Obstet Gynecol

ACOG 2025: New guidance issued to improve pain management in gynecologic procedures

May 20, 2025

Many in-office gynecologic procedures—such as IUD insertions, endometrial biopsies, and hysteroscopies—are known to be painful or uncomfortable, yet pain management has often been inconsistent or inadequate. The American College of Obstetricians and Gynecologists (ACOG) has released new clinical guidance at its annual meeting to address this gap, emphasizing the need for evidence-based, patient-centered pain control. The recommendations aim to reduce disparities, improve patient trust, and ensure equitable access to care by recognizing pain as a subjective experience influenced by systemic bias, trauma history, and individual tolerance.

Key recommendations for clinicians

• General principles: Discuss and offer pain management options to all patients undergoing in-office procedures. Use culturally competent, trauma-informed counseling tailored to individual needs. Consider deferring procedures to allow for better preparation if needed.
• IUD insertion: Use local anesthetics (e.g., lidocaine spray, gel, or paracervical block). NSAIDs may help with postprocedural pain but aren’t effective for intraprocedural relief. Avoid relying solely on misoprostol due to frequent adverse effects.
• Endometrial biopsy: Combine topical lidocaine with NSAIDs for optimal pain control. Intrauterine lidocaine instillation is effective, especially for sharp curettage or vacuum aspiration.
• Hysteroscopy and ablation: Recommend local injected anesthesia (paracervical or intracervical). Misoprostol may reduce pain but often causes GI side effects. Consider nonpharmacologic adjuncts like music or virtual reality, though evidence is mixed.
• Uterine aspiration: Use paracervical block and preprocedural NSAIDs. Oral opioids and anxiolytics don’t reduce procedural pain but may help with anxiety.
• Cervical procedures (loop electrosurgical excision procedure [LEEP], colposcopy, biopsy): Use local anesthetics for LEEP. Lidocaine spray or injection may reduce biopsy pain but can prolong procedure time. Distraction techniques (e.g., music, coughing) are low-risk but insufficient alone.
• Special populations: Tailor approaches for adolescents, trauma survivors, and gender-diverse patients. Use inclusive language and trauma-informed practices to improve comfort and trust.

Sources:

(2025, May 15). ACOG. ACOG Releases New Recommendations on Pain Management for IUD Insertions, Other In-Office Gynecologic Procedures. [News release]. https://www.acog.org/news/news-releases/2025/05/acog-releases-new-recommendations-on-pain-management-for-iud-insertions-other-in-office-gynecologic-procedures

(2025, May 15). Obstet Gynecol. Pain Management for In-Office Uterine and Cervical Procedures. https://pubmed.ncbi.nlm.nih.gov/40373312/