Dear Editor,

We thank the authors for their letter responding to our editorial and for highlighting some important points. However, we consider it disingenuous to suggest that the Royal College of Obstetricians and Gynaecologists Green-top Guideline (GTG 59) on outpatient hysteroscopy¹ “has nothing to offer women… in terms of routine pain relief”, and fundamentally disagree with the assertion that “it is difficult to reconcile this with the view that, if the GTG were fully implemented, this would improve women’s experience.”

GTG 59 was developed to minimise pain and optimise the overall experience of women undergoing outpatient hysteroscopy. Although approximately one-third of women report severe pain, acceptability remains high, with 97% rating their overall care positively.² This apparent disconnect highlights the importance of measuring pain and patient experience as distinct outcomes. The guideline evaluates not only pharmacological pain relief but also infrastructure, staffing, equipment and procedural technique. Drawing on evidence published since the 2011 guideline, it makes numerous recommendations, including promoting best practice (e.g., vaginoscopy) and discouraging interventions that may negatively affect patient experience (e.g., routine cervical preparation).

Unlike most Green-top Guidelines, GTG 59 is underpinned by eight independently conducted systematic reviews, with meta-analyses where appropriate-the highest levels of evidence. Seven of these reviews have been published in peer-reviewed journals. Where evidence was lacking, recommendations were informed by consensus from approximately 120 expert hysteroscopists within the British Society for Gynaecological Endoscopy Ambulatory Care Network.

The American College of Obstetricians and Gynecologists guidance³ cited by the authors is an opinion document and cannot be considered equivalent to the evidence-based methodology supporting GTG 59. The cited Faculty of Sexual and Reproductive Healthcare guidance⁴ relates specifically to intrauterine contraception insertion and cannot be directly extrapolated to outpatient hysteroscopy, although it remains a valuable resource for clinicians performing these procedures.

Penthrox offers a promising additional analgesic option. Although a small randomised controlled trial demonstrated reduced pain during hysteroscopy compared with placebo,⁵ robust evidence of its efficacy, safety, acceptability, feasibility, and cost-effectiveness from a large multicentre National Health Service trial is required before widespread adoption can be recommended. We have recently secured approximately £2 million from the National Institute for Health and Care Research to undertake such a study. If shown to be effective, Penthrox should complement, not compensate for, excellent technique, modern equipment, and appropriate infrastructure.

Ultimately, minimising pain and optimising the patient experience are inseparable goals. Achieving both requires a multimodal approach encompassing infrastructure, equipment, clinician training, procedural technique, patient preferences, and pharmacological and non-pharmacological interventions, including music and virtual reality.