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Hashem AT, Mahmoud M, Aly Islam B, Ibrahem Eid M, Ahmed N, Mohamed Mamdouh A, Elkomy R, Fouad Elgamel A, Hamada AAA, Khalil EM, Ashour ASA, Said Ali A, Taher A, Hasan Hussein A, Elzahaby I, Hafez Mohamed Younes M, Salah E, Mojahed EM, Talaat B, ElHodiby M, Kamal Osman N, Adel Nour D, Khamis Y, Aly Hamed Elsallamy A, Ahmed Gehad M, Kotb MMM, Gad Allah SH. Comparative efficacy of lidocaine-prilocaine cream and vaginal misoprostol in reducing pain during levonorgestrel intrauterine device insertion in women delivered only by cesarean delivery: A randomized controlled trial. Int J Gynaecol Obstet 2024; 165:634-643. [PMID: 35212402 DOI: 10.1002/ijgo.14157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 12/18/2021] [Accepted: 02/23/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To compare efficacy of lidocaine-prilocaine (LP) cream versus misoprostol versus placebo before levonorgestrel-releasing intrauterine device (LNG-IUD) insertion. METHODS This randomized controlled trial (RCT) was conducted in a tertiary referral hospital from April 30, 2020 to March 1, 2021 on 210 parous women willing to receive LNG-IUD and delivered only by elective cesarean delivery (CD). Participants received 200 μg vaginal misoprostol or 5 ml of LP cream 5% or placebo 3 h before LNG-IUS insertion. Primary outcome was pain during LNG-IUD insertion, while secondary outcomes were pain 10 min post-procedure, ease of insertion, patient satisfaction, insertion time, and drug side effects. RESULTS Pain during LNG-IUS insertion was reduced in LP group and misoprostol group compared to placebo group (2.1 ± 1.0 vs 3.7 ± 1.6; p <0.001) and (2.3 ± 1.3 vs 3.7 ± 1.6; p <0.001), respectively. Ease of procedure and patient satisfaction were significantly higher in LP and misoprostol groups than placebo (P <0.001). Need for additional analgesia was significantly higher in placebo group than in the other two groups (P = 0.009). Adverse events were not significantly different between the three groups except vomiting and abdominal cramps, which were higher with misoprostol. CONCLUSION LP cream and 200 μg of vaginal misoprostol administration before LNG-IUD insertion in women delivered only by elective CD effectively reduced pain during insertion and 10 min post-procedure with easier insertions, high patient satisfaction, and tolerable side effects. Pain reduction with LP cream was clinically significant.
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Affiliation(s)
- Ahmed T Hashem
- Department of Obstetrics &Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mostafa Mahmoud
- Department of Obstetrics &Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Bassem Aly Islam
- Department of Obstetrics & Gynecology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Mohamed Ibrahem Eid
- Department of Obstetrics & Gynecology, Faculty of Medicine, Mansoura University, Mansoura City, Egypt
| | - Nancy Ahmed
- Department of Obstetrics &Gynecology, Faculty of Medicine, Beni Suef University, Beni Suef, Egypt
| | - Ahmed Mohamed Mamdouh
- Department of Obstetrics & Gynecology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Rasha Elkomy
- Department of Obstetrics &Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Amira Fouad Elgamel
- Department of Obstetrics &Gynecology, Faculty of Medicine, Beni Suef University, Beni Suef, Egypt
| | - A A Ali Hamada
- Department of Obstetrics &Gynecology, Faculty of Medicine, Beni Suef University, Beni Suef, Egypt
| | - Eman M Khalil
- Department of Obstetrics &Gynecology, Faculty of Medicine, Beni Suef University, Beni Suef, Egypt
| | - Ahmed S A Ashour
- Department of Obstetrics &Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | - Ayman Taher
- Department of Obstetrics &Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Amr Hasan Hussein
- Department of Obstetrics &Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Iman Elzahaby
- Department of Obstetrics &Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | - Emad Salah
- Department of Obstetrics &Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Eman M Mojahed
- Department of Obstetrics &Gynecology, Faculty of Medicine, Fayoum University, Faiyum, Egypt
| | - Bassem Talaat
- Department of Obstetrics &Gynecology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Mohamed ElHodiby
- Department of Obstetrics and Gynecology, Faculty of Medicine, Misr University for Science and Technology, Giza, Egypt
| | - Nada Kamal Osman
- Department of Obstetrics &Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Dalia Adel Nour
- Department of Obstetrics &Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Yasser Khamis
- Department of Obstetrics &Gynecology, Faculty of Medicine, Beni Suef University, Beni Suef, Egypt
| | - Ayman Aly Hamed Elsallamy
- Department of Obstetrics and Gynecology, Faculty of Medicine, Misr University for Science and Technology, Giza, Egypt
| | - Mahmoud Ahmed Gehad
- Department of Obstetrics and Gynecology, Faculty of Medicine, Benha University, Benha, Egypt
| | | | - Sherine H Gad Allah
- Department of Obstetrics &Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
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Rahimi M, Haghighi L, Baradaran HR, Azami M, Larijani SS, Kazemzadeh P, Moradi Y. Comparison of the effect of oral and vaginal misoprostol on labor induction: updating a systematic review and meta-analysis of interventional studies. Eur J Med Res 2023; 28:51. [PMID: 36707858 PMCID: PMC9881312 DOI: 10.1186/s40001-023-01007-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 01/09/2023] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES This study is aimed to compare the effect of oral misoprostol with vaginal misoprostol to induce labor as a systematic review and meta-analysis. METHODS Electronic databases including PubMed [Medline], Scopus, Web of science, Embase, Ovid, Cochrane library, and ClinicalTrials.gov were searched using the relevant keywords. All RCTs comparing the effect of oral vs vaginal misoprostol on labor induction were considered. The Cochrane Risk of Bias checklist was used for assessing quality of included RCTs. All statistical analyses were completed using STATA (Version 16) and Revman (Version 5). RESULTS Thirty-three RCTs with 5162 patients (1560 in oral and 2602 in vaginal groups) were included in this meta-analysis. Labor induction length did differ significantly between the two routes of misoprostol administration [Standardized Mean Difference: 0.40 h, 95% confidence interval (CI) 0.34, 0.46; I2: 66.35%; P = 0.04]. In addition, the risk of neonatal death, tachysystole, uterine hyperstimulation, preeclampsia, non-FHR and abortion was lower in the oral misoprostol group and the risk of hypertonus, PROM, oxytocin need and cesarean fever was higher in this group than the vaginal misoprostol group. CONCLUSIONS Based on results of this meta-analysis, it can be inferred that currently, clinical specialists can decide to use this drug orally or vaginally on a case-by-case basis, depending on the condition of the pregnant mother and the baby.
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Affiliation(s)
- Maryam Rahimi
- grid.411746.10000 0004 4911 7066Department of Gynecology and Obstetrics, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Ladan Haghighi
- grid.411746.10000 0004 4911 7066Department of Gynecology and Obstetrics, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Hamid Reza Baradaran
- grid.7107.10000 0004 1936 7291 Ageing Clinical & Experimental Research Team, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK ,grid.411746.10000 0004 4911 7066Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Mobin Azami
- grid.484406.a0000 0004 0417 6812Student Research Committee, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Samaneh Saghafian Larijani
- grid.411746.10000 0004 4911 7066Department of Gynecology and Obstetrics, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Paniz Kazemzadeh
- grid.411746.10000 0004 4911 7066Department of Gynecology and Obstetrics, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Yousef Moradi
- grid.484406.a0000 0004 0417 6812Social Determinant of the Health Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran ,grid.484406.a0000 0004 0417 6812Department of Epidemiology and Biostatistics, School of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran
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Rund NMA, El Shenoufy H, Islam BA, El Husseiny T, Nassar SA, Mohsen RA, Alaa D, Gad Allah SH, Bakry A, Refaat R, Gehad MA, Kotb MMM, Osman OM, Ashour ASA, Ali AS, Taher A, Kholaif K, Hashem AT, Elsallamy AAH, Nour DA, Dahab S, Talaat B, Almohammady M. Determining the Optimal Time Interval between Vaginal Dinoprostone Administration and Diagnostic Office Hysteroscopy in Nulliparous Women: A Randomized, Double-blind Trial. J Minim Invasive Gynecol 2021; 29:85-93. [PMID: 34217851 DOI: 10.1016/j.jmig.2021.06.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 05/11/2021] [Accepted: 06/24/2021] [Indexed: 02/01/2023]
Abstract
STUDY OBJECTIVE To determine the optimal timing of vaginal dinoprostone administration before office hysteroscopy (OH) in nulliparous women. DESIGN Randomized, double-blind trial. SETTING Tertiary referral hospital. PATIENTS A total of 180 nulliparous women undergoing diagnostic OH. INTERVENTIONS We randomly allocated the women to long-interval or short-interval dinoprostone groups: three mg dinoprostone was administered vaginally 12 hours before OH in the long-interval group and 3 hours before OH in the short-interval group. MEASUREMENTS AND MAIN RESULTS The primary outcome was pain during OH measured using a 100-mm visual analog scale (0 = no pain; 100 = worst pain imaginable). The secondary outcomes were ease of hysteroscope passage, patient satisfaction score, and drug-related adverse effects. The patients in the long-interval dinoprostone group had lower pain scores during OH (p <.001). Contrarily, pain scores 30 minutes after the procedure were similar in both groups (p = .1). The patient satisfaction score was higher and clinicians found hysteroscope passage through the cervical canal easier and quicker in the long-interval dinoprostone group than in the short-interval group (p <.001, p = .003, and p <.001, respectively). Side effects were comparable in both study groups. CONCLUSION Vaginal dinoprostone administered 12 hours before OH was more effective than that administered 3 hours before OH in reducing pain during OH in nulliparous women, with easier hysteroscope insertion, shorter procedure duration, and higher patient satisfaction score.
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Affiliation(s)
- Nansy Mohamed Ali Rund
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University (Drs. Rund, Islam, and Nassar), Cairo
| | - Hossam El Shenoufy
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University (Drs. El Shenoufy, El Husseiny, Mohsen, Alaa, Gad Allah, Bakry, Kotb, Osman, Ashour, Taher, Kholaif, Hashem, Nour, Dahab, and Almohammady), Cairo
| | - Bassem Aly Islam
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University (Drs. Rund, Islam, and Nassar), Cairo
| | - Tarek El Husseiny
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University (Drs. El Shenoufy, El Husseiny, Mohsen, Alaa, Gad Allah, Bakry, Kotb, Osman, Ashour, Taher, Kholaif, Hashem, Nour, Dahab, and Almohammady), Cairo
| | - Salma Ashraf Nassar
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University (Drs. Rund, Islam, and Nassar), Cairo
| | - Reham A Mohsen
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University (Drs. El Shenoufy, El Husseiny, Mohsen, Alaa, Gad Allah, Bakry, Kotb, Osman, Ashour, Taher, Kholaif, Hashem, Nour, Dahab, and Almohammady), Cairo
| | - Doaa Alaa
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University (Drs. El Shenoufy, El Husseiny, Mohsen, Alaa, Gad Allah, Bakry, Kotb, Osman, Ashour, Taher, Kholaif, Hashem, Nour, Dahab, and Almohammady), Cairo
| | - Sherine H Gad Allah
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University (Drs. El Shenoufy, El Husseiny, Mohsen, Alaa, Gad Allah, Bakry, Kotb, Osman, Ashour, Taher, Kholaif, Hashem, Nour, Dahab, and Almohammady), Cairo
| | - Ahmed Bakry
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University (Drs. El Shenoufy, El Husseiny, Mohsen, Alaa, Gad Allah, Bakry, Kotb, Osman, Ashour, Taher, Kholaif, Hashem, Nour, Dahab, and Almohammady), Cairo
| | - Rania Refaat
- Department of Obstetrics and Gynecology, Faculty of Medicine, Misr University for Science and Technology, 6th October City, Giza (Drs. Refaat and Elsallamy)
| | - Mahmoud Ahmed Gehad
- Department of Obstetrics and Gynecology, Faculty of Medicine, Benha University, Benha (Drs. Gehad and Talaat), Egypt
| | - Mohamed Mahmoud Mohamed Kotb
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University (Drs. El Shenoufy, El Husseiny, Mohsen, Alaa, Gad Allah, Bakry, Kotb, Osman, Ashour, Taher, Kholaif, Hashem, Nour, Dahab, and Almohammady), Cairo
| | - Omneya M Osman
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University (Drs. El Shenoufy, El Husseiny, Mohsen, Alaa, Gad Allah, Bakry, Kotb, Osman, Ashour, Taher, Kholaif, Hashem, Nour, Dahab, and Almohammady), Cairo
| | - Ahmed S A Ashour
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University (Drs. El Shenoufy, El Husseiny, Mohsen, Alaa, Gad Allah, Bakry, Kotb, Osman, Ashour, Taher, Kholaif, Hashem, Nour, Dahab, and Almohammady), Cairo
| | - Ahmed Said Ali
- Faculty of Medicine, Al-Azhar University (Dr. Ali), Cairo.
| | - Ayman Taher
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University (Drs. El Shenoufy, El Husseiny, Mohsen, Alaa, Gad Allah, Bakry, Kotb, Osman, Ashour, Taher, Kholaif, Hashem, Nour, Dahab, and Almohammady), Cairo
| | - Khaled Kholaif
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University (Drs. El Shenoufy, El Husseiny, Mohsen, Alaa, Gad Allah, Bakry, Kotb, Osman, Ashour, Taher, Kholaif, Hashem, Nour, Dahab, and Almohammady), Cairo
| | - Ahmed T Hashem
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University (Drs. El Shenoufy, El Husseiny, Mohsen, Alaa, Gad Allah, Bakry, Kotb, Osman, Ashour, Taher, Kholaif, Hashem, Nour, Dahab, and Almohammady), Cairo
| | - Ayman Aly Hamed Elsallamy
- Department of Obstetrics and Gynecology, Faculty of Medicine, Misr University for Science and Technology, 6th October City, Giza (Drs. Refaat and Elsallamy)
| | - Dalia Adel Nour
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University (Drs. El Shenoufy, El Husseiny, Mohsen, Alaa, Gad Allah, Bakry, Kotb, Osman, Ashour, Taher, Kholaif, Hashem, Nour, Dahab, and Almohammady), Cairo
| | - Sherif Dahab
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University (Drs. El Shenoufy, El Husseiny, Mohsen, Alaa, Gad Allah, Bakry, Kotb, Osman, Ashour, Taher, Kholaif, Hashem, Nour, Dahab, and Almohammady), Cairo
| | - Bassem Talaat
- Department of Obstetrics and Gynecology, Faculty of Medicine, Benha University, Benha (Drs. Gehad and Talaat), Egypt; Department of Obstetrics and Gynecology, Faculty of Medicine, Zagazig University, (Dr. Talaat) Egypt
| | - Maged Almohammady
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University (Drs. El Shenoufy, El Husseiny, Mohsen, Alaa, Gad Allah, Bakry, Kotb, Osman, Ashour, Taher, Kholaif, Hashem, Nour, Dahab, and Almohammady), Cairo
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New EP, Sarkar P, Mikhail E, Plosker S, Imudia AN. Use of low dose vaginal misoprostol in office hysteroscopy: a pre-post interventional study. J OBSTET GYNAECOL 2020; 41:972-976. [PMID: 33962548 DOI: 10.1080/01443615.2020.1820968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
A pre-post interventional study of patients undergoing office hysteroscopy alone and in combination with endometrial biopsy was performed during October 2015-March 2018 to evaluate the effect of low dose vaginal misoprostol on patient's pain. Pain scores were assessed using the visual analog scale at the completion of the procedure. There were 646 patients included in the study. Of these, 462 had office hysteroscopy alone; 206 (44.6%) received 50 mcg of vaginal misoprostol the night prior to the procedure and the remaining 256 (55.4%) patients had no cervical ripening. The reported pain score following hysteroscopy was significantly lower among patients who received misoprostol [4(0-10) vs. 5(0-10); p=.001]. Most patients (78.2%) did not report any misoprostol related side effects. Of the 184 patients who underwent a combination of office hysteroscopy and endometrial biopsy, 97 (52.7%) received pre-procedure vaginal misoprostol while 87 (47.3%) did not. Post procedure pain was independent of pre-treatment with vaginal misoprostol (6.3 ± 2.7 vs. 6.6 ± 2.7; p = .54).Impact statementWhat is already known on this subject? Office hysteroscopy and endometrial biopsy is increasingly performed for evaluation of various gynaecologic conditions, however, patients' perceived pain at the time of procedure may lead to incomplete procedures. Various doses of misoprostol have been tested to reduce patients' pain, however none lower than 200 mcg vaginally, and at these doses, side effects are reported.What the results of this study add? To date, there is a scarcity of published data on the use of low dose misoprostol (50 mcg) in gynaecologic procedures. Our study found that the use of low dose vaginal misoprostol prior to office hysteroscopy is associated with lower reported pain and tenaculum utilisation during the procedure. However, vaginal misoprostol prior to successive office hysteroscopy and endometrial biopsy failed to decrease the reported pain, and the overall pain score was higher than hysteroscopy alone.What the implications are of these findings for clinical practice and/or further research? The use of low dose vaginal misoprostol (50 mcg) the evening prior to office hysteroscopy is associated with lower reported pain and tenaculum utilisation and is not associated with significant side effects. Therefore, 50 mcg of misoprostol could be used in clinical practice as a method to reduce patients' reported pain during office hysteroscopy.
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Affiliation(s)
- Erika P New
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Papri Sarkar
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Emad Mikhail
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Shayne Plosker
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, FL, USA.,Shady Grove Fertility of Tampa Bay, Brandon, FL, USA
| | - Anthony N Imudia
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, FL, USA.,Shady Grove Fertility of Tampa Bay, Wesley Chapel, FL, USA
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Riemma G, Schiattarella A, Colacurci N, Vitale SG, Cianci S, Cianci A, De Franciscis P. Pharmacological and non-pharmacological pain relief for office hysteroscopy: an up-to-date review. Climacteric 2020; 23:376-383. [PMID: 32396751 DOI: 10.1080/13697137.2020.1754388] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
In-office hysteroscopy is considered the standard technique for visualization of the uterine cavity and the diagnosis of intrauterine pathologies. Moreover, nowadays, it is possible to treat a vast number of intracavitary diseases in the office, without the need for the inpatient setting. However, in some cases, pain might occur, and this is the most common reason for not completing the procedure. Over the last 20 years, many efforts have been carried out to miniaturize the instrumentation and to improve the techniques in order to avoid discomfort. Nonetheless, hysteroscopy still provokes distress for many patients. For this reason, pharmacological and non-pharmacological treatments for intraoperative and postoperative pain relief have been widely used for in-office hysteroscopy, with different results in various groups of women. The purpose of this review was to analyze the current literature on pharmacological aids (non-steroidal anti inflammatory drugs, cyclooxygenase-2 inhibitors, antispasmodics, local anesthetics, prostaglandins, opioids) and non-pharmacological interventions (transcutaneous electrical nerve stimulation, uterine stretching, uterine pressure, warming of distension medium, hypnosis, music, vocal-local) and to evaluate their impact on the relief from pain experienced during in-office hysteroscopy.
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Affiliation(s)
- G Riemma
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - A Schiattarella
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - N Colacurci
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - S G Vitale
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - S Cianci
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - A Cianci
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - P De Franciscis
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania 'Luigi Vanvitelli', Naples, Italy
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