Latest news with #ACOG
Yahoo
6 days ago
- Health
- Yahoo
Too many women 'grin and bear it' when getting an IUD. I helped write new pain management guidelines to change that.
Millions of American women have had an IUD (a tiny T-shaped contraceptive device) inserted into their uterus. Many of them likely walked into their doctor's office with a bit of anxiety, not knowing what exactly the procedure would feel like: Would it be just a pinch or would it be incredibly painful? (There is no shortage of viral horror stories.) Also, would your doctor take your pain seriously? Up until recently, there wasn't a standard of care for IUD pain management. Women are often told to pop over-the-counter pain relievers before coming in for the procedure, even though they don't always control the pain. Any pain relief beyond that has been up to the woman's doctor or hospital, and depended on what options they had available. That's changing thanks to new guidelines on pain management for IUD placement issued by the American College of Obstetricians and Gynecologists last month, which follows the Centers for Disease Control and Prevention's updated guidelines in 2024. ACOG called out the 'urgent need' for doctors to acknowledge and treat patient pain and added that patients should 'have more autonomy over pain control options for their health care.' Genevieve Hofmann is a nurse practitioner who coauthored the new ACOG guidelines. In this interview with Yahoo Life's Rachel Grumman Bender, Hofmann explains why IUDs can be painful for some, why any fears shouldn't scare people off from getting this highly effective contraceptive and how these pain management guidelines are an important step in the right direction. IUDs are really one of the most effective birth control methods out there. We call them LARCs, or long-acting reversible contraceptives. Hormonal IUDs are over 99% effective at preventing pregnancy, and nonhormonal IUDs are equally effective. What's nice about hormonal IUDs is that we also use them to manage a lot of gynecologic conditions, such as heavy menstrual bleeding and painful periods. However, patients are coming to us and saying, 'I do not want to have this horrible experience with getting an IUD. How can we manage this?' I've been in practice for a little over 20 years and [when I started out], we would tell people to take some ibuprofen beforehand and try to do some distraction techniques while we're putting it in. There's a lot of grin and bear it in gynecology and in women's health. It's really challenging for us as providers to give people an accurate assessment of what they're going to experience with IUD placement. I've seen people who have had IUDs placed where it was like, That was not terrible, and then all the way to That was the worst pain that I've ever had in my entire life and I had a natural childbirth. There's a very large range of how people experience pain as well as anxiety. So I think as a provider, the guidelines really put the onus on us to help people anticipate the pain and have that conversation about what they can expect. Sometimes they won't know until they're in the throes of it, and so it's about being prepared with some pain options in anticipation that it could be a really painful and uncomfortable procedure for them. IUD insertion requires the placement of a speculum, which sort of holds open the vagina in a way that's not normal. So having a speculum in the vagina is not really comfortable. Then there's the procedure itself. A lot of times, we have to manipulate the position of the uterus, and we do that sometimes by putting a clamp on the cervix. It's this sort of sharp instrument that takes a little 'bite' out of the cervix to hold it in place. So that tenaculum placement can be very painful. IUDs are placed in the uterus, which is a muscular organ. To do that, you have to go through the cervix, which is the opening to the uterus. The cervix can be very tight, especially if someone has not had a vaginal birth. And so getting through that cervical opening can be really painful for some. The uterine body itself has some nerves, so something going into the uterus is just crampy and painful — it's a very deep, visceral pain that is hard to explain to people if they've never had any kind of instrumentation in the uterus before. We also have a really large nerve called the vagus nerve that goes through the cervix; so people can also have this kind of vasovagal-type response when we manipulate the cervix, which makes people feel really terrible too. It makes you feel like you're going to pass out and you get hot and you feel like you're going to throw up. And sometimes people feel like they have to poop and that is a really uncomfortable feeling as well. So there are many different aspects that cause pain. But not everyone's going to feel that way. As a provider, I don't want to scare people out of getting this really effective birth control method or way to manage heavy menstrual bleeding. So [it's about] finding that balance between giving people the information they need so they can feel, OK, I'm going into this with my eyes open, but also not terrifying and scaring people away that they say, Yeah, I'm never ever gonna do that. I always say it's like going to a restaurant. You're going to tell 25 people when you have a terrible restaurant experience. But if you have a great restaurant experience or a mediocre restaurant experience, you don't really tell anybody. So, I think there's a lot of people who do great with their IUD insertion and really manage it well, but they're not as vocal about it as somebody who's had a really awful experience. What the evidence for the guidelines really demonstrated was that using some sort of topical lidocaine, which is a numbing agent, on the cervix was beneficial compared to a placebo or compared to other distracting techniques or ibuprofen and other pain medications. Many of us have been offering better pain management options in the last several years compared to maybe what was happening 10 or 25 years ago. We know from the evidence that anxiety tends to worsen pain. I think providers will give anxiolytics [medications to treat anxiety], so telling patients to take a little bit of Xanax or some Ativan to help with the anxiety. And I do think people are using localized lidocaine, whether that's in a gel or a spray or putting in an injectable lidocaine through a paracervical (nerve) block. I think that is becoming much more typical. There's also IV sedation. The other big thing that comes out of these guidelines is that we as providers owe it to our patients to have a discussion about some options that are available to them. So, it's really having the conversation, guiding patients to make the best decisions for themselves and then hopefully being able to find some interventions that you can do in your clinic safely and effectively to give people some options. I hope that these guidelines get the conversation started in a way that we're meeting people where their needs are ... that they feel heard and can access things like IUDs that are really highly effective ... and that we believe patients when they say, 'This was really painful.' Or, 'I had a really terrible experience last time I did this.' [We should] trust them to know their bodies and say, 'OK, here are the things we're going to do to hopefully try to improve that experience this time.' So I hope that's what comes out of it. Patients need to feel like they're in a space where they can advocate for themselves and be heard. This interview has been edited for length and clarity.
Yahoo
6 days ago
- Health
- Yahoo
Too many women 'grin and bear it' when getting an IUD. I helped write new pain management guidelines to change that.
Millions of American women have had an IUD (a tiny T-shaped contraceptive device) inserted into their uterus. Many of them likely walked into their doctor's office with a bit of anxiety, not knowing what exactly the procedure would feel like: Would it be just a pinch or would it be incredibly painful? (There is no shortage of viral horror stories.) Also, would your doctor take your pain seriously? Up until recently, there wasn't a standard of care for IUD pain management. Women are often told to pop over-the-counter pain relievers before coming in for the procedure, even though they don't always control the pain. Any pain relief beyond that has been up to the woman's doctor or hospital, and depended on what options they had available. That's changing thanks to new guidelines on pain management for IUD placement issued by the American College of Obstetricians and Gynecologists last month, which follows the Centers for Disease Control and Prevention's updated guidelines in 2024. ACOG called out the 'urgent need' for doctors to acknowledge and treat patient pain and added that patients should 'have more autonomy over pain control options for their health care.' Genevieve Hofmann is a nurse practitioner who coauthored the new ACOG guidelines. In this interview with Yahoo Life's Rachel Grumman Bender, Hofmann explains why IUDs can be painful for some, why any fears shouldn't scare people off from getting this highly effective contraceptive and how these pain management guidelines are an important step in the right direction. IUDs are really one of the most effective birth control methods out there. We call them LARCs, or long-acting reversible contraceptives. Hormonal IUDs are over 99% effective at preventing pregnancy, and nonhormonal IUDs are equally effective. What's nice about hormonal IUDs is that we also use them to manage a lot of gynecologic conditions, such as heavy menstrual bleeding and painful periods. However, patients are coming to us and saying, 'I do not want to have this horrible experience with getting an IUD. How can we manage this?' I've been in practice for a little over 20 years and [when I started out], we would tell people to take some ibuprofen beforehand and try to do some distraction techniques while we're putting it in. There's a lot of grin and bear it in gynecology and in women's health. It's really challenging for us as providers to give people an accurate assessment of what they're going to experience with IUD placement. I've seen people who have had IUDs placed where it was like, That was not terrible, and then all the way to That was the worst pain that I've ever had in my entire life and I had a natural childbirth. There's a very large range of how people experience pain as well as anxiety. So I think as a provider, the guidelines really put the onus on us to help people anticipate the pain and have that conversation about what they can expect. Sometimes they won't know until they're in the throes of it, and so it's about being prepared with some pain options in anticipation that it could be a really painful and uncomfortable procedure for them. IUD insertion requires the placement of a speculum, which sort of holds open the vagina in a way that's not normal. So having a speculum in the vagina is not really comfortable. Then there's the procedure itself. A lot of times, we have to manipulate the position of the uterus, and we do that sometimes by putting a clamp on the cervix. It's this sort of sharp instrument that takes a little 'bite' out of the cervix to hold it in place. So that tenaculum placement can be very painful. IUDs are placed in the uterus, which is a muscular organ. To do that, you have to go through the cervix, which is the opening to the uterus. The cervix can be very tight, especially if someone has not had a vaginal birth. And so getting through that cervical opening can be really painful for some. The uterine body itself has some nerves, so something going into the uterus is just crampy and painful — it's a very deep, visceral pain that is hard to explain to people if they've never had any kind of instrumentation in the uterus before. We also have a really large nerve called the vagus nerve that goes through the cervix; so people can also have this kind of vasovagal-type response when we manipulate the cervix, which makes people feel really terrible too. It makes you feel like you're going to pass out and you get hot and you feel like you're going to throw up. And sometimes people feel like they have to poop and that is a really uncomfortable feeling as well. So there are many different aspects that cause pain. But not everyone's going to feel that way. As a provider, I don't want to scare people out of getting this really effective birth control method or way to manage heavy menstrual bleeding. So [it's about] finding that balance between giving people the information they need so they can feel, OK, I'm going into this with my eyes open, but also not terrifying and scaring people away that they say, Yeah, I'm never ever gonna do that. I always say it's like going to a restaurant. You're going to tell 25 people when you have a terrible restaurant experience. But if you have a great restaurant experience or a mediocre restaurant experience, you don't really tell anybody. So, I think there's a lot of people who do great with their IUD insertion and really manage it well, but they're not as vocal about it as somebody who's had a really awful experience. What the evidence for the guidelines really demonstrated was that using some sort of topical lidocaine, which is a numbing agent, on the cervix was beneficial compared to a placebo or compared to other distracting techniques or ibuprofen and other pain medications. Many of us have been offering better pain management options in the last several years compared to maybe what was happening 10 or 25 years ago. We know from the evidence that anxiety tends to worsen pain. I think providers will give anxiolytics [medications to treat anxiety], so telling patients to take a little bit of Xanax or some Ativan to help with the anxiety. And I do think people are using localized lidocaine, whether that's in a gel or a spray or putting in an injectable lidocaine through a paracervical (nerve) block. I think that is becoming much more typical. There's also IV sedation. The other big thing that comes out of these guidelines is that we as providers owe it to our patients to have a discussion about some options that are available to them. So, it's really having the conversation, guiding patients to make the best decisions for themselves and then hopefully being able to find some interventions that you can do in your clinic safely and effectively to give people some options. I hope that these guidelines get the conversation started in a way that we're meeting people where their needs are ... that they feel heard and can access things like IUDs that are really highly effective ... and that we believe patients when they say, 'This was really painful.' Or, 'I had a really terrible experience last time I did this.' [We should] trust them to know their bodies and say, 'OK, here are the things we're going to do to hopefully try to improve that experience this time.' So I hope that's what comes out of it. Patients need to feel like they're in a space where they can advocate for themselves and be heard. This interview has been edited for length and clarity.
Medscape
12-06-2025
- Health
- Medscape
VBAC Success Overestimated With Induction of Labor
MINNEAPOLIS — The vaginal birth after cesarean (VBAC) calculator may overestimate the likely success rate of a VBAC following induction of labor (IOL), according to research presented at American College of Obstetricians and Gynecologists (ACOG) 2025 Annual Meeting. The VBAC calculator does not distinguish between IOL and spontaneous labor, noted Daniel Lorido, MD, MPH, of Montefiore Medical Center in the Bronx, New York, and his colleagues. 'TOLAC [trial of labor after cesarean] patients who are undergoing IOL are significantly less likely to have a successful VBAC as compared to TOLAC patients undergoing spontaneous labor,' Lorido and his colleagues concluded. 'When offering indicated or elective inductions of labor, careful, individualized counseling on the likelihood of VBAC success is essential because a failed trial of labor after cesarean may cause increased perinatal morbidity when compared to successful VBAC or scheduled repeat cesarean delivery.' Noting that TOLAC IOL has higher rates of failure than spontaneous TOLAC, the authors sought to determine the success rate for TOLAC IOL and how it compares to spontaneous IOL and to the VBAC calculator's estimation of success for IOL. The researchers retrospectively analyzed all cases of patients who had a history of one prior cesarean and were undergoing an IOL between January 2020 and December 2023. All 270 patients had full-term, live-born, head-first, singleton births. Just over half the patients (51.1%) had a successful VBAC, but the VBAC calculator had predicted that 63.6% of patients would be successful ( P < .0001). The national rate of successful VBAC is 74.3%, the authors noted, but that includes both IOL and spontaneous labor. Factors associated with a successful VBAC include a history of prior vaginal delivery ( P = .0008), history of a prior VBAC ( P < .0001), and no history of arrest disorder ( P = .0007). Specifically, 72% of patients with a prior vaginal delivery had a successful VBAC after IOL compared to 46% of patients without a previous vaginal delivery. Similarly, 82% of patients with a previous VBAC had a successful VBAC after IOL compared to 43% of patients without a previous VBAC. Among the patients who had a successful VBAC, only 22% had a history of arrest disorder. The researchers did not find any associations between successful VBAC and age, BMI, chronic hypertension, or diabetes — even though age, weight, and treated chronic hypertension are all variables in the VBAC calculator score. Notably, the VBAC calculator was documented as a part of TOLAC counseling in only 11.39% of cases. 'In spite of these findings, we encourage offering TOLAC to all eligible patients while cautioning that accurate success rates be determined and communicated properly,' the authors wrote. 'TOLAC patients should be counseled about lower success rates of VBAC post-IOL to assist in their decision-making process.' It's important to keep in mind when considering these findings that they are all from a single center, Audrey Merriam, MD, MS, an associate professor of obstetrics, gynecology, and reproductive science at Yale School of Medicine, New Haven, Connecticut, told Medscape Medical News . 'There may be practice patterns or preferences at this one center that could impact these results,' Merriam said. She also noted that the study was moderately sized, which also adds caution to interpretation of the findings. That said, the study's key takeaway is that 'the VBAC calculator may not be as accurate when predicting TOLAC success for women who have had any prior cesarean delivery, not just a cesarean delivery for an arrest disorder,' Merriam said. 'The calculator is still just an estimate, so the decision to attempt a VBAC is still between the pregnant person and their physician/provider.' While the calculator provides one piece of information for patients and providers to consider when deciding whether to attempt a TOLAC, 'ultimately, the decision is a shared decision involving risks and benefits between the patient and provider,' Merriam said. The authors did not report receiving any external funding or having any disclosures. Merriam reported having consulted for Lily Link.
Medscape
12-06-2025
- Health
- Medscape
Untreated GSM Can Result in Serious Complications
MINNEAPOLIS — Untreated genitourinary symptoms of menopause (GSM) can result in serious complications aside from vaginal symptoms, including urinary tract infections (UTIs) that increase the risk for sepsis and, in rare cases, vulvovaginal obliteration, according to a poster presented at American College of Obstetricians and Gynecologists (ACOG) 2025 Annual Meeting. 'By identifying the risks associated with untreated GSM, this research underscores the need for early diagnosis and sustained, lifelong management to prevent serious and potentially life-threatening complications,' wrote Ruben Fernandez Ibanez, a final-year medical student at the University of Alcala in Alcalá de Henares, Spain, and his colleagues. The poster presented a narrative picture of data synthesized from three studies related to the complications of untreated GSM in more than 800 women over a period of more than 15 years. The poster addresses three categories of complications that may be related to untreated GSM: False abnormal Pap smears, recurrent UTIs and severe infections, and vulvovaginal obliteration. With what the poster currently reports, 'it is difficult to make any definitive statement' without more information about the extent to which untreated GSM contributed to each of the conditions they review, Monica Christmas, MD, an associate professor of obstetrics and gynecology and director of the Menopause Program at the University of Chicago Medicine, Chicago, told Medscape Medical News . That said, the poster does raise awareness about the potential undertreatment of GSM in older women. 'Recurrent UTIs in the nursing home population can contribute to higher morbidity and mortality. A number of risk-reducing interventions should be in place, one of which can be local low-dose vaginal estrogen therapy,' Christmas said. The poster noted that the absence of hormone therapy was associated with a higher incidence of recurrent UTIs. 'These infections did progress to systemic complications in some cases, with severe sepsis and usually secondary pneumonia,' the authors wrote about the observational finding. 'In contrast, the very few patients receiving hormone therapy rarely experienced such outcomes, suggesting that estrogen therapy plays a protective role not only in epithelial restoration but also in reducing infection risk and preventing renal sequelae, sepsis, and mortality.' Providers often do not necessarily think about treating GSM in people who are not sexually active, but treating 'atrophy isn't just for sexual activity,' she said. 'Even for people who aren't sexually active, they don't want dry, itchy vaginas either.' The poster also reported that more than 500 patients older than 40 years initially had an abnormal Pap, and after receiving local vaginal estrogen therapy, more than 90% of them saw full cytological resolution within 4-6 months. 'These findings confirm that estrogen deficiency-induced cellular atrophy mimics dysplasia, often resulting in false diagnoses,' the authors reported. 'Importantly, more than 80% of these cases were retrospectively linked to early, otherwise under-recognized GSM.' Christmas noted an important caveat to that conclusion, however, because the poster provides very little information about those Pap smears, including what was abnormal about them. 'In older people with vaginal atrophy, you often can't get enough cervical cells, and it will come back insufficient,' Christmas said. A 2-week treatment of vaginal estrogen therapy would bring back enough cervical cells to be assessed. Further, 'to truly be able to say the local estrogen therapy definitively improved outcome, you'd need a control group,' Christmas said. 'In most cases of ASCUS [atypical squamous cells of undetermined significance] Pap results, they revert to normal without intervention.' The authors highlighted that appropriate recognition and treatment of GSM could potentially reduce unnecessary patient anxiety and additional interventions. Last, the authors noted 12 cases of vulvovaginal obliteration with partial or complete labial fusion in patients aged 62-92 years. 'Total obliteration led to complications, including urinary retention, urocolpos, bilateral megaloureters, bilateral hydronephrosis, and renal insufficiency,' the authors reported. 'Immediate interlabial fusion release procedures provided relief, but long-term success was only achieved when hormone therapy was combined with gradual and continuous dilator use.' Christmas noted, however, that the poster did not address some potential confounders that could be present in a nursing home population such as incontinence and immobility. 'Based on the data shared here, it is not clear that vaginal estrogen therapy improved urologic complications in their population,' she said. It's possible, for example, that the patients had lichen sclerosis, which is prevalent in older populations and treated with high-potency steroids. In those with poor hygiene, lichen planus could be present, or patients could have one of these conditions along with untreated GSM. Although the relationship of all the cases listed in this poster to GSM could not be clarified with the data provided, the results still point to the fact that GSM can lead to serious effects if it goes undiagnosed and untreated. 'The genitourinary symptoms associated with menopause are common and can have a significant impact on quality of life and function and rarely improve without intervention,' Christmas said. 'Symptoms often go unrecognized and untreated, which is a travesty as local, low-dose vaginal estrogen therapy is widely recognized as a safe and highly effective treatment option with minimal side effects or risks.' No external funding or author disclosures were noted for the study. Christmas had no disclosures.
Yahoo
11-06-2025
- Health
- Yahoo
New guidelines tackle long-standing pain issues with IUD insertion
Pain is a predictable part of the process for many women walking into a reproductive healthcare clinic. That problem now is receiving renewed focus in the wake of a report released May 15 by the American College of Obstetrics and Gynecology. The report compiles recommended pain management techniques for eight of the more common pain-inducing procedures routinely performed in a clinic. These include intrauterine device (IUD) insertion, endometrial and cervical biopsies and hysteroscopies. The advised techniques include local anesthetic options and providing anti-inflammatory drugs. The report details dosages and side effects for each advised treatment. The American College of Obstetrics and Gynecology, or ACOG, is urging clinicians to communicate these options to their patients in a manner that is 'individualized, culturally competent, trauma-informed, and guided by shared decision-making.' Dr. Marie Forgie, an obstetrician and gynecologist performs all of the procedures mentioned in the report through her practice at Aurora Sinai Medical Center in Milwaukee. She said understanding, predicting and managing patient pain during gynecologic procedures has been a recent 'hot topic' for the field. 'There's been limited or conflicting evidence about different pain control options, and that information has been scattered across different publications,' Forgie said. 'Having this guidance will make clear all the options that we know could potentially work.' The report emphasizes how systemic racism and gender bias in medicine has historically affected the kind and quantity of pain control options offered to patients, with Black patients receiving less attention to their pain than White patients, and women's pain garnering less concern than that of men. In August 2024, the Center for Disease Control updated its own advice on pain management for IUD insertion, recommending topical numbing creams and paracervical block injections — both lidocaine-based local anesthetics, as potentially 'useful' for reducing patient pain. The CDC's updated guidelines also urged doctors to counsel their patients on pain management before they undergo the procedure to insert the contraceptive device. Dr. Allison Linton, Planned Parenthood of Wisconsin's chief medical officer, noted that pain is difficult to study because it is subjective, and can vary patient to patient. 'Our field of reproductive health has realized for a long time that even though IUDs are a very effective form of birth control, they can be really uncomfortable to place,' Linton said. 'For quite a long time, we've all been trying to figure out how we best support patients while making sure that we are keeping them as comfortable as possible and certainly not creating more trauma in an area that historically has had a lot of trauma for a lot of patients.' Linton's routine pain management protocol has focused on giving patients 'realistic expectations' of how IUD insertions and other procedures might feel, and helping patients cope with anxiety about upcoming procedures, sometimes by offering them a pre-procedure visit to talk through pain management options. In the past one to two years, Linton said, Planned Parenthood of Wisconsin clinicians have also started offering paracervical blocks to IUD insertion patients — one of the local anesthetics recommended by the recent CDC and ACOG recommendations. Dr. Laura Jacques, an associate professor in the University of Wisconsin's obstetrics and gynecology department, recalled she has offered local anesthesia for in-office procedures since 2017 at least. 'ACOG is the standard-setting body for our field, so their new guidance will undoubtedly have broad influence on OB-GYN practice,' Jacques wrote. 'While it doesn't change my individual practice, or our practice at UW, it helps promote patient-centered care across the field.' This article originally appeared on Milwaukee Journal Sentinel: Wisconsin OB-GYNs cheer new IUD insertion pain management guidance
