Information and updates about pelvic exams: Daniel A. Summers, M.D.
Over the past ten years or so, there have been a lot of changes and advances in how to detect diseases in the reproductive system. Until recently, sexually transmitted infections (STIs) were diagnosed by taking a sample from a woman’s cervix, which required a pelvic exam. There is now a urine test, which generally makes a cervical swab unnecessary. Also, it used to be recommended that all women have a pelvic exam and Pap test as soon as they started having sex. It was thought that Pap tests done as soon as possible would help find and treat cervical cancer at its earliest stages. However, with time it has been shown that starting Pap testing too early can lead to unnecessary tests and procedures. The current recommendations are for women to start having Pap tests at age 21, with women 21 or older who have not yet started having sex waiting until after they first have sex.
With the ability to detect STIs without a pelvic and the new recommendations about Pap smears, there are far fewer reasons to perform a pelvic exam on young women who are without any complaints. With rare exception, young women who have not yet started having sex do not need pelvic exams. Adolescent girls who have been sexually active but are without concerns also probably do not need a pelvic exam. However, certain problems (including vaginal discharge, pelvic pain or pain during sex, irregular or significantly delayed periods, or abnormal vaginal bleeding) may prompt your provider to recommend a pelvic exam. Starting oral contraceptive (or “birth control”) pills is not a reason for a pelvic exam.
If your provider feels a pelvic exam is indicated during your visit, he or she will take the time to explain the reasons for the exam, and will be sure to answer all of your questions.
The pelvic exam (also known as a gynecological or “gyn” exam) is an examination of a woman’s reproductive system, including the external genitals, the vagina, the uterus and the ovaries. It is often performed on women as a routine part of their health maintenance, but sometimes is a part of acute visits when there is concern about a problem in the patient’s reproductive system. Exams can often be done along with the rest of a complete physical exam, though sometimes a separate appointment is scheduled.
There is often confusion about the difference between a pelvic exam and a Pap test (or smear), which aren’t exactly the same thing. A Pap test is often part of the pelvic exam, but there’s more to the pelvic than just the Pap. In the Pap test, the person performing the exam takes a sample of cells from the patient’s cervix (the opening between the vagina and the uterus) using a brush or other instrument, and these cells are sent to a lab to be examined by a special doctor who checks for signs of cervical cancer.
If your provider thinks a pelvic exam is indicated, he or she will probably do it in several steps. It is typically performed with the patient’s feet in footrests, with the patient’s bottom at the end of the exam table. (This can feel odd or uncomfortable, but your provider will do everything he or she can to make you feel as comfortable and at ease as possible.) Usually the first part of the exam is an external inspection, when the provider looks at the external genitals (the labia, clitoris and outer part of the vagina) to make sure that everything appears normal and healthy, and there are no signs of infection.
There are two more parts of the exam, with the order varying by provider. One is the bimanual exam, which is called that because the provider uses both hands during this part of the examination. The provider may start by inserting one finger into the vagina and putting gentle pressure on the back of the vaginal wall, which sometimes gives patients a sense of the muscles to relax for an easier exam. Using one or two fingers, the provider checks the position of the cervix, and may move it slightly from side to side to check for any pain (which is sometimes a sign of infection). Next, he or she checks the position of the uterus, and also presses gently with a hand on the outside of the abdomen to check for pain. Finally, the provider checks for pain or enlargement of the ovaries on either side of the uterus.
The last part of the exam is done with an instrument called a speculum, which your provider can show and explain before your exam. The speculum is gently inserted into the vagina, with its ends positioned around the cervix, and then carefully opened. This allows the provider to see the lining of the vagina and the surface of the cervix, and to collect samples of vaginal fluid if needed. (It is during this part of the exam that the sample for a Pap test is done.)
It shouldn’t be painful. Many women describe a feeling of pressure, particularly during the speculum portion of the exam, and some find it a bit uncomfortable. However, your provider will take steps to explain each part of the exam as it is happening, and will make every effort to reduce your discomfort.
As an additional means of insuring patient comfort, many male providers have a female member of the clinical staff present in the room as a chaperone. Young women who would feel more comfortable with a friend or family member in the room as well are encouraged to have them present.
You may be under the impression that you need a referral to a gynecologist in order to have a pelvic exam. We’re glad to clarify that reproductive health care, including pelvic exams, is available at CMO. Drs. Winterkorn, Summers, and Poulter, as well as all of our PNP’s, are glad to provide these services to our patients. Dr. Summers has subspecialty training and certification in Adolescent Medicine, and is particularly interested in the care of teenage patients. Appointments for pelvic examinations can be made with any other these providers.
In cases where patients have complicated or chronic reproductive complaints, referral to a gynecologist may be an appropriate part of managing their care. However, most patients can have their reproductive health care needs managed at CMO.