rewrite this title Doctors urged to treat pain for IUD insertion and other procedures

Countless patients have suffered through in-office gynecological procedures like IUD insertions or cervical biopsies, with nothing more than ibuprofen and white knuckles.

Pain is complex and individual. One patient might feel little to no discomfort and for another it can be excruciating. But some clinicians don’t offer pain management because they believe it’s unnecessary.

In its new recommendations for cervical and uterine procedures, released last week, the American College of Obstetricians and Gynecologists says there is “an urgent need” for this to change.

ACOG directs clinicians to have an “upfront and thorough” conversation so patients know pain might occur and are offered options to manage that pain, such as a paracervical block.

The block is done by injecting a local anesthetic, often lidocaine, on top of and near the cervix. Lidocaine cream and spray are additional options for patients who want to avoid needles, though there is less research on their efficacy, said Dr. Danielle Tsevat, an OB/GYN at the University of North Carolina at Chapel Hill

Tsevat, who researches gynecological pain, noted that some physicians use a combination of these methods by applying a topical to numb the area first before going in with a syringe.

The guidelines include a comprehensive review of studies that analyze the efficacy of various pain management methods.

Sedation and anti-anxiety medication are briefly mentioned in the recommendations, which note these options might be beneficial for certain patients, including adolescents or survivors of sexual trauma.

“What I always tell patients is that I bring medical experience. But they bring the expertise in their life. And we partner together to help find the best option for them,” said ACOG fellow Dr. Jayme Trevino.

Norms change as women speak out

The new guidelines seek to prevent problems like the ones experienced by Melissa Stewart, a Memphis-based attorney whose doctor didn’t warn them that IUD insertion might hurt, as NPR has reported. For Stewart, the insertion felt like being stabbed. This kind of experience can lead to patient distrust and even make the pain worse, according to research cited in the recommendations.

ACOG’s guidelines come just nine months after the Centers for Disease Control and Prevention updated its guidance on IUD insertions, which also emphasize shared decision-making.

But while the CDC only acknowledged that local anesthetic can make an IUD insertion hurt less, ACOG explicitly states that clinicians should offer it along with other options.

It’s a subtle but meaningful difference and welcomed improvement, said Dr. Karen Meckstroth, who practices at the Obstetrics, Midwifery and Gynecology Clinic at San Francisco General.

For much of her career, Meckstroth has provided local anesthetic for in-office procedures, and now trains resident physicians to do the same.

“I can’t think of any other procedures where there’s a significant chance of severe pain where we don’t recommend at least local anesthetic when we know that it can help,” Meckstroth said.

But this norm is changing. Meckstroth told NPR that she knows OBGYNs who have started incorporating a paracervical block into their practice for in-office procedures after being resistant to it.

This coincides with the wave of social media advocacy over the last several years, with people discussing bad experiences at OBGYN clinics. Some patients have even filmed their own faces during IUD insertions and then posted those videos to TikTok.

While the CDC focused on pain management for contraception, ACOG’s guidance addresses the variety of in-office uterine and cervical procedures that involve the placement of an instrument into the cervix or uterus, such as an endometrial biopsy, which is often done to determine the cause of irregular bleeding after menopause.

Though some of these procedures are more common among older patients who might be less inclined to post on TikTok, Tsevat said they deserve the same attention, “because it’s the same probable level of pain.”

Acknowledging inequalities in the history of treating pain

The timing of ACOG’s release is significant and symbolic, said historian Deirdre Cooper Owens, a University of Connecticut professor. Cooper Owens has written about the birth of modern gynecology, including how 19th century physicians experimented on enslaved women who were not able to consent or object.

“In the wake of so much governmental legislation that has removed women’s voices, bodily autonomy, and agency concerning their bodies, these medical recommendations were especially needed,” Cooper Owens told NPR via email.

Both the CDC and ACOG’s guidelines note that racism and other structural inequities can affect the quality of patient care, including which patients receive treatment for pain management.

“Historically, Black patients have received less analgesics than White patients, and women have received less attention to their pain than men undergoing similar procedures.” ACOG states.

Cooper Owens said it’s good that these guidelines, which emphasize transparency and choice, acknowledge this history.