naturopathydigest.com -- The Pelvic Exam: Improving Your Patient's Experience

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The Pelvic Exam: Improving Your Patient's Experience

By Isis van Loon, ND

Let's face it, having a gynecologic exam is not exactly an event most women look forward to. Yet a regular gynecologic exam is an important part of women's health because it can help diagnose a broad range of disorders, most of which are treatable.

A woman who has a negative experience will be less likely to seek future health care, putting her at risk for many disorders and diseases that otherwise might be treatable. Even if the exam itself is painful or uncomfortable, by engaging the patient's full consent and participation in the process, the experience still can be positive. Furthermore, she will be more likely to return to you for future care.
Before starting the examination, evaluate your comfort level and skills. If you are nervous or embarrassed by this exam, your patient will know. You should have enough basic skill to technically perform an accurate and efficient bimanual and speculum exam. Take further training if needed.
Make sure your equipment is clean and ready for use. Having state-of-the-art equipment is great, but you can perform a good gynecological exam on a regular bed with gloves, a speculum and a flashlight, if necessary. Cloth drapes that can be wrapped around the waist sarong-like are handy and provide better coverage than standard exam gowns. Generally, cloth is better than paper in terms of patient comfort. Pillows can improve patient comfort as well, so have some ready. Make sure the room is warm enough, but have a small blanket just in case.
Now you are ready for your patient. It's important to let your patient know that you will stop at any point in the exam if she wants you to. Then be sure to check in with her during the exam by asking questions such as, "How are you feeling?" to give her the opportunity to inform you. Not all women are assertive enough - especially when exposed on an exam table - to be able to volunteer information.
Next, obtain (and chart!) informed consent. Explain the entire process and the importance of the exam in detection and treatment. Some medical terms might need clarification, but using correct terminology will indicate to your patient that you are acting in a professional manner. Not all women want all of the details, so be sensitive. Some women like to see how a speculum works and want a mirror to observe with; others do not. Take as long as needed, but not too long. Some women will just want you to hurry up and get it over with. If you have an assistant, introduce the assistant to your patient before having the patient disrobe.
At this point, your equipment is ready and your patient is participating and involved to the degree she is comfortable with. Give her the appropriate exam gown and/or drape, explain how to use them if necessary, and leave the room to allow her to change.
When you return, wash your hands, preferably in front of the patient, and make sure your hands are warm and appropriately gloved. While gynecological exams don't have to be performed under sterile conditions, they should be performed under clean conditions. Germs such as herpes have been cultured from lamps in doctors' offices. Gloves are cheap. If you have to touch something in the room, throw the gloves away and get new ones before touching your patient. Patients do notice and will appreciate your concern for their health.
Have the speculum ready in warm water - even plastic speculums get cold. Have water-based lubricant available. Multi-dose tubes are cheaper than single-use packets, but be very careful not to contaminate the lubricant by touching the mouth of the tube to anything.
Ask your patient to position herself on the table. Gynecological exams can be done with the woman lying sideways, but unless there are health reasons for doing so, the lithotomy position is most common. Having the woman partially sitting up allows you to maintain eye contact, reinforcing her participation in the exam. When she is positioned, instruct her to adjust the drapes for the exam.
As with all parts of the exam, during the visual inspection, ask permission before proceeding. Don't immediately touch the genital area; start somewhere less invasive. Explain what you are going to do next, and if she is interested (ask, if you can't tell), let her know what you observe. Reinforcing healthy findings can be reassuring, but keep in mind that if there is significant pathology, this might not be appropriate.
Don't touch your patient more than necessary. Lying exposed on a gynecological table is a very vulnerable position and having a doctor casually lean on the patient's leg while performing the exam is inappropriate.
The actual technique of the speculum exam is variable. Just do what works well for you. Locating the cervix manually before inserting the speculum will give you an indication of what size speculum to use and how to angle the insertion. If you notice the patient's pelvic muscles are very tense, you might be able to assist her to relax. Insert the speculum carefully, as it's very easy to pinch tissue or catch hair. Use lubrication as needed and as allowed by any tests to be performed. Warm water almost always is adequate.
Be efficient. There is no need to make this exam last longer than necessary. When finished, leave the room to allow your patient to get dressed. When you return, discuss any findings and instruct your patient on follow-up. Before she leaves, ask her how the experience was for her and listen to her answers carefully. Apologize for any discomfort/issues she might have had and learn from it. Your patients can, in turn, be your teachers.

About the Author: Dr. Isis van Loon is dean of clinical studies at Boucher Institute of Naturopathic Medicine in New Westminster, British Columbia. She graduated from Bastyr University in 1995 with the degree of Naturopathic Doctor and a Bachelor of Science (Human Sciences), and then joined Boucher in 2002, originally as a classroom instructor (bioethics, physical/clinical diagnosis, pediatrics, gynecology, naturopathic clinical arts and sciences). She also holds a TCM certificate from the Shanghai College of Traditional Chinese Medicine in Burnaby, British Columbia.