{"paper_id":"aa66acce-f442-4be7-9463-d6d28c564ce7","body_text":"Arch Obstet Gynecol. 2024\nVolume 5, Issue 4\nArchives of Obstetrics and Gynaecology  Original Research\n154\nArch Obstet Gynecol. 2024;5(4):154-159.\nEffect of Video-based Multimedia Information on Anxiety Levels \nand Pain Perception in Patients Undergoing Endometrial Sampling \nProcedure: A Prospective Randomized Case-control Study\nJule Eriç Horasanlı1,*, Hasan Energin1\n1Necmettin Erbakan Üniversity, Faculty of Medicine, Department of Gynecology and Obstetrics, Konya, Turkey\n*Correspondence should be addressed to Jule Eriç Horasanlı, juleesen@gmail.com\nReceived date:  November 10, 2024 , Accepted date: November 29, 2024\nCitation: Horasanlı JE, Energin H. Effect of Video-based Multimedia Information on Anxiety Levels and Pain Perception in \nPatients Undergoing Endometrial Sampling Procedure: A Prospective Randomized Case-control Study. Arch Obstet Gynecol. \n2024;5(4):154-159.\nCopyright:  © 2024 Horasanlı JE, et al. This is an open-access article distributed under the terms of the Creative Commons \nAttribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author  \nand source are credited.\nAbstract\nObjectives: The endometrial sampling procedure (ESP) with Pipelle is frequently used for diagnostic purposes in cases where endometrial \npathologies are suspected in abnormal uterine bleeding. This study aimed to investigate video-based multimedia information (MMI)’s effect \non anxiety and satisfaction levels of women undergoing endometrial sampling procedures.\nMethods: The study was conducted prospectively in patients undergoing ESP for medical indications. Patients were randomly assigned to \none of the two groups: the control group, which received verbal and written information before their ESP , and the video-based MMI group \n(case), which received video-based MMI before their ESP . Patients’ anxiety levels were measured with Beck Anxiety Inventory (BAI) 30 minutes \nbefore the procedure and ten minutes after ESP .\nResults: Median BAI scores in the MMI and control groups were 5 and 9, respectively, and it was significantly lower in the MMI group. The \nmean VAS score of both groups were 3.1 and 3.3, respectively (p<0.05). Both groups' procedural patient satisfaction rates were 91.1% and \n73.3%, respectively (p<0.05). Although there was no significant difference between the two groups in the VAS score of the ESP (p=0.42), the \nsatisfaction rate of patients in the MMI group was significantly higher than patients in the control group. \nConclusion: Women who undergo invasive gynecological procedures such as endometrial sampling procedures have high anxiety levels \nand require special attention to manage stress and anxiety. Video-based MMI before the process may increase patients' knowledge about the \nprocedure and decrease anxiety and dissatisfaction due to the procedure. \nKeywords: Anxiety, Endometrial Sampling Procedure, Multimedia Information\nIntroduction\nThe endometrial sampling procedure (ESP) with Pipelle \nis frequently used for diagnostic purposes in cases where \nendometrial pathologies are suspected in abnormal uterine \nbleeding [1,2]. Endometrial sampling in the office setting \nhas replaced the diagnostic dilatation and curettage (D&C) \nprocedure often performed in the hospital. ESP , based on D&C \nsampling in the Operating Room, is relatively inexpensive \nand associated with less morbidity. Although it is a minimally \ninvasive procedure that does not usually cause pain, it can \nsometimes cause anxiety in patients [3,4]. Anxiety is an \nabnormal and excessive sense of apprehension and fear, often \nmarked by physiological symptoms [5]. Studies report that \nwaiting for a surgical procedure is a very stressful period [6]. \nPhysiological symptoms such as tachycardia, hypertension, \nsweating, or psychological symptoms such as anxiety, \nirritability, and aggression can be seen in 60% to 80% of \npatients who will undergo invasive surgery [7]. Insufficient \nknowledge about the planned surgical procedure has been \nidentified as one of the most critical components associated \nwith preoperative anxiety [8].\n\n                                                                                                                                                      \n Horasanlı JE, Energin H. Effect of Video-based Multimedia Information on Anxiety Levels and Pain Perception in \nPatients Undergoing Endometrial Sampling Procedure: A Prospective Randomized Case-control Study. Arch Obstet \nGynecol. 2024;5(4):154-159.\nArch Obstet Gynecol. 2024\nVolume 5, Issue 4\n155\nAlthough various pharmacological agents, such as \nanxiolytics and sedatives, can often be administered in the \ninpatient setting to relieve preoperative anxiety, they also \nhave side effects. Pain can be minimized by explaining each \nstep before the procedure and avoiding using a cervical \ndilator and tenaculum. Some clinicians may use nonsteroidal \nanti-inflammatory drugs (NSAID), intrauterine local anesthetic \ninstillation, and paracervical block to reduce cramps [9]. The \nuse of non-pharmacological agents is preferred to avoid side \neffects [10].\nObtaining informed consent is a critical stage in the surgical \nprocess that had remained chiefly changed since 1957 when \nthe term was first used. A shift toward a more patient-centered \nhealthcare system has also increased the need for effective \ndoctor-patient communication and information transfer, \nwhich is critical to the consent process [11]. Alternatively, \npatient brochures can be used, but limited information can \nbe given. Therefore, verbal information can lead to insufficient \ninformation [12]. The use of multimedia (MMI) tools to obtain \npatient consent can be helpful in the informed consent \nprocess. The objective of this paper was whether video-based \nMMI affected the anxiety and intra-operative pain scores of \nindividuals undergoing endometrial sampling procedures. \nWe have identified two main objectives to investigate in \npatients undergoing ESP .\n1. Comparison of preoperative anxiety scores and pain \nperception in the MMI and control groups.\n2. To determine the effect of MMI and traditional information \non patient satisfaction. \nMaterials and Methods\nDesign\nOur study was conducted between October 2021 and April \n2022. It was performed on patients between 25 and 70 who \nunderwent ESP with medical indications. Informed consent \nforms were obtained from all participants, and study patient \ngroups were formed.\nInclusion criteria\nESP indications were presented; abnormal uterine bleeding, \npresence of AGC-endometrial, monitoring of patients with \nendometrial pathology (e.g., endometrial hyperplasia), \nscreening in patients at high risk of endometrial cancer (e.g., \nLynch syndrome).\nExclusion criteria\nThose who received treatment for anxiety and psychiatric \nreasons, those who were nulliparous, those with severe \ncervical infection, those with chronic pelvic pain and severe  \ndysmenorrhea, those with endometrioma, those who had \na previous ESP and bad experience, those with bleeding \ndiathesis, or those with a history of cervical stenosis were not \nincluded in the study.\nThe Institutional Ethical Committee approved the study, \nwhich was carried out in accordance with the most recent \nversion of the Helsinki Declaration. Institutional Ethical \nCommittee approval was obtained before the subject \nenrolment (NEÜ/2022.04.147).\nProcedure\nPatients were randomly assigned to one of two groups: the \ncontrol group, which received verbal and written information \nbefore their ESP procedure, and the video-based MMI \ngroup (case), which received video-based MMI before their \nESP procedure. In the MMI video, one of the researcher's \nobservations, ESP technique, benefits, side effects, personnel, \ninstruments, and more are all covered in this movie ( https://\nyoutu.be/at-CfWUiClg). The video played once during the first \nhospital visit in a different room. Patients were divided into \ngroups at random using randomization software (http://www.\nrandomization.com) (Figure 1).\nVerbal information:  The procedure is like a routine \ngynecological examination. The nurse will lay the patient on \na flat table. The doctor inserts a speculum into the vagina, \njust like in the examination, and the cervix is cleared. The \nassistance of a thin plastic catheter (pipelle) from the cervix \nopening to the beginning of the uterine canal aspiration is \nperformed with negative pressure. The procedure is generally \npainless.\nAnti-inflammatory medications, analgesics, and local \nanesthetics were not used as premedication administered. In \nboth groups, pain perception was evaluated with VAS score \nafter the procedure.\nProcess\nA bimanual examination was performed after preparing \nthe patient in the dorsal lithotomy position to determine the \nuterus position. After the speculum was inserted, the cervix \nand vagina were cleaned with antiseptic. It was pipetted \nthrough the cervical canal, the sheath was fixed with one \nhand, and the plunger was pulled out to create suction. \nAspiration was completed by moving the device tip along the \nendometrial surface using a corkscrew rotation with cephalic-\ncaudal movement.\nMeasures\nThe Beck Anxiety Inventory (BAI) was used to assess the \nanxiety levels of patients 30 min before the procedure [13]. \nThe patients responded to a questionnaire on an inventory \nscale that ranged from not at all (0) to severe (3). The overall \n\n                                                                                                                                                      \n Horasanlı JE, Energin H. Effect of Video-based Multimedia Information on Anxiety Levels and Pain Perception in \nPatients Undergoing Endometrial Sampling Procedure: A Prospective Randomized Case-control Study. Arch Obstet \nGynecol. 2024;5(4):154-159.\nArch Obstet Gynecol. 2024\nVolume 5, Issue 4\n156\nscore varied from 0 to 63 on a scale of one to one hundred. \nAnxiety was classified using cut-off ratings similar to those \nused in earlier studies on gynecological procedures. Anxiety \nratings were divided into four categories: 0-7, minimal, \n8-15, mild, 16-25, moderate, and 26-63, severe anxiety. The \nfollowing information was gathered: age, infertility type, \ninfertility period, gravidity, parity, and educational status. \nPatients' procedural discomfort was rated on a ten-point \nvisual analog scale (VAS) ten minutes after ESP .\nSatisfaction: Satisfaction status was assessed on a four-point \nLikert scale (0; not satisfied, 1; poorly satisfied, 2; satisfied, \n3; very satisfied). A Likert scale score ≥ 2 was assumed as \nsatisfaction.\nVAS Scale: All patients were observed for 60 minutes \nafter the procedure and were asked to mark the pain they \nexperienced on the VAS scale. In the 10 cm VAS scale, the \nabsence of pain was accepted as 0 points, and the maximum \npain was considered 10 points.\nVideo based MMI group \n(n = 45) \nAllocation \nA\nn\na\nl\ny\ns \ni \ns \nEnrollment \nAssessed for eligibility \nN= 94 \nExcluded (n =4) \n Psychiatric drug use (n=2)\n Endometrioma (n=2)\nRandomized:  \n(n = 90) \nControl group \n (n = 45) \nVideo based MMI*  \nbefore endometrial \nbiopsy \nAnalyzed \n(n = 45) \nAnalyzed \n(n = 45) \nVerbally and written \ninformed briefly \nbefore endometrial \nbiopsy \nFigure 1. Flow diagram. *MMI: Multimedia Information.\nAnalysisss\n\n                                                                                                                                                      \n Horasanlı JE, Energin H. Effect of Video-based Multimedia Information on Anxiety Levels and Pain Perception in \nPatients Undergoing Endometrial Sampling Procedure: A Prospective Randomized Case-control Study. Arch Obstet \nGynecol. 2024;5(4):154-159.\nArch Obstet Gynecol. 2024\nVolume 5, Issue 4\n157\nStatical analysis\nThe normality of continuous data was evaluated by The \nKolmogorov - Smirnov or Shapiro-Wilk tests. For comparing \ncontinuous data, an Independent-sample t-test or Mann-\nWhitney U test, whichever suits, were used. Categorical data \nwere analyzed with the chi-square test, and P values <0.05 \nwere considered significant.\nPrimary and secondary outcome\nIn this study, we aimed to investigate the effect of video-\nbased MMI on patients’ anxiety levels undergoing endometrial \nbiopsy procedures. The secondary outcome was to investigate \nthe impact of video-based MMI pain perception and \nsatisfaction status due to the endometrial biopsy procedure.\nResults\nNinety-four patients participated in this study. Two patients \nwere excluded due to psychiatric drug use, and two were \nexcluded due to endometrioma. Patients had randomly \ndivided into two groups; the first group was the control group \nconsisting of patients who were verbally and written informed \nbriefly before the ESP (control group), and the second group \nconsisted of patients who received video-based MMI before \nthe ESP . There were 45 patients in the first group and 45 in \nthe second group (Figure 1) . The mean ages of the study \npopulation, control group, and MMI group were 42.1, 43.0, and \n41.2, respectively. There was no significant difference in parity, \nbody mass index (BMI), number of postmenopausal patients, \nor education status between the two groups (Table 1).\nMedian BAI scores in the MMI group and control group were \n5 and 9, respectively, and it was significantly lower in MMI \ngroup. The degree of anxiety scores was classified into three \ngroups; minimal, mild, and moderate/severe. It was compared \nin both groups. Minimal anxiety was significantly higher in \nthe MMI group, but mild and moderate/severe anxiety were \nsignificantly higher in the control group (Table 2). The mean \nVAS score of both groups were 3.1 and 3.3, respectively. The \nprocedural patient satisfaction rates of both groups were 91.1 \n% and 73.3%, respectively. Although there was no significant \ndifference between the two groups in the VAS score of the \nESP , the satisfaction rate of patients in the MMI group was \nsignificantly higher than patients in the control group (Table \n3).\nTable 1. Comparison of characteristics of study and control group.\nStudy group (n=45) control group (n=45) p value\nAge (years) 43.0 ± 7.5 41.2 ± 8.3 0.18\nParity (n) 2.2 ± 1.2 2.7 ± 1. 3 0.21\nBMI (kg/m2) 27.4 ± 4.9 28.3 ± 4.3 0.28\nPostmenopausal patients (n,%) 10 (22.2%) 13 (28.8%) 0.31\nEducation\n> 8 years (n,%) 16 (35.5 %) 21 (46.6%)\n≤ 8 years (n,%) 54 (64.5 %) 49 (53.4%) 0.39\nBeck Score (median) 5 9 <0.05\nTable 2. Comparison of Becks Anxiety Inventory between study and control groups.\nBeck Score Study group Control group p value\nMinimal (n, %) 36 (80.0%) 16 (35.5%) <0.05\nMild (n, %) 8 (17.7%) 25 (55.7%) <0.05\nModerate/ severe (n, %) 1 (2.2%) 4 (8.8%) <0.05\nTable 3. Comparison of procedural pain scores and satisfaction between study and control group.\nStudy group Control group p value\nVAS score 3.1 3.3 0.42\nSatisfied with procedure (n, %) 41 (91.1%) 33 (73.3%) <0.05\n\n                                                                                                                                                      \n Horasanlı JE, Energin H. Effect of Video-based Multimedia Information on Anxiety Levels and Pain Perception in \nPatients Undergoing Endometrial Sampling Procedure: A Prospective Randomized Case-control Study. Arch Obstet \nGynecol. 2024;5(4):154-159.\nArch Obstet Gynecol. 2024\nVolume 5, Issue 4\n158\nDiscussion \nIn our prospective case-control study, we investigated the \neffectiveness of an information video in reducing anxiety in \npatients who underwent endometrial sampling procedures. \nWe found that in patients who will undergo ESP procedure, \nthe group informed by MMI had lower pre-procedural anxiety \nscores and higher satisfaction than the verbally informed \ngroup.\nMany surgical procedures increase patients' anxiety levels \nexcessively. The Pipelle procedure is a better and equally \ntolerated procedure by patients compared to other office-\nbased devices [14,15]. However, patients experience some \ndiscomfort during the procedure, which affects the effective \nuse of the procedure. Half of the patients report pain, and \nthe degree of this pain increases as the surgeon's experience \ndecreases. Adambekov et al.  [16], reported that patients \nwho underwent ESP were significantly correlated with their \npre-procedural anxiety scores and the pain scores they \nexperienced at the procedure. In our study, since equally \nwell-experienced surgeons performed the surgical procedure, \nthe difference that may occur in this respect was prevented. \nWhen transferring minor gynecological procedures from \nthe operating room to the office, healthcare providers must \nensure that patients are comfortable, and procedures are \ncarried out safely [17].\nProviding appropriate information about the procedure for \nwhich they are scheduled can reduce concerns about surgery \nor intervention. Application of MMI before surgery with the \nadvantages of visual perception can facilitate the education \nof patients and provide clear information instead of complex \nwritten information.\nThe effect of video information on anxiety is contradictory \nto previous studies. Freeman et al.  reported that video \ninformation reduces anxiety in treatments such as colposcopy \nperformed with the one-step see and treat method [18]. In a \nprevious study, Yılmaz et al. stated that the application of MMI \nwas associated with less anxiety and less postoperative pain \n[19]. While reducing patient stress in surgical interventions \nsuch as colonoscopy [20], Kazancıoğlu et al.  reported that \nvideo information before dental surgery increased the anxiety \nscores of patients [21]. Eriç et al.  also reported increased \nanxiety scores of informing with MMI in patients undergoing \nIUD (Intrauterine device) [22]. On the other hand, Wouters et al. \nreported that informing with video did not cause a significant \ndecrease in anxiety in patients who underwent colposcopy \n[23]. They also reported that the level of satisfaction did not \ndiffer between the two groups. They attributed these results \nto the fact that patients access information more easily from \nthe internet and ask questions until satisfied.\nIn our study, pre-procedural MMI provided lower anxiety \nscores and higher satisfaction than ESP patients' traditional \nwritten and verbal information.\nPain occurs during ESP Dilation of the cervix, uterine \nmanipulation, and removal of the uterus. The content may \ncause pain during ESP . Anxiety is a significant risk factor in pain \nperception [24]. Yılmaz et al. stated that patients with video \ninformation felt less procedural pain than the control group. \nFurthermore, attributed this to a decrease in stress hormones \n[19]. On the other hand, a study showed that while anxiety \nlevels decreased in ESP patients, procedural pain levels did \nnot change [25]. Consistent with this study; in our study, no \nstatistically significant difference was found between the two \ngroups in procedural pain.\nStrengths and limitations\nSome limitations can be stated regarding this study. \nCorrection of the axis by holding the cervix with the tenaculum \nmay also cause pain. We used the tenaculum in some difficult \nto enter endometrium cases during ESP , which may have \nprevented an accurate assessment of the pain experience. The \nlimitation of this study is that we did not exclude patients for \nwhom we used the tenaculum. Anxiety-related symptoms can \nbe determined hemodynamically. Our other limitation is that \nwe did not record and evaluate these parameters in patients.\nThis study aimed to investigate the MMI method to reduce \nanxiety and procedural pain in patients to increase success \nduring successful ESP . This study concluded that although \nMMI application reduced anxiety, it was ineffective in \nreducing procedural pain. Anxiety reduction may increase \nthe patient's acceptance and compliance with the procedure, \nand elimination of patient anxiety increases the procedure's \nsuccess and increases patient satisfaction.\nConflict of Interest\nThe author declares that there is no conflict of interest \nbetween the authors of the article. \nFunding\nThe author declares that she did not receive any financial \nsupport in this study.\nAuthor Contributions\nJule Eriç Horasanli: Writing – reviewing and editing, \nconceptualization, methodology, analysis and interpretation, \nand the final draft. Hasan Energin: Conceptualization, \nMethodology, video recording, analysis and interpretation, \nand the final draft.\nReferences\n1. Kazandi M, Okmen F, Ergenoglu AM, Yeniel AO, Zeybek B, \nZekioglu O, et al. Comparison of the success of histopathological \ndiagnosis with dilatation-curettage and Pipelle endometrial \nsampling. Journal of Obstetrics and Gynaecology. 2012 Nov \n1;32(8):790-4.\n\n                                                                                                                                                      \n Horasanlı JE, Energin H. Effect of Video-based Multimedia Information on Anxiety Levels and Pain Perception in \nPatients Undergoing Endometrial Sampling Procedure: A Prospective Randomized Case-control Study. Arch Obstet \nGynecol. 2024;5(4):154-159.\nArch Obstet Gynecol. 2024\nVolume 5, Issue 4\n159\n2. DEMİR ET. 10-year endometrium cancer management in our \nclinic. Selçuk Tıp Dergisi. 2019 Oct 26;37(2):166-71.\n3. Roomruangwong C, Tangwongchai S, Chokchainon A. \nPreoperative anxiety among patients who were about to \nreceive uterine dilatation and curettage. J Med Assoc Thai. 2012 \nOct;95(10):1344-51.\n4. Kaiyrlykyzy A, Linkov F, Foster F, Bapayeva G, Ukybassova \nT, Aimagambetova G, et al. Pipelle endometrial biopsy for \nabnormal uterine bleeding: do patient's pain and anxiety really \nimpact on sampling success rate? BMC Womens Health. 2021 \nNov 12;21(1):393.\n5. Crocq MA. A history of anxiety: from Hippocrates to DSM. \nDialogues Clin Neurosci. 2015 Sep;17(3):319-25.\n6. Leach M, Tanner S, Zernike W. How anxious are surgical patients?. \nACORN Journal: Official Journal of the Australian Confederation \nof Operating Room Nurses. 2000 Mar 1;13(1).\n7. Vetter D, Barth J, Uyulmaz S, Uyulmaz S, Vonlanthen R, Belli G, et \nal. Effects of Art on Surgical Patients: A Systematic Review and \nMeta-analysis. Ann Surg. 2015 Nov;262(5):704-13.\n8. Palmer JA. Decreasing anxiety through patient education. Plast \nSurg Nurs. 2007 Oct-Dec;27(4):215-20.\n9. Dogan E, Celiloglu M, Sarihan E, Demir A. Anesthetic effect of \nintrauterine lidocaine plus naproxen sodium in endometrial \nbiopsy. Obstet Gynecol. 2004 Feb;103(2):347-51.\n10. Wongkietkachorn A, Wongkietkachorn N, Rhunsiri P . Preoperative \nNeeds-Based Education to Reduce Anxiety, Increase Satisfaction, \nand Decrease Time Spent in Day Surgery: A Randomized \nControlled Trial. World J Surg. 2018 Mar;42(3):666-74.\n11. Nehme J, El-Khani U, Chow A, Hakky S, Ahmed AR, Purkayastha S. \nThe use of multimedia consent programs for surgical procedures: \na systematic review. Surg Innov. 2013 Feb;20(1):13-23.\n12. Ashraff S, Malawa G, Dolan T, Khanduja V. Prospective randomised \ncontrolled trial on the role of patient information leaflets in \nobtaining informed consent. ANZ J Surg. 2006 Mar;76(3):139-41.\n13. Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring \nclinical anxiety: psychometric properties. J Consult Clin Psychol. \n1988 Dec;56(6):893-7.\n14. Narice BF, Delaney B, Dickson JM. Endometrial sampling in low-\nrisk patients with abnormal uterine bleeding: a systematic review \nand meta-synthesis. BMC Fam Pract. 2018 Jul 30;19(1):135.\n15. Leclair CM, Zia JK, Doom CM, Morgan TK, Edelman AB. Pain \nexperienced using two different methods of endometrial \nbiopsy: a randomized controlled trial. Obstet Gynecol. 2011 \nMar;117(3):636-41.\n16. Adambekov S, Lopa S, Edwards RP , Bovbjerg DH, Linkov F, \nDonnellan N. Anxiety and Pain in Patients Undergoing Pipelle \nEndometrial Biopsy: A Prospective Study [11F]. Obstetrics & \nGynecology. 2020 May 1;135:63S.\n17. Urman RD, Punwani N, Bombaugh M, Shapiro FE. Safety \nconsiderations for office-based obstetric and gynecologic \nprocedures. Rev Obstet Gynecol. 2013;6(1):e8-e14.\n18. Freeman-Wang T, Walker P , Linehan J, Coffey C, Glasser B, Sherr \nL. Anxiety levels in women attending colposcopy clinics for \ntreatment for cervical intraepithelial neoplasia: a randomised trial \nof written and video information. BJOG. 2001 May;108(5):482-4.\n19. Yilmaz G, Akca A, Ay N, Koroglu N, Omaygenc DO, Ozdemir I, et \nal. The role of video-based multimedia information in reduction \nof anxiety before dilatation and curettage. North Clin Istanb. \n2020 Nov 23;8(1):76-81.\n20. Bytzer P , Lindeberg B. Impact of an information video before \ncolonoscopy on patient satisfaction and anxiety - a randomized \ntrial. Endoscopy. 2007 Aug;39(8):710-4\n21. Kazancioglu HO, Tek M, Ezirganli S, Demirtas N. Does watching \na video on third molar surgery increase patients' anxiety level? \nOral Surg Oral Med Oral Pathol Oral Radiol. 2015 Mar;119(3):272-\n7.\n22. Eriç J, Purut YE, Harmancı H. The Effect of Video Assisted \nInformation on Anxiety and Pain Associated with Intrauterine \nDevice Insertion. Gynecol Obstet Invest. 2020;85(1):82-87.\n23. Wouters T, Soomers J, Smink M, Smit RA, Plaisier M, Houterman \nS, et al. The effect of an animation video on consultation time, \nanxiety and satisfaction in women with abnormal cervical \ncytology: Animation video reduces colposcopy time. Prev Med \nRep. 2019 Jan 15;13:238-43.\n24. De Iaco P , Marabini A, Stefanetti M, Del Vecchio C, Bovicelli L. \nAcceptability and pain of outpatient hysteroscopy. J Am Assoc \nGynecol Laparosc. 2000 Feb;7(1):71-5.\n25. Sert ZS. Effect of video information on anxiety level in women \nundergoing endometrial biopsy. Journal of Contemporary \nMedicine. 2020;10(4):505-9.","source_license":"CC0","license_restricted":false}