Obstet Gynecol Sci.  2016 May;59(3):220-226. 10.5468/ogs.2016.59.3.220.

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

• Casadei L
• Piccolo E
• Manicuti C
• Cardinale
• Collamarini M
• Piccione E

• KMID: 2351788
• DOI: http://doi.org/10.5468/ogs.2016.59.3.220

Abstract

OBJECTIVE
To assess the efficacy and safety of vaginal misoprostol after a pretreatment with vaginal estradiol to facilitate the hysteroscopic surgery in postmenopausal women.
METHODS
In 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.
RESULTS
Demographic 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.
CONCLUSION
In 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.

Keyword

Cervical ripening; Estradiol; Hysteroscopy; Misoprostol; Postmenopause

MeSH Terms

Cervical Ripening*
Constriction, Pathologic
Dilatation
Estradiol*
Female
Humans
Hysteroscopy*
Labor Stage, First
Misoprostol*
Postmenopause
Pregnancy
Estradiol
Misoprostol

Figure

• 

  Fig. 1 Study flowchart.

Reference

1. Jansen FW, Vredevoogd CB, van Ulzen K, Hermans J, Trimbos JB, Trimbos-Kemper TC. Complications of hysteroscopy: a prospective, multicenter study. Obstet Gynecol. 2000; 96:266–270.

2. Gkrozou F, Koliopoulos G, Vrekoussis T, Valasoulis G, Lavasidis L, Navrozoglou I, et al. A systematic review and meta-analysis of randomized studies comparing misoprostol versus placebo for cervical ripening prior to hysteroscopy. Eur J Obstet Gynecol Reprod Biol. 2011; 158:17–23.

3. Selk A, Kroft J. Misoprostol in operative hysteroscopy: a systematic review and meta-analysis. Obstet Gynecol. 2011; 118:941–949.

4. Polyzos NP, Zavos A, Valachis A, Dragamestianos C, Blockeel C, Stoop D, et al. Misoprostol prior to hysteroscopy in premenopausal and post-menopausal women: a systematic review and meta-analysis. Hum Reprod Update. 2012; 18:393–404.

5. Ngai SW, Chan YM, Ho PC. The use of misoprostol prior to hysteroscopy in postmenopausal women. Hum Reprod. 2001; 16:1486–1488.

6. Fung TM, Lam MH, Wong SF, Ho LC. A randomised placebo-controlled trial of vaginal misoprostol for cervical priming before hysteroscopy in postmenopausal women. BJOG. 2002; 109:561–565.

7. Bunnasathiansri S, Herabutya Y, O-Prasertsawat P. Vaginal misoprostol for cervical priming before dilatation and curettage in postmenopausal women: a randomized controlled trial. J Obstet Gynaecol Res. 2004; 30:221–225.

8. Oppegaard KS, Nesheim BI, Istre O, Qvigstad E. Comparison of self-administered vaginal misoprostol versus placebo for cervical ripening prior to operative hysteroscopy using a sequential trial design. BJOG. 2008; 115:663e1–e9.

9. Barcaite E, Bartusevicius A, Railaite DR, Nadisauskiene R. Vaginal misoprostol for cervical priming before hysteroscopy in perimenopausal and postmenopausal women. Int J Gynaecol Obstet. 2005; 91:141–145.

10. Kant A, Divyakumar , Priyambada U. A randomized trial of vaginal misoprostol for cervical priming before hysteroscopy in postmenopausal women. J Midlife Health. 2011; 2:25–27.

11. Atmaca R, Kafkasli A, Burak F, Germen AT. Priming effect of misoprostol on estrogen pretreated cervix in postmenopausal women. Tohoku J Exp Med. 2005; 206:237–241.

12. Oppegaard KS, Lieng M, Berg A, Istre O, Qvigstad E, Nesheim BI. A combination of misoprostol and estradiol for preoperative cervical ripening in postmenopausal women: a randomised controlled trial. BJOG. 2010; 117:53–61.

13. Batukan C, Ozgun MT, Ozcelik B, Aygen E, Sahin Y, Turkyilmaz C. Cervical ripening before operative hysteroscopy in premenopausal women: a randomized, double-blind, placebo-controlled comparison of vaginal and oral misoprostol. Fertil Steril. 2008; 89:966–973.

14. Lee YY, Kim TJ, Kang H, Choi CH, Lee JW, Kim BG, et al. The use of misoprostol before hysteroscopic surgery in non-pregnant premenopausal women: a randomized comparison of sublingual, oral and vaginal administrations. Hum Reprod. 2010; 25:1942–1948.

15. Song T, Kim MK, Kim ML, Jung YW, Yoon BS, Seong SJ. Effectiveness of different routes of misoprostol administration before operative hysteroscopy: a randomized, controlled trial. Fertil Steril. 2014; 102:519–524.

16. Sennstrom MB, Ekman G, Westergren-Thorsson G, Malmstrom A, Bystrom B, Endresen U, et al. Human cervical ripening, an inflammatory process mediated by cytokines. Mol Hum Reprod. 2000; 6:375–381.