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.