Hysteroscopy & Nida

Rav Itiel Katz

Question: Does a woman become a Nida after undergoing a hysteroscopy?

Answer: To answer this question, further clarification is needed, including:

1. Was the procedure performed a hysteroscopy (via the vagina) or a laparoscopy (through the abdominal wall)?
2. Was it a diagnostic hysteroscopy or a therapeutic one?
3. Assuming it was therapeutic, what treatment was performed?
4. What was the diameter of the instrument that entered the uterus?
5. Was blood found? If so, what was the extent of the staining, and where was it found?
6. Was a forceps or tenaculum used to grasp the cervix?
7. Were there any stains before the procedure?
8. At what stage of the menstrual cycle was she when the procedure was performed?
9. What is the couple’s Halachic approach to this question (as there are several opinions in Halacha)?

Diagnostic Hysteroscopy – Background:

Hysteroscopy (hystero – uterus; scopy – to look at or examine) is a technique used for diagnosing and treating disorders within the uterus. A fiberoptic camera is inserted into the uterus, allowing visualization of the uterine cavity. This allows for the identification and diagnosis of intrauterine pathology, including bleeding due to polyps, fibroids, or cysts, intrauterine adhesions, or other causes of infertility.

The examination is typically done approximately one week after menstruation, when the uterine lining remains thin, providing a clear view of the uterine cavity and eliminating concerns about early pregnancy. During the procedure, an isotonic saline solution is infused into the uterus to expand the uterine cavity and provide an unobstructed view . The hysteroscope used for diagnostic procedures generally has a diameter of 3-5 mm; larger scopes are needed for therapeutic hysteroscopies to accommodate a working channel for instruments.

Diagnostic Hysteroscopy – in Halacha:

• Diagnostic hysteroscopy does not render a woman Nida, provided that no blood is found. The insertion of the instrument itself does not render her Nida, since the diameter of the instrument is very small.
• If a small amount of blood is found after the examination, the procedure does not render her Nida (Nishmas Avraham, 194, pp. 184, 197; Taharas haBayis, 2, p66; Shulchan Shlomo, Nida 16:1), provided that:
• The bloodstain found is minimal.
• The woman is not expecting her menstrual period to begin.

Stringent Opinions:

It should be noted that there are opinions that any intrauterine instrumentation renders one a Nida (Shiurei Shevet haLevi, 188:3–4). In addition, there are views that any instrument with a diameter of 3 mm or more that passes through the cervix renders one a Nida (R’ Moshe Shmuel Klein, in the name of R’ Wosner).

Examination During a Period of Tahara:

Accordingly, when a woman is scheduled to undergo a diagnostic hysteroscopy while in a state of Tahara, if no blood is found, the examination does not render her Nida. If a minimal amount of blood is found, it is generally possible to be lenient and rule that the examination does not render her Nida (although, as noted, there are opinions that the examination does render her impure).

Therapeutic Hysteroscopy – Background:

Operative (therapeutic) hysteroscopy is a surgical procedure performed within the uterine cavity. It is primarily carried out for purposes such as removing an intrauterine polyp, removing an intrauterine fibroid, removing intrauterine septa or adhesions, preventing irregular bleeding, and more.

The procedure involves inserting an instrument into the uterus with a diameter of approximately 7–10 mm, as well as additional instruments required to perform the necessary treatment. The instruments are inserted through the vagina, and fluid is infused to expand the cavity and provide clear visualization and convenient access for performing the procedure. This is usually performed in an operating room under general or local anesthesia. It is recommended to schedule the procedure immediately after menstruation has ended.

Therapeutic Hysteroscopy – in Halacha:

Therapeutic hysteroscopy is Halachically more complex than diagnostic hysteroscopy, both because of the larger diameter of the medical instruments and because it involves a surgical procedure that is usually accompanied by the release of blood.

When the procedure is a minor one, such as the removal of a pedunculated polyp (attached by a stalk), then even if minimal bleeding is caused, the blood is considered blood from an injury (Dam Maka), and the procedure does not render her Nida (Nishmas Avraham, Y.D. 194, p193; Taharas haBayis 2, p66).

However, when a more aggressive procedure like curettage is performed – such as removal of a fibroid or removal of a significant uterine septum – since the procedure involves increased bleeding, one should be stringent and consider her to be a Nida (Avnei Shoham, p232; ruling of R’ Mordechai Eliyahu to the Rabbanim of the Puah Institute).

Stringent Opinions:

It should be noted that according to the stringent opinions, since the diameter of the instruments is greater than 3 mm, the procedure renders one Nida in all cases, even if no blood is found. This is based on the halachic principle that any opening of the cervix necessarily causes the release of blood and therefore renders her Nida. In addition, according to these opinions, any intrauterine procedure that involves the release of blood always renders her Nida (Shiurei Shevet haLevi 188:3–4; Shevet haKohen, p65).

Operative Hysteroscopy During Shiva Nekiyim:

When a woman is scheduled to undergo operative hysteroscopy during Shiva Nekiyim, she should perform the Bedikos on the days before the procedure as usual.

On the day of the procedure, she should perform a Bedika before the treatment. After the procedure, Bedikos should be skipped until the seventh day.

In this case, it is correct to use a sanitary pad during these days. If tiny bloodstains appear, they do not render her impure (except according to the stringent opinions above). If blood is found on a white garment, one should consult a Rav specializing in these Halachos. The ruling will depend on the amount of blood and whether it can be attributed to the surgical procedure.

When the procedure is performed close to the end of the Shiva Nekiyim, and bloodstains appear on the seventh clean day, if the woman performs a Bedika and blood is found, she may become impure. In such a case, one should consult a Rav.

Consulting a Rav:

If there is any doubt regarding the procedure, the amount of bleeding, or similar issues, one should consult a Rav, since there are additional factors that may influence the ruling.

Tevila After Hysteroscopy:

A woman who underwent hysteroscopy during the Shiva Nekiyim and needs to do Tevila may do so without concern, following consultation with medical professionals – especially once 24 hours have passed since the procedure. If she is concerned about infection, she may request to be the first to immerse after the water has been changed to reduce anxiety.