While some discomfort is expected when visiting the gynecologist, experts say more education is needed for doctors and patients to better understand physical exams should not cause severe pelvic pain that can traumatize women and alienate them from care.
Gynecologist visits are rarely comfortable – whether it’s for a Pap test, IUD insertion or a biopsy, among other procedures – but for some women, the experience can be so excruciating they forgo further appointments, putting their health at risk. Making matters worse, this pain can often be minimized by primary physicians.
Dr. Rachel Spitzer, an associate professor at the University of Toronto and ob-gyn at Mount Sinai Hospital, told CTVNews.ca there are “numerous dangers” downplaying pelvic pain and painful experiences at the gynecologist’s office, including cancer or an underlying illness that could be prevented if caught early on.
“If we minimize their experiences of pain in our office then we’re not going to understand what may be underlying and we will be missing things,” Spitzer said in a telephone interview on Wednesday.
Spitzer said having a bad or painful experience at the gynecologist’s office and then being made to feel like those concerns aren’t being taken seriously can alienate people from care, making them hesitant to return for subsequent appointments or routine check-ups.
“When we minimize their experiences on any level, whether it’s minimizing their pain, whether it’s minimizing a description of another kind of difficult experience, we potentially lose that individual from care,” she explained.
Spitzer said there are a variety of factors that contribute to how someone experiences pain when it comes to pelvic exams, including their threshold of pain, previous painful experiences with doctors and a history of sexual abuse or other trauma.
However, getting to the root of whether it’s discomfort or severe pain can be difficult to address. Spitzer said this may require finding a physician or specialist who understands trauma-informed practices that focus on safety, choice, collaboration, trustworthiness and empowerment.
Spitzer said patients should feel supported in discussing their reproductive health with their doctor, not blamed for their painful experience.
“I let my patients know that if they asked me to stop, I will stop. You don’t want to ask your doctor to stop and [they say]’Just another 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 physicians may suggest taking ibuprofen ahead of pelvic exams to help, Spitzer said there are other options for those who don’t find over-the-counter pain medications don’t alleviate the pain, such as topical freezing agents and numbing gels, as well as doing procedures under sedation in certain scenarios with explicit consent.
However, Spitzer said the physician’s priority should be focused on getting to the bottom of why the pain is occurring, and how to treat it long-term.
Dr. Sukhbir Sony Singh, a gynecologic surgeon at The Ottawa Hospital and a professor at the University of Ottawa, says treating pelvic pain starts with education, followed by medication and alternative therapies in some cases, such as pelvic floor physiotherapy, exercise and mindfulness.
“Acknowledge the pain. Work with the patient to educate about what pain is, because pain is very complex and there are many reasons to have pain. Then start to treat the pain,” Singh told CTVNews.ca in a telephone interview on Wednesday.
TRAINING AND EDUCATION
While it can feel like a physician is dismissing one’s concern at the moment, Singh said the onus isn’t just on doctors. He said society has often dismissed reproductive health in general, specifically women’s issues like infertility, menstruation and endometriosis.
When a woman’s pelvic pain is dismissed, Singh said it can limit “their ability to really achieve their full life potential.” Data has shown that painful periods can result in girls having to miss school, hampering their education, and women with endometriosis report being passed over for promotions in their careers due to having to manage their symptoms.
“Once we are open as a society to discuss this, we will see that reflected in the emergency room, in family doctors offices and gynecologist offices,” Singh said.
Singh said a major issue is that there aren’t enough specialists in pelvic pain and more physicians need to be trained in trauma-informed care.
When he was a gynecology resident, Singh said he was taught that if someone comes to the emergency room with pelvic pain, he was to give them an ultrasound and if it showed no abnormalities, send the patient home. Singh has spent the last 15 years working to address this, helping colleagues and residents better understand gynecologic educational principles worldwide.
“We are teaching our students in our residence to do better — how to take a proper pain history, how to examine them properly to identify what kind of pain they have, where the pain sources, ultrasound imaging has gotten way better… and then how to interpret all of that to provide the patient with the best options,” he explained.
While he acknowledges there’s greater education around pain and reproductive health now, Singh says there’s still a lot more for physicians to learn, as well as patients.
“It all comes back to training,” he said. “From a patient’s perspective, do the research to learn about what kinds of pain there are. And yes, if you’re not getting the answers, advocate to move on to the next level.”
SHIFTING AWAY FROM 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 runs the Gynecology Dermatology clinic at Women’s College Hospital in Toronto, told CTVNews.ca the HPV test is more sensitive, and has shown to be cost-effective and safe.
“When you’re doing a Pap test, you’re looking for cells that are already potentially pre-cancer cells. When you’re doing an HPV test, you’re actually looking for the cause of the cancer. So you’re going an earlier step to who’s at actual risk of developing cervical cancer,” Selk said in a telephone interview on Friday.
Some provinces that have said they will be switching to HPV tests from Pap tests as the primary cervical cancer screening include British Columbia, Saskatchewan, Ontario, Quebec, Nova Scotia and Prince Edward Island. However, no timeline has been set for the change.
Selk said this wouldn’t be a “quick switch” as provincial health authorities have to make changes to the lab processes and documentation, as well as to training.
Selk said HPV tests are more effective at detecting those at risk and also have the potential for self-screening at home, addressing some of the concerns for those who suffer painful experiences when visiting their gynecologist.
However, switching to HPV tests as the primary form of screening for cervical cancer does not mean that Pap tests completely go away, Selk said.
“If you screen negative, it’s actually safe to go five years without being screened,” Selk said. “[But] if you do an HPV swab on yourself and it’s positive, the next step still involves a gynecologic exam with a speculum.”
While Selk acknowledges that this would essentially create an extra step for those who test positive, she said overall it is a better way to prevent cervical cancer, in addition to getting vaccinated against HPV.