Diagnostic hysteroscopy: how to describe polyps, submucosal fibroids and adhesions in the report

Diagnostic hysteroscopy answers a question that ultrasound raises and does not always resolve: what exactly is inside the uterine cavity. The report has value when it describes the finding the way the surgeon needs in order to plan operative hysteroscopy, or to decide that it is not necessary.

This article follows the order of the procedure, from entry into the canal to the cavity.

Cervical canal

External os, course of the canal, presence of stenosis, endocervical polyps, cysts and adhesions. Difficulty of advancement and the need for dilation should also be recorded: they affect the planning of the surgical procedure.

Uterine cavity and ostia

Shape of the cavity (normal, elongated, T-shaped, arcuate, with a septum), visibility of the two tubal ostia and appearance of the fundus. When an ostium is not seen, the report should state the probable reason (adhesion, fibroid, polyp, insufficient distension).

Endometrium

Apparent thickness, color, vascularity and surface, correlated with the cycle phase or with postmenopause. Atypical vascularity, irregular or friable areas should be described and biopsied, with the location noted.

Polyps

Number, location (anterior wall, posterior wall, lateral walls, fundus, cornua), estimated size, base (pedunculated or sessile) and appearance of the surface and vessels. A polyp with atypical vascularity or an irregular surface deserves emphasis, because it changes the priority of resection.

Submucosal fibroids: Wamsteker and Lasmar

The Wamsteker classification, adopted by the European Society for Gynaecological Endoscopy (ESGE), describes the proportion of the fibroid within the cavity:

• Type 0: pedunculated, entirely intracavitary.
• Type 1: sessile, with less than 50% intramural.
• Type 2: sessile, with 50% or more intramural.

The Lasmar (STEPW) classification adds up five criteria to estimate the complexity of hysteroscopic myomectomy:

• Size: up to 2 cm (0), 2 to 5 cm (1), above 5 cm (2).
• Topography: lower (0), middle (1) or upper (2) third of the cavity.
• Extension of the base: up to 1/3 of the wall (0), 1/3 to 2/3 (1), above 2/3 (2).
• Penetration into the myometrium: none (0), up to 50% (1), above 50% (2).
• Lateral wall: plus 1 point when the fibroid is on the lateral wall.

A sum of 0 to 4 indicates low complexity (group I), 5 to 6 high complexity, with a possible need for a two-step procedure (group II), and 7 to 9 indicates that another approach should be considered (group III). The two systems complement each other, and the report can include both. The FIGO classification, more commonly used in ultrasound, can also be included; see our article on uterine fibroids on ultrasound.

Adhesions and septum

Adhesions are described by the extent of cavity involvement, by consistency (thin, membranous or fibrous, muscular) and by involvement of the ostia. For a septum, the report records the extent (partial or complete) and the width of the base; differentiating a septate from a bicornuate uterus requires evaluation of the external contour by three-dimensional ultrasound or MRI.

Common errors

• Not stating whether both ostia were seen.
• Submucosal fibroid without Wamsteker or Lasmar classification.
• Polyp without number, location and base.
• Atypical-appearing endometrium described without location and without a recorded biopsy.
• Calling something a septum when it may be a bicornuate uterus, without citing the need to evaluate the external contour.

See also our article on thickened endometrium and endometrial polyp on ultrasound.

How Laudário helps

In the colposcopy and hysteroscopy module of Laudário:

• Submucosal fibroids with the Wamsteker, Lasmar and FIGO classifications.
• Image capture during the procedure, by foot pedal, Bluetooth controller, voice or smartphone.
• Recommendations in their own tab.

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