A Justice-Driven Approach to Painful Office-Based Gynecologic Procedures

Abstract: While office-based gynecologic procedures (OBGPs) offer many benefits, they cause significant pain for some patients. Despite extensive research of some methods, current pain management options fail to ensure comfort in this subpopulation. More expensive pain control methods like moderate sedation have not been thoroughly investigated. In contrast, dermatology and urology practices include myriad office-based procedures and offer adequate yet expensive pain management, enabling widespread patient comfort.

Applying a justice lens for cross-specialty comparison reveals systemic factors contributing to perceived permissibility of procedural pain in this gynecology subpopulation. Office procedures in dermatology and urology differ from OBGPs not only due to different anatomy but also structural differences in compensation and patient population. Dermatology and urology office procedures receive higher reimbursement than OBGPs. Additionally, dermatology patients have higher socioeconomic status (SES), and urology patients are majority male, compared with patients with uteri of diverse SES in gynecology. These structural differences and disparate responses to procedural pain suggest gender- and income-driven inequities. Furthermore, after increasing Center for Medicare & Medicaid Services reimbursement for office-based hysteroscopy, studies investigating hysteroscopy pain management increased, suggesting a correlation between procedural compensation and investigative interest in ensuring procedural comfort.

While patient testimonies of pain during OBGPs have gained attention, our analysis is the first to respond by investigating systemic injustices that permit this pain. A justice-driven approach calls for equitable reimbursement practices and increased high-quality pain management research to afford the same comfort in OBGPs. Future directions include exploring the moral distress this engenders for clinicians and trainees.

Louise King, MD, JD – Director of Research, Associate Fellowship Program Director, Minimally Invasive Gynecologic Surgery, Assistant Professor, Division of Minimally Invasive Gynecologic Surgery, Brigham and Women’s Hospital; Harvard Medical School; Parmida Maghsoudlou, BA – Clinical Research Assistant, Division of Minimally Invasive Gynecologic Surgery, Brigham and Women’s Hospital