Interpretation of findings
Ensuring adequate pain relief and allaying anxiety during outpatient
hysteroscopy can be challenging and can impact women’s satisfaction with
the experience. Appropriate patient selection, counselling and adequate
pain management during the procedure can improve patient experience,
reduce the number of failed procedures, and improve safety, accuracy and
effectiveness of the procedure.
There is a lack of consensus on the choice of analgesia for outpatient
hysteroscopy 9 with a recent metaanalysis and
systematic review suggesting oral NSAIDS and TENS for pain
relief.35 Despite this, there has been limited
research into the role of distraction techniques in the management of
pain and anxiety in ambulatory gynaecological procedures with no
published studies on virtual reality as a pain relief
modality.26 Nonpharmacological options of pain relief
at outpatient hysteroscopy include music 36,37,
hypnosis, vaginoscopic methods of hysteroscopy,38adjusting the temperature and pressure of distension medium, stretching
of the uterus with a full bladder and electricity via TENS26 watching the screen39 ,
conversation with positive suggestion and guided imagery. Our study
provides new evidence that VR distraction techniques could be used in
future to enhance the range of pain relief options.
Our qualitative findings are suggestive of the psychological mechanisms
by which VR reduces pain but further research is needed in this area.
Interaction with VR uses a substantial amount of the patient’s limited
controlled attentional resources.40.41 42 . By virtue of spending lesser
time thinking about the by via distracting the patients, the
intervention may operate to reduce pain scores.
From a service implementation perspective, insights generated from the
themes suggested offering a multimodal pain relief strategy to improve
experience at outpatient hysteroscopy. Qualitative analysis suggested
patient profiling based on history, taking into consideration patient
preferences by offering a variety of distraction techniques with a range
of videos to choose from were they to choose virtual reality as a
distraction technique. The analysis offered key insights around managing
patient expectations around the degree of pain relief with virtual
reality and implementation strategies around transferring research
finding into clinical setting.
The study showed a large sized reduction in scores in pain or anxiety
with virtual reality, even though it is unlikely to eliminate pain
completely. The intervention was well tolerated with no serious side
effects. It would be useful to compile core outcome sets based on
patient reported outcomes for pain and anxiety towards future research
in ambulatory gynaecological procedures. Algorithmic prediction of the
types of patients who would benefit most from the intervention should
also be modelled in future trials based on patient characteristics and
baseline pain and anxiety scores.
The type of VR equipment and the degree of interaction with the video is
likely to effect the analgesic effectiveness.19Virtual reality is an evolving technology and designing appropriate
content of the video with adequate duration, headsets and hygiene masks
to comply with infection control protocols and also have affordances and
good aesthetics that make it comfortable to wear would be paramount
prior to clinical adoption, which would need codesign with patients and
manufacturers. It would be appropriate to have a range of videos for the
patient to choose from, which might be with our without narration. Other
avenues include using virtual reality for patient education for
familiarisation with the procedure and using it as a triage prior to
offering it as an intervention for pain relief.