A hysteroscopy is a simple surgical procedure that is performed either to diagnose or to treat a problem within the uterine cavity. During hysteroscopy, the physician inserts a small fiber-optic telescope through the cervix and into the uterus. Either gas or liquid can be used to distend the uterus and allow the physician to directly visualize the uterine cavity. The physician may also introduce small instruments into the uterus to cut scar tissue or remove polyps or fibroids. Although diagnostic hysteroscopy can be performed in the physician’s office under local anesthesia, operative hysteroscopy usually requires anesthesia because of the cramping that occurs during uterine manipulation. Complications of hysteroscopy are rare but may include infection, bleeding, uterine perforation, damage to adjacent structures, and even death.

A water sonogram (hysterosonogram) is a specialized ultrasound examination performed using a transvaginal ultrasound probe. First, a small catheter is passed through the cervix and into the uterine cavity. Sterile saline is then introduced into the cavity while a transvaginal sonogram is performed, allowing the physician to visualize any uterine polyps or fibroids. Usually, a hysterosonogram does not provide any information about the status of the fallopian tubes. Nevertheless, hysterosonograms are helpful in identifying the presence of an endometrial polyp seen on routine sonogram or the location of a fibroid (see Figure 3). A hysterosonogram has limited benefit in evaluating for the presence of uterine scar tissue and is a diagnostic and not therapeutic procedure.

A hysterosalpingogram (HSG) is similar to a hysterosonogram in that fluid is introduced into the uterine cavity. However, the fluid is not saline but rather is a radio-opaque dye. This dye is introduced into the uterus and, under fluoroscopy, the dye is observed as it sequentially fills the uterine cavity and then passes out into the fallopian tubes and ultimately spills out of the ends of the tubes and into the pelvis. The HSG can be used to diagnose polyps and fibroids and is superior to hysterosonogram in evaluating the presence of uterine scar tissue. This imaging procedure also provides information on the status of the fallopian tubes, unlike either a hysteroscopy or a hysterosonogram. Because it employs traditional x-rays, an HSG is usually performed at a hospital’s radiology department or at a radiologist’s office, since few REs have this equipment in their offices.