This week’s NEJM online has a video on how to perform a pelvic examination. I thought they did a really nice job. Of course, since I do this all day, I have a few additional tips:
1. Make sure you have the right tool for the job. That means long narrow Pederson specula for postmenopausal ladies and large Graves specula for the more ample women, along with standard sizes of both for most patients.
2. For anxious patients and little old ladies, I apply lidocaine jelly to the introitus a few minutes before the exam (Step out and see another patient while it does it’s job). This is also useful for transvaginal sonos in the same crowd.
3. I use two separate slides (not one as shown in the video) for KOH and wet smears. Putting both of these on the same slide invariably leads to cross contamination by the KOH.
4. I still occasionally use the endobrush for paps, even when doing thin preps, because sometimes the larger cyto-broom does not enter the endocervical canal. Just rinse it in the vial like the cytobrush.
5. Get everything ready, including adjusting the light, before you start. I didn’t like seeing the doc in the video touching everything in the room with the gloved hand she was going to be using for the bimanual. If I find I have to use that hand, I change the glove before doing the bimanual. God knows how many hands have been on that light before yours!
6. Specimens for GC/Chlam PCR testing can be obtained from the vagina as well as the cervical os, and this is useful if blood or excess cervical mucus are present at the endocervix, since these can interfere with the sensitivity of these tests. Urine specimens are also appropriate for screening using PCR.
7. The video recommends asking the patient is she wants a chaperone present. I would not ask – just have one there, especially if you are male. The second pair of hands is helpful as well.
8. If you are going to be seeing older women, you’ve got to get good at the one finger exam. This is where the rectal part of the exam is critical – one finger in the vagina and the other in the rectum, and you’ll get a decent exam in most patients.
Questions?….
Hmmm… good tips. I didn’t know the one about the lidocaine jelly (not like I’m going to be doing speculum exams on postmenopausal ladies).
I’d like to echo the advice about the right speculum. Using a speculum that’s too large is obviously needlessly uncomfortable, but using one that’s too small will lead to hunting for the cervix which is also needlessly uncomfortable.
With the rectal exam, I was taught that a rectovaginal exam is mandatory in postmenopausal ladies because sometimes it can detect ovarian cancer.
I’m afraid while you two are chatting, I’m thinking “eep!” (And I bet I’m not the only one.)
I do have a question, though; how do you know what size speculum’s likely to be right?
WMAK:
I’ve picked up ovarian masses on rectal exams in women as young as age 16. It’s just part of the pelvic exam as far as I’m concerned. You’d be surprised how many new patients say to me “My other doctor never did that “.
Bardiac:
You decide based on the patient history and how things look externally. Little old lady, not sexually active? Go for the narrow pederson. Sexually active, normal weight? Regular pederson. Large woman, sexually active? Long large graves. And so on…
I’d disagree about not asking if they want a chaperone, unless you are male. I would not want a chaperone in the room with me with my regular (female) provider. If she demanded it, I’d leave. Males, unfortunately there is greater liability, but for female providers, there is absolutely no reason not to defer to the comfort of your patients. The exam is stressful enough, the presence of another unwanted person can just add to it.
We’re having an ongoing debate in our practice regarding rectovaginal exams. USPSTF and ACS both recommend against screening for ovarian cancer in asymptomatic women. A single hemoccult is an insufficient screen for colorectal cancer. Why should we be sticking fingers in places they don’t belong without any proven benefit?
I’d be interested in your thoughts, it’s been a heated debate between the EBM and tradition camps. I find myself wussing out and not taking a stand.
One question from an MS3:
Is the lidocaine jelly really that much a help? I understood the discomfort from the speculum came more from pressure/distention which would seem to not be relieved by a topical agent.
Regarding the lamp touching, I agree. In a community medicine rotation my first year, I tried to take over the lamp duties for a doctor doing a pap because he kept fiddling with it. When he asked, “What are you doing?” (apparently he didn’t want me messing with it), I simply replied, “Um, your hands are gloved.” He wrinkled his face and scoffed, “This isn’t a sterile procedure.” Right. I understand we’re in the sticks, but common sense shouldn’t be thrown out. It’s not just how many hands have touched the lamp at this point…I won’t write the rest.
Thanks for the addendum to the NEJM video!
Enrico:
THe lidocaine absolutely helps. It’s nto the pressure, its the stretching (and sometimes, I’m afraid) tearing od the delciate tissues at the introitus that causes the most discomfort. You can put some into the vagina as well, but not too far because you don’t want to interfere with the pap smear. If using it for a vaginal probe, just use it as your probe lubricant I got our ultrasound unit to get some and keep it to use for that purpose.
As for the gloves, well, you and I seem to have the same sensibilities…
Dr Smak:
I do a rectal on most of my patients. I don’t really think of it as a rectal exam – I think of it as an exam of the posterior wall of the uterus and the cul de sac, which are best reached through the rectum. Endometriosis likes to hide ther, and the ovaries are sometimes bak there, and for a retroverted uterus it’s mandatory as far as I’m concerned. I will admit that if I get a great exam without it in a really relaxed patient, I may skip it once in awhile.
I don’t do screening single hemoccults, but send them home with cards if that’s the screen I am doing. However what I mostly do is refer for screening colonoscopies.
Rebecca: The chaperone is there for both the patient and the doctor. That said, I very frequently do exams alone with patients I know, especially if my tech needs to be getting the next patient ready or is drawing blood. But most of them aslo know and love my tech, so having her there is not a problem for any of us. (Plus she’s a good hand holder for the patients who are frightened…)
I once used a vaginal speculum and a spinal needle to draw an ABG on a 500 pound person: the speculum in the inguinal fold to hold it open, and the spinal needle through it and into the femoral artery. I was a med student at the time, and alone. Rarely used one since, although I generally preferred recto-vaginal exam when trying to assess pelvic pain from the point of view of a general surgeon.
Just an ethical dilemma. In my ED practice I have several lesbian colleagues. While the males at our institution are required to have a chaperone when performing a pelvic exam, there is no thought about the lesbians. I never even considered it an issue, until one of the lesbian physicians told me she always has a chaperone to protect herself against accusations. None of the others have chaperones and one nurse in particular it performing several SANE exams a week. I’m not even sure how to bring this issue up without appearing discriminatory.
Anonymous:
One way to bring up the issue is to ask for a faculty discussion on the question of chaperones for all docs, male or female.
There is no formal recommendation from ACOG re chaperones, and they adknowledge that for some patients, another person in the room is embarrasing.
I think the idea of offering a chaperone to every patient is a good one.
Isn’t there also an anatomical issue on what instrument to choose? My GYN always goes and gets ‘the small speculum’ for me (which, sadly, she has to keep on hand for examining girls who have been abused/raped). Apparently I have a very small cervix and a normal speculum hurts like hell. (The small one doesn’t).
I’m not sure I would want lidocaine, though. I’d rather it be offered as an option rather than done as a matter of course. I’d actually rather deal with discomfort than with the strange sensation of being numbed.
As for chaperones – I have a female doctor now, but I’d probably only request something if things felt “hinky” to me. And I’d probably NOT go to a GYN who made me feel “hinky” anyway. But if he (or she, were my doctor lesbian) felt they needed one there for THEIR protection, okay. (Just, please, don’t troop in the class of med school students. I really don’t want a crowd viewing my pelvic exam.)
Anonymous:
Yes, we choose the speculum based on the women’s anatlmy – size of the vaginal opening, etc.
I do not use lidocaine routinely at all. But if I do an exam and it’s clear the patients is having problems, or if she tells me up front that it has been painful in the past and she is very frightened, I will offer it to her.
Thanks for reading.
Funny thing… I haven’t seen a gyn for my annual in probably 15 years. My FP does it. But my sister recently had an emergency hysterectomy (long story) and my FP suggested just once that I let a gyn do my annual. I went to the gyn (same one my sister used – also the same one who delivered both of my FP’s kids). I was unimpressed. The exams my FP has done over the years have always been painless (not even any discomfort) and thorough. The gyn raced through the whole thing to the point that I actually asked my FP to do another breast exam and pelvic (sans PAP) because I don’t think the gyn spent even 30 seconds total and damned did that speculum hurt! Not to mention the actual PAP! I found it to be very strange.
Going back the issue of chaperones for gyn exams… I personally hate having an extra person in the room. More often than not, doctors I have seen have used chaperones, and they have never asked me whether I wanted one. In a couple of instances, I had nurses stationed below my waist while my feet were in the stirrups– in full view of everything I didn’t care to show them.
Lots of people think its important to offer gyn patients chaperones, which is understandable. On the other hand, no one seems to be advocating an option not to have one. Any advice on how to get some privacy?
Anonymous –
Most nurse practitioners and midwives that I know work without chaperones, as do a fair number of female docs. Just ask. But be prepared for them to insist on someone being present in the room anyway. If that happens, simply ask the chaperone to stand to the side and not at the end of the table, make sure your doc keeps the parts she is not examining covered, and that should do the trick.
Hi there
Just wondering if anyone thinks that male gyns can enjoy doing the exam. I recently seen a new gyn doc and during the exam he called me sweetie.
I think your are overthinking this, saying that men will be men, so they probably do to some extent but they spent years being thought to be professional. If it makes you uncomfortable you could ask for a nurse to be present next time or find another gyn. You have every right to be comfortable.
American women seem to have a huge number of pelvic exams…thank goodness that's not the case in Australia…I'd refuse routine invasive exams anyway…
My Dr and her partners do not recommend routine pelvic/rectal exams – they are considered unnecessary in asymptomatic women and in fact, can be harmful.
I don't know any women having routine gyn. checks.
Of course, some women will ask for every exam and test, that's their choice, and they accept the risk of false positives and possible further testing.
I'm amazed American women don't question the need…
I've had ONE pelvic exam in 50 years!
I think it's important to question the need for all invasive procedures – exams and tests.
Also, ask for risk information with cancer screening – there are risks and benefits.
The practice of requiring American women to have invasive exams and tests to get the Pill is unethical – this practice continues despite the World Health Organization and many other Medical Associations stating the only required health exam is a blood pressure check.
Hurdles should never be imposed making it more difficult for women to access contraception – IMO this has nothing to do with health care – it's power, control and making lots of money.
I believe this practice will be abandoned shortly – I see some Clinics and Dr's are now providing the Pill on-line… (as long as women have a blood pressure check every 3 months)
(I understand full exams were never required in Aust – just a breast check and Pap smear every 2 years, but you could decline these checks and still get the Pill)
Women should be given honest and complete information including risk information and then left to make their own informed decisions about their health.
IMO anything less is unethical and disrespectful…
I have a risk v benefit test and then i consider my risk profile – if the risks outweigh the benefits, a line goes through the exam or Test.
My legal training means I'm not swayed by scare campaigns – I get to the truth….
I declined to participate in cervical screening 30 years ago and still decline & have recently decided against mammograms. Cancer screening has risks as well as benefits – women need to demand risk information – otherwise, it's impossible to give informed consent.
It's really important to be informed and stand up for yourself…it's the only way to safely negotiate the medical world.
The only exam I have annually, apart from blood tests and blood pressure check – is a professional breast exam. (started at age 40) I declined breast checks as a young women – the risks exceeded the benefits.
The new blood test that will
replace the pap smear – the cervical specific antigen test is almost 100% accurate, so I'll discuss this test with my Dr – with a reliable test (even though I'm very low risk) the benefits might exceed the risks.
Women need to demand access to this blood test…there are too many vested interests that will not be happy to say goodbye to the lucrative and unreliable pap smear.
I'd encourage all women to look at the research by Dr Angela Raffles and Prof Michael Baum about cervical and breast screening – the stuff that's withheld from women – it will make you very angry and to think some women are "forced" to have this screening to get the Pill.
Did you know 1000 women need to have regular cervical screening for 35 years to save ONE woman from cervical cancer? I wonder how many women are harmed in that time with false positives and unpleasant follow-up – colposcopy/biopsies? (Dr A. Raffles, cancer screening expert)
Did you know almost 78% of women will have a colposcopy & possibly biopsies during her screening lifetime, but only a very small number will have any sign of malignancy. (L. Koutsky, Cancer Prevention Fall 2004, Issue 4)
In an unscreened Australian population, 1.58% of women will get cervical cancer….
Does this Test pass your risk v benefit Test?
Good luck everyone!
Elizabeth-
I’ll have to disagree with you on this one, as will most of the medical community in both our countries.
The value of pap smears as a screening tool has been proven and is an accepted axiom. One can argue the frequency can be lower, and we are beginning to move towards that in low risk women, but cervical cancer screening remains a cornerstone of women’s health care.
One of the reasons why we have such low cervical cancer rates as opposed to, say, breast cancer rates, is because pap smear is such an effective tool for screening and because treatment exists in the precancerous stages.
Avoiding screening is a game of chance. The odds are generally in your favor, but that’s not a game I’m willing to play with my or my patient’s lives.
Thanks for reading.
If you do not want a chaperone – or do not feel comfortable with one – then say so. It is important to get medical treatment – but not at the expense of your dignity or safety.
I don't agree with the idea that avoiding screening is somehow irresponsible or a game of chance.
I think the decision to screen is a matter for every man and woman.
There are negative outcomes with every screening test.
In some cases, screening may be a game of chance. I know many screening tests are unreliable and can jeopardize our health.
High risk people will view it differently to low risk people.
I don't agree with general recommendations…I make up my own mind.
I've been unable to get information from my Dr…so I've spent a lot of time doing my own reading.
I will accept some screening and refuse other tests.
I can only make the best decision with the evidence in front of me.
I'm not prepared to accept my doctor's advice as I've found she generally just presents a positive assessment and glosses over any negatives.
I don't feel comfortable with that approach.
All cancer screening has negatives and positives and we all have different risk factors in our lives.
Like a prostitute would be high risk for cervical cancer and a smoker high risk for lung cancer.
After returning from Amsterdam last year, I have stopped having smears and will follow their guidelines.
I was impressed with the information I received in that country…they have far fewer smears and much less investigation and fewer incorrect test results.
I was told having smears too often or when you're very young is not a good idea and usually leads to colposcopy.
I was also told that one in 13 smears taken from women under 25 lead to colposcopy. That figure frightened me. Cancer in that age group is very rare.
I think it might be time for our doctors to have a fresh look at cancer screening and gyn exams.
As a result of this new knowledge I have also decided not to have any more annual gynecological exams. I realize now they are not done elsewhere and for good reasons.
I think there are better ways to protect our health…much better ways.
Thank you
Sarah Y –
Not sure where your numbers are coming from, but I don;t think even the womoen in Amsterdam have forgone Pap smears entirely. In the US, we ahve guidelines that allow for paps every 3 years if they ahve been normal in the past or if HPPV is negative, and in adolescents have stopped recommending colposcopy for low grade lesions, and in older women are beginning to follow CIN2 rather than treating. SO the trends are all in the right direction in terms of backing off on aggreessive management of low risk lesions. That said,pap smears have lowered the incidence and death rates from cervical cacner in countries where they are offered. That is indisputable. don't be so quick to thriow the baby out with the bathwater.
Thanks for reading.
Sorry Dr, my post must have been confusing.
I didn't mean to suggest Dutch women have forgone screening altogether…but there are lots of differences which mean fewer smears, false positives and biopsies.
No screening at all before age 30.
That's why I've stopped having smears, I'm 25 and started having smears at 20. My Dr refused to give me birth control unless I agreed to a gyn exam and smear every year.
I was told it is unethical to screen women under 30, as the risks of the test are very high for young women and the risk of this cancer extremely low.
I was also told the smear often doesn't pick up the very rare case of cancer in a young woman…they often get a false negative test result.
I have some references that were given to me…I can post them. (I don't have them with me at the moment)
At 30…your risk is assessed and some very low risk women choose not to have screening.
My Aunt and Uncle were virgins when they married and I know my Aunt has chosen not to have smears.
Other women have 5 yearly screening, so the most pap smears you'll have in your lifetime is 7 and some women have fewer than that…
I was shocked when I compared that to our recommendations.
Also, virgins are not screened at any age.
Our recommedations seem to suggest that even virgins should start having pap smears at 21….but the Dutch doctor said that must be incorrect.
On my reading, it seems to say that…and I certainly know women who were screened when they were still virgins.
In this country, doctors refuse to prescribe birth control pills unless you agree to pelvic exams and annual smears.
Now that I know that gyn exams are not done elsewhere and for good reasons, I don't want them…
My Dr insists on yearly pap smears…many of my friends face the same problem, even those in their 30's that have had many normal results.
We don't have a choice, if we refuse the pelvic and pap, we are refused birth control.
The risks of an unplanned pregnancy are much greater than not having exams and annual smears that are not even recommended elsewhere.
I think the situation in this country is very unfair to women and very likely to damage our health.
I'll have to use the HOPE program at Planned Parenthood in the future.
It is the only place that will give me options…no smears at all or having them every 5 years from age 30…
I haven't decided yet, but won't be following our recommendations.
I think this test is difficult for many women and we shouldn't be forced to have it more than absolutely necessary.
I feel like my body and rights are controlled unfairly by doctors in this country and that women have no rights at all and can be denied something as basic as birth control.
Dr, thank you for listening…
Do you also refuse your patient's birth control if they don't want a pelvic and pap?
Would you allow someone to use a foreign program that called for fewer paps and no gyn exam?
(They have less cancer than us and far fewer women have false positives and biopsies)
The mention of Amsterdam caught my attention.
Their recommendations are very different to ours.
One group that is rarely addressed in this country.
Virginal couples.
Yes, we do exist!
A doctor in the Netherlands told me I don't need to worry about smears.
This cancer is caused by a sexually transmitted virus and you can't catch it from a virgin.
Testing could in fact, be a very bad idea for me as testing often produces very worrying incorrect results that lead to colposcopy and biopsies. (the doctor's advice)
My doctor in this country recommends screening for all women including virgins.
Who are you to believe?
I certainly don't want this test if its not really necessary and I would be VERY unhappy to have treatment that was unnecessary.
When the advice is so black and white, it leaves the woman in a dilemma.
I've chosen not to have smears so far…
I have noticed many of my friends have had abnormal results that turned out to be nothing.
I don't want to go through that.
It would be helpful if there were worldwide recommendations.
Why are our recommendations so terribly different to other countries?
It's almost like we're talking about another disease entirely.
These countries don't have higher rates of cancer…in most cases, their rates are lower.
Dr, What is your advice to a virginal couple. (the forgotten ones)
Thank you for your time.
Talking about recommendations being different.
I'm an Australian woman who'll be living in the States for a couple of years.
I spent a few months in your great country in 2004.
During that stay I was very surprised at the vastly different recommendations.
The routine stirrup (gulp!)
yearly gyn exams that most of you have…not done or recommended in my country.
Routine breast exam…my doctor does not recommended them until I'm around 40
Smears…not recommended until I've been sexually active for about 3 years and then 2 to 5 yearly. The recommendation is 2 yearly however, my doctor believes that is too often for low risk women.
She'll probably recommed 5 yearly for me (starting in a couple of years)but the final decision will of course, be mine.
My Dr will still give me the Pill whether I have smears or not. Her only requirement is a blood pressure test.
I'm currently 29 years old.
I can't imagine having complete gynaecological exams every year from age 18 or younger.
One of my colleagues was refused the Pill or her repeat, until she had a pelvic, rectal and breast exam, smear and a mammogram.
I was amazed that all of that could be made a mandatory requirement for the Pill.
That would never happen in my country.
Given my doctor does not recommend these exams at all…I've decided to use HOPE at PP so I can get the Pill with a BPT (the same as home)
I guess we don't question what is the practice in our own country…but its certainly surprising that our doctors disagree on almost every thing.
Clearly, medicine is not black and white.
Perhaps, your doctors are more thorough and ours are more relaxed.
Who knows?…but I'm quietly relieved my future doesn't include a whole lot of routine and very intimate exams.
Okay, comments are closed on this post. It has somehow turned into a forum for folks who think pelvic exams or pap smears are unnecessary,That kind of talk gets no support here. Get your pap smears and exams, ladies. Here are the guidelines from the US PReventive Services Taskforce – They are what I follow. Thanks for reading!
U.S. Preventive Services Task Force
Screening for Cervical Cancer
Release Date: January 2003
Summary of Recommendations / Supporting Documents
Summary of Recommendations
The USPSTF strongly recommends screening for cervical cancer in women who have been sexually active and have a cervix.Grade: A Recommendation.
The USPSTF recommends against routinely screening women older than age 65 for cervical cancer if they have had adequate recent screening with normal Pap smears and are not otherwise at high risk for cervical cancer (go to Clinical Considerations).Grade: D Recommendation.
The USPSTF recommends against routine Pap smear screening in women who have had a total hysterectomy for benign disease.Grade: D Recommendation.
The USPSTF concludes that the evidence is insufficient to recommend for or against the routine use of new technologies to screen for cervical cancer. Grade: I Statement.
The USPSTF concludes that the evidence is insufficient to recommend for or against the routine use of human papillomavirus (HPV) testing as a primary screening test for cervical cancer. Grade: I recommendation.
I realized, thanks to Dr Sherman at the blog Medical Privacy, a Patient Oriented Discussion, that I may have offended some of you by closing comments on this post.
My decision was not made in response to the comments you see here, but to the many comments I was getting offline that, as a physician, I could not responsibly publish becuase they contained too many medical inaccuracies and I just did not have the time to respond to every one of them.
Clearly the topic of pelvic exams can lead to heated discussion, and you are free to take that discussion wherever you can find a blogger who has the time to host it.
As for the last commenter up there, I apologise for not answering your coment, and realize that my closing the comments looks like a diss. I apologise. I had had at least 4 offline comments that day in addition to yours, and that was what led to the closing of the comments. If I may answer your question now – I assume you are a virgin and asking if you need pap smears. If you are just a technical virgin (ie, you've done it all but intercourse), then I would definitely do a pap. If you really are a virgin in all aspects, one could make a case for forgoing paps.
However, there really is little risk of overtreatment due to a false positive pap if you are a real virgin now that we are using HPV status to triage. The group getting all the intervention are the women with HPV infection and mildly abnormal paps (LGSIL, ASCUS and CIN1). That's where guidlines are probably going to change, allowing us to monitor more of these owmen rather than subject them to treatment. I'll welcome that change.
Thanks again for reading, and one again, I apologise if I've offended anyone.
HI!
I belong to a womens group FULL of American women who have been utterly traumatised by FORCED pap smears and pelvics. Many of them are suicidal, most have stopped going to doctors for any treatment (gynaecological or not) at all. They live on herbal remedies and whatever they can think up themselves. This is the result of 'good American health care' where women are told they should accept being invasively violated by uncaring, over-controlling doctors.
Women in my group are refused care when they are pregnant because they say no to a pelvic exam. They can't endure it. There are currently two women who are pregnant who suffered sexual abuse and rape as children, and they cannot get any kind of prenatal care – at all! ZIP! They have tried many things to help them get over their fear of being violated 'down there' by anyone other than their caring husbands, but they can't. Is this a good reason why they should be left out in the cold and refused medical care? NO WAY!
How is forcing women who have been raped or abused to undergo intimate exams that leave them feeling suicidal, caring for their health? Does how they are left feeling mentally mean nothing? From comments made by you and most other doctors – thats a whopping big YES!
"Okay, comments are closed on this post. It has somehow turned into a forum for folks who think pelvic exams or pap smears are unnecessary,That kind of talk gets no support here. Get your pap smears and exams, ladies. Here are the guidelines from the US PReventive Services Taskforce – They are what I follow. Thanks for reading"
Quite simply, those guidelines are WRONG. No woman needs a pelvic exam unless they are showing signs and symptoms that something MAY be wrong down here. Period.
Women who are pregnant who say no to pelvics are refused ANY medical care. Women who simply want birth control, who refuse pelvics (a pelvic exam does nothing to show if it is safe or reasonable to be on the pill at all, monitoring blood pressure is the biggest thing to worry about), are refused a prescription for the pill. Other women are offered the proviso that they can't get the pill unless they have a pap smear every year. They are held to ransom. Pap smears have NOTHING to do with the pill!!
What on earth is going on over there?!
Thank God I live in Australia where the notion of being forced to undergo an invasive gyno exam EVERY YEAR is considered a laughable notion. So is the mantra, 'you must have a pap and a pelvic or else you will not be prescribed the pill'. Insane!
America is living in the dark ages with regards to gynaecological care for women, and I don't see that anything will change any time soon.
Before you say I'm crazy or don't know what I'm talking about, I may not be a doctor, but I am a fully qualified biologist (I used to work for the Australian Government Laboratory) who was raped by a female gynaecologist and forced to live with menorrahgia that was leaving me anaemic and unable to be away from the toilet for more than 20 minutes, because even the best tampons and pads couldn't stop blood from soaking through my clothing and running down my inner thighs.
I was refused help because any treatments would make me infertile, but I do not want children, never have since a very young age, and when I pushed for help I was digitally raped and abused and violated by the gynae I saw and I asked for help from.
I went searching the net for the stories of other women who have had bad gynae treatment, and I found an absolute minefield of horror of what American women are forced to put up with.
The above statement you made on your blog – and shutting it down when women who had been abused started speaking up and saying it is wrong to force pelvics and pap smears on women – is a disaster, and illustrates very well the mindset that American doctors have towards women. Disgraceful.
Thank you for your time,
Phoenix
Phoenix –
Thank you for your thoughtful comments. As you know, I respectfully disagree, but do recognize that some women have emotional issues of history of abuse that makes pelvic exams difficult for them. I like to think I handle such women with sensitivity in my practice, and in fact, am often referred such patient because I have that reputation.
I have no issue if you’d like to create a blog for women such as yourself to gather and discuss the issue further – but I have decided that my blog would not be that place. This is not the only post where I have shut down comments. Comments are fine when they relate to the initial post, but once it becomes more of a forum for gathering of folks with a single point of view, then I think it is time to move on.
I will post your comment and my response and let it stand at that.
A pelvic exam is rape.
“Discomfort/pain, shame/embarrassment, and/or a feeling of being violated, as a result of penetration of the sexual organs by a person in whom a woman has no sexual interest, achieved through coercion, fear, and/or intimidation.”
http://agalltyr.wordpress.com/2010/11/28/a-pelvic-exam-is-rape/
It seems like this issue is heating up in the States.
“Women after birth control get unneeded pelvic exams” appeared in the paper recently and is it my imagination or are more American doctors calling for the Pill to be made available with a blood pressure test (as it is in Australia and the UK and much of Europe) also, some are pushing for over-the-counter access.
I also find it hard to understand how a Dr (speaking generally) could consider a woman doesn’t have a choice about cancer screening. I’m currently reading an excellent book by Dr Gilbert Welch, “Over-diagnosis” – he’s made an educated decision not to have prostate cancer screening, can you imagine a Dr telling him he MUST screen or refusing him unrelated medications UNTIL he has prostate cancer screening? It would never happen and doesn’t appear to happen to American men, the coercion appears to be directed only at American women. The thing that puzzles me about that – you have so many female doctors, yet they haven’t changed paternalistic attitudes, but seem to have adopted them.
Our doctors don’t recommend well-woman exams at all unless you have symptoms of some sort, if you need STI testing, you’re offered a blood and urine test and might need to provide a self-sample swab.
Pap tests are on offer for sexually active women – that’s the other astonishing thing, you recommend testing of all women from 21, another example of paternalistic attitudes – “let’s assume all women have had sex or been sexually active by 21″….wow! Surely you’d give women the facts and let them decide.
In fact, 21 is too early…
“No country in the world has reported a decline in the incidence of or the mortality from cervical cancer in women under 30, irrespective of cervical cancer screening. Many countries do not perform cervical screening on women under 30”.
Taken from “Cervical cancer screening” pull-out guide for doctors, “Australian Doctor” 2006 by Assoc Prof Margaret Davy, Director, Gyn-oncology, Royal Adelaide Hospital & Dr Shorne, GP.
Yet research shows women under 30 produce lots of false positives, so there is a high potential for harm, fear and worry for no benefit.
Older women who want to screen should look at their level of risk and screen at an interval that reduces the risk of false positives.
The Australian program is also seriously out-of-date and many women (who want testing) are turning away from it – my friends who test are doing so at 3 or 5 yearly intervals from around 30. Our Govt is going to change the program to 3 yearly from age 25 (apparently) later this year. The delay is inexcusable and has resulted in a lot of unnecessary anxiety and harm to previously healthy women.
I don’t test at all – I simply believe cancer screening has been oversold to women and rarely lives up to expectations. I protect myself from this very small risk by always using condoms and sticking with the same partner. (he always used condoms with his previous partner) I don’t worry about rare cancers or common cancers for that matter, I just do what I can to stay healthy and get on with life. Personally, I love condoms – I’ve never had a UTI and put that down to condoms. There was also an American study that showed the risk of HPV is reduced by 70% with consistent condom use, maybe higher with perfect use. That’s a major benefit if you’re worried about this cancer.
It’s suspicious that women are still being sold the pap test, such an unreliable test – over these decades there have been self-test kits invented that are used in many countries and the cervical specific antigen blood test was patented in the States in around 2002, but was then apparently, blocked – you wonder whether vested interests keep the pap test in the market – all the false positives mean more money. I hope I’m wrong…
Of course, American women, even with a blood test instead of a pap test, will still have to find a Dr who practices evidence based medicine – healthy women just don’t need routine pelvic or breast exams, every exam and test exposes you to risk – why accept any risk if there is no real benefit?
I think more American doctors are questioning the need for all of these routine pelvic and breast exams and that’s a good thing for American women.
I do not trust OBGYNs like you…
Like at what you “doctors” have done to women. Are you blind?
As obstetricians you humiliate pregnant women to lie on their backs, despite all evidence showing this is harmful for the woman (decreases her pelvic size). The position justifies for her to be violated by you physicians via episiotimes and pelvic exams – all so unnecessary and degrading during birth but so lucrative and sadistically pleasurable for the obstetrician.
Honestly, when will you “doctors” admit that you have been abusing women this whole time? The midwives had it right the way they do not treat 98% of pregnancies like a disease. They encourage women to walk around, do lunges, etc. Anything but lie there spread eagle in the “stirrups”. Now this practice has been adopted by more female physicians who call themselves “feminists” Pffffft.
Anyway, the fact that you people harm pregnant women, and the strategies you use to “help” women during birth is already enough for me to simply know not to trust your other field of practice, including gynecology.
You tell us “Get your pap smears and exams, ladies.”
Do not tell another grown woman what to do, “Doctor”. Never do that again. You are not our parent who can change our diapers whenever she pleases. Stop that authoratative tone.
It is always about information and free will. We can get both of these things without your demands for us to respect your field of practice. We do NOT have to agree with your field of “caring” for women.
The CDC has finally issued a statement that it no longer supports pap smear screening, saying that it has caused more harm than good.
This has always been obvious to me.
Have fun with your so-called job.
The truth is emerging – listen up American women – see comments by Dr Carolyn Westhoff in “Questioning the value of the routine pelvic exam” also, “Is the routine pelvic exam obsolete?”
The exam is not recommended at all in symptom-free women in many other countries. I was disturbed to read recently of an American teenager who was sedated for her first routine pelvic exam, necessary because she wanted to play soccer. (???)
I cannot believe this is how girls and women are treated in the States. Where are your feminist leaders?
No woman needs routine pelvic exams and to sedate a teenager for that purpose should amount to professional misconduct. It would in the UK and Australia.
I agree!!! I live in ireland and unless you have symptoms they dont give you a pelvic exam and pap until you are 25! So i was shocked when i found out my 13 year old cousin was sedated for a pelvic exam during a back to school physical!!!!