The Hysteroscopy Encyclopedia

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Hysteroscopic appearance of the uterine cavity:
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The cavity is seen in a length wise direction and the proportions are no longer maintained, the foreground being enlarged compared with the background. The distortion is dramatically increased by the optical instrument. If this situation is advantageous for the study of small details, a mental correction is always necessary to restore the true size, extent of each structure relative to the other.(Barbot,1989).

    With panoramic hysteroscopy, the endocervical canal appears as a  barrel-shaped cavity, its cross section is cirular. It is best examined during the removal of the endoscope. The relief of arbor vitae, made up of long and oblique folds separated by furrowes is nicely displayed. (Barbot,1989).

    The internal os appears as a dark round hole, its size depends on the pressure of the distending medium.

    The cavity is viewed as a suite of two chambers connected by a large opening (circular or oval). The lower chamber (cone shaped) with the vertex down, often appears cylindrical because of the distortion of the optical system. The upper chamber is composed of a central portion, the fundus and two lateral conical parts which are the cornu joined by the tube. (Barbot,1989).

    The interior of the cavity, particularly when liquid media are used, appears cloudy with fine debris floating in the medium. When CO2 is the distending medium, the endometrium is artificially flattened. (Baggish,1992).

    The thickness, color, vasculature and consistency of the mucous membrane covering the uterine cavity vary with the time of menstrual cycle. The gland openings appear as white-ringed elevations surrounded with a netlike vessels. (Baggish,1992).

    The thickness of the endometrium can be easily appreciated by placing pressure on the telescope and pushing on the posterior wall of the uterus. This maneuver creates a groove in the endometrium (Baggish,1992).

    After menstruation and up to the 10th day of the cycle, the endometrium is pale with a smooth surface. With  a magnifigation of x20, the glands are well identified but do not stand out in relief, and capillary vascularisation is minimal. From day 11 to 13, the endometrium becomes more congested and pink as the capillary vessels grow and the thickness increases. At ovulation, the endometrium is pale and oedematous and the glands become more obvious. (Hamou & Lewis, 1991).

    During the secretory phase of the cycle, endometrial edema and vascularisation increase and the glands show slightly in relief, with a surrounding capillary network. Hamou and  Lewis, 1991, said that there are discrepancies between the predicted dates on hysteroscopy and the actual dates calculated from the last menstrual peroid. (Hamou & Lewis, 1991).

    The atrophic endometrium has a characteristic appearance, sometimes becoming very pale or brillian white. The endometrium is thin , being less than 1 mm thick, and glands are rarely seen even with higher magnification (Hamou & Lewis, 1991).

    In case of endometrial hyperplasia, the surface is rough, endometrium is thick with rich superficial vascularisation is observed. The endoscopic examination easily provokes haemorrhage.

    Hysteroscopically the tubal ostium may show various appearances.It is better seen during the proliferative phase.  It may be circumscribed by a circular mucosal fold followed by a dilated portion or the mucosal folds may be incomplete semicircular. Under direct CO2 flow the ostium presents a typical pattern of slow opening and rapid closure.  Sometimes, ostium is reduced to a plain, narrow hole without any fold or dilatation. In the premenstrual women, the cornual orifice may be partly obscured by endometrial edema  (Hamou & Lewis, 1991).
In reality, the tubal ostium is often punctiform only the pressure of the distending medium makes it wide open.