Normalizing Women’s Pain: A Critical Analysis of Analgesia Inequities in Gynecologic Procedures

A transperineal prostate biopsy involves passing an 18-gauge needle several times through the perineum directly into the prostate. Yet, in a prospective study, over 90% of men rated the procedure as tolerable under local anesthesia, with mean pain scores in the “mild” range during sampling.¹ Another study reported average biopsy-related pain as only 2.5 out of 10.²

In contrast, painful gynecologic procedures such as IUD insertions, endometrial biopsies, and cervical biopsies are frequently performed without adequate analgesia. A 2023 study of over 1000 IUD insertions found that 49.7% of patients reported “intense” pain and an additional 31.3% reported “moderate” pain.³ These stark differences reflect a much larger pattern of women’s pain being underestimated and undertreated. There is a persistent pain gap in gynecologic office procedures because women’s pain has been historically normalized, frequently dismissed, consistently underestimated by clinicians, and shaped by cultural beliefs that portray pelvic and reproductive pain as something women are expected to endure.

To understand why these procedures remain so poorly treated, we must first examine how the normalization of women’s pain has shaped clinical expectations for generations. Physiological experiences such as menstruation, dysmenorrhea, and childbirth—each associated with significant discomfort—are long considered routine obligations of womanhood.⁴ This framing reinforces the belief that pelvic and reproductive pain is something women are inherently equipped to endure.

These attitudes influence medical practice, leading clinicians to anticipate pain in gynecologic care but not necessarily treat it. The result is a clinical environment where even severe procedural pain is normalized rather than managed, despite the availability of effective analgesia.

Closely linked to the normalization of women’s pain is the frequent dismissal of their reports of pain. Research shows that women’s symptoms are more likely to be interpreted as exaggerated or emotionally driven compared with men’s. Clinicians may attribute their pain to stress, anxiety, or emotional sensitivity rather than a physical cause.⁵ This bias has many clinical consequences. In emergency departments women may wait longer for analgesia, receive lower doses of pain medication, and are less likely to be given opioids for the same reported pain intensity as men.⁶

In gynecologic care, dismissal can take the form of reassurance. Patients who describe significant discomfort during procedures are frequently told that their pain is normal or that it will be over quickly, rather than being offered meaningful pain management.⁷ These responses can leave patients feeling unheard and result in missed opportunities to provide effective analgesic strategies.

Another contributor to the pain gap is the underestimation of how painful gynecologic procedures actually are. Research shows that clinicians predict significantly lower pain levels than what patients ultimately report, particularly for procedures involving the cervix and uterus.⁸ These inaccurate expectations are shaped by limited training on procedural analgesia and the absence of standardized guidance on pain control in many gynecologic settings.⁹

When clinicians underestimate the severity of pain a procedure is likely to cause, they may not offer local anesthesia, pre-procedure medication, or supportive measures, assuming instead that discomfort will be brief or mild. This underestimation results in a mismatch between patient experience and clinician preparation, leaving many patients to endure significant procedural pain without preparation.¹⁰

Intrauterine device (IUD) placement exemplifies how gender biases can lead to disproportionate pain management. This procedure is often conducted without adequate analgesia, despite many reports from patients that they experienced significant pain during this procedure.¹¹ Only 30% of physicians offer anesthesia, despite approximately 70% of women reporting moderate to severe pain.¹¹ This statistic highlights that, to some patients, one of the most effective and safest forms of contraceptives may feel nonoptional due to expected discomfort and pain.

Per Sheffield et al. (2025), “[IUDs] are a safe and highly effective contraceptive method, but pain poses a significant barrier to IUD uptake and satisfaction. Data on existing modalities for insertional pain management are limited, and there remains no consensus on standard of care”.¹³

Studies show that women’s pain is consistently underestimated compared with men’s, even when reporting the same intensity—contributing to insufficient analgesia in clinical procedures.¹¹ Historical and modern evidence illustrates that gendered assumptions continue to shape clinical and procedural practice which contribute to the well-documented under-research and under-treatment of women’s health. This pattern is not limited to IUD placement.

Other routine gynecological procedures, unfortunately, share the same mismanagement of pain. Cystoscopy is often performed without analgesia, despite evidence that many women report burning or sharp pain during the procedure.¹² Together, these examples shed light on how gendered assumptions have impacted decision-making across women’s healthcare.

These patterns seen in pain management in women’s health have a meaningful impact and consequences for patients. When procedures, like those aforementioned, are more painful than anticipated. Many women can develop fear surrounding future gynecologic care or develop mistrust in clinicians. As Bayer and McWilliams (2025) explain, “Failure to recognize and adequately address pain during gynecologic exams and procedures results in unnecessary physical and psychological harm to patients; engenders patients’ distrust of the medical community, directly compromising their autonomy; and can lead to patients’ avoidance of crucial medical care”.¹⁴

Women can also develop procedural anxiety, which can worsen the body’s pain response. In a study of 222 women undergoing colposcopy, the researchers found a significant correlation between pre-procedure anxiety and increased pain/discomfort during the procedure.¹⁵ It is clear that when women have experienced inadequate pain management during gynecological procedures, this can heighten pre-procedural anxiety, and that anxiety can intensify pain perception, creating a self-reinforcing cycle that makes future procedures even more distressing.

The persistent under-treatment of pain in gynecologic office procedures is particularly concerning given that effective, evidence-based analgesic options already exist and are now explicitly emphasized in national guidance. In 2025, the American College of Obstetricians and Gynecologists (ACOG) issued a Clinical Consensus on pain management for in-office uterine and cervical procedures, underscoring that pain is predictable, clinically meaningful, and should not be minimized or treated as an unavoidable byproduct of “quick” procedures. ACOG’s guidance emphasizes proactive counseling and offering pain management options, while accounting for factors such as prior experiences, anxiety, and trauma history.^1,2

From an evidence-based perspective, best practice typically involves a multimodal, patient-centered approach, combining procedural technique, local anesthetic strategies, and supportive/adjunctive medications rather than relying solely on “take ibuprofen beforehand.” ACOG highlights multiple options that can be offered depending on the procedure and patient context, including local anesthetics (eg, paracervical block), topical anesthetics (sprays, gels, creams), oral analgesics, and anxiety-focused supports, with an emphasis on patient choice and shared decision-making.^1,2

Local anesthetic approaches are among the most evidence-supported options for pain reduction in IUD placement and other cervical/uterine instrumentation. For example, a randomized controlled trial in adolescents and young women demonstrated that a 10-mL 1% lidocaine paracervical nerve block reduced pain during IUD insertion compared with sham procedures.³ Broader reviews of IUD insertion pain management also conclude that lidocaine-based interventions (topical and injectable) are more consistently effective than pre-procedure NSAIDs alone, which have commonly been recommended despite mixed effectiveness for insertion pain.^4,5

Topical anesthetic strategies (eg, lidocaine sprays, gels, or anesthetic creams) are increasingly prominent in guideline discussions and reviews because they can be easier to implement in office workflow and may improve patient tolerance for specific steps (eg, tenaculum placement or cervical manipulation) in select settings. The CDC’s 2024 US Selected Practice Recommendations for Contraceptive Use includes a dedicated section on interventions for reducing IUD placement pain, reflecting a more explicit shift toward patient-centered counseling and consideration of lidocaine-based options.^6,7 Importantly, both ACOG and CDC emphasize that the goal is not a one-size-fits-all protocol, but routine offering of options paired with accurate counseling.^1,6

For procedures beyond IUD placement such as endometrial sampling evidence also supports local anesthetic strategies in at least some contexts. Clinical trials have examined paracervical blocks and intrauterine lidocaine approaches for endometrial biopsy-related pain, with varying outcomes across studies and patient populations.^8,9 This variability reinforces the need for individualized plans rather than blanket assumptions that “it’s brief, so it’s fine.” ACOG’s consensus approach similarly emphasizes tailoring pain management to the procedure, the patient’s baseline risk factors for higher pain, and patient preferences.¹

Pharmacists play a critical and often underrecognized role in closing the gap between guideline recommendations and lived patient experience. Pharmacists frequently participate in pre-procedure counseling, help patients interpret what to expect, and identify when a planned regimen may be inadequate (eg, NSAID-only approaches in patients with severe prior procedural pain, high anxiety, or trauma history). Pharmacists also improve safety and appropriateness by screening for contraindications (eg, NSAID risk, sedation interactions), advising on correct dosing/timing, and supporting adherence to evidence-based options. This is particularly relevant as CDC and ACOG guidance increasingly centers patient-centered counseling and noncoercive contraceptive care areas where pharmacist communication and education can meaningfully improve patient autonomy and trust.^1,6

Equally important is shared decision-making: patients should be informed before the procedure about the likely intensity/duration of pain and offered options rather than reassurance alone. Ethics-focused literature argues that failure to recognize and address procedural pain can cause avoidable harm and compromise autonomy, and that individualized, trauma-informed standards are a more appropriate benchmark than historically minimal approaches.¹⁰

The pain gap in gynecologic office procedures is not primarily explained by procedural risk, an absence of feasible interventions, or the inevitability of discomfort. Instead, it reflects deeply embedded cultural and clinical beliefs that normalize women’s pain, dismiss patient reports, and underestimate the intensity of procedures involving the cervix and uterus patterns—which persist even as professional guidance and evidence evolve.^1,10

This gap is particularly troubling because evidence-based options exist and are increasingly supported by authoritative recommendations. ACOG’s 2025 Clinical Consensus calls attention to the real magnitude of pain experienced during in-office uterine and cervical procedures and emphasizes routine counseling and offering pain management options.^1,2 CDC’s 2024 US Selected Practice Recommendations also reflect movement toward patient-centered counseling and the inclusion of lidocaine-based interventions as potential strategies to reduce IUD placement pain.^6,7 Together, these recommendations signal that unmanaged procedural pain should no longer be treated as an acceptable default.

When pain is inadequately managed, consequences extend well beyond transient discomfort. Patients may experience trauma, heightened anxiety, and loss of trust, which may delay or avoid future gynecologic care outcomes that directly undermine preventive health goals and reproductive autonomy. Ethics scholarship emphasizes that pain intensity and duration should inform standards of care and that addressing pain is part of trauma-informed, patient-centered practice rather than optional “comfort.”¹⁰

Pharmacists are uniquely positioned to help close this gap through reinforcing guideline-informed counseling, ensuring evidence-based medication strategies are accessible and safely used, and supporting interprofessional communication that centers the patient’s experience. As medication experts—and often among the most accessible healthcare professionals—pharmacists can validate patient concerns, correct misinformation (including outdated assumptions about NSAID-only approaches), and help translate evolving guidance into real-world practice.^1,6

Ultimately, the pain gap in women’s health is a correctable failure of practice, not an inevitable feature of biology. Closing it requires routine offering of evidence-based options, transparent counseling, and shared decision-making—supported by interdisciplinary accountability and consistent implementation of modern guidance.^1,10

REFERENCES

1. Solarino G, Patel L, Ziegelmann M, et al. Transperineal prostate biopsy under local anesthesia: tolerability and functional outcomes in a prospective single-operator study. World J Urol. 2024;42(5):1341-1349. doi:10.1007/s00345-023-04725-z

2. Stefanova V, Buckley R, Flax S, et al. Transperineal prostate biopsies using local anesthesia: experience with 1,287 patients. J Urol. 2019;201(6):1121-1126. doi:10.1097/JU.0000000000000156

3. Lopes-García EA, Bahamondes L, Hidalgo MM, et al. Assessment of pain and ease of intrauterine device placement according to type of device, parity, and mode of delivery. Eur J Contracept Reprod Health Care. 2023;28(3):163-167. doi:10.1080/13625187.2023.2184137

4. American College of Obstetricians and Gynecologists. Pain management for in-office uterine and cervical procedures. ACOG Clinical Consensus. 2025; May. Available at: https://www.acog.org/clinical/clinical-guidance/clinical-consensus/articles/2025/05/pain-m anagement-for-in-office-uterine-and-cervical-procedures

5. Benoit MH, Ma J, Deslauriers J, et al. The normalization of women's pain in healthcare settings. Pain Manag Nurs. 2020;21(1):26-34. doi:10.1016/j.pmn.2019.01.011

6. Samulowitz A, Gremyr I, Eriksson E, Hensing G. “Brave men” and “emotional women”: a theory-guided literature review on gender bias in health care. J Womens Health (Larchmt). 2018;27(3):401-411. doi:10.1089/jwh.2017.6396

7. Chen EH, Shofer FS, Dean AJ, et al. Gender disparity in analgesic treatment of emergency department patients with abdominal pain. Acad Emerg Med. 2008;15(5):414-418. doi:10.1111/j.1553-2712.2008.00102.x

8. Bayer L, McWilliams EA. How should intensity and duration of pain inform standard of care for pain management in non-labor and delivery OB/GYN procedures? AMA J Ethics. 2025;27(2):E98–E103. doi:10.1001/amajethics.2025.98

9. Zhang L, Chang Y, Lee S, et al. Gender biases in estimation of others’ pain. J Pain. 2021;22(9):1040-1050. doi:10.1016/j.jpain.2021.03.008

10. Hirsh AT, Hollingshead NA, Baird T, et al. Clinicians’ pain judgments: patients’ sex, race, and age. Pain. 2014;155(3):451-458. doi:10.1016/j.pain.2013.11.005

11. Grinberg, K., & Sela, Y. (2025). A literature review on pain management in women during medical procedures: Gaps, challenges, and recommendations. Medicina, 61(8), 1352. https://doi.org/10.3390/medicina61081352

12. Dougher, E., Zoorob, D., Thomas, D., Hagan, J., & Peacock, L. (2019). The effect of lidocaine gel on pain perception during diagnostic flexible cystoscopy in women: A randomized control trial. Urogynecology, 25(3), 178–184.

https://doi.org/10.1097/SPV.0000000000000680

13. Sheffield, S. M., Gilbert, A. F. R., Chang, K. R., Dotters-Katz, S. K., Gleeson, E. I., Hagey, J. M., & Kerner, N. P. (2025). Pain management for IUD insertion: A review of the clinical evidence on pharmacologic and nonpharmacologic options. Obstetrical & Gynecological Survey, 80(8), 516–529.https://doi.org/10.1097/OGX.0000000000001417

14. Bayer LL, McWilliams B. How should intensity and duration of pain inform standard of care for pain management in non–labor and delivery OB/GYN procedures? AMA J Ethics. 2025;27(2):E—E. doi:10.1001/amajethics.2025.xxxx.

15. Baser, E., Togrul, C., Özgu, E., Esercan, A., Caglar, M., & Gungor, T. (2013). Effect of pre-procedural state-trait anxiety on pain perception and discomfort in women undergoing colposcopy for cervical cytological abnormalities. Asian Pacific Journal of Cancer Prevention, 14(7), 4053–4056. https://doi.org/10.7314/APJCP.2013.14.7.4053PubMed