Assessing warm saline's role in alleviating pain in office hysteroscopy: A systematic review and meta-analysis

Background: This systematic review and meta-analysis evaluated the effectiveness of using warm saline as a distension medium compared to room temperature saline in reducing pain and improving patient satisfaction during office hysteroscopy. Methodology: Following PRISMA guidelines and registered in PROSPERO (CRD420251074073), we systematically searched MEDLINE, Scopus, Web of Science, and Cochrane Central for RCTs from inception to June 2025. Our search combined MeSH terms and keywords related to hysteroscopy, distension media, and pain management. We included RCTs that compared warm and room temperature saline in women undergoing diagnostic or operative office hysteroscopy. Two authors independently extracted data and assessed the risk of bias using the Cochrane Risk of Bias tool. Continuous outcomes were pooled as mean differences (MD) and dichotomous outcomes as odds ratios (OR) with 95% confidence intervals (CI) using RevMan software. Heterogeneity was assessed using the I² statistic, and sensitivity analyses were conducted to address variability. Results: Our meta-analysis included seven RCTs with a total of 541 women. Warm saline significantly reduced pain during the procedure, with a mean difference of -0.92 (95% CI: -1.50 to -0.34, p=0.002), despite high heterogeneity (I² = 83%). Post-procedure pain also significantly decreased, with a mean difference of -0.47 (95% CI: -0.79,-0.150, p = 0.004), and heterogeneity was substantial (I² = 67%). Patient satisfaction was significantly higher with warmed saline, with an odds ratio of 2.70 (95% CI: 1.49 to 4.91, p=0.001), although heterogeneity remained moderate (I² = 44%). Conclusion: Warm saline as a distension medium during office hysteroscopy significantly reduces procedural pain and enhances patient satisfaction. These findings support the adoption of warm saline to improve patient experience and compliance, promoting a more patientcentered approach in gynecological care.