The annual pelvic exam is often dreaded, but required (i.e. recommended) by all god-fearing citizens in possession of a vagina at the age of 21 or soon after the time of first initiating sexual activity. For our purposes letâ€™s flesh out that vague term and assume that sexual activity refers to any and all sexual play below the belt and not just the normative, vanilla brand of penile-vaginal penetration. After all, the penis isnâ€™t the only piece of equipment that can cause infection, but I digress.
The pelvic exam typically consists of a visual inspection, a Pap smear, and a physical check of the size, shape, and condition of the uterus, ovaries, and breasts. Depending on a womanâ€™s age, the practitioner might also include a rectal exam to check for tenderness or other unusual growths. The process usually begins with the breast exam. This is when the health care provider manually examines the breasts feeling for any unusual lumps or tenderness. She might also ask if you do your own regular self breast exams. During the visual inspection the practitioner looks for sores, swelling, or otherwise freakish abnormalities on the external genitalia. Next is the Pap smear. This is when the practitioner says â€œrelaxâ€ and inserts the speculum, does a quick visual inspection of the vaginal cavity and swabs the cervix for a sample of cells that will later be tested for abnormalities in the lab. After the speculum is removed the practitioner, keeping your comfort in mind, lubes up two gloved fingers, inserts them into your vagina and with her other hand presses on the outside of your abdomen to feel your uterus and ovaries, checking for tenderness, obvious growths, or any other irregular presentation. Given the often busy schedule of most practitioners, the exam itself doesnâ€™t usually last much longer than ten minutes.
I loathe the speculum and the stirrups and the paper-thin gown and all the other accoutrements that accompany the annual gynecological exam. I am nauseous and queasy from the moment I get the reminder call from my practitionerâ€™s office until well after I have left the building post-exam, clutching my appointment card for the next go â€˜round, which inevitably, is always exactly one year later. As a public health professional, I understand the need for preventive care. I might loathe the visits, but even if my doctor didnâ€™t threaten to withhold my pill prescription (and make good on those threats) the Catholic guilt would get me in the end. I would have to be mentally absent to willingly substitute reliable contraception, ten minutes of discomfort, and 24 hours of nausea for the alternative.
It is not the exam itself with which I take issue; it is the frequency of the exam that really irks me. The whole purpose of the pelvic exam is to check for signs that point to a potential problem, like detection of a sexually transmitted infection or early stage cancer. My lab work always comes back negative. I am the safer sex maven. Why then is it necessary for me to have an annual pelvic exam? The fact of the matter is that it isnâ€™t necessary. Yet every year I am forced to mentally strap on the boxing gloves and prepare my arguments as to why the annual exam is overkill for a woman at low risk and with my proven track record. It is more than an inconvenient hassle â€“ it is a waste of staff and lab time and resources.
The three main dogs in this fight all say something different about the screening guidelines, whether that is because they each take into consideration different factors or because they each have different issues at stake, only the shadow knows for sure. Here is a quick visual of the Pap smear guidelines from the American Cancer Society (ACS), the American College of Obstetricians and Gynecologists (ACOG), and the US Preventative Service Task Force (USPSTF):
USPSTF: Pap test every three years
ACS: Every 2 years using the newer liquid-based Pap test OR every year using the conventional Pap test
ACOG: Annual Pap test
USPSTF: Pap test every three years
ACS: For women who have had three normal Pap tests in a row should be screened every 2-3 years
ACOG: For women who have had three normal Pap tests in a row should be screened every 2-3 years
The idea behind these age-based divisions is that younger women are more sexually promiscuous than older women and therefore exposed to more disease and infection. Greater exposure leads to an increased risk of acquiring sexually transmitted infections, among them types of HPV that have been shown to cause pre-malignant cervical disease. Screening guidelines such as these are simplified to make it easer for practitioners and health care consumers to apply them. It is important to remember, though, that guidelines are not hard and fast rules carved with blood in stone. They have to be flexible since not every womanâ€™s sexual experience and practices fit into a neat and tidy box. Virginity and promiscuity are not birthrights lost or gained on a certain day of the year. There is no specific mathematical formula to determine sexual behavior â€“ it is different for everyone.
So while I understand why my physicianâ€™s automatic response might be for me to have a cervical exam and Pap test annually, my sexual history and behavior indicate otherwise. My father raised me paranoid so I am naturally a skeptic and this year my skepticism paid off. I finally convinced Dr. J that it wasnâ€™t necessary for me to return every year. We compromised and made a two year bargain â€“ I promised to report for a pelvic exam and Pap test in two years and she promised not to withhold my pill prescription. It is the little victories like these that make bucking the medical paradigm worth the hostility that Dr. J sometimes passive-aggressively throws my way when I question the infinite wisdom of her medical degree.
Ms. Skeptical has a Master’s degree in Public Health from Johns Hopkins University and works for a women’s health non-profit organization in Washington D.C. In her free time she enjoys reading technical health articles, graphic novels, and trashy smut romance. She’ll be dropping in every week to tell you what health issues you should be aware of, and when you should probably tell your doctor, “Let’s think about that diagnosis again, shall we?” (Our Lawyers Say: Skeptical is fabulous, but not a doctor, please consult a physician if you are experiencing any health-related problems.)
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