Middle East Fertility Society Journal (2015) 20, 154–158

Middle East Fertility Society

Middle East Fertility Society Journal

www.mefsjournal.org
www.sciencedirect.com

ORIGINAL ARTICLE

Factors affecting pain experienced during office

hysteroscopy
Shereef M. Zayed, Khaled A. Elsetohy *, Mohamed Zayed, Usama M. Fouda

Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt

Received 31 March 2014; revised 30 July 2014; accepted 25 August 2014

Available online 22 September 2014

KEYWORDS Abstract Study objective: To evaluate the effect of parity, menopausal status, menstrual cycle
Pain; phase, cervical or uterine pathology and duration of procedure on pain experienced during office
Office hysteroscopy; hysteroscopy.
Predictive factors Design: Cohort study (Canadian Task Force classification II-2).
Setting: University hospital.
Patients: Two hundred and fifty-four women.
Intervention: Office hysteroscopy without anesthesia.
Methodology: Pain intensity was assessed at the end of procedure using visual analog scale from
zero (no pain) to ten (intolerable pain).
Results: Eighty-six patients (33.86%) reported no pain or mild discomfort (0–3 pain score), 118
patients (46.46%) reported moderate pain (4–7 pain score), 44 patients (17.32%) experienced severe
pain (8–9 pain score) and 6 patients (2.36%) experienced intolerable pain (10 pain score) necessitat-
ing stoppage of the procedure. Bivariate analysis revealed that nulliparous patients had a higher risk
of developing severe or intolerable pain compared with non-nulliparous patients (26.67% vs.
11.76%, P value = 0.003). Moreover, severe or intolerable pain was reported more frequently in
patients with cervical pathology and duration of procedure more than 2 min (39.58% vs.
15.05%, P value = 0.0001 and 25.22% vs. 15.11%, P value = 0.044 respectively). Multivariate
analysis revealed that nulliparity, cervical pathology and duration of procedure more than 2 min
were strongly associated with severe or intolerable pain (8–10 pain score).
Conclusion: Nulliparity, cervical pathology and duration of procedure more than 2 min seem to
be the main factors associated with severe or intolerable pain during office hysteroscopy.
Ó 2014 Production and hosting by Elsevier B.V. on behalf of Middle East Fertility Society.

1. Introduction
* Corresponding author. Tel.: +20 1110006946.
E-mail address: kelsetohy@kasralainy.edu.eg (K.A. Elsetohy).
Peer review under responsibility of Middle East Fertility Society. Office hysteroscopy is considered a valuable addition to the
outpatient diagnostic modalities in gynecology clinic. Several
studies have shown that office hysteroscopy by the vaginoscop-
ic approach is a well accepted tolerable procedure without the
Production and hosting by Elsevier
need of analgesia or pain medication with a limited failure rate
http://dx.doi.org/10.1016/j.mefs.2014.08.003
1110-5690 Ó 2014 Production and hosting by Elsevier B.V. on behalf of Middle East Fertility Society.
Pain experienced during office hysteroscopy
of less than 4% (1,2). However, in some patients, premedica-
tion or simultaneous use of local analgesia as cervical block
may be necessary to accomplish the procedure (3).
Cicinelli et al. (4), based on an experience of 8000 cases of
office hysteroscopy, reported that approximately 10% of the
patients experienced mild pain, and 0.5% of the cases experi-
enced severe pain. Similarly, several studies have shown that
failure rate and pain are much reduced with the use of smaller
diameter scopes less than 4 mm as compared with traditional
hysteroscopy (5–7).
Anticipation for the need of premedication or additional
analgesia to relieve pain during the procedure may reduce
the failure rate of office hysteroscopy. This reduces psycholog-
ical burden on the patient and increases the effectiveness of the
medical service provided. In evaluating different predictors of
pain, several studies have reported controversial results for the
significance of clinical variables, such as parity, mode of deliv-
ery and menopausal status, presence of cesarean section scar
etc (8,9). Moreover, the effect of surgeon’s experience and
diameter of the scope have been controversial in other studies
(10–12). The aim of this study was to evaluate the effect of
patient parity, menopausal status, menstrual cycle phase, cer-
vical or uterine pathology and duration of procedure on pain
experienced during office hysteroscopy.
2. Methods
This prospective study, performed between July 2012 and July
2013, included 254 patients who were referred to the hysteros-
copy outpatient clinic of Cairo University hospital, Egypt. The
study protocol was approved by the institutional ethics com-
mittee and informed consent was obtained from the patients.
Women with infertility, abnormal uterine bleeding, abnormal
finding on ultrasound examination or hysterosalpingography
and missed intrauterine device were recruited to the study.
Contraindications for the office hysteroscopy were severe
bleeding, history of severe cardiovascular disease, endometrial
neoplasia and suspicion of pregnancy. Moreover, patients with
a history or suspicion of pelvic inflammatory disease were
excluded from the study.
Office hysteroscopy was performed using the vaginoscopic
approach as described by Betocchi and Selvaggi in 1997 (13).
A rigid 2.9 mm scope Hopkins type II forward oblique lens
(Karl Storz, Tuttlingen, Germany) and outer sheath diameter
of 4.3 mm diagnostic office hysteroscopy was used in the pro-
cedure (code 26153BI). Saline was used as a distending med-
ium and the pressure used was set between 80 and
100 mmHg. No premedication was given to the patient during
their waiting time and cervical preparation was not done.
In all the patients, office hysteroscopy started by introduc-
ing the scope into the vagina and performing vaginoscopy fol-
lowed by passage of the scope through the cervix slowly
allowing the fluid distend the cervix slowly while performing
cerviscopy. Since the passage of the scope through the internal
os was the most painful part of the procedure care was taken
to pass the scope as slowly without touching the uterine wall
at any time. Throughout the procedure a visual contact was
maintained with the patient to observe the patient response
to pain and tolerability while interacting with the patient
explaining the findings of the procedure. At the end of the
procedure the total duration of the procedure was recorded.
155
Immediately after the end of procedure, the patients were
asked to score pain experienced during the procedure accord-
ing to a 10 cm visual analog score (VAS) as follows; zero = no
pain, 1–3 = mild discomfort, 4–7 = moderate pain, 8–9 =
severe pain, 10 = intolerable pain.
Patients were divided into two groups; group A if no pain,
mild discomfort or moderate pain were felt during procedure
(pain score 0–7) and group B if patients experienced severe
or intolerable pain (pain score 8–10). Failure of the procedure
was defined as inability to complete the procedure either
because of the intolerable pain or inability to introduce the
scope into the uterine cavity.
Statistical analysis was performed via v2 test or Student
t-test as appropriate. A Yates correction equation was used
when the expected frequency was less than 5. P value <0.05
was considered statistically significant. Multivariate analysis
was done using multiple logistic regression to detect factors
associated with severe and intolerable pain and failure of hys-
teroscopy. All statistical calculations were performed using
Excel version 7 (Microsoft, New York, NY, USA) and SPSS
(SPSS, Chicago, IL, USA).
3. Results
Eighty-six patients (33.86%) reported no or mild pain, 118
patients (46.46%) reported moderate pain, 44 patients
(17.32%) experienced severe pain and 6 patients (2.36%) expe-
rienced intolerable pain necessitating stoppage of the proce-
dure. There were no significant differences in the age or
body mass index between patients with severe or intolerable
pain and patients with mild or moderate pain (33.52 ± 11.42
vs. 33.90 ± 10.04, P value = 0.831 and 31.7 ± 5.64 vs.
30.95 ± 4.71, P value = 0.39 respectively).
The indications for referral of the patients to the hysteros-
copy clinic were infertility (53.15%), reproductive age bleeding
(12.99%), post-menopausal bleeding (5.91%), preparation for
in vitro fertilization embryo transfer (IVF-ET) (11.02%), 2nd
look hysteroscopy (5.12%), missed intrauterine contraceptive
device (IUCD) (4.33%), suspected endometrial polyp
(3.94%), or intrauterine synechiae (2.36%), chronic pelvic pain
(0.79%) and amenorrhea (0.39%).
At the time of hysteroscopy examination, 181 patients were
in the proliferative phase (71.26%), 55 were in the secretory
phase (21.65%), 15 were menopausal (5.91%) and 3 were
amenorrheic (1.18%).
Cervical pathology was present in 48 patients (18.9%).
Twenty-three patients had cervical stenosis at internal os
(9.06%), eight patients had cervical polyp (3.15%), six
patients had adhesions (2.36%), five patients had nabothian
follicles (1.97%), three patients had hypertrophied cervix of
chronic infection (1.18%), two patients had stenosis at
external os (0.79%) and one patient had cervical septum
(0.39%).
Uterine pathology was detected in 117 patients (46.06%).
Anatomical abnormalities detected were arcuate uterus
(7.48%), subseptate uterus (5.91%), bicornuate uterus (1.97%),
unicornuate uterus (1.57%), hypoplastic uterus (0.39%) and
tubular cavity (0.79%). Other abnormalities detected were
endometrial polyps (9.84%), submucous myoma (5.91%),
polypoidal endometrium (3.94%), distorted irregular cavity
156 S.M. Zayed et al.

Table 1 Predictive factors for severe or intolerable pain. Table 2 Predictive factors for failure of hysteroscopy.
Severe or RR (95% CI) P value Failure n = 6 RR (95% CI) P value
intolerable
Parity
pain (n = 50)
Nulliparous 2/135 (1.48%) 0.44 (0.082, 2.36) 0.568
Parity Non-nullipara 4/119 (3.36%) 1.00 –
Nulliparous 36/135 (26.67%) 2.27 (1.29, 3.99) 0.003
Menopause
Non-nullipara 14/119 (11.76%) 1.00 –
Non-menopausal 6/239 (2.51%) NA 0.535
Menopause Menopausal 0/15 (0.00%) –
Non-menopausal 48/239 (20.08%) 1.51 (0.40, 5.61) 0.762
Menstrual phase
Menopausal 2/15 (13.33%) 1.00 –
Secretory phase 3/55 (5.45%) 3.29 (0.68, 15.84) 0.281
Menstrual phase Proliferative phase 3/181 (1.66%) 1.00 –
Secretory phase 11/55 (20%) 0.98 (0.54, 1.79) 0.92
Cervical pathology
Proliferative phase 37/181 (20.44%) 1.00 –
Present 6/48 (12.50%) NA 0.0001
Cervical pathology Absent 0/206 (0.00%) –
Present 19/48 (39.58%) 2.63 (1.63, 4.24) 0.0001
Uterine pathology
Absent 31/206 (15.05%) 1.00 –
Present 1/117 (0.85%) 0.23 (0.027, 1.90) 0.275
Uterine pathology Absent 5/132 (3.78%) 1.00 –
Present 19/117 (16.24%) 0.82 (0.48, 1.41) 0.48
Duration of the procedure
Absent 26/132 (19.70%) 1.00 –
P2 min 2/115 (1.74%) 0.60 (0.11, 3.24) 0.857
Duration of the procedure <2 min 4/139 (2.88%) 1.00 –
P2 min 29/115 (25.22%) 1.67 (1.01, 2.76) 0.044 Values are expressed as n/n (%), RR = risk ratio, CI = confidence
<2 min 21/139 (15.11%) 1.00 –
interval.
Values are expressed as n/n (%), RR = risk ratio, CI = confidence
interval.

Table 3 Factors associated with severe or intolerable pain.

(1.18%), intrauterine synechiae (3.94%), endometritis (2.76%)
and intracavitary bones from previous conception (0.39%).
Bivariate analysis revealed that nulliparous patients had a
higher risk of developing severe or intolerable pain compared
with non-nulliparous patients (26.67% vs. 11.76%, P
value = 0.003). Moreover, severe or intolerable pain was
reported more frequently in patients with cervical pathology
and duration of procedure more than 2 min (39.58% vs.
15.05%, P value = 0.0001 and 25.22% vs. 15.11%, P
value = 0.044 respectively).
No association was detected between the presence of uter-
ine pathology or menstrual phase and the occurrence of severe
or intolerable pain (Table 1).
Bivariate analysis revealed that the failure of hysteroscopy
was reported more frequently in patients with cervical pathol-
ogy (12.50% vs. 0%, P value = 0.0001). Moreover, no corre-
lation was determined between nulliparity, duration of
procedure, uterine pathology, menstrual phase or menopausal
state and failure of hysteroscopy (Table 2).
Multivariate analysis using multiple logistic regression
revealed that nulliparity, cervical pathology and duration of
procedure more than 2 min were strongly associated with
severe or intolerable pain (Table 3). On the other hand, no cor-
relation was found between failure of hysteroscopy and any
predictor factor.
4. Discussion
The data presented in this study revealed that office hyster-
oscopy is a painless procedure in most of the patients. In
our study, 33.86% of the patients have no or mild pain
and 46.46% have moderate pain, only 17.32% of patients
experienced severe pain and 2.32% of patients experienced
Variable OR 95% CI P value
Nulliparous 3.92 (1.691, 9.104) 0.001
Cervical pathology 2.395 (1.096, 5.234) 0.029
Duration P2 min 2.298 (1.112, 4.746) 0.025
OR = odds ratio, CI = confidence interval.
intolerable pain necessitating stoppage of the procedure.
The results of our study are in accordance with several
recent studies (Table 4). A prospective study including
558 patients undergoing office hysteroscopy revealed
that 32.3% of patients experienced severe pain (14).
De Carvalho Schettini et al. reported that 31.58% of
patients undergoing office hysteroscopy suffered moderate
or severe pain (10).
In our study, 26.67% of nulliparous women and 11.76% of
non-nulliparous women have severe or intolerable pain (risk
ratio 2.27, 95% CI (1.29, 3.99), P = 0.003). Moreover,
39.58% of women with cervical pathology experienced severe
or intolerable pain compared with 15.05% of cases with no
cervical pathology (relative risk 2.63, 95% CI (1.63, 4.24), P
value = 0.0001). Multivariate analysis confirmed a direct rela-
tion of nulliparity and the presence of cervical pathology with
severe and intolerable pain. The results of our study support
the hypotheses that the relation between the cervical width
and the diameter of the scope is the most important predicting
factor for the pain associated with office hysteroscopy. The
wider external os, cervical canal and internal os in multiparous
women compared with nulliparous women allow easier pas-
sage of hysteroscope. On the other hand, the presence of steno-
sis of external or internal os or cervical lesion narrowing the
cervical canal makes the passage of the hysteroscope more dif-
ficult and therefore more painful.
Pain experienced during office hysteroscopy 157

Table 4 Results of pain related risk factors in several studies.

Author Study No. of cases Nulliparity History Menopausal Instrument Surgeon
design of CS status size experience
Zayed et al. (current study) PS 254 S NA NS NA NA
De Angelis et al. (2003) (6) RCT 207 NA NA NA S NA
Campo et al. (2007) (8) RCT 480 NS NS NA S NS
Cicinelli et al. (2007) (1) PS 533 NS S S NA NA
De Carvalho Schettini et al. (2007) (10) PS 171 S NA S NA NA
Pluchino et al. (2010) (7) RCT 184 NA NA NA S S
Torok and Major (2013) (9) PS 70 NS NA NS NS NA
Romani et al. (2013) (5) RS 900 NA NA NA S NA
Sessa et al. (2012) (11) PS 558 NA NS NA NA NA
Pontrelli et al. (2005) (12) PS 9600 NA NA NA S NA
RCT = randomized controlled trial, PS = prospective study, RS = retrospective study, NA = not available, NS = non significant, S = sig-
nificant, CS = cesarean section.

Several studies have shown that higher tolerability, accept-
ability and lower pain and failure rate are associated with
the use of smaller scope or in multiparous women with wide
cervical canal, internal os and external os. Campo et al., in a
prospective randomized controlled trial study compared
traditional diagnostic hysteroscope (5 mm scope) versus
mini-hysteroscope (2.7 mm rigid scope or fiberoptic hystero-
scope of 2 mm) (8). They studied the effect of parity and his-
tory of vaginal delivery and surgeon experience in relation to
the pain during the procedure and success rate in both settings.
They reported that both parity and history of vaginal delivery
were important factors in relation to pain when using tradi-
tional hysteroscope but were no longer significant factors when
minihysteroscope was used. A prospective study including 171
women undergoing office hysteroscopy revealed that meno-
pause, speculum examination and nulliparity are the main fac-
tors associated with unacceptable pain (10).
In contrast to our findings, Cicinelli et al. reported that the
nulliparity is not a risk factor of pain at hysteroscopy (1).
Moreover, Torok and Major, concluded that there is no evi-
dence that parity, menopausal status, or the thickness of the
instrument influence the level of experienced pain (9).
In our sample of patients, severe or intolerable pain was
reported more frequently in patients who endured procedure
more than 2 min. A prospective study including 558 patients
undergoing office hysteroscopy without anesthesia reported
that the duration of hysteroscopy was significantly longer
in patients who experienced severe pain (14). On the other
hand, several authors reported that the duration of the
procedure has no direct correlation with severity of pain
(10,15,16).
No correlation was found between menstrual cycle phase,
uterine pathology and menopausal state and severe or intoler-
able pain. Torok and Major, reported no significance of the
menopausal state for pain prediction during office hysteros-
copy (9). In contrast to our findings, two prospective studies
revealed that menopause is correlated with severe pain during
office hysteroscopy (1,10).
In the present study, six patients experienced intolerable
pain necessitating stoppage of the procedure. All these patients
had cervical pathology. Although, bivariate analysis revealed
that patients with cervical pathology have a higher risk of
failure of office hysteroscopy compared with patients with no
cervical pathology (12.50% vs. 0%, P value = 0.0001), the
multivariate analysis revealed that cervical pathology had no
direct correlation with intolerable pain and failure of office
hysteroscopy. Moreover, bivariate analysis and multivariate
analysis revealed no correlation between nulliparity, duration
of procedure, uterine pathology, menstrual phase or meno-
pausal state and failure of office hysteroscopy.
In conclusion, nulliparity, presence of cervical pathology
and duration of the procedure more than 2 min are associated
with severe or intolerable pain during office hysteroscopy. On
the other hand, menstrual phase, menopausal status and pres-
ence of uterine pathology are not predictors of occurrence of
severe or intolerable pain during office hysteroscopy. We think
that the nulliparous patients and patients with cervical pathol-
ogy require special pain management considerations during
office hysteroscopy. The small number of cases with a failure
of office hysteroscopy (n = 6) may be the cause of failure of
detection of correlation between cervical pathology and failure
of office hysteroscopy by multivariate analysis. Further larger
studies are needed to detect the correlation of cervical pathol-
ogy and failure of office hysteroscopy.
Conflict of interest
The authors declare that they have no conflict of interest.
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