Study objective To measure pain using a visual analogue scale (VAS) and analyse its relationships with variables such as menopausal status, parity, uterine and cervical pathology, procedure length, and anxiety in patients undergoing ambulatory hysteroscopy (AH). Design Prospective observational study. Setting Dr DY Patil Medical Hospital and Research Centre, Dr.D.Y. Patil Vidyapeeth, Pimpri, Pune. Patients Seventy-five women. Intervention Ambulatory hysteroscopy(AH).
Methodology AH was performed in seventy-five patients using vaginoscopic approach. At the end of the procedure, the intensity of pain was assessed using the visual analogue scale (VAS), from the score of 0 (no pain) to 10 (intolerable pain). The factors determining pain were assessed.
Results Patients who underwent AH reported mild pain in 66% of cases, moderate pain in 22%, and severe pain in 12% of cases. The most frequent reason for referral was abnormal uterine bleeding (AUB). In the moderate pain group, the bivariate analysis was statistically significant for menopausal status (P values < 0.001), cervical pathology (< 0.001), and duration of procedure (0.001) and in multivariate analysis nulliparity (0.001) and menopausal status (0.001) were the significant determining factors. In severe pain group, the bivariate analysis was statistically significant for cervical pathology (P value = 0.001) and in multivariate analysis cervical pathology (0.003) and uterine pathology (0.002) were the significant determining factors.
Conclusion Hysteroscopy is a safe, painless and a gold standard procedure. Pain experienced during AH was significantly influenced by cervical pathology. Gynaecologists in practise should receive training and start using AH to assess the endometrial cavity.
Keywords : Ambulatory hysteroscopy · Factors · Pain
In hysteroscopy, a rigid or flexible endoscope is inserted
through the os of the cervix to view within the uterus, and
distending media are then used to enable comprehensive
visualisation of the endometrial cavity [1].
Current best practice and gold standard for assessing
the endometrial cavity is AH [2]. Traditional hysteroscopy
had several difficulties, including the use of larger diameter
instruments and the need for anaesthesia and admission.
To decrease this, “see and treat” method was developed in
the late twentieth century. Also known as office operative hysteroscopy where the concept of a single procedure with
the operative component integrated into the diagnostic
workup is done [3].
The emergence of AH and advancements made by pioneers
like Betocchi et al. who transformed contemporary
hysteroscopy [4], by incorporating the vaginoscopic technique,
use of small instruments and the Betocchi sheath
[3] have all contributed to the procedure's acceptance on
a global scale.
Despite claims that AH is painless, multiple studies
have shown that this is not the case. A large series conducted
by Cicinelli et al. inferred that 10% of the 8000
cases experienced mild pain and 0.5% severe pain [5].
Another study conducted by S. Bettocchi of 4863 cases
reported that 71.9–93.5% of women experienced low to
moderate pain except, where the endometrial polyp was
larger than the diameter of the internal os [6].
De Angelis stressed in 2003 the significance of reducing
the patient's pain or discomfort during hysteroscopy
to make the treatment generally accepted and widely tolerated
[7]. Hysteroscopy has been extremely successful;
however, the technique is still not painless. The factors
influencing pain during hysteroscopy have been investigated
with varying degrees of success. Our study is an
effort to comprehend the relationship between many variables
and the degree of pain felt during hysteroscopy. Our
study evaluates the relationship of the pain intensity with
factors like patient’s parity, menopausal status, anxiety,
cervical and uterine pathology and duration of procedure.
The visual analogue scale (VAS) was used to measure the
degree of pain [8].
A prospective observational study was carried out at Dr.
D. Y. Patil Medical College Hospital & Research Centre,
Dr.D.Y. Patil Vidyapeeth Pimpri, Pune from August 2020
to July 2022. A total of 100 patients were referred to the
OPD. Amongst these, 16 patients refused to undergo the
procedure. The remaining 84 patients consented for AH.
Failure of procedure was noted in 9 patients due to intolerable
pain, and the procedure was aborted. Hence, 75
patients in total were examined and assessed.
An ambulatory hysteroscopy employing the vaginoscopic
technique, as described by Betocchi and Selvaggi in 1997 [3],
was carried out. A rigid 2.9 mm hysteroscope made by Karl
Storz in Tuttlingen, Germany, with a 30° forward oblique
Hopkins type II lens and a 4.3 mm outer sheath diameter was
used. Normal saline was used as the distension medium, and a
pressure range of 60–100 mmHg was maintained. No cervical
cleaning or premedication was administered.
Patients who were referred to the OPD with complaints
of abnormal uterine bleeding (AUB), abnormal findings
on hysterosalpingography or ultrasonography, recurrent
abortions, infertility, missed intrauterine device, or women
needing targeted endometrial biopsies were included in
the study.
Suspicion of pregnancy, active vaginal bleeding, a history
of cardiovascular disease, a recent uterine perforation,
acute pelvic inflammatory disease were the exclusion
criteria.
Parity, mode of delivery (prior LSCS and vaginal delivery), menopausal status, uterine pathology, cervical pathology, duration of procedure, and anxiety score were the factors which were assessed for correlation with degree of pain during AH. The patient was informed about the procedure, its process, indication, complications, and prognosis before giving her informed consent. She received instruction on the two subscales that make up the Spielberger State-Trait Anxiety Inventory (STAI), State Anxiety (STAI-S) and Trait Anxiety (STAI-T) [9]. The visual analogue scale and its scoring methodology were also explained. It was ensured that there would be little waiting prior to the procedure. Using a vaginoscopic approach, hysteroscopy was performed without the aid of anaesthesia and analgesia. A rigid 2.9 mm hysteroscope made by Karl Storz in Tuttlingen, Germany, with a 30° forward oblique Hopkins type II lens and a 4.3 mm outer sheath diameter was used. Normal saline was used as the distension medium, and a pressure range of 60–100 mmHg was maintained. A sequential evaluation of the vagina, external os, cervical canal, internal os, uterine cavity, endometrium and each tubal ostium was done. A nurse supported the patient during the process (“vocal local”), which helped to alleviate anxiety. In order to further involve the patient in the process, the surgeon allowed her to view the monitor while outlining any potential irregularities. Any pathology found was evaluated, and procedural duration was recorded. A standardised hysteroscopy report was generated. The participant was monitored for any discomfort, pain, or complications and was shown the visual analogue scale (VAS) by the nurse after 10 min of the completion of procedure, and they evaluated it based on the level of pain felt during AH. Pain intensity was recorded as no pain = 0, mild pain = 1–3, moderate pain = 4–7 cm, severe or intolerable pain = 8–10 cm [8]. Patients were segregated into three groups as per pain intensity: Mild, moderate and severe pain groups. Those who experienced moderate to severe pain were evaluated for determining factors including parity, previous LSCS, menopausal status, uterine pathology, cervical pathology, anxiety score and duration of procedure. The data were analysed using the SPSS (statistical program for social sciences) Software version 20/Epi info/Primer/Win-pepi. Procedure failure was defined as either the inability to achieve scope insertion or being unable to complete the procedure due to excruciating discomfort [10].
A prospective observational study was conducted at Dr.
D Y Patil Medical College Hospital & Research Centre,
Dr.D.Y. Patil Vidyapeeth Pimpri, Pune from August
2020 to July 2022. A total of 75 cases were examined and
assessed. The average BMI was 29.4 kg/m2, and the average
age was 32.5 years.
During AH, 66% of patients reported mild pain and
accounted for majority of cases. Moderate pain and severe
pain were reported in 22% & 12% of case, respectively. 28%
of women were nulligravida, whereas 72% were parous. 20%
of patients were menopausal, and 34% had previously undergone
a lower segment caesarean section. The most frequent
reasons for treatment were; abnormal uterine bleeding, infertility,
post-menopausal bleeding, recurrent pregnancy loss,
and misplaced IUCD (intra uterine contraceptive device).
(38%, 25%, 18%, 9% and 8%, respectively.)
In the moderate pain group, the bivariate analysis was statistically significant for menopausal status (P values < 0.001), cervical pathology (< 0.001), and duration of procedure (0.001) and in multivariate analysis nulliparity (0.001) and menopausal status (0.001) were the significant determining factors. In the severe pain group, the bivariate analysis was statistically significant for cervical pathology (P value = 0.001) and in multivariate analysis cervical pathology (0.003) and uterine pathology (0.002) were the significant determining factors. Cervical pathology was present in 7 patients (35%) reporting severe pain. Three had cervical stenosis (15%), 2 patients had cervical polyp (10%), 1 had adhesions (5%) and one patient had cervical septum (5%). No procedural complications were noted (Tables 1, 2, 3, 4, 5 and 6).
The findings of this study’s demonstrated that ambulatory
hysteroscopy is a painless, safe treatment that may be performed
with good tolerability without the use of anaesthesia
or analgesics. During ambulatory hysteroscopy, 66% of
patients reported mild pain, 22% reported moderate pain,
and 12% reported severe pain.
In the moderate pain group, the bivariate analysis was
statistically significant for menopausal status (P values
< 0.001), cervical pathology (< 0.001), and duration of
procedure (0.001) and in multivariate analysis nulliparity
(0.001) and menopausal status (0.001) were the significant
determining factors. In the severe pain group, the bivariate
analysis was statistically significant for cervical pathology
(P value = 0.001) and in multivariate analysis cervical pathology (0.003) and uterine pathology (0.002) were the
significant determining factors
De Iaco et al. [11] in his study reported severe pain in 38% women who underwent diagnostic hysteroscopy, Freitas Fonseca et al. [12] reported severe pain, VAS > 7 in 32% immediately after the procedure, and a similar study by Shereef M et al. [10] reported that 46% of patients had moderate pain and 17% had severe pain. A large series conducted by Cicinelli et al. inferred that 10% of the 8000 cases experienced mild pain and 0.5% experienced severe pain [5]. Peter Torok et al. [13] included 70 cases for the examination of pain score and 100% of the patients were rated as having mild discomfort.
The variable that has been common to pain amongst moderate and severe pain groups is the presence of cervical pathology. The navigation of the hysteroscope through the cervical canal and the internal os is the place of maximum discomfort. This can be explained by the presence of the hypogastric plexus which provides strong innervation to the fibromuscular cervix. Factors like nulliparity, menopausal status, cervical pathologies, lesions, polyps, adhesions, stenosis of internal or external os limit the cervical canal making it more difficult for the hysteroscope to pass through and can increase the pain perception.
Our study is supported by studies of De Iaco et al. [11], and Raimondo et al. [14] who revealed a direct correlation between cervical pathology and pain intensity and Ivan Mazzon's study [15] according to which a VAS > 3, and the occurrence of synechiae is correlated. Menopause and nulliparity were found to be factors in a study by De Carvalho Schettini et al. [16] accounting for pain during hysteroscopy. According to a study by Ivan Mazzon et al. [15], the number of vaginal deliveries is inversely proportional to pain intensity. Shereff [10] found that nulliparity, procedure lasting longer than 2 min and the presence of cervical pathology are all related with excruciating discomfort. In patients who had considerable pain, the length of the hysteroscopy was much longer, according to prospective research by Fonseca et al. [12]
Contrarily, a study by Peter Torok [13] found no connection between the presence of discomfort and variables including menopausal state and parity. In a study of 8000 cases, Cicinelli et al. [5] found no connection between nulliparity and pain during hysteroscopy. No correlation was found between pain reporting with, a woman's parity, menopause, dysmenorrhea, a history of menorrhagia, a prior cervical surgery, or age, according to Antonio A. Paulo et al. [17] The postmenopausal status was an insignificant factor in study, and studies conducted by Ivan Mazzon’s [15], van Dongen et al. [18] and De Iaco et al. [11] revealed no association with pain in diagnostic hysteroscopy and menopause. De Carvalho Schettini [16] and Ivan Mazzon [15] reported no direct relation of the duration of procedure and severity of pain. Our study demonstrated a correlation of moderate pain with cervical pathology, nulliparity, menopausal status, and duration of the procedure. Correlation of severe pain with the presence of cervical and uterine pathology was done. Performing AH without analgesia and anaesthesia is a skill. Factors, such as cervical pathology, parity, menopausal status, and the duration of procedure, all affect the degree of pain during AH. However, mastering the technique, incorporation of the vaginoscopic approach, gentle movements while manoeuvring the scope and patient selection play a crucial role in reduction in pain perception.
Declarations
Conflict of interest There are no conflict of interest.
Ethical standard statement The institutional ethical committee approval by Helenskis declaration.
Consent statement Counselling was provided to all patients, and their informed consent was obtained.
