@MaMelon
Thanks for your response
Greybeardy
I would request a female clinician to do the procedure if I was sedated or had no sedation - although other procedures are routinely carried out by men on sedated women with other clinical staff in attendance without it being an issue.
Although a reasonable number of GI endoscopies are carried out without sedation my understanding is that most are.
You mentioned that sedation can also exacerbate some of the vagal side effects of cervical stimulation and create some hairy cardiac situations - can you explain how that might happen please?
If you look at the RCOG’s paper on best practice for outpatient hysteroscopy it suggests that sedation is no better than local at reducing pain. Local anaesthetic to the cervix though may reduce vagal symptoms, which are what cause the vomiting and feeling faint that some women experience. Part of the vagal response also involves the heart rate (and often BP) dropping. Most of the commonly used sedatives reduce BP, and opioids can reduce the heart rate. Sedation can also interfere with breathing and airway reflexes. The worst case scenario during a hysteroscopy under sedation would be a semi-conscious woman, supine, with reduced airway reflexes, vomiting, with a low heart rate and blood pressure, and who still experiences pain. Now a scenario like that would be pretty extreme and probably pretty uncommon, but it’s entirely avoidable and could result in harm.
With general anaesthesia (or spinal anaesthesia) the vagal response may be blunted somewhat so even though GA/spinal can drop the BP, it’s often more predictable and manageable (anaesthetists have much more experience and a wider range of drugs available to manage these cardiovascular issues than outpatient nurse sedationists).
So, in a nutshell, sedation doesn’t appear to improve satisfaction of the patient as often as you’d imagine, comes with potential significant side effects (and isn’t suitable for everyone to various other reasons), and still may not get the job done. GA/Spinal may seem like using a sledgehammer to crack a walnut, but for most women one or the other will be safe in terms of cardiac/respiratory physiology and they may be more likely to get the job done. There probably are people out there who offer hysteroscopy routinely with sedation, but I don’t think it’s very common.
A final thought though, if you read the rcog patient information leaflet on outpatient hysteroscopy, it suggests that the risk of surgical complications is higher under GA than with awake hysteroscopy (the surgical complications are not my area of expertise though and I don’t know how much higher those risks are, but suspect they relate to perforation or bleeding due to uterine relaxation caused by anaesthesia). It doesn’t comment on spinal but I suspect the same may be true.
So, while about 25% of women do have a bad time with awake hysteroscopy, that leaves 75% that do find it acceptable and avoid both the cardiac/ respiratory risks of sedation and the surgical problems associated with GA and it’s most likely this that explains why it’s often considered a reasonable first line approach at the moment. None of this is about trying to minimise the distress that a painful, failed, intimate procedure can cause, but hopefully this gives some background to some of the physiological things that may influence decision making. Hope that helps.