From pain gaslighting to gender biases in women's accounts of hysteroscopy: A qualitative reflexive thematic analysis.

Forums often contain extensive, detailed discussions that include multiple perspectives on a topic. 52 Reflexive thematic analysis 53 is designed to capture both the diversity and depth of these contributions and to focus on the coherence of the analysis, not on reaching a point of data saturation 54 , 55 as would have been intended by the positivist paradigm. The analysis maintained a constructivist epistemological stance that recognises meaning as co-constructed between participants, researchers, and context. 56 All posts were reviewed multiple times following a latent inductive orientation to the six Steps of RTA 53 : The analysis was led by SKC, an integrative psychotherapist (female, MSc), during familiarisation. Preliminary codes were then created and reviewed, with the coding scheme discussed and adjusted by SKC and KAF (chartered health psychologist/associate professor, female, CPsychol, PhD) and RH (women’s health researcher/lecturer, male, PhD). None of the authors have personal experience of hysteroscopy. The study was designed to generate naturalistic insights from online discussions rather than to examine clinically nuanced decision-making and therefore did not include a clinician as part of the research team. All members of the research team primarily work in clinical research pertaining to women’s health. Themes were created following open discussion and development of consensus between authors about the codes and their clustering. 57 In line with standardised recommendations, 53 divergent interpretations were explored within the research team through structured reflexive dialogue, returning to the original data extracts, and deep consideration of how theoretical assumptions and researcher positionality shaped interpretation. Themes were then further developed, critically reviewed, and reshaped collaboratively before finalising theme names and writing the reports. A reflective journal was kept throughout all stages of analysis and analytic decisions were documented as part of an audit trail in Microsoft Excel, enabling transparency in how codes were refined, collapsed, or reconfigured during theme development.

Diagnostic gynaecological procedures present a significant challenge for many women worldwide. Approximately 1-in-3 women live with heavy menstrual bleeding, 1-in-10 women experience endometriosis, and 2-in-3 women have a lifetime risk of uterine fibroids, 1 all requiring hysteroscopy as their first line of treatment. 2 In the United Kingdom, hysteroscopy is a procedure predominantly performed in the outpatient setting, 3 with 71,000 procedures undertaken per year in England. 4 Hysteroscopy numbers are rising: From March 2018, NICE recommended hysteroscopy as the initial intervention for heavy menstrual bleeding (HMB) 5 leading to an additional 10,000 hysteroscopies per year in England alone. 6 Though hysteroscopy is considered the gold standard for visualising the uterine cavity, 7 , 8 procedural success rates vary significantly, ranging from 77% to 97.2%. 9 – 12 Failure to complete outpatient hysteroscopy (OPH) is predominantly linked to procedural pain 10 , 13 – 15 : More than 85% of patients experience pain, with as many as 15%–34.8% of women reporting severe pain during OPH 12 , 16 , 17 and only 7.8% of patients reporting no pain at all. 16 While pain and patient satisfaction reports 7 , 16 , 18 , 19 provide some insight into the experience of hysteroscopy, such reports have been criticised as presenting limited, unidimensional representations of the true impact of the procedure. 7 , 16 , 18 , 19 The lived experience of hysteroscopy care is critically under-researched, 20 – 22 restricting the ability to apply patient experience into clinical improvement. The need to assimilate patient perspectives into clinical care through qualitative research is increasingly recognised as an important adjunct to improving the delivery of hysteroscopy services 17 , 21 and is recommended as a priority by the Royal College of Obstetricians and Gynaecologists (RCOG). 23 Women use online discussion forums to seek advice, share experiences, and access support from others in similar situations, 24 – 29 providing a source of rich qualitative data. This study aimed to explore the lived experience of hysteroscopy in the United Kingdom, as represented on Mumsnet.com, seeking to identify the primary concerns of patients, with the potential to optimise clinical care.

The data illustrated a profound sense of injustice, rooted in perceived gender biases in medical care: Posters traced this disparity to historic assumptions about female pain: The expectation that childbirth is naturally painful therefore all gynae[cological] procedures should have the expectation of pain is archaic and horrendous. ID1188 The expectation that childbirth is naturally painful therefore all gynae[cological] procedures should have the expectation of pain is archaic and horrendous. ID1188 This historical framing was felt to continue to shape and compromise modern clinical decision-making pointing to an inequality in expectations of pain-tolerance between male and female patients: It’s nothing less than utter misogyny. A man would NEVER be expected to undergo such an invasive procedure with nothing. ID22 It’s nothing less than utter misogyny. A man would NEVER be expected to undergo such an invasive procedure with nothing. ID22 The normalisation of female pain through insufficient analgesic protocols in gynaecological procedures was frequently contested. The use of distraction techniques instead of effective pain relief represented the unequal consideration of female pain: The idea that it’s ok to subject women to severe gynaecological pain as long as you chat to them about holidays, like a hairdresser, is abhorrent. ID97 The idea that it’s ok to subject women to severe gynaecological pain as long as you chat to them about holidays, like a hairdresser, is abhorrent. ID97 The minimisation of female pain and the imposition of stereotypes that frame them as childlike or emotionally fragile are experienced as infantilising women. I’ll tell you what I hate just as much [as insufficient pain relief] though is that patronising “good girl” when you’ve come down from the ceiling/stopped swearing/mashing the nurse’s hand. I’m not a [expletive] 3-year-old about to be given a lollipop, I’m a grown, middle-aged woman. ID608 I’ll tell you what I hate just as much [as insufficient pain relief] though is that patronising “good girl” when you’ve come down from the ceiling/stopped swearing/mashing the nurse’s hand. I’m not a [expletive] 3-year-old about to be given a lollipop, I’m a grown, middle-aged woman. ID608 Amid these inequities of treatment and pain-relief offering, forum users shared a prevailing sense of distrust explaining that self-advocacy became critical: You need to really fight for yourself because medical practices don’t fight for women, we’re left to suffer. ID736 You need to really fight for yourself because medical practices don’t fight for women, we’re left to suffer. ID736 This proactive stance was framed as vital when navigating medical systems that marginalise women’s experiences. There is also a fundamental tension between the practical necessity of self-advocacy and the ethical injustice of requiring women to fight for appropriate care: Women shouldn't have to “make a fuss” to get adequate pain relief. ID22 Women shouldn't have to “make a fuss” to get adequate pain relief. ID22 Forum users expressed a deep sense of discrimination, where gender biases in medical care normalise female pain, infantilise women, and create unequal standards for pain management, leading to a systemic lack of trust in healthcare providers and a prejudicial burden of self-advocacy.

This study utilised a qualitative, reflexive thematic analysis of social media posts. Mumsnet was identified as a particularly purposeful source meeting the criteria of UK-wide reach, large and active female userbase, and frequent publicly accessible discussions on women’s health. Mumsnet.com is a UK-based parenting site with 33.1 million monthly visits and 700,000 posts per month. It attracts a diverse user base, with 62.2% aged 25–54 and 52.61% identifying as female. 32 , 33 Mumsnet has been utilised by researchers across a range of disciplines as a repository of women’s perspectives and experiences, encompassing contemporary political debates, 34 , 35 socio-cultural dynamics, 36 – 38 and health-related issues. 39 – 41 Importantly, accounts shared on Mumsnet capture experiences from across the United Kingdom, thereby overcoming the geographical and organisational limitations of studies restricted to single NHS trusts. Forum posts and replies available on Mumsnet’s public discussion boards emerge naturally without researcher prompting or alignment with a pre-existing theoretical framework. 42 In line with established guidance for internet-mediated research, 43 the forum was treated as a public space. The authors recognise that contributors did not post for the specific purpose of research, but as a publicly available record of their thoughts. To respect this, no interaction with users occurred, no attempts were made to identify individuals, and all quotations were anonymised to uphold ethical standards. 44

Ethics approval and consent to participate: Ethics approval was obtained from University of Reading School of Psychology Ethics Research Committee approval (2023-096-KF). The study analysed posts from a publicly accessible online forum viewable without registration; in line with guidance on internet-mediated research, 30 individual consent was not required. No interaction with users occurred, and all quotations were anonymised to minimise potential harm. This research is reported according to the consolidated criteria for reporting qualitative research (COREQ). 31 See Supplemental Material .

Five themes were constructed representing the specific experiences of women along the hysteroscopy pathway: (1) Contingent Consent, (2) Unacknowledged Vulnerability, (3) Analgesia Roulette, (4) Gynaecological Pain Gaslighting, and (5) Gendered Pain Gap ( Table 1 ). Themes developed during reflexive thematic analysis.

To address sample representativeness and bias, Mumsnet forum posts were conceptualised for the purpose of this study as a large archive of naturally occurring UK health narratives rather than as a direct proxy for the wider OPH population, consistent with established approaches to online qualitative research. 58 – 60 As such, we acknowledge self-selection and differential posting, whereby individuals with particularly salient or distressing experiences may be more motivated to contribute, potentially amplifying negative accounts. 61 A systematic and exhaustive site search was undertaken, and all posts containing the term “hysteroscopy” within the defined timeframe were included without discretionary or directional sampling. Findings were interpreted as contextualised accounts of experience and sense-making within this online forum rather than estimates of prevalence or typicality.

The study is the first to qualitatively investigate online accounts of women’s experiences along the hysteroscopy pathway. It highlights that inadequate or misleading information compromises patients’ cognitive, emotional, and physiological preparation for the procedure undermining the validity of their consent. Emotional uncertainty, fear of harm, and physical exposure during hysteroscopy intersect to foster a problematic sense of helplessness and vulnerability. Disparities in clinical protocols resulted in considerable variability in pain management and an unpredictable patient experience. Adverse experiences were frequently perceived as being dismissed or invalidated by healthcare professionals, with some characterising this response as gaslighting. The perceived normalisation of women’s pain, conveying misogyny in healthcare practices heightened the need for forum users to self-advocate strongly in such situations of clinical vulnerability. Findings identify the hysteroscopy consent process as being insufficient and misleading, echoing data from other gynaecological procedures such as IUD insertions, cervical and pelvic examinations, where patients report unexpected pain, inadequate information, and the minimisation of discomfort. 28 , 64 Symptom urgency and clinician pressure often compelled women to endure more pain than they would have otherwise chosen, which parallels findings from cervical cancer screening where well-intended encouragement can manifest as coercive practices. 65 The adoption of validated, standardised consent checklists across NHS trusts could support shared decision-making and enhance psychological capability by ensuring that risks, alternatives, and pain expectations are consistently communicated. Forum users described how clinical set-up, genital exposure, and adverse clinician interactions contributed to feelings of vulnerability. Similar patterns are observed across routine gynaecological care, 66 – 68 where vulnerability, embarrassment, and dehumanisation are commonly reported occurrences. Unstandardised or inadequate pain management, 69 , 70 combined with unknown pathological and psychological risk factors for OPH pain, 71 create a “pain roulette” for patients reflected by varied hysteroscopy experiences. These diverse experiences suggest that current analgesic guidelines are insufficiently followed. 23 , 68 , 72 Crucially, a stringent evaluation of their implementation could provide the foundation for policy reforms that standardise these guidelines across gynaecological care. These policies could reduce patient harm 73 – 76 and reduce the strain on the healthcare system by decreasing short-term complications, 77 unscheduled healthcare visits, 77 and long-term healthcare avoidance. 78 Forum users described their hysteroscopy experiences being trivialised, which supports findings from a parliamentary inquiry and extensive research on gynaecological procedures, which highlight the widespread dismissal of women’s symptoms. 28 , 28 , 64 , 79 , 80 The long-term effects of this medical gaslighting include anxiety, depression, PTSD symptoms, trauma, distrust in healthcare providers, and avoidance of necessary medical treatment. 81 – 83 Routine collection of post-procedure patient-reported outcome measures (PROMs) relating to pain, distress, and perceived trauma would support 360-degree feedback loops 84 at both individual and service levels, supporting reflective practice and service improvement through the accountability of NHS trusts. Hysteroscopy experiences were seen to represent a gendered pain bias, corroborating findings from other gynaecological domains. 29 , 80 Findings suggest that the healthcare system fails to take women’s health seriously, forcing them to engage in high-level, pressurised self-advocacy. Forum users referred to their gendered experience as misogynistic and medical gaslighting, a term increasingly used in research investigating women’s healthcare experiences. 80 , 85 , 85 – 92 To optimise patient communication and address gender bias, clinical training should include awareness of heuristics – practical, experience-based “rules of thumb” shaping judgement under uncertainty – as well as trauma-informed pelvic care. Critically, organisational factors including communication, clinician practice, and access to analgesia can support more positive patient experiences. 93 As such, future qualitative research conducted within NHS trusts could usefully explore variation in practice and the conditions under which OPH is experienced positively. Acknowledging and addressing patients’ negative healthcare experiences allows for an evaluation of current practices and improving the quality of women’s health care as set out by the UK’s Women’s Health Strategy. 94 This study reveals that inconsistent analgesic protocols, opaque consent processes, and unacknowledged distress reflect broader structural neglect in women’s health care. This study highlights implications for clinical practice and the need for RCOG’s guidelines on informed decision-making, pain relief, and standardised consent for OPH, 23 , 95 – 97 to be implemented as robust policies across NHS trusts. A key strength of this study is its alignment with RCOG’s call for qualitative research into OPH experiences, 23 providing valuable insights into organisational, clinical, and non-clinical factors while contextualising existing quantitative data on pain and satisfaction. Although demographic details of Mumsnet users are kept anonymised on the public forum, the current dataset included over 4700 diverse accounts from across the United Kingdom. The data featured organic, unprompted discussions of individuals with mental health conditions, special educational needs, comorbidities, and varying menopausal statuses, referral symptoms, and pregnancy statuses, providing a wide array of experiences. While online data may not be fully representative of all hysteroscopy self-reporting, prior research supports the validity of online qualitative data in investigating gynaecological experiences. 28 , 29 , 80 However, the potential influence of negativity bias must be acknowledged, as studies suggest that negative health experiences are more frequently shared online 93 and may drive user engagement. 98 Indeed, evidence that approximately 70%–80% of women tolerate the procedure in some settings 17 , 76 , 99 highlights that negative experiences are not universal, nor should providers be uniformly characterised as dismissive or uncaring. Despite this, the data were representative of a spectrum of experiences as reflected by the themes, which align with offline mixed-methods research into OPH experiences, 21 reinforcing their relevance to clinical practice.

This study’s findings align with international recognition of systemic failings as outlined in the European Parliament’s definition of gynaecological violence . This includes procedures conducted without informed consent, using physical restraint, neglecting privacy and confidentiality, denial of pain relief, and the use of sexist, infantilising, or humiliating language. Such behaviours, though not necessarily intentional, represent broader structural issues, such as underfunded services, inadequate consent specific training, and entrenched power imbalances between clinicians and patients. This study positions hysteroscopy as a litmus test for examining the healthcare system’s engagement with women’s pain and medical autonomy, exposing the need for systemic reform in gynaecological practice. The prevention of post-procedural perceptions of gynaecological violence requires more than individual accountability: It demands institutional change and adoption of gold-standard consent processes within OPH.

Supplemental material, sj-pdf-1-whe-10.1177_17455057261440884 for From pain gaslighting to gender biases in women’s accounts of hysteroscopy: A qualitative reflexive thematic analysis by Susanne K. Cromme, Richard Harrison and Katherine A. Finlay in Women's Health