A systematic review and meta-analysis of randomized controlled trials on the effectiveness of cervical ripening with misoprostol administration before hysteroscopy

Assessing the Efficacy and Safety of Misoprostol Prior to Hysteroscopy in Women with Difficult Cervix: A Systematic Review and Meta-Analysis

Background/Objectives: Hysteroscopy has been used as both a diagnostic and therapeutic tool for intrauterine pathologies under direct visualization. However, this procedure may be associated with an increased risk of complications during entry, which can be reduced by cervical ripening before the operation. The efficacy of misoprostol in this context is influenced by factors such as estrogen levels, parity, and the mode of previous deliveries. This study aimed to assess the efficacy and safety of misoprostol in women with a challenging cervix while mitigating the influence of confounding variables. Methods: Three electronic databases, namely PubMed, Scopus, and ISI Web of Science, were searched until 14 May 2024. Randomized controlled trials focusing on postmenopausal patients, nulliparous women, and multiparous women with no prior history of vaginal delivery, undergoing hysteroscopy were included. The cervical width, time needed for cervical dilation, and the need for additional dilatation alongside the complications and adverse effects from all included studies were collected and analyzed using R (version 4.2.3). Results: Seven studies on premenopausal women and three on postmenopausal women were included. In premenopausal women, misoprostol significantly increased cervical width compared to placebo (SMD = 2.2, 95% CI 0.9 to 3.4) and reduced the need for additional cervical dilatation (OR = 0.36, 95% CI 0.17 to 0.74). No significant difference was found in the time required for cervical dilation between misoprostol and placebo groups. In postmenopausal women, misoprostol did not significantly affect cervical width compared to placebo (SMD = -0.55, 95% CI -1.3 to 0.21). Conclusions: Misoprostol is beneficial for cervical dilation in premenopausal women without a prior history of vaginal delivery but less effective in postmenopausal patients. While associated with postoperative risks, it reduces hysteroscopy-related complications. Future research should address discrepancies by controlling the confounding variables like menopausal status, parity, and mode of delivery to enhance the understanding of misoprostol's effects and pinpoint the specific patient populations that would derive the greatest benefits from its use.

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

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.

Comparison of Efficacy of Vaginal Misoprostol versus a Synthetic Osmotic Dilator (Dilapan-S) for Cervical Preparation before Operative Hysteroscopy: A Randomized Controlled Study

Objectives

To compare the need for mechanical cervical dilatation following vaginal misoprostol or synthetic osmotic dilator (Dilapan-S) usage for cervical preparation before operative hysteroscopy.

Materials and Methods

Fifty-five premenopausal women scheduled for operative hysteroscopic procedures with a 26 Fr resectoscope were included in this randomized, controlled clinical trial. After randomization, either 400 μg of vaginal misoprostol or intracervical synthetic osmotic dilator (Dilapan-S) was inserted 12 h before operative hysteroscopy. The need for additional mechanical cervical dilatation before insertion of the resectoscope was compared between the two groups. Initial cervical diameter before mechanical dilatation, intraoperative complications (cervical tears, creation of a false passage), and ease of dilatation were also compared between the two groups.

Results

In the misoprostol group, 92% of women required additional mechanical cervical dilatation, whereas only 36% of women in the Dilapan-S group required additional dilatation (P < 0.05). The median initial cervical diameter achieved with Dilapan was 9 mm (Q1: 7 mm; Q3: 10 mm), and with misoprostol, it was 6 mm (Q1: 4.5 mm; Q3: 8 mm) (P < 0.05). There was no significant difference in other outcome parameters between the two groups.

Conclusion

Synthetic osmotic dilator (Dilapan-S) is more efficacious than vaginal misoprostol at ripening the cervix before operative hysteroscopy.

Risk factors for intrauterine device embedment in postmenopausal women: an analysis of 731 participants undergoing hysteroscopy

OBJECTIVE

This study aimed to explore the risk factors for intrauterine device (IUD) embedment in postmenopausal women.

METHODS

A total of 731 women who underwent hysteroscopy for IUD removal from January 2019 to December 2021 were included in the trial, of whom 301 were diagnosed with IUD embedment (embedded group) and 430 had a normal IUD location (control group). The following data were collected from electronic medical records: demographic traits, ultrasound findings, IUD shapes, uterine features, and hysteroscopy findings. Bivariate contingency analysis and multiple logistic regression were performed to identify the significant independent variables that affect IUD embedment.

RESULTS

Prior IUD removal failure (14.3% vs 5.1%; adjusted odds ratio [aOR], 3.29; 95% CI, 1.90-5.71) and V-shaped IUD (18.9% vs 10.7%; aOR, 2.05; 95% CI, 1.33-3.16) were risk factors that were independently linked with IUD embedment. Uterine volume (22.7 [20.9-24.5] cm 3 vs 27.9 [24.8-30.9] cm 3 ; aOR, 0.99; 95% CI, 0.982-0.999) was negatively linked with IUD embedment. There were no differences in age, parity, menopause length, years with an IUD in situ, uterine position, or abortion times between the two groups. There were no differences in existing leiomyoma, prior cervical LEEP (loop electrosurgical excision procedure), or myomectomy between the two groups.

CONCLUSIONS

Prior IUD removal failure, V-shaped IUD, and a smaller uterine volume were risk factors for IUD embedment in menopausal women.

Misoprostol Administration Before Hysteroscopy Procedures - A Retrospective Analysis

OBJECTIVE

 To evaluate the use of misoprostol prior to hysteroscopy procedures regarding technical ease, the presence of side effects, and the occurrence of complications.

METHODS

 This is a retrospective, observational, analytical, case-control study, with the review of medical records of 266 patients followed-up at the Gynecological Videoendoscopy Sector of the Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto of the Universidade de São Paulo (HCFMRP - USP, in the Portuguese acronym) from 2014 to 2019, comparing 133 patients who used the drug before the procedure with 133 patients who did not.

RESULTS

 The occurrence of postmenopausal uterine bleeding was the main indication for hysteroscopy and revealed a statistical difference between groups (p < 0.001), being present in 93.23% of the patients in the study group and in 69.7% of the patients in the control group.: Only 2 patients (1.5%) in the study group reported adverse effects. Although no statistical differences were observed regarding the occurrence of complications during the procedure (p = 0.0662), a higher total number of complications was noted in the group that used misoprostol (n = 7; 5.26%) compared with the group that did not use the drug (n = 1; 0.75%), a fact that is clinically relevant. When evaluating the ease of the technique (measured by the complete performance of all steps of the hysteroscopy procedure), it was verified that although there was no difference between groups (p = 0.0586), the control group had more than twice as many incompletely performed procedures (n = 17) when compared with the group that used misoprostol previously (n = 8), which is also clinically relevant.

CONCLUSION

 The use of misoprostol prior to hysteroscopy in our service indicated that the drug can facilitate the performance of the procedure, but not without side effects and presenting higher complication rates.

Comparison between 200 μg and 800 μg of vaginal misoprostol for cervical ripening before operative hysteroscopy: A randomized controlled trial

OBJECTIVE

To compare between 200 and 800 μg of vaginal misoprostol for cervical ripening before operative hysteroscopy.

METHODS

Quadruple-blind randomized clinical trial conducted between November 2019 and September 2020 involving 76 patients undergoing cervical dilatation before surgical hysteroscopy at teaching hospitals in Pernambuco, Brazil. Women received the vaginal misoprostol dosage of 200 or 800 μg,10-12 h before operative hysteroscopy. The cervical width was the primary outcome, and secondary outcomes were patient satisfaction, adverse effects, surgical complications, and duration of cervical dilatation. Chi-square tests of association, Fisher's exact and Mann-Whitney U tests were used with an α error of <5%.

RESULTS

There was no statistical difference between the groups in the mean of the cervical width (800 μg: 6.5 ± 1.6 mm vs 200 μg: 5.8 ± 1.8 mm, P = 0.055), patient satisfaction, and surgical findings, but the duration of cervical dilatation was lower in the 800-μg group (28.16 ± 28.5 s vs 41.97 ± 31.0 s, P = 0.035). Among the adverse effects, diarrhea was more frequent in the 800-μg group with statistical difference (100% vs 0%; P = 0.01).

CONCLUSION

For cervical ripening, 200 μg misoprostol is equally effective with fewer adverse effects than 800 μg before operative hysteroscopy. ClinicalTrials.gov: NCT04152317. https://clinicaltrials.gov/ct2/show/NCT04152317.

Determining the Optimal Time Interval between Vaginal Dinoprostone Administration and Diagnostic Office Hysteroscopy in Nulliparous Women: A Randomized, Double-blind Trial

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.

Cervical dilatation and preparation prior to outpatient hysteroscopy: a systematic review and meta-analysis

BACKGROUND

There are uncertainties about the benefit of routine cervical preparation and/or cervical dilatation before outpatient hysteroscopy.

OBJECTIVE

To determine if cervical preparation and/or routine mechanical dilatation reduces pain during outpatient hysteroscopy.

SEARCH STRATEGY

MEDLINE, EMBASE, CINAHL and CENTRAL were searched on 19 October 2020, using keywords 'hysteroscopy', 'cervical preparation', 'cervical ripening', 'cervical dilatation', 'outpatient', 'office' and/or 'ambulatory' and associated medical subject headings.

SELECTION CRITERIA

Randomised controlled trials investigating the benefit of cervical preparation and/or cervical dilatation on pain in women undergoing outpatient hysteroscopy were included.

DATA COLLECTION AND ANALYSIS

Two independent reviewers selected eligible trials and extracted data on pain, feasibility, adverse events and satisfaction/acceptability for meta-analysis.

MAIN RESULTS

The literature search yielded 807 records, of which 24 were included for review and 19 provided data for meta-analysis. No trials investigated the role of routine mechanical cervical dilatation. Cervical preparation significantly reduced pain during outpatient hysteroscopy; standard mean difference (SMD) -0.67, 95% confidence interval (CI) -1.05 to -0.29. Feasibility also improved as priming provided significantly easier hysteroscopic entry (SMD 0.89, 95% CI 0.32-1.46), greater cervical dilatation (SMD 0.81, 95% CI 0.08-1.53) and shorter procedural times (SMD -0.51, 95% CI -0.88 to -0.13). Cervical preparation, however, incurred significantly more adverse effects, mainly comprising genital tract bleeding, abdominal pain and gastrointestinal symptoms (odds ratio 2.94, 95% CI 1.58-5.47). There were limited data regarding satisfaction, acceptability and complications.

CONCLUSIONS

Cervical preparation reduces pain and improves feasibility associated with outpatient hysteroscopy but increases the risk of adverse effects.

TWEETABLE ABSTRACT

Cervical preparation before outpatient hysteroscopy reduces pain, enhances feasibility but increases adverse effects.

Comparative Efficacy of Vaginal Misoprostol vs Vaginal Dinoprostone Administered 3 Hours Prior to Copper T380A Intrauterine Device Insertion in Nulliparous Women: A Randomized Controlled Trial

STUDY OBJECTIVE

To compare the effectiveness of misoprostol and dinoprostone tablets administered vaginally 3 hours before copper intrauterine device (IUD) insertion vs placebo in reducing pain and increasing ease of insertion among nulliparous women.

DESIGN

Randomized controlled trial.

SETTING

Tertiary referral hospital.

PARTICIPANTS

A total of 129 nulliparous women requesting a Copper T380A IUD insertion.

INTERVENTIONS

Women were randomized to receive 200 μg misoprostol or 3 mg dinoprostone or placebo 3 hours before IUD insertion.

MAIN OUTCOME MEASURE(S)

Primary outcome was patient-reported pain during IUD insertion using a 10-cm visual analog scale (VAS). Secondary outcomes include provider ease of insertion, women satisfaction level, and side effects.

RESULTS

Participants' baseline characteristics were comparable between the study groups. Mean pain score during IUD insertion was lower with misoprostol than placebo (3.1 ± 2.3 vs 4.4 ± 2.2; P = .02) and dinoprostone compared to placebo (2.4 ± 1.8 vs 4.4 ± 2.2; P < .001). Clinicians reported easier IUD insertion with misoprostol than placebo (2.4 ± 1.7 vs 4.0 ± 2.4; P = .001) and dinoprostone compared to placebo (2.0 ± 1.5 vs 4.0 ± 2.4; P < .001). Women's satisfaction levels were higher with both misoprostol and dinoprostone than placebo (P < .001). Side effects did not differ among the 3 study groups.

CONCLUSIONS

Premedication with vaginal misoprostol or dinoprostone effectively lowered pain during copper IUD insertion. However, the reduction in pain scores was clinically significant only in women who received dinoprostone. In both the misoprostol and dinoprostone groups, clinicians found the procedure easier, and women were more satisfied with IUD insertion. Side effects and complications were similar in all groups.

Misoprostol administration prior to intrauterine contraceptive device insertion: a systematic review and meta-analysis of randomised controlled trials

Objectives: Misoprostol has been used before intrauterine contraceptive device (IUCD) insertion to prime the cervical os. As the literature about this topic is controversial, we aimed to evaluate IUCD insertion failure, women's pain perception, use of cervical dilators and prevalence of side effects following the administration of misoprostol.Methods: Trials published in MEDLINE, Scopus, the Cochrane Library and ClinicalTrials.gov were searched (last search on 23 October 2019). The primary outcome was IUCD insertion failure; secondary outcomes were women's pain perception, use of cervical dilators to facilitate insertion, and prevalence of side effects.Results: Fourteen studies were eligible for inclusion. Misoprostol premedication reduced IUCD insertion failure rates and the use of cervical dilators but significantly increased the prevalence of side effects. The risk of IUCD insertion failure with misoprostol premedication was reduced among women who had undergone previous caesarean section and among women who had experienced previous IUCD insertion failure. Nulliparas did not benefit from misoprostol premedication. Buccal misoprostol administration did not seem to be effective in reducing IUCD insertion failure. Visual analogue scale pain scores were increased with both sublingual and buccal misoprostol administration if IUCD insertion was performed ≤2.5 h after misoprostol premedication.Conclusion: Our data demonstrate reduced IUCD insertion failure among women with previous caesarean section and those with previous IUCD insertion failure, suggesting that misoprostol may be a reasonable choice in these groups of women. Although misoprostol premedication reduced insertion failures, it significantly increased side effects and had a heterogeneous pattern of efficacy; thus, its routine use is not supported by the evidence.

Is IVF/ICSI [corrected] an Independent Risk Factor for Spontaneous Preterm Birth in Singletons? A Population-Based Cohort Study

The aim of our study was to explore the risk factors for very preterm (gestation under 32 weeks) and moderate preterm birth (gestation weeks 32-36 6/7) in singleton pregnancies in a national retrospective cohort study. We also wanted to establish whether IVF/ICSI is an independent risk factor for preterm birth after adjusting for already known confounders. We used data for 267 718 singleton births from 2002-2015 from the National Perinatal Information System of Slovenia, containing data on woman, pregnancy, birth, the postpartum period, and the neonate for each mother-infant pair. Mode of conception, maternal age, education, BMI, parity, smoking, history of cervical excision procedure, history of hysteroscopic resection of uterine septum, presence of other congenital uterine malformations, bleeding in pregnancy, preeclampsia or HELLP and maternal heart, and pulmonary or renal illness were included in the analyses. Unadjusted OR for very preterm birth after IVF-ICSI [corrected] was 2.8 and for moderate preterm birth was 1.7. After adjusting for known confounders, the OR was still significantly elevated (1.6 and 1.3, respectively). Risk factors for very preterm birth with OR higher than 2.4 were history of cervical excision procedure, resection of uterine septum, operation or having other congenital uterine malformations, and bleeding in pregnancy. Risk factors for very preterm birth with OR between 1.4 and 2.1 were age >35 years, being underweight or obese, not having professional education, smoking, first birth, preeclampsia/HELLP, and IVF/ICSI. Risk factors for moderate preterm birth with OR higher than 2.4 were history of cold knife conization and other congenital uterine malformations. We found that even after adjustment, IVF/ICSI represents a single risk factor for early and late preterm birth even after adjustment with other risks such as maternal age, smoking, or a history of invasive procedures for either cervical intraepithelial neoplasia or infertility treatment.

Office Operative Hysteroscopy: An Update

Hysteroscopy is considered the gold standard for the evaluation of intracavitary pathology in both premenopausal and postmenopausal patients associated with abnormal uterine bleeding, as well as for the evaluation of infertile patients with suspected cavity abnormalities. Office-based operative hysteroscopy allows patients to resume activities immediately and successfully integrates clinical practice into a "see and treat" modality, avoiding the added risks of anesthesia and the inconvenience of the operating room. For 2017, the Centers for Medicare and Medicaid Services has provided a substantial increase in reimbursement for a select number of office-based hysteroscopic procedures. This review provides an update on the indications, equipment, and procedures for office hysteroscopy, as well as the management of complications that may arise within an office-based practice.

Different Routes of Misoprostol for Same-Day Cervical Priming Prior to Operative Hysteroscopy: A Randomized Blinded Trial

STUDY OBJECTIVE

To compare the effectiveness of and patient satisfaction with different routes of misoprostol administration for short-term cervical priming before operative hysteroscopy.

DESIGN

Randomized blinded trial (Canadian Task Force classification I).

SETTING

University hospital.

PATIENTS

One hundred and twenty patients undergoing operative hysteroscopy.

INTERVENTIONS

Patients were randomly assigned to receive 400 μg of misoprostol administered orally (n = 40), vaginally (n = 40), or sublingually (n = 40) for cervical priming at 1.5 to 4 hours before undergoing operative hysteroscopy.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was preoperative cervical dilatation. Secondary outcomes included cervical consistency, ease of dilation and time of dilation, patient discomfort, and side effects. No differences were noted among the 3 groups in terms of patient age, parity, previous vaginal delivery, menopausal status, and time interval from preparation to procedure. Patients in the 3 groups reported similar discomfort and side effects. Initial mean cervical dilatation was 6.1 ± 2.0 mm in the oral group, 6.4 ± 2.1 in the vaginal group, and 6.4 ± 1.8 mm in the sublingual group (p = .75). Cervical consistency and ease of dilation were similar among the groups. The mean time of dilation was 37.2 ± 30.6 seconds in the oral group, 31.7 ± 29.0 seconds in the vaginal group, and 31.5 ± 21.7 seconds in the sublingual group (p = .59). Additional subanalyses according to menopausal status and parity did not demonstrate any differences among the groups.

CONCLUSION

Same-day cervical priming for operative hysteroscopy is achieved equally with all routes of misoprostol administration, with similar patient satisfaction and side effects.