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Çallıoğlu N, Kanza Gül D, Özer Aslan İ, Fendal Tunca A, Başlı Kasım K, Akay B, Uysal E, Ekin M. The effect of informing the patient about the procedure with video imaging before office hysteroscopy on pain. J Obstet Gynaecol Res 2023; 49:2387-2392. [PMID: 37462062 DOI: 10.1111/jog.15738] [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: 10/04/2022] [Accepted: 06/27/2023] [Indexed: 09/06/2023]
Abstract
OBJECTIVE To evaluate the effect of informing patients undergoing diagnostic office hysteroscopy via a video 24 h before the procedure and determine the changes in pain scores, channel transit time, the degree of difficulty of the procedure, and physiological parameters. DESIGN Single-blind randomized controlled trial. SETTING The study was conducted between September 1, 2021 and April 1, 2022 at the University of Health Sciences Bakirkoy Dr. Sadi Konuk Training and Research Hospital. PARTICIPANTS A total of 134 patients aged 18-65 years who needed diagnostic office hysteroscopy. INTERVENTIONS Participants were randomized into two groups, the standard information group (Group 1: controls), and the video information + standard information group (Group 2). After office hysteroscopy, a visual analog scale (VAS) and Likert scale were used to assess pain and the degree of difficulty of the procedure, respectively. Physiological parameters were evaluated before and after the procedure. MAIN OUTCOME MEASURE To determine the effect of video-based multimedia information administered 24 h before office hysteroscopy on post-procedure pain. RESULTS The mean VAS score of the group that watched the training video (3.02 ± 1.88) was significantly lower than the control group (4.72 ± 2.54) who did not watch the training video (p < 0.001). The mean cervical channel transit time in seconds (sec) during the procedure was found to be significantly higher in the control group (21.57 ± 15.10 s) than in the video-watching group (p = 0.011). There was no significant difference between the groups in terms of physiological parameters and the degree of ease of the procedure. CONCLUSION Our study has shown that informing patients in a pre-procedure video is an effective approach that shortens the duration of the channel transit time and reduces pain.
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Affiliation(s)
- Nihal Çallıoğlu
- Department of Obstetrics and Gynecology, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Derya Kanza Gül
- Medipol University School of Medicine Health, Istanbul, Turkey
| | - İlke Özer Aslan
- Department of Obstetrics and Gynecology, Faculty of Medicine, Tekirdağ Namık Kemal University, Tekirdağ, Turkey
| | - Aysun Fendal Tunca
- Department of Obstetrics and Gynecology, University of Health Sciences Istanbul, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Kardelen Başlı Kasım
- Department of Obstetrics and Gynecology, University of Health Sciences Istanbul, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Burcu Akay
- Department of Obstetrics and Gynecology, University of Health Sciences Istanbul, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Elif Uysal
- Department of Obstetrics and Gynecology, University of Health Sciences Istanbul, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Murat Ekin
- Department of Obstetrics and Gynecology, University of Health Sciences Istanbul, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
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Barel O, Preuss E, Stolovitch N, Weinberg S, Barzilay E, Pansky M. Addition of Lidocaine to the Distension Medium in Hysteroscopy Decreases Pain during the Procedure-A Randomized Double-blind, Placebo-controlled Trial. J Minim Invasive Gynecol 2020; 28:865-871. [PMID: 32798723 DOI: 10.1016/j.jmig.2020.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 08/06/2020] [Accepted: 08/08/2020] [Indexed: 10/23/2022]
Abstract
STUDY OBJECTIVE To evaluate the effect of adding a local anesthetic to the distension medium in office diagnostic hysteroscopy using the vaginoscopic approach on pain during the procedure. Secondary aims included documenting side effects, patient satisfaction, and the time needed to complete the procedure. DESIGN Randomized double-blind placebo-controlled study. SETTING University-affiliated hospital; office hysteroscopy clinic. PATIENTS Total of 100 patients who underwent office hysteroscopies divided in half with 50 in the intervention group and 50 in the control group. INTERVENTIONS Ten mL of lidocaine 2% added to 1000 mL of saline solution that was used as the distension medium for hysteroscopy in the study group vs 1000 mL of saline alone in the control group. MEASUREMENTS AND MAIN RESULTS A significant difference was found in the increment of pain as measured by visual analog scale after the hysteroscopy between the 2 groups. Patients receiving lidocaine had an average rise of 1.9 in the visual analog scale score after the procedure compared with 2.9 in the control group (p = .033). There was also a nonsignificant trend for shorter duration of hysteroscopy in the intervention group compared with the control group (180.1 vs 222.1 seconds, p = .08). Patients' satisfaction was high in both groups (98% for the study group and 92% for the control group). Success rates were also similar between the 2 groups at approximately 95%. No side effects were recorded in either group. CONCLUSION The addition of local anesthetic to the distension medium in office hysteroscopy produces significant reduction in pain during the procedure without adding time to the procedure and without side effects.
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Affiliation(s)
- Oshri Barel
- Department of Obstetrics and Gynecology, Samson Assuta Ashdod University Hospital, Ashdod and Faculty of Health Sciences, Ben Gurion University of the Negev, Be'er Sheva, Israel (all authors)..
| | - Elad Preuss
- Department of Obstetrics and Gynecology, Samson Assuta Ashdod University Hospital, Ashdod and Faculty of Health Sciences, Ben Gurion University of the Negev, Be'er Sheva, Israel (all authors)
| | - Natan Stolovitch
- Department of Obstetrics and Gynecology, Samson Assuta Ashdod University Hospital, Ashdod and Faculty of Health Sciences, Ben Gurion University of the Negev, Be'er Sheva, Israel (all authors)
| | - Shiri Weinberg
- Department of Obstetrics and Gynecology, Samson Assuta Ashdod University Hospital, Ashdod and Faculty of Health Sciences, Ben Gurion University of the Negev, Be'er Sheva, Israel (all authors)
| | - Eran Barzilay
- Department of Obstetrics and Gynecology, Samson Assuta Ashdod University Hospital, Ashdod and Faculty of Health Sciences, Ben Gurion University of the Negev, Be'er Sheva, Israel (all authors)
| | - Moty Pansky
- Department of Obstetrics and Gynecology, Samson Assuta Ashdod University Hospital, Ashdod and Faculty of Health Sciences, Ben Gurion University of the Negev, Be'er Sheva, Israel (all authors)
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De Silva PM, Carnegy A, Smith PP, Clark TJ. Local anaesthesia for office hysteroscopy: A systematic review & meta-analysis. Eur J Obstet Gynecol Reprod Biol 2020; 252:70-81. [PMID: 32570188 DOI: 10.1016/j.ejogrb.2020.05.062] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 05/27/2020] [Accepted: 05/29/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To compare the effects of different types and routes of administration of local anaesthetic for pain control during and after office hysteroscopy. METHODS Medline, Embase, CINAHL and the Cochrane library were searched from inception until October 2019, in order to perform a systematic review and meta-analysis of all randomised controlled trials investigating the use of a local anaesthetic compared to a control, for pain relief in women undergoing diagnostic or operative office hysteroscopy. Average pain scores and data regarding side-effects, feasibility, complications, acceptability and satisfaction were collected. RESULTS The literature search yielded 612 citations. A total of 37 studies were included for systematic review, of which data from 20 studies were used for meta-analysis. Local anaesthesia was associated with significantly reduced pain during (SMD -0.57, 95 % CI -0.79 to -0.34) and after (SMD -0.30, 95 % CI -0.54 to -0.06) office hysteroscopy but did not reduce vasovagal episodes (OR 0.73, 95 % CI 0.50-1.09). A reduction in intra-procedural pain was observed regardless of type or route of administration. Local anaesthesia did not significantly reduce the risk of procedural failure (OR 0.72, 95 % CI 0.47-1.11). Insufficient data regarding complications, acceptability and satisfaction were available for meta-analysis. CONCLUSION Local anaesthesia via any route of genital tract administration, should be considered when undertaking office diagnostic or operative hysteroscopy to reduce pain during and after the procedure. Further research is needed to understand whether the pain control benefits of local anaesthesia remain apparent with vaginoscopic approaches to office hysteroscopy that avoid genital tract instrumentation.
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Affiliation(s)
- Prathiba M De Silva
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK.
| | - Alasdair Carnegy
- Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
| | - Paul P Smith
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK
| | - T Justin Clark
- Birmingham Women's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Mindelsohn Way, Birmingham, B15 2TG, UK
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Shoab AY, Maged AM, Ramadan W, Dahab S, Deeb WS, Ali YZA, Mostafa WAI, Hussein EA. The value of endocervical and endometrial lidocaine flushing before office hysteroscopy: A randomized controlled trial. Int J Gynaecol Obstet 2020; 148:113-117. [PMID: 31593299 DOI: 10.1002/ijgo.12992] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 08/03/2019] [Accepted: 10/04/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To evaluate the safety and efficacy of flushing the cervical canal and the uterine cavity with local anesthetic in order to reduce the pain felt by patients during office hysteroscopy. METHODS A double-blind randomized controlled trial was conducted between May 1, 2018, and February 28, 2019, involving 260 women undergoing office hysteroscopy at Kasr Al Ainy Hospital, Cairo, Egypt. Women were randomized using a computerized random number generator to intrauterine and intracervical instillation 5 minutes before the procedure of either 5 mL lidocaine 2% diluted in 15 mL normal saline, or 20 mL normal saline alone. The primary outcome measure was the visual analog scale (VAS) pain score reported by women during the procedure. Secondary outcomes included VAS score at 10 and 30 minutes after the procedure, the need for analgesia, and occurrence of vasovagal attacks. RESULTS Women in the lidocaine flushing group reported a significantly lower VAS score during the procedure (1.8 ± 1.1 vs 5.2 ± 1.8) and 10 and 30 minutes after it (1.3 ± 1.15 and 0.8 ± 0.9 vs 4.3 ± 2.1 and 2.98 ± 1.96) when compared with control women (P<0.001). More women without lidocaine flushing experienced vasovagal attacks (25/130 vs 9/130, P<0.001) and needed analgesia (84/130 vs 13/130, P<0.001) when compared with women with lidocaine flushing. CONCLUSION Flushing of the cervical canal and uterine cavity with local anesthetic significantly decreased pain sensation in women undergoing office hysteroscopy. CLINICALTRIALS.GOV: NCT03530488.
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Affiliation(s)
- Amira Y Shoab
- Department of Obstetrics and Gynecology, Kasr Al Ainy, Cairo University - Faculty of Medicine, Cairo, Egypt
| | - Ahmed M Maged
- Department of Obstetrics and Gynecology, Kasr Al Ainy, Cairo University - Faculty of Medicine, Cairo, Egypt
| | - Wafaa Ramadan
- Department of Obstetrics and Gynecology, Kasr Al Ainy, Cairo University - Faculty of Medicine, Cairo, Egypt
| | - Sherif Dahab
- Department of Obstetrics and Gynecology, Kasr Al Ainy, Cairo University - Faculty of Medicine, Cairo, Egypt
| | - Wesam S Deeb
- Department of Gynecology and Obstetrics, Faculty of Medicine, Fayoum University, Fayoum, Egypt
| | - Yahia Z A Ali
- Department of Gynecology and Obstetrics, Faculty of Medicine, Fayoum University, Fayoum, Egypt
| | - Walaa A I Mostafa
- Department of Obstetrics and Gynecology, Kasr Al Ainy, Cairo University - Faculty of Medicine, Cairo, Egypt
| | - Eman A Hussein
- Department of Obstetrics and Gynecology, Kasr Al Ainy, Cairo University - Faculty of Medicine, Cairo, Egypt
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Genovese F, D'Urso G, Di Guardo F, Insalaco G, Tuscano A, Ciotta L, Carbonaro A, Leanza V, Palumbo M. Failed diagnostic hysteroscopy: Analysis of 62 cases. Eur J Obstet Gynecol Reprod Biol 2019; 245:193-197. [PMID: 31864715 DOI: 10.1016/j.ejogrb.2019.10.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 09/30/2019] [Accepted: 10/17/2019] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
- Fortunato Genovese
- Department of Medical Surgical Specialties, University of Catania, Via Tindaro 2, 95124, Catania, Italy
| | - Gisella D'Urso
- Department of Medical Surgical Specialties, University of Catania, Via Tindaro 2, 95124, Catania, Italy
| | - Federica Di Guardo
- Department of Medical Surgical Specialties, University of Catania, Via Tindaro 2, 95124, Catania, Italy.
| | - Giulio Insalaco
- Department of Medical Surgical Specialties, University of Catania, Via Tindaro 2, 95124, Catania, Italy
| | - Attlio Tuscano
- Department of Medical Surgical Specialties, University of Catania, Via Tindaro 2, 95124, Catania, Italy
| | - Lilliana Ciotta
- Department of Medical Surgical Specialties, University of Catania, Via Tindaro 2, 95124, Catania, Italy
| | - Antonio Carbonaro
- Department of Medical Surgical Specialties, University of Catania, Via Tindaro 2, 95124, Catania, Italy
| | - Vito Leanza
- Department of Medical Surgical Specialties, University of Catania, Via Tindaro 2, 95124, Catania, Italy
| | - Marco Palumbo
- Department of Medical Surgical Specialties, University of Catania, Via Tindaro 2, 95124, Catania, Italy
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Bosteels J, van Wessel S, Weyers S, Broekmans FJ, D'Hooghe TM, Bongers MY, Mol BWJ. Hysteroscopy for treating subfertility associated with suspected major uterine cavity abnormalities. Cochrane Database Syst Rev 2018; 12:CD009461. [PMID: 30521679 PMCID: PMC6517267 DOI: 10.1002/14651858.cd009461.pub4] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Observational studies suggest higher pregnancy rates after the hysteroscopic removal of endometrial polyps, submucous fibroids, uterine septum or intrauterine adhesions, which are present in 10% to 15% of women seeking treatment for subfertility. OBJECTIVES To assess the effects of the hysteroscopic removal of endometrial polyps, submucous fibroids, uterine septum or intrauterine adhesions suspected on ultrasound, hysterosalpingography, diagnostic hysteroscopy or any combination of these methods in women with otherwise unexplained subfertility or prior to intrauterine insemination (IUI), in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI). SEARCH METHODS We searched the following databases from their inception to 16 April 2018; The Cochrane Gynaecology and Fertility Group Specialised Register, the Cochrane Central Register of Studies Online, ; MEDLINE, Embase , CINAHL , and other electronic sources of trials including trial registers, sources of unpublished literature, and reference lists. We handsearched the American Society for Reproductive Medicine (ASRM) conference abstracts and proceedings (from 1 January 2014 to 12 May 2018) and we contacted experts in the field. SELECTION CRITERIA Randomised comparison between operative hysteroscopy versus control for unexplained subfertility associated with suspected major uterine cavity abnormalities.Randomised comparison between operative hysteroscopy versus control for suspected major uterine cavity abnormalities prior to medically assisted reproduction.Primary outcomes were live birth and hysteroscopy complications. Secondary outcomes were pregnancy and miscarriage. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion and risk of bias, and extracted data. We contacted study authors for additional information. MAIN RESULTS Two studies met the inclusion criteria.1. Randomised comparison between operative hysteroscopy versus control for unexplained subfertility associated with suspected major uterine cavity abnormalities.In women with otherwise unexplained subfertility and submucous fibroids, we were uncertain whether hysteroscopic myomectomy improved the clinical pregnancy rate compared to expectant management (odds ratio (OR) 2.44, 95% confidence interval (CI) 0.97 to 6.17; P = 0.06, 94 women; very low-quality evidence). We are uncertain whether hysteroscopic myomectomy improves the miscarriage rate compared to expectant management (OR 1.54, 95% CI 0.47 to 5.00; P = 0.47, 94 women; very low-quality evidence). We found no data on live birth or hysteroscopy complication rates. We found no studies in women with endometrial polyps, intrauterine adhesions or uterine septum for this randomised comparison.2. Randomised comparison between operative hysteroscopy versus control for suspected major uterine cavity abnormalities prior to medically assisted reproduction.The hysteroscopic removal of polyps prior to IUI may have improved the clinical pregnancy rate compared to diagnostic hysteroscopy only: if 28% of women achieved a clinical pregnancy without polyp removal, the evidence suggested that 63% of women (95% CI 45% to 89%) achieved a clinical pregnancy after the hysteroscopic removal of the endometrial polyps (OR 4.41, 95% CI 2.45 to 7.96; P < 0.00001, 204 women; low-quality evidence). We found no data on live birth, hysteroscopy complication or miscarriage rates in women with endometrial polyps prior to IUI. We found no studies in women with submucous fibroids, intrauterine adhesions or uterine septum prior to IUI or in women with all types of suspected uterine cavity abnormalities prior to IVF/ICSI. AUTHORS' CONCLUSIONS Uncertainty remains concerning an important benefit with the hysteroscopic removal of submucous fibroids for improving the clinical pregnancy rates in women with otherwise unexplained subfertility. The available low-quality evidence suggests that the hysteroscopic removal of endometrial polyps suspected on ultrasound in women prior to IUI may improve the clinical pregnancy rate compared to simple diagnostic hysteroscopy. More research is needed to measure the effectiveness of the hysteroscopic treatment of suspected major uterine cavity abnormalities in women with unexplained subfertility or prior to IUI, IVF or ICSI.
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Affiliation(s)
- Jan Bosteels
- Cochrane BelgiumAcademic Centre for General PracticeKapucijnenvoer 33blok J bus 7001LeuvenBelgium3000
| | - Steffi van Wessel
- Ghent University HospitalWomen’s ClinicCorneel Heymanslaan 10GhentBelgium9000
| | - Steven Weyers
- University Hospital GhentObstetrics and GynaecologyDe Pintelaan 185GhentBelgium
| | - Frank J Broekmans
- University Medical CenterDepartment of Reproductive Medicine and GynecologyHeidelberglaan 100UtrechtNetherlands3584 CX
| | - Thomas M D'Hooghe
- University Hospital GasthuisbergLeuven University Fertility CentreHerestraat 49LeuvenBelgium3000
| | - M Y Bongers
- Máxima Medisch CentrumDepartment of Obstetrics and GynaecologyVeldhovenNetherlands
| | - Ben Willem J Mol
- Monash UniversityDepartment of Obstetrics and Gynaecology246 Clayton RoadClaytonVictoriaAustralia3168
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Efficacy of misoprostol before diagnostic hysteroscopy in postmenopausal women: a randomized clinical trial. Menopause 2018; 25:789-794. [DOI: 10.1097/gme.0000000000001074] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ahmad G, Saluja S, O'Flynn H, Sorrentino A, Leach D, Watson A. Pain relief for outpatient hysteroscopy. Cochrane Database Syst Rev 2017; (10):CD007710. [PMID: 35611933 PMCID: PMC6485917 DOI: 10.1002/14651858.cd007710.pub3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Hysteroscopy is increasingly performed in an outpatient setting. Pain is the primary reason for abandonment of procedure or incomplete assessment. There is no consensus upon routine use of analgesia during hysteroscopy. OBJECTIVES To assess the effectiveness and safety of pharmacological interventions for pain relief in women undergoing outpatient hysteroscopy, compared with placebo, no treatment or other pharmacological therapies. SEARCH METHODS In September 2016 we searched the Cochrane Gynaecology and Fertility (CGF) Trials Register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL and two trials registers (ClinicalTrials.gov and WHO ICTRP), together with reference checking and contact with study authors and experts. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing use of pharmacological interventions with other pharmacological interventions and pharmacological interventions versus placebo or no treatment. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Our primary outcome was mean pain score. MAIN RESULTS We included 32 RCTS (3304 participants), of which only 19 reported data suitable for analysis. Most studies were at unclear or high risk of bias in most of the domains assessed. The evidence was low or very low quality, mainly due to risk of bias and imprecision. Baseline pain scores were relatively low in all groups. Analgesic versus placebo or no treatment Local anaesthetics Local anaesthetics reduced mean pain scores during the procedure [(SMD) -0.29, 95% CI -0.39 to -0.19, 10 RCTs, 1496 women, I2 = 80%, low-quality evidence)] and within 30 minutes (SMD 0.50, 95% CI -0.67 to -0.33, 5 RCTs, 545 women, I2 = 43%, low-quality evidence). This translates to a difference of up to 7 mm on a 0-10 cm visual analogue scale (VAS) during the procedure and up to 13 mm within 30 minutes, which is unlikely to be clinically meaningful. There was no clear evidence of a difference between the groups in mean pain scores after > 30 minutes (SMD -0.11, 95% CI -0.30 to 0.07, 4 RCTs, 450 women, I2 = 0%, low-quality evidence), or in rates of vasovagal reactions (OR 0.70, 95% CI 0.43 to 1.13, 8 RCTs, 1309 women, I2 = 66%, very low-quality evidence). There was insufficient evidence to determine whether there was a difference in rates of non-pelvic pain (OR 1.76, 95% CI 0.53 to 5.80, 1 RCT, 99 women, very low-quality evidence). Nonsteroidal anti-inflammatory drugs (NSAIDs) There was insufficient evidence to determine whether there was a difference between the groups in mean pain scores during the procedure (SMD -0.18, 95% CI -0.35 to 0.00, 3 RCTs, 521 women, I2 = 81%, low-quality evidence). Pain scores were lower in the NSAIDs group within 30 minutes (SMD -0.25, 95% CI -0.46 to -0.04, 2 RCTs, 340 women, I2=29%, low-quality evidence) and at over 30 minutes (SMD -0.27, 95% CI -0.49 to -0.05, 2 RCTs, 321 women, I2 = 78%, low-quality evidence). This equates to maximum differences of under 7.5 mm on a 0-10 cm scale, which are unlikely to be clinically significant. One RCT (181 women) reported adverse events: there was insufficient evidence to determine whether there was a difference between the groups in vasovagal reactions (OR 0.76, 95% CI 0.20 to 2.94, very low-quality evidence). For other reported adverse events (non pelvic pain and allergic reactions) evidence was lacking. Opioids One RCT utilised sublingual buprenorphine and one utilised oral tramadol. Data on pain scores during the procedure were unsuitable for pooling due to inconsistency. Tramadol was associated with a benefit of up to 22 mm on a 0-10 cm scale (SMD -0.76, 95% CI -1.10 to -0.42, 1 RCT, 140 women). However, the effect estimate for this outcome for sublingual opioids did not support a benefit from the intervention (SMD 0.08, 95% CI -0.22 to 0.39, 164 women). Compared with placebo, the pain score within 30 minutes of the procedure was reduced in the tramadol group, with a difference of up to 17mm on a 0-10cm scale (SMD -0.57, 95% CI -0.91 to -0.23 , 1 RCT, 140 women, low-quality evidence. There was no clear evidence of a difference between the tramadol and placebo groups at over 30 minutes (SMD -0.17, 95% CI -0.51 to 0.16, 1 RCT, 140 women, low-quality evidence). Nausea and vomiting occurred in 39% of the buprenorphine group, and in none of the placebo group (OR 107.55, 95% CI 6.44 to 1796.46) Analgesic versus any other analgesic Some comparisons did not report pain scores at all time frames of interest, and none reported data on adverse events. One RCT (84 women) compared local intracervical anaesthesia versus combined intracervical and paracervical anaesthesia. Pain scores were higher in the group with local intracervical anaesthesia during the procedure (SMD 4.27, 95% CI 3.49 to 5.06, very low-quality evidence), within 30 minutes (SMD 1.55, 95% CI 1.06 to 2.05, very low-quality evidence) and at more than 30 minutes (SMD 3.47, 95% CI 2.78 to 4.15, very low-quality evidence). This translates to a possible benefit in the combined group of up to 12 mm on a 0-10 cm scale during the procedure. Benefits at longer follow-up were smaller. One RCT compared antispasmodic + NSAID versus local paracervical anaesthesia. Pain scores were lower in the NSAID group than in the local anaesthesia group (during procedure: SMD -1.40, 95% CI -1.90 to -0.91; >30 minutes after procedure: SMD -0.87, 95% CI -1.33 to -0.41; 80 women, very low-quality evidence). This suggests a possible benefit of during the procedure of up to 23 mm on a 0-10 VAS scale and up to 11 mm >30 minutes after the procedure. Other comparisons included local intracervical anaesthesia versus combined intracervical, paracervical and topical anaesthesia, and opioid versus NSAIDs. Findings were inconclusive. AUTHORS' CONCLUSIONS There was no consistent good-quality evidence of a clinically meaningful difference in safety or effectiveness between different types of pain relief compared with each other or with placebo or no treatment in women undergoing outpatient hysteroscopy.
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Affiliation(s)
- Gaity Ahmad
- Pennine Acute Hospitals NHS TrustDepartment of Obstetrics and GynaecologyManchesterUK
| | - Sushant Saluja
- Pennine Acute Hospitals NHS TrustDepartment of Obstetrics and GynaecologyManchesterUK
| | - Helena O'Flynn
- Pennine Acute Hospitals NHS TrustDepartment of Obstetrics and GynaecologyManchesterUK
| | - Alessandra Sorrentino
- Pennine Acute Hospitals NHS TrustDepartment of RadiologyNorth Manchester General HospitalManchesterUKM8 5RB
| | - Daniel Leach
- The Royal Oldham Hospital, Pennine Acute Hospitals NHS TrustRochdale RdOldhamUKOL12JH
| | - Andrew Watson
- Tameside & Glossop Acute Services NHS TrustDepartment of Obstetrics and GynaecologyFountain StreetAshton‐Under‐LyneLancashireUKOL6 9RW
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del Valle C, Solano JA, Rodríguez A, Alonso M. Pain management in outpatient hysteroscopy. Gynecol Minim Invasive Ther 2016. [DOI: 10.1016/j.gmit.2016.08.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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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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Paulo AAS, Solheiro MHR, Paulo COS, Afreixo VMA. What proportion of women refers moderate to severe pain during office hysteroscopy with a mini-hysteroscope? A systematic review and meta-analysis. Arch Gynecol Obstet 2015; 293:37-46. [DOI: 10.1007/s00404-015-3836-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Accepted: 07/28/2015] [Indexed: 11/29/2022]
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Mohammadi SS, Abdi M, Movafegh A. Comparing Transcervical Intrauterine Lidocaine Instillation with Rectal Diclofenac for Pain Relief During Outpatient Hysteroscopy: A Randomized Controlled Trial. Oman Med J 2015; 30:157-61. [PMID: 26171120 DOI: 10.5001/omj.2015.35] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Accepted: 04/04/2015] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES There are a number of potential advantages to performing hysteroscopy in an outpatient setting. However, the ideal approach, using local uterine anesthesia or rectal non-steroidal anti-inflammatory drugs, has not been determined. Our objective was to compare the efficacy of intrauterine lidocaine instillation with rectal diclofenac for pain relief during diagnostic hysteroscopy. METHODS We conducted a double-blind randomized controlled trial on 70 nulliparous women with primary infertility undergoing diagnostic hysteroscopy. Subjects were assigned into one of two groups to receive either 100mg of rectal diclofenac or 5mL of 2% intrauterine lidocaine. The intensity of pain was measured by a numeric rating scale 0-10. Pain scoring was performed during insertion of the hysteroscope, during visualization of the intrauterine cavity, and during extrusion of the hysteroscope. RESULTS There were no statistically significant differences between the groups with regard to the mean pain score during intrauterine visualization (p=0.500). The mean pain score was significantly lower during insertion and extrusion of the hysteroscope in the diclofenac group (p=0.001 and p=0.030, respectively). Nine patients in the lidocaine group and five patients in diclofenac group needed supplementary intravenous propofol injection for sedation (p=0.060). CONCLUSIONS Rectal diclofenac appears to be more effective than intrauterine lidocaine in reducing pain during insertion and extrusion of hysteroscope, but there are no significant statistical and clinical differences between the two methods with regard to the mean pain score during intrauterine inspection.
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Affiliation(s)
- Sussan S Mohammadi
- Department of Anesthesiology, Tehran University of Medical Sciences, Tehran, Iran
| | - Mina Abdi
- Department of Anesthesiology, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Movafegh
- Department of Anesthesiology, Tehran University of Medical Sciences, Tehran, Iran
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Abstract
This review summarises current understanding and research on the association between anxiety and outpatient hysteroscopy. Women undergoing hysteroscopy suffer from significant levels of anxiety, with repercussions on pain perception, success rates and satisfaction. Using validated tools such as the Spielberger State-Trait Anxiety Index (STAI) or the Hospital Anxiety and Depression Scale (HADS) in the outpatient hysteroscopy setting, average state anxiety scores similar or greater than those measured before more invasive procedures under general anaesthesia have been consistently reported. This clearly suggests a significant gap between our clinical viewpoint of what is "minimally invasive" and patients' expectations. In spite of its potential role of confounder in studies on pain-reduction interventions, we found that patient anxiety was evaluated in only 9 (13 %) out of a sample of 70 randomised controlled trials on outpatient hysteroscopy published since 1992. Factors such as trait anxiety, age, indication and the efficiency of the clinic can be correlated to state anxiety before hysteroscopy, but more robust data are needed. Promising non-pharmacological interventions to reduce anxiety at hysteroscopy include patient education, communication through traditional or multimedia approaches, interaction and support during the procedure and music listening.
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Is pain better tolerated with mini-hysteroscopy than with conventional device? A systematic review and meta-analysis. Arch Gynecol Obstet 2015; 292:987-94. [DOI: 10.1007/s00404-015-3731-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 04/21/2015] [Indexed: 10/23/2022]
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Bosteels J, Kasius J, Weyers S, Broekmans FJ, Mol BWJ, D'Hooghe TM. Hysteroscopy for treating subfertility associated with suspected major uterine cavity abnormalities. Cochrane Database Syst Rev 2015:CD009461. [PMID: 25701429 DOI: 10.1002/14651858.cd009461.pub3] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Observational studies suggest higher pregnancy rates after the hysteroscopic removal of endometrial polyps, submucous fibroids, uterine septum or intrauterine adhesions, which are detectable in 10% to 15% of women seeking treatment for subfertility. OBJECTIVES To assess the effects of the hysteroscopic removal of endometrial polyps, submucous fibroids, uterine septum or intrauterine adhesions suspected on ultrasound, hysterosalpingography, diagnostic hysteroscopy or any combination of these methods in women with otherwise unexplained subfertility or prior to intrauterine insemination (IUI), in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI). SEARCH METHODS We searched the Cochrane Menstrual Disorders and Subfertility Specialised Register (8 September 2014), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2014, Issue 9), MEDLINE (1950 to 12 October 2014), EMBASE (inception to 12 October 2014), CINAHL (inception to 11 October 2014) and other electronic sources of trials including trial registers, sources of unpublished literature and reference lists. We handsearched the American Society for Reproductive Medicine (ASRM) conference abstracts and proceedings (from January 2013 to October 2014) and we contacted experts in the field. SELECTION CRITERIA Randomised comparisons between operative hysteroscopy versus control in women with otherwise unexplained subfertility or undergoing IUI, IVF or ICSI and suspected major uterine cavity abnormalities diagnosed by ultrasonography, saline infusion/gel instillation sonography, hysterosalpingography, diagnostic hysteroscopy or any combination of these methods. Primary outcomes were live birth and hysteroscopy complications. Secondary outcomes were pregnancy and miscarriage. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion and risk of bias, and extracted data. We contacted study authors for additional information. MAIN RESULTS We retrieved 12 randomised trials possibly addressing the research questions. Only two studies (309 women) met the inclusion criteria. Neither reported the primary outcomes of live birth or procedure related complications. In women with otherwise unexplained subfertility and submucous fibroids there was no conclusive evidence of a difference between the intervention group treated with hysteroscopic myomectomy and the control group having regular fertility-oriented intercourse during 12 months for the outcome of clinical pregnancy. A large clinical benefit with hysteroscopic myomectomy cannot be excluded: if 21% of women with fibroids achieve a clinical pregnancy having timed intercourse only, the evidence suggests that 39% of women (95% CI 21% to 58%) will achieve a successful outcome following the hysteroscopic removal of the fibroids (odds ratio (OR) 2.44, 95% confidence interval (CI) 0.97 to 6.17, P = 0.06, 94 women, very low quality evidence). There is no evidence of a difference between the comparison groups for the outcome of miscarriage (OR 0.58, 95% CI 0.12 to 2.85, P = 0.50, 30 clinical pregnancies in 94 women, very low quality evidence). The hysteroscopic removal of polyps prior to IUI can increase the chance of a clinical pregnancy compared to simple diagnostic hysteroscopy and polyp biopsy: if 28% of women achieve a clinical pregnancy with a simple diagnostic hysteroscopy, the evidence suggests that 63% of women (95% CI 50% to 76%) will achieve a clinical pregnancy after the hysteroscopic removal of the endometrial polyps (OR 4.41, 95% CI 2.45 to 7.96, P < 0.00001, 204 women, moderate quality evidence). AUTHORS' CONCLUSIONS A large benefit with the hysteroscopic removal of submucous fibroids for improving the chance of clinical pregnancy in women with otherwise unexplained subfertility cannot be excluded. The hysteroscopic removal of endometrial polyps suspected on ultrasound in women prior to IUI may increase the clinical pregnancy rate. More randomised studies are needed to substantiate the effectiveness of the hysteroscopic removal of suspected endometrial polyps, submucous fibroids, uterine septum or intrauterine adhesions in women with unexplained subfertility or prior to IUI, IVF or ICSI.
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Affiliation(s)
- Jan Bosteels
- Belgian Branch of the Dutch Cochrane Centre, Kapucijnenvoer 33 blok J bus 7001, 3000 Leuven, Leuven, Belgium.
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Pain in diagnostic hysteroscopy: a multivariate analysis after a randomized, controlled trial. Fertil Steril 2014; 102:1398-403. [DOI: 10.1016/j.fertnstert.2014.07.1249] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Revised: 07/15/2014] [Accepted: 07/25/2014] [Indexed: 11/21/2022]
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Mazzon I, Favilli A, Horvath S, Grasso M, Di Renzo GC, Laurenti E, Bini V, Gerli S. Pain during diagnostic hysteroscopy: what is the role of the cervical canal? A pilot study. Eur J Obstet Gynecol Reprod Biol 2014; 183:169-73. [PMID: 25461373 DOI: 10.1016/j.ejogrb.2014.10.045] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 10/09/2014] [Accepted: 10/22/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To evaluate whether a correlation exists between the pain perceived during diagnostic anesthesia-free hysteroscopy and the characteristics of the cervical canal. STUDY DESIGN Prospective observational pilot study of 255 women undergoing diagnostic hysteroscopy. Data analysis included characteristics of the patient and the cervical canal, and the pain experience during the procedure, assessed by visual analog score (VAS). A multiple logistic regression was then carried out in order to exclude confounding factors. RESULTS The degree of pain during hysteroscopy was equal to a median VAS score of 2 (range 0-10). Bivariate analysis between patients with VAS>3 and patients with VAS≤3 demonstrated a significant correlation between pain and the presence of synechiae in the cervical canal (P=0.022), the patient's age (P=0.003) and parity (P=0.001). Multivariate analysis revealed that the presence of cervical synechiae (P=0.0001) [OR=4.99 (95% CI 2.13-11.70)] and parity (P=0.014) [OR=0.42 (95% CI 0.21-0.83)] were significantly correlated with pain. There was no significant correlation with the different angles of the cervical canal. CONCLUSION Cervical synechiae appear as a major factor influencing pain during hysteroscopy. While parity acts as a protective factor, the angle of the cervical canal does not seem to play an important role for pain during diagnostic hysteroscopy.
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Affiliation(s)
- Ivan Mazzon
- "Arbor Vitae" Centre, Clinica Nuova Villa Claudia, 00191 Rome, Italy
| | - Alessandro Favilli
- Department of Obstetrics and Gynecology, University of Perugia, S.M. della Misericordia Hospital, 06156 Perugia, Italy
| | - Stefano Horvath
- "Arbor Vitae" Centre, Clinica Nuova Villa Claudia, 00191 Rome, Italy
| | - Mario Grasso
- "Arbor Vitae" Centre, Clinica Nuova Villa Claudia, 00191 Rome, Italy
| | - Gian Carlo Di Renzo
- Department of Obstetrics and Gynecology, University of Perugia, S.M. della Misericordia Hospital, 06156 Perugia, Italy
| | - Elena Laurenti
- Department of Obstetrics and Gynecology, University of Perugia, S.M. della Misericordia Hospital, 06156 Perugia, Italy
| | - Vittorio Bini
- Department of Obstetrics and Gynecology, University of Perugia, S.M. della Misericordia Hospital, 06156 Perugia, Italy
| | - Sandro Gerli
- Department of Obstetrics and Gynecology, University of Perugia, S.M. della Misericordia Hospital, 06156 Perugia, Italy.
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Abstract
Introduction: Nowadays minimally invasive techniques are a leading factors in medicine. According to this trend, hysteroscopy has been used in gynecology more and more frequently. Office hysteroscopy gives opportunity for a faster examination with less costs and strain for the patient. Aim: The aim of this work was to get familiar with the novel method. The author examined the level of pain during hysteroscopy performed for different indications with different types of instruments. In addition, the novel method invented for evaluating tubal patency was compared to the gold standard laparoscopy in 70 tubes. Method: Office hysteroscopy was performed in 400 cases for indications according to the traditional method. All examinations were performed in University of Debrecen, Department of Obstetrics and Gynecology in an outpatient setting. A 2.7 mm diameter optic with diagnostic or operative sheet was used. Hysteroscopies were scheduled between the 4th and 11th cycle day. For recording pain level VAS was used in 70 cases. Comparison of hysteroscopic evaluation of tubal patency to the laparoscopic method was studies in 70 cases. Results: It was found that office hysteroscopy can be performed in an outpatient setting, without anesthesia. Pain level showed no difference among subgroups (nulliparous, non-nulliparous, postmenopausal, diagnostic, operative) (mean±SD, 3.5±1.01; p=0.34). For the evaluation of tubal patency, office hysteroscopy showed 92.06% accuracy when compared to laparoscopy. Conclusions: Office hysteroscopy has several advantages over traditional method. This procedure is fast, it has less strain for the patient. The novel method, rather than traditional hysteroscopy, should be used in the work-up of infertility as well. Orv. Hetil., 2014, 155(40), 1589–1597.
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Affiliation(s)
- Péter Török
- Debreceni Egyetem, Klinikai Központ, Általános Orvostudományi Kar Szülészeti és Nőgyógyászati Klinika Debrecen Nagyerdei krt. 98. 4032
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Celik C, Tasdemir N, Abali R, Bastu E, Akbaba E, Yucel SH, Gul A. The effect of uterine straightening by bladder distention before outpatient hysteroscopy: a randomised clinical trial. Eur J Obstet Gynecol Reprod Biol 2014; 180:89-92. [DOI: 10.1016/j.ejogrb.2014.06.029] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 06/25/2014] [Accepted: 06/26/2014] [Indexed: 11/28/2022]
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Keyhan S, Munro MG. Office Diagnostic and Operative Hysteroscopy Using Local Anesthesia Only: An Analysis of Patient Reported Pain and Other Procedural Outcomes. J Minim Invasive Gynecol 2014; 21:791-8. [DOI: 10.1016/j.jmig.2014.03.006] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 03/02/2014] [Accepted: 03/05/2014] [Indexed: 11/29/2022]
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Identifying Predictors of Unacceptable Pain at Office Hysteroscopy. J Minim Invasive Gynecol 2014; 21:586-91. [DOI: 10.1016/j.jmig.2013.12.118] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 12/02/2013] [Accepted: 12/16/2013] [Indexed: 11/21/2022]
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Hysteroscopy: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians. Eur J Obstet Gynecol Reprod Biol 2014; 178:114-22. [PMID: 24835861 DOI: 10.1016/j.ejogrb.2014.04.026] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Revised: 04/18/2014] [Accepted: 04/22/2014] [Indexed: 01/02/2023]
Abstract
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.
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[Prevention of the complications related to hysteroscopy: guidelines for clinical practice]. ACTA ACUST UNITED AC 2013; 42:1032-49. [PMID: 24210234 DOI: 10.1016/j.jgyn.2013.09.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Bosteels J, Kasius J, Weyers S, Broekmans FJ, Mol BWJ, D'Hooghe TM. Hysteroscopy for treating subfertility associated with suspected major uterine cavity abnormalities. Cochrane Database Syst Rev 2013:CD009461. [PMID: 23440838 DOI: 10.1002/14651858.cd009461.pub2] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Observational studies suggest higher pregnancy rates after the hysteroscopic removal of endometrial polyps, submucous fibroids, uterine septum or intrauterine adhesions, which are detectable in 10% to 15% of women seeking treatment for subfertility. OBJECTIVES To assess the effects of the hysteroscopic removal of endometrial polyps, submucous fibroids, uterine septum or intrauterine adhesions suspected on ultrasound, hysterosalpingography, diagnostic hysteroscopy or any combination of these methods in women with otherwise unexplained subfertility or prior to intrauterine insemination (IUI), in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI). SEARCH METHODS We searched the Cochrane Menstrual Disorders and Subfertility Specialised Register (6 August 2012), the Cochrane Central Register of Controlled Trials (T he Cochrane Library 2012, Issue 7), MEDLINE (1950 to October 2012), EMBASE (1974 to October 2012), CINAHL (from inception to October 2012) and other electronic sources of trials including trial registers, sources of unpublished literature and reference lists. We handsearched the American Society for Reproductive Medicine (ASRM) conference abstracts and proceedings (from January 2008 to October 2012) and we contacted experts in the field. SELECTION CRITERIA Randomised comparisons between operative hysteroscopy versus control in women with otherwise unexplained subfertility or undergoing IUI, IVF or ICSI and suspected major uterine cavity abnormalities diagnosed by ultrasonography, saline infusion/gel instillation sonography, hysterosalpingography, diagnostic hysteroscopy or any combination of these methods. Primary outcomes were live birth and hysteroscopy complications. Secondary outcomes were pregnancy and miscarriage. DATA COLLECTION AND ANALYSIS Two authors independently assessed studies for inclusion and risk of bias, and extracted data. We contacted study authors for additional information. MAIN RESULTS Two studies met the inclusion criteria and neither reported the primary outcomes of live birth and complications from the procedure. In women with otherwise unexplained subfertility and submucous fibroids, there is no evidence of benefit with hysteroscopic myomectomy compared to regular fertility-oriented intercourse during 12 months for clinical pregnancy (odds ratio (OR) 2.4, 95% confidence interval (CI) 0.97 to 6.2, P = 0.06, 94 women) and miscarriage (OR 1.5, 95% CI 0.47 to 5.0, P = 0.47, 94 women) (very low-quality evidence). The hysteroscopic removal of polyps prior to IUI increases the odds of clinical pregnancy (experimental event rate (EER) 63%) compared to diagnostic hysteroscopy and polyp biopsy only (control event rate (CER) 28%) (OR 4.4, 95% CI 2.5 to 8.0, P < 0.00001, 204 women, high-quality evidence). AUTHORS' CONCLUSIONS Hysteroscopic myomectomy might increase the odds of clinical pregnancy in women with unexplained subfertility and submucous fibroids, but the evidence is at present not conclusive. The hysteroscopic removal of endometrial polyps suspected on ultrasound in women prior to IUI might increase the clinical pregnancy rate. More randomised studies are needed to substantiate the effectiveness of the hysteroscopic removal of suspected endometrial polyps, submucous fibroids, uterine septum or intrauterine adhesions in women with unexplained subfertility or prior to IUI, IVF or ICSI.
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Affiliation(s)
- Jan Bosteels
- Belgian Branch of the Dutch Cochrane Centre, Leuven,
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Bosteels J, Kasius J, Weyers S, Broekmans FJ, Mol BWJ, D'Hooghe TM. Hysteroscopy for treating subfertility associated with suspected major uterine cavity abnormalities. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2011. [DOI: 10.1002/14651858.cd009461] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Abstract
BACKGROUND Hysteroscopy is increasingly performed in an outpatient setting. The primary reason for failure is pain. There is no consensus upon the routine use of analgesia during hysteroscopy. OBJECTIVES The aim of the study was to compare the effectiveness of different types of pharmacological interventions for pain relief in patients undergoing hysteroscopy. SEARCH STRATEGY A search of medical literature databases including PubMed, EMBASE, PsycINFO and CINHAL (to February 2010). SELECTION CRITERIA Randomised controlled trials (RCTs) investigating pharmacological interventions for pain relief during hysteroscopy were investigated. DATA COLLECTION AND ANALYSIS Results for each study were expressed as a standardised mean difference with 95% confidence interval and combined for meta-analysis with Revman 5 software. MAIN RESULTS Twenty-four RCTS were identified involving a total of 3155 participants, with 15 studies included in the meta-analysis.Meta-analysis (nine RCTs, 1296 participants) revealed a significant reduction in the mean pain score for the use of local anaesthetics during the procedure compared with placebo (SMD -0.45, 95% CI -0.73 to -0.17, I(2) = 82%).Meta-analysis (4 RCTs, 454 participants) demonstrated a significant reduction in the mean pain score for the use of local anaesthetics within 30 minutes after the procedure compared with placebo (SMD -0.51, 95% CI -0.81 to -0.21, I(2) = 54%).There was no significant reduction in the mean pain score with the use of NSAIDS or opioid analgesics compared with placebo during or within 30 minutes after the procedure.There was no significant reduction in the mean pain score with the use of local anaesthetics, NSAIDS or opioid analgesics compared with placebo more than 30 minutes after the procedure.There was no significant difference between the number of incidents of failure to complete the procedure due to cervical stenosis between the intervention and control groups (OR 1.31, 95% CI 0.66 to 2.59; 6 RCTs, 805 participants).There were significantly fewer incidents of failure to complete the procedure due to pain in the intervention group than in the control group (OR 0.29, 95% CI 0.12 to 0.69; two studies, 330 participants).Meta-analysis demonstrated no significant difference between the intervention and placebo groups with regards to adverse effects. AUTHORS' CONCLUSIONS There was a significant reduction in the mean pain score with the use of analgesia during and within 30 minutes after outpatient hysteroscopy.
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Affiliation(s)
- Gaity Ahmad
- Obstetrics & Gynaecology, Pennine Acute NHS Trust, Manchester, UK
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Use of Local Anesthesia for Office Diagnostic and Operative Hysteroscopy. J Minim Invasive Gynecol 2010; 17:709-18. [DOI: 10.1016/j.jmig.2010.07.009] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2010] [Revised: 07/10/2010] [Accepted: 07/15/2010] [Indexed: 11/23/2022]
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Cooper NAM, Khan KS, Clark TJ. Local anaesthesia for pain control during outpatient hysteroscopy: systematic review and meta-analysis. BMJ 2010; 340:c1130. [PMID: 20332307 PMCID: PMC2844502 DOI: 10.1136/bmj.c1130] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To compare the effects of different types of local anaesthetic for pain control during outpatient hysteroscopy. DESIGN Systematic review and meta-analysis of randomised controlled trials. SETTING Outpatient hysteroscopy clinics. PARTICIPANTS Women undergoing diagnostic or operative hysteroscopy as outpatients-that is, without general anaesthesia. Study selection criteria Medline, Embase, CINAHL, the Cochrane library, and reference lists of relevant studies. Two reviewers independently selected trials. Data were abstracted on quality, characteristics, and results. RESULTS There were 20 trials (2851 participants). Data from 15 of these were meta-analysed in subgroups defined by type of intervention and study quality. Intracervical (standardised mean difference -0.36, 95% confidence interval -0.61 to -0.10, I(2)=0%) and paracervical (-1.28, -2.22 to -0.35, I(2)=97%) injections of local anaesthetic significantly reduced the pain in women undergoing hysteroscopy as outpatients, whereas transcervical (-0.11, -0.31 to 0.10, I(2)=27%) and topical application (-0.32, -0.97 to 0.33, I(2)= 90%) did not. Meta-regression showed that paracervical injection was superior to the other anaesthetic methods (P=0.04), a finding that was supported by the high quality subgroup of studies. Use of local anaesthetic did not have a significant effect on the incidence of vasovagal episodes (P=0.09). CONCLUSIONS Paracervical local anaesthetic injection is the best method of pain control for women undergoing hysteroscopy as outpatients.
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Affiliation(s)
- Natalie A M Cooper
- University of Birmingham, Birmingham Women's Hospital, Birmingham B15 2TG.
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Bosteels J, Weyers S, Puttemans P, Panayotidis C, Van Herendael B, Gomel V, Mol BWJ, Mathieu C, D'Hooghe T. The effectiveness of hysteroscopy in improving pregnancy rates in subfertile women without other gynaecological symptoms: a systematic review. Hum Reprod Update 2010; 16:1-11. [PMID: 19744944 DOI: 10.1093/humupd/dmp033] [Citation(s) in RCA: 119] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Although hysteroscopy is frequently used in the management of subfertile women, a systematic review of the evidence on this subject is lacking. METHODS We summarized and appraised the evidence for the benefit yielded by this procedure. Our systematic search was limited to randomized and controlled studies. The QUOROM and MOOSE guidelines were followed. Language restrictions were not applied. RESULTS We identified 30 relevant publications. Hysteroscopic removal of endometrial polyps with a mean diameter of 16 mm detected by ultrasound doubles the pregnancy rate when compared with diagnostic hysteroscopy and polyp biopsy in patients undergoing intrauterine insemination, starting 3 months after the surgical intervention [relative risk (RR) = 2.3; 95% confidence interval (CI): 1.6-3.2]. In patients with one fibroid structure smaller than 4 cm, there was a marginally significant benefit from myomectomy when compared with expectant management (RR = 1.9; 95% CI: 1.0-3.7). Hysteroscopic metroplasty for septate uterus resulted in fewer pregnancies in patients with subfertility when compared with those with recurrent pregnancy loss (RR = 0.7; 95% CI: 0.5-0.9). Randomized controlled studies on hysteroscopic treatment of intrauterine adhesions are lacking. Hysteroscopy in the cycle preceding a subsequent IVF attempt nearly doubles the pregnancy rate in patients with at least two failed IVF attempts compared with starting IVF immediately (RR = 1.7; 95% CI: 1.5-2.0). CONCLUSIONS Scarce evidence on the effectiveness of hysteroscopic surgery in subfertile women with polyps, fibroids, septate uterus or intrauterine adhesions indicates a potential benefit. More randomized controlled trials are needed before widespread use of hysteroscopic surgery in the general subfertile population can be justified.
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Affiliation(s)
- Jan Bosteels
- Department of Obstetrics and Gynaecology, Imeldahospital, Bonheiden, Belgium.
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Practical Tips for Office Hysteroscopy and Second-Generation “Global” Endometrial Ablation. J Minim Invasive Gynecol 2009; 16:384-99. [DOI: 10.1016/j.jmig.2009.04.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2009] [Revised: 03/23/2009] [Accepted: 04/03/2009] [Indexed: 11/19/2022]
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Sui L, Wan Q, Zheng RL, Chen M, Xie F, Diao WJ, Dong J, Song Y, Gao SJ. Transcervical incision of septa: 447 cases. Surg Endosc 2008; 23:2078-84. [DOI: 10.1007/s00464-008-0209-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2008] [Revised: 09/17/2008] [Accepted: 10/01/2008] [Indexed: 11/29/2022]
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Agostini A, Collette E, Provansal M, Estrade JP, Blanc B, Gamerre M. Bonne pratique et valeur diagnostique de l’hystéroscopie diagnostique et des prélèvement histologiques. ACTA ACUST UNITED AC 2008; 37 Suppl 8:S343-8. [DOI: 10.1016/s0368-2315(08)74774-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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