Effectiveness of Vaginal Misoprostol and Rectal Nonsteroidal Anti-Inflammatory Drug in Vaginoscopic Diagnostic Outpatient Hysteroscopy in Primarily Infertile Women: Double-Blind, Randomized, Controlled Trial

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.

Pain management for in-office hysteroscopy. A practical decalogue for the operator

Hysteroscopy is known to be the gold standard for evaluation of intrauterine pathologies, pre-menopausal and post-menopausal abnormal uterine bleeding and, in addition to this, it is a crucial examination in the infertility work-up. In-office operative hysteroscopy incorporates the outstanding possibility of seeing and treating an intracavitary pathology in the same examination, eliminating all the risk related to anesthesia and reducing procedure-related costs. By now, performing operative procedures in the office setting is recognized as feasible and safe. Over the last 20 years, many efforts have been made to implement the in-office operative approach worldwide. However, for some women, in-office hysteroscopy is still considered a painful experience, with reported discomfort at different steps of the hysteroscopic procedures. Moreover, uneventful and tedious sensations might be increased by a high level of anxiety for such examination. For this reason, despite the feasibility of the in-office approach, many clinicians are still afraid of provoking pain during the procedure and rather not to perform surgical procedures in the office, postponing the removal of the pathology in the operating room. To date, there is no consensus concerning pain management for in-office hysteroscopy and different approaches, pharmacological and non-pharmacological aids, as well as several procedural tips and tricks are utilized. Our purpose is to provide a feasible practical decalogue for the operator, to supply adequate management of pain during in-office hysteroscopic procedures, performing challenging operations, shrinking discomfort, aiming to upgrade both women's and operator's satisfaction.

Pharmacological and non-pharmacological pain relief for office hysteroscopy: an up-to-date review

In-office hysteroscopy is considered the standard technique for visualization of the uterine cavity and the diagnosis of intrauterine pathologies. Moreover, nowadays, it is possible to treat a vast number of intracavitary diseases in the office, without the need for the inpatient setting. However, in some cases, pain might occur, and this is the most common reason for not completing the procedure. Over the last 20 years, many efforts have been carried out to miniaturize the instrumentation and to improve the techniques in order to avoid discomfort. Nonetheless, hysteroscopy still provokes distress for many patients. For this reason, pharmacological and non-pharmacological treatments for intraoperative and postoperative pain relief have been widely used for in-office hysteroscopy, with different results in various groups of women. The purpose of this review was to analyze the current literature on pharmacological aids (non-steroidal anti inflammatory drugs, cyclooxygenase-2 inhibitors, antispasmodics, local anesthetics, prostaglandins, opioids) and non-pharmacological interventions (transcutaneous electrical nerve stimulation, uterine stretching, uterine pressure, warming of distension medium, hypnosis, music, vocal-local) and to evaluate their impact on the relief from pain experienced during in-office hysteroscopy.

Evaluation and ranking of different interventions for pain relief during outpatient hysteroscopy: A systematic review and network meta-analysis

AIM

To identify the highest-ranked pharmacological and nonpharmacological interventions for pain relief during outpatient hysteroscopy.

METHODS

We conducted an online bibliographic search in different databases from inception till July 2019. We included randomized controlled trials assessing effect of pharmacological and nonpharmacological interventions on pain relief during outpatient hysteroscopy. Our main outcomes were pain scores at different endpoints of the procedure. We applied this network meta-analysis based on the frequentist approach using statistical package 'netmeta' (version 1.0-1) in R.

RESULTS

The review included 39 randomized controlled trials (Women n = 3964). Misoprostol plus intracervical block anesthesia (mean difference [MD] = -3.32, 95% confidence interval [CI] [-6.06, -0.59]), misoprostol (MD = -1.92, 95% CI [-3.04, -0.81]) and IV analgesia (MD = -2.01, 95% CI [-3.27, -0.25]) were effective in reducing pain during the procedure compared to placebo. Ranking probability showed that misoprostol plus intracervical block anesthesia was the highest ranked pharmacological treatment for pain relief during the procedure (P score = 0.92) followed by misoprostol alone (P score = 0.78), and IV analgesia (P score = 0.76). Regarding nonpharmacological treatments, transcutaneous electrical nerve stimulation (TENS) showed a significant pain reduction compared to placebo (MD = -1.80, 95% CI [-3.31, -0.29]). TENS ranked as the best nonpharmacological treatment (P score = 0.80) followed by CO₂ distention (P score = 0.65) and bladder distention (P score = 0.60).

CONCLUSION

Combination of misoprostol plus local anesthesia appears to be the most effective pharmacological approach for pain reduction during and after outpatient hysteroscopy. Nonpharmacological approaches as TENS and bladder distention showed considerable efficacy but should be further investigated.

Perioperative pain management strategies among women having reproductive surgeries

This review presents opioid-sparing strategies for perioperative pain management among women undergoing reproductive surgeries and procedures. Recommendations are provided regarding the use of nonsteroidal anti-inflammatory drugs, acetaminophen, other adjunctive medications, and regional anesthetic blocks. Additional considerations for chronic opioid users or patients using opioid replacement or antagonist therapy are discussed.

Comparison of nonsteroidal anti-inflammatory drugs and misoprostol for pain relief during and after hysterosalpingography: prospective, randomized, controlled trial

STUDY OBJECTIVE

To assess whether vaginal misoprostol or oral nonsteroidal anti-inflammatory drugs (NSAIDs) reduce pain during and 30 minutes after hysterosalpingography (HSG).

DESIGN

Randomized prospective, controlled, parallel-group study (Canadian Task Force classification I).

SETTING

University teaching hospital.

PATIENTS

One hundred sixty-eight women with primary infertility who underwent HSG for evaluation of infertility.

INTERVENTIONS

Patients were randomly assigned to 1 of 3 groups. Group 1 received 200 μg misoprostol vaginally 6 hours before HSG; group 2, 50 mg diclofenac potassium orally 45 to 60 minutes before HSG; and group 3, no medication. The primary outcome of the study was to evaluate the severity of pain during and 30 minutes after the procedure using a visual analog scale (VAS) ranging from 1 (very favorable) to 10 (very unfavorable). The secondary outcomes were to assess the rate of completion and the vasovagal effects including nausea, vomiting, sweating, weakness, syncope, hypotension, and bradycardia.

MEASUREMENTS AND MAIN RESULTS

There was no statistically significant difference in the median (25%-75%) VAS pain scores between women administered vaginal misoprostol (median, 6.7 cm; range, 4.7-9 cm) and the control group (median, 6.7 cm; range, 4.6-8.8 cm) during the HSG. However, women in the NSAID group (median, 5.5 cm; range, 3-7.6 cm) reported less pain than did those in the misoprostol group (p = .009) and the control group (p = .03). At 30 minutes after HSG, there was no significant difference in the median VAS pain scores between patients administered NSAIDs (median, 2.3 cm; range, 1.4-4.2) or misoprostol (median, 2.3 cm; range, 1.2-4.4) and the control group (median, 2.2 cm; range, 1.3-4.4).

CONCLUSIONS

There is no benefit in terms of pain reduction with the use of misoprostol during HSG or at 30 minutes after the procedure. However, NSAIDs are associated with pain relief during the HSG procedure.