Need For Cervical Dilatation Research Articles

Assessing the Efficacy and Safety of Misoprostol Prior to Hysteroscopy in Women with Difficult Cervix: A Systematic Review and Meta-Analysis.

Background/Objectives: Hysteroscopy has been used as both a diagnostic and therapeutic tool for intrauterine pathologies under direct visualization. However, this procedure may be associated with an increased risk of complications during entry, which can be reduced by cervical ripening before the operation. The efficacy of misoprostol in this context is influenced by factors such as estrogen levels, parity, and the mode of previous deliveries. This study aimed to assess the efficacy and safety of misoprostol in women with a challenging cervix while mitigating the influence of confounding variables. Methods: Three electronic databases, namely PubMed, Scopus, and ISI Web of Science, were searched until 14 May 2024. Randomized controlled trials focusing on postmenopausal patients, nulliparous women, and multiparous women with no prior history of vaginal delivery, undergoing hysteroscopy were included. The cervical width, time needed for cervical dilation, and the need for additional dilatation alongside the complications and adverse effects from all included studies were collected and analyzed using R (version 4.2.3). Results: Seven studies on premenopausal women and three on postmenopausal women were included. In premenopausal women, misoprostol significantly increased cervical width compared to placebo (SMD = 2.2, 95% CI 0.9 to 3.4) and reduced the need for additional cervical dilatation (OR = 0.36, 95% CI 0.17 to 0.74). No significant difference was found in the time required for cervical dilation between misoprostol and placebo groups. In postmenopausal women, misoprostol did not significantly affect cervical width compared to placebo (SMD = -0.55, 95% CI -1.3 to 0.21). Conclusions: Misoprostol is beneficial for cervical dilation in premenopausal women without a prior history of vaginal delivery but less effective in postmenopausal patients. While associated with postoperative risks, it reduces hysteroscopy-related complications. Future research should address discrepancies by controlling the confounding variables like menopausal status, parity, and mode of delivery to enhance the understanding of misoprostol's effects and pinpoint the specific patient populations that would derive the greatest benefits from its use.

Evaluation of the Efficacy and Side Effects of Catheter-Specific Intrauterine Insemination in Infertile Couples, a Randomized Clinical Trial

Introduction: Intrauterine insemination (IUI) is one of the assisted reproductive techniques, which increases the likelihood of egg being exposed to sperm in the uterus and thus the chances of pregnancy. The purpose of the present study was to compare the efficiency of the Masstec catheter (the internal product) with imported catheter (PMIU) so that, if similar, use domestic production as an alternative to imported. Methods: This study was a randomized controlled clinical trial continuous sampling method performed in Shahid Beheshti Hospital in Isfahan between 2016-2017. In this study, out of 62 infertile couples, 30 used catheters (Masstec), produced by Salamat Yar Hakim Engineering Company - Iran, and 32 imported catheters (PMIU), produced by Ellios BioTek – France. Primary outcomes included difficulty in catheter placement, the need to use a tenaculum, and the need for cervical dilatation during IUI. Secondary outcomes included chemical pregnancy, clinical pregnancy, and abortion. The data were analyzed using Chi-square, t-test and logistic regression. Results: Fisher exact test results showed no significant difference in primary outcome between the two groups (P>0.05). Secondary outcomes, including chemical, clinical and abortion rates were not significantly different between the two groups (P>0.05). Efficacy and side effects of Masstec IUI catheter were not different from PMIU catheter. Conclusion: Our study showed that the efficacy and side effects of the Masstec IUI catheter were not different from PMIU catheter. Given the similar efficacy and side effects and lower cost of the IUI catheter produced by the local company than the imported catheter, the use of local catheter is recommended for IUI candidate patients.

Vaginoscopy for office hysteroscopy: A systematic review & meta-analysis

ObjectiveTo investigate the effect of the vaginoscopic approach to office hysteroscopy on patients’ experience of pain, when compared with the traditional approach where a vaginal speculum is used. MethodsMedline, Embase, CINAHL and the Cochrane library were searched from inception until December 2019, in order to perform a systematic review and meta-analysis of all randomised controlled trials investigating vaginoscopy compared to traditional hysteroscopy on pain experienced by women undergoing diagnostic or operative hysteroscopy in an office setting. Data regarding procedural time, feasibility, incidence of vasovagal reactions and complications, acceptability and satisfaction were also recorded. ResultsThe literature search returned 363 results of which seven were selected for systematic review, and six for meta-analysis. The vaginoscopic approach was associated with a statistically significant reduction in pain (4 studies including 2214 patients; SMD -0.27, 95 % CI -0.48 to -0.06), procedural time (6 studies including 2443 patients; SMD -0.25, 95 % CI -0.43 to -0.08) and the incidence of vasovagal episodes (3 studies including 2127 patients; OR 0.35; 95 % CI 0.15 to 0.82). Failure rates between the two techniques were similar (p = .90). No study reported significant differences in complications or patient or clinician acceptability or satisfaction. ConclusionClinicians performing office hysteroscopy should use the vaginoscopic technique because it makes office hysteroscopy quicker, less painful and reduces the likelihood of inducing a vasovagal reaction. The traditional approach should only be used when vaginoscopy fails or when the need for cervical dilatation is anticipated.

2495 A Retrospective Review of Outpatient Endometrial Ablation Using Minitouch for Treatment of Heavy Menstrual Bleeding

Study Objective To determine the outcomes of using Minitouch endometrial ablation as outpatient treatment for heavy menstrual bleeding (HMB) at an established ambulatory gynecology center in a UK teaching hospital. Design Retrospective cohort study. Setting Procedures were performed as outpatient at Central Treatment Suite at Royal Stoke University Hospital, as per department-approved protocol by one of six gynecology consultants. Patients were reviewed from 4 months post-op at consultation or by telephone. Patients or Participants Between March 2017 and March 2019, 35 patients with HMB who opted for outpatient endometrial ablation received the treatment. Interventions Minitouch without/with intracervical local anesthesia. Diagnostic outpatient hysteroscopy +/- endometrial sampling was performed immediately before treatment procedure confirming suitability. Where present, intrauterine device was removed before ablation. Patients were not selected for timing of their menstrual cycle and received no endometrial pre-treatment. Measurements and Main Results In 24 months, 35 patients received treatment. Average patient age was 46 (range 31-55). One patient was nulliparous, 9(26%) had previous caesarean section, 30(86%) received previous treatment for HMB. Utero-cervical length ranged from 6-10cm. Histology confirmed normal endometrium in all cases. Procedure was well tolerated overall with no failure of equipment. Average treatment time was 145s (Range 33-229s). Vasovagal episode was the only observed peri-operative complication (2/35, 5.7%) requiring conservative management. No uterine perforation occurred. No patient required emergency hospital admission post-op. To date, 22 patients were reviewed. Average time to follow-up was 4.9 months. 91% reported satisfactorily improved bleeding patterns including amenorrhea or oligomenorrhoea (14/22, 64%) and less HMB (6/22, 27%). 9% reported same or worsened bleeding requiring further management. Conclusion With its flexibility and smaller size over other devices minimizing the need for cervical dilatation and patient discomfort, the use of Minitouch for outpatient treatment of HMB at our center was shown to be well-tolerated, with high reliability of procedure completion, good safety and efficacy outcomes.

The use of misoprostol for cervical priming prior to hysteroscopy: a systematic review and analysis.

The effects of misoprostol use on cervical priming prior to hysteroscopy have been controversial. Therefore, a systematic literature review and meta-analysis of studies were conducted to assess the effect of misoprostol on cervical priming prior to hysteroscopy. All studies published before July 2014 with data related to the use of misoprostol for cervical priming compared with placebo or no medication prior to hysteroscopy, were identified. Twenty-five randomized controlled trials involving 2,203 females were systematically analyzed. The results showed that, compared with placebo or no medication, the use of misoprostol prior to hysteroscopy led to a significant relief of the need for cervical dilatation, resulted in a significantly greater cervical width, had fewer hysteroscopy complications, and mild and insignificant side effects. Subgroup analyses revealed that the regimen of 200 or 400 μg vaginal misoprostol may be a simple and effective method for cervical priming, especially prior to operative hysteroscopy.

Comparison of Effectiveness of Laminaria versus Vaginal Misoprostol for Cervical Preparation Before Operative Hysteroscopy in Women of Reproductive Age: A Prospective Randomized Trial

Study ObjectiveTo compare the effectiveness and safety of intracervical laminaria dilator versus intravaginal misoprostol administered before surgery to facilitate cervical dilation before operative hysteroscopy. DesignA prospective randomized study (Canadian Task Force classification 1). SettingA university hospital. PatientsA total of 150 women were assigned at random to the following groups: laminaria dilation (n = 50), misoprostol dilation (n = 50), and mechanical dilation (n = 50). InterventionsHysteroscopic surgery of intrauterine lesions. Measurements and Main ResultsIn this study, 150 women were assigned at random to receive cervical priming with an intracervical laminaria dilator, 200 μg of intravaginal misoprostol, or a mechanical dilator before operative hysteroscopy. Cervical response, surgical outcome, and complications of operative hysteroscopy were assessed. Visual analog scale (VAS) pain scores were recorded in the misoprostol and laminaria dilation groups. Demographic variables of the study groups were comparable (p = .278–.988). The duration of cervical pretreatment was similar with the intracervical laminaria dilator and intravaginal misoprostol (p = .803); however, intravaginal misoprostol was associated with more adverse effects (p = .031). Compared with the misoprostol dilation group, in which all patients required additional cervical dilation, notably fewer patients in the laminaria dilation group required additional cervical dilation after cervical preparation (p = .001). VAS pain scores were significantly higher in the laminaria dilation group, however (p = .001). ConclusionCervical priming with an intracervical laminaria dilator before operative hysteroscopy reduces the need for cervical dilation and better facilitates hysteroscopic surgery compared with intravaginal misoprostol. Oral analgesic use may be required before the use of this device.

Self-Administered Misoprostol or Placebo Before Intrauterine Device Insertion in Nulliparous Women

To estimate the effects of self-administered misoprostol compared with placebo before intrauterine device (IUD) insertion in nulliparous women. Nulliparous women requesting either the copper T380A or levonorgestrel IUD were randomized to self-administer either 400 μg of misoprostol or placebo (vaginally or buccally) 3-4 hours before the IUD insertion appointment. The primary outcome was health care provider-perceived ease of insertion recorded on a visual analog scale (anchors: 0 extremely easy, 100 impossible). Patients completed questionnaires addressing pain using a validated visual analog scale (anchors: 0 none, 100 worst imaginable) before insertion, immediately postinsertion, and before clinic discharge. Of the 108 women enrolled in the study, 54 received misoprostol and 54 received placebo. There was no significant difference in perceived ease of insertion between the two groups (25.0 mm [standard error 3.5] compared with 27.4 mm [standard error 3.5], P=.64). Patients who received misoprostol before IUD insertion had significantly higher pain scores before placement (17.1 mm [standard error 3.5] compared with 4.7 mm [standard error 2.0], P=.003). Groups did not differ in perception of pain during IUD insertion (58.4 mm [standard error 3.3] compared with 56.9 mm [standard error 3.0], P=.74). There were two expulsions in the misoprostol group and none in the placebo group. Failed insertions, need for adjuvant pain medication, and need for cervical dilation or ultrasonographic guidance did not differ between the two groups. Self-administered misoprostol before IUD insertion does not ease IUD insertion or reduce patient-perceived pain in nulliparous women. These data do not support the routine use of misoprostol before IUD insertion in nulliparous women. ClinicalTrials.gov, www.clinicaltrials.gov, NCT00886834. I.

A randomized controlled trial for cervical priming using vaginal misoprostol prior to hysteroscopy in women who have only undergone cesarean section

To evaluate the efficacy of misoprostol administrated vaginally on cervical priming and its complications prior to diagnostic or operative hysteroscopy in women who have undergone at least one cesarean section and who have never delivered vaginally before and/or had other transcervical procedure. A total of 55 patients undergoing hysteroscopy for various intra-uterine lesions were included in this study and were randomly allocated to two groups finally. Thirty patients in the study group were given 200 μg misoprostol vaginally 12 h before the procedure, whereas 25 patients in the control group did not receive any cervical priming. The countered outcome included the cervical width detected with Hegar dilatators and complication rates. Mean cervical width was greater in the study group (6.6 ± 1.3) than in the control group (5.1 ± 0.9). Complications and failure rates were lower in the study group. Application of 200 μg misoprostol vaginally 12 h before hysteroscopy softens the cervix, reduces cervical resistance and consequently the need for cervical dilatation, with only mild side effects.

Sublingual Misoprostol for Cervical Priming in Surgical First Trimester Pregnancy Termination

To determine the efficacy of 400mcg sublingual misoprost as an adjunct to suction evacuation in first trimester pregnancy termination. During the study period of January2006-June 2007, two hundred twenty-one pregnant women wanting first trimester pregnancy termination were randomised into two groups. In the study group of one hundred twenty-one women, sublingual misoprostol was used 3h prior to suction evacuation. In the control group of hundred women, direct suction evacuation was used. In cervical dilatation achieved by misoprostol, time required for suction evacuation, blood loss, pain perceived by patient and complications that occurred in the two groups were compared by STATA 9 stastistical software. In the study group, mean cervical dilatation was up to 5.61 with Hegar dilator and in control group, it was 5.03. (P=0.004). Average time required for suction evacuation was 7.28min in study group and 8.73min in control group (P<0.0001). Blood loss was less in study group as compared to those in the controls. In study group, only 10.74% women perceived pain compared to twenty percent women in control group. Use of sublingual misoprost prior to first trimester pregnancy termination by suction evacuation ripens the cervix so there is less need for cervical dilatation, pain perceived by patient is less, the time required for suction evacuation is less and there is reduction in blood loss. Sublingual misoprostol is effective and safe for cervical ripening and dilatation before suction evacuation.

Does cervical preparation before outpatient hysteroscopy reduce women’s pain experience? A systematic review

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. To compare the effect on pain and need for cervical dilatation of various methods of cervical preparation before outpatient hysteroscopy. 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. 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. 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. 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. 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.

Cervical priming with misoprostol before manual vacuum aspiration versus electric vacuum aspiration for first-trimester surgical abortion

Objective To compare the efficacy of manual vacuum aspiration (MVA) with electric vacuum aspiration (EVA) and to evaluate whether cervical priming with misoprostol facilitates cervical dilation and reduces complications associated with first-trimester medical abortion performed up to 10 weeks of pregnancy. Methods A total of 600 women who requested termination of pregnancy were randomized into 4 groups (150 women in each group). Group I and II received a vaginal placebo 3 hours before MVA or EVA, respectively. Group III and IV received 400 μg of vaginal misoprostol 3 hours before MVA or EVA, respectively. Results Complete abortion rates after MVA and EVA were both 97.9%; after cervical priming with misoprostol complete abortion rates were 98.6% versus 97.3% after cervical priming with placebo ( P > 0.05). Administration of misoprostol into the vagina before MVA resulted in 99.3% complete abortions ( P = 0.40), and the least operative blood loss, operating time, and need for cervical dilation ( P < 0.05). Overall complications and adverse effects were similar in all groups ( P > 0.05). Conclusion For surgical evacuation, EVA and MVA did not differ in efficacy. Cervical priming 3 hours before MVA for termination of pregnancy significantly reduced the need for cervical dilation and the operative time, and improved the efficacy of the procedure. Pretreatment with vaginal misoprostol before MVA is a safe and effective method for terminating pregnancies of up to 10 weeks of gestation. Clinical Trials Registry: CTRI/2009/091/000008

Laminaria Tent vs Misoprostol for Cervical Priming before Hysteroscopy: Randomized Study

Study Objective To compare the efficacy of laminaria tents and orally administered misoprostol in priming the cervix before operative hysteroscopy. Design Randomized, controlled study (Canadian Task Force classification I). Setting Tertiary medical center. Patients One hundred twenty premenopausal women who underwent operative hysteroscopy between March 2005 and January 2007. Intervention The women were randomized to receive a laminaria tent or misoprostol for cervical priming. Measurements and Main Results The primary outcomes were postpriming cervical width insofar as size of Hegar dilators and need for cervical dilation. The secondary outcomes were adverse effects from the priming methods. Postpriming cervical width was greater in the laminaria group but not significantly different from that in the misoprostol group. However, cervical dilation before hysteroscopy was required in more patients in the misoprostol group. Nausea, vomiting, diarrhea, and bleeding were more common in the misoprostol group, and the incidences of chills and headache were similar between the 2 groups. Conclusion Laminaria tents are superior to oral misoprostol insofar as less need for cervical dilation and fewer adverse effects.

Sublingual misoprostol for cervical ripening before diagnostic hysteroscopy in premenopausal women: A randomized, double blind, placebo-controlled trial

To evaluate the effectiveness of sublingual misoprostol for cervical ripening before diagnostic hysteroscopy in premenopausal women. Placebo-controlled, double-blind, randomized trial. University hospital. Fifty-two women with an indication for diagnostic hysteroscopy. Randomized women who had received either 200 mug of misoprostol (n = 25) or placebo (n = 27) sublingually 2 hours before hysteroscopy. Two subgroups (women with or without previous vaginal delivery) were formed. Number of women requiring cervical dilatation, duration of dilatation, ease of dilatation, and complications during procedure. In the misoprostol group, 14 patients needed cervical dilatation, versus 21 in the placebo group. Duration of dilatation was longer in the placebo group than in the misoprostol group. In subgroup 1, seven patients in the misoprostol group (n = 13) and nine patients in the placebo group (n = 12) needed cervical dilatation. The duration of the dilatation was similar between the groups. In subgroup 2, both the need for cervical dilatation (58.3% vs. 80.0%) and the duration of dilatation (31.0 +/- 18.8 vs. 73.0 +/- 82.0 seconds) were found to be lower in the misoprostol (n = 15) than in the placebo (n = 12) group, respectively. Those differences were all not significant. Sublingual misoprostol before diagnostic hysteroscopy did not seem to facilitate cervical ripening statistically; however, the results are remarkable and are promising clinically. Further studies are required to reassess the use of sublingual misoprostol in patients before hysteroscopy.

Which route of misoprostol application is more advantageous prior to fractional curettage in postmenopausal patients?

To determine the effectiveness and potential side effects of oral, vaginal, and sublingual intake of misoprostol on cervical dilatation prior to fractional curettage in patients with postmenopausal bleeding. Seventy-six patients with postmenopausal bleeding during a period of 18 months were included in this randomized controlled trial. Patients were given 400 microg of misoprostol through the vaginal, oral, and sublingual routes, 12 h prior to the fractional curettage procedure. The degree of cervical dilatation, duration of the procedure, the side effects and complications were noted. When compared with the control group, misoprostol administered orally or sublingually was found to have a significant effect on cervical dilatation (P < 0.05). Of the three groups, nausea was found to be more common in the orally administered misoprostol group. We conclude that the oral or sublingual application of misoprostol prior to fractional curettage in patients with postmenopausal bleeding decreases the need for cervical dilatation.

Vaginal misoprostol for cervical priming prior to diagnostic hysteroscopy––efficacy, safety and patient satisfaction: a randomized controlled trial

To evaluate the effectiveness and safety of vaginal misoprostol for cervical priming prior to diagnostic hysteroscopy and to assess impact on pain scores and patient satisfaction. One hundred women undergoing hysteroscopy were randomly allocated into two groups. The study group (n = 50) received 400 microg of misoprostol vaginally (self administered) 4-6 h prior to hysteroscopy while the control group (n = 50) did not receive any cervical priming. Primary outcome measured was need for cervical dilatation, analgesia or sedation. Secondary outcomes were pain scores, patient satisfaction and side effects. There was no significant difference in the need for cervical dilatation, analgesia or sedation in the two groups (P = 0.25, 0.64 and 0.5, respectively). In addition, there was no difference in subjective patient satisfaction (P = 0.70). However, those in the control group recorded a higher pain score (median +/- SD = 5 +/- 1.8) when compared to those who received misoprostol (median +/- SD = 4.5 +/- 2, P = 0.03). Only two women (4%) had bleeding per vaginum and one (2%) had a slight fever attributable to misoprostol. Vaginal misoprostol prior to diagnostic hysteroscopy did not facilitate cervical dilatation. It did effect a reduction in pain scores, but there was no difference in patient satisfaction, need for analgesia or sedation. No significant side effects were reported.

Hysteroscopy: a technique for all? Analysis of 5,000 outpatient hysteroscopies

1) To investigate the relationship between operator experience and the success of outpatient hysteroscopy; and 2) to determine if the introduction of normal saline and the use of narrow-caliber hysteroscopes and vaginoscopic approach are associated with a lower failure rate. Retrospective study. Teaching-hospital based outpatient hysteroscopy clinic. Five thousand consecutive women undergoing outpatient hysteroscopy between October 1988 and June 2003. The hysteroscopies were carried out both by experienced operators and by trainees. Procedures were performed using 4-mm and 2.9-mm telescopes with 5-mm and 3.5-mm diagnostic sheaths, respectively. Between October 1988 and 1996, the uterine cavity was distended with CO(2) (CO(2) period), whereas normal saline was preferred after 1997 (1997-2003: saline period). Traditional technique of hysteroscope insertion and vaginoscopic approach were used depending on operator preference and experience and patient characteristics. Success, failure, and complication rates. The hysteroscopies were successfully performed in nearly 95% of cases by 362 operators (mean 13.8 hysteroscopies per operator) with different levels of expertise. Failure and complication rates were 5.2% and 5.4%, respectively, without any significant difference between CO(2) and saline periods. Vasovagal attacks and shoulder pain were significantly higher during the CO(2) period. The success of outpatient hysteroscopy was negatively affected by postmenopausal status, nulliparity, need for cervical dilatation or local anaesthesia, traditional technique of hysteroscope insertion, and use of a 5-mm hysteroscope. A high level of expertise is not a prerequisite to performing hysteroscopy on an outpatient basis. Recent advances in technique and instrumentation facilitate this approach and might encourage greater adoption by the wider gynecology community.

Misoprostol administered before manual vacuum aspiration reduced the operative time and need for cervical dilatation

Commentary on article 'Comparison of oral and vaginal misoprostol for cervical ripening before manual vacuum aspiration of first trimester pregnancy under local anesthesia: a randomized placebo-controlled study', Contraception 2005;71:337-342

Development of a thinner and more flexible type of minihysteroscope with a controlled 90-degree bendable tip for vision-guided endometrium biopsy

Study objective Evaluation of the uterine cavity is limited with rigid 5-mm hysteroscopes because of the need for cervical dilatation, reduced movements inside the uterus, and no option for vision-guided biopsy. In cooperation with PolyDiagnost GmbH, Pfaffenhofen, Germany, a new type of flexible minihysteroscope with bendable tip was developed and evaluated. Design Prospective and parallel observational interindividual evaluation of flexible minihysteroscope and standard hysteroscope for diagnostic hysteroscopy (Canadian Task Force classification II-3). Setting Obstetrics and gynecology department of a university clinic. Patients Nine women, average age 65.0 years (range 46–89 years), with indications for diagnostic hysteroscopy. Interventions After defining requirements, a novel, thinner, and more flexible minihysteroscope, 18-cm long with a 2.67-mm outer diameter, was developed with straight zero-degree scope, 70-degree vision field, and 6000-pixel resolution. Two working channels, 1.2 mm and 0.55 mm, allow suction-irrigation and introduction of a 1.0-mm biopsy forceps or cytology brush. The tip of the instrument is 90-degree stageless bendable to both sides. Diagnostic hysteroscopy was performed with flexible minihysteroscope followed by standard rigid hysteroscopy to verify results. Measurements and main results From July 2003 through March 2004, both procedures were performed in nine patients with identical visual and histologic results. No complications occurred. No cervix-dilating instruments were necessary for introduction of the flexible minihysteroscope. Visualization of the entire uterine cavity is improved with the flexible scope because a bendable tip allows better peripheral vision (e.g., of the openings of the tubes). However, movement of the tip should be performed carefully due to potential risk of uterine perforation. Conclusion This new flexible minihysteroscope is less invasive compared with standard rigid hysteroscopy, which supports performance of ambulatory hysteroscopy and makes increased movements and vision-guided biopsy inside the uterine cavity possible.

Vaginal misoprostol for cervical priming before hysteroscopy in perimenopausal and postmenopausal women

Objective: To evaluate the effectiveness and possible adverse effects of vaginal misoprostol for cervical priming before hysteroscopy in perimenopausal and postmenopausal women. Methods: A total of 105 women scheduled for hysteroscopy were randomly assigned to 2 groups. The study group ( n = 51) received 400 μg of vaginal misoprostol at least 12 h before the procedure and the control group ( n = 54) received no cervical priming agent. The primary outcome measure was the number of women who required cervical dilation. Secondary outcomes were cervical width (the largest size of Hegar dilator inserted without resistance) as well as complications and adverse effects. Results: In the misoprostol group 27 women (52.9%) required cervical dilation vs. 53 (98.1%) in the control group ( P < 0.0001). The largest size of Hegar dilator inserted without resistance was 7.6 ± 1.4 mm in the misoprostol group vs. 5.0 ± 1.1 mm in the control group ( P < 0.0001). A similar effect of misoprostol on cervical dilation was also found in the subgroup of treated postmenopausal women. Only 2 women (3.9%) experienced mild lower abdominal pain after misoprostol application. Conclusion: Vaginal misoprostol applied before hysteroscopy reduced cervical resistance and the need for cervical dilation in perimenopausal and postmenopausal women, with only mild adverse effects.

Comparison of oral and vaginal misoprostol for cervical ripening before manual vacuum aspiration of first trimester pregnancy under local anesthesia: a randomized placebo-controlled study

The objective of this prospective randomized placebo-controlled study was to determine the effectiveness of 400 μg oral and 400 μg vaginal misoprostol administration for cervical priming 3 h prior to manual vacuum aspiration (MVA) under local anesthesia for voluntary termination of pregnancy before 10 weeks of gestation in comparison with placebo oral or placebo vaginal administration ( n=40 in each group). Postmedication cervical dilatation was similar in the oral (mean, 6.6±1.5) and vaginal (mean, 7.2±0.8) misoprostol groups but significantly higher compared with the oral (mean, 3.4±0.2) and vaginal (mean, 3.6±1.9) placebo groups. Duration of the procedure was also significantly shorter in the misoprostol groups in comparison with their placebo counterparts. Preoperative bleeding and side effects were more common in the misoprostol groups, but none required medical intervention. Intraoperative bleeding was less in the vaginal misoprostol group compared with the placebo groups. There was no significant difference in terms of visual analogue scores during the procedure, patient satisfaction, days of postoperative bleeding and rate of postoperative complications among the groups. Cervical priming with misoprostol administered orally or vaginally 3 h before MVA for termination of pregnancy under local anesthesia facilitates the procedure by decreasing the need for cervical dilatation and by shortening its duration without improving patients' pain perception and satisfaction mainly due to side effects.