title: Does cervical preparation before outpatient hysteroscopy reduce women's pain experience? A systematic review.
abstract: BACKGROUND
  Studies examining the use of pharmaceutical (prostaglandins, antiprogestogens) and mechanical (osmotic dilators) dilatation of the cervix before hysteroscopy under general anaesthesia have produced conflicting results regarding their effect on cervical dilatation and trauma during the procedure.
  
  
  OBJECTIVE
  To compare the effect on pain and need for cervical dilatation of various methods of cervical preparation before outpatient hysteroscopy.
  
  
  METHODS
  MEDLINE, EMBASE and CINAHL were searched using a combination of the keywords 'hysteroscopy', 'vaginoscopy', 'cervical ripening', 'laminaria', 'progest*', 'prostaglandin', 'oestrogen''cervical preparation' and their associated Medical Subject Headings The Cochrane Library was searched using the keywords 'hysteroscopy' and 'cervical'. There were no limits or filters placed on the searches.
  
  
  METHODS
  Randomised controlled trials that examined women undergoing outpatient hysteroscopy, where the intervention was the use of cervical preparation versus a control or placebo and the outcome was pain assessment.
  
  
  METHODS
  Two reviewers independently selected trials. Data were extracted on pain, the effect on dilatation, adverse effects, trauma and feasibility. Data regarding pain and cervical dilatation were unsuitable for meta-analysis. Meta-analyses were performed for adverse effects and feasibility using the random effects models to calculate the Peto odds ratio.
  
  
  RESULTS
  From 585 abstracts, six studies were selected for inclusion in the systematic review. The results suggest that there may be a benefit of using prostaglandins for postmenopausal women; however, there is no high-quality evidence that giving misoprostol before outpatient hysteroscopy reduces the pain experienced by women of reproductive age. There is some evidence that prostaglandins reduce the force and requirement for dilatation of the cervix beyond 5 mm.
  
  
  CONCLUSIONS
  There is no evidence to recommend the routine administration of mifepristone or misoprostol to women before outpatient hysteroscopy. Cervical priming with vaginal prostaglandins may be considered in postmenopausal women if using hysteroscopic systems >5 mm in diameter.
authors.affiliation: University of Birmingham, Birmingham, UK.
authors.forename: N A M
authors.initials: NA
authors.lastname: Cooper
authors.forename: P
authors.initials: P
authors.lastname: Smith
authors.forename: K S
authors.initials: KS
authors.lastname: Khan
authors.forename: T J
authors.initials: TJ
authors.lastname: Clark
mesh_terms: D000553:Ambulatory Care; D004106:Dilatation; D005260:Female; D006727:Hormone Antagonists / Q000008:administration & dosage; D006801:Humans; D015907:Hysteroscopy / Q000009:adverse effects / Q000379:methods*; D015735:Mifepristone / Q000008:administration & dosage; D016595:Misoprostol / Q000008:administration & dosage; D010146:Pain / Q000517:prevention & control*; D011292:Premedication
chemical_list: D006727:Hormone Antagonists; D016595:Misoprostol; D015735:Mifepristone