Vaginismus and Internal Exams:
Evidence-based best practices

One of the main complaints coming from women about internal exams is the feeling of disempowerment they feel during the procedure. Not surprisingly, whenever they are asked to express what would make their exams more comfortable, women overwhelmingly suggest the importance of finding an empathic doctor but also the ability to have some degree of control over the exam.

Sometimes little gestures such as offering the woman the option to self-insert the speculum or warming it up before insertion with the use of some warm water or with electric warming drawers, will go a long way to make your patient feel more at ease. However, women with vaginismus often report that doctors refused to carry out such procedures. This is probably due to lack of knowledge about studies which prove the safety and efficacy of procedures, which in turn can make the doctors reluctant to relinquish control to a patient.

You will find below the object, results, conclusions and references to some of these studies which show how such simple yet helpful procedures can be carried out without compromising results and how women benefit from them so that in the future you can make such exams more comfortable or even less traumatic for women in general, but in particular for women with vaginismus or who suffered from previous sexual abuse.

Also, we wrote a guide to help women have smooth gynecological exams. Although it is aimed at women, we believe Doctors can find some useful tips in it too.

1. Women Find It Easy and Prefer to Collect Their Own Vaginal Swabs

1. Chernesky, Max A PhD (2005) Women Find It Easy and Prefer to Collect Their Own Vaginal Swabs to Diagnose Chlamydia trachomatis or Neisseria gonorrhoeae Infections. Sexually Transmitted Diseases. 32(12):729-733.

Results: Women find it easy and prefer to collect their own vaginal swabs to diagnose Chlamydia trachomatis or Neisseria gonorrhoeae infections.

Conclusion: Self-collected vaginal swabs were easy to collect and patients preferred them over urine and cervical swabs.

2. Vaginal speculum lubrication (water and gel) does NOT increase unsatisfactory cervical cytology so it's safe to use it and helpful for the woman's comfort

- Griffith W. et al. : Vaginal speculum lubrication and its effects on cervical cytology and microbiology.
Contraception. Volume: 72, Issue: 1, Date: 2005 06 20, Pages: 60-4

The prevailing approach to Papanicolaou (Pap) and endocervical Gen-Probe(R) screening is to use an unlubricated vaginal speculum because of concerns that gel lubricant interferes with Pap smear adequacy and cervical microbiology.
This study tests the hypothesis that lubrication of metal specula with a bacteriostatic gel does not increase unsatisfactory cervical cytology or decrease detection rates of endocervical Chlamydia trachomatis or Neisseria gonorrhoeae.

Results: This study concludes that the use of a small amount of gel lubricant on metal vaginal specula did not increase unsatisfactory cytology or decrease endocervical C. trachomatis detection rates when compared to water lubricant.

- Hathaway, J. et al.: Is liquid-based pap testing affected by water-based lubricant?
Obstet Gynecol. Volume: 107, Issue: 1, Date: 2006 01 05, Pages: 66-70

CONCLUSION: Water-based lubricant does not affect liquid-based cervical cytology Pap testing. Water-based lubricant does not affect secondary diagnoses such as bacterial vaginosis or yeast infections.

- Amies, Anne-Marie E. et al. : The effect of vaginal speculum lubrication on the rate of unsatisfactory cervical cytology diagnosis.
Obstet Gynecol. Volume: 100, Issue: 5Pt1, Date: 2002 11 08, Pages: 889-92

Objective: Nonlubricated plastic specula can adhere to the vaginal introitus and cause discomfort with pelvic examination. We wanted to see if application of water-soluble gel lubricant to the plastic vaginal speculum would change the unsatisfactory cervical cytology diagnosis rate.

RESULTS: From July 1998 through December 1999, 8534 Papanicolaou smears were collected, with 1440 using gel lubrication from January 1999 through June 1999.

CONCLUSION: The use of a small amount of water-soluble gel lubricant on the outer inferior blade of the plastic vaginal speculum does not change cervical cytology results in a young, reproductive-age population.

- Harer, W Benson et al. : Lubrication of the vaginal introitus and speculum does not affect Papanicolaou smears.
Obstet Gynecol. Volume: 100, Issue: 5Pt1, Date: 2002 11 08, Pages: 887-8

OBJECTIVE:To test the hypothesis that lubrication of the vaginal introitus and external speculum does not adversely affect Papanicolaou interpretation.

CONCLUSION: Use of a water soluble lubricant on the vaginal introitus and external speculum facilitates examination with no adverse effect on Papanicolaou smear interpretation.

3. Women undergoing examination without stirrups had a reduction in mean sense of vulnerability

- Seehusen Dean A, Johnson Dawn R et al. (2006). Improving women's experience during speculum examinations at routine gynaecological visits: randomised clinical trial. British Medical Journal 333: 171
Retreived October 19 2006 from bmj.bmjjournals.com

Results: Women undergoing examination without stirrups had a reduction in mean sense of vulnerability from 23.6 to 13.1 (95% confidence interval of the difference ?-16.6 to ?-4.4). Mean physical discomfort was reduced from 30.4 to 17.2 ( ?-19.7 to ?-6.8). There was no significant reduction in sense of loss of control.

Conclusion Women should be able to have gynaecological examinations without using stirrups to reduce the stress and vulnerability associated with speculum examinations.

Discussion: perhaps the best take-home message is that gynecologists should ask their patients whether they would prefer an examination with or without stirrups.

4. Gynecologists’ characteristics that patients reported appreciating the most were Empathy and Receiving an explanation of what is about to be done to them.

- Broadmore J, Carr-Gregg M, Hutton (1986) Vaginal examinations: women's experiences and preferences. JD New ZealandMedical Journal. 99:8-10.

Results: Gynecologists’ characteristics that patients reported appreciating the most were Empathy and Receiving an explanation of what is about to be done to them. Among what they disliked was having a third person (chaperone) present, and this was not significantly correlated with the sex of the examiner.

5. Speculum self-insertion was acceptable to most women, especially younger women.

- Wright D et al. (2005) Speculum 'self-insertion': a pilot study. Journal of clinical nursing 14 (9): 1098-1111

Results: The study demonstrated that speculum self-insertion was acceptable to most women, especially younger women. Nearly 91% of women either agreed or strongly agreed that they were satisfied with the experience of self-insertion and would choose to self-insert the speculum again. This included the women who had not previously had a speculum examination. The quality of specimen collected was not detrimentally affected by speculum self-insertion.

Conclusions: The results of this pilot research, while needing to be replicated in a larger study, demonstrate that offering women the opportunity to self-insert a speculum during a routine pelvic examination is an acceptable, innovative, simple and cost-neutral change in clinical practice that increases women's comfort and satisfaction and potentially makes sexual health screening less threatening to women of all ages.