Hysterosalpingography (HSG) is a contrast X-ray method that visualizes the uterus and fallopian tubes. The procedure allows you to identify tubal obstruction, fibroids, endometrial polyps, isthmic-cervical insufficiency, malignant tumors, adhesions, congenital defects of the structure of the reproductive system. The introduction of a radiopaque drug is performed by catheterization of the uterus and fallopian tubes. In a standard study, the image is taken in an axial projection.
Hysterosalpingography is indicated for suspected infantilism, abnormalities of the development of female genital organs, tubal infertility, adhesions, isthmic-cervical insufficiency, submucosal fibroma of the uterus, endometrial cancer, internal endometriosis, hyperplasia and endometrial polyps. The time of metrosalpingography is determined taking into account the alleged pathology. In case of violations of the patency of the fallopian tubes, the study is prescribed in the second phase of the cycle, with internal endometriosis – on the 7-8 day of the cycle, with submucosal uterine fibroids – on any day of the cycle in the absence of bleeding.
It should be borne in mind that hysterosalpingography is mainly a screening method, since it has high sensitivity, but low specificity, that is, it allows you to confirm the presence of pathology, but it does not always make it possible to assess its severity and accurately differentiate a particular disease. The effectiveness of HSG in the detection of pathological conditions is 98%, at diagnosis – 35%. If necessary, the diagnosis is clarified using ultrasound, MRI and laparoscopic examinations.
The absolute contraindication to hysterosalpingography is intolerance to iodine preparations. As contraindications, inflammatory processes in the uterus, ovaries and fallopian tubes, cervicitis, bartholinitis, colpitis, general acute infections (acute respiratory infections, influenza, inflammation of ENT organs), the presence of local inflammatory foci (boils, purulent wounds), blood clotting disorders, heart disease, kidney and liver failure are also considered.
Hysterosalpingography is not performed in cases of thyroid dysfunction. In addition, the list of contraindications includes periods of menstruation, pregnancy and lactation. A contraindication to HSH is the presence of inflammatory changes in the blood (leukocytosis, increased ESR), even in the absence of external signs of the inflammatory process. The decision on the need for hysterosalpingography is made by the attending gynecologist individually, taking into account the peculiarities and severity of clinical symptoms and the likelihood of possible complications.
Hysterosalpingography is performed both on an outpatient basis and in the conditions of the gynecology department of the hospital. The patient is warned about the need to use a condom after the end of menstruation and refrain from sexual intercourse for 2 days before the prescribed HSG. During the week, douching and the use of medications for vaginal administration should be abandoned (with the exception of those prescribed by a doctor). The preliminary examination includes a general blood test, a biochemical blood test (according to indications), a general urine test, blood tests for syphilis, hepatitis and AIDS, a smear from the vagina and from the cervix. Before starting hysterosalpingography, the bladder should be emptied, an enema should be performed and the hair in the area of the external genitalia should be shaved.
Methodology of conducting
Before performing HSG, the patient is placed on a special X-ray transparent gynecological chair. The external genitals are treated with a disinfectant solution. Mirrors are inserted into the vagina, the walls of the vagina are wiped with a dry cotton ball, and then with a ball soaked in alcohol. Then a tube with a rubber tip is installed, which is fixed in the area of the cervical canal. The tube is held with bullet forceps. Mirrors are being removed. A contrast agent (cardiotrast, triombrast, urotrast or verografin) is injected into the tube, heated to 36-37 degrees.
Hysterosalpingography provides a series of images. The first image taken after the introduction of 2-3 ml of X-ray contrast preparation allows you to assess the relief of the uterine cavity. On the second radiograph, performed after an additional injection of 3-4 ml of contrast agent, the fallopian tubes usually become visible. If necessary, several more fractional injections of the drug are carried out until full visual information about the state of the uterus and fallopian tubes is obtained. Then the tube is removed, the woman is helped to lie down on the couch and is recommended to be in a lying position for 40-60 minutes.
Within a few days after hysterosalpingography, sanitary pads should be used, since a contrast agent will be released from the vagina (possibly with a slight admixture of blood). If there is abundant bloody discharge, an increase in body temperature and severe pain in the lower abdomen, you should immediately contact a gynecologist. Within 3 months after hysterosalpingography, it is necessary to use contraceptives to prevent pregnancy.
Interpretation of results
- Anomalies of the female genital organs. The infantile uterus is indicated by a decrease in the uterine cavity and an elongation of the cervix. With a single-horned uterus, HSG confirms the pronounced asymmetry of the uterine cavity, with an incomplete septum – the presence of two halves forming an acute angle, with a double uterus – the presence of two cavities forming an obtuse angle. In addition, during HSG, shortened, elongated or asymmetric fallopian tubes, congenital obstruction of the fallopian tubes, cleavage of the lumen and additional blind passages in the fallopian tubes are visible.
- Infertility in women. Normally, the contrast agent is distributed through the uterine cavity, then passes through the tube in the form of a strip and is distributed in the abdominal cavity, imitating the picture of freely diverging smoke of a burning cigarette. In case of violation of the patency of the pipes, the image obtained during hysterosalpingography changes. With sactosalpinx (accumulation of serous fluid in the tube cavity) in combination with adhesions of the abdominal orifice, a flask-like expansion is visible on radiographs. With partial preservation of patency of the abdominal opening, hysterosalpingography indicates the presence of a message between the tube and the abdominal cavity, the contrast agent seeps into the abdominal cavity in a thin trickle. With adhesions in the abdominal cavity, the X-ray contrast agent penetrates into the formed cavities, which are displayed on the images in the form of light areas.
- Genital tuberculosis. When performing HSG in patients with tuberculosis, the presence of flask-like extensions of the isthmic sections is detected, because of which the fallopian tubes begin to resemble smoking pipes. With advanced tuberculous endometritis, deformation, reduction or “disappearance” of the uterine cavity is detected during hysterosalpingography.
- Polyps and endometrial hyperplasia. In the process of hysterosalpingography, uneven contours of the uterus, uneven distribution of contrast medium and small filling defects of oval, rounded or (less often) linear shape are revealed, usually localized in the area of the bottom and corners of the uterus. As a rule, the size of defects does not exceed 0.7 cm, with large polyps their size can reach several centimeters. Sometimes large polyps can be difficult to differentiate with small submucosal uterine fibroids, creating a similar picture. With large submucosal fibroids, the images show deformation and enlargement of the uterine cavity in combination with a large filling defect.
- Endometrial cancer. With small tumors, a filling defect with uneven contours in the area of the corner or lateral surface of the uterus is visible on radiographs. With common neoplasms, hysterosalpingography confirms the deformation of the entire inner surface of the uterus. Multiple filling defects of various sizes and shapes with pitted contours are detected.
- Endometriosis. Hysterosalpingography allows you to detect multiple small shadows located behind the inner contour of the uterine cavity, mainly in the isthmic-cervical region. Shadows can take the form of pockets, lacunae or spikes. In some cases, the images reveal signs of endometriosis of the tubes, in which multiple short passages form in the isthmic department, forming a picture of a “Christmas tree branch”.
- Synechia of the uterus. With intrauterine splices, filling defects with clear contours are visible on radiographs.
- ICI. With isthmic-cervical insufficiency during hysterosalpingography, an expansion of the isthmic-cervical department to 1.5 cm or more is detected at a norm of less than 0.4 cm.