Pietro Gambadauro, Consultant in Gynaecology and Reproductive Medicine, Centre for Reproduction, Uppsala University Hospital, 751 85 Uppsala, Sweden
Adam Magos, Consultant Gynaecologist, University Department of Obstetrics and Gynaecology, Royal Free Hospital, NW3 2QG London, UK
03 April 2010 bmj.com Rapid Responses for Cooper NAM et al. BMJ 2010;340
In response to the comments by Dr. Sharma (1), and with reference to the study he quotes in support of routine pain relief for outpatient hysteroscopy, we suspect that the basic hysteroscopy technique used in that study was likely to be painful because:
a. They were not using a “no touch” (vaginoscopic) technique but using speculums and tenaculum which themselves are uncomfortable (and most of the times unnecessary).
b. They were over distending the uterine cavity to a pressure of 300 mmHg when 100 mmHg should have been more than sufficient in most cases. Excessive uterine distension causes pain, which then requires treatment.
c. They were using a 5 mm hysteroscope, large by today’s standards. A 5 mm hysteroscopy has a surface area which is almost twice as large as a modern “narrow” 2.9 mm scope fitted with a 3.7 mm sheath (19.6 mm2 versus 10.8 mm2).
d. They were routinely performing endometrial biopsy on patients with abnormal bleeding or infertility, whereas patients with normal findings do not need sampling.
e. They were using a Karman 4 mm cannula with negative pressure produced by means of a 20 ml syringe, rather than a narrower and more gently instrument such as the Pipelle or H Pipelle.
For all these reasons, it is not surprising that patients found the procedure a painful experience to the extent that the reported pain scores remained relatively high even after pain relief. Had they used a no touch technique, a narrow hysteroscope, reasonable uterine distension pressures, and a narrow biopsy instrument, the pain scores would have been much less, and it is likely that any benefit of analgesics, anaesthetics, antispasmodics or sedation would have been insignificant.
Pietro Gambadauro (a) and Adam Magos (b)
(a)Uppsala University Hospital, 751 85 Uppsala, Sweden
(b)Royal Free Hospital, NW3 2QG London, UK
References:
1. Sharma JB. Oral drotaverine and mefenamic acid are also effective for pain relief for hysteroscopy. http://www.bmj.com/cgi/eletters/340/mar23_2/c1130#233847
Competing interests: None declared