Diagnostic Hysteroscopy: A Close Look Inside the Uterus
Diagnostic hysteroscopy passes a thin telescope through the cervix so the doctor can see the inside of the uterus directly. It is usually done as an outpatient procedure, often without any anaesthetic, and it is the most direct way to confirm or exclude polyps, fibroids, adhesions and other problems of the cavity.
What diagnostic hysteroscopy is
A hysteroscope is a slim telescope with a light and a camera. It enters through the vagina and cervix, and the uterine cavity is gently filled with fluid (usually saline) so the lining, the tubal openings and the cavity shape can be seen on a screen. "Diagnostic" means the aim is to look, take a targeted biopsy if needed, and plan treatment. When a problem can be treated at the same visit, the term is "see-and-treat" hysteroscopy.
Ultrasound shows the uterus from the outside, through the abdomen or vagina. Hysteroscopy shows the cavity itself, which is why it can find small lesions that scans miss and lets the doctor take a biopsy exactly where it is needed.
Why it is done
Common reasons to advise diagnostic hysteroscopy include:
- Heavy, prolonged or irregular periods, or bleeding between periods, especially when polyps, submucosal fibroids or changes in the endometrium are suspected. In the FIGO PALM-COEIN system these are the structural causes of abnormal uterine bleeding (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia).
- Bleeding after the menopause, particularly when an endometrial biopsy is not possible or does not give a diagnosis, or when bleeding continues.
- An unclear scan or biopsy result, for example a thickened or irregular endometrium, or a suspected polyp.
- Difficulty conceiving or repeated miscarriage, where the cavity needs to be checked for polyps, adhesions or a septum.
- Suspected intrauterine adhesions, a uterine anomaly, retained tissue or a misplaced coil.
What the guidelines say
| Body | Document | Relevant position |
|---|---|---|
| NICE | Heavy menstrual bleeding, NG88 | Offer outpatient hysteroscopy when history suggests submucosal fibroids, polyps or endometrial pathology. Organise services so "see-and-treat" can happen in one setting where feasible. Take an endometrial sample only in the context of diagnostic hysteroscopy. If a woman declines outpatient hysteroscopy, offer it under general or regional anaesthesia. |
| RCOG / BSGE | Best Practice in Outpatient Hysteroscopy (Green-top 59) | Every unit should offer a dedicated outpatient service in a treatment room rather than a formal theatre, with a chaperone. Vaginoscopy should be the standard technique, miniature scopes (about 2.7 mm) should be used for diagnosis, and routine cervical preparation and routine blind dilatation should be avoided. |
| RCOG / BSGE | Management of Endometrial Hyperplasia (Green-top 67) | Consider hysteroscopy when outpatient biopsy fails or is not diagnostic, when bleeding persists, or when hyperplasia is found in a polyp or focal lesion. Atypical hyperplasia should be confirmed on formal hysteroscopy before fertility-sparing treatment. |
| AAGL / ESGE / GCH | Visually directed hysteroscopic biopsy, joint practice guideline (2026) | Recommends hysteroscopy with directed biopsy over blind sampling for hyperplasia, malignancy, polyps and submucosal fibroids, and advises building it into the abnormal and postmenopausal bleeding pathway when feasible. The authors note the evidence base is small and at risk of bias. |
| FIGO | PALM-COEIN classification of abnormal uterine bleeding | Separates structural causes found by imaging, hysteroscopy or histology from non-structural causes, so each woman is described with the same terms. |
How accurate is it?
Hysteroscopy is better at finding disease than at ruling it out. The RCOG/BSGE hyperplasia guideline, drawing on a systematic review, reports that a normal hysteroscopy lowered the chance of endometrial disease from 10.6% to 2.8%, while a suspicious one raised it to 55.2%. This is why a biopsy matters: the doctor sees a lesion, and the pathologist confirms what it is.
The same logic explains the joint society recommendation for visually directed biopsy. A blind sample can miss a focal lesion such as a polyp, and cannot confirm that a visible lesion has been completely removed. In a 2026 study of 250 women with infertility, hysteroscopy found intrauterine abnormalities in 51.6%, against 18.0% on transvaginal ultrasound, although these were women referred to a tertiary unit and the figures will not apply to everyone.
What to expect on the day
- Before. You should receive written information in advance and be asked for consent. Pregnancy is excluded first. Most women are advised to take a simple painkiller such as paracetamol or ibuprofen about an hour beforehand if they have used it safely before.
- During. You lie in a gynaecology position, usually with a nurse chaperone present. Using vaginoscopy, the small scope is passed through the vagina and cervix without a speculum or cervical grasping where possible. The cavity is distended with saline, the doctor inspects it, and a biopsy is taken if needed. The examination usually takes only a few minutes.
- Comfort. Cramping like period pain is common. Local anaesthetic around the cervix may be offered, especially after the menopause or if a larger scope is needed. Routine opioids and routine sedation are not recommended. Warm saline may reduce pain slightly, according to a Cochrane review.
- After. Most women go home soon afterwards and can return to normal activities the same day or the next. Mild cramps and light bleeding for a few days are common.
If a general anaesthetic is preferred or needed, for example when outpatient hysteroscopy is not tolerated or is declined, NICE advises that it should be offered.
Risks and when to seek help
Diagnostic hysteroscopy is a low-risk procedure. The RCOG/BSGE guideline estimates the risk of uterine perforation at between 0.002% and 1.7%, and notes it is lower with small scopes under direct vision. Risk factors include blind dilatation of the cervix, a narrowed or twisted cervical canal and a tilted uterus. A fainting-type (vasovagal) reaction can occur, and saline distension reduces it compared with carbon dioxide. Infection and heavy bleeding are uncommon.
Contact your clinic or seek urgent care if, after the procedure, you have fever, heavy bleeding, severe or worsening abdominal pain, or a foul-smelling discharge. This is general advice; follow the instructions your own team gives you.
When another approach may be better
- Tubes or pelvis are also in question. Hysteroscopy sees only the cavity. If tubal disease, endometriosis or pelvic adhesions are suspected, a combined hystero-laparoscopy may be considered. See our article on combined hystero-laparoscopy.
- Scan questions only. For some women a transvaginal ultrasound or saline sonography is a reasonable first step, as NICE advises choosing between ultrasound and hysteroscopy according to the history and examination.
- A lesion is found. Many polyps and some fibroids can be removed at the same visit or at a planned follow-up, depending on size and the unit's facilities.
Frequently asked questions
Is diagnostic hysteroscopy painful?
Most women describe period-like cramps that settle quickly. Vaginoscopy, a miniature scope, saline distension and simple painkillers all reduce discomfort, according to the RCOG/BSGE guideline. Tell your doctor if it becomes too uncomfortable; the procedure can be paused or stopped.
Will I need an anaesthetic?
Often not. Outpatient hysteroscopy is commonly done without any, using a small scope. Local anaesthetic can be added, and general anaesthesia is offered if you decline the outpatient route.
How long does it take?
The examination itself is usually brief, a few minutes. Plan for longer overall to allow for the consultation, consent and a short rest afterwards.
Sources
This article is educational and does not replace individual medical advice. Guideline details were taken from the pages below, some via summaries; confirm exact recommendations against the originals before clinical use.
- RCOG/BSGE Best Practice in Outpatient Hysteroscopy (Green-top 59)
- RCOG/BSGE Management of Endometrial Hyperplasia (Green-top 67)
- NICE NG88, Heavy menstrual bleeding: key points and GPonline summary
- AAGL/ESGE/GCH joint practice guideline on visually directed hysteroscopic biopsy (2026)
- Istanbul Medical Journal: AUB by PALM-COEIN classification
- Clark et al., Accuracy of hysteroscopy in endometrial cancer and hyperplasia, JAMA 2002
- Ghosh et al., combined hysterolaparoscopy yield, IJRCOG 2026
- Cochrane review: uterine distension media for outpatient hysteroscopy
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