By Dr. P. Sarrel
Do you, like so many women, approach a visit for a gynecologic “pelvic “ or “internal” exam with dread and leave feeling annoyed that your concerns weren’t addressed? It doesn’t have to be like that. There are steps you can take to change the experience into something you approach with confidence and leave understanding more about yourself.
In these days of HMOs and managed care, the biggest problem is lack of time. Your family practitioner, internist, gynecologist, or nurse practitioner may be allotted only ten minutes per patient visit. That is not enough time for anything more complex than a very routine, well-woman examination. If you feel that you need more time, for example you have a particular worry or problem or new symptom, you can request a longer visit. Sometimes it helps to get the doctor’s last appointment of the day so there won’t be the time pressure of the next patient.
The preexamination talk is best done in the doctor’s office while you are still dressed, but this is becoming less common because it takes more time. Now the usual procedure is to have you undress and sit on the examination table for the talk. If this is your first pelvic exam or your first visit with this doctor you can ask to meet first in his/her office. Your request may or may not be accommodated. Some women feel so strongly about this that they decide not to see a particular doctor if he/she denies this request.
A study, done a few years ago, found that, on average, doctors interrupt within eighteen seconds of a patient’s beginning to describe why they are there. If you need to tell your doctor about a problem or about symptoms you must do it assertively and in a carefully planned, condensed way. You might wish for a friendlier, more relaxed atmosphere but that is, unfortunately, rarely available these days. So plan on getting down to “business” right away. If you have signs or symptoms to report, come with a written list or, better yet, keep a diary of your symptoms for a week (or, if related to your menstrual cycle, for a month or two months) and hand a copy of the diary to your doctor. She/he will be very impressed, and it can go with your medical record.
If you have questions, go with a written list so you don’t forget to ask something important. If the doctor uses a word you don’t understand, say so. If an explanation is unclear, speak up. This is your time, you are the customer and you deserve good service.
When it comes to the actual examination, you probably understand that there are two parts to it. First a speculum (usually plastic) is inserted in the vagina and opened. Then a pap smear is taken by scraping some cells from your cervix with a wooden stick. After the speculum is removed, the examiner “palpates” (feels) your uterus and ovaries to check for internal abnormalities.
The examination should not hurt, except for when the doctor presses on your abdomen to feel your ovaries; this might be slightly painful. If the exam hurts at any other time, say “ouch.” Your pain may be important information for the doctor. Unfortunately, some doctors may do an exam too quickly or not gently enough. Again say “ouch.” You should not put up with any unnecessary pain or discomfort.
We have some additional suggestions that may sound unusual to you but they really work to transform a pelvic exam into a very positive experience. Some health care providers, particularly nurse-practitioners, use these methods already. Others are likely to be receptive to these ideas.
1) Ask to have the “head” of the examining table elevated so that you are in an almost sitting up position. This way you feel less vulnerable and passive, you and the doctor can have eye contact, you can see what’s going on and can talk more easily. It does not compromise the doctor’s ability to examine you and, in fact, may make the exam easier by relaxing your abdominal muscles.
2) Ask to have no “drape” (sheet or paper) across your knees or, if one is put in place, push it down somewhat, between your legs, so you can see the doctor.
3) The next procedure is not something that needs to be part of every pelvic exam but we strongly recommend it for every woman at least once. Ask if the doctor has a mirror you can hold to observe the process of the pelvic exam. Better yet, bring a mirror (at least six inches across) with you. Hold the mirror inside one knee so that your genital area is reflected in it clearly.
Then ask your doctor to explain the process of the exam as it proceeds, including showing you any instruments. The ‘speculum” and the wooden stick or cotton applicator are usually the only instruments and if you have never looked at the instruments you will probably think, “Oh, those don’t look so bad at all. What I imagined was actually scarier than the reality.”
4) If you have never looked carefully at your own genitals you may not know what all the parts are. Feel free to ask. One of the most commonly misunderstood parts is the hymen. Did you know that all women still have some hymeneal tissue even after they give birth? With the speculum inserted and you holding the mirror, you should be able to see into your vagina. Shining lamp light on the area helps. If you have never done this, we highly recommend it. This part of a woman’s anatomy is often mysterious and poorly understood. You will probably be able to see your cervix (the bottom part of the uterus — also called the “womb”). You will see the pink, glistening walls of the vagina.
We have talked with literally thousands of women after a mirror exam and they are almost always extremely positive about the experience. The whole experience of a pelvic exam is changed because you really understand the procedure. A pelvic exam can and should be a positive experience. You can help make it one.