Conscious sedation for office hysteroscopy: A systematic review and meta-analysis.

OBJECTIVE: To evaluate the role of conscious sedation on pain control in office hysteroscopy. METHODS: MEDLINE, EMBASE, CINAHL and CENTRAL were searched from inception to the 30th October 2020 in order to perform a systematic review and meta-analysis of all randomized controlled trials investigating women undergoing office hysteroscopic procedures, allocated to either conscious sedation or a suitable comparator, where the outcome was pain. Data regarding adverse events, feasibility and satisfaction/acceptability were also collected. The Risk of Bias 2 tool was used to assess study quality. Standard mean differences (SMD) or Odds Ratios (OR), and their 95% confidence intervals (CIs) were calculated for continuous (e.g. mean pain) and dichotomous (e.g. side-effects) outcomes, respectively. RESULTS: The literature search returned 339 results, of which seven studies were included for systematic review, with five studies having data suitable for meta-analysis. Intravenous conscious sedation, when compared with local anesthesia, reduced pain during (SMD -0.26, 95% CI -0.51 to -0.01), but not after (SMD -0.18, 95% CI -0.43 to 0.07) office hysteroscopy. No significant difference in side-effects were noted (OR 15.58, 95% CI 0.08 to 2891.91). Intravenous conscious sedation, when compared to an oral analgesic and antispasmodic, was associated with increased pain, both during (SMD 1.03, 95% CI 0.56 to 1.49) and after (SMD 0.49, 95% CI 0.04 to 0.93) hysteroscopy and had significantly more side-effects (OR 134.33, 95% CI 16.14 to 1118.17). Inhalational conscious sedation (70% N2O/30% O2), when compared to oral analgesia and anxiolysis, showed the greatest reduction in pain during hysteroscopy (SMD -1.04, 95% CI -1.57 to -0.52), however side-effects were not reported. Whilst patients and hysteroscopists were more satisfied with deeper levels of sedation, resulting side-effects, such as delirium, increased the level of post-procedural attention required, leading to a significantly lower level of satisfaction amongst nursing staff. CONCLUSION: The routine use of conscious sedation in contemporary hysteroscopic practice should be avoided in the absence of any clear reduction in pain and a higher risk of side-effects.

Pain and Operative Technologies Used in Office Hysteroscopy: A Systematic Review of Randomized Controlled Trials.

OBJECTIVE: To identify technologies associated with the least operative pain in women undergoing operative office hysteroscopic procedures. DATA SOURCES: MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central Register of Controlled Trials were searched until January 2021 using a combination of keywords "hysteroscop*," "endometrial ablation," "outpatient," "ambulatory," "office," and associated Medical Subject Headings. METHODS OF STUDY SELECTION: Randomized controlled trials evaluating the effect of hysteroscopic devices on pain experienced by women undergoing operative office hysteroscopy were included. Data were also collected regarding efficacy, procedural time, adverse events, and patient/clinician acceptability and/or satisfaction. TABULATION, INTEGRATION, AND RESULTS: The search returned 5347 records. Ten studies provided data for review. Two trials compared endometrial ablation using bipolar radiofrequency with thermal balloon energy, with no significant difference in pain observed (p <.05). Seven trials evaluated technologies for endometrial polypectomy, of which, 4 compared energy modalities: miniature bipolar electrode resection against resectoscopy (N = 1), morcellation (N = 2), and diode laser resection (N = 1). Two studies compared hysteroscope diameter, and one study compared methods of polyp retrieval. A significant reduction in pain was found using morcellators rather than miniature bipolar electrosurgical devices (p <.001), 22Fr rather than 26Fr resectoscopes (p <.001), and 3.5-mm fiber-optic hysteroscopes with 7Fr forceps rather than 5-mm lens-based hysteroscopes with 5Fr forceps (p <.05). One study investigating septoplasty showed significant reduction in pain when cold mini-scissors, rather than a miniature bipolar electrode, were used (p = .013). Average procedural times ranged from 5 minutes 28 seconds to 22 minutes. The incidence of adverse events was low, and data regarding efficacy and acceptability/satisfaction were limited. CONCLUSION: Pain is reduced when mechanical technologies such as morcellators and scissors are used compared with electrical devices for removing structural lesions in the office. For hysteroscopic and ablative procedures, smaller and quicker devices are less painful. Large-scale RCTs investigating patient pain and experience with modern operative devices in the office setting are urgently needed.

A Systematic Review of the Effect of Type, Pressure, and Temperature of the Distension Medium on Pain During Office Hysteroscopy.

OBJECTIVE: To identify the optimal distension medium type, pressure, and temperature to minimize pain during office hysteroscopy. DATA SOURCES: MEDLINE, EMBASE, CINAHL, and CENTRAL were searched from inception to January 29, 2020. METHODS OF STUDY SELECTION: We included randomized controlled trials in which women undergoing office hysteroscopy were randomized to either a distension medium type, pressure, or temperature against a suitable control, where pain was an outcome. Data regarding feasibility, visualization, complications, and satisfaction were also collected. TABULATION, INTEGRATION, AND RESULTS: The literature search returned 847 studies, of which 18 were included for systematic review and 17 for meta-analysis. There was no significant difference in intraprocedural pain when comparing the use of normal saline against carbon dioxide (standardized mean difference [SMD], -0.12; 95% confidence interval [CI], -0.36 to 0.13). Subgroup analysis of high-quality studies revealed a statistically significant reduction in postprocedural pain with normal saline (SMD, -0.65; 95% CI, -1.14 to -0.16). Side effects were less frequent (Peto odds ratio, 0.29; 95% CI, 0.20-0.40) and patient satisfaction was higher (SMD, 1.39; 95% CI, 0.51-2.28) with normal saline compared with carbon dioxide. Pressures of ≤40 mm Hg reduced intraprocedural pain (SMD, -0.67; 95% CI, -1.09 to -0.26) at the expense of a higher proportion of unsatisfactory views (81%-89% at ≤40 mm Hg vs 95%-99% at ≥50 mm Hg). Postprocedural pain was reduced with lower filling pressures. Warming saline did not reduce intraprocedural pain (SMD, 0.59; 95% CI, -0.14 to 1.33). CONCLUSION: Normal saline, instilled at the lowest pressure to acquire a satisfactory view, should be used for uterine distension during office hysteroscopy to minimize pain.

Vaginoscopy for office hysteroscopy: A systematic review & meta-analysis.

OBJECTIVE: To investigate the effect of the vaginoscopic approach to office hysteroscopy on patients' experience of pain, when compared with the traditional approach where a vaginal speculum is used. METHODS: Medline, Embase, CINAHL and the Cochrane library were searched from inception until December 2019, in order to perform a systematic review and meta-analysis of all randomised controlled trials investigating vaginoscopy compared to traditional hysteroscopy on pain experienced by women undergoing diagnostic or operative hysteroscopy in an office setting. Data regarding procedural time, feasibility, incidence of vasovagal reactions and complications, acceptability and satisfaction were also recorded. RESULTS: The literature search returned 363 results of which seven were selected for systematic review, and six for meta-analysis. The vaginoscopic approach was associated with a statistically significant reduction in pain (4 studies including 2214 patients; SMD -0.27, 95 % CI -0.48 to -0.06), procedural time (6 studies including 2443 patients; SMD -0.25, 95 % CI -0.43 to -0.08) and the incidence of vasovagal episodes (3 studies including 2127 patients; OR 0.35; 95 % CI 0.15 to 0.82). Failure rates between the two techniques were similar (p = .90). No study reported significant differences in complications or patient or clinician acceptability or satisfaction. CONCLUSION: Clinicians performing office hysteroscopy should use the vaginoscopic technique because it makes office hysteroscopy quicker, less painful and reduces the likelihood of inducing a vasovagal reaction. The traditional approach should only be used when vaginoscopy fails or when the need for cervical dilatation is anticipated.

Local anaesthesia for office hysteroscopy: A systematic review & meta-analysis.

OBJECTIVE: To compare the effects of different types and routes of administration of local anaesthetic for pain control during and after office hysteroscopy. METHODS: Medline, Embase, CINAHL and the Cochrane library were searched from inception until October 2019, in order to perform a systematic review and meta-analysis of all randomised controlled trials investigating the use of a local anaesthetic compared to a control, for pain relief in women undergoing diagnostic or operative office hysteroscopy. Average pain scores and data regarding side-effects, feasibility, complications, acceptability and satisfaction were collected. RESULTS: The literature search yielded 612 citations. A total of 37 studies were included for systematic review, of which data from 20 studies were used for meta-analysis. Local anaesthesia was associated with significantly reduced pain during (SMD -0.57, 95 % CI -0.79 to -0.34) and after (SMD -0.30, 95 % CI -0.54 to -0.06) office hysteroscopy but did not reduce vasovagal episodes (OR 0.73, 95 % CI 0.50-1.09). A reduction in intra-procedural pain was observed regardless of type or route of administration. Local anaesthesia did not significantly reduce the risk of procedural failure (OR 0.72, 95 % CI 0.47-1.11). Insufficient data regarding complications, acceptability and satisfaction were available for meta-analysis. CONCLUSION: Local anaesthesia via any route of genital tract administration, should be considered when undertaking office diagnostic or operative hysteroscopy to reduce pain during and after the procedure. Further research is needed to understand whether the pain control benefits of local anaesthesia remain apparent with vaginoscopic approaches to office hysteroscopy that avoid genital tract instrumentation.

Analgesia for Office Hysteroscopy: A Systematic Review and Meta-analysis.

OBJECTIVE: To identify the most effective analgesia for women undergoing office hysteroscopy. DATA SOURCES: We searched Medline, Embase, the Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library from inception until August 2019 for studies that investigated the effect of different analgesics on pain control in office hysteroscopy. METHODS OF STUDY SELECTION: We included randomized controlled trials that investigated the effect of analgesics on pain experienced by women undergoing diagnostic or operative hysteroscopy in an office setting compared with the control group. TABULATION, INTEGRATION, AND RESULTS: The literature search returned 561 records. Twenty-two studies were selected for a systematic review, of which 16 were suitable for meta-analysis. There was a statistically significant reduction in pain during office hysteroscopy associated with preprocedural administration of nonsteroidal anti-inflammatory drugs (NSAIDs) (standardized mean difference [SMD] -0.72; 95% confidence interval [CI] -1.27 to -0.16), opioids (SMD -0.50; 95% CI -0.97 to -0.03), and antispasmodics (SMD -1.48; 95% CI -1.82 to -1.13), as well as with the use of transcutaneous electrical nerve stimulation (TENS) (SMD -0.99; 95% CI -1.67 to -0.31), compared with the control group. Moreover, similar reduction in pain was observed after office hysteroscopy: NSAIDs (SMD -0.55; 95% CI -0.97 to -0.13), opioids (SMD -0.73; 95% CI -1.07 to -0.39), antispasmodics (SMD -1.02; 95% CI -1.34 to -0.69), and TENS (SMD -0.54; 95% CI -0.95 to -0.12). Significantly reduced pain scores with oral NSAID administration during (SMD -0.87; 95% CI -1.59 to -0.15) and after (SMD -0.56; 95% CI -1.02 to -0.10) office hysteroscopy were seen in contrast to other routes. Significantly more adverse effects were reported with the use of opioids (p <.001) and antispasmodics (p <.001) when compared with the control group, in contrast to NSAIDs (p = .97) and TENS (p = .63). CONCLUSION: Women without contraindications should be advised to take oral NSAIDs before undergoing office hysteroscopy to reduce pain during and after the procedure. TENS should be considered as an alternative analgesic in women with contraindications to NSAIDs.

Factors contributing to urban malaria transmission in sub-saharan Africa: a systematic review.

Sub-Saharan Africa suffers by far the greatest malaria burden worldwide and is currently undergoing a profound demographic change, with a growing proportion of its population moving to urban areas. Urbanisation is generally expected to reduce malaria transmission; however the disease still persists in African cities, in some cases at higher levels than in nearby rural areas. Objective. This paper aims to collate and analyse risk factors for urban malaria transmission throughout sub-Saharan Africa and to discuss their implications for control. Methods. A systematic search on malaria and urbanisation was carried out focusing on sub-Saharan Africa. Particular interest was taken in vector breeding sites in urban and periurban areas. Results. A variety of urban vector breeding sites were catalogued, the majority of which were artificial, including urban agriculture, tyre tracks, and ditches. Natural breeding sites varied according to location. Low socioeconomic status was a significant risk factor for malaria, often present in peri-urban areas. A worrying trend was seen in the adaptation of malaria vector species to the urban environment. Urban malaria is highly focused and control programs should reflect this. Conclusion. As urbanisation continues and vector species adapt, continued monitoring and control of urban malaria in sub-Saharan Africa is essential.