Outpatient hysteroscopy and endometrial biopsy are now replacing inpatient dilation and curettage as the
procedure of choice for the investigation of abnormal uterine bleeding. While several groups have been performing outpatient
hysteroscopy, there is a wide variation in the practice regarding the use of analgesia. Most authors report using local anesthe
agents in the form of paracervical block or intracervical infi
e purpose of our study was to assess the amount of pain
the patient faces during various stages of their hysteroscopy procedure.
We conducted a prospective observational study of 426 patients and a ten-point visual analogue score (VAS) was used
to determine the pain score during hysteroscopy ? at entry into the external os, while negotiating the internal cervical os, wh
inside the uterus and during procedures, for example, the Pipelle sampling, IUCD removal or polypectomy. All nulliparous
patients, those who had never delivered vaginally or any patient with an obviously tight cervical os were given 400 micrograms
oral misoprostol, 3 hours before the procedure.
Pain during the procedure was assessed using the 10-point visual analogue scale (Figure 1). Th
e procedure was generally
bearable; only eight patients could not tolerate the negotiation through the internal os due to cervical stenosis, resulting in
an unsuccessful hysteroscopy. Pipelle sampling (mean VAS = 5.63) was the most painful stage of the procedure, followed
by the negotiation through the internal os (mean VAS = 3.77). IUCD removal (mean VAS = 3.58) and polypectomy (mean
VAS = 1.26) was better tolerated than sampling of the endometrium. While multiparous patients had a lower VAS score, the
menopausal status and previous vaginal deliveries were not signifi
cantly correlated to the VAS.
Pain is an important factor in assessing the feasibility of outpatient hysteroscopy. In this study, we have
demonstrated that with the use of misoprostol, the need for analgesia can be eliminated and the procedure successfully
performed almost 95% of the patients.
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