Let’s be honest: gynaecological examinations are at the very least Very Very Uncomfortable. You’re lying with your knees up and spread wide. Your underpants off, your socks still on and your legs defenceless in the stirrups. ‘Just relax, ma’am’ is more difficult than it seems. Even though – as almost every patient website that explains the procedure insists – internal examinations shouldn’t hurt. Fact is that for some women examination by touching (feeling with the fingers) or looking with the help of a speculum (duckbill) is extremely painful and sometimes even downright traumatic.
Like a lady: legs decently crossed
Dutch doctor and sexologist Elise van Alderen – author of the enlightening Dutch book Wellust – is anything but surprised by this. ‘Women are socialised to be ashamed of their bodies, especially their vulva and vagina. This is reflected, for example, in products for ‘intimate hygiene’ or panty liners with fragrances. But you can also literally see it in the way women sit: with their legs decently crossed. So they don’t take up too much space, but also to cover the vulva and vagina. Many women find their own vulva and vagina dirty. They’re insecure and embarrassed by the way their vulva looks and by their vaginal discharge and menstrual blood.’
‘Legs wide open at the gynaecologist often means: loss of control’
For those who now think this is about others: ‘Put a finger in your mouth. No problem, right? Now put a finger in your vagina. Do you find that more difficult, uncomfortable or perhaps even dirty? Why? Isn’t it just another body orifice? If you have little knowledge about your vulva and vagina, and aren’t familiar with it, relaxing is difficult. In that case, having your legs wide open at the gynaecologist often means: loss of control. And if the vulva and vagina are only touched during sex, during the gynaecological examination this can also be seen as something – unwanted – sexual, which creates tension and the desire to protect yourself. The vaginistic reaction that can then occur – actually a contraction of your pelvic floor muscles – is actually a very good reaction from the body: you don’t want anything in your vagina.’
Apart from that, in many women the pelvic floor muscles are constantly very tense, which can make a gynaecological examination very painful, explains Van Alderen. ‘This can have a variety of reasons: sexual violence, pain during penis-in-vagina sex, a traumatic childbirth or even a very painful first insertion of a tampon. Whatever the cause of a tense pelvic floor may be, often women aren’t aware of their pelvic floor muscles. This means they don’t feel these muscles and can’t consciously contract or relax them. I therefore advise every woman who recognises herself in this to visit a pelvic physiotherapist to develop pelvic floor awareness. That way you get to know your own body much better, which can solve and prevent a lot of problems.’
Researching gynecological examinations
Quite strange: via Dr. Google you’ll find heaps of information about pain during sex (read: ‘pain during penis-in-vagina sex’) and what women can do to prevent this. But you’ll find very little about pain during gynaecological examinations and how women experience these examinations. That’s because not much research has been done into this. An exception to the rule is an Israeli study from 2020 among more than 6,500 women. Brief summary of the results: the internal examination was perceived as an embarrassing event by 47% of the participants, as painful by 35%, and as traumatic by 19%. Tragic is that only 43% of the respondents indicated they’ll inform the gynaecologist in case of experiencing any pain or physical discomfort during the examination. The rest keeps silent.
‘At least one in three women has bad experiences with gynaecological examinations’
Dutch social researcher Françoise Molenaar decided to conduct her own research, distributing questionnaires via her social media network. ‘Within a week I had 1,487 questionnaires back,’ she writes in a story worth reading in De Correspondent. Her findings appear to be comparable to those from Israel: ‘41% of my Dutch respondents perceive the gynaecological examination as embarrassing, 44% as painful and 23% as traumatic. Another 10% indicated they had received inappropriate questions or comments during the examination and 3% even experienced sexual harassment.’ Conclusion: ‘At least one in three women has a bad experience with a gynaecological examination: it hurts, the doctor makes rude comments, or a sexual trauma is triggered. Yet little attention is paid to this problem. This could be better.’
It should certainly be improved. Because there are quite a few moments in a woman’s life where internal examination is needed. For example with routine examinations for contraceptive questions, menstrual problems or vulvar and vaginal complaints (infection or STI), examinations that have to do with a child wish, pregnancy and birth, for the population screening for cervical cancer, etc. Internal examination is also needed if you want a (hormonal) IUD or require treatment against fibroids or polyps, heavy menstrual bleeding, gynaecological cancer or another medical condition that has to do with the female reproductive system.
Why does internal examination hurt?
Vaginismus & (sexual) trauma
If your vagina ‘locks up’ when something attempts to penetrate – or sometimes when it’s only pointing in the direction of the vulva -, this is called vaginismus. The pelvic floor muscles contract involuntarily, making insertion of a speculum, tampon, menstrual cup or penis – or even a cotton swab – painful and sometimes also impossible. Vaginismus can be the result of a sexual trauma or negative experiences in a previous physical examination, but this isn’t always the case. Once you’re afraid it’s going to hurt or won’t fit, relaxing your pelvic floor doesn’t get any easier.
Vulvar vestibulitis syndrome & lichen sclerosus
A vaginistic reaction isn’t necessarily ‘in the mind’. Sometimes the muscle tension reflex is the result of physical pain. In vulvar vestibulitis syndrome (VVS), the skin of the vulva feels burning and chapped, making touch and penetration difficult. The skin disease lichen sclerosus often means for women that the skin near the labia, the entrance to the vagina and the anus, is itchy and less flexible. With lichen planus, the mucous membranes in the vulva and/or vagina are inflamed. Vulvar pain can also be the result of an infection (bacterial vaginosis, candida) or an STI (chlamydia, HPV, trichomoniasis).
Tilted uterus & endometriosis
Anatomical abnormalities in the vulva/vagina can make it difficult to insert ‘something’. In at least 1 in 10 women, the uterus is tilted or tipped backwards. This isn’t always noticed, however, during internal examination this can give extra pain stimuli. Also endometriosis can cause pain during internal examination. The same applies to all kinds of other abnormalities and complaints in the pelvic area, such as prolapses, intestinal or bladder complaints, or even hip problems.
Also hormonal changes in and after menopause, causing the mucous membranes to become thinner, dryer, and less elastic, can lead to vulvar or vaginal pain. The medical term for these changes in the vaginal walls is atrophy.
Some women suffer from chronic vulvar pain or vaginal pain without having any anatomical or neurological abnormalities. The medical term for this is unexplained pain in the vulva is vulvodynia. And, oh the irony: to diagnose and rule out underlying health risks, a gynaecological examination is required. And with that, the vicious circle is round again.
What to do when you’re afraid of internal examinations?
- Relaxing is key. But that’s hard to do on command. It helps if the doctor creates a relaxed atmosphere. By chatting a bit before inserting the speculum, by taking the time (even if the consultation only takes 10 minutes), and by taking you seriously if you indicate that you’re in pain.
- It’s not a sign of weakness to ask for a female doctor if you think that’ll make you more relaxed.
- There are different sizes of specula. It might help if the doctor doesn’t grab the biggest duckbill right away. You could also ask to insert the speculum yourself, in your own pace.
- Speak up if you are in pain or scared. Preferably during the examination, but if for some reason you’re unable to do this, it’s also still possible to do this afterwards.
- Dress for the occasion. For example, by wearing a skirt, dress or long cardigan; clothes that you can keep on during the examination, which will make you feel less exposed and vulnerable.
- If you can’t handle it, ask for pain relief (vaginal suppository or anaesthetic cream). As a last resort it’s possible to have an examination under sedation.
4x Making a change
Pain doesn’t have to be a part of it. Even if this pain only lasts for a short while. In other words: discomfort and embarrassment surrounding internal examinations and/or fear of treatments at the gynaecologist deserve more attention. And please, someone come up with an innovative alternative for the dreaded duckbill!
1 Advice from the sexologist
Elise van Alderen: ‘There’s a lot you can do yourself to be more relaxed during a gynaecological examination. For example, it helps a lot if you’re already familiar with touching your own vulva and putting your fingers in your vagina. If not, you may experience a loss of control if someone else touches your vulva or vagina. Many women then try not to feel their vulva and vagina, but that creates tension. It’s precisely when you are aware of the touches that you can follow what’s happening and keep control.’
‘In addition, many women have attached all kinds of associations to their vulva and vagina over the course of their lives. They’re ashamed, feel discomfort, find it dirty or immediately associate touching these areas of their body with sex. If this is the case, practise touching your own vulva and vagina in a non-sexual way to make these associations disappear. Over time, you’ll simply experience your vulva and vagina as parts of your body, which they are. And that gives more relaxation.’
‘Bottom line is that the gynaecological examination isn’t something you have to endure passively’
‘Of course this doesn’t mean a gynaecological examination immediately and automatically becomes something without tension. It may help to bring someone you feel safe with, who’ll stay by your side during the examination. You can place your hands on your thighs or stomach to keep in touch with your body. And you can also achieve a lot with your breathing. For example, during the exam, try to imagine that you’re breathing in and out through your labia. This way you keep your breathing under control, you also continue to feel your vulva, vagina and pelvic floor, and it’s easier to indicate if you want something different, or want to take a break or stop completely.’
‘The bottom line is that the gynaecological examination isn’t something you have to endure passively. You can be in control yourself by feeling your body, always checking if it feels okay, and indicating if this isn’t the case. The doctor who conducts the examination shouldn’t force anything, but simply follow your feelings.’
Social designer Zoë Sluisdom of the Department of Extraordinary Affairs is working on Nomi: an information package with practical tools that can give women who have to undergo an internal examination more autonomy. Are you a healthcare provider and/or do you want to know more about this research project? Then take a look at https://afdelingbuitengewonezaken.nl/cases/nomi/ and contact Sluisdom.
3 Campaign against painful gynaecological treatments
The British organisation hysteroscopyaction.org.uk/ has been campaigning for years against painful gynaecological treatments. Positive and negative experiences about hysteroscopy treatments are currently being collected. The link to the survey can be found on the website.
4 Alternative for the speculum
Half the world’s population has a uterus. However, today’s speculum is still based on a mid-19th century design. Where are the innovations? The FemSpec, an inflatable speculum by the American company FemSuite (from 2005) has never been put into use. Allegedly because it was expensive. But perhaps also because of a patent issue. Wombs are big business.
Who dares to make a difference? Ceek Women’s Health recently launched Nella, a new vaginal speculum. Designed by women, for women. It comes in a reusable and a disposable speculum and even has an LED light. The main advantage, claim the American manufacturers, is that it’s shaped like a tampon, which should make inserting more comfortable. To be continued.
Bonus: What exactly is an internal examination?
During an internal examination, the doctor inserts a spreader (speculum or duckbill) through the vulva to view the vagina and cervix. Usually a smear is also made or some tissue is taken for a ‘culture’. Sometimes the doctor also feels the inside of the uterus by inserting one or two fingers and placing the other hand on the abdomen. This is called a vaginal examination. During external examination, the vulva is examined for any swelling or abnormalities.
At the gynaecologist it’s also possible to make an ultrasound. In order to do this, an ultrasound device is inserted through the vulva into the vagina. The female genitals are then visualised with the help of sound vibrations. During a hysteroscopy, the uterine cavity is viewed using a specially developed hysteroscope. This thin, hollow tube is also used for so-called minimally invasive treatments.
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