Does cervical preparation before outpatient hysteroscopy reduce women’s pain experience? A systematic review

Abstract

Background Studies examining the use of pharmaceutical (prostaglandins, antiprogestogens) and mechanical (osmotic dilators) dilatation of the cervix before hysteroscopy under general anaesthesia have produced conflicting results regarding their effect on cervical dilatation and trauma during the procedure.Objective To compare the effect on pain and need for cervical dilatation of various methods of cervical preparation before outpatient hysteroscopy.Search strategy MEDLINE, EMBASE and CINAHL were searched using a combination of the keywords 'hysteroscopy', 'vaginoscopy', 'cervical ripening', 'laminaria', 'progest*', 'prostaglandin', 'oestrogen' 'cervical preparation' and their associated Medical Subject Headings The Cochrane Library was searched using the keywords 'hysteroscopy' and 'cervical'. There were no limits or filters placed on the searches.Selection criteria Randomised controlled trials that examined women undergoing outpatient hysteroscopy, where the intervention was the use of cervical preparation versus a control or placebo and the outcome was pain assessment.Data collection and analysis Two reviewers independently selected trials. Data were extracted on pain, the effect on dilatation, adverse effects, trauma and feasibility. Data regarding pain and cervical dilatation were unsuitable for meta-analysis. Meta-analyses were performed for adverse effects and feasibility using the random effects models to calculate the Peto odds ratio.Results From 585 abstracts, six studies were selected for inclusion in the systematic review. The results suggest that there may be a benefit of using prostaglandins for postmenopausal women; however, there is no high-quality evidence that giving misoprostol before outpatient hysteroscopy reduces the pain experienced by women of reproductive age. There is some evidence that prostaglandins reduce the force and requirement for dilatation of the cervix beyond 5 mm.Author's conclusions There is no evidence to recommend the routine administration of mifepristone or misoprostol to women before outpatient hysteroscopy. Cervical priming with vaginal prostaglandins may be considered in postmenopausal women if using hysteroscopic systems >5 mm in diameter.

Pain in diagnostic hysteroscopy: a multivariate analysis after a randomized, controlled trial

“…Other studies have resorted to pharmacologic approaches (9)(10)(11), which at times can be relatively invasive (10,12), to find a solution for pain during hysteroscopy; but besides not reaching consensus on their actual effectiveness (13), those studies also altered the outpatient nature of the procedure (14).…”

Misoprostol Prior to Diagnostic Office Hysteroscopy in the Subgroup of Patients with No Risk Factors for Cervical Stenosis: A Randomized Double Blind Placebo-Controlled Trial

“…Moreover, prostaglandins and mifepristone were used to soften and widen the cervical canal to allow easy and painless insertion of the hysteroscope into the uterine cavity. Studies examining the efficacy of these treatments in relieving the pain experienced during office hysteroscopy have produced contradictory results and no solid conclusion on the ideal method for pain relief during office hysteroscopy was reached [4,14,15].…”

“…Several studies investigated the role of misoprostol in minimizing the pain associated with office hysteroscopy but the results were inconclusive. Moreover, these studies either enrolled only patients with risk factors for cervical stenosis (nulliparous or menopausal patients) or enrolled a heterogeneous population of patients (with and without risk factors for cervical stenosis) [1,4]. Till now, no studies have investigated whether the subgroup of patients with no risk factors for cervical stenosis (i.e., parous women of reproductive age who have no history of cesarean section or cervical surgery) can benefit from misoprostol administration prior to office hysteroscopy or not.…”

Complications of hysteroscopy and how to avoid them

“…The published literature demonstrates no benefit in using cervical preparation for those patients undergoing diagnostic hysteroscopy [11]. For those patients undergoing operative hysteroscopy and cervical dilatation beyond 5-mm diameter, these agents may be beneficial especially in premenopausal women [12].…”