Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Patient comfort important but secondary to cervical smear quality
- Anne Spaar, Milo A. Puhan (11 July 2006)
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Remember the individual
- Jan M Perkins (21 July 2006)
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Re: RCTs for 'non-inferiority'
- Anil Sharma (21 July 2006)
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We do not need to do a trail of smear quality
- James A Dickinson (21 July 2006)
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Pelvic Examination sans stirrups
- Sidha Sambandan (21 July 2006)
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Womens experiences during speculum examinations
- Fenella Lemonsky (21 July 2006)
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semi-seated position is even better
- Susan Levenstein, none (22 July 2006)
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A more caring approach might do wonders.
- Jeevan P Marasinghe, Amarasinghe A A W,MD, Mcdonough, Georgia, USA,WML Perera,Consultant Obstetrician and Gynecologist,Base Hospital,Dambulla,Sri Lanka,Eranthi Samarokoon,Head,Dept of Obstetrics and Gynecology,Faculty of Medicine,University of Peradeniya,Sri Lanka. (25 July 2006)
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Patient's perspective: US and UK
- Rosemary Slosek (25 July 2006)
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What is wrong with the left lateral position
- Francis C. Rutter (26 July 2006)
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Patient`s Choice
- Mercy E Ochuko-Emore (26 July 2006)
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What's in a name?
- J. Michael Szul (26 July 2006)
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Stirrups, schmirrups
- Martin Talbot (29 July 2006)
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Confounding variables not taken into account
- Babatunde A. Gbolade (2 August 2006)
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Race and Gender of Providers
- Dean A. Seehusen (3 August 2006)
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A modesty curtain
- Roger H Armour (7 August 2006)
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Re: What is wrong with the left lateral position
- David P B Pound (7 August 2006)
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Improving women's experience during speculum examinations at routine gynaecological visits: randomised clinical trial
- Nazar R DESSOUKI (8 August 2006)
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Re: A modesty curtain
- Nazar R DESSOUKI (8 August 2006)
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Positioning for gynecological exams
- Mary E Crowther (14 August 2006)
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putting women in control
- Céline Lemay (23 September 2006)
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Anne Spaar, research fellow Horten Centre for patient-oriented research and knowledge transfer, University Hospital of Zurich, Milo A. Puhan
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Seehusen et al. suggest performing the gynecological examination without stirrups to reduce stress for women.(1) They also conclude that based on their study the examination without stirrups does not affect the quality of cervical smears. The study addresses the very relevant problem of discomfort during the gynecological examination, which may hamper adherence to cervical cancer screening. However, the following aspects should be considered when interpreting the results. When obtaining cervical smears, the primary goal should always be to achieve the highest possible quality so that screening achieves its goal of detecting early stages of cervical cancer. Although reduction of pain and discomfort during the examination is important and highly welcomed, it needs to remain secondary to the quality of cervical smears. If latter is insufficient, wrong positive or negative findings can put the women at risk for undetected cancer or unnecessary psychological stress or procedures. If a study compares two methods of obtaining cervical smears, it has first to be shown that the alternative method does not yield clinically inferior results. Statistically non-significant differences between cervical smear quality (p=0.84 in the Seehusen study) does, however, not proof non-inferiority. The standard method to address non-inferiority is the confidence interval approach.(2) If, for example, it is accepted that the proportion of cervical smears of good quality may be 5% lower than with the standard method, the lower end of the 95% confidence interval for the between-group difference should be above this a priori defined threshold for non-inferiority. We did not find any randomised non-inferiority trials in Medline and the Cochrane database. It seems too early to conclude that gynecological examinations could safely be performed without stirrups offering thereby more comfort to patients. Non-inferiority in terms of cervical smear quality should be shown before this alternative method can be adopted in clinical practice. (1)Seehusen DA, Johnson DR, Earwood JS, Sethuraman SN, Cornali J, Gillespie K, et al. Improving women's experience during speculum examinations at routine gynaecological visits: randomised clinical trial. BMJ, doi:10.1136/bmj.38888.588519.55 (published 27 June 2006) (2)Jones B, Jarvis P, Lewis JA, Ebbutt AF. Trials to assess equivalence: the importance of rigorous methods. BMJ 1996;313(7048):36-39. Competing interests: None declared |
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Jan M Perkins, Assistant Professor CMU 48859
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I appreciate the article by Seehusen and colleagues in the current issue of BMJ and particularly praise their call for "Respect for patients' preferences" with regard to stirrups. I am a female health professional who has played the role of patient in practices that insisted on no stirrups, and in practices that used them at the patient's discretion. Personally, having no sense of vulnerability, tight adductors, and strong leg muscles (just who is vulnerable anyway?), I prefered stirrups for comfort and was delighted when a move meant I no longer had to have annual exams without stirrups. I suspect that many females of my age are uncomfortable with the idea of stirrups for reasons best explained by sociologists. I am not. Perhaps the best take-home message from the article is that practitioners should ask their patients whether they would prefer an examination with or without stirrups. I also, for various reasons, expect a cohort effect. This makes this study worthy of replication with age stratification. In practical terms, if both work well in terms of smear quality, why not let the patient make the choice? I thank Seehusen and colleagues for their article. Competing interests: I am a woman |
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Anil Sharma, Consultant Obstetrician & Gynaecologist Auckland, New Zealand
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Spaar and Puhan say that reduction of pain in obtaining specimens needs to remain secondary to the quality of cervical smears. I disagree. Cervical smears are a screening test undertaken on mainly asymptomatic healthy and well women to attempt to detect CIN (not cervical cancer). Therefore, any method that reduces stress and discomfort is appropriate as it is likely to increase future test uptake and less likely to reduce initial test uptake by negative word of mouth. Quality and lack of discomfort need to have equal emphasis. Furthermore it does not require the peformance of RCTs to allow the 'adoption of this alternative method' as the non- use of stirrups is the standard method of pelvic examination, cervical smears and spontaneous vaginal birth in the UK, Australia and New Zealand. There are no observational studies to the best of my knowledge that show that stirrups increase the quality of cervical screening samples. In the vast majority of women, the cervix is completely viewed after speculum examination without stirrups and smears are readily taken. Competing interests: None declared |
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James A Dickinson, Professor of Family Medicine University of Calgary Medical Clinic. 1632 14th Ave NW, Calgary Alberta T2N 1M7
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Predictably, in this age of evidence-based medicine, people have called for a randomised trial to determine whether using different positions for taking pap smears makes a difference to smear quality. A very large trial would be necessary to be confident no difference had been missed. This would comprise a wasteful and unnecessary use of resources. Since several countries routinely use stirrups, (notably US and Canada) while family physicians in others (such as Britain and Australia) routinely use feet on the couch positions, a simple ecological study to determine whether there is a substantial difference in smear quality between those countries would be sufficient. Perhaps the more important outcome (though more difficult to assess) would be effectiveness of the national cervical screening program, since extra discomfort may reduce the willingness of many women to attend for smears. In that case, even if the stirrups position produces slightly better smears, the gain would need to be greater than the loss due to women staying away from an uncomfortable procedure. Trials are wonderful but highly complex procedures. Doing them well is difficult, and their validity can easily be compromised by errors in their execution. The effort needed to perform them should be reserved for problems that really need such methods. Otherwise we use a sledgehammer to crack a nut. Competing interests: None declared |
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Sidha Sambandan, GP Yare valley Medical Practice,202,THorpe Road, Norwich NR1 1TJ,UK
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In UK, most GPs and Nurses in primary care dont do pelvic examinations or smears with legs in stirrups. This has been the practice for many decades! Competing interests: None declared |
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Fenella Lemonsky, Service User Consultant London Borough of Barnet/Mental Health Research Network
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I welcome this study however it is well known that women anxieties around intimate examinations. One issue that is forgotten is that a great deal of women experience Vulval pain that is often not diagnosed or known about as they are embarassed or reluctant for various reasons to seek advice about it. Vulval Pain affects many many women. For this reason Dr David Nunns a Consultant Gynaecologist in Nottingham set up the Vulval pain Society. To help women ensuretheir distress is understood and they can access good treatment. Many women have their vulval pain needs ignored and will not attend smears as its highly distressing, traumatic and uncomfortable. However a sensitive and aware practitioner makes a big difference. Please don't assume that merely removing stirrups will make things more comfortable-look a bit deeper and ask your patient if she is experiencing any pain in the genito urinary area and if its persistent. Good treatment and support is available -and all women should be offerred good evidence based treatment. Many women are still being refused referral to specialist clinics-please support these women. They need your help.The London Vulval Pain Support Group telephone: 07837 533 992 email: londonvps@yahoo.co.uk website: www.vulvalpainsociety.org/london/ Competing interests: None declared |
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Susan Levenstein, physician Aventino Medical Group, Via della Fonte di Fauno 22, 00153 Rome, Italy, none
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My patients' experience of pelvic exams was revolutionized for the better some 20 years ago when I tried following the suggestion of an article that proposed use of a semi-seated position for examinees, with feet in stirrups and the cranial segment of the exam table raised to 30º or 45º. This position, which offers full access to the perineum while allowing the patient to make eye contact with the examiner, has been universally judged by patients to be less humiliating and less uncomfortable than the standard "slab of meat" supine position. And, as an incidental side benefit, this position relaxes the abdominal muscles facilitating a thorough bimanual examination. Try it! Susan Levenstein, MD slevenstein@compuserve.com p.s. I would like to be able to credit the author of the article I got this idea from, but failed to find it in a quick Medline session. Competing interests: None declared |
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Jeevan P Marasinghe, Registrar in Obstetrics and Gynecology,General Hospital( Teaching), Peradeniya, Sri Lanka. 20300, Amarasinghe A A W,MD, Mcdonough, Georgia, USA,WML Perera,Consultant Obstetrician and Gynecologist,Base Hospital,Dambulla,Sri Lanka,Eranthi Samarokoon,Head,Dept of Obstetrics and Gynecology,Faculty of Medicine,University of Peradeniya,Sri Lanka.
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Speculum examination is part and parcel of routine gynecological examination and millions of patients undergo this perceived stressful experience at least once in their life time due to improved health care facilities, screening programs and patient awareness. There is no doubt that it is a painful and embarrassing experience to most of the patients and this may cloud the quality of examination findings and investigations performed. In long run this may affect the quality of management plan offered to the patient and it can be considered as a vicious cycle. Seehusen DA et al( 1) have been successful in demonstrating that women undergoing gynecological examination without stirrups had a reduction in mean sense of vulnerability and mean physical discomfort compared to those examined with stirrups . But there had been no significant difference in the sense of loss of control and the quality of pap smears obtained. But as the investigators themselves agree, their outcome variables had been too broad to come to definite conclusions and had to be much precisely defined in terms of better quantitative outcome variables. Other confounding factors seem to be much more important than the fact that the patients are examined with their heels placed in metal stirrups or placed on the corners of table extension. A negative emotional contact between the patient and the examiner seems to play a major role (2) along with dissatisfaction with present sexual life, history of sexual abuse and mental health problems which were strongly associated with physical discomfort in gynecological examination. Sympathetic inquiries into those issues are expected from the examiner when he comes across patients who express discomfort during the procedure. The anxiety and the embarrassment expressed on gynecological examination usually denote reluctance on the part of the examiner rather than the patient. A negative experience during the first gynecological examination is more correlated with a negative experience in general (3 ),(4 ),( 5).First gynecological examination seems to be a statistically powerful background factor for attitudes towards subsequent examinations. Allocating sufficient time to explain the reasons for the speculum examination and familiarizing the patient with the equipment might make the speculum examination, a comfortable experience. The gender of the examiner also seems to play a pivotal role along with the position of the patient and patient’s previous history of pelvic examinations (5). The embarrassment, apprehension, anxiety and discomfort during gynecological examination are considered major drawbacks of routine gynecological care and have to be converted to a pleasant and tolerable method to most patients. More innovative(6),simple and cost effective methods of clinical examination to increase patient compliance ,comfort and satisfaction are needed to improve the problems of sexual health .Gynecological examination without stirrups should be encouraged to improve physical discomfort of the patient and for her to feel less vulnerable.(7 ).Seeing the patient as a person and more human and caring approach can minimize anxiety and embarrassment and can improve the quality of examination findings, investigations performed and finally the productivity. References. (1)Seehusen DA ,Dawn R Johnson Scott Earwood,Sankar N Sethuraman,Jamie Cornali,Kelly Gillespie ,Maria Doria,Edwin Farnell IV,Jason Lanham.Improvimg experience during speculum examinations at routine gynecological visits: randomized clinical trial.BMJ 2006 ;333:171(22 Jul). (2)Hilden M, Women’s experiences of the gynecologic examination: factors associated with discomfort.Acta Obstet Gynecol Scand 2003 Nov; 82(11):1030-6. (3)Wijma B,Gullberg M,Kjessler B,Attitudes towards pelvic examination in a random sample of Swedish women.Acta Obstet Gynecol Scand.1998 Apr;77(4):422-28. (4)Ricciardi R.First pelvic examination in the adolescent. Nurse Pract Forum.2000 Sep; 11(3):161-9. (5)Seymore C,DuRant RH,Jay MS,Freeman D,Gomez L,Sharp C,Linder CW .Influence of position during examination, and sex of examiner on patient anxiety during pelvic examination .J Pediatr.1986 Feb;108(2):312-7. (6)Longmore PG, Veda –scope: more comfortable than the bivalve speculum and cytologically equivalent.Aust N Z Obstet Gynecol.2004 Apr; 44(2):140-5. (7)Pippa Oakeshott, Phillip Hay. Best practice in primary care.BMJ 2006; 333:173-174(22 Jul) Competing interests: None declared |
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Rosemary Slosek, Patient University of Nottingham
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I have had exams with and without stirrups in the US and UK. Prior to my move to the US, smears had always been done without stirrups and it was just another exam; no more uncomfortable than having teeth drilled. When I needed a routine pap by my (lovely female) GP in the US, I was in for a shock. I was supine and stirrups were used (objective). I was flat on my back with my bottom on the edge of a cliff and my legs held up over the edge (subjective). As for choice, she would not do the pap unless I had stirrups. Flat refusal. Even after I assertively stated my preference. Once back in the UK, skip forward to a referral to a consultant gynae. I had stirrups and it was great. As far as having a strange man looking at your intimates can be positive. Still supine, but the stirrups were placed lower and my bottom was not on the edge of the bed. It just felt like they supported my legs to give me a bit of a rest. In my experience, use of stirrups is not the issue. My lovely female GP used them; I hated it, felt out of control and extremely vulnerable. I almost didn't go back. The male consultant I didn't like used them; no problem. If the experience is not neutral or positive, women will not be examined, and you can't quality control a non existant sample. As with other things in life, it's what you do with it that counts. Competing interests: None declared |
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Francis C. Rutter, Retired GP Norwich
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I remember as a student in 1950 going into the gynaecological out patient department at the Rotunda Hospital in Dublin and seeing a row of ladies all with their legs up in stirrups and I thought at the time that it must have made them feel extremely undignified and vulnerable. I was taught to examine in the left lateral position and throughout my career in general practise [with a strong suit in Obs. and Gynae.] I always examined in that position. I have no figures to show if my smears were more or less successful than other peoples', but have no reason to believe that they were less so. What I am sure of, though, is that my patients were much more comfortable in this position and that examination was no more difficult. Certainly there was no problem with the handle of the speculum! Competing interests: None declared |
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Mercy E Ochuko-Emore, Senior House Officer in Psychitry Hellesdon Hospital, Norwich.NR5 6BE
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This is quiet an interesting article. I do agree with the author`s findings. However, l think individual patient should be allowed to make a choice between speculum examination with or without stirrup depending on what is most comfortable for them. Competing interests: None declared |
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J. Michael Szul, family physician Toronto M6S 2V7
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In my practice, staff used to refer to "stirrups" as foot supports. I often gave my patients the option of using the foot suppports or not. I also used to wrap diapers around the part of the metal supports that held the feet. This approach seemed softer. We did not measure vulnerability or patient preferences, but anecdotally there was positive feedback. J. Michael Szul Competing interests: None declared |
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Martin Talbot, Consultant Physician in Genitourinary Medicine/HIV Sheffield Teaching Hospitals, S10 2JF
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My unit has not used stirrups for gynaecological examination in women for 40 years. Stirrups must be quite limiting for the patient. We do, however, examine women in the lithotomy position with knees on leg SUPPORTS, enabling a good view for the examination of local lesions, multiple test sampling and facilitating bimanual pelvic assessment (as the pelvic organs are tilted slightly out of the bony pelvis). Although I once had a Dutch patient who criticised 'you English' for being 'so ridiculously sensitive about these matters', most women find any kind of genital examination embarrassing (one hopes never physically uncomfortable ). One should always, always establish eye contact and address oneself first to the head end, and AT the head end of the patient, and confirm her general level of comfort with the procedure before proceding. One should always return to explain one's findings, and offer to do so after she is fully-clothed again. Most patients seem to appreciate attention to these small but so important details. Even so, after 40 years, some of my older staff still refer to the leg supports as 'stirrups'. Clarifying the terminolgy would be helpful. Competing interests: None declared |
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Babatunde A. Gbolade, Consultant Gynaecologist & Director of Ferttility Control Unit St. James's University Hospital, Beckett Street, Leeds LS9 7TF
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In this interesting paper, there are confounding variables which may have influenced why women in this study showed differences in their perception of vulnerability and physical discomfort and no difference in perception of loss of control.(1) The two major racial groups in this study were black and white. Race labels are frequently used in clinical research in the USA; the participants often assigned into arbitrary race categories with the potential for alienation from the research team (“They think they know who I am, but aren’t really interested in me”).(2) It is therefore possible that the race of the study participants and the examiners and other variables unknown to the researchers such as history of sexual abuse, may independently impact on the study participants’ perceptions of vulnerability and physical discomfort. The same may apply to the gender of the examiner. One interesting detail easily missed is that in both groups, the 3 female examiners performed approximately 75% of the examinations relative to the approximately 25% of all the examinations performed by five male examiners. While data on the racial mix of the study participants was included in the paper, there was none on the racial mix of the examiners. It would be interesting to know if within group analysis shows the influence, if any, of the race of both study participant and examiner on the reported perception of vulnerability and discomfort. Towards this, it is instructive that there was no significant difference in the perception of loss of control and quality of smears between the two groups as these are the least likely to be affected by the gender or race of the examiner. A Danish study showed that discomfort during the gynaecologic examination was strongly associated with, among other variables, a negative emotional contact with the examiner and young age and concluded that gynaecologists need to focus on the emotional contact and to evaluate issues for communication before the examination.(3) References 1. Seehusen DA, Johnson DR, Heawood JS, Sethuraman SN, Conrail J, Gillespie K, et al. Improvimg experience during speculum examinations at routine gynaecological visits: randomized clinical trial.BMJ 2006; 333:171 -174. 2. Witzig R. The medialization of race: Legitimization of a flawed social construct. Ann Int Med 1996; 125: 675-679. 3. Hilden M, Sidenius K, Sandhoff-Roos J, Wilma B and Schei B. Women’s experiences of the gynaecologic examination: factors associated with discomfort. Acta Obstet Gynaecol Scand 2003; 82:1030–1036. Competing interests: None declared |
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Dean A. Seehusen, Research Director Dwight David Eisenhower Army Medical Center, Fort Gordon, GA, USA 30509
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Dr. Gbolade brings up the very legitimate concern of confounding variables in our study. We hope that the information below will adequately relieve those concerns. All eight examiners in our study were white. When discomfort and vulnerability levels are looked at in white verses non-white subjects, no difference is found. White subjects had a mean discomfort level of 23.8 mm (sd = 22.9 mm) and non-whites a mean of 23.8 (24.7). Mean vulnerability for whites was 19.2 (23.8); for non-whites 17.1(20.0). As for the gender of the examiner, female providers performed 75 out of 100 non-stirrup examinations and 74 out of 97 of the in-stirrup examinations. Mean discomfort for all subjects receiving examinations from female providers was 23.1(23.5); mean discomfort with male providers was 25.7(23.9). Mean vulnerability was 17.7(22.0) with female providers and 20.2(22.4) with male providers. Again, none of these findings are statistically significant. History of sexual abuse would could lead women to feel more vulnerable and possibly have more discomfort during an examination. While we were not able to look at this variable in the study, we have no reason to believe that the two groups would have differed greatly in this regard. Therefore, it is unlikely that history of sexual abuse would influence our result to any important degree. We appreciate Dr. Gbolade’s questions and hope that the above shows our results to be robust. Competing interests: None declared |
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Roger H Armour, Hon. Consultant Surgeon (retired consultant surgeon) Lister Hospital, Stevenage SG1 4AB
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I congratulate Seehusen and colleagues on a thoughtful and excellent paper (BMJ 22 July 2006). Anything that will make patients feel less threatened is good. When I was a medical student in Lahore, women undergoing gynaecological examinations or procedures without anaesthetic were half hidden behind a curtain that fell to their middle so that their faces were hidden during the procedure. Both they and the doctors or students, especially if male, felt more comfortable that the patient was being treated with respect. I suggest that Seehusen et al's method and a 'modesty curtain' be combined. Competing interests: None declared |
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David P B Pound, Retired GP Daventry
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I entirely agree with Dr. Rutter, and I came on line to ask exactly the same question. I was trained in obstetrics & gynaecology in the late 60s amd early 70s and the Sims speculum used in the left lateral position was the standard method of primary vaginal examination at that time. It is not suitable for surgical procedures involving the cervix, but during 5 years as an RAF specialist and then another 30 years in general practice I rarely used any other method for routine examinations. I certainly did all my smears using that method and, like Dr. Rutter, I have no reason to suppose that I missed important lesions. The patients seemed to be very comfortable with the method. Why does it seem to have disappeared? And if someone is tempted to respond to the effect that the lithotomy position is "better" perhaps they could say in what way and on what evidence that view is based. Competing interests: None declared |
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Nazar R DESSOUKI, CONSULTANT SURGEON ST BERNARDS HOSPITAL GIBRALTAR
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There is nothing wrong with the left lateral position for endoscopic examination of the vagina and cervix,anal and rectal examination.As a senior surgeon I used this practice for the last 35 years,and have not missed a significant lesions in these locations.It is certainly more digifying than the knee-chest position commonly used by the Amercan doctors.Lithotomy position is certainly suitable for EUA under GA. Competing interests: None declared |
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Nazar R DESSOUKI, CONSULTANT SURGEON ST BERNARDS HOSPITAL GIBRALTAR
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A "A modesty curtain "or some sort of barrier between the eaxamining doctor and the patient during gynaecological or anorectal examination is cetainly makes life easier for the patient and the doctor,dignifying,descent,humane and civilised practice.Medical students and junior doctors should be taught to adopt this basic procedure. Competing interests: None declared |
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Mary E Crowther, Attending Obstetrician & Gynecologist Virginia Hospital Center, Arlington 22205, US
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As an Obstetrician and Gynaecologist who has practised in Australia, the UK and now the US, and having been a patient in all three countries, I am perplexed by the dogmatism in some of the responses to the paper by Seehusen et al (BMJ 2006; 333:171). There is no anecdotal nor scientific evidence that examination in stirrups is superior to examination in the left lateral or dorsal "frog-leg" position. I am not aware that the ability to take smears properly or assess pelvic organs adequately is compromised in countries which do not routinely use stirrups. On the other hand, both from my own experience and what my patients tell me, I have no evidence that using stirrups renders the exam more uncomfortable for the woman. A greater sense of vulnerability in stirrups, perhaps, but that may have more to do with prior sexual vulnerability and discomfort than the position per se. I would agree with Professor Perkins - ask the patient what she wants. Certainly the left lateral position has advantages for those who are excessively modest or frightened, for the elderly or arthritic with limited hip movement, and for paraplegic or spastic patients who have spasms of the lower limbs. The "pelvic exam" is a highly ritualized affair in the US, far more so than in the UK. Women are exhorted from their teenage years to have an annual check which may or may not include a pelvic exam. Indeed, this is almost a rite of passage, where mothers bring their daughters to the gynecologist for their first exam, whether their daughter is sexually active or not. It is not surprising that the pelvic exam (with stirrups), therefore, is the subject of jokes on TV and in the media, and that many of my young patients make assumptions about how uncomfortable it will be, based on hearsay rather than their own personal experience. As a number of people pointed out, it may be the approach to the patient that is more important than the actual position - eye contact beforehand, calmness of movement, asking permission to do the exam, quietly explaining the procedure and findings. The really interesting study would be to find out whether many of the "annual" pelvic exams we do are really beneficial or not in terms of screening for gynecological pathology, the cervical smear excepted. Competing interests: None declared |
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Céline Lemay, midwife Québec, Canada
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I am so glad about this research. I just want to share a small text of an event that changed the practice of an obstetrician, and mine... The try was worthed. BMJ 2000;321:1454 ( 9 December ) Putting women in control: A doctor who changed my practice As a research registrar in obstetrics and gynaecology I was moonlighting and gaining extra experience doing family planning and youth clinics. Unlike most of my previous training I was expected to sit in and then be observed by a senior doctor. It was my great fortune to work with Fay Hutchinson, the medical director of the Brook Advisory Service, because she completely changed my approach to patients. Many of the women coming for contraception, pregnancy testing, and abortion advice were young and had never had vaginal examinations or smears. They would be prepared on the couch as usual and then they were given a speculum and asked to "put that inside, please." As if it was the most natural thing in the world that a doctor would ask a woman to insert a speculum! And most did so with no fuss. I was so shocked. I was shocked by the strangeness of what I was seeing and the topsy-turvy relationship between doctor and patient. This had been a stressful and complex procedure for me to learn as a medical student and senior house officer. Why did Fay do it? Because "women know best where their vaginas are. They put tampons, fingers, and penises in." She was absolutely right. It's easy for women to insert a speculum, except for those who have come to expect the doctor to do it or who find "down there" distasteful. It is a particularly valuable technique for "difficult examinations" on women who are frightened or who have had bad experiencesfor example, abuse or coercive sexor painful gynaecological examinations. The women determine when they are ready, control the insertion, and cannot adduct their thighs or clamp their legs closed. They relax and it never hurts. I have never had a problem since that day. Why had I never heard, seen, or even read about self insertion in my years of training? Because, Fay opined, "Male gynaecologists find it very hard to give up control." Having since resisted and yet reviewed many other aspects of my basic and routine practices I think she's wrong. All doctors find it hard to give up control, both sexes and all specialties. But sometimes it's beneficial for patients. Try it. Susan Bewley, consultant obstetrician. I do Pap test in an ordinary bed in my Birthing Center for 10 years now. No problem with the quality of specimen. Céline Lemay Competing interests: None declared |
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