1 Department of Gynaecology and Obstetrics, University of Padua and 2 Department of Pharmacology, Gynaecology and Obstetrics, University of Sassari, Italy
3 To whom correspondence should be addressed at: Department of Pharmacology, Gynaecology and Obstetrics, University of Sassari, Viale San Pietro 12, Sassari 07100, Italy. e-mail: dessole{at}uniss.it
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Abstract |
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Key words: distension media/outpatient hysteroscopy/pain measurement/visual analogue scale
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Introduction |
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Hysteroscopy requires distension of the uterine cavity with either a gas (CO2) or liquid medium (Hyskon; normal saline, 5% dextrose). Carbon dioxide has the same refractive index as air, provides optimal visibility (Van der Pas and Vancaille, 1990) and, as a gas, is easy to infuse, although vision can be impaired by bubbles or bleeding during the procedure.
Few objective reports have been published (Nagele et al., 1996a; Pellicano et al., 2003
) on the use of liquids for outpatient hysteroscopy, particularly low-viscosity fluids such as normal saline (0.9% sodium chloride). The attraction of these solutions is their ready availability, insufflation by use of a simple pressure bag, rapid reabsorption from the peritoneal cavity in case of transtubal leakage, good vision, low viscosity, and miscibility in the blood (Nagele et al., 1996a
).
The aim of this prospective, randomized study was to measure patients discomfort using a visual analogue scale (VAS) pain score after hysteroscopy with either CO2 or normal saline.
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Materials and methods |
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Indications for hysteroscopy included the following: abnormal uterine bleeding (AUB), thick endometrium or suspected intracavitary pathology such as endometrial polyps or myomas at ultrasonography, infertility, tamoxifen therapy and cytological endometrial hyperplasia.
Hysteroscopy was performed using a 2.9 mm-diameter hysteroscope with a 30° foreoblique lens. An electronic hysteroflator of CO2 (Storz, Tutlingen-Germany) was used with a pressure not exceeding 100 mmHg and a flow rate of 40 ml/min. Normal saline was infused with a 100 mmHg pressure bag. All procedures were performed by the same operator, and no local anaesthesia or systemic drugs were given to any patient.
The cervix was visualized using a speculum, after which the hysteroscope was slowly introduced into the cervical canal in order to evaluate carefully the endometrial surface and to visualize the tubal ostia. The endocervical canal was inspected during extraction of the hysteroscope. The same procedure was performed in the CO2 and normal saline groups. When indicated, endometrial biopsy was performed using a Novak curette. The procedure time was measured from insertion of the hysteroscope into the external uterine orifice until its removal.
At 10 min after hysteroscopy, women were asked by another operator, who was not directly involved with the procedure, to rate the pelvic pain experienced on a 100 mm VAS (0 = no pain; 100 = worst imaginable pain). The results of pain scores were expressed as mean ± SD, where a score of 040 indicated minimal pain, 4170 indicated moderate pain, and 71100 indicated severe pain.
Overall pelvic discomfort after the procedure was also assessed. Pelvic discomfort observed during the hysteroscopic procedure was mainly due to passage of the hysteroscope through the internal cervical os and to the induced uterine contraction that is determined by uterine cavity distension.
Satisfaction rate was evaluated on a 5-point scale, where 0 = no satisfaction, 1 = mild satisfaction, 2 = moderate satisfaction, 3 = satisfaction, and 4 = maximum satisfaction. Women were also interviewed about the presence or absence of shoulder tip pain.
The data were analysed using Students t-test; a P-value < 0.05 was considered to be statistically significant.
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Results |
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The mean procedure time was 115 ± 12 s in the CO2 group compared with 90 ± 10 s in the normal saline group (P < 0.01).
Irrespective of the distension medium used, pelvic discomfort was worse in nulliparous women (score 39.0 ± 26.5) than in multiparous women (score 30.4 ± 25.9) (P < 0.05; combined pre- and postmenopausal data not shown in table), especially if they were premenopausal (Table IV). However, when taking into consideration all patients and both distension media, pelvic discomfort was worse with normal saline than with CO2 (score 36.2 ± 26.8 versus 29.4 ± 25.4, P < 0.05; data not shown), especially if the women were nulliparous or premenopausal (Table V).
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Discussion |
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Improvements in technology resulting in the development of narrow-diameter hysteroscopes have made it possible to perform hysteroscopy both feasibly and safely on an outpatient basis (Nagele et al., 1996b; Wieser et al., 1998
).
Nowadays, CO2 is the most commonly used distension medium, mainly on the basis of its properties of excellent endoscopic visualization of the uterine cavity and low risk of side effects (Loffer, 1993), although the formation of bubbles and/or the presence of blood sometimes leads to an inadequate diagnostic examination (Pellicer and Diamond, 1988
). Some authors use low-viscosity fluids based on low cost, an absence of any side effects, simplicity of use and good vision. The advantages of this approach are a good visualization of the uterine cavity in the presence of blood clots, mucus and debris (Nagele et al., 1996a
). In cases of AUB [one of the most common indications for hysteroscopy (40%), and
44% in the present series], the use of low-viscosity fluids may be advantageous when exploring the uterine cavity (Valle, 1981
; Mencaglia et al., 1987
; Soderstrom, 1992
; Perez-Medina et al., 2000
).
When comparing the two most used distension media, one group (Nagele et al. 1996a) reported that the hysteroscopic procedure time with normal saline was generally shorter than with gas. The present data confirm that normal saline is certainly an excellent distension medium with a short procedure time (90 ± 10 s). Moreover, it allows good visualization and a more rapid distension compared with CO2, which requires a longer time to expand the uterine cavity, albeit in a characteristically different manner.
With regard to the patients discomfort during hysteroscopy, both distension media cause only minimal to moderate pelvic pain, and this permits the operator to perform the procedure with good patient compliance (Mantha et al., 1993; Giorda et al., 2000
).
In the present series, normal saline as a distension medium evoked a more intense pelvic discomfort than did CO2 (pain scores 36.2 ± 26.8 versus 29.4 ± 25.4; data not shown), especially in nulliparous or premenopausal patients. By contrast, another group recently reported (albeit in a smaller sample size than the present series; n = 189) a significant reduction in abdominal pain after distension with normal saline compared with CO2 (Pellicano et al., 2003). However, the same authors did not find any statistically significant difference between the two groups in terms of postoperative pain at 2 h after hysteroscopy. At present, both distension media provide good quality of vision, handling and safety, and are comparable in terms of cost and patient discomfort, which was shown to be minimal for both groups in the present series.
Unfortunately, our study did not use an adequate method for patient randomization. In fact, the method of randomization, which was to alternate the type of distension medium on a weekly basis, does not follow CONSORT (Consolidated Standards of Reporting of Trials) guidelines (Schultz et al., 1994; Grimes, 2002
).
In recent years, the use of hysteroscopy has been extended widely on the basis of its diagnostic accuracy and ease of performance. These aspects constitute important benefits for women who undergo this outpatient procedure, for which compliance is high and hospital costs are reduced (Valle, 1988).
In conclusion, when considering the high frequency of AUB as an indication for hysteroscopic examination and the significantly shorter procedure time, normal saline should be considered the most appropriate distension medium for outpatient hysteroscopy.
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References |
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Submitted on January 10, 2003; resubmitted on May 16, 2003; accepted on August 1, 2003.