Bone Tumors (ECC): 
    • A tissue sample is obtained from the endocervical canal.
    • Done at the time of colposcopy Colposcopy The examination, therapy or surgery of the cervix and vagina by means of a specially designed endoscope introduced vaginally. Cervical Cancer Screening and cervical biopsies if indicated based on history, HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomavirus (HPV) screening Screening Preoperative Care, and cytology results

Indications

  • Abnormal cervical cytology Cervical cytology A procedure in which ectocervical and endocervical cells are collected to evaluate the transformation zone (area at risk for cervical cancer). Cervical Cancer Screening (abnormal Pap smear Pap smear Cytological preparation of cells collected from a mucosal surface and stained with Papanicolaou stain. Cervical Cancer Screening)
  • High-risk types of HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomavirus (HPV) detected on cervical HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomavirus (HPV) testing
  • Evaluation of a palpably or visually abnormal cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy, vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy, or vulva Vulva The vulva is the external genitalia of the female and includes the mons pubis, labia majora, labia minora, clitoris, vestibule, vestibular bulb, and greater vestibular glands. Vagina, Vulva, and Pelvic Floor: Anatomy
  • In conjunction with treatment of cervical neoplasia, and posttreatment surveillance Surveillance Developmental Milestones and Normal Growth

Contraindications Contraindications A condition or factor associated with a recipient that makes the use of a drug, procedure, or physical agent improper or inadvisable. Contraindications may be absolute (life threatening) or relative (higher risk of complications in which benefits may outweigh risks). Noninvasive Ventilation

There are very few absolute contraindications Contraindications A condition or factor associated with a recipient that makes the use of a drug, procedure, or physical agent improper or inadvisable. Contraindications may be absolute (life threatening) or relative (higher risk of complications in which benefits may outweigh risks). Noninvasive Ventilation to colposcopy Colposcopy The examination, therapy or surgery of the cervix and vagina by means of a specially designed endoscope introduced vaginally. Cervical Cancer Screening and biopsies. Situations in which colposcopy Colposcopy The examination, therapy or surgery of the cervix and vagina by means of a specially designed endoscope introduced vaginally. Cervical Cancer Screening and biopsies are sometimes contraindicated include:

  • Acute cervicitis Cervicitis Inflammation of the uterine cervix. Gonorrhea: may obscure results
  • Pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care
    • Colposcopy Colposcopy The examination, therapy or surgery of the cervix and vagina by means of a specially designed endoscope introduced vaginally. Cervical Cancer Screening alone is often still performed in pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care, though physiologic changes may make interpretation more difficult.
    • Biopsies are taken only if invasive disease is highly suspected.
    • Endocervical curettage Curettage A scraping, usually of the interior of a cavity or tract, for removal of new growth or other abnormal tissue, or to obtain material for tissue diagnosis. It is performed with a curet (curette), a spoon-shaped instrument designed for that purpose. Benign Bone Tumors is absolutely contraindicated.
  • Life-threateningly severe immunosuppression: ↑ risk of bacterial translocation with speculum exams

Procedures

The procedure generally includes a gross examination of the vulva Vulva The vulva is the external genitalia of the female and includes the mons pubis, labia majora, labia minora, clitoris, vestibule, vestibular bulb, and greater vestibular glands. Vagina, Vulva, and Pelvic Floor: Anatomy, vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy, and cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy while placing the speculum, a colposcopy Colposcopy The examination, therapy or surgery of the cervix and vagina by means of a specially designed endoscope introduced vaginally. Cervical Cancer Screening examination, and biopsies and/or ECC as indicated based on screening Screening Preoperative Care results and findings on colposcopy Colposcopy The examination, therapy or surgery of the cervix and vagina by means of a specially designed endoscope introduced vaginally. Cervical Cancer Screening.

Colposcopy Colposcopy The examination, therapy or surgery of the cervix and vagina by means of a specially designed endoscope introduced vaginally. Cervical Cancer Screening:

  • A vaginal speculum is placed into the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy.
  • The colposcope is used to examine the entire surface of the visible cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy
  • Focus is on the transformation Transformation Change brought about to an organism’s genetic composition by unidirectional transfer (transfection; transduction, genetic; conjugation, genetic, etc.) and incorporation of foreign DNA into prokaryotic or eukaryotic cells by recombination of part or all of that DNA into the cell’s genome. Bacteriology zone (TZ): 
  • Application of acetic acid:
    • The cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy is examined 1st without acetic acid, and then with a solution of 3%–5% acetic acid. 
    • Allows improved colposcopic visualization of abnormal areas
    • Apply a generous amount of acetic acid to the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy; wait 30‒60 seconds. 
    • Look for acetowhite changes: 
      • Cervical cells with large or dense nuclei (metaplastic, dysplastic, and HPV-infected cells) will turn white.
      • Acetowhite changes fade after approximately 3 minutes
  • Alternative to acetic acid: Lugol solution
    • Can be used after acetic acid if no acetowhite changes are found
    • An iodine-based solution that is taken up by normal, glycogen-containing squamous cells, causing them to turn brown
    • Abnormal cells (nonglycogenated columnar cells and high-grade lesions) do not take up the dye and remain light yellow.
  • Abnormal findings on colposcopy Colposcopy The examination, therapy or surgery of the cervix and vagina by means of a specially designed endoscope introduced vaginally. Cervical Cancer Screening include: 
    • Acetowhite changes: 
      • Sharp margins on lesions suggest high-grade lesions.
      • Diffuse borders suggest low-grade lesions.
    • Mosaicism Mosaicism The occurrence in an individual of two or more cell populations of different chromosomal constitutions, derived from a single zygote, as opposed to chimerism in which the different cell populations are derived from more than one zygote. Chromosome Testing and punctation: abnormal vasculature in the TZ, suggestive of neoplasia  

Biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma

  • Done through the speculum using a long, thin instrument that reaches the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy.
    • Most commonly used instrument is called a Kevorkian cervical biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma instrument.
    • Has 2 small jaws that extract a 1‒2 mm MM Multiple myeloma (MM) is a malignant condition of plasma cells (activated B lymphocytes) primarily seen in the elderly. Monoclonal proliferation of plasma cells results in cytokine-driven osteoclastic activity and excessive secretion of IgG antibodies. Multiple Myeloma segment of tissue; known as a punch biopsy Punch Biopsy Actinic Keratosis  
  • Local anesthetics Local anesthetics Local anesthetics are a group of pharmacological agents that reversibly block the conduction of impulses in electrically excitable tissues. Local anesthetics are used in clinical practice to induce a state of local or regional anesthesia by blocking sodium channels and inhibiting the conduction of painful stimuli via afferent nerves. Local Anesthetics are not typically used:
    • Cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy has relatively poor innervation to detect sharp pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways is felt more as intense visceral cramping
    • Injection of location anesthesia Anesthesia A state characterized by loss of feeling or sensation. This depression of nerve function is usually the result of pharmacologic action and is induced to allow performance of surgery or other painful procedures. Anesthesiology: History and Basic Concepts is typically as uncomfortable as (or is more uncomfortable than) the biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma itself.
  • Each specimen is individually labeled according to its location on the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy.
  • Obtain targeted biopsies of all abnormal areas.
  • Control bleeding:
    • Usually stops spontaneously with pressure from a cotton-tipped swab
    • Can also use:
      • Silver nitrate sticks
      • Ferric subsulfate (Monsel’s solution)
      • Surgical packing
  • Pelvic rest (no intercourse/anything in the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy) for 24‒48 hours 
Example of a cervical biopsy forceps

Example of a cervical biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma forceps Forceps Surgical Instruments and Sutures

Image by Lecturio.

Endocervical curettage Curettage A scraping, usually of the interior of a cavity or tract, for removal of new growth or other abnormal tissue, or to obtain material for tissue diagnosis. It is performed with a curet (curette), a spoon-shaped instrument designed for that purpose. Benign Bone Tumors (ECC)

  • Considered a “ biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma” of the endocervical canal
  • Contraindicated in pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care
  • Uses a curette—a long, thin instrument with a sharp metal “basket” on the end
  • The curette is introduced into the canal and moved in and out to scrape all 4 quadrants (up, down, left, and right)
  • The curette is swirled in formalin to remove the tissue.
  • An endocervical brush is then inserted and rotated to remove any additional exfoliated tissue.
  • These specimens should be collected and labeled.
Endocervical curette

Endocervical curette:
The tip is referred to as the “basket” and is used to scrape the inside of the endocervical canal.

Image by Lecturio.

Complications

Complications from colposcopy Colposcopy The examination, therapy or surgery of the cervix and vagina by means of a specially designed endoscope introduced vaginally. Cervical Cancer Screening, biopsies, and ECC are all exceedingly rare, but may include:

  • Severe bleeding
  • Infection

Loop Electrosurgical Excision Procedure

Description

  • Used to diagnose and treat cervical dysplasia or very-early-stage cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer
  • An electrified loop of wire is used to excise the TZ and/or pathologic area on the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy.
  • Typically done under local anesthesia Anesthesia A state characterized by loss of feeling or sensation. This depression of nerve function is usually the result of pharmacologic action and is induced to allow performance of surgery or other painful procedures. Anesthesiology: History and Basic Concepts in the office, but occasionally is done in the surgical suite under general anesthesia Anesthesia A state characterized by loss of feeling or sensation. This depression of nerve function is usually the result of pharmacologic action and is induced to allow performance of surgery or other painful procedures. Anesthesiology: History and Basic Concepts
Schematic representation of cervical conization

Schematic representation of cervical conization Conization Cervical Cancer using an electrosurgical loop

Image by Lecturio.

Indications

  • Treatment of high-grade cervical dysplasia (primary indication)
  • Diagnosis:
    • Suspicion of high-grade cervical dysplasia based on colposcopy Colposcopy The examination, therapy or surgery of the cervix and vagina by means of a specially designed endoscope introduced vaginally. Cervical Cancer Screening exam with inadequate or unclear biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma results
    • Used as an alternative when pathologic discrepancy arises between high-grade cytology on Pap smear Pap smear Cytological preparation of cells collected from a mucosal surface and stained with Papanicolaou stain. Cervical Cancer Screening and low-grade histology on cervical biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma

Contraindications Contraindications A condition or factor associated with a recipient that makes the use of a drug, procedure, or physical agent improper or inadvisable. Contraindications may be absolute (life threatening) or relative (higher risk of complications in which benefits may outweigh risks). Noninvasive Ventilation

  • Multiple recurrent procedures resulting in an abnormally short cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy
  • Cervicitis Cervicitis Inflammation of the uterine cervix. Gonorrhea (e.g., active chlamydia Chlamydia Chlamydiae are obligate intracellular gram-negative bacteria. They lack a peptidoglycan layer and are best visualized using Giemsa stain. The family of Chlamydiaceae comprises 3 pathogens that can infect humans: Chlamydia trachomatis, Chlamydia psittaci, and Chlamydia pneumoniae. Chlamydia infection)
  • Pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care (strong but relative contraindication)
  • Anticoagulant use (relative)

Procedure

  • A speculum is inserted.
  • Colposcopy Colposcopy The examination, therapy or surgery of the cervix and vagina by means of a specially designed endoscope introduced vaginally. Cervical Cancer Screening is performed: 
    • Acetic acid is applied and the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy is visualized using a colposcope.
    • Extent of dysplasia is noted.
  • Smallest wire needed to excise the entire lesion should be selected.
  • Local anesthesia Anesthesia A state characterized by loss of feeling or sensation. This depression of nerve function is usually the result of pharmacologic action and is induced to allow performance of surgery or other painful procedures. Anesthesiology: History and Basic Concepts is injected creating a cervical block; typically:
    • 1%–2% lidocaine Lidocaine A local anesthetic and cardiac depressant used as an antiarrhythmic agent. Its actions are more intense and its effects more prolonged than those of procaine but its duration of action is shorter than that of bupivacaine or prilocaine. Local Anesthetics with epinephrine Epinephrine The active sympathomimetic hormone from the adrenal medulla. It stimulates both the alpha- and beta- adrenergic systems, causes systemic vasoconstriction and gastrointestinal relaxation, stimulates the heart, and dilates bronchi and cerebral vessels. Sympathomimetic Drugs
    • Approximately 10 mL (total) is injected at least at 5:00 and 7:00, and often at 11:00 and 1:00 as well.
    • Note: Direct injection at 3:00 and 9:00 should be avoided in order to avoid the cervical vessels.
  • The loop is activated (typically blended cutting and coagulation current at a relatively low voltage) 
  • The loop is carefully passed around and under the TZ, ideally in one continuous movement, thus excising it.
    • Moving too fast: the loop drags or sticks to the tissue and doesn’t adequately cut it
    • Moving too slowly: excessive thermal damage causing the loop to stick within the tissue, making additional passes necessary
  • Endocervical curettage Curettage A scraping, usually of the interior of a cavity or tract, for removal of new growth or other abnormal tissue, or to obtain material for tissue diagnosis. It is performed with a curet (curette), a spoon-shaped instrument designed for that purpose. Benign Bone Tumors is typically performed following removal of the loop electrosurgical excision procedure specimen.
  • Both loop electrosurgical excision procedure and ECC specimens are sent for histologic evaluation.
  • Control bleeding:

Complications

Vulvar Biopsy

Description

A sample of tissue is taken from the vulva Vulva The vulva is the external genitalia of the female and includes the mons pubis, labia majora, labia minora, clitoris, vestibule, vestibular bulb, and greater vestibular glands. Vagina, Vulva, and Pelvic Floor: Anatomy.

Indication

Vulvar biopsies are indicated in the evaluation of any abnormal-appearing vulvar lesions to rule out (or identify) neoplasia and to assist in the diagnosis of vulvar dermatitis Dermatitis Any inflammation of the skin. Atopic Dermatitis (Eczema).

  • Vulvar pruritus Pruritus An intense itching sensation that produces the urge to rub or scratch the skin to obtain relief. Atopic Dermatitis (Eczema) that is not due to infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease vulvovaginitis Vulvovaginitis The term vulvovaginitis is used to describe an acute inflammation of the vulva and vagina. Vulvovaginitis can be caused by several infectious and non-infectious etiologies, and results from disruption of the normal vaginal environment. Common signs and symptoms include pain, pruritus, erythema, edema, vaginal discharge and dyspareunia. Vulvovaginitis (e.g., candida Candida Candida is a genus of dimorphic, opportunistic fungi. Candida albicans is part of the normal human flora and is the most common cause of candidiasis. The clinical presentation varies and can include localized mucocutaneous infections (e.g., oropharyngeal, esophageal, intertriginous, and vulvovaginal candidiasis) and invasive disease (e.g., candidemia, intraabdominal abscess, pericarditis, and meningitis). Candida/Candidiasis infection)
  • Worrisome visible lesions (similar to the “ABCDEs” of melanoma Melanoma Melanoma is a malignant tumor arising from melanocytes, the melanin-producing cells of the epidermis. These tumors are most common in fair-skinned individuals with a history of excessive sun exposure and sunburns. Melanoma):
    • Asymmetry
    • (Irregular) Borders
    • Color variation
    • Diameter (larger lesions are more concerning)
    • Evolution (lesion is changing)
    • Others:
      • Underlying skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions retraction
      • Changes in the surrounding vulvar architecture
      • Nonhealing ulcers
      • Lesions that do not respond to standard therapy
      • Abnormal vasculature (Note: Do not attempt to biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma a highly vascular lesion in the office.)

Contraindications Contraindications A condition or factor associated with a recipient that makes the use of a drug, procedure, or physical agent improper or inadvisable. Contraindications may be absolute (life threatening) or relative (higher risk of complications in which benefits may outweigh risks). Noninvasive Ventilation

  • None 
  • If risk of bleeding is high, biopsies should be done in the OR instead of the office.

Procedure

  • Perform vulvar colposcopy Colposcopy The examination, therapy or surgery of the cervix and vagina by means of a specially designed endoscope introduced vaginally. Cervical Cancer Screening:
    • Generously apply acetic acid to the vulva Vulva The vulva is the external genitalia of the female and includes the mons pubis, labia majora, labia minora, clitoris, vestibule, vestibular bulb, and greater vestibular glands. Vagina, Vulva, and Pelvic Floor: Anatomy with soaked cotton balls.
    • Observe with a colposcope.
  • Avoid taking a biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma sample near the clitoris Clitoris An erectile structure homologous with the penis, situated beneath the anterior labial commissure, partially hidden between the anterior ends of the labia minora. Vagina, Vulva, and Pelvic Floor: Anatomy or the urethral or anal openings.
  • Prepare the area with antiseptic (e.g., povidone– iodine Iodine A nonmetallic element of the halogen group that is represented by the atomic symbol I, atomic number 53, and atomic weight of 126. 90. It is a nutritionally essential element, especially important in thyroid hormone synthesis. In solution, it has anti-infective properties and is used topically. Thyroid Hormones)
  • Inject 1‒2 mL of local anesthetic (typically 1%‒2% lidocaine Lidocaine A local anesthetic and cardiac depressant used as an antiarrhythmic agent. Its actions are more intense and its effects more prolonged than those of procaine but its duration of action is shorter than that of bupivacaine or prilocaine. Local Anesthetics with or without epinephrine Epinephrine The active sympathomimetic hormone from the adrenal medulla. It stimulates both the alpha- and beta- adrenergic systems, causes systemic vasoconstriction and gastrointestinal relaxation, stimulates the heart, and dilates bronchi and cerebral vessels. Sympathomimetic Drugs)
  • Obtain the biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma sample:
    • Punch biopsy Punch Biopsy Actinic Keratosis: A tool with a 3‒5 mm MM Multiple myeloma (MM) is a malignant condition of plasma cells (activated B lymphocytes) primarily seen in the elderly. Monoclonal proliferation of plasma cells results in cytokine-driven osteoclastic activity and excessive secretion of IgG antibodies. Multiple Myeloma sharp circular tip is twisted around the site to be excised.
    • Lift the lesion and cut the base with scissors.
  • Control bleeding:
  • Keep the site clean and dry until healed
Performing pu

A punch biopsy Punch Biopsy Actinic Keratosis tool is used to take an excisional biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma of the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions:
This tool is commonly used for vulvar biopsies.

Image: “Proper technique of holding the punch for performing punch biopsy Punch Biopsy Actinic Keratosis” by Nischal U. License: CC BY 2.0

Endometrial Biopsy

Description

  • A thin pipelle is used to sample the endometrium Endometrium The mucous membrane lining of the uterine cavity that is hormonally responsive during the menstrual cycle and pregnancy. The endometrium undergoes cyclic changes that characterize menstruation. After successful fertilization, it serves to sustain the developing embryo. Embryoblast and Trophoblast Development for direct histologic evaluation.
  • Done in the office, usually without anesthesia Anesthesia A state characterized by loss of feeling or sensation. This depression of nerve function is usually the result of pharmacologic action and is induced to allow performance of surgery or other painful procedures. Anesthesiology: History and Basic Concepts

Indication

  • Evaluation for precancerous Precancerous Pathological conditions that tend eventually to become malignant. Barrett’s Esophagus and neoplastic conditions of the endometrium Endometrium The mucous membrane lining of the uterine cavity that is hormonally responsive during the menstrual cycle and pregnancy. The endometrium undergoes cyclic changes that characterize menstruation. After successful fertilization, it serves to sustain the developing embryo. Embryoblast and Trophoblast Development
    • Abnormal uterine bleeding Abnormal Uterine Bleeding Abnormal uterine bleeding is the medical term for abnormalities in the frequency, volume, duration, and regularity of the menstrual cycle. Abnormal uterine bleeding is classified using the acronym PALM-COEIN, with PALM representing the structural causes and COEIN indicating the non-structural causes. Abnormal Uterine Bleeding ( AUB AUB Abnormal uterine bleeding is the medical term for abnormalities in the frequency, volume, duration, and regularity of the menstrual cycle. Abnormal uterine bleeding is classified using the acronym palm-coein, with palm representing the structural causes and coein indicating the non-structural causes. Abnormal Uterine Bleeding) in women with risk factors for neoplasia
    • Postmenopausal bleeding
  • Follow-up and surveillance Surveillance Developmental Milestones and Normal Growth of endometrial hyperplasia Hyperplasia An increase in the number of cells in a tissue or organ without tumor formation. It differs from hypertrophy, which is an increase in bulk without an increase in the number of cells. Cellular Adaptation

Contraindication

  • Pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care
  • Acute infection (pelvic inflammatory, cervical, or vaginal)
  • Cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer
  • Cervical stenosis Stenosis Hypoplastic Left Heart Syndrome (HLHS)

Procedure

  • The woman is placed in the lithotomy position, and a bimanual examination Bimanual Examination Female Genitourinary Examination is done to determine the uterine size and position.
  • Insert a speculum and identify the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy.
  • Prepare the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy with antiseptic (e.g., povidone– iodine Iodine A nonmetallic element of the halogen group that is represented by the atomic symbol I, atomic number 53, and atomic weight of 126. 90. It is a nutritionally essential element, especially important in thyroid hormone synthesis. In solution, it has anti-infective properties and is used topically. Thyroid Hormones)
  • Insert the endometrial pipelle through the cervical os until resistance Resistance Physiologically, the opposition to flow of air caused by the forces of friction. As a part of pulmonary function testing, it is the ratio of driving pressure to the rate of air flow. Ventilation: Mechanics of Breathing is felt at the uterine fundus Fundus The superior portion of the body of the stomach above the level of the cardiac notch. Stomach: Anatomy:
  • Pull the piston back on the pipelle to generate suction within the tube
  • Slide the pipelle in and out several times (while keeping the tip within the endometrial cavity), rotating the pipelle to obtain the most comprehensive sample possible.
  • Empty the sample into a labeled specimen container.
  • Control bleeding:
    • Small amounts of bleeding from the os and tenaculum sites are common and usually respond to pressure.
    • Severe bleeding would be suspicious for malignancy Malignancy Hemothorax or an underlying bleeding disorder.

Complications

  • Cramping
  • Uterine perforation Perforation A pathological hole in an organ, blood vessel or other soft part of the body, occurring in the absence of external force. Esophagitis (uncommon with modern plastic pipelles)
  • Infection
Endoemtrial biopsy

Schematic depiction of an endometrial biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma using a pipelle device:
The pipelle is inserted to the fundus Fundus The superior portion of the body of the stomach above the level of the cardiac notch. Stomach: Anatomy of the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy; then the piston on the opposite end is pulled back, creating space and generating suction within the tube. This suction pulls endometrial tissue Endometrial tissue The mucous membrane lining of the uterine cavity that is hormonally responsive during the menstrual cycle and pregnancy. The endometrium undergoes cyclic changes that characterize menstruation. After successful fertilization, it serves to sustain the developing embryo. Endometriosis into the tube, which can then be sent for histologic evaluation.

Image by Lecturio.

Sonography (Ultrasound)

Ultrasound is the most common diagnostic procedure used to visualize the internal female reproductive organs.

Types of studies

  • Transvaginal ultrasound Transvaginal Ultrasound Obstetric Imaging (TVUS):
    • Allows for the best visualization of female reproductive structures located within the pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy
    • Transducer Transducer A device placed on the patient’s body to visualize a target Ultrasound (Sonography) is placed inside the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy.
    • Transducer Transducer A device placed on the patient’s body to visualize a target Ultrasound (Sonography) is typically:
      • At or below the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy 
      • Angled slightly upward to visualize the reproductive organs
  • Transabdominal ultrasound (TAUS):
    • Transducer Transducer A device placed on the patient’s body to visualize a target Ultrasound (Sonography) is placed on the lower abdomen.
    • Best for visualizing structures above the true pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy, for example:
      • An enlarged uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy (e.g., during pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care)
      • Large cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change or fibroids Fibroids A benign tumor derived from smooth muscle tissue, also known as a fibroid tumor. They rarely occur outside of the uterus and the gastrointestinal tract but can occur in the skin and subcutaneous tissue, probably arising from the smooth muscle of small blood vessels in these tissues. Infertility extending out of the pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy
    • Useful in people who cannot tolerate transvaginal exams
  • Saline infusion sonography ( SIS SIS Infertility):
    • A catheter is placed into the endometrial cavity (same procedure as placing an endometrial pipelle).
    • Once the catheter is in place, a balloon is inflated to keep the catheter in place and the speculum is removed.
    • A TVUS probe Probe A device placed on the patient’s body to visualize a target Ultrasound (Sonography) is inserted into the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy and the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy identified.
    • While observing on TVUS in real time, sterile Sterile Basic Procedures saline is injected into the endometrial cavity
      • This fluid distends the cavity, allowing for evaluation of intracavitary lesions.
      • Although the fluid does efflux through the fallopian tubes Fallopian tubes The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The fallopian tubes receive an ovum after ovulation and help move it and/or a fertilized embryo toward the uterus via ciliated cells lining the tubes and peristaltic movements of its smooth muscle. Uterus, Cervix, and Fallopian Tubes: Anatomy, the tubes are too thin for this to be observed on TVUS (HSG is required; see below)
    • After images are taken, the balloon is deflated and the catheter and probe Probe A device placed on the patient’s body to visualize a target Ultrasound (Sonography) are removed.

Indications

TAUS/TVUS:

The indications for TVUS and TAUS are the same and generally include bleeding and/or pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways. Both are typically performed during the same exam to ensure a complete evaluation of the female reproductive organs.

  • Suspected ovarian or fallopian tube Fallopian Tube A pair of highly specialized canals extending from the uterus to its corresponding ovary. They provide the means for ovum transport from the ovaries and they are the site of the ovum’s final maturation and fertilization. The fallopian tube consists of an interstitium, an isthmus, an ampulla, an infundibulum, and fimbriae. Its wall consists of three layers: serous, muscular, and an internal mucosal layer lined with both ciliated and secretory cells. Uterus, Cervix, and Fallopian Tubes: Anatomy masses:
    • Cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change
    • Malignancy Malignancy Hemothorax
    • Ectopic pregnancy Ectopic pregnancy Ectopic pregnancy refers to the implantation of a fertilized egg (embryo) outside the uterine cavity. The main cause is disruption of the normal anatomy of the fallopian tube. Ectopic Pregnancy
  • To assess the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy in cases of abnormal bleeding  (including menstrual bleeding, postmenopausal bleeding, and bleeding in pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care), looking especially for:
    • Endometrial thickness → may indicate hyperplasia Hyperplasia An increase in the number of cells in a tissue or organ without tumor formation. It differs from hypertrophy, which is an increase in bulk without an increase in the number of cells. Cellular Adaptation (if thick) or atrophy Atrophy Decrease in the size of a cell, tissue, organ, or multiple organs, associated with a variety of pathological conditions such as abnormal cellular changes, ischemia, malnutrition, or hormonal changes. Cellular Adaptation (if thin)
    • Presence of leiomyomas:
    • Signs of adenomyosis Adenomyosis Adenomyosis is a benign uterine condition characterized by the presence of ectopic endometrial glands and stroma within the myometrium. Adenomyosis is a common condition, affecting 20%-35% of women, and typically presents with heavy menstrual bleeding and dysmenorrhea. Adenomyosis:
      • Enlarged uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy
      • Asymmetrical thickening of the myometrium
      • Myometrial cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change
      • Linear striations radiating out from the endometrium Endometrium The mucous membrane lining of the uterine cavity that is hormonally responsive during the menstrual cycle and pregnancy. The endometrium undergoes cyclic changes that characterize menstruation. After successful fertilization, it serves to sustain the developing embryo. Embryoblast and Trophoblast Development
      • Loss of a clear endomyometrial border
  • Pelvic pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways (looking for structural causes)
  • Evaluation of congenital Congenital Chorioretinitis anomalies
  • Infertility Infertility Infertility is the inability to conceive in the context of regular intercourse. The most common causes of infertility in women are related to ovulatory dysfunction or tubal obstruction, whereas, in men, abnormal sperm is a common cause. Infertility assessments
  • Assess the presence and location of intrauterine devices Intrauterine devices Contraceptive devices placed high in the uterine fundus. Hormonal Contraceptives (IUDs).
  • Pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care assessments:
    • Dating
    • Cervical length
    • Anatomic, fluid, and growth assessments of the fetus
  • Visually assist with other invasive procedures, including:
    • Aspiration of ova for in vitro fertilization Fertilization To undergo fertilization, the sperm enters the uterus, travels towards the ampulla of the fallopian tube, and encounters the oocyte. The zona pellucida (the outer layer of the oocyte) deteriorates along with the zygote, which travels towards the uterus and eventually forms a blastocyst, allowing for implantation to occur. Fertilization and First Week 
    • Aspiration of pelvic fluid
    • Obstetric uses, including:
      • Amniocentesis Amniocentesis Percutaneous transabdominal puncture of the uterus during pregnancy to obtain amniotic fluid. It is commonly used for fetal karyotype determination in order to diagnose abnormal fetal conditions. Polyhydramnios
      • Chorionic villus sampling

SIS SIS Infertility:

By distending the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy, SIS SIS Infertility allows identification Identification Defense Mechanisms of intracavitary pathology (in addition to everything seen on routine TVUS). A standard TVUS is typically performed before the SIS SIS Infertility procedure.

  • Can identify:
    • Polyps
    • Submucosal leiomyomas
    • Adhesions
    • Septa
    • Contour of the endometrial cavity
  • Typically done to evaluate:
    • Infertility Infertility Infertility is the inability to conceive in the context of regular intercourse. The most common causes of infertility in women are related to ovulatory dysfunction or tubal obstruction, whereas, in men, abnormal sperm is a common cause. Infertility
    • Abnormal uterine bleeding Abnormal Uterine Bleeding Abnormal uterine bleeding is the medical term for abnormalities in the frequency, volume, duration, and regularity of the menstrual cycle. Abnormal uterine bleeding is classified using the acronym PALM-COEIN, with PALM representing the structural causes and COEIN indicating the non-structural causes. Abnormal Uterine Bleeding with suspected endometrial pathology
    • Intrauterine surgical planning
Normal hysterosonography

Saline infusion sonogram Sonogram Chorioretinitis ( SIS SIS Infertility):
The sterile Sterile Basic Procedures saline instilled into the cavity of the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy is anechoic Anechoic A structure that produces no echo at all (looks completely black) Ultrasound (Sonography) (visible as the dark central portion of the image) and delineates the shape of the endometrial cavity. This image shows a normal endometrium Endometrium The mucous membrane lining of the uterine cavity that is hormonally responsive during the menstrual cycle and pregnancy. The endometrium undergoes cyclic changes that characterize menstruation. After successful fertilization, it serves to sustain the developing embryo. Embryoblast and Trophoblast Development (the hyperechoic Hyperechoic A structure that produces a high-amplitude echo (lighter grays and white) Ultrasound (Sonography)/brighter band around the cavity), without any focal changes. The endometrium Endometrium The mucous membrane lining of the uterine cavity that is hormonally responsive during the menstrual cycle and pregnancy. The endometrium undergoes cyclic changes that characterize menstruation. After successful fertilization, it serves to sustain the developing embryo. Embryoblast and Trophoblast Development is surrounded by the myometrium, which stretches almost to the right border of the image.

Image: “Normal hysterosonography” by Mikael Häggström. License: Public Domain

Contraindications Contraindications A condition or factor associated with a recipient that makes the use of a drug, procedure, or physical agent improper or inadvisable. Contraindications may be absolute (life threatening) or relative (higher risk of complications in which benefits may outweigh risks). Noninvasive Ventilation

Hysteroscopy (HSC)

Description

  • A scope is introduced into the endometrial cavity through the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy
  • Used to diagnose and/or treat intrauterine pathologies
  • It is a gold standard diagnostic tool for assessment of:
    • Endometrial cavity
    • Tubal ostia (where the tubes enter the endometrial cavity)
    • Endocervical canal
  • Can be performed in the office or in a surgical suite

Indications

From a diagnostic standpoint, HSC has similar indications as for SIS SIS Infertility. The primary advantage of HSC over SIS SIS Infertility is the ability to directly visualize lesions and treat them simultaneously. HSC is performed to:

  • Diagnose and investigate causes of:
    • Abnormal uterine bleeding Abnormal Uterine Bleeding Abnormal uterine bleeding is the medical term for abnormalities in the frequency, volume, duration, and regularity of the menstrual cycle. Abnormal uterine bleeding is classified using the acronym PALM-COEIN, with PALM representing the structural causes and COEIN indicating the non-structural causes. Abnormal Uterine Bleeding
    • Thickened endometrium Endometrium The mucous membrane lining of the uterine cavity that is hormonally responsive during the menstrual cycle and pregnancy. The endometrium undergoes cyclic changes that characterize menstruation. After successful fertilization, it serves to sustain the developing embryo. Embryoblast and Trophoblast Development seen on sonography; can distinguish between:
      • Diffusely thickened endometrium Endometrium The mucous membrane lining of the uterine cavity that is hormonally responsive during the menstrual cycle and pregnancy. The endometrium undergoes cyclic changes that characterize menstruation. After successful fertilization, it serves to sustain the developing embryo. Embryoblast and Trophoblast Development (a concern for hyperplasia Hyperplasia An increase in the number of cells in a tissue or organ without tumor formation. It differs from hypertrophy, which is an increase in bulk without an increase in the number of cells. Cellular Adaptation)
      • Polyps
    • Submucosal fibroids Fibroids A benign tumor derived from smooth muscle tissue, also known as a fibroid tumor. They rarely occur outside of the uterus and the gastrointestinal tract but can occur in the skin and subcutaneous tissue, probably arising from the smooth muscle of small blood vessels in these tissues. Infertility
    • Intrauterine adhesions
    • Endocervical lesions
    • Infertility Infertility Infertility is the inability to conceive in the context of regular intercourse. The most common causes of infertility in women are related to ovulatory dysfunction or tubal obstruction, whereas, in men, abnormal sperm is a common cause. Infertility
    • Postmenopausal bleeding
    • Dislocation of IUDs
  • Treat lesions via:
    • Adhesiolysis
    • Myomectomy/polypectomy
    • Endometrial ablation (or resection)
    • Removal of intrauterine foreign bodies

Contraindications Contraindications A condition or factor associated with a recipient that makes the use of a drug, procedure, or physical agent improper or inadvisable. Contraindications may be absolute (life threatening) or relative (higher risk of complications in which benefits may outweigh risks). Noninvasive Ventilation

  • Viable intrauterine pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care
  • Active pelvic infection
  • Known cervical or uterine cancer

Procedure

  • Cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy and vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy are prepared with antiseptic (e.g., povidone– iodine Iodine A nonmetallic element of the halogen group that is represented by the atomic symbol I, atomic number 53, and atomic weight of 126. 90. It is a nutritionally essential element, especially important in thyroid hormone synthesis. In solution, it has anti-infective properties and is used topically. Thyroid Hormones)
  • A speculum is inserted and the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy identified.
  • The anterior lip of the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy is grasped with a tenaculum forceps Forceps Surgical Instruments and Sutures to:
    • Provide countertraction during dilation and advancement of the scope
    • Straighten the uterocervical angle with gentle outward pressure
  • The cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy is dilated up to the diameter of the scope.
  • The hysteroscope (usually about 4‒5 mm MM Multiple myeloma (MM) is a malignant condition of plasma cells (activated B lymphocytes) primarily seen in the elderly. Monoclonal proliferation of plasma cells results in cytokine-driven osteoclastic activity and excessive secretion of IgG antibodies. Multiple Myeloma in diameter) is introduced through the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy.
  • The uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy is distended with a gas or fluid medium (most often, normal saline Normal saline A crystalloid solution that contains 9. 0g of sodium chloride per liter of water. It has a variety of uses, including: as a contact lens solution, in ophthalmic solutions and nasal lavage, in wound irrigation, and for fluid therapy. Intravenous Fluids).
  • Images are taken.
  • Surgical treatments (e.g., myomectomy) are performed
    • Camera is contained within a sheath.
    • These sheaths can also contain operative ports— channels Channels The Cell: Cell Membrane through which surgical instruments can be introduced.

Complications

  • Uterine perforation Perforation A pathological hole in an organ, blood vessel or other soft part of the body, occurring in the absence of external force. Esophagitis
  • Injury to internal organs
  • Hemorrhage 
  • Infection
  • Complications from distention media:
    • Air embolism Air embolism Blocking of a blood vessel by air bubbles that enter the circulatory system, usually after trauma; surgical procedures, or changes in atmospheric pressure. Nonthrombotic Embolism 
    • Fluid overload
    • Hyponatremia Hyponatremia Hyponatremia is defined as a decreased serum sodium (sNa+) concentration less than 135 mmol/L. Serum sodium is the greatest contributor to plasma osmolality, which is very tightly controlled via antidiuretic hormone (ADH) release from the hypothalamus and by the thirst mechanism. Hyponatremia
Hysteroscopy

Schematic depiction of hysteroscopy

Image by Lecturio.

Hysterosalpingography (HSG)

Description

  • A fluoroscopic examination that allows assessment of the uterine cavity shape and patency of the fallopian tubes Fallopian tubes The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The fallopian tubes receive an ovum after ovulation and help move it and/or a fertilized embryo toward the uterus via ciliated cells lining the tubes and peristaltic movements of its smooth muscle. Uterus, Cervix, and Fallopian Tubes: Anatomy
  • A catheter is inserted into the uterine cavity → dye is injected → x-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests images are taken

Indications

  • Assess tubal patency:
    • Usually as part of an infertility Infertility Infertility is the inability to conceive in the context of regular intercourse. The most common causes of infertility in women are related to ovulatory dysfunction or tubal obstruction, whereas, in men, abnormal sperm is a common cause. Infertility evaluation
    • Note: The tubal canal is very thin and not visible with other imaging methods.
  • Suspected congenital Congenital Chorioretinitis uterine anomalies

Contraindications Contraindications A condition or factor associated with a recipient that makes the use of a drug, procedure, or physical agent improper or inadvisable. Contraindications may be absolute (life threatening) or relative (higher risk of complications in which benefits may outweigh risks). Noninvasive Ventilation

  • Pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care
    • These procedures are typically done after menses Menses The periodic shedding of the endometrium and associated menstrual bleeding in the menstrual cycle of humans and primates. Menstruation is due to the decline in circulating progesterone, and occurs at the late luteal phase when luteolysis of the corpus luteum takes place. Menstrual Cycle but prior to ovulation Ovulation The discharge of an ovum from a rupturing follicle in the ovary. Menstrual Cycle in order to avoid interruption of early viable pregnancies.
    • For unclear reasons, there is an increased chance of conception during cycles in which HSG is performed.
  • Active undiagnosed vaginal bleeding
  • Active pelvic infection

Procedure

  • A speculum is inserted and the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy identified.
  • A balloon-tipped catheter is inserted through the cervical canal Cervical canal Uterus, Cervix, and Fallopian Tubes: Anatomy into the uterine cavity:
    • Balloon is inflated to hold the catheter in place and to prevent leakage of dye.
    • A tenaculum can be used if needed.
  • The contrast material is injected slowly and observed on fluoroscopy Fluoroscopy Production of an image when x-rays strike a fluorescent screen. X-rays in real time.
  • Images are taken.
  • The balloon is deflated; a final image is usually taken of dye filling the vaginal cavity while the catheter is withdrawn.

Findings

Normal: 

  • Normal uterine cavity contour
  • Fallopian tubes Fallopian tubes The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The fallopian tubes receive an ovum after ovulation and help move it and/or a fertilized embryo toward the uterus via ciliated cells lining the tubes and peristaltic movements of its smooth muscle. Uterus, Cervix, and Fallopian Tubes: Anatomy fill with dye → dye is seen spilling out the ends of both tubes into the pelvic cavity (“bilateral fill and spill”)

Abnormal:

  • Absence or partial filling of the tubes, or absence of spill → fallopian tube Fallopian Tube A pair of highly specialized canals extending from the uterus to its corresponding ovary. They provide the means for ovum transport from the ovaries and they are the site of the ovum’s final maturation and fertilization. The fallopian tube consists of an interstitium, an isthmus, an ampulla, an infundibulum, and fimbriae. Its wall consists of three layers: serous, muscular, and an internal mucosal layer lined with both ciliated and secretory cells. Uterus, Cervix, and Fallopian Tubes: Anatomy obstruction
  • Dilated fallopian tube Fallopian Tube A pair of highly specialized canals extending from the uterus to its corresponding ovary. They provide the means for ovum transport from the ovaries and they are the site of the ovum’s final maturation and fertilization. The fallopian tube consists of an interstitium, an isthmus, an ampulla, an infundibulum, and fimbriae. Its wall consists of three layers: serous, muscular, and an internal mucosal layer lined with both ciliated and secretory cells. Uterus, Cervix, and Fallopian Tubes: Anatomy hydrosalpinx Hydrosalpinx Gynecological Imaging
  • Intracavitary filling defects Filling Defects Imaging of the Intestines → submucosal leiomyomas or polyps
  • Abnormal uterine cavity contour → congenital Congenital Chorioretinitis uterine anomaly
Hysterosalpingographic evaluation of primary and secondary infertility

Normal HSG examination:
This radiograph shows a normal uterine contour with bilateral fill and spill of dye from the fallopian tubes Fallopian tubes The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The fallopian tubes receive an ovum after ovulation and help move it and/or a fertilized embryo toward the uterus via ciliated cells lining the tubes and peristaltic movements of its smooth muscle. Uterus, Cervix, and Fallopian Tubes: Anatomy.

Image: “Hysterosalpingographic evaluation of primary and secondary infertility Infertility Infertility is the inability to conceive in the context of regular intercourse. The most common causes of infertility in women are related to ovulatory dysfunction or tubal obstruction, whereas, in men, abnormal sperm is a common cause. Infertility” by Muhammad Usman Aziz, MBBS, FCPS (Radiology). Senior Registrar, Department of Radiology, Liaquat National Hospital. License: CC BY 3.0

Complications

  • Cramping
  • Leaking contrast material
  • Vaginal bleeding
  • Fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever
  • Severe pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways

Clinical Relevance

The following conditions are some of the most common gynecologic conditions diagnosed with the procedures discussed on this page:

  • Cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer: 3rd most common cancer in women in the world. Owing to effective screening Screening Preoperative Care, diagnosis, and treatment, however, most disease can be caught and treated at an early, preinvasive stage. Diagnosis is made using cervical Pap smears with assessing cytology, HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomavirus (HPV) testing, colposcopy Colposcopy The examination, therapy or surgery of the cervix and vagina by means of a specially designed endoscope introduced vaginally. Cervical Cancer Screening, and biopsies. Preinvasive disease is typically managed with loop electrosurgical excision procedures, while invasive disease requires more significant surgeries.
  • Abnormal uterine bleeding Abnormal Uterine Bleeding Abnormal uterine bleeding is the medical term for abnormalities in the frequency, volume, duration, and regularity of the menstrual cycle. Abnormal uterine bleeding is classified using the acronym PALM-COEIN, with PALM representing the structural causes and COEIN indicating the non-structural causes. Abnormal Uterine Bleeding ( AUB AUB Abnormal uterine bleeding is the medical term for abnormalities in the frequency, volume, duration, and regularity of the menstrual cycle. Abnormal uterine bleeding is classified using the acronym palm-coein, with palm representing the structural causes and coein indicating the non-structural causes. Abnormal Uterine Bleeding):  collective term for abnormalities in the frequency, volume, duration, and/or regularity of the menstrual cycle Menstrual cycle The menstrual cycle is the cyclic pattern of hormonal and tissular activity that prepares a suitable uterine environment for the fertilization and implantation of an ovum. The menstrual cycle involves both an endometrial and ovarian cycle that are dependent on one another for proper functioning. There are 2 phases of the ovarian cycle and 3 phases of the endometrial cycle. Menstrual Cycle. Etiologies include Polyps, Adenomyosis, Leiomyomas, Malignancy/ hyperplasia Hyperplasia An increase in the number of cells in a tissue or organ without tumor formation. It differs from hypertrophy, which is an increase in bulk without an increase in the number of cells. Cellular Adaptation, Coagulopathy, Ovulatory dysfunction, Endometritis and atrophy Atrophy Decrease in the size of a cell, tissue, organ, or multiple organs, associated with a variety of pathological conditions such as abnormal cellular changes, ischemia, malnutrition, or hormonal changes. Cellular Adaptation, Iatrogenic causes (official acronym: PALM-COEIN PALM-COEIN Abnormal uterine bleeding is the medical term for abnormalities in the frequency, volume, duration, and regularity of the menstrual cycle. Abnormal uterine bleeding is classified using the acronym palm-coein, with palm representing the structural causes and coein indicating the non-structural causes. Abnormal Uterine Bleeding). Diagnosis is done by extensive history taking, exam, lab workup, sonography, and/or endometrial biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma. Treatment is based on the underlying etiology. 
  • Uterine leiomyoma Uterine leiomyoma Uterine leiomyomas (or uterine fibroids) are benign tumors arising from smooth muscle cells in the uterine myometrium. Leiomyosarcomas, however, are malignant tumors, arising de novo (not from fibroids). Uterine Leiomyoma and Leiomyosarcoma: benign Benign Fibroadenoma tumors arising from smooth muscle cells in the uterine myometrium. Uterine leiomyomas are usually easily identified as a hypoechoic Hypoechoic A structure that produces a low-amplitude echo (darker grays) Ultrasound (Sonography), well-circumscribed, round masses on pelvic sonography. Treatment for leiomyomas may include surgical resection or medical options to reduce bleeding and/or bulk symptoms. 
  • Endometrial polyps Endometrial polyps Endometrial polyps are pedunculated or sessile projections of the endometrium that result from overgrowth of endometrial glands and stroma around a central vascular stalk. Endometrial polyps are a few millimeters to a few centimeters in size, can occur anywhere within the uterine cavity, and, while usually benign, can be malignant, particularly in postmenopausal women. Endometrial Polyps: pedunculated or sessile projections of the endometrium Endometrium The mucous membrane lining of the uterine cavity that is hormonally responsive during the menstrual cycle and pregnancy. The endometrium undergoes cyclic changes that characterize menstruation. After successful fertilization, it serves to sustain the developing embryo. Embryoblast and Trophoblast Development that result from overgrowth of endometrial glands and stroma around a central vascular stalk. Endometrial polyps Endometrial polyps Endometrial polyps are pedunculated or sessile projections of the endometrium that result from overgrowth of endometrial glands and stroma around a central vascular stalk. Endometrial polyps are a few millimeters to a few centimeters in size, can occur anywhere within the uterine cavity, and, while usually benign, can be malignant, particularly in postmenopausal women. Endometrial Polyps are a few millimeters to a few centimeters in size and can occur anywhere within the uterine cavity. These polyps can become malignant in postmenopausal women. Endometrial polyps Endometrial polyps Endometrial polyps are pedunculated or sessile projections of the endometrium that result from overgrowth of endometrial glands and stroma around a central vascular stalk. Endometrial polyps are a few millimeters to a few centimeters in size, can occur anywhere within the uterine cavity, and, while usually benign, can be malignant, particularly in postmenopausal women. Endometrial Polyps are suspected on a sonogram Sonogram Chorioretinitis showing a thickened endometrium Endometrium The mucous membrane lining of the uterine cavity that is hormonally responsive during the menstrual cycle and pregnancy. The endometrium undergoes cyclic changes that characterize menstruation. After successful fertilization, it serves to sustain the developing embryo. Embryoblast and Trophoblast Development and are more definitively diagnosed on SIS SIS Infertility, HSG, and/or hysteroscopy and are usually treated with hysteroscopic resection. 
  • Adenomyosis Adenomyosis Adenomyosis is a benign uterine condition characterized by the presence of ectopic endometrial glands and stroma within the myometrium. Adenomyosis is a common condition, affecting 20%-35% of women, and typically presents with heavy menstrual bleeding and dysmenorrhea. Adenomyosis: benign Benign Fibroadenoma uterine condition characterized by the presence of ectopic endometrial glands and stroma within the myometrium. Adenomyosis Adenomyosis Adenomyosis is a benign uterine condition characterized by the presence of ectopic endometrial glands and stroma within the myometrium. Adenomyosis is a common condition, affecting 20%-35% of women, and typically presents with heavy menstrual bleeding and dysmenorrhea. Adenomyosis typically presents with heavy menstrual bleeding Heavy menstrual bleeding Excessive menstrual blood loss (objectively defined as > 80 mL blood loss/cycle). Can be based on heavy flow, as determined by the patient Abnormal Uterine Bleeding and dysmenorrhea. Diagnosis is often made during history taking, with numerous findings suggestive of adenomyosis Adenomyosis Adenomyosis is a benign uterine condition characterized by the presence of ectopic endometrial glands and stroma within the myometrium. Adenomyosis is a common condition, affecting 20%-35% of women, and typically presents with heavy menstrual bleeding and dysmenorrhea. Adenomyosis on ultrasound. Management is based on the woman’s preference regarding future childbearing and may include hysterectomy (definitive treatment), other surgical options, or medical hormonal suppression Suppression Defense Mechanisms.
  • Ovarian cysts Ovarian cysts Ovarian cysts are defined as collections of fluid or semiliquid material, often walled off by a membrane, located in the ovary. These cysts are broadly categorized as either functional or neoplastic. Neoplastic ovarian cysts are subcategorized as either benign or malignant. Ovarian Cysts: collections of fluid or semiliquid material, often walled off by a membrane, located in the ovary. When the cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change occur as a result of normal physiologic processes, they are called functional, whereas if there is abnormal growth of ovarian cells, the cyst is referred to as neoplastic. Neoplastic ovarian cysts Ovarian cysts Ovarian cysts are defined as collections of fluid or semiliquid material, often walled off by a membrane, located in the ovary. These cysts are broadly categorized as either functional or neoplastic. Neoplastic ovarian cysts are subcategorized as either benign or malignant. Ovarian Cysts are subcategorized as either benign Benign Fibroadenoma or malignant and are categorized according to their cell of origin (e.g., epithelial, germ cell, or stromal cells).
  • Vulvar dermatoses:
    • Lichen sclerosis Sclerosis A pathological process consisting of hardening or fibrosis of an anatomical structure, often a vessel or a nerve. Wilms Tumor (LS): chronic, progressive dermatologic condition of the vulva Vulva The vulva is the external genitalia of the female and includes the mons pubis, labia majora, labia minora, clitoris, vestibule, vestibular bulb, and greater vestibular glands. Vagina, Vulva, and Pelvic Floor: Anatomy that is characterized by inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation and epithelial thinning, visible as porcelain-white “parchment-like” vulvar plaques; as LS progresses, scarring Scarring Inflammation can distort the anatomy. Lichen sclerosis Sclerosis A pathological process consisting of hardening or fibrosis of an anatomical structure, often a vessel or a nerve. Wilms Tumor itself is benign Benign Fibroadenoma, but it is associated with an increased risk for vulvar squamous cell carcinoma Squamous cell carcinoma Cutaneous squamous cell carcinoma (cSCC) is caused by malignant proliferation of atypical keratinocytes. This condition is the 2nd most common skin malignancy and usually affects sun-exposed areas of fair-skinned patients. The cancer presents as a firm, erythematous, keratotic plaque or papule. Squamous Cell Carcinoma (SCC) (SCC). Diagnosis is clinical, but definitive diagnosis requires vulvar biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma, which shows a thinned epidermal layer and homogenization of collagen Collagen A polypeptide substance comprising about one third of the total protein in mammalian organisms. It is the main constituent of skin; connective tissue; and the organic substance of bones (bone and bones) and teeth (tooth). Connective Tissue: Histology in the upper dermis Dermis A layer of vascularized connective tissue underneath the epidermis. The surface of the dermis contains innervated papillae. Embedded in or beneath the dermis are sweat glands; hair follicles; and sebaceous glands. Skin: Structure and Functions.
    • Lichen simplex chronicus Lichen Simplex Chronicus A benign vulvar skin disorder characterized by hyperkeratosis (thickening of the skin) that occurs secondary to chronic vulvar irritation Benign Vulvar Conditions: benign Benign Fibroadenoma vulvar skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions disorder characterized by hyperkeratosis Hyperkeratosis Ichthyosis Vulgaris (thickening of the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions) that occurs secondary to chronic vulvar irritation. Lichen simplex chronicus Lichen Simplex Chronicus A benign vulvar skin disorder characterized by hyperkeratosis (thickening of the skin) that occurs secondary to chronic vulvar irritation Benign Vulvar Conditions presents with intense pruritus Pruritus An intense itching sensation that produces the urge to rub or scratch the skin to obtain relief. Atopic Dermatitis (Eczema), often worse at night, and well-demarcated, dry patchy plaques; the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions is usually thick, scaly, and firm and may appear similar to some vulvar malignancies. Diagnosis is usually clinical (but a biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma may be needed to rule out malignancy Malignancy Hemothorax) and shows a hypertrophic epidermal layer.

References

  1. Feltmate, C. M., Feldman, S. (2020). Colposcopy. UpToDate. https://www.uptodate.com/contents/colposcopy#H17
  2. Lee, S. I., Kilcoyne, A. (2021). Hysterosalpingography. UpToDate. Retrieved December 14, 2021, Retrieved December 14, 2021,from https://www.uptodate.com/contents/hysterosalpingography#H1381205198
  3. Moore, J.F., Carugno, J. (2021). Hysteroscopy. StatPearls. Retrieved December 14, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK564345
  4. Bradley, L. D. (2021). Overview of hysteroscopy. UpToDate. Retrieved December 14, 2021, from https://www.uptodate.com/contents/overview-of-hysteroscopy?topicRef=3262&source=see_link#H47
  5. Carusi, D. A. (2021). The gynecologic history and pelvic examination. UpToDate. Retrieved December 14, 2021, from https://www.uptodate.com/contents/the-gynecologic-history-and-pelvic-examination?search=speculum%20exam&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H7
  6. Hoffman, M. S., Mann, W. J. (2021). Cervical intraepithelial neoplasia: Diagnostic excisional procedures. UpToDate. Retrieved December 14, 2021, from https://www.uptodate.com/contents/cervical-intraepithelial-neoplasia-diagnostic-excisional-procedures?search=LEEP&source=search_result&selectedTitle=1~36&usage_type=default&display_rank=1#H5
  7. Will, A.J., Sanchack, K.E. (2020). Endometrial Biopsy. StatPearls. Retrieved December 14, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK541135/

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