Daycase Hysteroscopy

What is a hysteroscopy with division of adhesions?

A hysteroscopy is an examination of the uterus using a thin telescope called a hysteroscope. During your procedure, a speculum will be gently inserted into your vagina, to display the cervix. Your surgeon introduces the hysteroscope through the cervix to visualise the uterus and endometrial lining on a monitor. Fine instruments are passed down the operating channel of the scope, to carefully divide the adhesions. X-ray and ultrasound is utilised to guide the surgeon to reduce the risk of perforation of the uterus or creation of a false passage.

How do I prepare for my division of adhesions?

Division of adhesions is performed as a day case. You will be given instructions on when to stop eating and drinking and if you should take medication as normal before coming into hospital when you receive your admission letter. It is also asked if possible, to arrive for the procedure with a full bladder.

If you are having this procedure under sedation or general anaesthesia, it is very important that you do not have any solid food for 6 hours prior to your appointment time. You may continue to have sips of water until 2 hours before your procedure.

Alternatively, a stent or contraceptive coil may be left in the uterus for a few weeks to help the endometrium heal. Your consultant with discuss these options prior to your

procedure and your nurse on the ward will ensure you fully understand your after care.

Diabetic patients: This change in diet may upset your diabetes. These changes are temporary. To assist maintenance of normal blood sugar levels, you may sip no more than 100mls in an hour, of a sugary drink such as Lucozade, up to 2 hours before your procedure if your sugars dip below 4mmols/L.

Unless directed otherwise by your consultant, continue to take your other normal medications.

Urine Pregnancy Test – please perform at home

Patients would usually be asked to give a urine sample for pregnancy testing in their room on the day of admission; however, Mr Lower would prefer your bladder at least half full for the procedure (he finds imaging is clearer). We do still need to ensure that you have not conceived (this is hospital policy) so please perform a urine pregnancy test at home the day before the procedure and record the result.

On the day of your procedure?

You will be asked to arrive at the Hospital 30-60mins before your procedure start time. You will be greeted at Reception team and guided through the admission process.

The procedure itself usually takes about 30-45 minutes.

Although every effort is made to minimise waiting times occasionally delays do occur and a form of entertainment (a book or a tablet) may make the time pass more comfortably. You will have access to free Wi-Fi I the Hospital.

You will be seen by your surgeon and anaesthetist prior to the operation. If you have not already done so your surgeon will go through the consent form with you, explaining the risks and benefits of the procedure to you

Will I have sedation?

A hysteroscopy with division of adhesions is usually carried out under general anaesthesia, meaning you will be asleep. Please ensure that a family member/friend is available to take you home from your procedure and to stay with you for 8 hours.

What happens after my procedure?

You will be taken to recovery for 15-30mins, where your vital signs will be monitored closely. Following this, the nurses will continue to monitor you for an hour or more, until you are well to go home. We usually recommend treatment with high dose oestrogen for a month or so after surgery to encourage the endometrium to regrow and reduce the risk of adhesions reforming.

What should I expect after my procedure?

Side effects of your procedure:

• Bleeding: You will experience some bleeding for up to 2weeks after your surgery. This will be at its heaviest in the initial 48hrs following your hysteroscopy and division of adhesions and are expected to be spotting to a light period level. After this, the bleeding should subside but you may continue to have some light spotting. It is advised that you use sanitary towels and avoid tampons.
• Pain: You are likely to experience some pelvic discomfort, similar to strong menstrual cramping. Your nurse will advise you fully on how to manage this and your consultant may prescribe some medication for you to take home.
• You may also find yourself feeling more fatigued than usual for the remainder of the day.

Risks & Presentation

As with all surgery, there are risks associated with hysteroscopy. They are, however, small and rare. The most significant risk is infection, bleeding, perforation of the uterus and thrombosis.

Signs of infection include:

• Temperature of 38.0 or higher
• Fever/chills
• Joint pain
• Discharge which has an unpleasant odour
• Excessive bleeding – passing large clots following your procedure or changing 4 or more pads per hour
• Bleeding which does not decrease 48hrs following your procedure (be aware spotting for up to 2 weeks after your procedure is normal)
  
• Perforation of the uterus: This is a particularly rare complication where a small hole is punctured through the uterus. The following symptoms could give rise to suspicion of a perforation:If this occurs, please observe for the following:
• Severe pelvic pain
• Abdominal distension (sudden swelling)
• Exhaustion
• Nausea and vomiting
• Thrombosis: Thrombosis can occur when the blood flow in the large veins in your legs slows down as a result of immobility after surgery. High oestrogen therapy can increase the tendency of the blood to clot and increase the risk of thrombosis. Signs of thrombosis include pain in the lower leg or behind the knee, shortness of breath, chest pain and a persistent dry cough.

For 24 hours after the procedure: (If you had sedation or general anaesthesia)

Do not:

• Drive or ride a vehicle
• Drink alcohol
• Operate machinery
• Sign documents or make important decisions
• Return to work

Do:

• Rest quietly at home
• Eat normal, healthy meals and drink plenty of fluids
• Take extra care with electrical appliances as your coordination may be affected if
  you have had an anaesthetic

Medication after Surgery for Division of Adhesions

Depending on the severity of any adhesions found, Mr Lower may leave a copper IUCD in situ which would be removed after four weeks, or insert a uterine balloon stent which would be removed after 17 days (the tiny tube to the stent can often hang slightly outside the vagina, this is normal and nothing to worry about, it cannot slip out although it can feel like it might.) If you have a stent in place, Mr Lower may prescribe Azithromycin tablets 250mg (take as directed) take one tablet daily for 17 days, starting from date of surgery. This is a mild antibiotic that you will take as a prophylactic to guard against any infection following the procedure. You may be asked to take hormone therapy for four weeks following the procedure. We commonly use the following protocol:

• Progynova (oestradiol valearate) 2mgs tablets (take as directed, starting from date of surgery – take two tablets twice daily for 28 days)
• Aspirin 75 mgs tablets (Usually as Junior Aspirin or cardioprotective aspirin – take one daily x 28 days (take this in addition to Progynova therapy for 28 days). This can reduce the risk of thrombosis.
• Provera 10mgs one tablet daily for 7 days (take for days 22-28 of progynova therapy, i.e. take in addition to the last 7 days of your oestrogen therapy)

Don’t worry if, during the course of the above medication, you experience some bleeding or watery discharge, this is called ‘breakthrough bleeding’ – it is common and nothing to worry about. Please continue and complete the 28-day course.
An operation report will follow in due course for you to forward to your GP.

If you notice any of the following or have any urgent queries as an emergency, please contact our office on 020 7486 2440 where, if after office hours, an emergency number is given :

• Severe abdominal pain and tenderness
• Visible swelling of the tummy
• Nausea or vomiting
• Dark vomitus
• Fevers and chills
• Shortness of breath or chest pain