A very useful office procedure is diagnostic hysteroscopy.  This is a procedure which has replaced the traditional D&C (dilatation and curettage) for evaluation of abnormal bleeding.

Diagnostic hysteroscopy is a surgical procedure in which the mouth of the uterus is stretched (dilated) and a scraping instrument (a curette) is inserted into the cavity of the uterus and the lining of the cavity is scraped.  The tissue is sent to a laboratory for analysis and a biopsy.  It is routinely performed in an office setting.  The procedure usually does not require anesthesia because it is usually not associated with pain.  Hysteroscopy involves the insertion of a very narrow scope through the vagina passing it through the opening of the cervix into the cavity of the uterus.  Normally a camera and a light system are affixed to the end of the scope allowing the image of the inside of the uterus to be displayed on a TV monitor.  This permits both the patient and the physician to see the inside of the uterus and to discuss any abnormalities that are detected.  One of the advantages of this procedure is that it allows for the diagnosis of subtle tumors that grow inside the cavity of the uterus known as submucous myomas. These are associated with extremely heavy bleeding and are quite commonly not detectable by other tests. 

The uterus itself may overall be normal in size on pelvic examination as well as in appearance on ultrasound or MRI.  Numerous women over the years who have had severe bleeding from what seemed to be a normal uterus by other evaluations have been subjected to hysterectomy in the belief that they had an unknown condition that could not otherwise be treated.

This is exemplified by the young woman patient I examined whose menstrual bleeding was so severe that she required blood transfusions.  The origin of the life-threatening bleeding which had led to multiple D&Cs as well as several transfusions had not been diagnosed by previous evaluation.  When we performed a diagnostic hysteroscopy, a small fibroid approximately one and a half inches in diameter was found inside the cavity of the uterus.  The detection of this small tumor then allowed us to simply remove this tumor avoiding the necessity of removing her uterus. – Francis Hutchins, Jr., M.D.