Pain relief for outpatient hysteroscopy

Background Hysteroscopy is increasingly performed in an outpatient setting. Pain is the primary reason for abandonment of procedure or incomplete assessment. There is no consensus upon routine use of analgesia during hysteroscopy. Objectives To assess the effectiveness and safety of pharmacological interventions for pain relief in women undergoing outpatient hysteroscopy, compared with placebo, no treatment or other pharmacological therapies. Search methods In September 2016 we searched the Cochrane Gynaecology and Fertility (CGF) Trials Register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL and two trials registers (ClinicalTrials.gov and WHO ICTRP), together with reference checking and contact with study authors and experts. Selection criteria We included randomised controlled trials (RCTs) comparing use of pharmacological interventions with other pharmacological interventions and pharmacological interventions versus placebo or no treatment. Data collection and analysis We used standard methodological procedures expected by Cochrane. Our primary outcome was mean pain score. Main results We included 32 RCTS (3304 participants), of which only 19 reported data suitable for analysis. Most studies were at unclear or high risk of bias in most of the domains assessed. The evidence was low or very low quality, mainly due to risk of bias and imprecision. Baseline pain scores were relatively low in all groups. Analgesic versus placebo or no treatment Local anaesthetics Local anaesthetics reduced mean pain scores during the procedure [(SMD) ‐0.29, 95% CI ‐0.39 to ‐0.19, 10 RCTs, 1496 women, I2 = 80%, low‐quality evidence)] and within 30 minutes (SMD 0.50, 95% CI ‐0.67 to ‐0.33, 5 RCTs, 545 women, I2 = 43%, low‐quality evidence). This translates to a difference of up to 7 mm on a 0‐10 cm visual analogue scale (VAS) during the procedure and up to 13 mm within 30 minutes, which is unlikely to be clinically meaningful. There was no clear evidence of a difference between the groups in mean pain scores after > 30 minutes (SMD ‐0.11, 95% CI ‐0.30 to 0.07, 4 RCTs, 450 women, I2 = 0%, low‐quality evidence), or in rates of vasovagal reactions (OR 0.70, 95% CI 0.43 to 1.13, 8 RCTs, 1309 women, I2 = 66%, very low‐quality evidence). There was insufficient evidence to determine whether there was a difference in rates of non‐pelvic pain (OR 1.76, 95% CI 0.53 to 5.80, 1 RCT, 99 women, very low‐quality evidence). Nonsteroidal anti‐inflammatory drugs (NSAIDs) There was insufficient ev