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Clinicians need to discuss and offer all patients a variety of pain management options for in-office gynecologic procedures ranging from intrauterine device (IUD) insertion to biopsies, according to new guidance published by the American College of Obstetricians and Gynecologists (ACOG). The guidelines, published on May 15, are the first formal ones from ACOG to not only acknowledge the range of pain experiences that can be associated with different procedures but also to explicitly lay out recommendations for the conversations providers should have with their patients about what pain management options are available.

“This guidance speaks to more than just Ob/Gyns,” Co-Author Genevieve Hofmann, DNP, women’s health nurse practitioner and assistant professor of Ob/Gyn at the University of Colorado School of Medicine in Aurora, Colorado, said during a discussion with the press on May 17 at American College of Obstetricians and Gynecologists (ACOG) Annual Meeting in Minneapolis. “It speaks to any physician who’s providing these types of services and certainly to advanced practice registered nurses who work in women’s health and provide these services.”

The types of procedures addressed in the guidelines include IUD insertion, endometrial and cervical biopsies, hysteroscopy, intrauterine imaging, endometrial ablation, uterine aspiration, and loop electrosurgical excision procedures (LEEP). The specific pain management options advised for each of these, however, differ according to what evidence was available to inform the guidance.

“It’s really important to equip clinicians with these tools to be able to have these conversations with patients,” not only about what pain to expect during the procedure but also about what pain management options there are and what the experience of receiving those pain management options is like, Jayme Trevino, MD, MPH, Ob/Gyn and complex family planning subspecialist, said during the press meeting at ACOG.

Not everybody needs pain management for procedures such as an IUD insertion or an endometrial biopsy, Hofmann said, “but they should be given the information to then make that decision, and as providers, we should be able to provide them with at least something that has some evidence behind it.”

According to Uchenna Acholonu, MD, MBA, chief of minimally invasive gynecologic surgery at Northwell Health’s Long Island Jewish Medical Center in New Hyde Park, New York, the guidance is very welcome for both patients and providers.

“ACOG made a big step in actually putting this out,” he said. “They try to come up with guidelines that are inclusive so that they don’t alienate providers or make it difficult for providers to help out. This guideline is helpful in that it’s not absolute, but it’s giving providers an opportunity to choose what they do to help patients.”

Even “more importantly,” he added, “it’s finally acknowledging that it’s not ‘just a little pinch’ or it’s not ‘just a little cramp,’” when it comes to the pain associated with many procedures.

That sentiment was echoed in comments that Nisha Verma, MD, MPH, Ob/Gyn and complex family planning subspecialist and assistant professor at Emory University in Atlanta, said at the ACOG press meeting.

“Patients have very reasonable mistrust of the medical system and have had their pain dismissed in a lot of cases by the medical system,” Verma said. “Women and people of color are, in many cases, offered less pain management or their pain is taken less seriously, and I think it’s important for us as clinicians to be aware that our patients are coming in with this reasonable mistrust.”

Verma emphasized that pain is a very individual experience as well. “My 10 out of 10 might be different from your 10 out of 10,” she said. “This is grounded in principles of shared decision-making, like so much of the other care we provide.”

The guidelines are particularly helpful and important for those just coming out of training. They are entering the profession with the understanding that pain is significant and something potentially worth an intervention.

“I don’t think all providers will see this as something to add to their practice right away,” Acholonu said. “I think it might take a little bit of a push from the patients. That’s not ideal,” he said, but the reality is that it may require a patient asking for something to help with the pain or discomfort for a doctor to think about offering it.

“Self-advocacy has come a long way, and I think it’ll continue to improve,” he said. At the same time, he added, “I think providers are going to take a step, as a result of this, to offer [pain management], even if it doesn’t seem like it’s necessary by their training, now that there is some sort of framework to help guide them.”

Acknowledging that the evidence base in gynecological pain management is still thin, Acholonu expects that this guidance may prompt new studies to look at head-to-head comparisons between pain options for different procedures.

The Pain Management Guidelines

The guidelines address gaps in the literature and the risks associated with different pain options. The section on hysteroscopy, ablation, and polypectomy, for example, notes that there isn’t enough evidence to recommend local injected anesthesia for these procedures, but that misoprostol can reduce pain during the procedure, albeit with an added risk for adverse effects such as abdominal pain or gastrointestinal symptoms. Imaging such as hysterosalpingography or sonohysterography similarly lacks evidence for specific interventions, but enough data exist to suggest that applying 5% lidocaine-prilocaine could help reduce pain with these procedures.

Local anesthetics are recommended for LEEP, and paracervical blocks are among the options for uterine aspiration. But while preprocedural nonsteroidal anti-inflammatory drugs can effectively reduce pain after uterine aspiration, oral opioids, and oral anxiolytics have not been found to effectively decrease pain, although the latter may reduce anxiety related to the procedure.

Verma highlighted the importance of recognizing that the anxiety associated with the perceived anticipation of pain is an important part of the experience for patients too.

“We don’t have any way to predict who is going to do fine with an IUD insertion and someone who’s going to just have a really miserable experience,” Hofmann said. She said they worked to ensure the document was not prescriptive in terms of what pain management patients receive, especially if lack of availability of certain options would make the procedures less accessible. But clinicians need to at least be having a conversation about the options that do exist, she said.

In addition to recognizing the variety of pain experiences that patients may have with these procedures, the guidelines also highlight historical failures to take many patients’ pain seriously and acknowledge marginalized groups and special populations whose needs have been neglected or whose history may interact with their experience of pain.

“The way pain is understood and managed by healthcare professionals is also affected by systemic racism and bias of how pain is experienced,” the guidelines stated. “Specific populations, such as adolescents and those with a history of chronic pelvic pain, sexual violence or abuse, and other pain conditions, may also have increased or decreased tolerance of pain and resistance to pain medications.”

“We have to recognize and acknowledge that [the field of gynecology] has probably not historically done a very good job at managing some of this, and I think the only thing that I can do as a clinician now is do better,” Hofmann said. “Hopefully, establishing trust with people and having good relationships and being open to the conversation is a good starting place.”

No external funding was noted in developing the guidelines and any disclosures were managed according to ACOG policy without specific mention in the guidance document. Shah, Verma, and Acholonu had no relevant financial disclosures.

Tara Haelle is a science/health journalist based in Dallas.