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Different interventions are appropriate for different patients.
Neither author has a conflict of interest to report in respect to the content of this article.
Minor gynecologic procedures are increasingly moving from the operating room to the office. Patients and ob/gyns both benefit from this relocation. Office procedures have lower complications and faster recovery1,2 and are easier to schedule, quicker, and more cost-effective. Procedures in the office can be painful. Average pain scores for common procedures are reported in Table 1.
Office-based hysteroscopy allows us to visualize the uterine cavity for diagnostic or therapeutic purposes. Indications for hysteroscopy include abnormal uterine bleeding, infertility, abnormal ultrasound findings, desire for permanent contraception, and localization and removal of embedded intrauterine devices (IUDs) or IUD remnants. The procedure is generally well-tolerated in the office setting, but the most common cause for discontinuation of office hysteroscopy is pain. Here we outline options for pain management for clinicians providing hysteroscopy in the office setting. We present the evidence for different pain interventions and discuss our office practice.
Physicians must carefully select patients for office-based procedures. The preoperative evaluation, including a complete history and physical examination, will help identify factors that would exclude patients from office-based surgery. Reviewing a patient’s menstrual and contraceptive history and appropriately scheduling her hysteroscopy are important, because best visualization is obtained during the early proliferative phase of the endometrium. This assessment will also identify risk factors for higher pain with the procedure (Table 2). Preoperative counseling should include setting realistic expectations for pain control.
Women who undergo outpatient hysteroscopy complain of discomfort primarily during cervical manipulation and cervical dilation, uterine distension, uterine contractions (caused by endometrial biopsy, polypectomy, or ablation), and tubal manipulation (transcervical sterilization). Each of these sensations is managed by the complex innervation of the uterus, cervix, fallopian tubes, and endometrium. The sympathetic nerves of the thoracic and lumbar spine (T10-L1) travel with the superior hypogastric plexus (presacral nerve). They then divide into the 2 hypogastric nerves and reach the uterine fundus via the uterosacral ligament. Sympathetic fibers further innervate the uterus via the ovarian plexus. Parasympathetic nerves of sacral origin (S2-S4) form the uterovaginal and inferior hypogastric plexus, innervating mainly the cervix and the lower uterine segment. This is known as Frankenhauser’s paracervical nerve plexus. The inferior ovarian nerves arise directly from the hypogastric plexus and innervate the fallopian tubes. The innervation of the endometrium and the myometrium is poorly understood. However, uterine activity has been shown to cause patient pain and discomfort.3 Procedures performed by experienced hysteroscopists (defined as those who have performed more than 500 cases) have been found to cause significantly less pain.4 Adequate pain management requires using the right equipment and a multimodal approach to reducing patient pain, including creating a calm and relaxing clinic environment and using multiple interventions.
Hysteroscopes are available in 3.5-mm and 5-mm diameters and flexible or rigid frames. Larger-diameter hysteroscopes are associated with increased pain during dilation, but the 5-mm hysteroscope may be necessary for certain procedures. Normal saline is the most common distension medium and affords excellent visibility. It has been shown that longer procedures are more uncomfortable for patients and therefore, knowledge of the instrument and preparation of the procedure room will optimize chances of success.
Speculum placement can be uncomfortable and in some studies of women undergoing dilation and curettage, average pain scores with dry speculum placement have been reported to be as high as 34 mm (mild pain) on a 0–100-mm visual analog scale. Using gel can reduce the discomfort of speculum placement to 14 ±12 mm (minimal pain).5 We recommend putting a small amount of gel on both blades of the speculum before inserting.
Local anesthesia can help attenuate the pain of tenaculum placement, and cervical manipulation including cannulation and dilation. Different iterations of local anesthesia have been proposed, including injectable anesthesia such as a paracervical block (PCB) or intracervical block, and topical anesthesia such as lidocaine spray and intrauterine instillation. In a meta-analysis of these methods, injectable anesthesia was found to be effective at reducing procedural pain, but topical anesthesia was not.6 Local anesthesia with a PCB has been found to decrease pain with introduction of the hysteroscope during transcervical sterilization.7 Injectable anesthesia itself is known to cause discomfort, so in order to decrease this effect, we recommend using buffered lidocaine. This is created by adding 2 mL of sodium bicarbonate (Figure 1). Data are limited on the effect of waiting after the PCB and before starting the procedure. Extrapolating from studies of other common office-based procedures such as office dilation and curettage, we have found that waiting 3–5 minutes following injection does not improve procedural pain.8 In one study, pain associated with hysteroscopy and endometrial biopsy in postmenopausal women was reduced when the procedure was started 10 minutes after mepivacaine was used for PCB.9 While we do not wait between administering the PCB and starting the procedure, you may consider waiting in patients who are uncomfortable with the initial cervical dilation and manipulation.
When administering local anesthesia, it is important to recognize the signs and symptoms of lidocaine toxicity. These include numbness or tingling around the mouth or face, tinnitus, and in extremely rare cases, cardiac dysrhythmias and seizures. Recommendations for maximum dosing state that providers should not exceed 4.5 mg/kg 1% lidocaine without epinephrine or 7 mg/kg 1% lidocaine with epinephrine.
In our practice, we recommend intracervical injection of 2–3 cc of 1% buffered lidocaine at the anterior cervix prior to placement of the tenaculum. Following placement of the tenaculum, the remaining can be injected in equal aliquots at 4 and 8 o’clock at the cervicovaginal junction as a PCB. The PCB reduces pain associated with placement of the tenaculum and cervical dilation.7 Start your PCB by placing your needle below the paravaginal mucosa, aspirate, and inject 1–2 mL. Next, advance the needle through the area you have already anesthetized, aspirate and inject an additional 1–2 mL and keep going until approximately 9 mL have been injected.
Once you start the procedure, if your patient is still having pain with cervical cannulation and dilation, consider injecting additional lidocaine until maximum dosing is attained (Figure 2) and/or inject 10–15 mL of normal saline instead. This second injection can be given paracervically or intracervically at 10, 2, 4, and 8 o’clock. While it is not an anesthetic, the distension of nerve innervation with saline can reduce pain.10
Because local anesthesia affects only some aspects of the hysteroscopic procedure, other interventions are needed to address uterine distension, the release of prostaglandins, and pain of tubal manipulation during placement of the transcervical coils.
Nonsteroidal anti-inflammatory drugs and opiates
According to a Cochrane review of hysteroscopic procedures, neither nonsteroidal anti-inflammatory drugs (NSAIDs) nor opiates have been shown to reduce pain of hysteroscopic procedures in the office including transcervical sterilization.11,12 Some of the studied medications included diclofenac,13 buprenorphine,14 mefenamic acid, and drotaverine hydrochloride,15 which are uncommonly used in the United States in the outpatient setting. One limitation of the studies included inadequate time for peak effect of medications.
In a randomized controlled trial (RCT) comparing oral sedation with oxycodone and naproxen to intravenous (IV) sedation with fentanyl and midazolam for transcervical sterilization, the authors found no difference in pain experienced during the procedure between the 2 groups except that IV sedation offered better pain control at the time of second coil insertion.16 Insertion of the second coil is considered the most painful portion of the transcervical sterilization procedure.
For patients who choose oral sedation in our office, we routinely offer oxycodone 10 mg, lorazepam 2 mg and ibuprofen 600 mg 30–40 minutes before the procedure. For patients undergoing transcervical sterilization we substitute 30–45 mg of ketorolac for the ibuprofen. Consider an additional 1 mg of sublingual lorazepam for patients who are not feeling the effects of the medications. No studies have evaluated the benefits of oxycodone and lorazepam for office-based hysteroscopy. If your clinic does not stock these medications, a prescription can always be written for patients to take the medications preoperatively. Consent forms would naturally need to be signed at a prior clinic visit and patients would need a ride to and from the clinic.
For patients desiring IV or moderate sedation, we offer fentanyl and midazolam. The provision of moderate sedation in our office necessitates specific policies and protocols as well as specialized training of clinicians and nursing staff, including advanced cardiac life support.
Misoprostol or mifepristone for cervical priming
Many studies have evaluated the efficacy of cervical priming using misoprostol or mifepristone. No evidence supports routine administration of these drugs because they do not appear to increase the likelihood of completing the procedure and in fact increase preoperative pain and cramping. However, providers who are considering hysteroscopy in a postmenopausal woman with a hysteroscope diameter > 5 mm may consider preoperative misoprostol.17 In addition, women who have had a previous unsuccessful attempt at traversing the cervix during an in-office procedure may also benefit from preoperative misoprostol cervical priming.
Nitrous oxide may be helpful in reducing pain from hysteroscopy and hysteroscopic sterilization. Nitrous oxide has analgesic, anxiolytic, and amnestic properties, and vasodilates smooth muscle.18,19 It has been effectively used in short painful procedures in dental, pediatric, and emergency room settings. More recently it is also making a comeback for use during labor and delivery. In a RCT we conducted at the University of New Mexico, nitrous oxide was found to significantly reduce pain from office transcervical sterilization compared to oral sedation with oxycodone and lorazepam.
The power of words
Providers should remember the power of their words. Words such as “pain,” “pinch,” “pressure,” and “cramp” convey negative sensations. Literature from interventional radiology finds that negative words increase the pain, anxiety, and discomfort that patients experience during outpatient procedures.20 In our practice, we encourage providers to consider reframing these warnings using neutral terms. For example, we use phrases such as, “I am going to place the speculum,” “You may feel me hold the cervix,” and “I am going to numb your cervix with medication.”20
Finally, music can have an important effect with little effort on the part of the clinic. Soft music played in the procedure room has been shown to decrease patient anxiety and pain with hysteroscopic procedures.21 We encourage clinics that provide outpatient procedures to use music in the procedure room.
1. Fothergill RE. Endometrial ablation in the office setting. Obstet Gynecol Clin North Am. 2008;35(2):317–330.
2. Kremer C. Endometrial ablation: the next generation. Br J Obstet Gynaecol. 2000;107:1443–1452.
3. Smith GM, Stubblefield PG, Chirchirillo L, McCarthy M. J. Pain of first-trimester abortion: its quantification and relations with other variables. Am J Obstet Gynecol. 1979;133:489–498.
4. de Freitas Fonseca M, Sessa FV, Resende JAD, Guerra CGS, Andrade CM, Crispi CP. Identifying predictors of unacceptable pain at office hysteroscopy. J Minim Invasive Gynecol. 2014;21(4):586–591.
5. Hill DA, Lamvu G. Effect of lubricating gel on patient comfort during vaginal speculum examination: a randomized controlled trial. Obstet Gynecol. 2012;119(2, Part 1):227–231.
6. Cooper NAM, Khan KS, Clark TJ. Local anaesthesia for pain control during outpatient hysteroscopy: systematic review and meta-analysis. BMJ. 2010;340(mar23 2):c1130–c1130.
7. Chudnoff S, Einstein M, Levie M. Paracervical block efficacy in office hysteroscopic sterilization: a randomized controlled trial. Obstet Gynecol. 2010;115(1):26–34.
8. Phair N, Jensen JT, Nichols MD. Paracervical block and elective abortion: the effect on pain of waiting between injection and procedure. AJOG. 2002;186(6):1304-1307.
9. Cicinelli E, Didonna T, Schonauer LM, Stragapede S, Falco N, Pansini N. Paracervical anesthesia for hysteroscopy and endometrial biopsy in postmenopausal women. A randomized, double-blind, placebo-controlled study. J Reprod Med. 1998;43(12):1014-1018.
10. Glantz JC, Shomento S. Comparison of paracervical block techniques during first trimester pregnancy termination. Int J Gynaecol Obstet. 2001;72:171-178.
11. Ahmad G, O’Flynn H, Attarbashi S, Duffy JM, Watson A. Pain relief for outpatient hysteroscopy. In: The Cochrane Collaboration, ed. Cochrane Database of Systematic Reviews [Internet]. Chichester, UK: John Wiley & Sons, Ltd; 2010 [cited 2015 Nov 1]. Available at: http://doi.wiley.com/10.1002/14651858.CD007710.pub2
12. Kaneshiro B, Grimes DA, Lopez LM. Pain management for tubal sterilization by hysteroscopy. In: The Cochrane Collaboration, ed. Cochrane Database of Systematic Reviews [Internet]. Chichester, UK: John Wiley & Sons, Ltd; 2012 [cited 2015 Nov 1]. Available at: http://doi.wiley.com/10.1002/14651858.CD009251.pub2
13. Tam WH, Yuen PM. Use of diclofenac as an analgesic in outpatient hysteroscopy: a randomized, double-blind, placebo-controlled study. Fertil Steril. 2001;76(5):1070–1072.
14. 4Lin Y-H, Hwang J-L, Huang L-W, Chen H-J. Use of sublingual buprenorphine for pain relief in office hysteroscopy. J Minim Invasive Gynecol. 2005;12(4):347–350.
15. Sharma J, Aruna J, Kumar P, Roy K, Malhotra N, Kumar S. Comparison of efficacy of oral drotaverine plus mefenamic acid with paracervical block and with intravenous sedation for pain relief during hysteroscopy and endometrial biopsy. Indian J Med Sci. 2009;63(6):244.
16. Thiel JA, Lukwinski A, Kamencic H, Lim H. Oral analgesia vs intravenous conscious sedation during Essure micro-insert sterilization procedure: randomized, double-blind, controlled trial. J Minim Invasive Gynecol. 2011;18(1):108–111.
17. Cooper N, Smith P, Khan K, Clark T. Does cervical preparation before outpatient hysteroscopy reduce women’s pain experience? A systematic review: Cervical preparation for outpatient hysteroscopy. Int J Obstet Gynaecol. 2011;118(11):1292–1301.
18. Zacny JP, Hurst RJ, Graham L, Janiszewski DJ. Preoperative dental anxiety and mood changes during nitrous oxide inhalation. J Am Dent Assoc. 2002;133(1):82–88.
19. Becker DE, Rosenberg M. Nitrous oxide and the inhalation anesthetics. Anesth Prog. 2008;55(4):124–130; quiz 31-32.
20. Lang EV, Hatsiopoulou TK, Berbaum K, et al. Can words hurt? Patient-provider interactions during invasive procedures. Pain. 2005;114:303–309.
21. Angioli R, De Cicco Nardone C, Plotti F, et al. Use of music to reduce anxiety during office hysteroscopy: prospective randomized trial. J Minim Invasive Gynecol . 2014;21(3):454–459.