Reference: Obstet Gynecol. 2025 Jun 12;146(2):279-284
Practice Point: Prioritize analgesia for in-office uterine and cervical procedures like IUD insertion, hysteroscopy, and D&C.
EBM Pearl: Correctly evaluating the right intervention in the right population is a critical step in best approximating the truth through trials.
Recently, the historical lack of analgesia for office-based uterine and cervical procedures has been a hot topic in social media—and for good reason. If you’re wondering how medicine missed the boat on this one, you have to go back a few decades. Multiple studies 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 we 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 updated its guidance around in-office gynecologic procedures to recommend routinely offering analgesia. 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 design of previous negative trials turned the organization’s head. That last part is of particular importance because revisiting methodology of prior studies has led us to reassess menopausal hormone therapy, the overall risks and benefits of alcohol use, and a variety of “truisms” in late 20th century medicine. The lesson? We have to use the correct methods to study the right treatment in the right population to get results you can trust and act upon with clinical certainty.
When it comes to previous studies looking at the effects of various applications of lidocaine to the cervix and uterus, earlier studies often underdosed anesthetics, did not target specific moments of pain (tenaculum, sounding, insertion), and underrepresented younger, nulliparous, and adolescent patients who are the ones most likely to experience pain with gyn procedures and to benefit from analgesia. Older studies also didn’t consider the effects of anesthetics on vasovagal events, anxiety, anticipated vs. remembered pain, or willingness to return.
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 5 mL of 2% lidocaine or placebo instillation via intrauterine catheter and followed them for 1 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 1-2 point improvement with lidocaine at each time point, and 30% of patients who got lidocaine vs. 2% who got placebo reported 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. Like 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 2, 4, 8, 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 the patients through the steps, and let them know you will pause or stop if they ask. In undoing the “just a pinch” mentality that has 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?
For more information, see the topic Hysteroscopy in DynaMed.
DynaMed EBM Focus Editorial Team
This EBM Focus was written by Katharine DeGeorge, MD, MS, Senior Deputy Editor at DynaMed and Associate Professor of Family Medicine at the University of Virginia. Edited by Alan Ehrlich, MD, FAAFP, Executive Editor at DynaMed and Associate Professor in Family Medicine at the University of Massachusetts Medical School; Dan Randall, MD, MPH, FACP, Senior Deputy Editor at DynaMed; Gayle Sulik, PhD, Senior Medical Editor and Team Lead for Palliative Care at DynaMed; McKenzie Ferguson, PharmD, BCPS, Senior Clinical Writer at DynaMed; Rich Lamkin, MPH, MPAS, PA-C, Clinical Writer at DynaMed; Matthew Lavoie, BA, Senior Medical Copyeditor at DynaMed; Hannah Ekeh, MA, Senior Associate Editor II at DynaMed; and Jennifer Wallace, BA, Senior Associate Editor at DynaMed.