Pain management for tubal sterilization by hysteroscopy

Management of anxiety and pain perception in women undergoing office hysteroscopy: a systematic review

PURPOSE

The aim of this review is to provide an overview of the literature about the perception and management of anxiety and pain in women undergoing an office hysteroscopic procedure.

METHODS

We performed a systematic literature search in Embase, PubMed/MEDLINE, Cochrane Library and Web of Science for original studies written in English (registered in PROSPERO 2019-CRD42019132341), using the terms 'hysteroscopy' AND 'pain' AND 'anxiety' published up to January 2019. Only original articles (randomized, observational and retrospective studies) about management of anxiety and pain related to the hysteroscopic procedure were considered eligible.

RESULTS

Our literature search produced 84 records. After exclusions, 11 studies including 2222 patients showed the following results: (a) pain experienced during hysteroscopy is negatively affected by preprocedural anxiety; (b) pharmacological interventions seem to be help in reducing pain during hysteroscopy; (c) waiting time before the procedure is a significant factor affecting patients' anxiety; (d) music during the procedure may be helpful in reducing anxiety.

CONCLUSIONS

The utilization of office hysteroscopy is hampered by varying levels of anxiety and pain perceived by women who are candidates for the procedure. For these reasons, it is essential to identify effective pharmacological and non-pharmacological strategies to alleviate these factors. We recommend further studies especially focusing on non-pharmacological interventions to facilitate the dissemination of good clinical practices among hysteroscopists.

Low-Dose Ketamine for Outpatient Hysteroscopy: A Prospective, Randomised, Double-Blind Study

Objective

Outpatient hysteroscopy is often accompanied by pain and discomfort along with frequent occurrence of bradycardia and hypotension. This study aimed to observe if intravenous low-dose ketamine reduces the pain scores along with lowering the incidence of bradycardia and hypotension during hysteroscopy.

Methods

This prospective, randomised, double-blind trial was conducted in operating rooms in a tertiary care hospital. In this study, we enrolled 72 patients with American Society of Anesthesiologists status I to II undergoing hysteroscopy. We randomised patients into two groups, and both groups received paracervical block. The control group received intravenous pentazocine and promethazine along with saline infusion. The ketamine group received ketamine infusion (0.75 mg kg⁻¹ bolus followed by infusion at the rate of 10 mcg kg⁻¹ min⁻¹). We analysed visual analogue scale (VAS), rescue analgesic consumption, hemodynamic parameters, lowest recorded heart rate, blood pressure, level of sedation, patient’s comfort, surgeon’s satisfaction and nursing staff’s satisfaction.

Results

Analysis of the data revealed that the pain scores were similar in both the groups (p=0.493, p<0.001). Rescue analgesic was required by 47% patients in control group, compared to only 5.6% patients in ketamine group. Episodes of bradycardia and hypotension were more pronounced in the control group than in the ketamine group [77.4±10.9 vs. 78.4±5.5; 67.6±8 vs. 70.1±6 respectively] (p<0.001). Patient comfort and surgeon’s satisfaction were higher in the ketamine group, but nursing satisfaction was higher in the control group. Disorientation was present in 75% patients in the ketamine group as compared to none in the control group.

Conclusion

We concluded that low-dose ketamine in day-care hysteroscopy is an effective and safe agent.

Effect of penehyclidine hydrochloride on heart rate variability in hysteroscopy

In order to evaluate the effect of different doses of penehyclidine hydrochloride (penehyclidine) on heart rate (HR) and HR variability (HRV) in hysteroscopy, 180 patients (American Society of Anesthesiologists grade I-II) were randomized equally to three groups: 0.5 mg penehyclidine and intravenous anesthesia (group I), 1.0 mg penehyclidine and intravenous anesthesia (group II) and saddle anesthesia combined with intravenous anesthesia (control group). HR and HRV, including total power (TP), low-frequency power (LF), high-frequency power (HF) and the LF to HF ratio (LF/HF), were recorded prior and subsequent to the induction of anesthesia (T₀ and T₁, respectively), following the start of surgery (T₂) and following completion of surgery (T₃). HR was lower at T₂ than at T₀ in the control patients, but no differences were observed in groups I and II. The HR at T₂ was increased in group II compared with that in group I. TP in group II was significantly higher compared with that in group I at T₂. At T₁ and at T₂, the LF and HF values were lower in group I than those in the controls. Patients in group II also had higher LF and HF at T₂ than patients in group I. The HF was higher at T₂ than that at T₀ in the controls; however, the HF and LF did not change significantly within groups I and II. No significant differences were observed in the LF/HF ratio among the three groups. At a dose of 0.5 mg, penehyclidine stabilized HRV and did not alter the autonomic nervous modulation of HR. A penehyclidine dose of 1.0 mg may be superior to a dose of 0.5 mg in maintaining HR, but is less effective at balancing sympathetic and parasympathetic activity.

Anxiety at outpatient hysteroscopy

This review summarises current understanding and research on the association between anxiety and outpatient hysteroscopy. Women undergoing hysteroscopy suffer from significant levels of anxiety, with repercussions on pain perception, success rates and satisfaction. Using validated tools such as the Spielberger State-Trait Anxiety Index (STAI) or the Hospital Anxiety and Depression Scale (HADS) in the outpatient hysteroscopy setting, average state anxiety scores similar or greater than those measured before more invasive procedures under general anaesthesia have been consistently reported. This clearly suggests a significant gap between our clinical viewpoint of what is "minimally invasive" and patients' expectations. In spite of its potential role of confounder in studies on pain-reduction interventions, we found that patient anxiety was evaluated in only 9 (13 %) out of a sample of 70 randomised controlled trials on outpatient hysteroscopy published since 1992. Factors such as trait anxiety, age, indication and the efficiency of the clinic can be correlated to state anxiety before hysteroscopy, but more robust data are needed. Promising non-pharmacological interventions to reduce anxiety at hysteroscopy include patient education, communication through traditional or multimedia approaches, interaction and support during the procedure and music listening.

Hysteroscopic sterilization in the office setting

Hysteroscopic sterilization is growing in popularity. Nearly 500,000 women have been sterilized using this method, and an increasing number of physicians are now performing this procedure in the office setting. The office setting can provide a cost-effective, convenient, and safe environment for hysteroscopic sterilization. Patients may benefit from avoiding hospital preoperative visits, excessive laboratory evaluation, operating room wait times, and expense associated with hospital care. Physicians may improve productivity through remaining in their office or avoiding operating room delays. This article reviews office-hysteroscopic sterilization with the Essure microinsert system.