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The ripples of trauma caused by severe pain during IUD procedures

BMJ 2021; 374 doi: https://doi.org/10.1136/bmj.n1910 (Published 05 August 2021) Cite this as: BMJ 2021;374:n1910

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The unbearable pain of “just a little pinch”

Dear editor,

As two medical students planning on going into Obstetrics and Gynecology, we are grateful to Stephanie O’Donohue for sharing her story. During our time on OB/GYN rotations, we regularly observed patients crying in pain after being told they would feel “just a little pinch.” We found this inconsistency troubling, especially given the historical trivialization of women’s pain in medicine. We began to wonder what we, as students, could do to address this for our future patients. If O'Donohue's piece serves as a call to arms, we hope to answer it by supporting a paradigm shift in our generation.

Obstetrics and Gynecology has historically had a complicated relationship with pain. Women’s pain has been dismissed as hysteria (menstruation, endometriosis), or held up as virtue (childbirth). Our experience, both as patients and as observers in clinics, reveals that women frequently experience moderate to severe pain during routine in-office gynecologic procedures. This pain is a barrier to optimal healthcare. For example, the safest and most effective method of birth control, the IUD, is underutilized due to fear of pain during and after the procedure [1].

The American College of Obstetricians and Gynecologists (ACOG) lists pain as a contributing factor in decreased provider willingness to recommend IUD placement in adolescents and nulliparous women.[1] However, current ACOG guidelines fail to recommend pain control during in-office procedures, including IUD placements. These guidelines were last updated in 2017, and are outdated. While early research was indeed equivocal, more recent evidence identifies safe, effective, and efficient methods of pain control during IUD placement [2-4].

We witnessed this failure to offer pain control across multiple clinics, multiple procedures, multiple patients. We did, however, routinely witness providers preface the procedure with “you’ll feel mild discomfort” or “you may feel some cramping.” This was followed by women writhing in the kind of agonizing pain Stephanie O’Donohue describes. Worst of all, pain control or sedation was available at many clinics but not offered to patients; instead, it was only accessible to the few who knew to ask for it.

Equally troubling is the glaring absence of medical teaching on this topic. This lapse in education maintains the historical silencing of women’s pain and fails to equip medical students with the knowledge to confront it. Students can be a powerful force for change in this arena. They can ask schools to revise curricula. They can stay abreast of the newest research on the forms of analgesia, why providers aren’t using it, and what patients desire. Finally, they can spend more time with patients. Typically, after in-office gynecologic procedures, patients are told that they can get changed and then stay as long as they need. In this time, students can check in with patients to ask about their experience, offer support, and note what could help future patients.

We wish we could have been there for Stephanie O’Donohue, to advocate for pain control during her appointment and to support her afterwards. Alongside our peers, we plan to be there for the women who follow her. We hope that the patient perspectives in “the ripples of trauma caused by severe pain during IUD procedures” will combine with new awareness of the issue among future providers to create a rising tide and end this pandemic of silent pain.

Yours sincerely,
Agnieszka Steiner and Simran Singh
Third Year Medical Students

References
[1] American College of Obstetricians and Gynecologists, Espey E, Hofler L. Long-Acting Reversible Contraception : Implants and Intrauterine Devices. ACOG Pract Bull. 2017;130(121):251-269.https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles /2017/11/long-acting-reversible-contraception-implants-and-intrauterine-devices.

[2] Perez-Lopez FR, Martinez-Dominguez SJ, Perez-Roncero GR, Hernandez AV. Uterine or paracervical lidocaine application for pain control during intrauterine contraceptive device insertion: a meta-analysis of randomised controlled trials. The European Journal of Contraception & Reproductive Health Care. 2018;23(3):207-217. doi:10.1080/13625187.2018.1469124

[3] Samy A, Abbas AM, Mahmoud M, et al. Evaluating different pain lowering medications during intrauterine device insertion: a systematic review and network meta-analysis. Fertility and Sterility. 2019;111(3):553-561.e4. doi:10.1016/j.fertnstert.2018.11.012

[4] Abu-Zaid A, Alshahrani MS, Albezrah NA, et al. Vaginal dinoprostone versus placebo for pain relief during intrauterine device insertion: a systematic review and meta-analysis of randomised controlled trials. The European Journal of Contraception & Reproductive Health Care. 2021;26(5):357-366. doi:10.1080/13625187.2021.1891411

Competing interests: No competing interests

21 February 2023
Agnieszka N. Steiner
Medical Student
Simran Singh
Michigan, USA