Paracervical anaesthesia in outpatient hysteroscopy: a randomised double-blind placebo-controlled trial

Intrauterine lidocaine infusion for pain relief during saline solution infusion sonohysterography: a randomized, controlled trial

STUDY OBJECTIVE

To evaluate the efficacy of intrauterine lidocaine instillation in reducing patient discomfort during saline solution infusion sonohysterography (SIS).

DESIGN

A double-blinded, randomized, controlled trial (Canadian Task Force classification I).

SETTING

Suleyman Demirel University School of Medicine, Department of Obstetrics and Gynecology, Isparta.

PATIENTS

One hundred-six women who underwent SIS.

INTERVENTIONS

Fifty-three patients were allocated to the lidocaine group and 53 to the saline solution group.

MEASUREMENTS AND MAIN RESULTS

The main outcome measures were the intensity of pain during, immediately after, and 20 minutes after the procedure, assessed by a visual analog scale and the patients' distress evaluated by the physician with a 3-point observer scale. There were no statistically significant differences between the study group and the control group in mean age, parity, past cervical surgery, history of chronic pelvic pain and dysmenorrhea, history of curettage, education, socioeconomic status, menopausal status, volume of saline solution infused (mL), tenaculum use, and indication for SIS. Pain scores demonstrated a statistically significant difference between groups during the procedure (placebo 5.09 +/- 1.25 [95% CI 4.74-5.43], lidocaine 3.90 +/- 1.02 [95% CI 3.61-4.18], p <.001); immediately after procedure (placebo 4.03 +/- 0.89 [95% CI 3.78-4.27], lidocaine 3.16 +/- 0.67 [95% CI 2.97-3.34], p <.001); and 20 minutes after procedure (placebo 3.32 +/- 0.54 [95% CI 3.17-3.46], lidocaine 2.43 +/- 0.72 [95% CI 2.23-2.62], p <.001). No significant pain relief in nulliparous patients was obtained by the use of lidocaine (4.88 +/- 1.01 [95% CI 4.60-5.15], 3.88 +/- 0.86 [95% CI 3.64-4.11], 3.22 +/- 0.55 [95% CI 3.06-3.37], respectively; p >.05). Pain rated by the physician during, immediately after, and 20 minutes after the procedure was significantly different between the groups (p <.001), and a significant correlation was noted between the visual analog pain score and the patients' distress recorded by the physician (r = 0.816, r = 0.697, r = 0.676; p <.001, respectively).

CONCLUSION

Intrauterine lidocaine seems to be effective in decreasing pain in parous women undergoing SIS.

A randomized trial comparing local intracervical and combined local and paracervical anesthesia in outpatient hysteroscopy

STUDY OBJECTIVE

To compare the amount of pain during and after hysteroscopy using local intracervical and combined local and paracervical anesthesia.

DESIGN

Prospective randomized trial (Canadian Task Force classification I).

SETTING

University teaching hospital.

PATIENTS

Eighty-four women who underwent outpatient hysteroscopy for evaluation of the uterine cavity at McGill University Health Center.

INTERVENTIONS

Randomization to local intracervical or combined local and paracervical anesthesia.

MEASUREMENTS AND MAIN RESULTS

Amount of pain experienced during the procedure and at 10, 30, and 60 minutes after the procedure was measured using a visual analog scale ranging from zero to 10 (zero = no pain; 10 = excruciating pain). The mean age of the patients in the local anesthesia group was 36.1 +/- 0.7 years and in the combined local and paracervical anesthesia group was 35.2 +/- 0.7 years. Patients experienced significantly more pain during than after the procedure. The mean pain scores in the local anesthesia group were significantly higher than in the combined anesthesia group during the procedure (3.2 +/- 0.3 vs 2.1 +/- 0.2; p <.01; 95% CI 0-2), 10 minutes after the procedure (1.9 +/- 0.2 vs 1.5 +/- 0.3; p = .03; 95% CI 0-1), and 30 minutes after the procedure (1.7 +/- 0.2 vs 1.0 +/- 0.2; p = .02; 95% CI 0-1). However, there was no significant difference in pain scores at 60 minutes after the procedure between the local anesthesia and combined anesthesia groups (0.9 +/- 0.2 and 0.7 +/- 0.1, respectively).

CONCLUSIONS

Outpatient hysteroscopy with local or combined local and paracervical anesthesia was well tolerated by patients. However, combined anesthesia was associated with less pain during and at 10 and 30 minutes after the procedure. Most patients considered the pain as mild.

Hysteroscopy and menopause: past and future

PURPOSE OF REVIEW

The main aim in investigating post-menopausal women is to exclude endometrial cancer. The purpose of this review is to define up-to-date clinical guidelines for the management of all post-menopausal women (asymptomatic as well as symptomatic).

RECENT FINDINGS

Thanks to improvements in both the technology and the technique, hysteroscopy has become a simple and painless procedure that can easily be performed in an office or outpatient setting without any particular discomfort for the patient. The new, easier procedure, well tolerated by patients, has excellent diagnostic and surgical accuracy. Assuming that office hysteroscopy could offer a better visualization of the uterine cavity without increasing patient discomfort if compared to ultrasound, various authors have recently proposed the use of hysteroscopy as a first-line procedure in the approach to the menopausal patient. This could be defined as a change in strategy that has yielded very interesting results in terms of a better understanding of the appearance of the uterine cavity and the clinical value of small intra-cavitary pathologies (and their related treatment), particularly in asymptomatic women.

SUMMARY

Hysteroscopy can be considered a routine outpatient method providing immediate results and causing minimal discomfort, especially when performed with the vaginoscopic approach. This technique has ushered in a new era of very-low-cost hysteroscopy, because only the hysteroscope is required in the outpatient procedure, with no need for additional instruments, medication, extra personnel or dedicated theatre. The time taken is comparable to that required for transvaginal sonography.

A New Approach to Office Hysteroscopy Compared With Traditional Hysteroscopy

OBJECTIVE

To compare a "no touch" approach to diagnostic hysteroscopy without anesthesia with traditional diagnostic hysteroscopy after intracervical injection of mepivacaine hydrochloride 3%.

METHODS

A total of 130 women undergoing diagnostic hysteroscopy were included in the study and were randomized, using a computer-generated randomization list to one of two treatment groups in a ratio of 2:1. Eighty-three women underwent hysteroscopy without speculum, tenaculum, or anesthesia. Forty-seven women received intracervical anesthesia with 10 mL of 3% mepivacaine hydrochloride solution injected at two sites (3:00 and 9:00 positions) and underwent traditional hysteroscopy. Hysteroscopy was performed using a rigid 3.7-mm hysteroscope and a medium of 0.9% saline, and the image was transmitted to a screen visible to the patient. A visual analog scale (VAS) consisting of a 10-cm line was used to assess the intensity of pain experienced during and after the procedure. Overall patient satisfaction was assessed during, immediately after, 15 minutes later, and 3 days after hysteroscopy.

RESULTS

The mean pain score was significantly lower in the group without the use of speculum, tenaculum, or anesthesia (VAS1: 3.8+/-2.7 versus 5.34+/-3.23, P=.01; VAS2: 3.02+/-2.50 versus 4.57+/-3.30, P=.008). Patient satisfaction rate was similar in both groups.

CONCLUSION

Patients reported significantly less pain with the altered approach to diagnostic hysteroscopy compared with patients undergoing the traditional procedure with anesthesia. This new approach can therefore be considered as a useful hysteroscopic technique.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT00319410

Vaginoscopic versus conventional approaches to outpatient diagnostic hysteroscopy: a two-centre randomized prospective study

BACKGROUND

To compare the tolerability and feasibility of the transvaginal and standard approaches in outpatient diagnostic hysteroscopy.

METHODS

This randomized prospective trial was carried out in two centres to compare the transvaginal (n = 200) and conventional (n = 200) approaches during outpatient hysteroscopy. Patients were randomized by a computer-generated list. The main outcome measure was pain during the examination, measured on a visual analogue scale (VAS) graded from 0 to 10 (0 = lowest, 10 = highest). Secondary criteria were ease of instrument passage through the cervix, investigation quality and its duration. For data analysis, we used the chi-squared test or Fischer's exact test for qualitative variables and the Mann-Whitney U-test for quantitative variables.

RESULTS

Median VAS was rated at 0.5 for the vaginoscopic and 2 for the standard (P < 0.0001) approaches. The approaches did not differ significantly in investigation quality, procedure duration or ease of cervical passage (although the latter was more often easy transvaginally).

CONCLUSIONS

The transvaginal approach is better tolerated than the conventional technique in outpatient diagnostic hysteroscopy.

General gynaecology: Intrauterine lignocaine as an anaesthetic during endometrial sampling: a randomised double-blind controlled trial

OBJECTIVE

To evaluate the effectiveness of intrauterine lignocaine as an anaesthetic during endometrial sampling.

DESIGN

Prospective, randomised, double-blind, placebo-controlled trial.

SETTING

Outpatient gynaecological minor operation unit in a public hospital.

POPULATION

Two hundred premenopausal women scheduled for endometrial sampling because of abnormal uterine bleeding.

METHODS

Transcervical intrauterine instillation of 5 mL of 2% lignocaine or 5 mL of normal saline before performing endometrial sampling with vacuum aspirator.

MAIN OUTCOME MEASURES

Evaluation of pain associated with the procedure using a visual analogue scale.

RESULTS

The use of intrauterine lignocaine reduced pain during suction curettage in endometrial sampling.

CONCLUSIONS

Transcervical instillation of lignocaine reduced pain during endometrial sampling.

New developments in ambulatory hysteroscopic surgery

In the last decade, advancements have been made in hysteroscopic techniques, instrumentation and indications. Vaginoscopic hysteroscopy is performed without medication, cervical dilation and use of vaginal speculum or cervical tenaculum. To prevent complications during uterine access, both misoprostol and laminaria are equally effective for cervical priming. The use of normal saline to distend the uterus prevents hyponatraemia, but hypervolaemia may still be a major problem. Irrigant fluid deficit is best monitored by automated devices. Bipolar electrosurgical systems do not require dispersive return electrodes and do not generate stray currents, thus minimizing the risk of electrical burns. Tissue debulking and extraction are facilitated by vaporizing electrodes or morcellators. Hysteroscopic indications have expanded to include diagnosis and treatment of missed abortion, and cervical and interstitial pregnancies. The most important advancement of hysteroscopy has been proximal tubal access for sterilization.

Anaesthesia and analgesia for ambulatory hysteroscopic surgery

Although ambulatory hysteroscopy is well established in dedicated centres, there is a delay in its general implementation. One reason for this may be the lack of consensus regarding a protocol for analgesia and anaesthesia in ambulatory hysteroscopy. This review looks at the various methods in use. These include the paracervical or intracervical injection of anaesthetic to establish a block. Topical anaesthetic may be applied to the surface of the endometrium in the uterine cavity or to the cervix. Oral analgesia is also used. A vaginoscopic approach to the uterine cavity without any anaesthesia is also becoming popular. Finally, combinations of the above methods have been employed for hysteroscopic surgical procedures, including the newer generation of endometrial ablation methods.

Use of sublingual buprenorphine for pain relief in office hysteroscopy

STUDY OBJECTIVE

To assess the efficacy of sublingual buprenorphine in the relief of pain associated with office hysteroscopy.

DESIGN

Prospective, randomized study (Canadian Task Force classification I).

SETTING

Tertiary medical center.

PATIENTS

One hundred sixty-four women referred for office hysteroscopy from September 2003 through March 2004.

INTERVENTION

Before hysteroscopy, 80 women received a tablet of buprenorphine (group A), and 84 women received a placebo (group B). Their pain sensations were evaluated on a 10-cm visual analog scale, and they were asked about the adverse reactions and level of satisfaction on the following day.

MEASUREMENTS AND MAIN RESULTS

The pain score in group A was 3.3 +/- 1.1, which was similar to 3.2 +/- 1.3 in group B. The pain scores in subgroups of women also were similar within the same group and between the two groups. Thirty-one women (38.8%) in group A reported adverse reactions, including nausea, vomiting, and drowsiness, while none in group B reported any adverse reactions.

CONCLUSION

Office hysteroscopy with a 3.1-mm flexible hysteroscope is a well-tolerated procedure. Sublingual buprenorphine is not helpful in relieving the pain associated with hysteroscopy but is associated with significant adverse reactions.

Outpatient hysteroscopy: traditional versus the 'no-touch' technique

OBJECTIVE

To assess whether outpatient hysteroscopy using the 'no-touch' technique confers any advantages in terms of patient discomfort over the traditional technique.

DESIGN

Prospective randomised controlled study.

SETTING

Outpatient hysteroscopy clinic in a large university undergraduate teaching hospital.

POPULATION

All women referred for outpatient hysteroscopy in a 12-month period.

INTERVENTIONS

Women were randomised to undergo either traditional saline hysteroscopy requiring the use of a speculum and tenaculum, or a 'no-touch' vaginoscopic hysteroscopy which does not require a speculum or tenaculum. Each group was further subdivided to have hysteroscopy with either a 2.9-mm or 4-mm hysteroscope. Patients were asked to complete pre- and postprocedure questionnaires ranking pain scores.

MAIN OUTCOME MEASURES

The relative success of each of these techniques, requirement for local anaesthetic and pain scores at different times during the hysteroscopy were recorded at the end of the procedure. The time taken to carry out each procedure was also measured.

RESULTS

One hundred and twenty women were recruited in this study: 60 were randomised to traditional hysteroscopy and 60 to 'no-touch' hysteroscopy. The overall success rate for hysteroscopy was 99%. There was no significant difference in the requirement for local anaesthetic between the two groups, but those who underwent 'no-touch' hysteroscopy with a 2.9-mm hysteroscope had the lowest requirement of local anaesthetic (10% compared with 27% in the no-touch hysteroscopy with a 4-mm hysteroscope group). The time taken to perform hysteroscopy and biopsy was significantly shorter with 'no-touch' hysteroscopy (5.9 vs 7.8 min; difference 1.9, 95% CI 0.7-3.1). There were no differences in pain scores between the groups at different times during hysteroscopy.

CONCLUSIONS

'No-touch' or vaginoscopic hysteroscopy is significantly faster to perform than the traditional technique. Although there was no difference in pain scores between the two techniques, local anaesthetic requirements were least in those who underwent 'no-touch' hysteroscopy with a narrow bore hysteroscope.

Thermachoice endometrial ablation in the outpatient setting, without local anesthesia or intravenous sedation: A prospective cohort study

OBJECTIVE

To determine whether Thermachoice endometrial ablation (EA) is a safe and acceptable procedure when performed in the outpatient (OP) setting without local anesthesia or IV sedation.

DESIGN

Prospective cohort (double group) study.

SETTING

Hysteroscopy clinic of large UK hospital.

PATIENT(S)

Twenty-seven women with menorrhagia.

INTERVENTION(S)

The first cohort of women underwent Thermachoice EA without elective analgesia. The second cohort underwent Thermachoice after taking ibuprofen.

MAIN OUTCOME MEASURE(S)

To map pain scores and the requirement of "rescue analgesia." To assess speed of recovery and time away from home.

RESULT(S)

Thermachoice EA was successfully performed in the OP setting on 89% (n = 24) of women. Four women in the first cohort required rescue analgesia compared to none in the second. During the procedure there was little difference between the groups visual analogue style pain scores-with the overall score being 3.6 (range = 0-10). Postoperatively there was a lower mean pain score in the second cohort, with fewer women experiencing nausea and vomiting. Mean time away from home was 2.6 hours and mean time to make a full recovery was 3.3 days. Women required analgesia for 2.6 days, on average, and returned to their normal activities at this time.

CONCLUSION(S)

Thermachoice EA without local analgesia or IV sedation can be safely and successfully performed in the OP setting and if ibuprofen is taken preoperatively few women require "rescue analgesia."

Women's views and experiences of outpatient hysteroscopy: implications for a patient-centered service

This study examined women's views and experiences of an invasive outpatient procedure and was undertaken in the context of the UK Government's policy of developing a patient-centered service. The research was based on a consecutive series of 30 attendees for outpatient hysteroscopy at a London hospital. Pain was recorded using linear analog scales, qualitative semistructured interviews were undertaken and a diary was completed for 3 days following the procedure. Overall pain ratings for 13 women (45%) were classified as a medium to high score. However, nearly all women preferred a future outpatient procedure. A range of factors influenced this preference, including their ability to cope with the pain, the reduced anxiety associated with undergoing the procedure immediately, a dislike of general anesthetics and the convenience of not disrupting usual routines. The psychosocial aspects of care were also identified as important in assisting women to cope, and form a key factor influencing patient's evaluation of services.

Outpatient Hysteroscopic Polypectomy in 237 Patients: Feasibility of a One-Stop “See-and-Treat” Procedure

STUDY OBJECTIVE

To evaluate the feasibility of a "see-and-treat" office polyp resection, using a 5-mm sheathed operative hysteroscope.

DESIGN

Retrospective study (Canadian Task Force classification II-2).

SETTING

Public hospital.

PATIENTS

Two hundred thirty-seven patients suffering from endometrial polyps who underwent outpatient hysteroscopy.

INTERVENTIONS

Office polypectomy with anesthetic paracervical block (120 patients) or without (117 patients) using either mechanical (104 patients) or bipolar coaxial electrosurgical (107 patients) instrumentation. In 26 patients, we stopped the procedure before surgery because of intervening adverse events or polyps judged unresectable with an office-based procedure. A 10-cm visual analog scale (VAS) was used to rate patients' pelvic pain perception.

MEASUREMENTS AND MAIN RESULTS

Overall effective polyp resection rate was 81.2% (191 of 235 evaluable patients). An inverse, although not significant (r = -.44) correlation was found between accomplished polypectomies and polyp size, ranging from 96.0% to 18.7% when the diameter of polyps was below 1 cm and above 4 cm, respectively (50 of 52 and 3 of 16 successfully accomplished procedures, respectively). No significant differences were found between successful resection rates (83.3% and 80.2%, respectively; p = .10) and VAS scores (2.2 +/- 2.6 and 3.6 +/- 2.9, respectively; p = .30) obtained in 79 premenopausal and 156 postmenopausal patients. Paracervical block administration (118 evaluable patients) matched with no anesthetic support (117 patients) was not associated either with an improved rate of resection (85.5% and 76.9%, respectively; p = .10) or with pelvic pain perception (VAS scores 3.3 +/- 2.9 and 3.0 +/- 2.8, respectively; p = .94). Visual analog scale scores were significantly lower (2.8 +/- 2.5 and 4.7 +/- 3.6, respectively; p = .001) and polyp resection rates were significantly higher (84.3% and 67.4%, respectively; p = .01) in 192 parous versus 43 nulliparous patients. Polypectomy failed in 44 of 235 patients (18.7%); the leading causes of failure were intolerable pelvic pain in 18 patients (7.6%) and polyp size in 17 patients (7.2%). Other than pelvic pain, the only adverse event we observed was clinical vasovagal reaction in four patients (1.7%).

CONCLUSION

One-stop outpatient hysteroscopic polypectomy is effective in about 80% of patients. With proper preoperative selection, it can be offered as a reliable option to avoid general anesthesia and resectoscopic surgery.

A Study of Complications Arising From Different Methods of Anesthesia Used in High-Dose-Rate Brachytherapy for Cervical Cancer

The purpose of this report is to review the complications related to different methods of anesthesia for high-dose-rate (HDR) brachytherapy for cervical carcinoma. All patients diagnosed with cervical cancer between 1999 and 2002 treated with 3-channel HDR brachytherapy were entered. Complications due to anesthesia for each fraction of brachytherapy were graded using the Common Toxicity Criteria. Eighty-four fractions of brachytherapy were delivered to 18 patients: 19 fractions with patients under general anesthesia (GA), 41 with patients under topical anesthesia and sedation, 5 with patients under paracervical nerve block, and 19 with patients under conscious sedation. Thirteen complications were reported: 12 related to GA and 1 due to paracervical nerve block. Of complications due to GA, 7 were grade 1 and 5 were grade 2. The complication due to paracervical nerve block (seizure) was grade 3. GA had significantly more complications than topical anesthesia or conscious sedation (both P < 0.001). HDR brachytherapy for cervical cancer under GA has significantly more complications than other methods. Given the increasing use of fractionated 3-channel brachytherapy, further investigation of risks and benefits of anesthetic techniques is required.

Office hysteroscopy

The indications for hysteroscopic procedures in gynecologic practice are ample and clearly charted: hysteroscopy is considered the gold standard not only for visualizing the cervical canal and the uterine cavity, but also for treating many different kinds of benign pathologies localized to that region. This article summarizes the authors' experience with this technique during the last 14 years, which have been devoted to improving the procedure by creating new instruments and modifying the technique.

The technique and overview of flexible hysteroscopy

Flexible hysteroscopy is a safe, successful, and reliable method of investigation for abnormal uterine bleeding. When compared with rigid hysteroscopy flexible hysteroscopy is associated with less pain both at introduction of the hysteroscope and during the procedure itself especially when the diameter of the scope is reduced. This article provides evidence of the benefits of flexible hysteroscopy to the health service provider, clinician, and patient. Flexible hysteroscopy is acceptable to most women when performed in the outpatient setting without analgesia and offers a suitable alternative to rigid hysteroscopy.

Pain Relief and Outpatient Hysteroscopy: A Literature Review

Our early experience in setting up an ambulatory hysteroscopy service provoked a review of the literature, due to an unacceptably high failure rate. A literature review has been undertaken to establish the accepted success rates and reasons for failure, and to assess evidence for various analgesic protocols through randomized controlled trials. The data suggest the procedure is acceptable to most patients, with a completion success rate over 90%, and the use of analgesia may enhance the success rate. Analgesic protocols studied were nonsteroidal anti-inflammatory drugs, intracervical block, paracervical block, transcervical block, and topical analgesia. Failures are due predominantly to pain, stenosis, and poor view.

The Use of Intrauterine Lidocaine to Minimize Pain During Hysterosalpingography: A Randomized Trial

OBJECTIVE

A hysterosalpingogram is an integral part of the evaluation of infertility but is often painful. Intrauterine anesthesia may help to alleviate the discomfort associated with this procedure.

METHODS

We conducted a randomized, double-blinded, placebo-controlled trial of intrauterine lidocaine in women undergoing hysterosalpingography (HSG). All women were instructed to take a nonsteroidal analgesic before the hysterosalpingogram. Patients received 3 mL of buffered 2% lidocaine solution or 0.9% normal saline instilled into the uterus before HSG. The primary outcome was the degree of pain experienced documented via 10-cm visual analogue pain scales. Systematic assessments of discomfort were also collected by the attending physician, radiology technician, and radiology physician.

RESULTS

Sixty-four patients were randomly assigned to placebo and 63 women were randomly assigned to the lidocaine group. There were no differences in mean age, race, parity, or history of dysmenorrhea or chronic pelvic pain. There were no differences in the pain scores at baseline, during, or after the study procedure between the 2 groups. Peak pain scale scores associated with the procedure were 5.3 +/- 0.4 in both the placebo and study groups. In addition, assessments of patient discomfort revealed no significant differences between the 2 groups.

CONCLUSION

We found no difference in pain between the intrauterine-lidocaine and placebo groups. Intrauterine lidocaine does not appear to be effective in decreasing pain in women undergoing HSG.

LEVEL OF EVIDENCE

I

Risk of Vasovagal Syndrome During Outpatient Hysteroscopy

STUDY OBJECTIVE

To evaluate influence of hysteroscope type and media used during outpatient hysteroscopy on vasovagal syndrome risk.

STUDY DESIGN

Prospective observational study (Canadian Task Force classification II-1).

SETTING

University hospital.

PATIENTS

Two thousand seventy-nine women undergoing outpatient hysteroscopy without analgesia.

INTERVENTION

Office hysteroscopy with a flexible or rigid hysteroscope and normal saline or CO(2).

MEASUREMENTS AND MAIN RESULTS

Fifteen cases of vasovagal syndrome were reported. The rate of vasovagal syndrome was higher with use of a rigid hysteroscope (12/647 [1.85%]) vs. a flexible hysteroscope (3/1432 [0.21%]), p =.00013; p =.009 after adjustment for medium used; and with the use of CO2 (10/426 [2.34%]) vs. saline solution (5/1653 [0.30%]), p <.0001; p =.014 after adjustment for hysteroscope type.

CONCLUSION

Risk of vasovagal syndrome is higher with the use of a rigid hysteroscope and CO2, regardless of the indication for hysteroscopy or the parity and menopausal status of the patient.

Improved Patient Compliance using Pediatric Cystoscope during Office Hysteroscopy

STUDY OBJECTIVE

To evaluate the use of a pediatric cystoscope in office diagnostic hysteroscopy.

DESIGN

Retrospective review (Canadian Task Force classification II-2).

SETTING

Maccabi Outpatient Women's Health Center.

PATIENTS

One thousand three hundred and thirty-five women; 959 (71.8%) premenopausal and 376 (28.2%) menopausal.

INTERVENTION

Office diagnostic hysteroscopy using 2.3-mm diameter pediatric cystoscope, without premedication or anesthesia.

MEASUREMENTS AND MAIN RESULTS

Hysteroscopy was successfully completed in 1298 patients (97.3%). The main reason for failure was cervical stenosis. Menopausal status was the only statistically significant factor correlating with increased failure rate. The analysis demonstrates that for every year of age, the OR for success decreases by 0.965, and success rises by 1.29 for every delivery the woman had. In menopausal women, the OR for success decreases by 0.45. Dilatation of the cervix was required in six women (0.46%), and local anesthesia was needed in only two women. One uterine perforation was recorded, and eight women (0.006%) developed vasovagal reflex or severe abdominal cramps. Post procedural oral analgesia was needed in 108 (8%) of the women.

CONCLUSION

The combination of a very small diameter continuous flow pediatric cystoscope, together with its ability to deliver high-quality images of the uterine cavity, make this instrument an excellent option for office diagnostic hysteroscopy.

Anesthetic Effect of Intrauterine Lidocaine Plus Naproxen Sodium in Endometrial Biopsy

OBJECTIVE

To compare the efficacy of intrauterine lidocaine with oral naproxen sodium on pain perception of the patients during endometrial biopsy using the Pipelle instrument and to investigate their effects when used in combination.

METHODS

One-hundred twenty women were randomly assigned to receive either 5 mL of intrauterine 2% lidocaine or saline and either 550 mg of naproxen sodium or a similar-appearing placebo tablet. Subsequently, each woman completed a 10-cm visual analog scale for subjective pain experience and a physician scored visible signs of the women's distress during the procedure using a 3-point observer scale.

RESULTS

There was no statistically significant difference between the 4 groups in age, vaginal parity, history of chronic pelvic pain, menopausal status, tenaculum use, previous endometrial biopsy, or difficulty in passing the cervical os. The mean pain scores of the women in the naproxen only (5.8 +/- 2.2) and lidocaine only (5.9 +/- 2.2) groups were not significantly different compared with placebo group (7.1 +/- 2.0). However, the mean pain score in the lidocaine plus naproxen group (4.6 +/- 1.8) compared with the placebo group showed significant reduction in pain (P <.05). Pain rated by the physician was significantly lower in the lidocaine plus naproxen group compared with other groups, and a significant correlation was noted between the visual analog pain score and the patients' distress recorded by the physician (r =.791, P <.001). One patient in the naproxen-only group had vasovagal syncope after the procedure.

CONCLUSION

Intrauterine lidocaine instillation significantly decreases pain associated with Pipelle endometrial biopsy when used in combination with oral naproxen sodium.

LEVEL OF EVIDENCE

I

Randomised comparison of distension media for outpatient hysteroscopy

OBJECTIVE

To compare saline with and without added lignocaine and carbon dioxide distension for out patient hysteroscopy with regards to patient discomfort and hysteroscopic view.

DESIGN

Single blind prospective randomised controlled trial.

SETTING

Specialist out patient clinics in a large teaching hospital.

POPULATION

Women undergoing out patient hysteroscopy and endometrial biopsy for abnormal uterine bleeding.

METHOD

Out patient hysteroscopy using carbon dioxide, saline or saline with lignocaine.

MAIN OUTCOME MEASURES

Visual analogue score (VAS) for pain and present pain intensity (PPI) as assessed by patients and the quality of hysteroscopic view as assessed by the operator.

RESULTS

Of the 305 women approached, 300 women were randomised into the study. The mean [SD] VAS for pain in the carbon dioxide group was 2.9 [2.3] and in the saline group was 3.1 [2.6], the difference was not statistically significant (P= 0.49). The mean [SD] VAS for pain in the saline plus lignocaine group was 3.2 [2.4]. This was not significantly different from the saline group (P= 0.72). There was a statistically significant difference between the confidence rating for the hysteroscopic view for the carbon dioxide compared with the saline group; mean [SD] was 8.3 [2.1] and 9.6 [1.1], respectively (P= 0.001).

CONCLUSION

Carbon dioxide and saline as distension media are comparable in terms of overall patient discomfort and satisfaction, but saline provides better views and increases confidence in diagnosis. Adding lignocaine to the saline distension medium does not confer any additional benefit.

What does 'diagnostic hysteroscopy' mean today? The role of the new techniques

PURPOSE OF REVIEW

Visual examination of the uterine cavity and contextual operative facilities have provided the gynecologist with the perfect 'diagnostic' tool, making it possible to examine the cavity and biopsy suspected areas under direct visualization.

RECENT FINDINGS

The approach used to insert the scope, together with the diameter of the hysteroscope and the distention of the uterine cavity, are of extreme importance in reducing patient discomfort to a minimum during an outpatient examination. The vaginoscopic approach (without speculum or tenaculum) has definitively eliminated patient discomfort related to the traditional approach to the uterus. One of the major problems for endoscopists is passing through the internal cervical os; the new generation of hysteroscopes, with an oval profile and a total diameter between 4 and 5 mm, are strictly correlated to the anatomy of the cervical canal. Miniaturized instruments have enabled the physician not only to perform targeted hysteroscopic biopsies, but also to treat benign intrauterine pathologies, such as polyps and sinechiae, without any premedication or anesthesia. This has been defined as a 'see & treat' procedure: there is no longer a distinction between the diagnostic and operative procedures, but a single procedure in which the operative part is perfectly integrated in the diagnostic work-up.

SUMMARY

Diagnostic hysteroscopy has long paid the price of being a purely visual method of investigation. Today, thanks to recent advances in instrumentation and to modified techniques related to the simultaneous use of the scope and of instruments, hysteroscopy is finally achieving the full accuracy that has been awaited for the last 20 years.

Patient-controlled sedation for outpatient thermal balloon endometrial ablation

STUDY OBJECTIVE

To evaluate the effectiveness, safety, and patient satisfaction with patient-controlled sedation during thermal balloon endometrial ablation.

DESIGN

Prospective observational study (Canadian Task Force classification II-2).

SETTING

University-affiliated teaching hospital.

PATIENTS

Thirty consecutive women with idiopathic menorrhagia refractory to medical treatment.

INTERVENTION

Thermal balloon endometrial ablation under patient-controlled sedation with a mixture of propofol and alfentanil through an analgesia pump.

MEASUREMENTS AND MAIN RESULTS

Pain was assessed using a descriptive pain score and the procedure was divided into four stages for assessment: catheter insertion, preheating phase, treatment cycle, and end of treatment. Patient satisfaction was assessed using the 8-item client satisfaction questionnaire. The procedure was well tolerated with good cooperation and no oversedation. Preheating was the most painful, and pain could be alleviated by asking the patient to self-administer a bolus of anesthesia before that phase. The median consumption of propofol was 35 mg (range 0-70 mg) and of alfentanil was 175 microg (range 50-200 microg). There were no intraoperative complications and the overall success rate in treating menorrhagia was 87%. Over 85% of the women did not think that general anesthesia was necessary. They all were highly satisfied and would recommend the procedure to others.

CONCLUSION

Patient-controlled sedation is a safe and effective method of alleviating pain and discomfort during thermal balloon ablation and is well accepted by patients.

Pain control in outpatient hysteroscopy

Office hysteroscopy has become increasingly used as first line investigation for abnormal uterine bleeding and other diseases involving the uterine cavity. The main limitation to its widespread use is pain and low patient tolerance. This review examines current literature on analgesia used in outpatient hysteroscopy with the purpose of establishing guidelines on methods of pain relief for the procedure. However, the review has failed to find substantial or conclusive evidence for the routine use of local analgesia in outpatient hysteroscopy. Most literature suggests that it is a well-tolerated procedure and recommends analgesic use only in selected patients. Additional research is indicated for developing superior narrow diameter hysteroscopes and endometrial biopsy devices to improve the acceptability of office hysteroscopy.

Is outpatient diagnostic hysteroscopy more useful than endometrial biopsy alone for the investigation of abnormal uterine bleeding in unselected premenopausal women? A randomised comparison

OBJECTIVE

To formally evaluate the clinical benefit of additional outpatient hysteroscopy over traditional vaginal examination and endometrial biopsy.

DESIGN

A prospective randomised controlled trial.

SETTING

A large teaching hospital in the northeast of Scotland. SAMPLE Premenopausal women with abnormal uterine bleeding referred to the general gynaecologic clinic and requiring endometrial biopsy. METHODS Women were randomised to either outpatient hysteroscopy and endometrial biopsy or endometrial biopsy alone.

MAIN OUTCOME MEASURES

PRIMARY OUTCOME

initial surgical intervention rates.

SECONDARY OUTCOMES

procedural success and acceptability, intrauterine pathology identified and changes in management.

RESULTS

Three hundred and seventy women were recruited to the study. Initial trends in clinical management were comparable in both groups. No woman was advised to have removal of a localised lesion found at outpatient hysteroscopy and a normal uterine cavity at hysteroscopy did not influence the hysterectomy rate, which was similar in both groups. Outpatient hysteroscopy was found to be as acceptable as an outpatient endometrial biopsy and successfully completed in 85% compared with 91% of women who underwent endometrial biopsy alone. No cases of endometrial malignancy were identified.

CONCLUSIONS

Outpatient diagnostic hysteroscopy is an acceptable procedure and may give more reassurance. It did not influence clinical management, especially with respect to hysterectomy rate. Outpatient hysteroscopy may be useful in selected cases, but when performed in a non-selective manner, it has little influence on clinical management and increases costs.

Current practical application of office endoscopy

Outpatient hysteroscopy has shown good correlation of findings compared with inpatient hysteroscopy, but one limitation is pain and discomfort in some women, and vasovagal reaction. Various forms of local anaesthesia have been evaluated in the past year, with controversial results, and a narrow 3.5 mm sheath hysteroscope has been introduced. Transvaginal hydrolaparoscopy as an outpatient procedure has been further investigated.

Anesthesia for hysteroscopy

Hysteroscopy is becoming a more widely used technique. Diagnostic hysteroscopy is replacing conventional dilatation and curettage in the diagnosis of intrauterine pathologies. Transcervical endometrial resection is often the first-line surgical treatment for dysfunctional uterine bleeding and carries less associated morbidity and morality. Overall, the technique is extremely safe, but vigilance is required particularly for intravasation of irrigation media. Complications such as gas embolus and hypo-osmolar hyponatremia require prompt treatment to reduce associated morbidity and morality. Careful monitoring of fluid deficit is paramount in avoiding the latter problem. Regional or general anesthetic techniques can be used and, in the ambulatory or office-based setting, in which these procedures are increasingly performed, the need for "street readiness" can influence the choice of the agents used.

The effect of an intrauterine application of two percent lignocaine gel on pain perception during Vabra endometrial sampling: a randomised double-blind, placebo-controlled trial

OBJECTIVE

To determine whether two percent lignocaine gel can reduce the perception of pain during Vabra endometrial aspiration.

DESIGN

Randomised, double-blind placebo-controlled trial.

SETTING

Women's Health Directorate, Warrington Hospital NHS Trust.

POPULATION

Women were referred to the endometrial sampling clinic for the investigation of pre and postmenopausal vaginal bleeding.

METHODS

Randomisation to either pre-sampling intrauterine two percent lignocaine gel or an inert gel. Patients, recruiters and assessors were blinded to the gel used.

MAIN OUTCOME MEASURES

The difference between the study groups in the proportion of women who, after Vabra sampling, recorded a pain score of > or = 6 out of 10 on a visual analogue scale.

RESULTS

Three hundred and eight women were randomised, 284 (92%) completed a pain scale before and immediately after the procedure. After the procedure, 84 women (30%) recorded a pain score of > or = 6, 38 (26%) received anaesthetic and 46 (33%) an inert gel. The difference in the proportion of women recording a pain score of 6 or above between the two study groups was not significant (relative risk (RR) for the anaesthetic gel = 0.79 95% CI, 0.55, 1.14).

CONCLUSIONS

Intrauterine application of 2% lignocaine gel did not significantly reduce the frequency with which women experienced unacceptable levels of pain or anxiety during endometrial aspiration compared with placebo.

The role of outpatient diagnostic hysteroscopy in identifying anatomic pathology and histopathology in the endometrial cavity

STUDY OBJECTIVE

To evaluate the role of outpatient diagnostic hysteroscopy.

DESIGN

Retrospective review (Canadian Task Force classification II-2).

SETTING

University teaching hospital-based outpatient clinic.

PATIENTS

One thousand six hundred women, 67.3% premenopausal and 32.7% postmenopausal.

INTERVENTION

Diagnostic hysteroscopy without premedication or anesthesia; endometrial sampling or hysteroscopy-guided biopsy was performed when appropriate.

MEASUREMENTS AND MAIN RESULTS

Outpatient hysteroscopy was successfully performed in 1468 women (91.8%). Eleven women (0. 7%) developed vasovagal response during the procedure, 18 required hospital admission because of pain or hemorrhage, and 2 were suspected of having uterine perforation. All recovered spontaneously without intervention. Intrauterine anatomic pathology was diagnosed in 17.0%; the overall frequency of myomas and endometrial polyps was 12.3% and 7.1%, respectively. The sensitivity and positive predictive value of hysteroscopy without biopsy in diagnosing endometrial carcinoma were only 58.8% and 20.8%, respectively. Of 1112 women with hysteroscopic impression of normal or atrophic endometrium, 10 (0.9%) had endometrial hyperplasia on biopsy.

CONCLUSION

Hysteroscopy without biopsy carries low sensitivity and positive predictive value in the diagnosis of endometrial carcinoma and hyperplasia. In our opinion the predictive value of a negative hysteroscopy is inadequate, and endometrial biopsy should be performed during hysteroscopy for accurate diagnosis of endometrial histopathology.

Stepwise pain score analysis of the effect of local lignocaine on outpatient hysteroscopy: a randomized, double-blind, placebo-controlled trial

OBJECTIVE

To assess the efficacy of lignocaine gel in reducing the overall pain and pain of individual steps during outpatient hysteroscopy in comparison with placebo (no anesthesia).

DESIGN

A prospective, randomized, double-blind, placebo-controlled trial.

SETTING

Outpatient hysteroscopy clinic in a regional hospital in Hong Kong.

PATIENT(S)

A total of 500 Chinese patients undergoing outpatient hysteroscopy.

INTERVENTION(S)

Application of lignocaine gel to the cervix during outpatient hysteroscopy.

MAIN OUTCOME MEASURE(S)

Mean pain score using present pain intensity, overall pain score measured by total area under the curve, and the pain score of individual steps in the procedure in patients receiving lignocaine gel were compared with those of patients having no anesthesia. The failure rate and poor-view rate in both groups were also compared.

RESULT(S)

There were no statistically significant differences in mean pain score, overall pain score, and pain score of individual steps between the lignocaine group and controls. The failure rate and poor-view rate also showed no statistically significant differences.

CONCLUSION(S)

Outpatient hysteroscopy without anesthesia is acceptable to most Chinese women, and the local application of lignocaine gel is not effective in reducing pain.

A randomised double-blind placebo-controlled trial of transcervical intrauterine local anaesthesia in outpatient hysteroscopy

OBJECTIVE

To assess whether transcervical intrauterine instillation of local anaesthetic agent reduces pain during diagnostic outpatient hysteroscopy and endometrial biopsy.

DESIGN

Prospective, randomised, double blind, placebo-controlled trial.

SETTING

Outpatient hysteroscopy clinic in a university teaching hospital.

POPULATION

Ninety women undergoing outpatient diagnostic hysteroscopy with or without endometrial biopsy.

METHODS

Transcervical intrauterine instillation of 5 mL of 2% lignocaine into the uterine cavity before performing the procedure.

MAIN OUTCOME MEASURES

Evaluation of pain at different stages of the procedure using a visual analogue scale and changes in blood pressure and heart rate.

RESULTS

The use of local anaesthetic did not alleviate pain experienced during hysteroscopy and endometrial biopsy. It did not prevent the occurrence of vaso-vagal reactions; however the incidence of these was low.

CONCLUSIONS

Transcervical instillation of local anaesthesia neither reduced pain nor prevented vaso-vagal reaction during hysteroscopy and endometrial biopsy.