Conscious sedation for office hysteroscopy: a systematic review and meta-analysis

Abstract Objective To evaluate the role of conscious sedation on pain control in office hysteroscopy. Methods MEDLINE, EMBASE, CINAHL and CENTRAL were searched from inception to the 30th October 2020 in order to perform a systematic review and meta-analysis of all randomized controlled trials investigating women undergoing office hysteroscopic procedures, allocated to either conscious sedation or a suitable comparator, where the outcome was pain. Data regarding adverse events, feasibility and satisfaction/acceptability were also collected. The Risk of Bias 2 tool was used to assess study quality. Standard mean differences (SMD) or Odds Ratios (OR), and their 95% confidence intervals (CIs) were calculated for continuous (e.g. mean pain) and dichotomous (e.g. side-effects) outcomes, respectively. Results The literature search returned 339 results, of which seven studies were included for systematic review, with five studies having data suitable for meta-analysis. Intravenous conscious sedation, when compared with local anesthesia, reduced pain during (SMD -0.26, 95% CI -0.51 to -0.01), but not after (SMD -0.18, 95% CI -0.43 to 0.07) office hysteroscopy. No significant difference in side-effects were noted (OR 15.58, 95% CI 0.08 to 2891.91). Intravenous conscious sedation, when compared to an oral analgesic and antispasmodic, was associated with increased pain, both during (SMD 1.03, 95% CI 0.56 to 1.49) and after (SMD 0.49, 95% CI 0.04 to 0.93) hysteroscopy and had significantly more side-effects (OR 134.33, 95% CI 16.14 to 1118.17). Inhalational conscious sedation (70% N2O/30% O2), when compared to oral analgesia and anxiolysis, showed the greatest reduction in pain during hysteroscopy (SMD -1.04, 95% CI -1.57 to -0.52), however side-effects were not reported. Whilst patients and hysteroscopists were more satisfied with deeper levels of sedation, resulting side-effects, such as delirium, increased the level of post-procedural attention required, leading to a significantly lower level of satisfaction amongst nursing staff. Conclusion The routine use of conscious sedation in contemporary hysteroscopic practice should be avoided in the absence of any clear reduction in pain and a higher risk of side-effects.