At the OB-GYN, pain control is possible—but often overlooked

This article was originally featured on Undark.

A couple years ago, Aggie Steiner and Simran Singh were having lunch with other medical students, all women, at Western Michigan University when the group started swapping horror stories about intrauterine devices, or IUDs. The roughly quarter-sized, T-shaped contraceptive device sits in the uterus, where it prevents pregnancies with close to 100 percent effectiveness for years.

Some women feel little discomfort when a provider inserts the IUD through the cervix—the muscular tunnel at the base of the womb—and places it at the top of the uterus. For others, though, the experience is excruciating. And many patients report that the standard advice given in American clinics—take an over-the-counter painkiller like Tylenol or Advil—doesn’t help at all.

That day at lunch, when someone pointed out that it’s possible to get IUDs under sedation, at least half the group let out a collective gasp, Singh recalled. The medical students had been through preclinical courses on reproduction and contraception, but many of them didn’t realize it was even an option to reduce the pain of IUD placement. If medical students don’t know it’s an option, then it’s likely that the general public doesn’t know, Singh said. “And at that point we’re doing them a disservice.”

Both Steiner and Singh are in the final year of medical school and plan to specialize in obstetrics and gynecology after they graduate in May. On their clinical rotations, they saw that many patients undergoing IUD insertions and other routine gynecological procedures were extremely uncomfortable. “Women cry,” said Steiner. “Women hold onto the exam table so hard that you can see their knuckles are white.” Pain control or sedation was often available, just not offered.

It’s no secret that some office procedures involving the cervix and the uterus can be painful. Thousands of women have shared agonizing on social media and other platforms. “It felt like a knitting needle was piercing my womb,” wrote one woman in a 2021 essay, adding that she “was left shaken for days and traumatised for many years.”

Despite the outcry, U.S. medical authorities have not systematically addressed the problem. Guidelines for physicians from the American College of Obstetricians and Gynecologists offer no recommendations for making IUD procedures more comfortable. And, as Steiner and Singh discovered during their own training, medical education doesn’t always address pain management during outpatient gynecological procedures.

Women experience a spectrum of pain during these procedures, and evidence does not show that any single form of pain control is right for everyone, said Jennifer Villavicencio, an OB-GYN and senior director of public affairs and advocacy at the Society of Family Planning, an international nonprofit organization.

But, she said, there are basic steps many providers could be taking to address patients’ pain, starting from the assumption that women deserve to be as comfortable as possible, then using a combination of available strategies to make that happen.

“It’s less of a data problem and more of a practice problem,” said Villavicencio. “As clinicians, we need to center the patient in our approach to pain control. That is where the advocacy should really lie.”

In 2017, Kaitlin Alper, then a graduate student in her mid-20s at the University of North Carolina at Chapel Hill, went to the university’s health center to get an IUD. Due to a previous gynecological health issue, Alper was a veteran of invasive exams. She assumed that this one wouldn’t be a big deal.

“But it was so bad,” said Alper. When the doctor measured her uterus before inserting the IUD, Alper added, “it was just the worst pain I’ve ever felt—and I’ve broken bone.” Alper said her doctor didn’t offer pain control options other than taking acetaminophen (Tylenol) beforehand, and she felt entirely unprepared for what followed: “It was so much more than I was told it was going to be.”

To her horror, about three years later Alper found herself in a similar situation. A routine screening for cervical cancer had revealed abnormalities, and her doctor needed to do a procedure called colposcopy to examine her cervix and then cut out several small tissue samples to test. This time, she said, she wasn’t even advised to take a pain reliever. Forced to relive her distressing IUD experience, Alper felt panicked and shaky from the start.

“It was super painful,” she said.

Alper’s experience isn’t typical, but it isn’t uncommon either. To measure pain, many researchers use what’s known as a visual analog scale, a straight line marked from zero to 10, with zero representing “no pain” and 10 “the worst pain possible.” A 2021 study of 413 women getting IUDs in Brazil found that patients’ pain levels fell roughly into thirds, with about one-third of women reporting that pain was mild (1 to 3); one-third, moderate (4 to 6); and one-third, severe (7 to 10.)

Because it’s easier to insert instruments through the cervix once it’s been stretched in childbirth, women who have given birth vaginally often report lower pain levels than those who have not. The Brazilian study found that, on average, women who’ve undergone a vaginal delivery report pain levels of 3.9 compared to 6.6 for those who’ve never had children and 5.5 for those who delivered by caesarean section.

Studies show that other in-office procedures—such as hysteroscopy, where the clinician passes a scope through the cervix to examine the uterus, or colposcopy with a cervical biopsy, like Alper had—are similarly uncomfortable, even painful, for many patients.

Alper was taken aback by her gynecologist’s seeming nonchalance about how painful a cervical biopsy could be. “She was really nice,” said Alper. “She was clearly good at her job but didn’t seem really concerned.”

Research suggests that clinicians tend to be poor judges of how much a procedure hurts, in some cases significantly underestimating the amount of pain their patients experience.

While physicians can’t predict with certainty whether a procedure involving the cervix and uterus will be easy or agonizing for someone, research has yielded important clues. In addition to not having had a vaginal birth, factors associated with more intense pain include a history of painful menstruation or pain during sexual intercourse, a previous painful experience with a gynecology procedure, and having a history of anxiety or just being especially anxious about the procedure.

Alper is one of thousands of women who have posted about agonizing experiences on the social media platform Reddit. Like many others, she’s frustrated that her doctor did not discuss the possibility of pain with her or how it might be managed.

“They seemed to know it was going to hurt me,” she said. “But it didn’t seem to occur to anybody that they should do anything about that.”

Fifty years ago, clinicians performed many gynecologic procedures in a hospital where they could sedate patients or put them under general anesthesia. But technological advances, especially the development of miniaturized instruments in the last 15 years or so, have made it possible to do minimally invasive procedures in the office.

That trend prompted a host of research into ways to minimize pain without knocking patients out. Unfortunately, the results largely have been inconsistent and contradictory. But many experts say that the evidence is good enough to provide patients with reasonable options to make procedures more comfortable.

It’s not a simple problem to solve. The nerves in the cervix and uterus trigger a different type of discomfort than those on your outside skin, say, or even inside your mouth, said Maureen Baldwin, an OB-GYN at Oregon Health & Science University. In some people, touching the cervix with an instrument causes a visceral reaction. “It’s not always a ‘it hurts here’ kind of a pain,” said Baldwin. “Sometimes it’s a ‘I just feel really sick and I feel like something is wrong’ kind of a pain, sort of like labor feels.” Touching the inside of the uterus causes cramping for some people, she said, and searing pain for others.

The most potentially painful aspects of procedures such as IUD insertion are when the provider grabs the cervix with an instrument resembling a set of pointy tongs called a tenaculum, then passes instruments through it. So, it makes sense that applying a topical numbing agent might help. Because studies of the effectiveness of various topical formulations have yielded mixed results, researchers have pooled data to look at overall trends. A 2018 meta-analysis of 15 randomized clinical trials found that a cream containing the anesthetic lidocaine offered modest pain reduction, while a 2019 meta-analysis of 38 trials suggested that a cream composed of lidocaine and another anesthetic, prilocaine, worked best. Several trials, mostly of women who’d given birth vaginally, also found that lidocaine spray reduced pain. The only real downside of topicals, some doctors say, is the need to wait several minutes for them to take effect.

Decent evidence also supports injecting the cervix with lidocaine in several spots, in what’s known as a paracervical or intracervical block. The good news is that the injections take effect quickly. The bad news is that they hurt, in some cases more than the procedure itself. “Not only is it painful, but people hate the idea of a needle in a very sensitive area,” said Eve Espey, chair of the OB-GYN department at the University of New Mexico. In her experience, because an IUD insertion typically only takes a couple of minutes, many patients turn down the nerve blocks.

Numerous studies show that taking an anti-inflammatory drug such as ibuprofen ahead of time doesn’t make the procedure itself more comfortable, but it can ease any cramping afterward.

Baldwin offers oral anti-anxiety medication to calm patients who feel like they need it. For those who have had or are anticipated to experience higher pain levels, she can also provide moderate sedation by intravenously administering a combination of an opioid and anti-anxiety drug. The only catch is that patients will need a ride home.

Finally, there are the big guns: deep sedation, a sleep-like state where patients are unaware of their surroundings, and general anesthesia, a drug-induced unconsciousness that requires breathing assistance. Those approaches eliminate pain but have numerous downsides. They are typically only available at surgery centers or hospitals, take way more time than an office procedure to schedule, perform, and recover from; can be more expensive for the patient; and can cause side effects such as headache, nausea, and drowsiness. General anesthesia, which is seldom necessary for minor gynecological procedures, can rarely trigger life-threatening complications.

After hearing horror stories from their colleagues, medical students Aggie Steiner and Simran Singh started digging into the medical literature, hoping to understand why pain management wasn’t a routine part of IUD placement.

Most frustrating for the medical students was a thread of dismissiveness they perceived running through the science. Even in studies finding that a measure helped, they recalled, researchers might decide the intervention wasn’t worthwhile, given that it required longer appointments as well as more staff and equipment. “It was like we’re basically saying to patients that us alleviating their pain isn’t worth our time,” said Singh.

The students were also dismayed to find that the American College of Obstetricians and Gynecologists, which provides influential recommendations to clinicians, gave short shrift to pain-relief options for IUD placement and other routine procedures.

In 2016, a committee of ACOG experts issued clinical guidance addressing challenges associated with long-acting reversible contraceptives, including IUDs. But they didn’t recommend any measures for pain management during IUD insertion. In 2020, ACOG greenlighted the same guidance without updating the evidence review, which doesn’t cite any studies done after 2015—including more recent papers suggesting that anesthetic creams and nerve blocks can help.

ACOG guidelines for other procedures also provide few recommendations for pain management. The 2018 ACOG clinical guidance on hysteroscopy, which the organization re-approved without changes this year, states that medications to dilate the cervix may reduce pain for some patients. The guidelines also note that clinicians can consider using vaginoscopy, a small scope that does away with the need for uncomfortable tools to open the vaginal walls and grasp the cervix. But research doesn’t support other pain control measures, the committee concluded.

In fact, the guidance cites evidence that “office hysteroscopy may be tolerated without the use of any analgesia,” although one-third of patients in the referenced study reported a pain level of 7 or higher—what the authors of that paper regard as “unacceptable pain.”

And recent ACOG-endorsed guidelines from the American Society for Colposcopy and Cervical Pathology find that evidence does not support the use of anesthetics during biopsies of the inside of the cervix. To back up that claim, the authors of the guidelines cite a 2019 study that actually concludes that local anesthetics do help, especially when taking small samples of the outer cervix, but that they are inadequate for more extensive, painful biopsies, such as those of the inner cervix. Those procedures call for more effective pain relief, according to the authors of the 2019 paper.

Some changes may be coming. Espey, who helped write the ACOG document on IUD insertion, said that the committee agrees that it’s time for a refresh.

In an emailed statement she said was attributable to ACOG, Rachel Kingery, a spokesperson for the group, wrote that the organization updates its guidelines every two to three years, based on the availability of data.  “ACOG’s committee is aware of the need for better pain management and improvements to the patient experience during in-office procedures and is working to address this need,” Kingery wrote. A thorough evaluation of the evidence will take some time, she said, and there’s no definite timeline for publishing updated guidance.

Some published clinical reviews and guidelines from other countries more thoroughly address pain. For example, 2023 IUD guidelines from the United Kingdom’s Faculty of Sexual and Reproductive Health Care make several recommendations for pain management, based on a thorough evidence review. And a 2019 review by an international group of researchers finds sufficient evidence to support several strategies, especially for patients at greater risk of a painful experience.

The lead author of that review, Kristina Gemzell Danielsson, an OB-GYN who practices in Stockholm, Sweden, said her country’s guidelines do address strategies for pain control, including sedation and general anesthesia where warranted.

Similarly, a 2022 review of pain management during hysteroscopy makes several specific recommendations, from using the opioid pain medication tramadol, to administering dinoprostone, a medication that dilates the cervix, to letting patients listen to music during the procedures.

For the most part, these other guidelines and reviews don’t uncover overwhelming evidence for any particular drug or technique. Instead, they offer advice on the art as well as the science of medicine: informing patients about what to expect, laying out options for pain management, and then sharing the decision-making for how to proceed.

Alongside the lack of guidance from ACOG, there are other barriers to providing pain management in U.S. clinics. In particular, insurance companies don’t always cover it, which is one big reason effective approaches such as sedation are off the table for many women.

Villavicencio at the Society of Family Planning finds the variations in coverage frustrating. Some patients worry about the pain of insertion and that their insurance wouldn’t cover more extensive anesthesia should it be necessary. “I’ve had patients not get an IUD, even though it was their first choice of birth control,” she said. “That’s a shame.”

Still, despite the barriers, some U.S. OB-GYNs today do manage to offer their patients a range of options.

Baldwin, the OB-GYN who practices at the Center for Women’s Health at Oregon Health & Science University, said that staff are trained to ask patients if they want to schedule an appointment to discuss sedation. She discusses the pros and cons of different pain-control strategies with her patients and refers them to resources such as Bedsider.org for comprehensive information on contraception that includes real patients’ perspectives on their experiences.

Listening to patients and respecting their autonomy is a common theme—for example, asking for a patient’s permission before doing anything. “I do reassure patients that I am an active listener throughout the procedure and if they are experiencing pain, never to feel uncomfortable expressing that,” said Espey.

“Because,” she added, “we can always stop, abandon ship, and then move to a more robust pain control.”

Beverly Gray, director of the Complex Family Planning Fellowship Program at Duke University School of Medicine, said that their program focuses on trauma-informed care, which involves recognizing that patients who have been the victims of sexual violence or trauma have different needs, navigating conversations in a respectful way, and helping patients feel in control, said Gray.

That thoughtful approach is difficult in health systems where doctors are expected to see patients every 15 minutes, she admitted. “I think that the medical system tries to beat that part out of us.”

Experts we spoke with emphasized that the disturbing stories on social media are not typical. After all, people are more likely to share a painful, impactful story than one where everything went fine. Nonetheless, it’s clear that many women aren’t getting the respectful care that these clinicians describe.

Sasha Prokopchuk of Benson, Arizona, is one of those women. She’s had two IUDs. The first insertion required two protracted painful visits. “Worst gynecologist I’ve ever had in my life,” she said. The doctor, she said, “talked about her boyfriend the whole time with her nurse. It was like I wasn’t even there.” The doctor who placed the second IUD was more attentive, said Prokopchuk, but still offered no pain control for what turned out to be another difficult insertion. She recalled bleeding quite a bit and feeling too lightheaded to stand. Prokopchuk says the doctor kept her for observation for an hour and a half.

“For me, it’s the lack of empathy, it’s the lack of attempting to make a patient feel better even if it doesn’t ameliorate the pain,” she said. “It’s the lack of attempt that really gets to me.”

In 2021, Steiner and Singh channeled their frustration and research into a letter published in The BMJ, advocating for more attention to pain during outpatient procedures.

Their views reflect a growing unwillingness to normalize pain as an integral aspect of womanhood, especially among young physicians. “People’s tolerance for pain and just the societal notion of what pain is acceptable—I think it’s changed a lot in the 30 years I’ve been in practice,” said Espey.

Recently, medical students affiliated with the American Medical Association took the lead in proposing that the organization officially address the issue. The AMA went on to adopt a policy recognizing disparities in pain management for gynecologic procedures and supporting further research. The policy also calls for insurers to cover pain-control options.

It’s not clear that the health care system is willing or able to take the steps necessary to ensure that horror stories about gynecology visits are a thing of the past. But at the level of individual practice, changes may be coming. Singh sees a huge shift in her chosen specialty, with the old guard retiring and residencies staffed predominantly by women who will themselves undergo gynecologic procedures and share stories about experiences with other women.

She wonders if that shift will help her profession view pain not as a necessary evil, but a solvable problem. Will doctors say “Oh yeah, in my practice, I’m going to offer pain management?” she asked. “I hope that I’m in that position one day.”