Addressing the Pain of an Office Hysteroscopy

The in-office hysteroscopy has become widely implemented in OBGYN offices. Doing this procedure in-office eliminates the risks that are associated with anesthesia and allows the possibility of seeing and treating an intracavitary pathology in the same examination.

Despite its many benefits, this accessible approach reveals a major obstacle that has inspired investigators to look at an array of options in order to manage a patient’s pain during the procedure.

In the past year alone, there has been research examining lidocaine, conscious sedation, warm distension fluid, hyoscine, and even virtual reality headsets, as a way to reduce pain during or after an in-office hysteroscopy.

In an interview with HCPLive, Greg Marchand, MD, FACS, FACOG, FICS, Director of the Marchand Institute for Minimally Invasive Surgery, and dual certified OBGYN, went into detail about the complexities of the procedure.

In most cases, he explained, it simply doesn’t make sense to administer a high level of anesthesia to the patient for a hysteroscopy because even if the pain might be intense, it’s short-lived. Whereas, the effects of anesthesia last for hours and come with the possibility of side effects.

Varying studies report varying degrees of efficacy. Pain is enigmatic, and while providers have been treating pain since the beginning of time, the search for solutions continues.

2021 Data

“Office hysteroscopy is a really neat thing, because if you pick the right patients, and you're able to do it, you're able to get a look inside that uterus while the patient is still right there in your office,” Marchand said.

His team was interested in investigating anything that could make the office hysteroscopy more comfortable for patients and therefore, making it available for more patients.

In one study, the investigators looked at the effectiveness of hyoscine in reducing pain during office hysteroscopy and the other study looked at how effective tramadol was at reducing pain during the procedure.

Contrary to previously published data, the results of Marchand’s study did not show hyoscine to be effective in reducing pain during hysteroscopy.

“My group did a really great analysis of hyoscine and we didn't find any real statistically significant benefit to using it for office hysteroscopy. But that isn't saying anything about the value of office hysteroscopy being any less just because this one agent didn't work,” Marchand explained. “A lot of people are having great results with tramadol, narcotics, and other IV anesthesias, and I think office hysteroscopy has a very, very bright future in gynecology.”

According to the research, tramadol was found to be an effective and safe option for patients. However, there’s not a singular correct way to manage a patient’s pain, whether it’s having an anesthesiologist give intravenous medications, like Marchand, or using an oral regimen.

“We want to take advantage of all the best literature we can to try to make these studies available and do the meta analysis when it's possible in order to get the highest level of data so that we can show surgeons what really works best for their patients,” Marchand said.

In minimally invasive gynecologic surgery, most procedures are outpatient now–including hysterectomies.

"We really fine tune minimally invasive gynecologic surgery to work through very, very small holes and to maximize recovery,” Marchand said, “and this goes hand in hand with something called Enhanced Recovery After Surgery."

Providers design regimens of what medications to give patients before, during and after surgery. This includes what to feed the patient and at what point the nurses should get them moving and active.

“These regimens have been extremely successful in turning procedures that would have required hospital stays of several days into outpatient procedures,” Marchand said, "and minimizing the pain that these patients have when they receive these procedures."

The Virtual Reality Trend

There have been numerous clinical settings in which virtual reality has been utilized to alleviate anxiety, reduce pain, support physical rehabilitation, and enable distraction.

Non-pharmacological techniques, like cognitive behavioral therapy (CBT), as well as relaxation techniques, have been shown to influence a patient’s perception of pain. Virtual reality technology can provide an immersive, multisensory, 3-dimensional environment that enables patients to modify their actual experiences.

Earlier this year, a team of investigators led by Yuval Fouks, MD, Lis Hospital for Women, Department of Obstetrics and Gynecology, evaluated the effectiveness of virtual reality for the management of acute pain and anxiety during operative hysteroscopy in the outpatient setting.

According to this study, the virtual reality method was not effective in decreasing pain during an outpatient operative hysteroscopy. The reported pain scores showed no significant difference during the procedure compared with the control group.

However, in another study conducted by Nandita Deo, MBBS, MD, FRCOG, MSc, Whipps Cross Hospital, the team of investigators found that women with virtual reality intervention experienced less average pain and anxiety during an outpatient hysteroscopy compared with standard care. 

“Compared with standard care, the virtual reality pain management intervention had a large effect in reducing pain and anxiety in outpatient hysteroscopy,” investigators wrote. “This effect was robust after controlling for baseline pain and anxiety expectations and a range of patient covariates.”

The 2 studies differed in their design, population and results, but are representative of the assortment of data collected in hopes of better managing pain during this procedure.

Managing Expectations to Manage Pain

As a dual board certified OBGYN and the director of the Marchand Institute for Minimally Invasive Surgery, Marchand is more than familiar with outpatient hysteroscopy.

He emphasized the importance of properly informing the patient about the potential for experiencing pain, whether it’s for a hysteroscopy or another outpatient procedure.

“I really think a big, big factor of this is, you have to inform the patient about what they're signing up for,” Marchand said. “Some office procedures are extremely painful–it may be a very short duration of the pain, and it may be something you just cringe for, and it's past.”

“If they previously had an IUD placed, well, that's something they can compare it to–that kind of deep, violating pain of having something placed in your uterus while you're awake,” he said.

There are various medication and treatment regimens that could be successful for managing pain in this situation, but above all else, managing a patient’s expectations is crucial.

“If they haven't had an IUD placed, you could compare it to a severe labor pain,” Marchand continued. “Very often, if they were able to have severe labor pains before they had an epidural they'll know what that pain is, that helps get them in the right mindset for what's going on.”