Clinical Factors Associated with Pain During Outpatient Hysteroscopy in a Standardized Vaginoscopic Setting: A Prospective Observational Study

Background: Outpatient hysteroscopy is the reference standard for the diagnosis and treatment of benign intrauterine pathology. Although several pharmacological and non-pharmacological strategies have been proposed to reduce procedural pain, the clinical and procedural factors primarily determining patient tolerability in a standardized vaginoscopic setting remain incompletely understood. This prospective study aimed to identify the main predictors of pain, procedural tolerability, successful completion, and patient acceptance during outpatient hysteroscopy. Methods: A prospective observational study was conducted between February and June 2026 at a second-level referral hospital. Consecutive women undergoing outpatient hysteroscopy were enrolled. All procedures were performed according to a standardized vaginoscopic “no-touch” protocol using a 15-Fr Bettocchi hysteroscope. Patients completed structured questionnaires before and after the procedure, while physicians recorded procedural findings immediately afterward. Clinical characteristics, psychological variables, procedural factors, pain scores, procedural tolerability, successful completion, and future patient preference were prospectively analyzed. Results: A total of 105 women were included. Diagnostic hysteroscopy was successfully completed in 94 patients (89.5%), and a see-and-treat procedure was performed in 57 (54.3%). Difficult cervical access occurred in 37 cases (35.2%) and emerged as the strongest determinant of poor procedural tolerability. These patients experienced significantly higher maximum pain scores (7.35 ± 2.81 vs. 4.04 ± 2.51; p < 0.001), a higher prevalence of severe pain (67.6% vs. 20.6%; p < 0.001), poorer procedural tolerability, greater preference for future hysteroscopy under anesthesia, and a higher risk of incomplete diagnostic examination. All incomplete hysteroscopies occurred in patients with difficult cervical access. Expected procedural pain was significantly associated with maximum pain (p = 0.0016), whereas pre-procedural anxiety was not. More than half of the patients identified cervical passage as the most painful procedural step. Patients undergoing successful see-and-treat procedures reported the lowest pain scores, suggesting that the operative phase itself was not the principal determinant of procedural discomfort. Conclusions: In a standardized vaginoscopic setting, procedural tolerability during outpatient hysteroscopy appears to depend primarily on difficult cervical access rather than on the operative intervention itself. Pain expectation may influence the hysteroscopic experience more than pre-procedural anxiety, whereas successful see-and-treat procedures remain well tolerated once uncomplicated access to the uterine cavity has been achieved. Early identification of patients at increased risk of difficult cervical access may improve patient counseling, optimize procedural completion, and preserve the benefits of outpatient hysteroscopy.