Of the 1167 citations retrieved, six studies met the criteria for inclusion and in four there was suitable data for meta-analysis. Vaginoscopy was found to be less painful than traditional approaches, with a standard mean difference in visual analogue scales (VAS) pain scores of -0.44 (95% CI -0.65 to -0.22)(Cooper et al., 2010). However there was statistically significant heterogeneity and this was also seen in the wide variation in procedure feasibility (failure rates varying from 2% to 17%) (Cooper et al., 2010). This inconsistency reflected the lack of standardisation of approach both in relation to vaginoscopy and traditional speculum based approaches where there was variation between studies in the administration of local cervical anaesthesia, application of cervical tenaculum forceps, and the size and angle of the rigid hysteroscope employed. None of these small RCTs (Almeida et al., 2008; Garbin et al., 2006; Guida et al., 2006; Paschopoulos et al., 1997; Sagiv et al., 2006; Sharma et al., 2005) had optimal randomisation processes in terms of using computer generated random number sequences and third party concealment. The review and subsequent Royal College of Obstetrics and Gynaecology (RCOG) guideline (Clark et al.; Cooper et al., 2010) recommended further higher quality adequately powered RCTs to examine more comprehensively the role of vaginoscopy in terms of pain, feasibility, acceptability and complications.