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CHAPTER 6

Medical Maintenance

THE VULVA AND VAGINA DO NOT REQUIRE regular checkups. If you have symptoms or concerns—for example, a pain or an itch, or even questions—then of course you need to be seen, but there is no reason your doctor needs to evaluate your vulva or vagina on a regular basis for disease prevention. Some organs do require screening for health purposes, including the cervix for cervical cancer (see chapter 26), screening for high blood pressure starting at the age of eighteen, and colon cancer screening for otherwise low-risk individuals starting at age fifty. However, not everything requires screening, and the vulva and vagina fall into that category. In fact, yearly pelvic exams are no longer recommended.

Screening vs. Diagnostic Test

A screening test is done when there are no symptoms of a condition—the idea is that finding and treating before there are symptoms will reduce complications and even save lives. As far as the lower genital tract is concerned, the best examples are screening for chlamydia and cervical cancer. Neither of those conditions produce symptoms in early stages, but identifying them early and starting therapy reduces complications, and in the case of cervical cancer, screening can save lives.

Screening can target everyone. For example, all women should be screened for cervical cancer. Screening may also target higher-risk individuals, such as people with multiple sexual partners and STIs.

A diagnostic test, on the other hand, is done to help identify the cause of symptoms. For example, if there is an ulcer on the skin, a swab may be taken to test for herpes or a biopsy may be taken to identify a skin condition. An important concept that doctors don’t always explain is that diagnostic tests are also ordered to rule out conditions—so the answer your doctor may be looking for is “not cancer.” This can be very frustrating for a patient who thinks they will be getting a definitive answer. A common scenario with the vulva is a biopsy for a persistent itch. A biopsy (a small procedure that removes a 3–4 mm piece of skin) may be recommended to rule out an early cancer. While the biopsy may help diagnose the cause of the itch, many times the results are nonspecific, so the best the biopsy did was rule out cancer (still very important).

Menstrual Cycle Primer

While this is The Vagina Bible and not the “Uterus and Ovary Bible,” having a good working knowledge of the changes that occur each month with the menstrual cycle will be helpful in understanding a lot of what follows in this book.

Menstruation is the shedding of the lining of the uterus (the endometrium) when a pregnancy has not occurred. The average age of menarche—the first menstrual cycle—is 12–13 years. The first day of the menstrual cycle, or day 1 of your cycle, is the first day of bleeding (so the first day of your period). Menstrual bleeding typically lasts 3–7 days (see chapter 17 for more on the amount of blood).

The menstrual cycle is regulated by several intricate hormonal circuits all working together in harmony. Sometimes I visualize this as three jugglers who occasionally have to throw one of their balls to another while they all continue to juggle. If everything is on point, then the system works flawlessly; however, one late throw or missed catch and everything gets out of whack. The three jugglers in the case of menstruation are the hypothalamus (a part of the brain), the pituitary gland (also in the brain), and the ovaries.

The hypothalamus releases a hormone called gonadotropin-releasing hormone (GnRH) and this process can be easily disturbed by stress, sleep disturbance, and weight loss or gain. GnRH triggers the pituitary gland to release the hormone follicle stimulating hormone (FSH), which tells the ovary to start developing follicles (eggs). The follicles produce estrogen, which makes the lining of the uterus thicken. The estrogen provides feedback to the pituitary gland. When estrogen levels are high enough, the pituitary releases a hormone called luteinizing hormone (LH), which triggers ovulation.

After ovulation the egg heads down the fallopian tube to the uterus, and the tissue left behind (like an eggshell, but soft), called the corpus luteum, produces progesterone. While estrogen thickens the uterine lining (think of it like stacking bricks), progesterone stabilizes the lining (a bit like mortar). The corpus luteum can only produce progesterone for approximately 14 days unless it gets a signal from a pregnancy. Without fertilization, the corpus luteum shrinks and the progesterone is rapidly withdrawn and this causes the lining of the uterus to come out as a period. And we are back at the beginning of the cycle, with day 1 being the day bleeding starts.

Estrogen and progesterone have wide-ranging effects beyond the ovaries, uterus, and vagina. The cyclic changes can affect mood, the immune system, and even sensitivity to touch.

When should I start seeing a gynecologist or other woman’s health care specialist?

Some women prefer a gynecologist; however, many prefer their family medicine doctors and nurse practitioners. Even some pediatricians are comfortable providing reproductive health care. Who you see for regular checkups and for symptoms, such as an itch or sexually transmitted infection (STI) screening, may vary depending on a number of factors.

A screening visit regarding reproductive preventive health care is recommended between the ages of thirteen years and fifteen years. This visit could be with any provider who is comfortable talking with teens about sex and reproductive health. This visit is an opportunity to discuss any reproductive health concerns, such as menstrual protection or safe sex. A pelvic exam (meaning checking inside the vagina) is not required unless there are symptoms, and for a teen who has not yet been sexually active a pelvic exam can almost always be avoided.

Screening for STIs should begin whenever a teen becomes sexually active and continue until the age of twenty-four (see chapter 28). Regardless of whether you have or haven’t been sexually active, cervical cancer screening starts at the age of twenty-one (see chapter 26). A “get to know you” visit before you may need to get reproductive health care of any kind is never a bad idea. This allows you to get comfortable with the person with whom you will be sharing intimate details before you need to share them. For women who have never been sexually active or never had a pelvic exam, this visit can be especially helpful to familiarize themselves with what the exam might entail and the medical equipment that is involved.

Any woman or teen twenty-four years or younger who is sexually active should be seeing a provider who is comfortable with gynecologic care for annual chlamydia screenings. Screening for other sexually transmitted infections may also be indicated. Urine screening is very effective, so taking a pelvic exam out of the equation often makes this screening easier for many women regardless of age.

What is a pelvic exam?

A pelvic exam has two components: looking inside the vagina with a speculum to see the vagina and cervix, and touching inside with gloved and lubricated fingers of one hand into the vagina (the other hand may press down on the lower abdomen to feel the uterus and ovaries). This second part of the exam may be called an internal exam or a bimanual exam. This evaluates the uterus, ovaries, pelvic muscles, and any masses or irregularities in the vagina or in the pelvis (meaning on or around the uterus and ovaries). Sometimes a rectal exam (inserting a gloved finger into the rectum) may be indicated. Whether an internal exam and/or rectal exam is needed depends on the reason for the exam.

A speculum is a medical tool for looking inside the body. There are many different kinds, and the type used for cervical cancer screening and STI testing is called a bivalve speculum. This is made of two blades (they are not sharp, just slightly curved).

A bivalve speculum is inserted closed, which makes insertion less painful, and then opened once it is deep enough. A screw or similar device keeps the blades open during the exam. When opened, the speculum allows the provider to see the cervix and the upper vagina. The sides of the speculum are open, and so if the speculum is rotated the vaginal walls can also be inspected.

Image 6: Speculum open (left) and closed (right). ILLUSTRATIONS BY LISA A. CLARK, MA, CMI.

There are several different types of bivalve speculums, all with minor modifications that can sometimes help make them more comfortable or practical, as every woman is shaped differently. The common speculums are Pedersen, Graves, and Cusco and are named after the men who designed the modifications. A Graves is wider at the tip (this is useful for seeing the cervix for procedures), but is almost never needed for a regular exam. The wider tip can make insertion more painful.

The speculums come in different sizes; a narrow speculum is approximately the width of a finger, and many times this can be used, reducing discomfort significantly. I liken this to trying on clothes at the store—I was always told to start with the smallest pair of pants that I think has a reasonable chance of fitting.

In general, someone who has used tampons or a menstrual cup successfully or who has been sexually active will do well with a speculum and pelvic exam performed by a provider who makes them feel at ease, proceeds at a comfortable pace, and is aware of physical cues that might suggest the exam has become painful and knows to stop and reaffirm that it is okay to proceed or make adjustments as necessary.

A speculum and pelvic exam shouldn’t be painful; there may be pressure or minor discomfort, but it should not hurt. If it does, speak up and ask your doctor to stop.

Annual pelvic examinations are no longer recommended, as screening the pelvic organs and vagina this way does not reliably identify any medical condition—in short, it is a poor screening test. If you have no symptoms, your exam is over after your cervical cancer screening.

DOES THE SPECULUM HAVE A RACIST LEGACY? Some women do not like the idea of a speculum because they have been told it was invented by Dr. Marion Sims, known to some as the father of modern American gynecology and to many others, including myself, as a shoddy doctor, a racist, and an all-around terrible man who experimented on enslaved women without consent and who was only in medicine for the money.

It is common medical lore that Dr. Sims reportedly developed the first reproducible surgical technique for vesicovaginal fistulas (a connection between the bladder and vagina due to injuries during childbirth). He did not. Other surgeons had been successful before his time, and reading the work of his peers, it is clear his technique was not easily (if at all) reproducible. Sims also opened the first public hospital for women dedicated to repairing injuries from pregnancy and childbirth. Fistulas were a significant source of distress for women, and Sims hypothesized if he could device a reliable fistula repair technique, he could make a fortune. Sims was eventually asked to leave that hospital for refusing to follow various policies.

Sims did design a speculum for looking in the vagina to facilitate surgery, but this is not a bivalve speculum. Sims was also hardly the first one to design such a speculum. The first speculum may date back to Roman times (one was excavated at Pompeii), and a vaginal speculum was in use by surgeons in 1818, so before Sims’s time. In 1825, a French midwife, Marie Anne Boivin, modified the speculum, and what we use today is a version of her creation—a top and a bottom blade that can be opened so the sides (vaginal walls) and top (cervix) can be seen. Sims’s device has one blade and a far different sort of handle. It is infuriating that in addition to all the medically unethical and racist things that Sims did to women, he also erased the fact that the bivalve speculum was created by a woman.

While I believe there could be modifications to speculum design to make the experience better for women and provide a better view for providers, for now you can rest assured that the speculum being used by your provider was not designed by Sims, nor based on his design.

WHAT IF SPECULUM EXAMS ARE ALWAYS PAINFUL? There are two reasons: you have a medical condition or your provider has poor technique.

If you only have pain with pelvic exams, then the technique is likely the issue. If you are nervous beforehand or have had a previous traumatic experience, either sexual trauma or a traumatic exam with a provider, those memories can come back during an exam and may make you more likely to have pain during the exam, but they are not the cause.

If you have pain with a tampon or menstrual cup insertion or with sexual activity, then it is possible that you have a medical condition that causes vaginal or vulvar pain, and those may make pelvic exams more painful. However, even in these situations it is best to stop and regroup. Exam techniques can almost always be modified to lessen the pain experience. Many women tell me just knowing their provider cares to minimize their pain matters greatly.

The only situation where a painful exam should continue, and even then this should be with consent, is a true medical emergency—meaning you are hemorrhaging and your provider needs to stop the bleeding immediately to save your life or to prevent other complications, such as needing a blood transfusion. Outside of the emergency department, that is rarely the situation. It does not apply to cervical cancer screening, evaluation of pain with sex, or any other symptoms discussed in this book.

Some women put on a stoic face, others mistakenly believe pelvic and speculum exams are painful for all women, and some women are clearly in pain and ignored by their providers. As I am not one of those providers, I am not sure I have an explanation. All I know is I evaluate women with pain every day, and every day I hear that it was the least painful exam they have ever had. It is better to invest in the outcome and start with a little information, and then as the medical condition starts to improve more evaluation can be done if needed. A lot of testing can be done with just a swab, and so a speculum can often be avoided, with the exception of dealing with vaginitis. However, even then we can start with swabs and build confidence and devise strategies to reduce pain. A narrow speculum, which many women find they can tolerate, is also often all that is needed.

The Potential Downside of Fewer Visits

The annual gynecological exam is really a thing of the past. There are a lot of upsides to avoiding unnecessary testing. Women avoid physical exams that are intrusive and can be embarrassing and/or painful. There is also the benefit of reducing expense as well as worry from false-positive results. In medicine, we have jargon for these incidental yet medically meaningless findings that we are now required to prove are meaningless—incidentalomas.

There is one downside that has not been studied: women who do not see their reproductive health provider annually may have less of a rapport. When you see someone every three or five years, it is a lot harder to bring up intimate concerns than when you see them once a year. It is also true that when annual pelvic exams were recommended, many providers never asked questions about sex, and so these visits involved a lot of frustrating missed opportunities. I am not sure fewer visits will help that.

I often wonder if an annual check-in by phone would be helpful, so a gynecological provider can hear a woman’s story and let her know if she needs STI testing outside of the routine screening recommendations, ask about sexual health or other vulvar and vaginal concerns, and provide any age-specific reproductive health advice. Women are exposed to so much misinformation and disinformation that giving women the option of checking in quickly might be something worth studying.

BOTTOM LINE

• Annual pelvic exams are not recommended.

• A pelvic exam should not be painful.

• If a speculum exam is necessary, narrow Pedersen or Cusco speculums are the smallest and are often all that is needed.

• The bivalve speculum used for vaginal exams and Pap smears was not invented by Dr. Sims.

• The only regular evaluations related to vaginal health are cervical cancer and STI screenings.