Clinicians urged to rethink gynecologic pain management

Editor's Note

Pain among patients undergoing in-office gynecologic procedures is widely underestimated and ineffectively treated, particularly for those with trauma histories, chronic pain, or marginalized identities, according to a new Clinical Consensus from the American College of Obstetricians and Gynecologists. The report stresses that individualized, evidence-informed, and trauma-sensitive strategies are urgently needed and should be guided by shared decision making.

The consensus is based on a structured literature review of studies published from 2000 to 2024, focused on pain control in common in-office procedures including intrauterine device (IUD) insertion, endometrial biopsy, hysteroscopy, uterine aspiration, and cervical procedures like LEEP and colposcopy. The research prioritized inclusion of diverse populations and evaluated both pharmacologic and nonpharmacologic interventions.

The consensus states that patients should be offered pain-management options. Furthermore, assumptions that certain procedures are “not painful” must be challenged. Even if pain cannot be reduced, share decision-making and anticipatory guidance can reduce anxiety and improve outcomes. Other findings and recommendations relate to specific procedures, including:

• IUD insertion. Local lidocaine (spray or injection) is more effective than NSAIDs, which help with post-procedure pain but not during insertion. Likewise for misoprostol, which is prone to causing side effects. Ultrasound-guided insertion and nonpharmacologic approaches like acupuncture show promise but need more study.
• Endometrial biopsy. Again, NSAIDs may help with postprocedure pain but offer inconsistent procedural relief, while postprocedural misoprostol may increase adverse effects. 10% lidocaine spray or intrauterine instillation of lidocaine reduces procedural pain.
• Hysteroscopy, ablation, polypectomy. Local injected anesthesia is effective. Misoprostol reduces pain but causes gastrointestinal side effects. Adjunct methods like TENS, music, and virtual reality show mixed efficacy.
• Hysterosalpingography (HSG). NSAIDs show limited benefit unless paired with local anesthesia. Alternatively, topical lidocaine-prilocaine cream applied to the cervix reduces pain from instrumentation.
• Uterine aspiration. Paracervical blocks clearly reduce procedural pain; NSAIDs reduce postoperative discomfort. Opioids and oral anxiolytics don’t reduce procedural pain, though anxiolytics may ease anxiety.
• LEEP and cervical biopsy. Local anesthesia is recommended for LEEP; no single method proves superior. For colposcopy and biopsy, local anesthetics may help but prolong procedures. Distraction techniques (eg, music, coughing) are ineffective.

The consensus also emphasizes the importance of trauma-informed care, particularly for adolescents, gender-diverse patients, and those with prior abuse or chronic pain. Clinicians are encouraged to use inclusive language, offer control over the exam, and consider anesthesia or sedation where appropriate.