Original Article

Office Diagnostic and Operative Hysteroscopy Using Local

Anesthesia Only: An Analysis of Patient Reported Pain and Other
Procedural Outcomes
Sanaz Keyhan, MD*, and Malcolm G. Munro, MD
From the Departments of Obstetrics and Gynecology, Kaiser Permanente Los Angeles Medical Center (Drs. Keyhan and Munro), and the David Geffen
School of Medicine at UCLA (Dr. Munro), Los Angeles, California.

ABSTRACT Study Objective: To evaluate the effectiveness of a multimodality local anesthetic protocol for office diagnostic and operative
hysteroscopy.
Design: Retrospective cohort study (Canadian Task Force classification II-3).
Setting: Academic communitybased institution.
Patients: Five hundred sixty-nine women undergoing 639 office-based diagnostic or operative hysteroscopic procedures.
Interventions: Multimodality local anesthetic protocol addressing vagina, cervix, paracervical region, and endometrial cavity.
Measurements and Main Results: Primary outcomes were numeric pain scores and rate of premature termination because of
pain. Secondary outcomes included procedure pain and parity, delivery route, menopausal status, procedure type, and cost
effect on procedure delivery. The overall mean (SD) pain score across 535 evaluable procedures was 3.7 (2.5). Patients
undergoing operative hysteroscopy had a higher mean maximum pain score than did those who underwent diagnostic hysteroscopy only (4.1 vs 3.2; p , .001). There was no difference among women in different age groups; however, those with both
cesarean section and vaginal delivery had scores higher than the mean (4.7 [0.4]; p , .001). The estimated cost savings was
almost $2 million.
Conclusion: Using a multimodality approach to local anesthesia, a broad spectrum of diagnostic and operative procedures can
be performed successfully, comfortably, and inexpensively in the context of an office procedure room, without the need for
procedural sedation. Journal of Minimally Invasive Gynecology (2014) 21, 791798 2014 AAGL. All rights reserved.
Keywords:

Hysteroscopic procedures; Hysteroscopy; Local anesthesia; Office hysteroscopy

DISCUSS

You can discuss this article with its authors and with other AAGL members at
http://www.AAGL.org/jmig-21-4-JMIG-D-14-00046

Use your Smartphone

to scan this QR code
and connect to the
discussion forum for
this article now*
* Download a free QR Code scanner by searching for QR
scanner in your smartphones app store or app marketplace.

Hysteroscopy is an important technique for evaluation of

the uterus in women with infertility, abnormal uterine
bleeding, and recurrent pregnancy loss. Moreover, a number
of important therapeutic interventions such as metroplasty,
sterilization, lysis of intrauterine adhesions, removal of

Disclosures: None declared.

Presented at the 42nd AAGL Global Congress of Minimally Invasive
Gynecology, November 14, 2013, Washington, DC.
Corresponding author: Sanaz Keyhan, MD, Department of Obstetrics and
Gynecology, Duke University, 200 Trent Dr, DUMC Box 3084, Durham,
NC 27710.
E-mail: Sanaz.Keyhan@dm.duke.edu
Submitted January 27, 2014. Accepted for publication March 5, 2014.
Available at www.sciencedirect.com and www.jmig.org
1553-4650/$ - see front matter 2014 AAGL. All rights reserved.
http://dx.doi.org/10.1016/j.jmig.2014.03.006

foreign bodies, endometrial ablation, and excision of polyps

and submucous myomas can be performed under hysteroscopic guidance. Both diagnostic and operative hysteroscopic procedures have been performed for several years in the
office setting; however, the experience of pain and the potential difficulty of uterine access can be deterrents for both
patients and physicians to proceed with office hysteroscopy,
in particular with the patient under local anesthesia [1].
Several studies have evaluated various local anesthetic
regimens for outpatient hysteroscopy, and other studies
have demonstrated the utility of the vaginoscopic approach
to office hysteroscopy without anesthesia [219]. In the
studies in which local anesthesia was used, most have
compared only one technique of local anesthesia vs
placebo, generally allowing only a short time between

792

Journal of Minimally Invasive Gynecology, Vol 21, No 5, September/October 2014

application of anesthesia to initiation of the procedure. In

most instances, only diagnostic hysteroscopy is evaluated
with or without biopsy [214]. Some high-quality randomized clinical trials have demonstrated that local anesthesia
has no benefit, whereas others have suggested that local
anesthesia regimens are associated with reduced procedural
pain and only a few have evaluated combined approaches to
local anesthesia [16,17]. Moreover, there is a paucity of data
insofar as local anesthesia in operative hysteroscopy,
with only 1 randomized clinical trial published to date
that evaluated the use of paracervical block during
hysteroscopic sterilization [15].
When considering local anesthetic approaches to hysteroscopic surgery, it is important to keep in the mind the complex innervation of a number of structures including the
vagina, uterine cervix, and corpus. In 2012, Keskin et al
[20] addressed innervation of the vagina by randomizing
postmenopausal women to receive EMLA 5% Cream (lidocaine 2.5% and prilocaine 2.5%) vs lubricant gel vs nothing
in the vagina before a speculum examination, and concluded
that topical application of EMLA Cream on the vaginal
epithelium significantly reduces pain associated with a speculum examination in postmenopausal women. The cervix is
innervated via sacral nerve roots (S2S3), whereas the
corpus receives its nerve supply from the thoracic nerves
(T8T10), some of which gain access to the uterus along
the uterine vessels, and others (T10) do so via the uterovarian
ligament [1]. As a result, injected intracervical or paracervical anesthesia will not block fundal innervation of the uterus.
In the present study, the overriding objective was to determine the utility of performing diagnostic and in particular
operative hysteroscopy in the office setting using only local
anesthesia with a multimodality approach. Our hypothesis
was that by combining multiple techniques and targets for
local uterine anesthesia we would achieve an acceptable
degree of patient comfort and have a low procedural failure
rate. As secondary outcomes, the relationship between procedure pain and factors such as parity, previous cesarean section, menopausal status, and procedure type were examined.
Other secondary outcomes included failed uterine access
and pain associated with anesthesia administration vs pain
associated with the procedure itself. In addition, we
analyzed the system-wide cost effect of such an approach.
Materials and Methods
The study was performed at Kaiser Permanente Los
Angeles Medical Center, an academic communitybased
institution. Approval for the study was obtained from the
Institutional Regional Board of Southern California Permanente Medical Group (SCPMG) Regional Research for this
7-year retrospective cohort study using a prospectively
collected database originally designed for quality assessment. The database included patient identifiers, indication
for hysteroscopy, menopausal status, parity and delivery
route if applicable, largest diameter of the hysteroscope,

anesthetic components, procedure performed, and procedure

pain scores. As part of the informed consent process, patients
were counseled that the procedure would be stopped if the
pain became unacceptable.
All patients undergoing either diagnostic or operative
hysteroscopic procedures from July 19, 2005, to October
23, 2012, in an office-based uterine procedure and imaging
center (UPIC) were included; however, patients with
missing pain data were excluded. The UPIC is a referral center that includes procedure rooms in which contrast imaging
as well as both diagnostic and operative hysteroscopy can be
performed in women with known or suspected uterine abnormalities such as polyps, leiomyomas, adhesions, and m
ullerian fusion/absorption defects. Transcervical sterilization
can be performed, as well as diagnostic hysteroscopy, in
women with postmenopausal bleeding, in particular those
in whom cervical access was difficult in the office or operating room. All patients were seen in consultation to ensure
that they were appropriate candidates for a hysteroscopic
procedure. Patients scheduled for hysteroscopy were
instructed to use a cyclooxygenase inhibitor, either 600 mg
ibuprofen 3 times daily or 440 mg sodium naproxen twice
daily for the 48 hours before hysteroscopy. In premenopausal women, the endometrium was prepared using 20
mg medroxyprogesterone acetate twice daily for at least 4
weeks before the procedure unless suppression had already
been achieved using progestins, combination oral contraceptives, or gonadotropin-releasing hormone agonists. All
patients referred underwent office hysteroscopy unless previous imaging and/or hysteroscopy confirmed that myomectomy was required because of large (.2 cm), deep type I or
type II leiomyomas, or multiple submucous leiomyomas.
The specific criteria for myomas evolved over time as new
equipment and techniques enabled removal of larger and
more complex myoma configurations in the office setting.
With this exception, women were not offered hysteroscopy
in the operating room.
The multiple modality anesthetic protocol began with 2%
lidocaine gel, which was typically used to coat the vaginal
speculum before insertion. Patients who were identified at
the original consultation as having substantial discomfort
during bimanual or speculum examination, who were typically postmenopausal, either self-administered the lidocaine
gel or the physician applied it approximately 1 hour before
the procedure. After placement of the speculum, the anterior
and posterior aspects of the cervix were injected with about 3
mL 0.5% lidocaine with 1:200 000 adrenaline via a 22-gauge
spinal needle to enable painless attachment of a cervical
tenaculum. A paracervical block was then administered
via the uterosacral ligaments at the level of the cervicovaginal epithelial junction using the same spinal needle to inject
a total of 20 to 30 mL 0.5% lidocaine with 1:200 000 adrenaline equally distributed bilaterally. A small amount of 4%
liposomal lidocaine paste (LMX; Ferndale Laboratories,
Inc., Ferndale, MI) was applied to the cervical canal using
2 or 3 sterile cotton-tipped applicators. Then 10 mL 2%

Keyhan and Munro.

Office Hysteroscopy Using Local Anesthesia Only

lidocaine gel was injected into the endometrial cavity via a

prefilled applicator (International Medical Systems, Ltd,
South El Monte, CA). Hysteroscopy was begun at least 10
minutes and up to 20 minutes after administration of anesthetic, depending on patient response to passage of the liposomal lidocainecoated cotton tipped applicators. Other
than the oral cyclooxygenase inhibitors administered for
48 hours before the procedure, no other systemic agents
were used.
The endometrial cavity was distended using either
normal saline solution or sterile water, depending on the
requirements of the instrumentation, with a gravity inflow
system assisted by a pressurized cuff as needed. An automated fluid management system was not used in the study.
Standard hysteroscopic instrumentation included a 5.5-mm
outside diameter (OD) Olympus continuous flow sheath
and either a 12- or 30-degree 3-mm OD Olympus hysteroscope (Olympus America, Inc., Center Valley, PA). Occasionally a sheath or system with a larger OD (up to 6.5
mm) was used because of baseline cervical diameter or the
need for specific instrumentation. In some instances, for performance of resectoscopic myomectomy, a 9-mm OD sheath
was used to accommodate a Gynecare Versapoint resectoscope (Ethicon, Inc, Somerville, NJ). Where necessary, to
facilitate access of these instruments, the cervix was dilated
using Pratt dilators.
Polyps were generally removed using scissors, and were
extracted using forceps. Adhesiolysis was performed using
scissors, metroplasty with a radiofrequency bipolar needle,
and myomectomies initially with the bipolar needle or the
resectoscope. Intrauterine mechanical morcellators were
increasingly used for selected myomectomies toward the
end of the study period. Details of polyp size and number
and of myoma types and sizes were not recorded in the database. However, myomas that were removed were generally
type 0 or 1 and typically were %2 cm in mean diameter.
In many cases, the procedure was begun with diagnostic hysteroscopy that clarified the need for an operative procedure.
In instances in which polyps, small leiomyomas, or adhesions were identified, the procedure was converted to an
operative procedure. For the purpose of the study, these procedures were recorded as operative procedures.
Procedure room staff was composed of 1 trained vocational nurse/technician who handled the endoscope tower,
hysteroscopes, and distention media, as well as room preparation and clean-up. Anesthesia was administered by an
attending physician or a resident after appropriate training
was completed, which included use of video and observation
of several procedures. The database did not include procedure time; typically, 3 procedures were performed per 3.5
hours.
At the end of the procedure, patients were asked to
verbally report the peak pain experienced using a numeric
scale of 0 to 10. From 2005 to 2009, patients were asked
about their maximum pain score throughout the entire hysteroscopic procedure. Starting in 2009, patients were asked

793

about the maximum pain during both anesthetic administration and the hysteroscopic procedure. The patient was asked
to report the most severe pain experienced, rather than a
perceived mean, even if the most severe pain lasted only seconds. The surgeon recorded all pain scores in the database.
All statistical analyses were performed using SAS 4.3
software (SAS Institute, Inc, Cary, NC). Wilcoxon signedrank tests were used to compare mean pain scores during
anesthetic administration vs during the procedure. Nonparametric tests were used because anesthesia and procedure
pain scores from a procedure for the same patient were
treated as paired data, and the underlying distributions of
the paired score differences were unknown, in particular
for procedures with a small sample size. For patients who
underwent multiple procedures on different days, we
assumed independence between their paired score differences to simplify analyses. Pain scores for diagnostic, operative, and all procedures were collectively analyzed using
linear mixed-effects regression models to account for
within-subject correlation between pain scores per patient.
Pain scores were analyzed in terms of anesthesia-related
pain, procedure-related pain, and overall pain. An overall
pain score of a procedure refers to the maximum value of
the anesthesia and procedure scores. In addition, linear
mixed-effects modeling was performed to determine the
effects of age, menopausal status, previous delivery method,
and category of surgeon performing the procedure on pain
scores during hysteroscopic procedures. We first compared
diagnostic and operative procedures with respect to anesthesia pain scores. On finding no significant difference in
anesthesia pain scores between the diagnostic and operative
procedures, we considered that all procedures had the same
baseline anesthesia pain score. The procedure pain scores
were then adjusted for age and obstetric delivery history.
All statistical tests were 2-sided, with significance set at .05.
Resource use was estimated for diagnostic hysteroscopic
procedures via review of 3 randomly selected institutional
cases, with determination of mean line item costs (not
charges) by the SCPMG Clinical Analysis group in 2006,
the first year of the study. The office procedure room costs
were determined by a system-wide analysis of line item
costs of a large sample of procedures in multiple SCPMG
centers, including our own. These means were calculated
and placed on a spreadsheet (Excel; Microsoft Corp.,
Redmond, WA) for analysis.
Results
A total of 569 consecutive women underwent either diagnostic hysteroscopy or hysteroscopically directed surgical
procedures at UPIC during the study. Because some patients
underwent multiple procedures, 639 procedures were
eligible for the study.
Of these women, 478 were available for analysis of their
surgical pain experience; 91 were excluded owing to missing
pain data. The 478 patients underwent 535 procedures, with

794

Journal of Minimally Invasive Gynecology, Vol 21, No 5, September/October 2014

pain scores available for each. The missing data were due to a
number of surgeons not being compliant with recording pain
scores. For an additional 12 patients, parity data were missing.
None of the patients with missing data had failed uterine
access or other complications. A total of 639 procedures
were performed: 412 by 1 primary surgeon (M.M.); 136 by
the primary surgeon along with a resident, who administered
anesthesia; and 91 by another surgeon alone. The baseline
characteristics of the study population are given in Table 1.
Of the 639 procedures, 5 were prematurely terminated
because of procedure-related pain, and 3 because of failed
endometrial cavity access. One patient in whom premature
termination was required because of pain returned for a second time after nonsteroidal anti-inflammatory drug prophylaxis and underwent a successful endometrial polypectomy.

Table 1
Patient demographic dataa
Procedure type
Variable
Age, yr
Mean (SD)
Median
Q1, Q3
Range
Age group
1829
3039
4049
5059
R60
Postmenopausal status
No
Yes
Previous obstetric
delivery
Cesarean section
Vaginal
Both
Nulliparous
Indication for
hysteroscopy
Abnormal bleeding
Contraception
management
Infertility
M
ullerian anomaly
Postmenopausal
bleeding
Recurrent pregnancy
loss
Cervical stenosis
Other/Unknown
a

Diagnostic
(n 5 212)

Operative
(n 5 427)

Total
(n 5 639)

41.5 (10.16)
40
35.0, 45.0
(18.082.0)

42.1 (10.97)
39
35.0, 46.0
(20.086.0)

41.9 (10.71)
39
35.0, 46.0
(18.086.0)

14 (6.6)
91 (42.9)
75 (35.4)
16 (7.5)
16 (7.5)

28 (6.6)
189 (44.3)
128 (30)
41 (9.6)
41 (9.6)

42 (6.6)
280 (43.8)
203 (31.8)
57 (8.9)
57 (8.9)

187 (88.2)
25 (11.8)

355 (83.1)
72 (16.9)

542 (84.8)
97 (15.2)

26 (12.3)
62 (29.2)
11 (5.2)
105 (18.9)

43 (10.1)
173 (40.5)
30 (7)
177 (13.3)

69 (10.8)
235 (36.8)
41 (6.4)
282 (15.2)

109 (51.4)
2 (0.9)

115 (26.9)
112 (26.2)

224 (35.1)
114 (17.8)

70 (33)
2 (0.9)
22 (10.4)

110 (25.8)
9 (2.1)
64 (15)

180 (28.2)
11 (1.7)
86 (13.5)

1 (0.5)

5 (1.2)

6 (0.9)

3 (1.4)
3 (1.4)

0
12 (2.8)

3 (0.5)
15 (2.3)

One of the patients who experienced failed access returned

for a second time after being given misoprostol vaginally
and also underwent a successful diagnostic hysteroscopy
to treat postmenopausal bleeding. Other than 3 transient
vasovagal reactions, there were no complications or hospital
admissions.
The overall mean (SD) procedure pain score was 3.7
(2.5). The score for patients undergoing diagnostic hysteroscopy was 3.2 (2.5), and for patients undergoing operative
hysteroscopy was 4.1 (2.5). The overall pain score for each
type of procedure is given in Table 2.
There were 325 procedures that had both a procedure pain
score and an anesthesia pain score. There was no difference
in anesthesia pain scores among patients who underwent
diagnostic (2.7 [0.3]) vs operative procedures (2.7 [0.2])
(p 5 .84). Operative procedures were associated with a
mean pain score that was 0.95 units higher compared with
diagnostic procedures (p , .001; 95% confidence interval,
0.391.5) (Table 3). This was also true when adjusted for
age and delivery history (p 5 .001).
In terms of the 5 age groups, there was no statistically
significant difference in overall procedure pain (p 5 1.0).
There was also no statistical difference in overall pain score
among premenopausal vs postmenopausal women (p 5 .45)
(Table 4). When comparing pain scores for procedures
performed by the primary surgeon plus a resident vs either
the primary surgeon alone (p 5 .25) or another surgeon
(p 5 .50), there was no difference.
Patients who had undergone both a cesarean section and
vaginal delivery had higher overall pain scores than did those
who were nulliparous (p , .01) or had undergone a previous
cesarean section (p , .03) or a previous vaginal delivery
(p , .06). Compared with nulliparous patients, those with
a previous vaginal delivery only or previous cesarean section
only did not have a significantly different overall pain score.

Table 2

Unless otherwise indicated, values are given as No. (%).

Pain scores based on procedure

Procedure

Procedures Overall pain score

(n 5 535) Mean SD Median Q1, Q3

Adhesiolysis
Catheter placement
Cervical stenosis
Diagnosis
Endometrial ablation
Endometrial biopsy catheter
Endometrial biopsy forceps
Metroplasty
Myomectomy
Polyp, cervix
Polyp, endometrium
Sterilization

21
5
7
189
6
6
11
7
31
4
156
77

IUD 5 intrauterine device.

4.5
2.2
3.3
3.2
5.3
6.0
3.9
4.7
4.8
3.5
3.8
4.4

2.9
1.8
2.7
2.4
3.6
3.0
2.7
3.1
2.6
1.3
2.1
2.6

4.0
1.0
2.0
3.0
5.0
6.5
5.0
4.0
5.0
3.5
3.0
4.0

2, 6
1, 3
1, 6
1, 5
2, 9
3, 9
1, 7
2, 7
3, 6
2.5, 4.5
2, 5
2, 7

Keyhan and Munro.

795

.8
ND
1.0
.01
.25
.19
.50
.36
1.0
.01
.25
.52
.02
1.6
ND
1.1
0.7
1.9
0.8
1.7
0.9
1.0
0.7
1.1
0.3
0.4

Age group, yr
1829
3039
4049
5059
R60
Postmenopausal status
No
Yes
Obstetric delivery history
Cesarean section
Vaginal
Both
Abortiona
Never pregnant

IUD 5 intrauterine device; ND 5 not determined because all 4 scores 51.

2.5, 5
1, 1
1, 2
1, 4
2, 9
1, 2
1, 4
1, 2.5
2, 6
1, 2
2.5, 4.5
2, 4
2, 3
4
1
2
2
3
2
2
1
2
2
4
3
3
2.8
0.0
0.8
2.1
3.8
1.2
1.5
2.2
3.2
2.0
1.3
1.8
1.9
4.3
1.0
1.7
2.7
4.7
1.9
2.3
2.0
3.9
2.0
3.5
2.8
2.8
8
3
6
93
3
9
3
12
7
24
4
90
63
Adhesiolysis
Catheter placement
Cervical stenosis
Diagnosis
Foley catheter
Foley forceps
Endometrial ablation
IUD insertion/removal
Metroplasty
Myomectomy
Polyp, cervix
Polyp, endometrium
Sterilization

Only procedures after 2009 for which there were separate anesthesia and procedure pain scores. Scores are based on a numeric scale of 0 to 10.
a
Wilcoxon signed rank test.

0.0
0.0
0.7
20.6
23.3
1.2
3.0
20.8
0.0
2.4
22.0
20.2
0.9
4
1
2
1
1
2
5
0
4
5
2
2
3

Overall pain score

4.3
1.0
2.3
2.1
1.3
3.1
5.3
1.2
3.9
4.4
1.5
2.6
3.6

3.8
0.0
2.9
2.4
0.6
3.1
4.5
1.7
2.7
2.9
1.3
2.5
3.0

1, 7.5
1, 1
1, 2
0, 3
1, 2
0, 6
1, 10
0, 2
1, 6
2.5, 6
0.5, 2.5
0, 5
1, 7

p Value
Median
Median
Procedures (n 5 325)

Anesthesia score

SD

Q1, Q3

Procedure score

SD

Mean differencea

Variable

Q1, Q3

Pain scores based on characteristics of 478 patients

SE

Table 4

Procedure

Anesthesia and procedure pain scores based on procedure

Table 3

Office Hysteroscopy Using Local Anesthesia Only

Mean

SE

95% CI

3.8
3.7
3.8
3.7
3.8

0.4
0.2
0.2
0.4
0.4

3.04.6
3.44.1
3.44.1
3.04.4
3.14.5

3.7
3.9

0.1
0.3

3.54.0
3.44.5

3.6
3.9
4.7
3.7
3.5

0.3
0.2
0.4
0.3
0.2

3.04.2
3.54.3
3.95.5
3.14.2
3.13.9

CI 5 confidence interval; SE 5 standard error.

a
Spontaneous or elective.

Results of the cost analysis are given in Table 5 and

demonstrate a net savings per case of $3021.14 if a diagnostic hysteroscopy was performed in the office procedure
room. By design, the costs related to the gynecologic surgeon are not included because they were considered to be
the same regardless of the site of service. In addition, the
capital costs of surgical devices and instruments were not
considered because they would likely be considered similar
regardless of location of service. On the basis of these data, if
one were to assume that there was no inflation and that the
cost savings for each of the 639 procedures in this cohort
were the same, the total savings to the system would be about
$1,930,500
Discussion
Data from the present study support the contention that a
spectrum of hysteroscopic procedures can be performed
safely and effectively in an office setting, without the need
for systemic anesthesia, anxiolytic agents, or narcotic
agents. The low rate of failed completion of the procedure
and the reported pain scores are consistent with a high
degree of patient acceptance of the approach.
A primary concern of clinicians when considering office
hysteroscopy is the ability to achieve adequate patient comfort in the office setting, a concern that is often compounded
by lack of experience with local anesthesia techniques. In
addition, there is the legitimate concern that pain can be
induced by the anesthesia techniques themselves, thereby
defeating the purpose of the process. Indeed, such a result
was reported in 1992 by Broadbent et al [2] in a study that
demonstrated that application of intracervical lignocaine in

796

Journal of Minimally Invasive Gynecology, Vol 21, No 5, September/October 2014

Table 5
Total cost comparison: institution operating room vs office procedure room
Office procedure rooma

Institutional operating room

Timed items
Variable
b,c

Preop visit
Preop roomc
Preop laboratory testsc,d
OR/procedure room suppliese
Lidocaine gel 2%
OR time
OR/procedure room staffing
Surgeonf
Anesthesiologist
CRNA
Recovery room
Total

Timed items

Item cost

Cost/Min

Minutes

Cost

Item cost

Cost/Min

Minutes

Cost

$254.85
$224.68
$37.19
$101.81
$44.15
NA
In OR time
Not calculated
NA
NA
NA

NA
NA
NA
NA
NA
$28.97
NA
$0.00
$8.02
$7.73
$6.08

NA
NA
NA
NA
NA
53
NA
Not calculated
30
60
60

$254.85
$224.68
$37.19
$101.81
$44.15
$1535.41
$0.00
$0.00
$240.60
$463.80
$364.80
$3627.29

0.00
0.00
0.00
36.00
44.15
NA
$136.00

NA
NA
NA
NA
NA
NA
NA

NA
NA
NA
NA
NA
NA
NA

$0.00
$0.00
$0.00
$36.00
$44.15
$0.00
$136.00

NA
NA
NA
Total

NA
NA
NA

NA
NA
NA

$0.00
$0.00
$0.00
$216.15

CRNA 5 Certified Registered Nurse Anesthetist; NA 5 not applicable, included in OR; OR 5 operating room; Preop 5 preoperative.
a
Diagnostic hysteroscopy only.
b
At Kaiser Permanente Los Angles Medical Center a preop visit is mandatory before operating roombased procedures.
c
No preop visit, room, or laboratory tests are required for office-based procedures.
d
Type and screen, complete blood cell count.
e
Drapes, anesthesia, supplies.
f
Surgeon calculation not included because it was believed to be equal regardless of site.

outpatient hysteroscopy causes as much or more pain than

the procedure itself. However, using the multimodality
approach to anesthesia described in this work, the minimal
discomfort associated with anesthetic use was overshadowed
by the general comfort with the wide spectrum of procedures
performed.
Some have suggested that office hysteroscopy should be
performed without any anesthesia, and there are examples
of this approach used successfully. For example, Sagiv
et al [21] analyzed the vaginoscopic approach to hysteroscopy, demonstrating mean pain scores to be significantly lower
in the group without use of a speculum, tenaculum, or anesthesia compared with traditional hysteroscopy with use of
intracervical anesthesia. Furthermore, Cooper et al [22] conducted a systematic review and meta-analysis of the vaginoscopic approach to outpatient hysteroscopy, analyzing the
patients pain experience and comparing it with a traditional
approach using a vaginal speculum and cervical tenaculum.
They also concluded that use of the vaginoscopic approach
to hysteroscopy was less painful and suggested that this
approach should become standard practice for outpatient
hysteroscopy [22]. However, these studies were limited to
diagnostic rather than operative hysteroscopy, in which
manipulation and dissection in the uterine fundus is potentially associated with a greater degree of pain because of
the differential innervation.
Bettocchi et al [23] reported a study that compared the
efficacy and patient satisfaction of office hysteroscopy
with and without anesthesia. They concluded that office hysteroscopy without anesthesia is a valid alternative in selected

patients. However, in their study, the primary procedure performed was polypectomy, and the procedure was limited on
the basis of the size of the polyps. In 2007, Bettocchi et al
[24] conducted a study of 260 patients undergoing metroplasty with or without local anesthesia in the office using a
vaginoscopic approach. Overall, the authors were able to
complete the metroplasty successfully in 93.1% of patients,
and no patients experienced any particular discomfort, pain,
or excessive bleeding. However, this was not a randomized
trial, and there was no comparison of pain scores between
patients who received anesthesia vs those who did not.
Moreover, the present study included a larger spectrum of
invasive procedures such as myomectomy and transcervical
sterilization.
In the present study, we were able to effectively demonstrate that the pain associated with application of anesthesia
was not rated any higher than the pain associated with the
procedure itself for operative hysteroscopy (anesthesia/procedure, 2.7 vs 3.1) but not for diagnostic hysteroscopy (anesthesia/procedure, 2.7 vs 2.1). Although vaginoscopy is a
reasonable and practical option for diagnostic hysteroscopy,
it is not always practical in nulliparous women, when larger
diameter instrumentation is required, or when anatomic issues such as cervical stenosis make access to the endometrial
cavity difficult.
Another comparison to highlight involves the metaanalysis by Cooper et al [22] that showed paracervical injection of local anesthetic to be the most effective anesthesia
technique when compared with intracervical, transcervical,
and topical types of anesthesia used during diagnostic office

Keyhan and Munro.

Office Hysteroscopy Using Local Anesthesia Only

hysteroscopy. In the present study, many of these techniques

were combined, and this approach may have been responsible for the low rate of abandonment because of procedure
pain.
To date, local anesthesia and operative hysteroscopy have
been evaluated in only a single randomized study, in which
166 women with surgically treatable lesions associated
with infertility or abnormal uterine bleeding were randomized into 2 groups, either local anesthesia or conscious sedation [25]. That study found that both methods can be used
effectively for pain control during operative hysteroscopy
in the office with no significant difference insofar as patient
satisfaction or pain levels experienced. Potential problems
related to conscious sedation are the requirements of intraoperative and postoperative monitoring protocols and that the
patient must be taken home by a driver. In our program, no
such requirements were necessary; most women drove
themselves home or to work.
The cost savings associated with office hysteroscopy vs
hysteroscopy in the operating room demonstrated in the present study were substantial; however, we believe that these
data underestimate the difference for a number of reasons.
First, our baseline institutional data were from the beginning
of the study, in 2006, whereas the costs associated with the
office procedure room were from 2012. Even with a conservative estimate of 10% rate of inflation, the differences
between the 2 sites would be much larger, exceeding
$3 million. Furthermore, this assumption is based on performing only diagnostic hysteroscopy in the office setting;
greater savings would be anticipated for other procedures
such as myomectomy, metroplasty, polypectomy, and transcervical sterilization. The costs reported herein may seem
low for a US center; however, it should be remembered
that these are estimated costs, not prices, as ours is a prepaid
system in which patients are not charged for services.
Different costs or charges could be substituted for different
health care systems to aid in estimating the local effect of
such an initiative.
The present study has a number of limitations. Because
the anesthesia protocol was not compared with placebo,
there was no ability to estimate how many patients would
have done equally well without any anesthesia. However,
such a design was deemed somewhat impractical given
that many patients are not willing to participate in a study
when they know that there is a chance they may not receive
any anesthesia.
A component of selection bias may also exist. The gynecologists who referred patients to the UPIC for evaluation
and consideration of office hysteroscopy may have selected
patients they thought would be good candidates for an officebased procedure. However, most of the patients were primary referrals for management, and some patients were
even referred after a procedure in the operating room had
failed. Moreover, once referred to the UPIC, they were not
offered operating roombased hysteroscopy unless they
required myomectomy because of large, multiple, or deep

797

lesions deemed inappropriate for removal outside of the

operating room.
There are also limitations to using a numeric pain score
because visual analog scales are the preferred instrument,
and frequent contemporaneous sampling of pain during the
procedure would have been preferable to self-reporting after
the procedure was over. On the other hand, asking the patient
to identify the single worst pain experienced, even if only
momentary, as we did in the present study, may have resulted
in overstatement of the pain experience. The pain scores
were also given in the presence of the investigators or surgeons rather than being acquired by an unbiased third party,
a design that might lead to bias. However, ,1% of patients
requested termination of the procedure despite being continually provided the option to do so.
Another limitation of the present study is that not every
patient received the identical combination of local anesthesia techniques for a number of reasons ranging from
inability to access the endometrial cavity to reduction or
elimination of adrenaline in the lidocaine for women with
hypertension or cardiac disease, circumstances that could
account for some variability in outcomes. However, these
variations in technique occurred in a minority of patients
and were considered unavoidable. Recording of polyp size
and number and of myoma type and number would have provided a useful set of data. However, most myomas resected
in our study were type 0 or 1 and typically were %2 cm in
mean diameter, and all polyps were removed, regardless of
size or number, but occasionally in more than 1 session in
the instance of multiple lesions.
In some instances, the small sample sizes of subgroups
limited our ability to provide reliable information on
procedure-specific pain scores. Examples include metroplasty, endometrial ablation, and endometrial catheter
biopsy.
Despite these limitations, as a whole, the present study
supports the notion that a combination of local anesthesia
methods is effective and does not incur a significantly higher
level of pain than the procedure itself. Strengths of the study
include a large sample size with few failed procedures overall and only 3 vasovagal episodes, which is inconsistent with
the study by Lau et al [10], which concluded that paracervical block leads to frequent hypotension and bradycardia.
Furthermore, compared with parous and premenopausal
women, both nulliparous and postmenopausal women tolerated the procedures well, which many would assume could
have had a significant role in the pain levels experienced.
Women who had undergone both a cesarean section and
vaginal delivery had higher mean pain scores than did
women who had undergone only a cesarean section or
vaginal delivery. The reason for this difference is unknown
and deserves further study.
In conclusion, we believe that our data support the value
of a multimodality approach to local anesthesia that can be
used either uniformly or selectively when performing diagnostic or operative hysteroscopy in an office setting. By

798

Journal of Minimally Invasive Gynecology, Vol 21, No 5, September/October 2014

moving many patients from the operating room to the office

procedure room, there is a dramatic effect on overall direct
costs. Although indirect costs, that is, those related to lost
opportunity on the part of the patient because of lost income
or requirements for home care of dependents, were not
measured, this approach would have a positive effect. It
will be important to design prospective comparative studies
evaluating these approaches in other clinical environments
performed by other clinicians to confirm the usefulness of
this approach.
Acknowledgments
We thank Dr. Dana Steenhard of Kaiser Permanente Los
Angeles Medical Center for assistance in writing aspects of
the manuscript and Ms. Eunis Ngor for assistance with
statistical analysis.
References
1. Munro MG, Brooks PG. Use of local anesthesia for office diagnostic
and operative hysteroscopy. J Minim Invasive Gynecol. 2010;17:
709718.
2. Broadbent JA, Hill NC, Molnar BG, Rolfe KJ, Magos AL. Randomized
placebo controlled trial to assess the role of intracervical lignocaine in
outpatient hysteroscopy. Br J Obstet Gynaecol. 1992;99:777779.
3. Vercellini P, Colombo A, Mauro F, Oldani S, Bramante T,
Crosignani PG. Paracervical anesthesia for outpatient hysteroscopy.
Fertil Steril. 1994;62:10831085.
4. Zupi E, Luciano AA, Marconi D, Valli E, Patrizi G, Romanini C. The
use of topical anesthesia in diagnostic hysteroscopy and endometrial biopsy. J Am Assoc Gynecol Laparosc. 1994;1:249252.
5. Zupi E, Luciano AA, Valli E, Marconi D, Maneschi F, Romanini C. The
use of topical anesthesia in diagnostic hysteroscopy and endometrial biopsy. Fertil Steril. 1995;63:414416.
6. Stigliano CM, Mollo A, Zullo F. Two modalities of topical anesthesia
for office hysteroscopy. Int J Gynaecol Obstet. 1997;59:151152.
7. Cicinelli E, Didonna T, Ambrosi G, Schonauer LM, Fiore G,
Matteo MG. Topical anaesthesia for diagnostic hysteroscopy and endometrial biopsy in postmenopausal women: a randomised placebocontrolled double-blind study. Br J Obstet Gynaecol. 1997;104:
316319.
8. Cicinelli E, Didonna T, Schonauer LM, Stragapede S, Falco N,
Pansini N. Paracervical anesthesia for hysteroscopy and endometrial biopsy in postmenopausal women: a randomized, double-blind, placebocontrolled study. J Reprod Med. 1998;43:10141018.
9. Lau WC, Lo WK, Tam WH, Yuen PM. Paracervical anaesthesia in
outpatient hysteroscopy: a randomised double-blind placebo-controlled
trial. Br J Obstet Gynaecol. 1999;106:356359.

10. Lau WC, Tam WH, Lo WK, Yuen PM. A randomised double-blind placebo-controlled trial of transcervical intrauterine local anaesthesia in
outpatient hysteroscopy. BJOG. 2000;107:610613.
11. Giorda G, Scarabelli C, Franceschi S, Campagnutta E. Feasibility and
pain control in outpatient hysteroscopy in postmenopausal women: a
randomized trial. Acta Obstet Gynecol Scand. 2000;79:593597.
12. Soriano D, Ajaj S, Chuong T, Deval B, Fauconnier A, Darai E. Lidocaine spray and outpatient hysteroscopy: randomized placebocontrolled trial. Obstet Gynecol. 2000;96:661664.
13. Wong AY, Wong K, Tang LC. Stepwise pain score analysis of the effect
of local lignocaine on outpatient hysteroscopy: a randomized, doubleblind, placebo-controlled trial. Fertil Steril. 2000;73:12341237.
14. Costello MF, Horrowitz S, Steigrad S, Saif N, Bennett M, Ekangaki A.
Transcervical intrauterine topical local anesthetic at hysterosalpingography: a prospective, randomized, double-blind, placebo-controlled
trial. Fertil Steril. 2002;78:11161122.
15. Chudnoff S, Einstein M, Levie M. Paracervical block efficacy in office
hysteroscopic sterilization: a randomized controlled trial. Obstet Gynecol. 2010;115:2634.
16. Al-Sunaidi M, Tulandi T. A randomized trial comparing local intracervical and combined local and paracervical anesthesia in outpatient hysteroscopy. J Minim Invasive Gynecol. 2007;14:153155.
17. Kabli N, Tulandi T. A randomized trial of outpatient hysteroscopy with
and without intrauterine anesthesia. J Minim Invasive Gynecol. 2008;
15:308310.
18. Makris N, Xygakis A, Dachlythras M, Prevedourakis C, Michalas S.
Mepivacaine local cervical anesthesia for diagnostic hysteroscopy: a
randomized placebo-controlled study. J Gynecol Surg. 2001;17:711.
19. Esteve MS, Machado SB, Borges SA, Santos CR, Coutinho E. The
efficacy of intracervical lidocaine in outpatient hysteroscopy. Gynaecol
Endosc. 2002;11:3336.
20. Keskin AE, Onaran Y, Duvan IC, Simavli S, Kafali H. Topical anesthetic (lidocaine-prilocaine) cream application before speculum examination in postmenopausal women. J Minim Invasive Gynecol. 2012;19:
350355.
21. Sagiv R, Sadan O, Boaz M, Dishi M, Schechter E, Golan A. A new
approach to office hysteroscopy compared with traditional hysteroscopy: a randomized controlled trial. Obstet Gynecol. 2006;108:387392.
22. Cooper NA, Khan KS, Clark TJ. Local anaesthesia for pain control during outpatient hysteroscopy: systematic review and meta-analysis.
BMJ. 2010;340:1130.
23. Bettocchi S, Ceci O, Nappi L, et al. Operative office hysteroscopy
without anesthesia: analysis of 4863 cases performed with mechanical
instruments. J Am Assoc Gynecol Laparosc. 2004;11:5961.
24. Bettocchi S, Ceci O, Nappi L, Pontrelli G, Pinto L, Vicino M. Office
hysteroscopic metroplasty: three diagnostic criteria to differentiate
between septate and bicornuate uteri. J Minim Invasive Gynecol.
2007;14:324328.
25. Guida M, Pellicano M, Zullo F, et al. Outpatient operative hysteroscopy
with bipolar electrode: a prospective multicentre randomized study between local anaesthesia and conscious sedation. Hum Reprod. 2003;18:
840843.