Pain Management for Gyn Procedures

I’ve found this an interesting topic - and an important one - for some time now.

Given the stories I’ve read about the awful experiences some women have with… Colposcopy with cervical biopsies… Endometrial Biopsies… IUD insertion… and others, one has to wonder, why is it like this?

So I’ve researched it. I’ve come across numerous studies on PubMed where they try to prove that local anesthetic makes a clear improvement, but … it rarely does. The statistics in the blind study usually end up showing that even when it helps some women, other women find the injections more painful. Or that they find the injections on the cervix painful AND the procedure still hurts just as much, or almost as much (for the paracervixal block).

I can’t even imagine how frustrating and scary this must be for most women, and how much it generally sucks. But for the life of me, I’m not sure what I would say should be changed….

If the local anesthetic doesn’t help overly much then should more thorough anesthesia, like general anesthesia, be used? Is twilight anesthesia, like what is used for colonoscopies, something that should be used? I do know that the local works for *some* women - but the inconsistency of the results would seem to imply it should be a choice offered by the provider and selected by the patient. “This may work, but it doesn’t work for all women - it’s your choice whether you want to try it.” Especially for those women with bad experiences, I’d think it would be an easy choice.

What say you medical geeks? Wherefore art the state of pain control for gynecology these days?

Well damn…

Can some mod edit the title so it doesn’t say “gun procedures”?? Or am I doomed to have started the thread with the stupid title forever and ever? 😂

As a woman who has somewhat recently had to endure an endometrial biopsy with zero pain management, as well had an ultrasound where they filled my uterus with saline - just being told to take ibuprofen 30 minutes before…

I’d just…like to be offered *something*, you know? Knowing the decision was in my hands to try either a local with low success, or twilight anesthesia would be very helpful in itself for me. Just give me the option even if I were to decline it. Rather then feel like my concerns about the pain are just being shoved aside from the start.

They were the two most painful procedures of my life and I have a high pain tolerance. I nearly fainted during my biopsy. I’ll never forget the horrific pain in my belly during the saline ultrasound, silently begging for it to end. My favorite part is when they tell you you’ll just feel some “pressure” or “light” cramping - but it feels like your organs are being ripped apart. Then the procedure is over and you’re just expected to dust yourself off, put your clothes back on and go home as if you didn’t just experience something mild to moderately traumatic pain-wise.

I just feel as though a little more tenderness could go into these things for us overall. 🥺

Thanks for asking an important question, @TrustYourDoctor . I hope the “real” licensed medical community will put more effort into mitigating gyn procedure pain. The medical community at large seems to overlook this topic.

@Mumford , I’m really sorry you had to go through both procedures, especially without options, and I hope the results are helpful and favorable. You’re strong to have gotten through them and to speak about your experiences.

Personally, a standard pap smear (the scraping itself) is an 8 out of 10 on the pain scale. My general pain tolerance is more moderate. I’m probably a bit of an anomaly when it comes to pap smears, but I can’t be the only one. How the hell am I or others like me supposed to go through a more intense procedure without options? Not only being offered options, but to get insurance assistance to help pay for them. Women’s pain tends to be delegitimized and overlooked.

This is a ‘2 M’ issue. Misogyny and Money. Anesthesia is expensive and there seems to be a belief in the gyn community that theses procedures ‘aren’t that painful’ which is pure bullshit.

I have an appointment coming up to get my IUD taken out and a new one put in. Because it was so painful when it was being inserted, I'm really scared and nervous about my upcoming appointment. I wasn't warned that it would hurt so bad, I believe that I was told that I would feel some pressure or a pinch. It was intense pain, which although didn't last long, it made me cry out loudly and I had to hold back tears. I've avoided getting my old IUD removed and a new one put in because of how painful it was, but finally made the appointment and it's coming up soon. I spoke with my new gynecologist about my concerns and she prescribed me three Ativan to take before the procedure, but I am still terrified.

I would completely agree with @Nurse_Phillips on this one - leaning more towards the money than misogyny. At least in my experience, I have been blessed to have incredibly affirming and accommodating physicians for the better part of the past decade. I think there are very few women working in the field of gynecology that want to HURT their patients, after all. But it’s impossible to negotiate with the insurance systems. Is anesthesia medically necessary for a procedure that’s been done without it for at least half a century? Nah. Don’t need to spend the extra money on that.

I was offered an IUD replacement under anesthesia (granted, it was simultaneously offered with a gynecological surgery that required me being unconscious). I’d say it came with it’s own challenges and issues in the end. Like, I’m (super, super, super) thrilled I wasn’t awake for it. But I hated the way I felt after anesthesia. Maybe that’s the amount I was given, maybe it’s just the way my body responded to it, but I can honestly say, I’m not keen to undergo procedures that will require anesthesia unless they are critically medically necessary in the future.

That said, I would say any procedure that involves penetrating (and potentially scraping off) internal parts of the body should have SOME sort of offer for pain management beyond what I can just go and pick up at the corner pharmacy. And honestly, I don’t think we’re going to get that without some sort of major changes to the health insurance system.

@tmitrue i agree it’s not the average provider. I attribute the misogyny as institutional misogyny- as you point out ‘we’ve done this for years this way’. Of course it doesn’t help that the majority of industry leaders still have penises too.

I had a friend from my grad school program do did her master's thesis on this very topic. There are a myriad of very good options for analgesia prior to colposcopy or endometrial biopsy. Sterile, topical or injectable lidocaine can be used. Pre-administration of Ketorolac and acetaminophen is another. Single dose narcotics administration in appropriate amounts such as fentanyl or even oral hydrocodone are an option too. TENS and aroma therapies were also something in the literature that seem to have some potential.

100% there is an issue of providers just not really caring about the patient's pain, and this is an issue for female and male OBGYNs alike. Another issue is money. Many providers don't really want to deal with waiting up to 30 minutes for meds to kick in for what is often times a 5 minute procedure, pay for those meds, tie up the exam room for longer, etc. Another thing is if narcotics are used, any decent provider will have rightful hesitancies about allowing a patient to drive themselves right after the procedure, which means they need to wait like an hour to ensure something like fentanyl is fully worn off if the patient does not have someone driving them.

General anesthesia would never be used for a biopsy like this for a couple reasons. First: the price. The procedure can't justify the cost of all the equipment. Second: risk. Far more risk is being introduced with IV or gas induction/sedation/pain management agents. You'd need a CRNA or anesthesiologist, you would need to have a risk assessment done 2 weeks in advance, etc.

Conversely, urologists also commonly don't use anesthesia when doing chemical erections for evaluations. We commonly don't use analgesia putting in foley catheters either. It's an issue across the board because no one wants to pay for it, and insurances are trying to fight back on rising costs with cost containment with these types of things being one category.

@Vin Hubby had a cystoscopy here in Texas. They gave him topical lidocaine squirted into the urethra before the procedure (I was there for it). 5 years earlier, I had the same procedure done in Massachusetts. No lidocaine. Granted, my urethra is a lot shorter than his, but there you go.

This may be off topic somewhat but @Nurse_Phillips I have an annual cystoscopy to check for a return of bladder cancer. For me, the likocaine works well. It's when the camera is inserted through my enlarged prostate that there is any real pain and then also when the stiff tube on which the camera is attached being moved around the prostate orifice. There is a little stinging when the lidocaine is squirted but that soon dissipates as does the prostate pain and I usually walk out of the office normally. There is also some stinging when urinating for the first few times at home later but I sometimes get a prescription for that or use Azo.

@Vin "Conversely, urologists also commonly don't use anesthesia when doing chemical erections for evaluations. We commonly don't use analgesia putting in Foley catheters either."

Indeed. Pain management is not used optimally in procedures for males as well. A close friend of mine had a prostate biopsy; multiple holes poked through his rectum to take plugs out of his inflamed, cancer-riddled prostate. He said it was the worst pain he experienced in his life, and he had a high pain tolerance level. I was speaking to a male urology nurse about this. He told me their patients never experience much pain. They titrate sedation to pain.

As for catheterizations, I've seen countless men catheterized without lidocaine, and experiencing significant pain. For some reason it's not packaged with the lube and catheter, so whether one gets lido or not depends on the (primarily female) nurse performing the procedure.

I think another angle should be brought up here as well: how pain during gyno procedures affects rape victims. Gyno procedures are hard enough physically and emotionally without adding in pain, but when pain occurs it’s hard to stay focused on the here and now and not have flash backs. I have to have an IUD replaced soon, and I’m almost in tears just thinking about it. The last time I had one replaced was excruciating mentally and physically. I had told my gyno about how sensitive I was to things around my cervix , so she gave me a shot. That was a mistake. That really hurt and did little to mitigate the pain of the IUD going in, or the psychological chaos the pain caused. Sigh. I guess I’ll just take a lot of Ativan and a Naproxen and hope for the

best.

I have an appointment coming up to get my IUD taken out and a new one put in. Because it was so painful when it was being inserted, I'm really scared and nervous about my upcoming appointment. I wasn't warned that it would hurt so bad, I believe that I was told that I would feel some pressure or a pinch. It was intense pain, which although didn't last long, it made me cry out loudly and I had to hold back tears. I've avoided getting my old IUD removed and a new one put in because of how painful it was, but finally made the appointment and it's coming up soon. I spoke with my new gynecologist about my concerns and she prescribed me three Ativan to take before the procedure, but I am still terrified.

Sorry, that's bullshit. You have a valid concern about significant pain and their answer is to give you an anxiolytic? The problem isn't the anxiety, the problem is the PAIN.

Sorry to hear that @Corn_Flower . I hope things go better this time.

Most times they give you nothing! Had nothing even offered for IUD and they just say discomfort, not pain

It is unbelievable that in the year of 2025 women have to go these procedures without some pain reducing medication.

I would stand up with any female insisting, asking, discussion of pain reducing medication with their doctor.

If any doctor refuses to discuss what they can do to reduce the pain of what ever procedure is being told to you that you need to have it done to you.

ALSO, any female patient being told that they need this procedure done. The patient must ask the doctor Why? What will the procedure do? Will this procedure cure my problem?

And most importantly EVERY person being told they have to have a procedure NEEDS to ask the doctor what are my options? And before you have any procedure done make sure you know what is being done, why it is being done and any after care that needs to be in place.

GOOD LUCK TO ALL THAT HAVE TO HAVE ANY PROCEDURE!!!!!!!!!!!!

@moliere been in the same boat myself. Was given xanax twice to get through a transvaginal ultrasound. And guess what pelvic floor PT identified as the issue months later? A giant muscle knot and super tight muscles. Protective mechanism from the history of sexual assault and incompetent gyns. It needed not just work from the mental angle, but a physical angle. Manipulation, twice daily stretches, dilator and massage wand 5 times a week, and weekly concurrent psychotherapy, to get the muscles to realize it's safe to loosen up, if there's something inside the vagina it doesn't hurt.

Did the anxiety make it worse? Yes, the muscles clenched in anticipation of the pain and that made it hurt more, nasty vicious cycle.

Did I still have trouble drugged? Yes. Grade 4 vaginismus spasm. Oddly enough in the PT's office, stone cold sober, only ever had a grade 2. Took 18 months hard work, but I move to maintenance most likely next week.

Did anyone else see the news in May? The American College of Obstetrics and Gynecology released new guidelines for physicians in regard to pain management during in-office gynecological procedures, including IUD insertion/removal, endometrial biopsy, hysteroscopy, intrauterine imaging, and cervical biopsy (which I had done without pain management and it was *bad*).

Read more here: https://www.acog.org/news/news-releases/2025/05/acog-releases-new-recommendations-on-pain-management-for-iud-insertions-other-in-office-gynecologic-procedures

This means it's perfectly reasonable to demand pain medication before any procedure one could reasonably anticipate will be painful. If your doctor does not want to discuss or administer it, it's also reasonable to tell him or her that you're going to find another doctor because he is ignoring the professional standards for pain management.

It's about fucking time, eh?