It would even be a funny anecdote, were it not for the fact that I often see these women at such an advanced stage of cancer that there is little I can do for them.
This is sad and difficult for me, because I know that most of them could be alive and enjoying their grandchildren in their golden years if only they had decided to see a doctor regularly. I also know that women from the LGBT community are reluctant to see gynecologists. I wonder why this is the case. However, I would also like to appeal to LGBT women to get checked by gynecologists. I understand that for transgender people, such a visit can be difficult because it reminds them all the more of the gender they do not accept. But despite this, I encourage you to come in; together, we’ll try to get through it as gently as possible.
I wrote this text with the intention of answering the following questions: how to prepare for the visit, what questions to expect from me, how the exam proceeds, and when it is best to have such exams done.
I begin every appointment with a patient by asking how I can help
Some women come for a routine visit, some to confirm a pregnancy, and some with a specific concern. It is very important to me that the patient immediately tells me if this is her first visit and whether she has already been sexually active. I strive to ensure that every visit takes place in a positive, supportive atmosphere, but I pay special attention to women who are visiting for the first time in their lives, because this determines whether they will be put off for many years or will come in for regular check-ups. Among older patients who haven’t been to a gynecologist in years, the trauma associated with seeing a gynecologist is one of the main reasons they avoid doctors. During the first visit, I don’t push for an exam—we do only as much as the patient consents to and feels comfortable with. Sometimes we skip the exam if it’s not possible or turns out to be too painful.
In that case, we schedule another appointment, depending on the needs. That is why I want to encourage you to have an open conversation right from the start about your concerns regarding the exam. I try to sense and ask the patient, but without her help, I don’t know what her fears or reservations are. I need to know if the patient is very stressed, if she has questions or doubts, if she feels anxious about the exam, if this is her first visit, or if she suffers from vaginismus or vulvodynia. Examining women with vaginismus (i.e., those who involuntarily resist the insertion of anything into the vagina) takes time. In such cases, I encourage them to schedule a 40- to 60-minute appointment instead of the standard 20 minutes. This gives us time to get comfortable with the office, with me, and with the prospect of the exam. We do relaxation and breathing exercises before the exam. Sometimes it is not possible to examine the patient on the first attempt. I believe that forcing a woman at all costs is not always justified and can cause significant harm. But usually, by the second visit, patients feel comfortable enough and have gained enough trust that we are able to insert the speculum and even collect a Pap smear.
It is always a good idea to have answers prepared for the following questions:
The first day of the last menstrual period, whether periods are regular, how often they occur, how many days they last, and whether they are heavy. Number of pregnancies—this includes both pregnancies that resulted in live births as well as spontaneous or induced abortions.
I respect a patient’s refusal to provide certain information, such as details about a miscarriage. However, in exceptional situations, information about how the miscarriage occurred is important—for example, when a patient is trying to conceive and there is a suspicion of intrauterine adhesions. It is worth telling the doctor about these intimate and difficult details; everything remains in my office, and it serves as an important diagnostic clue. In addition to pregnancies, I always ask about childbirth, chronic illnesses, surgeries, medications taken, and drug allergies (it’s a good idea to jot these down on a piece of paper). If the patient is considering hormonal contraception, I also ask about smoking, a history of cancer in the family or in the patient herself, liver disease, thromboembolic disease (including in the family), and the occurrence of migraines with aura.
Gynecological Examination
In better-equipped offices, patients have access to a bathroom where they can change into a disposable gown and foot covers (you can keep your shoes and socks on—some may find this amusing, but patients often ask about it). Dear ladies—it is you who should feel comfortable, as much as this visit can be comfortable.
I begin the gynecological exam by inserting a speculum. I use the smallest speculums and only use larger ones in exceptional cases. If I am not performing a Pap smear, I always lubricate the speculum with ultrasound gel, which makes insertion less painful. The speculum exam is the least pleasant part of the visit. Then I check the uterus by inserting one or two fingers into the vagina and pressing on the lower abdomen. Usually, this part is better tolerated by patients.
Dear Ladies, please schedule your Pap smear, pelvic ultrasound, and breast ultrasound immediately after your menstrual bleeding has stopped!!! During the first phase of the cycle, any changes in the endometrium are more clearly visible on a pelvic ultrasound, and breast diseases are also more easily detected. Have these exams done once a year. It’s such a small effort, and it can save your life. I say this with great conviction. Because most reproductive organ cancers can be completely cured in the early stages, and screening methods are extremely effective!!!!
Usually, patients prepare for their visit—they wash, spray on perfume, and shave. Sometimes, however, especially during consultations in the emergency room—that is, in acute situations—in sudden, unexpected cases, patients arrive, as they put it, “unprepared.” They feel very self-conscious about this and apologize from the moment they walk in. Unnecessarily. Pubic hair is a natural occurrence, and its presence or absence is simply a matter of personal preference. It’s worth trimming it a bit before scheduled procedures or even a visit if it’s long, for a simple reason—it won’t get caught, and thus won’t be pulled, which is painful. But its presence or absence absolutely does not bother me. The second issue is bleeding. Patients worry a great deal about this during the examination. Ladies, you come in with a problem, such as prolonged bleeding from the reproductive tract, and that bleeding needs to be stopped. We can’t wait until you stop bleeding, because then the visit would be pointless. So there is no reason to feel self-conscious. As part of their work, gynecologists attend births, procedures, and surgeries. Blood, amniotic fluid, or pus are not unfamiliar or shocking to them. Patients often change their pads right before entering the office. And I need to see that pad to determine whether the bleeding is actually heavy or not, because it’s not always obvious during the exam. Similarly, with intimate odor—of course, I encourage maintaining hygiene and washing, but if there is a concerning odor, this is important information for me regarding the type of infection I am dealing with. Sometimes the odor can raise suspicion of cancer. I do not encourage you to douche (rinse the vagina) before your visit (I advise against this idea altogether), because discharge is also an important source of information.
Breast and underarm examination.
Always insist on having them examined. When I examine patients, I teach them how to examine their own breasts. I know this is often forgotten, but it’s enough to get into the habit of massaging your breasts while lathering up in the shower. That way, you won’t miss any new, concerning changes.
At the end of the visit, there’s always time for questions. If there aren’t any, I summarize all the recommendations once more, write them down on a note, and if I see that the patient feels confused, I ask her to go over everything with me again. I draw diagrams and demonstrate. I believe that understanding all the information during the visit saves everyone work and heartache later on. This is especially important for pregnant women, who, when well-informed, don’t make unnecessary trips to the hospital but know which symptoms are cause for concern and when to go to the Emergency Room immediately.
I’d like to address one more important aspect of a gynecological visit. It’s also a time to address any sexual concerns!!! Sometimes, while a patient is lying on the gynecological chair, I hand her a mirror and we examine her intimate areas together. I explain to the patient what anatomical features she is looking at and what their functions are. It’s not very common for a woman to look “down there.” And that’s a shame, because it’s a source of valuable information about pleasure, health, and fertility. Sometimes, we teach the patient how to locate the cervix—for the purpose of self-examination. Women who rely on natural family planning methods need to know how to assess cervical mucus and the external os of the cervix.
So I also encourage you to explore the intimate aspects of our femininity, to perform self-examinations, and to get to know yourselves. And we gynecologists are here to help.
Maja Świetlicka, MD
