Know your rights Getting questions answered before pelvic exams should help ease patients' anxiety By: Jen Zoratti Posted: 7:00 PM CDT Monday, Jul. 16, 2018

Opinion

Hey there, time traveller!
This article was published 16/07/2018 (2624 days ago), so information in it may no longer be current.

Two weeks ago, Winnipeg doctor Ramon Eduardo Jovel was sentenced to prison for sexually assaulting a female patient more than 20 years ago.

These assaults happened during unnecessary sexual examinations conducted over three years, which he claimed were being conducted to see if the patient he was treating was ovulating. The woman learned Jovel’s exams were unnecessary after she switched physicians.

(Jovel is not the only Winnipeg doctor to face sexual assault charges in recent months; in October 2017, Dr. Amir Houshang Mazhariravesh was charged with sexually assaulting nine of his patients. He has yet to face trial.)

These incidents raise important questions: what should, and should not, happen during a gynecological exam?

Dr. Carol Scurfield is the medical director of Women’s Health Clinic. She says a pelvic exam is done for a number of reasons, and a patient should be clear about why they’re having an exam in the first place.

One reason is to screen for cervical cancer, using what’s called a Pap test (or Pap smear, cervical smear, or smear test). Cervical cancer screening is usually done every three years.

“That’s done by taking a sample from the cervix to look for cells that might become cancerous in the future,” Scurfield explains.

The doctor or nurse will insert a sterile speculum, which is made from either metal or plastic, into the vagina. The speculum is opened a centimetre or two so a cell sample can be collected from the cervix. The doctor or nurse will use a small stick, spatula, or brush to gently scrape the surface of the cervix. Some people experience light bleeding for a day or two afterwards.

“People should not panic if they have an abnormal Pap result; generally it’s something that will heal up and be fine,” Scurfield says. “But if they do have an abnormal Pap, it needs to be watched and repeated over time.”

In addition to the Pap test, doctors can also test for sexually transmitted infections, which involves taking a vaginal swab — similar to a Q-Tip — and sending it to the lab. STI tests are not necessarily done alongside a Pap test, so it’s a good idea to bring up any concerns to the practitioner conducting the test. Doctors or nurses may also look for yeast infections or bacterial vaginosis, which is a bacterial imbalance in the vagina.

Some STIs do not require vaginal swabs for diagnosis.

“There are some alternatives, now, to not having the speculum inserted,” Scurfield says. “If you’re worried about a sexually transmitted infection, a urine test can test for gonorrhea and chlamydia now.”

Sometimes, a doctor will use his or her hands to examine patients. Scurfield says this kind of exam is usually only done when there’s a specific concern about the size of a patient’s uterus, or if the patient is experiencing pain in their uterus or ovaries.

“That involves the person, with gloves on, putting two fingers into the vagina to feel the cervix and, with their other hand, feeling through the abdominal wall to get a feel of your uterus and ovaries between there,” she explains. “Again, it doesn’t have to happen all the time; usually just if there’s a concern.”

These exams should be done efficiently. “Those two examinations (a Pap test and a manual exam), together, shouldn’t take more than a couple of minutes,” Scurfield says. “It should involve the speculum going in once. If they are using their hands, there is some movement, but it shouldn’t be more than 30 seconds. If you feel something isn’t right, you need to speak up. (The doctor) will explain what they’re doing.”

That said, while a play-by-play is appropriate — “Now, I will insert the speculum,” or “You may feel some pressure, here,” — a running commentary on how someone’s body looks is not.

“I avoid phrases such as ‘That looks good,’ because that implies a value judgment,” Scurfield says. “‘Your cervix looks healthy,’ ‘I don’t see anything of concern,’ — those are appropriate comments.”

Getting a Pap test or a pelvic exam can be uncomfortable, but the exam itself should not be painful. If a person is anxious about the exam, their muscles might be more tense, which can also lead to added discomfort.

“It’s important for the person doing the exam to be aware of that, and help you feel as comfortable as you can in an awkward position,” Scurfield says.

Scurfield adds that a patient doesn’t need to take all their clothes off to have a pelvic exam. “You can leave your shirt, you can leave your socks on,” she says. “Sometimes that makes people feel more comfortable.”

As well, another staff member can be present in the room during the exam.

“I’ve even had friends or family members in, I’ve had people phone someone while we’re getting an exam,” Scurfield says. “These are generally people who have lots of anxiety, or maybe have had a history of trauma, or bad experiences with pelvic exams in the past.

“It is a fairly invasive procedure that can make you feel pretty powerless,” she acknowledges. “The important thing to realize is you still have the power in this experience.”

To that end, Dr. Scurfield says patients should feel they have control over what’s happening to them in the exam room.

“This is a procedure you consent to,” she says. “So if you say, ‘No, stop,’ the person who is doing the exam should immediately cease and desist.”

Some women avoid gynecological care for a host of reasons, from past sexual assault trauma to shame about their bodies. Many women worry about how their vulvae look or smell. “We work very carefully to make women feel comfortable,” Scurfield says. “There are studies that show that women who are ashamed of their bodies have poorer health care.”

Kate McIntyre, a sexual health educator at Women’s Health Clinic, recommends patients spend some time preparing before a gynecological exam, especially if they’ve never had one before.

“If they know their rights as a person receiving that care, they can feel a little more equipped to advocate for themselves,” she says. “Like, ‘I know if I want to I can have someone in the room.’ ‘I know I can ask for the draping to be positioned so I can see my doctor’s face.’ ‘I can ask the practitioner to be communicating with me when they touch me and explain what they’re doing.’ “

“If you have concerns, let the person doing (the exam) know,” Scurfield says. “If you’ve had a bad experience, let them know. If they are a good health care provider, they will then take that on and try and make this the best they can for you.”

jen.zoratti@freepress.mb.caTwitter: @JenZoratti