Misoprostol for cervical priming prior to office hysteroscopy works in premenopausal nulliparous but not in postmenopausal women.

Abstract

This randomised controlled trial (RCT) by Tasma et al. reports on pain at hysteroscopy. This is an important subject because hysteroscopy is the single most common procedure in gynaecology. There has been limited or conflicting evidence regarding misoprostol for cervical priming prior to hysteroscopy. Although there have been three meta-analyses and 25 RCTs published to date, the heterogeneity among regimens, doses, and route of administration, plus clinical diversity, make analysis of the data difficult. This well-designed, multi-centre RCT employed a novel method of measuring pain in real time throughout the hysteroscopy procedure, and provides much needed evidence for the vaginoscopic approach. Broadly in accordance with the meta-analysis of Polyzos et al. (Hum Reprod Update 2012;18:393–404), which included 21 RCTs involving 1786 patients, the results of Tasma et al. favours misoprostol cervical priming prior to office hysteroscopy for premenopausal nulliparous women, but not for postmenopausal women. Interestingly, though, a more recent systematic review by Hua et al. (Drug Des Devel Ther 2016;10:2789–2801) involving 2203 patients in 25 RCTs showed that misoprostol efficacy is related to the type of hysteroscopy (i.e. it is more beneficial in operative rather than diagnostic procedures) and route of administration (vaginal compared to other routes). There remain some unresolved uncertainties necessitating further studies, however. Firstly, this study was placebo controlled, but the placebo does not represent standard care, as analgesics are routinely offered for outpatient hysteroscopy. Secondly, although the authors provide a strong rationale for their choice of dose and timing, the optimal dose and schedule remains uncertain. So, in spite of the numerous RCTs addressing the subject, further guidance is needed on how to use misoprostol for different patient groups (parity, mode of delivery, and menopause all being relevant). Future RCTs targeting women from carefully selected populations should be performed to identify the ideal conditions for the use of misoprostol prior to hysteroscopy. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.