23 Nov Office Hysteroscopy without Anesthesia, Is it really possible?
During the last decade the number of procedures performed in an office setting has been increasing constantly. Initially it was only the diagnostic hysteroscopy that was performed in office but today we are performing an increasing number of surgical procedures in office and without any kind of anesthesia.
Pain is something we can deal with, develop strategies/treatments to decrease it, but anxiety is the most important reason of impossibility to perform the procedure. The anxiety increases the perception of pain, pain is subjective but we always have to respect what the patients says, even if our perception is different.
In order to reduce anxiety there are some steps we must follow.
1. Inform the patient about the procedure and all the steps. The moments that may be associated with discomfort. Assure the patients that “she is the boss” and if she asks us to stop we will respect her.
2. Avoid long waiting time before the procedure. To seat and wait to come in increases very much the anxiety.
3. To be in constant verbal communication with the patient during the procedure. The way we talk, our words, our voice tone must be clear, understandable and calm.
What are the factors that make it possible to reduce pain?
1. Vaginoscopy. One of the most important factors for women´s discomfort is the use of speculum, specially if it is associated to tenaculum/Pozzi. The vaginoscopy approach allows us to avoid this discomfort.
2. Smaller diameter optics. With the use of an optic with an external diameter lower than 5mm, the pass through the endocervical channel can be performed with minimal discomfort to the patient, and it is achieved in most of the cases. This is the most important limiting factor. Depending on parity (nuliparus) or menopausal stage (post menopausal), the discomfort may increase. Sometimes stenosis with important fibrosis of the internal ostium will increase the difficulty of passing through. The use of misoprostol and/or the use of scissors/laser for cutting the fibrosis will help to overcome the problem in a well tolerated way. Another important factor associated to patient´s discomfort is the hysteroscopist´s experience.
3. Distension medium. CO2 and saline solution. Some authors report that the discomfort is lower with saline solution and this is the most used distension media
4. Intrauterine Pressure during the procedure. Although there are different recommendation to what should be the minimal and the maximal pressure, we should use the minimal pressure for achieve the maximum distension of the endometrial cavity. Some patients will need just “2 drops” and others, specially multiparous fertile women will need the maximum and not always will help to get a good distension of the cavity. The precaution of not using to much pressure brings us to the second limiting factor of a procedure without anesthesia, the uterine cavity distension is associated to a discomfort that gradually increases in time. The time limits goes in most cases from 15 to 30 minutes depending on the patient tolerance.
5. New small surgical devices/energies. To day we can find new small diameter devices. Those that have a diameter of more of 5mm will need the use of at least local anesthesia (morcellators/mini-resectoscope), others that can be introduced through the 5Fr working channel of the hysteroscope (Laser/mechanical instruments/Bipolar) wont need any kind of anesthesia.
Strategies. Based on the subjective perception of the pain we try to develop distraction strategies during the procedure.
We asked our patients to concentrate on the ball performing serials of 10 times pressing then stop 1 second and continue doing so. We randomized 2 groups of similar patients, 20 patients in each group. After the procedure we gave a Visual Analogue Scale(VAS) for level of pain evaluation.There were not any significative differences in the pain score between the groups.
VAS – Visual Analogue Scale
We randomized our patients into 2 groups of 30 women each, one with music and the other without. Similar in characteristics and procedures. The music group had to choose in Spotify the music they usually listen to and is relaxing. We used wireless headphones. A VAS was used after the procedure, again there were not significative differences between the groups regarding pain but we found a statically significance regarding satisfaction in favor of the music group.
So, the next questions is, why distraction is not so useful when dealing with pain tolerance to an hysteroscopic procedure? To understand this we need to know what is the pain a woman usually feels during the procedure. In our case, based in 2200 procedures in office using diode laser (polypectomy/myomectomy/septoplasty etc…) without any kind of anesthesia, 90,5% of the women referred that what they felt was equal or less than their normal menstruation. Still, we have cancelled around 5% of the hysteroscopies based on intolerance to the procedure.
Basically, office hysteroscopy is a well tolerated procedure, but we still need to find more strategies to improve the tolerance and avoid pain/anxiety in those patients that still need it.
This topic is included in the program of the Global Congress on Hysteroscopy that will take place next year in Barcelona. I would like to invite you to participate and come to this nice city. For those of you that like the Barcelona Football Team (Barça) a game will be held in Barcelona the weekend before and the weekend after the congress.