European Journal of Obstetrics & Gynecology and Reproductive Biology 154 (2011) 915

Contents lists available at ScienceDirect

European Journal of Obstetrics & Gynecology and

Reproductive Biology
journal homepage: www.elsevier.com/locate/ejogrb

Review

Pain relief in outpatient hysteroscopy: a survey of current UK clinical practice

Helena OFlynn a, Lauren L. Murphy a, Gaity Ahmad b, Andrew J.S. Watson c,*
a

University of Manchester Medical School, Manchester, UK

Department of Obstetrics and Gynaecology, Pennine Acute Trust, Greater Manchester, UK
c
Department of Obstetrics and Gynaecology, Tameside General Hospital, Fountain Street, Ashton-under-Lyne, Lancashire OL6 9RW, UK
b

A R T I C L E I N F O

A B S T R A C T

Article history:
Received 28 February 2010
Received in revised form 7 August 2010
Accepted 25 August 2010

Background: Outpatient hysteroscopy is increasingly being used as a cost-effective alternative to inpatient hysteroscopy under general anaesthesia. Like other outpatient gynaecological procedures,
however, it has the potential to cause pain severe enough for the procedure to be abandoned. There are
no national guidelines on pain relief for outpatient hysteroscopy.
Methods: A postal survey of UK gynaecologists was carried out to evaluate current clinical practice
regarding methods of pain relief used during ofce hysteroscopy. A total of 250 questionnaires were sent
out and 115 responses received.
Results: Outpatient hysteroscopy was offered by 76.5% of respondents. Respondents reported a wide
variation in the use of routine and rescue analgesia, and also in the nature of the analgesia used. Onequarter of those offering outpatient hysteroscopy used no form of analgesia.
Conclusion: The results showed that whilst there is no consensus on the type of analgesia provided,
rescue analgesia is commonly being used, particularly in the form of intracervical blocks.
2010 Published by Elsevier Ireland Ltd.

Keywords:
Outpatient hysteroscopy
Pain relief
Analgesia
Local anaesthesia

Contents
1.
2.
3.

4.

5.

Introduction . . . . . . . . . . . . . . . . . .
Method . . . . . . . . . . . . . . . . . . . . . .
Results . . . . . . . . . . . . . . . . . . . . . .
3.1.
Routine premedication . . . .
3.2.
Non-routine premedication
Discussion . . . . . . . . . . . . . . . . . . .
4.1.
Oral analgesia . . . . . . . . . . .
4.2.
Local anaesthesia . . . . . . . .
4.3.
Paracervical block . . . . . . . .
4.4.
Intracervical anaesthesia . .
4.5.
Topical anaesthesia . . . . . . .
4.6.
Intrauterine anaesthesia . . .
Conclusions . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . .

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1. Introduction
Hysteroscopy is increasingly being used in the ofce setting, as
it is well tolerated by many women, even without the use of

* Corresponding author. Tel.: +44 161 331 6158.

E-mail addresses: andy.watson@tgh.nhs.uk, watsoaj3@doctors.net.uk
(Andrew J.S. Watson).
0301-2115/$ see front matter 2010 Published by Elsevier Ireland Ltd.
doi:10.1016/j.ejogrb.2010.08.015

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.. 9
. 10
. 10
. 10
. 10
. 11
. 11
. 12
. 12
. 13
. 13
. 13
. 13
. 15

anaesthesia [1]. It can, however, still be a painful experience for

some and there is no consensus on the use of analgesia. The rate of
successful completion of hysteroscopy varies from 77% to 97.2%
[25]. Various methods of pain relief have been described,
including paracetamol, non-steroidal anti-inammatory drugs
(NSAIDs) such as ibuprofen, diclofenac and mefenamic acid,
opioid analgesics, and local anaesthesia including intracervical
blocks, paracervical blocks and topical cervical or intrauterine
anaesthesia.

[(Fig._1)TD$IG]

H. OFlynn et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 154 (2011) 915

10

3. Results
A total of 250 postal questionnaires were sent out, to which 115
recipients responded (46%). OPH was offered by 88 (76.5%)
respondents. Of those offering OPH, 32 (36.4%) offered routine
premedication with either oral analgesia (paracetamol or NSAID)
or local anaesthesia; 55 (62.5%) did not offer pain relief routinely,
and one (1.1%) was unsure of what was used. Opioid analgesia was
not offered by any respondent.
3.1. Routine premedication

Fig. 1. Proportion of routine premedications used. Of the respondents using routine

premedication, the majority (13 (41%)) offered a combination of oral analgesics
(paracetamol and/or NSAID) and local anaesthesia.

Outpatient hysteroscopy (OPH) is a well tolerated procedure

and many women nd it acceptable. Its benets over hysteroscopy
under general anaesthetic include reduced costs, shorter hospital
stay and faster recovery and return to work times [6]. A survey was
carried out to explore current UK clinical practice with regard to
the use of analgesia for OPH.
2. Method
A list of gynaecologists regularly performing laparoscopic
surgery was derived using the British Society for Gynaecological
Endoscopy senior membership list and an internet search. Each UK
healthcare trusts website was searched using the following
keywords: laparoscopic surgeries; endoscopies; minimal access
surgery and reproductive medicine. An anonymous questionnaire
(Appendix A) was sent to the identied parties; excluding trainees
and specialist nurses.
Data were collected on a number of items relating to the
method of pain relief, if any, routinely chosen for hysteroscopy, and
the time prior to the procedure at which it was administered.
Demographic information relating to the year the gynaecologist
answering the questionnaire became a consultant, and also the
grade of persons in the department (consultants, trainees or nurse
practitioners) performing hysteroscopy, was also collected. A selfaddressed envelope was provided for the questionnaire to be
returned. The data were collated using Microsoft Access.

[(Fig._2)TD$IG]

Oral analgesics (paracetamol and NSAIDs) and local anaesthetics were used for routine premedication, and were offered by
32 respondents (27.8%) (Fig. 1). Local anaesthesia accounted for 21
(65.6%) of routine premedication offered. Twenty-four (75%)
respondents gave oral analgesia, and 11 (34.4%) used it as their
only form of routine pain relief prior to the procedure. The use of
local anaesthesia in conjunction with oral analgesics was described
by 13 (40.6%) of those offering routine premedication (Fig. 2).
The wide variety in the timing of routine oral premedication is
displayed in Fig. 3. Oral premedication is offered by 24
respondents. One gynaecologist mentioned use of paracetamol
and an NSAID at both 30 min to 1 h, and 12 h pre-procedure,
accounting for the total of 25 uses in Fig. 3. The most common form
of routine oral premedication was the use of NSAIDs at 30 min to
1 h pre-procedure (7 uses (21.9%)), but a combination of
paracetamol and NSAID (6 uses (18.8%)), or NSAID alone (5 uses
(15.6%)) at 12 h pre-procedure were also utilised.
3.2. Non-routine premedication
The majority of units do not routinely offer premedication (55,
62.5%) but an extra six (6.8%) respondents reported the use of
rescue local anaesthesia in addition to analgesic premedication
they already offer, taking the total to 61 (69.3%). This rescue
analgesia was used when pain prevented a full examination. Local
anaesthesia was far more likely than oral analgesics to be used as
rescue analgesia during hysteroscopy37 (42.0%) (Fig. 4). Only three
respondents (3.4%), however, offered oral analgesia on a rescue
basis, in each case in conjunction with an intracervical block.
A total of 22 (25.0%) gynaecologists offering OPH used no form
of premedication, whilst one (1.1%) gave post-procedure paracetamol or NSAID, and one other gave post-procedure analgesia on an
as required basis.

6
5
4
3
2
1

No additional drugs
With Paracetamol
With NSAID

With Paracetamol & NSAID

Fig. 2. Use of routine local anaesthesia alone and in combination with pharmacological analgesia.

[(Fig._3)TD$IG]

H. OFlynn et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 154 (2011) 915
14

ligament, thus explaining how paracervical block can relieve pain

arising from cervical dilatation and uterine distension [10].
It has also been suggested that certain patient attributes act as
risk factors for the experience of signicant pain [4]:

12
10
8
Paracetamol & NSAID

NSAID
4

Paracetamol

2
0
30 minutes pre
procedure

30 minutes to 1 hour 1 hour to 2 hours pre

pre procedure
procedure

Over 2 hours pre

procedure

Timing of Premedication

Fig. 3. Timing of routine oral premedication with paracetamol and/or NSAID.

[(Fig._4)TD$IG]

20
18
16
14
12
No additional drugs
10
8

With NSAID
With Paracetamol & NSAID

6
4
2
0

Fig. 4. Use of rescue local analgesia alone and in combination with oral analgesics
(paracetamol and/or NSAID).

4. Discussion
Diagnostic hysteroscopy is increasingly being performed in the
outpatient setting. It has replaced dilatation and curettage as a
means of investigating abnormal uterine bleeding [7]. The results
and ndings obtained through OPH also compare well with those
from in-patient hysteroscopy, for many women negating the risks
involved with a general anaesthetic, and for the healthcare
provider reducing the associated costs and theatre time [8].
Pain occurs at several points during OPH and endometrial
biopsy procedures, due to the necessary instrumentation [9]:







11

Insertion of a speculum;
Cervical manipulation;
At the insertion of the hysteroscope;
At uterine distension;
During endometrial biopsy/sampling;
At spillage of the distension medium into the peritoneal cavity
occurs.

Innervation of the vagina, cervix and lower uterus arises from

the Frankenhauser plexus, running with the parasympathetic
nerve supply from S2 to S4. Innervation of the uterine fundus
travels via sympathetic nerves from the ovarian plexus, part of the
pelvic splanchnic nerves that originate in the lower thoracic spinal
cord, and which go on to cross the infundibulopelvic ligament.
These nerves all travel together as the uterovaginal nerve plexus,
following the course of the uterine artery at the junction of the base
of the broad ligament and the superior transverse cervical






Extremes of age;
Anxiety;
Previous painful experience of hysteroscopy;
Cervical stenosis.

Our survey investigated the use of pain relief in OPH. A total of

250 questionnaires were sent, with 115 responses, of which 88
respondents perform the procedure. A source of bias exists in that
those who offer pain relief would be more likely to respond
positively to the questionnaire: hence this survey represents the
clinical practice of those more concerned in the issue of the
patients pain experience during hysteroscopy. It is acknowledged
that the small sample size (250) of our review may also act as a
source of bias.
Two Cochrane reviews have been carried out analysing pain relief
in hysterosalpingography [11], and the use of paracervical block in
cervical dilatation and uterine distension [12]. Both of these
procedures carry similar risks for pain as OPH, including cervical
instrumentation, uterine distension, and potential for spillage of the
distension medium into the peritoneal cavity. Neither review was
able to conclude with a recommended method of pain relief. This
postal survey supports the ndings of these reviews.
OPH can be a painful procedure for some women, but others
state that pain experienced during the procedure is less than they
would normally experience during menstruation [6]. A retrospective study also found that it was feasible for OPH to be performed
without anaesthesia as it was well tolerated, even in postmenopausal women [1]. OPH is also more acceptable in women when a
hysteroscope of a smaller diameter is employed [13,14]. Numerous
studies have reported outcomes for various methods of pain relief
during OPH and other ofce gynaecological procedures and
investigations, but there is no consensus on effective pain relief
during OPH. Here, only the methods of pain relief utilised by study
participants are reviewed in detail.
4.1. Oral analgesia
Uterine pain during ofce gynaecological procedures may be
due to excessive prostaglandin concentrations occurring around
the uterus, with high levels having been found in endometrial
curettings [15]. Prostaglandins are derived from arachidonic acid
by the cyclo-oxygenase enzymes COX-1, COX-2 and to a lesser
extent COX-3. They are involved in physiological responses,
particularly the stimulation of inammation [16]. The methods
of oral analgesia chosen by respondents in our survey were
paracetamol or unspecied NSAIDs. Both of these act to inhibit the
production of prostaglandins.
NSAIDs directly inhibit the COX enzymes, but each isoenzyme
to a different degree, thereby preventing the synthesis of
prostaglandins. NSAIDs are commonly used in the treatment of
primary dysmenorrhoea and have been studied in the context of
pain relief in OPH, with drugs such as ibuprofen, diclofenac,
dexketoprofen and mefenamic acid being chosen [15,17,18]. When
given as a single 50 mg oral dose, maximum peak plasma
concentrations of 3.8 mmol/L of diclofenac are achieved between
20 and 60 min after administration, indicating that this would be
the best time for routine premedication with this drug [19].
However, NSAIDs are not suitable for all, and may precipitate
asthma due to diversion of arachidonic acid into the leukotriene
synthesis pathway. They are also contraindicated in those with
gastric ulceration, and severe heart failure [20].

12

H. OFlynn et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 154 (2011) 915

Paracetamol (acetaminophen) has a different mechanism of

action. During the metabolism of arachidonic acid by COX
isoenzymes, hydroperoxides are created, which exert a positive
feedback control on the activity of COX. It is believed that
paracetamol mainly acts by blocking the feedback mechanism,
although it also has some inhibitory effect on COX-3 in the central
nervous system. It is classied as a simple analgesic, and has no antiinammatory properties [21]. The peak analgesic effect of a standard
1 g dose of paracetamol is reached 2 h after administration [22].
Opioid analgesics are not used in ofce gynaecological
procedures as they have common side effects of nausea, vomiting
and drowsiness, especially when used for acute pain. They also
have no anti-inammatory effects [23].
A total of six respondents (5.2%) co-administered paracetamol
and an unspecied NSAID for premedication. Co-administration of
paracetamol and NSAIDs can be of great benet in procedures such
as OPH. Both drugs are deemed to be simple analgesics on the World
Health Organisation analgesic ladder that was initially created for
relief of pain in cancer [24]. Together, they can be used in the
treatment of minor acute pain, with paracetamol providing a
peripherally acting analgesic, and NSAID playing an anti-inammatory and anti-prostaglandin role [21]. This is of great use in
gynaecological procedures, where instrumentation of the female
reproductive organs will result in pain and release of inammatory
mediators, as previously described. Merry et al. demonstrated that
the analgesic effects of a combination of paracetamol and ibuprofen
were superior to either drug alone, and also that the time to peak
plasma concentration of paracetamol was reduced, but that of
ibuprofen increased when in combination (Table 1) [25]. For the
purpose of OPH, co-administration of paracetamol and ibuprofen
would be best between 30 min and 1 h 30 min prior to the
procedure.
In summary, the times to achieve peak analgesic effect for
paracetamol, NSAID and a combination of the two are 2 h, 20
60 min and 30 min to 1 h 30 min, respectively. Oral analgesia is
only suitable for use as pre-medication, due to the time taken to
reach peak analgesic effect. This could cause unacceptable delays
in the clinic should a woman require rescue analgesia, leading to
unnecessary expense and time losses. A total of 24 out of 88 (27.3%)
gynaecologists offering OPH in our survey gave patients instructions to take oral analgesia, though this does not truly reect how
many patients may choose to take premedication.
A benet of using paracetamol and/or NSAID for OPH is that
they are cheap, readily available drugs, to which the woman is
likely to have access already. NSAIDs are commonly used drugs for
menstrual disorders, providing both analgesia and a reduction in
menstrual blood loss [26]. Even if prescription-only NSAIDs are not
accessible to the woman, ibuprofen can be bought over the
counter. The advantages here are that women can be given
instructions to self medicate at home before attending for OPH,
saving both cost and time as the women do not need to have
medication prescribed in hospital prior to the procedure.
4.2. Local anaesthesia
Effective pain relief from local anaesthesia requires a suitable
drug at a suitable concentration, the most advantageous route of
administration, and a sufcient time interval between its

administration and the commencement of the procedure. Several

different methods of local anaesthesia for OPH have been
investigated:





Paracervical block;
Intracervical anaesthesia;
Topical anaesthesia, e.g. sprays and gels;
Intrauterine anaesthesia.

The injection of any local anaesthetic carries a risk of accidental

intravasation, which can lead to cardiovascular compromise due to
systemic vasodilation, and also central nervous system effects such
as light-headedness and even sedation [27].
Local anaesthesia lends itself more to use in the non-routine
setting, with a shorter time to peak anaesthetic effect. As the need
for this is unlikely to be known before starting the procedure, this
is likely to account for the reason why in our survey, of the 88
respondents offering OPH, 27 (30.7%) used intracervical blocks as
rescue anaesthesia, and only 9 (10.2%) used them routinely.
4.3. Paracervical block
A recent systematic review analysing the use of local
anaesthesia in outpatient hysteroscopy concluded that paracervical local anaesthetic injection is superior to other methods of local
anaesthesia [28]. That review, however, did not include studies
analysing oral analgesia as a method of pain relief. Paracervical
block was found to be benecial in studies by Giorda et al. and
Cicinelli et al. [14,29], although those studies examined only its use
in postmenopausal women. Both were randomised controlled
trials and it is possible that as postmenopausal women tend to
have a greater likelihood of cervical stenosis, they will feel more
pain, hence exaggerating the difference between the anaesthetised
and placebo arms of the studies. In premenopausal women, OPH
seems to be a more acceptable procedure even without the use of
pain relief, with local anaesthesia required signicantly less often
[30].
Paracervical block is not without its problems. In Giordas study,
22 of 121 women receiving a paracervical block (18.2%) found the
injection itself painful, although the results of their study seem to
indicate that such a block is effective, compared to hysteroscopy
without local anaesthesia. However, they did not have a placebo
control arm to this group [14]. Lau et al. question the effectiveness
of paracervical anaesthesia as injection of paracervical local
anaesthetic is painful in itself [9]. Their study demonstrated that
paracervical anaesthesia failed to signicantly block the pain
arising from uterine distension, and therefore they concluded that
its use in OPH cannot be justied. Chudnoff et
al. also
demonstrated that paracervical anaesthesia signicantly reduced
pain caused by cervical manipulation but failed to reduce pain
arising from uterine/tubal manipulation during hysteroscopic
sterilisation [31]. Revisiting the innervation of the uterus, however,
it has been demonstrated that innervation to the cervix, lower
uterus and fundus meets and travels together as the uterovaginal
nerve plexus, following the course of the uterine artery at the
junction of the base of the broad ligament and the superior
transverse cervical ligament [10]. With a paracervical block,
theoretically pain signals from both the cervix and uterus should

Table 1
Mean (SD) pharmacokinetic properties of paracetamol and ibuprofen alone and in combination. Cmax: maximum concentration; Tmax: time to achieve Cmax. Taken from Merry
et al. [25].

Tmax (h)
Cmax (mg/L)

Paracetamol alone

Paracetamol in combination

Ibuprofen alone

Ibuprofen in combination

1.09 (1.12)
15.8 (6.5)

0.64 (0.31)
19.2 (6.4)

1.16 (0.90)
30.8 (8.3)

1.44 (0.93)
19.1 (7.8)

H. OFlynn et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 154 (2011) 915

be blocked. This was conrmed by the studies of Giorda and

Cicinelli [14,29]. Giorda et al. also state that in postmenopausal
women a smaller diameter hysteroscope is more effective than a
paracervical block to minimise pain [14], but that a larger diameter
hysteroscope may have to be reverted to later in the procedure for
a satisfactory examination.
4.4. Intracervical anaesthesia
Broadbent et al. found injection of intracervical anaesthesia to be
just as painful as or even worse than OPH itself, despite the fact that it
is a well tolerated form of anaesthesia for other gynaecological
procedures [32], and advocate its use only where cervical dilation is
required. As the need for cervical dilatation is unlikely to be known
before starting the procedure, this is likely to account for the reason
why in our survey, of the 88 respondents offering OPH, 27 (30.7%)
used intracervical blocks as rescue anaesthesia, and only 9 (10.2%)
used them routinely. An issue that was raised in a study by Downes is
the method by which intracervical anaesthesia is delivered [33].
Broadbent used a 22-gauge needle, whereas Downes used a dental
syringe. In other surgical specialties, the use of a dental syringe has
been shown to reduce the pain experienced by the patient at
injection of local anaesthetics [34].
4.5. Topical anaesthesia
Topical anaesthetics can also be applied in spray, gel and cream
form to the cervix. Sprays and creams have been found to be

13

effective in anaesthetising the cervix, but no studies have proven

the effectiveness of lignocaine gel [35,36].
4.6. Intrauterine anaesthesia
Intrauterine anaesthesia is performed by the instillation of a
local anaesthetic into the uterine cavity through the cervical canal,
and can be considered to be another form of topical anaesthesia.
Whilst in theory the use of this type of anaesthesia should block
pain signals from nerve endings in the endometrium, this was not
shown in Laus study [37]. Anaesthesia of the uterine body is
required to block pain signals from the uterine fundus during
distension of the uterus.
5. Conclusions
This postal survey demonstrates wide variation in practice
regarding the use of oral analgesics or local anaesthetics for pain
relief during OPH. The majority of respondents offering OPH (55,
62.5%) did not offer routine analgesia for OPH, and 22 (25%) gave no
form of analgesia. Intracervical blocks formed the largest single
group of stand-alone rescue anaesthesia, followed by paracervical
blocks. Among respondents using routine premedication, oral
analgesics are predominately offered. In order to evaluate the
efcacy of pain relief in OPH, more high powered, randomised
placebo-controlled trials need to be carried out on a wide
population, assessing the optimum mode of pain relief and the
most appropriate dose.

14

H. OFlynn et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 154 (2011) 915

Appendix
A. Questionnaire for pain relief in outpatient hysteroscopy
[TD$INLE]

1) When did you become a Consultant?

2) Out of the following, who performs hysteroscopy outside of theatre in your unit?
All
Consultants.

Most trainees.

Selected
Consultants.

Trainees undertaking
specific outpatient
hysteroscopy training

Nurse Practitioners

3) Do patients receive analgesia for outpatient hysteroscopy routinely?

Yes
No

If yes, please select from the following;

a) Pre procedural
Paracetamol

NSAID

Opioid

If analgesia is given pre procedure, please indicate the time period in which medication is
administered;
30 minutes
before
procedure

30 minutes to
1 hour before
procedure

1 hour to
Over 2 hours
2 hours beforebefore
procedure
procedure

b) Intraprocedural
Intracervical block

Paracervical block

c) Other, please specify;

THANK YOU

Topical anaesthesia

H. OFlynn et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 154 (2011) 915

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