Pap Series Part 5: Special Speculums

***In order to keep this series light-hearted and easy to read I am not going to quote or site any sources except the knowledge of what I have learned through conferences, school, from pathologists and others who have gone on before me. THIS IS NOT TO REPLACE ANYTHING YOUR DOCTOR/NURSE PRACTITIONER/MIDWIFE/PA etc IS TELLING YOU. This is just some easy to read information*** Part 1 Part 2 Part 3 Part 4

So I have told you how to prepare, what to expect before hand, why we do it, and additional testing but I haven't actually told you what to expect when you actually get that pap smear. Most of you reading this have already had a pap smear so some of this may explain some of the sensations that you have felt, and for those of you who haven't ever had a pap smear, this might clear up some fears that you may have.

A pap smear isn't scary. Okay fine, it shouldn't be scary. It shouldn't be scary but it may be scary if you have a history of sexual abuse, rape, vaginal trauma, a bad or painful pap smear in the past, or you just don't know what is going on or what to expect.

There aren't very many names for this instrument, I have heard a "duck bill," "clampy thing," "the scary metal thing," and that is about all. However, the real name is a Speculum. There are different kinds of speculums, but a speculum is basically the only name for it.

image via wikipedia

A speculum is an instrument that allows us to see inside the vagina so that we can visualize the cervix. A light is either attached to the speculum itself, or positioned in place so that there is a clear view of the cervix.

Sounds simple right? Well, after time it does become simple for a practitioner to visualize the cervix in order to do a pap smear, however, not all anatomy is created equal. The cervix is sometimes towards the top of the vagina (anterior), the back of the vagina (posterior), or it can be towards the right or left sides. None of these positions are bad or abnormal, but if a provider mentions to you where you cervix is, remember it! This way you can tell future providers where to look if they seem to be taking a long time to visualize your cervix.

Example, "I am so sorry it is taking so long for the pap smear Ashley, your cervix is just posterior, and sometimes that makes it hard to see. But don't worry, I found it just fine and the pap smear will be over in just a few seconds."

Now I am starting to get ahead of myself. The speculum, when placed properly, shouldn't hurt you as a patient. There is increased vaginal and rectal pressure... this is sometimes mistaken for pain. So if you start to feel like you are going to "pass gas" "toot" "fart" or whatever, that is normal. Not pleasant, but a normal feeling when having a pap smear.

If the speculum is plastic you may hear a clicking noise as it is locked into place, if it is a metal one then you probably won't hear much of anything. There isn't a big difference between the metal and the plastic, except sometimes the metal speculums are a little colder. If that is the case, hopefully your provider will give you a heads up to that so it doesn't surprise you.

Well, I am not sure how much more I can say about speculums. They aren't fun, but they are necessary for a provider to be able to see your cervix and to collect enough cells for a pap smear.

Pap Series part 4: Human Pap-a What? or HPV

***In order to keep this series light-hearted and easy to read I am not going to quote or site any sources except the knowledge of what I have learned through conferences, school, from pathologists and others who have gone on before me. THIS IS NOT TO REPLACE ANYTHING YOUR DOCTOR/NURSE PRACTITIONER/MIDWIFE/PA etc IS TELLING YOU. This is just some easy to read information*** Part 1 Part 2 Part 3

Isn't HPV a pretty molecule?? Found HERE

Let me tell you, the HPV, or Human Papillomavirus, is some crazy stuff. This is an additional test that is often done at the same time as your pap smear. This additional test checks to see if they can identify a virus in the cervical cells that may increase your risk of cervical cancer.

The HPV virus is crazy because there are sooo many variations of the virus. I think they have identified at least 40 different strains of the virus that effect the lower genital tract... ie... the girly parts. Some of these HPV strains are considered "LOW RISK" because they only produce genital warts. The others are considered "HIGH RISK" because they have been found to be the cause of certain cervical cancers.

The debate comes in as if this is a true STD. Well, yes, it is a sexually transmitted disease, but they are investigating other modes of transmission, so sex might not be the only way to transmit HPV. Skin to skin contact for one. Some are researching transmission through childbirth as well. However it is transmitted, it is transmitted and unfortunately we don't test men for it. Men don't know when they have HPV, there isn't a treatment for it, and they just recently started recommending vaccinating for HPV (only 4 of the 40+ strains are covered in the vaccine).

So men don't know they have it but it is transmitted and then women become infected with the HPV virus. An infection of the virus can lay dormant for years, only surfacing in times of decreased immunity- like pregnancy, sickness, stress, etc. This infection can lay dormant for years and then it can start "acting up" or causing changes in the cells on the cervix.

Over time the HPV can cause damaging changes on the cervical cells which can eventually lead to cervical cancer if your body isn't strong enough to fight off the HPV and heal the damaged cells. We don't have signs or symptoms of HPV, we really only detect it through testing with your pap smear. When I say eventually this is usually a long process--- sometimes 5 to 10 to even 20 years later!

If you are under the age of 30 the current standard of care is to only check for HPV if the cells are abnormal on your pap smear. After the age of 30 the standard of care is to check for HPV on all pap smears.

"PAP" Series part 3: What the PAP?

***In order to keep this series light-hearted and easy to read I am not going to quote or site any sources except the knowledge of what I have learned through conferences, school, from pathologists and others who have gone on before me. THIS IS NOT TO REPLACE ANYTHING YOUR DOCTOR/NURSE PRACTITIONER/MIDWIFE/PA etc IS TELLING YOU. This is just some easy to read information***

ps- there is a diagram of a cervix on this page- just a warning. I found the image HERE

So what exactly is a pap smear? and why is it called that?? I really have no idea why it is called that- and I don't want to look on Wikipedia for the answer- so let's just say some it is named after some man named Dr Pap Smear (ugh- I couldn't help myself- I looked on wikipedia and the guy's name is Georgios Papanikolaou.)

A pap is a collection of a small sample of cells about 5 million cells- eh- no biggie) on your cervix (the entrance to your uterus). It is called a "smear" because we used to take those cells, smear them onto a slide, and look at them under a microscope (like 15 years ago). Now we just take the sample of cells- deposit them into a container of liquid and send it off to the lab for them to evaluate. So that is the reason why it kind of pinches when it happens... We are scraping off cells from a very sensitive area of your body. This is also why you might have a little spotting or cramping after your exam.

Bleeding after your pap smear doesn't mean your cells are abnormal or not... it doesn't mean you have an infection... it just means your cervix sometimes bleeds with a pap smear. About 50% of the pap smears I do a day have a little bleeding.

Anyway, a pap smear is a screening test for cervical cancer. SCREENING. It does not show if you have cancer of your cervix.

Then why get a pap smear? Well, a pap smear gives us an indication on which women need to have further evaluations or a DIAGNOSTIC procedure. To diagnose if there is cervical cancer or even any precancer cells.

other couple other examples of this:

-glucose test in pregnancy- if this screening test is elevated you do a 3 hour test as a diagnostic procedure to see if you actually have diabetes in pregnancy.

-Mammogram- if you have abnormal breast tissue you do a diagnostic breast biopsy in order to see if you actually have breast cancer

-AFP testing in pregnancy- a screening test to find out if there is a risk of your baby having downs, spina bifida, etc. The diagnostic test is an amniocentesis.

Like any of these tests there are false negatives and false positives. The pap smear could indicate you have abnormal cells, and then we do a diagnostic test and you don't have any. It could also show that there are no abnormal cells, when in all reality you may have them. However, this is the best we have currently. Since there are really no signs on cervical cancer- no pain, weird bleeding (unless far progressed) it is important to have your pap smears done.

Stay tuned for the current guidelines of when and how often to get your pap smear done.

"PAP" series part 2: At the office

***In order to keep this series light-hearted and easy to read I am not going to quote or site any sources except the knowledge of what I have learned through conferences, school, from pathologists and others who have gone on before me. THIS IS NOT TO REPLACE ANYTHING YOUR DOCTOR/NURSE PRACTITIONER/MIDWIFE/PA etc IS TELLING YOU. This is just some easy to read information***

When you show up at the office for your pap smear here are a couple tips for you.

1. The paperwork they make you fill out is not because they want to torture you. It has a purpose. Either insurance verification, change in health history, change in family history, or whatever, it is important and we do look at those papers. If you have questions about any of it, ask someone.

2. Expect to pay a co-pay. The girls at the front desk who are asking for your money aren't doing it to be mean. So don't get mad at them. If you have a co-pay and they don't collect it from you they could potentially get in trouble with the insurance contracts because your insurance expects the provider to follow the rules that they set out for you.

One of the fabulous things about president Obama is that he has made some healthcare reforms. A lot of insurance companies now cover well woman care (usually pap smears!!) 100%. Even if you have a high deductible it usually covers it 100%. Thank you, thank you for making this important health screening tool more accessible to women everywhere.

However, if your insurance plan hasn't hopped on board with this, or if you are at the office because you have a history of abnormal pap smears, then you may still have to pay a co-pay.

3. If you have to pee, leave a urine sample. I have no idea if anything will happen with it, but nothing is worse than going to the bathroom and then 20 minutes later someone telling you that you have to leave a sample and you can't. The medical assistants might look at you like you are crazy, but just tell them "I left one just in case the doctor/midwife/PA/ Nurse practitioner needed one."

4. When you are called back, expect to be weighed and have your blood pressure taken. This is standard. You may think it is to torture you, but we really do care how your weight has changed or not over the past year. This is another part of your well care. Do we need to discuss risk for diabetes? Do we need to ask about a diet or congratulate you on a well done job? I know you don't want to go to talk about your weight, but it is a part of your overall health, so suck it up, suck it in, and get weighed.

5. When the medical assistant looks at you and hands you a drape or a paper gown just smile. If your medical assistant hands you a laborlooks gown, jump up and down and scream thanks!! Just joking. Most offices have paper drapes and covers. The paper gown for your top half can either open to the front or the back. If you feel more comfortable with it opening to the back then just know when we do your breast exam we will have to bring the paper drape up and it kind of goes into your face. However, if you have the top with the opening in the front, then we can gently slide it to the side and still talk with you as we are doing our exam. The provider preference is to have it open to the front, but we work with whatever way you put it on.

6. You see those stirrups in the picture at the top. They don't have covers on them. Trust me... this may be cold, but much more sanitary. After every patient we clean these. When there are fabric covers you are lucky if these get washed weekly. So about 100 patients may put their feet on these before you get your feet on them. If you are worried, wear your socks! I always wear my socks...

up next.... what actually is a pap smear??

"PAP" series part 1: The Pap Prep

***In order to keep this series light-hearted and easy to read I am not going to quote or site any sources except the knowledge of what I have learned through conferences, school, from pathologists and others who have gone on before me. THIS IS NOT TO REPLACE ANYTHING YOUR DOCTOR/NURSE PRACTITIONER/MIDWIFE/etc IS TELLING YOU. This is just some easy to read information.***

Image via HERE

So this mini series I am going to write is all about Pap Smears. The majority of the patients that come to my office have no idea why we do a pap smear, all they know is that they have to get it done in order to get birth control. They know it is supposed to happen once a year but really, what the heck is a freakin pap smear??

We will get there... but today I am going to give you a few tips about how to prepare for this visit.

1. If you normally wax or shave or laser or go hairless for some reason or another- no problem, keep it that way. However, if you do not normally do this... Please DON'T do it for me. I often see patients with irritated skin, cuts, chafing, and I feel so bad that they went to all that trouble when it doesn't matter either way if it is done or not.

Sometimes cuts or bumps from shaving can be confused with herpes outbreaks, bad yeast infections, warts, or cysts. We don't want to alarm you and you sure don't want to alarm us.

I promise. If you are unshaven it doesn't make our job easier or harder. We don't notice one hairless or not patient from the next. Do whatever you are comfortable with. Please don't be embarrassed. If someone ever makes you or has made you feel uncomfortable in the past do not return to that provider. Shaven or not is none of our/their business and it is not appropriate to comment on that or make you feel self conscious.

2. If you are on day one or two of your period, call ahead and let us know. Sometimes we are perfectly find doing a pap smear when you are bleeding, we wipe away the blood- get the pap smear and then you go on your merry way. If you are bleeding HEAVY please call to reschedule, don't just not show up. Common courtesy. If you call and cancel early in the morning or the day before we will fill your slot with someone who needs to be seen that day, if you don't call, we will sit around and wait, which wastes everyone's time.

3. Don't have intercourse right before your pap smear. If your husband/boyfriend/partner has some sort of fantasy about you being at the gyno- tell them you will replay it after your appointment. The semen on the pap can interfere with the results and we don't want you to have a false abnormal result.

4. Know your insurance. Some insurance companies pay for a pap smear once every year- like 2011, 2012, 2013- any time during the year. Other companies pay for one no sooner than every 365 days. We will try to verify insurance before your pap smear, but double check- just in case.

5. If you have a whole list of problems- your practitioner may not be able to cover them all in the allotted time slot. Please tell the scheduler if you have more concerns so that they can schedule the right amount of time for you. If you want blood work, come fasting; if you want an STD check, let them know; if you need birth control, ask for it. We aren't mind readers even if we have your chart in front of us.

6. Let us know if you have had an abnormal pap smear in the past, it can change if we add extra testing to your pap smear. If you are unclear what this means, let us know so we can discuss it with you (or stay tuned for the rest of the mini series by me..haha).

7. Last but not least- know that we are trying to be sensitive. We don't do this to intentionally inflict pain. We don't want it to be uncomfortable for you, but sometimes it will be. Let us know if you have had a hard time with pap smears in the past, or if you have a history of sexual abuse because both of these things can make pap smears more difficult for you and we want to understand how we can help you better.

Stay tuned...