Pain Management for Office Gynecologic Procedures

Effective pain control is a critical aspect of patient care during common in-office gynecological procedures. These procedures, which include endometrial biopsies, intrauterine device (IUD) insertions, and colposcopies, can cause significant discomfort and anxiety for patients. As healthcare providers, it is essential to employ evidence-based strategies to minimize pain and enhance the overall patient experience. Below is a summary of the latest ACOG guidance. For more detail regarding dosage and route of administration, see Table 1 in ‘Learn More – Primary Sources’ reference below).

• Uterine Procedures
  • IUD Insertion
  • Endometrial Biopsy
  • Hysteroscopy
  • Endometrial Ablation
  • HSG
  • Uterine Aspiration
• Cervical Procedures
  • LEEP
  • Colposcopy & Cervical Biopsy

UTERINE PROCEDURES

IUD Insertion

• Unpredictable pain experience | Counsel all patients regarding potential pain and possible pain management interventions
• IUD pain is a known barrier to use

Evidence-Based Interventions

• Lidocaine spray: 10% 3 puffs
• Paracervical block (PCB): Total 20 ml 1% | 2 ml in external cervix at 12 o’clock and 18 ml into vaginal fornices at 4 and 8 o’clock
• Lidocaine (2.5%) – prilocaine (2.5%) cream

Additional Notes

• Lidocaine spray potentially more effective than injection but less available
• Dinoprostone may afford some benefit but data limited
• Misoprostol may ease difficult insertions but adverse events are common
• NSAIDs are Ineffective for insertion pain but may reduce post-procedure pain

Endometrial Biopsy

Evidence-Based Interventions

• Lidocaine spray: 10% 4 puffs
• PCB + intrauterine lidocaine: 10 mL 1% PCB + 5 mL 2% intrauterine via catheter
• PCB + intrauterine lidocaine: 5 mL 2% PCB + 5 mL 2% intrauterine via catheter
• Lidocaine gel: 3 mL 2%
• Levobupivacaine instillation: 5 mL 0.5% intrauterine
• Lidocaine instillation (5 mL 2% through endocervix into the uterine cavity)
• Naproxen (500 mg) PO 30 mins before procedure

Additional Notes

• NSAIDs may offer benefit when combined with lidocaine
• Biopsy Technique
  • Sharp curettage is more painful | Avoid in office setting
  • Lidocaine spray useful for tenaculum pain
• 2% intrauterine lidocaine instillation reduces pain during biopsy

Hysteroscopy

Evidence-Based Interventions

• Misoprostol: 50 mcg vaginally night before | 200 mcg sublingually 2 h before | 400 mcg orally or vaginally 12 h and 24 h before
• Intracervical block: 10 mL 1% prilocaine at 4 and 8 o’clock

Additional Notes

• Misoprostol reduces pain and facilitates cervical dilation but associated with abdominal pain and GI symptoms
• Insufficient evidence to recommend nonpharmacologic methods
• Providers should consider and offer multimodal approach

Endometrial Ablation

Evidence-Based Intervention

• Intrauterine cornual block: 1 mL 3% mepivacaine + 1 mL 0.5% bupivacaine at each tubal ostium

HSG

Evidence-Based Interventions

• 5% Lidocaine and prilocaine cream
  • Apply to genital mucosa
  • Reduces pain from instrumentation (not dye injection phase)
• Indomethacin: 50 mg 30 min before

Uterine Aspiration

Evidence-Based Interventions

• PCB: 20 mL 1% at cervicovaginal reflection (3 and 9 o’clock sites)
• Ibuprofen: 800 mg PO 1 hour before

Additional Notes

• Maximum dose of lidocaine
  • Without epinephrine: 4.5 mg/kg or 300 mg total
  • With epinephrine: 7 mg/kg or 500 mg
• Toxicity symptoms: Visual disturbances | Confusion | Seizure | Cardiorespiratory arrest
• Aspirate before injection to reduce intravascular injection and toxicity
• Neither oral opioids nor oral anxiolytics decrease procedural pain, but oral anxiolytics may decrease anxiety

CERVICAL PROCEDURES

LEEP

Evidence-Based Interventions

• Lidocaine spray (10%): 4 puffs
• Lidocaine spray (10%) + bupivacaine injection: 5 pumps spray to ectocervix + 2 mL bupivacaine injection to ectocervix at 3, 6, 9, and 12 o’clock
• Bupivacaine injection: 2 mL 0.5% at 2, 4, 7 and 11 o’clock

Colposcopy & Cervical Biopsy

Evidence-Based Interventions

• Prilocaine with felypressin injection
  • 5 mL 3% prilocaine + 0.03 IU/mL felypressin
• Lidocaine spray (10%)
• Lidocaine injection: 1 mL 10% intracervical next to biopsy site
• Etoricoxib (COX-2 inhibitor): 90 mg PO 30 mins before

Additional Notes

• Distraction techniques are inadequate for pain control in colposcopy and cervical biopsy and should not be the only option

KEY POINTS:

• Discuss pain management with all patients prior to in-office procedures
  • Do not minimize pain
• Common less invasive procedures (e.g., IUD insertion, colposcopy, HSG and biopsy)
  • Typically requires minimal to no analgesia
• More invasive procedures (e.g., hysteroscopy, LEEP)
  • Usually require additional pain control
• Preprocedural counseling points to discuss
  • Expected discomfort
  • Pain control options (pharmacologic and nonpharmacologic)
  • Consideration of individual factors (e.g., age, trauma history, anxiety, prior procedures)
• Consider offering enhanced education (e.g., videos vs. handouts)
• Aim for culturally competent, patient-centered and shared decision-making approach
• Discuss trade-offs (e.g., lidocaine may add time but reduce pain)

Learn More – Primary Sources:

ACOG Clinical Consensus 9: Pain Management for In-Office Uterine and Cervical Procedures