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Women’s reproductive health conditions, such as endometriosis, adenomyosis and heavy menstrual bleeding are highly prevalent in the UK. This report looks at the experiences of care women with reproductive conditions get in England. It states that many women find their symptoms dismissed and normalised by those they turn to for help. For some conditions, it highlights that accessing diagnosis and treatment can take years, leaving patients to endure pain that interferes with every aspect of their daily lives, while their conditions worsen. Key issues highlighted in this report include: Pervasive stigma associated with gynaecological and urogynaecological health, a lack of education and “medical misogyny” has contributed to poor awareness of these conditions. Diagnosis is slow not only because reproductive health conditions often have non-specific symptoms, but because of a lack of expertise and resource. Women continue to undergo harrowing experiences of painful procedures such as hysteroscopy and having a contraceptive coil fitted. This includes not being informed of the potential pain, feeling they cannot stop procedures and not having access to sufficient pain relief. This is against medical best practice and guidelines. Women’s health hubs are being established across integrated care boards as part of the previous Government’s Women’s Health Strategy for England. The model has the potential to be a positive step towards providing the joined-up care and commissioning needed to support women with reproductive health conditions but it requires funding to do so effectively. Research into women’s reproductive health conditions lags behind other, similarly prevalent conditions. It is not adequately prioritised by funders or commissioners and is not incentivised enough in clinical academia. Although there are patches of progress since the Women’s Health Strategy for England published in 2022, it has been too slow. The strategy lacks an implementation plan and resource, yet studies show that increases in funding for gynaecology services for early diagnosis and treatment provide a significant return on investment, reduces the burden on primary and secondary care settings and helps reduce sick leave and unemployment. The report makes a wide range of recommendations relating to the following areas: Public understanding of reproductive health conditions. Accessing diagnosis. Accessing treatment and support. Training and standards. Research into women’s reproductive health conditions. In relation to the Women’s Health Strategy for England, it recommends that: This should be updated to include priorities for specific, common conditions. The Government commits to reducing waiting times for an endometriosis diagnosis to less than two years by the end of this Parliament and to improved understanding, diagnosis and treatment of heavy menstrual bleeding over the same period. The Government should allocate increased, ringfenced funding to support research into the causes, diagnosis and treatment of women’s reproductive health conditions. While increased funding will in itself attract more researchers to this area, NHS England and research bodies should also consider what steps they can take to increase interest among clinical academia. The Government should publish an implementation plan for the Women’s Health Strategy for England detailing timelines, costs and resource. Related reading Failures of informed consent and the impact on women’s health: a Patient Safety Learning blog Hysteroscopy: 6 calls for action to prevent avoidable harm Medicines, research and female hormones: a dangerous knowledge gap One hour with a women's health expert and finally I felt seen The normalisation of women’s pain Sex bias in pain management decisions Misogyny is a safety issue: a blog by Saira Sundar Dangerous exclusions: The risk to patient safety of sex and gender bias Unconscious bias: gynaecological pain, the elephant in the womb! Pain bias: The health inequality rarely discussed

Outpatient and daycase hysteroscopy and polypectomy (OPHP) are widely recognised methods for the treatment of endometrial polyps. There have been concerns regarding pain affecting satisfaction and tolerability of the outpatient procedure. Dr Bhawana Purwar and colleagues from the Royal Wolverhampton Hospitals NHS Trust conducted a service evaluation of their outpatient hysteroscopy and polypectomy (OPHP) and compared it with their daycase procedures. They concluded that the OPHP is cost-effective and efficient method with reasonable acceptability. It is well tolerated with remarkable success rates and excellent patient satisfaction. As compared to daycase group, it requires less time for recovery and sooner returns to work.

In this special edition episode of 'I forgot to ask the doctor', host Dr Gail Busby interviews Professor Justin Clark and Dr Helgi Johnannsson about the options for pain relief for the important procedure of hysteroscopy.  Click on the image below to hear Dr Gail Busby's interview with Professor Justin Clark and Dr Helgi Johnannsson.

In this article for Chamber UK magazine, Lyn Brown MP warns that hysteroscopy could be the next big women's health scandal and calls for dramatic improvements in care. She describes the accounts of women being encouraged to undergo hysteroscopy without anaesthesia and appropriate pain relief, and how lack of informed consent is leaving women feeling violated and scared to undergo future gynaecological procedures. She also describes how she raised the issue in the House of Commons and outlines the failure of the Royal College of Obstetrics and Gynaecology's new 'Good Practice Paper' to properly address the decision making process and acknowledge the severity of the pain experienced by many women who undergo hysteroscopy. The article can be found on page 64 of the e-magazine.

This is Patient Safety Learning’s submission to the consultation by the Royal College of Obstetricians and Gynaecologists seeking views on a draft Green-top Guideline on outpatient hysteroscopy. The aim of this guideline is to provide clinicians with up to date, evidence-based information regarding outpatient hysteroscopy, with particular reference to minimising pain and optimising the patient experience. The consultation is now closed. Click on the attachment below to read the full consultation response. Further reading Hysteroscopy: 6 calls for action to prevent avoidable harm Painful hysteroscopy - Patient stories Through the hysteroscope: Reflections of a gynaecologist

The following account has been shared with Patient Safety Learning anonymously. We’d like to thank the patient for to sharing their experience to help raise awareness of the patient safety issues surrounding outpatient hysteroscopy care. I recently had a hysteroscopy. I was put onto the urgent 2-week wait for gynaecology after some suspicious pelvic and trans-vaginal scans. I am 53, peri-menopausal, and had one vaginal childbirth aged 23. I received no information on the procedure beforehand, just a brief phone call from the clinic to say it would be similar to a smear test, followed by the appointment letter. I researched the procedure myself using the NHS website and took the advised paracetamol/ibuprofen before arrival. On the day I wasn't asked to sign any consent form or the like. I just had to give a urine sample on arrival. After a long wait in reception I was called into a small anteroom with a strange cut-out tilting chair with a bucket underneath. I know I was anxious, but in my high alert state it seemed a very alarming set up. After explaining that I have panic attacks, and worried that this environment could be a trigger, my husband came into the room with me (otherwise I think I'd have ran back out again). They gave me a sheet to wrap around my naked bottom half, no gown with a fastening was available. I did not receive any pain relief or anaesthesia. I was really frightened as I saw the hysteroscope and thought how on earth is that going to get through my cervix and into my uterus! I like to think that I've a good pain threshold; but this was like nothing I've ever experienced. I felt the hysteroscope break through my cervix (this made me cry out in pain), and then saline was pumped into my uterus and that was extremely unpleasant. I was deep breathing to try to control myself but I couldn't stop crying and shaking with the shock of it all. I felt such distress that I couldn't speak. It was a terrible deep searing/dragging pain. The nurses were lovely and held my hand while my husband held the other, but I have to say that it was the most frightening experience I've ever been through. I looked up at my husband who was comforting me and I could see tears in his eyes too. The doctor said that all appeared ok, but took some biopsies just to double check. That cutting into my womb hurt a great deal. They then put in a Mirena coil which I had agreed to just before the procedure started, as the doctor said it would help alleviate my heavy periods and thickened womb lining. No one said that I may experience such intense pain during the hysteroscopy, just likely some period type pain. This comparison is not accurate at all. After the procedure I was asked to get dressed. My husband helped me out of the room and I sat down in the reception area trying to hide my distress from the other people waiting in there. I eventually felt able to walk back to the car and my husband drove me home. I have to say that I've been left feeling horrible after all this and I can’t stop thinking about it. I will never undergo a hysteroscopy procedure in this way again. I’m also already very frightened about when the Mirena coil will need to be removed… and that’s 4 or 5 years in the future. The fear of any future internal procedures is now very real, and I find this sad as I’ve never had any concerns about undergoing these in the past This hysteroscopy is such a brutal outpatient procedure and I can't believe that there was no pain relief or anaesthesia offered. I’m still cramping and bleeding and I feel a bit of a wreck. I felt I needed to get my hysteroscopy experience written down to try help me make sense of it, whilst wondering if this is the norm? I’m so confused if it is. I felt embarrassed by my crying and shaking… but it was shockingly painful. It's also left me feeling upset that this may be happening to other women who are already worried about their health and need to know if there’s anything wrong internally; and, like me, believe that there’s no option other than having to go through this ordeal. This is just my personal experience and I do appreciate that there may be other women who have had a different experience to mine. Even so, regardless of any data collected about this procedure, I find it unacceptable for any woman to be expected to bear this terrible pain and trauma. Further reading on the hub: Hysteroscopy: 6 calls for action to prevent avoidable harm The normalisation of women’s pain What is your experience of hysteroscopy? Share and read other accounts in our Painful hysteroscopy community thread.

This presentation was submitted by the patient group Campaign Against Painful Hysteroscopy, as an oral presentation to the British Society for Gynae Endoscopy’s Annual Scientific Meeting 2021. It includes patient testimonials and statistical data gathered around painful hysteroscopies and informed consent.  OP86 Tylko (1).mp4

This is a presentation detailing the manuscript which investigated the presence of pain during hysteroscopy, delivered by pain researcher, Richard Harrison to the annual meeting of the Royal College of Obstetricians and Gynaecologists in 2021.

In this blog, pain researcher, Richard Harrison, reflects on the presentation he recently made to the Royal College of Obstetricians and Gynaecologists, based on his research into pain during hysteroscopy. Follow the link below to read Richard's blog, or you can watch the RCOG presentation here. 

In this blog Patient Safety Learning reflects on responses received from Robin Swann MLA, Minister of Health (Northern Ireland), Jeane Freeman MSP, Cabinet Secretary for Health and Sport (Scotland) and Vaughan Gething MS, Minister for Health and Social Services (Wales), regarding concerns about painful hysteroscopy procedures in the NHS. In November, Patient Safety Learning published a blog outlining five calls to action to improve the safety of hysteroscopy procedures in the NHS.[1] This has been an issue raised by patients, campaign groups and politicians in recent years, highlighting concerns that women have been suffering avoidable harm from hysteroscopies. To raise awareness of this issue and call for urgent action to prevent future harm, we wrote to several key stakeholders in healthcare across the UK, including: Nadine Dorries MP, Minister of State for Mental Health, Suicide Prevention and Patient Safety (UK Government) Robin Swann MLA, Minister of Health (Northern Ireland Executive) Jeane Freeman MSP, Cabinet Secretary for Health and Sport (Scottish Government) Vaughan Gething MS, Minister for Health and Social Services (Welsh Government) In January we published a blog reflecting on the response we received from Nadine Dorries on this issue.[2] Here we will consider responses we’ve received from Robin Swann in Northern Ireland, Jeane Freeman in Scotland and Vaughan Gething in Wales. We have included our correspondence with the ministers in full at the end of this blog. Concerns about painful hysteroscopy Hysteroscopy is a procedure used as a diagnostic tool to identify the cause of common problems, such as abnormal bleeding, unexplained pain or unusually heavy periods in women. It involves a long, thin tube being passed into the womb, often with little or no anaesthesia. Informed by insights from patients, researchers and clinicians, we have identified several key patient safety concerns relating to these procedures in the NHS around issues of informed consent, access to pain relief and the implementation of good practice guidance. When writing to healthcare stakeholders, we have been highlighting five calls for action to improve hysteroscopy safety: 1) National guidance for outpatient hysteroscopy to be consistently applied 2) Women to be provided with information and advice to inform their consent 3) Women to be offered and provided with pain relief 4) Significant pain to be consider an adverse event, and recorded and reported as such 5) Research to assess the scale of unsafe care and pain, the extent to which women are suffering, and to inform the implementation of national guidelines and the appropriateness of financial incentives without proper safeguards Response from the Northern Ireland Executive In his response Robin Swann provided an overview of guidance currently followed in Northern Ireland for hysteroscopy procedures, referring to information provided by National Institute of Health and Care Excellence (NICE) and the professional guidance produced by the Royal College of Obstetricians and Gynaecologists (RCOG) and the British Society for Gynaecological Endoscopy (BSGE). He acknowledges concerns about the provision of pain relief for patients having hysteroscopy procedures, advising that his department will: “write to the HSC Trusts in Northern Ireland to highlight this guidance and remind the service about the importance of the consistent application of the guidance” While we welcome this step, we believe more robust action will be required, given the concerns we have seen in cases where good practice guidance is simply not followed. We also reflect positively on the Minister’s comments, placing this issue within the wider context of his department’s response to the Independent Medicines and Medical Devices Safety Review (also known as the Cumberlege Review).[3] He notes that this Review highlighted the wider importance of listening to patients’ voices and concerns, and advises that the issues we have raised on hysteroscopy procedures will be used to inform this work. Response from the Scottish Government We received a response on behalf of Jeane Freeman at the end of January which sets out the position of the Directorate for Healthcare Quality and Improvement. Their response initially focused on the importance of patient safety to the Scottish Government, emphasising they have put in place a number of policies to “promote the input of patients and the public to decisions about their care”. Their response notes their plans to establish a Patient Safety Commissioner for Scotland, with proposals to be published for consultation shortly. On the issue of hysteroscopy procedures, the response refers to the guidance provided by NICE, RCOG and the BSGE, while noting that “ultimately decisions are for local clinicians, based on patients’ individual circumstances and clinical expertise”. It also acknowledges the importance of informed consent and shared decision-making, stating that: “we would expect that prior to attending an outpatient hysteroscopy appointment, women should be provided with patient information resources, such as the BSOG and BSGE ‘Information for you – Outpatient Hysteroscopy’ leaflet” While we welcome the Scottish Government’s stated support for the use of patient information resources, the issue remains that support at a policy level does not necessarily translate into the experience of patients undergoing this procedure. Response from the Welsh Government At the end of January, we also received a formal response from a representative from the Department of Health and Social Services on behalf of Vaughan Gething. The response gave a brief overview of the guidance form NICE and RCOG currently followed for hysteroscopy procedures in Wales, but disappointingly did not engage with any of the five calls to action we set out in November. While the response notes the Minister has been receiving an unprecedented amount of correspondence as a result of the pandemic, in our view this is not an adequate response when serious patient safety concerns relating to a healthcare procedure have been highlighted. More work is needed to ensure that patients’ voices are heard There are many examples of hysteroscopies being performed without women being fully informed beforehand. The high levels of pain experienced by a significant number of these women, coupled with the realisation they were not given the information to make a decision that was right for them, has left some feeling traumatised and violated. Recent testimonials from women show this is still happening today, highlighting that guidance is not being followed in practice. Considering responses we have now received from UK, Northern Irish, Scottish and Welsh ministers, it appears clear that, at a departmental level, concerns around the safety of hysteroscopy procedures remain focused on overarching principles and guidance. Although most ministers accept that there is a significant safety concern, we believe that they do not look closely enough at the difference between the guidance and its practical implementation, which for many women results in severe pain and avoidable harm. There is also still much more work needed to make patients’ voices heard on hysteroscopy. Data needs to be collected through patient reported outcomes in order to understand the scale of harm, identify the barriers to safe care and to hear from those with lived experience. The cursory response received from the Welsh Government appears to suggest that patient safety concerns around hysteroscopy are not yet recognised as a significant issue by all healthcare leaders at a devolved level. Collaboration between clinicians and patients In addition to highlighting patients’ voices with politicians on painful hysteroscopies, we’re also seeking to work with healthcare professionals to further explore patient safety concerns, raise awareness and encourage best practice. At the end of last month, we published an interview with a Obstetrics and Gynaecology consultant, Dr Saira Sundar, who provided her clinical insight and highlighted some of the challenges involved when it comes to managing pain during hysteroscopies.[4] We will continue to work collaboratively with patients, researchers and clinicians to campaign for safer hysteroscopy care. If you have insights you would like to share around hysteroscopy procedures, please get in touch with the Patient Safety Learning team at [email protected] or share your thoughts with us on the hub here. References 1. Patient Safety Learning, Improving hysteroscopy safety, Patient Safety Learning’s the hub, 6 November 2020. 2. Patient Safety Learning, Minister acknowledges patients’ concerns about painful hysteroscopies; but will action be taken?, Patient Safety Learning’s the hub, 20 January 2021. 3. The Independent Medicines and Medical Devices Review, First Do No Harm, 8 July 2020. 4. Patient Safety Learning, Through the hysteroscope: Reflections of a gynaecologist, Patient Safety Learning’s the hub, 26 January 2021.

In this blog, Patient Safety Learning reflects on a recent response from Nadine Dorries MP, Minister of State for Mental Health, Suicide Prevention and Patient Safety, regarding concerns about painful hysteroscopy procedures in the NHS. Towards the end of last year, Patient Safety Learning published a blog outlining five calls to action that could be taken to improve the safety of hysteroscopy procedures in the NHS.[1] This has been an issue raised by patients, campaign groups and politicians in recent years, highlighting concerns that women having been suffering avoidable harm from hysteroscopies. We wrote to several key stakeholders in healthcare across England, Northern Ireland, Scotland and Wales, to raise awareness of this issue and call for urgent action to prevent future harm. While we welcome the Minister in her response supporting the general principles of informed consent and good practice guidance for hysteroscopy, we know that many women are still not being offered a choice of pain relief or given adequate information before consenting to the procedure. It remains unclear from her response whether the Government will take action to investigate the frequency of these experiences and respond to improve hysteroscopy safety. Concerns about painful hysteroscopy Hysteroscopy is a procedure used as a diagnostic tool to identify the cause of common problems, such as abnormal bleeding, unexplained pain or unusually heavy periods in women. It involves a long, thin tube being passed into the womb, often with little or no anaesthesia. In a blog late last year, we reflected on some key patient safety concerns relating to these procedures in the NHS: Despite a significant number of women who undergo this procedure and experience high levels of pain, in many cases their remains little or no access to pain relief. Recent research, published in the British Journal of Anaesthesia, shows that 17.6% of women rate their pain during hysteroscopy as greater than 7/10, and only 7.8% report no pain at all.[2] A growing number of women do not believe they were given sufficient information about this procedure beforehand and were therefore unable to provide informed consent. Patient experiences and concerns are not being adequately captured, recognised or listened to. Some women have been left traumatised by their experience of hysteroscopy, fearful to access further gynaecological investigations or screenings. There are reports that the good practice guidance available from the Royal College of Obstetricians and Gynaecologists (RCOG) is not being adhered to.[3] We wrote to several key stakeholders in healthcare across England, Northern Ireland, Scotland and Wales highlighting these issues, including Nadine Dorries MP, Minister of State for Mental Health, Suicide Prevention and Patient Safety. Below, we reflect on the response we recently received from her on these issues, in the context of our five calls for action to improve hysteroscopy safety. We have also included our correspondence with her in full at the end of this blog. Nadine Dorries’ response to our five calls to action 1) National guidance for outpatient hysteroscopy to be consistently applied The Minister states her support for the NHS England and NHS Improvement position on this issue, specifically that the information leaflet produced by RCOG and the British Society for Gynaecological Endoscopy should be provided to all patients prior to their hysteroscopy. While her support for the use of this guidance is welcome, she does not address the problem that, in many cases, this guidance is simply not followed. She also advises that RCOG are now in the process of developing a second edition of its patient leaflet. However, while there remains barriers which may prevent clinicians from using this guidance, or where clinicians may be reluctant to follow the guidance, women will continue to be susceptible to varied standards of NHS hysteroscopy care. 2) Women to be provided with information and advice to inform their consent Nadine Dorries indicates her support that patients are provided with all the information they need prior to hysteroscopy procedures to help inform their consent. As with the previous point regarding the consistent application of the guidance, however the issue remains that support for this in principle does not necessarily translate into the experience of patients undergoing this procedure. We are disappointed that the Minister fails to acknowledge that this remains a significant issue and does not provide any assurance that action will be taken to address a failure of informed consent. 3) Women to be offered and provided with pain relief Her response notes support for women having the choice of a general or regional anaesthetic for the procedure. She also outlines forthcoming changes in the NHS that intend to remove the best practice tariff. This is important as this system has provided a financial incentive for hospital trusts to perform procedures, such as hysteroscopy, as outpatient services without a general anaesthetic, creating a perverse incentive against the use of pain relief. 4) Significant pain to be considered an adverse event and recorded and reported as such and 5) Research to assess the scale of unsafe care and pain, the extent to which women are suffering, and to inform the implementation of national guidelines and the appropriateness of financial incentives without proper safeguards Finally, on the issue of the pain experienced by a significant number of women who undergo a hysteroscopy procedure, in her response the Minister acknowledges that, in cases of severe pain, “it has become clear over the last few years that we can do better in terms of the services we provide for women”. However, on both this and the issue of further research, she does not make any specific commitments on hysteroscopy. Patient Safety Learning believes that significant pain resulting from procedures such as hysteroscopy should be considered as an adverse event, being recorded, reported and responded to appropriately. We also believe that there needs to be specific research into the scale of unsafe care and pain of these procedures. We recently shared a blog on the hub by Dr Richard Harrison, a pain researcher at the University of Reading, reflecting on his recent research on this issue.[4] Improved guidance requires practical implementation While the Department of Health and Social Care shows a clear recognition of concerns about hysteroscopy procedures in the NHS, the Minister’s response is focused on overarching principles and guidance, rather than how this is implemented in practice. We know that many women are still not being offered a choice of pain relief or given adequate information before consenting to the procedure. It remains unclear from this response whether any action will be taken to investigate the prevalence of these experiences and respond accordingly. This is an example of the type of patient safety issue that we believe the recently announced Patient Safety Commissioner for England should investigate, and is something we intend to promote with them when this role is introduced.[5] Patient Safety Learning is working collaboratively with patients, researchers and clinicians to understand the barriers to safe hysteroscopy care. We continue to speak to and support patient groups to help raise awareness of safety concerns and amplify their voices. Our aim is that all patients have access to pain relief and the information they need to properly consent to treatments. Read our initial email to Nadine Dorries MP (also attached) Read Nadine Dorries' full response (also attached) References [1] Patient Safety Learning, Improving hysteroscopy safety, Patient Safety Learning's the hub, 6 November 2020. [2] Harrison, Richard., Kuteesa, William., and Kapila, A, Pain-free day surgery? Evaluating pain and pain assessment during hysteroscopy, British Journal of Anaesthesia, 2020. [3] RCOG, Information for you: Outpatient hysteroscopy, December 2019. [4] Harrison, Richard, Pain free hysteroscopy, Dr Richard Harrison’s website, 2020. [5] Hughes, Helen, Early thoughts on a Patient Safety Commissioner for England (a blog by Helen Hughes, Chief Executive of Patient Safety Learning), Patient Safety Learning’s the hub, 23 December 2020.

This month, we’ve been looking back over 2020 and highlighting some of the key areas of health and care that Patient Safety Learning has worked in this year. First, Chief Executive, Helen Hughes, gave an overview, detailing some of the main ways we’ve been achieving our aims as an organisation. Following that, we looked at the impact of the COVID-19 pandemic on patient safety, and, earlier this week, we focused on advice and support for people living with Long COVID. In this blog, Patient Safety Learning reflect on the work we’ve been doing to highlight serious patient safety concerns relating to hysteroscopy procedures in the NHS and how we’ve been making the case for change. As an additional option to the text below, you might like to watch the following video from Stephanie O'Donohue, Content and Engagement Manager of Patient Safety Learning's the hub: Sharing patients’ experiences on the hub In February this year, we heard from the Campaign Against Painful Hysteroscopy (CAPH) about the high numbers of women experiencing painful hysteroscopies. This prompted us to start a new Community discussion on our patient safety platform, the hub, titled ‘Painful hysteroscopy’, asking members to share their experiences with us. This has, by far, been the most popular discussion on the hub. To date, there have been close to 100 comments made, over 30 members have contributed to the discussion, and the conversation itself has received nearly 6,000 page views, with people viewing the discussion daily. Engaging with patients, clinicians, researchers and leaders Through our contact with CAPH and hearing from patients, clinicians and researchers on the hub, we’ve identified the main patient safety issues to be around consent, access to pain relief and implementation of guidance. Since identifying these issues, we have written to key political stakeholders, including Nadine Dorries MP, Minister for Patient Safety, Suicide Prevention and Mental Health, and Jeremy Hunt MP, Chair of the Health and Social Care Select Committee. More recently, we have made a request for data from the National Reporting and Learning System (the central NHS database for patient safety incident reports) to understand whether the experiences we are hearing about are being accurately captured. We believe patients’ experiences of hysteroscopy should be proactively gathered and used to evidence and inform improvements. Looking forward In 2021, we will continue calling for patients’ experiences of hysteroscopy, and their concerns about this procedure, to be heard and responded to. We want to see systems put in place to support patient safety, and evidence-based conversations occurring between clinicians and patients before procedures take place. These conversations should aim to ensure patients are well-informed of the benefits, risks and alternatives of the procedure, as well as what impact it will have on them if they choose not to proceed. You can read more about the action we believe is needed to address the patient safety issues around painful hysteroscopies.

In this short video produced by Endometriosis Explained, retired gynaecologist, MJ Quinn, talks about the neuropathic causes of painful hysteroscopy. This includes seven recommendations for how to avoid severe pain outpatient hysteroscopy. 

Hysteroscopy is a diagnostic gynaecological procedure traditionally requiring administration of general anaesthesia, but more frequently completed using local anaesthesia within a day-case (ambulatory) setting. Advantages associated with this transition include decreased completion times, fewer risks, and lower clinical costs. Numerous services advertise the procedure as being either pain free or low pain; however, it is estimated that 25% of patients report experiencing intense or intolerable pain. For severe pain, local anaesthetic can be administered, but this does not guarantee effective pain management. This research, published in the British Journal of Anaesthesia, found that very few patients feel no pain and a significant number felt pain of greater than 7/10. It also found a disconnect between the patient's experience of pain and the clinician's perception of it. This research paper is paywalled, but can be purchased via the link below.

This was an Adjournment Debate from the House of Commons on the 24 September 2020 on NHS Hysteroscopy Treatment tabled by Lyn Brown MP. What is an Adjournment Debate? There is a 30 minute Adjournment Debate at the end of each day's sitting of the House of Commons. They provide an opportunity for an individual backbench MP to raise an issue and receive a response from the relevant Minister. Unlike many other debates, these take place without a question which the House of Commons must then make a decision on.[1] NHS Hysteroscopy Treatment In this debate Lyn Brown MP outlined the issue of significant numbers of women who experience extreme levels of pain when undergoing a hysteroscopy, highlighted by groups such as the Campaign Against Painful Hysteroscopy. She noted concerns around: Lack of access to pain relief. Lack of informed consent - noting that while improved information leaflets have been produced by the Royal College of Obstetricians and Gynecologists, many women are still not being provided with this information prior to the procedure. Lasting trauma for patients. Best Practice Tariff and perverse financial incentives Lyn Brown also noted a particular issue of a financial incentive that deters the use of pain relief in hysteroscopy procedures. She noted that NHS trusts are encouraged to perform hysteroscopies as outpatient procedures, through the NHS best practice tariff. She noted that the way the tariff is designed means that a trust will lose money if it provides general anesthetic for such procedures. In her response the Minister for Patient Safety, Mental Health and Suicide Prevention, Nadine Dorries MP, indicated that forthcoming technical changes to the tariff for 2021-22 may address this issue for hysteroscopy procedures. References UK Parliament, Adjournment Debates, Last Accessed 25 September 2020.

The aim of this review, published in Archives of Gynaecology and Obstetrics, is to provide an overview of the literature about the perception and management of anxiety and pain in women undergoing an office hysteroscopic procedure.

This leaflet, produced by the Royal College of Obstetricians and Gynaecologists and the British Society for Gynaecological Endoscopy, is for individuals who have been offered hysteroscopy as an outpatient. It may also be helpful if you are a partner, relative or friend of someone who has been offered this procedure. Key points: Outpatient hysteroscopy (OPH) is a procedure carried out in the outpatient clinic that involves examination of the inside of your uterus (womb) with a thin telescope. There are many reasons why you may be referred for OPH, such as to investigate and/or treat abnormal bleeding, to remove a polyp seen on a scan or to remove a coil with missing threads. The actual procedure usually takes 10-15 minutes. It can take longer if you are having any additional procedures. You may feel pain or discomfort during OPH. It is recommended that you take pain relief 1-2 hours before the appointment. If it is too painful, it is important to let your healthcare professional know as the procedure can be stopped at any time. You may choose to have the hysteroscopy under general anaesthetic. This will be done in an operating theatre, usually as a day case procedure. Possible risks with hysteroscopy include pain, feeling faint or sick, bleeding, infection and rarely uterine perforation (damage to the wall of the uterus). The risk of uterine perforation is lower during OPH than during hysteroscopy under general anaesthesia. Join the conversation on the hub about hysteroscopies.

This study, published by the International Institute of Gynaecology and Obstetrics, evaluates the safety and efficacy of flushing the cervical canal and the uterine cavity with local anaesthetic in order to reduce the pain felt by patients during office hysteroscopy.

One woman's account, published by Care Opinion, of her traumatic experience of having a hysteroscopy. "At no point was any pain relief, sedation or anaesthetic offered to me or discussed at all."

Patients are not always given a choice between an outpatient hysteroscopy and a general anaesthetic. Radio's 4's Women's Hour discusses the issue of inadequate pain relief for hysteroscopies. The discussion includes one patient's story of the trauma she suffered and a response from a consultant in reproductive health. The interview was published on the Hysteroscopy Action website, please follow the link below to listen. 

This patient story essay was produced by the Campaign against painful hysteroscopy to highlight the extreme levels of pain many women experience when undergoing the procedure. The campaign calls for an end to inadequate pain relief for hysteroscopies.