Abstract
OBJECTIVES: Hysterectomy, a common surgical procedure, is frequently associated with moderate-to-severe postoperative pain and a high incidence of postoperative nausea and vomiting (PONV). Dexamethasone, a corticosteroid, may help alleviate these symptoms; however, existing evidence is largely drawn from mixed surgical populations and does not specifically address its efficacy and safety in hysterectomy patients. This meta-analysis provides a focused and updated synthesis of randomised controlled trials (RCTs) in this population, incorporating time-stratified pain outcomes and subgroup analyses by dose, surgical approach, timing and route of administration to evaluate the role of dexamethasone in postoperative recovery. DESIGN: Systematic review and meta-analysis using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. DATA SOURCES: PubMed, Scopus, Google Scholar and The Cochrane Central Register of Controlled Trials (CENTRAL) were searched through 1 November 2024. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: We included RCTs comparing dexamethasone with placebo for postoperative outcomes in hysterectomy patients. DATA EXTRACTION AND SYNTHESIS: Two independent reviewers used standardised methods to search, screen and code included studies. Risk of bias was assessed using the Cochrane Collaboration and Evidence Project tools. Meta-analysis was conducted using random effects models. Findings were summarised in GRADE evidence profiles and synthesised qualitatively. RESULTS: 15 RCTs (1362 patients) were included. Dexamethasone significantly reduced PONV (risk ratio (RR): 0.53, 95% CI 0.47 to 0.61, p<0.00001, I(2): 0% high certainty) and pain scores at 24 hours (mean difference (MD): -0.20, 95% CI -0.35 to -0.05, p=0.009, I²=0%, moderate certainty), 8-12 hours (MD: -0.60, 95% CI -0.88 to -0.31, p<0.0001, I(2): 27%, moderate certainty and 4 hours (MD: -0.43, 95% CI -1.07 to 0.21, p=0.19, 93%, moderate certainty). It also decreased the use of rescue antiemetics (RR: 0.57, 95% CI 0.43 to 0.75, I(2): 39%, high certainty) and postoperative opioid consumption (standardised MD: -0.48, 95% CI -0.90 to -0.05, p=0.03, I(2): 74%, low certainty). The effects of rescue analgesics and hospital stay duration were nonsignificant. Subgroup analyses showed consistent antiemetic efficacy of dexamethasone across doses, timings, routes and procedures. For pain, greater analgesic effects were seen with higher doses and perineural administration, particularly at 8-12 hours. The risk of bias was low in most studies, but evidence of publication bias was observed for the pain score outcome. CONCLUSIONS: Dexamethasone is an effective adjunct in hysterectomy, significantly reducing PONV and postoperative pain at 8-12 and 24 hours, particularly with 4-10 mg doses. Benefits are consistent across routes, timings and surgical approaches, with greater early analgesia after perineural use. It reduces opioid consumption but has a limited effect on rescue analgesia, supporting its role as a complementary analgesic. While generally considered safe, current safety data are limited, highlighting the need for further research. These results support its use in multimodal recovery protocols and identify priorities for future studies in high-risk and diverse surgical populations. PROSPERO REGISTRATION NUMBER: CRD42024608067.