ACOG Issues New Guidance on Pain Management for In-Office Gynecologic Procedures
The American College of Obstetricians and Gynecologists (ACOG) has released updated guidelines focusing on pain management during in-office uterine and cervical procedures. The guidance, developed by ACOG’s Clinical Consensus Committee on Gynecology, emphasizes the importance of patient counseling and outlines effective pain management techniques for procedures such as IUD insertion, endometrial biopsy, hysteroscopy, intrauterine imaging, and cervical biopsy. These often painful but essential procedures necessitate improved pain relief strategies and enhanced communication with patients about available options.
In-office gynecologic procedures are common, but pain during these procedures is often underestimated. Health care professionals need to better understand and address pain management, considering factors like systemic racism, bias, and individual patient histories, including trauma and chronic pain. Current pain-control methods have limited or conflicting evidence, so treatments should not be assumed to work universally. Shared decision-making is crucial, as pain experiences vary. Future research must be more inclusive, addressing racial, ethnic, gender, and age diversity, and focusing on patient-centered care.
There is an urgent need for clinicians to better understand pain management options and recognize and address patient pain, and for patients to have more autonomy over pain control options for their health care.
“The way that pain is managed by health care professionals has been affected by a number of factors, including the fact that many of the pain management interventions had limited or conflicting evidence supporting their effectiveness,” said Christopher M. Zahn, MD, FACOG, chief of clinical practice and health equity and quality at ACOG. “Additionally, systemic racism and bias as to how pain is experienced and who experiences it also has, unfortunately, influenced pain management considerations. This guidance is an important step toward both identifying evidence-based approaches to pain management and reducing those biases by offering all patients more autonomy in deciding how to best approach the pain they experience. What I hope clinicians will take away from this guidance is the absolute importance of comprehensive pain management counseling—not just for mitigating pain in the moment but also for improving trust with our patients and ensuring better access to gynecologic health care for every person.”
The guidance recommends clinicians offer local anesthetics for IUD insertions, such as lidocaine spray, lidocaine-prilocaine cream, and paracervical block. For other procedures, options vary but can include, for example, local anesthetics such as topical or injected anesthetics, NSAIDs, and other medications such as misoprostol.
Pain and anxiety about pain can present barriers to patients accessing needed or beneficial health care. The document importantly recommends that ob-gyns and clinicians discuss and offer pain management options to every patient seeking an in-office gynecologic procedure and ensure that pain management counseling is individualized, culturally competent, trauma-informed, and guided by shared decision-making.
“As a women’s health nurse practitioner, I treat patients every day who express anxiety about pain related to common procedures like IUD placement. Unfortunately, many patients feel their pain has been diminished or dismissed by their clinicians, which data shows can lead to patient dissatisfaction and distrust. ACOG’s new guidance provides critically important patient-centered recommendations on how to help our patients have better experiences and will help improve trust between patients and clinicians,” said Genevieve Hofmann, DNP, WHNP, coauthor of the guidance. “Though some clinicians have been able to offer some of these pain management options already, I am excited that this guidance will ensure more ob-gyns and clinicians are discussing pain management options with their patients, and, most importantly, that fewer people will have to endure pain to obtain procedures that are necessary for their health and well-being.”
As discussed in the guidance, there exist several challenges to adequately addressing pain during in-office gynecologic procedures. Predicting how much pain a person will experience with a procedure is difficult. Patient age, pelvic examination experience, past trauma, and baseline anxiety all may influence how someone experiences pain. Additionally, available research comparing a variety of methods at varying points within the same procedure may have mixed results, which create difficulties in determining a singular best approach. Regarding IUD insertion, for example: though there is a significant body of research around pain management, differing study protocols do not provide one clear best practice. As such, ACOG’s new guidance recommends that clinicians counsel patients about all the available options and engage in shared decision-making to decide on a method of pain management.
“Comprehensive counseling is key because patients must be able to decide for themselves what interventions, if any, they would like to try. Patients know their own bodies best and know what their priorities are for a procedure-whether they want it to be completed as quickly as possible, whether their priority is reduction in acute pain, or whether they’d prefer to be able to pause the procedure if needed to try a different intervention,” said Kimberly Hoover, MD, FACOG, coauthor of the guidance. “I have some patients for whom the paracervical block, for example, is quite helpful for their IUD insertion experience. I have other patients who would prefer to avoid needles and may want to try another approach. Presenting patients with all the options and using shared decision making is best practice.
Additionally, while ACOG’s new guidance focuses on in-office procedures, it does note that comprehensive pain management counseling should include offering patients the option to undergo uterine procedures under intravenous sedation, monitored anesthesia, or general anesthesia when and where available.
“As a minimally invasive gynecologic surgeon and pelvic pain specialist, I am proud to have helped in creating this guidance because I know that for many patients who already experience pelvic pain in their daily lives, being presented with multiple options for pain management for gynecologic procedures is critical to improving their health care experience-especially for people whose pain has previously been dismissed. I’m also hopeful that my fellow scientists will continue to research more techniques for gynecologic procedure pain management, and that future research will be more racially and ethnically diverse and consider broader patient ages and those with history of trauma and pelvic pain, because all people deserve access to evidence-based care,” said Kristin Riley, MD, FACOG, coauthor of the guidance.
