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Vitagliano A, Dellino M, Favilli A, D' Amato A, Nicolì P, Laganà AS, Noventa M, Bochicchio MA, Cicinelli E, Damiani GR. Patients' Use of Virtual Reality Technology for Pain Reduction during Outpatient Hysteroscopy: A Meta-analysis of Randomized Controlled Trials. J Minim Invasive Gynecol 2023; 30:866-876. [PMID: 37648150 DOI: 10.1016/j.jmig.2023.08.427] [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: 06/28/2023] [Revised: 08/23/2023] [Accepted: 08/24/2023] [Indexed: 09/01/2023]
Abstract
OBJECTIVE To summarize evidence from randomized controlled trials (RCTs) on the effectiveness of virtual reality technology (VRT), as used by patients, for reducing pain during outpatient hysteroscopy. DATA SOURCES Electronic databases and clinical registers were searched until June 21, 2023. The review protocol was registered in PROSPERO before the data extraction (CRD42023434340). METHODS OF STUDY SELECTION We included RCTs of patients receiving VRT compared with controls receiving routine care during outpatient hysteroscopy. TABULATION, INTEGRATION, AND RESULTS The primary outcome was average pain during hysteroscopy. Pooled results were expressed as mean differences (MDs) with 95% confidence interval (CI). Sources of heterogeneity were investigated through sensitivity and subgroups analysis. Five RCTs were included (435 participants). The comparison between the intervention and control groups showed a borderline difference in perceived pain during hysteroscopy (MD -0.88, 95% CI -1.77 to 0.01). Subgroup analysis based on the type of VRT (active or passive) indicated that active VRT potentially reduced the perception of pain (MD -1.42, 95% CI -2.21 to -0.62), whereas passive VRT had no effect (MD -0.06, 95% CI -1.15 to 1.03). CONCLUSION Patients' use of active VRT may be associated with a reduction in pain during outpatient hysteroscopy (evidence Grading of Recommendations Assessment, Development, and Evaluation 2/4). Future research should focus on conducting methodologically robust studies with larger sample sizes and more homogeneous populations.
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Affiliation(s)
- Amerigo Vitagliano
- 1st Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine (Drs. Vitagliano, Dellino, D' Amato, Nicolì, Cicinelli, and Damiani), University of Bari, Bari, Italy.
| | - Miriam Dellino
- 1st Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine (Drs. Vitagliano, Dellino, D' Amato, Nicolì, Cicinelli, and Damiani), University of Bari, Bari, Italy
| | - Alessandro Favilli
- Section of Obstetrics and Gynecology, Department of Medicine and Surgery (Drs. Favilli), University of Perugia, Perugia, Italy
| | - Antonio D' Amato
- 1st Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine (Drs. Vitagliano, Dellino, D' Amato, Nicolì, Cicinelli, and Damiani), University of Bari, Bari, Italy
| | - Pierpaolo Nicolì
- 1st Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine (Drs. Vitagliano, Dellino, D' Amato, Nicolì, Cicinelli, and Damiani), University of Bari, Bari, Italy
| | - Antonio Simone Laganà
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE) (Dr. Laganà), University of Palermo, Palermo, Italy
| | - Marco Noventa
- Gynaecologic and Obstetrics Clinic, Department of Women's and Children's Health (Dr. Noventa), University of Padua, Padua, Italy
| | | | - Ettore Cicinelli
- 1st Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine (Drs. Vitagliano, Dellino, D' Amato, Nicolì, Cicinelli, and Damiani), University of Bari, Bari, Italy
| | - Gianluca Raffaello Damiani
- 1st Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine (Drs. Vitagliano, Dellino, D' Amato, Nicolì, Cicinelli, and Damiani), University of Bari, Bari, Italy
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Mazzon I, Etrusco A, Laganà AS, Chiantera V, Di Angelo Antonio S, Tosto V, Gerli S, Favilli A. Training in Diagnostic Hysteroscopy: The "Arbor Vitae" Method. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1019. [PMID: 37374222 PMCID: PMC10302144 DOI: 10.3390/medicina59061019] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/16/2023] [Accepted: 05/23/2023] [Indexed: 06/29/2023]
Abstract
Background and Objectives: Diagnostic hysteroscopy is the gold standard in the diagnosis of intrauterine pathology and is becoming an essential tool in the daily practice of gynecology. Training programs for physicians are necessary to ensure adequate preparation and learning curve before approaching patients. The aim of this study was to describe the "Arbor Vitae" method for training in diagnostic hysteroscopy and to test its impact on the knowledge and skills of trainees using a customized questionnaire. Materials and Methods: A three-day hysteroscopy workshop combining theory and practical "hands on "sessions with dry and wet labs has been described. The aim of the course is to teach indications, instruments, the basic principles of the technique by which the procedure should be performed, and how to recognize and manage the pathologies that can be identified by diagnostic hysteroscopy. To test this training method and its impact on the knowledge and skills of the trainees, a customized 10-question questionnaire was administered before and after the course. Results: The questionnaire was administered to 34 participants. All trainees completed the questionnaire, and no missing responses were recorded. Regarding the characteristics of the participants, 76.5% had less than 1 year of experience in performing diagnostic hysteroscopy and 55.9% reported performing fewer than 15 procedures in their career. For 9 of the 10 questions embedded in the questionnaire, there was a significant improvement in the scores between pre- and post-course, demonstrating a perceived significant improvement in theoretical/practical skills by the trainees. Conclusions: The Arbor Vitae training model is a realistic and effective way to improve the theoretical and practical skills required to perform correct diagnostic hysteroscopy. This training model has great potential for novice practitioners to achieve an adequate level of proficiency before performing diagnostic hysteroscopy on live patients.
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Affiliation(s)
- Ivan Mazzon
- Arbor Vitae Endoscopic Centre, 00191 Rome, Italy; (I.M.); (S.D.A.A.)
| | - Andrea Etrusco
- Unit of Gynecologic Oncology, ARNAS “Civico—Di Cristina—Benfratelli”, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy; (A.E.); (A.S.L.); (V.C.)
| | - Antonio Simone Laganà
- Unit of Gynecologic Oncology, ARNAS “Civico—Di Cristina—Benfratelli”, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy; (A.E.); (A.S.L.); (V.C.)
| | - Vito Chiantera
- Unit of Gynecologic Oncology, ARNAS “Civico—Di Cristina—Benfratelli”, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy; (A.E.); (A.S.L.); (V.C.)
| | | | - Valentina Tosto
- Centre for Research in Perinatal and Reproductive Medicine, University of Perugia, 06123 Perugia, Italy;
| | - Sandro Gerli
- Section of Obstetrics and Gynecology, Department of Medicine and Surgery, S. Maria della Misericordia Hospital, Perugia University, 06123 Perugia, Italy;
| | - Alessandro Favilli
- Section of Obstetrics and Gynecology, Department of Medicine and Surgery, S. Maria della Misericordia Hospital, Perugia University, 06123 Perugia, Italy;
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Pain Management during Office Hysteroscopy: An Evidence-Based Approach. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58081132. [PMID: 36013599 PMCID: PMC9416725 DOI: 10.3390/medicina58081132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/10/2022] [Accepted: 08/18/2022] [Indexed: 11/17/2022]
Abstract
Background and Objectives: Hysteroscopy is a reliable technique which is highly useful for the evaluation and management of intrauterine pathology. Recently, the widespread nature of in-office procedures without the need for anesthesia has been requesting validation of practical approach in order to reduce procedure-related pain. In this regard, we performed a comprehensive review of literature regarding pain management in office hysteroscopic procedures. Materials and Methods: MEDLINE, EMBASE, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register), Global Health, Health Technology Assessment Database and Web of Science, other research registers (for example Clinical Trials database) were searched. We searched for all original articles regarding pain relief strategy during office hysteroscopy, without date restriction. Results have been collected and recommendations have been summarized according to the Appraisal of Guidelines for Research and Evaluation (AGREE) tool. Moreover, the strength of each recommendation was scored following the Grading of Recommendations Assessment (GRADE) system, in order to present the best available evidence. Results: Both pharmacological and non-pharmacological strategies for pain management are feasible and can be applied in office setting for hysteroscopic procedures. The selection of strategy should be modulated according to the characteristics of the patient and difficulty of the procedure. Conclusions: Accumulating evidence support the use of pharmacological and other pharmacological-free strategies for reducing pain during office hysteroscopy. Nevertheless, future research priorities should aim to identify the recommended approach (or combined approaches) according to the characteristics of the patient and difficulty of the procedure.
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Guraslan H, Senturk MB, Dogan K, Yuksel B, Kaya C, Karacan T, Karabay Akgul O, Ceylan Y. Diagnostic office hysteroscopy; why is it still painful procedure despite the surgical experience and mini-hysteroscope? J Obstet Gynaecol Res 2022; 48:1418-1425. [PMID: 35274418 DOI: 10.1111/jog.15219] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Revised: 12/16/2021] [Accepted: 02/28/2022] [Indexed: 12/13/2022]
Abstract
AIM To evaluate the effect of cervical canal features on pain during outpatient hysteroscopy performed by experienced surgeons using mini-hysteroscope. METHODS A prospective observational study was conducted on 303 women undergoing diagnostic hysteroscopy without anesthesia. Pain intensity was evaluated using the visual analog scale (VAS) when the cervical canal was passed. The patients were divided into two groups according to the VAS score: painless or mild pain (VAS <4) and moderate or severe pain (VAS ≥ 4). The relationship between cervical canal characteristics (length, version, and flexion positions, history of cervical intervention, stenosis, synechiae), obstetric and gynecological history, preoperative anxiety level, procedure duration, and pain intensity was examined. RESULTS Moderate pain (4 ≤ VAS < 7) was observed in 38% of patients (n = 117) and 14 patients (5%) experienced severe pain (VAS ≥ 7). In multivariate analysis, nulliparity (p = 0.01; OR, 4.6; 95% CI, 1.7-13.2), postmenopausal state (p = 0.02; OR, 2.2; 95% CI, 1.2-4.3), excessive flexion of the cervix and retroverted uterus (p <0.001; OR, 4.1; 95% CI, 2.0-8.5) were identified as risk factors for a painful procedure. Diagnostic hysteroscopy was successful in 98% of the patients. The pain was the primary cause of the failed hysteroscopy. CONCLUSION In addition to nulliparity and postmenopausal status, unfavorable features of the cervical canal, such as the excessive flexion position of the cervix and uterine retroversion are significant causes of pain during outpatient hysteroscopy.
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Affiliation(s)
- Hakan Guraslan
- Department of Obstetrics and Gynecology, Bagcilar Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Mehmet B Senturk
- Department of Obstetrics and Gynecology, Tekirdag Namik Kemal University, Tekirdag /, Turkey
| | - Keziban Dogan
- Department of Obstetrics and Gynecology, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Berkay Yuksel
- Department of Obstetrics and Gynecology, Antalya Training and Research Hospital, University of Health Sciences, Antalya, Turkey
| | - Cihan Kaya
- Department of Obstetrics and Gynecology, Acibadem Mehmet Ali Aydinlar University, Acibadem Bakirkoy Hospital, Istanbul, Turkey
| | - Tolga Karacan
- Department of Obstetrics and Gynecology, Bagcilar Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Ozlem Karabay Akgul
- Department of Obstetrics and Gynecology, Bagcilar Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Yasin Ceylan
- Department of Obstetrics and Gynecology, Bagcilar Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
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Abstract
BACKGROUND Hysteroscopy done in an outpatient setting is the 'gold standard' method for evaluating the uterine cavity. Media used to distend the uterine cavity include gas as carbon dioxide and liquid as saline that can be used at room temperature or warmed to body temperature. Both media offer advantages as well as disadvantages. OBJECTIVES The objective of this review is to compare the effectiveness, tolerability, and safety of gas (carbon dioxide) and liquid (normal saline) used for uterine distension during outpatient hysteroscopy. SEARCH METHODS We searched the Cochrane Gynaecology and Fertility (CGF) Group Specialised Register, CENTRAL, MEDLINE, Embase and PsycINFO on 28 April 2021. We checked references of relevant trials and contacted study authors and experts in the field to identify additional studies. CINAHL records and ongoing trials from the trial registries were included in the CENTRAL search. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing saline with carbon dioxide, as well as RCTs comparing saline at different temperatures, for uterine distension in outpatient hysteroscopy done for any indication. DATA COLLECTION AND ANALYSIS We used standard methodological procedures recommended by Cochrane. Primary review outcomes were patient tolerability and adverse events or complications related to the distending medium. Secondary outcomes were quality of the hysteroscopic view and duration of the procedure. MAIN RESULTS We included 12 RCTs (1946 women). The quality of evidence ranged from very low to high: the main limitations were risk of bias due to absence of blinding due to the nature of the procedure, imprecision, and inconsistency. Saline versus carbon dioxide Analysis ruled out a clinically relevant difference in pain scores during the procedure between saline and carbon dioxide, but the quality of evidence was low (standardised mean difference (SMD) -0.07, 95% confidence interval (CI) -0.17 to 0.02; 9 RCTs, N = 1705; I² = 86%). This translates to differences of 0.39 cm (lower) and 0.05 cm (higher) on a 10-cm visual analogue scale (VAS). Evidence was insufficient to show differences between groups in the proportion of procedures abandoned due to intense pain (Peto odds ratio (OR) 0.48, 95% CI 0.09 to 2.42; 1 RCT, N = 189; very low-quality evidence). We are uncertain whether saline decreases the need for analgesia compared to carbon dioxide (Peto OR 0.34, 95% CI 0.12 to 0.99; 1 RCT, N = 189; very low-quality evidence). Saline compared to carbon dioxide is probably associated with fewer vasovagal reaction events (Peto OR 0.53, 95% CI 0.32 to 0.86; 6 RCTs, N = 1076; I² = 0%; moderate-quality evidence) and fewer shoulder-tip pain events (Peto OR 0.28, 95% CI 0.14 to 0.54; 4 RCTs, N = 623; I² = 0%, moderate-quality evidence). Evidence suggests that if 10% of women undergoing outpatient hysteroscopy experience a vasovagal reaction event with the use of carbon dioxide, this rate would be between 3% and 9% with the use of saline. Similarly, if the rate of shoulder-tip pain with carbon dioxide is 9%, it would be between 1% and 5% with saline. We are uncertain whether saline is similar to carbon dioxide in terms of endometrial bleeding (Peto OR 0.83, 95% CI 0.25 to 2.75; 2 RCTs, N = 349; I² = 0%; very low-quality evidence). Infection was not reported by any study in this comparison. Saline may result in fewer procedures with an unsatisfactory hysteroscopic view than carbon dioxide (Peto OR 0.51, 95% CI 0.32 to 0.82; 5 RCTs, N = 1082; I² = 67%; low-quality evidence). The duration of the procedure was shorter with saline in three of the four studies that reported this outcome, and duration was similar in both arms in the fourth study. Warm saline versus room temperature saline Use of warm saline for uterine distension during office hysteroscopy may reduce pain scores when compared with room temperature saline (mean difference (MD) -1.14, 95% CI -1.55 to -0.73; 3 RCTs, N = 241; I² = 77%; low-quality evidence). Evidence is insufficient to show differences between groups in either the proportion of procedures abandoned due to intense pain (Peto OR 0.97, 95% CI 0.06 to 15.87; 1 RCT, N = 77; very low-quality evidence) or the need for analgesia (Peto OR 1.00, 95% CI 0.14 to 7.32; 1 RCT, N = 100; very low-quality evidence). Analysis ruled out a clinically relevant difference in duration of the procedure between warm and room temperature saline, but the quality of evidence is low (MD 13.17 seconds, 95% CI -12.96 to 39.29; 2 RCTs, N = 141; I² = 21%). No cases of infection were reported in either group (1 RCT, N = 100). No other adverse events and no information on quality of the hysteroscopic view were reported by any study in this comparison. AUTHORS' CONCLUSIONS Evidence was insufficient to show differences between different distension media used for uterine distension in outpatient hysteroscopy in terms of patient tolerability, operator satisfaction, or duration of the procedure. However, saline was superior to carbon dioxide in producing fewer adverse events (shoulder-tip pain and vasovagal reaction).
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Affiliation(s)
- Karim S Abdallah
- Department of Obstetrics and Gynecology, Women's Health Hospital, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Moustafa A Gadalla
- Department of Obstetrics and Gynecology, Women's Health Hospital, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Maria Breijer
- Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Centre, Amsterdam, Netherlands
| | - Ben Willem J Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Australia
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A Systematic Review of the Effect of Type, Pressure, and Temperature of the Distension Medium on Pain During Office Hysteroscopy. J Minim Invasive Gynecol 2021; 28:1148-1159.e2. [PMID: 33444792 DOI: 10.1016/j.jmig.2021.01.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 12/18/2020] [Accepted: 01/05/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To identify the optimal distension medium type, pressure, and temperature to minimize pain during office hysteroscopy. DATA SOURCES MEDLINE, EMBASE, CINAHL, and CENTRAL were searched from inception to January 29, 2020. METHODS OF STUDY SELECTION We included randomized controlled trials in which women undergoing office hysteroscopy were randomized to either a distension medium type, pressure, or temperature against a suitable control, where pain was an outcome. Data regarding feasibility, visualization, complications, and satisfaction were also collected. TABULATION, INTEGRATION, AND RESULTS The literature search returned 847 studies, of which 18 were included for systematic review and 17 for meta-analysis. There was no significant difference in intraprocedural pain when comparing the use of normal saline against carbon dioxide (standardized mean difference [SMD], -0.12; 95% confidence interval [CI], -0.36 to 0.13). Subgroup analysis of high-quality studies revealed a statistically significant reduction in postprocedural pain with normal saline (SMD, -0.65; 95% CI, -1.14 to -0.16). Side effects were less frequent (Peto odds ratio, 0.29; 95% CI, 0.20-0.40) and patient satisfaction was higher (SMD, 1.39; 95% CI, 0.51-2.28) with normal saline compared with carbon dioxide. Pressures of ≤40 mm Hg reduced intraprocedural pain (SMD, -0.67; 95% CI, -1.09 to -0.26) at the expense of a higher proportion of unsatisfactory views (81%-89% at ≤40 mm Hg vs 95%-99% at ≥50 mm Hg). Postprocedural pain was reduced with lower filling pressures. Warming saline did not reduce intraprocedural pain (SMD, 0.59; 95% CI, -0.14 to 1.33). CONCLUSION Normal saline, instilled at the lowest pressure to acquire a satisfactory view, should be used for uterine distension during office hysteroscopy to minimize pain.
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Law HY, Ng DYT, Chung CD. Use of music in reducing pain during outpatient hysteroscopy: Prospective randomized trial. J Obstet Gynaecol Res 2020; 47:904-912. [PMID: 33336450 DOI: 10.1111/jog.14608] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 11/08/2020] [Accepted: 12/05/2020] [Indexed: 11/27/2022]
Abstract
AIM To evaluate the effect of music in reducing pain during outpatient hysteroscopy under no anesthesia. METHODS We conducted a prospective randomized controlled trial From June 2019 to December 2019 in Pamela Youde Nethersole Eastern Hospital in Hong Kong. A total of 107 patients were randomized to music group (n = 54) or non-music group (n = 53). Music was played during outpatient hysteroscopy in the music group. Patients in the non-music group had the procedure done in the same setting without music. Primary outcome was the level of pain measured using the visual analog scale (VAS) score before and during the procedure. Secondary outcomes were vital parameters that reflect the level of pain including blood pressure and heart rate. RESULTS Patients in the music group experienced significantly less pain during outpatient hysteroscopy (VAS score 4.54 ± 2.89 vs 5.88 ± 2.90; P = 0.02). The anticipated pain level was similar in both groups (VAS score 5.59 ± 2.27 vs 6.11 ± 2.43; P = 0.27). There was no statistically significant difference between the two groups in all the vital parameters. CONCLUSION Listening to music during outpatient hysteroscopy under no anesthesia significantly reduces pain in a well-matched Chinese population. Music is easy to provide with low-cost equipment and manpower. We recommend the routine use of music during outpatient hysteroscopy to improve patient care.
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Affiliation(s)
- Ho Ying Law
- Department of Obstetrics and Gynaecology, Pamela Youde Nethersole Eastern Hospital, Hong Kong, China
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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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Ferrari F, Forte S, Arrigoni G, Ardighieri L, Coppola MC, Salinaro F, Barra F, Sartori E, Odicino F. Impact of endometrial sampling technique and biopsy volume on the diagnostic accuracy of endometrial cancer. Transl Cancer Res 2020; 9:7697-7705. [PMID: 35117372 PMCID: PMC8799147 DOI: 10.21037/tcr-20-2074] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/06/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Histotype and tumor grading of endometrial cancer are the most important factors that have to be assessed by preoperative endometrial sampling, and their concordance with the final surgical and definitive histological findings is of paramount importance. We aim to compare histotype and tumor grading concordance of various endometrial sampling techniques (ESTs) and to investigate the role of endometrial volume biopsy. METHODS We performed a retrospective analysis of patients with apparent early stage endometrial cancer collecting demographic, clinical data, type of EST, pathological characteristics of endometrial biopsies and final specimens. We classified ESTs as dilation and curettage (D&C), diagnostic hysteroscopy with D&C, outpatient hysteroscopy and operative hysteroscopy with or without D&C. Diagnostic and operative hysteroscopy were performed with Bettocchi's 5 mm hysteroscope. We evaluated concordance for histotype, and tumor grading, and we performed subgroup analysis based on the technique and final tumor grading. Concordance was classified from good, moderate, sufficient, fair, poor and none using Cohen k-statistic. Finally, we investigated the existence of independent risk factors for discordant tumor grading using multivariate binary logistic regression. RESULTS We collected 148 patients and of these 131 (88.5%) were diagnosed with endometrioid histotype and 65 (44%), 46 (31%) and 37 (25%) respectively with well, moderate and poor differentiated tumors. Atypical hyperplasia (AH) was detected preoperatively in 28 patients (19%). Histotype concordance was fair (k=0.35) and tumor grading concordance was moderate (k=0.45); particularly, concordance was fair in well-differentiated cases (k=0.38); concordance was moderate in moderate- and poor-differentiated cases (k=0.52) and good (k=0.71). Operative hysteroscopy showed moderate concordance for histotype (k=0.41), while grading concordance was fair for G1 (k=0.41), moderate for G2 (k=0.58) and good for G3 (k=0.72), regardless the use of D&C. Preoperative volume biopsy did not impact the concordance of tumor grading, while the adoption of operative hysteroscopy (with or without D&C) decreased the risk of grading discordance in G3 tumors (HR 0.17; 95% CI: 0.03-0.94; P=0.04). Conversely, time elapsed from diagnosis to treatment in well-differentiated tumors increased the risk of discordant results (HR 1.06; 95% CI: 1.02-1.52; P=0.04). CONCLUSIONS Operative hysteroscopy demonstrated the best tumor grading concordance, especially in poor-differentiated tumors. The volume of biopsy did not affect the tumor grading concordance.
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Affiliation(s)
- Federico Ferrari
- Department of Obstetrics and Gynecology, Spedali Civili of Brescia, Brescia, Italy
| | - Sara Forte
- Department of Obstetrics and Gynecology, University of Brescia, Brescia, Italy
| | - Giulia Arrigoni
- Department of Obstetrics and Gynecology, University of Brescia, Brescia, Italy
| | - Laura Ardighieri
- Department of Pathology, Spedali Civili of Brescia, Brescia, Italy
| | | | - Federica Salinaro
- Department of Obstetrics and Gynecology, Spedali Civili of Brescia, Brescia, Italy
| | - Fabio Barra
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| | - Enrico Sartori
- Department of Obstetrics and Gynecology, University of Brescia, Brescia, Italy
| | - Franco Odicino
- Department of Obstetrics and Gynecology, University of Brescia, Brescia, Italy
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Is every patient eligible to have an office hysteroscopy? A retrospective analysis of 1301 procedures. Wideochir Inne Tech Maloinwazyjne 2020; 15:337-345. [PMID: 32489495 PMCID: PMC7233160 DOI: 10.5114/wiitm.2019.89609] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 08/23/2019] [Indexed: 11/17/2022] Open
Abstract
Introduction Hysteroscopy is the gold standard for diagnosis and treatment of uterine pathologies. The office setting seems to be safe, reducing the anesthesia risks and also decreasing the overall costs of the procedure. Recent literature suggests that hysteroscopy performed without anesthesia may not be as painless as it was previously considered. Moreover, not every patient can be referred for a hysteroscopy in an office setting. Aim To analyze the factors correlated with a successful hysteroscopy in an office setting. Material and methods We analyzed the documentation of 1301 patients who underwent hysteroscopy at our department in the period 2013-2016. The impact of the type of the procedure and the various demographic factors on the need for general anesthesia was assessed. Results Almost 80% of all hysteroscopies were performed without analgesia in an office setting. The remaining patients underwent a hysteroscopy in general anesthesia. The key aspect for successful office hysteroscopy is the scope of the performed surgery. Over 91% of diagnostic hysteroscopies have been done without analgesia, but only about 30% of extensive endometrial scratching procedures were performed in an office setting. A previous vaginal delivery increases the chances for a successful office hysteroscopy by about 21%, and in the case of diagnostic procedures, multiparous patients were at an about 79% lower risk of analgesia necessity. Conclusions It is possible to perform nearly all diagnostic hysteroscopies in an office setting. In the case of operative hysteroscopy, the most crucial factor is the scope of the procedure.
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Amer-Cuenca JJ, Marín-Buck A, Vitale SG, La Rosa VL, Caruso S, Cianci A, Lisón JF. Non-pharmacological pain control in outpatient hysteroscopies. MINIM INVASIV THER 2019; 29:10-19. [DOI: 10.1080/13645706.2019.1576054] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Juan J. Amer-Cuenca
- Department of Physiotherapy, Universidad Cardenal Herrera-CEU CEU Universities, Valencia, Spain
| | - Alejandro Marín-Buck
- Department of Surgery, Universidad Cardenal Herrera-CEU CEU Universities, Valencia, Spain
- Department of Gynecology, Hospital Provincial de Castellón, Castellón de la Plana, Spain
| | - Salvatore Giovanni Vitale
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | | | - Salvatore Caruso
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - Antonio Cianci
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - Juan F. Lisón
- Department of Medicine, Universidad Cardenal Herrera-CEU CEU Universities, Valencia, Spain
- CIBER of Physiopathology of Obesity and Nutrition CIBERobn, CB06/03 Carlos III Health Institute, Madrid, Spain
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How the Location of Intracavitary Lesions Influences Pain during Office Hysteroscopy. J Minim Invasive Gynecol 2019; 26:1334-1339. [PMID: 30659962 DOI: 10.1016/j.jmig.2018.11.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 11/11/2018] [Accepted: 11/19/2018] [Indexed: 11/21/2022]
Abstract
STUDY OBJECTIVE To assess how the location of intracavitary lesions during office hysteroscopy influences pain scores. DESIGN Cohort study. SETTING Department of Obstetrics and Gynecology, Hospital das Forças Armadas, Lisbon, Portugal. PATIENTS Two hundred ninety-eight patients undergoing operative office hysteroscopy. INTERVENTIONS Pain intensity was assessed by patients using a numeric rating scale (0-10) 10 minutes after hysteroscopy. MEASUREMENTS AND MAIN RESULTS Statistical analysis assessed the association between pain score and clinical, obstetric, and gynecologic history. Associations with procedure-related factors were also assessed. Lesion location did not influence the perception of pain in the current sample. Hysteroscopic anesthesia allowed for a significant reduction in pain scores, regardless of lesion location. Multivariate analysis revealed that only the type of operative procedure and operating time significantly influenced pain scores. CONCLUSION Hysteroscopic anesthesia allows for a well-tolerated procedure, regardless of lesion location during office hysteroscopy. Lesion location should not be regarded as a technical limitation.
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New EP, Sarkar P, Sappenfield E, Mikhail E, Plosker S, Imudia AN. Comparison of patients' reported pain following office hysteroscopy with and without endometrial biopsy: a prospective study. ACTA ACUST UNITED AC 2018; 70:710-715. [DOI: 10.23736/s0026-4784.18.04215-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Optimal Order of Successive Office Hysteroscopy and Endometrial Biopsy for the Evaluation of Abnormal Uterine Bleeding. Obstet Gynecol 2017; 130:565-572. [DOI: 10.1097/aog.0000000000002202] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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15
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Pain in office hysteroscopy: it is not just a matter of size. Comment on: "Paulo AA, Solheiro MH, Paulo CO. Is pain better tolerated with mini-hysteroscopy than with conventional device? A systematic review and meta-analysis: hysteroscopy scope size and pain. Arch Gynecol Obstet. 2015 May 7". Arch Gynecol Obstet 2016; 293:687-8. [PMID: 26721830 DOI: 10.1007/s00404-015-3997-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 12/17/2015] [Indexed: 10/22/2022]
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Senturk MB, Guraslan H, Babaoğlu B, Yaşar L, Polat M. The Effect of Intrauterine Lidocaine and Rectal Indomethacin on Pain during Office Vaginoscopic Hysteroscopy: Randomized Double-Blind Controlled Study. Gynecol Obstet Invest 2015; 81:280-4. [DOI: 10.1159/000441787] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 10/15/2015] [Indexed: 11/19/2022]
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A Prospective, Randomized Comparison of Intramuscular Phloroglucinol Versus Oral Misoprostol for Cervix Pretreatment Before Diagnostic Hysteroscopy. Int Surg 2015; 100:1207-11. [PMID: 25956954 DOI: 10.9738/intsurg-d-15-00073.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The aim of this study was to compare the effectiveness and safety of intramuscular phloroglucinol and oral misoprostol for cervix pretreatment before diagnostic hysteroscopy. Several modalities for cervical priming and pain reduction have been adopted to reduce the complications related to cervical dilatation before hysteroscopy. Among them, the prostaglandin analog misoprostol is the most frequently used agent. Phloroglucinol, a spasmolytic, has also been showed to have an effect in inducing cervical dilatation but is rarely used before hysteroscopy. One hundred twenty outpatients undergoing anesthesia-free diagnostic hysteroscopy were randomly assigned to receive 80 mg intramuscular phloroglucinol and 400 mg oral misoprostol before diagnostic hysteroscopy. The main outcome measures were preoperative cervical width, visual analog scales (VAS) for pain, cervical passage time, and adverse reactions. Intramuscular phloroglucinol resulted in a significantly wider cervical width, lower VAS pain score, shorter cervical passage time, and a lower adverse effects rate compared with oral misoprostol. Intramuscular phloroglucinol is more effective and safer than oral misoprostol in inducing proper cervical priming and may be the optimal choice for cervical pretreatment before diagnostic hysteroscopy.
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Studying Surgical Innovations: Challenges of the Randomized Controlled Trial. J Minim Invasive Gynecol 2015; 22:573-82. [DOI: 10.1016/j.jmig.2015.02.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 02/16/2015] [Indexed: 11/20/2022]
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