Evaluation and ranking of different interventions for pain relief during outpatient hysteroscopy: A systematic review and network meta-analysis

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 Management during Office Hysteroscopy: An Evidence-Based Approach

Background and Objectives: Hysteroscopy is a reliable technique which is highly useful for the evaluation and management of intrauterine pathology. Recently, the widespread nature of in-office procedures without the need for anesthesia has been requesting validation of practical approach in order to reduce procedure-related pain. In this regard, we performed a comprehensive review of literature regarding pain management in office hysteroscopic procedures. Materials and Methods: MEDLINE, EMBASE, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register), Global Health, Health Technology Assessment Database and Web of Science, other research registers (for example Clinical Trials database) were searched. We searched for all original articles regarding pain relief strategy during office hysteroscopy, without date restriction. Results have been collected and recommendations have been summarized according to the Appraisal of Guidelines for Research and Evaluation (AGREE) tool. Moreover, the strength of each recommendation was scored following the Grading of Recommendations Assessment (GRADE) system, in order to present the best available evidence. Results: Both pharmacological and non-pharmacological strategies for pain management are feasible and can be applied in office setting for hysteroscopic procedures. The selection of strategy should be modulated according to the characteristics of the patient and difficulty of the procedure. Conclusions: Accumulating evidence support the use of pharmacological and other pharmacological-free strategies for reducing pain during office hysteroscopy. Nevertheless, future research priorities should aim to identify the recommended approach (or combined approaches) according to the characteristics of the patient and difficulty of the procedure.

Determining the Optimal Time Interval between Vaginal Dinoprostone Administration and Diagnostic Office Hysteroscopy in Nulliparous Women: A Randomized, Double-blind Trial

STUDY OBJECTIVE

To determine the optimal timing of vaginal dinoprostone administration before office hysteroscopy (OH) in nulliparous women.

DESIGN

Randomized, double-blind trial.

SETTING

Tertiary referral hospital.

PATIENTS

A total of 180 nulliparous women undergoing diagnostic OH.

INTERVENTIONS

We randomly allocated the women to long-interval or short-interval dinoprostone groups: three mg dinoprostone was administered vaginally 12 hours before OH in the long-interval group and 3 hours before OH in the short-interval group.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was pain during OH measured using a 100-mm visual analog scale (0 = no pain; 100 = worst pain imaginable). The secondary outcomes were ease of hysteroscope passage, patient satisfaction score, and drug-related adverse effects. The patients in the long-interval dinoprostone group had lower pain scores during OH (p <.001). Contrarily, pain scores 30 minutes after the procedure were similar in both groups (p = .1). The patient satisfaction score was higher and clinicians found hysteroscope passage through the cervical canal easier and quicker in the long-interval dinoprostone group than in the short-interval group (p <.001, p = .003, and p <.001, respectively). Side effects were comparable in both study groups.

CONCLUSION

Vaginal dinoprostone administered 12 hours before OH was more effective than that administered 3 hours before OH in reducing pain during OH in nulliparous women, with easier hysteroscope insertion, shorter procedure duration, and higher patient satisfaction score.

Systematic review of the safety and efficacy of tramadol during office hysteroscopy

Office hysteroscopy (OH) is a common procedure in gynecology. Pain is the most frequently reported problem in OH. In this study, we aimed to investigate the role of tramadol administration in relieving pain in women undergoing OH. We searched PubMed, the Cochrane Library, ClinicalTrials.gov, MEDLINE, Scopus, and Web of Science databases for relevant clinical trials based on our search terms. We included randomized controlled trials and included all published trials in all six searched databases from their inception until February 28th 2021. We included pain as the primary outcome, and the incidence of adverse events of tramadol as secondary outcomes. We performed the analysis of continuous data using mean difference (MD) and dichotomous data using risk ratio (RR). We found that tramadol led to significantly less pain during the actual procedure [MD=-1.27, 95% confidence interval (CI): (-1.66, -0.88); p<0.001], immediately after the procedure [MD=-1.03, 95% CI: (-1.40, -0.67); p<0.001], and 30 minutes after the procedure [MD=-0.74, 95% CI: (-1.06, -0.41); p<0.001]. Regarding safety endpoints, no significant difference was noted for dizziness [RR=1.88, 95% CI: (0.79, 4.47); p=0.16] or vomiting [RR=1.80, 95% CI: (0.40, 8.18); p=0.45]. Based on the available data, we conclude that tramadol administration seems to be both effective and safe for patients undergoing office hysteroscopy.