Pain relief for hysteroscopy as an outpatient

Hysteroscopy is a diagnostic test frequently undertaken to find out the cause of abnormal uterine bleeding. Hysteroscopy involves fluid or gas being injected via the cervix (neck of the womb) into the uterus (womb), which enables the visualisation of the cervical canal and uterine cavity with a hysteroscope (small telescopic camera). This can be a painful procedure. The purpose of this review was to determine which, if any, pain relief drug should be used during outpatient hysteroscopy. Analysis of 13 studies investigating 1881 women found evidence of benefit for pain relief with the use of analgesia during or within 30 minutes after the procedure, especially in post-menopausal women.

Further high quality, well powered trials should be undertaken in order to provide the data necessary to estimate the efficacy of oral analgesics, the optimal route of administration, and dose of local anaesthetics to be used.

Authors' conclusions: 

There was a significant reduction in the mean pain score with the use of analgesia during and within 30 minutes after outpatient hysteroscopy. 

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Background: 

Hysteroscopy is increasingly performed in an outpatient setting. The primary reason for failure is pain. There is no consensus upon the routine use of analgesia during hysteroscopy.

Objectives: 

The aim of the study was to compare the effectiveness of different types of pharmacological interventions for pain relief in patients undergoing hysteroscopy.

Search strategy: 

A search of medical literature databases including PubMed, EMBASE, PsycINFO and CINHAL (to February 2010).

Selection criteria: 

Randomised controlled trials (RCTs) investigating pharmacological interventions for pain relief during hysteroscopy were investigated.

Data collection and analysis: 

Results for each study were expressed as a standardised mean difference with 95% confidence interval and combined for meta-analysis with Revman 5 software.

Main results: 

Twenty-four RCTS were identified involving a total of 3155 participants, with 15 studies included in the meta-analysis.

Meta-analysis (nine RCTs, 1296 participants) revealed a significant reduction in the mean pain score for the use of local anaesthetics during the procedure compared with placebo (SMD -0.45, 95% CI -0.73 to -0.17, I2 = 82%).

Meta-analysis (4 RCTs, 454 participants) demonstrated a significant reduction in the mean pain score for the use of local anaesthetics within 30 minutes after the procedure compared with placebo (SMD -0.51, 95% CI -0.81 to -0.21, I2 = 54%).

There was no significant reduction in the mean pain score with the use of NSAIDS or opioid analgesics compared with placebo during or within 30 minutes after the procedure.

There was no significant reduction in the mean pain score with the use of local anaesthetics, NSAIDS or opioid analgesics compared with placebo more than 30 minutes after the procedure.

There was no significant difference between the number of incidents of failure to complete the procedure due to cervical stenosis between the intervention and control groups (OR 1.31, 95% CI 0.66 to 2.59; 6 RCTs, 805 participants).

There were significantly fewer incidents of failure to complete the procedure due to pain in the intervention group than in the control group (OR 0.29, 95% CI 0.12 to 0.69; two studies, 330 participants).

Meta-analysis demonstrated no significant difference between the intervention and placebo groups with regards to adverse effects.