Recent social media videos highlight growing conversations among healthcare practitioners (HCP) and patients about how women’s pain is acknowledged and managed in gynecological settings. 

 

In a recent TikTok video, an intensive care unit doctor and anesthesiologist under the username of icudoctor responds to another TikTok user’s question about why anesthesia isn’t used for procedures like intrauterine device (IUD) placement or colposcopy: “In…gynecology…it seems like, unless you’re actively in labor, your pain as a woman doesn’t really get a lot of attention. It doesn’t get the treatment that it deserves.”

Icudoc on tiktok. TikTok.

 

 

He goes on to say, “I believe that it’s likely due to patriarchy and misogyny in medicine that is so pervasive today….Why aren’t we doing more for this?”

Pain management doctor Kanal Sood, MD,  who posts TikTok videos under the username doctorsood, shared a video response to another TikTok video in which the user said her husband was offered sedation for an ultrasound of the scrotum. Sood’s response?: “[W]e have thousands of women who go for gynecological procedures every day—which is far more invasive—and are not offered even local anesthesia at the minimum.”

Kunal sood m. D. On tiktok. TikTok

 

 

Sood continued, “It is time we as healthcare providers change our mindset when it comes to women’s pain. Just because women go through labor does not mean they are better able to tolerate pain.”

Alyssa Dweck, MS, MD, FACOG, a practicing gynecologist with intimina, tells MDLinx that even diagnosing women’s health issues has been problematic. “Endometriosis, for example, can cause significant pain and negatively impact quality of life for those affected,” Dweck says. “Historically, time to diagnosis averages upwards of seven years, and oftentimes multiple practitioners are seen prior to diagnosis.” 

 

Why isn’t general anesthesia more common?

 

According to G. Thomas Ruiz, MD, OB/GYN lead at MemorialCare Orange Coast Medical Center in Fountain Valley, CA, many doctors were taught one way of practicing—and it stuck. “Most MDs my age weren’t trained to use [general] anesthesia, say, during insertion of IUD,” Ruiz says. Echoing this, one small study found that HCPs may underestimate a patient's pain level during an IUD insertion.

Akintomide H, Brima N, Sewell RDE, Stephenson JM. Patients’ experiences and providers’ observations on pain during intrauterine device insertion. Eur J Contracept Reprod Health Care. 2015;20(4):319-326.

 

 

In some cases, the lack of pain management may be due to risk. “While [general anesthetic] is appropriate for some people, it is not benign,” Ruiz adds. “The complication rate is low, but it is there,” he says. However, “there are certain patients who benefit from it, and you have to recognize and make it available to them.” 

Ruiz also notes that many health insurance plans won’t cover general anesthetic for patients who come in for, say, an IUD placement, which is considered an ambulatory procedure. He also says that many OB/GYN office settings “are not equipped to do these things under conscious sedation. For that, you need to have a nurse monitoring vitals...so there is specific protocol.” Any procedures requiring anesthesia, he says, would need to occur in an outpatient surgery center.  

But for Christine Gibson, MD, a family physician and trauma therapist consultant based in Calgary, Canada, it’s about the fact that women are just expected to handle pain or fear. “Most procedures can be done pain-free with excellent local freezing, conscious sedation (awake but the brain is asleep), or actual anesthesia,” Gibson says. 

 

How can physicians mitigate patient pain and trauma?

 

She goes on to say that her HCPs did offer her valium—but “it was not the fix that I needed for the panic and anxiety that these exams cause me,” she adds. Now, she says, her gynecologist schedules all of her appointments at the outpatient surgery center, where her appointment is listed as an “outpatient anesthetic event.” In response to one of her commenters, callmemoprah said that anesthesia wasn’t offered to her and that she had to ask for it due to exam anxiety. 

Some HCPs may not even be aware of exactly how painful certain procedures are for patients. Research in The European Journal of Contraception & Reproductive Health Care found that, regarding IUD placement procedures, “providers were not usually accurate in their observations and tended to underestimate the degree of pain experienced by their patients during IUD insertion procedures.” It went on to say that “[p]atients' reported pain levels were significantly higher than those reported to have been observed by their providers.”

Akintomide H, Brima N, Sewell RDE, Stephenson JM. Patients’ experiences and providers’ observations on pain during intrauterine device insertion. Eur J Contracept Reprod Health Care. 2015;20(4):319-326.

 

 

How can physicians better help patients?

 

Noticing how patients behave during routine exams can help you understand their anxiety or pain level, Ruiz suggests. “A pap smear shouldn’t be painful, so if they’re lifting their body up or having vaginismus in a pap smear…providers must recognize patient pain and talk to them through the procedures.”

Gibson also notes that acknowledging patient fear and pain is key, as anxiety and pain can form a feedback loop. “We tend to dismiss, gaslight, or misunderstand women's genuine perceptions, which creates more medical trauma and a vicious circle of anticipatory stress. When the body is apprehensive, the resulting muscle tension and sympathetic tone will make the pain experience all the more heightened,” Gibson says. 

It is beneficial “for any clinician to be aware of a previous negative experience with an exam/procedure [or] prior history of abuse/assault/traumatic experience,” Dweck emphasizes. 

Additionally, Gibson says that HCPs need to be willing to update their practices: “We sensitize ourselves to the harms medicine has done in the community. Just because this is the way ‘things have been’ doesn't make it right.” 

Gibson notes that women, along with people of color and LGBTQ+ people, often “fall outside of the medical paradigm…This has led to women's health being a particularly incongruent approach. We know many procedures are painful but haven't used our power to prevent this,” she says. 

Dweck believes that speaking out can help shift the way things are done. “I am hopeful that this will improve as practitioners are more attuned to this fact and women are becoming more open to discussing their concerns and advocating for themselves in the medical setting,” Dweck notes. “Likewise, I am optimistic that social media can help to bring awareness to addressing pain due to procedure.”