Lignocaine aerosol spray in outpatient hysteroscopy: a randomized double-blind placebo-controlled trial

Warm distension fluid reduces pain severity in office hysteroscopy: a randomized controlled trial

BACKGROUND

Abnormal uterine bleeding (AUB) affects approximately 14% to 25% of women of reproductive age. The most common use of office hysteroscopy is to evaluate pathologies related to AUB and reproductive health, but office hysteroscopy can also be used for the diagnosis and treatment of other intrauterine pathologies.

OBJECTIVE

Investigate the effects of the temperature of the distension fluid on pain severity in patients undergoing diagnostic office hysteroscopy due to AUB.

DESIGN

Randomized controlled clinical trial.

SETTING

Tertiary care center in Turkey.

PATIENTS AND METHODS

One hundred perimenopausal patients with AUB were randomly allocated according to the temperature of the distension fluid used in office hysteroscopy (37°C or 25°C). Pain intensity was assessed using a visual analog scale (VAS). Six VAS measurements were compared over the course of the hysteroscopy: pre-treatment (VAS-1), at vaginal entry (VAS-2), at the cervical ostium transition (VAS-3), while in the cavity (VAS-4), at the end of the procedure (VAS-5), and 30 minutes after the end of the procedure (VAS-6).

MAIN OUTCOME MEASURE

VAS SAMPLE SIZE: Fifty in each group enrolled, one drop out.

RESULTS

The VAS-3, VAS-4, and VAS-5 scores were significantly lower for patients in the warm fluid group than in the room temperature group (P<.05), whereas the VAS-1, VAS-2, and VAS-6 scores were similar in both groups.

CONCLUSION

The application of warm distension fluid in office hysteroscopy reduces pain severity compared with the application of an unheated fluid.

LIMITATIONS

The main limitations of the study were that a subgroup analysis could not be performed due to an insufficient number of cases, and we were unable to evaluate vasovagal symptoms.

CONFLICT OF INTEREST

None.

Local anaesthesia for office hysteroscopy: A systematic review & meta-analysis

OBJECTIVE

To compare the effects of different types and routes of administration of local anaesthetic for pain control during and after office hysteroscopy.

METHODS

Medline, Embase, CINAHL and the Cochrane library were searched from inception until October 2019, in order to perform a systematic review and meta-analysis of all randomised controlled trials investigating the use of a local anaesthetic compared to a control, for pain relief in women undergoing diagnostic or operative office hysteroscopy. Average pain scores and data regarding side-effects, feasibility, complications, acceptability and satisfaction were collected.

RESULTS

The literature search yielded 612 citations. A total of 37 studies were included for systematic review, of which data from 20 studies were used for meta-analysis. Local anaesthesia was associated with significantly reduced pain during (SMD -0.57, 95 % CI -0.79 to -0.34) and after (SMD -0.30, 95 % CI -0.54 to -0.06) office hysteroscopy but did not reduce vasovagal episodes (OR 0.73, 95 % CI 0.50-1.09). A reduction in intra-procedural pain was observed regardless of type or route of administration. Local anaesthesia did not significantly reduce the risk of procedural failure (OR 0.72, 95 % CI 0.47-1.11). Insufficient data regarding complications, acceptability and satisfaction were available for meta-analysis.

CONCLUSION

Local anaesthesia via any route of genital tract administration, should be considered when undertaking office diagnostic or operative hysteroscopy to reduce pain during and after the procedure. Further research is needed to understand whether the pain control benefits of local anaesthesia remain apparent with vaginoscopic approaches to office hysteroscopy that avoid genital tract instrumentation.

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.

The value of endocervical and endometrial lidocaine flushing before office hysteroscopy: A randomized controlled trial

OBJECTIVE

To evaluate the safety and efficacy of flushing the cervical canal and the uterine cavity with local anesthetic in order to reduce the pain felt by patients during office hysteroscopy.

METHODS

A double-blind randomized controlled trial was conducted between May 1, 2018, and February 28, 2019, involving 260 women undergoing office hysteroscopy at Kasr Al Ainy Hospital, Cairo, Egypt. Women were randomized using a computerized random number generator to intrauterine and intracervical instillation 5 minutes before the procedure of either 5 mL lidocaine 2% diluted in 15 mL normal saline, or 20 mL normal saline alone. The primary outcome measure was the visual analog scale (VAS) pain score reported by women during the procedure. Secondary outcomes included VAS score at 10 and 30 minutes after the procedure, the need for analgesia, and occurrence of vasovagal attacks.

RESULTS

Women in the lidocaine flushing group reported a significantly lower VAS score during the procedure (1.8 ± 1.1 vs 5.2 ± 1.8) and 10 and 30 minutes after it (1.3 ± 1.15 and 0.8 ± 0.9 vs 4.3 ± 2.1 and 2.98 ± 1.96) when compared with control women (P<0.001). More women without lidocaine flushing experienced vasovagal attacks (25/130 vs 9/130, P<0.001) and needed analgesia (84/130 vs 13/130, P<0.001) when compared with women with lidocaine flushing.

CONCLUSION

Flushing of the cervical canal and uterine cavity with local anesthetic significantly decreased pain sensation in women undergoing office hysteroscopy. CLINICALTRIALS.GOV: NCT03530488.

Failed diagnostic hysteroscopy: Analysis of 62 cases

OBJECTIVE

The aim of the presented study is to improve the office hysteroscopy success rate identifying some of the factors associated to an unsuccessful procedure. Moreover it would highlight the importance of an adequate patients follow up after office hysteroscopy failure enlightening the uterine pathologies missed at the first attempt.

STUDYDESIGN

This is a retrospective observational study. The Authors reviewed the medical records related to 516 office hysteroscopies performed from January 2016 to November 2018, extrapolating the data from the failed hysteroscopies occurred during this period. After the procedure failure all patients were offered to repeat the hysteroscopy under regional anesthesia in order to identify and treat uterine pathologies. Those patients, who declined to repeat the procedure, received an appropriate follow up. Each failure case is correlated with patient clinical characteristics, indications to hysteroscopy, risk factors presence, hysteroscopy patient compliance, pathology result and patient follow up.

RESULTS

The presented study shows an office hysteroscopy failure rate of about 12 %. Severe pain due to cervical stenosis, previous uterine surgery, postmenopausal status and marked uterine ventrifixation/retroflexion, represent the main reason why the procedure was not completed in an office setting. The uterine cavity was subsequently examined in only 26 (42 %) out of 62 patients who reported hysteroscopy failure, mostly repeating the procedure under regional anesthesia (24 cases) or performing vaginal hysterectomy for associated benign gynaecological pathology (2 cases). Endometrial malign pathology (endometrioid carcinoma) was diagnosed in 2 cases of them (7.7 %). Moreover the endometrial cavity remained so far unexplored in 36 (58 %) out of 62 patients, due to the patient refuse to repeat the hysteroscopy under anesthesia.

DISCUSSION AND CONCLUSION

Results of the present study suggest that office hysteroscopy should be sussessful at the first attempt due to the patients' refuse, in majority of cases, to repeat the procedure after a failure. To not repeat the hysteroscopy may lead to lose or delay important diagnosis, such as that of endometrial cancer. In this context, to counsel all patients prior the procedure may singnificanly help to identify those who may benefit of pharmacological cervical softening, local anesthetic injection or small caliber hysteroscopes usage, increasing the procedure success rate.

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 Efficacy of Lidocaine Spray in Pain Relief during Outpatient-Based Endometrial Sampling: A Randomized Placebo-Controlled Trial

Abnormal vaginal bleeding is one of the most frequent problems found in gynecology. Endometrial histopathology is needed for definite diagnosis. It was obtained either from endometrial tissue sampling or from standard uterine curettage. Office endometrial tissue sampling is an easy and low morbid procedure. It is usually associated with pain and discomfort. Topical anesthetic agent is needed for pain relieving. This study was conducted in outpatient gynecology clinic, Thammasat University Hospital, Thailand. It was a double blind randomized controlled trial. A total of 140 participants were enrolled in study and control group. Each group consisted of 70 cases. Study group received topical spray of 10% lidocaine (40 mg) before endometrial aspiration. Topical spray of 0.9% normal saline was performed in control group. Novak curettage was an application for endometrial tissue obtaining in this study. Visual analog scale (10cm-VAS) was used for pain evaluation. Demographic character of both groups showed no statistical difference. The percentage of participants who had severe pain (VAS≥7) during tenaculum application and Novak curettage insertion and during procedure were 28.5% (20/70) versus 12.9% (9/70), 55.7% (39/70) versus 38.5% (27/70), and 78.5% (55/70) versus 60% (42/70) in control and study group, respectively. Both groups had no significant differences of postoperative pain at 15 minutes and 2 hours. This study indicates that topical lidocaine spray can relieve pain during endometrial tissue sampling.

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.

Evidence-based pain management for endometrial biopsies and IUD insertions

Intrauterine device (IUD) insertions and endometrial biopsies (EMB) are common outpatient office procedures performed by advanced practice nurses. There are currently no guidelines for pain management with either IUD insertions or EMB procedures. Combination modalities are the most likely to impact pain perception, but more research is required in this area.

[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.

The effect of different local anesthesia methods on pain relief in outpatient endometrial biopsy: randomized clinical trial

INTRODUCTION

Endometrial biopsy is necessary for diagnosing the reason of abnormal uterine bleeding in perimenopausal women. Currently outpatient endometrial biopsy is used for evaluation of abnormal uterine bleeding which is associated with moderate to severe pain. Using lidocaine is one of the procedures which is used for pain relief while biopsy. This study is aimed at comparing the effect of different local anesthesia procedures on pain relief during endometrial biopsy.

METHODS

In this randomized clinical trial, 160 multiparous 40-55 years old women with AUB, candidates for endometrial biopsy, were randomly assigned into four equal groups, to receive: 1-intrauterine lidocaine; 2-cervical spray lidocaine; 3- intrauterine lidocaine plus cervical spray lidocaine; or 4-intrauterine distilled water. Pain relief was measured at 3 different times: during endometrial biopsy, just after and 15 minutes after biopsy.

RESULTS

Pain intensity was reduced significantly at different times in intrauterine lidocaine and intrauterine lidocaine with cervical spray lidocaine receivers in compare with the groups which received cervical spray lidocaine and distilled water. The mean of difference pain relief during biopsy and 15 minutes after that was reduced significantly in the group which received intrauterine lidocaine and intrauterine lidocaine with cervical spray lidocaine in comparison with the other two groups.

CONCLUSION

Intrauterine lidocaine was effective during endometrial biopsy, and using it with cervical spray lidocaine had no more beneficial effect.

Intrauterine infusion of lidocaine does not reduce pain scores during IUD insertion

BACKGROUND

Potential pain with IUD insertion is a concern for women. Studies have found that systemic and local cervical therapies do not reduce pain scores. Since intrauterine infusion of lidocaine may reduce pain with endometrial aspiration, in this pilot study, we tested whether such infusion through an inexpensive endometrial aspirator could reduce IUD insertion pain scores with IUD insertion.

STUDY DESIGN

In this randomized, double-blinded, placebo control pilot study of 40 women undergoing IUD insertion, pain scores of women receiving 1.2 mL 2% lidocaine versus normal saline (1:1) infused 3 min prior to IUD insertion were measured using a 0-9-point scale.

RESULTS

Pain at tenaculum placement was similar between groups. There was no difference in mean pain scores during IUD insertion of women infused with lidocaine (2.95) versus normal saline (3.75), p=.37. Considerable variation in pain scores was noted; 46% of subjects had pain scores ≤2 while 33% had pain scores ≥5.

CONCLUSION

Use of 2% lidocaine administered through an endometrial aspirator did not significantly reduce IUD insertion pain scores in this pilot study.

Review of new office-based hysteroscopic procedures 2003-2009

Office operative hysteroscopy is a recent technique that enables treatment of uterine pathologic disorders in the ambulatory setting using miniaturized hysteroscopes with mechanical or electric instruments. The available international literature from 1990 to 2002 has clearly demonstrated that such technique enables performance of hysteroscopically directed endometrial biopsy and treatment of uterine adhesions, anatomic disorders, polyps, and small myomas safely and successfully without cervical dilation and the need for anesthesia. This review provides a comprehensive survey of further advancements of office operative hysteroscopy in the treatment of other gynecologic pathologic conditions that have not been included in the schema of treatment indications for office procedures proposed in 2002. A search of MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews identified articles published from 2003 to 2009. Eighteen articles were identified: 9 on hysteroscopic sterilization; 1 on office-based metroplasty, 8 on office-based treatment of some uncommon gynecologic pathologic conditions (e.g., hematometra, diagnosis and treatment of vaginal lesions, treatment of uterine cystic neoformations, bleeding from the cervical stump, diagnosis and treatment of endocervical ossification, and removal of uterovaginal packing). All performed procedures were carried out safely and successfully in the office setting, with high patient tolerance and minimal discomfort. The success of the procedures has been confirmed by resolution of symptoms and at follow-up ultrasonographic and hysteroscopic examinations. Currently, as a result of technologic advancements and increased operator experience, an increasing number of gynecologic pathologic conditions traditionally treated in the operating room may be treated safely and effectively using office operative hysteroscopy.

Comparison of oral nonsteroidal analgesic and intrauterine local anesthetic for pain relief in uterine fractional curettage: a randomized, double-blind, placebo-controlled trial

OBJECTIVE

We sought to investigate the analgesic efficacy of oral dexketoprofen trometamol and intrauterine lidocaine in patients undergoing fractional curettage.

STUDY DESIGN

A randomized, double-blind, placebo-controlled trial was conducted on 111 women. Subjects were randomly assigned into 4 groups to receive either 25 mg of dexketoprofen or similar-appearing placebo tablets and either 5 mL intrauterine 2% lidocaine or saline. The main outcome measure was the intensity of pain measured by a 10-cm visual analog scale. Pain scoring was performed prior to, during, and 30 minutes after the procedure.

RESULTS

No statistically significant difference was found among the mean pain scores of women during the procedure in the dexketoprofen and saline, placebo and lidocaine, and dexketoprofen and lidocaine groups. The mean pain scores in all 3 groups revealed significant reduction when compared with placebo and saline combination (P = .001).

CONCLUSION

Administration of intrauterine lidocaine or oral dexketoprofen appears to be effective in relieving fractional curettage associated pain. However, a combination of them does not work better in further reduction of pain.

Local anaesthesia for pain control during outpatient hysteroscopy: systematic review and meta-analysis

OBJECTIVE

To compare the effects of different types of local anaesthetic for pain control during outpatient hysteroscopy.

DESIGN

Systematic review and meta-analysis of randomised controlled trials.

SETTING

Outpatient hysteroscopy clinics.

PARTICIPANTS

Women undergoing diagnostic or operative hysteroscopy as outpatients-that is, without general anaesthesia. Study selection criteria Medline, Embase, CINAHL, the Cochrane library, and reference lists of relevant studies. Two reviewers independently selected trials. Data were abstracted on quality, characteristics, and results.

RESULTS

There were 20 trials (2851 participants). Data from 15 of these were meta-analysed in subgroups defined by type of intervention and study quality. Intracervical (standardised mean difference -0.36, 95% confidence interval -0.61 to -0.10, I(2)=0%) and paracervical (-1.28, -2.22 to -0.35, I(2)=97%) injections of local anaesthetic significantly reduced the pain in women undergoing hysteroscopy as outpatients, whereas transcervical (-0.11, -0.31 to 0.10, I(2)=27%) and topical application (-0.32, -0.97 to 0.33, I(2)= 90%) did not. Meta-regression showed that paracervical injection was superior to the other anaesthetic methods (P=0.04), a finding that was supported by the high quality subgroup of studies. Use of local anaesthetic did not have a significant effect on the incidence of vasovagal episodes (P=0.09).

CONCLUSIONS

Paracervical local anaesthetic injection is the best method of pain control for women undergoing hysteroscopy as outpatients.

A prospective, randomised, single-blinded, controlled trial comparingtwo topical anaesthetic modalities for the application ofatenaculum to the cervix

The aim of this study was to compare the efficacy of equivalent doses of lignocaine spray vs lignocaine jelly in reducing pain during the application of a tenaculum to the cervix. A total of 58 women undergoing hysterosalpingography were prospectively randomised to receive either two doses of 10% lignocaine spray or 1 ml of 2% lignocaine jelly (both doses equivalent to 20 mg of lignocaine base) topically onto the cervix before tenaculum attachment. There was no difference in pain scores (measured by visual analogue scale and 4-point verbal descriptor scale) between lignocaine spray and lignocaine jelly during the attachment of the tenaculum to the cervix. In conclusion, there was no difference in pain during tenaculum attachment to the cervix following topical application of equivalent doses of either lignocaine jelly or spray.

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.

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.

A New Approach to Office Hysteroscopy Compared With Traditional Hysteroscopy

OBJECTIVE

To compare a "no touch" approach to diagnostic hysteroscopy without anesthesia with traditional diagnostic hysteroscopy after intracervical injection of mepivacaine hydrochloride 3%.

METHODS

A total of 130 women undergoing diagnostic hysteroscopy were included in the study and were randomized, using a computer-generated randomization list to one of two treatment groups in a ratio of 2:1. Eighty-three women underwent hysteroscopy without speculum, tenaculum, or anesthesia. Forty-seven women received intracervical anesthesia with 10 mL of 3% mepivacaine hydrochloride solution injected at two sites (3:00 and 9:00 positions) and underwent traditional hysteroscopy. Hysteroscopy was performed using a rigid 3.7-mm hysteroscope and a medium of 0.9% saline, and the image was transmitted to a screen visible to the patient. A visual analog scale (VAS) consisting of a 10-cm line was used to assess the intensity of pain experienced during and after the procedure. Overall patient satisfaction was assessed during, immediately after, 15 minutes later, and 3 days after hysteroscopy.

RESULTS

The mean pain score was significantly lower in the group without the use of speculum, tenaculum, or anesthesia (VAS1: 3.8+/-2.7 versus 5.34+/-3.23, P=.01; VAS2: 3.02+/-2.50 versus 4.57+/-3.30, P=.008). Patient satisfaction rate was similar in both groups.

CONCLUSION

Patients reported significantly less pain with the altered approach to diagnostic hysteroscopy compared with patients undergoing the traditional procedure with anesthesia. This new approach can therefore be considered as a useful hysteroscopic technique.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT00319410

Office hysteroscopy and adenomyosis

Adenomyosis, the heterotopic presence of endometrial glands and stroma within the myometrium, has traditionally been diagnosed by the pathologist in hysterectomy specimens. However, the recent development of high-quality non-invasive techniques such as transvaginal sonography (TVS), magnetic resonance imaging (MRI) and hysteroscopy has renewed interest in diagnosing adenomyosis in the office prior to any treatment. Hysteroscopy offers the advantage of direct visualization of the uterine cavity, and since nowadays it is performed in the office, it can be offered as a first-line diagnostic tool for evaluation of uterine abnormalities in patients with abnormal uterine bleeding and/or infertility. The available data clearly indicate that high-quality mini-hysteroscopes, saline as a distension medium, and atraumatic insertion technique are essential for the success of office hysteroscopy. The procedure is indicated in any situation in which an intrauterine anomaly is suspected; it is immediately preceded by a physical exam and a TVS to evaluate uterine characteristics, and it is followed by a second TVS to take advantage of the intracavitary fluid for a contrast image of the uterus. Although diagnostic hysteroscopy does not provide pathognomonic signs for adenomyosis, some evidence suggests that irregular endometrium with endometrial defects, altered vascularization, and cystic haemorrhagic lesion are possibly associated with the entity. In addition to the direct visualization of the uterine cavity, the hysteroscopic approach offers the possibility of obtaining endometrial/myometrial biopsies under visual control. Since they can be performed in the office, the combination of TVS, fluid hysteroscopy and contrast sonography is therefore a powerful screening tool for detecting endometrial and myometrial abnormalities in association with adenomyosis.

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.

Anaesthesia and analgesia for ambulatory hysteroscopic surgery

Although ambulatory hysteroscopy is well established in dedicated centres, there is a delay in its general implementation. One reason for this may be the lack of consensus regarding a protocol for analgesia and anaesthesia in ambulatory hysteroscopy. This review looks at the various methods in use. These include the paracervical or intracervical injection of anaesthetic to establish a block. Topical anaesthetic may be applied to the surface of the endometrium in the uterine cavity or to the cervix. Oral analgesia is also used. A vaginoscopic approach to the uterine cavity without any anaesthesia is also becoming popular. Finally, combinations of the above methods have been employed for hysteroscopic surgical procedures, including the newer generation of endometrial ablation methods.

Use of sublingual buprenorphine for pain relief in office hysteroscopy

STUDY OBJECTIVE

To assess the efficacy of sublingual buprenorphine in the relief of pain associated with office hysteroscopy.

DESIGN

Prospective, randomized study (Canadian Task Force classification I).

SETTING

Tertiary medical center.

PATIENTS

One hundred sixty-four women referred for office hysteroscopy from September 2003 through March 2004.

INTERVENTION

Before hysteroscopy, 80 women received a tablet of buprenorphine (group A), and 84 women received a placebo (group B). Their pain sensations were evaluated on a 10-cm visual analog scale, and they were asked about the adverse reactions and level of satisfaction on the following day.

MEASUREMENTS AND MAIN RESULTS

The pain score in group A was 3.3 +/- 1.1, which was similar to 3.2 +/- 1.3 in group B. The pain scores in subgroups of women also were similar within the same group and between the two groups. Thirty-one women (38.8%) in group A reported adverse reactions, including nausea, vomiting, and drowsiness, while none in group B reported any adverse reactions.

CONCLUSION

Office hysteroscopy with a 3.1-mm flexible hysteroscope is a well-tolerated procedure. Sublingual buprenorphine is not helpful in relieving the pain associated with hysteroscopy but is associated with significant adverse reactions.

Topical Analgesia for Endometrial Biopsy

OBJECTIVE

To estimate whether benzocaine spray applied to the cervix and the endocervical canal before performing office endometrial biopsy improves patient comfort during the procedure.

METHODS

Eighty-eight women were randomly assigned to receive either 20% benzocaine spray or placebo to the outside of the cervix and into the endocervical canal before an endometrial biopsy was performed. The main outcome measure was pain during the endometrial biopsy, assessed by a visual analog scale. Statistical analysis was performed using Wilcoxon rank-sum test and Student t test.

RESULTS

There were no statistically significant differences between the study group and the control group in mean age, race, parity, body mass index, menopausal status, tenaculum use, or history of chronic pelvic pain. No statistically significant differences were found in median pain scores between the 2 treatment groups.

CONCLUSION

Topical benzocaine spray does not appear to offer effective pain control in patients undergoing an endometrial biopsy.

LEVEL OF EVIDENCE

I.

Outpatient hysteroscopy: traditional versus the 'no-touch' technique

OBJECTIVE

To assess whether outpatient hysteroscopy using the 'no-touch' technique confers any advantages in terms of patient discomfort over the traditional technique.

DESIGN

Prospective randomised controlled study.

SETTING

Outpatient hysteroscopy clinic in a large university undergraduate teaching hospital.

POPULATION

All women referred for outpatient hysteroscopy in a 12-month period.

INTERVENTIONS

Women were randomised to undergo either traditional saline hysteroscopy requiring the use of a speculum and tenaculum, or a 'no-touch' vaginoscopic hysteroscopy which does not require a speculum or tenaculum. Each group was further subdivided to have hysteroscopy with either a 2.9-mm or 4-mm hysteroscope. Patients were asked to complete pre- and postprocedure questionnaires ranking pain scores.

MAIN OUTCOME MEASURES

The relative success of each of these techniques, requirement for local anaesthetic and pain scores at different times during the hysteroscopy were recorded at the end of the procedure. The time taken to carry out each procedure was also measured.

RESULTS

One hundred and twenty women were recruited in this study: 60 were randomised to traditional hysteroscopy and 60 to 'no-touch' hysteroscopy. The overall success rate for hysteroscopy was 99%. There was no significant difference in the requirement for local anaesthetic between the two groups, but those who underwent 'no-touch' hysteroscopy with a 2.9-mm hysteroscope had the lowest requirement of local anaesthetic (10% compared with 27% in the no-touch hysteroscopy with a 4-mm hysteroscope group). The time taken to perform hysteroscopy and biopsy was significantly shorter with 'no-touch' hysteroscopy (5.9 vs 7.8 min; difference 1.9, 95% CI 0.7-3.1). There were no differences in pain scores between the groups at different times during hysteroscopy.

CONCLUSIONS

'No-touch' or vaginoscopic hysteroscopy is significantly faster to perform than the traditional technique. Although there was no difference in pain scores between the two techniques, local anaesthetic requirements were least in those who underwent 'no-touch' hysteroscopy with a narrow bore hysteroscope.

Thermachoice endometrial ablation in the outpatient setting, without local anesthesia or intravenous sedation: A prospective cohort study

OBJECTIVE

To determine whether Thermachoice endometrial ablation (EA) is a safe and acceptable procedure when performed in the outpatient (OP) setting without local anesthesia or IV sedation.

DESIGN

Prospective cohort (double group) study.

SETTING

Hysteroscopy clinic of large UK hospital.

PATIENT(S)

Twenty-seven women with menorrhagia.

INTERVENTION(S)

The first cohort of women underwent Thermachoice EA without elective analgesia. The second cohort underwent Thermachoice after taking ibuprofen.

MAIN OUTCOME MEASURE(S)

To map pain scores and the requirement of "rescue analgesia." To assess speed of recovery and time away from home.

RESULT(S)

Thermachoice EA was successfully performed in the OP setting on 89% (n = 24) of women. Four women in the first cohort required rescue analgesia compared to none in the second. During the procedure there was little difference between the groups visual analogue style pain scores-with the overall score being 3.6 (range = 0-10). Postoperatively there was a lower mean pain score in the second cohort, with fewer women experiencing nausea and vomiting. Mean time away from home was 2.6 hours and mean time to make a full recovery was 3.3 days. Women required analgesia for 2.6 days, on average, and returned to their normal activities at this time.

CONCLUSION(S)

Thermachoice EA without local analgesia or IV sedation can be safely and successfully performed in the OP setting and if ibuprofen is taken preoperatively few women require "rescue analgesia."

Prospective multicentre randomized controlled trial to evaluate factors influencing the success rate of office diagnostic hysteroscopy

BACKGROUND

Diagnostic hysteroscopy is not widely performed in the office setting, one of the reasons being the discomfort produced by the procedure. This randomized controlled trial was performed to evaluate the effects of instrument diameter, patient parity and surgeon experience on the pain suffered and success rate of the procedure.

METHODS

Patients were randomly assigned to undergo office diagnostic hysteroscopy either with 5.0 mm conventional instruments (n=240) or with 3.5 mm mini-instruments (n=240). Procedures were stratified according to patient parity and surgeon's previous experience. The pain experienced during the procedure (0-10), the quality of visualization of the uterine cavity (0-3) and the complications were recorded. The examination was considered successful when the pain score was <4, visualization score was >1 and no complication occurred.

RESULTS

Less pain, better visualization and higher success rates were observed with mini-hysteroscopy (P <0.0001, P <0.0001 and P <0.0001, respectively), in patients with vaginal deliveries (P <0.0001, P <0.0001 and P <0.0001, respectively) and in procedures performed by experienced surgeons (P=0.02, P=NS and P=NS, respectively). The effects of patient parity and surgeon experience were no longer important when mini-hysteroscopy was used.

CONCLUSIONS

Our data demonstrate the advantages of mini-hysteroscopy and the importance of patient parity and surgeon experience, suggesting that mini-hysteroscopy should always be used, especially for inexperienced surgeons and when difficult access to the uterine cavity is anticipated. They indicate that mini-hysteroscopy can be offered as a first line office diagnostic procedure.

Pain Relief and Outpatient Hysteroscopy: A Literature Review

Our early experience in setting up an ambulatory hysteroscopy service provoked a review of the literature, due to an unacceptably high failure rate. A literature review has been undertaken to establish the accepted success rates and reasons for failure, and to assess evidence for various analgesic protocols through randomized controlled trials. The data suggest the procedure is acceptable to most patients, with a completion success rate over 90%, and the use of analgesia may enhance the success rate. Analgesic protocols studied were nonsteroidal anti-inflammatory drugs, intracervical block, paracervical block, transcervical block, and topical analgesia. Failures are due predominantly to pain, stenosis, and poor view.

Anesthetic Effect of Intrauterine Lidocaine Plus Naproxen Sodium in Endometrial Biopsy

OBJECTIVE

To compare the efficacy of intrauterine lidocaine with oral naproxen sodium on pain perception of the patients during endometrial biopsy using the Pipelle instrument and to investigate their effects when used in combination.

METHODS

One-hundred twenty women were randomly assigned to receive either 5 mL of intrauterine 2% lidocaine or saline and either 550 mg of naproxen sodium or a similar-appearing placebo tablet. Subsequently, each woman completed a 10-cm visual analog scale for subjective pain experience and a physician scored visible signs of the women's distress during the procedure using a 3-point observer scale.

RESULTS

There was no statistically significant difference between the 4 groups in age, vaginal parity, history of chronic pelvic pain, menopausal status, tenaculum use, previous endometrial biopsy, or difficulty in passing the cervical os. The mean pain scores of the women in the naproxen only (5.8 +/- 2.2) and lidocaine only (5.9 +/- 2.2) groups were not significantly different compared with placebo group (7.1 +/- 2.0). However, the mean pain score in the lidocaine plus naproxen group (4.6 +/- 1.8) compared with the placebo group showed significant reduction in pain (P <.05). Pain rated by the physician was significantly lower in the lidocaine plus naproxen group compared with other groups, and a significant correlation was noted between the visual analog pain score and the patients' distress recorded by the physician (r =.791, P <.001). One patient in the naproxen-only group had vasovagal syncope after the procedure.

CONCLUSION

Intrauterine lidocaine instillation significantly decreases pain associated with Pipelle endometrial biopsy when used in combination with oral naproxen sodium.

LEVEL OF EVIDENCE

I

Randomised comparison of distension media for outpatient hysteroscopy

OBJECTIVE

To compare saline with and without added lignocaine and carbon dioxide distension for out patient hysteroscopy with regards to patient discomfort and hysteroscopic view.

DESIGN

Single blind prospective randomised controlled trial.

SETTING

Specialist out patient clinics in a large teaching hospital.

POPULATION

Women undergoing out patient hysteroscopy and endometrial biopsy for abnormal uterine bleeding.

METHOD

Out patient hysteroscopy using carbon dioxide, saline or saline with lignocaine.

MAIN OUTCOME MEASURES

Visual analogue score (VAS) for pain and present pain intensity (PPI) as assessed by patients and the quality of hysteroscopic view as assessed by the operator.

RESULTS

Of the 305 women approached, 300 women were randomised into the study. The mean [SD] VAS for pain in the carbon dioxide group was 2.9 [2.3] and in the saline group was 3.1 [2.6], the difference was not statistically significant (P= 0.49). The mean [SD] VAS for pain in the saline plus lignocaine group was 3.2 [2.4]. This was not significantly different from the saline group (P= 0.72). There was a statistically significant difference between the confidence rating for the hysteroscopic view for the carbon dioxide compared with the saline group; mean [SD] was 8.3 [2.1] and 9.6 [1.1], respectively (P= 0.001).

CONCLUSION

Carbon dioxide and saline as distension media are comparable in terms of overall patient discomfort and satisfaction, but saline provides better views and increases confidence in diagnosis. Adding lignocaine to the saline distension medium does not confer any additional benefit.

Suppression of pelvic pain during hysteroscopy with a transcutaneous electrical nerve stimulation device

OBJECTIVE

To evaluate the effectiveness of transcutaneous electrical nerve stimulation (TENS) as a pain control method during office hysteroscopy.

DESIGN

A prospective, randomized study.

SETTING

Centre for Minimally Invasive Surgery, Department of Gynecological Science and Perinatology, "La Sapienza" University, Rome, Italy.

PATIENT(S)

One hundred forty-two patients undergoing office hysteroscopy.

INTERVENTION(S)

Application of a TENS device on the patient's abdomen before and during office hysteroscopy.

MAIN OUTCOME MEASURES

The level of pain experienced by the patients was assessed using a 10 cm visual analog scale; the side effects and changes in the hemodynamic parameters were evaluated.

RESULT(S)

The patients treated with TENS during hysteroscopy (group A, n = 71) were compared with a control group (group B, n = 71) on whom the TENS device was not used. The women in the TENS group experienced a significantly lower level of pain during hysteroscopy. No differences in side effects were observed between both group.

CONCLUSION(S)

TENS is a simple, efficient, and safe method of relieve pain during office 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.

Topical anesthesia for minor gynecological procedures: a review

This article reviews the published literature for topical anesthetics that have been used for pain relief during minor gynecological procedures. EMLA (an eutectic mixture of the local anesthetics, lidocaine 2.5% and prilocaine 2.5%), which is the best-studied topical anesthetic, produces effective analgesia for superficial surgical procedures after application for 5 to 10 minutes and has been extensively studied in various procedures including removal of genital warts, vulval biopsy, laser treatment of CIN lesions, and hysteroscopy. EMLA is well tolerated and provides good pain relief for procedures involving the surface tissues such as removal of genital warts and hysteroscopy. For procedures involving deeper tissues, EMLA reduces the pain of local anesthetic injection. Other topical anesthetics, such as lidocaine gel and spray, benzocaine 20% gel, mepivacaine solution, tetracaine solution, and cocaine spray, have been less extensively studied in these indications, and benefits seem to be limited.