Randomized Trial of Oral Misoprostol Before Endometrial Biopsy

Guideline No. 451: Asymptomatic Endometrial Thickening in Postmenopausal Women

OBJECTIVE

To formulate strategies for clinical assessments for endometrial thickening on ultrasound in a postmenopausal woman without bleeding.

TARGET POPULATION

Postmenopausal women of any age.

OUTCOMES

To reduce unnecessary invasive interventions and investigations in women with asymptomatic endometrial thickening while selectively investigating women at risk for endometrial cancer.

BENEFITS, HARMS, AND COSTS

It is anticipated that the adoption of these recommendations would save postmenopausal women unnecessary anxiety, pain, and risk of procedural complications. It is also expected to decrease the cost to the health care system by eliminating unnecessary interventions.

EVIDENCE

English language articles from Medline, Cochrane, and PubMed databases for relevant peer-reviewed articles dating from 1995 to 2022 (e.g., asymptomatic endometrial thickness, endometrial cancer, postmenopausal bleeding, transvaginal ultrasound, endometrial biopsy, cervical stenosis, hormone therapies and the endometrium, tamoxifen, tibolone, aromatase inhibitors). Results were restricted to systematic reviews and meta-analyses, randomized controlled trials/controlled clinical trials, and observational studies.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).

INTENDED AUDIENCE

Physicians, including gynaecologists, obstetricians, family physicians, radiologists, pathologists, and internists; nurse practitioners and nurses; medical trainees, including medical students, residents, and fellows; and other providers of health care of the postmenopausal population.

SOCIAL MEDIA ABSTRACT

Postmenopausal women often have a thickening of the lining of the uterus found during ultrasound. Without bleeding, an endometrium <11 mm is rarely a serious problem but should be evaluated by a health care provider.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Endometrial Biopsy: Indications and Technique

Abnormal uterine bleeding is a frequent medical concern for premenopausal and postmenopausal patients. Endometrial biopsy is a safe, cost-effective option offered in the office setting. Although endometrial biopsy may result in insufficient tissue or false-negative results, data suggest that endometrial biopsy is 90% sensitive for endometrial cancer and 82% sensitive for atypical hyperplasia, with specificity of 100% for postmenopausal patients and similar results in premenopausal patients. Topical cervical analgesia and oral nonsteroidal anti-inflammatory drugs decrease a patient's discomfort during endometrial biopsy. Aftercare instructions and how patients want to receive results should be reviewed in advance of performing the endometrial biopsy.

Methods of pain control during endometrial biopsy: A systematic review and meta-analysis of randomized controlled trials

AIM

To review effectiveness of methods for reducing pain during endometrial biopsy.

METHODS

PubMed, Scopus, Cochrane Central Register of Controlled Trials and ClinicalTrials.gov databases were searched for randomized controlled trials that examined effectiveness of pain control methods for endometrial biopsy. Risk of bias was assessed from sequence generation, allocation concealment, blinding, incomplete outcome data and selective outcome reporting. Heterogeneity was examined from forest plot, statistical tests of homogeneity, and I² statistic. For meta-analysis of pain scores, weighted mean difference with 95% confidence interval (CI) were estimated.

RESULTS

Twenty-six studies were included in the review. Marginally significant reduction in the pain score during the procedure in participants with intrauterine lidocaine relative to control was observed (mean difference [MD] -1.31, 95% confidence interval [CI] -2.70 to 0.09, P = 0.07). Subgroup analysis showed that in studies that used low-pressure suction devices, intrauterine lidocaine was associated with statistically significant reduction in pain during the procedure (MD -2.22, 95% CI -3.72 to -0.73, P = 0.004). There was a significantly lower pain score during biopsy in the anesthetic spray group compared to control (MD -0.96, 95% CI -1.53 to -0.39, P = 0.001). Significant heterogeneity on types of intervention and outcome measures among studies that examined paracervical block and nonsteroidal anti-inflammatory drugs (NSAID) was observed. However, paracervical block and NSAID were associated with significant pain reduction compared to placebo in most of the related studies.

CONCLUSION

Intrauterine anesthetics, anesthetic cervical spray, paracervical block and oral NSAID provide effective pain control during endometrial biopsy.

[The risk factors and preventive measures of hospital infections on preoperative children with cleft lips and palates]

OBJECTIVE

To analyze the risk factors of preoperative upper respiratory infections in children with cleft lips and palate (CLP) and investigate preventive measures to reduce infections and improve the quality of treatments.

METHODS

A total of 510 children with CLP of ages 3 years old or younger were selected from hospital cases from June to December 2017. The test group comprised 50 children with upper respiratory infections, whereas the control group comprised 460 children without upper respiratory infections. A t-test and a multivariate logistic analysis were utilized to analyze the risk factors and to investigate the preventive measures.

RESULTS

Feeding patterns, the presence of infected companions during hospitalization, and ventilation at night were statistically significant. The feeding patterns and the presence of infected companions during hospitalization were independent risk factors for upper respiratory infections in children with CLP.

CONCLUSIONS

Bottle feeding, infected companions during hospitalization, and the absence of window ventilation at night are risk factors for preoperative upper respiratory infections in children 3 years old or younger with CLP. Among the risk factors identified, feeding patterns and the presence of infected companion during hospitalization were the most influential. Medical staff members should streng-then corresponding health education and nursing measures to control the risk factors.

Effectiveness of Intrauterine Lignocaine in Addition to Paracervical Block for Pain Relief during Dilatation and Curettage, and Fractional Curettage

PURPOSE OF STUDY

Dilatation and curettage (D&C) and fractional curettage (F/C) are commonly performed gynecological procedures. Randomized controlled trials have concluded that topical anesthesia effectively reduces pain in endometrial sampling and hysteroscopy. Our study was aimed at investigating this modality of pain relief in setting of a developing country where, due to lack of resources, successful completion of these procedures in an outpatient setting is a necessity.

METHODS

This study was a prospective, randomized, placebo-controlled, double-blind study conducted in 84 patients. All patients received either intrauterine 2 % lignocaine or normal saline along with oral NSAID and paracervical block prior to the procedure. The pain was analyzed at three steps: at the time of curette, immediately post-procedure, and 30 min later using 10-cm visual analog score.

RESULTS

The patients in the experimental and control groups were well matched for age, parity, body mass index, menopausal status, and the indications for intervention. At all the three stages, pain perceived in the lignocaine group was significantly less as compared to that in placebo group. As compared to lignocaine group (55 %), significantly higher number of women in placebo group (88 %) perceived severe pain during endometrial curettage (p = 0.001).

CONCLUSIONS

The present study indicates that two percent intrauterine lignocaine significantly decreases the pain perception during intrauterine gynecological procedures such as D&C and F/C. This is a simple, effective, inexpensive, and low-risk intervention which can potentially increase the patient acceptability and compliance with such procedures.

Effect of lidocaine spray in pain management during office-based endometrial sampling: A randomised placebo-controlled trial

Office-based endometrial sampling is the most frequently performed gynaecological procedure. The procedure is usually associated with pain and discomfort. Several anaesthetic and analgesic techniques (e.g., non-steroidal anti-inflammatory drugs, paracervical block, misoprostol and topical anaesthetics) are used for pain management during endometrial sampling. There is no comprehensive study using lidocaine in spray form; we sought to investigate the analgesic efficacy of 10% lidocaine spray in patients undergoing office-based endometrial biopsy. We conducted a prospective, randomised (lidocaine spray (n = 60) and placebo (n = 60), respectively), double-blind study. The mean pain score during procedure was 3.51 ± 1.51 in the lidocaine spray group and 5.11 ± 1.66 in the placebo group. Lidocaine spray treatment significantly lowered the pain scores compared with placebo (p < 0.001). Lidocaine spray can be accepted as a non-invasive, easy to apply and more comfortable anaesthetic method for office-based endometrial sampling.

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.