Women’s groups are pressing the NHS to improve pain relief and informed consent for hysteroscopies after patients described severe pain during procedures often carried out without sedation. About 71,000 hysteroscopies took place in England in 2021, according to the source material.
Hysteroscopy Action has campaigned since 2010 for patients to be told about the risk of severe pain and offered choices including local anaesthetic, gas and air, conscious sedation, epidural or general anaesthetic. The renewed Women’s Health Strategy, published in April, called for informed consent and a choice of pain relief, but the campaign says there has been no further action.
Why hysteroscopies are performed
A hysteroscopy uses a thin instrument passed through the vagina and cervix to view the inside of the womb. It is most commonly used to investigate heavy or unexplained bleeding, and can also assess unexplained infertility or recurrent miscarriage and remove fibroids, polyps or scar tissue.
National Institute for Health and Care Excellence guidelines made hysteroscopy the primary diagnostic tool for heavy or unexplained bleeding in 2018 because it provides an inside view that can help rule out conditions such as endometrial cancer. NHS targets currently call for 90% of diagnostic and 50% of operative hysteroscopies to take place as outpatient procedures.
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Pain levels and patient experiences
A 2020 multicentre study found a mean pain score of 5.2 for outpatient hysteroscopies, while 35% of women recorded severe pain of seven or higher. Outpatient procedures have a failure rate of about 10%, with pain identified as the main reason, according to Reading University pain researcher Richard Harrison and colleagues.
Beth Harris, who underwent a procedure to remove a fibroid in February, said local anaesthetic was administered without a pause to check whether it had worked. She described the procedure as unbearable and said the experience left her crying and fearful of future medical appointments. Helen Garnett, who had previously experienced severe pain, said she requested pain relief before a later procedure but was not offered it.
What changes are being tested
Pain-relief options differ across the country. Consultant gynaecologist Gail Busby now offers deep sedation at her NHS practice at St Mary’s Hospital in Manchester and at a private clinic. At Chelsea and Westminster Hospital, consultant obstetrician and gynaecologist Richard Flint introduced conscious sedation one day a week in 2023 and is expanding the service to five days a week.
Chelsea and Westminster is also trialling the Wid-easy vaginal swab for women with abnormal bleeding. The test is intended to check for womb cancer and, according to Flint, has reduced the number of hysteroscopies needed at the clinic. The Royal College of Obstetricians and Gynaecologists says patients should be fully informed and made aware of alternative settings and pain-relief options, while its leaders are reviewing why that best practice is not always delivered.
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