Other Exams

The Colposcopic Exam

Colposcopic examination includes gross visualization of the vulva and vagina, examination of the cervix before and after application of acetic acid (common household vinegar), biopsy of suspicious lesions, and endocervical sampling in certain women (Figure 1).[2,17] Both a regular white light (such as used during a Pap test) and a green light are used during colposcopy. The green filter enhances visualization of blood vessels by making them appear darker in contrast to the surrounding epithelium.[4]

Figure 1.

Surgical tray containing the most commonly used supplies for performing a colposcopy.

A speculum is inserted into the vagina while examining the perineum, vulva, vagina, and cervix for lesions using the colposcope's white light and magnification (Figure 2). Some colposcopists may repeat a Pap test during the examination; however, both retrospective and prospective studies have shown limited clinical utility in repeating either liquid-based or conventional cytology at the time of colposcopy.[18,19,20] Screening for gonorrhea and chlamydia may be considered in high-risk populations.[21,22,23]

The entire cervix is viewed under both low- and high-power magnification.[16,17] Higher-power magnification is required to view smaller features.[16] Satisfactory colposcopy is defined as visualization of the entire squamo-columnar junction and margins of any visible lesions.[24] The squamo-columnar junction may be difficult to visualize in its entirety, which is a requirement of a satisfactory colposcopic examination. A small, double-blind, randomized controlled trial demonstrated the efficacy of vaginal misoprostol in converting an unsatisfactory colposcopy to a satisfactory colposcopy in nonpregnant patients.[25]

Dilute acetic acid is used to enhance any epithelial findings. It is applied to the entire cervix, causing abnormal tissue and some normal tissue to turn white.[16] Under white light, the cervix is visualized for acetowhite changes. A record is made of the location of the squamo-columnar junction, transformation zone, abnormal and atypical vessels, and areas of acetowhite changes.

How to Make Your Next Pelvic Exam and Gyno Visit Easier, According to a Gynecologist

Every year millions of women trek to their gynecologist or other healthcare provider and reluctantly climb into the stirrups. Though no one particularly likes a pelvic exam, most women put up with the brief discomfort to make sure all is well.

Many women, however, skip a gynecologic exam, even if they have a problem they know should be addressed. There are many reasons for this, but in one survey of over 2,000 women, one-third skipped a gynecologic exam because they were embarrassed. Of these women, 35% were ashamed of their body shape, 34% were embarrassed by the appearance of their vulva, and 38% had concerns about odor. And that doesn’t include women who avoid an exam because they find it painful or traumatic.

I’ve performed over 200,000 gynecological exams in my career—here are tips to make the most common issues I see a lot less stressful.

Many women feel they’d rather suffer from a gynecologic problem than put on a skimpy paper gown that barely covers their breasts and belly. I always provided roomy cloth gowns for my patients, and I honestly think that’s a big reason they kept coming back. It would be nice if every office did this, but there’s no rule that says you can’t bring your own exam gown. A wraparound robe or a loose dress with a front zipper is fine. Or check out Get Janes, which sells comfortable examination gowns and also donates some of its profits to help women get mammograms. Another option: Tell the medical assistant that you are on the modest side (or cold!) and would like an extra gown or cloth.

For some women, it’s a weight issue. They may be embarrassed about their body, but also just tired of a doctor being so focused on weight that their real concerns don’t get addressed. I had one patient tell me that she’d left her gynecologist because by the time he finished telling her she was at risk of dropping dead from a heart attack unless diabetes got her first, it just didn’t seem appropriate to bring up her lack of libido.

The best solution if you want to avoid a discussion about your weight? Start by saying, “I bet you’ll want to talk about my weight, but since we have a limited amount of time, I’d prefer to discuss other health concerns today.” Then whip out your list and go for it. That way, the things that are important to you will be addressed as priorities.

Also, I know some women avoid their annual exam because they don’t want to get weighed. Remember: It’s not the Army. No one is going to force you to do anything. It’s much better to get everything you need done other than being weighed rather than not to come at all. If someone declines to be weighed, I’ll generally ask for a ballpark figure. You also have the option of getting weighed “backward”—we’ll see your weight, but you won’t. Exceptions to taking a pass on getting weighed? Pregnancy, certain medications, and surgery, all of which require an accurate weight.

If this is your concern, it could be one of two scenarios. One is that there actually is no odor other than the normal healthy scent present in all vaginas—and if that’s the case, you need someone to let you know that. The second: There is a foul odor, perhaps from bacterial vaginosis or a forgotten tampon (that happens more often than you think!), in which case you need to eliminate the reason for the odor. These odors are never because of a lack of hygiene, and there will be no judgment on the part of your gynecologist!

For many women, avoiding the gynecologist is about the pain of a speculum.

A typical gynecologic exam includes a visual inspection of the external genitalia, a speculum exam to look inside the vagina, and then a bimanual exam in which the physician places one or two fingers in the vagina and the other hand on the abdomen. The external inspection checks for growths or abnormal skin changes on the vulva. The speculum exam allows the gynecologist to do a Pap test and check for abnormal discharge, abnormal growths on the cervix, or changes in the vagina such as thinning and/or dryness of the vaginal walls. The bimanual exam lets the doctor evaluate the uterus and ovaries and check for any pelvic masses.

Depending on the reason for your visit, you may not need a speculum exam. Bleeding, cervical cancer screening, and vaginal discharge do require that someone take a peek inside, but if your main concern is a sore on your vulva, bladder leakage, or a loss of libido, a speculum exam isn’t always necessary.

“Depending on the reason for your visit, you may not even need a speculum exam.”

If you do require one, don’t be shy about telling your clinician that the speculum often hurts—and then say something if the exam goes beyond “a little pressure” and pinches, bites, or causes pain. Sometimes a minor readjustment or changing instruments can make a world of difference. Specula are not “one size fits all,” and yes, sometimes it’s just a matter of using a smaller one to ensure that the exam is not agonizing. Believe it or not, most gynecologists routinely use the smallest one possible. No one wants to hurt you! My choice of speculum is dependent not only on the size of the vaginal opening but also on the length of the vagina, the elasticity of the vaginal walls, the position of the uterus, and what I need to accomplish. For example, the amount of exposure I need to swab vaginal discharge is different from what I need to do a Pap test, a uterine sampling, or a major procedure. The speculum I use for a 16-year-old virgin is a completely different instrument than the one I would use for a 40-year-old woman with three kids or a 70-year-old who is well into menopause.

If you’re not an easy fit, you’re probably better off seeing a gynecologist as opposed to an internist or a family medicine doctor. Gynecologists are the most experienced at inserting specula, and they have multiple sizes that vary in length, width, and how far theyopen. Non-gynecologists typically have only one or two sizes to choose from.

And then there are women who avoid an exam because of vaginismus, or a history of sexual abuse or medical trauma. Most gynecologists, if they know that to be the case, will facilitate an exam by slowing down the process, asking permission every step of the way, and telling you exactly what they are doing so you’re in control. Using a mirror so you can see what’s happening is also sometimes helpful. Some doctors specialize in trauma-informed care, but unfortunately, there’s no standardized way to find such a clinician. Sometimes the best ways to find one are by word of mouth and via trauma centers and therapists.

Can a woman get anesthesia to have an exam? Absolutely. If you know from past experience that an exam without it is truly out of the question, or if the exam is going to be prolonged or likely to be painful because of an IUD placement or some other procedure, you can—and should—request anesthesia.