Why are pelvic exams so uncomfortable? And why hasn't the speculum been updated in 170 years? Ob-gyns explain.

Speculum portrait with pink and yellow flowers on either side.
The speculum — the medical device used during pelvic exams — hasn't changed much in 170 years. (Getty Images; illustration: Nathalie Cruz)

Anyone who has ever had been screened for cervical cancer, aka gotten a Pap smear, during a pelvic exam knows how uncomfortable it can be — and the speculum plays a key role in that.

The duckbill-shaped medical device, which has been around for more than 170 years, allows doctors to separate the vaginal walls and “see what’s going on inside the vagina and look at the cervix to obtain a Pap smear or look to see why someone is bleeding,” Dr. Christine Greves, an ob-gyn at Winnie Palmer Hospital in Orland, Fla., tells Yahoo Life.

It’s part of a routine pelvic exam that includes looking for any abnormalities on the external genitalia, such as the vulva and perineum, and performing a bimanual exam where a doctor feels the size, shape and positioning of the internal pelvic organs, including the uterus and ovaries, and checks for any masses, tenderness or pain.

But why is having a speculum inserted during the exam such an uncomfortable experience? And why hasn’t the commonly used device been updated in well over a century and a half? Here's what ob-gyns say — and how to make pelvic exams more comfortable.

Why are pelvic exams with speculums often uncomfortable?

Experts say there are several reasons these exams are unpleasant and, for some, even downright painful. Inserting and opening the speculum in the vagina creates pelvic pressure, not to mention the fact that the cold metal and "horrible clicking noises are among its most-hated features," according to Cedars-Sinai.

A woman's stage of life and health history are also factors. "Women who are not sexually active or women who are menopausal may find speculum devices difficult to tolerate," ob-gyn Dr. Gil Weiss, a partner at the Association for Women's Healthcare and assistant professor of clinical medicine in the department of obstetrics and gynecology at Northwestern Memorial Hospital, tells Yahoo Life. "Certain health conditions may also make the device much more uncomfortable."

One such condition is vaginal atrophy. Weiss explains that transient vaginal atrophy can occur after childbirth, while a more permanent form is common after menopause. "Atrophy makes tissues less flexible and in turn makes the speculum exam more uncomfortable," he says.

Women with other conditions such as vaginismus (involuntary contraction of the vaginal muscles, which can make insertion — whether it's a speculum, penis or tampon — painful), vulvodynia (chronic pain, burning or irritation of the vulva) and lichen sclerosus (a condition marked by genital skin that’s thin, irritated and itchy) may experience more pain with a speculum exam as well, notes Weiss.

"Women who have suffered sexual assault or transgender women may also experience more pain during speculum exams," he adds.

A history of trauma can make pelvic exams and having a speculum inserted "triggering and more uncomfortable for folks," Dr. Alson Burke, an ob-gyn with UW Medicine, tells Yahoo Life. Burke explains that the vagina is made up of an "intricate set of muscles that we don't always have great control in relaxing. Those muscles can involuntarily tense, which can narrow the opening and create more discomfort."

What are some ways to make the exam more comfortable?

There are several ways to make pelvic exams and cervical cancer screenings with speculums better for patients, starting with having doctors explain each part of the exam so there are no surprises. "It's making sure patients understand what’s going on and why this part of the exam is needed," says Burke. "Knowing what's the 'why' behind it can be helpful."

Weiss agrees, saying that the most important thing is to communicate with your health provider during the exam, particularly if you're nervous or are experiencing any pain. “Slowing your breathing down is always the second step after communication,” he says. "As your breathing slows down, your body tends to become less tense, which usually will help." Because speculums create pelvic pressure, emptying your bladder prior to the exam is a good idea, says Weiss.

Finding the right speculum also makes a difference. "Speculums come in different sizes and designs," says Weiss. For example, the Pederson speculum is commonly used in those who have had sex but haven't yet given birth, while the Graves speculum is larger and may be better for women with longer vaginal canals, according to the Cleveland Clinic. For others, "switching to a smaller-size speculum such as a pediatric speculum" — which is narrower and shorter than other speculums — "or switching to a different type of device may all help," says Weiss.

As Burke puts it: "It's about finding the shape and size that works well for that person's body."

Using a lubricant can make insertion of the speculum more comfortable, notes Greves. Although there's some debate about whether lubricants can affect Pap smear results, some studies show that water-based lubricants are fine.

For patients who are feeling nervous about the exam, Burke encourages them to bring a support person — "someone who helps you feel more comfortable at the bedside is great," she says — or suggests they distract themselves during the exam by watching a favorite video or listening to music to stay calm. For patients with a history of trauma, she recommends using an antianxiety medication, and for those patients who find pelvic exams painful, she says that applying a topical numbing gel prior to placing the speculum can be helpful.

Why haven't speculums been updated in over a century and a half?

The medical device itself dates back to the Roman empire and, as Greves points out, was found in Pompeii as far back as A.D. 79. But the modern speculum, which has a dark history, was invented in the 19th century by Dr. James Marion Sims — the controversial "father of modern gynecology," who, starting in 1845, experimented on enslaved women without any anesthesia.

Weiss acknowledges that the speculum design "has not really changed" in the past 170 years.

That may be because it's hard to improve upon the design. Burke says that, in some ways, the speculum is a tool that does its job "pretty well," but notes that "unfortunately, with a lot of women's health and reproductive health, there isn't a lot of money toward innovation." She adds: "There are places where it could be better."

Weiss says that some new devices have come to market, which have used different ways of separating the vaginal walls from the cervix. So far, though, "none of these devices have ever gained traction," he says.

Some are working to change that, however, by listening to both patients and physicians. Ceek Women’s Health Nella NuSpec speculum, for example, has a very narrow bill — about the width of a tampon — and is made out of a "temperature-neutral" material that doesn't get cold like metal speculums. Others include Yona, which is still in its early design stages and uses three silicone-coated metal "leaves" to separate the vaginal walls, instead of two bills, for better viewing without creating more pressure, while Orchid Spec is an eco-friendly speculum made from 100% sugarcane that prevents pinching and is silent (so no stressful clicking sounds as the speculum opens up, which can make patients tense up).

"I honestly believe that if a new device came to market, which was perceived as an improvement by clinicians and was more tolerable by patients," says Weiss, "the traditional speculum would be abandoned."

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