The gynecological examination is usually never tops on anyone’s list of favorite activities. Having to strip naked, don a flimsy papery gown, lay down on a table with legs spread wide and feet in stirrups…it can be vaguely unsettling for some to downright terror-inducing for others. As awkward and uncomfortable as this examination can be, it should NEVER be extremely painful.
What are some of the reasons behind painful exams? Previous negative experiences and heightened anxiety can be significant contributors. Anxiety and fear place the nervous system on high alert, which often includes increased muscle tension throughout the body. This tension also affects the pelvic floor muscles, which is why the general instructions during an exam are to “Relax.”
In addition, medical issues such as infections, or skin conditions such as lichen sclerosus, can cause irritation to the skin and lining of the vulva and vagina, causing pain with insertion of fingers or a speculum.
Very often, dysfunction within the pelvic floor muscles themselves can cause pain. Pelvic floor dysfunction often accompanies medical diagnoses like endometriosis and interstitial cystitis/painful bladder syndrome, and can occur with pelvic, abdominal or hip pain; it can also occur on its own. Tight, spasmed muscles do not like to be stretched; they particularly resist quick stretch, which is what most commonly occurs during an internal exam. In an effort to preserve modesty and minimize discomfort, the exam is often performed quickly and vigorously. For people with painfully tight pelvic floor muscles, this can be excruciating. Sometimes, the pelvic floor is so tight and painful, the examination cannot be performed. A negative, painful experience can then set up a cycle of anxiety and pain that persists for years.
Unfortunately, women experiencing pain with exams are given very little guidance other than to “relax and breathe.” While this is actually very good advice, it is woefully inadequate for most women.
So what, then, can be done? Here are some tips to help reduce pain and improve your experience during an internal exam:
1. Establish a relationship with your provider. The American Council of Obstetrics and Gynecology recommends that the first visit occur between 13-15 years of age. Beginning regular visits at this age could help build a relationship of trust between you and your practitioner that could significantly reduce anxiety by the time the first internal exam is performed, usually at age 21.
2. Advocate for yourself. Communicate your fears and worries with your practitioner prior to the exam. Request that they move slowly to give you time to accommodate, and that they give you plenty of notice prior to inserting anything. Ask that they use the pediatric speculum if the adult size is too large/painful. Tell them if you are having pain; you do not have to submit to anything if you don’t want to.
3. Request pelvic floor physical therapy. Pelvic floor PTs are uniquely qualified to assess and treat pelvic floor dysfunction, and can significantly improve the likelihood of a successful, pain-free examination.
4. Breathe and relax. Do not underestimate the importance of calming the body and the nervous system; this can significantly reduce your body tension. In addition, meditation and mindfulness techniques can also help by focusing your attention, rather than letting your brain spiral into anxious thoughts. Stay tuned for a video of a short breath practice to help prepare you for your exam. Feel free to practice it anytime, especially while you are laying on the examination table, and let me know what you think!