Association Between Menstrual Pain and Procedural Pain During Office Hysteroscopy: A 10-Year Cohort Study

Office hysteroscopy (OH) is the standard diagnostic method for evaluating intrauterine and endocervical pathology, yet the fear of procedural pain remains a major barrier to patient acceptance. This study examined whether menstrual pain can be used as a clinical reference to anticipate OH procedural pain and explored other predictors of procedural discomfort.

A historical cohort study was conducted among women undergoing OH for abnormal uterine bleeding or postmenopausal bleeding at a tertiary referral hospital between 2014 and 2024. All procedures were performed by a single experienced hysteroscopist using a 4.9-mm vaginoscopic technique with preprocedural acetaminophen. Menstrual pain and OH procedural pain were assessed using a 0-10 visual analogue scale (VAS). Demographic and clinical variables were extracted from medical records. Associations with OH pain were evaluated using Mann-Whitney U tests and multivariable linear regression.

A total of 488 women were included (median age: 45 years and median BMI: 24.5 kg/m²). Median VAS for menstrual pain was 1.0 (interquartile range [IQR]: 0-3) and for OH pain was 0.0 (IQR: 0-2). Mean OH pain was lower than mean menstrual pain. In bivariate analyses, younger age, nulliparity, and higher menstrual pain were associated with higher OH pain. In multivariable analysis, menstrual pain and nulliparity remained independent predictors of higher OH procedural pain, while increasing age was associated with slightly lower pain.

OH was generally well tolerated, with pain typically lower than menstrual pain. Although menstrual pain, parity, and age explained only a modest proportion of pain variability, menstrual pain history offers a simple and patient-centered way to help clinicians set realistic expectations about procedural discomfort.