Use of Misoprostol Before Hysteroscopy: A Systematic Review

Objective: To evaluate the effectiveness of administering misoprostol prior to hysteroscopy in achieving cervical dilatation and reducing complications including cervical laceration. Data Sources: Computerized searches of MEDLINE, PubMed and EMBASE were conducted using the key words "hysteroscopy" and "misoprostol." References from identified publications were manually searched and cross-referenced to identify additional relevant articles. Study Selection: We included randomized clinical trials that compared women undergoing hysteroscopy who received misoprostol before the procedure with those who received placebo. Studies were excluded if there was no control group, if placebo was not used, if women were not randomized, or if only the abstract was available. Ten of 19 articles identified met the criteria for systematic review. Data Extraction and Synthesis: The two co-authors separately abstracted data. Any differences in data abstraction were resolved through discussion, and a consensus was reached. QUORUM guidelines for meta-analyses and systematic reviews of randomized controlled trials were followed. In premenopausal women, misoprostol before hysteroscopy resulted in a reduced need for further cervical dilatation (relative risk [RR] = 0.61; 95% confidence interval [CI] = 0.51, 0.73), a lower rate of cervical laceration (RR 0.22; 95% CI 0.09, 0.56) and increased cervical dilatation (weighted mean difference 2.64; 95% CI 1.73, 3.54). In premenopausal women, misoprostol also resulted in a higher rate of side effects, including vaginal bleeding (RR 11.09; 95% CI 3.08, 40.00), cramping (RR 7.98; 95% CI 3.38, 18.84), and elevated temperature (RR 5.24; 95% CI 1.37, 20.09). For every four premenopausal women who received misoprostol prior to hysteroscopy, one woman avoided the need for further cervical dilatation. For every 12 premenopausal women receiving misoprostol, one cervical laceration was avoided. Conclusion: In premenopausal women, misoprostol appears to be promising as a cervical ripening agent prior to hysteroscopy, although further research is needed to identify the ideal dose, route, and timing. Further research in postmenopausal women or those receiving GnRH agonists is also needed, to determine whether misoprostol is effective in cervical ripening in this population.