ACOG issues new guidance on pain management for in-office cervical and uterine procedures

Key takeaways:

• The guidance says clinicians should offer local anesthetics, like lidocaine spray, for IUD insertions.
• ACOG also advised using shared decision-making when determining the pain management strategy.

ACOG released new recommendations on pain management for in-office uterine and cervical procedures such as intrauterine device insertion, hysteroscopy and cervical biopsy.

The guidance recommends that clinicians offer local anesthetics for IUD insertions, including lidocaine-prilocaine cream, lidocaine spray and paracervical block.

ACOG noted that options for other gynecologic procedures vary but can include “local anesthetics such as topical or injected anesthetics, NSAIDs and other medications such as misoprostol.”

“[This] came because a lot of providers, even prior to the CDC’s recommendations, were seeking guidance on how we universally, as a specialty, offer pain management to patients,” Kimberly Hoover, MD, FACOG, guideline coauthor and a professor at the University of Alabama at Birmingham, told Healio.

According to an ACOG press release, pain and anxiety can represent significant barriers to patients accessing health care.

“As a women’s health nurse practitioner, I treat patients every day who express anxiety about pain related to common procedures like IUD placement,” Genevieve Hofmann, DNP, WHNP, an assistant professor at the University of Colorado and guideline coauthor, said in the release. “Unfortunately, many patients feel their pain has been diminished or dismissed by their clinicians, which data show can lead to patient dissatisfaction and distrust. ACOG’s new guidance provides critically important patient-centered recommendations on how to help our patients have better experiences and will help improve trust between patients and clinicians.”

ACOG said that there are several challenges to sufficiently addressing pain during in-office gynecologic procedures, like predicting how much pain a patient will experience based on factors like past trauma, the patient’s age, pelvic examination experience and baseline anxiety.

The association added that evidence on pain management methods for certain procedures like IUD insertion is mixed, “which create difficulties in determining a singular best approach.”

Thus, the guidance recommends clinicians counsel patients about all the available options and perform shared decision-making to decide on what type of pain management will be used.

ACOG added that the guidance is focused on in-office produces but “it does note that comprehensive pain management counseling should include offering patients the option to undergo uterine procedures under intravenous sedation, monitored anesthesia, or general anesthesia when and where available.”

Hoover underlined that a key takeaway from the guidance is recognizing that people have different levels of pain and pain perception, “and I think just knowing that as a provider, it is highly suggestive that you offer different forms of pain management counseling to your patients and [make] patients feel heard and that their points are valid.”

References: