Pain management of office-based hysteroscopy
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.
Patient selection and preparation
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.