Improving women's experience during speculum examinations at routine gynaecological visits: randomised clinical trial
BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.38888.588519.55 (Published 20 July 2006) Cite this as: BMJ 2006;333:171
All rapid responses
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.
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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.
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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.
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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.
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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:
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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
Competing interests: No competing interests
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:
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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:
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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
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putting women in control
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
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