What are the guidelines and preparations for a patient undergoing a Hysterosalpingogram (HSG)?

Hysterosalpingogram: Guidelines and Preparation

For patients undergoing HSG, perform the procedure during the proliferative (follicular) phase of the menstrual cycle, administer pre-procedural NSAIDs one hour before the appointment, and obtain mandatory pregnancy testing regardless of patient-reported menstrual history. 1, 2, 3

Timing of the Procedure

• Schedule HSG during the proliferative phase of the menstrual cycle (typically days 7-10 after the start of menses), which occurs after menstrual bleeding has stopped but before ovulation. 2, 4
• This timing minimizes radiation exposure to a potential early pregnancy and reduces the risk of disrupting a fertilized ovum. 2
• For hysteroscopic sterilization confirmation, HSG must be performed exactly 3 months post-procedure to verify bilateral tubal occlusion before the patient can rely on the sterilization for contraception. 5

Pre-Procedural Pregnancy Screening

• Obtain mandatory urine or serum pregnancy testing on the day of the procedure, regardless of patient-reported pregnancy status or recent menstrual bleeding. 3
• Patient self-reporting and menstrual cycle dating are unreliable—a multi-institutional study identified 10 unsuspected pregnancies (0.16% rate) in patients who would have otherwise undergone HSG despite reporting they were not pregnant. 3
• HSG is absolutely contraindicated in pregnancy due to potential physical, economic, and psychosocial consequences. 3

Pain Management

• Instruct patients to take standard-dose oral NSAIDs (such as ibuprofen 400-600mg) one hour before their scheduled appointment. 1, 6
• Routine local cervical anesthesia is not recommended for standard HSG procedures. 6
• Consider local anesthesia only if cervical dilation is anticipated (cervical stenosis) or if larger-diameter instruments (≥5mm) will be used. 6

Antibiotic Prophylaxis Considerations

• Administer antibiotic prophylaxis at the discretion of the referring physician, particularly in patients with: 1
  • History of pelvic inflammatory disease
  • Known or suspected hydrosalpinx detected on imaging
• The American College of Radiology recommends considering prophylaxis in these high-risk scenarios to prevent post-procedural pelvic infection. 1

Patient Education and Informed Consent

• Provide written information prior to the appointment detailing the procedure, benefits, risks, alternative diagnostic options, and contact information for the hysteroscopy/radiology unit. 6
• Explain that HSG evaluates tubal patency (65% sensitivity, 85% specificity compared to laparoscopy) and can detect uterine abnormalities including intrauterine adhesions, polyps, and leiomyomas. 1, 7, 8
• Inform patients about the potential therapeutic benefit: tubal flushing during HSG increases pregnancy rates up to 38% compared to 21% in women who do not undergo HSG. 1, 7
• Advise patients they can request the procedure be stopped at any point if pain or distress becomes intolerable. 6

Contraindications to Screen For

• Active pelvic infection or suspected pelvic inflammatory disease (absolute contraindication). 2, 4
• Pregnancy (absolute contraindication—hence mandatory testing). 3, 4
• Active uterine bleeding beyond normal menstruation. 4
• Known allergy to iodinated contrast (if using oil- or water-soluble iodinated contrast). 2

Technical Considerations

• The procedure uses either water-soluble or oil-soluble contrast medium instilled through the cervix. 2
• Saline should be instilled at the lowest possible pressure to achieve satisfactory visualization while minimizing patient discomfort. 6
• Avoid excessive contrast injection, which can obscure diagnostic findings. 2

Common Complications to Counsel About

• Pain and cramping (most common—managed with pre-procedural NSAIDs). 2, 8
• Pelvic infection (risk reduced with appropriate antibiotic prophylaxis in high-risk patients). 2, 8
• Vasovagal reactions (clinical team should monitor for signs and stop procedure if occurs). 6
• Intravasation of contrast medium (rare). 2
• Allergic reactions to contrast (rare). 2

Post-Procedural Instructions

• Patients may experience mild cramping and spotting for 1-2 days following the procedure. 8
• For patients undergoing HSG after hysteroscopic sterilization, emphasize that they must continue using effective contraception until bilateral tubal occlusion is confirmed on the 3-month HSG. 5
• Instruct patients to contact their provider if they develop fever, severe pain, or heavy bleeding, which may indicate infection. 8