The effect of music in gynaecological office procedures on pain, anxiety and satisfaction: a randomized controlled trial

Best practices for reducing pain associated with intrauterine device placement

Intrauterine devices are highly effective, long-acting, reversible forms of contraception. Despite their benefits, limited uptake persists, particularly among underserved populations, adolescents, and young adults. While most intrauterine device placement procedures are uncomplicated, pain is commonly reported, with more severe pain reported in certain groups. No current standard of care has been established specifically to manage pain with intrauterine device placement, resulting in wide variation in clinical practice. This article aims to provide practical, evidence-based, and expert-informed guidelines for managing pain during intrauterine device placement. The authors (a group of board-certified obstetrician-gynecologists, pediatricians, and a family physician) conducted a virtual expert meeting to develop consensus-based recommendations for pain management. The meeting covered environmental considerations, nonpharmacological, and pharmacological options. Key strategies include using a person-centered care model that focuses on patient values, needs, and preferences to promote shared decision-making around pain relief. Clinicians should assist patients in setting realistic expectations, including a discussion of the placement procedure, anticipated pain, and all options for pain relief, to allow for a comprehensive informed consent process. Nonpharmacological interventions, such as the use of therapeutic language and comforting environmental, complementary and integrative, and mind-body elements, are recommended to reduce patient anxiety and discomfort. In terms of pharmacological options, clinicians may offer pre-procedural-specific nonsteroidal antiinflammatory drugs (eg, naproxen and ketorolac) and anxiolytics to patients with significant anxiety, as well as intraprocedural application of topical anesthesia and paracervical or intracervical blocks. Finally, additional techniques, such as using appropriately sized instruments and ensuring gradual and gentle procedural steps, can also help enhance patient comfort during insertion. These expert guidelines emphasize the importance of personalized, trauma-informed, and evidence-based care, prioritizing patient autonomy and preferences to facilitate a safe and acceptable insertion experience. They are critical to reducing barriers to intrauterine device uptake and improving overall patient outcomes.

Smooth Operator: Nonpharmacologic Approaches for Overcoming Barriers to Office Hysteroscopy

Importance

Despite the known advantages and incentives for providers and patients, reticence to performing office hysteroscopy remains due to provider inexperience, challenges to adequate pain management, and greater comfort level in the operating room setting. The relatively low utilization across the field of gynecology necessitates a deeper understanding of essential elements of hysteroscopy and the shared skills gained by experience.

Objective

This review serves to aid providers in optimizing periprocedural patient experience and procedural outcomes during in-office hysteroscopy.

Evidence Acquisition

A comprehensive literature review was conducted to evaluate nonpharmacologic approaches to pain and anxiety management during in-office hysteroscopy. PubMed, Scopus, and Cochrane Library databases were searched for peer-reviewed articles published in English. Search terms included combinations of "in-office hysteroscopy," "pain management," "anxiety management," "non-pharmacologic," communication," and "office set-up." Additional references were identified from citations within relevant articles. Studies were selected based on relevance, focusing on randomized controlled trials, systematic reviews, meta-analyses, and observational studies. Findings were synthesized to provide a comprehensive overview of current evidence and highlight areas for future research.

Results

Nuanced approaches to pain and anxiety management during in-office hysteroscopy identified include virtual reality, music, hypnosis, and transcutaneous nerve stimulation. Simple strategies such as optimizing office setup while utilizing the newest technological advances and effective communication were identified as ways to alleviate patient discomfort and increase procedure acceptability.

Conclusions and Relevance

An understanding of the basic elements of in-office hysteroscopy will benefit patients and providers alike, aiding the transition out of the operating room and into the office setting.

Evaluating the therapeutic use of music to address anxiety for women undergoing gynaecological and fertility treatments

BACKGROUND

Music has been effectively used to address anxiety associated with medical treatments across broad applications. However, scant evidence exists about using music to reduce the significant anxiety experienced by women undergoing gynaecological procedures and fertility treatments. Such anxiety relates to the nature of procedures/examinations, invasiveness of the procedures, uncertainty around expectations, and intimate body part exposure, potentially affecting outcomes in triggering sympathetic nervous system responses. Music potentially contributes to anxiety management via known physiological and emotional effects. This funded collaborative project investigates therapeutic uses of music to address anxiety before and during gynaecology and fertility procedures, in order to assist participants with reducing their anxiety.

METHODS

Participants attending office, day surgery and other hospital procedures (N = 41) completed validated self-report surveys before and after procedures, listening to specific music via a purpose-designed Music Star. Additional contextual and qualitative data was sought to understand the nature of the experience for the women.

RESULTS

Results of this study indicated that the music intervention appeared to have a significant effect of reducing anxiety for women awaiting gynaecological and fertility procedures (p < .001, r = .82).

CONCLUSIONS

The use of music forms an acceptable intervention to decrease anxiety in this context and can enhance the experience of women during treatment. Such an increased use of music can provide anxiety management benefits to women undergoing gynaecological and fertility treatments, with these experiences suggesting potential educational benefits to support women through this extremely stressful and complex stage of their life.

Effectiveness of Virtual Reality in Reducing Pain and Stress During Office Hysteroscopy: A Randomized Controlled Trial

Introduction: Office hysteroscopy (OH) offers a "see and treat" strategy, enabling most gynecological conditions to be addressed outside the operating room without anesthesia. Despite its convenience, the associated pain and stress remain significant barriers to its widespread success among women. Both pharmacological and non-pharmacological interventions have been explored to mitigate these challenges, albeit with mixed outcomes. Methods: This study aimed to evaluate the effectiveness of virtual reality (VR) in reducing pain and stress associated with OH using objective measurements. Results: Our findings indicate that VR significantly reduced pain during OH compared to the control group (-1.08, 95%CI; -1.93-0.23, on the Visual Analogue Scale (VAS), p = 0.013) and 10 min post-procedure (-1.24, 95%CI; -1.99-0.48, p = 0.001), without significant effects on stress-related variables. Stratified analyses further revealed that the efficacy of VR in pain reduction is influenced by individual patient characteristics, with greater effectiveness observed in women with lower baseline stress, premenopausal status and a history of childbirth, regardless of vaginal delivery. Conclusions: VR represents a promising strategy for managing OH-associated pain, with its effectiveness largely depending on patient-specific variables.

Detecting the impact of diagnostic procedures in Pap-positive women on anxiety using artificial neural networks

INTRODUCTION

Women who receive a result of an abnormal Papanicolaou (Pap) smear can fail to participate in follow up procedures, and this is often due to anxiety. This study aimed to apply artificial neural networks (ANN) in prediction of anxiety in women with an abnormal Pap smear test, prior to and following diagnostic procedures.

METHODS

One hundred-seventy two women who received an abnormal Pap screening result took part in this study, completing a questionnaire about socio-demographic characteristics and Hospital Anxiety and Depression Scale (HADS), right before and two to four weeks after diagnostics (i.e. colposcopy/biopsy/endocervical curettage). A feedforward back-propagation multilayer perceptron model was applied in analysis.

RESULTS

Prior to diagnostic procedures 50.0% of women experienced anxiety, while after diagnostics anxiety was present in 61.6% of women. The correlation-based feature selection showed that anxiety prior to diagnostic procedures was associated with the use of sedatives, worry score, depression score, and score for concern about health consequences. For anxiety following diagnostics, predictors included rural place of residence, depression score, history of spontaneous abortion, and score for tension and discomfort during colposcopy. The ANN models yielded highly accurate anxiety prediction both prior and after diagnostics, 76.47% and 85.30%, respectively.

CONCLUSION

The presented findings can aid in identification of those women with a positive Pap screening test who could develop anxiety and thus represent the target group for psychological support, which would consequently improve adherence to follow-up diagnostics and enable timely treatment, finally reducing complications and fatal outcome.

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.

The effect of music intervention in decreasing pain and anxiety during outpatient hysteroscopy procedure: a systematic review and meta-analysis of randomized control trials

BACKGROUND

Hysteroscopy is a common outpatient procedure but procedural pain limits its use. Music could be used as a pain-relieving intervention. We performed a systematic review and meta-analysis to investigate the effect of music on pain and anxiety during outpatient hysteroscopy.

METHODS

Four electronic databases were searched: PubMed, Scopus, Web of Science, and Cochrane Library, from inception to September 2022. We included only the Randomized Controlled Trials (RCTs) that investigated the effect of music on women who underwent outpatient hysteroscopy in reducing pain and anxiety levels compared to no music. We assessed the quality of included RCTs using the risk of bias tool 1 reported in the Cochrane Handbook of Systematic Reviews of Interventions. Data were pooled as the Mean Differences (MDs) with a 95% Confidence Interval (CI) in a random-effects model, using Review Manager 5.3 software. Also, we assessed the evidence of the results using the Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS

Three RCTs (540 women) were included. Music significantly reduced visual analogue scale (VAS) pain scores as well as State-Trait Anxiety Inventory (STAI) scores compared to controls (MD = -1.28; 95% CI [-2.19, -0.36]; P = 0.007) and (MD = -3.91; 95% CI [-6.98, -0.85]; P = 0.01) respectively. Also, the decrease in VAS score for pain was significantly greater in the music group (MD = 1.44; 95% CI [0.44, 2.45]; P = 0.005). However, the change in STAI showed no significant difference between the two groups. The GRADE ratings for all outcomes were very low.

CONCLUSION

Music is a potentially promising method for controlling pain for patients undergoing outpatient hysteroscopy; however, its effect in controlling anxiety is controversial.

The effect of an informative 360-degree virtual reality video on anxiety for women visiting the one-stop clinic for abnormal uterine bleeding: A randomized controlled trial (VISION-trial)

OBJECTIVE

To evaluate the effect of an informative 360-degree virtual reality (VR) video on preoperative anxiety before visiting a one-stop clinic for abnormal uterine bleeding.

STUDY DESIGN

A randomized controlled trial was performed in a teaching hospital in the Netherlands. A total of 83 women scheduled for a first consultation at the one-stop clinic between April 2017 and September 2017 were included in the analysis. All women received a standard information leaflet about the clinic. 40 women were randomized to receive a 360-degree VR-video of the clinic in addition. The primary outcome was change in the Visual Analogue Scale for Anxiety (VAS-A), measured at baseline (before randomization) and in the waiting room (before visit, after randomization). Anxiety assessed with the State-Trait Anxiety Inventory (STAI-S) was a secondary outcome. Other secondary outcomes included anxiety during the visit and the opinion of the women about the provided information.

RESULTS

Only 27 out of the 40 women actually watched the VR-video. Women in the VR-group who actually watched the video reported lower levels of anxiety at baseline compared to women in the VR-group who did not watch the video. In the intention-to-treat analysis, there was no difference in change in anxiety between the VR-group and the control group (mean difference VAS-A = 0.07, 95% CI -0.96 to 1.10; mean difference STAI-S = 1.97, 95% CI -1.82 to 5.77). In the per-protocol analysis, women in the VR-group reported lower anxiety scores in the waiting room. However, the change in anxiety scores between baseline and waiting room was comparable in both groups. 31% of the women who watched the VR-video reported that the video resulted in a reduction of anxiety, 69% reported that the video is of added value and 65% would use a VR-video again in future.

CONCLUSIONS

Adding the informative 360-degree VR-video to conventional information did not result in a reduction of anxiety prior to visiting the one-stop clinic. However, the majority of women who watched the video felt that it was of added value. Remarkable was that women who reported higher anxiety at baseline seemed less willing to watch the video.

Efficacy of Listening to Music on Pain Reduction during Colposcopy-Directed Cervical Biopsy: A Randomized, Controlled Trial

Background and Objective: To investigate the efficacy of listening to music on pain reduction during colposcopy-directed cervical biopsy (CDB). Materials and Methods: From June 2020 to November 2021, 240 women undergoing CDB were enrolled. The participants were randomized into three groups: Group 1, colposcopic examination while wearing headphones and listening to music; Group 2, colposcopy while wearing headphones but not listening to music; Group 3 (control group), colposcopy while neither listening to music nor wearing headphones. All participating women completed a 10 cm visual analog scale for subjective pain at three time points: baseline, immediately after cervical biopsy, and 15 min after the procedure. The primary endpoint was the biopsy pain score. Result: Of the 240 women, a sample size of 80 was randomly assigned per group. The clinical–pathological and procedure-related characteristics of the participants in all groups were similar. The mean baseline pain score between each group was not significantly different (2.83 in the music group, 2.54 in group 2, and 2.94 in the control group, p = 0.47). There were no significant differences between each group in terms of mean biopsy pain score (4.21 in the music group, 4.24 in group 2, and 4.30 in the control group, p = 0.98). The differences in changes between the baseline pain score and the biopsy pain score were not statistically significant (1.39 in the music group, 1.70 in group 2, and 1.36 in the control group, p = 0.69). In the multiple comparison analysis, the differences in changes between the biopsy pain score and the baseline pain score between each group were also not statistically significant. There were no complications with the intervention observed. Conclusion: This study demonstrated that there was no beneficial effect of listening to music on pain reduction during colposcopy-directed cervical biopsies.

Quality of life and sexuality of postmenopausal women with intrauterine pathologies: a recommended three-step multidisciplinary approach focusing on the role of hysteroscopy

Intrauterine pathologies are common in postmenopausal women and clinicians must identify signs and symptoms accurately to provide the adequate diagnosis and treatment. The quality of life (QoL) and sexuality of women are important outcomes to be considered to provide adequate clinical management of the postmenopausal patient with gynecologic pathologies. The aim of this paper is to propose a simple and replicable three-step multidisciplinary approach to evaluate the psychological outcomes of postmenopausal women with intrauterine pathologies, focusing on the role of hysteroscopy. In particular, the article describes three evaluation steps of those psychological outcomes corresponding to three fundamental moments of the patient's diagnostic and therapeutic path: the initial symptoms, diagnosis, and treatment. In our viewpoint, the standard use of such a protocol might considerably improve the QoL of postmenopausal patients undergoing hysteroscopic procedures due to intrauterine pathologies.

Use of music in reducing pain during outpatient hysteroscopy: Prospective randomized trial

AIM

To evaluate the effect of music in reducing pain during outpatient hysteroscopy under no anesthesia.

METHODS

We conducted a prospective randomized controlled trial From June 2019 to December 2019 in Pamela Youde Nethersole Eastern Hospital in Hong Kong. A total of 107 patients were randomized to music group (n = 54) or non-music group (n = 53). Music was played during outpatient hysteroscopy in the music group. Patients in the non-music group had the procedure done in the same setting without music. Primary outcome was the level of pain measured using the visual analog scale (VAS) score before and during the procedure. Secondary outcomes were vital parameters that reflect the level of pain including blood pressure and heart rate.

RESULTS

Patients in the music group experienced significantly less pain during outpatient hysteroscopy (VAS score 4.54 ± 2.89 vs 5.88 ± 2.90; P = 0.02). The anticipated pain level was similar in both groups (VAS score 5.59 ± 2.27 vs 6.11 ± 2.43; P = 0.27). There was no statistically significant difference between the two groups in all the vital parameters.

CONCLUSION

Listening to music during outpatient hysteroscopy under no anesthesia significantly reduces pain in a well-matched Chinese population. Music is easy to provide with low-cost equipment and manpower. We recommend the routine use of music during outpatient hysteroscopy to improve patient care.

Pain management for in-office hysteroscopy. A practical decalogue for the operator

Hysteroscopy is known to be the gold standard for evaluation of intrauterine pathologies, pre-menopausal and post-menopausal abnormal uterine bleeding and, in addition to this, it is a crucial examination in the infertility work-up. In-office operative hysteroscopy incorporates the outstanding possibility of seeing and treating an intracavitary pathology in the same examination, eliminating all the risk related to anesthesia and reducing procedure-related costs. By now, performing operative procedures in the office setting is recognized as feasible and safe. Over the last 20 years, many efforts have been made to implement the in-office operative approach worldwide. However, for some women, in-office hysteroscopy is still considered a painful experience, with reported discomfort at different steps of the hysteroscopic procedures. Moreover, uneventful and tedious sensations might be increased by a high level of anxiety for such examination. For this reason, despite the feasibility of the in-office approach, many clinicians are still afraid of provoking pain during the procedure and rather not to perform surgical procedures in the office, postponing the removal of the pathology in the operating room. To date, there is no consensus concerning pain management for in-office hysteroscopy and different approaches, pharmacological and non-pharmacological aids, as well as several procedural tips and tricks are utilized. Our purpose is to provide a feasible practical decalogue for the operator, to supply adequate management of pain during in-office hysteroscopic procedures, performing challenging operations, shrinking discomfort, aiming to upgrade both women's and operator's satisfaction.

Favorite Music Mediates Pain-related Responses in the Anterior Cingulate Cortex and Skin Pain Thresholds

Purpose

Music therapy is widely used to enhance well-being, reduce pain, and distract patients from unpleasant symptoms in the clinical setting. However, the degree to which music modulates pain perception is unknown. The medial pain pathway including the limbic system is associated with emotion, but how music alters pathway activity is unclear. The aim of the study was to investigate pain thresholds and pain-related responses in the anterior cingulate cortex (ACC) and whether they were modulated when subjects listened to their favorite music genre.

Subjects and Methods

First, 30 subjects were examined for left forearm pain threshold using electrical stimulation with Pain Vision PS-2011N. The pain thresholds with and without music were compared. Second, when an 80-μA current from Pain Vision was applied to the left ankle of eight women, the pain-related responses of the ACC with and without music were observed with functional magnetic resonance device (fMRI). The changes in the pain-related activity in both parameters were discussed.

Results

The median pain threshold with favorite music was 38.9 μA, compared to 29.0 μA without, which was significantly different (p<0.0001). The men’s thresholds were significantly higher than women’s both with music (p<0.05) and without music (p<0.01). The pain threshold in women was more strongly affected by music than in men. The fMRI results showed that the pain-related response in the ACC in five of eight subjects was attenuated while they listened to their favorite music. No change was observed in the other three subjects.

Conclusion

The present findings suggest that pain perception might be strongly affected by listening to favorite music, possibly through modulation of pain-related responses in the ACC.

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.

Virtual reality for acute pain in outpatient hysteroscopy: a randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of virtual reality as a distraction technique in the management of acute pain and anxiety during outpatient hysteroscopy.

DESIGN

Parallel group, prospective randomised controlled trial.

SETTING

UK University Hospital.

METHODS

Forty consenting, eligible women were randomised to virtual reality intervention (immersive video content as a distraction method) or standard care during outpatient hysteroscopy from August to October 2018.

MAIN OUTCOME MEASURES

Pain and anxiety outcomes were measured as a numeric rating score (scale 0-10).

RESULTS

Compared with standard care, women with virtual reality intervention experienced less average pain (score 6.0 versus 3.7, mean difference 2.3, 95% CI 0.61-3.99, P = 0.009) and anxiety (score 5.45 versus 3.3, mean difference 2.15, 95% CI 0.38-3.92, P = 0.02).

CONCLUSION

Virtual reality was effective in reducing pain and anxiety during outpatient hysteroscopy in a mixed-methods randomised control trial. Its wide potential role in ambulatory gynaecological procedures needs further evaluation.

TWEETABLE ABSTRACT

Virtual reality can be used as a part of a multimodal strategy to reduce acute pain and anxiety in patients undergoing outpatient hysteroscopy.

Pharmacological and non-pharmacological pain relief for office hysteroscopy: an up-to-date review

In-office hysteroscopy is considered the standard technique for visualization of the uterine cavity and the diagnosis of intrauterine pathologies. Moreover, nowadays, it is possible to treat a vast number of intracavitary diseases in the office, without the need for the inpatient setting. However, in some cases, pain might occur, and this is the most common reason for not completing the procedure. Over the last 20 years, many efforts have been carried out to miniaturize the instrumentation and to improve the techniques in order to avoid discomfort. Nonetheless, hysteroscopy still provokes distress for many patients. For this reason, pharmacological and non-pharmacological treatments for intraoperative and postoperative pain relief have been widely used for in-office hysteroscopy, with different results in various groups of women. The purpose of this review was to analyze the current literature on pharmacological aids (non-steroidal anti inflammatory drugs, cyclooxygenase-2 inhibitors, antispasmodics, local anesthetics, prostaglandins, opioids) and non-pharmacological interventions (transcutaneous electrical nerve stimulation, uterine stretching, uterine pressure, warming of distension medium, hypnosis, music, vocal-local) and to evaluate their impact on the relief from pain experienced during in-office hysteroscopy.

Management of anxiety and pain perception in women undergoing office hysteroscopy: a systematic review

PURPOSE

The aim of this review is to provide an overview of the literature about the perception and management of anxiety and pain in women undergoing an office hysteroscopic procedure.

METHODS

We performed a systematic literature search in Embase, PubMed/MEDLINE, Cochrane Library and Web of Science for original studies written in English (registered in PROSPERO 2019-CRD42019132341), using the terms 'hysteroscopy' AND 'pain' AND 'anxiety' published up to January 2019. Only original articles (randomized, observational and retrospective studies) about management of anxiety and pain related to the hysteroscopic procedure were considered eligible.

RESULTS

Our literature search produced 84 records. After exclusions, 11 studies including 2222 patients showed the following results: (a) pain experienced during hysteroscopy is negatively affected by preprocedural anxiety; (b) pharmacological interventions seem to be help in reducing pain during hysteroscopy; (c) waiting time before the procedure is a significant factor affecting patients' anxiety; (d) music during the procedure may be helpful in reducing anxiety.

CONCLUSIONS

The utilization of office hysteroscopy is hampered by varying levels of anxiety and pain perceived by women who are candidates for the procedure. For these reasons, it is essential to identify effective pharmacological and non-pharmacological strategies to alleviate these factors. We recommend further studies especially focusing on non-pharmacological interventions to facilitate the dissemination of good clinical practices among hysteroscopists.

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

AIM

To identify the highest-ranked pharmacological and nonpharmacological interventions for pain relief during outpatient hysteroscopy.

METHODS

We conducted an online bibliographic search in different databases from inception till July 2019. We included randomized controlled trials assessing effect of pharmacological and nonpharmacological interventions on pain relief during outpatient hysteroscopy. Our main outcomes were pain scores at different endpoints of the procedure. We applied this network meta-analysis based on the frequentist approach using statistical package 'netmeta' (version 1.0-1) in R.

RESULTS

The review included 39 randomized controlled trials (Women n = 3964). Misoprostol plus intracervical block anesthesia (mean difference [MD] = -3.32, 95% confidence interval [CI] [-6.06, -0.59]), misoprostol (MD = -1.92, 95% CI [-3.04, -0.81]) and IV analgesia (MD = -2.01, 95% CI [-3.27, -0.25]) were effective in reducing pain during the procedure compared to placebo. Ranking probability showed that misoprostol plus intracervical block anesthesia was the highest ranked pharmacological treatment for pain relief during the procedure (P score = 0.92) followed by misoprostol alone (P score = 0.78), and IV analgesia (P score = 0.76). Regarding nonpharmacological treatments, transcutaneous electrical nerve stimulation (TENS) showed a significant pain reduction compared to placebo (MD = -1.80, 95% CI [-3.31, -0.29]). TENS ranked as the best nonpharmacological treatment (P score = 0.80) followed by CO₂ distention (P score = 0.65) and bladder distention (P score = 0.60).

CONCLUSION

Combination of misoprostol plus local anesthesia appears to be the most effective pharmacological approach for pain reduction during and after outpatient hysteroscopy. Nonpharmacological approaches as TENS and bladder distention showed considerable efficacy but should be further investigated.

Music Reduces Pain Unpleasantness: Evidence from an EEG Study

BACKGROUND

Music is sometimes used as an adjunct to pain management. However, there is limited understanding of by what means music modulates pain perception and how the brain responds to nociceptive inputs while listening to music, because clinical practice typically involves the coexistence of multiple therapeutic interventions. To address this challenge, laboratory studies with experimental and control conditions are needed.

METHODS

In the present investigation, we delivered nociceptive laser stimuli on 30 participants under three conditions - participants were sitting in silence, listening to their preferred music, or listening to white noise. Differences among conditions were quantified by self-reports of pain intensity and unpleasantness, and brain activity sampled by electroencephalography (EEG).

RESULTS

Compared with the noise and silence conditions, participants in the music condition reported lower ratings on pain unpleasantness, as reflected by reduced brain oscillations immediately prior to the nociceptive laser stimulus at frequencies of 4-15 Hz in EEG. In addition, participants showed smaller P2 amplitudes in laser-evoked potentials (LEPs) when they were listening to music or white noise in comparison to sitting in silence. These findings suggest that a general modulation effect of sounds on pain, with a specific reduction of pain unpleasantness induced by the positive emotional impact.

CONCLUSION

Music may serve as a real-time regulator to modulate pain unpleasantness. Results are discussed in view of current understandings of music-induced analgesia.

[Perioperative music-induced analgesia : Comparison of the effect of music on pain between preoperative, intraoperative and postoperative application]

BACKGROUND

Despite suitable analgesia procedures and interventions only approximately 24% of inpatients with strong to very strong pain receive adequate treatment. Besides opioids, which are associated with numerous side effects and risks, non-pharmacological approaches are increasingly being used. In this context, one of the oldest known methods are music interventions; however, the state of evidence is heterogeneous and there are no explicit manuals and recommendations for the effective implementation of music interventions.

OBJECTIVE

This review aimed to determine the optimal time point at which perioperative music interventions can most effectively relieve pain.

MATERIAL AND METHODS

A PubMed search was conducted and publications investigating the effect of music during the preoperative, intraoperative and postoperative stages of various interventions were identified.

RESULTS

During the preoperative phase, only positive effects of music on pain relief have been reported but availability of data is sparse. During the intraoperative stage of a medical intervention the effect of music seems to be mediated by the type of anesthesia procedure and sedation depth. Only patients who can consciously perceive the music seem to profit from it. Positive alleviating effects on subjective pain perception and analgesia needs were shown in the postoperative stage.

CONCLUSION

Music is a non-pharmacological method to alleviate pain, which is free of side effects. Important considerations for the use of music interventions for relief of acute pain associated with surgery are discussed taking into account numerous mediating factors, which influence the efficacy of the treatment.

Benefit of Watching a Live Visual Inspection of the Cervix With Acetic Acid and Lugol Iodine on Women's Anxiety: Randomized Controlled Trial of an Educational Intervention Conducted in a Low-Resource Setting

Background

Women undergoing pelvic examination for cervical cancer screening can experience periprocedural anxiety.

Objective

The aim of this study was to assess the anxiety level experienced by women undergoing a visual inspection with acetic acid and Lugol iodine (VIA and VILI) examination, with or without watching the procedure on a digital screen.

Methods

This prospective randomized study took place in the district of Dschang, Cameroon. A previous cervical cancer screening campaign tested women aged between 30 and 49 years for human papillomavirus (HPV). HPV-positive women were invited for the 12-month follow-up control visit, including a VIA/VILI examination. During that visit, we recruited women to participate in this study. Before the examination, participants were randomized in a 1:1 ratio to a control group (CG) and an intervention group (IG). Women in both groups underwent a pelvic examination and were verbally informed about the steps undertaken during the gynecological examination. The IG could also watch it live on a tablet screen. Women’s anxiety was assessed before and immediately after the examination, using the Spielberger State-Trait Anxiety Inventory (STAI). A paired t test was used to compare the mean STAI score for each question before and after VIA/VILI while a nonpaired, 2-sided t test was used to compare the mean differences of the STAI score between the 2 study groups.

Results

A total of 122 women were randomized in the study; 4 of them were excluded as they did not undergo the pelvic examination, did not answer to the second STAI questionnaire because of personal reasons, or the cervix could not be properly visualized. Thus, the final sample size consisted of 118 patients of whom 58 women were assigned to the CG and 60 to the IG. The mean age was 39.1 (SD 5.2) years. Before the examination, the mean (SD) STAI score was 33.6 (SD 10.9) in the CG and 36.4 (SD 11.8) in the IG (P=.17). The STAI score after pelvic examination was significantly reduced for both groups (CG: 29.3 [SD 11.2]; IG: 28.5 [SD 12.0]). Overall, the difference of the STAI scores before and after the pelvic examination was lower in the CG (4.2 [SD 9.0]) than in the IG (7.9 [SD 14.3]), although the difference was not significant (P=.10). However, the women’s emotional state, such as I feel secure and I feel strained, was improved in the IG as compared with the CG (CG: P=.01; IG: P=.007).

Conclusions

Watching the VIA/VILI procedure in real time improved the women’s emotional state but did not reduce the periprocedural anxiety measured by the STAI score. Furthermore, larger studies should assess women’s satisfaction with watching their pelvic examination in real time to determine whether this tool could be included in VIA/VILI routine practice.

Trial Registration

ClinicalTrials.gov NCT02945111; http://clinicaltrials.gov/ct2/show/NCT02945111