Diagnostic office hysteroscopy; why is it still painful procedure despite the surgical experience and mini-hysteroscope?

Aim To evaluate the effect of cervical canal features on pain during outpatient hysteroscopy performed by experienced surgeons using mini-hysteroscope. Methods A prospective observational study was conducted on 303 women undergoing diagnostic hysteroscopy without anesthesia. Pain intensity was evaluated using the visual analog scale (VAS) when the cervical canal was passed. The patients were divided into two groups according to the VAS score: painless or mild pain (VAS = 4). The relationship between cervical canal characteristics (length, version, and flexion positions, history of cervical intervention, stenosis, synechiae), obstetric and gynecological history, preoperative anxiety level, procedure duration, and pain intensity was examined. Results Moderate pain (4 = 7). In multivariate analysis, nulliparity (p = 0.01; OR, 4.6; 95% CI, 1.7-13.2), postmenopausal state (p = 0.02; OR, 2.2; 95% CI, 1.2-4.3), excessive flexion of the cervix and retroverted uterus (p