Pain control in outpatient hysteroscopy

The effect of informing the patient about the procedure with video imaging before office hysteroscopy on pain

OBJECTIVE

To evaluate the effect of informing patients undergoing diagnostic office hysteroscopy via a video 24 h before the procedure and determine the changes in pain scores, channel transit time, the degree of difficulty of the procedure, and physiological parameters.

DESIGN

Single-blind randomized controlled trial.

SETTING

The study was conducted between September 1, 2021 and April 1, 2022 at the University of Health Sciences Bakirkoy Dr. Sadi Konuk Training and Research Hospital.

PARTICIPANTS

A total of 134 patients aged 18-65 years who needed diagnostic office hysteroscopy.

INTERVENTIONS

Participants were randomized into two groups, the standard information group (Group 1: controls), and the video information + standard information group (Group 2). After office hysteroscopy, a visual analog scale (VAS) and Likert scale were used to assess pain and the degree of difficulty of the procedure, respectively. Physiological parameters were evaluated before and after the procedure.

MAIN OUTCOME MEASURE

To determine the effect of video-based multimedia information administered 24 h before office hysteroscopy on post-procedure pain.

RESULTS

The mean VAS score of the group that watched the training video (3.02 ± 1.88) was significantly lower than the control group (4.72 ± 2.54) who did not watch the training video (p < 0.001). The mean cervical channel transit time in seconds (sec) during the procedure was found to be significantly higher in the control group (21.57 ± 15.10 s) than in the video-watching group (p = 0.011). There was no significant difference between the groups in terms of physiological parameters and the degree of ease of the procedure.

CONCLUSION

Our study has shown that informing patients in a pre-procedure video is an effective approach that shortens the duration of the channel transit time and reduces pain.

Predictive Factors of Tolerance in Office Hysteroscopy - a 3-Year Analysis from a Tertiary Center

OBJECTIVE

 Pain is the primary limitation to performing hysteroscopy. We aimed to evaluate the predictive factors of low tolerance to office hysteroscopic procedures.

METHODS

 Retrospective cohort study of the patients who underwent office hysteroscopy from January 2018 to December 2020 at a tertiary care center. Pain tolerance to office-based hysteroscopy was subjectively assessed by the operator as terrible, poor, moderate, good, or excellent. Categorical variables were compared with the use of the Chi-squared test; an independent-samples t-test was conducted to compare continuous variables. Logistic regression was performed to determine the main factors associated with low procedure tolerance.

RESULTS

 A total of 1,418 office hysteroscopies were performed. The mean age of the patients was 53 ± 13.8 years; 50.8% of women were menopausal, 17.8% were nulliparous, and 68.7% had a previous vaginal delivery. A total of 42.6% of women were submitted to an operative hysteroscopy. Tolerance was categorized as terrible or poor in 14.9% of hysteroscopies and moderate, good, or excellent in 85.1%. A terrible or poor tolerance was more frequently reported in menopausal women (18.1% vs. 11.7% in premenopausal women, p = 0.001) and women with no previous vaginal delivery (18.8% vs. 12.9% in women with at least one vaginal birth, p = 0.007). Low tolerance led more often to scheduling a second hysteroscopic procedure under anesthesia (56.4% vs. 17.5% in reasonable-to-excellent tolerance, p < 0.0005).

CONCLUSION

 Office hysteroscopy was a well-tolerated procedure in our experience, but menopause and lack of previous vaginal delivery were associated with low tolerance. These patients are more likely to benefit from pain relief measures during office hysteroscopy.

Pain and anxiety in office histeroscopy

BACKGROUND

Anxiety is almost always present before medical interventions and may play a role in pain perception. We aim to evaluate factors associated with pain intensity reported by patients submitted to Office Hysteroscopy (OH).

METHODS

Cross-sectional observational study, with data from April to November 2015. It included patients attended at the Assis Chateaubriand Maternity School (MEAC/UFC) with an indication of office hysteroscopy. Before the examination, the patients answered a validated questionnaire about anxiety (STAI). After the examination, women answered the Visual Analogue Scale (VAS). The data were analyzed using the Statistical Package for the Social Sciences (SPSS) 15.0, with Spearman correlation, Mann-Whitney U-test, and analyses of variance.

RESULTS

252 patients were included, with a mean age of 45.7 years, of whom 29% were postmenopausal (mean pain 5.5) and 71% were in menacme (mean pain 5.1) (p = 0.258). The anxiety trait and state showed a significant influence on the pain scale (p <0.001 and p=0.001), but age or endometrial sample did not. 27% of the patients were nulliparous. Less pain was associated with the number (p=0.01) and vaginal (p=0.005) of deliveries. The main indication for the procedure was abnormal uterine bleeding (54.4%).

CONCLUSION

OH may be associated with moderate but tolerable discomfort. There was a significant correlation between higher scores on the pain scale and anxiety. There was evidence of reduced pain with parity and type of delivery, but not with reproductive age or endometrial biopsy.

Use of video-based multimedia information to reduce anxiety before office hysteroscopy

Introduction

Use of multimedia tools has been shown to improve patient comprehension, reduce pre-procedural anxiety, and increase patient satisfaction in various surgical settings.

Aim

To investigate the impact of video-based multimedia information (MMI) on the anxiety levels of patients undergoing office hysteroscopy (OH).

Material and methods

All consecutive women aged 18–65 years and scheduled for diagnostic OH were enrolled in this prospective randomized study. Subjects were assigned to receive video-based MMI or conventional written information (controls). The trait and state anxiety were assessed using the State and Trait Anxiety Inventory (STAI) before the MMI or written information. STAI-state (STAI-S) was repeated after application of the MMI or written information. All patients underwent a standardized transvaginal hysteroscopy procedure by the same gynecologist. Following the hysteroscopy, patient satisfaction and procedural pain were ranked using a Likert scale and visual analogue scale.

Results

Fifty-two patients were randomized to receive a video-based MMI, and 52 patients were randomized to receive written information. Post-information STAI-S score was significantly lower in the MMI group than that of the written information group (45.0 ±8.0 vs. 49.4 ±8.4, p < 0.001, 95% CI for the difference: 1.36–7.79). Moreover, the satisfaction rate of the video group was significantly higher than the satisfaction rate of the controls (92.3% vs. 63.5%, p < 0.001). VAS score of procedural pain was similar for the two groups.

Conclusions

A video-based MMI before OH might be preferred to conventional information methods in order to reduce the pre-procedural anxiety and to increase patients’ satisfaction.

Evaluation of Paracervical Block and IV Sedation for Pain Management during Hysteroscopic Polypectomy: A Randomized Clinical Trial

BACKGROUND

The aim of this study was to compare the effectiveness of paracervical block (PB) and IV sedation (IVS) on women's pain perception during operative hysteroscopy.

METHODS

A total of 84 patients with uterine polyps were randomized to either PB or IV sedation or general anesthesia (GA) as control group. In PB group, the patients received oral diazepam 10 mg and 100 mg diclofenac Na suppository 60 min before surgery and 10 cc of 2% buffered lidocaine was injected at cervix. Conscious sedation was performed with the IV administration of 2-3 mg/kg/h propofol 1% and midazolam 0.02 mg/kg and fentanyl (1-2 μg/kg) with o2 4-5 lit/min via face mask.

RESULTS

There were no significant differences between groups on VAS score at 3 hours after operation (PB: 1.22 ± (1.31), IVS: 1.10 ± (1.68), GA: 1.29 ± (2.03), P = 0.671) and during recovery (PB: 0.85 ± (1.06), IVS: 0.68 ± (1.33), GA: 1.21 ± (2.04), P = 0.458). There was no difference between PB (3.33 ± (2.81)) and IVS (2.31 ± (2.63)) groups at hysteroscopy (P = 0.182). Patients undergoing IVS reported lower VAS score than PB group at dilation and curettage, although the difference was not statistically significant (PB: 2.59 ± (1.78), IVS: 1.72 ± (2.34), P = 0.051). Moreover, patients undergoing IVS obtained lower VAS score than PB group at polypectomy, while the difference was not statistically significant (PB: 1.81 ± (1.52), IVS: 1.10 ± (1.32), P = 0.073).

CONCLUSION

The finding of the present study revealed that IVS and PB showed the same effect in reducing pain during and after gynecological surgical procedures. The study was registered in Iranian Registry of Clinical Trial with the number IRCT2016031426855N3, on April 28, 2016.

The potential role of endometrial nerve fibers in the pathogenesis of pain during endometrial biopsy at office hysteroscopy

We aimed to evaluate whether nerve fibers are present in the endometrial layer of patients submitted to office hysteroscopy and their potential contribution to the pathogenesis of pain during that procedure. Through a prospective case-control study performed in tertiary centers for women's health, endometrium samples were collected during operative office hysteroscopy from 198 cycling women who previously underwent laparoscopy and/or magnetic resonance imaging investigation for infertility assessment. Samples were classified according to the degree of the pain patients experienced and scored from values ranging from 0 (absence of discomfort/pain) to 10 (intolerable pain) on a 10-cm visual analog scale (VAS). The presence of nerve fiber markers (S100, NSE, SP, VIP, NPY, NKA, NKB, NKR1, NKR2, and NKR3) in the endometrium was also evaluated by morphologic and immunohistochemical analyses. We found that S-100, NSE, NKR1, NK-A, NK-B, VIP, and NPY, were immunolocalized in samples of endometrium, in significantly (P < .01, for all) higher levels in samples collected from patients with VAS score > 5 (group A) than ≤ 5 (group B) and significantly (P < .0001 for all) positively correlated with VAS levels. A statistically significant (P = .018) higher prevalence of endometriosis and/or adenomyosis was depicted in patients of group A than group B. Data from the present study led us to conclude that nerve fibers are expressed at the level of the functional layer of the endometrium and may contribute to pain generation during office hysteroscopy, mainly in women affected by endometriosis and adenomyosis.

Prospective study of combined colon and endometrial cancer screening in women with lynch syndrome: a patient-centered approach

BACKGROUND

Endometrial and colorectal cancers are the most common cancers in Lynch syndrome. Consensus guidelines recommend annual endometrial biopsy (EMB) and regular colonoscopies. We assessed the feasibility of concurrently performing EMB and colonoscopy and evaluated women's perception of pain, satisfaction, and acceptability.

METHODS

From July 2002 to December 2009, women who had a gene mutation for Lynch syndrome, met the Amsterdam II criteria, or had a high-risk situation that required screening were prospectively enrolled. After conscious sedation, the procedures were sequentially performed. Patients completed pre- and postprocedure questionnaires assessing pain, level of satisfaction, and acceptability. The Wilcoxon rank test and Mann-Whitney test were used to compare pain scores.

RESULTS

Forty-two women completed the study. Median age was 37 years (range, 25 to 73). Nineteen had previously had an EMB in the office setting. Women reported significantly lower median levels of pain in the combined procedure compared with previous office setting biopsies (P < .001). Regardless of parity, women reported significantly less pain for an EMB as part of the combined screen compared with an office EMB (parous, P = .003; nulliparous, P = .026). Women also reported a high level of satisfaction and more convenience in the combined procedure. All participants preferred combined to separately scheduled procedures and would recommend the combined procedure to their relatives.

CONCLUSION

Combined colon and endometrial cancer screening is a patient-centered approach that is feasible, acceptable, and may improve adherence to Lynch syndrome screening recommendations.

Ear Acupoint Detection before and after Hysteroscopy: Is it Possible to Clarify the Representation of the Uterus on the Outer Ear?

Background

In the auricular maps introduced over the past 50 years by the French and Chinese schools, most organs and systems overlap consistently. One exception is the reproductive system, which shows a markedly different somatotopic representation—for example, for the uterus and the ovary.

Objective

To identify the distribution of points with increased tenderness to pressure or with reduced electrical resistance, on the outer ear of a group of women undergoing hysteroscopy.

Methods

For diagnostic purposes the auricles of 78 women were examined before and after hysteroscopy using a pain–pressure test and electrical skin resistance test. The points identified were transcribed onto a graphic system called Sectogram. Spatial cluster analysis was used to identify the statistically significant clusters of sectors with a higher concentration of points appearing after hysteroscopy.

Results

The points identified after hysteroscopy tend to be concentrated in specific areas not previously recognised and which only partially overlap with the French and Chinese representation of the uterus.

Conclusion

When auricular acupuncture is applied to reduce discomfort during hysteroscopy, particular attention must be paid when choosing the points/areas to be stimulated, which are not only those indicated in the Chinese or French maps.

Pain relief for outpatient hysteroscopy

BACKGROUND

Hysteroscopy is increasingly performed in an outpatient setting. The primary reason for failure is pain. There is no consensus upon the routine use of analgesia during hysteroscopy.

OBJECTIVES

The aim of the study was to compare the effectiveness of different types of pharmacological interventions for pain relief in patients undergoing hysteroscopy.

SEARCH STRATEGY

A search of medical literature databases including PubMed, EMBASE, PsycINFO and CINHAL (to February 2010).

SELECTION CRITERIA

Randomised controlled trials (RCTs) investigating pharmacological interventions for pain relief during hysteroscopy were investigated.

DATA COLLECTION AND ANALYSIS

Results for each study were expressed as a standardised mean difference with 95% confidence interval and combined for meta-analysis with Revman 5 software.

MAIN RESULTS

Twenty-four RCTS were identified involving a total of 3155 participants, with 15 studies included in the meta-analysis.Meta-analysis (nine RCTs, 1296 participants) revealed a significant reduction in the mean pain score for the use of local anaesthetics during the procedure compared with placebo (SMD -0.45, 95% CI -0.73 to -0.17, I(2) = 82%).Meta-analysis (4 RCTs, 454 participants) demonstrated a significant reduction in the mean pain score for the use of local anaesthetics within 30 minutes after the procedure compared with placebo (SMD -0.51, 95% CI -0.81 to -0.21, I(2) = 54%).There was no significant reduction in the mean pain score with the use of NSAIDS or opioid analgesics compared with placebo during or within 30 minutes after the procedure.There was no significant reduction in the mean pain score with the use of local anaesthetics, NSAIDS or opioid analgesics compared with placebo more than 30 minutes after the procedure.There was no significant difference between the number of incidents of failure to complete the procedure due to cervical stenosis between the intervention and control groups (OR 1.31, 95% CI 0.66 to 2.59; 6 RCTs, 805 participants).There were significantly fewer incidents of failure to complete the procedure due to pain in the intervention group than in the control group (OR 0.29, 95% CI 0.12 to 0.69; two studies, 330 participants).Meta-analysis demonstrated no significant difference between the intervention and placebo groups with regards to adverse effects.

AUTHORS' CONCLUSIONS

There was a significant reduction in the mean pain score with the use of analgesia during and within 30 minutes after outpatient hysteroscopy. 

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.

Office hysteroscopy: current trends and potential applications: a critical review

Office hysteroscopy is an excellent method of identifying and treating intracavitary uterine lesions. It has become easy to learn and perform; as an aid of modern technological applications, it is safe, accurate, provides immediate results under direct visualisation, and offers the additional benefit of histological confirmation and the discomfort of patients is minimal. We applied an extended literature search to explore the special features and details of the technique itself, as it evolved since it first appeared 30 years back. Our initial goal was to examine potential changes/improvements of the modality, in terms of the instrumentation used and the technique itself, the indications of use, its incorporation in daily practice, and patients' and clinicians' acceptability.

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.

Hysteroscopy: a technique for all? Analysis of 5,000 outpatient hysteroscopies

OBJECTIVE

1) To investigate the relationship between operator experience and the success of outpatient hysteroscopy; and 2) to determine if the introduction of normal saline and the use of narrow-caliber hysteroscopes and vaginoscopic approach are associated with a lower failure rate.

DESIGN

Retrospective study.

SETTING

Teaching-hospital based outpatient hysteroscopy clinic.

PATIENT(S)

Five thousand consecutive women undergoing outpatient hysteroscopy between October 1988 and June 2003.

INTERVENTION(S)

The hysteroscopies were carried out both by experienced operators and by trainees. Procedures were performed using 4-mm and 2.9-mm telescopes with 5-mm and 3.5-mm diagnostic sheaths, respectively. Between October 1988 and 1996, the uterine cavity was distended with CO(2) (CO(2) period), whereas normal saline was preferred after 1997 (1997-2003: saline period). Traditional technique of hysteroscope insertion and vaginoscopic approach were used depending on operator preference and experience and patient characteristics.

MAIN OUTCOME MEASURE(S)

Success, failure, and complication rates.

RESULT(S)

The hysteroscopies were successfully performed in nearly 95% of cases by 362 operators (mean 13.8 hysteroscopies per operator) with different levels of expertise. Failure and complication rates were 5.2% and 5.4%, respectively, without any significant difference between CO(2) and saline periods. Vasovagal attacks and shoulder pain were significantly higher during the CO(2) period. The success of outpatient hysteroscopy was negatively affected by postmenopausal status, nulliparity, need for cervical dilatation or local anaesthesia, traditional technique of hysteroscope insertion, and use of a 5-mm hysteroscope.

CONCLUSION(S)

A high level of expertise is not a prerequisite to performing hysteroscopy on an outpatient basis. Recent advances in technique and instrumentation facilitate this approach and might encourage greater adoption by the wider gynecology community.

Predictive factors for pain experienced at office fluid minihysteroscopy

STUDY OBJECTIVE

Fluid minihysteroscopy is in most cases a painless procedure. However, rarely, severe pain and side effects are reported. The goal of this study was to identify predictive factors of pain at minihysteroscopy.

DESIGN

Prospective study (Canadian Task Force classification II-2).

SETTING

Academic environment.

PATIENTS

Five hundred thirty-three women undergoing fluid minihysteroscopy.

INTERVENTIONS

Diagnostic fluid minihysteroscopy.

MEASUREMENTS AND MAIN RESULTS

The women were asked to score pain perception on a visual analog scale from zero (no pain) to 5 (unbearable pain). Correlation between pain at procedure and parity, previous cesarean section (PCS), menopausal status, anxiety, and chronic pelvic pain (CPP) was evaluated. Four hundred thirteen women (78%) reported no pain or discomfort (0-1 pain score, group A), while 120 (22%) experienced mild to unbearable pain (2-5 pain score, group B). Instances of PCS, CPP, anxiety, and menopause were significantly lower in group A than in group B (4% vs 82%, 0% vs 29%, 62% vs 72%, 25% vs 72%, respectively), whereas menopausal status was less frequent in group A (25.2%) than in group B (72.5%). At binary logistic regression, all the variables were independent risk factors for pain; however, when CPP was stratified for intensity, no correlation between pain at procedure and intensity of CPP was found.

CONCLUSION

Previous cesarean section, CPP, anxiety, and menopause are predictive factors for pain perception during fluid minihysteroscopy, and history of CPP even of low intensity is predictive of pain at hysteroscopy. These patients may benefit from local anesthesia.

Efficacy of intravenous tramadol treatment for reducing pain during office diagnostic hysteroscopy

OBJECTIVE

To assess whether IV tramadol before outpatient hysteroscopy could reduce procedure-related pain.

DESIGN

A randomized double-blind placebo controlled trial.

SETTING

Outpatient Hysteroscopy Centre in the Department of Obstetrics and Gynaecology of Cagliari University.

PATIENT(S)

Fifty healthy, parous, women who underwent outpatient diagnostic hysteroscopy and endometrial biopsy.

INTERVENTION(S)

Random IV infusion of tramadol or placebo before hysteroscopy and endometrial biopsy were performed.

MAIN OUTCOME MEASURE(S)

Visual analogue scale of pain was measured both immediately after and 15 minutes after the procedure. Stress hormones (ACTH, cortisol), blood pressure, and heart frequency were evaluated before, during, and 15 minutes after the procedure.

RESULT(S)

In the tramadol group, the visual analogue scale of pain was significantly lower than in the placebo group both immediately after the procedure and 15 minutes later. Basal levels of ACTH and cortisol did not differ between the groups. In both groups, the ACTH levels remained unchanged during the study, and the cortisol levels were higher 15 minutes after the procedure than before the procedure. Procedure time, heart frequency, blood pressure, and adverse effects did not differ between the groups.

CONCLUSION(S)

In parous women without uterine malformations, a treatment with tramadol before hysteroscopy and endometrial biopsy appears to be capable of reducing the pain and discomfort that are associated with this procedure.

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.

Vaginoscopic versus traditional office hysteroscopy: a randomized controlled study

BACKGROUND

A randomized, controlled study was performed to compare vaginoscopic versus traditional (speculum with or without tenaculum) hysteroscopy in terms of pain score and procedure time.

METHODS

Three hundred patients were randomized in two groups: Group A, diagnostic hysteroscopy with vaginoscopic approach (150 patients) and Group B, diagnostic hysteroscopy with traditional approach (150 patients). All procedures were performed using a semi-rigid 3.5-mm minihysteroscope with a 0 degrees grade optic. Patients of each group were divided into three subgroups according to their reproductive status: fertile nulliparous (FN), fertile multiparous (FM) and post-menopausal (MEN) women. Women were asked to rate their degree of pain during four phases of the procedure: introduction of hysteroscope (Group A) or speculum (Group B) into the vagina (Phase I) and progression through cervical canal up to internal uterine orifice (IUO) (Phase II), inspection of uterine cavity (Phase III) and performing of endometrial biopsy (Phase IV). A total pain score was calculated for each group. For each patient, the duration of hysteroscopy was recorded from the introduction to the extraction of the scope (Group A) or of the speculum (Group B).

RESULTS

Although the median total pain scores were 2 in each group, the 95% confidence interval for vaginoscopic hysteroscopy (1.86-2.01) was significantly (P < 0.05) lower than that for traditional hysteroscopy (2.10-2.26). Comparison between the corresponding phases of the procedure showed the only significant difference during Phase I of the procedure [Group A: 1 (95% CI 1.0-1.18) versus Group B: 2 (95% CI 2.3-2.8); P < 0.05]. No significant differences in terms of duration of the procedure were observed between the two approaches.

CONCLUSIONS

When surgeons using vaginoscopic hysteroscopy with a semi-rigid minihysteroscope were compared with those using traditional approach and the same instrumentation, the operating times and the patients' pain scores were similar.

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.

Women's views and experiences of outpatient hysteroscopy: implications for a patient-centered service

This study examined women's views and experiences of an invasive outpatient procedure and was undertaken in the context of the UK Government's policy of developing a patient-centered service. The research was based on a consecutive series of 30 attendees for outpatient hysteroscopy at a London hospital. Pain was recorded using linear analog scales, qualitative semistructured interviews were undertaken and a diary was completed for 3 days following the procedure. Overall pain ratings for 13 women (45%) were classified as a medium to high score. However, nearly all women preferred a future outpatient procedure. A range of factors influenced this preference, including their ability to cope with the pain, the reduced anxiety associated with undergoing the procedure immediately, a dislike of general anesthetics and the convenience of not disrupting usual routines. The psychosocial aspects of care were also identified as important in assisting women to cope, and form a key factor influencing patient's evaluation of services.

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.

Hysteroscopy under general anaesthesia, a near painless procedure

Anecdotally, hysteroscopy and curettage under general anaesthesia causes crampy postoperative pain. A randomised, double-blind trial to investigate whether intrauterine lignocaine could decrease such pain was initiated by us. At an interim analysis, the results of the study found that almost half of all women studied so far (n = 53) were completely painfree from the moment they awoke with no difference between placebo and treatment groups. Of the remainder, most rated pain as either 'mild', or less. For most women, hysteroscopy, dilatation and curettage causes either none or very little pain postoperatively.