Role of vaginal estradiol pretreatment combined with vaginal misoprostol for cervical ripening before operative hysteroscopy in postmenopausal women

Abstract

ObjectiveTo assess the efficacy and safety of vaginal misoprostol after a pretreatment with vaginal estradiol to facilitate the hysteroscopic surgery in postmenopausal women.MethodsIn this observational comparative study, 35 control women (group A) did not receive any pharmacological treatment,26 women (group B) received 25 µg of vaginal estradiol daily for 14 days and 400 µg of vaginal misoprostol 12 hours before hysteroscopic surgery, 32 women (group C) received 400 µg of vaginal misoprostol 12 hours before surgery.ResultsDemographic data were well balanced and all variables were not significantly different among the three groups. The study showed a significant difference in the preoperative cervical dilatation among the group B (7.09±1.87 mm), the group A (5.82±1.85 mm; B vs. A, P=0.040) and the group C (5.46±2.07 mm; B vs. C, P=0.007). The dilatation was very easy in 73% of women in group B. The pain scoring post surgery was lower in the group B (B vs. A, P=0.001; B vs. C, P=0.077). In a small subgroup of women with suspected cervical stenosis, there were no statistically significant differences among the three groups considered. No complications during and post hysteroscopy were observed.ConclusionIn postmenopausal women the pretreatment with oestrogen appears to have a crucial role in allowing the effect of misoprostol on cervical ripening. The combination of vaginal estradiol and vaginal misoprostol presents minor side effects and has proved to be effective in obtaining satisfying cervical dilatation thus significantly reducing discomfort for the patient.

Anaphylactic shock to vaginal misoprostol: a rare adverse reaction to a frequently used drug

“…However, misoprostol has been more frequently used in obstetrics/gynecology for cervical ripening and labor induction, although it is an off-label usage [ 1 2 3 4 5 ]. It is applied via the oral, sublingual, vaginal, and rectal routes, and compared to misoprostol administered orally, misoprostol administered via the sublingual and vaginal routes persists longer in the plasma [ 5 ]. Although a severe allergic reaction or anaphylactic shock due to misoprostol is very rare, obstetricians and gynecologists warn about the risks [ 7 ].…”

“…Although we did not perform skin testing because of the patient's refusal, the patient had no allergies to any of the drugs administered before the anaphylactic shock other than the misoprostol because exactly the same drugs were used at the time of the aneurysm clipping and again at the time of cholecystectomy. A tentative diagnosis of anaphylactic shock to misoprostol was made based on case reports obtained after a PubMed search for unexplained shock performed 20 hours after the event [ 5 6 7 8 ]. The patient was in the intensive care unit for 24 hours until she was hemodynamically stable, and the generalized edema disappeared in 48 hours.…”

“…Although extremely rare, life-threatening anaphylactic shock can occur after misoprostol administration. This adverse event has previously only been reported in pregnant women, in one case during labor induction and in another during abortion [ 4 5 ]. Here we report a case of vaginal misoprostol as a cause of anaphylaxis prior to hysteroscopic myomectomy in a non-pregnant woman, a common indication of misoprostol application.…”

Operative Hysteroscopy Complications

“…In the case of cervical stenosis, medical options such as osmotic dilators and use of cervical ripening agents (i.e. misoprostol, oestrogen in post-menopause) may be considered [24,25]. Initial dilation with a pipelle® or entry with 2 mm diagnostic hysteroscope may also be considered before advancing with larger operative hysteroscopes [20].…”

Clinical observation of different dosages of dexmedetomidine combined with a target-controlled infusion of propofol in hysteroscopic submucosal myomectomy

“…Mechanical operations like intraoperative cervical dilatation, uterine traction, and negative pressure suction may cause abdominal pain, nausea, and irritability, which may result in discomfort to patients and may even be life threatening (2). The anesthesia protocol choice is closely tied to the safety and comfort of patients and the prognosis of hysteroscopic surgery (3). Propofol is widely applied in outpatient examination and treatment because it takes effect quickly, has a short action time, and results in a high level of patient consciousness.…”