Hysteroscopy Newsletter is an opened forum to all professionals who want to contribute with their knowledge and even share their doubts with a word-wide gynecological community

Endometrial Cycle

Endometrial Cycle

The endometrium has the ability to experience cyclical changes in response to different hormonal stimuli that occur during the menstrual cycle. These changes are known as the endometrial cycle. The endometrial cycle is divided into three phases: the proliferative phase, the secretory phase and the menstrual phase.

1- The proliferative phase: starting from the end of the menstrual period to ovulation, ie, between the 4th to 14th day of the cycle. During this phase, egg development occurs and is mainly mediated by estrogen. The endometrium reaches a thickness of 1-3 mm. During this phase the endometrial lining grows due to development of the endometrial glands, the stroma and the vascular component.

2- The secretory phase: also known as the luteal phase begins at the time of ovulation up to menstruation, ie between the 14th to 28th days of the cycle. It is this phase the corpus luteum produces high levels of estrogen and progesterone. The endometrium reaches 5-6 mm thickness. The glands have some morphological changes and secretory activity becoming more tortuous and dilated. The endometrial spiral arteries are also developed.

3- The menstrual phase: in the absence of pregnancy, a sudden decline of estrogen and progesterone production by the corpus luteum produces endometrial ischemia due to vasoconstriction of the spiral arteries between 1 to 24 hours before menstruation. After the period of vasoconstriction there is return of blood flow to the superficial layers of the endometrium, resulting in detachment only of the basal layer. During this phase, uterine contractions occur to facilitate the expulsion of endometrial tissue.


“Hysteroscopic” endometrial cycle.

Hysteroscopic endometrial cycle

The changes occurring during the endometrial cycle, give the endometrium different hysteroscopic patterns typical of each phase, allowing the assessment of normal “hysteroscopic” endometrial cycle.

1- Proliferative phase: the endometrium has a light pink color due to the presence of small vessels. The surface is smooth and glands are small and rounded, appearing as small and uniform dots. The endometrial notch is small and generally hemorrhagic.

2- Secretory phase: The endometrium has a pale pink color. The surface is slightly wavy and irregular. The glands are larger, open and rose at the level of the superficial layer. The vessels disappear from the endometrial surface due to stromal edema. The endometrium reaches its maximum thickness at this stage, showing a deep avascular endometrial notch.

3- Menstrual phase: the endometrium takes on a reddish color, with indentations and bleeding. In this phase there are alternating areas of detaching and well preserved endometrium.

Endometrial cancer and its relation with cupper T IUD

Many epidemiological studies have linked the use of the intrauterine device with decreased risk of endometrial cancer. Tao MH, et al in China, studied 1204 patients with newly diagnosed endometrial cancer, compared with a cohort of 1212 healthy patients. Patients who developed endometrial cancer (485) had used IUDs for more than years, compared to 687 patients in the control group.

IUDIt is speculated that the reduction in endometrial cancer in patients with IUD is related to inhibition of the binding of estrogen and progesterone to the endometrial receptors, decreasing the concentration of receptor the number of nuclear endometrial cells, these changes can influence the activity of estrogen and progesterone which has protective effect at the level of the endometrium.
Continued use of TCu intrauterine device, after 6 months, induces a significant reduction in the mitotic index of endometrial cells, as well as reducing the concentration of estrogen receptors, but does not affect the levels of serum progesterone, estradiol or the concentrations of progesterone receptors, which could interfere with the protective effect of copper IUD in endometrial cancer. Other factors such as obesity, ethnicity, specially Hispanic or African American race, low socioeconomic status and / or the presence of chronic degenerative disease, play a crucial and defining role in the development of endometrial cancer. Of note, all these are modifiable factors, and 40% of obese women with endometrial cancer or endometrial hyperplasia, know that obesity is the determining factor for the development of this disease.

In office hysteroscopyc polypectomy

EEndometrial polypsndometrial polyps originate as focal hyperplasia of the basalis layer of the endometrium and become localized growths of endometrial tissue covered by epithelium containing therein a variable number of glands, stroma and
blood vessels. They are usually benign, but 0.5-1% can become malignant.

The diagnosis of endometrial polyps is more frequent due to the spread use of vaginal ultrasound. The highest incidence occurs between 40 and 65 years of age.

Polypectomy is indicated for any symptomatic endometrial polyp. Removal of asymptomatic polyps is also frequently recommended, but has not shown a significant benefit.


Full article at Hysteroscopy Newsletter

Retained Products of Conception

Hysteroscopy picture retained products of conception

The concept of placental polyp (retained products of conception) refers to the presence
of placental, or deciduous fetal remains, retained into the uterine cavity after an abortion, vaginal delivery or a cesarean section. It is estimated that occurs in about 1% of all births at term and likely to have a higher incidence in preterm births and abortions.

Two theories have been proposed to explain the pathogenesis of this condition. One theory proposed by Eastman and Hellman suggest that the presence of retained products is probably due to a certain degree of placenta accreta. A second theory described by
Ranney explains the retained products of conception due to differences in thickness, tone and contractility of the myometrium after injury during the current pregnancy.

The treatment options used in the management of this condition include expectant
management, medical and surgical option. Within the medical treatments, misoprostol is
the most frequently used drug. Surgical options include blind sharp and suction curettage. Other alternatives include ultrasound guided trophoblastic tissue evacuation, and hysteroscopic removal under direct visualization with resectoscope which is currently considered a safe and effective surgical option.

Interview with Bruno Van Herendael

Bruno van Herendael

“A young physician embarking in our speciality I always advise to be aware of the differences in the speciality like there are fertility, oncology etc. and if he or she wants to become pelvic surgeon they have to master all techniques within the spectrum of endoscopy: laparoscopy, hysteroscopy and transvaginal laparoscopy. We do train with virtual reality and I always stress the fact that laparoscopy is different form hysteroscopy and that not all of them will be able to perform hysteroscopy at the highest level as this
discipline is more difficult than laparoscopy due to the reduced space and the scarcity of referral points.”


Read the full interview in Hysteroscopy Newsletter

Osseous metaplasia

Osseous metaplasia of the endometrium

Osseous metaplasia is a rare condition in which there is a transformation of the
normal endometrial tissue into bone. It is an uncommon clinical finding with an
incidence of 0,3/1000 and most cases occur after miscarriage or abortion. The
presence of bone in the endometrium was first described by Virchow who related this
condition to a spontaneous differentiation of fibroblasts into osteoblasts. Typically, this
type of metaplasia occurs during reproductive years and more than 80% of reported
cases ocurr after pregnancy.
There are two main theories to explain the existence of bone fragments in the
endometrial tissue. The one by Thaler, who relate this entity to retention of osseous
fetal parts after abortion or miscarriage after 12 weeks of pregnancy. This first theory
cannot explain cases that occurr in patients without previous pregnancies. The second
theory is that of a true endometrial osseous metaplasia, in which there is a osseus
transformation of the endometrial stromal cells, this metaplasia is consequence of
irritative, toxic or hormonal stimuli. Probably both theories are right, with cases of true
metaplasia and cases in which retained bones, causes an endometrial inflammation
which leads to a secondary osseous metaplasia.

Hysteroscopy Quiz

During the past Global Congress on Hysteroscopy we had the opportunity to close the Hysteroscopy Trainees Session surprising with a live Quiz to all the attendees. What better way to end the conference after 3 days exclusively dedicated to hysteroscopy? What a better way to finish the motivational talks of this session?

The entire conference room, live polls via smartphones, hysteroscopic on-screen displays, 4 answer options, 30 seconds to respond, all the players competing with live ranking on the home screen … it was just Awesome!!

Quiz 2.JPG

We are totally satisfied with the participation and the results obtained. It was truly an exciting day with a very high level of participation, bearing in mind that we competed with 2 other rooms simultaneously. From the Hysteroscopy Newsletter team, we can say that we are very happy with the development of the Quiz, the participation, the Feed-back of the assistants and the results, that we want to share with you.

The total correct answers of the players were 55.97% with 44.03% of wrong answers. The 5 questions with the highest number of participants were: 1. Complete vaginal septum (97.33%) [1] , 2. IUD trapped by adhesions (85.92%) [2] , 3. Hysteroscopic image of uterine septum (93.22%) [3], 4. Bone metaplasia (82.54%) and 5. Isthmocele (76.92%). The 5 questions with the least participation were: 1. Endometrial smooth muscle metaplasia (13.56%) [4] , 2. Uterine septum MRI image (14.06%) [5] , 3. unicornuate uterus (17.65%) [6] , 4. Retained products of conception (25 %) and dysmorphic uterus (25.42%).


Uterine contractility in women with type 3 uterine leiomyoma


Investigation of uterine contractility in women with uterine leiomyoma non-deforming uterine cavity (type 3) may be one of the criteria that can be used for decision about whether myomectomy should be performed avoiding unnecessary risks of surgery in women with ‘good prognosis peristalsis’.

Mykhailo Medvediev, Oleksiy Aleksenko, Valentin Potapov
SE “Dnipropetrovsk Medical Academy of Health Ministry of Ukraine”


Read the full article: Hysteroscopy Newsletter

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