Guy Waddell

Cervical ripening using vaginal misoprostol before hysteroscopy: a double-blind randomized trial.

STUDY OBJECTIVE The aim of this study was to evaluate the use of vaginal misoprostol to decrease both the force required to dilate the cervix and the pain experienced during a hysteroscopy. DESIGN Randomized clinical trial (RCT) (Canadian Task Force classification I). SETTING University hospital gynecology clinic. PATIENTS A total of 101 patients needing a diagnostic hysteroscopy. Fifty patients were randomized to the misoprostol group and 51 to the placebo group. Patient characteristics were similar in the 2 groups. INTERVENTIONS Self-administration of 400 microg of vaginal misoprostol or vaginal placebo 12 to 24 hours before a hysteroscopy. MEASUREMENTS AND MAIN RESULTS The force needed to dilate the cervix was assessed by a tonometer, and pain was measured by a visual analog scale. The force to dilate the cervix to 6mm was significantly less in the misoprostol group (5.0 vs 7.5N, p=.02). Pain-related measurements after dilatation of the cervix to 6mm were significantly reduced in the misoprostol group (42.1 vs 57.2, p=.004). The main side effect reported with the use of the drug was pelvic cramping. CONCLUSION The use of 400 microg of vaginal misoprostol 12 to 24 hours before hysteroscopy reduces the pain and the force needed to dilate the cervix, with only mild side effects.

Efficacy of transcranial direct-current stimulation in women with provoked vestibulodynia

BACKGROUND: Provoked vestibulodynia is a highly prevalent condition characterized by acute recurrent pain located at the vaginal entrance in response to pressure application or attempted vaginal penetration. Despite a wide variety of treatments offered to women with provoked vestibulodynia, a high proportion of women are refractory to conventional treatment. Transcranial direct‐current stimulation is a noninvasive brain stimulation technique that has been shown effective for improving various chronic pain conditions. Growing evidence suggests that the central nervous system could play a key role in provoked vestibulodynia. Targeting the central nervous system could therefore be a promising treatment for women with provoked vestibulodynia. OBJECTIVE: The purpose of this study was to evaluate and compare the efficacy of active and sham transcranial direct‐current stimulation in reducing pain intensity during intercourse in patients with provoked vestibulodynia. STUDY DESIGN: We conducted a triple‐blind, parallel‐group, randomized controlled trial. Women aged 17‐45 years diagnosed with provoked vestibulodynia by a gynecologist using a validated protocol were randomized to 10 sessions of either active transcranial direct‐current stimulation (intensity = 2 mA) or 10 sessions of sham transcranial direct‐current stimulation, over a 2‐week period. Both active and sham transcranial direct‐current stimulation were applied for 20 minutes, with the anode positioned over the primary motor cortex, and the cathode over the contralateral supraorbital area. Outcome measures were collected at baseline, 2 weeks after treatment, and at 3‐month follow‐up by an evaluator blinded to group assignment. The primary objective was to assess pain intensity during intercourse, using a numerical rating scale. Secondary outcomes focused on sexual function and distress, vestibular sensitivity, psychological distress, treatment satisfaction, and patient impression of change. Statistical analyses were conducted on the intention‐to‐treat basis, and treatment effects were evaluated using a mixed linear model for repeated measures. RESULTS: A total of 40 patients were randomly assigned to receive either active (n = 20) or sham (n = 20) transcranial direct‐current stimulation treatments from November 2014 through February 2016. Baseline characteristics were similar between the active and sham transcranial direct‐current stimulation groups. In full compliance with the study protocol, every participant followed all courses of the study treatment, including assessments at 2‐week and 3‐month follow‐up. Pain during sexual intercourse was not significantly different between active and sham treatment groups 2 weeks after treatment (P = .84) and at follow‐up (P = .09). Mean baseline and 2‐week assessment pain intensity were, respectively, 6.8 (95% confidence interval, 5.9–7.7) and 5.6 (95% confidence interval, 4.7–6.5) for active transcranial direct‐current stimulation (P = .03) vs 7.5 (95% confidence interval, 6.6–8.4) and 5.7 (95% confidence interval, 4.8–6.6) for sham transcranial direct‐current stimulation (P = .001). Nonsignificant differences between the 2 groups were also found in their sexual function and distress after treatment (P > .20) and at follow‐up (P > .10). Overall, at 2‐week assessment 68% assigned to active transcranial direct‐current stimulation reported being very much, much, or slightly improved compared to 65% assigned to sham transcranial direct‐current stimulation (P = .82), and still comparable at follow‐up: 42% vs 65%, respectively (P = .15). CONCLUSION: Findings suggest that active transcranial direct‐current stimulation is not more effective than sham transcranial direct‐current stimulation for reducing pain in women with provoked vestibulodynia. Likewise, no significant effects were found on sexual function, vestibular sensitivity, or psychological distress.