The Cervix
Vol. 28 No 2 | Winter 2026
Feature
Pain Management During Colposcopy: Time to Reframe “Well Tolerated”
Dr Ed Hyde
Dr Ed Hyde
MBChB, FRANZCOG
Dr Sumi Saha
Dr Sumi Saha
MBBS, DRANZCOG Advanced, M Reproductive Med, FRANZCOG, M Pain Management

Introduction

Colposcopy is a fundamental component of cervical cancer prevention programs, enabling the assessment of abnormal screening results and guiding management of cervical intraepithelial neoplasia. Within Australia and Aotearoa New Zealand, the transition to HPV-based screening under the National Cervical Screening Program has increased the importance of timely and effective colposcopic assessment.

Colposcopy is frequently described as “well tolerated” by patients. However, a growing body of evidence and patient-reported outcomes suggest that this characterisation is overly simplistic. Many patients experience moderate to severe pain, particularly during biopsy or endocervical curettage (ECC), and a substantial proportion report distress that impacts future screening participation.1,2 A recently published qualitative study reported that people who experienced moderate or severe pain more frequently expressed fear of future gynaecological procedures.3

Improving pain management during colposcopy is therefore not only a matter of patient comfort but also a critical factor in maintaining engagement with cervical screening pathways. Patients should have more autonomy over their pain-control options during colposcopy.

Understanding Pain During Colposcopy

Pain is a highly subjective and personal experience that transcends age, geography, and culture.4 The International Association for the Study of Pain defines pain as “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.”5 On the other hand, suffering is the interpretation of that experience and involves thoughts, beliefs, or judgments and the ability to cope with pain.6

Undoubtedly, during a consultation with a short patient encounter, it can be challenging for the clinician to comprehend the multitudes of factors which could influence the experience.7 Pain during colposcopy is multifactorial and influenced by physiological, procedural, and psychological factors. Procedural contributors include speculum insertion, application of acetic acid or iodine, cervical biopsy, and ECC.  Various studies demonstrated that higher levels of preprocedural anxiety or of expectations of pain are associated with higher levels of patient-reported pain during an office procedure.8,9

Patients with a history of dyspareunia, dysmenorrhoea, nulliparity, and postmenopausal patients with genitourinary syndrome of menopause are likely to reports more pain experience during office gynaecological procedures.10,11 Patients with a history of chronic pelvic pain, and survivors of sexual or physical violence, substance abuse disorder, or other chronic pain conditions require meticulous pain management planning for the colposcopic procedures due to their higher levels of distress and pain experience.12 There can also be systemic injustices, such as the effects of historical colonialisation or racism that need accounting for. Screening for, discussing, and managing these issues in a time-limited appointment is a significant challenge for the clinician.

Pain Management Options

Effective communication, reassurance, and anticipatory guidance through improved preprocedural education and counselling reduces anxiety and procedural pain.13,14 The universal application of trauma-informed reproductive healthcare is essential given the high prevalence of childhood sexual abuse and sexual assault among adults, as well as the fact that many individuals do not disclose their trauma histories.15,16 Many patients also carry trauma from previous healthcare experiences such as prior gynaecological or colposcopic examination. A trauma-informed approach assumes the possibility that everyone may have prior experiences that alter how their care needs to be provided. This incorporates explicit patient control, consent at each step, and sensitivity to prior experiences. When caring for gender-diverse patients, using gender-neutral anatomical language, such as “genitals” or “external genitalia,” and mirroring the preferred language of the patient, can alleviate anxiety during counselling, examination, and procedures.17

Although some older studies reported that distraction techniques (e.g. forced coughing, music, and visual distraction) may reduce pain and anxiety levels associated with colposcopy-directed cervical biopsies,18,19 recent studies revealed that these techniques are ineffective.20,21 There is limited conflicting data available regarding the usages of NSAIDs.22 A randomised controlled trial in 2023 reported that etoricoxib, a COX-2 inhibitor and NSAID, was effective at managing pain during colposcopy and up to 24 hours post-procedure.23

Several small clinical trials reported topical application of local anaesthetic may reduce pain during colposcopy-directed cervical biopsy but a clinically meaningful effect is lacking.22,24,25 A systemic review and meta-analysis published in 2019 evaluating the efficacy of local anaesthetics for pain relief during colposcopy-directed cervical biopsy found no significant difference between local anaesthesia and a control for post-procedure pain, pain during ECC, pain expectancy, or overall pain scores. The option to have sedation prior to colposcopic-guided biopsy should also be available to those with history of significant trauma and chronic pelvic pain.

 

Conclusion

In an era of individualised patient-centred care, shared decision-making is pivotal when discussing pain-management options, including during colposcopic examinations. Current Australian28 and Aotearoa New Zealand29 clinical guidance and education do not include comprehensive information on pain management or analgesia beyond the use of local anaesthetic for LLTEZ. This should be urgently addressed and further funding for research into this area prioritised to improve the evidence base.

The implications of undertreated pain in women and people with a cervix are profound. The experience of having one’s pain dismissed or inadequately addressed may, and likely will, erode trust in healthcare providers and the system they work in. Creating clinical environments where patients feel heard, respected, and believed is foundational to improving both satisfaction and treatment adherence.

References

  1. Comba C, Demirayak G, Erdogan SV, Karaca I, Demir O, Guler O, Ozdemir IA: Comparison of pain and proper Sample status according to usage of tenaculum and analgesia: a randomized clinical trial. Obstet Gynaecol Sci. 2020, 63:506-13.
  2. Gage JC, Duggan MA, Nation JG, Gao S, Castle PE: Detection of cervical cancer and its precursors by endocervical curettage in 13,115 colposcopically guided biopsy examinations. Am J Obstet Gynecol. 2010,203:481.e1-9.
  3. Caddy C, Temple-Smith M, Coombe J.Do women feel unprepared for the experience of an intrauterine device insertion: Findings from an Australian study. Perspectives on sexual and Reproductive Health. 2025 Sep;(3):368-373.
  4. Fillingim RB. Individual differences in pain: understanding the mosaic that makes pain personal. Pain. 2017;158 Suppl 1 (Suppl 1): S 11- S 18.
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  8. Callahan DG, Garabedian LF, Harney KF, DiVasta AD. Will it hurt? The intrauterine device insertion experience and long-term acceptability among adolescents and young women. J Pediatr Adolesc Gynecol. 2019;32:615-21.
  9. Kola S, Walsh JC, Hughes BM, Hpward S. Attention focus, trait anxiety and pain perception in patients undergoing colposcopy. Eur J Pain. 2012;16:890-900.
  10. De Freitas Fonseca M, Sessa FV, Resende JA Jr, Guerra CG, Andrade CM Jr, Crispi CP. Identifying predictors of unacceptable pain at office hysteroscopy. J Minim Invasive Gynecol. 2014;21:586-91.
  11. McGee AE, Alibegashvili T, Elfgren K, et al.: European consensus statement on expert colposcopy. Eur J Obstet Gynecol Reprod Biol. 2023, 290:27-37.
  12. Coleman JN, Arthur SS, Shelby RA. Psychological distress and pain related to gynaecological exams among female survivors of sexual and physical violence: A systemic review. Journal of Traumatic Stress. 2024;37(2),217-239.
  13. Eric J, Purut YE, Harmanci H. The effect of video assisted information on anxiety and pain associated with intrauterine device insertion. Gynecol Obstet Invest. 2020;85 (1):82-87.
  14. Guvenc G, Bektas Pardes B, Kinci MF, Karasahin KE. Effect of education and counselling on reducing pain and anxiety in women undergoing hysterosalpingography: a randomised controlled trial. J Clin Nurs. 2020;29:1653-61.
  15. Owens L, Terrell S, Low LK, et al. Universal precautions: the case for consistently trauma-informed reproductive healthcare. Am J Obstet Gynecol.2022;226(5):671-677.
  16. Caring for patients who have experienced trauma: ACOG Committee Opinion, number 825. Obstet Gynecol. 2021;137(4):e94-e99.
  17. Pain Management for In- Office Uterine and Cervical Procedures. ACOG Clinical Consensus. Obstet Gynecol. 2025;146(1):161-177.
  18. Galaal K, Bryant A, Deane KHO, Al-Khaduri M, Lopes AD. Interventions for reducing anxiety in women undergoing colposcopy. Cochrane Database of Systematic Reviews. 2011;12. Art. No.: CD006013. DOI: 10.1002/14651858.CD006013.pub3.
  19. Chantawong N, Charoenkwan K. Effects of music listening during loop electrosurgical excision procedure on pain and anxiety: a randomized trial. J Low Gent Tract Dis. 2017;21:307-10.
  20. Kuhn T, Ukazu A, Strickland PO, Roche N, Taveras Y, Kovalenko O, et al. The effect of forced cough to minimize pain and discomfort at the time of colposcopy-guided cervical biopsy. J Low Gent Tract Dis. 2020;24:211-4.
  21. Chantawong N, Charoenkwan K. Effects of music listening during loop electrosurgical excision procedure on pain and anxiety: a randomized trial. J Low Genit Tract Dis. 2017;21:307-10.
  22. Gajjar K, Martin-Hirsch PP, Bryant A, Owens GL. Pain relief for women with cervical intraepithelial neoplasia undergoing colposcopy treatment. The Cochrane Database of Systematic Reviews. 2016;7. Art.No.: CD 006120
  23. Sivapornpan S, Punyashthira A, Chantawong N, Wisarnsirirak P, et al. The efficacy of oral etoricoxib in pain control during colposcopy-directed cervical biopsy: a randomized control trial. Asian Pac J Cancer Prev. 2023;24: 2855-9.
  24. Duncan ID, McKinley CA, Pinion SB, Wilson SM. A double- blind, randomised, placebo- controlled trial of prilocaine and felypressin (Citanest and Octopressin) for the relief of pain associated with cervical biopsy and treatment with the Semm coagulator. J Low Genit Tract Dis. 2005;9:171-5.
  25. Kiviharju M, Kalliala I, Nieminen P, Dyba T, et al. Pain sensation during colposcopy and cervical biopsy, with or without local anesthesia: a randomized trial. J Low Genit Tract Dis. 2017;21:102-7
  26. Wongluecha T, Tantipalakorn C, Charoenkwan K, Srisomboon J. Effect of lidocaine spray during colposcopy-directed cervical biopsy: a randomized controlled trial. J Obstet Gynaecol Res. 2017;43:1460-4
  27. Mattar Om, Samy A, Shehata M, et al. The efficacy of local anesthetics in pain relief during colposcopic- guided biopsy: a systematic review and meta- analysis of randomized controlled trials. Eur J Obstet Gynecol Reprod Biol.2019;237: 189-97.
  28. Cancer Council Australia. National Cervical Screening Program Guidelines. Updated 8 April 2026. cancer.org.au/health-professionals/clinical-practice-guidelines/cervical-cancer-screening
  29. Te Whatu Ora Health New Zealand. Cervical screening guidelines, standards and reports. Updated 21 May 2026. healthnz.govt.nz/health-professionals/guidance-standards/topic/cervical-screening/cervical-screening-guidelines-standards-and-reports
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