Predictors of Pain Associated With Hysterosalpingography (HSG): A Prospective Cohort Study

Research Article

Austin J Womens Health. 2014;1(2): 4.

Predictors of Pain Associated With Hysterosalpingography (HSG): A Prospective Cohort Study

Aubrey Park1, Alexander M Quaas1, Karl R Hansen1, Blake Porter2, Heather Burks3 and LaTasha B Craig1*

1Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, USA

2Department of Obstetrics and Gynecology, University of Missouri at Kansas City, USA

3Department of Obstetrics and Gynecology, University of Southern California, USA

*Corresponding author: LaTasha B Craig, Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, MDP.O. Box 26901; WP 2540; Oklahoma City

Received: September 26, 2014; Accepted: November 24, 2014; Published: November 28, 2014


Predictive factors of pain were evaluated prospectively in a cohort of 157 women undergoing hysterosalpingography (HSG). 94% of women experienced pain associated with the procedure. A history of dysmenorrhea or tubal obstruction at time of procedure was a significant predictor of increased pain associated with HSG. Pre-procedure treatment with Non-Steroidal Anti- Inflammatory Drugs (NSAIDs) was not associated with changes in pain scores.

Objective: To identify predictive factors of pain associated with Hysterosalpingography (HSG).

Design: Prospective cohort study.

Setting: Academic medical center.

Patients: 157 consecutive women undergoing HSG as part of infertility evaluation.

Interventions: Completion of standardized pre- and post-procedure questionnaires, including Post-Procedure Visual Analog Scale (VAS), Present Pain Intensity (PPI) and Short Form McGill Pain Questionnaire (SF-MPQ).

Main Outcome Measures: Prevalence and nature of HSG-associated pain, VAS, PPI and SF-MPQ results, predictors of HSG-associated pain.

Results: Of the 157 women undergoing HSG, 94% of patients experienced pain during the procedure. Not surprisingly, the most common description of the nature of pain was “cramping” (86.5%). The severity of reported pre-procedure dysmenorrhea was statistically significantly associated with the occurrence of HSG-associated pain (r=0.315, p<0.01). Additionally, women with tubal obstruction experienced a significant increase in HSG-associated pain (p=0.011). Patients using pre-procedure non-steroidal anti-inflammatory drugs (NSAIDs, 85.4% of women) experienced no significant decreases in VAS pain scores (73.7 versus 82.0, p=0.40).

Conclusion: The majority of women experience pain during HSG. A history of dysmenorrhea and a finding of tubal obstruction were statistically significant predictors of HSG-associated pain.Pre-procedure treatment with NSAIDs reduced pain scores, however this was not statistically significant.

Keywords: Hysterosalpingography; HSG; Visual Analog Scale; Short Form McGill Pain Questionnaire; Dysmenorrhea; Non-Steroidal Anti-Inflammatory Drugs


The workup of the infertile patient commonly consists of a battery of tests designed to identify the cause of infertility. Hysterosalpingography (HSG) is a first-line investigation in the evaluation of infertility to assess tubal patency and uterine cavity contour [1,2]. The vast majority of women experience pain during the HSG procedure [3]. Despite its common use, little information is available regarding the characteristics of HSG-associated pain, factors predisposing to increased pain experience, and methods to decrease pain experienced during the procedure. Various strategies to reduce HSG-associated pain have been proposed and studied [4-8]. However, risk factors for the occurrence of HSG-associated pain have not been established.

Understandably, the infertility workup can be a cause of anxiety for many patients. The pain associated with HSG may contribute to the negative experience in the infertility workup. The primary aim of this study was to identify predictors of pain associated with hysterosalpingography in a prospective fashion. The secondary aim was a quantitative and qualitative description of the presence, character and severity of HSG-associated pain. With a better understanding of pain characteristics, women may be better counseled on what they may experience during their HSG. Additionally, identifying predisposing factors may give us a better understanding of the pathophysiology of HSG-associated pain and lead to future advances in this area.

Materials and Methods

The University of Oklahoma Health Sciences Center (OUHSC) Institutional Review Board approved this study. During the study period of February 1, 2010 to March 1, 2011, all women who met the inclusion and exclusion criteria were invited to participate in the study. Inclusion criteria were: age ≥18 and undergoing clinically indicated HSG for evaluation of infertility or recurrent pregnancy loss. Exclusion criteria were: age <18, and patients who declined participation in the study.

HSG procedure

Prior to scheduling the procedure, participating women were given an HSG educational handout from the American Society for Reproductive Medicine(ASRM) providing information about the procedure and advising patients to take an oral medication for menstrual cramps prior to the procedure [9]. On the reverse side of the provided patient fact sheet, the specific recommendation was made that she take an NSAID (Ibuprofen 400-800 mg po or Naproxen 220 mg) one hour prior to the procedure, although this was not required. All HSGs were performed on an outpatient basis by a general gynecologist or a reproductive endocrinologist. In lithotomy position, a speculum was placed in the vagina and an iodine solution was applied to the cervix. The anterior lip of the cervix was then injected with 1-2 ml of 0.5% lidocaine, and a tenaculum placed. A transcervical acorn cannula was placed into the area near the internal os. Five to 20 ml of the water-soluble nonionic radio-opaque dye Iopamidol (Isovue; Bracco Diagnostics Inc., Princeton, NJ) was injected under fluoroscopic visualization. Multiple radiograph films were obtained.

Standardized questionnaires

Immediately prior to the HSG procedure, participants were asked to complete an anonymous, coded health questionnaire to collect demographic data and information on obstetric and gynecologic history, including prior pregnancies and mode of delivery, menstrual history, and any prior gynecologic diagnoses. Data on pre-procedure NSAID use was also collected. Within 10 minutes of completing the HSG procedure, participants were asked to complete an anonymous, coded pain questionnaire.In order to characterize pain quality ,intensity, and overall experience the questionnaire contained three tools: the McGill Pain Questionnaire- Short Form” (MPQ-SF), a Visual Analog Scale (VAS) and the Present Pain Intensity (PPI) index. Nominal data was collected from the MPQ-SF and PPI pain tools, and continuous data was collected from the VAS.

Pain characteristics were recorded using the MPQ-SF, as described by Melzack et al. [10]. The MPQ-SF included 15 word descriptors of pain rated on a scale 0 to 3, (0 = no pain, 1 = mild pain, 2 = moderate pain, 3 = severe pain). The first 11 descriptors refer to sensory quality of the pain experience. The final 4 descriptors relate to the affective dimension of the pain. The scale has been found to be valid, reliable, and repeatable in a variety of acute and chronic conditions [11,12].

The VAS consisted of a 100-mm horizontal line with anchors of “no pain” on the left and “the most intense pain imaginable” on the right. Patients indicated the maximum pain intensity experienced during the HSG by making a vertical line on the VAS. The VAS pain measurement tool has been used extensively and it has been validated for quantitative pain assessment in a variety of settings [13,14].

The final scale completed by the subject was the PPI Index, an overall assessment of the pain experienced during the HSG. The PPI is a powerful overall intensity score, provided by the numerical value associated with the five verbal descriptors which are psychologically equally distant from each other (0 = No pain, 1 = Mild, 2 = Discomforting, 3 = Distressing, 4 = Horrible, 5 = Excruciating) [10].

Following the HSG procedure, the performing physician documented results and details of the procedure, including instruments used and use of topical cervical anesthetic on a de-identified, coded form that could be linked only to the questionnaires completed by the subject. Tubal patency and anatomy of the fallopian tubes and uterus were also recorded.

Statistical analysis

Pain scores reported by VAS and PPI were reported as mean ± standard error.

TheMann-Whitney Uand Kruskal-Wallis tests were used to compare non-parametric continuous and nominal measures (PPI and MPQ-SF), and Spearman correlation coefficients were calculated to correlate predictors of pain with the VAS and PPI results.SAS Statistical software was used for analysis (SAS version 9.2, Cary, NC). A p value of ≤0.05 was considered statistically significant.


One hundred fifty-seven participants met the inclusion and exclusion criteria and consented to study. The mean age of participants was 30.8 ± 3.1 years. The majority of subjects were Caucasian (74.5%). Demographic information, pain quantity as assessed by VAS, quality of pain as assessed by MPQ-SF, pre-procedure use of analgesia, and study results are described in Table 1.