Intrauterine anesthesia for gynecologic procedures: a systematic review

Pain Management for In-Office Uterine and Cervical Procedures

SUMMARY

In-office gynecologic procedures, such as intrauterine device insertion, endometrial biopsy, hysteroscopy, intrauterine imaging, and cervical biopsy, among others, are common procedures experienced by many patients. There is an urgent need for health care professionals to have a better understanding of pain-management options and to not underestimate the pain experienced by patients and for patients to have more autonomy over pain-control options during in-office procedures. The way pain is understood and managed by health care professionals is also affected by systemic racism and bias of how pain is experienced. Specific populations, such as adolescents and those with a history of chronic pelvic pain, sexual violence or abuse, and other pain conditions, may also have increased or decreased tolerance of pain and resistance to pain medications. Several pain-management interventions being used have limited or conflicting evidence supporting their effectiveness at providing adequate pain control during in-office gynecologic procedures. Health care professionals therefore must be cautious when extrapolating data on what works for one procedure to another. Shared decision making with the patient should be practiced when discussing pain-management options because options that work for one patient may not work for another. Future research on pain and the management of pain must be more racially and ethnically diverse. Studies should include gender-diverse participants, focus on patient preferences and goals, and consider the needs of patients of various ages and those who have a history of trauma.

Transcutaneous Electric Nerve Stimulation for Analgesia During Outpatient Endometrial Biopsy: A Randomized Controlled Trial

OBJECTIVE

To evaluate whether transcutaneous electric nerve stimulation (TENS) decreases pain at the time of outpatient endometrial biopsy.

METHODS

We conducted a randomized, double-blind trial of active TENS compared with placebo TENS at the time of endometrial biopsy. The primary outcome was pain measured on a 0- to 100-mm visual analog scale immediately after biopsy, with secondary outcomes including satisfaction and tolerability of TENS and pain scores at other procedural time points. To detect a 15-mm reduction in pain with a 30-mm SD, 80.0% power, and a significance level of 0.05, 64 participants were required in each arm.

RESULTS

From December 2022 to December 2023, 135 participants were randomized with 67 in the placebo TENS arm and 68 in the active TENS arm. Baseline demographic and clinical characteristics were similar between groups. The median (interquartile range) pain score immediately after biopsy was 50 mm (20-80 mm) in the active TENS group and 60 mm (40-100 mm) in the placebo TENS group ( P =.039). Pain scores at other time intervals were not statistically significantly different. In a subset analysis, participants with higher-than-median baseline anxiety had postprocedural pain scores (interquartile range) of 50 mm (40-80 mm) in the active TENS group compared with 80 mm (50-100 mm) in the placebo TENS group. Overall satisfaction (interquartile range) with pain control (with 100 mm representing completely satisfied) was 87.5 mm (60-100 mm) for active TENS and 70 mm (41-100 mm) for placebo TENS; 85.3% of active TENS participants would use TENS in a future endometrial biopsy. Minimal side effects were associated with TENS, with one participant reporting itching at the pad sites.

CONCLUSION

Despite a statistical difference in pain scores, a clinical difference was not seen between active and placebo TENS for pain during endometrial biopsy. Satisfaction was higher in the active TENS group, and there were overall minimal side effects associated with TENS.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov , NCT05472740.

Optimizing analgesia for endometrial biopsy: A prospective, randomized comparative study

AIM

This prospective, randomized, observational study aimed to compare the efficacy of intrauterine lidocaine, oral dexketoprofen, cervical lidocaine spray, and paracervical block with prilocaine for pain management during outpatient endometrial biopsy (EMB).

METHODS

One hundred ninety-seven women aged 18-75 undergoing EMB were randomly assigned to one of four groups: intrauterine lidocaine (n = 49), oral dexketoprofen (n = 48), cervical lidocaine spray (n = 50), or paracervical block with prilocaine (n = 50). Pain intensity was assessed using a visual analog scale (VAS) immediately post-procedure and at 30 min, with additional analgesia needs recorded at 60 min. Statistical analyses included Kruskal-Wallis, chi-square tests, and post hoc analysis.

RESULTS

The intrauterine lidocaine group had the lowest pain scores, while oral dexketoprofen had the highest (p < 0.001). Intrauterine lidocaine and paracervical block scores were significantly lower than those in the lidocaine spray and dexketoprofen groups (p < 0.001). Additional analgesia was needed in 30% of the lidocaine spray group, with none required in other groups. Severe pain (VAS ≥5.8) was more frequent in the dexketoprofen group compared to others (p < 0.001).

CONCLUSION

Intrauterine lidocaine and paracervical block are more effective than lidocaine spray and oral dexketoprofen in reducing procedural pain during EMB, highlighting the importance of appropriate analgesic selection to enhance patient comfort in office-based gynecological procedures.

Efficacy of intrauterine device procedural analgesics

ABSTRACT

Nearly half of all pregnancies worldwide are unintended. Intrauterine devices are an effective, long-acting form of pregnancy prevention that require minimal maintenance, and also can be used in patients with menorrhagia. However, they are underused because of pain associated with their insertion. Topical and local anesthesia are good options for reducing procedural pain in select patients. IUD placement falls within the scope of practice for physician associates/assistants (PAs) practicing in family medicine, internal medicine, and women's health. PAs should be aware of these additional analgesia options available to patients in order to increase use of effective contraception.

Safety and Efficiency Outcomes of Ambulatory Gynaecologic Procedures in Canadian Surgical Centres Adopting a Common Model

OBJECTIVE

The present study aims to compare the safety and efficiency outcomes of ambulatory gynaecologic procedures performed under conscious sedation and/or local anaesthetic at 2 Canadian institutions.

METHODS

A retrospective cohort study was completed over 1-year on patients presenting to the ambulatory care centres at 2 Canadian institutions that shared a common care model. Outcomes of interest were lead time (registration to discharge), procedural time, and intraoperative complications. Surgical data was derived from a retrospective chart review and outcomes were compared using the independent t test and one-way analysis of variance.

RESULTS

A total of 1495 and 1098 patients presented to the 2 sites. The average age of patients was 35.5 ± 12.3 years and 41.7 ± 10.2 years. The most commonly performed procedures were dilatation and curettages at the first centre and operative hysteroscopies at the second centre. Average lead times were similar: 170.3 ± 35.8 minutes and 171.6 ± 45.4 minutes (P = 0.45). There was a significant difference in mean procedural time being 9.8 ± 5.5 minutes and 17.0 ± 10.0 minutes (P < 0.001). The rate of minor intraoperative complications was 3.8% and 6.6% (P = 0.002); whereas the rate of major complications was 2.7% and 3.3% (P = 0.43).

CONCLUSION

In Canada, the majority of gynaecologic procedures are performed under general anesthesia. By comparing outcomes at 2 separate Canadian centres, we demonstrated the reproducibility of a common ambulatory model for minor gynaecologic procedures, supporting the implementation of similar care models across Canada.

Is Forced Coughing Effective in Reducing Pain During Cervical Biopsy?: A systematic review and meta-analysis

This review aimed to compare the potential analgesic effect of forced coughing (FC) with that of local anaesthetics (LA) or placebo during cervical biopsy. A total of 5 electronic databases-Scopus, PubMed, Web of Science, Cochrane Library and Google Scholar-were systematically searched from inception till March 2021. Data were extracted from 6 randomised controlled trials and analysed. During cervical biopsy, the overall effect favoured LA over FC (mean difference [MD] = 1.06, 95% confidence interval [CI]: 0.58 to 1.54; P <0.0001). Compared to no pain management, pooled data were comparable between the two groups (MD = -1.2, 95% CI: -3.35 to 0.94; P = 0.27). Procedure duration was significantly longer in the LA group than in the FC group (MD = -1.94, 95% CI: -2.47 to -1.41; P <0.00001). FC and LA are both useful pain-lowering modalities during cervical biopsy, depending on the setting and their availability.

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.

Intrauterine Levobupivacaine Instillation for Pain Control in Women Undergoing Diagnostic Hysteroscopy

OBJECTIVES

Many women experience pain and discomfort after hysteroscopic procedure. Pain and discomfort after hysteroscopic procedures can be explained by the cervical dilatation, intrauterine manipulation, and/or hydrodistension. This study designed to evaluate the efficacy of intrauterine levobupivacaine instillation for pain control in women undergoing diagnostic hysteroscopy.

MATERIALS AND METHODS

One hundred and twenty (120) women scheduled for diagnostic hysteroscopy and endometrial biopsy due to uterine bleeding were included in this study and randomized either to levobupivacaine group or controls. At the end of hysteroscopy, 5 mL of 0.5% levobupivacaine was instilled intrauterine in levobupivacaine group, while 5 mL of 0.9% saline was instilled intrauterine in controls. Participants were kept in the hospital for 12 h after diagnostic hysteroscopy to detect the postoperative (PO) pain intensity using visual analog scale (VAS), and PO required analgesics.

RESULTS

The VAS was significantly lower in levobupivacaine group compared to controls 3 h. PO (1.31 ± 1.02 vs. 1.62 ± 0.76, respectively), (P = 0.01), 6 h. PO (0.81 ± 1.24 vs. 1.53 ± 0.88, respectively), (P = 0.004), and 9 h. PO (0.55 ± 1.25 vs. 1.12 ± 0.95, respectively), (P = 0.01). The total PO required analgesics were significantly lower in levobupivacaine group compared to controls (P = 0.005).

CONCLUSION

The intrauterine levobupivacaine instillation was simple, and effective for pain relief after diagnostic hysteroscopy, it significantly decreased pain score assessed by VAS at 3, 6, and 9 h., PO, and it significantly decreased PO required analgesics.

The Choice of Anesthetic Drugs in Outpatient Hysteroscopic Surgery: A Systematic Review and Network Meta-Analysis

Objective

Hysteroscopy is a minimally invasive gynecologic technique that is widely practiced in outpatient procedures. The choice of anesthesia is a key factor for the surgical outcome and postoperative recovery. This study was conducted to assess the effects of different anesthetic modalities based on dexmedetomidine in outpatient hysteroscopic surgery anesthesia.

Methods

We did a systematic review and network meta-analysis of outpatient hysteroscopic surgery anesthesia. We searched Pubmed, Embase, and Cochrane-Library from database inception to December 31, 2021. Duplicate literature was excluded and screened separately for initial screening at three tiers: article title, abstract, and full text before deciding whether to include in this study against the above criteria. Results after analysis of categorical variables were expressed as ORR Ratio (95% CI) and continuous variables were expressed as Mean Difference (95% CI). Data collation and analyses were performed using the gemtc package in the R language.

Results

Four trials were finally included with data for 301 participants, three anesthetic drugs, and five anesthetic modalities. A fixed-effects model was used for the different anesthesia modalities without significant heterogeneity (all I2<20%) in the analysis of adverse events (AEs), the incidence of respiratory depression, operative time, and time in the post-anesthesia care unit (PACU). Remimazolam tosylate was associated with a lower incidence of AEs versus dexmedetomidine, and significant differences between dexmedetomidine and propofol were absent. Propofol and various doses of remimazolam tosylate resulted in a lower incidence of respiratory depression versus dexmedetomidine, with an absence of differences between propofol and dexmedetomidine. The operative time for different anesthetic modalities was, in descending order, dexmedetomidine < remimazolam tosylate (0.60 mg/kg/h <0.48 mg/kg/h) < propofol < remimazolam tosylate (1.00 mg/kg/h), despite the absence of intergroup differences. Propofol was associated with a longer time in PACU versus dexmedetomidine and remimazolam tosylate (1.00 mg/kg/h); those of dexmedetomidine and remimazolam tosylate (1.00 mg/kg/h) were similar. The time in PACU for different anesthetic modalities, in descending order, was dexmedetomidine < remimazolam tosylate (1.00 mg/kg/h) < propofol. Propofol was associated with a longer time in PACU versus dexmedetomidine and remimazolam tosylate.

Conclusion

In outpatient hysteroscopic surgery anesthesia, dexmedetomidine was associated with a higher incidence of AEs and respiratory depression and a shorter operative time and time in PACU versus remimazolam tosylate and propofol. Remimazolam tosylate showed safety benefits with a similar duration of PACU stay versus dexmedetomidine. Therefore, the choice of anesthetic drugs in outpatient surgery requires consideration of the patient's conditions and preferences.

Analgesic Efficacy of Intrauterine Lidocaine Flushing in Hysterosalpingo-foam Sonography: A Double-blind Randomized Controlled Trial

STUDY OBJECTIVE

To evaluate the efficacy of flushing the uterine cavity with lidocaine before hysterosalpingo-foam sonography (HyFoSy) to reduce procedure-related pain.

DESIGN

A double-blind randomized controlled trial was conducted at the Department of Obstetrics and Gynecology, Shamir Medical Center, Israel between June 2020 and September 2020 involving 80 women undergoing a HyFoSy procedure.

SETTING

University-affiliated medical center.

PATIENTS

A total of 40 women were assigned randomly to the lidocaine group and 40 to the saline (placebo) group using a predetermined randomization code. Intrauterine instillation before the procedure consisting of either lidocaine 2% or normal saline alone was conducted, respectively.

INTERVENTIONS

The primary outcome measure was the visual analog scale (VAS) pain score during the phase of intrauterine foam instillation reported by the women after the procedure. The VAS consisted of a 10-cm line ranging from 0 to 10 (anchored by 0 = no pain and 10 = very severe pain). On the basis of the VAS scores, the pain level ratings were classified as mild (rated 1-3), moderate (4-6), or severe (7-10).

MEASUREMENTS AND MAIN RESULTS

The patient characteristics and obstetric data were found to be similar in both groups. Comparison of the VAS pain scores experienced during the procedure showed that women in the lidocaine flushing group rated the procedure less painful than the women in the saline group (3.0 ± 1.3 vs 6.3 ± 1.5, respectively; p = .001). The incidence of severe pain was significantly lower in the lidocaine group than the saline group (2.5% and 45.0%, respectively, p = .001).

CONCLUSION

Lidocaine flushing of the uterine cavity before HyFoSy significantly decreased the pain known to be caused by this procedure and had the advantage of no side effects. It is easily applied, relatively inexpensive, and may affect compliance with this procedure.

Addition of Lidocaine to the Distension Medium in Hysteroscopy Decreases Pain during the Procedure-A Randomized Double-blind, Placebo-controlled Trial

STUDY OBJECTIVE

To evaluate the effect of adding a local anesthetic to the distension medium in office diagnostic hysteroscopy using the vaginoscopic approach on pain during the procedure. Secondary aims included documenting side effects, patient satisfaction, and the time needed to complete the procedure.

DESIGN

Randomized double-blind placebo-controlled study.

SETTING

University-affiliated hospital; office hysteroscopy clinic.

PATIENTS

Total of 100 patients who underwent office hysteroscopies divided in half with 50 in the intervention group and 50 in the control group.

INTERVENTIONS

Ten mL of lidocaine 2% added to 1000 mL of saline solution that was used as the distension medium for hysteroscopy in the study group vs 1000 mL of saline alone in the control group.

MEASUREMENTS AND MAIN RESULTS

A significant difference was found in the increment of pain as measured by visual analog scale after the hysteroscopy between the 2 groups. Patients receiving lidocaine had an average rise of 1.9 in the visual analog scale score after the procedure compared with 2.9 in the control group (p = .033). There was also a nonsignificant trend for shorter duration of hysteroscopy in the intervention group compared with the control group (180.1 vs 222.1 seconds, p = .08). Patients' satisfaction was high in both groups (98% for the study group and 92% for the control group). Success rates were also similar between the 2 groups at approximately 95%. No side effects were recorded in either group.

CONCLUSION

The addition of local anesthetic to the distension medium in office hysteroscopy produces significant reduction in pain during the procedure without adding time to the procedure and without side effects.

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.

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.

Perioperative pain management strategies among women having reproductive surgeries

This review presents opioid-sparing strategies for perioperative pain management among women undergoing reproductive surgeries and procedures. Recommendations are provided regarding the use of nonsteroidal anti-inflammatory drugs, acetaminophen, other adjunctive medications, and regional anesthetic blocks. Additional considerations for chronic opioid users or patients using opioid replacement or antagonist therapy are discussed.

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.

Interventions for pain with intrauterine device insertion

BACKGROUND

Fear of pain during insertion of intrauterine contraception (IUC) is a barrier to use of this method. IUC includes copper-containing intrauterine devices and levonorgestrel-releasing intrauterine systems. Interventions for pain control during IUC insertion include non-steroidal anti-inflammatory drugs (NSAIDs), local cervical anesthetics, and cervical ripening agents such as misoprostol.

OBJECTIVES

To review randomized controlled trials (RCTs) of interventions for reducing IUC insertion-related pain

SEARCH METHODS

We searched for trials in CENTRAL, MEDLINE, EMBASE, POPLINE, ClinicalTrials.gov, and ICTRP. The most recent search was 22 June 2015. We examined reference lists of pertinent articles. For the initial review, we wrote to investigators to find other published or unpublished trials.

SELECTION CRITERIA

We included RCTs that evaluated an intervention for preventing IUC insertion-related pain. The comparison could have been a placebo, no intervention, or another active intervention. The primary outcomes were self-reported pain at tenaculum placement, during IUC insertion, and after IUC insertion (up to six hours).

DATA COLLECTION AND ANALYSIS

Two authors extracted data from eligible trials. For dichotomous variables, we calculated the Mantel-Haenszel odds ratio (OR) with 95% confidence interval (CI). For continuous variables, we computed the mean difference (MD) with 95% CI. In meta-analysis of trials with different measurement scales, we used the standardized mean difference (SMD).

MAIN RESULTS

We included 33 trials with 5710 participants total; 29 were published from 2010 to 2015. Studies examined lidocaine, misoprostol, NSAIDs, and other interventions. Here we synthesize results from trials with sufficient outcome data and moderate- or high-quality evidence.For lidocaine, meta-analysis showed topical 2% gel had no effect on pain at tenaculum placement (two trials) or on pain during IUC insertion (three trials). Other formulations were effective compared with placebo in individual trials. Mean score for IUC-insertion pain was lower with lidocaine and prilocaine cream (MD -1.96, 95% CI -3.00 to -0.92). Among nulliparous women, topical 4% formulation showed lower scores for IUC-insertion pain assessed within 10 minutes (MD -15.90, 95% CI -22.77 to -9.03) and at 30 minutes later (MD -11.10, 95% CI -19.05 to -3.15). Among parous women, IUC-insertion pain was lower with 10% spray (median 1.00 versus 3.00). Compared with no intervention, pain at tenaculum placement was lower with 1% paracervical block (median 12 versus 28).For misoprostol, meta-analysis showed a higher mean score for IUC insertion compared with placebo (SMD 0.27, 95% CI 0.07 to 0.46; four studies). In meta-analysis, cramping was more likely with misoprostol (OR 2.64, 95% CI 1.46 to 4.76; four studies). A trial with nulliparous women found a higher score for IUC-insertion pain with misoprostol (median 46 versus 34). Pain before leaving the clinic was higher for misoprostol in two trials with nulliparous women (MD 7.60, 95% CI 6.48 to 8.72; medians 35.5 versus 20.5). In one trial with nulliparous women, moderate or severe pain at IUC insertion was less likely with misoprostol (OR 0.30, 95% CI 0.16 to 0.55). In the same trial, the misoprostol group was more likely to rate the experience favorably. Within two trials of misoprostol plus diclofenac, shivering, headache, or abdominal pain were more likely with misoprostol. Participants had no vaginal delivery. One trial showed the misoprostol group less likely to choose or recommend the treatment.Among multiparous women, mean score for IUC-insertion pain was lower for tramadol 50 mg versus naproxen 550 mg (MD -0.63, 95% CI -0.94 to -0.32) and for naproxen versus placebo (MD -1.94, 95% CI -2.35 to -1.53). The naproxen group was less likely than the placebo group to report the insertion experience as unpleasant and not want the medication in the future. An older trial showed repeated doses of naproxen 300 mg led to lower pain scores at one hour (MD -1.04, 95% CI -1.67 to -0.41) and two hours (MD -0.98, 95% CI -1.64 to -0.32) after insertion. Most women were nulliparous and also had lidocaine paracervical block.

AUTHORS' CONCLUSIONS

Nearly all trials used modern IUC. Most effectiveness evidence was of moderate quality, having come from single trials. Lidocaine 2% gel, misoprostol, and most NSAIDs did not help reduce pain. Some lidocaine formulations, tramadol, and naproxen had some effect on reducing IUC insertion-related pain in specific groups. The ineffective interventions do not need further research.

Anxiety at outpatient hysteroscopy

This review summarises current understanding and research on the association between anxiety and outpatient hysteroscopy. Women undergoing hysteroscopy suffer from significant levels of anxiety, with repercussions on pain perception, success rates and satisfaction. Using validated tools such as the Spielberger State-Trait Anxiety Index (STAI) or the Hospital Anxiety and Depression Scale (HADS) in the outpatient hysteroscopy setting, average state anxiety scores similar or greater than those measured before more invasive procedures under general anaesthesia have been consistently reported. This clearly suggests a significant gap between our clinical viewpoint of what is "minimally invasive" and patients' expectations. In spite of its potential role of confounder in studies on pain-reduction interventions, we found that patient anxiety was evaluated in only 9 (13 %) out of a sample of 70 randomised controlled trials on outpatient hysteroscopy published since 1992. Factors such as trait anxiety, age, indication and the efficiency of the clinic can be correlated to state anxiety before hysteroscopy, but more robust data are needed. Promising non-pharmacological interventions to reduce anxiety at hysteroscopy include patient education, communication through traditional or multimedia approaches, interaction and support during the procedure and music listening.

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

IMPLICATIONS

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

Local anesthetic versus forced coughing at colposcopic-guided biopsy: a prospective study

OBJECTIVE

To evaluate whether the administration of local anesthetic (LA) reduces pain in comparison with forced coughing (FC) for the execution of colposcopically guided biopsies (CGBs).

STUDY DESIGN

Data of 100 consecutive patients undergoing CGBs with the use of LA or FC were prospectively evaluated. Procedure-related pain was assessed with the use of a 100-mm visual analogue scale.

RESULTS

Fifty-one and 49 patients had CGBs using LA and FC, respectively. No between-group differences were observed in terms of pain related to speculum insertion, CGBs and pain recorded after the procedures (p>0.05). However, patients in the LA group experienced pain related to cervical injection for administration of anesthesia (mean (±SD): 12.4 (±1.6)). Operative time was longer in the LA than in the FC group (7.2 (±0.2) vs. 5.0 (±0.1)min; p<0.001).

CONCLUSIONS

FC should be preferred over LA. Although CGB-related pain levels do not differ, the omission of intracervical injection is associated with undoubted advantages.

Introduction of a manual vacuum aspiration service: a model of service within a NHS Sexual Health Service

BACKGROUND

We assessed the applicability, acceptability and cost implications of introducing the manual vacuum aspiration (MVA) technique with local anaesthesia for fully conscious first-trimester termination of pregnancy within our service and for our population.

SETTING

The outpatient setting of a Pregnancy Advisory Service within a NHS Sexual Health Service.

METHODS

Self-administered misoprostol and diclofenac, extra-amniotic local anaesthetic gel and paracervical mepivicaine prior to MVA. Routinely collected data were used to provide information on uptake, demographic details, timing, pain score, complications, contraceptive uptake, and economic implications for our service.

RESULTS

MVA was chosen by 305/1681 potentially eligible women. Forty percent had the procedure on the day they attended for assessment. Seventy-nine percent gave a pain score of 3 or less out of 10. Complications occurred in six cases (2%); these included cervical rigidity, a false passage, retained products of conception, bleeding (more than 200 ml) and one allergic reaction. Eighty percent of women chose to commence a long-acting reversible contraception (LARC) method at the time of MVA. Operating theatre utilisation was reduced by one termination list per week and cost savings of around £60,000 per annum were realised.

CONCLUSIONS

The technique for fully conscious MVA was very suitable for our outpatient setting. It was associated with very low levels of pain and bleeding. The uptake of LARC was high, and particularly the ability to provide intrauterine contraception at MVA was associated with a very high uptake.

Hysteroscopic sterilization in the office setting

Hysteroscopic sterilization is growing in popularity. Nearly 500,000 women have been sterilized using this method, and an increasing number of physicians are now performing this procedure in the office setting. The office setting can provide a cost-effective, convenient, and safe environment for hysteroscopic sterilization. Patients may benefit from avoiding hospital preoperative visits, excessive laboratory evaluation, operating room wait times, and expense associated with hospital care. Physicians may improve productivity through remaining in their office or avoiding operating room delays. This article reviews office-hysteroscopic sterilization with the Essure microinsert system.

Safety considerations for office-based obstetric and gynecologic procedures

The migration of gynecologic procedures to office-based settings provides numerous advantages for patients and providers alike, including reduced patient expenses, improved scheduling convenience, favorable provider reimbursement, and enhanced continuity of care and patient satisfaction. With rising health care costs-a major concern in health care-procedures will continue to shift to practice environments that optimize care, quality, value, and efficiency. It is imperative that gynecologic offices ensure that performance and quality variations are minimized across different sites of care; physicians should strive to provide care to patients that optimizes safety and is at least equivalent to that delivered at traditional sites. The gynecologic community should nonetheless heed the Institute of Medicine's recommendations and embrace continuous quality improvement. By exercising leadership, office-based gynecologists can forge a culture of competency, teamwork, communication, and performance measurement.