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Most women do not like going to the gynecologist. The reason is often bad memories related to the speculum examination, which translate into avoiding cytology or colposcopy – examination of the cervix. Although designers and doctors are working on developing more body-friendly tools, even the best in the hands of non-delicate gynecologists will do nothing. Stress, anxiety, discomfort, and embarrassment will remain. What to do to make the impressions of patients leaving the gynecological chair positive? The matter is complex, but it is worth trying, because their comfort translates into the quality of doctors’ work.
- Fear and stress – this is what many women feel before visiting the gynecologist’s office. Some people feel so anxious that they completely give up testing and control
- What to do to prevent women from feeling traumatized? One solution is to create friendlier gynecological tools
- According to gynecologists, this is not enough. What matters most is the approach to patients
- You can find more such stories on the TvoiLokony home page
A brief history of the speculum and its inventor
In 1845, an Alabama grower asked 32-year-old surgeon James Marion Sims to examine a young slave woman suffering from a vesico-vaginal fistula. After giving birth, the girl felt severe pains connected with urinary incontinence and she could not work. Her case turned out to be so interesting that in the years 1845-49 Sims performed (without anesthesia) 10 similar procedures. In the course of his experiments, he developed the technique of fistula surgery and invented a gynecological speculum. The tool was in the shape of a duckbill, consisting of two tin arms hinged with a screw. Thanks to him, the surgeon was hailed the “father of modern gynecology” and was honored with a monument in Central Park.
Thanks to the technicians trained on southern slaves, Sims’ career sped up. He moved to New York, where he founded the country’s first gynecological hospital for a wealthy white clientele, and in the 60s he traveled to Europe to treat, among others, patients from royal families. After returning to his homeland, he was the president of the American Medical Association.
The speculum solved a problem that had plagued gynecology since its inception: how can a man examine a woman “without disturbing her intimacy”. It allowed the doctor to gain access to the cervix and, above all, “meant touching not with the hand, but with the object”. Despite this, critics believed that the colonoscopy “jeopardized morals” and were concerned that it might lead patients into non-professional relationships with doctors.
In 1850, The Lancet reported that, at a meeting of the Royal Medical and Surgical Society in London, opponents of speculae complained about “indecent use” of the instrument.
Soon the word hysteria appeared in the debates. It was about an affliction of wealthy women, which was believed to have originated in the uterus. British and American doctors warned that a speculum could induce “furor uterinus” (female hysteria), symptoms of which were nervousness, insomnia, loss of appetite, loss of sex drive, irritability and “trouble-prone”.
The speculum has also become a police surveillance tool used to screen prostitutes suspected of carrying STDs and a symbol of sexual defiance. British Infectious Diseases Act in the 60s introduced mandatory speculum testing. Similar regulations were also in force in France and Germany.
Although gynecology currently has modern tools in the form of, for example, ultrasound examinations, the speculum has hardly changed for over 170 years. The most notable difference between the Sims instrument and its modern version is that it is made of stainless steel or plastic, not tin. The feeling of discomfort during the examination did not change as well. American polls show that many women have a cold metal speculum so frightening that they avoid visiting a gynecologist.
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Time to improve the sight glass or maybe give it up altogether?
Fear of the speculum coupled with a sense of vulnerability are the two biggest obstacles to screening for cervical cancer in women. That is why designers join forces with gynecologists to create the most convenient device to use.
The changes consist in introducing minor improvements, which, however, significantly increase the comfort of a woman. The American team of Ceek Women’s Health is implementing a series of new gynecological instruments – including a speculum with a narrower beak and a speculum that patients handle on their own. There are plans to create a range of instruments designed for different patients. There will be a speculum for women who have had more than two natural births or are obese, a speculum for women who have had an injury or rape, another one for postmenopausal women who have vaginal atrophy, and for trans people.
The specula should be soundless and should not cause a feeling of coolness or stretching. They should also have a modern design (smooth surfaces, soft rounded edges, improved design) so that they are not associated with medieval torture devices.
In addition to plastic and metal instruments, silicone-coated sight glasses are autoclavable. Silicone is a very smooth, body-friendly material that does not cause a feeling of cold, makes the device silent, facilitates insertion into the vagina, reducing the risk of tissue damage. It also looks nice.
Dr. Artur Kucharski, a gynecologist from the Private Polyclinic “Na Grobli” and the Multispecialist Hospital ORTHOS in Wrocław, has been using disposable plastic specula for 15 years. She remembers that the patients reacted positively to the change.
“The metal speculum was often cool,” he says, “which always caused discomfort during the examination.” Both metal and plastic sight glasses do not hurt. However, there are situations in which double-branch specula, the metal ones, enable better visualization of the vaginal vault area and visualization of possible lesions.
– 99 percent tests can be performed using disposable plastic specula, and their widespread use is a matter of debunking stereotypes – adds Dr. Kucharski. – I’m not saying that they are better. They are simply different, and the fact that we are switching to disposable equipment is a sign of the times. It is true that this generates higher costs and the ecological aspect should also be taken into account, because the production of plastic is certainly not environmentally friendly.
However, the above solutions are based on the assumption that the cervix and vaginal walls are viewed from the outside and therefore a widening of the vaginal canal is required, leading to discomfort. Therefore, a device called Callascope was developed, which eliminates the need for a speculum at all. The Callascope is the size of a tampon and consists of two separate components – a calla flower-shaped introducer and a matching 2-megapixel camera with contrast spraying mechanism. The effectiveness of visualization of the cervix during an examination by a doctor is comparable to a speculum (83%) and increases up to 95%. in women who use the device on their own. In addition, all test participants reported that they preferred Callascope to the speculum test.
When asked about its usefulness, Dr. Kucharski replies that the device can additionally give credibility to the doctor in the eyes of the patient, in the event that the doctor finds an illness that will surprise her or raise doubts. However, it does not matter whether the gynecologist sees something with a camera or with the naked eye. Obviously, this type of visualization cannot be confused with examination using a colposcope in the diagnosis of cervical lesions. In such cases, it is considered a recommended procedure.
What else can be done so that the gynecological examination does not stress?
Teams developing more woman-friendly specula and camera devices have concluded that this is not enough. To make your visit to the gynecological office less stressful, you also need to design it. And so that it turns into an experience that is at least neutral.
A list of guidelines for doctors was written, including simple advice, such as: providing patients with a place where they can comfortably undress or explaining what the examination is about and how it will be conducted. There are also an anti-stress ball and … socks. Everything together is to evoke positive emotions in women and make them feel the benefit of the visit.
– A visit to a gynecologist generates two types of stress – says Marta Boczkowska, a psychologist from the SWPS University and IP PAN. – First, it is embarrassing, because it is a very intimate meeting, and not always in the spirit of intimacy. There are not always conditions for this, and the doctor does not always take care not to damage the patient’s dignity. On the other hand, there is the pain aspect, the medical background, and awareness of what it is like. It is not just the situation that causes stress. The concept of psychologists Richard Lazarus and Susan Folkman is that people are concerned not with events, but with how they think about them. Stress is therefore a transaction between the situation and our judgment. In other words, if I find a visit to the gynecologist stressful, I will be stressed. On the other hand, the fact that I know that there are female-friendly tools influences my assessment of the situation. It can minimize stress. It all depends on my judgment.
– Whether the gynecological examination will be stressful depends on several things – notes Dr. Kucharski. – From the delicacy of the doctor and the friendly atmosphere in the office as well as the positive attitude of the patient. If she has ever experienced a trauma related to a visit to a gynecologist, it is hardly surprising that she is afraid of this contact.
- See also: What do patients hear in the office? The worst texts of gynecologists
– The appropriate approach of a doctor makes up 70-80 percent. a successful visit – adds Dr. Kucharski. The patient’s comfort only to a small extent depends on the tools used by the doctor, but mainly depends on proper contact with the doctor. It is not even that the examination may be unpleasant, but the mere contact with an unprofessional, unpleasant and arrogant doctor may stress the patient. If he is rude, the test is in a bad atmosphere and no super devices will help. The patient will endure them because she knows it is necessary, but I suspect that she will not come back to this doctor, no matter how modern his surgery is.
– The key to everything is a specialist with the right approach – says Dr. Mikołaj Karmowski, head of the Medicus Clinic Endometriosis Treatment Center in Wrocław. – Technology that miniaturizes the specula, improves its shape to suit the anatomy of the vagina, helps doctors. In addition, the digitization of diagnostic devices, thanks to which we can show the patient the examination process, makes her feel appreciated. I treat each patient as a partner, I invite her to this “adventure” of examination and diagnostics. It is precisely such actions that make a woman leave me less traumatized, knowing what she is or why she is okay.
How the gynecologist builds a positive experience for the patient
– Any procedure that does not interfere with the performance of a thorough examination is possible – says Dr. Kucharski. – If the patient wants to stay in socks, go ahead, because it does not interfere with the examination. If he wants to stay in shoes or slippers, it doesn’t bother him either; if I want to wear a pareo, please. I am flexible in this respect. It seems to me that only unwise stubbornness on the part of a doctor causes him to follow the patterns he approves and force him to follow some well-worn procedures. Of course, it is difficult to allow the patient to drive into a sterile operating room in her own clothes. This is definitely not, although during aesthetic gynecology procedures we often allow the patient to put on her own T-shirt, because the operating area is so far away that there is no risk of contamination of the operating field. We must strive for a compromise, give the patient a chance to feel as comfortable in our office as possible. It seems to me that it is up to the gynecologist to sense what the patient expects and meet those expectations. Don’t wait for her to ask if she can stay in your socks, just say: you don’t have to take them off. It encourages and avoids embarrassing situations.
– If we are talking about vaginal colonoscopy, which is the most intimate moment of the gynecological examination, we must say that the atmosphere is created from the beginning of the visit – says Dr. Karmowski. A visit here takes an average of 45 minutes or even an hour. This is an expert visit. Only after collecting the interview and getting to know the patient, we propose an examination, one of which is endoscopy. It is embarrassing for every woman, just like a man’s visit to a urologist, because it involves exposure, showing an intimate part of the body.
– We should also remember about the marketing of tool manufacturers, we should not believe in a miracle speculum that can be inserted into the vagina so that the patient does not feel it – points out Dr. Karmowski. – It’s about the doctor’s skills, his approach to the patient, relaxing the atmosphere before the examination. A woman should not feel embarrassed, because then she can tighten the Kegel muscles, and we should not fight her.
At the clinic of Dr. Karmowski, each patient gets a disposable skirt and slippers, and has access to her own bathroom where she can wash. There she also changes clothes and, prepared in this way, stands in front of the doctor. She does not feel embarrassed because she is not exposed.
– The patient is dressed in a colorful disposable fleece skirt, she walks through the office dressed, then I invite her to the chair, sometimes I help raise her leg on the gynecological support – says Dr. Karmowski. Only then does the woman reveal her skirt, but she also covers it to some extent, making her feel calmer. Then I am asking you to relax the pelvic muscles as I will be wearing a speculum. The worst thing is to lie staring at the ceiling and not know what the doctor is doing. You need to explain the next steps to the patient. If we talk to him, explain, he feels safe.
Dr. Karmowski uses very narrow size S specula. These are double vaginal specula which do not stretch the entrance to the vagina.
– The most unpleasant for the patient is the entry of the speculum through the scaphoid atrium of the vagina – she says. – The vagina itself is a stretchy organ, while the entrance above the perineum is strongly innervated and it is the beginning of the colonoscopy that causes the greatest discomfort. I lubricate each speculum with an ultrasound gel, which not only eliminates the feeling of cold, but also makes the speculum slide in without causing friction. If the patient is frightened, her muscles tighten, then pain occurs. The colonoscopy should be virtually imperceptible, because the mere presence of the chair is stressful. Once the patient is familiar with the test, we can ask for more muscle relaxation and not lifting the buttocks, as pelvic rotation is very important.
– At the end of the colonoscopy performed in this way, I usually hear: oh my, it didn’t hurt! Before that, patients often ask for delicacy due to the pain during the examination. Meanwhile, it usually comes from the traumatic experience of brutal research.
Doctors also agree that patients should be given time, because it is impossible to create an atmosphere of comfort during a five-minute visit. A woman should get to know her gynecologist, trust him, feel that he approaches her with the appropriate delicacy.
– Taking care of the psychological comfort of the patient shortens the visit time – agrees Marta Boczkowska. – That is why I believe that doctors need systemic support and psychological training. Until that happens, patients will be stressed.
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