How to Do a Pelvic Exam
Posted by Rachel on June 28, 2007
New England Journal of Medicine has just added a video on pelvic examination* to its instructional series, “Video in Clinical Medicine” - unfortunately, it’s behind their subscription wall, but I wish you could see it. It’s not often that women get to see a pelvic exam from the other side of the thin paper drape, so if you have access to a NEJM electronic subscription through your library, I recommend checking it out. However, I’m going to try to describe some of the information presented (blogging as I watch), so you have a better idea of what exactly is going on during an exam.
Section 2, Indications, states that women should have a pelvic examination when they have:
-Vulvar or vaginal complaints, such as pain, discharge, abnormal bleeding, itching, and/or a mass;
-When pregnancy is suspected or proven;
-In women who have been exposed to sexually transmitted infections.
It also highlights the American Cancer Society’s recommendations for pap screening, listed here (scroll down to section on cervical cancer). The ACS guidelines mention that women who are older than 30 and have had 3 normal paps in a row can switch to every-three-year screening unless they have risk factors such as HIV infection; the NEJM video adds new sexual partners as another risk factor for screening more frequently.
Section 2: Preparation
Regarding patient history, viewers are instructed to ask women about their total number of sexual partners and sexual orientation. I have never, ever been asked by a physician about my sexual orientation, and am curious as to whether any of you have.**
I was pleased to see the instruction to ask women about prior discomfort during a pelvic exam, although I don’t think I’ve ever been asked that, either.
The preparation section also includes an equipment list - they forgot the instruction about “find the coldest piece of metal known to humankind.” 
Section 3, Procedure:
Did you know that one reason you should urinate prior to the exam is that “a full bladder may compress the vaginal canal and obstruct the view of the cervix?”
This section also provides the instruction to make sure the patient has been offered the opportunity to have a chaperone in the room during the examination. Are you generally offered this option? Do you want this option? I’ve had “chaperones” in the room without being asked, which I find disturbing.
On patient positioning - “You should be able to easily visualize her vulva, but still keep her knees covered.” Sweethearts, when you’re feeling up my boobs and poking around my vagina, the privacy of my knees is the least of my worries.
One qualm with this - the model patient is completely shaved. I’m sure that’s for video purposes, so it’s easier to see the woman’s anatomy while learning about the procedure. However, in the real world, this is not what many women are going to look like. How does that change how well the woman can be “visualized” on exam? How does presenting models in this manner shape those learning to perform the exams?
So, what are they looking at down there? According to the video, it’s the “entire vulva, perianal area, vaginal canal, and Bartholin glands.” I thought this was interesting, because I don’t think I’ve ever, ever heard the words “Bartholin glands” in an exam. [See the vulvar anatomy] Among the things they’re looking for are rashes, lesions, swelling, and trauma, as well as areas of irritation, discomfort, or pain.
The video then informs us that some of the more common findings include:
-Lichen sclerosus
-Vulvar dermatitis
-Vulvar ulceration
-Condyloma
-Vaginal varicosities (none of you mommy bloggers told me about this!)
[See list and description of "benign vulvar lesions," "vulvar problems," and "self-help tips for vulvar skin care."]
Hey! Wait! They just said to warm the speculum with warm water! C’mon, people, follow the instructions! Speculum goes in to a “depth of 4-5 centimeters,” in case you were wondering. Sure seems like more.
Oh! I wish you could see what the pap part of the exam looks like! There’s the cervix! Okay, so if you get one kind of pap test, it’s a wide brush that looks like a push broom that they sweep over the cervix. If you get the other kind, it’s a “spatula” (seriously, they call it that), followed by a small brush that looks more like something you would clean out an instrument with.
“A healthy adult vaginal pH is 4.”
“Trichomonads will appear to vibrate on the slide.”
“Let the patient know she may have a small amount of bleeding after pap smear sampling.” - Nope, don’t think I’ve ever been told that, either.
Next, the part where one hand goes in the vagina and the other goes on your belly - “The abdominal hand should be used to sweep the pelvic organs downward, while the vaginal hand is simultaneously elevating them.” This is for size, shape, and symmetry, mobility(!), position, and consistency(!!) of the uterus, and checking for appropriately sized, mobile ovaries. (Is “mobile ovaries” taken as a band name?) They’re also looking for “adnexal masses” (that would be a mass on the ovary).
Reasons for rectovaginal examination: assess retroverted uterus; screen for colorectal cancer; evaluate for pelvic pathology. The animation (used for the internal bits) for this is priceless, especially given the purple disembodied hands.
Section 4 is called “Troubleshooting.” What is there to troubleshoot about a pelvic exam? According to the video, “In obese patients, the cervix can be difficult to visualize, due to excess vaginal tissue.” The solution? Cut off the thumb tip of an exam glove, and slide it over the speculum like a sleeve. This gives the speculum two extra “sides” to hold the tissue out of the way.
Yep, apparently that’s the only troubleshooting that is needed. Hmm.
Section 5: Contraindications
Apparently, there are “relatively few,” including physical or mental disability, abnormal anatomy, or physical immaturity. Consider examination under anesthesia in the case of physical immaturity with an intact hymen. Delay if liquid-based pap is not available and the patient is “menstruating heavily.”
And that’s a wrap!
[Also, the Feminist Women's Health Center sells a self-exam kit for looking at your own cervix and vagina, with instructions.]
*Obviously you shouldn’t go running around performing pelvics on strangers just based on this blog post.
**None of my observations apply to my current pelvic exam provider, who is awesome.
June 28, 2007 at 7:18 pm
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June 30, 2007 at 12:26 am
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July 5, 2007 at 7:23 am
When I lived in MN and was having severe problems with my endometiosis, I was sent to four doctors in one day. The fourth and final doctor’s questionnaire was extremely detailed and included sexual orientation and a huge checklist for any activities I may or may not have been involved in. Even though I was in a lot of pain that day I wondered if any of the younger or shy patients would fully disclose the information expected on paper rather than in an interview. I understand they probably assumed it to be time-saving, but even as an adult I found the list somewhat embarrassing to read, much less fill out.
July 13, 2007 at 10:56 am
I think it depends on the person. Many people would probably rather do a paper checklist, then only have to talk about the things that raise a red flag, rather than having to answer sensitive questions face-to-face. One thing I dislike is going to the doctor and getting a paper form in the waiting room for whether I’m in pain or anyone has hurt me. That feels like something I want to talk about rather than check off.
July 19, 2007 at 8:32 am
In one midwifery class i was looking at (i think i’d be rushing things a bit if i just started taking midwifery enrichment classes while only a doula) there is a class on well-woman exams and in the last class you pair off and perform them on each other…
July 19, 2007 at 8:55 am
Connie - sounds interesting! I wonder if you get to pick your partner?
July 24, 2007 at 7:10 am
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August 7, 2007 at 3:54 pm
Wow, when you are hemorrhaging and walk into an ER and explain, between muffled screams, that you are miscarrying, they cut out all of the small talk when they do your pelvic.
I think “Dr. Big-hands,” my ER doc that evening, had just refreshed his pelvic-exam giving skills with this video. At least it felt like it. I don’t think he had done a pelvic exam in a long, long, long time.
I have always had a chaperon, even with my regular female OB doctor. They make it less obvious, however, by informing me a nurse is coming in to “assist.”
August 7, 2007 at 4:03 pm
MC, what do you think about that “assist” language, when the nurse is standing in a corner the whole time? I suppose they don’t want to say, “Nurse here is going to make sure I don’t do anything inappropriate with your woman parts.” “Assist” sounds much more pleasant.
August 7, 2007 at 4:22 pm
Well, if the nurse is just going to be in the room, they give her stuff to do so the “assistant” title is warranted. I guess when you are wrist deep inside someone, it can be a little awkward to have to reach for your own utensils and swab your own pap-smear slide.
My favorite, though, is when they TALK to said “assistant” as if you are not there with your knees splayed open. “So, how was you weekend? Do anything fun? Hey, can you pass me some more towels, she is REALLY bleeding? And did you like camping?”
August 20, 2007 at 4:49 pm
As far as the “option to have a chaperone” goes, I fully welcome having the “option.” The part I object to is when I have brought my chaperone with me and he is sent from the room so that some complete stranger can chaperone. The first OB/GYN I ever went to did this. He asked some nurse to come in a watch. I asked him what was wrong with my chaperone and he said “he’s male.” I said “yeah, but she’s your nurse and he’s my husband, so who do you think I’m gonna trust more? Forget it, exam over.” I left. Funny thing is, the hospital with which this doctor is affiliated called the next day to ask about my experience. He doesn’t work there anymore.
August 20, 2007 at 6:01 pm
Good for you, Maggie.
September 27, 2007 at 11:52 pm
Thank the lawyers for the chaperone. It is done to protect the examiner, not the examinee. Believe it or not, some women come with a male accomplice with the covert intention of suing the examiner for “improper touching”, whatever that is. A chaperone is not necessary in a relationship of mutual trust. Besides, most doctors have done it a thousand times and are not thrilled at the sight of female genitalia. There is always the exception, though.
September 28, 2007 at 8:31 am
Juanita,
Thanks for your comment.
November 1, 2007 at 9:32 pm
Surprisingly, most women I do paps on now are shaved. And hair doesn’t obscure anything, so I wouldn’t worry. I’ve been asked my sexual orientation or the gender of my partners. If they don’t know, how would they know how to assess my risk for STI’s and need for contraception. Most male providers will have a chaperone for their own sake. As a woman, I ask my patients if they would like one.
November 2, 2007 at 7:53 am
Rebecca, thanks for your comment!
December 4, 2007 at 4:23 pm
My wife was born in China and always ask me to join her when she is having her yearly exam and the doctors have had no problem wit me being there when she is being examined. Last Saturday when we went to a new doctor since the old one moved, my wife advised the doctor that she wanted me to be there while she had her exam. The doctor told her that this was against her policy. My wife then told her that I always accompany her and that she feels much more at ease since her English is not that good and she is very uneasy being there alone. However, I did leave the office as the doctor requested. Shortly afterwards the nurse came and told me to come back. My wife was not able to answer all the questions and refused to go on with the exam. Te doctor asked me why she was there and when I explained that she was there for an HPV test. which she had about 4 months ago and that we were told to get a new one in 4 months. The doctor responded that once you had a positive HPV test, it will always be positive and that it takes about 25-30 years before it possibly would develop into cancer and by that time my wife would be 75!. I told my wife to get dressed and we immediately left the office… My question to you is how do you find a really good doctor who has no objection to the husband being there as a chaperone as well as making my wife feel at ease since she is refusing to be examined without me being there?
Thank you.
December 4, 2007 at 4:34 pm
It’s hard to know in advance which doctors will be a good fit for you. However, you could certainly call the doctors’ offices (whoever she might want to see, your insurance covers, etc.) and explain the situation, and see who is agreeable to your being there, and make an appointment with them. Also, I wonder if your old doctor meant for your wife to have a pap test after 4 months because of the HPV result, and the new doctor just didn’t understand that?
December 4, 2007 at 4:37 pm
Also, I don’t think it’s correct that someone with a positive HPV test will always test positive.
December 4, 2007 at 8:59 pm
I’ve never had a rectal exam as part of the pelvic exam, although in your posting about Farrah Fawcet, one of the links recommends men over 50 have an annual rectal exam, adding this recommendation does not apply to women because they get the rectal as part of their pelvic.
I’ve had three children and five pregnancies and now have grandchildren. I’ve NEVER had a rectal as part of a pelvic. I’ve had a rectal three times in my life, and a colonoscopy twice. The second colonoscopy was at my INSISTENCE, where polyps and a diverticulitis were found.
It seems to me it’s the medical profession needs to pull up its socks here, not the consumer.
December 5, 2007 at 8:59 am
Ricky, you know, I’ve only had it once or twice with the pelvic. My mom’s doc does it every time. My current provider never does it. I wonder why that is?
January 5, 2008 at 8:22 pm
Rachel and Ricky-
A rectal exam is not necessary in an asymptomatic healthy young woman under the age of 50. Some providers will do it if a woman is retoverted - her uterus points to the back instead of the front - making it more difficult to palpate. As a health care provider to mostly young healthy woman, I do not do a rectal even on retoverted women because it does not really give me any vital information and women generally hate it. I know I did when I was on the receiving end. I think older providers were trained to do it regardless, so they are more likely to do it. Screening for colon cancer begins at 50 and that includes a rectal with the pelvic exam along with other tests.
Other issues-
As for shaved pubic hair…it is in fashion now and I see a lot of it, so that shaved model is actually an accurate reflection on what’s out there.
As for chaperones…more complicated than you think. Male providers have to have them for their protection, women providers don’t, which is a little silly if you think about it because women providers are just as vulnerable to false accusations as male providers. As a female provider I generally let patients bring whoever they want into the exam. But I’m leery of moms coming in with their daughters (daughter unlikely to be honest about sexual history)and male partners that seem just a little too possesive (potential abusive relationship). In those cases I like to take the health history alone and size things up, then they can come into the exam for moral support if truly desired.
Asking about sexual orientation…there is a place to check that on the intake form. It is best to not make a big deal over it. Sad but true, it can freak out the young heterosexual women to even be thinking about it let alone asking about it and they are the majority. Most of my lesbian and bisexual clients don’t need to talk about it and frankly it doesn’t change anything but need for birth control. Anyone can get an STI. If I happen to miss it on the intake form and I ask a lesbian about what she uses for birth control, she sets me straight (so to speak) and we just laugh at my mistake, it doesn’t seem awkward.
As for HPV lasting forever…old thinking. Now we know that HPV is very common, most women get it and it clears from their body fairly quickly. Even if it causes problems like abnormal PAP smears or genital warts, even though the abnormal cells on the cervix or the warts will need to be treated, the HPV virus will eventually clear…it doesn’t stay in the body forever. Unfortunately there are some people out there who are spouting the old information.
-a women’s health care nurse practitioner
January 5, 2008 at 9:55 pm
Women’s health NP, thanks for your insights, and for verification on the HPV issue. I think you’re probably right that older providers may have been trained to do the rectal regardless, because the only time I’ve had one do it, it was an older gentleman. I think you’re right about the chaperone issue, on both counts - I never understood why female providers wouldn’t have one as well, and think people are probably more honest when they don’t have a parent/spouse hanging over them. Thanks again!
January 7, 2008 at 3:13 pm
Vaginal ph is very important–interesting post.
January 18, 2008 at 10:04 am
1. My nurse asked me about my sexual orientation when I went in for a check up. Nothing overt, just if I was sexually active, and was it with men or women.
2. A recto-vaginal exam is also used to test for ovarian cancer, when patients present with symptoms (see: 2007 Consensus Statement on Ovarian Cancer). That, a Transvaginal Ultrasound and a CA-125 blood test are used to detect ovarian cancer.
3. I’m also about 95% positive (I can check) that HPV does not stick around forever - even the kinds that can cause cancer.
January 30, 2008 at 1:49 pm
Despite popular belief, HPV does not cause cervical cancer–this has never been concluded. Some strains (like type 16) are almost always associated with 98% of cervical cancers, but do not CAUSE cancer. Furthermore, the CDC statistics show that nearly 100% of all sexually active adults will be develop HPV infections at some point in their life. If HPV were the CAUSE of cervical cancer, there would be far more greater incidence and deaths due to cervical cancer. Persistant HPV infection of the cervix may increase susceptibility to cervical cancer, but in-and-of-itself, HPV DOES NOT CAUSE CANCER. http://www.FDA.Gov–look up HPV–you will not a find a single document that states a cause and effect, only an association, big difference.
The HPV hoax is designed to scare women into the stirrups every year, utlimately to provide an easy customer base for pharmaceutical companies to sell vaccines and unnecessary surgery, like colposcopy, cryo, leep and hysterectomy, the single most over-used surgery.
January 30, 2008 at 3:15 pm
Lisa, I’d refer you to http://www.cancer.gov/cancertopics/factsheet/Risk/HPV
February 21, 2008 at 12:50 am
Interesting posts and I’ll look forward to seeing this video. Sounds like some sensitive approaches. I am currently directing a film called “At Your Cervix” about the most ethical and empowering way that medical providers learn to perform pelvic exams–on Gynecological Teaching Associates. I’ve taught exams using my own body for the last 7 years, and some of the GTAs have done so for nearly 30! (www.atyourcervixmovie.com)
We teach rectal exams and they are NOT a throw away unnecessary part of exams. Providers typically do not offer them because they are squeamish about giving them or think their patients won’t want them. A rectal exam is the only way to check the underside of the uterus–which is very significant in retroverted uteri, but important no matter what. Lots of stuff can go on there and go undetected without routine rectal exams. There are also rectal structures which are checked and palpated during an exam. Recently, I was discussing these teaching methods with a rectal specialist who asked, “Why aren’t providers doing rectal exams? Women come to me with advanced cancers because no one is examining them and finding it.” Rectals are important and you can ask your provider to do one for you. Sadly, I once asked a provider and she did a horrible rectal that could not possibly have given her any useful information.
About sexual orientation. There is no need to ask what people’s orientation is–how they identify themselves in not what a provider needs to know. They need to know what BEHAVIORS a person engages in. So “Are you sexually active with men, women or both?” followed by other specific behavioral questions, would be a better approach to determine risks. I could call myself “heterosexual” and be engaging in other activity I don’t want to tell you about, especially since I’ve just identified myself heterosexual.
Thanks for all the posts.
February 21, 2008 at 8:09 am
Amy Jo, thanks for your comment. I’d love to see the film when it’s available.
March 10, 2008 at 6:50 am
Rachel, Unless you have the bare necessity for it, the doctor may not do the check up. If it is required then they will not ignore it. Else if you feel that taking one such checkup will be good, you can suggest to your physician and she will explain in detail or perhaps may do the check up.
March 11, 2008 at 8:44 pm
The 4-5 cm insertion of the speculum is simply not true! Why have a speculum with 4 inch blades if you only insert 2 inches?
April 3, 2008 at 6:10 pm
I see the midwife I used during pregnancy for all of my exams because I liked her so much. She’s a nurse practitioner so my insurance will cover it.
The main reason I go to her is because the first time I saw her and got an exam from her during my pregnancy, she asked me if I had ever been uncomfortable during a pelvic exam, or had anyone hurt me during a pelvic exam, and I said yes. She pointed out certain muscles for me to relax using a breathing exercise and the exam was not painful at all which was a first for me. Also, they use real sheets in the office instead of those disgusting paper things, and I was sold.
Also, I had seen four different gynecologists before her and not one of them had bothered to mention to me that my uterus tilted, and that my cervix is mis located. Thanks, docs.