Michael Abrahams | What women have taught me about the speculum examination

As a male gynaecologist, much of what I learnt in medical school and during my postgraduate training was written and taught to me by men. Indeed, men have contributed greatly to women’s health.

For example, the Pap smear, named after the man whose research led to the development of the test, Dr Georgios Papanikolaou, has saved the lives of countless women by detecting precancerous changes in their cervices, allowing timely and life-saving intervention. I am indeed grateful to the male doctors, lecturers and professors who have guided me to where I am today.

However, I have also learnt that studying women’s bodies is one thing but listening to them and paying attention to their behaviour is another. We as men or, to be politically correct, cis men, do not possess vaginas, uteri and other female genitalia. We do not have menstrual cycles, cannot conceive, carry pregnancies and give birth, and will not go through menopause. Books have taught me a lot, but a wealth of information has also been gleaned by listening to the people who own and operate vaginas. I have learnt much about what happens between their legs by sitting at their feet.

An example of this is the use of the speculum, the instrument used to part the front and back walls of the vagina, to enable visualisation of the cervix and vaginal walls. In a healthy woman, the front and back walls of the vagina are in contact with each other.

Unlike a throat examination, a normal woman cannot just ‘open wide’ and allow you to see her cervix, unless she has a condition known as uterovaginal prolapse, in which the cervix descends into the vagina and may actually protrude from it. The speculum is therefore the most essential instrument for a gynaecologist. We need speculums like how politicians need lies. We just cannot function without them.

But women tend to be not so crazy about the instrument. To be honest, many literally hate it. I have heard it being called the ‘nuni jack’, ‘duckbill’ and ‘ice-cream scoop’ among other things. Some women have asked if it can be redesigned, to be shaped like a penis, to make its insertion more tolerable. It sounds like a good idea, but ladies may enjoy the examination a bit too much, and then ethical issues and ‘entanglements’ could arise. But I digress.

MORE NUANCED APPROACH

In medical school, we were taught how to insert the speculum. We were told to lubricate the instrument and instructed how to manoeuvre it in order for us to see what we need to see.

But I have learnt that there is much more to a speculum examination than just placing an instrument into a vagina. And this is where learning from my patients comes in. When they express apprehension about the procedure, I listen and ask questions, and this had led me to adopt a more nuanced approached to a routine, albeit invasive, inspection.

A common comment I hear is them referring to it as “that cold metal thing”. I do not have a vagina (although I have been called one several occasions), but I have thought about how I would feel if a ‘cold metal thing’ was abruptly shoved into my nether regions. To be suddenly touched with a cold object, on any part of the body, is somewhat jarring. So, I imagine that for that to take place in somewhere as sensitive as the vagina can be very uncomfortable.

So, to minimise the discomfort, I keep a thermos with hot water in my office and use the water in it, along with water from the pipe, to bring the instrument to a reasonable temperature before insertion. Occasionally, I may miscalculate and warm it a tad too much, but I try to ensure that such occurrences are rare.

SIZE MATTERS

Observing a woman’s facial expressions during the insertion of the instrument can teach one a lot about how well she tolerates the procedure. For example, this has led me to understand the value of using the appropriately sized speculum for the patient. Speculums are available in different sizes, ranging from those designed to be used on virgins to those that are used to inspect more capacious vaginas, such as those of some large women who have delivered multiple children vaginally.

The medium-sized speculum will suffice for most sexually active women, especially those who have borne children. However, I have realised that the reason many women have been traumatised by speculum examinations is because the size used may have been inappropriate. Several women who have had vaginal deliveries and are sexually active actually require a small speculum.

Speculum examinations are not exactly women’s favourite pastime, but some women are literally terrified at the mere thought of the exam. Paying attention to a woman’s body language and energy has also led to conversations about sexual abuse and trauma, which can be barriers to being properly examined. A vaginal exam can be a trigger for women who have been sexually violated. In some instances, the examination is better tolerated if the patient is allowed to insert the instrument herself. This gives her the psychological advantage of being somewhat in control and therefore able to determine the pace at which the examination proceeds, minimising her discomfort.

The lessons learnt in my office have made significant contributions to my continuing medical education. So today I extend gratitude to the women I have examined, who have inadvertently been my teachers. The learning continues.

Michael Abrahams is an obstetrician and gynaecologist, social commentator and human rights advocate. Email feedback to columns@gleanerjm.com and michabe_1999@hotmail.com, or tweet @mikeyabrahams.