A PAP SMEAR IS NOT A PELVIC EXAM


No woman likes to go for a pelvic exam. You never hear, "Oh, boy, I just can't wait to visit my gynecologist!" And why should anyone look forward to it? The position is ignominious; you feel like a plucked chicken spread-eagled on the table. The instruments may be icy cold. The poking around can be painful. The experience may be humiliating and dehumanizing. I have been on both sides of the stirrups and I know.
The first time I went to a gynecologist, I was about to be married and there were many questions I wanted to ask. I chose a woman physician and assumed we would have a warm and useful chat in her office before she examined me. Instead, a nurse ordered me to disrobe and don a paper gown, which, despite my clutching fingers, billowed one way while I billowed another. Self-conscious and draft-ridden, I sat on the table in the examining room and waited. For two hours. Nobody bothered to come tell me that Dr. X was delayed, and when Dr. X herself finally rushed in, she barely spoke, just ordered me into the stirrups and inserted a poorly made plastic speculum that pinched, then rushed off again without giving me a chance to ask the questions I had come with.
When a woman has an experience like that, it is not surprising if she tells herself that as long as her internist does a Pap smear once a year, she can skip being seen by a gynecologist. But a Pap smear does not really substitute for a pelvic examination. Let me describe what I think a thorough gynecologic examination consists of so that you will understand why this is so and why you may want to change gynecologists, as I did, if the experience is not a comfortable one. Once you have the information, you will know better what to expect and what to ask for, and because you will understand why certain procedures are necessary, you may well find that you mind the whole experience a great deal less.


WHEN SHOULD A WOMAN START SEEING A GYNECOLOGIST?

The American College of Obstetricians and Gynecologists recommends that a woman should start seeing a gynecologist for a Pap smear at 21 years of age or 3 years after her first sexual intercourse, whichever comes first. However, a “get to know you” encounter with the gynecologist should first take place between 13 and 15 years of age. A physical examination may not warranted and questions can be asked and answered in a non-threatening manner. Females who have not had sexual intercourse tend to believe that if the hymen has not been perforated, the gynecologist cannot do an examination, but that is not the case. The hymen is fenestrated—that is, there is an opening or several small openings that allow the menstrual flow to emerge—and this fenestration permits a small speculum to be introduced, a speculum being an instrument like a pair of tongs that is used to spread the walls of the vagina apart. Either a baby Pederson speculum or a nasal speculum can be used to allow the gynecologist to view the vagina and cervix.

Sexually Active Women. If you have made the decision to become sexually active, no matter what age you are, it is important that you protect yourself, for intercourse may cause a change in your previous state of health. There may be a cyst or an abnormality such as two cervices that requires medical attention. Unintended pregnancy is, of course, a concern, and if the partner has had previous sexual experience, infection is a possibility. A gynecologist who already knows you is in a better position to evaluate an acquired infection, just as she is in a better position to offer advice about birth control measures. Gynecologists understand the pressures girls experience to become sexually active, and they are non-judgmental, interested only in ensuring their patients' health and well-being. Just to clarify the term “sexually active”. It means sexual activities involving vaginal, oral, or anal sex.

Vaccinations. Vaccinations or immunizations are given to protect against diseases caused by bacteria and viruses. The following vaccines should have been (or be) given to all young women by the time they are between 11–18 years on a routine basis:

* Tetanus—diphtheria—pertussis (Tdap) booster
* Hepatitis B virus vaccine
* Meningococcal
* Varicella (chickenpox) vaccine
* Measles—mumps—rubella vaccine

Recently, with the FDA approval of Gardasil (Quadrivalent Human Papillomavirus (Types 6, 11, 16, 18) Recombinant Vaccine) in 2006, young women were asked to consider being vaccinated against the Human Papillomavirus (HPV). This recommendation came with much controversy regarding the need to be vaccinated. A male or female of any age who is sexually active is at risk. Many parents still believe that their daughters will be virginal until marriage and that this vaccine was not necessary. However, according to a national governmental survey, 62% of female 12th graders have had sexual intercourse and at least 50% of sexually active people catch HPV during their lifetime. Certain types of HPV (most notably HPV 16, 18, 31 and 45) have been shown to be associated with nearly all cases of squamous cell cervical cancer causing a change in the lining of the cervix from normal to precancerous lesions, which can progress to cancer. The vaccine also helps protect against genital warts caused by certain types of HPV (Types 6 and 11). The four types of HPV were selected for Gardasil because they cause approximately 70% of cervical cancers and 90% of genital warts.

If my daughter were between 9 and 26 years of age, I would definitely encourage her to receive the vaccine in order to protect her from developing cervical cancer. The vaccine requires three injections: the first dose, followed by another in 2 months and the last dose is given 6 months after the first dose. The vaccine is well tolerated and the side effects are rare and minimal.