Vital staining is a useful and known technique to study normal and abnormal endometria [1Marconi G Vilela M Quintana R Diradourián M Young E Sueldo C. New observations on endometrial physiology after transcervical injection of methylene blue dye.Fertil Steril. 2004; 82: 1700-1704Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar, 2Gupta T Singh S Verma AK. Role of chromohysteroscopy in evaluation of endometrial pathology using methylene blue dye.J Obstet Gynaecol India. 2019; 69: 363-368Crossref PubMed Scopus (1) Google Scholar, 3Küçük T Deveci S. “Chromohysteroscopy” for evaluation of endometrium in recurrent miscarriage.Clin Exp Obstet Gynecol. 2008; 35: 133-136PubMed Google Scholar, 4Küçük T Safali M. “Chromohysteroscopy” for evaluation of endometrium in recurrent in vitro fertilization failure.J Assit Reprod Genet. 2008; 25: 79-82Crossref PubMed Scopus (11) Google Scholar]. A 25-year-old woman with 2-year primary infertility was taken up for hysteroscopic evaluation. The entire uterine cavity was unremarkable for any pathologic condition. The endocervical canal was then stained with Waterman blue ink (Chelpark blue ink; Chelpark Company Private Ltd., Bangalore, India, or Parker blue ink; Luxor Writing Instruments Pvt. Ltd., New Delhi, India) [5Kumar A Kumar A Microcolpohysteroscopy.J Am Assoc Gynecol Laparosc. 2004; 11: 131-132Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar] by inserting a cotton pledget into the endocervical canal for a few seconds. The transformation zone when viewed at 80 × magnification in the contact mode using the Hamou Microhysteroscope II (26157 BT; Karl Storz, Tuttlingen, Germany) [5Kumar A Kumar A Microcolpohysteroscopy.J Am Assoc Gynecol Laparosc. 2004; 11: 131-132Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar,6Hamou JE Taylor PJ Sciarra JJ. The optical basis for and principals of endoscopic instruments.Hysteroscopy and Microcolpohysteroscopy: Text and Atlas. Appleton & Lange, Norwalk1991: 18Google Scholar] revealed a papillary structure of the transformation zone lined by initial squamous metaplastic cells; the nuclei of the initial squamous metaplastic cells were well visualized; the afferent, efferent, and interconnecting arterioles containing red blood cells were clearly visible; and the papillary stroma contained cellular infiltrate (Fig. 1). Columnal cells remain unstained with Waterman blue. By dragging the microhysteroscope II over the left lateral wall toward the external os, the transformation zone was seen; the squamous metaplastic cells located superiorly appeared a bit hazy, being a little out of focus, and the inferiorly located squamous cells were seen (Fig. 2). By rotating the microhysteroscope to the posterior wall, the multiple papillae of the transformation zone lined by squamous metaplastic cells were seen; the stroma contained cellular infiltrate (Fig. 3). The squamous cells were not seen, being out of focus. By further dragging the microhysteroscope toward the inferior rim of the transformation zone near the external os, multiple polyhedral squamous cells of the proximal transformation zone with prominent pyknotic nuclei were clearly seen, and the junctions between the squamous cells were starkly visible [5Kumar A Kumar A Microcolpohysteroscopy.J Am Assoc Gynecol Laparosc. 2004; 11: 131-132Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar] (Supplemental Fig. 1). The nucleocytoplasmic ratio of the squamous cells seemed normal, and no mitotic spindles were seen inside the cytoplasm of the squamous cells. The biopsy from this region of the transformation zone consisted of tissue lined by columnar epithelium, and the subepithelial tissue showed endocervical glandular tissue. The entire picture was suggestive of a normal study.Fig. 2The transformation zone. Squamous metaplastic cells are toward the right side, and the squamous cells toward the left side are out of focus.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig. 3The transformation zone. Squamous metaplastic cells are toward the left side, and the squamous cells are out of focus.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Download .jpg (1.64 MB) Help with files Supplemental Fig. 1. Squamous cells of the transformation zone.

A 27-year-old woman with 3-year primary infertility and 3 failed cycles of in vitro fertilization was referred for a hysteroscopic evaluation. On hysteroscopy, the endocervical canal and the uterine cavity appeared unremarkable for any pathology; thus, attention was focused on the cervix. The ectocervix was diffusely covered with a subtle hyperemia, which also could be overlooked (Fig. 1). The anterior and the posterior lips of the cervix were visualized with a Hamou II micro-hysteroscope (model 26157 BT; Karl Storz, Tuttlingen, Germany) in the contact mode [ 1 Hamou J.E. Taylor P.J. Sciarra J.J. The optical basis for and principals of endoscopic instruments. in: Hamou J.E. Taylor P.J. Hysteroscopy and Microcolpohysteroscopy: A Text and Atlas. Appleton & Lange, Norwalk, CT1991: 18 Google Scholar , 2 Kumar A. Kumar A. Microcolpohysteroscopy. J Am Assoc Gynecol Laparosc. 2004; 11: 131-132 Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar ] by placing the tip of the hysteroscope over the cervix and using 80× at-source magnification. Tortuous, unusually engorged capillaries filled with red blood cells were seen over the posterior lip of the cervix (Fig. 2), as well as over the anterior lip of the cervix (Fig. 3). Contact scanning of the squamocolumnar junction after methylene blue staining revealed multiple papillae lining the columnar epithelium and containing unusually engorged afferent, efferent vessels and interconnecting vessels filled with red blood cells (Fig. 4). Fig. 2Dilated capillaries containing red blood cells over the posterior lip of the cervix. View Large Image Figure Viewer Download Hi-res image Fig. 3Dilated capillaries containing red blood cells over the anterior lip of the cervix. View Large Image Figure Viewer Download Hi-res image Fig. 4Prominent papilla containing afferent, efferent, and interconnecting vessels filled with red blood cells over the squamocolumnar junction. View Large Image Figure Viewer Download Hi-res image

A 57-year-old menopausal woman, gravida 5 para 5, with no history of any hormonal therapy presented with irregular heavy bleeding per vaginum after 5 years of amenorrhea. A vaginal ultrasound scan was unremarkable, showing an endometrial thickness of 2.5 mm. This patient was posted for hysteroscopic evaluation. The anterior uterine cavity wall seen in panoramic view revealed multiple whitish abscess like circumscribed lesions that appeared distinctly pale in comparison with the surrounding endometrium (Fig. 1). A closer visualization (Fig. 2) revealed lesions that were oval in shape and had sharp regular margins, and the endometrium surrounding the lesions appeared dirty, pale, and irregular with no visible endometrial gland openings. The endometrium did not bleed on touch. Targeted biopsies were taken from the rounded lesions. Histopathology revealed endometrium with atrophic changes along with caseating epitheloid granulomata; there was no evidence of malignancy. BACTEC culture (Becton, Dickinson and Company, Sparks, MD) was also suggestive of endometrial tuberculosis. The patient was administered antitubercular therapy, to which she subsequently responded. Fig. 2Closer visualization reveals the regular sharp contours of the endometrial tubercular abscesses. View Large Image Figure Viewer Download Hi-res image

Hysteroscopically, chronic endometritis is characterized by micropolyps <1 mm in size, endometrial edema, irregular endometrium, and hyperemic areas with prominent white glands [ 1 Cicinelli E. Resta L. Nicoletti R. et al. Detection of chronic endometritis at fluid hysteroscopy. J Minim Invasive Gynecol. 2005; 12: 514-518 Abstract Full Text Full Text PDF PubMed Scopus (96) Google Scholar , 2 Cicinelli E. Resta L. Nicoletti R. et al. Endometrial micropolyps at fluid hysteroscopy suggest the existence of chronic endometritis. Hum Reprod. 2005; 20: 1386-1389 Crossref PubMed Scopus (108) Google Scholar ]. A 30-year-old woman suffering with secondary infertility and menorrhagia was referred for hysteroscopic evaluation. A vaginal ultrasound was unremarkable, and the endometrial thickness was 5 mm.

Adenomyotic cysts are frequently implicated with dysmenorrhea and menometrorrhagia [ 1 Preutthipan S. Herabutya Y. Hysteroscopic rollerball endometrial ablation as an alternative treatment for adenomyosis with menorrhagia and/or dysmenorrhea. J Obstet Gynaecol Res. 2010; 36: 1031-1036 Crossref PubMed Scopus (16) Google Scholar , 2 Dakhly D.M. Abdel Moety G.A. Saber W. Gad Allah S.H. Hashem A.T. Abdel Salam L.O. Accuracy of hysteroscopic endomyometrial biopsy in diagnosis of adenomyosis. J Minim Invasive Gynecol. 2016; 23: 364-371 Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar , 3 Gordts S. Campo R. Brosens I. Hysteroscopic diagnosis and excision of myometrial cystic adenomyosis. Gynecol Surg. 2014; 11: 273-278 Crossref PubMed Scopus (42) Google Scholar , 4 Basak S. Saha A. Adenomyosis: still largely under-diagnosed. J Obstet Gynaecol. 2009; 29: 533-535 Crossref PubMed Scopus (17) Google Scholar ]. Endometrial resection was performed in a 29-year-old woman suffering with menorrhagia and dysmenorrhea. Suddenly, a large crater-like tear appeared over the left posterolateral uterine cavity wall and brownish turbid fluid began gushing out; this was momentarily confused with a perforation (Fig. 1). Within about 15 seconds the initially gushing brownish fluid was reduced to a mere trickle, which finally stopped. A closer inspection of the ruptured cavity revealed the dark red mucosal lining of an approximately 10-mm cyst (Fig. 2), the wall of which was accidentally cut during endometrial resection. The myometrium adjacent to the cystic crater was resected only to find that the crater was extending deep into the myometrium (Fig. 3). The entire cyst was carefully resected along with its mucosal lining. The surgery was completed satisfactorily, and the postoperative period was uneventful. The histopathology of the endomyometrial tissue pieces revealed myometrium with adenomyosis and endometrium in the proliferative phase. Three years after the surgery the patient is symptom free with respect to menorrhagia and dysmenorrhea. Rupture of an adenomyotic cyst is a rare complication associated with endometrial resection, but it can unnecessarily alarm a surgeon who encounters it for the first time. Fig. 2The myometrial cyst cavity is seen lined by reddish mucosa. View Large Image Figure Viewer Download Hi-res image Fig. 3A crater-like ruptured cyst extending deep into the myometrium. View Large Image Figure Viewer Download Hi-res image

You can discuss this article with its authors and with other AAGL members at http://www.AAGL.org/jmig-22-4-JMIG-D-15-00044

You can discuss this article with its authors and with other AAGL members at http://www.AAGL.org/jmig-21-4-JMIG-D-13-00663 Comment on “Broken Tip of Karman Cannula Removed at Hysteroscopy”Journal of Minimally Invasive GynecologyVol. 22Issue 4PreviewWe recently came across the article by Kumar and Kumar, “Broken tip of Karman cannula removed at hysteroscopy” [1], in the “Images in Gynecologic Surgery” section of the Journal, and we were very surprised. We previously published a case of pyometra due to the retained broken tip of a plastic cannula [2]. Our case was a 48-year-old, gravida 2 para 2, who complained of purulent and foul-smelling vaginal discharge. Transvaginal ultrasound showed a 3-cm-thick fluid collection in the intrauterine cavity along with a hyperechoic mass (Fig. 1). Full-Text PDF

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The purpose of this study is to demonstrate high resolution hysteroscopic images of surface architecture in 7 cases of endometrial tuberculosis by utilizing 20X at source magnification.

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This article describes the benefit of monitoring the intravasation rate in addition to the conventional measurement of fluid deficit in hysteroscopic surgical procedures. The intravasation rate is the rate, in milliliters per minute, at which fluid enters the systemic circulation, whereas fluid deficit is the amount of irrigation fluid, in milliliters, already absorbed by the patient. To determine the intravasation rate, a manually operated intravasation monitoring pump was constructed, with which one of us (Dr. Atul Kumar) performed 966 hysteroscopic procedures from May 1993 to February 2010. Because the intravasation rate had to be manually calculated by an assistant, it was decided to replace the assistant with a controller to monitor intravasation rate. The surgical experience gathered from the manually operated pump was used to develop algorithms for the controller. The controller-operated intravasation monitoring pump was constructed, with which 41 hysteroscopic procedures were performed from March 2010 to August 2011. In hysteroscopic procedures, this pump simultaneously displays the real-time intravasation rate and the fluid deficit on an LCD screen.

You can discuss this article with its authors and with other AAGL members at http://www.AAGL.org/jmig-19-3-11-00295

This video demonstrates benign mullerian papilloma of the cervix in a 4 year old girl with spotting per vaginum who was referred for vaginoscopy. The hysteroscope was introduced through the intact hymen opening. The vaginal walls were unremarkable, and there was no evidence of any foreign body. The cervix had a rough surface with irregular contours. Prominent capillary vessels were observed over the ectocervix, and such dilated superficial vessels were more clearly visualized in the contact mode. A biopsy specimen was obtained from the cervix, with no bleeding during the process. Histopathologic analysis revealed squamous and flattened epithelium with underlying benign mesenchymal tissue and occasional small basophilic spherules. The overall histopathologic appearance was that of a benign mullerian papilloma. This tumor, which occurs exclusively in the age group 2 to 5 years, carries a small risk of malignant transformation later in life hence this patient was advised long term follow up.

A 50-year-old woman with menometrorrhagia was referred for hysteroscopy. A 20-mm polyp was seen arising from the anterior uterine wall. The polyp was unremarkable except that its external surface appeared bright red (Fig. 1). However, an area over the posterior uterine cavity wall, which was in apposition with the polyp, appeared bright red in a well-circumscribed area (Fig. 2), and for the sake of illustration this area is termed as “mirror lesion.” “Mirror lesion” was rounded, confirming to the shape of the polyp, it had well-defined sharp margins, and its bright red texture differentiated it from the surrounding endometrium. The entire polyp was resected, and histopathologic study revealed an adenomatous polyp. Two muscle deep biopsy specimens were also taken, 1 biopsy specimen from the “mirror lesion” and the other from the region outside the mirror lesion, and histopathologic study found that both biopsy specimens comprised mainly of myometrium and occasional endometrium showed early atrophic changes. No pyogenic aerobic bacteria were grown on culture of the endometrium and the polyp tissue after 2 days incubation at 37°C. Figure 2A bright red, well-circumscribed rounded “mirror lesion” over the posterior uterine cavity wall. View Large Image Figure Viewer Download Hi-res image

Intraluminal adhesions in the interstitial part of the fallopian tube were viewed at hysteroscopy by placing the microhysteroscope tip very close to the tubal orifice and viewing with a source magnification of 25x.