Pain and Gynecology: Raising Standards of Care

Authored by: Nicole Loy

Pain has been an accepted part of office gynecologic procedures for far too long. Procedures such as IUD insertion, cervical biopsy, and uterine biopsies have been known to cause pain in patients, ranging anywhere from mild to severe [1]. However, this is often insufficiently addressed by healthcare providers, making many common gynecologic procedures a painful experience. This is especially problematic because fear of painful procedures may prevent patients from receiving an IUD, a highly effective and long-term form of birth control, or from following up on abnormal readings from pap smears [2]. These issues lower the standard of care for patients and increase fear and discomfort around essential healthcare. Multiple factors culminate in substandard gynecologic care, including improper training, medical misogyny, and insufficient pain management options for patients. 

Healthcare providers often underestimate the pain that procedures such as IUD insertions cause in their patients [3]. This causes an underestimation of the pain management required for gynecologic procedures and produces a substandard quality of care. A possible contributing factor is the fact that many gynecologists were taught that the cervix is unable to feel pain. This teaching is likely based on the 1953 book Sexual Behaviour in the Human Female, which incorrectly claims that the cervix has no sensory nerve endings and can be cut or manipulated without pain [4]. While the teaching of this medical accuracy has decreased, many still believe the cervix is a low-pain area, contributing to the substandard use of pain management for painful gynecologic procedures. 

The downplaying of a patient’s pain is especially problematic when combined with the lack of standards for office gynecologic pain management. In August 2024, the CDC released new recommendations for pain management for IUD insertion, suggesting lidocaine gel to reduce patient pain [5]. However, they also clarified that lidocaine only “might” be useful, citing conflicting information from various studies without providing any further recommendations. Without strong regulations established by organizing bodies, practitioners are left to determine their own approaches to pain management, which can result in insufficient treatment of patient pain.

This coincides with another glaring issue: the lack of reliable pain management for cervical and uterine procedures. While many gynecologists recommend NSAIDs like ibuprofen to mitigate pain, studies have shown that ibuprofen does not decrease pain for these procedures [6]. Even lidocaine gel, the treatment recommended by the CDC, often fails to show decreases in cervix pain when compared to placebos. Paracervical blocks have shown a slight effect on reducing pain during IUD insertion but are usually painful to administer, negating their effectiveness for patients [7]. With a limited number of effective options for pain management, many gynecologists are left to rely on insufficient methods like lidocaine gel for their patients, which often leads to disappointing results. 

The patient’s pain can also be affected by their history with gynecologic procedures and their preconceived ideas about pain management. Anxiety related to healthcare procedures, including fear of a procedure being painful, can predict an increase in pain [8]. It is especially significant to consider that many women have trauma related to gynecological care from previous experiences with improper pain management. Some also have experienced medical gaslighting, which contributes to a high level of medicine-related anxiety. Compounded with racial disparities, as women of color are less likely to have their pain taken seriously by medical professionals, many patients are set up for failure before they even enter the office [9]. 

Women’s healthcare cannot be allowed to remain in this sorry state. First, new doctors must be educated on the sensitivity and innervation of the cervix and uterus. Many in-office procedures use tools like the tenaculum, which pierce the cervix and cause varying pain levels in patients [10]. Doctors must acknowledge and appropriately prepare patients for such pain rather than diminishing it. Additionally, new methods of pain management must be explored, as the current use of NSAIDs, lidocaine, and paracervical blocks are inadequate options for pain management. With time, clear communication and respect for patients will repair the damaged relations between doctor and patient and establish a higher standard of care for a previously neglected population. 

References 

1. Kim, K., Lee, B., Park, Y., Suh, D. H., No, J. H., & Kim, Y. B. (2018). Factors affecting pain during outpatient clinic based surgical procedures in gynecologic oncology. Medicine, 97(31), e11721. https://doi.org/10.1097/MD.0000000000011721

2. Estevez, E., Hem-Lee-Forsyth, S., Viechweg, N., John, S., & Menor, S. P. (2024). Advancing Pain Management Protocols for Intrauterine Device Insertion: Integrating Evidence-Based Strategies Into Clinical Practice. Cureus, 16(6), e63125. https://doi.org/10.7759/cureus.63125

3. Brima, N., Akintomide, H., Iguyovwe, V., & Mann, S. (2015). A comparison of the expected and actual pain experienced by women during insertion of an intrauterine contraceptive device. Open access journal of contraception, 6, 21–26. https://doi.org/10.2147/OAJC.S74624

4. Kinsey, A.C., Pomeroy, W.P., & Martin, C.E. (1954). Sexual Behaviour in the Human Female. The Indian Medical Gazette, 89, 644 - 645. 10.2307/823986

5. Curtis KM, Nguyen AT, Tepper NK, et al. (2024). U.S. Selected Practice Recommendations for Contraceptive Use. MMWR Recomm Rep 2024;73(No. RR-3):1–77. DOI: http://dx.doi.org/10.15585/mmwr.rr7303a1

6. Lopez, L. M., Bernholc, A., Zeng, Y., Allen, R. H., Bartz, D., O'Brien, P. A., & Hubacher, D. (2015). Interventions for pain with intrauterine device insertion. The Cochrane database of systematic reviews, 2015(7), CD007373. https://doi.org/10.1002/14651858.CD007373.pub3

7. Allen RH, Micks E, Edelman A. Pain relief for obstetric and gynecologic ambulatory procedures. Obstet Gynecol Clin North Am. 2013 Dec;40(4):625-45. doi: 10.1016/j.ogc.2013.08.005. PMID: 24286993.

8. Smith, G. M., Stubblefield, P. G., Chirchirillo, L., & McCarthy, M. J. (1979). Pain of first-trimester abortion: its quantification and relations with other variables. American journal of obstetrics and gynecology, 133(5), 489–498. https://doi.org/10.1016/0002-9378(79)90282-5

9. Shastri, D., Bose, D., & Hunter, K. (2024, August 21). It’s not just iuds. gynecologists and patients are focused on making procedures less painful. AP News. https://apnews.com/article/iud-pain-lidocaine-gynecologist-f25a198bada157a53514e84dbf57c5a7 

10. Lambert, T., Truong, T., & Gray, B. (2020). Pain perception with cervical tenaculum placement during intrauterine device insertion: a randomized controlled trial. BMJ sexual & reproductive health, 46(2), 126–131. https://doi.org/10.1136/bmjsrh-2019-200376