Key Takeaways
Practice Point: Prioritize analgesia for in-office uterine and cervical procedures like IUD insertion, hysteroscopy, and dilation & curettage (D&C).
EBM Pearl: Correctly evaluating the right intervention in the right population is a critical step in best approximating the truth through trials.
EBM Focus Article
Recently, the historical lack of analgesia for office-based uterine and cervical procedures has been a hot topic in social media—and for good reasons. For decades, medicine relied on data from multiple studies that seemed to show no significant clinical benefit to lidocaine when applied topically, injected into the cervix, or instilled into the uterus. This approach happened to align with the ever-increasing goal of moving patients through the clinic faster, so clinicians just kept telling patients “You might feel a pinch!” and moved on.
Fast forward to May 15, 2025. In a clear departure from previous norms and practice, the American College of Obstetricians and Gynecologists (ACOG) updated its guidance to recommend analgesia for in-office gynecologic procedures. Seemingly, a combination of pressure from social media influencers, a meta-analysis demonstrating the benefit of paracervical blocks, and a careful look back on the research designs of previous negative trials turned the organization’s head. That last part is of particular importance because revisiting the methodology of prior studies has led to a reassessment of a variety of “truisms” in late 20th century medicine including menopausal hormone therapy and the overall risks and benefits of alcohol use. The lesson? Researchers must use the correct methods if they are to understand the right treatment in the right population with clinical certainty.
Previous studies looking at the effects of various applications of lidocaine to the cervix and uterus for instance, often underdosed anesthetics, did not target specific moments of pain (such as tenaculum, sounding, or insertion), and underrepresented the younger, nulliparous, and adolescent patients who are the ones most likely to experience pain with gynecologic procedures and therefore benefit from analgesia. Earlier studies also didn’t consider the effects of anesthetics on vasovagal events, anxiety, anticipated vs. remembered pain, or willingness to return to the clinic.
A recent double-blind, randomized trial published in Obstetrics and Gynecology contributed to the paradigm shift with an evaluation of procedural pain in patients having planned hysteroscopy-guided endometrial biopsy in India to evaluate abnormal uterine bleeding or postmenopausal bleeding. Investigators randomized 126 adults (mean age 45) to receive either five mL of two percent lidocaine or a placebo instillation via intrauterine catheter and followed them for one hour after the procedure. Tenaculums were not used. The primary outcome was pain assessed on the visual analog scale (score range 0-10 points, 10 = most pain) measured during hysteroscope insertion, during the biopsy, and at 30 and 60 minutes after the biopsy. Results showed a one-two point improvement with lidocaine at each time point, and 30 percent of patients who got lidocaine vs. two percent who got the placebo reported that they were very satisfied with the procedure.
This particular study is an example of a well-done trial describing one effective analgesic method for one particular procedure in one specific population. As with other types of pain management, the use of multiple modalities can be synergistic and improve the overall experience of pain and anxiety for patients. So premedicate your patients with acetaminophen and an NSAID; coat the cervix with lidocaine jelly, inject lidocaine at two, four, eight, and 10 o’clock on the lateral fornix, and/or instill lidocaine into the uterus, but also put on some music (whether it be relaxing or just their favorite jam), ask about past sexual or exam trauma, talk them through the steps, and let them know you will pause or stop if they ask. In undoing the “just a pinch” mentality that shaped decades of practice, prioritizing analgesia in the office isn’t just about numbing the cervix, it’s about correcting a painful oversight, and speaks to making the patient feel cared for. And at the end of the day, isn’t that what matters the most?
References
Reference: Obstet Gynecol. 2025 Jun 12;146(2):279-284
For more information, see the topic Hysteroscopy in DynaMedex.
