Common Office Gyn Procedures: Disclosures Tips, Tricks and Pain Control Dr. Meckstroth receives an honorarium from Danco, Inc. to serve as an expert for an FDA‐ mandated hotline for clinicians with questions regarding medical abortion. Karen R. Meckstroth, MD, MPH Director, UCSF Women’s Options Center Clinical Professor, UCSF Dept. of Obstetrics, Gynecology & Reproductive Sciences Zuckerberg San Francisco General Acknowledgements to Jody Steinauer, MD, MS Office Procedure or Not? Gyn Office Procedures: Overview • Pain and comfort • My skills • Procedures we could talk about: – • Safety Polyp removal ‐ cervical or endometrial – IUD removal • Pain/comfort – Pessary placement – IUD insertion: Now there are 5! – Endometrial biopsy – Manual uterine aspiration with cervical dilation Components of Pain The Peak‐End Rule • People judge an experience largely based on how Attention Cognitive‐evaluation component they felt at its peak (most intense point) and its end, Thought concerning the cause and Past Meaning of significance of the pain experience not on the sum or average situation • “Duration neglect” ‐ judgment of unpleasantness of painful experiences depends little on the duration Anxiety Motivation‐affective Fear component Depression Quality Sensory‐discriminative Location Intensity component AMA Pathophysiology of Pain 2005 Fredrickson and Kahneman 1993 and many after Cultural Differences and Pain Physician characteristics and acute pain • Cultural differences exist in the understanding and • Physician non-white race associated with report of pain significantly better pain treatment in ED (in Mobile, Alabama)1 • Unfair and unhelpful to make assumptions • Provider gender as opposed to patient gender • Multiple studies document inferior treatment of was a factor: acute (ED) and postoperative pain in U.S. minorities – Female physicians more likely to administer analgesics than male physicians (66% vs 57%, P = 0.009)2 Anderson et al. Racial and Ethnic Disparities in Pain: Causes and 1. Heins J. Pain 2010; 2. Safdar Pain Medicine 2009 Consequences of Unequal Care. J. Pain 2009 Factors Associated with Discomfort with Routine Pelvic Exams • Mean pain 3.2/10 • 17% had pain of 6‐10/10 with pelvic exam • 30% of those with a history of sexual abuse Creating rapport is pain control. • Factors associated with high pain: – Age < 26 (OR=2.75) – Presence of one or more mental health problems (OR=1.9) – History of sexual abuse (OR=1.85) – Dissatisfaction with present sexual life (OR=1.7) – Negative emotional contact with the examiner (OR=8.2) Adjusted odds ratios, Hilden et al., Acta Ob G Scand. 2003 Minimizing Pain with a Speculum: 201 Language considerations… • Gel lubrication significantly decreases pain1 • “Relax” • Use the right size (shortest possible for uterine “Let these muscles relax on to the table” procedures, open angle for large buttocks) “try taking a deep breath” • Avoid scraping sensitive anterior wall • Don’t open more than needed. • You might feel “a pinch” or ”a stick and a burn” You might feel “something/a twinge” • Avoid “popping” the cervix into view or snapping it at time of speculum removal • “You’re doing great” • Don’t push legs apart. “Let your knees relax to here” “I can see you’ve had practice with relaxation.” • Give women the time they need to relax their hips “It’s a natural reaction to lift up. I’ll just touch here until (“heavy hips”, “all your weight on your hips” ) you are able to let these muscles relax.” Gungorduk K et al. Eur J ObG and Repro Bio 2015 Strategies for Acute Pain NSAIDs Multimodal pain management • Inhibit synthesis of PGʼs by COX enzymes • More than 1 class of meds or analgesic technique in peripheral tissues and CNS • local +/‐ NSAID +/‐ narcotic +/‐ benzo +++ • COX-2 selective GI risk/side effects nonpharmacologic strategies • Little difference in efficacy in population Preemptive analgesia • *Large inter-individual difference* • Intervention more effective PRIOR to tissue injury • Ibuprofen: nonselective, most common, • Increased pain response to subsequent stimulation minimal effect on platelet aggregation (“wind‐up” or “hyperanalgesia”) • Modest reduction in intra- & post- uterine procedure pain Crews. JAMA 2002 AMA Pathophys of Pain 2005 Nonpharmacologic pain management Local Anesthesia 1 Other specialties expect • Patient control: participation in decisions it to work. • Counseling techniques (Positive suggestion, guided imagery) They aim to block all the • Diversion of attention “Vocal local” nerves they will irritate 3 and use as much as • Visual distraction (ceiling art ) needed within safety • Heat: continuous low abd heat as effective as range ibuprofen for dysmenorrhea2 •Music4a (but not pt choice by headphones4b) “I would never do a • Less available: Acupuncture,5 Hypnosis6 block and not test it to be sure it worked.” –Dentist to me, 2003 2. Atkin ObGyn 2001; 3. Carwile, JLGTD 2014; 4.Cepeda.Cochrane Review 2006 4b. Guerrero Contrac 2012; 5.Kotani Anesth 2001; 6. Famonville. Pain 1997; Cervical & uterine nerves Safe Dosing of Lidocaine Uterine fundus • 300 mg max dose for an adult (30 mL of 1%) Sympathetic nerves via: • (200 mg in pregnancy if term fetus considered) • infundibulopelvic pelvic ligament utero‐ovarian lig • 4.5 mg/kg without epinephrine = • inf hypogastric nerve through – 22 mL for a 50 kg (110 lb.) patient uterosacral ligaments T10 ‐ L1 – 30 mL for a 68 kg (150 lb.) patient – 40 mL for a 90 kg (200 lb.) patient (beyond max. dose) Lower uterus/cervix • 7 mg/kg with epinephrine (similar effect to • Parasympathetic Frankenhauser plexus lateral to cervix, S2 ‐ S4 vasopressin) Sensory nerves! Tingaker. Repro bio & endoc 2006 Variables in LA effect Cervical blocks can HURT • Dose, volume and concentration • Most painful part of procedure sometimes • Distance to nerves, size/type of nerves • Deep blocks hurt more • Tissue perfusion (vasodilation) • Minimize pain with block: • Temperature and pH of solution – Small gauge needle (25-27G) • Depth and rate of injection – Slow injection – Inject ahead of needle Bottom Line: TEST for anesthesia before beginning – Buffered lidocaine (2mL in 200 mg lidocaine) procedure and add more if safe – Topical anesthetic first 1 Wiebe Am J Ob Gyn, 1992, 2. Stubblefielf. Int J Gynecol Obstet 1989, 3. Wiebe Int J Gynecol Obstet 1995, 4. Wiebe Am J Ob Gyn, 1992, 5. Phair Am J Ob Gyn, 2002, 6. Wiebe Contraception. 2003 Tenaculum placement Cervical Injections Inject here Paracervical vs. Intracervical Superficial vs. Deep injection • If you place it, you’ll likely USE it • More stretch receptors than pinpoint • Most effective: Intracervical injection1 • Also helpful: Forced cough2 Spray or gel3 Hybrid • I use 3‐5 mL with 25G needle (spinal or 1.5 in) and think no one should EVER feel a tenaculum placed. • 1‐2 mm deep and inject slowly 1. Naki Ob Gyn Invest 2011 & Allen 2013; 2. Bogani Eur J Ob G 2014; 2. Gooldhwaite Contrac 2014; 3. Rabin 1989; Davies 1997; Costello 2005 Intrauterine anesthesia Intrauterine anesthesia • EMB & lost IUC removal: 5mL 2% lidocaine - • 5mL 2% lidocaine significant improvement1 • 16 or 18 gauge angiocath • Sonohysterography: improved pain 5.03.9/ • Advance through cervix, SLOW infusion into cavity 10.3 • Hold syringe at cervix for 2 minutes • HSC: Mixed evidence.4-6++ • MVA: 5mL of 4% lidocaine led to 2-point/10 • Can combine with para/intracervical block improvement2 Sys Rev Mercier ObGyn 2012 1. Gyney 2006; 2. Edelman 2006; 3. Guney J Min Inv gyn 2007; 4. Frishman ObGyn 2004, Costello Fert Steril 2002. Isley Contr 2012 Local Anesthesia: Intra‐myometrial injections Combining Evidence to do Better With a 22G spinal needle Like intrauterine: • Larger dose – 20 ml of 1% is not enough in many studies of aspiration and it is safe to use more. • Aim to reach fundus and Add MORE if patient feels any pain with dilation or significant pain with uterine involution. myometrium • Minimize pain with block – Buffer. Inject ahead of Unlike intrauterine: the needle. Small gauge. Topical gel or spray. • Get tissue distension • Aim for all nerves you will stimulate – attempt to (hurts) • Fluid doesn’t drain out reach fundal nerves. • No question about • Wait till it works – RCT’s without difference, obs absorption through decidua studies, pharmacokinetics, neurobiology say yes. Superficial on the outside and the inside • Don’t need diff equipment Cervical Polyp Removal Gyn Office Procedures: Overview If you aren’t doing this, you should! Procedures: • Can remove cervical polyps and small 1. Polyp removal ‐ cervical or endometrial (<2cm) visible endometrial polyps 2. IUD removal • Equipment: 3. Pessary placement 1. Ring forceps. 2. Silver nitrate sticks. 4. IUD insertion—LNG IUDs, Copper T 3. Optional: allis clamp 5. Endometrial biopsy Typically well tolerated without anesthesia. 6. Manual uterine aspiration with cervical dilation Occasionally, twisting is painful and procedure should be done with block or sedation. Polyp Removal IUD Removal • Clean with betadine • If you aren’t currently doing this, you should. • If polyp on a stalk, grasp as high as possible with ring forceps and begin to twist in one direction. When meet resistance in • No training necessary! that direction, twist other way. Do not pull. Continue twisting process until polyp has been removed. Cauterize base with • Most important: offer other form of reliable silver nitrate (helps kill remaining cells) contraception, if desired. • If polyp not on a stalk: Unlikely that ring forceps will grasp it. Try allis clamp to “chomp it off”. Cauterize base with silver nitrate • Equipment: • Send to pathology. • Ring forceps • Cytology brush Back IUD Removal Copper T Removal • If strings visible, ask pt. to cough and pull quickly on strings as she coughs (helps with the visceral feeling pt often has when you remove it) • If strings not visible: try to tease them out by twisting cytology brush within the endocervix. • Complications: String can break off or if IUD embedded you won’t be able to remove it or will remove part. • Occasionally it hurts to remove (usually not). Back 00:40 Endometrial Biopsy Endometrial Biopsy Supplies: 1.