New Guidelines Finally Recommend Pain Relief for Gyno Procedures—Here’s How to Get It

Last week, the American College of Obstetricians and Gynecologists (ACOG) acknowledged in writing what people with a uterus have shouted from the rooftops for years: In-office gynecological procedures, like intrauterine device (IUD) insertions or cervical biopsies, can be far more agonizing than the “pinch” often promised. The org published new guidelines on May 15 calling on doctors to “not underestimate” this pain and instead offer patients evidence-based options for managing it. It’s overdue, yes—but it also paves the way for patients to advocate for themselves and actually be taken seriously.

One of the biggest changes in this document, though it may seem trivial, is the push for doctors to talk to patients about pain management in these contexts in the first place, Eve Espey, MD, MPH, chair of the obstetrics and gynecology department at the University of New Mexico, tells SELF. It builds on CDC recommendations released last fall (on pain management for IUD insertion, specifically), which were the first to urge doctors to routinely have this kind of convo.

If you’re wondering what took so long, part of the reason it’s been so commonly skipped boils down to implicit bias: Research shows providers more readily dismiss women’s pain and Black women’s pain in particular. Logistics may also play a role, Dr. Espey says. There can be so much for your doctor to go over in a short appointment: They need to explain the risks of the procedure, for instance, and what to expect afterward, so the issue of pain during the operation may have fallen by the wayside. The new ACOG guidance, by contrast, encourages doctors to recognize what a big deal the procedure itself can be to patients and treat it as such, Dr. Espey says.

Another reason why doctors may have hesitated to discuss pain control for gyno procedures? Pain is tricky to study because of its subjectivity (not to mention, women’s health is underfunded in general), so there’s not as much conclusive research on the available options as many would prefer, Rachel Blake, MD, FACOG, a board-certified ob-gyn in New Jersey, tells SELF. But the new guidelines suggest there’s now enough data to recommend certain types of pain management for particular procedures, Dr. Blake says. The consensus is that, given how miserable these surgeries can be for some people, it’s well worth it for doctors to at least present these relief options and give patients the autonomy to choose whether they’ll use them.

As with any new medical guidance, though, it may take some time for this kind of care to be incorporated into standard practice, Dr. Blake notes. If your ob-gyn doesn’t bring up pain control when talking through an upcoming procedure, here’s how to broach the topic and weigh your options to make it as manageable as possible.

1. Feel empowered to ask about pain directly.

The exciting thing about not one but two large orgs coming out with guidelines about gynecological pain in recent months is that it lends a lot of credence to the issue. It’s tougher for your doctor to wave away your concerns when both the CDC and ACOG have recommended they address them. Dr. Espey suggests simply posing the question: “I’ve heard this is a painful procedure. Can you let me know what options are available to address the discomfort that I think I’m going to feel with this?”

Hopefully, that’s the tip-off for them to ask you some important follow-up questions, Dr. Espey says, like whether you’ve had previous rough experiences with gyno operations or pelvic exams, or if you have a history of sexual violence or abuse, substance use disorder, or chronic pelvic pain—all of which the ACOG guidelines note could up your risk of feeling pain during a procedure and warrant particular kinds of pain relief over others.

2. Brush up on what kind of pain relief is available and recommended for your procedure.

Coming to your appointment armed with information can be helpful, whether your doctor balks when you bring up pain management or you simply want to prep your follow-up questions. Read on to learn the options for pain relief covered in the new ACOG guidelines:

• Topical anesthetic. Your doctor can apply a numbing cream, gel, or spray (made with lidocaine, prilocaine, or both) to your cervix or surrounding areas to basically help desensitize things. ACOG points to this option for an IUD insertion procedure or endometrial biopsy, as well as cervical operations (like colposcopy and cervical biopsy), and certain imaging procedures to examine the uterus.
• Anesthetic shot (a.k.a. paracervical block). It’s also possible to get an injection of a numbing agent like lidocaine near your cervix, which may help tamp down pain during an IUD insertion—but it could trigger some discomfort, too, as the shot goes in, Dr. Blake points out. (Think about the pinch of novocaine in your gum before getting a cavity filled.) Evidence also supports getting an injectable anesthetic for an endometrial biopsy and certain cervical and uterine imaging procedures, as well as uterine aspiration (which involves removing tissue from the uterus to manage a miscarriage or end a pregnancy), per ACOG. Just note, there can be some gnarly side effects here, like tingling, irritation, metallic taste, and, more rarely, changes in heart rate, Dr. Blake notes, which are all trade-offs to consider.
• Oral pain meds. You might be wondering about typical OTC drugs like ibuprofen (Advil) or naproxen (Aleve). Based on the research, the ACOG review concluded that these nonsteroidal anti-inflammatory drugs (NSAIDs) actually aren’t all that helpful for IUD insertion pain. But they can help with the cramping that can occur afterward and for up to two days, which is why Dr. Blake offers patients these meds to take once the operation is done. The ACOG guidelines do, however, suggest taking an NSAID before an endometrial biopsy or uterine aspiration as one way to cut down on discomfort during and after the operation.
• Oral or vaginal misoprostol. This is a prescription drug that dissolves either in your vagina or in your mouth and that softens and dilates your cervix, which can reduce pain during a hysteroscopy (a procedure that lets your doc check out your uterus by placing a thin tube through your cervix), per ACOG. Though some research shows misoprostol may also help your provider more easily insert an IUD, it doesn’t actually provide pain relief during that procedure. And the drug can also bring unpleasant side effects like belly pain, nausea, diarrhea, and low-grade fever.
• IV sedation or general anesthesia. Technically, getting knocked out for any gynecological procedure offers the maximum pain relief, Dr. Espey says. But she notes that this is “beyond the scope” of most ob-gyn offices—also why the ACOG guidelines only mention it briefly. It typically requires an anesthesiologist and the infrastructure of a surgical center or hospital, and it may not be covered by insurance, or it could come with a higher out-of-pocket cost, Dr. Blake notes. Because it can cause drowsiness post-procedure, it also means having someone on standby to escort you home afterward. That said, surmounting these barriers may be well worth it for some, particularly those with a history of medical or sexual trauma (and for whom being awake during any gyno operation may not just be painful, but retraumatizing).

Prompting your doctor with specific questions like, “Would it be possible to get some form of topical anesthetic for the procedure?” or “I’ve heard a paracervical block can help with pain while getting an IUD—do you use these in your practice?” can encourage them to evaluate what makes the most sense for your situation. After all, they should be familiar with these pain-relief options and able and willing to speak with you about them, even if they’re not necessarily able to administer them at their clinic for whatever reason, Dr. Blake points out. (And if they’re not, there’s nothing wrong with scouting out a new ob-gyn equipped to offer the care you need.)

3. Remember these options still come with challenges.

You might hit some hurdles when trying to access pain relief for gyno procedures—the first being time. Even if your doctor is happy to chat through the options, the block they’ve set aside for your appointment may not be long enough to cover a conversation about pain and the procedure itself. In that case, “don’t feel pressured to get the procedure done that day,” Dr. Blake says. You can have a consult visit, talk through your options, and come back once you’ve decided on the best route, she says. Just note: That could delay things quite a bit depending on appointment wait times.

Speaking of time, pain relief might add some to the procedure itself too, Dr. Blake points out: Even with topical or injectable numbing, you may have to wait three to five minutes for the medication to kick in…. Which just extends how long you’re in that uncomfy spread-eagle position with the speculum in.

You may also run into barriers when it comes to accessing the specific type of pain relief you’re after. As noted, plenty of clinics aren’t capable of providing full-fledged sedation, and it may not be worth your while to pay extra or wait longer for an appointment elsewhere (if your doctor is able to offer one). Keep in mind that some gyno offices also may not do paracervical blocks or topical anesthetic—though Dr. Blake says these options are becoming increasingly available, particularly the creams and sprays.

It’s also important to keep your expectations in check. “I tell patients not to expect 1srcsrc% pain control,” Dr. Blake says. Exactly how much discomfort you feel and the nature of it (e.g., cramping, pinching, pressure) hinges on a number of factors, ranging from your individual pain perception to your anatomy to the particular procedure and even the type of IUD (if you’re having one inserted), she says.

As the ACOG guidelines note, we need more well-designed studies on gynecological pain—including gender-diverse participants and folks of various races and ethnicities—to determine the most effective options for particular groups. Additional research can also help us delve into specifics, like how different pain-relief modalities can work in tandem and the role of anti-anxiety meds in this setting. Not to mention, future science could also lead to an entirely different analgesic that functions better and with fewer downsides, Dr. Espey points out.

Still, the methods we have can “significantly dull” the pain during “some of the more uncomfortable portions” of gynecological procedures, Dr. Blake says. And the new ACOG guidance formally recommending these options doesn’t just empower us all to ask for them; it helps to make pain management a routine part of gynecological care at last.

Related:

• Medical Gaslighting Is Real—Here’s How to Recognize It and Respond
• 1src Vaginal Problems You Should Always Tell Your Gynecologist About
• What an Abnormal Pap Smear Really Means—And What Comes Next

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