“Nitrous Oxide for GYN Office Procedures & Exams: It’s no laughing matter!” – with Dr. Stephanie Melka

Today Dr. Stephanie Melka joins Dr. Nathan Fox to talk more about nitrous oxide (AKA Laughing Gas) for use in GYN procedures and exams. Listen in to learn about how it works, what it’s used for, and what their experiences have been in practice. 

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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 OB-GYN 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. How goes it? How’s life?

Dr. Melka: It’s great. So excited to be back.

Dr. Fox: We’re excited to have you. We’re just super duper excited to have you. This is, like, a followup to our prior podcast that we did on will this hurt, right. I’m going to the gynecologist. Will this hurt? And at the time, and people, you can go back and listen to the podcast, we went over all these various options for, you know, pain control, pain relief, you know, for the gynecologist, for complicated procedures, less complicated procedures, just an exam. And we’re going through all of that. And then, right after we recorded that podcast, we had a big development in our office. What was that?

Dr. Melka: We now offer nitrous oxide, also known as laughing gas in both of our patient offices, both Carnegie Women’s and Maternal Fetal Medicine Associates.

Dr. Fox: Yeah. So at the time, we were sort of trying to figure out if we could do it. There’s some logistics involved in getting it and having the right equipment and this or that. And so, we rolled it out a couple of months ago and it’s been really helpful for a lot of our patients, and I predict probably more and more over time. And we decided it’d be a good idea to sort of append the prior podcast and talk about this. I think in its own right, because this is a little bit, I don’t want to say out of the box, because it’s used all the time for other procedures. But it’s not something that we sorta had available to us when we were training. A lot of OBGYN offices don’t have this ability. And so, this is something that potentially is a little bit new to people in terms of pain relief options for going to the gynecologist specifically. Obviously, when you go to the dentist, this is very common. But going to the gynecologist, not so much. So let’s talk about that. So what was the impetus to have this?

Dr. Melka: That sometimes what we do causes pain, discomfort, emotional distress, all sorts of different things. And this is a way to help ease some of that.

Dr. Fox: Right. And we do have some experience with this or have had in the world of OBGYN, but mostly in labor. And again, a lot in Europe, not as much in the U.S., although many labor floors have it and are sort of advancing that a little bit further, but we know about it in pregnancy, mostly from labor. And then, obviously for gynecology, it’s not related to pregnancy, but we have just experience in it so we have a working knowledge of it, is what I would say. And what is basically happening when someone takes nitrous?

Dr. Melka: So nitrous is a gas that somebody breaths in, that works sort of at the level of the brain to basically decrease anxiety and causes a dissociative effect, where people will still feel pain, but they sort of just don’t care. You know, some people say they feel like they’re flying, they’re loopy, they’re out of it, they’re giggly. They feel a speculum being placed, but instead of thinking, “Ow, that hurts,” they’re just, like, “Oh, I feel that” and it doesn’t have that same discomfort associated with it.

Dr. Fox: Right. And that’s why it’s sometimes called laughing gas.

Dr. Melka: Laughing gas.

Dr. Fox: Right. You know, again, I think that if people have had the experience of going to the dentist and having this, it’s sort of the same conceptually that there’s things a dentist does that could actually, like, objectively cause people pain and it sort of helps with that. But also, a lot of people, because of those experiences or the anticipation of that, have anxiety over what’s gonna happen at the dentist. And so, even if, let’s say, two people come and they’re gonna have the same amount of pain, even if they experience pain the same way, one person might be much more anxious about it than the other person, which can clearly make the experience worse, and laughing gas is very, very helpful for that regard. Now could you use it to operate on someone to do, like, a C-section?

Dr. Melka: No.

Dr. Fox: Right. So it’s not full board anesthesia and it’s not meant to be, and that’s not the point to this. It’s just meant to be maybe take a procedure that was gonna be more painful and make it less painful or not painful, ideally. That would be the goal. Now when someone is getting nitrous, what is happening? Is it strapped onto their face? Is it sort of like put on a mask?

Dr. Melka: That’s the beauty of it. It’s entirely patient-controlled. So they have a nose clip that they sort of pinch the bridge of their nostrils to make sure that every air they’re getting is through their mouth and it’s a little mouth piece. It’s like a giant straw that they put in their mouth and they just breath in and out through it. It takes about two or three minutes to take effect and for as long as they’re holding that mouthpiece and breathing through it, they’re getting the effect of the nitrous. And then, as soon as we’re done or if the feeling is getting too overwhelming, they just take it out and breath room air. And it wears off within a few breaths.

Dr. Fox: Right. It’s really, it’s a great form of what they say in the anesthesia world, is patient-controlled anesthesia, where the control over how much you’re getting is in the hands of the patient and not in the hands of the doctor. And the advantage to that is people can take more or less of it as they are experiencing pain or not. And the other thing about this, which is particularly helpful, and this is true, you know, in the office setting, it’s true in labor, is since it’s something that the patient herself has to hold into her mouth or by her face, if she gets so, like, loopy to the point that she’s nearly passing out, it’s just gonna fall from her face and it’ll sort of, that’s like a safety mechanism that you can’t “overdose” on it. So we don’t, like, strap it to someone’s face and put it on for the whole procedure. We let them decide how they’re gonna do it and if they get so, they fall asleep, it’s just gonna fall off their face and then, again, if they sort of potentially wake up, they could put it back on. So that’s a really nice advantage and also in sort of the psychology of experiencing pain and anxiety, having that control over your own pain medicine is potentially very, very helpful for a lot of people on top of the physical pain, but just sort of that experience of it.

Okay. And then, when you said that it wears off very quickly, how quickly are we talking about?

Dr. Melka: Two, three minutes.

Dr. Fox: Right. So this is also nice because you don’t have that hangover, that groggy feeling afterwards for when we were talking about maybe taking narcotics or Valium or something, which work but they’re gonna last for two, four, six, eight, whatever hours based on what dose you took. Again, general anesthesia, if you go to a hospital and you get put to sleep, it’s also gonna have, like, a lingering effect on you for X amount of time. But this really, I mean, do you tell people they need someone to drive them home?

Dr. Melka: No. No escort. They rest in the room for a few minutes and stand up, they’re good to go.

Dr. Fox: It’s really pretty impressive stuff. And so, let’s say someone is considering this, right. Just take us through what happens logistically, step by step from the point of conversation to the procedure, to afterwards, just so someone knows what to expect.

Dr. Melka: Yeah. So when I’m counseling a patient on an office procedure, which is typically IUD, colposcopy, certain biopsies, I will offer this as a form of pain relief. If the patient wants it, it does end up being an additional out of pocket charge, since it’s not covered with insurance. But then, they sign a consent form, go to an exam room and basically we get everything ready for the procedure. And then, right when we’re ready to start, they take the mouth piece, they start breathing and then we look at our watch and time three minutes, because it takes about three minutes for it to take full effect. And what I found is often at 90 seconds to 2 minutes, the patient sorta looks at me and the eyes are all glassy, and I just get the thumbs up. And it’s like, all right, there we go.

Dr. Fox: We’re good. And then, these are portable canisters.

Dr. Melka: Yes. Oh, yes.

Dr. Fox: So we can wheel it from room to room.

Dr. Melka: Yeah.

Dr. Fox: It’s not attached to the wall or anything like that.

Dr. Melka: No, no. It’s on a little cart with wheels. It’s an oxygen tank and a nitrogen tank. It’s light. One person can use one hand to wheel it around. There’s a big tubing system that goes along with it. All that’s stored in a closet somewhere.

Dr. Fox: Right. And then, the tubing, it’s disposable.

Dr. Melka: Yeah.

Dr. Fox: So we change those patient to patient. The tanks are obviously the tanks and we refill them as they empty them. We mentioned the cost, we should talk about that. So unfortunately, this is not covered by insurance, right. If we write a prescription for Valium and Percocet, typically it’s gonna be covered by insurance when you go to the pharmacy with whatever your co-pay is. If you have a procedure in the hospital or if you have anesthesiologist administer you intravenous anesthesia, usually that’s covered by insurance, again, with co-payments, whatever it is. But this is not yet covered by commercial insurance, again, unfortunately. So we sort of have to figure out what to do about that, right. So on the one hand, we want to offer it to people. On the other hand, there is a cost. So we basically try to pick a price point that was reasonable, that it’s, you know, essentially cover our cost. It’s not meant to be a big moneymaker. I think it’s, like, $100 or something like that. Yeah. And so, it’s not nothing but it’s meant to be something that’s not prohibitive and allows us to be able to offer it to people And obviously, if it got to the point that we’re doing a bajillion of these, the price could come down. But, you know, we’re not at that point yet. We’ll see. So there is an out of pocket cost and I think that’s probably pretty typical for OBGYN offices to offer it. Maybe when you go to the dentist, it is part of the coverage.

Dr. Melka: It is also. It depends.

Dr. Fox: I don’t really know. Yeah.

Dr. Melka: You know, I know a few oral surgeons that use this and asked them and they said, like, if you’re just getting nitrous, then you pay for it. But if you’re getting, like, nitrous with other anesthetics, [inaudible 00:10:29]…

Dr. Fox: Oh, interesting.

Dr. Melka: …I think they just lump it together because it’s sort of easier.

Dr. Fox: Yeah. This is part of the oddities of commercial health insurance and what is and is not covered, and it’s definitely beyond the scope of this podcast and the two of us trying to understand it. But that’s the unfortunate reality. Okay. So someone has this and they’re done and basically it’s gone. It wears off.

Dr. Melka: Correct.

Dr. Fox: All right. So who would this be ideal for?

Dr. Melka: Pretty much anyone that wants it. We initially, the initial thought is procedures, which can be uncomfortable. But there’s plenty of women out there that have had a difficult pelvic exam before, where they have anxiety. Some women with vaginismus where they have physical pain and these things often limit their ability to get an exam. Some women physically can’t deal with the discomfort with an exam. Some women emotionally just don’t go to the gynecologist to avoid having a pelvic exam. And this definitely can help with that.

Dr. Fox: Yeah, and I think that’s a really important point. I mean, it makes a lot of sense that, okay, someone’s having an office D&C. Maybe this will help. Or someone’s having IUD placed or a colposcopy with biopsies or whatever it is, it’s something where we expect there to be some amount of pain. And different people tolerate pain differently and this is really a good option. Again, for some people, maybe it’s not enough. Maybe for certain people, for procedures, they do need, like, a narcotic, something that’s a little bit denser, pain block, more long acting, deeper, or they might need to be in an operating room and get literally put to sleep by an anesthesiologist. Fine. If that’s what someone needs, that someone needs. But for a lot of people, it’ll allow them to have office procedures.

But I think that next category that you were talking about is really the critical part here, because it’s totally reasonable for people to have a lot of difficulty going to the gynecologist and getting an exam. Most people are fine. They do it. They don’t love going but they do okay and fine. But there’s a lot of people who that’s not the case and it’s really painful for them and it’s really anxiety provoking for them. And like you said, it could also lead them to not get the care that they need because they’re avoiding going to the doctor, avoiding exams that they might need, which is unfortunate but it’s understandable. And we really didn’t have great options for them, right. We do our best obviously to be, you know, to talk people through it, be very gentle, to do all the things we can try to do. Very hard to book a case in the operating room and say, “What are you doing? Pap smear.” And it’s just very hard, yeah, logistically.

Dr. Melka: And that cost is often very prohibitive for patients.

Dr. Fox: Yeah, because even if technically you can figure out a way to get something covered, there’s big co-pays from your hospital and things like that. And so, that’s very, very difficult. And not everyone wants to take a Valium and a Percocet to go to the gynecologist. They’re out for half a day. And so, this is really an opportunity for people who are out there and, like, I dread going to the gynecologist. It’s really uncomfortable. It’s really painful. It’s really anxiety provoking. This might be a way that you can do it and really not feel that. And then, number one, the day of, it won’t be as unpleasant. And number two, probably for the next visit, you won’t have the same level of anxiety coming into it because you know that there’s an option that it won’t be. And either you’ll use that option every time or maybe just having an experience that wasn’t so painful might lead you to feel differently the next time. And I think that that’s, I mean, that’s the future for this. It’s not so much to be able to switch operating room procedures to office procedures. That’s not really the goal. It’s more to just make the experience for people less unpleasant, because we don’t want it to be unpleasant, you know. Yeah. It’s a really cool thing. So you’ve had experience with this.

Dr. Melka: Yes.

Dr. Fox: So I’ve heard just I’m not doing procedures that require this currently. I’m sure I could or would. But what’s been the experience for you and for our office thus far?

Dr. Melka: Everybody has had positive things to say about it. With a recent procedure, that patient just sort of stayed calm and relaxed. And afterwards was like, “That was wonderful,” you know. She’s like, “I’ve made the mistake of going down the TikTok rabbit hole of how miserable IUDs are and this was the opposite of that.” Some patients have even appreciated just that we offer it, even though they opted not to do it, where they’re like, wow, that’s so nice of you. But nobody else does this.

Dr. Fox: Yeah. We’re really happy about this. We’re really proud that we’re offering this. Again, it took a lot of legwork from the doctor’s perspective to get the right protocol, to make sure we’re doing it in a safe way and everything. Obviously from Frida, our clinical manager, who was sort of overseeing, teaching all of our medical assistants, you know, there’s an inservice for how to use it, what to do, what to expect. So there’s a lot of time. I know you put a lot of time into this, developing sort of our guidelines for it and how we’re gonna roll it out and we spend a lot of time, as a practice, talking about it, and now that we’re doing it, obviously, reviewing how it’s been going. But it’s something that’s really, it is a, you know, a point of pride for our practice so we can offer this to our patients. Hopefully, this is something that more and more doctors will be able to offer to their patients. If not, come to us. Happy to have you, you know, whatever. Come for some. And you were saying, there’s other uses for nitrous that are more recreational potentially.

Dr. Melka: Many years ago in the hospital on the labor floor, a patient was using nitrous and the husband pulled me aside very serious. If I go to a Phish concert, they’re selling balloons outside of laughing gas. Is this what they’re selling? I was like, yes. He was like, “Oh, Honey, you’re gonna be fine. This stuff’s great.”

Dr. Fox: It is great. Bring the tank and let’s head over to the Phish concert. It is short-acting so, you know, don’t expect it to last by the time you get there. We have not had any use by the staff as of yet, so we are not doing that. It’s for patient use only. But again, fortunately it’s a very safe and effective method. And so, for all of our listeners out there, if you are not by us and you have an opportunity to try this out with your doctor’s office, do so. If not, you can ask them. Hey, I heard about this on a podcast. Is this something you can consider getting in your office? And maybe they haven’t thought about it to realize that it was an option and absolutely, not absolutely, but probably it is. They just have to figure out, again, the logistics of it, where to get it from, how to do the tubing, how to do it, you know, are we gonna charge for it, are we not, exactly how to do that. And if you’re someone, a patient of ours or potentially patient of ours and this is something you’re interested in, how would they ask about it?

Dr. Melka: So typically, best done in the counseling before the procedure. You know, the way our office is set up, people aren’t usually coming in for, like, same-day first appointment and procedure. Usually they have the first appointment first, let’s say it’s birth control. We plan an IUD and then it’s a separate appointment. But even if it is something where it’s all same-day, we’re always talking to our patients first. Like, we’re not meeting them in the exam room undressed. We’re not meeting them when everything’s already been decided. So there is that face time with the physicians beforehand.

Dr. Fox: Right. Or even if it’s just for, again, a first-time gynecology visit and you’re somebody who knows that that exam’s gonna be really, really anxiety provoking or possibly painful for you. You don’t have to arrange this in advance. I mean, you could. You could call and say, “Hey, listen, I’m pretty sure I’m gonna want to use this.” Or you can just wait, talk to the doctor and say, “Hey, you know, exam’s been really, really hard on me in the past,” and they’ll say, “Hey, do you want to use nitrous?” And we can set it up same day. Since it’s portable, we can bring it to any exam room. It’s really, fortunately really straightforward and it’s not something you don’t need like a procedure room for, because again, after a few minutes, everyone’s fine. They get up and walk out.

Dr. Melka: And our schedulers know if a patient says, “I want nitrous” to just put it on the schedule. So if you were scheduled a new visit, you could say, “I need a new GYN appointment with nitrous,” and they’d put it on the schedule. You’d still have the time to talk about it, but that also helps logistically.

Dr. Fox: Right. Just to make sure that it’s available, which it should be because we do have it available. Awesome.

Dr. Melka: Cool.

Dr. Fox: Nitrous. Good stuff, Melka.

Dr. Melka: I know. I’m so excited about it.

Dr. Fox: Awesome. All right. For all you out there, if you need it, if you want it, let us know and we’re really happy to be able to offer it to you, and hopefully this will be a regular thing across the country for doctor’s offices.

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. It 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.