reproductive health

Gynecology Has a Pain Problem

Our discomfort is routine. What if it didn’t have to be?

Photo-Illustration: Josiah Whitfield; Photos: Getty
Photo-Illustration: Josiah Whitfield; Photos: Getty

Routine Pap smears — in which a medical provider uses small tools to scrape cells from the cervix to test for cancer or precancerous conditions — are recommended by the American College of Obstetricians and Gynecologists once every three years for patients over 21 whose results are normal. Lauren Capps, 28, is due for her next one in October. She’s worried about it. “Honestly, it’s a bit scary,” she says. “I don’t want to go.”

When she was 20, Capps went to her college clinic for birth-control pills. They told her she needed a Pap smear before they could prescribe them. And it went okay, actually. That one really did feel like a pinch, she says.

Two years later, she went to a different provider, who required a Pap smear before providing another birth-control prescription. She was expecting a similar experience to her first. “She started the speculum insertion and she wasn’t even at the cervix yet, and I just remember the most terrible pain,” Capps says. “I just started screaming out.”

The doctor stopped and said she didn’t understand why Capps was feeling pain. In fact, she told Capps that she had a “beautiful cervix.” “I was like, ‘I don’t know either,’” Capps says. “‘I’ve never felt this before. It’s terrible.’”

When the doctor asked if she should continue, Capps said yes. Like so many patients I spoke with, Capps wanted to just get it over with. On the way home, she was sore and bleeding. “I remember feeling violated,” she says.

Three years later, Capps saw someone else for her third Pap smear. She explained what happened at her previous appointment to the nurse practitioner, who was calm and kind. But during the exam and Pap, Capps started shaking. Although this one wasn’t as painful, she felt like she was being split in two, and when she walked to get blood drawn in a different room, she passed out.

As anyone who has spent time in stirrups can attest, Capps’s experience — the discomfort, the nerves, the gritting teeth — isn’t uncommon. Getting my IUD removed was the worst pain I have ever felt — and I gave birth this past year. (Yes, I did get an epidural but only after a few hours of contractions.) For me, getting the IUD out was a sharp pain that felt like someone was plucking my internal organs like a guitar string. I felt disassociated from my body as the pain became a thing to survive. Like so many other patients, doctors told me to take over the counter pain medication to help with the removal. The ibuprofen may have helped some — but for me and plenty others, it wasn’t enough.

Pain management in gynecology is complicated. As Andrew Goldstein, a doctor at the Centers for Vulvovaginal Disorders, explains, the cervix has three types of nerves, so what pain it can feel, and at what intensity, is quite complex. “Some people could have cervical biopsies and they don’t feel it,” he says. “Other people, you do a very gentle Pap smear and they’re writhing in pain. It’s not that they’re whiners, it’s not that they’re complainers, it’s just how they’re ‘wired.’”

Many factors contribute to how someone experiences pain, including their pain threshold, previous experience with doctors, history of sexual abuse, medical conditions, and more. Pain can also be a message, and when people come to believe that intense pain is normal, they can miss when pain means that something is wrong. The line between unavoidable discomfort and pain that signals something wrong with the body can be difficult to articulate, and complicated by people’s unique lived experiences.

Because of this complexity, pain is particularly difficult to study — making some clinicians slow to address pain if they feel there aren’t enough randomized controlled trials to inform pain management procedures, says Karen Meckstroth, professor and medical director at the UCSF Center for Pregnancy Options.

Of course there’s also the fact that the pain women experience is often minimized in medical settings. “It will just be a pinch” has been said so often by gynecologists it loses meaning, like a word that turns into gibberish after too much repetition. And even if in-office procedures like Pap smears, IUD insertions, and endometrial biopsies actually did objectively feel like a pinch, pinches usually happen on the outside of your body. Several patients I spoke with described their own experiences at the gynecologist as feeling like someone was rummaging around your insides.

A lot of women are told by doctors themselves that pain is normal: that periods hurt, and childbirth hurts. But experiencing pain at the doctor’s office can have significant consequences. One 2005 study found that middle-aged African American women — a group at the time who had the highest incidence and mortality rate of invasive cervical cancer in the U.S. — who perceived Pap tests as painful were almost five times more likely not to undergo regular Paps. Women who felt it was the most painful on a scale of one to ten were even less likely to get the test done. “I have met in my career quite a few people who were hurt during a pelvic exam,” says Ashley Hill, medical director of AdventHealth Medical Group and OB/GYN. “And they never came back. And they developed cervical cancer or some other problem that could have been prevented if they had just come back and had their exams done.”

Of course gynecology itself was built on inflicting pain on women, mainly Black women. James Marion Sims, often credited as inventor of the speculum and a leading doctor in early gynecology, grew his expertise in the 1840s by performing experimental surgery on enslaved Black women to attempt to repair vaginal fistulae (a hole in the wall of the vagina that can lead to other organs). Historian Deidre Cooper Owens writes in her book Medical Bondage that medical experiments by Sims and others included surgeries without anesthesia, even though it was regularly used at that time. Slave owners had particular interest in gynecology so that enslaved women could continue to bear children — and therefore remain a good investment. They also had a vested interest in promoting the false idea that Black women felt less pain than white women and were predisposed to have more children. Scientific racism also linked pelvic size to things like intelligence — and sensitivity to pain.

These beliefs inform what historian Dana-Ain Davis calls “obstetric hardiness”: the belief that Black women are able to experience childbirth with less pain than other groups of people. “We gather a lot of information from the past that we’re not always concretely aware of,” Davis says. “There’s been an accrual of those things over time. And they work their way into how I think medical professionals are trained.”

(This history continues to affect how Black patients may be treated in medical offices. In her book, Cooper Owens described her own experience as a Black woman with fertility specialists. One specialist dilated her cervix twice without using any anesthesia. “I had never gone through that kind of physical agony in my 43 years of life,” she wrote. “To live through a medical procedure in the 21st century in which the expectation was that I could tolerate acute pain seemed surreal.” Another specialist commented in surprise that her uterus was small for her body, even though it is not. One 2016 study found that about 50 percent of the white medical professionals in the sample believed at least one false medical belief about Black people. The medical students and residents in this study also assessed Black patients as feeling less pain than white patients. The study, led by behavioral scientist Kelly Hoffman, also found that white medical professionals were less likely to give Black patients appropriate pain medication based on World Health Organization standards. A 2019 study on postpartum pain management also found that Black and Latinx women experienced higher pain and were given less pain medication than white women after a Cesarean delivery.)

Bad experiences can lead to avoiding care entirely. Fifty-three-year-old Robyn Lydick steered clear of the gynecologist for two years after she felt pain during an exam that led a doctor to misdiagnose her. She didn’t go back until she suspected she was pregnant. “When you’re in the stirrups and all but strapped down, you’re not in any charge of what’s going on with your body,” she says. “I have not done annuals because it’s so luck of the draw.”

“If you’d previously had pain, everything in your system tells you don’t go there again,” says Yoon Frederiksen, lead author of a study that looked at factors that predicted pain in the egg retrieval process of fertility treatments. She found that having a negative gynecological experience increased the risk a patient would feel more intense pain during the egg retrieval procedure. Other factors associated with experiencing higher pain intensity were anxiety and perceived lack of control. The only medical factor associated with higher pain was duration of the procedure — meaning that anxiety may matter more than things like needle size when it comes to pain. Anxiety making pain worse is not exclusive to gynecological procedures. But being at the gynecologist can be embarrassing or vulnerable in a way that other doctors visits may not be.

Patients are often told to speak up when they are hurting, but it’s not always that simple. For one, when women of color speak up, their pain may not be taken seriously. And when patients do speak up, they’re not always heard in the ways they really need.

When Capps told her doctor she was in pain, the doctor responded by saying she shouldn’t be because she couldn’t see anything immediately that could cause it. Other patients I spoke with were told they were dramatic, or their providers didn’t seem concerned with their pain, or the possibility of pain was downplayed (it will only be a pinch, after all!).

Who is believed when they are in pain and who gets appropriate pain treatment can be influenced by larger cultural beliefs about women, race, addiction, and more. Goldstein says they get a lot of patients at their clinic who are told that the pain is in their head. “You want to make a completely ‘sane’ woman crazy? If she’s having pain, have ten doctors tell her that it’s all in her head and it’s psychological,” he says. Pain is not something that can be objectively measured, so it’s up to doctors to believe someone when they say something hurts, Goldstein says. But all too often in medicine, women’s symptoms are ignored or mistaken, leading to misdiagnosis and what some patients are now calling “medical gaslighting.”

Just as complicated as determining the root cause of a patient’s pain, so too is figuring out how to manage it. Because pain itself is so individualized, there isn’t a universal solution. That said, this happens often in other medical settings, too. Take, for instance, the dentist. When most dentists inject novocaine, they wait for it to take effect, and then test that it works, adding more if needed and if it’s safe to do so.

It may surprise some patients who have gritted their teeth through exams and procedures to learn that there are options for pain management at the gynecologist. There’s of course over the counter medication like ibuprofen — which is generally low cost and low risk. Prescription medication like Ativan relieves anxiety and is often used before surgery or other medical procedures. For some procedures, clinicians can perform a paracervical block, which is when a local anesthetic is injected near the cervix to numb the area. A block wouldn’t help during an exam, OB/GYN Nisha Verma says, because it works higher up in the uterus and would not relieve discomfort felt in the vagina. It can be helpful, though, for things like IUDs.

There are also topical anesthetics available, which can help without using any needles or can be used before a block to help with the pain of the injection. A local anesthetic cream can even be used to help with discomfort from speculums. The patient can also ask for a smaller speculum. (Though Meckstroth warns that smaller doesn’t always equal better. Doing a procedure with a smaller speculum may mean that the vaginal walls could feel instruments as they go in and out and require more movement during the procedure.) If all else fails, a patient may be able to undergo anesthesia for the procedure to be performed in an operating room — it’s rare that a patient would need that, but it could be a possibility for those that do.

But a lot of patients don’t know these pain-management options, and a lot of providers don’t offer them. Some clinicians may not feel they have enough experience to perform a paracervical block, or assume that doing the block will hurt more than the procedure itself. (“Yes, if you use a big fat needle and inject it really quickly, yes, it can hurt a lot to do the block,” Meckstroth says.) There is solid evidence that for patients who haven’t had a baby, a local anesthetic block decreases pain with IUD insertions, and there are a number of studies that help with how to do a block in a way that isn’t painful. “Although the evidence isn’t as clear, many people who have had a delivery also benefit from local anesthesia for IUDs,” Meckstroth explains in an email.

Part of the solution may just be medical providers rethinking the way they do things. Some of the pelvic exams that cause pain may not be necessary in the first place. ACOG recommends against performing regular pelvic exams in asymptomatic, non-pregnant women, and against requiring pelvic exams before prescribing birth control. (The exception is for IUDs — ACOG says a pelvic exam is still needed then.) But some clinicians, including the ones Capp saw, keep performing these exams on a regular basis or before prescribing birth control. A 2010 study said that despite this guidance, nearly one-third of medical professionals reported always requiring a pelvic exam to prescribe oral contraception. Another study from 2020 found that more than half of pelvic exams and almost three-quarters of Pap tests performed among young women 15 to 20 years old during 2011 through 2017 may have been unnecessary. That’s an estimated 1.4 million women and girls.

Getting the word out about new research and guidance — and getting providers onboard to change from how they’ve been trained — can be a long journey. Some new research and procedures are picked up by providers widely right away, but for others, it can take years. “It’s very health-care-provider specific as to who is keeping up and who is not,” Hill says. “There are doctors that I’ve met who haven’t read a medical journal in five years. They don’t pick it up, they don’t care, they’re just practicing their own day to day thing. There are others, like myself and many others I know, who read every one they can get a hold of — which takes time, and it’s after hours.”

Take, for instance, that clinicians were trained for many years to not use gel lubrication on the speculum because of the belief that the gel could affect testing results on procedures like Pap smears. They used water instead. Then various studies in the early 2000s found that a small amount of gel doesn’t interfere with test results. Hill says when those studies came out, he started using gel for speculum insertion — and was reprimanded by other doctors and nurses, who said water worked just fine. It wasn’t until 2012 that a study — led by Hill — bothered testing if lubrication helped patient comfort. (It does.) “Other than clinical inertia,” the study reads, “we see no challenges to the implementation of this recommendation.”

“I think the center of this whole discussion is patient-centered care,” Verma says. (Verma is also a member of ACOG.) Patient-centered care prioritizes an individual’s needs, respects their values and preferences, and provides adequate information and education, among other factors that emphasize community and continuity of care. This kind of care is supposed to put patients’ needs first, but the reality of the medical system in the U.S. often keeps that from happening. “It’s a problem from gynecology training all the way through what is supported clinically. The extra time needed to discuss individualized pain control and do a block is often not allotted for procedures because it’s not paid for by insurance,” Meckstroth says. Additionally, insurance may not completely cover procedures under anesthesia, leaving some costs to fall to the patient. This can be especially an issue in abortion care, which already isn’t covered by many insurance plans. Mixing medications to help safely increase an anesthetic dose and make it work faster with less pain is also highly regulated, which can create roadblocks if clinics want to use these medications in the office.

When clinicians do use anesthetic, they may not be using the full dose recommended for adults. The prescribing information for lidocaine, which is used often in paracervical blocks, recommends limiting dosage for use in pregnancy to about one-third less than what is recommended for nonpregnant adults (20 milligrams compared with 30 milligrams, Meckstroth says). Because of unclear language in the labeling, many assumed that all paracervical blocks should use this lesser amount. This led to clinical studies using that smaller dosage, reinforcing that amount for other gynecological procedures. (Lidocaine, by the way, is used for IUD placements, hysteroscopy, miscarriage, abortion, and more.)

When patients do find good care that prioritizes their pain, it may look something like what happened to 47-year-old Kendra Perry when she needed an endometrial biopsy. When her gynecologist first tried to do the biopsy in the office, it did not go well. It was painful, and her doctor had trouble getting the access she needed for the procedure. So they stopped. Her doctor prescribed an oral medication that helps dilate the cervix, she recommended over the counter painkillers, and they made a different appointment to try again. That appointment didn’t go any better. So her doctor stopped again, telling Perry that she didn’t want to cause her any more pain and scheduled an appointment to do the procedure under general anesthesia.

The outpatient appointment went well, and Perry had no issues with insurance or setting the appointment up. “I felt very well cared for,” Perry says. “She respected what my body could and couldn’t tolerate, or could and couldn’t do, and she responded in a helpful way to still get the information she needed without causing me a lot of stress or pain.”

If only every patient could say the same.

Gynecology Has a Pain Problem