What is a hysteroscopy? How is it used to diagnose and treat various uterine conditions? Explore the details of this procedure and its potential benefits and risks.

Understanding Hysteroscopy: Definition and Purpose

A hysteroscopy is a medical procedure that allows healthcare providers to examine the inside of a woman’s cervix and uterus. It involves the use of a thin, lighted tube called a hysteroscope, which is inserted through the vagina and into the uterus. The hysteroscope has a camera attached to it, which sends images of the uterine cavity to a video screen, allowing the provider to get a clear view of the internal structures.

Hysteroscopy is primarily used to diagnose and treat various uterine conditions, such as abnormal bleeding, infertility, repeated miscarriages, and the presence of fibroids or polyps. It can also be used to remove an intrauterine device (IUD) or to implant a permanent birth control device in the fallopian tubes.

Reasons for Undergoing a Hysteroscopy

There are several reasons why a woman may be recommended to undergo a hysteroscopy:

• Abnormal uterine bleeding, including heavier than normal periods or bleeding between periods
• Bleeding after menopause
• Difficulty getting or staying pregnant (infertility)
• Recurrent miscarriages (more than two consecutive miscarriages)
• Desire to have a permanent form of birth control
• Need to remove an intrauterine device (IUD)

What Happens During a Hysteroscopy Procedure?

A hysteroscopy is typically performed in a hospital or outpatient surgery center. The procedure generally follows these steps:

1. You will be asked to undress and put on a hospital gown.
2. An intravenous (IV) line may be placed in your arm or hand.
3. You may be given a sedative or general anesthesia to help you relax and block any pain.
4. Your vaginal area will be cleaned with a special soap.
5. A tool called a speculum will be inserted into your vagina to spread the vaginal walls.
6. The hysteroscope will be inserted into your vagina and advanced through the cervix and into the uterus.
7. A liquid or gas may be injected through the hysteroscope to expand the uterus, allowing for a better view.
8. Your provider may take a small sample of tissue (biopsy) for further testing.
9. If any abnormal growths or tissue are found, your provider may be able to remove them during the procedure.

The entire hysteroscopy procedure typically takes 15 minutes to an hour, depending on the specific treatment or diagnostic needs.

Preparing for a Hysteroscopy

To prepare for a hysteroscopy, you may be asked to do the following:

• Fast (not eat or drink) for 6-12 hours before the procedure if you are receiving general anesthesia.
• Avoid using douches, tampons, or vaginal medications for 24 hours before the test.
• Schedule the procedure when you are not menstruating, if possible. Inform your provider if you unexpectedly get your period, as the procedure may need to be rescheduled.
• Notify your provider if you are pregnant or think you may be pregnant, as a hysteroscopy should not be performed on pregnant women.

Risks and Complications of Hysteroscopy

Hysteroscopy is generally a safe procedure, but as with any medical intervention, there are some potential risks and complications, including:

• Mild cramping and light bleeding for a few days after the procedure
• Infection
• Heavy bleeding
• Tears in the uterus

Serious complications are rare, but it is important to discuss any concerns or questions with your healthcare provider before the procedure.

Understanding Hysteroscopy Results

If the results of your hysteroscopy are not normal, it may indicate the presence of one or more of the following conditions:

• Fibroids, polyps, or other abnormal growths in the uterus
• Scar tissue in the uterus
• Abnormal size or shape of the uterus
• Blocked fallopian tubes

Your healthcare provider will be able to explain the findings and discuss any necessary next steps, such as additional testing, treatment, or follow-up care.

Key Takeaways

In summary, a hysteroscopy is a valuable diagnostic and treatment tool that can be used to examine the inside of the uterus and address various uterine conditions. By understanding the purpose, procedure, and potential outcomes of a hysteroscopy, women can be better prepared to participate in their healthcare decisions and work collaboratively with their providers to achieve the best possible outcomes.

Hysteroscopy: MedlinePlus Medical Test

What is a hysteroscopy?

A hysteroscopy is a procedure that allows a health care provider to look at the inside of a woman’s cervix and uterus. It uses a thin tube called a hysteroscope, which is inserted through the vagina. The tube has a camera on it. The camera sends images of the uterus onto a video screen. The procedure can help diagnose and treat causes of abnormal bleeding, uterine diseases, and other conditions.

Other names: hysteroscopic surgery, diagnostic hysteroscopy, operative hysteroscopy

What is it used for?

A hysteroscopy is most often used to:

• Diagnose the cause of abnormal bleeding
• Help find the cause of infertility, the inability to get pregnant after at least a year of trying
• Find the cause of repeated miscarriages (more than two miscarriages in a row)
• Find and remove fibroids and polyps. These are types of abnormal growths in the uterus. They are usually not cancerous.
• Remove scar tissue from the uterus
• Remove an intrauterine device (IUD), a small, plastic device placed inside the uterus to prevent pregnancy
• Perform a biopsy. A biopsy is a procedure that removes a small sample of tissue for testing.
• Implant a permanent birth control device into the fallopian tubes. Fallopian tubes carry eggs from the ovaries into the uterus during ovulation (the release of an egg during the menstrual cycle).

Why do I need a hysteroscopy?

You may need this test if:

• You are having heavier than normal menstrual periods and/or bleeding between periods.
• You are bleeding after menopause.
• You are having trouble getting or staying pregnant.
• You want a permanent form of birth control.
• You want to remove an IUD.

What happens during a hysteroscopy?

A hysteroscopy is often done in a hospital or outpatient surgery center. The procedure usually includes the following steps:

• You will remove your clothing and put on a hospital gown.
• You will lie on your back on an exam table with your feet in stirrups.
• An intravenous (IV) line may be put in your arm or hand.
• You may be given a sedative, a type of medicine to help you relax and block the pain. Some women may be given general anesthesia. General anesthesia is a medicine that will make you unconscious during the procedure. A specially trained doctor called an anesthesiologist will give you this medicine.
• Your vaginal area will be cleaned with a special soap.
• Your provider will insert a tool called a speculum into your vagina. It is used to spread open your vaginal walls.
• Your provider will then insert the hysteroscope into the vagina and move it through your cervix and into your uterus.
• Your provider will inject a liquid or gas through the hysteroscope and into your uterus. This helps expand the uterus so your provider can get a better view.
• Your provider will be able to see images of the uterus on a video screen.
• Your provider may take a sample of tissue for testing (biopsy).
• If you are having a uterine growth removed or another uterine treatment, your provider will insert tools through the hysteroscope to perform the treatment.

A hysteroscopy may take 15 minutes to an hour, depending on what was done during the procedure. The medicines you were given may make you drowsy for a while. You should arrange for someone to drive you home after the procedure.

Will I need to do anything to prepare for the test?

If you will be getting general anesthesia, you may need to fast (not eat or drink) for 6–12 hours before the procedure. Do not use a douche, tampons, or vaginal medicines for 24 hours before the test.

It’s best to schedule your hysteroscopy when you are not having your menstrual period. If you get your period unexpectedly, tell your health care provider. You may need to reschedule.

Also, tell your provider if you are pregnant or think you might be. A hysteroscopy should not be done on pregnant women. The procedure may be harmful to an unborn baby.

Are there any risks to the test?

A hysteroscopy is a very safe procedure. You may have mild cramping and a little bloody discharge for a few days after the procedure. Serious complications are rare, but they may include heavy bleeding, infection, and tears in the uterus.

What do the results mean?

If your results were not normal, it may mean one of the following conditions:

• Fibroids, polyps, or other abnormal growths were found. Your provider may be able to remove these growths during the procedure. He or she may also take a sample of the growths for further testing.
• Scar tissue was found in the uterus. This tissue may be removed during the procedure.
• The size or shape of the uterus did not look normal.
• Openings on one or both fallopian tubes are closed.

If you have questions about your results, talk to your health care provider.

Is there anything else I need to know about a hysteroscopy?

A hysteroscopy is not recommended for women with cervical cancer or pelvic inflammatory disease.

References

1. ACOG: Women’s Healthcare Physicians [Internet]. Washington D.C.: American College of Obstetricians and Gynecologists; c2020. Hysteroscopy; [cited 2020 May 26]; [about 3 screens]. Available from: https://www.acog.org/patient-resources/faqs/special-procedures/hysteroscopy
2. Cleveland Clinic [Internet]. Cleveland (OH): Cleveland Clinic; c2020. Hysteroscopy: Overview; [cited 2020 May 26]; [about 3 screens]. Available from: https://my.clevelandclinic.org/health/treatments/10142-hysteroscopy
3. Cleveland Clinic [Internet]. Cleveland (OH): Cleveland Clinic; c2020. Hysteroscopy: Procedure Details; [cited 2020 May 26]; [about 4 screens]. Available from: https://my.clevelandclinic.org/health/treatments/10142-hysteroscopy/procedure-details
4. Cleveland Clinic [Internet]. Cleveland (OH): Cleveland Clinic; c2020. Hysteroscopy: Risks/Benefits; [cited 2020 May 26]; [about 5 screens]. Available from: https://my.clevelandclinic.org/health/treatments/10142-hysteroscopy/risks–benefits
5. Mayo Clinic [Internet]. Mayo Foundation for Medical Education and Research; c1998–2020. Uterine fibroids: Symptoms and causes; 2019 Dec 10 [cited 2020 May 26]; [about 3 screens]. Available from: https://www.mayoclinic.org/diseases-conditions/uterine-fibroids/symptoms-causes/syc-20354288

Mayo Clinic [Internet]. Mayo Foundation for Medical Education and Research; c1998–2020. Uterine polyps: Symptoms and causes; 2018 Jul 24 [cited 2020 May 26]; [about 3 screens]. Available from: https://www.mayoclinic.org/diseases-conditions/uterine-polyps/symptoms-causes/syc-20378709

6. St. Luke’s [Internet]. Boise (ID): St. Luke’s 1999-2020. Hysteroscopy; [cited 2021 Aug 26]; [about 4 screens]. Available from: https://www.stlukesonline.org/health-services/health-information/healthwise/2017/06/27/13/28/hysteroscopy
7. UF Health: University of Florida Health [Internet]. Gainesville (FL): University of Florida Health; c2020. Hysteroscopy: Overview; [updated 2020 May 26; cited 2020 May 26]; [about 2 screens]. Available from: https://ufhealth.org/hysteroscopy
8. University of Rochester Medical Center [Internet]. Rochester (NY): University of Rochester Medical Center; c2020. Health Encyclopedia: Hysteroscopy; [cited 2020 May 26]; [about 2 screens]. Available from: https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=92&contentid=P07778

Hysteroscopy | Kaiser Permanente

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Test Overview

A hysteroscopy is a procedure to find and treat problems with your uterus. It may be done to remove growths from the uterus, such as fibroids or polyps. It may also be used to diagnose and treat abnormal bleeding or fertility problems.

The doctor will guide a lighted tube through the cervix and into the uterus. This tube is called a hysteroscope, or scope. The doctor will fill your uterus with air or liquid. This makes it easier to see the inside of your uterus with the scope. The doctor may also put tools through the scope to treat a problem.

During this procedure, the doctor may take out a small piece of tissue for study. This is called a biopsy. Or the doctor may gently scrape tissue from the inner wall of the uterus. This is called a dilation and curettage, or D&C.

If your doctor filled your uterus with liquid, most of it will flow out when the scope is removed.

You will most likely go home the same day. And you will probably be able to go back to work the next day. But it depends on what was done and the type of work you do.

Why It Is Done

A hysteroscopy may be done to:

• Find the cause of severe cramping or abnormal bleeding. Your doctor can pass heated tools through the hysteroscope to stop the bleeding.
• See if a problem in the shape or size of the uterus or if scar tissue in the uterus is the cause of infertility.
• Look at the uterine openings to the fallopian tubes. If the tubes are blocked, your doctor may be able to open the tubes with special tools passed through the hysteroscope.
• Find the possible cause of repeated miscarriages.
• Find and remove a misplaced intrauterine device (IUD).
• Find and remove small fibroids or polyps.
• Check for endometrial cancer.
• Use tools to remove problem areas in the lining of the uterus (endometrial ablation).

How To Prepare

Preparing for the procedure

• Schedule your test for when you won’t be having your period. Your doctor may suggest that the test be done soon after your period ends and before your ovary releases an egg (ovulates). This timing allows your doctor to see the inside of your uterus better. It also avoids doing the test when you could be pregnant.
• Your doctor may give you medicine to take before the test that will help open your cervix. This medicine may be placed in your vagina or taken as a pill. Or you may go to your doctor’s office on the day before the procedure so that your doctor can put a small sponge in your cervix. This also helps to open your cervix.
• You may be asked not to douche, use tampons, or use vaginal medicines for 24 hours before the hysteroscopy.
• Ask your doctor if you will need someone to take you home. Anesthesia and pain medicine can make it unsafe for you to drive or get home on your own.
• Understand exactly what procedure is planned, along with the risks, benefits, and other options.
• Tell your doctor ALL the medicines, vitamins, supplements, and herbal remedies you take. Some may increase the risk of problems during your procedure. Your doctor will tell you if you should stop taking any of them before the procedure and how soon to do it.
• If you take a medicine that prevents blood clots, your doctor may tell you to stop taking it before your procedure. Or your doctor may tell you to keep taking it. (These medicines include aspirin and other blood thinners.) Make sure that you understand exactly what your doctor wants you to do.
• Make sure your doctor and the hospital have a copy of your advance directive. If you don’t have one, you may want to prepare one. It lets others know your health care wishes. It’s a good thing to have before any type of surgery or procedure.

How It Is Done

Hysteroscopy is usually done by your gynecologist in the operating room of a hospital or surgery center. You will probably go home the same day. In some cases, the procedure can be done in your doctor’s office.

You may be given medicine (anesthesia) to help you relax, to numb the area, or to help you sleep.

You will take off all of your clothes and wear a gown for the test. You will empty your bladder before the test. You will then lie on your back on an examination table with your feet and legs supported by footrests.

Your doctor may place a lubricated tool called a speculum into your vagina. The speculum gently opens the vaginal walls so your doctor can see inside the vagina.

The hysteroscope will be placed at the entrance to your vagina and gently moved through the cervix into your uterus. Air or liquid will be put through the hysteroscope into your uterus. It helps your doctor see the lining clearly. Your doctor looks through the hysteroscope at a magnified view of the lining of your uterus. Your doctor can also see the uterine openings of the fallopian tubes. A video screen may be used during the test.

If a biopsy or other procedure is done, your doctor will use small tools through the hysteroscope.

Right after the test, you will be taken to a recovery area where nurses will care for and observe you until you go home.

How It Feels

If you are given a sedative or local or regional anesthesia, you may have some cramping during the test.

If you had general anesthesia, you will be asleep and won’t feel pain during the procedure.

Risks

If a fluid is used during the test to help your doctor see the uterine lining clearly, you may absorb some fluid and feel bloated. It may also change the level of sodium in your blood. If air is used, you have a small risk for an air bubble (air embolism) in a blood vessel, though this is very rare.

Hysteroscopy can cause injury to the uterus or cervix, an infection, or bleeding. In rare cases, the uterus, bladder, or bowel can be punctured during the test and require surgical repair. If general anesthesia is used, there is a small risk of problems from the anesthesia.

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  Why It Is Done

Treatment of uterine bleeding in Khimki and Krasnogorsk, an appointment with a doctor

Bleeding from the uterus is the main factor in other pathologies of the hip organs and the list of pathologies of systems (except for the genital one). When it appears, the fair sex does not have to wait until the last to visit a specialist, since if therapy is not started on time, this can turn into a factor of negative consequences.

The management of uterine bleeding is a complex procedure due to the large number of precipitating factors. For a competent diagnosis, you need a lot of experience and good skills not only in the gynecological system, but also in other medical fields. In YourMed, examinations and therapy are carried out by experienced specialists who have extensive experience in treating this type of disease, which helps to perform diagnostics and surgical interventions at the highest quality level. Innovative methods of YourMed medical centers help to quickly make a complex diagnosis of the patient and determine the exact factor that caused uterine bleeding, develop effective therapy, using drugs or surgical interventions.

YourMed medical centers have high-quality devices for performing both planned and urgent surgical interventions.

What is uterine bleeding?

Bleeding from the uterus differs from normal menstruation by a large time period, the absence of a correct cycle and a huge amount of blood lost, or vice versa, a small amount of blood causes discomfort to the female sex.

Statistics have established that half of the situations of their occurrence is associated with the presence of pathologies of the reproductive organs in the female, and the remaining half with a violation of the hormonal background, the functioning of which is provoked by various factors. This pathology appears in women in different age categories. More often, bleeding is detected during menopause or during puberty. Dangerous for the body is the smallest discharge of blood during the postmenstrual pause.

Under what circumstances is therapy necessary?

The main complaints of patients with whom they mainly visit a specialist:

• Large volume of blood discharge
• Large clots in formation
• Blood loss that occurs for one week or more

• Blood that appeared at the end of the first sex

• Discharge from older women who are in the period of menstrual pause

• Blood between periods

Types of pathology

There are several types of bleeding. Each of them has its own peculiarity:

• Polymenorrhea – frequent periods, the cycle of which lasts less than 3 weeks
• Menorrhagia – frequent periods that take longer than usual, with a large amount of blood loss
• Menometrorrhagia – infrequent and long periods
• Metrorrhagia – infrequent bleeding, mostly occurs in the middle of the cycle, may be of small volume
• Bleeding leads to iron deficiency in women. A decrease in hemoglobin provokes the following symptoms:
• Pale skin
• Headaches
• Severe dyspnea
• High fatigue
• Regular nail loss

Bleeding groups

Depending on the pathology factor, they were divided into several large groups:

• Dysfunctional. They are diagnosed in females at the age of 15-49. Accompanied by long or large and often appearing bleeding. Associated with an imbalance of hormones, which is caused by various factors.
• Organic. The main component of the composition is endometriosis, inflammation, benign neoplasms and pathologies of the oncological system of the reproductive organs
• Due to pathologies of the liver or blood systems, as well as other diseases of the endocrine system. Diagnosed in rare cases

What is the danger of bleeding from the uterus

Abundant discharge puts a woman’s life at great risk. It can serve as a shock factor or lead to death in everything. Also dangerous and not heavy bleeding, but long. Blood loss can provoke the development of anemia of iron, apparently worsen the patient’s condition. With treatment that was not done on time, the cost of therapy increases significantly, the time period lengthens, and the pathology worsens.

Survey

In the case of prolonged bleeding in the female, the use of hysteroscopy and separate canal curettage is often recommended. In the process of diagnosis, the uterus is examined, after which a scraping is done, which is subsequently given for laboratory diagnosis. The results of the analysis help either to make sure that there is no cancer or that it is present, and also to prescribe the right course of therapy for the woman. Also, a girl with bleeding from the uterus is prescribed the following diagnostics (the necessary procedures are prescribed by a specialist):

• Hip ultrasound
• HCG detection
• Blood analysis
• Determination of hormonal levels
• Blood diagnostics for oncological markers
• MRI of the hip organs
• Performing consultations of doctors of narrow profiles

YourMed Medical Center has all the necessary devices to quickly complete a full range of patient diagnostics and identify the factor that provoked bleeding from the uterus.

Therapy

Therapy for bleeding from the uterus consists of the following goals:

Stopping the discharge in the female during the period of fertility and menopause is achieved by performing curettage or conservative therapy. In adolescents, hemostasis of hormones is done, which is achieved by the use of progestogens or estrogens. Curettage in girls before the age of majority can be performed only in the presence of serious reasons.

To stop and treat bleeding from the uterus, drugs are used that affect blood clotting and the ability to contract myometrium.

In such situations, when tumors of various types of the intimate zone are a factor, the woman is advised to use surgical interventions. During the operation, the uterus is excised, and in case of dangerous tumors, radiation therapy or chemical therapy is possible. In other situations, hormone therapy is prescribed to help reduce the likelihood of their return. The main goal of therapy is the rehabilitation of the standard cycle. Women are put on therapy using hormones, which should be applied for 8 months.

During its use, patients should consult with specialists frequently. With hyperplasia in the female in the period before menopause, the process of entrainment of substances from the endometrium can be carried out. In the process of this diagnosis, the layer inside the uterus dies under temperature or a laser. In the future, the endometrium no longer appears.

Surgical interventions are well tolerated by women and achieve excellent results of therapy, while there is no discharge from the uterus almost immediately. The process of carrying away the substance from the arteries of the uterus can be done.

Drug therapy for uterine bleeding consists of hormonal treatment and treatment of complicating conditions such as iron deficiency. Medication therapy for uterine bleeding can be prescribed in the form of tablets or injections. Also, during therapy, it is necessary to remove painful sensations: if a woman has abdominal pain, then she must take special medications.

Preventive measures

Preventive measures consist in the prevention of pathologies provoking bleeding. It is quite understandable and consists of the following manipulations:

• Frequent examinations by a specialist
• Timely treatment of pathologies of gynecological type
• Prevention of casual sex
• Therapy of existing pathologies
• Do not disturb the hygiene of the intimate area
• Proper diet plan
• And conduct only protected intercourse

Advantages of uterine bleeding therapy at YourMed Medical Center

• Highly qualified specialists who have all the necessary knowledge and skills for the treatment of pathologies of the gynecological type
• Large list of diagnostics carried out in the laboratory
• The center has innovative equipment of various types
• Presence of hospitals with patient comfort

By contacting the YourMed medical center, you can be sure of the promptness of the examination and effective therapy, as well as the polite attitude of employees towards each patient.

Our other services

• Computed tomography
• Radiography and fluorography
• Magnetic resonance imaging (MRI)
• Ultrasound examination (ultrasound)
• Colonoscopy
• ENT Endoscopy

You can also take various types of laboratory tests any day, get detailed advice from our specialists0001

Laparotomy hysterectomy is a surgical intervention in which all manipulations are carried out through an incision on the anterior abdominal wall of a woman. Access during laparotomy can be longitudinal and transverse, the decision on the type of laparotomy is made by the surgeon and depends on many factors, such as the size of the tumor, previous surgical interventions and the presence of a postoperative scar in the patient.

Subtotal hysterectomy – is a surgical procedure in which only the body of the uterus is removed, the cervix remains in place. In some cases, together with the body of the uterus, the surgeon removes the fallopian tubes and ovaries. The decision on the extent of the surgical intervention is made by the gynecologist during the preoperative consultation.

Indications: 1. Malignant neoplasms of the uterus and appendages.2. Fibroids (leiomyoma, fibromyoma)

• – Fibroids larger than 12 weeks of pregnancy.
• – Rapid progressive growth of uterine fibroids.
• – Multiple myomatous nodes.
• – Myoma, accompanied by profuse uterine bleeding, leading to anemia.
• – Myoma with questionable biopsy results (suspicion of malignancy).

3. Endometriosis of the uterus (adenomyosis) grade 3-4, not amenable to conservative treatment.

4. Recurrent endometrial hyperplasia, atypical hyperplasia.

5. Complete prolapse of the uterus.

You can undergo the entire volume of preoperative examination in Paracel Multidisciplinary Clinic in one day! Examination for surgery and the validity of the results of the examination:

• – colposcopy-12 months
• – Ultrasound of the pelvic organs
• – Ultrasound of the kidneys, bladder, retroperitoneal space.
• – Ultrasound of the veins of the lower extremities – 3 months
• – smear for flora, bacteriological culture from the cervical canal -10 days
• – oncocytology from the cervix – 6 months
• – Urinalysis-10 days,
• – Complete blood count and reticulocytes -10 days,
• – Electrocardiogram with interpretation -14d,
• – Blood for HIV, Hepatitis B, Hepatitis C, Syphilis 3 months.
• – Biochemical blood test: general, direct, indirect Bilir., Total Protein, albumin, urea, glucose, creatinine, uric acid, AST, ALT, alkaline phosphatase, blood sodium and potassium, cholesterol, blood pH -10 days
• – Coagulogram – 10 days
• – Blood type and Rh factor
• – Fluorography – 6 months
• – Mammography – 24 months (after 36 years), 12 months (after 50 years)
• – Consultation of a general practitioner, anesthetist and other specialists according to indications.

Other tests may be added as indicated.

Pain relief: These operations are performed under spinal anesthesia or endotracheal anesthesia. The method of anesthesia is chosen jointly by the anesthesiologist and the surgeon, of course, taking into account the wishes of the patient.

Contraindications:

Elective intervention is not carried out in case of clinically significant bleeding disorders, acute infections, decompensated somatic diseases (hypertension, unstable angina pectoris, severe diabetes mellitus, severe anemia).

Sexual life after hysterectomy. One of the most important questions of interest to patients before planning a hysterectomy is the effect of the operation on sexual life. Surgeons suggest abstaining from sexual activity for at least 6 to 8 weeks after a hysterectomy. After this time, intercourse should not cause pain or discomfort. Sexual activity after hysterectomy has been extensively studied. Hysterectomy has not been proven to cause significant changes in sex drive or ability to enjoy sex.