A team of women in San Francisco are redesigning the pelvic exam experience with patients’ physical and emotional needs in mind.
Ask any woman how she feels about her annual pelvic exam and her response will range from an ambivalent groan to recalling a nightmarish experience.
Wearing a paper hospital gown, with legs spread-eagle in awkward stirrups, a woman’s most sensitive parts are examined with a tool that looks like a medieval torture device.
It’s no surprise women report feeling fear, embarrassment, and anxiety during their exam.
The pelvic exam screens for cervical abnormalities, sexually transmitted diseases, and a number of other health issues, which is why many women endure the appointment each year.
But the experience can be so traumatic for some people that they avoid making their annual appointment altogether.
The American College of Physicians (ACP) says that unless a woman is experiencing symptoms of pelvic problems, that’s fine.
In 2014, the ACP found that annual exams for healthy women exposes them to avoidable harms, such as anxiety and discomfort, with no benefit of reduced mortality rates.
Does taking care of women’s bodies have to be such an unbearable experience?
They took a human-centered approach to improving a critical instrument that hasn’t seen much innovation in around 170 years: the speculum.
But they also took a holistic look at other key moments throughout the exam, including waiting in the doctor’s office, interacting with the OB-GYN, and interpreting exam results.
They found that with a greater emphasis on women’s physical, emotional, and experiential needs, pelvic exams could be transformed into an empowering event that patients no longer dread or skip.
A better speculum
Most speculums you see today look similar to the original design by American physician James Marion Sims from the 1840s.
They have two lips, made of cold stainless steel, that open like a duckbill to separate the vaginal walls so doctors can inspect the cervix.
“Most people are petrified of the speculum. Not only does it look scary, but the standard system has a bright light shining down between her legs. It feels like a spotlight, which makes women more anxious,” said Dr. Cindy Duke, a board-certified OB-GYN and medical director at the Nevada Fertility Institute.
Anxiety from the speculum can actually cause the exam to take longer for the doctor to perform — and the patient to endure.
“The [cold] temperature in the room and tension in your body naturally make it a lot more difficult to navigate the tissue out of the way to see the cervix. [The provider] has to go more slowly and might have to take [the speculum] out and start over again,” explained Hailey Stewart, Yona’s industrial designer and design researcher.
Stewart and her colleagues decided to rethink the speculum.
They added a third lip, which gives doctors a clear view of the cervix and makes dilation more comfortable for the patient.
They covered the stainless steel in silicone, a warmer material that slides in more smoothly. Visible screws of past models are gone.
The Yona designers also created a way for a light to slip into the handle, eliminating that “spotlight” experience.
The Yona speculum took into account the physicians’ experience, as well.
Designers relaxed the angle of the handle, so it’s more comfortable for the doctor.
The speculum can be operated with just one hand and it doesn’t venture too far from the design on which most gynecologists were trained.
“[We needed to] keep it patient-centric while also considering what could keep the design from seeing the light of day,” said mechanical engineer Fran Wang, adding that the speculum needed to be easy for doctors to use and cost-effective for practices.
Still in development and facing a lengthy U.S. Food & Drug Administration (FDA) review process, the Yona speculum won’t be available for mainstream use for several years.
In the meantime, healthcare providers don’t have to rely on the old-school stainless steel speculums that can scare patients.
Welch Allyn, a medical diagnosis device manufacturer, offers four sizes of disposable plastic vaginal speculums with built-in LED lights.
Jamie Wood, manager of the women’s health category at Welch Allyn, said that about 55 percent of providers have ditched metal specula in favor of the plastic version.
“As a patient, you go in for the exam, you’re getting a brand new, out-of-the-bag speculum that hasn’t been used on anyone else. You know that speculum is going to be clean,” Wood told Healthline.
Think about all five senses
When a woman is in a vulnerable position — nearly nude on a medical exam table, legs spread, and feet in stirrups — she’s hyper aware of every noise, every material, and every touch.
Paying attention to all of her senses is important in turning the pelvic exam into a positive experience.
Patients tense up when the speculum is inserted and they hear the clicking noises it makes, said Duke. The Yona design silences those unnerving sounds.
Doctors can make the noises of plastic and stainless-steel speculums less alarming by talking the patient through the experience.
“I let them know I’m going to place the speculum inside of them and it’s going to make a clicking sound. I assure them that nothing’s being broken or injured, just to verbalize a common fear. Usually, she laughs at that point and it lightens the mood,” said Duke.
Another area of concern is temperature, considering patients are undressed.
The Yona team addressed that by creating a comfort kit that includes socks, a weighted blanket, and a stress ball.
“We identified key moments in the exam process where if you change one thing, it will elevate the experience for the patient and won’t be a burden on providers,” said Stewart.
Stirrups give the provider easier access to the vagina, but they restrict patient movement, reduce comfort, and potentially increase anxiety.
Some healthcare providers, like certified nurse-midwife Stephanie Tillman, have decided to ditch stirrups altogether. But Duke has found that stirrups actually help make the pelvic exam less painful, so she doesn’t advocate for getting rid of them.
“Without stirrups, you might have to push the speculum in deeper and press harder to see the cervix. For the vast majority of patients, it just doesn’t work,” Duke said.
While the Yona project has developed innovative solutions to solve some of women’s biggest concerns at the OB-GYN’s office, doctors have the ability to improve pelvic exams right now, with little to no additional costs incurred.
“Doctors need to take the time to remember that patients are human beings with emotions. Sometimes we forget that this is a really intimate part of a women’s body and the exam is a big deal for her,” said Duke.
Help patients relax and learn
Pre-exam jitters are the norm for most patients waiting for their gynecology appointment.
“We learned the anxiety when you’re sitting around waiting for your doctor is as high as that moment the speculum’s inserted,” shared Rachel Hobart, visual designer at Yona.
That’s where Yona’s app comes into play. It offers a guided meditation that people can use to self-soothe in the waiting room or in the chair.
Doctor’s offices could also help patients to relax by injecting humor into the experience, when appropriate.
Yona designed a “cheekily printed sheet” for the exam table that reads “Your butt goes here” and clues in patients on where they should sit.
Not only does it make the exam room feel more personal and thoughtful, but it also helps patients get in the right position early on in the appointment — no more awkward requests to scooch down.
While most women understand the importance of the annual exam for their health, they usually don’t know what’s happening “down there” during it.
The Yona app would allow patients to ask questions they feel embarrassed about, confidently connect with their doctors, and read their results in plain English.
Some doctors, including Duke, have already developed strategies to educate patients and earn their trust without digital technology, though.
She consults with patients, shows them a model of their organs, and demonstrates what happens during the exam — all before the patient removes her clothes.
“The exam is the opportunity for you to ask the questions you’ve always been afraid to ask. It’s really important to explain what will happen and hear her anxieties,” said Duke.
The Yona project has the opportunity to shake up the future of women’s reproductive health.
But healthcare providers don’t have to wait for innovations.
By spending a bit of extra time with patients, using the most comfortable speculums available, and considering the end-to-end experience, doctors can start creating a more comfortable pelvic exam experience for women.
Written by Joni Sweet and Whitney Akers