Intrauterine adhesions (Asherman syndrome) (HSG)

Intrauterine Adhesions (Asherman Syndrome) – Hysterosalpingography

Intrauterine adhesions, also known as Asherman syndrome, result from partial or complete obliteration of the uterine cavity due to fibrous scar tissue. They most commonly follow uterine instrumentation such as dilatation and curettage, postpartum curettage, or uterine surgery. On hysterosalpingography (HSG), the condition is characterized by irregular, angular filling defects, non-opacified segments of the uterine cavity, and reduced uterine cavity volume (Fig. 1).

Fig-1

Fig. 1—Hysterosalpingogram demonstrating intrauterine adhesions. Irregular linear and angular filling defects are seen within the uterine cavity with areas of non-opacification and cavity distortion (arrows).

Findings: The uterine cavity appears partially obliterated with irregular outlines and reduced volume. Contrast outlines fibrous bands bridging opposing walls of the uterus. Tubal filling may be reduced or absent depending on the severity of adhesions.

Conclusion: Hysterosalpingographic findings are consistent with intrauterine adhesions (Asherman syndrome).

Patient Symptoms

Patients may present with secondary amenorrhea, hypomenorrhea, infertility, recurrent pregnancy loss, or cyclic pelvic pain due to outflow obstruction.

Procedure (Hysterosalpingography)

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

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. Injection should be slow and gentle, typically 4–8 mL, to avoid uterine perforation.

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

Contrast injection should be minimal and under low pressure due to the risk of uterine perforation. Pregnancy and active pelvic infection must be excluded. HSG may underestimate disease severity.

Related Conditions

Differential diagnoses include endometrial polyps, submucosal fibroids, and congenital uterine anomalies. Hysteroscopy is the gold standard for definitive diagnosis and treatment planning.

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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.

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.