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    Pain management of office-based hysteroscopy

     

    Uterine distension and other sources of pain

    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

    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.

     

    Rameet Singh, MD, MPH
    Dr Singh is Chief, Division of Family Planning at University of New Mexico School of Medicine, Albuquerque.
    Lauren Thaxton, MD, MBA
    Dr Thaxton is Family Planning Fellow at University of New Mexico School of Medicine, Albuquerque.

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    • [email protected]
      Great article. Succinct. I use almost all those strategies with great success. One woefully missing aspect of the article is the discomfort that can arise with patient and physician in regards to patient positioning. Having your feet in regular metal stirrups for 20-30 minutes can be uncomfortable and downright dangerous when a patient is sedated. Comfortable and secure positioning is important with every case. Besides spending $10-$15k on a procedure table (which negates your in-office reimbursements), surgeons can employ tools like the GStirrup. Patients can easily dose-off during these procedures, and secure placement of their legs is crucial to your reputation and to the patient's satisfaction with the procedure.

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