Use of Misoprostol Prior to Hysteroscopy in Postmenopausal Women: A Randomized, Placebo-Controlled Clinical Trial

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.

Implementation of Office Hysteroscopy for the Evaluation and Treatment of Intrauterine Pathology

Hysteroscopy provides a minimally invasive strategy to evaluate intrauterine pathology and manage conditions such as abnormal uterine bleeding, infertility, intrauterine adhesions, müllerian anomalies, and intrauterine foreign bodies. Increasing access to hysteroscopy procedures in the office has the potential to improve patient care by minimizing financial and logistical barriers, aiding in streamlined diagnosis and treatment planning, and potentially averting unnecessary operative procedures and anesthesia. Office hysteroscopy refers to procedures performed in outpatient settings where pain management involves no medications, oral nonsedating medications, local anesthetic agents, or oral or inhaled conscious sedation. We present best practices for the implementation of hysteroscopy in an office setting. These include appropriate patient selection, optimal procedural timing, cervical preparation for patients at highest risk of cervical stenosis or pain with dilation, individualized pain-management strategies, use of distension media, and video monitoring to engage patients in the procedure. We describe miniaturized equipment for use in the office setting and "no-touch" vaginoscopic approaches to limit patient discomfort. With appropriate training and experience, office hysteroscopy presents a simple and cost-effective modality for optimizing gynecologic care for our patients.

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.

Pain management during diagnostic office hysteroscopy in postmenopausal women: a randomized study

Objective: This study aimed to compare efficacy and safety of lidocaine versus tramadol versus placebo in reducing the pain of diagnostic outpatient hysteroscopy (OH) in postmenopausal women.Materials and methods: This randomized double-blinded study included 156 menopausal women who received intrauterine lidocaine infusion or oral tramadol (50 mg) or placebo before diagnostic OH (52 women/group). Primary outcome was pain severity during the procedure using a 10-cm visual analog scale. Secondary outcomes were pain scores 10 and 30 min post procedure, satisfaction level, and ease of cervical entry.Results: Lidocaine had lower pain scores compared to placebo during and 10 min after the procedure (p < 0.001). Tramadol had lower pain scores than placebo during the procedure (p = 0.04), 10 min after the procedure (p = 0.03), and 30 min after the procedure (p = 0.04). Both lidocaine and tramadol resulted in an easier procedure than placebo (p < 0.001 and p = 0.04, respectively). Lidocaine had an easier cervical entry compared to tramadol (p = 0.004). Satisfaction scores in the lidocaine and tramadol groups were significantly higher than in the placebo group (p < 0.001).Conclusions: Lidocaine and tramadol were effective in reducing postmenopausal women-reported pain during and after diagnostic OH. However, lidocaine was better than tramadol in facilitating hysteroscope passage through the cervical canal and the reduction in pain levels with lidocaine was clinically relevant.Trial registration number: NCT03701984.

Failed diagnostic hysteroscopy: Analysis of 62 cases

OBJECTIVE

The aim of the presented study is to improve the office hysteroscopy success rate identifying some of the factors associated to an unsuccessful procedure. Moreover it would highlight the importance of an adequate patients follow up after office hysteroscopy failure enlightening the uterine pathologies missed at the first attempt.

STUDYDESIGN

This is a retrospective observational study. The Authors reviewed the medical records related to 516 office hysteroscopies performed from January 2016 to November 2018, extrapolating the data from the failed hysteroscopies occurred during this period. After the procedure failure all patients were offered to repeat the hysteroscopy under regional anesthesia in order to identify and treat uterine pathologies. Those patients, who declined to repeat the procedure, received an appropriate follow up. Each failure case is correlated with patient clinical characteristics, indications to hysteroscopy, risk factors presence, hysteroscopy patient compliance, pathology result and patient follow up.

RESULTS

The presented study shows an office hysteroscopy failure rate of about 12 %. Severe pain due to cervical stenosis, previous uterine surgery, postmenopausal status and marked uterine ventrifixation/retroflexion, represent the main reason why the procedure was not completed in an office setting. The uterine cavity was subsequently examined in only 26 (42 %) out of 62 patients who reported hysteroscopy failure, mostly repeating the procedure under regional anesthesia (24 cases) or performing vaginal hysterectomy for associated benign gynaecological pathology (2 cases). Endometrial malign pathology (endometrioid carcinoma) was diagnosed in 2 cases of them (7.7 %). Moreover the endometrial cavity remained so far unexplored in 36 (58 %) out of 62 patients, due to the patient refuse to repeat the hysteroscopy under anesthesia.

DISCUSSION AND CONCLUSION

Results of the present study suggest that office hysteroscopy should be sussessful at the first attempt due to the patients' refuse, in majority of cases, to repeat the procedure after a failure. To not repeat the hysteroscopy may lead to lose or delay important diagnosis, such as that of endometrial cancer. In this context, to counsel all patients prior the procedure may singnificanly help to identify those who may benefit of pharmacological cervical softening, local anesthetic injection or small caliber hysteroscopes usage, increasing the procedure success rate.

ACOG Technology Assessment No. 13: Hysteroscopy

Hysteroscopy is performed to view and treat pathology within the uterine cavity and endocervix. Diagnostic hysteroscopy allows visualization of the endocervical canal, endometrial cavity, and fallopian tube ostia. Operative hysteroscopy incorporates the use of mechanical, electrosurgical, or laser instruments to treat intracavitary pathology and perform hysteroscopic sterilization procedures. Selection of a distending medium requires consideration of the advantages, disadvantages, and risks associated with various media as well as their compatibility with electrosurgical or laser energy. A preoperative consultation allows the patient and physician to discuss the hysteroscopic procedure, weigh its inherent risks and benefits, review the patient's medical history for any comorbid conditions, and exclude pregnancy. Known pregnancy, genital tract infections, and active herpetic infection are contraindications to hysteroscopy. The most common perioperative complications associated with operative hysteroscopy are hemorrhage, uterine perforation, and cervical laceration. The procedure is minimally invasive and can be used with a high degree of safety.

Audit of operative hysteroscopies among infertile women in a resource-poor setting

OBJECTIVE

To evaluate the operative hysteroscopy procedures performed among infertile women at two hospitals in Nigeria.

METHODS

A prospective case series was undertaken among all patients with infertility who underwent operative hysteroscopy between November 2015 and April 2017. The outcome measures included the frequency and type of operative hysteroscopy and the reproductive outcome.

RESULTS

The series included 159 women, 70.4% (n=112) of whom had abnormal findings at hysteroscopy. A total of 162 operative hysteroscopic procedures were performed; the most common procedures were adhesiolysis (76 [46.9%]), polypectomy (28 [17.3%]), and septum resection/incision (17 [10.5%]). The instruments used were mainly scissors (65 [40.1%]) and a resectoscope (52 [32.1%]). Complete removal of the lesions was achieved in 86.4% (n=140) of the procedures and a normal cavity in 87.0% (n=141). The complication rate was 6.8% (n=11); the most common complication was minor hemorrhage (5 [3.1%]). The main challenges included poor distention (10 [6.2%]) and poor vision (8 [4.9%]). Menstrual normalization was achieved in 64 (40.3%) of the patients, the cumulative pregnancy rate was 19.5% (n=31), and the live birth rate was 3.8% (n=6).

CONCLUSION

Operative hysteroscopy was feasible and safe in the present resource-poor region. There is a need to build capacity for the performance of hysteroscopy to facilitate the management of infertility in the region.

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.

The use of misoprostol for cervical priming prior to hysteroscopy: a systematic review and analysis

The effects of misoprostol use on cervical priming prior to hysteroscopy have been controversial. Therefore, a systematic literature review and meta-analysis of studies were conducted to assess the effect of misoprostol on cervical priming prior to hysteroscopy. All studies published before July 2014 with data related to the use of misoprostol for cervical priming compared with placebo or no medication prior to hysteroscopy, were identified. Twenty-five randomized controlled trials involving 2,203 females were systematically analyzed. The results showed that, compared with placebo or no medication, the use of misoprostol prior to hysteroscopy led to a significant relief of the need for cervical dilatation, resulted in a significantly greater cervical width, had fewer hysteroscopy complications, and mild and insignificant side effects. Subgroup analyses revealed that the regimen of 200 or 400 μg vaginal misoprostol may be a simple and effective method for cervical priming, especially prior to operative hysteroscopy.

Hysteroscopy: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians

The objective of this study was to provide guidelines for clinical practice from the French College of Obstetrics and Gynecology (CNGOF), based on the best evidence available, concerning hysteroscopy. Vaginoscopy should be the standard technique for diagnostic hysteroscopy (Grade A) using a miniature (≤3.5mm sheath) (Grade A) rigid hysteroscope (Grade C), using normal saline solution distension medium (Grade C), without any anaesthesia (conscious sedation should not be routinely used), without cervical preparation (Grade B), without vaginal disinfection and without antibiotic prophylaxy (Grade B). Misoprostol (Grade A), vaginal oestrogens (Grade C), or GnRH agonist routine administration is not recommended before operative hysteroscopy. Before performing hysteroscopy, it is important to purge the air out of the system (Grade A). The uterine cavity distention pressure should be maintained below the mean arterial pressure and below 120mm Hg. The maximum fluid deficit of 2000ml is suggested when using normal saline solution and 1000ml is suggested when using hypotonic solution. When uterine perforation is recognized during operative hysteroscopy using monopolar or bipolar loop, the procedure should be stopped and a laparoscopy should be performed in order to eliminate a bowel injury. Diagnostic or operative hysteroscopy is allowed when an endometrial cancer is suspected (Grade B). Implementation of this guideline should decrease the prevalence of complications related to hysteroscopy.

[Prevention of the complications related to hysteroscopy: guidelines for clinical practice]

OBJECTIVE

To provide clinical practice guidelines (CPGs) from the French college of obstetrics and gynecology (CNGOF), based on the best evidence available, concerning the adverse events related to hysteroscopy.

MATERIALS AND METHODS

Review of literature using following Keywords: hysteroscopy; vaginoscopy; infection; perforation; intrauterine adhesions

RESULTS

Vaginoscopy should be the standard technique for outpatient hysteroscopy (grade A) using a miniature (≤ 3.5mm sheath) (grade A) rigid hysteroscope (grade C), using normal saline solution distension medium (grade C), without any anesthesia (conscious sedation should not be routinely used), without cervical preparation (grade B), without vaginal disinfection and without antibiotic prophylaxy (grade B). Misoprostol (grade A), vaginal estrogens (grade C), or GnRH agonist routine administration is not recommended before operative hysteroscopy. Before performing hysteroscopy, it is important to purge the air out of the system (grade A). The uterine cavity distention pressure should be maintained below the mean arterial pressure and below 120 mmHg. The maximum fluid deficit of 2000 mL is suggested when using normal saline solution and 1000 mL is suggested when using hypotonic solution. When uterine perforation is recognized during operative hysteroscopy using monopolar or bipolar loop, the procedure should be stopped and a laparoscopy should be performed in order to eliminate a bowel injury. Diagnostic or operative hysteroscopy is allowed when an endometrial cancer is suspected (grade B).

CONCLUSION

Implementation of this guideline should decrease the prevalence of complications related to office and operative hysteroscopy.

Geriatric gynecology: promoting health and avoiding harm

Age increases vulnerability, commonly accompanied by greater reliance on others and susceptibility to maltreatment. Physiologic processes become less resilient; the potential for harm from medical care increases. Awareness of frailty, functional, social, and potential maltreatment issues enables early referrals to help the patient maintain her independence. Health issues that may impede both gynecologic care and self-sufficiency include sensory deficits, physical disability, and cognitive impairment. Speaking slowly and providing contextual information enhance patient comprehension. Cancer screening depends on life expectancy. Osteoporosis treatment requires managing fall risk. Gynecologic symptoms more likely have multiple contributing factors than one etiology. Incontinence is a particularly complex issue, but invariably includes bladder diary assessment and pelvic floor muscle training. Function and frailty measures best predict perioperative morbidity. Communication with the patient, her family, other providers, and health care organizations is an important frontier in avoiding errors and adverse outcomes.

Evaluation of pain in outpatient diagnostic hysteroscopy with gas

OBJECTIVE

To evaluate the intensity of pain reported by patients undergoing outpatient diagnostic hysteroscopy.

METHODS

Exam performed with a 5-mm lens hysteroscope, vaginal speculum, tenaculum and uterine distention with carbon dioxide gas. Before and after the examination, patients were interviewed to define, in a verbal scale from 0 to 10, pain values that they expected to feel and that they experienced after the end, and also if they would repeat it if indicated. Data were analyzed using Statistical Package for the Social Sciences 15.0, statistic significance was defined as p < 0.05 with a study power of 95%.

RESULTS

Fifty-eight patients were included with mean age of 50.9 years, with 32.8% at postmenopause and 6.9% nulliparous. Among those with previous deliveries, mean parity was 2.21 and at least one vaginal delivery had occurred in 63.8%. Only 24.1% of patients knew how the exam would be done, 62.1% needed an endometrial sample and the result was considered satisfactory in 89.7%. The means of expected and experienced pain were similar (6.0 versus 6.1), and 91.4% of women would repeat the hysteroscopy if necessary. The only factor associated with less pain after the exam was previous vaginal delivery, with a decrease of pain score from 7.1 to 5.5 (p = 0.03). Mean pain was significantly lower in those who agreed to repeat the exam (5.8 versus 9.4; p = 0.003).

CONCLUSIONS

Outpatient diagnostic hysteroscopy with gas can be associated with moderate but tolerable discomfort and satisfactory results.