Written by Julia Ellis-Kahana, MD and Mollie Nisen, MD

Effective management of pain during uterine aspiration is critical for patient autonomy, satisfaction and safety.¹ A patient’s experience of pain is influenced by a combination of distinct physical, emotional, and social factors. Therefore, a multimodal approach, guided by shared-decision making, and incorporating both nonpharmacologic and pharmacologic strategies is optimal.¹

Nonpharmacologic approaches for managing pain have the advantage of being low-cost and highly accessible across various clinical contexts. Using supportive verbal communication, referred to as “vocal-local” or, “verbicaine” heat, music, meditation, and deep breathing can decrease pain and associated anxiety.² 

Preprocedural oral non-steroidal anti-inflammatory drugs (NSAIDs) decrease pain both during and after uterine aspiration.³ They are recommended in the most recent ACOG clinical guidelines for in-office gynecologic procedures which includes uterine aspiration.⁴  In addition, both SFP³ and NAF⁵ provide up-to-date clinical guidelines for pain control during uterine aspiration for surgical abortion. Preprocedural oral opioids have not been shown to reduce pain, but do increase postoperative nausea.⁶ While oral benzodiazepines such as lorazepam and midazolam do not lower overall pain scores, they do reduce procedure-related anxiety.⁷ A double blind randomized study found that there was no difference in pain and satisfaction between oral sedation with hydrocodone/acetaminophen and lorazepam compared to inhaled nitrous oxide, during first-trimester surgical abortion.⁸ Nitrous oxide’s effects are limited to the duration of inhalation, allowing patients to transport themselves home independently, thereby reducing transportation-related barriers to care.⁸

Intravenous (IV) sedation with an opioid and benzodiazepine provides superior pain control when compared to oral sedation of the same medication classes during first-trimester surgical abortion,⁹ but requires more advanced clinic infrastructure and support. IV ketamine is noninferior to IV fentanyl for patient satisfaction with anesthesia for first-trimester surgical abortion.¹⁰ Ketamine is associated with a higher incidence of hallucinations but avoids the respiratory depression associated with opioids and benzodiazepines.¹¹

There is consistent data that 1% lidocaine is better than a saline injection, while 2% lidocaine is not superior. Local anesthesia, particularly the paracervical block (PCB) with 1% lidocaine, remains the most effective single intervention for procedural pain control. High-certainty evidence demonstrates that a 20 mL 1% lidocaine PCB significantly reduces pain with both dilation and aspiration, with few adverse events reported. The injection itself may cause brief discomfort or be painful, but the overall benefit is substantial. Of note, a 1.5 cm injection as opposed to a 3 cm injection is satisfactory.¹¹ However, there is mixed evidence regarding the superior efficacy of a two-site versus a four-site block.¹²

Clinicians should prioritize shared decision making by ensuring that patients understand their options and can select an approach for pain management that aligns with their preferences, medical needs and available resources. Continued adherence to evolving guidelines from professional societies in conjunction with clinic infrastructure and provider training will further uplift the quality and equity of pain management during uterine aspiration.