When it comes to pelvic exams (vaginal exams), our urogynecologist Dr. Angel Marie Johnson always starts where you are—learning what you're comfortable with, understanding what your concerns are, and explaining what to expect each step of the way as she conducts the exam.
That said, many women are afraid of the exam due to the "fear of the unknown," so we thought we'd provide some insight into Dr. Johnson's process.
As with all content on Greater Boston Urology's blog, the following information is educational in nature, not medical advice. Always talk to your physician about your specific health care questions and conditions.
[Editor's note: This article was reviewed and updated on 5/18/21 with additional links and media.]
Is your vagina healthy and functioning normally? That's the main reason why vaginal exams are necessary. A thorough vaginal exam (commonly referred to as a pelvic exam) provides Dr. Johnson with an important baseline regarding your vagina's health, particularly its structure.
Dr. Johnson explains, "None of my treatments work unless everything is structurally sound, meaning everything is in the right place, there's no abnormality, there's no injury. That's the first kind of big benchmark that I need. I have to make sure there's no cancer, there's no abnormal growths, all of those things."
Dr. Johnson says the first part of her exam is straightforward and gentle: She tests the nerves around the perineal region, which is the inner thigh area. She does this by using the soft part of a Q-tip. Then, she breaks the wooden Q-tip in half and gently uses the sharper side. She tests the different areas around the perineum and maps it out in order to understand whether the patient is experiencing normal nerve sensations. (Nerve issues would require specific treatment protocols.)
Dr. Johnson also conducts a visual exam. She explains, "I can tell based on appearance if the area is atrophic, which is when a vagina looks pale in color, it's irritated, those kind of things."
An internal exam typically comes next, which requires the use of a vaginal speculum, which helps spread the vaginal walls so that Dr. Johnson can examine the inside of the vagina and the cervix.
Dr. Johnson notes, however, that if the patient is experiencing pelvic pain, she might not use the speculum, which, as she notes, tends to strike fear in many female patients.
She says, "If someone has pain, then I won't even use it. I might just continue with a Q-tip, and I literally will map out the areas that cause them pain. The last place I go is where they reported the pain. Once you elicit pain, you lose everything from then on. Everything hurts. It's kind of hypersensitivity."
If a patient presents with pelvic organ prolapse, Dr. Johnson will use the speculum to help her do the prolapse assessment (which is called a POP-Q). This involves measuring different parts of the vagina, such as the anterior and posterior walls. These measurements are important. "That's what goes into my surgical planning, and my counseling of what surgery I think is best for them," Dr. Johnson says. "That's why I do the exam. It's also a way for me to see if there are any surprises. You never want to put a patient to sleep and not know what their anatomy is."
Dr. Johnson understands that internal exams can be overwhelming for many patients. "Some patients, no matter how much I discuss an exam, they're not ready for an exam during their first visit and that's fine," she says.
"I recently saw a young woman with a complex social history, and the exam literally made her shake. She was shaking in fear. I told her I'm not going to do an exam. I don't need to get that information right now. I did tell her that while I hoped to do the exam during the next visit, if she's still not ready, we can wait. As I work on that physician/patient relationship, as we develop that trust on both sides, then she'll get to the point where she's comfortable having an exam."
Here's the good news: Dr. Johnson doesn't need to conduct a vaginal exam every time she sees you. As she explains, "I don't need to examine you every visit. I just need to have one good baseline exam, and then we go from there. If something changes, you let me know, but it's not as if I need to do a full exam every time I see you. That's falling out of favor now."
Dr. Johnson is the director of our Women's Health Centers and practices out of GBU's headquarters in Dedham, Mass. Schedule an appointment with her here.
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