Synopsis
Distinguish uterine-cavity hysteroscopy from peritoneal laparoscopy, select each procedure for a defined unresolved question, and provide consent-led preparation, analgesia, operative planning and complication follow-up.
- Hysteroscopy passes a narrow telescope through the cervix to inspect the uterine cavity; laparoscopy passes a telescope through the abdominal wall under anaesthesia to inspect and potentially treat pelvic and abdominal disease.
- Choose hysteroscopy for focal cavity questions such as polyps, submucosal fibroids or endometrial pathology, and laparoscopy for peritoneal disease, adhesions, tubal pathology or selected unresolved pelvic pain.
- NICE prioritises outpatient hysteroscopy for heavy menstrual bleeding when history suggests submucosal fibroids, polyps or endometrial pathology; ultrasound alone can miss cavity lesions.
- Outpatient hysteroscopy should include written information, pregnancy exclusion, options for pain control, a chaperone, the right to stop and an alternative anaesthetic setting when the awake procedure is unacceptable.
- A vaginoscopic technique with a small hysteroscope often avoids speculum and cervical instrumentation; biopsy or see-and-treat polypectomy requires specific advance consent.
- Diagnostic laparoscopy requires general anaesthesia and consent for entry injury, bleeding, infection, organ injury, thromboembolism, conversion to laparotomy and any planned additional treatment.
- NICE supports considering laparoscopy for suspected endometriosis even when ultrasound or MRI is normal; inspection should be systematic and suspicious lesions biopsied, but negative histology does not fully exclude disease.
- Neither procedure is automatically therapeutic: define whether the plan is look only, biopsy, remove a lesion, treat endometriosis, test tubal patency or stop if unexpected disease is found.
- After discharge, give specific contacts and triggers for heavy bleeding, increasing pain, fever, offensive discharge, vomiting, distension, urinary difficulty, wound change, calf swelling, chest pain or breathlessness.
Key red flags
Possible pregnancy generally precludes elective hysteroscopy or laparoscopy until status and clinical need are clarified; urgent pregnancy complications follow specialist pathways.
Severe pain during outpatient hysteroscopy, a suspected perforation or vasovagal collapse requires the procedure to stop and an immediate structured assessment.
Delayed bowel or urinary tract injury after laparoscopy may present with escalating pain, tachycardia, fever, vomiting, ileus, oliguria or peritonism rather than an intraoperative event.
A patient who withdraws consent at any point during awake hysteroscopy must have the procedure stopped; anticipated diagnostic benefit does not override refusal.
A negative laparoscopy does not make persistent pelvic pain imaginary and should trigger review of whether all relevant areas were inspected and what alternative mechanisms remain.
Sudden loss of resistance, unexpected instrument depth, severe pain, bleeding or instability during hysteroscopy raises perforation and requires immediate cessation and assessment.
Increasing pain, tachycardia, fever, ileus, vomiting, peritonism or reduced urine after laparoscopy can signal bowel, bladder, ureteric or vascular injury.
Investigation priorities
Directly inspect the uterine cavity and identify focal polyps, submucosal fibroids or endometrial abnormalities.
Management branches
Symptoms or imaging suggest a focal uterine-cavity or endometrial lesion.
- Confirm indication, pregnancy status, bleeding and infection context, and explain outpatient, analgesic, anaesthetic and no-procedure alternatives with their limitations.
- Obtain specific consent for visualisation, biopsy and any see-and-treat intervention, then use a small atraumatic technique and stop for withdrawal, severe pain or suspected perforation.
- Document completeness, lesion location, samples, fluid and complications, and assign histology and symptom follow-up to a named clinician.