What Has Been Discovered Since 2014 About Pain Mitigation in Outpatient Hysteroscopy Without General Anesthesia? [ID 1356]

INTRODUCTION: Outpatient hysteroscopy is standard for diagnosis and treatment of intrauterine pathology, and pain is the most common cause of procedural failure. There is no guideline for pain management in outpatient hysteroscopy. Developing one could reduce the need and risks associated with conducting hysteroscopic procedures under general anesthesia. The aim of this study is to analyze updated methods for pain mitigation in outpatient hysteroscopy since 2014 and highlight significant interventions targeted to cervical stenosis and nulliparity. METHODS: A detailed PubMed search was performed to identify pain interventions for outpatient gynecologic procedures and Covidence software was used for screening and data extraction. This review focuses on outpatient hysteroscopic procedures. Exclusion criteria were as follows: publication before 2015, protocols that did not assess pain during procedure, general anesthesia use, and pregnancy termination. RESULTS: Of 2,537 publications, 28 evaluated pain mitigation for outpatient hysteroscopy. The largest categories of interventions were vaginal prostaglandins, oral interventions, and intrauterine anesthetic installations. The most common medication utilized was misoprostol followed by lidocaine, dinoprostone, and tramadol. Misoprostol administered 12 hours prior to hysteroscopy significantly decreased pain in nulliparous women, and dinoprostone administration 12 hours before hysteroscopy reduced pain in postmenopausal patients. Other significant interventions included intrauterine instillation of local anesthetics, oral tramadol 1 hour before hysteroscopy, and inhalation of nitrous oxide. CONCLUSIONS/IMPLICATIONS: As more interventions demonstrate significant reductions in pain during outpatient hysteroscopies, future research should help develop best practices and determine targeted treatments for nulliparous and stenotic cervices.