Factors affecting pain experienced during office hysteroscopy

Ambulatory Hysteroscopy: Evaluating Pain and Determining Factors

Study objective

To measure pain using a visual analogue scale (VAS) and analyse its relationships with variables such as menopausal status, parity, uterine and cervical pathology, procedure length, and anxiety in patients undergoing ambulatory hysteroscopy (AH).

Design

Prospective observational study.

Setting

Dr DY Patil Medical Hospital and Research Centre, Dr.D.Y. Patil Vidyapeeth, Pimpri, Pune.

Patients

Seventy-five women.

Intervention

Ambulatory hysteroscopy(AH).

Methodology

AH was performed in seventy-five patients using vaginoscopic approach. At the end of the procedure, the intensity of pain was assessed using the visual analogue scale (VAS), from the score of 0 (no pain) to 10 (intolerable pain). The factors determining pain were assessed.

Results

Patients who underwent AH reported mild pain in 66% of cases, moderate pain in 22%, and severe pain in 12% of cases. The most frequent reason for referral was abnormal uterine bleeding (AUB).In the moderate pain group, the bivariate analysis was statistically significant for menopausal status (P values < 0.001), cervical pathology (< 0.001), and duration of procedure (0.001) and in multivariate analysis nulliparity (0.001) and menopausal status (0.001) were the significant determining factors.In severe pain group, the bivariate analysis was statistically significant for cervical pathology (P value = 0.001) and in multivariate analysis cervical pathology (0.003) and uterine pathology (0.002) were the significant determining factors.

Conclusion

Hysteroscopy is a safe, painless and a gold standard procedure. Pain experienced during AH was significantly influenced by cervical pathology. Gynaecologists in practise should receive training and start using AH to assess the endometrial cavity.

Diagnostic office hysteroscopy; why is it still painful procedure despite the surgical experience and mini-hysteroscope?

AIM

To evaluate the effect of cervical canal features on pain during outpatient hysteroscopy performed by experienced surgeons using mini-hysteroscope.

METHODS

A prospective observational study was conducted on 303 women undergoing diagnostic hysteroscopy without anesthesia. Pain intensity was evaluated using the visual analog scale (VAS) when the cervical canal was passed. The patients were divided into two groups according to the VAS score: painless or mild pain (VAS <4) and moderate or severe pain (VAS ≥ 4). The relationship between cervical canal characteristics (length, version, and flexion positions, history of cervical intervention, stenosis, synechiae), obstetric and gynecological history, preoperative anxiety level, procedure duration, and pain intensity was examined.

RESULTS

Moderate pain (4 ≤ VAS < 7) was observed in 38% of patients (n = 117) and 14 patients (5%) experienced severe pain (VAS ≥ 7). In multivariate analysis, nulliparity (p = 0.01; OR, 4.6; 95% CI, 1.7-13.2), postmenopausal state (p = 0.02; OR, 2.2; 95% CI, 1.2-4.3), excessive flexion of the cervix and retroverted uterus (p <0.001; OR, 4.1; 95% CI, 2.0-8.5) were identified as risk factors for a painful procedure. Diagnostic hysteroscopy was successful in 98% of the patients. The pain was the primary cause of the failed hysteroscopy.

CONCLUSION

In addition to nulliparity and postmenopausal status, unfavorable features of the cervical canal, such as the excessive flexion position of the cervix and uterine retroversion are significant causes of pain during outpatient hysteroscopy.

Addition of Lidocaine to the Distension Medium in Hysteroscopy Decreases Pain during the Procedure-A Randomized Double-blind, Placebo-controlled Trial

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.

What should the optimal intrauterine pressure be during outpatient diagnostic hysteroscopy? A randomized comparative study

AIM

The aim of this study was to evaluate and compare lower and higher uterine filling pressures during outpatient diagnostic hysteroscopy.

METHODS

One hundred and seventy-five women eligible for outpatient diagnostic hysteroscopy were included in this randomized double blind comparative study. The subjects were randomized into two groups. Group 1 (n = 80) underwent surgery with lower intrauterine filling pressures (30, 40, and 50 mmHg) and group 2 (n = 81) underwent surgery with higher filling pressures (70, 80, and 100 mmHg). The primary outcome measure was adequate visibility during the procedure. The secondary outcome measure was pain perceived by the patient during and 30 min after the procedure.

RESULTS

In total, 161 patients completed the trial. Group 2 had significantly higher adequate visibility than group 1 (71/80, 88.75% in group 1 and 79/81, 97.5% in group 2, P = 0.008). There was a trend toward increase in pain scores with higher pressures during the procedure. However, there were no significant differences between the two groups in terms of visual analog scale pain scores measured 30 min after the procedure.

CONCLUSION

Lower uterine filling pressure was associated with lower pain scores with a higher trend towards inadequate visibility. It appears that higher filling pressure can be used for performing office hysteroscopy, but it is associated with higher pain scores.