Pain control in hysteroscopy. Finesse, not local anaesthesia

Categories: Articles&Publications.

Pietro Gambadauroconsultant in gynaecology and reproductive medicine1
Adam Magosconsultant gynaecologist2

1 Centre for Reproduction, Department of Obstetrics and Gynaecology, Uppsala University Hospital, 751 85 Uppsala, Sweden, 2University Department of Obstetrics and Gynaecology, Royal Free Hospital, London NW3 2QG

BMJ 2010;340:c2097;881

The take home message of the systematic review and meta-analysison local anaesthesia during outpatient hysteroscopy is misleading.1
The conclusion, “Injectable, preferably paracervical, administration of local anaesthetic should be used for women undergoing hysteroscopy as outpatients to reduce the amount of pain experienced,” is based on five randomised trials, two of which found paracervical blocks to be ineffective.2, 3The benefit reported in the three other studies was clinically modest, two showing a one point reduction in pain on a 10 point scale. Even the authors of the study showing the largest effect (6.66 to >1.55 on a 20 point scale with 5 being “low pain”) did not support the routine use of paracervical anaesthesia when very thin hysteroscopes are used. Statistical significance must not be confused with clinical significance.

Another argument against routine paracervical blockade is the principle of first do no harm. Such injections can cause vasovagal reactions in up to a third of patients.3

Cooper and colleagues also recommend topical anaesthetics beforeapplying a tenaculum. Although sensible, this ignores the fact that with narrow hysteroscopes and modern techniques such as “no touch” (vaginoscopic) hysteroscopy combined with a suitable sampling device the cervix rarely has to be held either for hysteroscopy or endometrial biopsy.4 Many of the studies analysed by Cooper and colleagues were done more than 10 years ago andare out of date.

Narrow hysteroscopes and vaginoscopy are widely accepted as being more important to ensure patient comfort than local anaesthesia.5 Instead of recommending anaesthesia to cover up the deficiencies of larger hysteroscopes, uncomfortable speculums, and tenaculums, we should be recommending the adoption of a minimalist approach and reliance on technical finesse rather than metal in the vagina.

Cite this as: BMJ 2010;340:c2097

Pietro Gambadauroconsultant in gynaecology and reproductive medicine1,Adam Magosconsultant gynaecologist2

1 Centre for Reproduction, Department of Obstetrics and Gynaecology, Uppsala University Hospital, 751 85 Uppsala, Sweden, 2 University Department of Obstetrics and Gynaecology, Royal Free Hospital, London NW3 2QG

Competing interests: None declared.

References

  1. Cooper NA, Khan KS, Clark TJ. Local anaesthesia for pain control during outpatient hysteroscopy: systematic review and meta-analysis.BMJ 2010;340:c1130. (23 March.)[Abstract/Free Full Text]
  2. Vercellini P, Colombo A, Mauro F, Oldani S, Bramante T, Crosignani PG. Paracervical anesthesia for outpatient hysteroscopy. Fertil Steril1994;62:1083-5.[Web of Science][Medline]
  3. Lau WC, Lo WK, Tam WH, Yuen PM. Paracervical anaesthesia in outpatient hysteroscopy: a randomised double-blind placebo-controlled trial. Br J Obstet Gynaecol 1999;106:356-9.[Web of Science][Medline]
  4. Madari S, Al-Shabibi N, Papalampros P, Papadimitriou A, Magos A. A randomized trial comparing the H Pipelle with the standard Pipelle for endometrial sampling at “no touch” (vaginoscopic) hysteroscopy. Br J Obstet Gynaecol 2009;116:32-7.
  5. Sagiv R, Sadan O, Boaz M, Dishi M, Schechter E, Golan A. A new approach to office hysteroscopy compared with traditional hysteroscopy: a randomized controlled trial. Obstet Gynecol2006;108:387-92.[CrossRef][Web of Science][Medline]