Pain relief in office gynaecology: a systematic review and meta-analysis

Hysteroscopy, hysterosalpingography (HSG), sonohysterography and endometrial ablation are increasingly performed in an outpatient setting. The primary reason for failure to complete these procedures is pain. The objective of this review was to compare the effectiveness and safety of different types of pharmacological intervention for pain relief in office gynaecological procedures. A systematic search of medical databases including PubMed, EMBASE, Cochrane Central register of controlled trials, PsychInfo and CINHAL was conducted in 2009. Randomised controlled trials (RCTs) investigating the use of local anaesthetics, opioid analgesics, non-opioid analgesics and intravenous sedation for pain relief during and after hysteroscopy, HSG, sonohysterography and endometrial ablation were reviewed. Secondary outcomes included adverse effects and failure to complete procedures. Where RCTs were not identified, the best available evidence was sought. Each study was assessed against inclusion criterion. Results for each study were expressed as a standardised mean difference (SMD) with 95% confidence intervals and combined for meta-analysis with Revman 5 software. Meta-analysis revealed beneficial effect of the use of local anaesthetics during and within 30 min after hysteroscopy; SMD -0.45 (95% CI -0.73, -0.17) and SMD -0.51 (95% CI -0.81, -0.21) respectively. No beneficial effect was noted during HSG. One RCT found evidence of benefit for pain relief during hysterosalpingo-contrastsonography; SMD -1.04 [95% CI -1.44, -0.63]. There was no significant difference in failure to complete hysteroscopy due to cervical stenosis between the intervention and control groups (OR 1.31 (95% CI 0.66, 2.59)), but the incidence of failure to complete the procedure due to pain was significantly less in the intervention group (OR 0.29 (0.12, 0.69)). There is evidence of benefit for the use of local anaesthetics for outpatient hysteroscopy and hysterosalpingo-contrastsonography. Local anaesthetics may be considered when performing hysteroscopy in postmenopausal women to reduce the failure rate.