Use of diclofenac as an analgesic in outpatient hysteroscopy: a randomized, double-blind, placebo-controlled study

The Effect of Virtual Reality on the Reduction of Pain in Women with an Indication for Outpatient Diagnostic Hysteroscopy: A Randomized Controlled Trial

Background: The cognitive distraction caused by Virtual Reality (VR) seems to cause a decrease both in pain and its perception as in the time spent thinking about possible pain, among anxiety about hysteroscopy procedure. The main objective of this investigation was to evaluate the efficacy of virtual reality for pain relief during outpatient hysteroscopy. Method: A total of 83 patients underwent outpatient diagnostic hysteroscopy in a single-centre, open-label, randomized control trial. Overall, 180 women with medical indication for an outpatient diagnostic hysteroscopy were randomized. Ten were excluded due to the impossibility of entering the endometrial cavity caused by a cervical canal that was not permeable, and 15 did not tolerate the pain at the beginning and during the procedure, excluding themselves from the final model. Finally, 154 were analysed per protocol to use VR (n = 82, study group) or standard treatment (n = 72, control group) assessing the differences between both groups by reduction in pain using Visual Analogue Scale score (VAS: 0-10 cm) and clinical data (arterial pressure, heart rate, and oxygen saturation) at the end of hysteroscopy, at 15 and 30 min after hysteroscopy. Results: Women with VR outpatient diagnostic hysteroscopy experienced less pain at final (VAS score 2.451 vs. 3.972, standard mean difference (SMD) -1.521, 95% CI -2.601 to -0.440; p = 0.006), at 15 min (VAS 1.769 vs. 3.300, SMD -1.531, 95% CI -2.557 to -0.504; p = 0.004), and at 30 min (VAS 1.621 vs. 2.719, SMD -1.099, 95% CI -2.166 to -0.031; p = 0.044) after the ending of the hysteroscopy, compared with no VR. Conclusions: The use of VR during outpatient diagnostic hysteroscopy proved effective in the reduction of pain in this randomized control trial. It shows wide potential role in ambulatory gynaecologic procedures to avoid repeating tests, perform surgeries without anaesthesia, and the use of medication and its side effects.

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.

Pain relief for outpatient hysteroscopy

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.

The effect of music in gynaecological office procedures on pain, anxiety and satisfaction: a randomized controlled trial

Background

Pain can interfere with office procedures in gynaecology. The aim of this study is to measure the positive effect of music in gynaecological office procedures.

Methods

A randomized controlled trial was performed between October 2014 and January 2016. Women scheduled for an office hysteroscopy or colposcopy were eligible for randomization in the music group or control group. Stratification for hysteroscopy and colposcopy took place. The primary outcome is patients’ level of pain during the procedure measured by the visual analogue scale (VAS). Secondary outcomes include patients’ level of pain after the procedure, anxiety and satisfaction of patient and doctor.

Results

No positive effect of music on patients’ perception of pain during the procedure was measured, neither for the hysteroscopy group (57 mm vs. 52 mm) nor for the colposcopy group (32 mm vs. 32 mm). Secondary outcomes were also similar for both groups.

Conclusions

This study showed no positive effect of music on patients’ level of pain, anxiety or satisfaction of patient or doctor for office hysteroscopy and colposcopy. We believe a multimodal approach has to be used to decrease patient distress in terms of pain and anxiety, with or without music.

Trial registration

Dutch Trial Register, NTR4924

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.

Role of oral tramadol 50 mg in reducing pain associated with outpatient hysteroscopy: A randomised double-blind placebo-controlled trial

BACKGROUND

Several drugs have been used to reduce hysteroscopy-associated pain. Although the Royal College of Obstetricians and Gynaecologists has recommended against the use of opiates in outpatient hysteroscopy, we wished to investigate if opioids can be used if the appropriate opioid was given in the appropriate dose.

AIM

To study the effectiveness of tramadol 50 mg in reducing pain associated with outpatient hysteroscopy.

MATERIALS AND METHODS

A prospective randomised double-blind placebo-controlled trial conducted in the outpatient hysteroscopy clinic at Cairo University Hospital. Main outcome measures were the severity of pain during the procedure, immediately after the procedure and 30 minutes later assessed by a visual analogue scale (VAS). VAS of 0 indicates no pain and VAS of 10 indicates the worst possible pain.

RESULTS

A total of 140 women who had diagnostic outpatient hysteroscopy were randomised to receive oral tramadol 50 mg or placebo one h before performing outpatient hysteroscopy. There was no difference between the groups in the age, parity, duration of the procedures or indications of hysteroscopy. The median pain score was significantly lower in the tramadol group during the procedure (5 vs 6; P = 0.013), immediately after the procedure (3 vs 4; P < 0.036), and 30 minute later (1 vs 2; P = 0.034). Two women in the tramadol group reported nausea, but this was mild and did not warrant cancelling the procedure.

CONCLUSIONS

Oral administration of tramadol 50 mg before hysteroscopy reduces the pain evoked by the procedure and the drug was well tolerated by women.

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.

Pain relief for outpatient hysteroscopy

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. 

Single dose oral diclofenac for acute postoperative pain in adults

BACKGROUND

Diclofenac is a non-steroidal anti-inflammatory drug (NSAID), available as a potassium salt (immediate-release) or sodium salt (delayed-release). This review updates an earlier review published in The Cochrane Database of Systematic Reviews (Issue 2, 2004) on 'Single dose oral diclofenac for postoperative pain'.

OBJECTIVES

To assess single dose oral diclofenac for the treatment of acute postoperative pain.

SEARCH STRATEGY

Cochrane CENTRAL, MEDLINE, EMBASE, Biological Abstracts, the Oxford Pain Relief Database, and reference lists of articles were searched; last search December 2008.

SELECTION CRITERIA

Randomised, double-blind, placebo-controlled clinical trials of single dose, oral diclofenac (sodium or potassium) for acute postoperative pain in adults.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion and quality, and extracted data. The area under the pain relief versus time curve was used to derive the proportion of participants with at least 50% pain relief over 4 to 6 hours, using validated equations. Relative benefit (risk) and number needed to treat to benefit (NNT) were calculated. Information on adverse events, time to remedication, and participants needing additional analgesia was also collected.

MAIN RESULTS

Fifteen studies (eight additional studies) with 1512 participants more than doubled the information available at each dose. Overall 50% to 60% of participants experienced at least 50% pain relief over 4 to 6 hours at any dose with diclofenac, compared to 10 to 20% with placebo, giving NNTs of about 2.5 for doses of 25 mg to 100 mg (similar to earlier review); no dose response was demonstrated. At 50 mg and 100 mg, NNTs for diclofenac potassium (2.1 (1.8 to 2.4) and 1.9 (1.7 to 2.2)) were significantly lower (better) than for diclofenac sodium (6.7 (4.2 to 17) and 4.5 (3.2 to 7.7)). The median time to use of rescue medication was 2 hours for placebo, 4.3 hours for diclofenac 50 mg and 4.9 hours for diclofenac 100 mg. Adverse events were reported at a similar rate to placebo, with no serious events.

AUTHORS' CONCLUSIONS

Oral diclofenac is an effective single-dose treatment for moderate to severe postoperative pain. Significantly more participants experienced at least 50% pain relief over 4 to 6 hours with diclofenac potassium than with diclofenac sodium. There was no significant difference between diclofenac and placebo in the incidence of adverse events.

Ambulatory hysteroscopy: evidence-based guide to diagnosis and therapy

Healthcare providers are facing increasing demands for improvement in quality of life for patients. Improvements in service provision for women are being ensured by the introduction of minimally invasive technologies into all spheres of gynaecologic practice. Ambulatory hysteroscopy (direct endoscopic visualization of the endometrial cavity) is an extremely exciting and rapidly advancing field of gynaecologic practice. It advanced dramatically during the 1990s, shifting the focus in healthcare away from inpatient diagnosis and treatment. Hysteroscopy is used extensively in the evaluation of common gynaecological problems that were previously evaluated with blind and inaccurate techniques (e.g. premenopausal menstrual disorders, infertility and postmenopausal bleeding). It allows direct visualization of the uterine cavity and the opportunity for targeted biopsy, safe removal of endometrial polyps, and treatment of submucous fibroids, septa and adhesions. Ambulatory hysteroscopy is safe, with a low incidence of serious complications; it has a small failure rate. There is a general consensus that hysteroscopy is the current gold standard for evaluating intrauterine pathology, including submucous myomas, polyps, hyperplasia and cancer. Hysteroscopy in the ambulatory setting appears to have an accuracy and patient acceptability equivalent to inpatient hysteroscopy under general anaesthetic. The primary goal of this chapter is to provide a high-quality, evidence-based text on ambulatory diagnostic and operative hysteroscopy. The chapter includes in-depth analysis of the indications for outpatient hysteroscopy, its contraindications, the accuracy of diagnostic hysteroscopy, relevant risk management issues and, training and teaching.

The technique and overview of flexible hysteroscopy

Flexible hysteroscopy is a safe, successful, and reliable method of investigation for abnormal uterine bleeding. When compared with rigid hysteroscopy flexible hysteroscopy is associated with less pain both at introduction of the hysteroscope and during the procedure itself especially when the diameter of the scope is reduced. This article provides evidence of the benefits of flexible hysteroscopy to the health service provider, clinician, and patient. Flexible hysteroscopy is acceptable to most women when performed in the outpatient setting without analgesia and offers a suitable alternative to rigid hysteroscopy.

Pain control in outpatient hysteroscopy

Office hysteroscopy has become increasingly used as first line investigation for abnormal uterine bleeding and other diseases involving the uterine cavity. The main limitation to its widespread use is pain and low patient tolerance. This review examines current literature on analgesia used in outpatient hysteroscopy with the purpose of establishing guidelines on methods of pain relief for the procedure. However, the review has failed to find substantial or conclusive evidence for the routine use of local analgesia in outpatient hysteroscopy. Most literature suggests that it is a well-tolerated procedure and recommends analgesic use only in selected patients. Additional research is indicated for developing superior narrow diameter hysteroscopes and endometrial biopsy devices to improve the acceptability of office hysteroscopy.