Review article| Volume 266, P89-98, November 2021

Download started.


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

Published:September 03, 2021DOI:



      To evaluate the role of conscious sedation on pain control in office hysteroscopy.


      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.


      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.


      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.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


        • Ahmad G.
        • Saluja S.
        • O’Flynn H.
        • Sorrentino A.
        • Leach D.
        • Watson A.
        Pain relief for outpatient hysteroscopy.
        Cochrane Database of Systematic Reviews. 2017;
        • Jivraj S.
        • Dass M.
        • Panikkar J.
        • Brown V.
        Outpatient hysteroscopy: an observational study of patient acceptability.
        Medicina (Kaunas). 2004; 40: 1207-1210
        • del Valle C.
        • Solano J.A.
        • Rodríguez A.
        • Alonso M.
        Pain management in outpatient hysteroscopy.
        Gynecology and Minimally Invasive Therapy. 2016; 5: 141-147
      1. Clark TJ, Cooper NAM, Kremer C. Green-top Guideline No. 59 Best Practice in Outpatient Hysteroscopy. London: 2011.

        • American Society of Anesthesiologists
        Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia.
        Quality Management and Departmental Administration, Committee of Origin2019
        • Apfelbaum J.L.
        • Gross J.B.
        • Connis R.T.
        • Agarkar M.
        • Arnold D.E.
        • Coté C.J.
        • et al.
        A Report by the American Society of Anesthesiologists Task Force on Moderate Procedural Sedation and Analgesia, the American Association of Oral and Maxillofacial Surgeons.
        American. Anesthesiology. 2018; 2018: 437-479
        • de Silva P.M.
        • Carnegy A.
        • Smith P.
        • Clark T.J.
        Conscious sedation for pain control during outpatient hysteroscopy.
        International Prospective Register of Systematic Reviews, PROSPERO2019 (
      2. Cochrane. Cochrane Handbook for Systematic Reviews of Interventions version 6.1 (updated September 2020) 2020. (accessed November 1, 2020).

        • Sterne J.A.C.
        • Savović J.
        • Page M.J.
        • Elbers R.G.
        • Blencowe N.S.
        • Boutron I.
        • et al.
        RoB 2: a revised tool for assessing risk of bias in randomised trials.
        Br Med J. 2019; 366: 1-8
      3. Review Manager (RevMan) [Computer program]. 2014; 5.3
        • Guida M.
        • Pellicano M.
        • Zullo F.
        • Acunzo G.
        • Lavitola G.
        • Palomba S.
        • et al.
        Outpatient operative hysteroscopy with bipolar electrode: A prospective multicentre randomized study between local anaesthesia and conscious sedation.
        Hum Reprod. 2003; 18: 840-843
        • Sharma J.B.
        • Aruna J.
        • Kumar P.
        • Roy K.
        • Malhotra N.
        • Kumar S.
        Comparison of efficacy of oral drotaverine plus mefenamic acid with paracervical block and with intravenous sedation for pain relief during hysteroscopy and endometrial biopsy.
        Indian J Med Sci. 2009; 63: 244-252
        • Thiel J.A.
        • Lukwinski A.
        • Kamencic H.
        • Lim H.
        Oral Analgesia vs Intravenous Conscious Sedation during Essure Micro-Insert Sterilization Procedure: Randomized, Double-Blind, Controlled Trial.
        Journal of Minimally Invasive Gynecology. 2011; 18: 108-111
        • Schneider E.N.
        • Riley R.
        • Espey E.
        • Mishra S.I.
        • Singh R.H.
        Nitrous oxide for pain management during in-office hysteroscopic sterilization: a randomized controlled trial.
        Contraception. 2017; 95: 239-244
        • Asgari Z.
        • Razavi M.
        • Hosseini R.
        • Nataj M.
        • Rezaeinejad M.
        • Sepidarkish M.
        Evaluation of Paracervical Block and IV Sedation for Pain Management during Hysteroscopic Polypectomy: A Randomized Clinical Trial.
        Pain Res Manage. 2017; 2017: 1-7
        • Bingol Tanriverdi T.
        • Koceroglu I.
        • Devrim S.
        • Gura Celik M.
        Comparison of sedation with dexmedetomidine vs propofol during hysteroscopic surgery: Single-centre randomized controlled trial.
        J Clin Pharm Ther. 2019; 44: 312-317
        • Goswami D.
        • Nisa N.
        • Sharma A.
        • Dadhwal V.
        • Baidya D.K.
        • Arora M.
        Low-dose ketamine for outpatient hysteroscopy: A prospective, randomised, double-blind study.
        Turkish Journal of Anaesthesiology and Reanimation. 2020; : 134-141
        • de Silva P.M.
        • Carnegy A.
        • Smith P.P.
        • Clark T.J.
        Vaginoscopy for office hysteroscopy: A systematic review & meta-analysis.
        European Journal of Obstetrics and Gynecology and Reproductive Biology. 2020; 252: 278-285
      4. National Guideline Alliance (UK). Anaesthesia or sedation for surgical abortion: Abortion care: Evidence review N. NICE Guideline [NG140] 2019.

        • Bayer L.L.
        • Edelman A.B.
        • Fu R.
        • Lambert W.E.
        • Nichols M.D.
        • Bednarek P.H.
        • et al.
        An Evaluation of Oral Midazolam for Anxiety and Pain in First-Trimester Surgical Abortion: A Randomized Controlled Trial.
        Obstet Gynecol. 2015; 126: 37-46
        • Allen R.H.
        • Fitzmaurice G.
        • Lifford K.L.
        • Lasic M.
        • Goldberg A.B.
        Oral compared with intravenous sedation for first-trimester surgical abortion: a randomized controlled trial.
        Obstet Gynecol. 2009; 113: 276-283
        • Academy of Medical Royal Colleges
        Safe Sedation Practice for Healthcare Procedures: Standards and Guidance.
        Academy of Medical Royal Colleges, London2013