Friday's News - HSG

I had a hysterosalpingogram (HSG) with saline in my doctor's office on Friday. The procedure is initiated with a small catheter that is inserted through the cervix, then a small balloon is inflated to keep the catheter in place within the uterus and to prevent the saline from leaking out. It is similar to a foley balloon used for dilation of the cervix and induction in labor, but much smaller.

Saline (100 cc or more) is then injected via the catheter into the uterine cavity in order to examine the uterus and surrounding structures via ultrasound.

The procedure itself is not painful - felt like a typical pelvic exam. However, upon first insertion, the catheter was not staying in place and they had to use a tenaculum on my cervix in order to insert the catheter further inside the uterus.

While medicine and science say there are no nerve endings in the cervix, the pain experienced when the tenaculum was placed was intense (you can see here it pierces the cervix in order to hold on to it). It was a searing, tugging pain that felt like my whole uterus was going to be pulled out. I became overly hot, sweaty and nauseous. At one point I even thought I was going to pass out. The nurse gave me a magazine to fan myself, and I began to feel better. Thankfully the tenaculum was only in place for a few minutes until the catheter was inserted further and the balloon was re-inflated. Then they proceeded with injecting the saline.

As an aside: Even though the tenaculum was only in place for mere minutes, I am still having cramping, soreness and an achy discomfort in my uterus a day later. Many practitioners use tenaculums to place IUDs, but after yesterday's experience, I am definitely going to ensure I learn how to insert them without a tenaculum. Hands down, that was the worst gynaecological experience of my life.

My US revealed a few nabothian cysts on my cervix, but nothing to be concerned about there. They are small and benign and typically disappear on their own.

The spot in my myometrium was reviewed. Last time it was fluid filled, possibly blood, but this time it was empty. A second area was also noted with this US. Both appear to be adenomyosis. On one hand, this is a relief as it is not cancer, but on the other, it is still somewhat concerning for me due to the possible effects on fertility and the increasing menstrual cycle pain I have been experiencing. I am also quite stressed by the fact that this has shown up only after commencing with fertility treatments.

Adenomyosis is when endometrial tissue that lines the uterine cavity grows into and within the myometrial (muscle) tissue of the uterus. This endometrial tissue is a glandular tissue that secretes essential nutrients for implantation and growth, as well as blood during menses thereby essentially causing bleeding within the walls of the uterine muscle. This is what causes the extreme pain during the menstrual cycle.

My two spots on US, however, appear to be isolated islets (like these spots on far right) instead of endometrial tissue growing into the muscle (as seen by the arrows here). This is why my RE is not 100% sure of the diagnosis, although she says she is quite confident that what she is seeing is not going to affect our chances of conceiving.

Adenomyosis can cause menorrhagia - heavy or prolonged menstrual bleeding (yes to heavy, no to prolonged), dysmenorrhea - severe cramping or sharp, knife-like pelvic pain during menstruation (yes, definitely - began with fertility treatments and became increasingly worse with each month), menstrual cramps that last throughout period and worsen as one ages (no, only first 2 days), pain during intercourse (no, thankfully), bleeding between periods (no, hopefully never), and passing blood clots during menses (yes - has increased with fertility treatments). The uterus can also increase to double or triple its normal size (don't know yet). Adenomyosis can cause a bearing down feeling (yes) along with pressure on the bladder (no).

I have not asked for my measurements of my uterus, but plan to at my MRI. I have been feeling rectal pressure and lower back pain more and more frequently of late and am wondering if this is due to the increasing size of my uterus. Previously my RE told me my uterus was anteflexed, but I have always been told previously that it was retroverted. We shall see and confirm on both counts with the MRI.

Adenomyosis is mostly found in women over the age 35 (that's me!), typically between ages 40-50. Adenomyosis is dependent on estrogen and grows with an increase in unopposed estrogen or in the presence of an estrogen imbalance. Due to this, adenomyosis often goes away with menopause.

I did not know this before, but someone experiencing uterine surgery, i.e., cesarean section, is at higher risk for adenomyosis due to the cutting through the uterine layers of myometrium and endometrium. However, I have had no uterine surgeries, and am not sure why I would be predisposed to this.

Treatment for adenomyosis is via hormone suppression and balance with oral contractive pills, IUD with progesterone (Mirena), or Depo-Provera. I have also read online about the use of natural progesterone cream as a way to balance the estrogen dominance. Heavy menstrual flow and pain can be controlled with around the clock ibuprofen (decreases blood flow by 25-30% and cramping pain due to anti-prostaglandin action). Lupron can also be used, but it causes a menopausal state with complete cessation of ovarian function and menses, eliciting many menopausal type side effects like hot flashes and can only be used for 6 months. Typically all symptoms of adenomyosis resume after medication cessation. Sadly, at this point in medicine, an hysterectomy is the only permanent cure outside of menopause.

Next Friday, I will have a pelvic MRI to determine a definitive diagnosis as well as to see if the adenomyosis is diffuse - throughout the myometrium - or only localised to the two spots seen on US. I will have the results a week from next Friday. I am hoping my RE is right and that this will cause no impediment to our chances of conceiving and having a healthy baby. I definitely do not want to have a hysterectomy.

My theory is that I have an estrogen dominance issue due to:

1. Drastic increase in weight gain since moving back to US (up 9 kg/20# in 10 months).
2. Fertility treatments.
3. Not practicing Ashtanga/working out regularly.
4. Age - over age 35 estrogen levels rise and progesterone levels fall, progesterone levels are lower due to less consistent ovulation and short luteal phases, the latter which I have. Unopposed estrogen (without progesterone) leads to estrogen dominance symptoms and diseases.

So my personal plan now is to:

1. Return to my acupuncturist (I stopped going when I found out that our fertility issues were due to my husband's low sperm count).
2. Make an enquiry to the acupuncturist regarding DIM and Myomin - I read online both can reduce and balance excess estrogen thereby reducing adenomyosis symptoms.
3. Add supplementation - vitamin E 600 IU at bedtime, magnesium 300 mg/day and B6 50 mg/day - along with my prenatal vitamins.
4. Take a month break from fertility medications to clean out my system.
5. Do a juice fast for 20 days to detox, rebalance and lose the excess weight - I will be following the Reboot plan.
6. Return to practicing Ashtanga 5-6x a week for de-stressing, fitness, health, detoxing and re-balancing. Many asanas in Ashtanga also work to increase blood flow (prana) to the reproductive organs and mula bandha helps strengthen the pelvic floor.
7. Feel better in 30 days!