Hearing the words “pelvic exam” is enough to make anyone born with vaginal anatomy cross their legs and clench their pelvic floor muscles. Although vital for monitoring and caring for your sexual and reproductive health, the annual gynecological (GYN) pelvic exam can be not only anxiety-producing, but also invasive and even painful. As many as 60% of people who receive GYN pelvic exams may report pain or discomfort, and as many as 80% may report negative feelings like fear, anxiety, or embarrassment.
“Individuals who have had a bad experience with doctors or the medical system, suffered sexual trauma or violence, or patients with significant pain with exams can understandably be uncomfortable with a pelvic exam,” says Dr. Lindsey Harper, an OB-GYN, CEO of sexuality site Rosy, and Origin advisor.
Research shows that sexual trauma, in particular — which over half of people assigned female at birth may experience — can lead to avoidance of preventive care like cervical cancer screenings (aka Pap smears) and more negative and painful experiences with GYN pelvic exams. Discomfort during pelvic exams can also limit how useful and informative the examination can be.
Clearly, GYN pelvic exams need to change for the better. Pelvic floor physical therapists can help in two important ways. First, they can effectively treat the pain that some patients experience during a GYN pelvic exam due to pelvic floor muscle dysfunction. Second, they can model a more patient-centered exam that is inherently designed to prevent pain and reduce discomfort, fear, and anxiety.
What happens during a GYN pelvic exam?
A pelvic exam is a physical examination of the external genitalia and the internal pelvic organs to get a better sense of sexual and reproductive health.
GYNs and OB-GYNs may conduct pelvic exams in order to:
- Understand symptoms related to potential gynecological conditions (e.g., abnormal vaginal bleeding or discharge, pelvic pain, or pain during sex)
- Screen someone with a history of gynecological conditions
- Facilitate a pelvic procedure (e.g., getting an intrauterine device)
- Monitor your health as part of a prenatal care visit
The typical pelvic exam is a quick yet multistep process. The person receiving the exam will first remove all clothing beneath the waist and then cover up with a sheet or hospital gown. They will then lie down on their back on the exam table and insert their feet into foot or leg rests (aka stirrups), before scooting their hips way down to the edge of the table.
Next, the GYN will look at the external genitals, look at the vagina and cervix using a speculum to keep the vaginal walls open, and may even collect a sample of cells from your cervix in order to screen the cells for changes that may indicate a medical abnormality (aka a Pap smear). They will then examine the internal organs using gloved fingers after removing the speculum. While the inserted fingers push up toward the cervix, the other hand will apply pressure to the abdomen, allowing for a more thorough check of the internal organs from both the inside and the outside of the body.
In some cases, a pelvic exam in GYN care may also include a rectovaginal exam. In a rectovaginal exam, the GYN inserts two gloved fingers: one into the vagina and one into the rectum.
Easing pain that can occur with GYN pelvic exams
The factors that contribute to patient pain during a GYN pelvic exam can be different for everyone, but for many, pelvic floor muscle dysfunction is coming into play. “When your pelvic floor muscles are tight and painful, the pelvic exam can become an even more excruciating experience,” explains Dr. Ashley Rawlins, PT, DPT, a pelvic floor PT and Origin’s Clinical Learning & Development Lead. “When the speculum is introduced and opened, overly tight pelvic floor muscles are forced to stretch and this causes pain.”
When this is the case, pelvic floor physical therapy can provide relief. Treatment can include various exercises, manual therapy, and neuromuscular re-education techniques that can help improve pelvic floor muscle health — and help to heal a patient's emotional relationship with pain.
“The ability to experience a pain-free pelvic exam is a very common goal for patients who have overactive pelvic floor dysfunction, and pelvic floor PT is very effective in helping people get to this goal.” assures Rawlins. “What can be especially helpful to make progress for these patients, is making sure that the pelvic floor muscle exam and the treatment that follows is healing and reduces the discomfort and feelings of vulnerability that are common during a GYN pelvic exam.
Why pelvic floor physical therapy exams are different
Although it is a totally different examination, like GYNs, pelvic floor physical therapists also perform examinations transvaginally, but a PT pelvic floor muscle exam involves a slower exploration of the muscles, tissues, and nerves in the pelvic floor area — and involves a very different set-up and communication process (more on that below). Because pelvic floor physical therapists are focused on preventing and treating pelvic pain, they've taken extra measures to make their examination techniques as comfortable and comforting as possible.
“During training, we practice pelvic floor muscle examination and treatment techniques on fellow students and PTs, with a special focus on getting and giving feedback on how our examination technique and bedside manner is experienced by the patient,” she explains. “This learning advantage really helps us to understand what makes patients feel more at ease and in control.”
That's not to say that patients never find pelvic floor PT exams uncomfortable. The same anxiety, discomfort, and vulnerability that are common during GYN pelvic exams can be present during a PT exam. “Any time someone has a history of pain with vaginal penetration (tampon, finger, penis, toy, speculum, etc.) or feels shame related to their vulvar anatomy, it is more likely that they will experience some challenges surrounding the pelvic floor muscle examination,” explains Dr. Rawlins. But because PTs have a deep understanding of this muscle-clenching response, they are better equipped to conduct a transvaginal pelvic floormuscle exam without triggering pain or the anticipation of pain.
Here are 5 ways the pelvic floor PT approach to the pelvic floor muscle exam is designed to improve people’s experiences:
1. There are no stirrups.
“We don’t use stirrups to help position our patients and instead use pillows,” Dr. Rawlins says. “A reliable examination is only able to be completed if the patient feels comfortable and can relax their muscles for the exam, which is a lot more difficult in stirrups.”
Research backs this up for OB-GYN care as well. A 2006 study found that removing stirrups from exam tables can help people feel less vulnerable and uncomfortable during gynecological pelvic exams. So why are stirrups still in use? Before changes to the exam can be made, researchers must first prove that pelvic exams without stirrups can provide the same level of clinical information. Until that research exists, major health organizations can't endorse the change — so stirrups remain a part of the process.
2. There is no speculum.
In addition to the speculum’s racist and violent history, the gynecological instrument can be uncomfortable for anybody and especially painful for people with genitopelvic pain/penetration disorder. And its design hasn’t been revisited for over 150 years.
In pelvic floor PT exams, only a single gloved finger is used. This means less stretching and pressure in and on the vagina and surrounding muscles.
3. You’re in control.
Dr. Rawlins says she takes many steps to help patients feel more agency and self-determination in their exam experiences. These include continuously getting informed consent before doing anything, tuning in to non-verbal communication of discomfort or anxiety, only discussing any findings while a patient is dressed, and taking a trauma-informed approach (which most pelvic floor PTs have extensive training in) throughout the process.
4. You gain a deeper understanding of your body.
Many pelvic floor PTs, including Dr. Rawlins, incorporate education into exams before a patient undresses so they can make the right decisions for them without being in a state of increased vulnerability.
“I use anatomical diagrams and even a 3D pelvic model to verbally describe and verbally demonstrate the entire exam to the patient — as well as examination options that do not include a transvaginal or transrectal approach,” she says. “I want [patients] to feel fully informed before the exam so they can make an informed decision.”
5. It's never mandatory.
Unlike gynecological pelvic exams, which may be medically necessary, pelvic floor muscle exams are never required. Patients can choose to skip the exam and opt for an alternative option — or they can even be guided through the process of doing a self-exam.
Where GYN pelvic exams need to go from here
From who needs to have annual GYN pelvic exam, to how exams are conducted, there are some obvious changes that are likely to make a significant difference.
1. We need to make patient experience a priority.
OB-GYNs like Dr. Harper see the need for standard pelvic exams to change. We even see this demonstrated in more recent guidelines from the American College of Obstetricians and Gynecologists, which, unlike in previous years, suggest the exam isn’t always necessary.
“Many OB-GYNs are beginning to rethink the way that pelvic exams are performed, including creating more comfortable and comforting environments, warming speculums or using speculums that are more ergonomic and comfortable, and providing trauma-informed care,” she explains. “[These adjustments] do not alter the ability of the OB-GYN to complete the tests, but in many cases enable us to do so effectively … allowing [patients] easier and faster access to care when they need it.”
OB-GYNs can also take their own steps to improve the experiences of the pelvic exams they give their patients. “I always try to take time to connect with patients prior to a pelvic exam, understand their context and any worries or fears they may have about the exam, and communicate clearly during and after the exam,” Dr. Harper adds. “I find that this level of communication and attention create a team-like environment that supports all of our healthcare goals.”
2. We need to get rid of the speculum as we know it.
Setting aside talks of removing the speculum and considering self-insertion, the speculum itself has plenty of room for improvement. And people are interested in making that happen.
Organizations like Bridea Medical, Yona Care, a duo of OB-GYNs plus a medical student, and other designers are breathing new life into the centuries-old look and feel of the speculum. We hope to see broader uptake of these options from healthcare practitioners soon.
3. We need trauma-informed pelvic exams.
Trauma-informed care is heavily recommended in obstetrics and gynecology, but future doctors aren’t necessarily receiving the same level of training in medical school to provide it.
The Reproductive Health Access Project has also released a trauma-informed guide to gynecological pelvic exams that any provider can review and implement.
Whether it’s an OB-GYN or a pelvic floor PT who are examining things in the pelvic area, the tenets of trauma-informed care can help them make the experience as positive and supportive as possible.
4. We need to ban all pelvic exams done without consent.
The horrific reality is that some teaching hospitals allow medical students to perform non-consensual pelvic exams on unconscious patients. Laws have been passed to ban the practice in only 21 states.
No state should allow non-consensual exams of any kind — especially invasive ones like pelvic exams — to be performed on unconscious patients.
Caring for Your Pelvic Health
At Origin, we firmly believe in the importance of the exams performed in both GYN care and pelvic floor physical therapy. Our PTs take a trauma-informed, patient-centered approach to pelvic floor physical therapy and are committed to finding the best evaluation techniques and treatment options for every single patient. Opting out of an internal pelvic floor muscle exam — or waiting until you're further along in your treatment — is always an option and always honored.
If you’re managing uncomfortable symptoms like pain during vaginal penetration, incontinence, constipation, abdominal separation after pregnancy, or any other pelvic floor-related conditions, don't let anxiety about the internal muscle exams stop you from getting the care you need. We’re here to help!