ACOG Conference Coverage

Pain Mitigation Strategies for Outpatient Hysteroscopy

Miranda Manier, BA

Key Highlights

  • Misoprostol significantly reduced pain in nulliparous women when given 12 hours before the procedure.
  • Dinoprostone reduced pain in postmenopausal patients when administered 12 hours prior.
  • Oral tramadol, intrauterine anesthetics, and nitrous oxide were also effective.

A review of recent literature identified several effective methods for reducing pain during outpatient hysteroscopy without the use of general anesthesia. Among the interventions, vaginal prostaglandins—especially misoprostol and dinoprostone—as well as oral and intrauterine medications demonstrated significant pain reduction, particularly in women who are nulliparous and postmenopausal. This paper was presented at the American College of Obstetricians and Gynecologists 2025 Annual Clinical & Scientific Meeting in Minneapolis, MN.

Outpatient hysteroscopy is the standard approach for diagnosing and treating intrauterine pathology, but procedural pain remains a barrier. Despite its routine use, there is currently no established guideline for pain management during outpatient hysteroscopy. Since pain is the most common reason for procedural failure, identifying effective interventions could improve procedural success and reduce reliance on general anesthesia, which carries greater risks and costs.

To address this gap, researchers conducted a focused review using PubMed and Covidence software to screen and extract data from studies evaluating pain interventions in outpatient gynecologic procedures. Exclusion criteria included studies published before 2015, use of general anesthesia, procedures involving pregnancy termination, and those that did not assess pain during hysteroscopy.

Out of 2537 articles screened, 28 met the criteria for inclusion. The most studied interventions fell into three categories: vaginal prostaglandins, oral medications, and intrauterine anesthetic instillations. Misoprostol was the most commonly used drug and was shown to significantly reduce pain when administered 12 hours before hysteroscopy in women who are nulliparous. Dinoprostone was also effective for patients who are postmenopausal when given on the same schedule. Additional pain mitigation strategies included oral tramadol administered 1 hour prior to the procedure, intrauterine local anesthetic instillation, and nitrous oxide inhalation.

“As more interventions demonstrate significant reductions in pain during outpatient hysteroscopies, future research should help develop best practices and determine targeted treatments for nulliparous and stenotic cervices,” the authors concluded.

Reference

Etcheverry AK, Hillard M, Smotrich G, Cigna ST. What has been discovered since 2014 about pain mitigation in outpatient hysteroscopy without general anesthesia? Poster presented at: American College of Obstetricians and Gynecologists 2025 Annual Clinical & Scientific Meeting; May 16–18, 2025; Minneapolis, MN. Accessed May 19, 2025. https://annualmeeting.acog.org/