“I’m going to the gynecologist: will it hurt and what can I do about that?” – with Dr. Stephanie Melka

Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OBGYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness.

All right, Melka, welcome back to the podcast.

Dr. Melka: It’s been a while.

Dr. Fox: It’s been a while, a few minutes since our last one. So this is an interesting topic.

Dr. Melka: Yes.

Dr. Fox: Which I basically titled, “Going to the gynecologist, will it hurt? And what can I do about it?”

So, I’ve never been to the gynecologist.

Dr. Melka: Really?

Dr. Fox: Full disclosure. I’ve been a gynecologist, but I’ve never been to one. But the point of this is not for us to discuss our own experiences or lack thereof of being a patient in the gynecology office, but our experience as doctors, as providers, as they say, as the kids say, in a gynecologist’s office, sort of what things might be going on. Do we expect them to hurt, right, or not? And if so, how do we sort of help people either prevent or treat that pain so it’s not a painful and unpleasant experience, or more unpleasant. I don’t…It’s hard to say a gynecology experience is pleasant. But you know, whatever, we want it to be as least unpleasant as possible.

Dr. Melka: Yes.

Dr. Fox: You know, obviously, in all medical fields that’s one of the goals, but obviously we are special in a certain sense, and unique, I guess, for people because it, you know, it could be painful, it’s obviously…you know, there’s disrobing, it’s like, you know…everyone listening knows, obviously.

Dr. Melka: Yes.

Dr. Fox: Okay. So obviously I’m bringing you in, Melka, because you’re our local expert in pain, and pain management.

Dr. Melka: Really?

Dr. Fox: I guess, I don’t know.

Dr. Melka: Okay, sure.

Dr. Fox: You’re the person sitting across from me right now who knows a lot about this.

Dr. Melka: Cool.

Dr. Fox: So we’re going to talk…

Dr. Melka: So you just butter up whoever’s sitting across from you, to get their…cool.

Dr. Fox: Some more than others. Some more than others. I mean, again, this is not something that I do in my own practice routinely. I have done pretty much all of these procedures at some point in my career, and most of them a long time ago, so I do have an understanding of them, and I do other procedures. But this is more so for me to be the host, and you to be the source of knowledge.

Dr. Melka: Mm-hmm. Great.

Dr. Fox: So let’s start just straight up the annual exam, right?

Dr. Melka: Yes.

Dr. Fox: And this is, again, for most people, for most people listening, for most people out in the world, their sort of interaction with the gynecologist is just going to be the annual exam. So there’s definitely many listeners who have never been to one before, and those who have, but maybe had different experiences. So what should someone expect in terms of discomfort or pain for a typical annual gynecologic exam?

Dr. Melka: Mild discomfort, and more…often more mental than physical. If we’re talking just specific for the GYN, and for the Pap smear and the pelvic exam, it can be uncomfortable.

Dr. Fox: Right. Right.

Dr. Melka: It’s often not an ow, this hurts type pain. Most patients are often just like, oh, that feels a little bit uncomfortable.

Dr. Fox: Right.

Dr. Melka: I don’t know that there’s a great other way to put it.

Dr. Fox: Right. Right. I mean, the classic phrase, “just a little pressure…”

Dr. Melka: I don’t believe that.

Dr. Fox: Yeah. I think I’ve told this story before that I myself had to see a physician, the great Dr. Norman Sohn, who is a proctologist. Right? So there you go, we’re just…we are very open on this podcast of our own medical situations. So I’m seeing Dr. Sohn because I had some issues I had to deal with, and I’m there, you know, exposed, I feel…you know, I’m feeling with my patients, I’m exposed, I’m leaning over the table in the other direction, he says to me, he says, “Natey, you’re going to feel a little pressure.” And I turn around and I said, “Dr. Sohn,” I said, “I say that all the time. This is going to hurt, right?” He goes, “Oh, yeah.”

So yes, but I think that if the doctor says just a little pressure, typically for a gynecology exam, we actually mean that. It’s not intended to be painful. Definitely sometimes it is.

Dr. Melka: Yep.

Dr. Fox: So in what circumstances might it actually be painful to have your, you know, speculum exam or pelvic exam?

Dr. Melka: Women with current…you know, if they’re coming in with pain or an infection, there can be vaginal irritation.

Dr. Fox: Yeah.

Dr. Melka: Women with vaginismus, or they can have a spasm of the vaginal muscle.

Dr. Fox: Right.

Dr. Melka: Those tend to be the two biggest ones.

Dr. Fox: Yeah. Yeah. I mean, obviously someone who’s…yeah.

Dr. Melka: Sometimes just pain in general, like if they have a ruptured cyst, you know, they’re going to have a lot of pelvic discomfort, sort of everything’s going to be uncomfortable.

Dr. Fox: Right, right. And people’s…obviously, their own experience with pain is different. Some people, the same sensations will cause some people more pain than others. People talk about, I have a high tolerance for pain, I have a low tolerance for pain. We don’t really know what that means, but there’s definitely people for whom, if you do the same thing, they either actually hurt more or less, or they just respond to the pain differently.

Dr. Melka: Sure. Yeah.

Dr. Fox: And again, this is very complicated. We don’t quite understand that. What are some of the things that we do, or we try to do to reduce or minimize or take away entirely the pain or the discomfort that they might feel during the exam?

Dr. Melka: So this sounds a little bit silly, but meeting and talking with our patients before we do the exam.

Dr. Fox: Yeah.

Dr. Melka: So bring a patient into the office, sit at the desk, clothes on, have a conversation, talk about the history, go over what the exam is, what to expect.

Dr. Fox: Right.

Dr. Melka: And then for patients having their first GYN exam, I tell them that I’ll talk them through it, so that way they know what to expect.

Dr. Fox: Yeah, I agree. I think that, again, obviously pain is complex, and there’s, like, the sharp physical pains, and then there’s some of the pain or discomfort that is definitely lessened by just someone feeling a sense of comfort in general with what’s about to happen and what’s going on. And I think that it’s, you know, being very open about what’s going to happen, and describing it. And some people don’t want that, and they’ve been through it before, and they’re like, you know, I’m in a hurry, just like, go, fine.

Dr. Melka: Yeah. Yeah.

Dr. Fox: But a lot of people, that’s why a lot…you’re going to feel me touching here, you’re going to feel this, you know, and just sort of what…so people know what to expect, and I think that that does help a lot of people. I think that, obviously, we try to use, like, lubricants on the speculums…

Dr. Melka: Yeah. We use…I like the metal speculums just because of the way they open. They’re not opening the introitus, which is the opening to the vagina, so it’s a little bit more comfortable.

Dr. Fox: Right. Right.

Dr. Melka: Warmed speculum, lubricant on the speculum, and then we have the narrow Pederson speculums, which are also more comfortable.

Dr. Fox: Right. I think people might find that counterintuitive, that when they see that metal speculum, that looks, like, medieval, they’re like, wait that hurts less than the sort of like, plastic, see-through one that, you know, just seems so light and gentle… But just the mechanics of it…

Dr. Melka: Yeah. Yeah.

Dr. Fox: …like you said, is in how they open the…I have to try to explain it. If you put your hand…yeah.

Dr. Melka: The metal one opens like a duckbill. Like the far part of it to see the cervix, like, hinges open.

Dr. Fox: Right.

Dr. Melka: So the part that’s at the opening to the vagina stays where it is.

Dr. Fox: Stays put. Right.

Dr. Melka: Whereas the plastic one, they open parallel. So you’re opening the…when you open the speculum, you’re opening that introitus, and that’s more uncomfortable.

Dr. Fox: Right. So for a visual, because this is what Melka was doing, and you can’t see it in a podcast, like if you put your hands together, and say that…

Dr. Melka: We should be on video for this.

Dr. Fox: Right. And you say that your hands together is the speculum, the plastic one opens by basically pulling your hands apart from each other. And so however far apart they go, that’s what’s going to be on the inside and the outside. Whereas the metal one, the heel of your hands, the palm of your hands stays together and just the fingers separate.

Dr. Melka: Yeah.

Dr. Fox: It’s like a V. And so, yes, inside it’s open, and you can see, but outside not as much. Again, the reason people use plastic speculums is just they’re easier because you don’t have to clean them and sterilize them, you just use them and throw them out, so they’re used a lot of times in places like emergency rooms, or places that don’t have the capacity or the capabilities to sort of clean them. But lot of gynecology offices do this all the time, so we have, you know, a sterilizing for the speculums, so we can do that on a daily basis.

Dr. Melka: Yeah.

Dr. Fox: Okay, so that’s the exam. Do people need to, like, pre-medicate for their annual exam?

Dr. Melka: Very, very rarely. Very rarely.

Dr. Fox: Yeah. I would say if someone has a significant, and they would know, if you have a significant anxiety disorder, and you’re really just a lot of just straight up anxiety over the exam, or any doctor’s visits, sometimes taking something for anxiety beforehand is very helpful. And that’s not unique to a gynecology exam, but that’s just in general, if going to the doctor is going to trigger a tremendous amount… And it happens. A lot of people have that, you know, a fear of doctors or doctors offices. That’s sometimes… And we’ve done that in the past, we say all right, you know, the morning of, here’s, you know, a quarter-milligram of Xanax, or whatever it might be. It kind of depends on the circumstance.

All right, so in the annual exam, is there any additional pain that is added by doing something like a Pap smear, or cultures, or something like that.

Dr. Melka: The Pap smear and the culture can be a bit of discomfort, just with the sort of scraping and touching of the cervix. Usually the specimen’s collected within, like, five seconds so it doesn’t add that much more time.

Dr. Fox: Right.

Dr. Melka: Some GYN exams do include a rectal exam, so some of our patients have gone through what you’ve gone through.

Dr. Fox: Yep, absolutely. Yeah.

Dr. Melka: That’s done based on age, history, a variety of different things. Some women find the breast exam to be uncomfortable, especially based where they are in their menstrual cycle.

Dr. Fox: Right, right. Or if they’re pregnant sometimes.

Dr. Melka: Yeah.

Dr. Fox: Yeah, yeah that could definitely be more painful. Now, we’ve gone through the sort of general annual exam, pelvic exam, speculum exam, cultures, breast exam, let’s talk about a few procedures. So let’s say someone is, and this is in no particular order, let’s say someone’s coming to get an IUD placed, right? So why might that hurt more, and what should they expect, without any sort of pain medicine?

Dr. Melka: That’s a tough one.

Dr. Fox: Okay.

Dr. Melka: So again, with IUD, placing a speculum, looking at the cervix, typically there’s a little instrument, like a clamp that we use to sort of hold the cervix in place, and kind of pull on it a little bit to help straighten out the uterus to make the placement a little easier. That, again, it’s like a weird pinch-pressure discomfort. And then opening the cervix to measure it is like internal cramping discomfort, and then you feel that, and then the same discomfort when the IUD is placed.

Dr. Fox: Right. And so for most women getting an IUD placed, do they need premedication?

Dr. Melka: Most don’t need anything. Some will take… We’ll usually tell our patients to take ibuprofen beforehand, which is a non-steroidal, so it helps a little bit with inflammation.

Dr. Fox: Right. So ibuprofen is either ibuprofen generic, Motrin, or Advil.

Dr. Melka: Or Advil, yeah.

Dr. Fox: Same thing. Yeah, okay.

Dr. Melka: Yes. Yeah. I think it helps a little bit with the cramping, but I’ve not found it to help that much.

Dr. Fox: Right. And are there some ways you could predict who might have more or less pain, either based on sort of the shape of the uterus, or based on whether they’ve had kids before? Like, are there some people who it’s better, or worse?

Dr. Melka: I can often have a good sense from when I’ve done their prior exams. So usually when I’m doing a GYN exam, and I’m talking a patient through it, I can tell, you know, how uncomfortable are they just with placing the speculum to see the cervix. History-wise, women that have delivered vaginally before, it tends to be a little bit easier, usually because the cervix is a little bit larger, softer, already dilated.

Dr. Fox: Right. It’s a little bit more forgiving so to speak, to let things pass.

Dr. Melka: Correct. The way the uterus is pointed I think makes the placement a little bit easier or harder. I don’t know that it really affects their discomfort.

Dr. Fox: Uh-huh. Now, are there people who they just can’t tolerate it?

Dr. Melka: Yeah.

Dr. Fox: Like you try to put an IUD in, and they’re like, not happening, too much pain.

Dr. Melka: Correct. Correct.

Dr. Fox: Right. And so, is that… What would you say, ballpark, the percent of women who that’s their experience? Is it like 50%, 10%, 2%, like what would you guess?

Dr. Melka: One percent?

Dr. Fox: Oh, so very…the minority. The extreme minority.

Dr. Melka: That’s what I’ve found, yeah.

Dr. Fox: Yeah. So the likelihood of being able to place an IUD, again, there’s technical reasons why you might not want to place one, but just simply due to pain, it’s a 1% chance that you’re not going to do it sue to pain?

Dr. Melka: That’s what I’ve found, you know? I’m sure there’s more people out there. But usually, with again, talking people through it… One other thing we do sometimes is lidocaine injection into the cervix, which sort of numbs the cervix.

Dr. Fox: Right.

Dr. Melka: It’s an option. The reason I don’t love it is I find you’re just taking one pain, and exchanging it for another.

Dr. Fox: Because it hurts to get the lidocaine injection.

Dr. Fox: It hurts to get the lidocaine, then they don’t feel the clamp being placed, and maybe they don’t feel the dilation of the cervix, but they feel the IUD going in, and like, everything inside the uterus.

Dr. Fox: Right.

Dr. Melka: Because all you’re numbing is the cervix, you’re not numbing the uterus. So it can work if you have somebody that’s never had children before, where like, it’s hard to open the cervix. It can help in that case. But it doesn’t take away that other cramping pain.

Dr. Fox: Mm-hmm. And then, what about after the IUD is placed? Is most of the pain gone, or does it persist?

Dr. Melka: It gets worse maybe, like, five, ten minutes afterwards, and then it gets better, and then it just tends to be irregular cramping for days to weeks, sometimes months. But once you get past the first week or so, it’s typically very mild.

Dr. Fox: Okay. And then, what do you do for the small subset of women who just, you can’t place it because of pain? Do they use something else for contraception, or do you, like, bring them in an operating room and place it?

Dr. Melka: So, depends what the discomfort was. So if it’s trouble opening the cervix, one option is giving them a medication beforehand called mesoprostol, which helps the cervix to soften. Another plan is doing a little bit more lidocaine, like maybe numbing more of the cervix, you might be able to dilate them a little easier. Or doing the procedure in the operating room.

Dr. Fox: Right, meaning where they get put to sleep, basically. Yeah.

Dr. Melka: Yes. Yeah. Which there are people out there that say, like, why don’t we do this for everybody? Which would be great, to do procedures and never feel pain, but it’s not… It’s hard to get insurance to cover it. It’s very, very expensive out of pocket.

Dr. Fox: Right.

Dr. Melka: You know, if you’re looking at, like, offices that have ambulatory rooms, where you’re looking at anesthesia there, you’re often just paying out-of-pocket for an anesthesia cost, which is not nothing.

Dr. Fox: Right.

Dr. Melka: And logistically, it’s hard to find operating rooms to do these. Yeah.

Dr. Fox: Right. Okay.

So now let’s move on to colposcopy. So in our Pap smear podcast, which is either going to have already dropped or will drop soon [inaudible 00:15:14] back to back, I haven’t decided who’s going first, so we talked about colposcopy, which is basically, we were saying at the time, a procedure, speculum, you look at the cervix with sort of like this fancy microscope, and then you do biopsies, right?

Dr. Melka: Yeah.

Dr. Fox: So what is someone’s expected pain with that procedure?

Dr. Melka: It’s a weird, pulling, cramping discomfort that hurts for five seconds, and then it gets better.

Dr. Fox: So less than an IUD?

Dr. Melka: Different.

Dr. Fox: Different.

Dr. Melka: Yeah.

Dr. Fox: Okay, fair. And is it something you typically tell people to premedicate for?

Dr. Melka: Again, I think Motrin can help a little bit. I don’t know that it helps that much.

Dr. Fox: Okay. And is that something where you would be able to numb the cervix before, or just so many injections…?

Dr. Melka: So I was always taught not to because the injection itself, the medication can distort the cells of the cervix, where it can make it harder for the pathologist to interpret.

Dr. Fox: Okay, fair.

Dr. Melka: I don’t know if that’s real, and I think someone is studying this, or there’s some talk, like, looking into whatever data was out there on this. Again, just as sort of this move to try to make pain meds more accessible to patients having these procedures.

Dr. Fox: Right. Now what about hysteroscopy, where you actually go inside the uterus with a camera? There are options to do this in an office.

Dr. Melka: Yeah.

Dr. Fox: As opposed to an operating room. So what would that experience be like for someone?

Dr. Melka: So I don’t do office hysteroscopy. I just never trained in it. I do sonograms pre-op, and then based on the size of what it is, take them to the operating room. But often, the hysteroscopy, you’re limited in the office because of how much you can open the cervix. That’s the painful part. So all of the office hysteroscopy, it’s like three, four millimeter, right, so you’re really not…it’s like the same as an IUD, to put a tiny little camera in to look.

Dr. Fox: Right.

Dr. Melka: So it feels probably similar to an IUD. I think a little bit more uncomfortable , since you are, like, sort of distending the cervix, putting a little water in to be able to look.

Dr. Fox: Right, probably more uncomfortable while it’s happening, but probably…

Dr. Melka: Better afterwards. Yeah.

Dr. Fox: …more comfortable after you’re done because everything’s out, as opposed to IUD, where it stays in place.

Dr. Melka: Yeah.

Dr. Fox: Okay, so similar recommendations. Now, what about some bigger procedures, like let’s say a LEEP procedure, which we also spoke about briefly in the past in our podcast, where you actually have to, like, excise a portion of the cervix, like the size of let’s say a fingertip or something like that using a cautery, or a knife or something.

Dr. Melka: In this case, lidocaine can work well.Because if you’re doing, like, a full para-cervical block because you’re going deeper, it can help, where then you’re able to numb the cervix, and sort of take that sample.

Dr. Fox: Right. And then, LEEP is something that some people do in their office, some people do in operating rooms. And is that really just because of pain?

Dr. Melka: Yeah. I think it’s more just surgeon preference. Like, some of us were taught to do all of these in the office, some of us were taught to do them all in the hospital. Some of it is concern of a cervix can bleed, and if it does bleed, sometimes you’re a little more limited in the office as opposed to being in a hospital, in an operating room setting.

Dr. Fox: Right.

Dr. Melka: Sometimes it’s when you do the physical exam, being able to see the entire cervix, and remove it without sort of damaging the walls of the vagina next to the cervix. It can be harder to do that in the office, as opposed to when you have full IV sedation, where a patient’s asleep.

Dr. Fox: Right. And I’m of..

Dr. Melka: Some of it is a patient, where they’re like, what are you talking about? You’re not going to take off part of my cervix while I’m awake. Like, I’m going to the operating room for it.

Dr. Fox: Right. I want to be…

Dr. Melka: And I’ve had patients., I’m like, no, like, I did your colpo, we talked through it. Like, you were okay with the pain, like, it’s going to feel the same when we do the lidocaine, and they’re just like, nope.

Dr. Fox: Okay. Yeah, that’s fair.

Dr. Melka: Yeah.

Dr. Fox: Now, what about something like an MVA? Not motor vehicle accident…

Dr. Melka: Manual vacuum aspiration.

Dr. Fox: Yeah. Right. Which is basically like…it’s like a D&C, but without, like, the big suction machine.

Dr. Melka: Yeah. Yeah.

Dr. Fox: It’s like a handheld D&C, which is done frequently, like, for early miscarriages, or early terminations, like very early pregnancy.

Dr. Melka: Yeah.

Dr. Fox: So what do you do in that situation, pain-wise? What should people expect?

Dr. Melka: So again, it’s similar to an IUD, where you’re sort of opening the cervix, and doing something inside the uterus. Here, the cervical block works well. We also give oral pain meds here. We do Percocet and Valium. Again, not that Valium is going to take away pain, but it’s just going to sort of help keep someone more relaxed.

Dr. Fox: Right.

Dr. Melka: And again, there you’re just limited in how much you’re able to dilate a cervix.

Dr. Fox: Right. Because the…yeah.

Dr. Melka: In a patient that’s awake and feeling something.

Dr. Fox: Right, because the device to do the MVA is wider than an IUD.

Dr. Melka: Yeah. Yeah.

Dr. Fox: It’s like, 5 millimeters, or something, or 6, or 8? I don’t even know.

Dr. Melka: They can go up to 12. It’s because they’re using the…yeah. Yeah.

Dr. Fox: Yeah [crosstalk 00:20:12.858] okay. Okay. So that’s going to be typically more painful, so is that something you routinely tell people to pre-medicate with those, or it’s an option? Or how do you do it in your own practice?

Dr. Melka: I routinely do.

Dr. Fox: Right.

Dr. Melka: I’ll have a handful of patients that are already cramping and spotting, and like, basically it’s a miscarriage in process, where their cervix is already open, where it’s not going to be as uncomfortable for them in terms of dilating, you know, where we might not premedicate. But I would always, always offer it/recommend it.

Dr. Fox: Yeah. Yeah.

Dr. Melka: But I had someone who was like, I don’t have someone to take me home, and I don’t feel like waiting. I’m going to be fine.

Dr. Fox: Right.

Dr. Melka: And she just, like, you know, sort of dealt with the pain, and then was able to leave sooner afterwards.

Dr. Fox: Right. Now, a question I get a lot is, why can’t the doctor just give me something intravenously, like knock me out for the procedure in the office. And it’s not…yeah.

Dr. Melka: Because we’re not smart enough to be anesthesiologists. We’re only gynecologists.

Dr. Fox: Yeah, it’s not an unreasonable question, because it used to be done all the time, right?

Dr. Melka: Yeah.

Dr. Fox: People definitely, you know, you’re a doctor, you can prescribe, you administer, like, it was all kosher.

Dr. Melka: Yes.

Dr. Fox: I think there’s so… Nowadays, for better and worse, there is a ton of regulations about doing this in the office.

Dr. Melka: Yeah.

Dr. Fox: Again, for better in that you want it to be safe, you want it to be standardized, like, clearly, you don’t want people going rogue on this. But the downside is it’s made it less accessible to people to get stronger pain medicine. Really, the only way to get an IV placed, and something to really knock you out is to either have an anesthesiologist, which means you’re in an operating room, or you have an anesthesiologist coming to the office, or to a surgery center, or the office has to go through a tremendous amount of, like, certifications and training, and you know, crash carts, and like, all these things have to be there, and it’s just very difficult to do in every gynecology office. Some very big ones have that, and I would say most don’t, and so it’s just not an option.

Dr. Melka: And you can’t really do both.

Dr. Fox: Right.

Dr. Melka: You can’t really be doing surgery, and keeping a patient asleep, and monitoring their vitals and their airway, and…

Dr. Fox: Right. It’s tough. So I think that, again, there are definitely some offices around the country that you can have these procedures, and they’re going to offer you, hey, either we do it, or we have an anesthesiologist who comes every other day or whatever it is, and you can be put to sleep for this. And it’s really not much different from an operating room, from your perspective, because you’re being put to sleep. Obviously, it’s not an operating room. But that’s, I would say, the exception, and most offices don’t have that capacity.

Dr. Melka: Right.

Dr. Fox: And either you do it sort of with, like we were talking about, oral pain meds, different strategies, or you have to, like, totally flip the card, and go to a hospital, an operating room. Which again, from a pain perspective, it’s great. You’ll be put to sleep, you’ll get, you know…you’ll get everything. But there’s a lot of paperwork, there’s a lot of scheduling issues, and you have to sort of, like, go somewhere else, and then there may be insurance or billing issues. Again, it’s very individualized for each person, and for each carrier, for each procedure, for each hospital. Like, there’s a lot of things that go into it. But that’s the reason we can’t just shoot you up with something before the procedure anymore, even though, you know, maybe they would have 30 years ago. I’m not quite sure.

Dr. Melka: Yeah.

Dr. Fox: Yeah, do you find that when you’re talking about these with patients, that… Like, how much of this conversation is about the procedure, and like, sort of the recovery, what do we do, what are we going to find, how are we going to follow it up, versus like, the pain, like the actual experience of the procedure?

Dr. Melka: It’s a good mix of both. Sometimes I don’t even get to the procedure because, like, I’ll start talking to a patient about an IUD, and she’ll be like, I don’t want an IUD, they’re too painful.

Dr. Fox: Right.

Dr. Melka: And it’s, oh, I heard from my friend, or I saw on TikTok… Like, I’m not on TikTok, but a lot goes around about awful stories of women screaming in pain while their IUD was placed, and it’s, like, horrifying to hear.

Dr. Fox: Right.

Dr. Melka: And I’ll tell patients, like, look, if you don’t want an IUD, that’s fine. I’m not going to talk you into it. But like, I don’t ever want someone to be screaming in pain.

Dr. Fox: Yeah.

Dr. Melka: Can you imagine you’re at your doctor, and you hear through the wall next to you, like, someone screaming in pain for 20 minutes, like, for a procedure? Like, it’s awful, you know?

Dr. Fox: Yeah. Yeah.

Dr. Melka: And for people that are really worried, like, they don’t want it, that’s fine. But I’ll also go over these other options with them, and sometimes people are willing to try. And I’m telling patients, like, now you have to go on TikTok and tell your, like, boring IUD story. Like, I had an IUD, and it was fine.

Dr. Fox: I mean, the procedures that I’m doing typically are ones related to ultrasound and pregnancy, and one of the lines I frequently have with patients is if this is hurting you terribly, tell me, and I’ll stop.

Dr. Melka: Yeah. Yeah.

Dr. Fox: Because this is not a life-saving procedure, right? It’s not… You know what I mean? Like, there are certain things you roll to the emergency room, and you know, you’re about to die, and they’re doing something to save your life, like, this is how it has to be. But that’s not what we’re talking about here. Putting in an IUD is not a life-saving procedure.

Dr. Melka: Yeah. No. Yeah.

Dr. Fox: Doing these things, you know, it’s really not… And so I think that one of the important sort of lessons about this is before you have a procedure or anything, obviously, speak to your doctor about, like, hey, is this going to hurt? What can I do to decrease the pain? And also, what can I do if during the procedure, this is very, very painful to me? And the doctor or midwife or whoever should say, tell me, right? And then I can stop, or I can do something different. And if they say, like, too bad, you may want another opinion, you know?

Dr. Melka: Right.

Dr. Fox: You may want to find another… Because it’s not supposed to be like that. Like, none of us ever, we don’t want to inflict pain on anyone. That’s like, the last thing we want to do.

Dr. Melka: Yeah.

Dr. Fox: And so, you know, on the other hand, someone wants an IUD, we want to be able to help them, and provide it for them, and so it’s a balance. You sort of want to give them expectations that it may be uncomfortable, but you don’t want to do it in a way that’s going to, you know, traumatize them. Like, that’s awful.

Dr. Melka: Yeah.

Dr. Fox: Oh, my God, that’s the last thing we want to do.

Dr. Melka: I know. Yeah.

Dr. Fox: And so it is important to have open communication about this in both directions. I mean, we’re supposed to talk to the patients, here’s what you’re going to feel, this is what you can expect, here’s what to do. But if you’re on the patient end, like, speak up, and say, like, hey, I’m in a lot of pain. Is that normal? Is that not normal? Can you stop? Can you…you know?

Dr. Melka: Yeah.

Dr. Fox: And the doctor should, and typically will be very responsive to those types of comments or questions, or whatever it might be.

Dr. Melka: Yeah. I mean, MVA is probably the one that’s the most uncomfortable just because when you’re doing that, like sort of curetting, the cleaning in the uterus, like, you can’t numb the uterus.

Dr. Fox: Right.

Dr. Melka: And I’ll tell people, like I’ll be up front, like, it’s going to hurt. But it’s going to be, like, one minute at the very end that it’s going to hurt the worst, and then it’s going to be done. You know?

Dr. Fox: Right.

Dr. Melka: And it’s never a procedure I talk someone into.

Dr. Fox: Right.

Dr. Melka: You know, I’ve never regretted having someone go to the hospital. I have regretted doing the MVA, and then being like, okay…like, then they’re like, that was too painful. Like, I wish I didn’t do that, you know? And it’s not that they didn’t know, but whatever it was, they didn’t want to wait for the operating room, t hey just wanted to be done faster, they just wanted to avoid the hospital…yeah.

Dr. Fox: Right. Right.

Excellent. I think was a great podcast.

Dr. Melka: Cool.

Dr. Fox: No, I think it’s very helpful for people. Again, we’re talking about gynecology, but it’s not… These same principles apply for anything when you’re going to a doctor, are they going to do something that’s expected to hurt, or not? And if so, what should you expect? What can you do to reduce the pain? And what are your options about speaking up? And I think that that’s, again, the principles, doctors are not here to hurt people. Like again, that’s not what we want to do. It doesn’t make our day any better.

Dr. Melka: No.

Dr. Fox: Right? It makes it much, much, much worse, obviously, if that happens. And so it’s really something to be…to communicate about in both directions.

Dr. Melka: Yeah,

Dr. Fox: Great. Melka, thank you.

Dr. Melka: Thank you.

Dr. Fox: Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast, or any other topic you would like us to address, please feel free to email us at HW@healthfulwoman.com. Have a great day.

The information discussed in “Healthful Woman” is intended for educational uses only, and does not replace medical care from your physician. “Healthful Woman” is meant to expand your knowledge of women’s health, and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.