Cervical preparation prior to outpatient hysteroscopy: Friend or
foe?
Xulin Foo,1 Sania Latif,1 Shirin
Khanjani1
1) Reproductive Medicine Unit, University College London Hospital,
London, UK
The advent of outpatient hysteroscopy has revolutionised the diagnosis
and management of uterine pathology by circumventing the need for
general anaesthesia and its associated complications, reducing
post-operative recovery time and decreasing the financial burden on the
NHS. However, 12% of outpatient hysteroscopies fail, commonly due to
pain from cervical stenosis, which is encountered frequently in
nulliparous and postmenopausal women. (Genovese et al, Eur J
Obstet Gynecol Reprod Biol 2020;245:193-197) Current RCOG guidance
(Best Practice in Outpatient Hysteroscopy 2011 ) advises against
routine cervical dilatation and notes that evidence for routine cervical
priming before outpatient hysteroscopy is lacking.
De Silva et al. (BJOG 2020 xxxx) have provided a welcome
update on current evidence for cervical preparation and dilatation prior
to outpatient hysteroscopy. They included all randomised controlled
trials of women undergoing outpatient hysteroscopy randomised to
cervical preparation (misoprostol/ mifepristone/ carboprost/
dinoprostone) or dilatation compared to a control/placebo. The primary
outcome was pain. Their systematic review and meta-analysis revealed
that cervical preparation using vaginal misoprostol and dinoprostone
significantly reduced pain during outpatient hysteroscopy compared to
placebo, with premenopausal and nulliparous women being the most likely
to benefit. Cervical priming with these agents also improved feasibility
by providing easier hysteroscopic entry, greater cervical dilatation and
shorter procedure times. Hysteroscopic approach following misoprostol
administration showed significantly reduced pain scores when vaginoscopy
was performed. Cervical preparation did, however, incur significantly
more side-effects including genital tract bleeding, abdominal pain and
gastrointestinal symptoms, and made no difference to clinician
experience. Two thirds of studies reported a degree of bias, which is
unsurprising given the nature of hysteroscopic procedures and the need
for patient selection.
In light of the evidence, cervical preparation with vaginal misoprostol
or dinoprostone should be considered in premenopausal and nulliparous
women, and vaginoscopy without speculum performed where possible.
Notably, there were no trials investigating mechanical dilatation, and
future work on this topic is needed.
No disclosures: Completed disclosure of interest forms are
available to view online as supporting information.