Have you had a painful hysteroscopy? Your h... - Women's Health

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Have you had a painful hysteroscopy? Your help is needed

distractonaught
distractonaught
43 Replies

Hi everyone

I wanted to share an important survey with you, aimed at women in the UK who have experienced 'office hysteroscopy' - a procedure where a camera is inserted into the uterus and biopsies taken - while awake and without anaesthetic. The survey form is here:

docs.google.com/forms/d/e/1...

It's believed that up to 30% of patients find this procedure intolerably painful, and many faint, vomit or have to abandon the procedure. I've spoken to many who have suffered long term PTSD as a result. Despite this, there are calls for this cheap and nasty method of doing hysteroscopy the norm. As is so often the case, women are not believed about their pain.

I myself had to undergo a hysteroscopy recently and I was lucky to be well informed: I knew from reading countless testimonials how painful it could be, and I insisted on a general anaesthetic. The experience was great: I was at home a couple of hours later and had virtually no pain.

I strongly believe this is how it should be done - unless the patient strongly wants to go ahead with an outpatient procedure having been made aware of the risk of severe pain.

But other women are not so lucky, and many have no idea they can have this procedure with proper pain relief. In fact, many are told it will be no more uncomfortable than a smear :(.

The test is often used to detect womb cancer, so women are understandably anxious to have it done, and without being given all the information, many think they have no option but to have it with no pain relief.

If you've had this experience can you please, please complete the survey and help to raise awareness of the problems with outpatient hysteroscopy among those with influence in this area of women's health? This could help many women in future to be at least fully informed about what this procedure entails.

Many thanks

x

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wobblybee
wobblybeeAdministrator

🙂 Information on D & C Procedure (info from the Mayo Clinic)

Contact your doctor if you experience any of the following after a D&C:

Bleeding that's heavy enough that you need to change pads every hour

Fever

Cramps lasting more than 48 hours

Pain that gets worse instead of better

Foul-smelling discharge from the vagina

How you prepare

Dilation and curettage may be performed in a hospital, clinic or your doctor's office, and it's usually done as an outpatient procedure.

Before the procedure:

Follow your doctor's instructions on limiting food and drink.

Arrange for someone to help you get home because you may be drowsy after the anesthesia wears off.

Clear your schedule to allow enough time for the procedure and recovery afterward. You'll likely spend a few hours in recovery after the procedure.

In some cases, your doctor may start the process of dilating your cervix a few hours or even a day before the procedure. This helps your cervix open gradually and is usually done when your cervix needs to be dilated more than in a standard D&C, such as during pregnancy terminations or with certain types of hysteroscopy.

To promote dilation, your doctor uses a medication called misoprostol (Cytotec) — given orally or vaginally — to soften the cervix or inserts a slender rod made of laminaria into your cervix. The laminaria gradually expands by absorbing the fluid in your cervix, causing your cervix to open.

What you can expect

During the procedure

How D&C procedure is done

Dilation and curettage (D&C)

For dilation and curettage, you'll receive anesthesia. The choice of anesthesia depends on the reason for the D&C and your medical history.

General anesthesia makes you unconscious and unable to feel pain. Other forms of anesthesia provide light sedation or use injections to numb only a small area (local anesthesia) or a larger region (regional anesthesia) of your body.

During the procedure:

You lie on your back on an exam table while your heels rest in supports called stirrups.

Your doctor inserts an instrument called a speculum into your vagina, as during a Pap test, in order to see your cervix.

Your doctor inserts a series of thicker and thicker rods into your cervix to slowly dilate your cervix until it's adequately opened.

Your doctor removes the dilation rods and inserts a spoon-shaped instrument with a sharp edge or a suction device and removes uterine tissue.

Because you're either unconscious or sedated during a D&C, you shouldn't feel any discomfort.

After the procedure

You may spend a few hours in a recovery room after the D&C so that your doctor can monitor you for heavy bleeding or other complications. This also gives you time to recover from the effects of anesthesia.

If you had general anesthesia, you may become nauseated or vomit, or you might have a sore throat if a tube was placed in your windpipe to help you breathe. With general anesthesia or light sedation, you may also feel drowsy for several hours.

Normal side effects of a D&C may last a few days and include:

Mild cramping

Spotting or light bleeding

For discomfort from cramping, your doctor may suggest taking ibuprofen (Advil, Motrin IB, others) or another medication.

You should be able to resume your normal activities within a day or two.

Wait to put anything in your vagina until your cervix returns to normal to prevent bacteria from entering your uterus, possibly causing an infection. Ask your doctor when you can use tampons and resume sexual activity.

Your uterus must build a new lining after a D&C, so your next period may not come on time. If you had a D&C because of a miscarriage, and you want to become pregnant, talk with your doctor about when it's safe to start trying again.

Results

Your doctor will discuss the results of the procedure after the D&C or at a follow-up appointment.

Info from NHS

A hysteroscopy is a procedure used to examine the inside of the womb (uterus).

It's carried out using a hysteroscope, which is a narrow telescope with a light and camera at the end. Images are sent to a monitor so your doctor or specialist nurse can see inside your womb.

The hysteroscope is passed into your womb through your vagina and cervix (entrance to the womb), which means no cuts need to be made in your skin.

When a hysteroscopy may be carried out

A hysteroscopy can be used to:

investigate symptoms or problems – such as heavy periods, unusual vaginal bleeding, postmenopausal bleeding, pelvic pain, repeated miscarriages or difficulty getting pregnant

diagnose conditions – such as fibroids and polyps (non-cancerous growths in the womb)

treat conditions and problems – such as removing fibroids, polyps, displaced intrauterine devices (IUDs) and intrauterine adhesions (scar tissue that causes absent periods and reduced fertility)

A procedure called dilatation and curettage (D&C) used to be common to examine the womb and remove abnormal growths, but now hysteroscopies are carried out instead.

What happens during a hysteroscopy

A hysteroscopy is usually carried out on an outpatient or day-case basis. This means you do not have to stay in hospital overnight.

It may not be necessary to use anaesthetic for the procedure, although local anaesthetic (where medication is used to numb your cervix) is sometimes used.

General anaesthetic may be used if you're having treatment during the procedure or you would prefer to be asleep while it's carried out.

A hysteroscopy can take up to 30 minutes in total, although it may only last around 5 to 10 minutes if it's just being done to diagnose a condition or investigate symptoms.

Read more about what happens during a hysteroscopy.

Is a hysteroscopy painful?

This seems to vary considerably between women. Some women feel no or only mild pain during a hysteroscopy, but for others the pain can be severe.

If you find it too uncomfortable, tell the doctor or nurse. They can stop the procedure at any time.

If you're worried, speak to the doctor or nurse before having the procedure about what to expect and ask them about pain relief options.

Recovering from a hysteroscopy

Most women feel able to return to their normal activities the following day, although some women return to work the same day.

You may wish to have a few days off to rest if general anaesthetic was used.

While you're recovering:

you can eat and drink as normal straight away

you may experience cramping that's similar to period pain and some spotting or bleeding for a few days – this is normal and nothing to worry about unless it's heavy

you should avoid having sex for a week, or until any bleeding has stopped, to reduce the risk of infection (see below)

Your doctor or nurse will discuss the findings of the procedure with you before you leave hospital.

Read more about what happens after a hysteroscopy.

Risks of a hysteroscopy

A hysteroscopy is generally very safe but, like any procedure, there is a small risk of complications. The risk is higher for women who have treatment during a hysteroscopy.

Some of the main risks associated with a hysteroscopy are:

accidental damage to the womb – this is uncommon but may require treatment with antibiotics in hospital or, in rare cases, another operation to repair it

accidental damage to the cervix – this is rare and can usually be easily repaired

excessive bleeding during or after surgery – this can occur if you had treatment under general anaesthetic and can be treated with medication or another procedure; very rarely, it may be necessary to remove the womb (hysterectomy)

infection of the womb – this can cause smelly vaginal discharge, a fever and heavy bleeding; it can usually be treated with a short course of antibiotics from your GP

feeling faint – this affects 1 in every 200 women who have a hysteroscopy carried out without an anaesthetic or just a local anaesthetic

A hysteroscopy will only be carried out if the benefits are thought to outweigh the risks.

Alternatives to hysteroscopy

Your womb could also be examined by using a:

pelvic ultrasound – where a small probe is inserted in the vagina and uses sound waves to produce an image of the inside of your womb

endometrial biopsy – when a narrow tube is passed through your cervix into your womb, with suction used to remove a sample of your womb's lining

These alternatives may be performed alongside a hysteroscopy, but do not provide as much information and can't be used to treat problems in the same way as a hysteroscopy.

Page last reviewed: 5 December 2018

Next review due: 5 December 2021

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distractonaught

It's good that this information leaflet does include admission of the fact that pain can be 'severe'. However, some hospitals still omit this information from their own leaflets which they hand out to patients at their clinics.

If you look on sites like Careopinion you'll see that there is a regular stream of women reporting that they have gone for a hysteroscopy having been told it will be no more painful than a smear and to just take over-the-counter painkillers like paracetamol. They have no idea of the risk of severe pain and are traumatised when they experience it.

I had mine under general anaesthetic and do not think that this should be routinely done as an outpatient procedure. Ideally, women would have the option of sedation rather than the current offering, which is basically GA or nothing - which forces many women to choose nothing because they don't want to wait for weeks or take loads of time off work. But sedation would at least provide another option that would be better than the status quo.

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thelordsanger

Hi nice to meet you my wife has a hysteroscopy in March under GA and her treatment was fantastic I ended up having a bit of a brake down with worry the GP scared my wife needless with the word cancer she did not give the wife leaflets and only mention the word camera and biopsy so I looked it up on the NHS website and that is where it mentions the risk of pain being sever so I went with the wife for her swabs and smear and the GP mention camera so I said do you mean hysteroscopy to witch the doctor sqermed in her seat that's when I knew some thing was not right . When we went to see the consultant no leaflets were given or pain mention I interrupted her when she said it's done in outpatient I mention green top gydlines the RCOG stamens had only been reaseaed a couple of months at this point I said she wants GA to witch she said she was going to ofer I do believe her she said some women do not want to be awake for it but no mention of pain she was also not suitable for OPH For a list of reasons witch I'm only comftable saying in a pm the preamps nurse was fantastic saying she had the right to chose her treat ect but here is the kicker 30 mins before she was due the consult a different one Sid why are you here this is normally done in outpatient we gave out reasons to witch she totally eggnored and said there are less complication in outpatient witch is not true for purely dionostic she took a bit longer to recover than you but not by much but she was constpeted a few days but a small price to pay I hope you don't mind me telling my storie on your thread and it won't let me do paragraphs sorry

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thelordsanger

Dilation medication is never given any more and is not affective on postmenopursle women also endometrial biopsy can be exstreamly pain full and I know one woman personal who has PTSD because of this cheap test may I ask why you posted all this info as it is not how it is carried out in the real world

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wobblybee
wobblybeeAdministrator
in reply to thelordsanger

The procedure shouldn't be painful. However, you may experience some cramping during the procedure. Your doctor may order some type of sedative for you to take beforehand so that you'll be more relaxed. The extent of anesthesia you need will depend on the purpose of your hysteroscopy.27 Jun 2017

healthline.com › health

Hysteroscopy: Cost, Procedure, and Recovery - Healthline

🙂 If you look online at information on Hysteroscopy, the general theme running through is that ‘it shouldn’t be painful’. And, that ‘the extent of anaesthesia given will depend on the purpose of the Hysteroscopy’.

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thelordsanger

If you look at the pear revived studies it is severely painfull for %33 to 25% of women if you do not believe me ring the nurse on eve Appel tracy because she has stopped many a hysteroscopy if you look on line like care opion you will see many women told it should not be painfull but often is there is about 5 hospitals in the country that offer sedation and hospitals like guys and Saint Tomas deny women cervical blocks ie local anathetic I have spoken to these women personally you will also see a consistent theam that they do not stop when it is painfull my wife's friend was screaming as they removed her polyps I know these women personally they are not just hora stories

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wobblybee
wobblybeeAdministrator
in reply to thelordsanger

A hysteroscopy is not usually carried out under anaesthetic, as it's a relatively quick procedure and does not involve making cuts (incisions) in your skin. ... Longer or more complicated procedures, such as the removal of fibroids, may be done under general anaesthetic.

nhs.uk › conditions › w...

Hysteroscopy - What happens - NHS

🙂 ‘Longer, or more complicated procedures, such as removal of fibroids, may be done under general anaesthetic’.

When a medical procedure is programmed, it is wise to do your own research beforehand, discuss anything you’re not sure of with the Consultant involved, including adequate pain relief.

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thelordsanger

No you need to look in to this it is often done with out anathetic including polop removal fibroids ect one friend was in for 28 mins that is not quick I don't understand why you think it's done with anathetic may be done often mean will not be done with the nhs

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thelordsanger

Do you know what see and treat is many hospitals do a TUVS and then offer a hysteroscopy with out any warning often putting presuer on the woman to have it done there and then as a opponent can be weeks if not months away do not offer pain relief and when they some times do they said to my friend now or 3to6 moths for a genral

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distractonaught

Right. It "shouldn't be painful", but for a significant set of women it is, extremely painful, and we know this. Personally I wasn't willing to take the risk, and I don't think anyone should feel they have to.

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HopingToHelp

Please, please wobblybee, will you take a look at the "Care Opinion" site, filtered on "Hysteroscopy".

Some accounts are positive but many of these are "GA" cases. Too many carried out in Out Patients are really traumatic to read. They use words like agonising, traumatic, barbaric, medieval torture, as causing panic and nausea.

Many women feel violated. They were not warned of the very real possibility of extreme pain beforehand, so could not make an informed choice about their treatment. They are sent on their way, bewildered and struggling to come to terms with what has just happened.

I specifically asked about pain as I'd suffered during a procedure some years earlier. I was assured there'd be none. I was then subjected to the worst off-the-scale pain I have ever known. No one treating me was alarmed or particularly concerned, so I have to assume it happens day in day-out.

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wobblybee
wobblybeeAdministrator
in reply to HopingToHelp

🙂 I have logged onto careopinion.org.uk ...and fully accept everything that is said about this procedure, and also that it won’t be the same for everyone.

I read one post where someone was distraught about having the procedure, and was given the option of a general anaesthetic. Obviously it’s likely that this will only be available in a Hospital situation, so there’s a need to know this when deciding where to actually have the procedure.

The purpose of ‘women’s health’ is to discuss, support and advise whenever possible. None of us here are medical professionals, we can only advise, using either general information or personal experience.

It’s to the benefit of us all that situations such as ‘painful Hysteroscopy’ are brought to light. And, hopefully as women persist in demanding adequate pain relief (as required personally), this situation will satisfactorily resolve.

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distractonaught

Thanks Wobblybee, I completely agree that the more we talk about these issues the better able we'll be to ensure proper treatment for everyone.

Nobody is saying that everyone who has an outpatient hysteroscopy will have a terrible experience, but that a significant enough minority will (some studies say up to 30% and with certain risk factors this could be even higher) and that anyone being referred for one should be getting this information along with the option of a GA up front. They certainly should not be expected to try it and only get GA if they can't take it.

As to your point about setting, this actually won't enter into most patients' decision making at all, because all hysteroscopies are carried out in hospitals - it's a surgical procedure. The term 'outpatient' is simply being used to refer to the lack of anaesthetic and a 'quicker' procedure in theory, so patients can usually drive home etc, as opposed to an 'inpatient' procedure that might only take a couple of hours but requires patients to be looked after following the procedure and escorted home.

The 'outpatient' service is being used to cut costs by some trusts, and is being presented as 'improving choice', but it's not really a choice if women don't know that this is a form of surgery that's actually quite invasive and that it's always been done under GA until recently for a reason. And there are questions to be asked about why this cost-cutting is not happening in comparable procedures that men also undergo such as colonoscopy - where sedation is always offered.

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thelordsanger

hysterscopy should only be done in a hospital setting even if they do not use anathetic as although it is rare perforated wombs and some times death does occur most still happen at hospital. comunaty setting are rare and should not be promoted this offering a GA is actually a legal right and if they can not have a GA there is epidural ect. Supporting and advice does not always mean saying it will all be ok some times it means saying the treatment they want to/or have given you is unexseptable and often illegal ie informed consent laws please look up Nadine Montgomery 2015/16

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distractonaught

As far as I'm aware hysteroscopy is always done in a hospital. It's an operation.

I think it's perhaps telling that people hear the word 'outpatient' and think of it as something less invasive. And I suspect that's why it's being referred to in this way.

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thelordsanger

there called community hospitals and unfortunately itis increasing although very rare because of how the NHS is run there are elements of privatized as was the case in my wife (health haromine) as there community hospital witch is nothing more than a desiccated doctors surgery they don,t have any local as they are Birmingham based and im stoke based it has to be said if i han not of done my research she might of opted for it as you can park not get as anxios not wait with other women haveing the same thing(not here other women scream) they are more plesant to go to i might ask health harmonie about falsity in case of emergansys

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HopingToHelp

Hello Wobblybee. Not sure I have understood your reply.

To my knowledge they're always done in hospital. Regardless though, the lack of access to GA is not due to WHERE they are carried out, it is because women are

1) Not even told that it is an option

2) Not told that this might be so painful they NEED GA ( told it is "just like a smear")

3) terrified they have womb cancer, are desperate for a result. They believe that if they curtail this hysteroscopy they'll just have to come back and endure it all over again.

The account you read where a woman was distressed then given the offer of GA was not typical. Normally the procedure continues. Please see the VERY RECENT Care Opinion posts that state:

~ ~ ~ "it was the worse pain I've ever experienced. In the past I've had a c-section, spinal surgery and a colonoscopy (with gas & air). Speculum insertion was fine however thereon in: biopsies and polyp removal, (which was discovered whilst I was there and they struggled to remove) was absolutely excruciating. I thought I had a high pain tolerance but this was off the scale. I sobbed like a baby and was desperate for it to be over.". This woman was offered NO pain relief.

~ ~ ~ "I was told it would be "Uncomfortable" well that was the understatement of the year, it was sheer agony I felt like I was being stabbed inside then I had water inserted to open up the cervix this was unbearable just when I thought it couldn't get any worse I was told that a biopsies would be take the pain i cannot describe i was writhing in agony i begged them to stop in the end i lifted my legs out of the stirrups and grabbed their arm and shrieked PLEASE STOP which they did,"

~ ~ ~ "What happened next I could only describe as one of the worst experiences of my life. As I said before I've given birth naturally twice but this was nothing in comparison. I felt severe pain immediately as this rod pierced through my cervix and I immediately started to panic." Again - no offer of pain relief.

You have to agree this is pretty barbaric?!

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wobblybee
wobblybeeAdministrator
in reply to HopingToHelp

It is barbaric.

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Lora7again

I have had 3 because of fibroids and I had mild period like pains afterwards and felt ok. I wasn't given a general for them either ... it was like having a smear.

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Lora7again

I also had a cervix biopsy and when I arrived the Doctor was surprised I had not brought anyone with me and that I had driven myself. I soon found out why because even though the procedure was painless on the way home in the car I felt a rush of blood and I started to bleed heavily so when I got home I rang my GP. She said that a biopsy from the cervix can cause heavy bleeding so I must raise my legs and see if it stops after an hour if it doesn't call an ambulance. Luckily it did stop but I was very alarmed by it. All tests showed I didn't have cancer just fibroids and thyroid disease which had caused the bleeding and the lining of my womb to build up.

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thelordsanger

That,s great you had no problems but were you offered a GA was there gas and air on hand because is is not uncommon to have server pain afterwards did they take your history like are births csection ect what we have seen a lot of is when women have a bad time at least %25 and that is being generous when they have a bad time they are told there unusual and I know of one lady she was told but all the other women that find it of would have there treatment delayed if we gave pain relief so blame the victim I know of women being told by there consultant that find it ok to tell other women to stop making a fuss. Instead we should be educating women to see if there sutable and to know it is always a Rick even in the beast cases

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Lora7again

No I wasn't offered anything just told to take paracetamol. I do have a high pain threshold and gave birth to my son with no pain killers. However when I had kidney stones I had to take strong pain killers to pass them. Everyone is different. children

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thelordsanger

paracetamol only helps with the after pain. but they have broken the law by not telling you your options called informed consent laws (Nadine Montgomery vs larkishire 2015) but unfortunately litigation is rare

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distractonaught

Have you ever given birth? I have heard this can make it easier for some women (but not all). One of the reasons I insisted on a GA was that I have not, and this is a risk factor for severe pain - but not all women are warned about this. I have had some similar tests done in the past (colposcopy etc) and I screamed and nearly leapt off the bed at one point due to sudden pain. The dr said that all he had done was touched my cervix with an instrument - so I can't even imagine how excruciating it would have been to have something pushed through it, let alone biopsies taken without anaesthetic.

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Lora7again

I have had two children

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Clarke67

So pleased you were offered a GA . This didn’t happen with me , I was told it would be like a smear. Just how wrong could they be. The worst pain I ever experienced. Of the VAS scale. That was over 18 months ago, still have problems with flashbacks and nightmares . No relevant history was taken I was only asked 4 questions. This is a very important test for womb cancer that should have pain control it is barbaric no place in a civilised society.

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Dolphin14

I've been a member on the sidelines of this group.

I live in the US. I've had this procedure and it was torture. I never complain of pain. At one point I said yo the MD I would rather have a hysterectomy than be put through this!

The cramping after was horrible. I feel for everyone that has gone through it. " Take Motrin" does nothing.

I've used the word barbaric and in humane

To describe it.

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Dolphin14
Dolphin14
in reply to Dolphin14

I will also add it was done in the md office not a hospital. I tell you right now if I ever had to have it again it will be in a hospital.

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distractonaught

Thanks for checking in. It's awful that this seems to be seen as acceptable practice everywhere, when we're talking about countries that can easily afford proper healthcare for all. It's as if women don't count.

I think it's a lot more common to have procedures done in a primary care setting in the US than it is here in the UK. They don't even take blood tests in most doctor's surgeries here, and any sort of procedure with a surgical element happens in a hospital.

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Dolphin14

It's totally insane. I was not prepared at all for that.

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77Horse

I had a hysteroscopy with no pain relief crying with pain and bleeding . I got to the point where I don't want to go to a genecology appointment ever again!

Well I have another appointment have to have a hysteroscopy do I

just ask for pain relief ? Very worried about it .

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distractonaught

Hi there, really sorry to hear about your experience. Have you filled in the survey yet?

If you need to have another one it will have to be under general anaesthetic. There's no reliable 'pain relief' for hysteroscopy, as local anaesthetic doesn't work well for this type of surgery and the injection itself can make the experience even more painful. GA is really the only effective means of making the procedure comfortable.

Have you called the clinic yet to tell them you won't be having another one while you're awake? I would suggest you do this ASAP as you'll need to be rebooked and have a pre-assessment consultation too. This was what I did. Good luck, and don't let anyone try to talk you into having this done in an outpatient clinic.

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77Horse

No I haven't . How long is the recovery as I may have to have in outpatients !?

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distractonaught

With a GA? I had the operation in the morning, about 10am. I was home by about 2.30pm. Felt absolutely fine afterwards.

You DO NOT have to have this done in outpatients. Tell the hospital that you want it rebooked as a day case under GA.

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77Horse

Is it bad to say I am so anxious about it?

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distractonaught

Of course not - how could you not be anxious knowing what it's like?

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77Horse

Well that is what I say but people don't see it like that . The thought of it makes me want to cry . How ill do you feel with ga ?

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distractonaught

I'm sorry. Please trust me when I say that plenty of people DO see it like that and are very much on your side. I didn't feel ill at all with the GA, it was done very quickly and I must have only been under for about half an hour. Had little to no pain afterwards. I think it's the only way they should do it.

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77Horse

No pain or spotting or bleeding ? Maybe ga is the way forward it makes me feel worried the time under . Maybe I should just suffer the pain .

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distractonaught

Hi there, well I had virtually no pain and a small amount of bleeding/spotting. I was worried about it too, but I decided it was far less of a concern than enduring pain unnecessarily. Up to you of course, but why should you have to suffer the pain when they can easily give you a light GA? Seems very unreasonable in 2019.

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77Horse

I will go for GA but I personally think there should be other pain relief options as not everyone would want to go ga and may suffer . Ga is such a worry for some . With all the pain relief out there maybe there should be something else . Do you agree with me ?

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77Horse
77Horse
in reply to 77Horse

Thank you for all your support .

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distractonaught

Oh I COMPLETELY agree. I thought it was really over-the-top that the options seemed to be no pain relief whatsoever or full GA. I couldn't understand why it wasn't done under conscious sedation for example (as is the case with most other endoscopy procedures). This is one point that Hysteroscopy Action are campaigning for.

My advice is purely based on the available options at the present moment in time. It's a lesser evil. Though I would stress once again that I was terrified about GA and only did it because I didn't want pain and knew I would not be able to complete the procedure awake so it would have been a waste of doctors' time to even try it. In the event, I had no reason to be scared as the theatre staff were wonderful and completely put me at ease. It's such a short op that it really isn't a big risk.

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