‘Green whistle’ for IUDs and new pain standard after inquiry reveals women’s suffering

Women who are getting an often painful contraceptive device implanted will be offered the “green whistle” analgesic as part of the Victorian government’s new standard to manage women’s pain.

The state will introduce a women’s pain standard to set benchmarks for management of debilitating pain. A clinic to support girls and adolescents with reproductive-system conditions such as endometriosis will also open at the Royal Children’s Hospital next year, part of a suite of measures to end the disproportionate suffering among Victorian girls and women.

The nation’s first Inquiry Into Women’s Pain released its report, Bridging the Gender Pain Gap, on Sunday, and its instigator, Premier Jacinta Allan, acknowledged that Victorian women’s daily lives were badly affected by inadequate responses to their pain.

“It’s time we stop hearing that our pain doesn’t exist,” said Allan, who lives with endometriosis, a condition that is often accompanied by chronic pain.

“Too many women, for too long, have lived with pain that was belittled or dismissed.”

The inquiry, co-chaired by Royal Women’s Hospital chief executive Professor Sue Matthews (who is overseas), recognised that many women had been gaslit by medical professionals or made to feel at fault or like addicts for asking for medication.

Of 13,000 women who shared their experiences with the eight-month process, 90 per cent of respondents experienced pain that lasted over a year, with 54 per cent experiencing it daily.

Some 65 per cent reported pain intensity as 7-9 out of 10 while one in four respondents to the inquiry – led by Safer Care Victoria, the Victorian Women’s Health Advisory Council and a sub-committee of three professors, three doctors and a consumer advocate – rated their pain as a 10 out of 10 in terms of intensity.

Almost nine in 10 (89 per cent) said their pain impacted their mental health. The most common conditions causing unmanaged pain were menstrual, hormonal (40 per cent), endometriosis (26 per cent) and musculoskeletal problems (26 per cent).

Lack of adequate training in women’s health issues, medical models and guidelines that overlooked sex and gender differences, and a historical lack of inclusion of women in clinical trials and research were identified as contributing factors to women’s experiences in the health system.

Nearly all those who contributed to the inquiry via surveys, submissions, focus groups and public forums had sought help for their pain, but nearly three-quarters said they had encountered “widespread dismissal by healthcare professionals”.

The inquiry is personal for the premier, who has described the isolating effect of monthly pelvic pain on her as a girl. Earlier this year, she said she was “wild with rage” when a Melbourne radio host said on air that endometriosis was made up.

The condition affects 14 per cent of Australian women by the age of 44, and many report pain bad enough to regularly stop them doing daily activities, or at worst to cause them to vomit or pass out.

Inquiry co-chair Fi Macrae, a consumer advocate and founder of online community Private Parts, is also an endometriosis sufferer. As the inquiry kicked off in early 2024, she described doctors responding to her intense pain with suggestions she take mood stabilisers.

“If someone presents in vomiting amounts of pain to an emergency department, the go-to shouldn’t be antidepressants. It should be: What is happening? What’s the root of this problem?” Macrae told The Age.

Research studies have shown women receive less pain medication after surgery than men, and women are more likely to be prescribed antidepressants or sedatives.

Macrae, who is also currently travelling, is not alone in having had serious pain brushed off: The report notes that “71 per cent of respondents report being ignored, dismissed or having their pain minimised by healthcare professionals. Being dismissed is the most common challenge experienced by women and girls seeking help for their pain”.

Women reported being told there was nothing wrong with them, that their pain was all in their heads or that they were exaggerating.

“When advocating for their daughters’ health, some parents told us they were reprimanded for supposedly making their children paranoid about their health,” the authors noted. The inquiry found the reality to be that chronic pain disproportionately affects women and that women experience gender bias in the health system.

Healthcare professionals were also surveyed and recognised women’s adverse experiences in the system compared with men’s. “There is almost an expectation that a woman should be able to ‘handle’ being in severe pain when the opposite is expected for male patients,” one noted.

That clinician agreed with the report’s overall finding that there needs to be more education during medical training about the causes of pain in women and “education that their pain is valid”.

Another clinician said: “I wish that I had been better equipped with knowledge to help those who I feel I failed.”

The peak body representing Australia’s 18,000 medical students made a submission to the inquiry stating a survey of their membership showed education on gender-based pain management is unsatisfactory.

The inquiry report described “unmet healthcare needs, gaps in research and presentation, gender bias in healthcare [and] barriers across communities” as key issues, and made 27 action recommendations. A women’s pain action plan will be developed in the next six months.

One measure, suggested at the outset by obstetrician and gynaecologist Dr Nisha Khot – now president of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists – is the provision of the instant pain-killing inhaler the “green whistle” for women having IUDs inserted at all 20 sexual and reproductive health hubs.

Khot introduced a trial of the green whistle, Penthrox, which contains the analgesic methoxyflurane for women having IUDs inserted or removed at Frankston Hospital, and said it was popular.

An IUD, or intrauterine device, is a form of contraception inserted into the uterus, and is considered among the best forms of contraception due to its 99 per cent effectiveness rate, long-lasting effectiveness and its “set-and-forget” nature.

But due to word-of-mouth about the pain of having IUDs inserted, Khot has said uptake is low because women fear the pain. They are missing out on “the best and most reliable method of contraception”, she has said.

Another action recommended by the review, the new women’s pain standard, will be developed in consultation with clinicians, experts and consumers, and will apply to all public hospitals and health services. It will be designed to help guarantee consistent, high-quality pain counselling and relief, starting with common gynaecological procedures.

Health Minister Mary-Anne Thomas thanked women who participated in the inquiry and said their contribution would help “create generational change to our health system”.

The premier said she wanted women to know they had been listened to: “This work will ensure that no woman ever feels unseen and unheard in our health system again.

“These tangible steps will improve the lives of women and girls everywhere. The RCH clinic is going to be life-changing because when young girls face delays in diagnosis and treatment, it can affect them permanently,” she said.