A 42-year-old nulliparous woman with known uterine fibroids (confirmed on ultrasound 6 months ago) now presents with severe dysmenorrhea and heavy menstrual bleeding unresponsive to NSAIDs and hormonal contraceptives. She is being counselled for myomectomy. Which investigation is most appropriate to assess the impact of fibroids on the endometrial cavity and guide the surgical approach?

## Investigation of Choice for Preoperative Assessment of Submucosal Fibroid Extension ### Diagnostic Hysteroscopy with Saline Infusion Sonography (SIS) **Key Point:** Diagnostic hysteroscopy combined with saline infusion sonography (SIS) is the most appropriate investigation to assess the impact of fibroids on the endometrial cavity, determine the extent of submucosal involvement, and guide the surgical approach (hysteroscopic myomectomy vs. abdominal myomectomy). **High-Yield:** Diagnostic hysteroscopy with SIS provides: - Direct visualization of the endometrial cavity - Assessment of submucosal fibroid extent (FIGO classification) - Evaluation of fibroid size relative to cavity - Detection of concurrent intrauterine pathology (polyps, septum, adhesions) - Determination of feasibility of hysteroscopic resection - Planning of surgical approach and patient counselling ### FIGO Classification of Submucosal Fibroids (Hysteroscopic Assessment) | Type | Location | Intramural Extension | Management | |------|----------|----------------------|-------------| | **Type 0** | Pedunculated, entirely in cavity | 0% | Hysteroscopic resection | | **Type 1** | Sessile, <50% intramural | <50% | Hysteroscopic resection | | **Type 2** | Sessile, ≥50% intramural | ≥50% | Staged resection or myomectomy | **Clinical Pearl:** SIS (saline infusion into the uterine cavity under ultrasound guidance during hysteroscopy) distends the cavity and allows precise measurement of fibroid dimensions and intramural extension, which is critical for deciding between hysteroscopic resection (minimally invasive) and abdominal myomectomy (more morbid). ### Why Other Investigations Fall Short | Investigation | Limitation | |---------------|----------| | **3D ultrasound with Doppler** | Provides morphology but no direct visualization; cannot assess cavity distortion or concurrent pathology | | **Hysterosalpingography** | Assesses tubal patency and cavity outline only; does not allow visualization or intervention; uses radiation | | **Transabdominal ultrasound** | Limited by acoustic window; poor visualization of endometrial cavity and submucosal extension | **Mnemonic: DHS for Diagnostic Hysteroscopy + SIS** — **D**irect visualization, **H**elps classify FIGO type, **S**aline distension for precise measurement. ### Clinical Context In this nulliparous woman seeking myomectomy (uterus-sparing surgery), hysteroscopic assessment is essential because: 1. It determines if hysteroscopic resection is feasible (minimally invasive, faster recovery) 2. It guides counselling about operative time, blood loss, and need for staged procedures 3. It excludes concurrent intrauterine pathology that may contribute to dysmenorrhea 4. It allows intraoperative decision-making (proceed vs. convert to abdominal approach)