Adenomyosis (HSG)

Adenomyosis – Hysterosalpingography

Adenomyosis is a benign uterine condition characterized by the presence of endometrial glands and stroma within the myometrium, resulting in uterine enlargement and myometrial hypertrophy. Although hysterosalpingography (HSG) is not the primary modality for diagnosis, characteristic indirect features may be seen, particularly in patients undergoing infertility evaluation. On HSG, adenomyosis is suggested by irregular uterine cavity contours and contrast intravasation into the myometrium, producing a stippled or spiculated appearance (Fig. 1).

Fig-1

Fig. 1—Hysterosalpingogram suggestive of adenomyosis. Multiple fine linear or stippled extensions of contrast are seen radiating from the endometrial cavity into the myometrium (arrows).

Findings: The uterine cavity appears mildly enlarged with irregular or shaggy margins. Fine contrast-filled channels extend into the myometrium, representing endometrial sinus tracts. Tubal patency may be normal or reduced due to associated uterine spasm.

Conclusion: Hysterosalpingographic features are suggestive of adenomyosis. Correlation with ultrasound or MRI is recommended.

Patient Symptoms

Patients commonly present with menorrhagia, dysmenorrhea, chronic pelvic pain, dyspareunia, or infertility. Symptoms often worsen with age and parity.

Procedure (Hysterosalpingography)

The examination is performed during the early proliferative phase of the menstrual cycle. A cervical cannula or balloon catheter is inserted, and water-soluble contrast is injected slowly under fluoroscopic guidance to delineate the uterine cavity and fallopian tubes.

Contrast Medium & Administration

A water-soluble iodinated contrast agent such as Iohexol or Iopamidol (300–350 mg iodine/mL) is used. The patient is positioned in the lithotomy position. Approximately 6–10 mL of contrast is administered with gentle pressure to reduce intravasation.

Instruments Used

• Sterile vaginal speculum (Cusco’s or Sims’)
• Uterine tenaculum (if required)
• Leech–Wilkinson cannula
• Rubin cannula
• Balloon HSG catheter
• 10–20 mL sterile Luer-lock syringe
• Sterile connecting tubing
• Antiseptic solution
• Fluoroscopy unit

Safety Considerations

Slow and gentle contrast injection is essential to minimize pain and excessive intravasation. Pregnancy and active pelvic infection must be excluded. HSG findings are nonspecific and should be interpreted cautiously.

Related Conditions

Differential diagnoses include submucosal fibroid, endometrial polyp, and chronic endometritis. Transvaginal ultrasound and MRI are the preferred modalities for definitive diagnosis of adenomyosis.

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Declaration

This case is presented for academic and educational purposes only. Patient confidentiality has been preserved and no identifiable information is disclosed.