Transcervical intrauterine topical local anesthetic at hysterosalpingography: a prospective, randomized, double-blind, placebo-controlled trial

EMLA (lidocaine-prilocaine) cream for pain relief during hysterosalpingography: a systematic review and meta-analysis of randomised placebo-controlled trials

We systematically investigated the efficacy and safety of EMLA (5% lidocaine-prilocaine cream) versus placebo for pain relief among infertile patients undergoing hysterosalpingography (HSG). We screened four databases from inception until 25 November 2020. We included only randomised placebo-controlled trials (RCTs) and assessed their risk of bias. The main efficacy outcomes included safety and pain scores during the different stages of HSG. The pooled outcomes were summarised as mean difference (MD) with 95% confidence interval (CI). Three RCTs were included, comprising 258 patients (131 and 127 patients received EMLA and placebo, respectively). All RCTs revealed an overall low risk of bias. EMLA significantly reduced pain perception during cervical instrumentation of tenaculum and cannula (MD = -1.53, 95% CI [-2.59, -0.47], p = 0.005) and at 24 h after completion of HSG (MD = -1.30, 95% CI [-2.57, -0.03], p = 0.04). Despite EMLA decreased pain perception during the other procedural stages of HSG, the differences were not statistically significant compared with placebo. EMLA was safe and free of local and systemic adverse reactions. This meta-analysis advocates that topical application of 5% EMLA cream is safe and correlates with decreased pain perception during HSG, particularly during the cervical instrumentation step and at 24 h after HSG completion.

The effect of virtual reality on women's perceived pain, fear, anxiety, and views about the procedure during hysterosalpingography: A randomized controlled trial

BACKGROUND

Hysterosalpingography is a stressful procedure that causes pain and anxiety. Therefore, measures must be taken to reduce or eliminate the pain and anxiety associated with it.

OBJECTIVES

This paper investigated the effect of virtual reality (VR) during hysterosalpingography on pain, anxiety, fear, physiological parameters, and satisfaction.

METHODS

A randomized controlled trial design was used. Patients were randomized into two groups (VR group = 31, control group = 31). The study was conducted between April 26 and June 30, 2022. Anxiety was evaluated using the State Anxiety Inventory. Pain, fear, and satisfaction were evaluated using the Visual Analogue Scale (VAS). Temperature, pulse, blood pressure, and oxygen saturation were followed up.

RESULTS

There was a significant difference in the mean VAS scores during and 15 min after hysterosalpingography between the VR and control groups. There was no significant difference in the mean SAI scores between the groups. The VR group participants were significantly more satisfied with hysterosalpingography than the control group. There was no significant difference in physiological parameters just before, immediately after, and 15 min after hysterosalpingography between the groups.

CONCLUSION

Virtual reality helps patients experience less pain and fear and makes them more satisfied with hysterosalpingography. However, it does not affect their anxiety and vital signs. Patients are highly satisfied with VR technology.

Assisted Reproductive Technology Outcomes in Women With Heart Disease

Background

Women with infertility and heart disease (HD) are increasingly seeking assisted reproductive technology (ART). There is only one other study that examines the safety profile of ART in this population. This study aims to evaluate the cardiac, reproductive, and obstetric outcomes of ART in women with HD.

Methods

We conducted a retrospective case-control study of women with underlying congenital or acquired HD who underwent ART at a single University fertility center from 1/2010-3/2019. Women undergoing in-vitro fertilization (IVF), oocyte cryopreservation (OC) or embryo banking (EB) with HD were included. Cases were matched 3:1 with age-, cycle type- and cycle start date- matched controls without HD. Outcomes included cardiovascular (CV), reproductive, and obstetric complications during or following ART.

Results

Twenty women with HD were included. 15 (75%) had congenital HD, 1 (5%) had valvular disease, 1 (5%) had acquired cardiomyopathy, and 3 (15%) had arrhythmias. 90% were New York Heart Association class I. 55% of HD cases were modified WHO (mWHO) risk classification 1-2, 40% were mWHO 2-3 or 3, 5% were mWHO 4. Cases underwent 25 IVF, 5 OC, and 5 EB cycles and were compared with 79 controls who underwent 174 cycles. No CV complications or deaths occurred amongst cases following ART or pregnancy. There was no difference in risk of ART or obstetric outcomes amongst cases versus controls.

Conclusion

For women with HD in this small, low -risk cohort, ART posed few risks that were similar in frequency to healthy controls.

The efficacy of oral naproxen and cervical lidocaine spray on perceived pain during hysterosalpingography

Objective

This study was carried out to evaluate the efficacy of the combined use of oral naproxen and cervical lidocaine spray during hysterosalpingography (HSG) compared to the use of oral naproxen or cervical lidocaine spray alone. Materials and Methods: This prospective randomised controlled study was carried out using a total of 240 patients who were randomly assigned to four groups. Group 1 received cervical lidocaine spray only, Group 2 received oral naproxen only, Group 3 received cervical lidocaine spray and naproxen tablet, whereas Group 4 was the control group. A visual analogue scale was used for subjective pain assessment at three pre-defined steps.

Results

The mean pain scores of the patients in each of the four groups are Group 1 (3.6 ± 2.0, 5.1 ± 1.8, 5.8 ± 2.2); Group 2 (2.7 ± 1.4, 3.6 ± 2.0 and 3.9 ± 1.9); Group 3 (2.8 ± 1.5, 3.4 ± 2.0 and 4.2 ± 2.3); Group 4 (4.7 ± 1.7, 5.9 ± 1.7 and 5.3 ± 1.7) at T1, T2 and T3, respectively. Pain perception was statistically significantly reduced by naproxen and combined naproxen plus lidocaine spray at all the stages of HSG while cervical lidocaine spray had a statistically significant reduction in pain perception only during cervical instrumentation.

Conclusion

Oral naproxen and combined naproxen plus cervical lidocaine spray were effective in reducing HSG-associated pain during all the stages of HSG. However, combined oral naproxen and lidocaine spray did not show superior efficacy over oral naproxen alone. Cervical lidocaine spray was not an effective method.

Immersive virtual reality as analgesia for women during hysterosalpingography: study protocol for a randomized controlled trial

BACKGROUND

Hysterosalpingography (HSG) is an accepted radiologic diagnostic modality for initial infertility workup, and is generally considered uncomfortable and painful. However, the management of pain related to HSG remains inefficient. As an emerging nonpharmacologic and noninvasive pain control strategy, virtual reality (VR) distraction has been successfully used in areas such as burns, blunt force trauma, hospital-based needle procedures, dental/periodontal procedures, and urological endoscopy patients. This study aims to evaluate the analgesic effect of VR during HSG.

METHODS/DESIGN

A single-center, parallel-group, randomized controlled trial will be carried out in the Radiology Department of Yinchuan Women and Children Healthcare Hospital, Yinchuan. A total of 200 participants who are scheduled for HSG will be enrolled in this study. The participants will be randomized (1:1) into two groups: a VR group and a blank control group. The VR group will receive routine care plus immersive VR intervention and the blank control group will receive routine care. Outcomes will be monitored at baseline, immediately after HSG and 15 min after HSG for each group. The primary outcome is the worst pain score during HSG by a visual analog scale (VAS). The secondary outcomes include: affective pain, cognitive pain, and anxiety during the HSG procedure; worst pain within 15 min after HSG; patient satisfaction and acceptance with pain management; physiological parameters; adverse effects; HSG results; and immersion perception score of the VR system (for the VR condition only).

DISCUSSION

This study will focus on exploring a simply operated, noninvasive and low-cost analgesia during the HSG procedure. The results of this trial will provide data on the feasibility and safety of VR distraction therapy during HSG.

TRIAL REGISTRATION

Chinese Clinical Trial Register, ChiCTR1900021342. Registered on 16 February 2019.

Comparison of midazolam and dexmedetomidine for pain relief during and after hysterosalpingography in women with infertility

Patients feel uncomfortable with cervical manipulation, uterine distension and stimulation of peritoneum during hysterosalpingography (HSG) and experience lower abdominal pain during and after the procedure. Pain during the procedure has a negative effect on the adaptation of patients to treatment and physicians are trying to overcome this unpleasant situation. Therefore, the aim of this study was to compare the effect of midazolam and dexmedetomidine on reducing pain and spasm of fallopian tubes during and after HSG procedure in women with infertility. In a double-blind randomized controlled trial, 102 patients were randomly divided into two groups, midazolam and dexmedetomidine. The pain was recorded during injection and immediately after injection and 30 minutes after HSG, and then the complications of injection were recorded. Finally, the data were analyzed using SPSS version 20. Based on the results presented herein, no significant difference was found between the two groups in terms of vasovagal reaction, spasticity of the tube and the side of the spastic tube and uterine cavity anomalies (p <0.05). However, the pain showed a significant difference between the two groups during the injection, immediately or at 30 minutes after the procedure (p = 0.0001). The pain in the midazolam group was less than that of dexmedetomidine. Furthermore, there was no significant difference between the two groups regarding spasticity (p <0.05). There is a benefit in terms of pain reduction with the use of dexmedetomidine when comparing with midazolam injection. However, dexmedetomidine does not cause side effects in patients and can be used to reduce pain during injection.

Intrauterine lidocaine and naproxen for analgesia during intrauterine device insertion: randomized controlled trial

Background

This study evaluates oral naproxen and intrauterine instillation of lidocaine for analgesia with intrauterine device (IUD) placement as compared to placebo.

Methods

This was a randomized, double-blind, placebo-controlled trial. Patients desiring levonorgestrel 52 mg IUD or Copper T380A IUD were randomized into treatment groups. Patients received either oral naproxen 375 mg or placebo approximately 1 h prior to procedure in conjunction with 5 mL of 2% lidocaine or 5 mL of intrauterine saline. The primary outcome was pain with IUD insertion measured on a visual analog scale immediately following the procedure. Prespecified secondary outcomes included physician pain assessment, post procedure analgesia, satisfaction with procedure, satisfaction with IUD, and pain assessment related to IUD type.

Results

From June 4, 2014 to October 28, 2016 a total of 160 women desiring Copper T380A or levonorgestrel 52 mg intrauterine device insertion and meeting study criteria were enrolled and randomized in the study. Of these, 157 (78 in the Copper T380A arm, 79 in the levonorgestrel 52 mg) received study treatment medication. There were 39 in naproxen/lidocaine arm, 39 in placebo/lidocaine arm, 40 in naproxen/placebo arm, and 39 in placebo/placebo arm. There were no differences in the mean pain scores for IUD placement between treatment groups (naproxen/lidocaine 3.38 ± 2.49; lidocaine only 2.87 ± 2.13; naproxen only 3.09 ± 2.18; placebo 3.62 ± 2.45). There was no difference in self-medication post procedure or in satisfaction with the procedure and IUD among women in the treatment arms or by type of IUD.

Conclusion

Naproxen with or without intrauterine lidocaine does not reduce pain with IUD placement.

Clinical trial registration

Clinicaltrials.gov, NCT02769247. Registered May 11, 2016, Retrospectively registered.

The optimal analgesic method in saline infusion sonogram: A comparison of two effective techniques with placebo

Objective:

Operations performed with local anesthesia can sometimes be extremely painful and uncomfortable for patients. Our aim was to investigate the optimal analgesic method in saline infusion sonograms.

Materials and Methods:

This study was performed in our Clinic of Obstetrics and Gynecology between March and August 2011. Ninety-six patients were included. Patients were randomly divided into groups that received saline (controls, group 1), paracervical block (group 2), or paracervical block + intrauterine lidocaine (group 3). In all groups, a visual analogue scale score was performed during the tenaculum placement, while saline was administered, and 30 minutes after the procedure.

Results:

When all the patients were evaluated, the difference in the visual analogue scale scores in premenopausal patients during tenaculum placement, during the saline infusion into the cavity, and 30 minutes following the saline infusion sonography were statistically different between the saline and paracervical block groups, and between the saline and paracervical block + intrauterine lidocaine group. However, there was no statistically significant difference between paracervical block and paracervical block + intrauterine lidocaine groups.

Conclusion:

As a result of our study, paracervical block is a safe method to use in premenopausal patients to prevent pain during saline infusion sonography. The addition of intrauterine lidocaine to the paracervical block does not increase the analgesic effect; moreover, it increases the cost and time that the patient stays in the dorsolithotomy position by 3 minutes.

Effectiveness of interventions for pain relief in hysterosalpingographyAnetwork meta-analysis and systematic review

Objective:

We aimed to evaluate the effectiveness of placebo, oral opioid analgesic (OOA), intravenous opioid analgesic (IOA), non-opioid analgesic (NOA), topical anesthetic (TA) and locally injected anesthetic (LIA) for pain relief duringhysterosalpingography (HSG) using a Bayesian network meta-analysis of data from randomized controlled trials.

Methods:

PUBMED, EMBASE, and CENTRAL search engines were used to search and identify clinical trials that evaluated interventions for pain relief in HSG. Methodological studies quality was assessed by the Cochrane Collaboration tool for assessing risk of bias.

Result:

Sixteen trials involving 1263 participants were included in this study. IOA got excess but not statistically significant lower visual analogue score (VAS) pain score during HSG or more than 30 minutes after HSG compared with the other groups. OOA resulted in excess but not statistically significant higher VAS pain score during HSG compared with the other groups except placebo group. According to SUCRA regarding the lower VAS pain score during HSG, the treatments rank was the following: IOA, TA, NOA, LIA, OOA and placebo; as regard lower VAS pain score at 30 minutes or more after HSG, the treatments rank was the following: IOA, LIA, OOA, TA, NOA and placebo.

Conclusion:

This new Bayesian data network meta-analysis from randomized controlled trials demonstrated that IOA resulted in the highest probability to reduce the pain during HSG or at 30 minutes or more after HSG among the six interventions considered.

Managing subfertility in patients with heart disease: What are the choices?

More women with heart disease are reaching reproductive age and will want to embark upon pregnancy. Furthermore, many of these women are delaying pregnancy until later in life when they may be exposed to a greater number of complications from their heart disease. A relatively high proportion of these women will pursue fertility treatment to achieve a pregnancy; consequently, the management of subfertile couples where the woman (or man) has heart disease is of growing importance. In this review, we discuss how fertility investigations and treatment can impact a women with heart disease and how some of the potential complications can be minimized or avoided. We also consider surrogacy, which is an important option when pregnancy is contraindicated.

Information seeking and perceptions of anxiety and pain among women undergoing hysterosalpingography

OBJECTIVE

Hysterosalpingography (HSG) is an accepted diagnostic tool for infertility workup and is considered an invasive procedure that is generally regarded as uncomfortable and painful, though research on psychological consequences is scarce and outdated. The study objective was to investigate women's experience of HSG in terms of fear, anxiety and pain, as compared to colposcopy.

STUDY DESIGN

This cross sectional questionnaire study was conducted at two public women's health clinics in Israel between January 2013 and March 2014. 137 women were included in the study. 42 consecutively sampled women referred for outpatient HSG and 95 consecutively sampled women referred for outpatient diagnostic colposcopy. The main outcome measures were: state-trait anxiety, information seeking behavior, fear of pain, fear of the results, retrospective pain.

RESULTS

Compared to those undergoing colposcopy, women undergoing HSG expressed significantly higher anxiety prior to the procedure, feared the pain involved more, and rated the procedure as more painful retrospectively. HSG patients tended to report a higher degree of information seeking. Information seeking was correlated with higher anxiety among HSG but not colposcopy patients.

CONCLUSION(S)

HSG is a highly stressful procedure associated with fear, anxiety, pain and information seeking. Research is needed to find possible ways of ameliorating these emotions and behaviors as they may have negative impact on patient cooperation.

Comparison of lidocaine spray and paracervical block application for pain relief during first-trimester surgical abortion: A randomised, double-blind, placebo-controlled trial

Surgical abortion is one of the most frequently performed gynaecological procedures and its associated pain has always been a problem in gynaecology. Here we studied the analgesic efficacy of lidocaine spray and paracervical block (PCB) in patients undergoing first-trimester surgical abortion. A randomised double-blind placebo-controlled study was conducted on 108 women requesting pregnancy termination. The subjects were randomly assigned into four groups: Group 1 (PCB plus lidocaine spray) (n=27), Group 2 (PCB) (n=27), Group 3 (lidocaine spray) (n=27) and Group 4 (placebo) (n=27). Intra-procedural and post-procedural pain scores were measured with a standard visual analogue scale (VAS). The median VAS scores during procedure in placebo, lidocaine spray, PCB plus lidocaine spray and PCB groups were 8 (7-9), 5 (4-8), 4 (3-4) and 5 (3-5), respectively. The most effective method of pain relief during first-trimester abortion can be achieved through a combined use of PCB plus lidocaine spray. Therefore, lidocaine spray is a non-invasive complementary anaesthetic method versus traditional PCB for first-trimester surgical abortion.

Comparison of four different pain relief methods during hysterosalpingography: a randomized controlled study

BACKGROUND

Hysterosalpingography (HSG) is the most commonly used method for evaluating the anatomy and patency of the uterine cavity and fallopian tubes, and is an important tool in the evaluation of infertility. The most frequent side effect is the pain associated with the procedure.

OBJECTIVES

To evaluate four analgesic methods to determine the most useful method for reducing discomfort associated with HSG.

METHODS

In the present prospective study, 75 patients undergoing HSG for evaluation of infertility were randomly assigned to four groups: 550 mg of a nonsteroidal anti-inflammatory drug (NSAID) (group 1); 550 mg NSAID + paracervical block (group 2); 550 mg NSAID + paracervical analgesic cream (group 3); or 550 mg NSAID + intrauterine analgesic instillation (group 4). A visual analogue scale was used to assess the pain perception at five predefined steps.

RESULTS

Instillation of the liquids used for HSG was found to be the most painful step of HSG, and this step was where the only significant difference among groups was observed. When comparing visual analogue scale scores, group 2 and group 3 reported significantly less pain than the other groups. Group 1 reported significantly higher mean (± SD) scores (7.2 ± 1.6) compared with groups 2 and 3 (4.7 ± 2.5 and 3.8 ± 2.4, respectively) (P<0.001). In addition, group 2 reported significantly less pain than group 4 (4. 7 ± 2.5 versus 6.7 ± 1.8, respectively) (P<0.02).

CONCLUSIONS

For effective pain relief during HSG, in addition to 550 mg NSAID, local application of lidocaine cream to the posterior fornix of the cervix uteri and paracervical lidocaine injection into the cervix uteri appear to be the most effective methods.

Randomized, controlled, double-blind trial of topical lidocaine gel and intrauterine lidocaine infusion for pain relief during saline contrast sonohysterography

OBJECTIVES

To evaluate the efficacy of topical lidocaine gel and intrauterine lidocaine infusion administered prior to saline contrast sonohysterography (SCSH) in reducing pain level during the procedure.

METHODS

This was a randomized, double-blind, placebo controlled trial. We recruited 120 women scheduled to undergo SCSH and randomized them into one of three groups according to administration of gel and intrauterine infusion immediately prior to the procedure: (1) the 'lidocaine gel' group received 3 mL 2% lidocaine gel applied to the cervix and intrauterine infusion, using an infant feeding tube without balloon, of 5 mL normal saline; (2) the 'lidocaine infusion' group received 3 mL gel lubricant applied to the cervix and intrauterine infusion of 5 mL 2% lidocaine; (3) the placebo group received 3 mL gel lubricant applied to the cervix and intrauterine infusion of 5 mL normal saline. The tube was left in place for the SCSH procedure. The primary outcome measure was the overall pain level (on a scale of 0-100) reported by the women during the SCSH procedure. Women also rated their pain levels at various other time points and an observer assessed visible signs of the women's discomfort during the procedure, producing a distress score.

RESULTS

There were no significant differences among the three groups in baseline characteristics, volume of saline solution infused, tenaculum use and duration and difficulty level of the SCSH procedure. The median (range) pain scores during normal saline infusion for the SCSH procedure were 0 (0-65) in the placebo group, 2.5 (0-80) in the lidocaine gel group, and 0 (0-70) in the lidocaine infusion group. The pain scores at other time points, the overall pain score and the distress score were also comparable for the three groups. No significant adverse events were reported.

CONCLUSIONS

SCSH performed with an infant feeding tube without balloon is associated with very low pain levels. Topical lidocaine gel application and intrauterine lidocaine infusion do not further reduce pain levels during SCSH.

Pain relief in hysterosalpingography

BACKGROUND

Hysterosalpingography (HSG) is a method of testing for tubal patency. However, women struggle to tolerate the procedure, as it is associated with some discomfort. Various pharmacological strategies are available that may reduce pain during the procedure, though there is no consensus as to the best method.

OBJECTIVES

To compare the effectiveness of different types of pharmacological interventions for pain relief in women undergoing HSG for investigation of subfertility.

SEARCH METHODS

This review has drawn on the search strategy developed for the Cochrane Menstrual Disorders and Subfertility Group (MDSG). We searched the following databases to 15 April 2015: MDSG Specialised Register, CENTRAL, MEDLINE, EMBASE, CINAHL and PsycINFO.

SELECTION CRITERIA

All identified randomised controlled trials investigating pharmacological interventions for pain relief during HSG were investigated for selection.

DATA COLLECTION AND ANALYSIS

Four review authors independently extracted data. We combined data to calculate mean differences (MDs) with 95% confidence intervals (CIs). Statistical heterogeneity was assessed using the I² statistic. We assessed the overall quality of the evidence for the main comparisons using GRADE methods.

MAIN RESULTS

The search identified 23 trials (1272 women) that were eligible for inclusion into the study. Oral opioid analgesia versus placebo/no treatmentThere was no evidence of effect for oral opioid analgesia in reducing pain during the procedure (MD -0.91, 95% CI -1.88 to 0.06, 1 study, n = 128, low quality evidence) or more than 30 minutes after the procedure (MD -0.99, 95% CI -1.75 to -0.23, 1 study, n = 128, moderate quality evidence)No studies reported on the effect of oral opioid analgesia, when taken prior to the procedure, in reducing pain within 30 minutes after the procedureThere was insufficient evidence to reach conclusions regarding adverse effects. Intravenous opioid analgesia versus placebo/no treatmentThere was evidence that intravenous opioids may improve pain relief during the procedure compared to no treatment (MD -3.53, 95% CI -4.29 to -2.77, 1 study, n = 62, moderate quality evidence)No studies reported on the effect of intravenous opioid analgesia, when taken prior to the procedure, in reducing pain within 30 minutes and more than 30 minutes after the procedureIn terms of adverse effects, one trial reported 1/32 participants had apnoea with intravenous remifentanil. Recovery time was nearly 4 minutes longer in the remifentanil group compared to the control. Oral non-opioid analgesia versus placebo/no treatmentThere was no evidence of effect for oral non-opioid analgesia in reducing pain during the procedure (MD -0.13, 95% CI -0.48 to 0.23, 3 studies, n = 133, I² = 61%, low quality evidence), less than 30 minutes after the procedure (MD -0.30, 95% CI -1.03 to 0.43, 2 studies, n = 45, I² = 97%, very low quality evidence), or more than 30 minutes after the procedure (MD -0.36, 95% CI -1.06 to 0.34, 3 studies, n = 133, I² = 58%, low quality evidence).There was insufficient evidence to reach conclusions regarding adverse effects. Topical anaesthesia versus placebo/no treatmentThere was evidence that topical anaesthetics may reduce pain during the procedure (MD -0.63, 95% CI -1.06 to -0.19, 9 studies, n = 613, I² = 66%, low quality evidence).There was no evidence of effect for topical anaesthesia, when applied prior to the procedure, in reducing pain less than 30 minutes after the procedure (MD 0.42, 95% CI -0.03 to 0.86, 5 studies, n = 373, I² = 59%, very low quality evidence).There was evidence of effect for topical anaesthesia, when applied prior to the procedure, in reducing pain more than 30 minutes after the procedure (MD -1.38, 95% CI -3.44 to -0.68, 2 studies, n = 166, I² = 92%, very low quality evidence).There was insufficient evidence to reach conclusions regarding adverse effects. Locally injected anaesthesia versus placebo/no treatmentThere was evidence of effect that locally injected anaesthetic can reduce pain during the procedure (MD -1.31, 95% CI -1.55 to -1.07, 2 studies, n = 125, I² = 0%, very low quality evidence).There was no evidence of effect for locally injected anaesthesia, when applied prior to the procedure, in reducing pain less than 30 minutes after the procedure (MD -1.31, 95% CI -2.14 to -0.49, 2 studies, n = 125, I² = 46%, low quality evidence).No studies were included into the analysis of the effect of locally injected anaesthesia, when injected prior to the procedure, in reducing pain more than 30 minutes after the procedure.There was insufficient evidence to reach conclusions regarding adverse effects. Any analgesic versus any other analgesicThere was no evidence of a difference between the groups when oral non-opioid analgesia was compared to opioid analgesia for pain relief during the procedure (MD 1.10, 95% CI -0.26 to 2.46, 1 study, n = 91, low quality evidence); less than 30 minutes following the procedure (MD -0.30, 95% CI -1.00 to 0.40, 1 study, n = 91, low quality evidence); and more than 30 minutes following the procedure (MD -0.60, 95% CI -1.56 to 0.36, 1 study, n = 91, low quality evidence). Topical anaesthetics were found to be more effective than paracervical block for pain relief during HSG (MD -2.73, 95% CI -3.86 to -1.60, 1 study, n = 20, moderate quality evidence). This benefit did not extend to within 30 minutes following HSG (MD -1.03, 95% CI -2.52 to 0.46, 1 study, n = 20, low quality evidence); or 30 minutes or more after HSG (MD 0.31, 95% CI -0.87 to 1.49, 1 study, n = 20, low quality evidence).There was insufficient evidence to reach conclusions regarding adverse effects.

AUTHORS' CONCLUSIONS

Topical anaesthetic applied before the procedure may be associated with effective pain relief during HSG, though the quality of this evidence is low. Intravenous opioids may also be effective in pain relief, though this must be weighed against their side effects and their effects on the recovery time. There is insufficient evidence to draw conclusions on the efficacy of other analgesics for HSG, or to reach any other conclusions regarding adverse effects.

Intrauterine lidocaine for pain control during laminaria insertion: a randomized controlled trial

OBJECTIVE

To determine if intrauterine administration of 5 cc of 2% lidocaine in addition to paracervical block reduces pain during laminaria insertion, when compared with paracervical block and saline placebo.

STUDY DESIGN

This was a randomized, double blind placebo-controlled trial. Women presenting for abortion by dilation and evacuation (D&E) at 14-24 weeks gestational age were randomized to receive an intrauterine instillation of either 5 mL of 2% lidocaine or 5 mL of normal saline, in addition to standard paracervical block with 20 cc of 0.25% bupivacaine. Our primary outcome was self-reported pain scores on a 100mm Visual Analogue Scale (VAS) immediately following laminaria insertion. Secondary outcome was self-reported VAS pain score indicating the maximum level of pain experienced during the 24-48-h interval between laminaria insertion and D&E procedure.

RESULTS

Seventy-two women were enrolled, and data for 67 women were analyzed, only two of whom were more than 21 weeks on gestation. The range of pain scores at both time points was large (1-90 mm at laminaria insertion; 0-100mm in laminaria-D&E interval). Mean pain scores were not different between treatment groups at laminaria insertion, (33 vs. 32, p=.8) or in the laminaria - D&E interval (43 vs. 44, p=.9).

CONCLUSION

Intrauterine administration of 5 cc of 2% lidocaine in addition to paracervical block did not reduce pain with laminaria insertion when compared to paracervical block with saline placebo.

IMPLICATIONS

Intrauterine lidocaine combined with paracervical block does not improve pain control at laminaria insertion when compared with paracervical block and saline placebo. Wide variation in pain scores and persistent pain after laminaria insertion suggests patient would benefit from more effective methods of pain control at laminaria insertion and during the post-laminaria interval.

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.

Randomized controlled trial of benzocaine versus placebo spray for pain relief at hysterosalpingogram

Many women experience pain during hysterosalpingogram (HSG). This prospective, randomized, double-blinded, placebo-controlled study assessed whether the use of benzocaine spray during HSG is associated with reduced pain as compared with placebo. Thirty women presenting for HSG were enrolled and randomized to either benzocaine or saline spray. Treatment groups were similar in age, race, parity, pre-procedure oral analgesic use and history of dysmenorrhoea and/or chronic pelvic pain. Median change in pain score from baseline to procedure was 50.6mm (-7.4 to 98.8mm) in the benzocaine group and 70.4mm (19.8 to 100mm) in the placebo group. There was no difference between groups after adjusting for history of dysmenorrhoea. There was no difference in resolution of pain in benzocaine versus placebo groups at 5 min post procedure--median pain score difference -11.1 (-90.1 to 18.5) versus -37.0 (-100 to 1.2)--or at 30 min post procedure. Satisfaction scores did not differ by treatment and did not correlate with pain score during the procedure (rho=0.005). The use of benzocaine spray does not significantly improve pain relief during HSG nor does it hasten resolution of pain post HSG. Of interest, patient satisfaction was not correlated with pain. Many women experience pain during hysterosalpingogram (HSG), which is a test used to evaluate the uterine cavity and fallopian tube. We conducted a prospective, randomized, double-blinded, placebo-controlled study to assess whether the use of benzocaine spray during HSG is associated with reduced pain as compared with placebo. Thirty women presenting for HSG were enrolled and randomized to either benzocaine or saline spray. Treatment groups were similar in age, race, previous pregnancies, pre-procedure oral analgesic use and history of dysmenorrhoea (painful periods) and/or chronic pelvic pain. There was no difference in pain scores or resolution of pain between the two groups. Satisfaction scores did not differ by treatment group and did not correlate with the pain score during the procedure. We conclude that the use of benzocaine spray does not significantly improve pain relief during HSG nor does it hasten resolution of pain post HSG. Of interest, patient satisfaction was not correlated with pain.

Transcervical intrauterine levobupivacaine or lidocaine infusion for pain control during endometrial biopsy

BACKGROUND

Endometrial biopsy is a common procedure for the investigation of many gynecological disorders including abnormal uterine bleeding, postmenopausal bleeding, abnormal cytology and infertility. Most women experience some degree of discomfort and pain during the procedure. Pain may occur during dilation of the cervix for insertion of the catheter and during endometrial biopsy, which further aggravates pain by inducing uterine contraction.

OBJECTIVES

To determine pain levels during endometrial biopsy by comparing intrauterine instillation of levobupivacaine or lidocaine with placebo in a randomized, double-blinded trial in pre- and postmenopausal women.

METHODS

Ninety patients were allocated to either control or experimental groups before endometrial biopsy. The trial medication was intrauterine anesthesia, either 5 mL 0.9% saline (control group), or 5 mL 0.5% levobupivacaine or 2% lidocaine (experimental groups). Resident doctors used the same endometrial biopsy technique to minimize the risk of technical variation. All tissue specimens were sent for cytopathological examination. The pathologists, who were blinded to the study solution, analyzed all tissue specimens. The primary outcome measure was pain experienced during the procedure. Pain was assessed using a 10 cm visual analogue pain scale. All observed adverse effects were recorded until the patients were discharged.

RESULTS

Pain scores of the intrauterine lidocaine and levobupivacaine groups were found to be significantly lower than the control group. There was no difference between the levobupivacaine and lidocaine groups with regard to pain scores. There was a moderately positive correlation between pain scores and endometrial thickness. No complications were observed due to the procedure. Most of the biopsy results were proliferative and secretory endometrium. Insufficient material causing inconclusive results was observed mostly in the control group.

CONCLUSION

Transcervical intrauterine topical instillation of levobupivacaine or lidocaine causes pain relief during endometrial biopsy. However, further studies are needed to evaluate the effectiveness of intrauterine anesthesia, to determine optimal concentration, volume and waiting time according to the type of local anesthetic agent, and to assess the applicability of the method to other intrauterine procedures.

Effectiveness of a single education and counseling intervention in reducing anxiety in women undergoing hysterosalpingography: a randomized controlled trial

Hysterosalpingography (HSG) is generally considered a stressful and painful procedure; we aimed to evaluate whether a single education and counseling intervention could reduce women's distress and pain after undergoing HSG for infertility. Patients were randomized into control group (n = 108) and intervention group (n = 109). All patients filled the following questionnaires before and after HSG: Zung self-rating anxiety scale (Z-SAS), Zung self-rating depression scale (Z-SDS), and an ad hoc questionnaire designed to evaluate HSG procedure knowledge. Pain was scored using a visual analog scale. The intervention consisted in a 45-minute individualised session 48 h before HSG. We observed a reduction of anxiety and depression scores in the intervention arm compared to the control group. After controlling for potential confounding variables, intervention was an independent predictor of the difference of Z-SAS score before and after HSG. This is the first randomised controlled trial to assess the potential effectiveness of a single education and counseling intervention to lower anxiety in a diagnostic setting.

Intrauterine anesthesia for gynecologic procedures: a systematic review

OBJECTIVE

To assess the effectiveness of intrauterine local anesthesia in reducing pain associated with outpatient gynecologic procedures.

DATA SOURCES

We searched online databases PubMed or MEDLINE, Embase, Google Scholar, and Clinicaltrials.gov and hand-searched reference lists from reviews evaluating pain-control methods for gynecologic office procedures. We identified randomized controlled trials using intrauterine local anesthetic in gynecologic procedures.

METHODS

Titles and abstracts were screened for 1,236 articles. We identified 45 potential articles for inclusion. We excluded 22 of these studies because: 1) they were not randomized controlled trials; 2) they did not describe a quantifiable dose of medication used in the study; 3) they did not investigate an intrauterine anesthetic; 4) they did not study a potentially awake, outpatient procedure; and 5) they did not clearly report results or represented duplicate publication. Twenty-three articles were ultimately included for review.

TABULATION, INTEGRATION, AND RESULTS

Two authors independently reviewed full search results and assessed eligibility for inclusion and independently abstracted data from all articles that met criteria for inclusion. Disagreements regarding eligibility or abstraction data were adjudicated by a third independent person. Our primary end point was the reported effect of intrauterine local anesthesia on patient-reported pain scores. As a result of heterogeneity in study methods, outcome measures, and reporting of outcomes, results could not be combined in a meta-analysis. Good evidence supports use of intrauterine anesthesia in endometrial biopsy and curettage, because five good-quality studies reported reduced pain scores, whereas only one good-quality study reported negative results. We found moderate evidence to support intrauterine anesthesia in hysteroscopy, because one good-quality study and two fair or poor quality studies reported reduced pain scores, whereas two good-quality studies had negative results. Good evidence suggests that intrauterine anesthesia is not effective in hysterosalpingography; three good-quality studies reported that pain scores were not reduced, and no good quality studies showed a beneficial effect in that procedure. Evidence was insufficient concerning first-trimester abortion, saline-infusion ultrasonogram, tubal sterilization, and intrauterine device insertion.

CONCLUSION

Intrauterine local anesthesia can reduce pain in several gynecologic procedures including endometrial biopsy, curettage, and hysteroscopy and may be effective in other procedures as well.

Could antispasmodic drug reduce pain during hysterosalpingo-contrast sonography (HyCoSy) in infertile patients? A randomized double-blind clinical trial

OBJECTIVE

To assess the effectiveness of an antispasmodic drug, hyoscine-N-butylbromide, in reducing pain during hysterosalpingo-contrast sonography (HyCoSy).

METHODS

Eight hundred and sixteen patients undergoing HyCoSy were randomized to receive 10 mg hyoscine-N-butylbromide (n = 408) or placebo (n = 408) per os, 30 min before the procedure, in a double-blind randomized controlled trial. Immediately after the procedure, the patient was asked to describe any pain experienced in comparison with pain usually suffered during the menstrual cycle, and the operator assigned a pain score between 0 and 4 as follows: 0 (no reaction or discomfort), 1 (slight pain, less than menstrual pain), 2 (moderate pain, exceeding menstrual cramps but no vasovagal reaction), 3 (vasovagal reaction or pain requiring observation in a hospital) and 4 (vasovagal reaction or pain requiring resuscitation). The primary aim was to estimate the difference in pain score, considered as a categorical value, between the active arm of the trial and the control group. The secondary aim was to evaluate if pain is related to tubal patency.

RESULTS

There was no difference in pain score between the hyoscine-N-butylbromide group and the placebo group (P = 0.807). There was a negative correlation between pain and tubal patency, regardless of treatment group (P < 0.0001).

CONCLUSIONS

Administration of 10 mg antispasmodic drug hyoscine-N-butylbromide does not reduce pain in patients undergoing HyCoSy.

Transcervical intrauterine levobupivacaine infusion or paracervical block for pain control during endometrial biopsy

The aim of this study was to determine pain during endometrial biopsy by comparing the use of intrauterine instillation of levobupivacaine or paracervical block with a placebo in a randomized, double-masked trial in premenopausal and postmenopausal women. A total of 90 women were enrolled in the study. Patients were allocated to either the control or case groups. Group 1 consisted of 30 cases with intrauterine anesthesia with 5 ml 0.5% levobupivacaine. Group 2 consisted of 30 patients who underwent paracervical block with lidocaine. No analgesic agent was given to the remaining 30 patients; these cases comprised the control group. The primary outcome measures were pain or discomfort experienced during the procedure. When the pain scores of the different groups were compared, the scores in the intrauterine levobupivacaine and paracervical block groups were found to be significantly lower compared to those in the control group. There was no difference between the levobupivacaine and paracervical block groups in terms of pain scores. There was a marked positive correlation between biopsy indications and pain scores. Pain scores were lower in cases with the indication of polymenorrhea, hypermenorrhea and metrorraghia compared to those in the cases with other indications. In conclusion, the transcervical intrauterine instillation of levobupivacaine or paracervical block with lidocaine brings about pain relief during and after endometrial biopsy.

Male factor infertility may be associated with a low risk for tubal abnormalities

This study assessed the association of an abnormal hysterosalpingography (HSG) with clinical characteristics and infertility investigation results in 1359 women who underwent HSG as part of their infertility work-up. A normal HSG result was found in 1031 tests (75.9% of all HSG tests). Significantly positive predictors of tubal occlusion on multivariate analysis were longer duration of infertility (OR 1.072, 95% CI 1.006-1.143), previous pelvic inflammatory disease (PID; OR 2.172, 95% CI 1.176-4.008), extrauterine pregnancy (EUP; OR 15.74, 95% CI 6.66-37.16) and any abdominal surgery (except Caesarean section; OR 1.503, 95% CI 1.120-2.017) and negative predictor was male factor infertility (OR 0.543, 95% CI 0.401-0.735). The presence of male factor decreased the risk of tubal abnormality from 32.4% to 15.6% (P<0.001) in women with known risk factors for tubal abnormalities (previous PID, EUP or abdominal surgery) and from 17.8% to 11.5% (P=0.01) in women at low risk for tubal abnormalities. As the risk for tubal factor is approximately 1:10 in patients with male factor infertility without other risk factors, the practice of postponing HSG until after one or two treatment cycles may be considered.

Analgesic efficacy of intravenous paracetamol for outpatient fractional curettage: a randomised, controlled trial

OBJECTIVE

To determine the efficacy of intravenous (i.v.) paracetamol for decreasing pain associated with fractional curettage.

MATERIALS AND METHODS

This double-blind, randomised, placebo-controlled trial included 70 women who underwent fractional curettage. Patients were randomly assigned to receive i.v. infusion of either 1000 mg paracetamol (n = 36) or 0.9% normal saline as placebo (n = 34) prior to the procedure. The main outcome measure was the intensity of pain assessed by a 10-cm visual analogue scale. Pain scoring was performed at t(1) = prior to the procedure, t(2) = during the procedure and t(3) = 30 min after the procedure. Statistical analysis was performed using the Student's t-test, chi-squared and Pearson's correlation analysis.

RESULTS

The pain scores at t(2) and t(3) were significantly higher than the score at t(1) in both groups. There was no statistically significant difference between the pain scores at t(1), t(2) and t(3) among the two groups. Menopausal status had no effect on the pain scores and on the treatment outcome. The pain scores prior to the procedure were significantly higher in women with a history of endometrial curettage when compared with women who have no history.

CONCLUSIONS

Fractional curettage is associated with mild pain. We were unable to detect a significant difference in pain scores in patients undergoing fractional curettage when comparing the use of i.v. paracetamol with placebo. History of prior endometrial curettage seems to be a predictor of the basal pain scores at admission although it does not affect the pain intensity related to the procedure.

Intrauterine lidocaine infusion for pain relief during saline solution infusion sonohysterography: a randomized, controlled trial

STUDY OBJECTIVE

To evaluate the efficacy of intrauterine lidocaine instillation in reducing patient discomfort during saline solution infusion sonohysterography (SIS).

DESIGN

A double-blinded, randomized, controlled trial (Canadian Task Force classification I).

SETTING

Suleyman Demirel University School of Medicine, Department of Obstetrics and Gynecology, Isparta.

PATIENTS

One hundred-six women who underwent SIS.

INTERVENTIONS

Fifty-three patients were allocated to the lidocaine group and 53 to the saline solution group.

MEASUREMENTS AND MAIN RESULTS

The main outcome measures were the intensity of pain during, immediately after, and 20 minutes after the procedure, assessed by a visual analog scale and the patients' distress evaluated by the physician with a 3-point observer scale. There were no statistically significant differences between the study group and the control group in mean age, parity, past cervical surgery, history of chronic pelvic pain and dysmenorrhea, history of curettage, education, socioeconomic status, menopausal status, volume of saline solution infused (mL), tenaculum use, and indication for SIS. Pain scores demonstrated a statistically significant difference between groups during the procedure (placebo 5.09 +/- 1.25 [95% CI 4.74-5.43], lidocaine 3.90 +/- 1.02 [95% CI 3.61-4.18], p <.001); immediately after procedure (placebo 4.03 +/- 0.89 [95% CI 3.78-4.27], lidocaine 3.16 +/- 0.67 [95% CI 2.97-3.34], p <.001); and 20 minutes after procedure (placebo 3.32 +/- 0.54 [95% CI 3.17-3.46], lidocaine 2.43 +/- 0.72 [95% CI 2.23-2.62], p <.001). No significant pain relief in nulliparous patients was obtained by the use of lidocaine (4.88 +/- 1.01 [95% CI 4.60-5.15], 3.88 +/- 0.86 [95% CI 3.64-4.11], 3.22 +/- 0.55 [95% CI 3.06-3.37], respectively; p >.05). Pain rated by the physician during, immediately after, and 20 minutes after the procedure was significantly different between the groups (p <.001), and a significant correlation was noted between the visual analog pain score and the patients' distress recorded by the physician (r = 0.816, r = 0.697, r = 0.676; p <.001, respectively).

CONCLUSION

Intrauterine lidocaine seems to be effective in decreasing pain in parous women undergoing SIS.

Pain relief in hysterosalpingography

BACKGROUND

Hysterosalpingography (HSG) is a method of testing for tubal patency. Various pharmacological strategies are available that may reduce the pain during the procedure.

OBJECTIVES

To compare the effectiveness of different types of pharmacological interventions for pain relief in women undergoing hysterosalpingography (HSG) for investigation of subfertility.

SEARCH STRATEGY

This review has drawn on the search strategy developed for the Menstrual Disorders and Subfertility Group. In addition MEDLINE and EMBASE were searched up to July 2006.

SELECTION CRITERIA

All randomised controlled trials investigating the pharmacological interventions for pain relief during HSG were investigated.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by the first two authors. Differences of opinion were registered and resolved by the third author. Results for each study were expressed as mean pain score and standard error of the mean with 95% confidence intervals.

MAIN RESULTS

The included eight trials reported on 570 women undergoing HSG.Overall, there was no evidence of benefit of using any analgesia compared with placebo for pain relief during the procedure (standard mean difference (SMD) of -0.05 (95%CI -0.25 to 0.14) or up to 29 minutes after HSG SMD 0.17, (95%CI -1.00 to 1.34)). Four RCTs involving 219 women found evidence of benefit with any analgesia in comparison to placebo for pain relief more than 30 minutes after HSG, with the SMD of -0.82(95%CI-1.18 to -0.45). One RCT involving 91 women compared the effectiveness of opioid analgesics versus non-opioid analgesics and reported no evidence of difference in pain relief at any stage of the procedure. One RCT involving 20 women compared the use of topical analgesia with a paracervical block, with analysis demonstrating more benefit to be gained from using topical analgesia during HSG, with the SMD of -2.03 (95%Cl-3.16 to -0.91).

AUTHORS' CONCLUSIONS

There is little evidence of benefit in terms of pain relief of any of the interventions considered in this study during or immediately after HSG. However, there is limited evidence of pain reduction 30 minutes after the procedure. Further RCTs should consider the role of non steroidal antiinflammatories (NSAIDs) and intrauterine anaesthetic during HSG.

Intrauterine lidocaine plus buccal misoprostol in the endometrial biopsy

OBJECTIVE

To evaluate the efficacy of intrauterine lidocaine plus buccal misoprostol in reducing the discomfort caused by endometrial biopsy with a suction curette.

METHODS

In this double-blind, randomized, placebo-controlled trial 126 women undergoing endometrial biopsy were administered a 200-microg tablet of misoprostol buccally, followed by a 5-mL uterine instillation of either of 2% lidocaine or a saline solution. The main outcome measures were the intensity of pain during, immediately following, and 20 min following the biopsy, as assessed on a 10-cm visual analog scale. Statistical analysis was performed using the Friedman test with the Bonferroni correction, the t test, and the chi(2) test.

RESULTS

There were no statistically significant differences between the study and control groups in mean age, parity, or relevant medical history. A statistically significant difference in pain scores was noted in premenopausal women during the procedure (lidocaine, 4.93+/-1.67; placebo, 6.17+/-1.26; P<0.001) as well as immediately later (lidocaine, 4.12+/-1.14 vs. placebo, 5.42+/-1.08; P<0.001) and 20 min later (lidocaine, 3.60+/-1.10; placebo, 4.22+/-1.46; P<0.001). No significant differences in pain scores were observed in postmenopausal women for any of the 3 time points (6.72+/-2.01, 5.18+/-1.22, and 4.56+/-0.80, respectively; P>0.05). The number needed to treat was 2.6 (95% confidence interval, 1.9-4.8).

CONCLUSION

Intrauterine lidocaine plus buccal misoprostol appears to be effective in decreasing pain in premenopausal women undergoing endometrial biopsy with a suction curette.

Lidocaine–Prilocaine (EMLA) cream as analgesia for hysterosalpingography: a prospective, randomized, controlled, double blinded study

BACKGROUND

The aim of our study is to evaluate the efficacy of applying lidocaine 25 mg-prilocaine-25 mg/G cream (EMLA 5%) on the uterine cervix for pain relief when performing hysterosalpingography (HSG).

METHODS

Eighty-two patients undergoing HSG as part of infertility evaluation were randomized into groups receiving EMLA (42) or placebo cream (40) in a double-blinded prospective study from which four women were later excluded. The cream was applied to the uterine cervix by means of a cervical cup 30 min before the HSG. Pain perception related to the HSG procedure was scored by visual analogue scale (VAS) at five predefined steps: after speculum application, after cervical instrumentation of the tenaculum and cannula, at the end of uterine filling, at completion of tubal spillage, and immediately following instrument removal. In addition, the patients were asked to retrospectively rate the pain during the entire procedure in a telephone interview the following day.

RESULTS

Cervical instrumentation was found to be the most painful step of HSG (P < 0.001). When comparing the VAS pain scores, cervical instrumentation in the EMLA-treated patients was associated with significantly less pain than the control group: 3.3 +/- 2.9 versus 4.9 +/- 2.7, respectively (P = 0.02).

CONCLUSIONS

Topical application of EMLA 5% cream on the uterine cervix before performing HSG significantly reduced the pain during this procedure.

Intracervical Block and Pain Perception During the Performance of a Hysterosalpingogram

OBJECTIVE

To estimate whether an intracervical block of 1% lidocaine decreased pain perception compared with placebo during the performance of a hysterosalpingogram.

METHODS

A randomized controlled trial was conducted with 120 patients assessing pain perception during a hysterosalpingogram. Patients were randomly assigned to one of three groups. Patients received either a 1% lidocaine intracervical block, an intracervical saline injection, or no injection. Visual analog (VAS) and qualitative scales were used to assess study participants' pain at six different time points during the hysterosalpingogram.

RESULTS

Subjects receiving the lidocaine block had significantly less pain (P<.001) by VAS during tenaculum placement (approximately 61% less, 1.303 cm) and with tenaculum traction (approximately 40% less, 2.804 cm) compared with both the intracervical saline injection group and the no injection group (tenaculum placement, 3.384 cm and 3.354 cm, and tenaculum traction, 4.705cm and 4.961 cm, respectively). There was no improvement seen with pain perception during instillation of the contrast in the lidocaine group compared with the saline or no injection group (P<.073). Subjects who received the saline injection had statistically more pain (P<.001) by VAS (2.647 cm) immediately after the injection compared with the lidocaine (approximately 79% greater, 1.476 cm) and no injection groups (115% greater, 1.232 cm).

CONCLUSION

Lidocaine intracervical block provides better pain relief than placebo during tenaculum placement and tenaculum traction during a hysterosalpingogram. This study suggests that patients should be offered an intracervical block before placement of the cervical tenaculum to decrease pain during the performance of a hysterosalpingogram.

CLINICAL TRIAL REGISTRATION

(www.ClinicalTrials.gov), NCT00372658

LEVEL OF EVIDENCE

I.

Efficacy of Intrauterine Lidocaine for Removal of a “Lost” Intrauterine Device

OBJECTIVE

To evaluate the efficacy of intrauterine lidocaine instillation in reducing patient discomfort during the removal of a "lost" intrauterine device (IUD).

METHODS

This double-blinded, randomized, placebo-controlled trial included 68 women who underwent removal procedure for a "lost" IUD. Thirty-four women were allocated to the lidocaine group and 34 to the saline group. The main outcome measure was the intensity of pain during, immediately after, and 20 minutes after the procedure, assessed by a visual analog scale. Statistical analysis was performed using the Friedman test with Bonferroni correction, Student t test, and chi2.

RESULTS

There were no statistically significant differences between the study group and the control group in mean age, parity history of chronic pelvic pain and dysmenorrhea, history of curettage, education, socioeconomic status, menopausal status, breastfeeding, type of IUD, and duration of IUD. Pain scores demonstrated a significant difference between groups during the procedure (placebo 6.41 +/- 1.15, lidocaine 5.23 +/- 0.69, P < .01), immediately after procedure (placebo 6.05 +/- 1.01, lidocaine 4.94 +/- 0.60, P < .01), and 20 minutes after procedure (placebo 4.32 +/- 0.63, lidocaine 4.44 +/- 0.66, P < .01). The number needed to treat was 3 (95% confidence interval 2-9).

CONCLUSION

Intrauterine lidocaine appears to be effective in decreasing pain in women undergoing the removal procedure of a "lost" IUD.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov, NCT00308841.

LEVEL OF EVIDENCE

I.