Why is conscious sedation not routinely offered for a hysteroscopy?

[MaMelon]

I've been referred for one of these beauties and have been doing my research, as you do. There's absolutely no way I'm "tolerating" such a procedure (to quote the Dr I spoke to) so have dug my heels in and they've taken me off the outpatients list and have put me onto the GA list - I have to see another Dr first to discuss this, but it will happen. I am not going through it without anaesthetic - for several reasons.

I asked the gynae secretary why conscious sedation isn't offered as standard as it is in other clinics such as colonoscopy or endoscopy, but she didn't know.

Anyone know why? It seems bonkers that it's either outpatient (possibly with local - although from what I've read this isn't effective)or a GA, with nothing in between.

I asked the gynae secretary why conscious sedation isn't offered as standard as it is in other clinics such as colonoscopy or endoscopy, but she didn't know.

Well no, why would she? She's a secretary.

And it's not always offered.

For a gastroscopy, it's impossible to do it if the patient gags.

A colonoscopy- not all people find it painful.

DP had a gastroscopy with no sedation just a numbing throat spray. It wasn't pleasant but not unbearable.

He had a 2nd one some time later and this time decided to choose sedation. At the same time they did another colonoscopy but he was assured that the discomfort from that would be minimal, but as both were done within minutes, he was already sedated from the gastroscopy.

Going back to your first question, OP, the reason there is no choice is probably down to theatre usage and staffing.

Sedation needs to be monitored with the same level of care as a GA because it's possible to over-sedate someone and cause more serious issues. It's not a trivial procedure and they need to get it spot-on.

@LucindaT73 im mot lying my consent form lists bowel perforation on the consent form. Im not making this up. Also the gynae dept have stated in a letter that bowel perforation is an accepted known complication that all patients are warned of so we can't complain when it happens.

I certainly had a crack handed surgeon but it's been made clear that her performance was within accepted standards and bowel perforation is just "one of those things that happen". This all happened even though you don't want to accept that.

I will keep banging on about it as long as people here keep insisting it didn't happen.

Well no, why would she? She's a secretary

I said “out of curiosity, do you happen to know…” as it might have been something they’re asked regularly and so she might have been able to answer. That was the total extent of the conversation, it wasn’t a big deal - I asked, she said “I’m not sure”, we moved on and talked about moving me to the GA list snd she explained the process for that.

Sedation needs to be monitored with the same level of care as a GA because it's possible to over-sedate someone and cause more serious issues. It's not a trivial procedure and they need to get it spot-on

Oh no, I totally understand that - I just wondered why, when sedation is offered (as a standard alternative to being awake) for other procedures involving scopes, why it’s not for this one. No-one really seems to know why.

You won’t like this but mental attitude makes a huge difference

Nonsense. Utter nonsense.

On the whole it’s not necessary and the risks don’t outweigh the benefits. Lots of endoscopic procedures are carried out without sedation and many are not ‘women’s procedures.

It’s about risks. Sedation is higher risk than no sedation. GA is higher risk than no GA.

The overwhelming majority of women find it a very minor procedure and need Paracetamol, at most.

Some women don’t or unlikely tolerate it, for whatever reason and a GA is possible. As part of the consent process there should be a mention of alternatives with risk and benefits explained. This gives women a GA option.

Sedation does not confer any advantage in an outpatient setting in terms of pain control but carries extra risks. If you are admitting and treating in theatre then a GA is more appropriate.

I had endometrial ablation in august last and as part of the pre-op checks I had various scans and an appointment with a gynaecologist which I went along to expecting a chat about the procedure and maybe an internal/speculum exam, as I have a dodgy battered, scared and generally crap cervix . Unbeknown to me I also had to have an endometrial biopsy which the consultant did without much discussion and with no pain relief. It fucking well hurt, a lot! I thought at the time that they’d never get away with doing that to men.

Tbh the ablation was amazing and I’m so pleased to have had it done but omg I a slurp of Entinox might have been nice for the biopsy bit. We were on the maternity ward after all!

I actually asked the anaesthetist this as I was offered the procedure with GA only and would have preferred either local anaesthetic or sedation. It was a couple of years ago so I may not be remembering correctly but I think they said it was if they needed to do anything else while they were there such as a biopsy or removal of adhesions they need you to be completely still. If my memory isn’t correct I do apologise, I ended up having the GA.

Lots of endoscopic procedures are carried out without sedation and many are not ‘women’s procedures

But lots are - most endoscopies or colonoscopies are carried out with sedation.

The overwhelming majority of women find it a very minor procedure and need Paracetamol, at most

Yes, around 75% - but anything up to 25% of women find it extremely painful. 1 in 4 women. That’s a significant number.

As part of the consent process there should be a mention of alternatives with risk and benefits explained

I agree - and yet I haven’t been through any consent process. I have had a letter confirming my appointment date for an out patient hysteroscopy with no discussion whatsoever about the alternatives. I wonder how many other women have the same experience which completely contradicts the British Society for Gynae Endoscopy’s statement.

I think they said it was if they needed to do anything else while they were there such as a biopsy or removal of adhesions they need you to be completely still

Surely that’s the case for any biopsy or removal of lesions - but they offer sedation for other procedures without this being an issue

@OnGoldenPond I'm sorry if I missed one of your posts, but as far as I could read, you didn't say you had suffered bowel perforation. You drew attention to the theoretical risk. Obviously, I hope you recovered with no lasting effects.

It is a risk of hysterectomy, but I didn't see it listed as a risk on the information I had for a hysteroscopy.

But lots are - most endoscopies or colonoscopies are carried out with sedation.

Not sure where you are getting your info from, but I don't think they are.

I have known several people having colonoscopies and no sedation. Endoscopy is different because of the gag reflex.

I’ve just been through this particular mill and I’m with you, OP.

I’d never heard of hysteroscopy when I was referred for one so like you, I did my research. Some of the stories online are horrific! And the minute I saw that there’s actually an organised ‘Campaign for pain-free hysteroscopy’, that was enough to set my alarm bells ringing.

What you can do is, when they give you the consent form, you can consent only to the investigative part of the procedure to be done at that initial appointment. There’s a separate part of the form to sign to give consent for treatment (eg removal of polyps or fibroids) which is usually done at the same time, on what they call a ‘see and treat’ basis - so without any pain relief. I wasn’t prepared to consent to that in advance and I told them so. They weren’t happy about it and rolled their eyes a lot, and made lots of doom & gloom pronouncements but I stuck to my guns.

You can also request that they do as much as possible of the procedure without using a speculum. They don’t actually need one to get the camera up there, and again although they’ll moan, they can even take a biopsy of the womb lining this way. I had a slight advantage in this case because it was already in my notes that I find speculum examination painful (due to menopause), but basically you can tell them to stop the hysteroscopy at any point if you’re finding it too painful, and request to have it completed under GA. I’ve just had this done for a polypectomy this week and although I was petrified, it was preferable to the alternative.

But I agree with you, I can’t understand why it’s one extreme or the other. It’s scarcely a choice, is it? - have a full-on operation (which I’m phobic about) or endure medieval barbarism where they may as well just tell you to bite down on a stick, for all the good taking a couple of paracetamol before the procedure will do!

It might be worth researching all the hospitals in your area, as a small number have revised their practices in the face of campaigning, and do now actually offer gas & air or an epidural for this procedure. I found this out too late, after I’d picked the wrong hospital from the list they offered me (this might only happen if you’re on the fast track though).

As I said I can’t quite remember as it was a couple of years ago but the explanation I was provided with was quite reasonable and I opted for the GA in the end. Can you email the receptionist and ask them to have the doctor email/call you to explain? This is what I did and got the explanation I needed to feel comfortable booking the appointment.

Thanks so much thisisnotmyllama, that’s all really helpful - I wasn’t aware of those choices.

Without going into details it’s not just the potential for significant pain that’s putting me off having the procedure while awake, but as you say - it doesn’t feel like a choice at the moment.

chillychills I spoke to my GP on Friday and she said she was surprised that I had been given the appointment, she felt the gynae dept “had gone from 0 to 100” so she’s writing to them to request an appointment to with a Consultant discuss my options. She’s asked them to keep me on the GA list for now and then at least I’m on it if Gynae really feel it’s 100% necessary for me to have the procedure.

I had a hysteroscopy for a biopsy, it was horrific, I thought it was just an appointment to discuss it so had no pain relief, and had to stop it. I felt so traumatised I insisted on a GA which I had eventually. I have rheumatoid arthritis and have had several operations and I know what pain is. I have not had natural childbirth and have never had a problem with smear tests. Nothing to do with mind set, I wasn't tense and was not thinking it would go that way. Never again, so wrong to put women through this

Lots of endoscopic procedures are carried out without sedation and many are not ‘women’s procedures

But lots are - most endoscopies or colonoscopies are carried out with sedation.

Yes, 35% of colonoscopy is without sedation - men tolerate it better than women. The sedated and unseated pain and discomfort scores were very similar. About 40% of bronchoscopes are without sedation and the majority of gastroscopies are sedation free.

Yes, around 75% - but anything up to 25% of women find it extremely painful. 1 in 4 women. That’s a significant number.

I think the figure is nearer 94% who tolerate it well according to RCOG

I’m not suggesting people shouldn’t have a choice, but the risks need to be made clear and scaremongering about how awful it is doesn’t help. Most women are fine with this quick procedure. A few are very uncomfortable or too stressed to consider it without GA. That’s fine and should already be discussed.
I’d much prefer to have it as a very quick appointment and drive home after a cup of tea.

I think the figure is nearer 94% who tolerate it well according to RCOG

Between 5-25% experience significant pain according to the Hysteroscopy Action Group. That’s a significant number, including the posters on here who are not scaremongering but recounting their own experiences. These should not be dismissed or minimised.

The alternatives to being awake should be discussed - but they aren’t.

@MaMelon I am wondering what you will do if the dr simply refuses to do it with a GA? Talking to his PA is no guarantee you will have one.

You can find ALL the information you want about sedation here. From the RCOG.

www.rcog.org.uk/globalassets/documents/guidelines/gtg59hysteroscopy.pdf

You will find it helpful to read the whole doc, but the part about sedation is this:

Conscious sedation
^Conscious sedation should not be routinely used in outpatient hysteroscopic procedures as it confers no advantage in terms of pain control and the woman’s satisfaction over local anaesthesia.
Life-threatening complications can result from the use of conscious sedation. Appropriate monitoring and staff skills are mandatory if procedures are to be undertaken using conscious sedation^

The vast majority of women find this procedure okay, with figures quoted here between over 7 out of 10, to 9+ out of 10.

For whatever reason, (unknown) you have decided in advance that you will be one of the 10-20% of women who would find it painful.

Going into anything, certain of a negative outcome in advance, is known to guarantee that result.

It would be much more rational to keep an open mind and try without a GA. If you found it unbearable, it could be stopped.

I'd previously had a biopsy in the dr's surgery, without anything. It was all done in 5 mins and was fine.

The hysteroscope is not much bigger than the instrument used to take a biopsy. NOTE in the link about that a miniature scope should be used.

You are coming from a place of 'this is going to be awful' based (I assume) on reports online.. Sorry to say so but you are being a bit irrational. You'd rather take all the very real risks of a GA over the possible (unknown) discomfort of a few minutes.

It would be much more rational to keep an open mind and try without a GA. If you found it unbearable, it could be stopped.

You’re entirely ignoring the fact that OP, along with many other women, have additional reasons why they cannot tolerate this procedure.

For women with previous sexual assault PTSD or medical related PTSD the idea of even making an attempt may be intolerable.

Decisions should be made jointly and should take into account all the risks.

@WiseUpJanetWeiss

It would be much more rational to keep an open mind and try without a GA. If you found it unbearable, it could be stopped.

You’re entirely ignoring the fact that OP, along with many other women, have additional reasons why they cannot tolerate this procedure.

For women with previous sexual assault PTSD or medical related PTSD the idea of even making an attempt may be intolerable.

Decisions should be made jointly and should take into account all the risks.

If this is the case, OP should say so. You are assuming.

Indeed, decisions should be made jointly.

She's not exactly doing that, is she? She's demanding without even discussing it.

She says she has 'been doing her research' and she has decided it would be painful.

It's a pity she didn't actually do some proper research and find the info by the RCOG linked to by me now, or the actual figures about pain. It took me 30 seconds to find it.

It would have saved her the effort of asking on a forum why sedation isn't offered.

She has implied there are other reasons. And this discussion is about women in general, not just the OP’s situation.

I haven't rtft but I had this procedure recently.

My experience was absolutely pain free, much to my happy surprise. I was given the option of having sedation/GA in my consultation a week before the procedure but because I wanted to be in and out as quickly as possible I decided to go without.
That gamble paid off for me because I didn't have any pain, and was able to leave the hospital 15 mins after the end of the procedure.

My opinion is that GA should be offered to any woman who wants it, with all the pros and cons discussed properly.

@WiseUpJanetWeiss

She has implied there are other reasons. And this discussion is about women in general, not just the OP’s situation.

I know she implied. Could be anything.

The point is, look at her subject line (why no sedation?) ...the answer is online and easily found.

The discussion is in the guidance by the RCOG.

In a nutshell, they advise no pain relief (as most women are fine) or cervical block.

They also advise a tiny scope and no use of a speculum if that helps.