Pain management guidance for in-office uterine, cervical procedures updated by ACOG
Shared decision making and individualized strategies are emphasized in the new ACOG consensus.
Pain management guidance for in-office uterine, cervical procedures updated by ACOG |Image Credit: © rh2010 - stock.adobe.com.
A new Clinical Consensus from the American College of Obstetricians and Gynecologists (ACOG), released on May 15, 2025, outlines updated recommendations for pain management during in-office uterine and cervical procedures. The guidance urges clinicians to prioritize shared decision making and offer individualized, evidence-based pain relief strategies to all patients undergoing these procedures.
Recognizing and addressing pain
The document acknowledges that in-office procedures such as intrauterine device (IUD) insertion, endometrial biopsy, hysteroscopy, and cervical biopsy are frequently performed without adequate pain control. Clinician underestimation of pain, systemic bias, and limited evidence for certain interventions have contributed to inconsistent practices. ACOG emphasizes that pain should not be minimized and that options for managing it should be discussed proactively.
"Options to manage pain should be discussed with and offered to all patients seeking in-office gynecologic procedures," the consensus states. The recommendations highlight the importance of taking patient age, trauma history, anxiety, and prior experiences into account when discussing pain-control strategies.
Procedure-specific recommendations
For IUD insertion, local anesthetic agents such as lidocaine spray or paracervical block may reduce pain. While misoprostol has been explored as a cervical ripener, it is associated with side effects such as cramping and gastrointestinal symptoms. Preprocedural NSAIDs are not effective for pain at insertion but may help with postprocedural discomfort.
In endometrial biopsy, topical anesthetics and NSAIDs like naproxen may offer relief. Intrauterine instillation of lidocaine has also demonstrated benefits in certain settings. The data on misoprostol are conflicting, and its role remains uncertain.
For hysteroscopy and ablation, local anesthesia—especially paracervical or intracervical blocks—is supported by evidence. Misoprostol can reduce intraprocedural pain, but adverse effects are common. Nonpharmacologic interventions such as music or virtual reality show promise but lack sufficient evidence to be widely recommended.
In uterine aspiration, paracervical blocks effectively reduce procedural pain, and preprocedural NSAIDs improve postoperative pain. Oral opioids and anxiolytics do not reduce procedural pain, though anxiolytics may help reduce anxiety.
For cervical procedures such as loop electrosurgical excision procedures (LEEP), local anesthetic agents are recommended. Although techniques vary, no single approach has proven superior. Distraction methods like forced coughing or music are not consistently effective.
Promoting equity and future research
ACOG calls for more inclusive research that considers racially and ethnically diverse populations, gender-diverse participants, and individuals with a history of trauma. It also stresses the need for more data on preprocedural education, nonpharmacologic interventions, and the use of anxiolytics.
"Although there is heterogeneity in studies evaluating methods for pain management during office procedures, gynecologists and other health care professionals should have a broad knowledge of the options available to patients and individualize treatment accordingly," the document concludes.
Reference:
American College of Obstetricians and Gynecologists. ACOG releases new recommendations on pain management for IUD insertions, other in-office gynecologic procedures [news release]. Published May 15, 2025. Accessed May 16, 2025. https://www.acog.org/news/news-releases/2025/05/acog-releases-new-recommendations-on-pain-management-for-iud-insertions-other-in-office-gynecologic-procedures
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