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Diagnostic procedures for detecting endometriosis: x rays DIAGNOSTIC PROCEDURES FOR DETECTING ENDOMETRIOSIS: X RAYS
"My doctor thinks I'm almost recovered from endometriosis." a thirty-year-old woman from Indiana wrote to me. "and I wonder. I've been trying to get pregnant for a year and a half, but have had no luck so far. My gynecologist told me mat he suspects my tubes may be blocked from the endometriosis. He wants to X ray them. Isn't this dangerous? I want a baby, but I'm afraid of all this radiation."
Diana's query is one that we commonly hear from women who are recommended for special work-ups when infertility is involved. X rays should be used advisedly and infrequently, but they can be instrumental in deciding the degree of tubal damage.
Abdominal X rays will pick up only large tumors or hard masses, because these will form a shadow on the exposed film. Since endometriosis is soft tissue, it will not show up on these standard X rays. However, a hysterosalpingogram, or X ray of the uterus, used along with an injection of dye, has aided doctors in making an accurate diagnosis. The amount of radiation from a hysterosalpingogram is very low.
If Diana decides to go ahead with this X ray, she will find it pain-free. The procedure is simple. The test is performed while a woman is resting on an examining table. The doctor inserts a speculum into the vagina and the cervix is steadied with a special clamp. A small hollow tube, or cannula, is placed inside the cervical canal and will serve as the conduit for the injected dye. When the dye enters the uterine cavity, it is seen on a fluoroscope screen, and the doctor simultaneously takes an X ray. (If you refer to the illustration below, you can see that the dye has pushed into the uterine cavity, which appears to be normal. The right fallopian tube is open, indicated by dye spilling from the tube. The left tube is closed and damaged as a result of endometriosis; the dye has collected there and does not spill out into the pelvic cavity.)
Normally, the uterine cavity is small and triangular. If it is enlarged or if there is certain "intravasation"—that is, the dye fails into small pockets in the wall of the uterus—these signs might indicate a condition called endometriosis interna, or adenomyosis. Confined to the inside wall of the uterus and weakening it, adenomyosis can coexist with endometrial implants outside the uterus, or it may exist alone. Adenomyosis creates heavier menstrual flow and is responsible, in part, for continuous pain.
Sometimes, endometrial implants stick on the outside of the fallopian tubes, causing them to narrow. This X ray will outline the tubes to reveal whether or not they are open, since the dye will be pushed through the hair-thin fallopian tubes. A healthy tube shows up with the dye already expelled and spilling toward the ovary and bowel. The circumstances are different when the tube is damaged. The dye won't escape, but will be trapped within one of its fimbriae, the ringerlike ends of fallopian tubes. Chances of pregnancy are nearly impossible with such a damaged tube.
Recall for a moment Sampsons theory. It proposed that the fallopian tubes were conduits for endometrial fragments during retrograde menstruation. The fallopian tube may be first to come in contact with the endometrial fragments outside the uterine cavity. Surprisingly, however, endometriosis is rarely found in the tubes. When there are endometrial implants on the tubes, they can be recognized by their characteristic dark blue color. In advanced cases, implants may penetrate deep into the wall of the tube, forming dense adhesions with the surrounding organs.
Tubal problems are often the cause of infertility, although it is not always endometriosis causing the problem, as it is in Diana's case.
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