Can Pain Be Better Controlled During Office Procedures?

The addition of gabapentin to the routine oral sedation medications during office-based uterine aspiration does not reduce perioperative pain for patients, according to a Duke study, but the findings could pave the way for broader insights into pain management for office procedures and help reduce the use of opioids.

Published in Obstetrics & Gynecology in September 2019, the study found that a 600mg dose of gabapentin, in combination with oral sedation and paracervical block, did not have a significant effect on a five-minute postoperative pain measurement taken during first trimester uterine aspiration; however, it did decrease patients’ opioid use in the one to two days following the procedure.

Beverly Gray, MD, a Duke ob-gyn and senior author of the study, says the researchers chose to study gabapentin because it’s known to reduce postoperative pain in a variety of clinical settings, in addition to successfully treating neuropathic and chronic pain.

“Although the results showed that gabapentin didn’t reduce pain during the procedure,” says Gray, “we found that only 15% of participants who received it used narcotic pain medication within 24 hours of the procedure, vs. 31% of participants who received a placebo. As a result, many of us have changed our practice around opioid prescribing, and now we mostly use ibuprofen alone.”

As more gynecologic procedures such as endometrial biopsy, intrauterine device insertion and removal, colposcopy, loop electrosurgical excisional procedure, uterine aspiration, and hysteroscopy are being safely and conveniently performed in a clinic setting instead of an operating room, the goal of improving patient comfort is prompting research and clinical trials into various pain control techniques.

“We’re continuing to ask how we can make patients more comfortable during office procedures,” says Gray, “because there are so many advantages to performing low-risk procedures in the office setting rather than the operating room. We’ve found that there are some small things we can do that have a big impact on their experience.” For example, patients are encouraged to bring a support person with them, which helps them relax during the procedure.

Gray anticipates the publication of additional Duke studies on pain control techniques in the near future, including her collaboration with a gynecology resident on a study of pain management during IUD insertions, which involved a specific technique to stabilize the cervix and reduce pain. She has also researched methods of tenaculum placement to identify a standard practice among the several different methods commonly used by ob-gyns.

Gray stresses that patients who have a high degree of anxiety have a different pain experience than those with a low anxiety level, as their perceived pain level is higher. For those patients, she says, procedures such as uterine aspiration are better suited to the operating room. While this study has not led to a change in practice, it might be appropriate to consider gabapentin for patients with chronic pain or who may already use opioids at baseline.

“Office-based procedures are generally well tolerated, and while we’ve shown that gabapentin doesn’t improve pain during a procedure, we continue to stay up to date with evidence on what does help and will keep looking for other possible adjuncts to help with pain.”