Surgical Techniques
Hysteroscopic myomectomy using a mechanical approach
Compared with resectoscopy, the mechanical approach offers improved visualization and requires fewer insertions of the hysteroscope, shortening...
Interestingly, in the music group, the STAI scores were lower after both diagnostic and operative hysteroscopy when classical music was selected rather than pop music.
Anxiety and pain are highly correlated
Angioli and colleagues found that patients who listened to music intraoperatively had a lower perception of pain and less anxiety. In addition, systolic blood pressure and heart rate were significantly lower in the music group than the no-music group, implying that patients who listened to music experienced less physical stress during the procedure.
Angioli and colleagues also noted that the level of anxiety and perception of pain were highly correlated. Pain is not an emotionally neutral experience but is almost always accompanied by distress. Investigators concluded that “anxiety can enhance painful sensations at all levels of the nervous system, from the peripheral receptors to the cortical level.”
What this EVIDENCE means for practice
Music is a useful complementary method to control patient anxiety and reduce the perception of pain during office hysteroscopy by creating a more relaxed and comfortable environment.
What are the risk factors for pain and discomfort during office hysteroscopy?
De Freitas FM, Sessa FV, Resende AD Jr, et al. Identifying predictors of unacceptable pain at office hysteroscopy. J Minim Invasive Gynecol. 2014;21(4):586–591.
De Freitas and colleagues conducted their prospective observational study to identify predictors of unacceptable pain during diagnostic office hysteroscopy (with or without directed or curette endometrial biopsy) and at the time of discharge. They hoped that any identifiable causes of unacceptable pain could be addressed individually in future patients undergoing office hysteroscopy to reduce their level of discomfort.
Details of the trial
A total of 558 procedures were evaluated. Hysteroscopists had varying levels of experience, with some having performed fewer than 50 procedures and others having performed more than 500.
A verbal response scale (range, 0–10) was used to assess pain at the end of each procedure and at the time of discharge. Investigators considered a score of 7 or more at the time of the procedure and a score of 4 or more at the time of discharge to be unacceptable.
A diagnostic, single-channel hysteroscope with an outside diameter of 3.5 mm was used with normal saline (at room temperature), along with a gravity system with pressure established to maintain intrauterine pressure at approximately 110 mm Hg. All hysteroscopic procedures were performed using a vaginoscopic approach, and biopsies were obtained as clinically indicated. Any patients who reported cramping at discharge (ie, a verbal response scale score of 4 or more) were offered an oral nonsteroidal anti-inflammatory drug.
Overall, the prevalence of unacceptable pain during office hysteroscopy was 32.3%. Experience of the hysteroscopist had a significant protective effect against pain. Longer procedures were significantly associated with unacceptable procedural pain.
The prevalence of unacceptable cramping at discharge was 28.6%. The risk of discomfort at discharge was significantly higher for women who reported dyspareunia or dysmenorrhea. Surgeon experience was significantly protective against unacceptable pain at discharge, and longer procedures were significantly associated with increased discomfort at discharge.
Dysmenorrhea and dyspareunia were significant predictors of pain at discharge
In this study, dysmenorrhea was a significant predictor of unacceptable pain at discharge, increasing the risk of unacceptable cramps by approximately threefold. Women who reported dyspareunia were nearly twice as likely to report unacceptable cramping at discharge.
Although a high level of expertise is not a prerequisite for office hysteroscopy, the skill and experience of the hysteroscopist, as well as shorter procedures, proved to be protective against procedural pain and discomfort at discharge but did not eliminate them altogether. Therefore, De Freitas and colleagues recommend that patients who can be identified as high-risk for procedural or discharge pain, such as women with dysmenorrhea or dyspareunia, should be offered preprocedure analgesia and/or anesthesia to reduce overall discomfort.
What this EVIDENCE means for practice
If a patient reports dysmenorrhea or dyspareunia preoperatively, she may benefit from preprocedure anesthesia or analgesia, or both, in an office setting.
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