by Eileen Fitzgerald, M.D.
Many women dread their annual pelvic exam because they feel it is painful or embarrassing. Dr. Eileen Fitzgerald walks you through the basics of an internal exam to help you feel less apprehensive and more empowered.
Beginning at either age 18 or the onset of sexual activity, it is recommended that women have an annual pelvic (internal) exam. This may be included in a routine physical, as part of a family planning visit or, less ideally, as part of an exam for a specific problem related to the female reproductive system.
As with any medical exam, an internal begins with a thorough clinical history. This is best provided when you are fully clothed and sitting in a chair rather than laying on an exam table wearing a skimpy paper gown. Many offices will provide you with a questionnaire to fill out, which reduces some of the anxiety that a personal interview sometimes provokes. Either way, the information obtained is critical for ensuring an accurate examination and discussion of sexual health.
You'll be asked questions about when you first started to menstruate, and what your periods have been like with regards to timing, heaviness of flow, cramping, and nausea. You will be asked if you have premenstrual symptoms such as moodiness and irritability, bloating, and headaches. You'll also be asked to provide information about the menstrual history of other female family members. If you have premenstrual symptoms, the clinician will want to know what measures you take to relieve the discomfort (e.g. medication, exercise, rest, heating pads, etc).
Included in the history are questions related to any previous pregnancies, abortions, miscarriages, previous use of birth control, and present and/or future use of birth control and family planning.
It is important for your clinician to know if you have a past history of urinary tract infections or sexually transmitted diseases, such as herpes, chlamydia, gonorrhea, or trichomonas. You will also be asked if you've noted any problems with vaginal discharge, painful urination, abdominal pain, pelvic pain, or pain with sexual intercourse, any of which may be suggestive of active infection. You'll also be asked about any family history of breast cysts, breast canceror diseases of the ovaries, cervix or uterus.
You and your clinician should also have a frank and open discussion about the number of sexual partners, use of barrier protection during sexual activity, and sexually transmitted diseases. This is particularly important for adolescents whose information is often based on hearsay and who are unfortunately part of a population with a rapidly rising presence of HIV infection.
A sensitive clinician will allot time for questions about the impending pelvic exam. Being able to ask questions before the first exam goes a long way towards alleviating stress and discomfort--not only for the first visit but for all future ones as well.
Before the exam begins, you should be offered the option of having a chaperone present, regardless of the gender of the examiner. The chaperone could be a nurse, your spouse or significant other, or a family member. You may decide you are comfortable with the clinician alone, but it should be your decision.
Being told to relax while laying on your back with your legs spread apart seems rather silly. However, relaxation will make the exam much easier for both clinician and patient. A good clinician will help you to relax by telling you exactly what is about to happen before it does, a calm and sensitive manner, and a quality technique in the exam itself. Even simple measures such as providing cotton, rather than paper gowns, placing socks on the stirrups, warming the speculum, and hanging pictures on the ceiling can all help reduce patient anxiety.
The procedure itself consists of two parts; the speculum and the bimanual examinations. Although the speculum appears to be a 14th century device designed by men for torture of women, this is not true. In actuality, the speculum is simply a plastic or metal instrument used to keep the entry to the vagina open. This enables the examiner to visualize the cervix (the opening of the uterus) and perform any diagnostic procedures that might be necessary.
Although no two clinicians work in exactly the same way, the goal should be the same--to obtain accurate medical information in a nonthreatening and nonpainful manner. When I perform a pelvic exam, I explain exactly what I am doing. I encourage my patients to visualize whatever they find relaxing--laying on a beach, sleeping in on Sunday morning, or maybe warming themselves in front of a fireplace. Whatever works for them.
Once you are supine, we'll gently move your knees apart to optimize the opening of the vagina. You'll next feel the warmed speculum, first on the inside of your left thigh and then the right. Then the clinician will use gloved fingers to spread open your labia and then gently insert the speculum. You'll feel some pressure but it shouldn't hurt. If it does, say so right away. Many women find that pushing out with the muscles on their bottom helps relieve the pressure. Proper insertion of a speculum should not hurt--if you've had a painful experience in the past, you should discuss this with your clinician.
Once the speculum is in proper position, the cervix should be visible. The clinician will note its size and position, and then take a smear or scraping with a swab or brush to obtain cells for a Pap smear. Cultures are taken (with a cotton swab) for chlamydia and gonorrhea and smears made (with a cotton swab) for yeast and trichomonas. This is done even if there are no symptoms, because half of the women with these infections feel completely well. If there are spots suggestive of herpes then they are cultured as well. All smears and cultures are sent to the lab for evaluation.
The speculum is then removed and the bimanual exam is done. The clinician places one hand on the abdomen and then gently inserts one lubricated gloved finger into your vagina to examine the uterus for position, size, and presence of masses. The presence, size, and position of the ovaries is also noted. If you've requested a diaphragm for birth control, you'll be fitted for the appropriate size at this point in the exam. An optional rectal examination with a different finger of the same hand is then done if indicated.
This concludes the pelvic examination. You'll then be helped upright and asked to dress once the clinician leaves the room. After you're dressed, the clinician will come back in and should talk to you about the results of the your exam. If you've requested contraception, or if further testing or treatment for conditions found during the exam are indicated, these are now prescribed. You are given the opportunity to have all your questions answered and an appointment for a follow up is made if needed.
Laboratory results of cultures and the Pap smear should be available within a week. Many offices will relay a general message even if they are normal, but all offices should call if there is an abnormality.
The routine pelvic exam is integral to maintaining every woman's health. It should not be viewed as something painful and stressful, but rather as a way of ensuring that all is well with your reproductive system.
Many women dread their annual pelvic exam because they feel it is painful or embarrassing. Dr. Eileen Fitzgerald walks you through the basics of an internal exam to help you feel less apprehensive and more empowered.
Beginning at either age 18 or the onset of sexual activity, it is recommended that women have an annual pelvic (internal) exam. This may be included in a routine physical, as part of a family planning visit or, less ideally, as part of an exam for a specific problem related to the female reproductive system.
As with any medical exam, an internal begins with a thorough clinical history. This is best provided when you are fully clothed and sitting in a chair rather than laying on an exam table wearing a skimpy paper gown. Many offices will provide you with a questionnaire to fill out, which reduces some of the anxiety that a personal interview sometimes provokes. Either way, the information obtained is critical for ensuring an accurate examination and discussion of sexual health.
You'll be asked questions about when you first started to menstruate, and what your periods have been like with regards to timing, heaviness of flow, cramping, and nausea. You will be asked if you have premenstrual symptoms such as moodiness and irritability, bloating, and headaches. You'll also be asked to provide information about the menstrual history of other female family members. If you have premenstrual symptoms, the clinician will want to know what measures you take to relieve the discomfort (e.g. medication, exercise, rest, heating pads, etc).
Included in the history are questions related to any previous pregnancies, abortions, miscarriages, previous use of birth control, and present and/or future use of birth control and family planning.
It is important for your clinician to know if you have a past history of urinary tract infections or sexually transmitted diseases, such as herpes, chlamydia, gonorrhea, or trichomonas. You will also be asked if you've noted any problems with vaginal discharge, painful urination, abdominal pain, pelvic pain, or pain with sexual intercourse, any of which may be suggestive of active infection. You'll also be asked about any family history of breast cysts, breast canceror diseases of the ovaries, cervix or uterus.
You and your clinician should also have a frank and open discussion about the number of sexual partners, use of barrier protection during sexual activity, and sexually transmitted diseases. This is particularly important for adolescents whose information is often based on hearsay and who are unfortunately part of a population with a rapidly rising presence of HIV infection.
A sensitive clinician will allot time for questions about the impending pelvic exam. Being able to ask questions before the first exam goes a long way towards alleviating stress and discomfort--not only for the first visit but for all future ones as well.
Before the exam begins, you should be offered the option of having a chaperone present, regardless of the gender of the examiner. The chaperone could be a nurse, your spouse or significant other, or a family member. You may decide you are comfortable with the clinician alone, but it should be your decision.
Being told to relax while laying on your back with your legs spread apart seems rather silly. However, relaxation will make the exam much easier for both clinician and patient. A good clinician will help you to relax by telling you exactly what is about to happen before it does, a calm and sensitive manner, and a quality technique in the exam itself. Even simple measures such as providing cotton, rather than paper gowns, placing socks on the stirrups, warming the speculum, and hanging pictures on the ceiling can all help reduce patient anxiety.
The procedure itself consists of two parts; the speculum and the bimanual examinations. Although the speculum appears to be a 14th century device designed by men for torture of women, this is not true. In actuality, the speculum is simply a plastic or metal instrument used to keep the entry to the vagina open. This enables the examiner to visualize the cervix (the opening of the uterus) and perform any diagnostic procedures that might be necessary.
Although no two clinicians work in exactly the same way, the goal should be the same--to obtain accurate medical information in a nonthreatening and nonpainful manner. When I perform a pelvic exam, I explain exactly what I am doing. I encourage my patients to visualize whatever they find relaxing--laying on a beach, sleeping in on Sunday morning, or maybe warming themselves in front of a fireplace. Whatever works for them.
Once you are supine, we'll gently move your knees apart to optimize the opening of the vagina. You'll next feel the warmed speculum, first on the inside of your left thigh and then the right. Then the clinician will use gloved fingers to spread open your labia and then gently insert the speculum. You'll feel some pressure but it shouldn't hurt. If it does, say so right away. Many women find that pushing out with the muscles on their bottom helps relieve the pressure. Proper insertion of a speculum should not hurt--if you've had a painful experience in the past, you should discuss this with your clinician.
Once the speculum is in proper position, the cervix should be visible. The clinician will note its size and position, and then take a smear or scraping with a swab or brush to obtain cells for a Pap smear. Cultures are taken (with a cotton swab) for chlamydia and gonorrhea and smears made (with a cotton swab) for yeast and trichomonas. This is done even if there are no symptoms, because half of the women with these infections feel completely well. If there are spots suggestive of herpes then they are cultured as well. All smears and cultures are sent to the lab for evaluation.
The speculum is then removed and the bimanual exam is done. The clinician places one hand on the abdomen and then gently inserts one lubricated gloved finger into your vagina to examine the uterus for position, size, and presence of masses. The presence, size, and position of the ovaries is also noted. If you've requested a diaphragm for birth control, you'll be fitted for the appropriate size at this point in the exam. An optional rectal examination with a different finger of the same hand is then done if indicated.
This concludes the pelvic examination. You'll then be helped upright and asked to dress once the clinician leaves the room. After you're dressed, the clinician will come back in and should talk to you about the results of the your exam. If you've requested contraception, or if further testing or treatment for conditions found during the exam are indicated, these are now prescribed. You are given the opportunity to have all your questions answered and an appointment for a follow up is made if needed.
Laboratory results of cultures and the Pap smear should be available within a week. Many offices will relay a general message even if they are normal, but all offices should call if there is an abnormality.
The routine pelvic exam is integral to maintaining every woman's health. It should not be viewed as something painful and stressful, but rather as a way of ensuring that all is well with your reproductive system.