Melanie Cole, MS (Host): In-office procedures have many advantages for patients and physicians alike. At the same time, women have been sharing a lot of painful IUD insertion and removal experiences on social media, and that's really creating a lot of attention. So today we're talking with OBGYN, Dr. Holly Miller. She's a Lead Physician with A Woman's Place in Naples, Florida, and she's here to share her experience on managing pain and approaching those conversations with patients. Welcome to Women's Health Perspectives, a podcast from Unified Women's Healthcare. I'm Melanie Cole. Dr. Miller, I'm so glad to have you join us today. So let's start by talking about those in-office procedures. When did you start doing them? How are they going? How many do you do on a typical week now?

Holly R. Miller, MD: Well, Melanie, I am excited to be here and I'm excited to share my experience. I've been doing procedures in the comfort of my office for more than 16 years, and my patients have great success in terms of their surgical outcomes, but also how well we manage pain. Personally, I probably do four to six procedures weekly.

And as a practice, all surgeries that qualify for an in-office procedure, 75% of them are done within the comfort of our office.

Host: That's great. The convenience for the patients and for you and for your staff. So let's focus for a second on your mindset as a physician. What barriers do you have? What did you need to overcome? How did you achieve a level of comfort and confidence with managing a patient's pain? Because pain management is just this burgeoning huge field now, and certainly we women, with so many things going on, we can experience pelvic pain for many reasons. So tell us about your mindset when you're doing these and how you got comfortable doing them.

Holly R. Miller, MD: Well, I think like most physicians, we get comfortable doing something by doing it over and over again. I brought in-office procedures to my practice more than 16 years ago, and when we started there wasn't the wealth of information that there is now. And so I'm so happy to be able to share my experience with my colleagues so that they can improve what they're already doing and maybe offer a larger variety of services to their own patients. When we first started, we stumbled a little bit to try to find that perfect pain protocol, but now I know that pain management starts at that first conversation with my patient. So I find that when I'm counseling a patient that needs surgery; I start by giving her, of course, a conversation about what the surgery is going to entail, and then I put the choice of location of procedure into her lap.

So the beginning of the conversation is letting her know that her procedure can be done in the comfort of our office, and going over all of the benefits of choosing that location for her and then also going into how we're going to manage her pain appropriately when it's done in an office-based setting.

Host: Dr. Miller, tell us about some specific pain protocols that you're using now as we're being stewards for opioids and trying to move away from those as the sole pain management protocol. You're doing all kinds of procedures. Tell us a little bit about what you're doing.

Holly R. Miller, MD: So as I'm really thinking through pain management, we're starting it at that initial conversation of giving a patient the choice of having her procedure in the office. On arrival to the office space, we are usually providing her some type of oral or injectable NSAID. For example, Toradol or ketorolac is readily used in my practice, as an IM injection given 30 minutes or so before the procedure is to begin so that we do that on arrival at the practice.

Meanwhile, we're encouraging the patient to sit, to relax, to just kind of adjust herself to being in that office-based setting. Some patients do take oral medications prior to arrival. Different patients have different needs, and each physician has to adjust that oral medication based on the patient's needs and based on the planned procedure.

I would say that my very basic protocol, if a patient is having a basic hysteroscopy, so maybe a hysteroscopy, a hysteroscopy with polypectomy is going to include Toradol as an injected product, an excellent paracervical block and a whole lot of talking to the patient during the procedure. So it does not necessarily require a lot of oral medications ahead of time. We can keep them comfortable, with a minimal amount of actual medications given.

Host: What about nitrous oxide? Is that in the mix at all?

Holly R. Miller, MD: Nitrous is definitely in the mix in my practice. I've been offering the option of an inhaled nitrous product for the last three years. Some patients choose to use it and some choose not to use it. The benefit of having it, is she can change her mind right at the end, so if she drove herself in for procedure, she's used an NSAID product like Toradol. We've done our paracervical block. We are also playing relaxing music. We're talking to her throughout the procedure. But if she's at a point where she's just a little bit more uncomfortable than she wants, then even last minute; we can add that inhaled nitrous gas, it works within a couple of minutes just to take away some of her anxiety and to help provide some analgesia, and when the procedure is over, within five to 10 minutes, she can safely drive herself home.

So I love it as an adjunct to what I'm already doing for my patients.

Host: What a comfortable surrounding. And Dr. Miller, since we know that pain is somewhat subjective, people have different levels of tolerance of pain really. So some may find it very painful and some can just kind of let it go. Certain medications also can be resistant for a patient. So how do you communicate with the patients to personalize those interventions you were just telling us about with that shared decision making?

Holly R. Miller, MD: Absolutely. Again, that comes in that pre-procedure conversation. I like to ask my patient questions such as during childbirth, did you have an epidural or not have an epidural? We discuss prior PAP smear experiences or if I've done an endometrial biopsy, how was her perceived pain experience at that time?

And from there, I talk with her about what she might need for pain. I may give her a little bit of a narcotic to take ahead of time. Such as five milligrams of a hydrocodone containing product. Of course, only if she has a driver and if she has a lot of anxiety about procedure, I might give her a low dose of an alprazolam to take an hour or so ahead of procedure just to help minimize any anxiety that she has about procedure.

Again, I tailor that protocol to her prior experiences and to her perceived needs at the time of procedure. During procedure, I rely very heavily on my staff to help to maintain her in a calm manner. My circulating MA is talking to the patient, distracting her, not just taking her vitals, but also keeping eye to eye contact with the patient.

We do that vocal local where we're discussing what we're seeing on the TV screen. We're talking her through the actual procedure. Maybe we're asking her about her weekend to distract her. We also do a little touching of the patient, so at any moment where the procedure could be painful, such as right at the time of paracervical block, I'll have an assistant tap the patient potentially on the shoulder as a way of distracting them.

And I also like to use a coughing technique. So right at the time, I'm placing the needle in for paracervical block, I'll have the patient cough. Again, it helps to distract her perception of that pain. So we don't just use medication, we use everything available in that awake, office-based environment to keep her comfortable.

Host: It's a very comprehensive approach. And what about complications? I imagine you get this question from patients all the time. What if there is a complication? Has that ever happened to you? What? What do you do in that situation?

Holly R. Miller, MD: I'm very thankful, not just in my practice, but across the state of Florida, we've actually looked at this and the overall complication rate from office-based surgeries is extremely low. I do have a very extensive protocol and training that I put my staff through to talk through any possible complication that we could envision happening, because in these procedures, I am the surgeon. I am the anesthesia team, and I am the operating room along with my nurse that's with me, but that's it. We only have two providers usually in the room with the patient, even though we always have other people, readily available in our office suite. So we need to be prepared for there to be a complication. We have an AED machine, we have a, a series of rescue medications that you would consider a crash cart or a crash kit, and every six to 12 months when we're doing staff training, we talk through all of those emergency protocols. And thankfully, we've never had to use any of them.

Host: Because you're so well prepared, and thank you for telling us about the environmental experiences and other non analgesic techniques that you're using. It sounds like you really make the environment welcoming and relaxing and compassionate and comfortable, because that's really what it's about for women.

Our anxiety gets to the point where, we tense up and that makes your job harder and makes it more painful for us. So Dr. Miller is, we get ready to wrap up, where do you see this field of pain management, which again, we said at the beginning, it's just really huge now. There are so many techniques and protocols going on today.

Where do you see this going for specifically women's health and the pain that we experience, but also in-office procedures? Tell us what you see happening and what you hope to see happen.

Holly R. Miller, MD: Well, I hope to see both an increase in women that are able to access needed surgical care in the office-based setting, it is better for them. And it saves them time. It saves them money. It allows them to get in quickly, get their procedure done. And as I tell my patients, you can have an entire normal morning.

You can go to work, you can take care of your family, come in, have your procedure, and you're back home by mid-afternoon. I've only taken one hour out of your life and we've done the surgery that you need. So I'm excited about expanding office-based procedures in the nation as a whole, and I'm really excited that people overall are talking about the need for improved pain management.

We need to be having this conversation. If you go on social media and you search for pain with IUD insertion, it is sad that women have perceived that they just have to grin and bear it because we have techniques available. We have medications available. We can make this comfortable for our patients, whatever the procedure is from something simple like an IUD insertion to doing an endometrial ablation in the office. All of these can be done safely and with an extremely minimal amount of pain perceived by our patients.

 I think one other thing that I always like to stress is that I always leave my patient in control. So when I'm doing a procedure, now, endometrial ablation is probably the procedure that I do that has the highest potential for pain during the procedure. For two minutes, we are heating that uterus. It is contracting down, and it could be extremely painful. And I tell my patient from the first time she's decided to have that procedure in my office, that during the entirety of that surgery, at any point in time, if she's too uncomfortable, she can tell me to stop. We continue to talk it through for the entire surgery.

I have never had a patient tell me to stop her ablation, but the whole time she knows that she's in control and she knows that she has that ability to say that if she needs it. So it's important that we educate our patient on what to expect during the surgery and that we continue to talk to her from start to finish.

And if she's uncomfortable or if I'm uncomfortable, then we terminate procedure in-office and we transfer it to a surgery center setting or something that offers a different level of anesthesia, if that's what the patient needs.

Host: Thank you so much, Dr. Miller for joining us today and sharing your incredible expertise for us. To watch and download all of our Women's Health perspective episodes, visit unifiedwomen'shealthcare.com/podcast. Thank you so much for listening to Women's Health Perspectives presented by Unified Women's Healthcare.

I'm Melanie Cole. Thanks so much for joining us today.