Factors Associated with Pain Levels During Office Hysteroscopy: A Cross-Sectional Study

Abstract

The goal of this study was to identify factors associated with pain sensitivity, procedural discomfort, and referral for surgical hysteroscopy, aiming to improve office hysteroscopy success rates. This was an observational prospective cross-sectional study that analyzed data from women who underwent outpatient hysteroscopy between October 2022 and October 2023. Epidemiological, clinical, and procedural data were collected from medical records. Pain levels were assessed using a visual analog scale (VAS), categorized as acceptable (0–6) or severe (7–10). Statistical analyses were performed to explore associations between patient characteristics and pain levels, with p-values < 0.05 considered significant. This study evaluated 1662 women. The mean age was 54.0 (±12.4) years, and 59.1% were postmenopausal. Nulliparity, menopause, lower body mass index (BMI), and fewer vaginal deliveries were associated with higher pain levels (p < 0.05). Cervical stenosis significantly increased procedural pain: 20.8% and 27.6% of patients with stenosis resolved during the procedure, respectively, reported severe pain. In the multivariate logistic regression analysis, protective factors against severe pain included having ≥2 vaginal deliveries (OR 0.53, 95% CI 0.39–0.72), patent internal (OR 0.53, 95% CI 0.38–0.75) and external cervical orifices (OR 0.47, 95% CI 0.30–0.72), presence of myomas (OR 0.53, 95% CI 0.34–0.83), and biopsy performance (OR 0.55, 95% CI 0.41–0.74). Severe pain, uterine lesions, and stenosis were the main reasons for surgical referral. Lower BMI, nulliparity, menopause, and cervical stenosis were significant predictors of increased pain during outpatient hysteroscopy. These findings may help identify patients at higher risk for procedural discomfort and support strategies to improve success of office hysteroscopy.

1. Introduction

Office hysteroscopy has become a cornerstone of contemporary gynecologic care because it allows “see-and-treat” diagnosis and therapy while avoiding general anesthesia, shortening recovery, and reducing surgical backlogs. Current guidance endorses outpatient hysteroscopy for people with heavy menstrual bleeding and suspected submucosal fibroids, polyps, or endometrial pathology explicitly emphasize minimizing pain, optimizing patient experience, and ensuring informed choice of setting and analgesia [1,2]. These recommendations align with international trends and underscore the need to identify patients at risk of significant procedural pain to target preventive strategies.

Hysteroscopy has seen numerous advancements in instrumentation and techniques to improve uterine visualization and distension [3]. Since the 1980s, it has become essential in diagnosing abnormalities in the uterine cavity and endocervical canal, particularly for addressing abnormal uterine bleeding [4]. Hysteroscopy is considered the gold standard for endometrial assessment (excluding biopsy) due to its ability to combine diagnostic and therapeutic functions through direct uterine visualization [5].

In Brazil, office hysteroscopy has gradually been expanded and become more widely available over time, particularly after 2018, when the Ministry of Health implemented measures to broaden access. This progressive incorporation reflects both the growing recognition of hysteroscopy as a valuable diagnostic and therapeutic tool and the efforts to make it accessible to a wider population within the public system.

Recent innovations have facilitated the use of hysteroscopy in outpatient settings for therapeutic procedures. However, patient discomfort remains a critical challenge to its success [6]. This discomfort stems from multifactorial causes, such as parasympathetic stimulation during sheath passage through the internal cervical orifice, resulting in cramping and vasovagal effects [3]. Of note, pre-procedural anxiety is another contributing factor. A systematic review demonstrated a clear link between anxiety and heightened pain perception during hysteroscopy, with prolonged waiting times exacerbating anxiety. Interventions like music therapy have been shown to mitigate anxiety and reduce pain [6].

Pain during office hysteroscopy arises from multifactorial mechanisms, such as distension of the uterus (visceral nociception), traversal of the internal cervical os (dense autonomic and sensory innervation), and instrumentation of a stenotic or less elastic cervix—features more common after menopause [7]. Cervical and lower uterine segment stimulation can trigger vagally mediated reflexes, explaining bradycardia, hypotension, and syncope in a small subset. Understanding these pathways supports targeted measures (smaller scopes, careful passage at the internal os, judicious distension pressure) and anticipatory management in women with suspected stenosis [7,8].

Sedation during hysteroscopy is a proven method for minimizing discomfort, significantly reducing pain scores, and improving patient satisfaction [9]. However, many facilities lack a standardized analgesia protocol for outpatient hysteroscopy, exposing patients to unnecessary discomfort and procedural failure. Postmenopausal women, a significant proportion of hysteroscopy patients, often experience challenges due to cervical stenosis caused by hormonal changes that reduce cervical elasticity [10]. Such cases frequently lead to incomplete exams.

Outpatient hysteroscopy is also used for therapeutic interventions, such as polypectomy and myomectomy. However, lesion characteristics, such as size or consistency, may necessitate referral for surgical hysteroscopy [11]. This increases waiting times, which in our service currently stand at nine months, further straining public healthcare systems.

Despite the progress in hysteroscopy techniques, there remains a gap in optimizing strategies to address pain management, patient comfort, and procedural success, particularly in outpatient settings for postmenopausal women. Therefore, our study aims to identify factors influencing pain sensitivity and procedural outcomes in outpatient hysteroscopy with the distinctive feature of including patients from the Brazilian public health system in São Paulo, the largest city in the country. This design allows for the validation of findings in a population with diverse socioeconomic backgrounds, which is often underrepresented in the literature.

2. Methods

2.1. Study Design

An observational prospective cross-sectional study was conducted involving patients who underwent office hysteroscopy at the Vila Santa Catarina Municipal Hospital in São Paulo, Brazil, between October 2022 and October 2023. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist for cross-sectional studies guidelines [12] and the Declaration of Helsinki [13].

2.2. Data Collection and Variables

Data were collected from electronic medical records following approval by the Research Ethics Committee of Albert Einstein Hospital (CAAE. 69386023.6.0000.0071). All participants signed the informed consent form. After collection, epidemiological data were compiled using the encrypted electronic platform SILOG. Data entry was conducted exclusively by medical residents and preceptors from the service.

The study included patients aged 18 years or older who underwent office hysteroscopy at Vila Santa Catarina Municipal Hospital between October 2022 and October 2023. Exclusion criteria were incomplete or duplicated medical records.

The variables collected included demographic data, medical history, clinical findings, transvaginal ultrasound results, hysteroscopic observations, and histopathological results. Variables were categorized and coded to facilitate analysis. Continuous variables included age, body mass index (BMI), and endometrial thickness, while categorical variables included hypertension, diabetes, and postmenopausal bleeding status. All data processing procedures adhered to confidentiality and data protection regulations.

Pain was assessed using a visual analog scale (VAS). At the end of the examination, patients were asked to observe the VAS ruler and report their pain scores to the performing physician. Pain scores ranged from 0 (no pain) to 10 (worst possible pain) as a continuous variable, directly reflecting the discomfort experienced by each patient. This scale was chosen for its validity, practicality, and acceptance in studies of this nature. Pain was stratified into two groups, acceptable pain (scores 0–6) and unacceptable/severe pain (scores 7–10), following the classification used in previous studies [14].

2.3. Hysteroscopic Procedure

The hysteroscopic evaluations were performed in an ambulatory setting at Vila Santa Catarina Municipal Hospital, under the management of the Albert Einstein Israeli Society. In our hospital, all patients undergo office hysteroscopy as a mandatory preliminary step before being referred for surgical hysteroscopy. Procedures were carried out by medical staff and residents under supervision, ensuring consistent technique and a high standard of care despite operator variability. This structured approach also supported the educational training of residents, maintaining procedural uniformity and enhancing the reliability of clinical findings.

All procedures were performed using vaginoscopy with the patient in the lithotomy position, as previously described [15]. Two types of rigid hysteroscopic equipment were used: the Mistra hysteroscopic (Sttratner, Barueri, Brazil) set, with a total diameter of 3 mm, and the Wolf set (Richard Wolf GmbH, Knittlingen, Germany), with a total diameter of 3.2 mm.

Hysteroscopies were performed without the administration of any analgesics or anesthetics by the medical team, either locally, intramuscularly, or intravenously.

2.4. Statistical Analysis

Quantitative variables were described using means and standard deviations (SDs), medians, and ranges (minimum and maximum values). Categorical variables were presented as frequencies and percentages. The Shapiro–Wilk test was applied to assess the normality of continuous variable distributions.

Comparative statistical tests examined associations between various risk factors and pain levels. The Mann–Whitney U test was applied for nonparametric continuous variables, while Student’s t-test was used for parametric continuous variables. Categorical data were compared using Pearson X² statistics to calculate bivariate association. A two-sided p-value of 0.05 was set as statistically significant.

A logistic regression multivariate analysis was conducted using Generalized Linear Models, considering the selection of covariates based on their clinical relevance rather than their statistical significance to generate the “fully adjusted” model. Additionally, multicollinearity was assessed and appropriately addressed before selecting the final model. The output of the logistic regression was reported in Odds Ratio (OR) and their respective 95% Confidence Interval (95% CI). A sensitivity analysis using the backward stepwise approach was performed to check the consistency of our results.

A pre-specified subgroup analysis was performed to identify variables that were exclusively relevant to patients in menopause and menacme (e.g., contraceptive use and postmenopausal bleeding).

All analyses were performed using R software (R Foundation for Statistical Computing) version 4.4.2.

3. Results

3.1. Study Population

In this cross-sectional study, we included a total of 1662 participants after applying our eligibility criteria. The mean age of the included individuals in this study was 54.0 (SD 12.4) years, with a BMI of 29.5 (SD 6.1). Among the total cohort, 59.1% (982/1662) participants were postmenopausal (45.7% [760/1662] for more than five years), and 7.0% (68/976) of them were undergoing hormone replacement therapy. Postmenopausal bleeding affected 33.6% (325/968) of the postmenopausal participants. Additionally, in the total cohort, 14.8% (246/1662) participants were nulliparous, 61.9% (1029/1662) had previous uterine surgery, and 4.2% (70/1662) had an oncological history.

Among the comorbidities, systemic arterial hypertension (SAH) was the most prevalent, affecting 45.4% (754/1662) of the participants, followed by diabetes or prediabetes (323/1662, 19.4%), dyslipidemia (291/1662, 17.5%), and thyroid disorders (258/1662, 15.5%). Demographic data and clinical characteristics are summarized in

Table 1. Association of demographic and clinical data with level of pain during outpatient hysteroscopy.

Variable	0–6 (n = 1032)	7–10 (n = 630)	Missing or Not Applicable	p-Value
Age, mean (SD)	53.5 (12.3)	55.0 (12.4)	0	0.010
BMI, mean (SD)	29.9 (6.3)	28.9 (5.8)	11	0.007
Hypertension, n (%)	457 (44.3)	297 (47.1)	0	0.300
Ischemic heart attack, n (%)	19 (1.8)	17 (2.7)	0	0.200
Diabetes or prediabetes, n (%)	193 (18.7)	130 (20.6)	0	0.300
Psychiatric disorders, n (%)	84 (8.1)	58 (9.2)	0	0.500
Dyslipidemia, n (%)	170 (16.5)	121 (19.2)	0	0.200
Thyroid disorders, n (%)	147 (14.2)	111 (17.6)	0	0.060
Endometriosis, n (%)	4 (0.4)	5 (0.8)	1	0.300
Previous uterine surgery	624 (60.5)	404 (64.1)	0	0.140
Reproductive stage, n (%)			0	<0.001
Menacme	464 (45.0)	216 (34.3)
Menopause	568 (55.0)	414 (65.7)
Menopause over 5 years, n (%)	439 (42.5)	321 (51.0)	682	>0.900
Contraception, n (%)	147 (14.2)	54 (8.6)	29	<0.001
HRT use, n (%)	39 (3.8)	29 (4.6)	686	>0.900
Postmenopausal bleeding, n (%)	203 (19.7)	122 (19.4)	694	0.039
Vaginal deliveries, n (%)			0	<0.001
No vaginal delivery	419 (40.6)	327 (51.9)
1	187 (18.1)	95 (15.1)
≥2	426 (41.3)	208 (33.0)
Cesarean deliveries, n (%)			0	0.100
No cesarean delivery	520 (50.4)	291 (46.2)
≥1	512 (49.6)	339 (53.8)
Abortions, n (%)			0	0.200
No abortions	733 (71.0)	467 (74.1)
≥1	299 (29.0)	163 (25.9)
Ultrasound findings pre-hysteroscopy
Endometrial thickness, mean (SD)	10.0 (11.7)	9.7 (12.6)	55	0.036
Polyp, n (%)	280 (27.1)	177 (28.1)	0	0.700
Thickening, n (%)	321 (31.1)	187 (29.7)	0	0.500
Myoma, n (%)	321 (31.1)	187 (29.7)	0	0.500
Adenomyosis, n (%)	12 (1.2)	3 (0.5)	0	0.200
Analgesia with music, n (%)	247 (23.9)	175 (27.8)	0	0.081
Analgesia with lights, n (%)	124 (12.0)	77 (12.2)	0	>0.900
Analgesia with oral medications, n (%)	489 (47.4)	280 (44.4)	0	0.200
External orifice, n (%)			0	0.001
Persistent stenosis	52 (5.0)	19 (3.0)
Resolved stenosis	76 (7.4)	133 (21.1)
Patent	904 (87.6)	478 (75.9)
Internal orifice, n (%)			107	0.001
Persistent stenosis	28 (2.7)	81 (12.8)
Resolved stenosis	147 (14.2)	176 (27.9)
Patent	783 (75.9)	340 (54.0)
Endometrium type, n (%)			239	0.001
Atrophic	501 (48.5)	321 (51.0)
Physiologic	366 (35.5)	151 (24.0)
Suspicious	61 (6.0)	23 (3.7)
Hysteroscopy findings, n (%)
Thickening	113 (10.9)	55 (8.7)	218	0.500
Myoma	138 (13.4)	53 (8.4)	217	0.026
Endometrial polyp	520 (50.4)	301 (47.8)	218	0.110
Biopsy, n (%)	549 (53.2)	263 (41.7)	0	0.001

SD, standard deviation; n, number; BMI, body mass index; HRT, hormone replacement therapy. The association between the two groups was calculated through Student-t, Mann–Whitney, and Chi-square. p values < 0.05 were considered statistically significant.

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3.2. Indications for Office Hysteroscopy, Clinical Findings, and Complications

The primary indication for office hysteroscopy was endometrial polyp (540/1662, 32.5%), closely followed by endometrial thickening in postmenopausal women (538/1662, 32.4%), postmenopausal bleeding (158/1662, 9.5%), myoma (150/1662, 9.0%), and abnormal uterine bleeding (121/1662, 7.3%). Less common reasons are represented in Figure 1A.

During the procedure, evaluating the external cervical orifice, 4.3% (71/1662) of participants presented persistent stenosis, 12.6% (209/1662) had resolved stenosis (passage through the cervical orifice was possible after resolution of the stenosis using office hysteroscopy instruments), and 83.1% (1382/1662) had patent orifice. Evaluating the internal cervical orifice, persistent stenosis was observed in 7.0% (109/1555), resolved stenosis in 20.8% (323/1555), and patent orifice in 72.2% (1123/1555), with missing or not applicable data from 107 participants.

Pathologies diagnosed during the hysteroscopic procedure included endometrial polyps (56.9%), myoma (13.2%), and thickening in postmenopausal women (11.6%). Biopsy was performed in 48.9% of participants to investigate further tissue abnormalities. Complete resection of lesions was achieved in 50.3% of the procedures.

On a pain scale ranging from 0 to 10, the mean pain score was 5.32 (SD 3.06). Other complications are detailed in

Table 2. Complications related to office hysteroscopy observed in the study cohort.

Complication	Total Cohort (n = 1662)	Missing or Not Applicable
Persistent stenosis, n (%)	133 (8.0)	0
Pain, n (%)	201 (12.1)	0
Incomplete pseudo-pathway, n (%)	11 (0.7)	0
Uterine perforation, n (%)	3 (0.2)	0
Clinical instability, n (%)	1 (0.1)	0
Referral for surgical hysteroscopy, n (%)	490 (29.5)	0
Pain (0–10 scale), mean (SD)	5.32 (3.1)	63

and represent reasons why some patients could not complete the examination. Pain (201/1662, 12.1%) was the primary reason for interruptions occurring, followed by persistent stenosis (133/1662, 8.0%). Additionally, 29.5% (490/1662) of participants were referred for surgical hysteroscopy. The most common reasons for referral were the size and number of uterine lesions (285/490, 58.1%), pain (137/490, 28%), and stenosis (36/490, 7.3%) (Figure 1B).

3.3. Association Between Demographics, Clinical Data, and Pain Level

Pain levels were stratified to classify the population into two groups: acceptable (0–6) and unacceptable/severe (7–10). Higher pain levels were experienced by older participants (p = 0.010), those with a lower BMI (p = 0.007), and those in the menopausal period (p < 0.001). Our findings indicated that postmenopausal women tended to report 7–10 pain levels more frequently than menacme women (65.7% vs. 34.3%). Also, patients with a greater number of vaginal deliveries experienced lower levels of pain (p < 0.001). Use of contraception was associated with lower levels of pain (p < 0.001).

Regarding uterine orifices with stenosis, persistent stenosis of both the external (p = 0.001) and internal (p = 0.001) cervical orifices was associated with higher levels of pain. Finally, individuals referred for surgical hysteroscopy reported significantly higher pain levels during the office procedure (p = 0.001). The proportion of level of pain according to the stenosis status of the cervical orifices are presented in Figure 2, with a higher frequency of severe pain scores in patients with resolved stenosis in the external uterine orifice (63.6%), and persistent (74.3%) or resolved (54.5%) stenosis in the internal uterine orifice.

Vaginal deliveries (OR 0.54, 95%CI 0.36–0.80, p = 0.003), internal (OR 0.53, 95%CI 0.38–0.75, p < 0.001) and external (OR 0.47, 95%CI 0.30–0.72, p < 0.001) cervical patency, presence of myomas (OR 0.53, 95%CI 0.34–0.83, p = 0.006), and biopsy performance (OR 0.55, 95%CI 0.41–0.74, p < 0.001) were considered strong protective factors against pain perception (p < 0.050), as shown in Figure 3.

Considering subgroup analysis, at least two vaginal deliveries were a potent protective factor (OR 0.37, 95%CI 0.19–0.69, p = 0.002) for menacme patients, as well in the menopause subgroup (OR 0.66, 95%CI 0.44–0.99, p = 0.043).

4. Discussion

The findings of this study indicate that women with lower BMI, nulliparous, with fewer vaginal deliveries, and in the menopausal period reported higher levels of pain undergoing hysteroscopy. These results align with previous studies, which observed that nulligravid, nulliparous, and postmenopausal women more frequently required local anesthetics and cervical dilation during the procedure [16]. This heightened pain sensitivity is likely attributable to the fact that the cervical ostium in these individuals is generally less dilated and less elastic, exacerbating procedural discomfort.

Cervical stenosis, defined as narrowing of the cervical canal, was identified alongside pain as one of the most frequent reasons for office hysteroscopy failure [17]. In our study, stenosis was the second most common reason for incomplete exams. Among participants with resolved external orifice stenosis, 20.8% experienced severe pain, while 27.6% of those with resolved internal orifice stenosis also reported severe pain. Consistent with our findings, some studies reported that synechiae, or adhesions within the cervix, significantly influence pain during hysteroscopy, with parity serving as a protective factor [18].

Mechanistically, traversal of a less compliant internal os concentrates nociceptive input; menopausal hypoestrogenism contributes to decreased cervical elasticity and stenosis, amplifying discomfort and vasovagal susceptibility [7,19]. These pathways explain the sizable pain burden we observed when stenosis was present or had to be resolved during the procedure.

The overall average BMI of the study population exceeded the normal range established by the World Health Organization (WHO), classifying participants as overweight. This is a common characteristic among menopause women, a phase associated with significant changes in body composition, including reduced bone mineral content, decreased lean body mass, and increased total and abdominal fat mass [20].

BMI is a critical factor in pain perception, as obesity and overweight conditions are associated with systemic inflammation driven by cytokine release from adipose tissue [21]. This systemic inflammation may heighten pain sensitivity during medical procedures. Additionally, visceral fat accumulation, more prevalent during menopause, alters hormone levels and pain modulation pathways, potentially amplifying pain perception [22]. Interestingly, in our study, participants reporting higher pain levels had lower BMIs, although still within the pre-obese range per WHO criteria. The weak correlation between BMI and pain levels (r = 0.085) suggests that BMI alone may not strongly predict procedural pain. Other factors, such as hormonal changes, cervical elasticity, and psychological components, likely play a more significant role in pain perception during hysteroscopy [23,24]. These findings highlight the importance of a multifactorial approach when evaluating pain sensitivity and developing practice protocols to enhance procedural success in this population.

Lifestyle factors significantly influence symptoms experienced during menopause, with estrogen playing a key role in menopause-related body composition changes [25]. Estrogen deficiency, the primary physiological hallmark of menopause, is associated with a wide range of symptoms [26]. Several studies have explored the relationship between pain sensitivity and estradiol, a key hormone within the estrogen group. The evidence suggests that estradiol levels influence pain tolerance, with higher levels during the follicular phase correlating with increased pain tolerance compared to the luteal phase [27]. Another study has shown that the altered menstrual cycle and pain perception in women with menstruation-related migraines are consistent with our earlier findings on estrogen levels and dermal blood flow [28]. Given that 77.6% of participants were menopausal, estrogen deficiency likely contributed to heightened pain sensitivity and procedural challenges. In line with this, we found that postmenopausal women reported significantly higher pain scores during office hysteroscopy compared to their premenopausal counterparts (p < 0.001), reinforcing the role of estrogen deficiency in procedural discomfort. Additionally, our findings suggest that cervical stenosis, which was more prevalent among postmenopausal participants, may further exacerbate pain, highlighting the multifactorial nature of pain in this population.

Efforts have been made to identify pharmacological and anesthetic alternatives to improve office hysteroscopy success rates. A study demonstrated that oral administration of misoprostol 12–24 h before office hysteroscopy effectively reduced pain, particularly in premenopausal nulliparous individuals. However, this pain reduction was not sustained throughout the procedure, and gastrointestinal side effects impacted patient tolerability [29]. Of note, the combination of estradiol and misoprostol pretreatment has shown promise in improving cervical dilation and reducing discomfort, especially in postmenopausal women undergoing surgical hysteroscopy [22]. These findings suggest that targeted pretreatment protocols, such as combining misoprostol and estradiol, could significantly improve cervical dilation and minimize pain, particularly in postmenopausal women undergoing hysteroscopy. Personalized pretreatment approaches may further enhance outcomes and patient comfort during office hysteroscopy.

This study has several limitations that should be acknowledged. First, the setting in a public hospital may introduce selection bias, as patients treated in public institutions often differ from those in private settings in terms of socioeconomic background, healthcare access, and baseline health status, which may limit the generalizability of the findings. Second, operator experience was not recorded, representing a potential unmeasured source of heterogeneity in the procedures. Third, the cross-sectional design precludes the ability to establish causal relationships between identified risk factors and pain levels during hysteroscopy. Additionally, the use of convenience sampling may further contribute to selection bias. Pain assessment was based on self-reported scores using a visual analog scale, which, while widely used, is inherently subjective and may vary between individuals. Lastly, despite efforts to standardize the procedure, inter-operator variability could have influenced outcomes such as perceived pain and procedural success.

However, our rates of interruption and referral provide real-world context. Large cohorts show very low complication rates for diagnostic office hysteroscopy (≈0.1–0.2% overall; perforation typically <1%), with higher rates in operative cases; most perforations occur at entry/dilation [30]. These data support efforts to keep procedures ambulatory while selectively escalating to surgical settings when anatomy or pain prevents safe completion.

5. Conclusions

This study identified key clinical and anatomical factors associated with increased pain perception during outpatient hysteroscopy. Menopause, nulliparity, lower BMI, and cervical stenosis—particularly involving the internal orifice—were independently associated with higher pain scores. In contrast, previous vaginal deliveries, presence of myomas, and the ability to obtain a biopsy during the procedure were protective factors against procedural pain. These findings suggest that hormonal changes and structural cervical alterations play a central role in pain sensitivity among women undergoing office hysteroscopy.

Importantly, a significant proportion of patients experiencing severe pain were referred for surgical hysteroscopy, often due to incomplete procedures or failure to adequately manage cervical stenosis. This highlights the clinical relevance of anticipating anatomical challenges and implementing pretreatment strategies when appropriate.

Given the high prevalence of menopausal women in the outpatient hysteroscopy population and the association between menopause and procedural discomfort, tailored interventions aimed at improving cervical compliance—such as the use of misoprostol and estradiol—should be further explored. The identification of patients at higher risk of pain may guide individualized preparation protocols and optimize the efficiency of outpatient services.

In summary, this study underscores the importance of considering reproductive history, menopausal status, and cervical anatomy when planning outpatient hysteroscopy. Personalized approaches may not only improve patient comfort but also reduce procedure failure rates and unnecessary surgical referrals.