***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: OBJECTIVE To assess whether IV tramadol before outpatient hysteroscopy could reduce procedure-related pain . DESIGN A r and omized double-blind placebo controlled trial . SETTING Outpatient Hysteroscopy Centre in the Department of Obstetrics and Gynaecology of Cagliari University . PATIENT(S ) Fifty healthy , parous , women who underwent outpatient diagnostic hysteroscopy and endometrial biopsy .  INTERVENTION(S ) R and om IV infusion of tramadol or placebo before hysteroscopy and endometrial biopsy were performed . MAIN OUTCOME MEASURE(S ) Visual analogue scale of pain was measured both immediately after and 15 minutes after the procedure . Stress hormones ( ACTH , cortisol ) , blood pressure , and heart frequency were evaluated before , during , and 15 minutes after the procedure . RESULT ( S ) In the tramadol group , the visual analogue scale of pain was significantly lower than in the placebo group both immediately after the procedure and 15 minutes later . Basal levels of ACTH and cortisol did not differ between the groups . In both groups , the ACTH levels remained unchanged during the study , and the cortisol levels were higher 15 minutes after the procedure than before the procedure . Procedure time , heart frequency , blood pressure , and adverse effects did not differ between the groups . CONCLUSION ( S ) In parous women without uterine malformations , a treatment with tramadol before hysteroscopy and endometrial biopsy appears to be capable of reducing the pain and discomfort that are associated with this procedure OBJECTIVE The aim of this study was to compare traditional hysteroscopy with mini-hysteroscopy in terms of compliance , side effects and diagnostic efficacy . STUDY DESIGN We prospect ively considered 950 female c and i date s for an IVF programme . All women underwent outpatient hysteroscopy ; in 602 cases ( Group A ) a mini-hysteroscope was employed ; in 348 women ( Group B ) a 5-mm hysteroscope was adopted . RESULTS Cavity findings were similar in both groups . Endometrial polyps and uterine septum seem to be more frequent in our infertile patients than in the general population . No significant differences in terms of side effects were found between the groups . Mean visual analogue pain scale score was significantly lower in the patients of Group A than in those of Group B ( p<0.001 ) . CONCLUSIONS Office mini-hysteroscopy is a very effective diagnostic tool in an infertility work-up and is more widely accepted than traditional hysteroscopy . Routine use of the technique should be considered OBJECTIVE To compare the efficacy of two modalities of local anesthesia for diagnostic hysteroscopy in different steps of the procedure in terms of pain control and time required for the examination . STUDY DESIGN One hundred eighty women undergoing diagnostic hysteroscopy were included in the study and r and omly allocated to one of two groups . Group A ( n = 88 ) , treated with prilocaine plus lidocaine cream , and group B ( n = 92 ) , treated with lidocaine spray , were compared with group C , a control group ( n = 165 ) , including all the hysteroscopies performed without anesthesia in the same period . Duration of the hysteroscopic examination was recorded ; intensity of pain induced by the procedure and shoulder pain 10 minutes after the end of the examination were recorded for all patients on the basis of a four-point pain scale . RESULTS Duration of the procedure required was two minutes in a significantly lower percentage of patients in group A as compared to groups B and C. Furthermore , in group A we found a significant reduction in pain at placement of the tenaculum in comparison to groups B and C. In groups A and B , no patient experienced a " very painful " grade of pain versus 4.8 % in group C. The vasovagal reaction rate was also significantly lower in both treated groups in comparison to the control group . Furthermore , the intensity of shoulder pain was significantly lower in the group receiving prilocaine plus lidocaine cream as compared to the other two groups . CONCLUSION Local anesthesia has a beneficial effect , at least in those hysteroscopies presumed to be , for whatever reasons , more cumbersome to perform . Prilocaine plus lidocaine cream was more effective than lidocaine spray in decreasing pain at placement of the tenaculum and shoulder pain after the procedure BACKGROUND Diagnostic hysteroscopy is not widely performed in the office setting , one of the reasons being the discomfort produced by the procedure . This r and omized controlled trial was performed to evaluate the effects of instrument diameter , patient parity and surgeon experience on the pain suffered and success rate of the procedure . METHODS Patients were r and omly assigned to undergo office diagnostic hysteroscopy either with 5.0 mm conventional instruments ( n=240 ) or with 3.5 mm mini-instruments ( n=240 ) . Procedures were stratified according to patient parity and surgeon 's previous experience . The pain experienced during the procedure ( 0 - 10 ) , the quality of visualization of the uterine cavity ( 0 - 3 ) and the complications were recorded . The examination was considered successful when the pain score was < 4 , visualization score was > 1 and no complication occurred . RESULTS Less pain , better visualization and higher success rates were observed with mini-hysteroscopy ( P < 0.0001 , P < 0.0001 and P < 0.0001 , respectively ) , in patients with vaginal deliveries ( P < 0.0001 , P < 0.0001 and P < 0.0001 , respectively ) and in procedures performed by experienced surgeons ( P=0.02 , P = NS and P = NS , respectively ) . The effects of patient parity and surgeon experience were no longer important when mini-hysteroscopy was used . CONCLUSIONS Our data demonstrate the advantages of mini-hysteroscopy and the importance of patient parity and surgeon experience , suggesting that mini-hysteroscopy should always be used , especially for inexperienced surgeons and when difficult access to the uterine cavity is anticipated . They indicate that mini-hysteroscopy can be offered as a first line office diagnostic procedure STUDY OBJECTIVE To assess acceptability and cardiovascular complications of hysteroscopy performed with minihysteroscopes compared with those performed with conventional hysteroscopes . DESIGN Prospect i ve , r and omized clinical trial ( Canadian Task Force classification I ) . SETTING Academic research center . PATIENTS One hundred women with abnormal uterine bleeding . INTERVENTIONS Hysteroscopy with a 3.5-mm minihysteroscope or conventional 5-mm endoscope with no anesthesia . MEASUREMENTS AND MAIN RESULTS Duration of examinations , pain , and occurrence of vasovagal reactions were recorded . Pain was assessed by visual analog scale ranging from zero to 20 before ( pain expectancy ) and at the end of the procedure . Occurrence of vasovagal reactions was assessed by monitoring blood pressure and pulse rate at 1-minute intervals during the procedure . A heart rate of less than 60/minute or a reduction greater than 20 % compared with baseline was considered a vasovagal reaction ; similarly , a reduction in blood pressure exceeding baseline value by 20 % was considered a result of vagal stimulation . Mean duration was shorter for minihysteroscopy than for conventional hysteroscopy . The mean ( SD ) level of pain experienced during minihysteroscopy also was significantly lower ( 0.76 + /- 0.65 vs 1.46 + /- 0.86 , 95 % CI-1.0 - 0.4 , p < 0.0001 ) . The number of instrumentally recorded ( 1 vs 11 cases ) and clinical vasovagal reactions ( 0 vs 6 cases ) was also significantly lower in the minihysteroscopy group than in the conventional hysteroscopy group ( p < 0.002 and < 0.02 , respectively ) . CONCLUSION New-generation minihysteroscopes make hysteroscopy easier and less painful , and carry a lower risk of vasovagal reactions than hysteroscopy performed with conventional instruments . In our experience , minihysteroscopy with vaginoscopic approach and saline distention is well tolerated , effective , and a true outpatient procedure Purpose Dilatation and curettage is frequently performed in gynecological practice . Aim of this prospect i ve r and omized double-blind placebo-controlled study was to evaluate the safety and efficacy of oral misoprostol to prime non-pregnant cervix before this procedure . Method Women requiring dilatation and curettage were included in the study . Exclusion criteria were visible growth in cervix or vagina , pregnancy , allergy to prostagl and ins , some medical disorders . Each participant was instructed to take either 400 µg of misoprostol or placebo orally 12 h before the procedure . Primary outcome measure was : diameter of the largest negotiable Hegar ’s dilator through internal os without any resistance at the beginning of the procedure . Secondary outcome measures were : percentage of women with initial cervical dilatation of ≥5 mm , time required for optimum cervical dilatation , percentage of failed procedures and complications . t test , Chi-square test and Fisher ’s test were used to compare the variables . Result Misoprostol significantly increased baseline cervical diameter in the pre-menopausal group ( p < 0.001 ) , but not in post-menopausal subjects ( p = 0.1 ) and reduced time required for cervical dilatation in both pre- and post-menopausal women . The number of patients achieving initial cervical dilatation ≥5 mm was significantly greater in pre-menopausal subjects receiving misoprostol , but not significant in post-menopausal ones . The drug was also found to be effective in both nulliparous and multiparous patients .  Side effects were comparable between two groups . Only nausea and vomiting were more frequent in post-menopausal misoprostol group than placebo ( p = 0.018 ) . Conclusion Four hundred micrograms of oral misoprostol 12 h prior to dilation and curettage was found to be beneficial in cervical priming in pre-menopausal subjects . It was also found to be effective irrespective of the parity of the patients OBJECTIVE : To compare a “ no touch ” approach to diagnostic hysteroscopy without anesthesia with traditional diagnostic hysteroscopy after intracervical injection of mepivacaine hydrochloride 3 % . METHODS : A total of 130 women undergoing diagnostic hysteroscopy were included in the study and were r and omized , using a computer-generated r and omization list to one of two treatment groups in a ratio of 2:1 . Eighty-three women underwent hysteroscopy without speculum , tenaculum , or anesthesia . Forty-seven women received intracervical anesthesia with 10 mL of 3 % mepivacaine hydrochloride solution injected at two sites ( 3:00 and 9:00 positions ) and underwent traditional hysteroscopy . Hysteroscopy was performed using a rigid 3.7-mm hysteroscope and a medium of 0.9 % saline , and the image was transmitted to a screen visible to the patient . A visual analog scale ( VAS ) consisting of a 10-cm line was used to assess the intensity of pain experienced during and after the procedure . Overall patient satisfaction was assessed during , immediately after , 15 minutes later , and 3 days after hysteroscopy . RESULTS : The mean pain score was significantly lower in the group without the use of speculum , tenaculum , or anesthesia ( VAS1 : 3.8±2.7 versus 5.34±3.23 , P=.01 ; VAS2 : 3.02±2.50 versus 4.57±3.30 , P=.008 ) . Patient satisfaction rate was similar in both groups . CONCLUSION : Patients reported significantly less pain with the altered approach to diagnostic hysteroscopy compared with patients undergoing the traditional procedure with anesthesia . This new approach can therefore be considered as a useful hysteroscopic technique . CLINICAL TRIAL REGISTRATION : Clinical Trials.gov , www . clinical trials.gov , NCT00319410 LEVEL OF EVIDENCE : PURPOSE to compare the pain reported by patients su bmi tted to hysteroscopy by the st and ard technique with carbon dioxide ( CO2 ) and to  vaginal hysteroscopy with physiological saline ( 0.9 % NaCl ) . METHODS this was a prospect i ve cohort study conducted at an ambulatory hysteroscopy service . A total of 117 patients with indication for the exam were included , being r and omly assigned to one of the groups . All patients answered an epidemiological question naire and scored the pain expected before the exam and that felt after the end of the procedure on a verbal pain scale from 0 to 10 . A speculum , traction of the cervix , insertion of a 30 masculine light source and a diagnostic shirt with a total diameter of 5 mm were used for the st and ard technique . The cavity was distended with CO2 under a pressure of 100 mmHg controlled with a hysteroflator , and a biopsy was obtained with a Novak curette . Vaginoscopy was performed without a touch by distention of the vagina with fluid , direct visualization of the cervix and introduction of the light source with two continuous-flow shirts , with an accessory channel with an oval profile , the whole set measuring 5 mm in diameter . The medium distention was 0.9 % NaCl and the pressure used was that considered to be necessary for an adequate visualization of the canal and of the cavity with an external pneumatic pressurizer . The biopsy was obtained in a directed manner using an endoscopic clamp . The mean and st and ard deviation were calculated for the quantitative variables and the frequency was calculated for the qualitative variables . The Student 's t-test was used to compare the means , and the chi 
    Output:
    
Results revealed a high prevalence of pain in outpatient  mini-hysteroscopy  .
Conclusions Office mini-hysteroscopy is painful