Prediction of Pain Before Biopsy: An Experimental Pain Assessment During Endometrial Sampling

ORİJİNAL ARAŞTIRMA Prediction of Pain Before Biopsy: An Experimental Pain Assessment During Endometrial Sampling Filiz ÇAYAN, MD, a Arzu DORUK, MD, a Bahar TAŞDELEN, b Mehmet Ali SUNGUR, b Şebnem ATICI, MD, c Saffet DİLEK, MD, a Departments of a Obstetrics and Gynecology, b Biostatistics, c Anesthesiology, Mersin University Faculty of Medicine, Mersin Ge liş Ta ri hi/re ce i ved: 19.05.2009 Ka bul Ta ri hi/ac cep ted: 05.01.2010 Ya zış ma Ad re si/cor res pon den ce: Filiz ÇAYAN, MD Mersin University Faculty of Medicine, Department Obstetrics and Gynecology, Mersin, TÜRKİYE/TURKEY filizcayan@yahoo.com ABS TRACT Objective: Experimental human pain models have been used as a predictor of pain producing interventions. We prospectively evaluated whether the assessment of experimental pain perception using the modified tourniquet test before the procedure could predict the level of pain scores during endometrial sampling. Material and Methods: Sixty premenopausal women who underwent endometrial biopsy for abnormal uterine bleeding were prospectively enrolled in the present study. The day before biopsy, a modified submaximal effort tourniquet test was performed on all patients. During the test, pain scores were recorded at 30, 60, 90 and 120 seconds after inflation of the blood pressure cuff. Pain scores were also recorded during cannula introduction into the uterus and endometrial biopsy. Pain was assessed using a visual analogue scale (VAS). Results: There was a significant correlation between the VAS scores in the tourniquet test and the VAS scores during cannula introduction and the VAS scores during endometrial biopsy (p<0.0001). The most significant correlation was found between the VAS scores during endometrial biopsy and the VAS 90-second scores during the tourniquet test (p<0.0001, r=0,836). Conclusion: A simple and quick tourniquet test could be useful to identify patients who may experience severe pain during endometrial biopsy. In light of our data, personal adjustment of analgesic treatment would increase the patient acceptability and compliance with the procedure. Key Words: Biopsy; pain measurement ÖZET Amaç: Ağrı yaratan girişimlerde öngörüde bulunmak için deneysel insan modelleri kullanılmıştır. İşlemden once modifiye turnike testi kullanılarak deneysel ağrı algısının değerlendirilmesinin endometrial örnekleme sırasında ağrı skorlarının düzeyini öngörüp göremeyeceğini prospektif olarak değerlendirdik. Gereç ve Yöntemler: Bu çalışmada anormal uterin kanama için endometrial biyopsi yapılan altmış premenopozal kadın prospektif olarak kaydedildi. Biyopsiden önceki gün tüm hastalara modifiye submaksimal efor turnike testi uygulandı. Test sırasında, kan basıncı manşonu şişirildikten sonraki 30,60,90 ve 120. saniyelerde ağrı skorları kaydedildi. Ağrı skorları aynı zamanda kanül uterusa girdiği sırada ve endometrial biyopsi sırasında da kaydedildi. Ağrı vizüel analog skala (VAS) kullanılarak değerlendirildi. Bulgular: Turnike testi, kanülün girişi ve endometrial biyopsi sırasındaki VAS skorları arasında anlamlı ilişki vardı (p<0.0001). En anlamlı ilişki endometrial biyopsi sırasındaki VAS skoruyla turnike testi sırasındaki 90. saniye VAS skoru arasında bulundu (p<0.0001, r=0,836). Sonuç: Basit ve hızlı bir turnike testi endometrial biyopsi sırasında ciddi ağrı çekebilecek hastaları belirlemek için yararlı olabilir. Bizim verilerimiz ışığında, ağrı kesici tedavinin bireysel olarak ayarlanması hastanın işleme uyumunu artıracaktır. Anah tar Ke li me ler: Biyopsi; ağrı ölçümü :1196-200 Cop yright 2010 by Tür ki ye Kli nik le ri ndometrial biopsy is a very common investigation performed for various indications, such as abnormal uterine bleeding, postmenopausal bleeding, abnormal cytology and infertility. Although it is usually performed as an outpatient procedure under either local or no anesthesia, 1196

Gynecology and Obstetrics pa ti ent ac cep ta bi lity and comp li an ce with the proce du re might be dif fi cult be ca u se of as so ci a ted pa - in. 1-6 Pa in is a sub jec ti ve ex pe ri en ce, and the pa ti - ent s per cep ti on of pa in du ring en do met ri al bi opsy chan ges from per son to per son. So me in di vi du als se em to be highly sen si ti ve to pa in du ring this proce du re, whe re as ot hers se em to be not. To da te, se - ve ral stu di es ha ve be en eva lu a ted the ro le of dif fe rent anest he ti cal met hods inc lu ding pa ra cer - vi cal block, de ep pa ra cer vi cal block, in tra u te ri ne li do ca i ne, to pi cal spray lig no ca i ne, and cons ci o us se da ti on to re li e ve this pa in. 7-9 On the ot her hand, anal ge sic re qu i re ment du ring the pro ce du re is highly va ri ab le among wo men. In this res pect, it is im por tant to de ter mi ne which pa ti ent would fe el se ve re pa in du ring en do met ri al bi opsy. Ex pe ri men tal hu man pa in mo dels ha ve be en used as a pre dic tor of pro ce du re- re la ted pa in. Pa - in in du ced by elec tric cur rent, he at, pres su re, icewa ter and isc he mic sti mu li are the most com monly used met hods of ex pe ri men tal hu man pa in as sess - ment. 10 Alt ho ugh se ve ral stu di es ha ve exa mi ned the ex pe ri men tal pa in res pon se as a pre dic tor of out co mes af ter pa in pro du cing in ter ven ti ons, 11 the re la ti ons hip bet we en the ex pe ri men tal pa in as sess - ment be fo re en do met ri al bi opsy and pa in sco res du ring the pro ce du re has not be en pre vi o usly repor ted. The re fo re, the aim of the pre sent study was to eva lu a te whet her the as sess ment of ex pe ri men - tal pa in per cep ti on using the mo di fi ed to ur ni qu et test be fo re the bi opsy pro ce du re co uld pre dict the pa in sco res du ring en do met ri al bi opsy. MA TE RI AL AND MET HODS This pros pec ti ve study inc lu ded 75 pre me no pa u sal wo men with nor mal Pap tests, who un der went endo met ri al samp ling for ab nor mal ute ri ne ble e ding, between Ja nu ary 2008 and Ju ne 2008. Fif te en pa ti - ents we re exc lu ded from the study: seven of them re fu sed to par ti ci pa te in the study, and eight did not me et the inc lu si on cri te ri a (cer vi cal ste no sis in four, acu te cer vi ci tis in three, and epi lepsy in one). The re fo re, the study inc lu ded 60 wo men who under went en do met ri al samp ling for ab nor mal ute ri - ne ble e ding. Çayan et al All pa ti ents we re eva lu a ted with a de ta i led his tory and physi cal exa mi na ti on. Any pa ti ent with a his tory of se ve re me di cal ill ness (e.g., he art fa i lu - re, di a be tes mel li tus, ne u ro lo gic di se a se), chro nic pa in con di ti ons inc lu ding fib rom yal gi a, art hri tis, chro nic pel vic pa in that might le ad to pa in, cer vi - cal ste no sis, preg nancy, sus pec ted pel vic inf lam - ma tory di se a se, acu te cer vi ci tis or ne ed for co in ci dent en do cer vi cal cu ret ta ge as well as any patient who was currently on analgesic treatment was exc lu ded from the study. Be fo re at ten ding for en do met ri al samp ling, a writ ten in for med con sent was ob ta i ned from all pati ents, and the study pro to col was ap pro ved by the Me di cal Et hics Com mit te e of the Uni ver sity of Mer sin Scho ol of Me di ci ne, and we con for med to the et hi cal gu i de li nes of the 1975 Hel sin ki dec la - ra ti on. No par ti ci pant was gi ven se da ti on or lo cal anest he si a. Du ring en do met ri al samp ling pro ce du - re, pa ti ents we re pla ced in a lit ho tomy po si ti on, and a bi ma nu al exa mi na ti on was per for med to assess the si ze and the po si ti on of the ute rus. The cer - vix was ex po sed with a bi val ve spe cu lum and cle a ned with be ta di ne (10% po vi di ne-io di ne so lu - ti on). The 5 mm Kar man Va cu um As pi ra tor Cu ret - te was then pus hed in to the ute ri ne ca vity for a mi ni mum of 4 pas ses to en su re full samp ling. Each suc ti on samp le was fi xed in 10% for mal dehy de and sta i ned with ha e ma toxy lin-eo sin sta in. To ma in ta - in con sis tency and li mit con fo un ding va ri ab les, all pro ce du res we re per for med by the sa me gyne co lo - gist (A.D.) who used the sa me tech ni qu e to samp - le the en do met ri um on an out pa ti ent ba sis. The day be fo re en do met ri al bi opsy, a mo di fi ed sub ma xi mal ef fort to ur ni qu et test was used to evo - ke isc he mic pa in. 10 First, the non do mi nant arm was occ lu ded with a stan dard blo od pres su re cuff inf la - ted to 20 mmhg hig her than the pa ti ent s own systo lic blo od pres su re to abo lish ar te ri al blo od supply and to ren der the arm hypo xic. Pa ti ents we re then ins truc ted to per form 20 hand grip exer ci ses. Isc he - mic pa in thres hold was de ter mi ned by re cor ding the ti me (se conds) when sub jects first re por ted hand or fo re arm dis com fort. Isc he mic pa in to le ran - ce was de ter mi ned by re cor ding the ti me (se conds) when sub jects co uld no lon ger en du re the ir isc he - 1197

Çayan ve ark. mic arm pa in. Du ring the test, pa in sco res we re re - cor ded 30, 60, 90 and 120 se conds af ter inf la ti on of the cuff. We al so re cor ded pa in sco res du ring cannu la in tro duc ti on in to the ute rine ca vity and en do - met ri al bi opsy. The pa in sco res we re re cor ded using a vi su al ana lo gu e sca le (VAS), and a tra i ned nur se ins truc ted the pa ti ents be fo re the pro ce du re how to sco re the ir pa in. 12 Ac cor ding to the VAS, 0 cor res - pon ded to no pa in and 10 to the gre a test pa in ima - gi nab le. The re la ti ons hips bet we en the VAS sco res in the to ur ni qu et test, tho se du ring can nu la in tro - duc ti on and en do met ri al samp ling we re exa mi ned. The most com monly used met hods of ex pe ri men - tal hu man pa in as sess ment inc lu de elec tri cal, he at, pres su re, ice wa ter, and isc he mic pa in. We used a mo di fi ed sub ma xi mal ef fort to ur ni qu et test as an isc he mic pa in pro ce du re. Sta tis ti cal da ta analy sis was per for med using The Sta tis ti cal Pac ka ge for So ci al Sci en ces, ver si on 11.5, for Win dows (SPSS, Chi ca go, ІІІ). Sin ce VAS sco res did not show nor mal dis tri bu ti on, the re la ti - ons hip bet we en the VAS sco res du ring the bi opsy pro ce du re and to ur ni qu et test were eva lu a ted using Spe ar man s rank cor re la ti on analy sis. A P va lu e less than 0.01 was con si de red sta tis ti cally sig ni fi cant. RE SULTS Me an age of the pa ti ents in the pre sent study was 45.87 ± 9.08 ye ars (as me an ± SD) (ran ge 30 to 55). VAS sco res in the to ur ni qu et test and at va ri o us sta - ges of the en do met ri al bi opsy we re shown in Fi gu - re 1. Me di an VAS sco res in the to ur ni qu et test at 30, 60, 90 and 120 se conds we re 2 (ran ge 1 to 6), 4 (ran ge 2 to 8), 5 (ran ge 3 to 9) and 7 (ran ge 3 to 10), res pec ti vely. Tab le 1 shows the Spe ar man s rho cor re la ti on co ef fi ci ents among the VAS sco res in the to ur ni - qu et test, du ring can nu la in tro duc ti on and en do - met ri al bi opsy, and P va lu es be long to the se cor re la ti on co ef fi ci ents. A sig ni fi cant cor re la ti on was fo und bet we en the VAS sco res in the to ur ni - qu et test, can nu la in tro duc ti on and en do met ri al bi - opsy (p< 0.01). The most sig ni fi cant cor re la ti on was fo und bet we en the VAS sco res du ring en do met ri - al bi opsy and the VAS 90-se cond sco res in the to - ur ni qu et test (p< 0.01, r= 0.836; Tab le 1 and Fi gu re Kadın Hastalıkları ve Doğum TABLE 1: Spearman s rank correlation coefficient between visual analog scale scores in tourniquet test and endometrial biopsy. Tourniquet test (s) Cannula introduction Endometrial biopsy VAS 30 r=0.091 p>0.01 r=0.184 p>0.01 VAS 60 r=0.507 p<0.01 r=0.607 p<0.01 VAS 90 r=0.516 p<0.01 r=0.836 p<0.01 VAS 120 r=0.378 p<0.01 r=0.401 p<0.01 FIGURE 1: Median VAS scores in tourniquet test and biopsy procedure. VAS: Visual analog scale. 1). Anot her sig ni fi cant cor re la ti on was fo und bet - we en the VAS sco res du ring en do met ri al bi opsy and the VAS 60-se cond sco res in the to ur ni qu et test (p< 0.01, r= 0.607; Tab le 1 and Fi gu re 1). The - se re la ti ons can be interpreted as subs tan ti al cor re - la ti ons. No ma jor comp li ca ti ons oc cur red, and no pa ti ent re qu i red ad mis si on to hos pi tal af ter the proce du re. Only one pa ti ent ex pe ri en ced va so va gal synco pe and re co ve red spon ta ne o usly. DIS CUS SI ON En do met ri al bi opsy is an es tab lis hed gyne co lo gic offi ce pro ce du re to col lect tis su e for his to lo gic eva lu - a ti on of the en do met ri um. 1-6 It is as so ci a ted with so me dis com fort and pa in from the pro ce du re it self which is one of the most com mon si de ef fects. Alt - ho ugh this pro ce du re is con si de red sa fe and is commonly per for med on an out pa ti ent ba sis, the pa in du ring en do met ri al bi opsy is the most com mon re - a son for fa i lu re to comp le te the pro ce du re. 13,14 1198

Gynecology and Obstetrics The re ha ve be en se ve ral conf lic ting re ports on va ri o us met hods of pa in re li ef du ring an en do met - ri al bi opsy, and the conf lic ting re sults can be exp - la i ned as in di vi du al dif fe ren ces in pa in sen si ti vity and va ri a ti ons in the pa in as sess ment met hods. 15-19 Be ca u se of the pa in ex pe ri en ced du ring en do - met ri al bi opsy is highly va ri ab le among wo men, the le vel of pa in in ten sity is cri ti cal. Ex pe ri men tal hu man pa in mo dels ha ve be en wi dely used, and pre o pe ra ti ve pa in sen si ti vity has be en fo und to pre dict for the se ve rity of pos to pe - ra ti ve pa in by se ve ral in ves ti ga tors. 11 Ho we ver, no sing le best ex pe ri men tal pa in test has be en ac cep - ted in pub lis hed re ports. It has be en re por ted that pre o pe ra ti ve ra ting of an in ten se no xi o us ther mal sti mu lus was strongly cor re la ted with jo int pa in ra ting af ter an te ri or cru ci a te li ga ment re pa ir. 20 Granot et al. de mons tra ted that pre o pe ra ti ve ex pe ri - men tal pa in me a su re ment was use ful in iden tif ying tho se pa ti ents who would ex pe ri en ce se ve re pa in af ter Ce sa re an sec ti on. 21 Si mi larly, Bis ga ard et al. re por ted that pre o pe ra ti ve ex pe ri men tal pa in was sig ni fi cantly re la ted to the in ten sity of pos to pe ra ti - ve pa in in pa ti ents who un der went la pa ros co pic cho lecy stec tomy. 22 Re cently, So yu pek et al. fo und that the re was a strong cor re la ti on bet we en ex pe - ri men tal pa in as sess ment be fo re bi opsy and amo - unt of pa in ex pe ri en ced du ring the tran srec tal ul tra so und gu i ded pros ta te bi opsy. 23 The suc cess ful re sults of tho se pre vi o us stu di - es led us to in ves ti ga te an ex pe ri men tal hu man pa - in mo del for en do met ri al bi opsy. We used a mo di fi ed sub ma xi mal ef fort to ur ni qu et test as an isc he mic pa in pro ce du re, and the pre sent study is the first one that shows the ex pe ri men tal pa in assess ment be fo re the pro ce du re can ser ve as a predic tor of the pa in ex pe ri en ced du ring en do met ri al bi opsy. In the pre sent study, pa in sco res as ses sed by the mo di fi ed to ur ni qu et test be fo re en do met ri al bi - opsy cor re la ted sig ni fi cantly with the pa in sco res du ring the pro ce du re. Mo re o ver, the best cor re la - ti on was fo und bet we en the VAS sco res du ring endo met ri al bi opsy and the VAS 90-se cond sco res in the to ur ni qu et test. In this res pect, the VAS 90-se - Çayan et al cond sco res in this ex pe ri men tal pa in mo del may be use ful in iden tif ying tho se pa ti ents who will expe ri en ce se ve re pa in du ring en do met ri al bi opsy. It is im por tant to iden tify and know which pati ents are mo re li kely to ha ve se ve re pa in, sin ce certa in anal ge sics co uld be re ser ved for the pa ti ents who are at risk of pa in in to le ran ce. In ad di ti on, targe ting this gro up be fo re en do met ri al bi opsy may eli mi na te the oc cur ren ce of in to le ran ce due to pa - in and interruption of the procedure. Ex pe ri men tal pa in mo dels are al so used to inves ti ga te anal ge sic drug ef fects and are im por tant to ols to com pa re the anal ge sic po tency of dif fe rent drugs. To da te, the anal ge sic po tencies of pa in re li - e ving tre at ments du ring en do met ri al bi opsy has not be en in ves ti ga ted in ex pe ri men tal hu man pa in mo dels. As we did not per form any pa in re li e ving met hods in the pre sent study, it was pos sib le to eva lu a te the re la ti ons hip bet we en the ex pe ri men - tal pa in as sess ment be fo re en do met ri al bi opsy and pa in sco res du ring the bi opsy pro ce du re. In the light of the se fin dings, ad di ti o nal pros pec ti ve stu d- i es will be ne ces sary to eva lu a te whet her ex pe ri - men tal pa in as sess ment be fo re the pro ce du re co uld pre dict the anal ge sic po tency of pa in re li e ving tre - at ments du ring en do met ri al bi opsy. Ho we ver, targe ting the pa ti ents who will to le ra te the pro ce du re wit ho ut anest he si a be fo re en do met ri al bi opsy co - uld re sult in sa vings by avo i ding un ne ces sary analge sic use. CONC LU SI ON The re sults of our study emp ha si zed that the re was a cor re la ti on bet we en ex pe ri men tal pa in as sess - ment be fo re bi opsy and amo unt of pa in ex pe ri en - ced du ring the en do met ri al bi opsy. We sug gest that iden tif ying tho se pa ti ents who might ex pe ri en ce se ve re pa in be fo re en do met ri al bi opsy may le ad to chan ges in prac ti ce that would be cost ef fec ti ve and ti me ef fi ci ent and pa ti ent sa tis fac ti on might be improved. Furt her stu di es will be ne e ded to eva lu a te whet her ex pe ri men tal pa in as sess ment be fo re the pro ce du re co uld pre dict the anal ge sic po tency of pa in re li e ving tre at ments du ring en do met ri al bi - opsy. 1199

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