ACOG Issues Consensus Guidance to Improve Pain Control During In-Office Gynecologic Procedures

Clinicians should offer evidence-based analgesia for pain management for in-office uterine and cervical procedures and to engage every patient in shared, trauma-informed decision-making, according to long-awaited guidance from The American College of Obstetricians and Gynecologists (ACOG) released May 15.¹

The clinical consensus document, Pain Management for In-Office Uterine and Cervical Procedures, covers common interventions such as intrauterine device (IUD) insertion, endometrial biopsy, hysteroscopy, intrauterine imaging, and cervical biopsy. ACOG recommends that obstetrician-gynecologists routinely discuss local anesthesia — including topical lidocaine spray, lidocaine–prilocaine cream, or a paracervical block — for IUD placement and tailor similar strategies, along with nonsteroidal anti-inflammatory drugs or misoprostol, to other office procedures.¹

Christopher M. Zahn, MD, FACOG, ACOG’s chief of clinical practice, health equity, and quality, said limited or conflicting evidence on analgesic techniques, coupled with systemic bias, has historically impeded optimal pain control.

“The way that pain is managed by health care professionals has been affected by a number of factors, including the fact that many of the pain management interventions had limited or conflicting evidence supporting their effectiveness,” Zahn said in a news release. “Additionally, systemic racism and bias as to how pain is experienced and who experiences it also has, unfortunately, influenced pain management considerations. This guidance is an important step toward both identifying evidence-based approaches to pain management and reducing those biases by offering all patients more autonomy in deciding how to best approach the pain they experience. What I hope clinicians will take away from this guidance is the absolute importance of comprehensive pain management counseling—not just for mitigating pain in the moment but also for improving trust with our patients and ensuring better access to gynecologic health care for every person.”¹

The document emphasizes that anxiety, prior trauma, and baseline pelvic pain can magnify procedural discomfort, making individualized counseling critical.

Genevieve Hofmann, DNP, WHNP, a coauthor, noted that many patients report their pain has dismissed by their clinicians, which can erode trust.

“Though some clinicians have been able to offer some of these pain management options already, I am excited that this guidance will ensure more ob-gyns and clinicians are discussing pain management options with their patients, and, most importantly, that fewer people will have to endure pain to obtain procedures that are necessary for their health and well-being,” Hofmann said in the news release.¹

The consensus highlights persistent obstacles to effective analgesia in office-based gynecologic care. Procedural pain is difficult to predict and is modulated by factors such as patient age, prior pelvic examination experience, past trauma, and baseline anxiety. Comparative trials of analgesic techniques yield heterogeneous results, precluding endorsement of a single best approach. Intrauterine device insertion exemplifies this problem: although extensively studied, disparate protocols prevent a uniform recommendation. The guidance urges clinicians to review all available options and employ shared decision-making to craft an individualized pain-management plan.¹

Kimberly Hoover, MD, FACOG, another coauthor, stressed that patients should decide what interventions they want to consider, whether the priority is speed, reduced acute pain, or the ability to pause a procedure to switch strategies. The consensus also calls for equitable access to deeper sedation, such as intravenous, monitored, or general anesthesia, when warranted and available.¹

ACOG’s recommendations aim to standardize counseling, mitigate disparities in pain recognition, and expand the analgesic toolkit for office gynecology—changes the organization says will strengthen patient trust and procedural uptake.¹

Reference

1. American College of Obstetricians and Gynecologists. ACOG releases new recommendations on pain management for IUD insertions, other in-office gynecologic procedures [news release]. Published May 15, 2025. Accessed May 16, 2025. https://www.acog.org/news/news-releases/2025/05/acog-releases-new-recommendations-on-pain-management-for-iud-insertions-other-in-office-gynecologic-procedures