• Pelvic examination  (Mrs. B. Phipps )
• Ultrasound Scan  (Mrs. B. Phipps )
• Hysteroscopy & Currettage  (Mrs. B. Phipps )

An internal examination which can be carried out in the surgery and aims to initially assess pelvic organs status, i.e. the position, size & shape of the uterus (womb) & ovaries.

• Having a pelvic examination
• What is being assessed?

Having a pelvic examination

This investigation can be carried out in the clinic, it requires no special instruments.

The woman needs to remove the clothing from the lower half of her body, and slip on a gown.
She lies on her back on the examination couch and is asked to draw her knees up, placing her heels together and allowing her legs to relax. The doctor will insert two gloved fingers into the vagina whilst using the other hand to feel over the outside area of the lower abdomen.
This bimanual examination allows the doctor to establish an initial impression of the pelvic organs size, position & shape as well as noting the presence of any lumps or tenderness.

The procedure is often not one from which an immediate diagnosis can be reached but rather an initial investigation, which indicates what other investigations/care, if any, may be necessary.

What is being assessed?



Figure 1

Author:
B. Phipps
Clinical Nurse Specialist
Last Review: 21/02/2003

A procedure which can be carried out in two ways. One way is by using a probe placed on the abdomen - transabdominal ultrasound scan. The second is by using a probe inserted into the vagina - transvaginal ultrasound scan. In both of these procedures sound waves are used to produce echos off the pelvic organs, resulting in a visual appreciation of the internal organs status.

• Having an ultrasound scan
• Purpose of an ultrasound scan
• Images obtained from this procedure

Having an ultrasound scan

The woman removes the clothes from the lower half of her body and slips on a gown. She lies on the examination couch on her back. If the scan is to be carried out transvaginally the woman will be asked to lift her legs into supports or stirrups. The probe is then placed either into the vagina or on the lower abdominal wall. The procedure is relatively non invasive, painless and well tolerated. If having a transvaginal scan then there may be some minimal discomfort associated with the presence of the probe in the vagina.



Figure 2



Figure 3

Purpose of an ultrasound scan

This procedure provides more detailed information on the uterus and pelvic anatomy. The size of the uterus in total, as well as the individual layers of the organ can be determined. A measurement of the lining tissue alone can indicate the presence of abnormal cellular changes. Structural abnormalities of the uterus such as polyps, fibroids and tumours can also be diagnosed. Ovaries can be visualised and measured and the presence of cysts or tumours determined. The advent of this procedure has meant that women can be more easily & speedily screened using a relatively non invasive procedure. The vast majority of those women will require no further investigation. Whilst the few who demonstrate specific abnormalities in need of additional investigations can access them more readily. It is a cost effective measure which eliminates the need for all women to undergo the more invasive practices.



Figure 4 - Transvaginal ultrasound scan of the uterus showing Endometrial echo



Figure 5 - Saline instillation sonohysterography showing an endometrial polyp.
Courtesy of Mr N Amso, University Hospital of Wales, Cardiff

Images obtained from this procedure



Figure 6 - Hysteroscopic view of atrophic Endometrium in a post Menopausal woman



Figure 7 - Hysteroscopic view of fibroid polyp



Figure 8 - Hysteroscopic view showing fleshy polyp on the right lateral uterine wall

Author:
B. Phipps
Clinical Nurse Specialist
Last Review: 21/02/2003

A procedure which enables visualisation of the uterine cavity with the taking of an endometrial sample.

• Having a hysteroscopy & currettage
• Purpose of this procedure
• Information obtained from this procedure

Having a hysteroscopy & currettage

This procedure is generally carried out as an outpatient investigation in the gynaecological clinic.
As such the duration of the event is likely to take no more than 10 minutes.

The woman removes the clothes from the lower half of her body, slips on a gown and lies on the examination couch on her back. She will be asked to lift her legs into supports or stirrups. An instrument called a speculum will be inserted into the vagina, this then allows the walls of the vagina to be gently parted so that the neck of the womb (cervix) can be seen. A local anaesthetic is usually then injected into the cervix and allowed to take effect (usually after a minute or two) before the procedure continues. Firstly the doctor will open the cervix slightly using a dilator to enable the hysterscope (fig 6) to be gently inserted via the cervix into the cavity of the womb (uterus). As the walls of the uterus are normally in contact with each other the doctor instills some air or salt solution into the cavity to enable visualisation of the cavity to occur. The hysterscope has an eye piece which allows the doctor to view the uterine cavity and take a selected biopsy from the lining tissue (endometrium). It may also be that the pictures the doctor can see of the inside of the uterine cavity are displayed on a monitor allowing the woman to view the images too. This procedure whilst being perhaps the most invasive one performed in the out patient clinic, should be relatively pain free. Some discomfort may be experienced because of the speculum in the vagina and there may be a period like pain experienced when the cevix is dilated or when the biopsy is taken. After the procedure is over and the woman gets up off the couch she may experience a pain in the region of her shoulder. This is due to the air that was used during the procedure dissipating and settling beneath the diaphragm, which may produce a referred pain in the shoulder. Whilst uncomfortable momentarily it is perfectly harmless and the woman should not only be warned that this might happen but reassured if it does.



Figure 9

NB: whilst it is now common practice to perform this procedure under a local anaesthetic it is also occasionally requested that the woman has a general anaesthetic for the procedure. This is step is usually reserved for a woman in whom the insertion of the hystersope may be technically more difficult. This may be the case because of previous surgery that the woman has undergone to this part of the body.

Purpose of this procedure

A hysteroscopy allows a detailed assessment of the uterus to be carried out. It is a procedure that may follow earlier lower grade investigations such as the bimanual examination, endometrial sampling or pelvic scan. It may however be the first investigation ordered as in cases of abnormal vaginal bleeding. This is because the information gleaned from this investigation is more detailed and accurate than the lower grade investigations.

Information obtained from this procedure