In caring for patients undergoing a uterine aspiration procedure, there are a number of techniques a clinicians can practice to reduce patient pain and discomfort. For many, simple non-pharmacological steps can be taken before the procedure to reduce anxiety and subsequent experience of pain. These steps include:
- Giving patients an opportunity to ask questions
- Addressing any concerns a patient may express about the procedure
- Assuring the person that abortion is a very safe an common procedure, and
- Promoting a culture of dignity and respect in your office setting
During the procedure, there are a variety of pharmacologic agents that can be used to reduce pain. Understanding the aspects of pain management for uterine aspiration is key component of providing patient centered care. It’s important for learners to understand that patients should be counseled to explore which paint management regiment will make them comfortable during their procedure.
What is Pain?
Pain is a complex interaction of sensory signals, emotional state and the cognitive evaluation of the cause and significance of the stimuli.[Melzack & AMA]
Even brief periods of intense pain may have long-term consequences for women, including difficulty with future gynecological exams, pelvic pain or psychological issues Evidence shows that significant pain is not rare from a standard pelvic exam and is most correlated with a negative emotional reaction to the clinician.
Key Teaching Points
- Multimodal pain control includes:
- Non-pharmacologic strategies – strongly recommended for all women
- Systemic medications – NSAIDs and IV moderate sedation reduce pain. Individualized oral medications may improve experience and comfort.
- Local medication – strongly recommended for all women
Uterine aspiration for undesired pregnancy or miscarriage affects all three levels in many, ways, so a multimodal approach to comfort is especially useful. [Hilden 2003] Many studies of pain with uterine aspiration find mean pain scores of 5-7/10 with varying types of anesthesia. Clinicians consistently underestimate patient pain[Singh 2008] so careful attention to local anesthesia, individualization of care on all three levels, and/or moderate-dose IV sedation can reduce pain. General anesthesia increases risk and expense and is not recommended for routine procedures. Asking for pain scores after a procedure provides education for the clinician as well as information for clinical care.
Evidenced-based non-pharmacologic strategies that improve comfort for the patient include: establishing relationship and rapport with a patient; preparation leading to a higher level of understanding; participation in the choice of anesthesia; relaxing atmosphere including ambient music (though not via headphones); and counseling techniques such as positive suggestion and diversion of attention.
Physical non-pharmacologic interventions include lower abdominal heat; moving slowly without abrupt change; and avoiding initial pain from the speculum or anesthetic injections. These elements of care are most critical when women have no or a low level of systemic medication, though are important for pre- and post-procedure comfort for all women.
NSAID medications help with uterine pain, especially post procedure. Women often have preferences regarding feeling more awake or more relaxed/less aware for uterine aspiration. Groups that choose no systemic medications or IV sedation have similar pain and satisfaction. A study of women in a community abortion clinic found that IV moderate sedation with 100 mcg fentanyl + 2 mg midazolam provided significantly better pain control than oral medication with 10 mg oral oxycodone + 1mg sublingual lorazepam. Studies where all women are given the same dose have not demonstrated benefit of oral benzodiazepines or oral narcotics. If oral medications are used, they should be individualized to the preference and estimated tolerance of the woman.
Local medication significantly improves pain with tenaculum placement, dilation and aspiration when an adequate amount is used, and is critical for uterine aspirations when women are awake. Less than the equivalent of 20 mL of 1% lidocaine is generally inadequate. See the separate blog post entry on this topic for more information.
Karen Meckstroth, MD, MPH, is an Associate Clinical Professor of Obstetrics, Gynecology, and Reproductive Sciences at UCSF. She is also the Director of the UCSF Women’s Options Center at Mount Zion.