Q&A: Recognizing and adequately treating pain during gynecologic procedures
Key takeaways:
- Pain during gynecologic exams is often dismissed, not recognized and undertreated by some clinicians.
- Clinicians should provide patient-centered, trauma-informed care with adequate access to pain relief.
Pelvic exams and procedures are a routine part of ambulatory gynecology, yet research suggests some women experience pain that goes unrecognized or undertreated, eroding trust and putting patients at risk for having pain poorly managed.
Although many gynecologic procedures are common and last a few minutes, some are performed under stressful conditions, such as obtaining a biopsy to rule out cancer or completing a uterine aspiration procedure for early pregnancy loss, which can lead to higher pain perception, according to Lisa Bayer, MD, MPH, an OB/GYN and complex family planning subspecialist, medical director for the Center for Women’s Health and codirector for the Complex Family Planning Fellowship at Oregon Health and Science University. In addition to underestimating pain during such procedures, clinicians may focus on the short duration during the consent process, Bayer said, thereby minimizing and normalizing moderate to severe pain.
“This phenomenon is known as the ‘peak and end rule,’ which describes how our recall of emotional episodes focuses on the peak moments and the end of the experience rather than the overall duration,” Bayer wrote in the AMA Journal of Ethics. “A related phenomenon, known as ‘duration neglect,’ holds that the duration of an experience has minimal impact on the recollection of the experience. In effect, when we apply these ideas to clinic-based pain experiences, even when a procedure is short in duration, the intensity of peak pain and how peak pain ended will be the most important parts of an experience a patient recalls. By prioritizing duration over peak intensity, clinicians might harm patients by undertreating their pain.”
Healio spoke with Bayer about why pain during gynecologic exams continues to go unrecognized, the need for access to adequate pain relief and how clinicians can build trust with patients and promote a sense of safety.
Healio: Your article highlights the roots of poor pain management in obstetrics and gynecology. Can you briefly explain this history of what you call “the normalization of pain?”
Bayer: On a basic level, pain has been normalized as part of the lived female experience. There are many medical conditions and experiences specific to women — having a painful monthly menstrual period, pain during childbirth or pain related to endometriosis. Our society also values a quiet and stoic tolerance to pain; those who “grin and bear it.” Women who speak up about their pain are often dismissed as having an emotional response.
On a deeper level, beyond the normalization of pain, there is also the dismissal of pain. This connects to the historical origins of our specialty. The field of modern gynecology was built through the exploitation, assault and nonconsent of enslaved women. These women underwent forced examinations or underwent surgical experiments without anesthesia.
Modern examples of dismissing pain are seen today and are a continuation of this legacy, and these examples are even more pronounced among marginalized populations. One example in the news recently was about women undergoing oocyte retrievals without pain medication — an invasive, very painful procedure. This went on for many months.
That highlights that this legacy is still very much present today.
Healio: Pain in the OB/GYN setting continues to be undertreated by clinicians. Why?
Bayer: In other professions, patients are not typically expected to endure painful procedures without pain medication or analgesia. Why in OB/GYN is this pain not only to be expected but tolerated? This goes back to sociocultural expectations, that women are “capable” of enduring this pain.
Pain assessment is also vulnerable to clinician biases. If a patient grins and bears it, the clinician may wrongly assume the procedure was well tolerated. That perpetuates the cycle of underrecognizing and undertreating pain.
Healio: What are the consequences of undertreating pain, even for short procedures like an IUD insertion?
Bayer: There is psychological and physical harm that comes with having your pain undertreated. But it also erodes the trust in the physician/patient relationship and also the trust in our larger medical system. This can lead to avoidance of medical care. Beyond the individual patient, reports of undertreating pain have widespread impact in how people view the medical system. Medical care should be a place of healing, not a place of trauma.
Healio: How do clinicians begin to address this issue, OB/GYNs in particular?
Bayer: On an individual clinician level, we are always striving for continuous improvement in the care we provide. Practicing humility goes a long way. Acknowledge the failures of undertreating pain in the past. Acknowledge patient concerns about pain. And acknowledge patients are the best authority on themselves.
There has been a shift away from medical paternalism — where clinician knows best — to a patient-centered care model, where the clinician can focus on the individual needs, values and preferences of the patient.
On a larger level, I would love to see more research on how to best address pain related to OB/GYN procedures. More research is needed to create guidelines or standards of care.
I would also like to see improved access to all pain control options. Health disparities do exist related to who can and cannot access sedation for these procedures.
We must listen to our patients and not minimize their concerns. Be curious about what they have heard from friends, family or social media. Some people make up their mind beforehand based on what they have seen or heard. You can address those patient concerns head-on and come up with a plan together.
Reference:
For more information:
Lisa Bayer, MD, MPH, can be reached at bayerl@ohsu.edu.