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While some inconvenience can be expected when visiting a gynecologist, experts say more education is needed for doctors and patients to better understand that physical exams should not cause severe pelvic pain, which can traumatize women and alienate them from care.
Gynecologist appointments are rarely convenient — whether for a Pap test, IUD insertion, or biopsy, among other procedures — but for some women, the experience can be so excruciating that they put off further appointments and put their health at risk. To make matters worse, this pain can often be minimized by general practitioners.
dr Rachel Spitzer, an associate professor at the University of Toronto and a gynecologist at Mount Sinai Hospital, told CTVNews.ca there are “numerous dangers” that downplay pelvic pain and painful experiences in the gynecologist’s office, including cancer or an underlying disease if detected early avoidable.
“If we minimize their pain experiences in our office, we won’t understand what’s behind it and we’ll miss things,” Spitzer said in a phone interview on Wednesday.
Spitzer said having a bad or painful experience in the gynecologist’s office and then feeling that those concerns aren’t being taken seriously can alienate people from the care and make them reluctant to return for later appointments or routine checkups.
“If we minimize their experience at any level, whether it’s minimizing their pain or minimizing a description of some other type of difficult experience, we may lose that person from care,” she explained.
Spitzer said there are a variety of factors that contribute to how someone experiences pain during pelvic exams, including pain threshold, previous painful experiences with doctors, and a history of sexual abuse or other trauma.
However, it can be difficult to get to the bottom of the cause, whether it is discomfort or severe pain. Spitzer said this could potentially require finding a doctor or specialist who understands trauma-related practices that focus on safety, choice, collaboration, trustworthiness, and self-determination.
Spitzer said patients should feel supported when discussing their reproductive health with their doctor and not be held responsible for their painful experience.
“I have let my patients know that if they ask me to stop, I will stop. You don’t want to ask your doctor to stop and [they say]’Just a moment, I’m almost done,'” she said.
“There has to be trust and respect and acknowledging that some people may have had difficult experiences in their past that can make this particularly challenging for them.”
While doctors may suggest taking ibuprofen before pelvic exams to help, Spitzer said there are other options for those who don’t find over-the-counter pain relievers aren’t relieving pain, such as: B. topical freezing and anesthetic gels and procedures under sedation in certain scenarios with explicit consent.
But Spitzer said the doctor’s priority should be getting to the root cause of the pain and treating it long-term.
dr Sukhbir Sony Singh, a gynecologic surgeon at Ottawa Hospital and a professor at the University of Ottawa, says treating pelvic pain begins with education, followed by medication and alternative therapies in some cases, such as pelvic floor physical therapy, exercise and mindfulness.
“Acknowledge the pain. Work with the patient to educate them about what pain is because pain is very complex and there are many reasons for being in pain. Then start treating the pain,” Singh said in a phone interview with CTVNews.ca on Wednesday.
INITIAL AND CONTINUING EDUCATION
While it can feel like a doctor is shrugging off their concerns at the moment, Singh said the responsibility doesn’t rest solely with doctors. He said society has often dismissed reproductive health in general, particularly women’s issues such as infertility, menstruation and endometriosis.
When a woman’s pelvic pain is dismissed, Singh said, it “can limit her ability to truly reach her full potential in life.” Data has shown that painful periods can cause girls to miss school, hampering their education, and women with endometriosis report being passed over for career advancements because they are coping with their symptoms.
“Once we as a society are open to discussing this, we will see that reflected in the ER, GP offices and gynecologists,” Singh said.
Singh said a key problem is that there are not enough specialists in abdominal pain and more doctors need to be trained in trauma-informed care.
When he was a gynecologist, Singh said he was taught that when someone comes into the emergency room with pelvic pain, to do an ultrasound and send the patient home if they don’t show any abnormalities. Singh has spent the last 15 years addressing this issue and helping colleagues and residents better understand gynecological education principles worldwide.
“We teach our students in our dorm to do better – how to take a correct pain history, how to properly examine it to determine what kind of pain they have, where the sources of pain are, ultrasound imaging has gotten much better… and then how to interpret all of that to give the patient the best options,” he explained.
While acknowledging that there is now better education about pain and reproductive health, Singh says there is much more to learn for doctors and patients.
“It all comes down to training,” he said. “Research from a patient’s perspective to find out what types of pain there are. And yes, if you don’t get answers, advocate moving to the next level.”
POSTPONEMENT OF PAP TESTS
Researchers say swab testing for high-risk human papillomavirus (HPV) will soon replace the Pap test for primary cervical cancer screening in Canada.
dr Amanda Selk, a gynecologist who heads the Gynecology-Dermatology Clinic at Women’s College Hospital in Toronto, told CTVNews.ca the HPV test is more sensitive and has proven to be inexpensive and safe.
“When you do a Pap test, you’re looking for cells that may already be precursor cells to cancer. When you do an HPV test, you’re actually looking for the cause of the cancer, an earlier step in who is at actual risk of developing cervical cancer,” Selk said in a phone interview on Friday.
Some provinces that have announced they will switch from Pap testing to HPV testing as the primary screening for cervical cancer are British Columbia, Saskatchewan, Ontario, Quebec, Nova Scotia and Prince Edward Island. However, no timeline has been set for the change.
Selk said this is not a “quick change” as provincial health officials would need to make changes to lab processes and documentation, as well as training.
Selk said HPV testing is more effective at identifying those at risk and also has the potential to screen themselves at home, addressing some of the concerns of those who suffer from painful experiences when visiting their OB/GYN.
However, the shift to HPV testing as the primary form of cervical cancer screening does not mean Pap testing will go away entirely, Selk said.
“If you screen negative, it’s actually safe to go five years without screening,” Selk said. “[But] If you do an HPV smear test on yourself and it is positive, the next step is still a pelvic exam with a speculum.”
While Selk acknowledges that this would essentially mean an extra step for those who test positive, she said it’s overall a better way to prevent cervical cancer on top of getting vaccinated against HPV.
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