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Misoprostol in Operative Hysteroscopy: A Systematic Review and Meta-Analysis

Selk, Amanda MD, FRCSC; Kroft, Jamie MD, FRCSC

doi: 10.1097/AOG.0b013e31822f3c7b

OBJECTIVE: To estimate the benefits and harms of misoprostol use for cervical dilation in patients undergoing operative hysteroscopy.

DATA SOURCES: We searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (from inception to February 2011). We also searched trial registries, other sources of unpublished or gray literature, and the reference lists of retrieved studies.

METHODS OF STUDY SELECTION: Randomized controlled trials (RCTs) of patients undergoing operative hysteroscopy that used misoprostol compared with placebo were included.

TABULATION, INTEGRATION, AND RESULTS: The two coauthors independently screened search results for inclusion, assessed trials for methodologic quality, extracted data, and resolved disagreements through discussion. A total of seven RCTs with 568 patients met inclusion criteria. The quality of evidence for all outcomes was low. The pooled estimate did not rule out a beneficial effect of misoprostol on cervical dilation (six studies, 506 participants; mean difference 0.85 mm, 95% confidence interval [CI] −0.58 to 2.27). The pooled estimate did not rule out a beneficial effect of misoprostol on surgical complications (cervical lacerations, uterine perforations, and false passages [seven studies, 545 patients, pooled relative risk [RR] 0.65, 95% CI 0.19–2.26]). There was an increase in side effects (cramps, vaginal bleeding, nausea, and diarrhea) in the misoprostol group (four studies, 374 patients; RR 4.28, 95% CI 1.43–12.85). The number needed to harm to have one patient with preoperative vaginal bleeding was six, for diarrhea was seven, and for nausea was 13.

CONCLUSION: This review did not rule out a beneficial effect of misoprostol on cervical dilation or surgical complications. There was an increase in side effects in operative hysteroscopy patients treated with misoprostol. Current evidence does not support the routine use of preoperative misoprostol in operative hysteroscopy.

The use of misoprostol in operative hysteroscopy increases side effects without a definite reduction in complications.

From the Department of Gynecology, Women's College Hospital, University of Toronto, and the Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada.

The authors thank Elie Akl for his advice, mentorship, and editorial support.

Corresponding author: Amanda Selk, Women's College Hospital – Gynecology Clinic 3 East, 76 Grenville St, Toronto, ON M5S 1B2, Canada; e-mail:

Financial Disclosure The authors did not report any potential conflicts of interest.

© 2011 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.