Identifying risk factors for procedural pain in outpatient hysteroscopy: A multivariable analysis

BACKGROUND: To identify patient-related clinical and anatomical factors associated with increased pain during office hysteroscopy. METHODS: This retrospective study included women who underwent office hysteroscopy without anesthesia at a tertiary referral center between August and November 2024. Pain intensity was assessed immediately after the procedure using a 10-cm visual analogue scale (VAS). Patients were categorized into no-to-mild pain (VAS < 4) and moderate-to-severe pain (VAS ≥ 4) groups. Clinical characteristics, obstetric history, uterine position, dysmenorrhea severity, and cervical width were analyzed. Univariate and multivariable logistic regression analyses were performed to identify predictors of moderate-to-severe pain. RESULTS: Among 338 women included in the analysis, aged 15-91 years, 138 (40.8%) experienced moderate-to-severe pain during outpatient hysteroscopy. Moderate-to-severe pain was significantly associated with nulligravidity, absence of prior vaginal delivery, dysmenorrhea, retroflexed uterine position, and cervical width < 4 mm. In multivariable analysis, dysmenorrhea (VAS ≥ 4) (adjusted odds ratio [aOR], 9.42; 95% confidence interval [CI], 4.87 - 18.22, p < 0.001) and cervical width < 4 mm (aOR, 6.51; 95% CI, 2.79 - 15.16, p < 0.001) were identified as independent predictors of moderate-to-severe procedural pain. Absence of prior vaginal delivery and retroflexed uterine position showed borderline associations with increased pain risk. CONCLUSION: Dysmenorrhea and narrow cervical width are strong independent predictors of moderate-to-severe pain during outpatient hysteroscopy. Recognition of these patient-specific and anatomical factors may facilitate individualized procedural planning, targeted pain management strategies, and improved tolerance of office hysteroscopy.