Cervical dilatation and preparation prior to outpatient hysteroscopy: a systematic review and meta‐analysis

Abstract

Background There are uncertainties about the benefit of routine cervical preparation and/or cervical dilatation before outpatient hysteroscopy. Objective To determine if cervical preparation and/or routine mechanical dilatation reduces pain during outpatient hysteroscopy. Search strategy MEDLINE, EMBASE, CINAHL and CENTRAL were searched on 19 October 2020, using keywords ‘hysteroscopy’, ‘cervical preparation’, ‘cervical ripening’, ‘cervical dilatation’, ‘outpatient’, ‘office’ and/or ‘ambulatory’ and associated medical subject headings. Selection criteria Randomised controlled trials investigating the benefit of cervical preparation and/or cervical dilatation on pain in women undergoing outpatient hysteroscopy were included. Data collection and analysis Two independent reviewers selected eligible trials and extracted data on pain, feasibility, adverse events and satisfaction/acceptability for meta‐analysis. Main results The literature search yielded 807 records, of which 24 were included for review and 19 provided data for meta‐analysis. No trials investigated the role of routine mechanical cervical dilatation. Cervical preparation significantly reduced pain during outpatient hysteroscopy; standard mean difference (SMD) ‒0.67, 95% confidence interval (CI) ‒1.05 to ‒0.29. Feasibility also improved as priming provided significantly easier hysteroscopic entry (SMD 0.89, 95% CI 0.32–1.46), greater cervical dilatation (SMD 0.81, 95% CI 0.08–1.53) and shorter procedural times (SMD ‒0.51, 95% CI ‒0.88 to ‒0.13). Cervical preparation, however, incurred significantly more adverse effects, mainly comprising genital tract bleeding, abdominal pain and gastrointestinal symptoms (odds ratio 2.94, 95% CI 1.58–5.47). There were limited data regarding satisfaction, acceptability and complications. Conclusions Cervical preparation reduces pain and improves feasibility associated with outpatient hysteroscopy but increases the risk of adverse effects. Tweetable abstract Cervical preparation before outpatient hysteroscopy reduces pain, enhances feasibility but increases adverse effects.

Opinion paper: gynecological surgery in local anesthesia?

“…Preoperative priming of the cervix eases entry into the cavum and allows further dilatation, which can shorten the operation time. However, significantly more side effects such as bleeding, abdominal pain, and gastrointestinal symptoms occur under this [ 24 ]. Oral and vaginal administration of misoprostol appear equivalent, but side effects such as diarrhea are less common with vaginal administration [ 25 ].…”

Hysteroscopy, the Window into the Uterine Cavity

“…Cervical priming facilitated hysteroscopy by dilating the cervix, allowing for easier entry and reducing procedural time. Administration of a cervical preparation, however, increased the risk of adverse effects, namely genital tract bleeding, abdominal pain/cramping and gastrointestinal disturbance [18].…”

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

“…Due to similarity in the mechanism of action, we believe that vaginal dinoprostone exhibits similar time-dependent efficacy as demonstrated in misoprostol; however, this was not previously investigated in randomized controlled trials (RCTs). Additionally, a recent systematic review by De Silva et al [30] concluded that uncertainties still remain regarding the ideal dose, timing, and route of PG administration before OH. They advised further research to identify the optimal cervical preparation regimen with regards to the timing of administration.…”