Tuesday, 5 December 2017

Speculums for the Terrified: a guide for patients

Speculums for the Terrified: a guide for patients


A speculum is a piece of medical equipment which is inserted into the vaginal canal to visualise the cervix in gynaecological procedures such as smear tests and fertility treatments. It is often described by the medical profession as “uncomfortable but not painful” but many women do find speculums to be painful and traumatising.

However, sometimes in life one might choose to undergo a procedure using a speculum, to achieve a greater good. This guide is for anyone who is new to the process, and for anyone who has already had difficult, painful experiences with speculums, and aims to provide the skills and knowledge to deal with speculums in the gentlest possible way.

It is normal to find speculums painful and  hard to cope with!

Speculum examinations are performed by doctors or nurses who are trained in their use. Although the language used is different, the use of a speculum is sexual penetration by a professional using a rigid object. There is no reason why you should be automatically okay with this, and yet women who have a problem with it are frequently told they are having an abnormal reaction. If you find speculums deeply unpleasant, this is normal. Vaginas are not designed for this kind of penetration and the body’s natural reaction is to try to expel the speculum. Your body may feel under attack even if you have intellectually consented to a particular procedure.

Medical language regarding pain/discomfort

There is a bias in the medical profession against describing speculums as painful, because of a fear of deterring people from potentially life-saving procedures. For example, for one widely-accepted-as-painful-gynaecological procedure, any patients who manage to stay conscious get reported as having experienced “mild discomfort”, even though what they experienced was extreme. “Moderate discomfort” means they passed out! 

There are various negative effects of this minimizing pain language –

(a) it isn’t honest in that it doesn’t accurately reflect reality for many people;

(b) medical professionals who haven’t been through the procedures themselves might believe the procedures are much less painful than they actually are, and blame the patients for not coping; and

(c) it breaks trust: sensitive patients are deeply shocked that their reality is different then described, experience a lack of empathy from the medical staff, and ether feel lied to or blame themselves for being weak.

Why might some people find speculums harder to cope with than others?

There are lots of valid reasons that speculums are harder for some than for others – none of which is weakness of lack of capacity:

· Unusual anatomy. For example, the cervix may be tilted (behind the public bone or very far back in the vagina).  This makes it much more difficult for the practitioner to get the speculum into the right place. This can mean extra insertion attempts and additional pain.

· Anxiety/PTSD. Pain can be reduced by relaxing your vaginal muscles to allow the speculum to enter with the least resistance. If you’re anxious, your whole body tenses, and relaxing them is very difficult.

E.g.  Survivors of rape and sexual violence – very likely to have anxiety and PTSD issues. The gynaecological procedure may trigger bad memories and/or flashbacks.

· People who haven’t ever had sexual intercourse. The vaginal canal might be particularly tight as it hasn’t ever experienced the entry of anything as large as a speculum, and all the sensations are particularly new. Also, your hymen might be partially intact and broken by the speculum, which is painful and can cause bleeding.

· Highly sensitive people. Just as we all have different heights and IQs, we all have different pain thresholds. 20% of people are highly sensitive, which means that sensory input is experienced more intensely than the rest of the population.

· Slow processing speed. If you process sensory input slowly, there isn’t time to work out what you are feeling, to deal with it, and to relax your body.

        E.g.  Autistic women – are both highly sensitive and have a slow processing speed. Most autistic women are undiagnosed and may not be aware of their differences.

Some people might have more than one of these reasons which apply.

Super-sensitive method for dealing with speculums

If you are one of the Terrified, here are some steps you can take to make speculums as easy for yourself as possible. If you don’t need some of the preparatory steps, just skip them out. If any of the preparatory steps are particularly difficult, practice over a week or so, be super-kind to yourself, give yourself a big reward afterwards, and take your time before moving onto the next step.

To Prepare 

Dealing with a speculum being inserted into you involves being naked from the waist down. If nudity is a problem, practice becoming comfortable with seeing yourself naked in the privacy of your room at home. Use a mirror to see your vulva area and try to become okay with your body and your sexual parts.

Go swimming and get undressed in the communal changing area as opposed to the private cubicles. Get used to other people seeing you naked, to normalise it.  

Speculums are typically 3 or 4 centimetres in diameter and vaguely resemble staplers; they are significantly larger than tampons. You can practice for a speculum with vibrators.  Buy some vibrators of different sizes. If this is deeply distasteful, remember that this advance practice will make the speculum easier to cope with. You don’t need to use the vibratory function.  If you can’t insert an object into your own body, how will you cope when someone else does this?

Starting with the smallest vibrator, try to insert this into your vagina. If/when you experience resistance, this is your vaginal muscles tensing up. Stop pushing, take some deep breaths and think some relaxing thoughts. When you’ve relaxed, gently try to push the vibrator slightly further in. Stop and repeat the relaxation steps every time you feel pain/resistance. 

When you have mastered the smallest vibrator, do the same with the next size up, until you are able to use a large size.

At the appointment

Bring a friend/family member to support you. Also, bring a flask of hot chocolate/a favourite chocolate bar.

Take your support person into the appointment if they are willing to go (not everyone is comfortable with this, so check carefully that they are okay to go in with you). Explain to the medical professional that you are anxious and ask them to show you the speculum and how they are going to move it inside your body. The process is approximately:
a. They touch the vulva with their hands
b. They insert the speculum by a few centimetres
c. They turn the speculum by 90 degrees
d. They insert the speculum a few more centimetres to reach the cervix
e. The jaws of the speculum are opened up to push the cervix open

Tell the medical professional that you need them to take it very slowly to give you time to process the sensations and relax, and say that it would help you greatly to feel in control of the process. To be in control, you are the one who needs to say when they can move the speculum and when they need to stop.  

Ask them to only move the speculum when you say so, and to stop moving it when you say so.

Get undressed and lie on the examination table. Take some deep breaths and relax as much as possible. Say to the medical professional that they can touch your vulva with their hands and then stop. Get used to the sensation of the touch. If this has made you tense up, take some more deep breaths, realise that you’re feeling something a bit funny but you’re okay, and relax any muscles that you may have tensed, e.g. at the back of your neck and the small of your back.  

When you are relaxed again, ask them to insert the speculum by one centimetre and then stop. Process the sensations, realise you are okay, take some deep breaths, and relax any muscles which have tensed up. When you are ready, tell them to insert the speculum by one further centimetre – and repeat your relaxation. 

Repeat like this, all the time with small movements. When the speculum is in the position to be rotated by 90 degrees, as them to do this and then stop. Carry on in this way with the rest of the steps until the speculum is fully inserted and your cervix is open.  

 Your support person can help you by reminding you to relax and breathe throughout the procedure – it can be hard to remember if you are overwhelmed.

 If the process makes you yell, cry or shake, that’s okay, that’s a perfectly normal reaction to pain. If it’s possible to suppress this, it’s a good idea because the conventional social rule in these circumstances is to pretend (for the benefit of the person performing the speculum examination) that you’re not in pain, so that they don’t feel bad. It may not be possible to fully suppress/hide your reaction, and if not, that’s fine too. Hopefully you will experience empathy from your practitioner and an honest communication of pain (which is all screaming or crying really is) will be taken as such.

When it’s all over, congratulate yourself for having done something amazing and have your chocolate. Tell yourself that have done fantastically well and enjoy feeling very proud of yourself.

Thinking about speculums

How you feel about this procedure is how you should feel. You might feel afterwards that it was slightly uncomfortable but really very alright. Or you might feel it was upsetting and traumatic and you might need to take care of yourself very well for the next few days until you feel safe again. All feelings are valid. No value judgements are being made here about whether you should or should not choose to undergo any procedure involving a speculum; that’s entirely up to you. However, if the procedure you are undergoing is something you have chosen to do, e.g. because you want a smear test result, or because you want to go through fertility treatment, then dwelling on any very negative thoughts and language will only increase your anxiety and stress for next time, which is unhelpful.

How you choose to frame this experience will affect how you feel about this later and will affect your stress levels for the next time. It might be more beneficial to think of it as a necessary few moments of pain for the greater good, and that it’s an unpleasant sensation but one which you can deal with. In life, there are moments of pleasure and moments of suffering. This can be seen as a brief moment of suffering. It is over relatively quickly, you’ll get to the hot chocolate stage and you can be on your way.

·         Never beat yourself up mentally if you are having a hard time with this. Hopefully the medical professionals you are working with will affirm your feelings and be encouraging and supportive. But if they don’t, it’s doubly important for you to affirm yourself and trust your own feelings.
·         Having a speculum inserted into you is unnatural, and you are right to feel however you do feel about it. Always tell yourself that you are good and capable and brave.

·        Don’t compare yourself or your reactions to anyone else – every woman is different and it might be genuinely much harder for you than for others.

...and good luck!


· Speculums are experienced by many people as very painful, even though they are not generally described as such by the medical profession.

· There are valid reasons to experience this as painful, and this is not because you are a wimp.

· You can prepare yourself for the procedure by undertaking some preparatory “homework”.

· By asking the medical professionals to do the procedure at your pace and direction, you can control what’s going on and take your time to deal with it in the best way for you.

· How you choose to think about it will affect how you feel about speculums and your stress level if/when you encounter them again.

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