Pain Management for In-Office Uterine and Cervical Procedures (2025)

Number 9

Committee on Clinical Consensus–Gynecology. This Committee Opinion was developed by the American College of Obstetricians and Gynecologists' Committee on Clinical Consensus–Gynecology in collaboration with Genevieve Hofmann, DNP, WHNP-BC, Kimberly Hoover, MD, and Kristin Riley, MD.

Background

The purpose of this Clinical Consensus is to review the available data on pain management for in-office gynecologic procedures and provide health care professionals evidence-based pain-management options they may offer their patients. In-office gynecologic procedures are common and experienced by many patients. There is an urgent need for health care professionals to have a better understanding of pain-management options and for patients to have more autonomy over pain-control options during in-office procedures. Pain is a highly subjective and personal experience for the individual patient 1. The International Association for the Study of Pain defines pain as, “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage” 2; suffering is the interpretation of that experience and involves thoughts, beliefs, or judgments and the ability to cope with pain 3.

In a short patient encounter, it may be difficult to ascertain all the numerous factors that could affect the patient's experience 4. The way pain is understood and managed by health care professionals is also affected by systemic racism and bias of how pain is experienced 5. Historically, Black patients have received less analgesics than White patients, and women have received less attention to their pain than men undergoing similar procedures.

A review of the literature demonstrates that many of the pain-management interventions being used have limited or conflicting evidence supporting their effectiveness at providing adequate pain control during in-office gynecologic procedures. In surveys of health care professionals and patients regarding in-office intrauterine device (IUD) insertion and manual vacuum aspiration, health care professionals tend to underestimate the pain that patients report 6 7. Pain management may be perceived by health care professionals as unnecessary, and in turn, may not be discussed with or offered to patients. Notably, despite patients reporting a higher level of pain than clinicians expect, patients still report a high level of satisfaction with office procedures 8. Higher levels of preprocedural anxiety or of expectations of pain are associated with higher levels of patient-reported pain with office procedures 9 10. Better anticipatory guidance from health care professionals and decreased waiting time on the day of the appointment could help to improve this experience and have the potential to decrease patient pain 11 12.

The specific type of procedure and the anatomy that the procedure involves affect the type and amount of pain the patient may experience. For example, whether the procedure involves the intrauterine cavity and the fundus or the cervix can affect the perception of pain. The intraperitoneal parts of the uterus (fundus and body) receive their innervation from the lowest thoracic and highest lumbar nerves. The afferent pain fibers follow the sympathetic nerves through the superior hypogastric plexus to the spinal ganglia. The destination of the nerves varies between T10 and L2. The afferent pain fibers of the subperitoneal parts of the uterus (cervix) and vagina travel with the parasympathetic fibers through the inferior hypogastric plexus and pelvic splanchnic nerves to the S2–S4 spinal ganglia 13 14 15.

Patients with a history of dyspareunia, dysmenorrhea, or nulliparity may experience more pain during office procedures 16. In addition, specific populations may have increased or decreased tolerance of pain and resistance to pain medications. Patients with a history of chronic pelvic pain, sexual violence or abuse, pain sensitization, vaginismus, substance use disorder, and other pain conditions should be given special consideration when planning for pain management at the time of in-office procedures. Strong evidence to guide management of these patients is lacking, but, as with other patients undergoing gynecologic procedures, it is important to explore pain-management options and offer options that may be beneficial for them. The principles in this Clinical Consensus may be useful in the absence of clear guidance for these specific populations.

Methods

This Clinical Consensus document was developed using an a priori protocol in conjunction with the authors listed above. The a priori protocol was modeled after the Clinical Consensus methodology; a full description of the Clinical Consensus methodology is available online at https://www.acog.org/clinical/clinical-guidance/clinical-consensus/articles/2021/09/clinical-consensus-methodology . The description below is specific to this Clinical Consensus document.

Summary of Consensus Recommendations

Consensus Recommendations and Discussion

Intrauterine Device Procedures

Local anesthetic agents may reduce pain associated with intrauterine device insertion.

Intrauterine devices are highly effective contraceptives and highly effective at managing gynecologic conditions such as heavy menstrual bleeding, dysmenorrhea, endometriosis, and endometrial hyperplasia. However, individuals may not consider this highly effective option out of concern about the pain and discomfort associated with insertion 64 65. Patient acceptance of IUDs for contraception and management of other gynecologic conditions can be improved by addressing anticipated pain and providing adequate pain management during insertion. Not every individual will experience intense pain with IUD insertion, but there are no reliable predictive factors that health care professionals can use to gauge an individual’s potential for pain 66. Every patient who has an IUD placed should receive thorough counseling about the potential for pain associated with this procedure and should be provided with options to mitigate potential pain.

Although there is a significant body of research around pain with IUD insertion, the heterogeneity of study protocols does not provide a clear best practice. Not only do studies use variable local anesthetic formulations and methods of application (eg, spray, gel, injection), they sometimes compare agents with each other and sometimes with placebo. Additionally, studies evaluate pain at various points of the procedure (eg, speculum insertion, tenaculum placement, uterine sounding, IUD deployment, and postinsertion), so they are not easily comparable. Studies also differ on whether they account for patient parity, potentially a significant variable.

Overall, a series of systematic reviews supports the use of local anesthetic agents, specifically lidocaine (as paracervical block or by genital mucosa application), for management of pain associated with IUD insertion over other interventions such as misoprostol 63 67 68 69. Multiple studies demonstrate that lidocaine in various forms is superior to placebo 17 18 70 71 and control 19. A 2017 randomized controlled trial (RCT) compared anesthetic sprays, gels, and paracervical injection and found lidocaine spray superior to lidocaine injection for IUD insertion–related pain 72. However, lidocaine spray for mucosal applications may not be readily available.

A systematic review that evaluated dinoprostone compared with placebo found a decrease in IUD insertion–related pain 73. However, the data using cervical-ripening agents to ease IUD insertion pain are conflicting. Although cervical-ripening agents may be a useful intervention for individuals with a history of unsuccessful insertion attempts, overwhelmingly, studies demonstrate increased pain and adverse effects associated with misoprostol use 62 63 69 74 75 76 77. Adverse effects of misoprostol include abdominal pain, diarrhea, low-grade fever, and increased risk of IUD expulsion.

Interestingly, available evidence does not support preprocedural administration of nonsteroidal anti-inflammatory drugs (NSAIDs) as an effective intervention for reducing pain at time of IUD insertion, despite evidence demonstrating their efficacy in managing pain during endometrial biopsy, a seemingly similar procedure 22 28 78 79. Although recommending preprocedural NSAIDs is a benign, low-risk intervention unlikely to cause harm, relying on NSAIDs alone for pain management during IUD insertion is ineffective and does not provide the immediate pain control patients need at the time of the procedure. Small studies demonstrate conflicting evidence on the efficacy of preprocedural administration of 50 mg oral tramadol (an opiate) compared with 550 mg oral naproxen 80 81. However, there is some evidence to suggest that oral NSAIDs, including ibuprofen, are effective in reducing postprocedural pain 59. There is insufficient evidence to recommend the use of inhaled nitrous oxide (N ₂O) for pain management during IUD insertion, though a small study was able to demonstrate that women who received N ₂O during IUD insertion were more likely to recommend IUD placement to a peer than those who underwent IUD placement without N ₂O 82. Evidence regarding the efficacy of preprocedural administration of anxiolytics in relation to pain management for IUD insertion remains lacking. Additional research is needed to evaluate risks and benefits associated with providing intravenous sedation for IUD insertion, including accessibility and cost effectiveness.

Evidence is lacking on nonpharmacologic pain-management interventions during IUD insertion. A 2023 systematic review and meta-analysis of RCTs evaluating the use of transabdominal ultrasound guidance during IUD insertion is promising 83. Compared with blind IUD insertion, using ultrasound guidance during insertion was effective at reducing pain scores, procedure time, and complications, with better patient satisfaction. Noted overall limitations to ultrasound guidance include needing access to ultrasound equipment and a knowledgeable ultrasound assistant. A small RCT assessed postprocedure pain, not pain during insertion, in patients receiving acupuncture before IUD insertion and demonstrated lower pain scores in those receiving the intervention 84. Further research into nonpharmacologic pain interventions, including interventions to reduce anxiety, are needed.

Although pain associated with the removal of an IUD was included in this Clinical Consensus’s search strategy, data are lacking. Thus, this document does not include pain-mitigation recommendations for IUD removal. Challenges with IUD removal, such as missing strings and embedded IUDs, were also considered out of scope for this clinical consensus and, therefore, are not included. ACOG’s Committee Opinion 672, Clinical Challenges of Long-Acting Reversible Contraceptive Methods, addresses some of these issues in further detail.

Endometrial Biopsy

Topical anesthetics and preprocedural administration of nonsteroidal anti-inflammatory drugs may reduce pain with endometrial biopsy.

Patients often report discomfort during and immediately after endometrial biopsy. Although there are several studies evaluating the use of NSAIDs for pain relief during endometrial biopsy, data on their effect on preprocedural and postprocedural pain when sampling the uterus with Pipelle (endometrial suction curette) are conflicting. Some studies report little or no benefit in reduction of pain with the use of preprocedural NSAIDs alone 85 86. A study of 151 patients randomized to either vaginal misoprostol, rectal NSAIDs, or self-administered vaginal placebo for endometrial biopsy using endometrial suction curette found no significant differences in pain scores among the groups 86. However, some studies indicate that NSAIDs, such as naproxen, especially when used in combination therapies (such as with lidocaine spray), may be effective in reducing postprocedural pain 22 28.

The data on the use of misoprostol before endometrial sampling are conflicting. A study of patients undergoing manual vacuum aspiration for abnormal uterine bleeding who were randomized to receive either sublingual misoprostol or placebo 2 hours before the procedure under nurse supervision found that procedure times for the misoprostol group were significantly shorter than those for the control group 87. Cervical dilation and duration of procedure were better for the misoprostol group; although adverse effects of misoprostol were higher, they were perceived as manageable by patients. Additionally, pain scores in the misoprostol group were lower than in the placebo group. Though vaginal misoprostol for endometrial biopsy by endometrial suction curette did not demonstrate improved pain, there does appear to be evidence that sublingual administration of misoprostol may have some benefit for pain management over other routes of misoprostol use 86 87.

Multiple studies have reported on the use of topical analgesics, specifically 10% lidocaine spray, for procedural pain and postprocedural pain for endometrial sampling. In a study of 120 patients who received either an application of 10% lidocaine spray (3 puffs to the cervical surface and one puff towards the cervical os) or placebo, a significant reduction in pain scores was noted in the treatment group 21. A similar study of 140 patients randomized to either 4 puffs (40 mg) of 10% lidocaine spray or 4 puffs of 0.9% normal saline before endometrial biopsy shows a significant reduction in intraprocedural pain in the treatment group. However, no postprocedure pain differences were noted at 15 minutes or 2 hours 20. There appear to be some benefits to the use of topical lidocaine for pain control during endometrial biopsy in the outpatient setting. Topical lidocaine spray is more consistently associated with pain reduction over other forms of topical lidocaine. A systematic review and metanalysis demonstrated significantly lower pain scores during biopsy in the anesthetic spray group compared with the control group 88. Other studies, however, found that the use of topical anesthetic with lidocaine spray did not improve pain scores 89 90. Studies comparing the preprocedural use of topical lidocaine on the cervix with placebo gel showed that there was significantly less pain during the procedure; however, there were no differences in postprocedural pain 25. An older RCT of 308 patients randomized to either presampling intrauterine 2% lidocaine gel or placebo reported no statistically significant difference in pain relief 91.

There are some data to suggest that the method of biopsy may play a role in pain scores for patients undergoing endometrial sampling 89. Topical anesthetic agents may be effective at reducing pain from cervical manipulation with tenaculum use. However, intrauterine pain with use of endometrial suction curette compared with dilation and sharp curettage may explain why topical analgesics at times do not seem to improve pain scores. The method of biopsy may be particularly important when considering endometrial biopsy to rule out concurrent carcinoma in patients diagnosed with endometrial intraepithelial neoplasia or atypical endometrial hyperplasia. Recent data suggest higher rates of endometrial cancer in preoperative samples using endometrial suction curette compared with standard dilation and curettage 92. Intrauterine instillation of topical lidocaine over placebo does appear to be effective for pain reduction in patients undergoing endometrial biopsy and does not interfere with pathology interpretation. Intrauterine instillation of 2% lidocaine 5 mL compared with intrauterine instillation of distilled water has been demonstrated to improve pain scores and should be considered when sampling requires sharp curettage or vacuum aspiration 26. Health care professionals should be mindful that the use of sharp curettage should be extremely limited, especially in the office setting.

Although the use of paracervical block compared with intrauterine lidocaine results in similar pain scores during a procedure, postprocedural pain appears to be substantially lower in patients who received intrauterine instillation of lidocaine after the procedure 24. An RCT divided 123 patients into four groups: 1) paracervical block and endometrial suction curette sampling 1 minute after block, 2) paracervical block and endometrial suction curette sampling 3 minutes after block, 3) control group with placebo, or 4) premedicated with NSAIDs and biopsy 1 hour after administration 93. Significant pain reduction was seen in both paracervical block groups compared with the control and NSAID groups; no difference in scores was found between the control and oral NSAID groups during endometrial sampling.

In addition to pharmacologic methods of managing pain, one study looked at the effect of a full bladder on pain during endometrial suction curette sampling and concluded that sampling with a full bladder reduced pain during the procedure, among other improvements (such as reduced failure rate of insertion, duration of procedure, and increased patient satisfaction) 94.

Hysteroscopy, Ablation, and Polypectomy

There is sufficient high-quality evidence to recommend local injected anesthesia at the time of diagnostic and operative hysteroscopy and endometrial ablation. Misoprostol reduces intraprocedural pain, though its use is associated with a high incidence of preprocedural adverse effects (eg, abdominal pain, gastrointestinal symptoms).

In-office diagnostic and operative hysteroscopy give patients options for expedited evaluation and management of intrauterine pathology without the need to schedule a procedure in the operating room setting. Both ACOG and the AAGL agree that vaginoscopy (the insertion of a hysteroscope to visualize the vagina) to achieve hysteroscopy may be considered when performing office hysteroscopy because studies have shown that it can significantly reduce procedural pain with similar efficacy 95. Because vaginoscopy has been shown to be a less painful procedure than in-office hysteroscopy, health care professionals typically do not place a concurrent local anesthetic. If in-office hysteroscopy is chosen, local anesthesia injected intracervically, transcervically, or paracervically at the time of the procedure may be used 96 97 98.

Although there are multiple studies supporting the use of local injected anesthesia at the time of office hysteroscopy for the management of pain, there is wide variation in the way local anesthesia is administered and the type of anesthetics used. Paracervical and intracervical injections are the most commonly used methods. Paracervical anesthesia (paracervical block) involves several injections into the cervix at the level of the vaginal fornices, whereas intracervical anesthesia involves injections directly into the cervix. For both techniques, there is variation in the type of anesthetic used, as well as in the concentration and volume used. The number of injections and injection sites also may vary. Intrauterine injections and topical medications are less commonly used methods. Intrauterine topical medication and injections have been found to provide additional pain relief for operative hysteroscopy procedures such as endometrial ablation and polypectomy, given the different innervation 34 99. Paracervical and intracervical blocks, in combination or alone, improve pain with hysteroscopic polypectomy 100.

In a large systematic review and meta-analysis, preprocedural cervical preparation with prostaglandins was found to decrease pain and improve feasibility of in-office hysteroscopy 101. Misoprostol was the most effective agent for this approach. One study reported the use of vaginal misoprostol dosed at 400 micrograms the morning of the procedure 102, and another study used 50 micrograms of vaginal misoprostol the night before the procedure 29. However, patients experienced increased adverse effects, including bleeding, abdominal pain, cramping, nausea, and vomiting. These adverse effects were reported regardless of route of administration of misoprostol, though most studies used a vaginal route. A systematic review of studies evaluating the use of NSAIDs, opioids, antispasmodics, and transcutaneous electrical nerve stimulation (TENS) units at the time of diagnostic and operative hysteroscopy showed an improvement in pain with all of these methods, with the strongest data supporting the use of NSAIDs; opioids were associated with the most adverse events 103.

There are conflicting data on the efficacy of treatment strategies with nonpharmacologic methods, such as TENS units, virtual reality headsets, music, and guided imagery. Some RCTs support the use of music to decrease pain 104 105, but one did not show a difference in pain 106. Virtual reality technology showed a decrease in pain 107 108 109 and a decrease in anxiety 110 111 in some studies. Although one available study showed only minimal improvement in pain with the use of a TENS unit at the time of hysteroscopy 112, deSilva et al 103 were able to show improvement in pain with TENS units. Currently, there is insufficient evidence to recommend one of these approaches over another. Health care professionals should consider and offer a multimodal approach to pain management for office hysteroscopy.

Other Imaging (Hysterosalpingography, Sonohysterography)

Data on the efficacy of a specific intervention for the management of pain associated with the performance of hysterosalpingography and sonohysterography are inconclusive. However, data support that cervical application of 5% lidocaine–prilocaine cream reduces pain associated with cervical instrumentation of tenaculum and cannula for hysterosalpingography.

Most available data focus on pain management at the time of HSG; there are very few data evaluating pain management at the time of saline infusion sonohysterography. In a systematic review and meta-analysis of RCTs comparing topical lidocaine 2.5% and prilocaine 2.5% cream with placebo at the time of HSG, the application of cream to the cervix consistently decreased pain perception during cervical instrumentation of the tenaculum and cannula 35 113. However, there was no difference in pain at the time of contrast injection, which was reported to be the most painful part of the procedure. Patients in the cream group reported substantially less pain than those in the placebo group during cervical manipulation and uterine traction. It is important to note that there are different methods for performing HSG and that cervical application of topical lidocaine 2.5% and prilocaine 2.5% cream may support pain relief depending on the cervical manipulation required.

A prospective randomized study that used rectal indomethacin before HSG demonstrated notable pain improvement in the intervention group compared with placebo 36. However, other studies were unable to show improvement after the use of NSAIDs unless used in combination with paracervical block 114 115. Studies looking at alternative pain-management strategies, such as virtual reality and acupuncture, were unable to show improvement in pain 116 117. Currently, the best available evidence for pain management at the time of HSG and saline infusion sonohysterography is cervical topical application of lidocaine 2.5% and prilocaine 2.5% cream.

Uterine Aspiration

Paracervical blocks decrease procedural pain for uterine aspiration, and preprocedural administration of NSAIDs decreases postprocedural pain.

Uterine aspiration for pregnant individuals is one of the most commonly performed in-office procedures. It is essential that adequate analgesia be offered to decrease pain experienced with uterine aspiration. Multiple studies have explored the effectiveness of reducing pain with local anesthesia before a procedure, particularly with procedures performed during the first trimester. Data show that paracervical block with lidocaine is superior to placebo 37 38 39. An RTC of 140 patients demonstrated significant pain reduction with the use of a paracervical block with divided dosing injections of 20 mL 1% lidocaine at the 3 o’clock and 9 o’clock cervicovaginal junction at a 1-cm depth when compared with saline injection 38. Similarly, a 2024 Cochrane review reported that, although mild discomfort was associated with paracervical block placement, the reduction of intraprocedural pain was clear 37. In a randomized, double-blind, placebo-controlled trial of women undergoing in-office uterine aspiration of a first-trimester pregnancy or an early pregnancy loss, 20 mL of 1% lidocaine was used to perform paracervical block, with injection sites at the 2, 4, 8, and 10 o’clock portions of the cervicovaginal junction 39. When comparing buffered lidocaine with nonbuffered lidocaine, there was no increase in patient satisfaction, and similar pain relief was experienced during procedures 39. A study of 158 women undergoing vacuum aspiration who were randomized to either 50 mg tramadol or 800 mg ibuprofen orally found greater postoperative pain control in the NSAID arm 40.

The maximum dose of lidocaine without epinephrine should not exceed 4.5 mg/kg or 300 mg total to avoid adverse effects and toxicity. The maximum dose of lidocaine with epinephrine is 7 mg/kg or 500 mg 118. Toxicity can result in visual disturbances, confusion, seizure, or cardiorespiratory arrest. Techniques such as aspiration before injection can reduce intravascular injection and aid with tissue distribution of the anesthetic. Combining preprocedural NSAID use with paracervical block has been shown to decrease intraoperative and postoperative pain in uterine aspiration 57.

Neither oral opioids nor oral anxiolytics decrease procedural pain, though oral anxiolytics may decrease anxiety related to the procedure.

Health care professionals should be aware that anxiety related to uterine aspiration has an important effect on a patient’s experience of procedural pain. Health care professionals should acknowledge a patient’s procedure-related anxiety and provide anticipatory counseling. Although studies have focused on procedural and postoperative pain control with opioids, data on the use opioids for uterine aspiration do not demonstrate improvement in intraoperative or postoperative pain and are associated with increased nausea 57 119. Higher levels of sedation, such as propofol, are out of the scope of this document; see the Society of Family Planning clinical recommendations 120. Although anxiolytics decrease anxiety related to the procedure, they do not improve pain control over NSAIDs and paracervical block 57 121. Health care professionals should tailor approaches to anxiety and pain relief based on an individual patient’s expectations of pain and preprocedural anxiety.

Cervical Procedures (Colposcopy, Loop Electrosurgical Excision Procedures [LEEP], Cervical Biopsy)

The use of local anesthetic agents is recommended for loop electrosurgical excision procedures (LEEP).

It is important to manage the pain associated with in-office LEEP. These procedures are successfully performed in the office and routinely are well tolerated by patients 43 44. Local anesthetics are efficacious, and studies have shown a reduction in pain using paracervical block (10 mL of 2% lidocaine with 1:100,000 of epinephrine), intracervical injection (four injections of 0.5% bupivacaine hydrochloride), and lidocaine spray (40 mg of 10% lidocaine spray); however, the available evidence has not identified a superior method to provide local anesthesia for LEEP 41 44. Studies vary in their assessment of pain during LEEP and postprocedure pain. Pain scores during LEEP using local anesthesia by paracervical block or lidocaine spray were similar, though the median postanesthesia score from baseline was higher in the injection group 41 42. Cervical injection of local anesthesia through paracervical block is itself associated with pain and discomfort. Injection and topical application of local anesthesia often lead to longer procedure times, which may contribute to increased anxiety and perceived pain and decreased overall satisfaction 42 47 48 122 123.

Colposcopy and Cervical Biopsy

The evidence for managing pain associated with colposcopy and cervical biopsy is similar to other in-office uterine and cervical procedures. The data are heterogeneous and often conflicting, with studies using variable local anesthetic formulations compared with each other, compared with placebo, and compared with other medications (eg, NSAIDs). Based on individual small trials and older reviews, topical application of local anesthetic may reduce pain associated with colposcopy-directed cervical biopsies, but evidence of this intervention having a clinically meaningful effect is lacking 45 46 124 125. More recently, a 2019 systematic review and meta-analysis of 11 studies, including two of the studies referenced above 124 125, evaluating the efficacy of local anesthetics for pain relief during colposcopy-directed cervical biopsy found no significant difference between local anesthesia and control (eg, forced coughing, no local anesthesia, placebo) for postprocedure pain, pain during endocervical curettage, pain expectancy, and overall pain scores 122. The evidence supporting NSAID use is limited and conflicting 124. A 2023 RCT demonstrated that etoricoxib, a COX-2 inhibitor and NSAID, was effective at managing pain during colposcopy and up to 24 hours postprocedure 49.

Two studies that compared forced coughing with local anesthesia (injection of 1 mL 1% lidocaine with 27-gauge needle and 10% lidocaine spray to ectocervix, respectively) found local anesthesia to be superior for pain relief. However, the use of local anesthesia led to longer procedure times 47 48. There is a robust amount of research on the efficacy of distraction techniques (eg, forced coughing, music, and visual distraction) to decrease pain during cervical biopsy and LEEP. In one study that assessed pain during cervical biopsy, the use of music as a distraction technique demonstrated no significant difference in pain against a control group 126. Studies that examined both pain and anxiety through the distraction techniques of coughing or music, respectively, also showed no significant differences in either pain or anxiety scores 127 128. Although older evidence suggests that distraction techniques may decrease anxiety levels associated with colposcopy-directed cervical biopsies and LEEP 51 129, more recent data suggest that these techniques are not effective. For colposcopy and cervical biopsy, although distraction techniques essentially are risk-free, they provide inadequate pain control and should not be the only options offered to patients undergoing these procedures. Before the performance of colposcopy, it is reasonable for health care professionals to discuss with patients use of local lidocaine to mitigate the pain associated with cervical biopsy. However, the evidence is mixed on its efficacy and may lead to longer procedure times.

Special Considerations

Populations such as adolescents, gender-diverse individuals, patients with physical or cognitive disabilities or both, patients with chronic pain, and patients with a history of trauma may have different needs that health care professionals should consider when approaching pain control for examinations and in-office procedures. Thorough preprocedural counseling about the procedure itself with both patients and their caregivers as well as about anticipated pain and anxiety can alleviate misconceptions and increase patient satisfaction. Use of models or handouts to explain procedures can dispel misconceptions 130 131 132 133. Adolescents cite pain (perceived and experienced) as the number-one deterrent to IUD placement. As with adult patients, preprocedural anxiety for adolescents and young adults may be addressed by offering an anxiolytic or sedation for IUD insertion 9. Additionally, when counseling patients and their caregivers, gynecologic care professionals can reassure them that more than 95% of adolescents have successful outpatient placement of an IUD on first attempt, without premedication of anxiolytics 134. Based on expert opinion, treating pain proactively with anxiolytics may be effective for all patients, especially adolescents, who choose IUDs 9 130 135.

Physical and emotional trauma can negatively affect both physical and mental health outcomes. A history of trauma can cause patient anxiety toward medical facilities, examinations, and procedures. Obstetrician–gynecologists should become familiar with the trauma-informed model of care and strive to universally implement a trauma-informed approach to all of their patients across all levels of their practice, with close attention to avoiding stigmatization and prioritizing resilience 133. Employing trauma-informed care models when counseling and interviewing all patients, including gender-diverse patients, has been shown to improve satisfaction with gynecologic procedures and may help avoid situations that retrigger a patient’s trauma 132 133. Examples of trauma-informed care include asking a patient about past sexual trauma before an examination (when the patient is fully clothed), allowing a patient to have control of the examination with the placement of the speculum, and replacing words such as “stirrups” with “footrests” and “bed” with “table.” Another example includes offering intravenous sedation or general anesthesia for procedures in a setting in which higher levels of anesthetic are available because some patients who have experienced trauma may benefit from those options. When caring for gender-diverse patients, using alternative language for body parts, such as “genitals” or “external genitalia” (as opposed to using “penis” or “vulva”) or using “organs you currently have” compared with using “penis, vagina, testicles, [or] ovaries,” and mirroring the preferred language of the patient, can alleviate anxiety during counseling, examination, and procedures 132 133 136.

Further Research

Future research on pain and the management of pain must be more racially and ethnically diverse. Studies should include gender-diverse participants, focus on patient preferences and goals, and consider the needs of individuals of various ages and those who have a history of trauma. For specific gynecologic procedures, more data are needed on the role and effectiveness of preinsertion education as an intervention to manage IUD pain and the effects of preprocedural administration of anxiolytics. Future research should focus on the efficacy of nonpharmacologic interventions (eg, acupuncture) and the practicality and cost effectiveness of in-office intravenous sedation. More data are needed on the role of misoprostol for endometrial biopsy, as well as the dose, vehicle, and timing of topical lidocaine for endometrial biopsy with endometrial suction curette. For management of pain with procedural uterine aspiration, data are needed on when to administer pain medication, the ideal modality combination to treat pain, and patient perspectives of pain and satisfaction. For cervical procedures, including colposcopy, LEEP, and cervical biopsy, more research is needed to understand the role of anxiety reduction and the efficacy of preprocedural anxiolytics.

Appendices

Conflict of Interest Statement

All ACOG committee members and authors have submitted a conflict of interest disclosure statement related to this published product. Any potential conflicts have been considered and managed in accordance with ACOG's Conflict of Interest Disclosure Policy. The ACOG policies can be found on acog.org. For products jointly developed with other organizations, conflict of interest disclosures by representatives of the other organizations are addressed by those organizations. The American College of Obstetricians and Gynecologists has neither solicited nor accepted any commercial involvement in the development of the content of this published product.