A national organization that sets practice standards for physicians has for the first time outlined how doctors can give patients pain-relief options during the insertion of intrauterine devices and other common gynecological procedures.
The new guidelines, published today by The American College of Obstetricians and Gynecologists, urge doctors to “not underestimate the pain experienced by patients,” marking a significant change for the organization. In years past, ACOG acknowledged that common gynecological procedures can be painful, but stopped short of recommendations because of mixed evidence on the efficacy of pain management options. These new guidelines echo those issued for I.U.D. insertion pain by the Centers for Disease Control and Prevention in the fall, but are more expansive in that they cover pain management for a range of other procedures, including cervical biopsy, endometrial biopsy and intrauterine imaging.
To decrease the pain associated with these procedures, ACOG now recommends either an anesthetic cream, a spray or an injected local anesthetic known as a paracervical block.
The change is in part a response to a groundswell of complaints from patients on social media, in the news and directly with physicians. “There’s really a push from our patients to understand what the options are — what’s available to them,” said Dr. Kristin Riley, an obstetrician-gynecologist and co-author of the new guidelines. “I mean, we’re all on social media, and we all see it,” she said. That feedback was “certainly on our minds.”
After assessing available data on pain management, the group acknowledged that evidence on effectiveness during common gynecological procedures is still conflicting and limited, but noted that doctors should advise patients on what to expect and discuss the options. The organization also noted that particularly vulnerable populations, including those with a history of chronic pelvic pain, sexual violence or abuse, or substance use disorder, should be given special consideration as they may have a different pain tolerance than other patients, or a resistance to pain medications.
The update represents a positive shift for an industry that has in the past been accused of dismissing female pain, said Dr. Ashley Jeanlus, a private practice gynecologist and complex family planning specialist in Washington, D.C. “ACOG is making it very clear that we should be treating our patients with equity, dignity and trust and ensuring that they’re not expected to kind of tough it out anymore.”
The way that pain has historically been managed has long been influenced by racism and sexism, ACOG noted in the guidance. Studies have found that health care professionals sometimes underestimate how much pain a female patient experiences and don’t perceive female pain to be urgent, said Amanda Williams, a pain researcher and professor of clinical health psychology at University College London.
In a 2016 study co-authored by Dr. Williams, 63 pain doctors and medical students were shown images of people in pain and were asked what the appropriate treatment for that pain would be. Participants suggested “more medical referrals for the male images and more psychologist or psychiatrist referrals for females,” Dr. Williams said. The findings underscore a notion that “women can’t distinguish pain from emotion, whereas men can suppress their emotions and give you a pure account of their pain,” she added.
About eight years ago, Brianne Hwang was doubled over in pain in an elevator at a Los Angeles hospital. She had just gotten an intrauterine device inserted and the pain — a cramping that she described as a labor “contraction that never ends” — kicked in almost immediately. “I stumbled to the hospital bathroom and just had to sit down there,” she said.
Once at home, “I called my doctor and was like ‘I don’t think this is in right — I think it’s stabbing me,’” Ms. Hwang, 38, said. “They were like, ‘oh yeah, this can happen,’” but they hadn’t warned her of this outcome nor did they offer solutions to help reduce the pain.
The new ACOG measures are just a start; doctors will need to figure out how to implement them into routine practice, said Dr. Eve Espey, chair of the obstetrics and gynecology department at the University of New Mexico. The paracervical block, for example, is an injection that can be uncomfortable for some patients.
For other anesthetic measures, the guidelines suggest waiting roughly three minutes for the medication to take effect — putting both doctors and patients in an awkward position. “Waiting three minutes with a speculum in place is a long time,” she noted. “Do you stay there? Do you put the drape back on? You wouldn’t want to take the speculum out because it hurts putting a speculum back in.”
These extra steps might be why a majority of physicians in the U.S. have not historically offered their patients pain medications in the first place, Dr. Espey said, even though most are trained and capable of administering them.
But even knowing that the options exist would have been a huge relief, Ms. Hwang said. “I would have taken any of those options,” she said. “I would have even taken, like, just some advanced warning.”
Alisha Haridasani Gupta is a Times reporter covering women’s health and health inequities.
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