Correct Answer: C. Asherman syndrome
Asherman syndrome (intrauterine adhesions) is the classic indication for hysteroscopic management in the OT list. Hysteroscopy is the gold-standard diagnostic and therapeutic tool for this condition—it allows direct visualization of the uterine cavity, identification of adhesions, and simultaneous lysis under direct vision using scissors, electrosurgical instruments, or laser. The procedure prevents recurrence of adhesions by allowing controlled, precise division while minimizing further trauma. In Indian practice, hysteroscopic adhesiolysis is preferred over blind curettage because it reduces the risk of uterine perforation and allows graded, safe separation of adhesions. Post-operative measures (estrogen therapy, IUD placement, or barrier agents like hyaluronic acid gels) further reduce re-adhesion rates. Asherman syndrome often presents with secondary amenorrhea or hypomenorrhea and is confirmed by hysteroscopy; treatment is both diagnostic and therapeutic, making it the ideal hysteroscopic procedure among the options given.
Why the other options are wrong
A. Endocervical polyp — Endocervical polyps are located in the cervical canal, not the uterine cavity. They are best managed by cervical polypectomy under direct visualization using a speculum and cervical instruments (polyp forceps or diathermy loop), not hysteroscopy. Hysteroscopy visualizes the endometrial cavity and is not the preferred approach for cervical pathology. This option exploits confusion between cervical and uterine procedures. B. Tubal ligation — Tubal ligation is a sterilization procedure performed via laparoscopy (most common in India) or minilaparotomy, not hysteroscopy. Hysteroscopy cannot access the fallopian tubes; it is limited to the uterine cavity. While hysteroscopic tubal occlusion (Essure/Adiana) exists, it is not standard practice in most Indian centers and is not the preferred method. This is a clear anatomical mismatch trap. D. Subserosal fibroid — Subserosal fibroids lie outside the uterine cavity (on the serosal surface) and are not accessible via hysteroscopy. They require laparoscopic myomectomy or open myomectomy depending on size and location. Hysteroscopy is only useful for submucosal fibroids that distort the endometrial cavity. This option tests understanding of fibroid classification and the anatomical limits of hysteroscopy.
High-Yield Facts
- Asherman syndrome = intrauterine adhesions (IUA) causing secondary amenorrhea; hysteroscopy is both diagnostic and therapeutic gold standard.
- Hysteroscopy indications: submucosal fibroids, endometrial polyps, septate uterus, IUA, retained products of conception—all require visualization of the uterine cavity.
- Hysteroscopic adhesiolysis reduces re-adhesion risk vs. blind curettage by allowing precise, controlled division under direct vision.
- Post-operative Asherman management: estrogen therapy (conjugated estrogen 2.5 mg TDS × 21 days) + IUD insertion or hyaluronic acid gels to prevent re-adhesion.
- Hysteroscopy cannot access: cervical pathology (endocervical polyps), tubal pathology, or subserosal/intramural fibroids—these require different approaches.
Mnemonics
HYSTEROSCOPY INDICATIONS (INSIDE cavity only) Intrauterine adhesions (Asherman) | Normal cavity variants (septate uterus) | Submucosal fibroids | Infertility workup | Dysfunctional bleeding (polyps, hyperplasia) | Endometrial ablation. Remember: all are INSIDE the uterine cavity. Fibroid location & management Submucosal → Hysteroscopic myomectomy | Intramural → Laparoscopic/open myomectomy | Subserosal → Laparoscopic/open myomectomy. Hysteroscopy only for submucosal.
NBE Trap
NBE pairs Asherman syndrome with other uterine/gynecological procedures to test whether students confuse hysteroscopic indications (intrauterine pathology) with laparoscopic/open surgical indications (tubal, subserosal, or cervical pathology). The trap is anatomical: students may not clearly distinguish what hysteroscopy can and cannot reach.
Clinical Pearl
In Indian practice, a patient presenting with secondary amenorrhea post-curettage (often for incomplete abortion or retained products) is suspected of Asherman syndrome. Hysteroscopy confirms the diagnosis and simultaneously treats it—making it the single most important procedure for both diagnosis and management. Many Indian centers now use hyaluronic acid gels (Hyalobarrier) post-operatively to reduce re-adhesion, improving fertility outcomes.
_Reference: DC Dutta's Textbook of Gynaecology (6th ed.), Ch. 13 (Hysteroscopy & Endometrial Ablation); OP Ghai's Essential Obstetrics (9th ed.), Ch. 22 (Asherman Syndrome)_