While pain is a universal experience, in clinical settings, it's common for women's pain to be downplayed or ignored.
"Pain can be dismissed in many ways. Women may have been told to ignore their severe menstrual cramps because 'periods are supposed to be painful,' or may have felt excruciating pain during an IUD insertion after being told they should feel 'nothing more than a pinch,'" says Maria Rodriguez, M.D., M.P.H., professor of obstetrics and gynecology in the Oregon Health & Science University School of Medicine and director of the OHSU Center for Reproductive Health Equity.
These situations occur regularly in women's health care settings, and the frustration and isolation many women feel when seeking care is an all too common experience.
A number of studies show the clear gender differences in how health care professionals view and treat pain. For example, men wait an average of 49 minutes in the emergency room with severe stomach pain before receiving pain medication, while women wait an average of 65. Even within the field of obstetrics and gynecology, research shows that physicians under-recognize the pain experienced by their patients during IUD placement or hysteroscopy procedures. As a result, patients are at risk for being undertreated during painful procedures and exams.
Experts at the OHSU Center for Women's Health, including Rodriguez and Lisa Bayer, M.D., M.P.H., are committed to reducing these disparities in gynecological procedures, from standardizing pain management options to surveying patients on their experiences.
"In the medical field, there is both an under-recognition of women's pain as well as a failure to address it," Rodriguez says. "There's a general sense that women's pain is normal and thus should be tolerated without medicine.
"Many patients I see never had the expectation that an exam wouldn't hurt them. That horrified and saddened me because it certainly doesn't need to be that way."
Individualized pain management
One of the most effective approaches to pain management is individualizing care to meet each patient's needs. This requires having a variety of options for pain management available, as well having clinicians on staff who are comfortable providing those options. At the Center for Women's Health, pain management can include:
- Comfort measures, such as a heating pad, dimmed lights or listening to music.
- Oral medicine, such as ibuprofen or Tylenol.
- Local anesthetic, such as anesthetic gel placed around opening of the vagina or an injection of numbing medication around the cervix.
- Minimal sedation, such as an opiate pain medication, an anti-anxiety medication, or nitrous oxide through a nose piece
- Moderate sedation, such as an anti-anxiety medication combined with an opiate pain medication through an IV.
- Sedation in the operating room, such as deep sedation or general anesthesia, which is managed by an anesthesiologist.
Building a trusting relationship between patients and clinicians — one where the patient feels safe and heard — can also help reduce pain and create a more positive experience.
"It's so important to take the time to listen to each patient and really hear about their concerns and past experiences," Rodriguez says. "For example, is there a history of sexual assault? Is there a history of pain with intercourse? What have exams been like for them in the past? Everyone is wired differently and will respond to pain in a different way, so discussing these things will help you understand what the best care options for each patient will be."
Survey for patient insights
To deepen understanding of patients' experiences with pain, as well as how the center's efforts are translating across OHSU's many campuses and provider types, Rodriguez, Bayer and colleagues from OHSU's patient experience team are collaborating to distribute a survey seeking direct patient feedback.
The survey will be sent to OHSU patients who have recently received a pelvic exam or procedure, which could include an IUD placement, vulvar biopsy or number of other standard gynecological procedures. Survey questions will gauge patients' overall comfort levels, including how effectively they felt their clinician addressed their needs and concerns.
"A big factor in this issue is that there aren't pain management options that are offered as standard of care across all health care settings," says Bayer, associate professor of obstetrics and gynecology in the OHSU School of Medicine. "When I counsel patients at OHSU, many often comment that they didn't even realize there were options available.
"It's rewarding tell them that they don't need to suffer through another painful exam or procedure."
The survey insights collected will be used to help OHSU clinicians implement guidelines and procedures that further minimize pain, and enhance efforts to create a safe, comfortable environment for patients. The survey will also consider key patient demographics, recognizing that gender discrepancies for pain are even more severe for women of color and trans women.
Above all, Bayer notes the importance of collaboration and open communication before, during and after a visit.
"Each patient will have unique needs, and it's our job as clinicians to identify those," she says. "Sometimes we have to pivot during a procedure or even abandon a procedure altogether because those needs aren't being met. We always want the patient to feel comfortable and in control of their body."
