A hysteroscopy examines the inside of the uterus directly, using a thin telescope passed through the vagina and the cervix, with no incisions. It shows the uterine cavity and the endometrium on a screen and allows a biopsy to be taken or a finding to be removed in the same session, as well as surgery for certain uterine malformations (metroplasty), which is what separates it from imaging tests. It is used for abnormal bleeding, suspected polyps or submucosal fibroids, retrieval of a coil and assessment of the cavity within a fertility investigation. There are two forms, diagnostic and operative, and almost everything else depends on which one you are having.
Diagnostic and operative hysteroscopy: what is the difference
The type of hysteroscopy determines the pain, the anaesthetic, the preparation and the days of recovery.
Diagnostic hysteroscopy, known in the UK as outpatient hysteroscopy, is carried out in a clinic room with fine instruments. It takes 5 to 10 minutes, with no anaesthetic or with a local anaesthetic, and you walk out afterwards. A small finding, a polyp of a few millimetres or fine adhesions, can often be dealt with in the same session: this is known as see and treat.
Operative hysteroscopy is carried out in a theatre, under sedation or general or spinal anaesthetic, with a larger instrument (8 to 10 millimetres) carrying a resection loop or a morcellator. It requires the cervix to be dilated, takes 15 to 45 minutes, and you are discharged the same day. It is the route for large or multiple polyps, submucosal fibroids, septa, adhesions and metroplasty.
Why a hysteroscopy is done
The most frequent indications are gynaecological: abnormal uterine bleeding (very heavy periods or bleeding after the menopause), a polyp, submucosal fibroid or thickened endometrium suspected on a scan, a targeted biopsy of the abnormal area rather than a blind one, retrieval of a coil whose threads cannot be found, and assessment of the cavity in recurrent miscarriage, implantation failure or suspected uterine malformation.
What a hysteroscopy does not show
Three things fall outside its reach, and they are asked about often:
- Tubal patency. The hysteroscope sees the openings where the tubes begin, but not whether they are open. That is assessed by a hysterosalpingogram, using iodinated contrast, or by contrast sonography with foam. The boundary is anatomical: those look at the tubes, a hysteroscopy looks at the cavity.
- The ovaries. They are not visible from inside the uterus and are assessed by transvaginal ultrasound scan.
- Endometriosis outside the uterus. Peritoneal deposits and endometriomas are investigated by ultrasound, MRI or laparoscopy. A hysteroscopy may suggest adenomyosis from the appearance of the endometrium, without confirming it. If adenomyotic deposits are present in the endometrium, they may be seen and even removed during the procedure.
What happens during the procedure
In the standard examination position, the gynaecologist passes the telescope. Vaginoscopy, without a speculum or tenaculum on the cervix, is the reference outpatient approach for the European Society of Human Reproduction and Embryology (ESHRE) and noticeably reduces discomfort. The route is always the same: cervical canal, cavity, distension with saline, then inspection of the walls, the fundus, the tubal openings and the endometrium. If needed, a biopsy is taken or the lesion is removed. As the instrument is withdrawn the saline comes out, which is sometimes mistaken for bleeding.
Does a hysteroscopy hurt?
In the diagnostic procedure you are awake. Most people describe period-type pain at two moments: passing through the cervix, which lasts seconds, and distension of the cavity, which lasts a couple of minutes. With a fine telescope and vaginoscopy, most rate it in the lower half of a 0 to 10 scale.
That average hides something important, and UK practice has moved to say it plainly. The Royal College of Obstetricians and Gynaecologists reports that around a third of women rate their pain above 7 out of 10 during outpatient hysteroscopy. You cannot know in advance which group you will fall into, which is why the conversation about pain relief belongs before the appointment, not during it.
Pain is more likely to be severe in four situations:
- No previous vaginal births. The cervical canal is narrower and less elastic.
- After the menopause. Atrophy and cervical stenosis make the telescope harder to pass.
- Previous cervical surgery, such as a LLETZ or cone biopsy, because of the scarring it leaves.
- High anxiety, which raises muscle tone and lowers the pain threshold.
In the operative procedure you feel nothing, because it is done under sedation or anaesthetic. The discomfort comes afterwards: period-type cramping for a few hours, which settles with ordinary painkillers.
Pain relief and anaesthetic options
The options run from least to most: nothing, an oral anti-inflammatory, local anaesthetic injected around the cervix, inhaled gas and air, conscious sedation, and general anaesthetic.
Two things are worth knowing before the appointment. All of them can be discussed and requested in advance rather than accepted by default. And you can ask for the procedure to stop at any point, including once it has started. That an examination is done in an outpatient room does not oblige you to get through it without pain relief.
Recovery: bleeding, cramping and going back to normal
After a diagnostic hysteroscopy, you are discharged immediately and normal activity resumes the same day or the next.
After an operative hysteroscopy, you are discharged the same day with someone to accompany you, and the first 24 to 48 hours are for relative rest, with no driving while the sedation wears off. Returning to work usually takes 2 to 7 days, with the upper end applying to extensive resections and to physically demanding jobs or long hours standing. There is no single figure: it is judged by the clinician who performed the procedure.
Afterwards it is expected to have light bleeding or spotting for a few days and watery or pink discharge for up to one or two weeks, using pads rather than tampons while it lasts. Baths and penetrative sex are on hold until it stops, and your next period may come a few days early or late.
Seek urgent help for a temperature above 38 °C, severe abdominal pain that does not settle with painkillers, bleeding heavier than a period, or offensive-smelling discharge.
Hysteroscopy on the NHS and privately: what affects the cost
Cost depends almost entirely on one variable: whether the procedure takes place in an outpatient room or in a theatre. An outpatient diagnostic hysteroscopy uses a clinic room, fine instruments and a few minutes. An operative one uses a theatre, an anaesthetist and considerably more time, and the price difference between the two is an order of magnitude. A biopsy, where taken, is sometimes charged separately.
On the NHS, hysteroscopy is provided where there is a clinical indication: abnormal uterine bleeding, postmenopausal bleeding, suspected endometrial pathology or retrieval of a coil. Referral may come from your GP or another clinical service. The pathway and waiting times vary by area; check with the service arranging your procedure. Within an infertility investigation, access follows local referral criteria.
Hysteroscopy and fertility
A hysteroscopy is not part of the basic infertility work-up. The evidence gathered by ESHRE has not shown that performing it routinely before a first round of IVF improves the live birth rate when the ultrasound scan is normal. The indication rests on a previous finding, and it arises in four scenarios:
- An endometrial polyp or submucosal fibroid seen on a scan. Removing them before a transfer does change the outlook, and with fibroids what matters is how much they distort the cavity.
- Implantation failure after several transfers of good quality embryos, to rule out something the scan cannot see.
- Recurrent miscarriage, where a uterine septum and adhesions (Asherman’s syndrome) are findings that can be corrected under direct vision.
- A niche or isthmocele, the scar from a previous caesarean section that collects fluid and can interfere with implantation.
At Love Fertility Clinic we assess the uterine cavity first by ultrasound scan, in 3D where the case calls for it, within the fertility test. If a finding appears that needs direct vision, we assess the indication in consultation, coordinate the procedure with the specialist who performs it and bring the result into your plan.
Frequently asked questions about hysteroscopy
How long does a hysteroscopy take?
The diagnostic procedure takes 5 to 10 minutes. The operative one takes 15 to 45, plus an hour or two of observation before discharge.
Do I need to fast beforehand?
Not for an outpatient diagnostic hysteroscopy. For an operative one under sedation or general anaesthetic, yes: 6 to 8 hours.
Do I need to shave beforehand?
No. Access is vaginal, there is no incision in the skin and the area needs no preparation.
Can a polyp or fibroid be removed during a hysteroscopy?
Yes. A small polyp is often dealt with in the outpatient room, with discomfort similar to the diagnostic examination; if it is large or there are several, it moves to a theatre. Of fibroids, only submucosal ones.
Do I need someone to come with me?
Not for the diagnostic procedure. For the operative one, yes: you cannot drive after sedation.
When do the results come through?
What is seen on the screen is discussed at the end. Where a biopsy was taken, the histology report takes two to three weeks and is what completes the diagnosis.
Can I have a hysteroscopy during my period?
It is better not to. The first half of the cycle is preferred, after bleeding has stopped and before ovulation, when the endometrium is thin and the view is clearer. With heavy bleeding underway the procedure is postponed. In some cases, the clinician prescribes hormonal contraception to prepare an endometrium similar to that of the first half of the cycle and allow more flexible scheduling.
