Pain evaluation in outpatients undergoing diagnostic anesthesia-free hysteroscopy in a teaching hospital: A cohort study

Journal of Minimally Invasive Gynecology (2007) 14, 729 –735

Pain evaluation in outpatients undergoing diagnostic anesthesia-free hysteroscopy in a teaching hospital: A cohort study Juliana A. de Carvalho Schettini, MD, MSc, Melania Maria Ramos de Amorim, MD, PhD, Aurélio Antônio Ribeiro Costa, MD, PhD, and Luiz Cavalcante Albuquerque Neto, MD, PhD From the Instituto Materno Infantil de Pernambuco, Recife, Brazil (Drs. de Carvalho Schettini, Ramos de Amorim, and Ribeiro Costa) and UNIFESP-Universidade Federal de São Paulo (Dr. Albuquerque Neto), São Paulo, Brazil. KEYWORDS: Hysteroscopy; Pain; Visual analog scale; Complications

Abstract STUDY OBJECTIVE: To evaluate and determine the main causes for pain occurrence and intensity in outpatients undergoing anesthesia-free hysteroscopy in a medical school hospital. DESIGN: Cohort study (Canadian Task Force classification II-2). SETTING: Diagnosis Center of the Instituto Materno-Infantil de Pernambuco. PATIENTS: One hundred seventy-one outpatients undergoing anesthesia-free diagnostic hysteroscopy. INTERVENTION: To assess pain occurrence, intensity, and associated factors reported by patients undergoing anesthesia-free diagnostic hysteroscopy. MEASUREMENTS AND MAIN RESULTS: Pain frequency and intensity were determined by visual analog scale (VAS) at the end of the procedure and at 15-, 30-, and 60-minute intervals. Data analysis of clinical, obstetric, and gynecologic history and its association with pain was performed. Association through ␹2 test (Pearson), risk ratio with 95% CI, and multiple logistic regression were used for statistical analysis. Pain score was higher immediately after the procedure with a median of 6, decreasing to 3, 1, and 0 at 15-, 30-, and 60-minute intervals, respectively. Multiple logistic regression was performed, and the only parameters remaining that were significantly associated with pain were menopause, speculum placement, and the absence of previous vaginal delivery. CONCLUSION: Anesthesia-free diagnostic hysteroscopy is often associated with pain, and it has been determined that menopause, speculum placement, and absence of previous vaginal delivery are factors associated with pain occurrence and intensity. © 2007 AAGL. All rights reserved.

The authors have no commercial, proprietary, or financial interest in the products or companies described in this article. Corresponding author: Juliana Araújo de Carvalho Schettini, MD, MSC, Rua dos Coelhos 300, Boa Vista, Recife-PE, CEP: 50070-550, Brasil. E-mail: [email protected] Submitted January 3, 2007. Accepted for publication May 18, 2007.

1553-4650/$ -see front matter © 2007 AAGL. All rights reserved. doi:10.1016/j.jmig.2007.05.009

Diagnostic hysteroscopy is currently considered the most reliable test to assess pathologic conditions in the endometrial cavity.1 Other techniques, such as dilation and uterine curettage, transvaginal ultrasonography, hysterosalpingography, or sonohysterography, are useful for uterine cavity evaluation as well, although in an indirect way, for they do not provide unequivocal differentiation of endometrial images.1–5 Some authors have stated that anesthesia is not required in most diagnostic hysteroscopies.6 However, pain in

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women undergoing this technique has been the subject of several literature studies, with 34.8% of patients reporting pain when undergoing anesthesia-free diagnostic hysteroscopy.7 Pain has been described as the main cause of diagnostic hysteroscopy failure,8,9 and several factors have been studied concerning this. Some studies have emphasized that nulliparous, nulligravid, and postmenopausal patients face a greater chance of unsatisfactory hysteroscopies due to incomplete visualization of the uterine cavity.10 Postmenopausal status has been related to more acute pain in patients undergoing hysteroscopy, with added vasovagal reaction in 25% of postmenopausal patients because of uterine involution and cervical stenosis. Other anti-estrogenic factors such as smoking and the use of drugs in breast cancer therapy cause alterations in the endocervical canal, increasing the risk for stenosis.11–14 Concerning hysteroscopy techniques, cervical dilation and endometrial biopsy have been reported as the most painful parts of the examination.15,16 Some factors are associated with an increased need for cervical dilation, such as menopause and absence of vaginal delivery.8,16 In relation to hysteroscopy findings, patients with previous abnormal uterine findings have higher pain scores possibly associated with emotional stress.17 Several alternatives have been proposed to reduce pain during hysteroscopy, such as a thinner-diameter optical; flexible hysteroscopy; vaginoscopy; differing distention media; lidocaine spray; lidocaine and prilocaine gel; paracervical anesthetic blockers; intrauterine anesthesia; cervical preparation with misoprostol or topical estrogens; oral nonsteroidal anti-inflammatory drugs before the examination; and, more recently, transcutaneous electronic nerve stimulation.18 –24 Investigation of the issue remains open due to different pain-related results during or after diagnostic hysteroscopy procedures. This study was performed to assess pain occurrence, intensity, and associated factors reported by patients undergoing anesthesia-free diagnostic hysteroscopy in our hospital.

Materials and methods An observational cohort study was performed from October 2003 through May 2004, with outpatients undergoing anesthesia-free diagnostic hysteroscopy in the Diagnosis Center of the Instituto Materno Infantil de Pernambuco (IMIP). Gynecology and obstetrics senior residents being trained in gynecologic videoendoscopy performed all examinations under the assisting physician’s personal supervision. All patients were evaluated before and 60 minutes after the procedure. Exclusion criteria were patients who had undergone cervical preparation with topical estrogens or misoprostol before hysteroscopy; patients with previous surgical procedures involving the cervix (uterine curettage,

conization, or amputation of the cervix); vaginal surgeries or invasive tests through the cervical orifice (transvaginal sonography, hysterosalpingography, diagnostic or surgical hysteroscopy) fewer than 2 months before the procedure; patients unable to complete the visual analog scale (VAS); and those receiving hormone replacement therapy before or after menopause. A 3-mm rigid hysteroscope with an optic of 30 degrees with a diagnostic sheath of 4 mm or a 4-mm hysteroscope with a diagnostic sheath of 5 mm was used, as determined by the surgeon. The distending medium used was CO2 or physiologic saline, and a xenon light source was used. All procedures took place at IMIP with no analgesia or anesthesia. Endometrial biopsy was performed with a 3-mm Novak curette when needed. Examination duration was measured by a chronometer, from the introduction of the hysteroscope in the cervical canal through its removal. Independent variables (exposure) were: biological (age); demographic (education and religion); gynecologic and obstetrical (parity, vaginal delivery, number of vaginal deliveries, time elapsed from last vaginal delivery, menopause, and tubal sterilization); length of examination; technical devices features (distending medium, hysteroscope diameter, placement of tenaculum, cervical dilation, and endometrial biopsy). Dependent variable (outcome) was pain intensity as measured by the pain VAS, a horizontal scale of 100 mm in which each value corresponds to pain intensity; from the left side (100 mm) to the right (0 mm) the results were: severe pain and no pain. Results were obtained from the patients immediately after the examination and at 15, 30, and 60 minutes later. Pain score between 0 and 4 was rated mild or absent (not ill); pain score of 5 or higher was rated moderate or severe (ill). Data analysis was performed using Epi-Info 3.2.2 for Windows, a public domain software. The ␹2 test was used at a 5% significance level, and risk ratio (RR) at 95% CI was calculated as a measurement the relative risk for severe/ moderate pain. Multivariate analysis was also performed through multiple logistic regression to determine the main factors associated with moderate/severe pain. The research was conducted following the rules and ethical guidelines of Resolution 196/96 from the Health National Council of the Ministry of Health (Brazil), regulating information privacy and confidentiality. The initial project was approved by the IMIP research ethics committee.

Results A total of 171 patients were included in the study, with a broad age range from 14 to 87 years (mean 40.5 ⫾ 11.1); the majority of patients (64.4%) were younger than 45 years old. Education level varied from 0 to 13 years of education (median 7). Diagnostic hysteroscopy lasted a mean of 3 to 4 minutes with a variation of 1 to 7.8 minutes. Details of these and other clinical characteristics are shown in Table 1.

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Table 1 Clinical characteristics of patients and procedure statistics in outpatient hysteroscopy without anesthesia Clinical characteristic

No.

Age ⬍ 35 years 35–44 years 45–54 years 55–64 years ⬎ 65 years Education None 1–3 years 4–7 years 8–11 years ⬎ 11 years Religion Catholicism Protestant Other None Gynecologic and obstetrical history Previous vaginal delivery Vaginal delivery ⬎20 years ago Postmenopause Tubal sterilization Duration ⬎3 min ⬍3 min Distending medium CO2 CO2 ¡ SF SF Diameter of sheath 4 mm 5 mm Procedures Placement of the tenaculum Endometrial biopsy Cervical dilatation

%

49 61 46 11 4

28.7 35.7 26.9 6.4 2.3

13 24 49 21 64

7.6 14.0 28.7 12.3 37.4

102 64 4 1

59.6 37.4 2.3 0.6

79 39 24 91

46.2 22.8 14.0 53.2

99 72

57.9 42.1

77 26 68

45.0 15.2 39.8

94 77

55.0 45.0

114 151 11

66.7 88.3 6.4

SF ⫽ physiologic saline.

Moderate/severe pain as measured by a VAS score of 5 or more immediately after the examination was reported by 68.4% of patients but none reported moderate or severe pain 60 minutes after the examination (Table 2).

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No association was determined between education, religion, tubal sterilization history, type of distending medium, or diameter of hysteroscope with moderate/severe pain (VAS score ⱖ5). Twenty-five patients age 50 or older (89.3%) reported a VAS score of 5 or more immediately after hysteroscopy, a risk 39% higher than that of patients younger than 50 years old (95% CI 1.16 –1.66) (Table 3). Patients with no vaginal delivery presented a 27% higher risk of a VAS score of 5 or more immediately after examination (95% CI 1.04 –1.55) than those who had one or more deliveries. In cases where delivery occurred 20 or more years ago, the RR was 57% higher (95% CI 1.13–2.1) than those with deliveries fewer than 20 years ago (Table 3). Postmenopausal patients presented a risk of a VAS score of 5 or more after hysteroscopy 42% higher (95% CI 1.20%–1.68) than premenopausal patients. Details of these and other clinical characteristics are shown in Table 3. During multiple logistic regression analysis to determine predictor factors (independent variables) with stronger association with hysteroscopy pain, it was noted that the only variables significantly associated with pain were menopause, tenaculum placement, and previous vaginal delivery (Table 4). This model has accurately predicted 86% of pain causes. In the presence of the 3 associated factors (menopause, tenaculum placement, and absence of vaginal delivery), pain frequency was 95.6% (Table 4).

Discussion Our findings coincide with a few recently published studies questioning whether anesthesia-free diagnostic hysteroscopy is a painless procedure and indicating the selection of patients who should be using pain-relief techniques.22,23 Bivariate analysis determined an association between age of 50 or older and VAS pain score of 5 or more. However, when focusing on age, multivariate analysis did not show any association with apparent pain, possibly because menopause is implicit in age and pain association. In our study, 92% of postmenopausal patients versus 65% of premenopausal women had VAS scores of 5 or more after hysteroscopy. Pain and menopause association remained

Table 2 Quantitative evaluation of pain intensity at different intervals on VAS in outpatients undergoing diagnostic hysteroscopy without anesthesia VAS

Evaluation interval

Variation

Median

0–4 (mild or absent pain) No. (%)

ⱖ5 (moderate or severe pain) No. (%)

Immediately after examination 15 minutes later 30 minutes later 60 minutes later

0–10 0–9 0–5 0–3

6 3 1 0

54 123 165 171

117 (68.4) 48 (28.1) 6 (3.5) –

VAS ⫽ visual analog scale.

(31.6) (71.9) (96.5) (100)

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Table 3 Quantitative evaluation of pain intensity through VAS in outpatients undergoing diagnostic hysteroscopy without anesthesia VAS ⱖ5 Clinical characteristics and procedures Age ⱖ 50 years ⬍ 50 years Education None 0–3 years 4–7 years 8–10 years ⱖ 11 years Religion None/Other Catholicism Protestant Vaginal delivery None One or more ⱖ 20 years ⬍ 20 years Tubal ligation Yes No Menopause Postmenopausal Premenopausal Diameter of hysteroscope 4 mm 5 mm Distending medium SF CO2¡ SF CO2 Placement of tenaculum Yes No Endometrial biopsy Yes No Cervical dilatation Yes No Duration ⬎ 3 min ⱕ 3 min

No.

VAS ⬍5 %

No.

%

RR

95% CI

25 92

89.3 64.3

3 51

10.7 35.7

1.39 1.00

1.16–1.66

10 19 31 13 44

76.9 79.2 63.3 61.9 68.8

3 5 18 8 20

23.1 20.8 36.7 38.1 31.2

1.12 1.15 0.92 0.90 1.00

0.8–1.57 0.88–1.5 0.70–1.21 0.62–1.31 -

4 73 40

80.0 71.6 63.5

1 29 24

20.0 28.4 37.5

1.28 1.15 1.00

0.79–2.06 0.91–1.44 -

61 56 30 26

77.2 60.9 76.9 49.1

18 36 9 27

22.8 39.1 23.1 50.9

1.27 1.00 1.57 1.00

1.04–1.55 1.13–2.17 -

59 50

64.8 72.5

32 22

35.2 27.5

0.90 1.00

0.73–1.09

22 95

91.7 64.6

2 52

8.3 35.4

1.42 1.00

1.20–1.68 -

66 51

70.2 66.2

28 26

29.8 33.8

1.06 1.00

0.86–1.30 -

45 18 54

66.2 69.2 70.1

23 8 23

33.8 30.8 29.9

0.94 0.99 1.00

0.75–1.18 0.74–1.33 -

87 30

76.3 52.6

27 27

23.7 47.4

1.45 1.00

1.11–1.89 -

101 16

66.9 80

50 4

33.1 20

0.84 1.00

0.65–1.07 -

11 106

100 66.3

54

33.8

1.51 1.00

1.36–1.69 -

75 42

75.8 58.3

24 30

24.2 41.7

1.30 1.00

1.04–1.63 -

RR⫽ relative risk; SF ⫽ physiologic saline; VAS ⫽ visual analog scale.

following multivariate analysis. Menopause alterations in the female genitalia usually require the need for additional cervical dilation and tenaculum use, which is another factor associated with pain, especially in patients not having experienced previous vaginal delivery.24,25 Patients not having experienced vaginal deliveries were at 27% higher risk as compared with patients having experienced vaginal deliveries. In cases of vaginal deliveries performed 20 or more years ago, the risk of VAS pain score of 5 or more was 57% higher. Multivariate analysis determined that time elapsed since the last vaginal delivery had

no direct relation to pain, although former vaginal deliveries reduced pain risk in 30% notwithstanding the number of deliveries. Other authors have reported that nulligravidas, nulliparous, and postmenopausal patients are at higher risk for pain.25,26 Vaginal delivery seems to be a facilitating factor for hysteroscope passage through the endocervical canal, because the cervix is more dilated. The external cervix orifice is circular, 4 to 6 mm wide in nulliparous women and 10 to 15 mm in multiparous women. The endocervical canal is approximately 3 cm long including the external cervix ori-

de Carvalho Schettini et al Table 4

Diagnostic anesthesia-free hysteroscopy

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Factors associated with pain in diagnostic hysteroscopy without anesthesia (multiple logistic regression analysis)

Variable (yes/no)

Coefficient

SD

OR

95% CI

p

Menopause Placement of the tenaculum Vaginal delivery Constant

2.0285 1.0826 ⫺1.3556 2.2287

0.7771 0.3697 0.4230 0.7566

7.6 2.9 0.3 *

1.65–34.86 1.43–6.09 0.11–0.59 *

.009 .003 .001 .003

fice, with diameters varying between 4 and 5 mm in nulliparous women and between 7 and 8 mm in multiparous women.27 The wider cervix orifice in multiparous women eases hysteroscope passage through the endocervical canal reducing dilation need, and that could explain lower pain scores. Similar findings have been described by other authors, such as Pansky et al, although using a 2.3-mm pediatric cystoscope for anesthesia-free diagnostic hysteroscopy. Their age-related findings determined that for each year of age, the odds ratio for successful hysteroscopy was reduced by 0.9 and that success increased 1.29 for each vaginal delivery. In menopausal patients, the odds ratio for success decreased to 0.45, menopause being the main factor associated to hysteroscopy failure.28 In menopause, there is reduction of secretions and rugosity in the vagina with atrophy of the uterine cervix narrowing the endocervical canal and internal orifice.29 These factors present difficulties for the passage of the hysteroscope through the endocervical canal and this could require more cervix instrumentation to perform the hysteroscopy. Some factors such as religion and education affect pain perception. Among the subjects of this study, the prevalent religion was Roman Catholic (59.6%) but no association between VAS score of 5 or more and religion was determined. Approximately 7.6% of patients were illiterate, and the schooling median was 7 years, indirectly impacting the conduction of the study and understanding of the VAS. Nevertheless, there was no association between pain and education. Other studies relating religion and education and the presence of pain during diagnostic hysteroscopy were not found in the reviewed literature. In addition to the technique employed, placement of the tenaculum was performed in 66.7% of patients, a high percentage considering 86% of study subjects were young patients. This percentage could be associated with the fact that residents in training were the ones in charge of performing the examination, and they could have required more cervix instrumentation to cross the endocervical canal. However, pain intensity data collection did not take into account who performed the procedure, considering the practice of personal supervision by the attending physician. Through bivariate analysis, patients who underwent placement of the tenaculum were at a 45% increased risk of pain, and this association persisted after control of multivariate analysis of confounding factors, with an adjusted

odds ratio of 2.9. Literature has reported that placement of the tenaculum in the effort to dilate may cause menstruallike pain.1 In a randomized, nonmasked study, the use of lidocaine cream with prilocaine (25 mg of each anesthetic per g of cream) applied to the ectocervix and endocervix proved to be effective in reducing pain in the placement of the tenaculum and examination duration, probably due to lubrication of the hysteroscope passage through the endocervical canal. This cream was more efficient in reducing in the placement of the tenaculum pain than lidocaine spray (10 mg/dose) and even more so than the non-use of anesthetic on the uterine cervix.20 According to Wieser et al, in a nonrandomized and nonmasked study, lidocaine spray (10 mg/dose) reduced the odds ratio of pain by 75%. The authors suggest applying the spray to the cervix and removing the tenaculum so that the entire cervix is embedded in anesthetic. In cases of cervix dilation, dilators should be moisturized with anesthetic before dilation (which allows bathing of the cervix and embedding of the dilator with local anesthetic if dilation is required), considering that instrumentation of the cervix is the most painful part of the examination.8 Davies et al, however reported that although the spray reduced the tenaculum placement pain, it did not reduce the hysteroscopy procedure’s discomfort.30 Diagnostic hysteroscopy lasted a mean of 3.4 minutes with 57.9% of examinations surpassing 3 minutes. Bivariate analysis determined that patients who endured examinations lasting more than 3 minutes were at 30% more at risk of pain; however, multivariate analysis determined that hysteroscopy duration had no direct association with pain. A possible explanation is that duration of examination is an indicator of the need to grasp the cervix using the tenaculum, a factor truly associated with pain. Similar findings were observed by other authors.17,20 A randomized and nonmasked study, pursued to establish whether endometrial biopsy was more painful than hysteroscopy, considered hysteroscope diameter and anesthesia. In anesthesia-free patients in whom a diagnostic sheath of 5 mm was used, 26% of the patients reported that biopsy was more painful; this compares with 20% of patients in whom a 5-mm sheath with paracervical block was used and 10% of patients in whom a 3.5-mm sheath without anesthesia was used reporting that biopsy was more painful (p ⬍.01). De Iaco et al noted 28.7% patients had a VAS score of 6 or more in the performance of endometrial biopsy, but 82% of acceptance of the procedure in a study

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with a hysteroscope using a diagnostic sheath of 5 mm and anesthesia free.7 In our study, 88.3% of the patients underwent endometrial biopsy with no association either in bivariate or multivariate analysis between biopsy and pain as determined by VAS score of 5 or more. The endometrial tissue does not have nerve terminals; only the myometrium does,27,31 and that could explain the absence of association between biopsy and pain reported by patients. Cervical dilation is required in cases of cervical stenosis with narrowing of endocervical canal and reduction of the internal cervix orifice caliber to enable hysteroscope passage.1 Some factors are associated with the need for added cervical dilation, such as postmenopausal status and absence of vaginal deliveries.8,17 As for the hysteroscopic technique, cervical dilation and endometrial biopsy were considered the most painful parts of the examination.15,17 Cervical dilation was performed in 6.4% of our patients, a percentage considerably lower than that reported by Wieser et al, who used an hysteroscope of 4 mm and a diagnostic sheath of 5 mm and observed need for dilation in 45% of a population similar to ours (15% were postmenopausal women, median age 41.4 years).8 There are studies demonstrating a higher incidence of endocervical canal dilation and placement of the tenaculum in postmenopausal patients as the most prevalent cause for hysteroscopy failure. According to Fung et al, evaluating postmenopausal patients, endocervical canal dilation was a requirement for 73% of the placebo group (without misoprostol). However, their population had a median age of 58.5 years, considerably older than in our study with subjects at a median age of 40.5.24 The use of a good image resolution but smaller diameter optic has been recently suggested to reduce patients’ discomfort and side effects.32,33 According to De Angelis et al, patients undergoing hysteroscopy with a 3.3-mm hysteroscope (minihysteroscope) had lower VAS pain scores, less menstrual-like pain (pelvic pain reduction), and bradycardia than those examined with a 5-mm hysteroscope.33 In our sample, 55% had the examination with a 4-mm sheath hysteroscope; however, in both bivariate and multivariate analysis, there was no relation between hysteroscope diameter and pain as scored by VAS of 5 or more. De Iaco et al report that anesthesia-free diagnostic hysteroscopy with a 5-mm sheath is a painful procedure, with one-third of the patients reporting severe pain, even when performed by experienced surgeons, using the least traumatic technique possible and careful procedure information before the examination.7 Giorda, in a randomized, nonmasked study, noted that VAS-scored pain after hysteroscopy depicted mean scores of 6.33 with 5-mm sheaths as opposed to 4.5 with 3.5-mm sheaths.9 De Angelis et al carried out a randomized study, comparing anesthesia-free diagnostic hysteroscopy (using CO2) with a rigid 4-mm hysteroscope and 5-mm diagnostic sheath (conventional) and hysteroscope of 2.7-mm with a 3.3-mm sheath (minihysteroscope) and VAS-measured pain score of

10 cm. The authors concluded that image quality was practically the same in the 2 types of hysteroscope, with less pain with the use of the minihysteroscope.33 Valli et al reported the need to replace CO2 with a saline solution in 1.67% of cases to avoid excessive bleeding.34 In our study, surgeons sometimes initiated the procedure using CO2 and, due to technical difficulties such as excessive bleeding or mucus, poor distension of the uterine cavity by CO2, or instrument-related technical problems, replaced the use of CO2 with physiologic saline, to avoid examination cessation. The use of CO2 did not produce higher pain scores. Cicinelli et al observed that hysteroscopy by vaginoscopy with saline solution was better tolerated than conventional hysteroscopy by patients with lower pain scores due to the placement of the tenaculum in the uterine cervix and using thinner hysteroscopes (minihysteroscopes).32 Vaginoscopy with CO2 is a well-tolerated method as well. Paschopoulos et al noted that 65% of patients underwent the examination without discomfort.19 The main criticism of performing the examination without anesthesia is pain. Therefore, many hysteroscopy examinations continue to be performed with regional or general anesthesia.19,23,35–37 Tong et al observed that hysteroscopy and dilation and curettage under anesthesia are low pain score procedures, with more that 50% of patients acknowledging the procedure as painless after recovering from anesthesia.36 Pain may occur during different hysteroscopy stages: when the hysteroscope is introduced in the endocervical canal, especially when crossing the internal cervical orifice; by the contractile activity of the myometrium during endometrial biopsy or by uterine cavity distention by CO2 or saline solution; and by direct stimulation of the uterine walls when in contact with the hysteroscope.33 Other factors such as cervical manipulation, cervix grasping with a tenaculum, and cervical dilation are associated with pain.1,15,17,37 Findings suggest that patients who are postmenopausal, have no previous vaginal delivery, and/or need cervical grasping should not have diagnostic hysteroscopy without anesthesia. An alternative for patients not meeting the criteria above in the event of an anesthesia-free diagnostic hysteroscopy during which the unexpected need for grasping the cervix with a tenaculum arises, is the use lidocaine gel at 2% or lidocaine spray (10 mg/dose), allowing for a 4-minute wait for the anesthetic to act in the cervical epithelium when cervical dilation is required. Dilators should be moisturized with local anesthetic. Furthermore, we suggest the use of vaginal estrogens 2 weeks before hysteroscopy for postmenopausal patients. Results of this study demonstrated that hysteroscopy is a painful procedure, with approximately 69% of the patients reporting VAS pain score of 5 or more. Logistic regression multivariate analysis established 2 inherent risk factors (i.e., lack of previous vaginal delivery and menopause) plus hys-

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teroscopy techniques (tenaculum placement) associated with pain occurrence and intensity. Reviewing the medical literature, our study suggested that the ideal hysteroscopy service should emphasize the use of minihysteroscopes and vaginoscopy, avoiding as much as possible grasping the cervix with the tenaculum and cervical dilation. In the event these procedures are required, local anesthetic in the cervix should be used. Hysteroscopy with or without anesthesia should be an option depending on the patient’s clinical and gynecologic history and physical examination. There should be prior contact between the patient and doctor who will eventually perform the examination, and if required, prescription of estrogens or general anesthesia recommendation should be made.

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