title: [Pain evaluation in office hysteroscopy: comparison of two techniques].
abstract: OBJECTIVE
  to compare the pain reported by patients submitted to hysteroscopy by the standard technique with carbon dioxide (CO2) and to vaginal hysteroscopy with physiological saline (0.9% NaCl).
  
  
  METHODS
  this was a prospective cohort study conducted at an ambulatory hysteroscopy service. A total of 117 patients with indication for the exam were included, being randomly assigned to one of the groups. All patients answered an epidemiological questionnaire and scored the pain expected before the exam and that felt after the end of the procedure on a verbal pain scale from 0 to 10. A speculum, traction of the cervix, insertion of a 30 masculine light source and a diagnostic shirt with a total diameter of 5 mm were used for the standard technique. The cavity was distended with CO2 under a pressure of 100 mmHg controlled with a hysteroflator, and a biopsy was obtained with a Novak curette. Vaginoscopy was performed without a touch by distention of the vagina with fluid, direct visualization of the cervix and introduction of the light source with two continuous-flow shirts, with an accessory channel with an oval profile, the whole set measuring 5 mm in diameter. The medium distention was 0.9% NaCl and the pressure used was that considered to be necessary for an adequate visualization of the canal and of the cavity with an external pneumatic pressurizer. The biopsy was obtained in a directed manner using an endoscopic clamp. The mean and standard deviation were calculated for the quantitative variables and the frequency was calculated for the qualitative variables. The Student's t-test was used to compare the means, and the chi-square or exact Fisher test was used (when n<5) for the categorical analysis using the SPSS 15.0 software. The study was designed for a 95% test power, with the level of significance set at p<0.05.
  
  
  RESULTS
  the groups were similar regarding age, parity, previous uterine surgeries, menopausal status, and the need for a biopsy. In comparison to the group submitted to the standard technique, the vaginoscopy group involved a lower technical difficulty (5.1 versus 17.2%, p=0.03), a higher rate of exams considered to be satisfactory (98.3 versus 89.7%, p=0.04) and a lower pain index (4.8 versus 6.1; p=0.01), as the difference were more evident when patients who never had a previous normal delivery were compared (4.9 versus 7.1; p=0.0001). When the pain scale was stratified as mild (0-4), moderate (5-7) or intense (8-10), the vaginoscopy technique was found to be associated with a 52% reduction of the frequency of intense pain (p=0.005).
  
  
  CONCLUSIONS
  vaginohysteroscopy was proved to be a less painful procedure than the technique based on the use of a speculum and CO2, regardless of age, menopause or parity, with more satisfactory results and lower technical difficulty.
authors.affiliation: Serviço de Ginecologia e Obstetrícia, Hospital do Servidor Público Estadual Francisco Morato de Oliveira, São Paulo, SP, Brasil. dradanieladiniz@hotmail.com
authors.forename: Daniela Barreto Fraguglia Quental
authors.initials: DB
authors.lastname: Diniz
authors.forename: Daniella De Batista
authors.initials: Dde B
authors.lastname: Depes
authors.forename: Ana Maria Gomes
authors.initials: AM
authors.lastname: Pereira
authors.forename: Simone Denise
authors.initials: SD
authors.lastname: David
authors.forename: Umberto Gazi
authors.initials: UG
authors.lastname: Lippi
authors.forename: Fausto Farah
authors.initials: FF
authors.lastname: Baracat
authors.forename: Reginaldo Guedes Coelho
authors.initials: RG
authors.lastname: Lopes
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000553:Ambulatory Care; D005260:Female; D006801:Humans; D015907:Hysteroscopy / Q000009:adverse effects*; D008875:Middle Aged; D009819:Office Visits; D010147:Pain Measurement / Q000379:methods*; D010149:Postoperative Pain / Q000175:diagnosis* / Q000209:etiology; D011446:Prospective Studies; D055815:Young Adult