Ladies First

Women are never more vulnerable than when they’re having a gynecologic exam. For some, embarrassment or fear of undergoing a painful procedure have them adopting an “out of sight, out of mind” attitude toward annual exams and other in-office procedures, even though they know how important these visits are.

To address these concerns, the American College of Obstetricians and Gynecologists (ACOG) in May 2025 released new recommendations on pain management for in-office uterine and cervical procedures, including intrauterine device (IUD) placement. For Women’s Health Nurse Practitioner (WHNP) and Certified Nurse Midwife (CNM) Katherine Donaldson-Fletcher, RN, the recommendations validated the way she and her colleagues at Washington Women’s Health Specialists have always practiced.

“As a group, we prioritize building trusting relationships with our patients,” Donaldson-Fletcher said. “We emphasize the importance of education and informed decision-making in all of our interactions with patients.”

The ACOG recommendations, “Pain Management for In-Office Uterine and Cervical Procedures,” by ACOG’s Clinical Consensus Committee on Gynecology, discuss the importance of counseling patients about pain management options and pain management techniques for common procedures, including IUD placement, endometrial biopsy, hysteroscopy, intrauterine imaging and cervical biopsy. These procedures are often painful or uncomfortable for patients, but critically important for gynecologic health, heightening the need for better pain management options and patient counseling about the options available to them.

“It’s only been in the last decade or so that women have been really included in discussions about their obstetric and gynecologic health,” Donaldson-Fletcher said. “In the past, women were expected to simply tolerate pain or uncomfortable procedures and weren’t always informed about different ways to control that pain or relieve the discomfort. We are committed to listening to our patients, sharing information and working with them to find the best way to meet their needs.”

Donaldson-Fletcher emphasizes that women need to feel heard and have control over their experiences. “Gynecology is the most intimate of practices and many women feel extremely vulnerable during procedures,” she observed. “Take placement of an IUD, for example. Before we even get to the procedure, I have an open discussion with my patient. We talk about their birth control goals, and the options available to them to best fit their needs, lifestyle and preferences. If an IUD is the best option, I move on to talk about the pros and cons, including the potential of pain during insertion.

The recommendations from ACOG are designed to help clinicians better understand pain management options for in-office procedures and to give patients more autonomy over their own pain. The brief calls out systemic bias as to how pain is experienced by women and includes guidance in identifying evidence-based approaches to pain management. Some pain is tied to use of surgical tools during procedures, including a tenaculum, a type of forceps used to stabilize the cervix during IUD insertions and in other procedures.

Donaldson-Fletcher noted the ACOG recommendations include a variety of options to reduce or mitigate pain. These include using topical anesthetics such as lidocaine spray or lidocaine-prilocaine cream applied to the cervix before IUD insertion, or using a lidocaine-based paracervical block. Both methods have been extensively studied and offer patients good opportunities for less painful procedures.

A paracervical block is a localized anesthesia technique that involves injecting an anesthetic, such as lidocaine, near the cervix to block pain impulses from the uterus and cervix. It is used to relieve pain during various gynecological procedures, including cervical biopsies, endometrial biopsies, loop electrosurgical excision procedure (LEEP), and IUD placement.

“Lidocaine spray is a good option for reducing the pain experienced during IUD placement and other procedures,” she explained. “It reduces pain related to both tenaculum use against the surface of the cervix and the insertion itself. It’s fast and easy. We use it in our practice.

“On the other hand, a paracervical lidocaine injection has been shown to have the same level of pain with placement as placement without it, but the quality of the pain is different,” Donaldson-Fletcher continued. “Patients describe it as sharp and stinging pain with the block, as opposed to cramping dull pain without it. The benefit seems to be that people get to decide for themselves and any level of choice and control is helpful for pain tolerance and for patient satisfaction. I don’t use paracervical blocks with my patients, but there are physicians in our practice that do, so that’s always an option for our patients. We usually prescribe a course of over-the-counter ibuprofen beginning before the procedure and lasting two days following the procedure for cramping pain that may occur.”

While pain management is the goal of the new recommendations, it’s a regular part of practice for Donaldson-Fletcher and her colleagues.

“We listen to our patients, educate them on the options, then partner with them to find what works best for them,” she said. “Options that work for one woman may not work for another. Shared decision making is the ultimate goal for individualized care”

For more information about Donaldson-Fletcher, scan the below QR code. For information on Washington’s Women’s Health Center, visit https://www.mywtmf.com/services/obstetrics-gynecology/.