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ORIGINAL ARTICLE
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Are there possible predictors of pain during office hysteroscopy among infertile women in Port Harcourt Nigeria?


 Department of Obstetrics and Gynaecology, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State, Nigeria

Date of Submission28-Mar-2020
Date of Acceptance28-Aug-2020
Date of Web Publication27-Oct-2020

Correspondence Address:
Vaduneme Kingsley Oriji,
Department of Obstetrics and Gynaecology, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State
Nigeria
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ajiac.ajiac_2_20

  Abstract 


Context: Invasive office procedures such as office hysteroscopy are usually carried out without analgesia as they are thought to cause minimal or no pain to the patient. Hysteroscopy has been found to be a cause of significant pain in some patients. Aims: To determine factors inherent in infertile patients experiencing pain during office hysteroscopy in Port Harcourt, Nigeria. Settings and Design: A cross-sectional comparative study amongst infertile women undergoing office hysteroscopy. Methods and Material: Assessment of Pain perceptions using a numerical pain scale in 101 women following office hysteroscopy. Demographic, Social, and gynecological factors of these patients were analysed for association with to pain perception. Statistical Analysis Used: Bivariate logistic regression analysis was conducted for associations between pain perception and suspected factors with P≤ 0.05 as statistically significant. Results: The mean age of the patients was 35.95±4.65 years. 53(52.5%) and 48(47.5%) of the patients experienced moderate/severe pain and mild/no pain respectively. Moderate/severe pain in participants was not associated with age, parity, type or period of infertility, dysmenorrhea or previous pregnancy terminations. However, it was associated with education below secondary level (OR=1.82; P value=0.21, 95%CI 0.81-4.11) and over one previous miscarriages (OR=1.11, P value = 0.948.;95% CI 0.51-2.43). Conclusions: Moderate/severe pains at office hysteroscopy occurred in more than one half of the patients increased risk of pain occurred in patients with miscarriages and those with less than secondary education. We recommend analgesia for patients undergoing office hysteroscopy.

Keywords: Office hysteroscopy, vaginoscopic approach, predictors of pain



How to cite this URL:
Nyengidiki KT, Oriji VK, Amike I. Are there possible predictors of pain during office hysteroscopy among infertile women in Port Harcourt Nigeria?. Afr J Infertil Assist Concept [Epub ahead of print] [cited 2021 Nov 28]. Available from: https://www.afrijiac.org/preprintarticle.asp?id=299126




  Introduction Top


Invasive procedures often cause pain and may require analgesia or anesthesia. Office hysteroscopy is associated with minimal pain and therefore may not require analgesia.[1],[2] However, many studies have reported significant pain in patients undergoing hysteroscopy as a cause for failed office hysteroscopy.[3],[4] Modern miniaturized instruments used for office hysteroscopy and the vaginoscopic approach are thought to be responsible for the reduced pain at office hysteroscopy.[1]

Several but inconsistent factors determining pain perception in patients having office hysteroscopy have been reported in studies.[5],[6],[7],[8],[9],[10],[11],[12] This study seeks to determine predictors of pain in infertile patients undergoing office hysteroscopy and those who may require intraoperative analgesia for office hysteroscopy.


  Materials and Methods Top


This study was approved by the Ethics Committee of the University of Port Harcourt Teaching Hospital with number UPTH/ADM/90/S.11/VOL XI/710. The participants in the study gave written informed consent before joining the study. This was a cross-sectional study conducted among infertile women undergoing office hysteroscopy at the University of Port Harcourt Teaching Hospital from December 1, 2018 to July 31, 2019. All women being assessed for infertility were enrolled for the study except those who withheld consent for participation in the study. Women with cervicitis or active pelvic infection and cervical malignancies were also excluded from the study. The sample size was determined using a formula, n = N/1+ N (e)2; where n = sample size, N = was the average number of new cases of infertility seen at the gynecology clinic over a period of 6 months, and e = Margin of error or precision expected (0.05). The sample size thus calculated was 92, but allowing a 10% attrition rate, the sample size for the study was increased to 101. Women who consented to the study were recruited for diagnostic hysteroscopy as they presented to the clinic until the required sample size was obtained. The procedure was explained to the patient before consent and recruitment. Sociodemographic data were collected through a structured questionnaire. These data included age, level of education, parity, type, and duration of infertility. Outpatient diagnostic hysteroscopy was performed between the 7th and 10th day of the proliferative phase of the menstrual cycle by the principal investigators. Vaginoscopic (non-touch) technique using a 2.9 mm Ø continuous flow 30° rigid office hysteroscope (Bettocchi Office Hysteroscope; Karl Storz GmbH and Co., Tuttlingen, Germany) was used. For each hysteroscopic procedure, the patient was placed in the lithotomy position, about 300 ml of normal saline was used as a distension medium at a flow delivery pressure of 80–100 cm H2O. This pressure was achieved using an infusion pump (C-Fusor 1000 Mx4810 by Smiths Medicals). No analgesic agents were administered to the patients before each procedure was conducted. Within 10 min of completing the hysteroscopy, participants were asked to rate their pain experience using the eleven-point numerical pain rating scale. They were asked to score their pain perception from 0 to 10 during the procedure using the proposed classification (0 = No pain, 1–3 = Mild pain; 4–6 = Moderate pain; 7–10 = Severe pain). Descriptive statistics were computed for all relevant data and presented in tabular form. The effect of pain predictors on pain perception by participants was assessed using a McNemar Chi-square test and bivariate logistic regression analysis with P < 0.05 as statistically significant.


  Results Top


A total of 101 infertile women were recruited for the study with a mean age of 35.95 ± 4.65 years. Majority of the participants 92.08 (93%) had attained educational level beyond primary education. About 66.34 (67%) were nulliparous, whereas others 33.66 (34%) had parity ranging from 1 to 4 as shown in [Table 1]. Among these patients undergoing office hysteroscopy, 53 (52.5%) and 48 (47.5%) experienced moderate/severe pain and mild pain, respectively, sas shown in [Table 2]. The occurrence of moderate/severe pain in patients was not associated with most of the suspected factors that may predict pain in gynecological invasive procedures, such as age <35 years (odds ratio [OR] = 0.71, P = 0.512; 95% confidence interval [CI] 0.32–1.55), parity (OR = 0.57, P = 0.262; 95% CI 0.24–1.31), type of infertility (OR = 0.78, P = 0.06; 95% CI 0.29–2.11), duration of infertility beyond 2 years (OR = 0.91, P = 0.98; 95% CI 0.41–2.01), and dysmenorrhea (OR = 0.39, P = 0.09; 95% CI 0.15–1.03). However, moderate/severe pain was associated with educational level below secondary education in the patients (OR = 1.82; P = 1.54; 95% CI 0.81–4.11) and >2 previous miscarriages (OR = 1.11, P = 0.95; 95% CI 0.51–2.43). These were not however statistically insignificant as shown in [Table 3].
Table 1: Characteristics of patients undergoing hysteroscopy

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Table 2: Perception of pain among participants (n=101)

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Table 3: Predictors of pain during office hysteroscopy

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  Discussion Top


Outpatient hysteroscopy for the evaluation of the endometrial cavity is largely branded as painless.[1] In this review we saw, an equal number of patients with mild pain as well as moderate/severe pain. Hence, the practitioner is faced with the dilemma of identifying those with a tendency of having pain enough to affect the outcome of the procedure. Pain has been linked to the failure of outpatient hysteroscopy and patients' aversion to the procedure with delay in the diagnosis of endometrial pathologies.[3] The fact that moderate/severe pain was experienced by nearly half of the patients emphasizes the need to consider pain relief during office hysteroscopy. Opinions defer on possible predictors of pain during office hysteroscopy that will enable the practitioners to anticipate, before the procedure, and those patients that will benefit from pain ameliorations.[5],[6],[7],[8] Age had been identified as a predictor of pain during office procedures with the older age group more at risk of intolerable pain as compared with younger patients.[7] The findings from this study showed no relationship between age and pain perception as similar number of patients experienced mild pain or moderate/severe pain with no significant age relationship.

Patients with secondary education or less had 1.56 times the risk of having moderate/severe pain as compared to those with tertiary education, though not statistically significant. Köppen et al. in their review indicated that a higher level of education was associated with less pain experience.[13] This has been linked to easy attainment of health literacy which provides increased opportunities/information for pain management.

Some investigators have highlighted a positive link between the previous history of dysmenorrhoea and intolerable pain at office hysteroscopy;[11] however, this was not observed in this study.

This study showed that patients with two or more miscarriages were noted to have 1.10 times the risk of having moderate/severe pain as compared with that of mild pain though not statistically significant. Reasons adduced by some investigations are the possibility of trauma to the cervix following treatment for incomplete miscarriages and consequent difficulty during the introduction of the hysteroscope and the prolonged operating time needed to overcome the cervical resistance which adds to increased pain experienced at hysteroscopy.[13],[14] The investigators, however, did not confirm the nature of the possible injury to the cervix.

Other possible predictors such as nulliparity, type, and duration of infertility were also assessed using bivariate logistic regression analysis but were noted to have no relationship with the pain experience of the infertile women at hysteroscopy. However, some authors have highlighted, though not of our study population, menopausal status, instrument diameter, previous cesarean section, and the surgeons experience as impacting on the pain experience during hysteroscopy.[14],[15],[16]

The incongruences by various investigators in determining predictors of pain experience clearly demonstrate the multifactorial nature of the pain experienced by the women during office hysteroscopy. This may be explained by the multiple pathways of pain transmission during the procedure.[16],[17],[18]


  Conclusion Top


The infertile patients having office hysteroscopy have various degrees of significant pain and 52.5% of our patients had moderate/severe pain while the rest had mild pain. There was increased risk of pain in patients with more than one miscarriage and those with less than secondary education among these patients. The suspected variables for pain prediction reviewed in this study did not discriminate between those who had moderate/severe pain from those who had mild pain. We recommend intraoperative analgesia for office hysteroscopy since pain is very common to those undergoing office hysteroscopy.

Study limitation

The study limitation is that of small sample size and other possible predictors examined by other investigators were excluded in the study. The sample size of this study may have reduced the power of the study. We recommend a future larger multicentre study to better evaluate pain experienced during office hysteroscopy among infertile women.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bettocchi S, Ceci O, Nappi L, Di Venere R, Masciopinto V, Pansini V, et al. Operative office hysteroscopy without anesthesia: Analysis of 4863 cases performed with mechanical instruments. J Am Assoc Gynecol Laparosc 2004;11:59-61.  Back to cited text no. 1
    
2.
Cicinelli E, Parisi C, Galantino P, Pinto V, Barba B, Schonauer S. Reliability, feasibility, and safety of minihysteroscopy with a vaginoscopic approach: Experience with 6,000 cases. Fertil Steril 2003;80:199-202.  Back to cited text no. 2
    
3.
Clark TJ, Voit D, Gupta JK, Hyde C, Song F, Khan KS. Accuracy of hysteroscopy in the diagnosis of endometrial cancer and hyperplasia: A systematic quantitative review. JAMA 2002;288:1610-21.  Back to cited text no. 3
    
4.
Ahmad G, Saluja S, O'Flynn H, Sorrentino A, Leach D, Watson A. Pain relief for outpatient hysteroscopy. Cochrane Database Syst Rev 2017, Reviews 2017, Issue 10. Art. No.: CD007710. DOI: 10.1002/14651858.CD007710.pub3.  Back to cited text no. 4
    
5.
Favilli A Grasso M, Gertli S, Mazzon I. How to overcome a resistant cervix for hysteroscopy. In Hysteroscopy. Springer, Cham Publishers. 2018. 47-57.  Back to cited text no. 5
    
6.
Cooper NA, Smith P, Khan KS, Clark TJ. Vaginoscopic approach to outpatient hysteroscopy: A systematic review of the effect on pain. BJOG 2010;117:532-9.  Back to cited text no. 6
    
7.
Paulo AA, Damasceno-Costa J, Pipa A, Afreixo VM. Hysteroscopy and pain: What risk factors should we consider in office hysteroscopy? Are there really any? Int J Reprod Contracept Obstet Gynecol 2016;5:74-9.  Back to cited text no. 7
    
8.
Andréa P, Marcelo ES, Jean TT, Waldemar D, Renato D, Caio PB, Ângela VN. Prevalence and intensity of pain during diagnostic hysteroscopy in women attending an infertility clinic: analysis of 489 cases. Einstein (São Paulo). 2020; 18:1-7  Back to cited text no. 8
    
9.
Libera T, Ilenia D, Cristina R, Francesca LV, Cinzia O, Sandro R et al. Factors affecting pain perception in outpatient hysteroscopy. Gynecol, Obstet. 2019; 1(1):39-42  Back to cited text no. 9
    
10.
Carta G, Palermo P, Marinangeli F, Piroli A, Necozione S, De Lellis V, et al. Waiting time and pain during office hysteroscopy. J Minim Invasive Gynecol 2012;19:360-4.  Back to cited text no. 10
    
11.
Balci O, Acar A, Mahmoud AS, Colakoglu MC. Effect of preamniocentesis counseling on maternal pain and anxiety. J Obstet Gynaecol Res 2011;37:1828-32  Back to cited text no. 11
    
12.
Jivraj S, Dass M, Panikkar J, Brown V. Outpatient hysteroscopy: An observational study of patient acceptability. Medicina (Kaunas) 2004;40:1207-10.  Back to cited text no. 12
    
13.
Köppen PJ, Dorner TE, Stein KV, Simon J, Crevenna R. Health literacy, pain intensity and pain perception in patients with chronic pain. Wien Klin Wochenschr 2018;130:23-30.  Back to cited text no. 13
    
14.
De Freitas Fonseca M, Sessa FV, Resende JA Jr, Guerra CG, Andrade CM Jr., Crispi CP. Identifying predictors of unacceptable pain at office hysteroscopy. J Minim Invasive Gynecol 2014;21:586-91.  Back to cited text no. 14
    
15.
Zayed SM, Elsetohy KA, Zayed M, Foud UM. Factors affecting pain experienced during office hysteroscopy. Middle East Fertility Society J 2015;20:154-8.  Back to cited text no. 15
    
16.
Paulo AA, Solheiro MH, Paulo CO. Is pain better tolerated with mini-hysteroscopy than with conventional device? A systematic review and meta-analysis: Hysteroscopy scope size and pain. Arch Gynecol Obstet 2015;292:987-94.  Back to cited text no. 16
    
17.
Török P, Major T. Evaluating the level of pain during office hysteroscopy according to menopausal status, parity, and size of instrument. Arch Gynecol Obstet 2013;287:985-8.  Back to cited text no. 17
    
18.
Munro MG, Brooks PG. Use of local anesthesia for office diagnostic and operative hysteroscopy. J Minim Invasive Gynecol 2010;17:709-18.  Back to cited text no. 18
    



 
 
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  [Table 1], [Table 2], [Table 3]



 

 
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