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Research

Local anaesthesia for pain control during outpatient hysteroscopy: systematic review and meta-analysis

BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c1130 (Published 23 March 2010) Cite this as: BMJ 2010;340:c1130

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Speculum, tenaculum and endometrial biopsy are not routinely needed during diagnostic hysteroscopy

In response to the comments by Dr. Sharma (1), and with reference to
the
study he quotes in support of routine pain relief for outpatient
hysteroscopy,
we suspect that the basic hysteroscopy technique used in that study was
likely to be painful because:

a. They were not using a “no touch” (vaginoscopic) technique but
using
speculums and tenaculum which themselves are uncomfortable (and most of
the times unnecessary).

b. They were over distending the uterine cavity to a pressure of 300
mmHg
when 100 mmHg should have been more than sufficient in most cases.
Excessive uterine distension causes pain, which then requires treatment.

c. They were using a 5 mm hysteroscope, large by today's standards. A
5 mm
hysteroscopy has a surface area which is almost twice as large as a modern

"narrow" 2.9 mm scope fitted with a 3.7 mm sheath (19.6 mm2 versus 10.8
mm2).

d. They were routinely performing endometrial biopsy on patients with

abnormal bleeding or infertility, whereas patients with normal findings do
not
need sampling.

e. They were using a Karman 4 mm cannula with negative pressure
produced
by means of a 20 ml syringe, rather than a narrower and more gently
instrument such as the Pipelle or H Pipelle.

For all these reasons, it is not surprising that patients found the
procedure a
painful experience to the extent that the reported pain scores remained
relatively high even after pain relief. Had they used a no touch
technique, a
narrow hysteroscope, reasonable uterine distension pressures, and a narrow

biopsy instrument, the pain scores would have been much less, and it is
likely that any benefit of analgesics, anaesthetics, antispasmodics or
sedation
would have been insignificant.

Pietro Gambadauro (a) and Adam Magos (b)

(a)Uppsala University Hospital, 751 85 Uppsala, Sweden

(b)Royal Free Hospital, NW3 2QG London, UK

References:

1. Sharma JB. Oral drotaverine and mefenamic acid are also effective
for pain
relief for hysteroscopy.
http://www.bmj.com/cgi/eletters/340/mar23_2/c1130#233847

Competing interests:
None declared

Competing interests: No competing interests

03 April 2010
Pietro Gambadauro
Consultant in Gynaecology and Reproductive Medicine
Adam Magos, <br>Consultant Gynaecologist, <i>University Department of Obstetrics and Gynaecology, Royal Free Hospital, NW3 2QG London, UK<i>
Centre for Reproduction, Uppsala University Hospital, 751 85 Uppsala, Sweden