Misoprostol prior to hysteroscopy in premenopausal and post-menopausal women. A systematic review and meta-analysis.

BACKGROUND Although several randomized controlled trials (RCTs) have examined the effect of misoprostol prior to hysteroscopy for cervical dilatation, no solid conclusion has been reached. We therefore set out to perform a meta-analysis of RCTs. METHODS We searched MEDLINE, the ISI Web of Science and the Cochrane Library to identify RCTs comparing misoprostol versus placebo or control prior to hysteroscopy. No restrictions on language or time were applied. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated for all dichotomous outcomes, whereas mean differences (MDs) and 95% CIs were calculated for continuous outcomes using the Mantel-Haenszel or DerSimonian-Laird model according to the heterogeneity. RESULTS Of the initial 141 potentially relevant articles that were retrieved, 21 RCTs involving 1786 patients were included in the meta-analysis. Subgroup analyses were performed according to menopausal status and according to whether diagnostic or operative hysteroscopy was performed. Premenopausal women treated with misoprostol had a significantly lower risk for further cervical dilatation in the diagnostic setting [RR (95% CI): 0.56 (0.34-0.92)] and a significantly lower risk for cervical laceration in the operative setting [RR (95% CI): 0.22 (0.09-0.54)], compared with placebo. In contrast, post-menopausal patients did not experience any clear benefit from misoprostol compared with placebo regarding the need for further cervical dilatation [RR (95% CI): 0.99 (0.76-1.30)] and the cervical laceration rate [RR (95% CI): 1.15 (0.40-3.29)]. In addition, the mean cervical width prior to hysteroscopy was significantly higher in premenopausal women treated with misoprostol compared with placebo [MD (95% CI): 2.47 mm (1.81-3.13)] but did not differ among post-menopausal patients [MD (95% CI): 0.39 mm (-0.42 to 1.21)]. CONCLUSIONS Misoprostol prior to hysteroscopy appears to facilitate an easier and uncomplicated procedure only in premenopausal women.