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July 18, 2019

A Complete Guide to What Happens During a Pelvic Exam

Image by Yona

Today’s topic: the dreaded pelvic exam and pap smear.😳 Whether you are a pro or anxiously awaiting your first exam, here’s what happens during a pelvic exam.

Are you avoiding your pelvic exam? You aren’t alone… In 1988, about 42% of those aged 15 to 20 had a yearly gynecologic exam, but by 2017 that number had dropped by half, to just under 22%, according to researchers from the U.S. Centers for Disease Control and Prevention. And for women aged 21 to 29, the rate fell from about 75% in 1988 to 56.5% by 2017.[1] Some of this decline may be related to more relaxed cervical cancer screening guidelines, but getting out of the yearly habit makes us more likely to forget altogether.

With this said, there are many reasons patients avoid having pelvic exams, in one particular study it concluded that people who have been survivors of sexual assault are less likely to submit to regular pelvic exams, making it more likely that their cancers and diseases are caught at late stages. And let’s be honest, exposing private parts of your body and the fear of the unknown is uncomfortable and anxiety producing. Besides the foot rests or “stirrups” are just plain strange. [2]

But, pelvic exams and pap smears are important to help maintain gynecological health, screen for sexually transmitted diseases (STDs) and cancer. It is expected that your physician will walk you through the exam each step of the way, ensuring your comfort at each step. If this isn’t happening — speak up!

Lady Parts Dictionary

Pelvic exams involve a variety of external and internal sex organs. Here’s an easy review of what your doc is checking out down there. First they start with the external exam and then move to an internal one.

External Organs

  • Clitoris: spongy tissue located at the top of the vulva (becomes swollen when you are turned on)
  • Labia (majora and minora): folds of skin around your vaginal opening (fleshy and can be covered with pubic hair)
  • Opening to the vagina (introitus): located right below urethral opening (main attraction)
  • Opening to the urethra: located below clitoris (tiny hole where urine exits)
  • Bartholin’s glands: glands that release fluid to lubricate your vagina when you are turned on (these can get swollen and infected)

Internal Organs

  • Vagina: Attaches vulva to the cervix and uterus (Menstruation and babies exit during here and the opening is used for penetration)
  • Cervix: Lower part of uterus that has a small opening which connects the uterus to vagina (scraped for cells during pap smear; dilates and thins during childbirth)
  • Ovaries: stores eggs and makes hormones
  • Fallopian tubes: carries eggs from the ovaries to uterus
  • Uterus aka the “womb”: stores the fetus while it is developing

Prep before the pap and pelvic exam

Preparation for your pap smear and pelvic exam is simple. Make sure that you have an empty bladder to ensure that your doctor is able to get the best view and you won’t feel like you have to pee throughout the entire exam. [3] Avoid sexual intercourse, douches, tampons, or anything in the vagina (including medications) for 48 hours prior to your exam. This is important because they may interfere with the accuracy of the screening tests. [4]

The basics of what happens during a pelvic exam

Pelvic exams are performed to evaluate pain, bleeding, and vaginal discharge, to screen for cervical cancer and sexually transmitted infections. [5] There are four components to the exam:

1. Examination of outer genitalia (the inspection)

To begin the exam, you will position your body so that you are laying on the table with your legs spread apart and feet resting on the foot pads. This position is known as the lithotomy position and provides a clear view of your pelvic region for the doctor. During this portion of the exam the doctor will observe the vulva and vaginal opening to search for signs of redness, cysts, discharge, warts or anything that looks out of the ordinary.

2. Pap smear (testing for human papilloma virus (HPV) and cervical cancer)

Next, comes the pap smear test which samples cells from the cervix to make sure there are no abnormal cells or cancer present. Pap smear gadgets aka the “speculum and sampling devices” help collect the cells.

The speculum is first inserted into the vagina to help separate the walls of the vagina for better visualization. Once they have access to the cervix they use a sampling device such as the spatula or brush in the picture above. The sampling device is wiped against the cervix to collect cervical cells to be sent to the lab for testing. You may feel pressure or a pinching feeling during the speculum being inserted or taken out, but it should not cause pain. STD testing may be performed at this time as well.

Pro-tip: Once the speculum has been taken out, it’s normal to experience some light bleeding.

3. Bimanual examination (taking a closer look)

You are almost done with your exam. The bimanual examination is when the doctor inserts their index and middle finger into the vagina. With the other hand, they will gently press down on the area they are feeling (you’ll be glad your bladder is empty). They are able to evaluate for tenderness, determine the size, shape, and position of the uterus, and analyze enlarged ovaries, fallopian tubes, ovarian cysts or tumors. [6]

4. Rectovaginal examination (rectum+vagina)

Depending on how the other examinations go you may or may not have this examination. A recto-vaginal exam allows doctors to examine and identify abnormalities in the pelvic area, most specifically those of the uterus and ovaries. It provides a better assessment by feeling deep inside the pelvis to determine the size and location of the pelvic organs. [7] This examination is performed by the doctor inserting their index finger into the vagina and the middle finger into the rectum and applying pressure. (Super awkward — we know…)

Why do I have to have pelvic exams?

Although it may seem like an inconvenience to get a pelvic exam, it is extremely important not only for your overall gynecological health, but for early detection of potential diseases, such as cervical cancer. Early detection can save your uterus and your life. So it’s important to pay attention to your body and schedule routine check-ups.

Pro tip: Not only are pelvic exams essential for early detection, but self breast exams can be too! Check out our blog post to learn how to accurately perform the exam.

What is the purpose of pap smears and STD screening?

Pelvic examinations enable tests not only help detect for cervical cancer like the pap smear, but your doctor can also check for some sexually transmitted diseases (STDs) such as chlamydia and gonorrhea. Many STDs such as chlamydia and HPV are asymptomatic (no symptoms) so when you think you are in the clear, you may just not be having symptoms. But that doesn’t mean they aren’t causing long term damage. Chlamydia can lead to infertility and HPV can cause cervical cancer. Having your annual pelvic exam can help you catch a sneaky STD that’s been lingering around and early detection can enable earlier treatment and cure.

When should I start getting pelvic exams and how often?

Normally your first pelvic exam begins when you turn 21 years old, but if you have vaginal pain/concerns, are pregnant or have been exposed to a sexually transmitted disease you should request an exam sooner.

If your pelvic exams have all been normal then current medical guidelines suggest that you have a pap smear and HPV testing every 3rd year for ages 21- 29 and every 5th year for ages 30–65.[8] If you have multiple sexual partners or are at high risk for STDs check with your doctor to see how often you should be seen.

Now you are ready to tackle your next pelvic exam! It’s okay to still feel anxious for your exam but now you know what happens during a pelvic exam and hopefully this guide alleviates some stress. The more pelvic exams you have, the less scary they will become.

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Sources:

  1. https://www.usnews.com/news/health-news/articles/2019-06-26/big-decline-seen-in-use-of-annual-pelvic-exam-by-young-women
  2. https://srh-bmj-com.unh.idm.oclc.org/content/38/4/214
  3. https://www-nejm-org.unh.idm.oclc.org/doi/full/10.1056/NEJMvcm061320
  4. https://www.cdc.gov/cancer/cervical/basic_info/screening.htm
  5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3101979/
  6. https://www.plannedparenthood.org/learn/health-and-wellness/wellness-visit/what-pelvic-exam
  7. https://www.verywellhealth.com/recto-vaginal-exam-514003
  8. https://www.cdc.gov/cancer/knowledge/provider-education/cervical/recommendations.htm