"Wrap your penis in cold steel" said no doctor, ever.

October 6, 2017 7:46 PM

In 2014, the American College of Physicians went so far as to recommend against pelvic exams, citing the "harms, fear, anxiety, embarrassment, pain, and discomfort" associated with speculum examinations. -- The Speculum Finally Gets a Modern Redesign (Arielle Pardes, Wired)
posted by Room 641-A (35 comments total)

After they pitched the idea of a little camera and then abandoned it I was kind of insulted by the continuing talk about inflating it like a ballon and some stupid new app for filling out forms.
posted by bleep at 7:59 PM on October 6, 2017 [4 favorites]

The Speculum Finally Gets a Modern Redesign

This was a great article about an actually important issue that I can personally relate to, but I think the design team failed when choosing the name. The name of this new object is clearly the "duck-billed vagina gun."
posted by xyzzy at 7:59 PM on October 6, 2017 [19 favorites]

Argh they’ve made a historical error in attributing the bivalve speculum to Sims (the Sims speculum is still in use but is a different device) and I can’t log in to comment and prove my obscure knowledge superiority.

Interestingly, by checking the Wikipedia article for speculum (which has the same error) it shows exactly how deep their research got.

Good read otherwise, I’ll file this with breast pumps in “areas ripe for innovation that mans don’t care about”.
posted by chiquitita at 8:18 PM on October 6, 2017 [11 favorites]

I had a septoplasty and FESS done a few years ago. After the surgery, the doctor was examining his work, and was using this tiny speculum looking thing. My wife, who had done work with SIV (simian immunodeficiency) studies on non-human primates, burst out laughing.

Turns out that the primate researchers had utilized a device otolaryngologists used as an exam tool to use as a speculum for the monkeys, and now I had one shoved in my face.

She sometimes delights in reminding me of this.
posted by Pogo_Fuzzybutt at 8:21 PM on October 6, 2017 [20 favorites]

They could have done with talking to one or two end users of specula though - I think we will always need something for direct vision for procedures and IUDs, so I am a bit hesitant about the idea of the video scope.

At least in my mind a pelvic exam and a speculum exam are two different things so that bothered me too. Frustratingly shy of the mark as a piece of science writing.
posted by chiquitita at 8:22 PM on October 6, 2017 [6 favorites]

Yeah, a video camera is fine and all, but the whole point of looking into the vagina is usually to, you know, actually do something like a Pap or a swab or a biopsy. If you put a camera up there and then decide to do your procedure, you've got to take the camera out and put something else in.

I do think it's funny that they're trumpeting the idea that women of different shapes and childbearing status need different shaped specula like it's an innovation. The gynecologist who works in our clinic is very particular about hers and has at least 4 different kinds available.
posted by The Elusive Architeuthis at 8:29 PM on October 6, 2017 [13 favorites]

Personally I have a very cool doctor with great bedside manner, so if she could just get a better device I am fine without them creating an app and an experience and all that. I mean, I get ticklish and giggle through the whole breast exam and to me that's much worse than the stirrups.
posted by Emmy Rae at 8:36 PM on October 6, 2017 [4 favorites]

Yeah, like The Elusive A said, this does smack of designers kind of not exploring history or doing on-location observation, yet again. My understanding is that second-wave feminist gynos did a lot of thinking about this and made changes, but I don't have citations aside from vague memories of learning why various of my gynos put oven mitts over their stirrups. Anyone have better cites on this?
posted by gusandrews at 8:47 PM on October 6, 2017 [1 favorite]

(Also, A+ for the title.)
posted by gusandrews at 8:49 PM on October 6, 2017 [1 favorite]

There was a cool article in the Atlantic a few years ago about the history of the speculum and why, in 150 years, nobody's really managed to improve on the design. (Materials, yes; the first one was made out of a spoon.) It's good background reading for this one.
posted by fuzzy night at 8:53 PM on October 6, 2017

My NP has one of those plastic ones that glows blue when you turn the light in it on. It's a huge improvement on the metal ones, and not uncomfortably cold. She was so excited to show it to me before starting the exam. "This thing is so cool, I feel like I'm on Star Trek!"
posted by zoetrope at 8:59 PM on October 6, 2017 [16 favorites]

"one review of the medical literature talking to like two women found that some women even avoid the gynecologist because of the dreaded device."

FTFT.

And yeah, like, a camera not-speculum is cool, but 90% of the times a doctor has been interested in my cervix, it's been to snip some cells for a pap smear or to palpate a baby's descending head. I'm a little unclear on when a camera would be routinely useful.

Also, regarding the freezing cold specula mentioned in the article-- if your ob/gyn doesn't keep their speculum in a warming unit, SWITCH OB/GYNs. (Also crazy rainbow knitted socks clearly made of leftover yarn put over the stirrups seem super-popular, I just assume every office has one employee with a knitting problem who provides a large enough quantity of stirrup socks for frequent laundering.)
posted by Eyebrows McGee at 9:17 PM on October 6, 2017 [18 favorites]

frequent laundering

They wash those?
posted by Dip Flash at 9:22 PM on October 6, 2017

I shouldn't even be saying this without reading the article first but the worst part for me is when it, like, clicks as it locks open. That sound always makes me shudder.
posted by janey47 at 10:11 PM on October 6, 2017 [17 favorites]

Oh hahaha having just started the article I see I'm not alone lol
posted by janey47 at 10:12 PM on October 6, 2017 [7 favorites]

My personal -- and admittedly limited -- experience has been the one-size fits all approach. The only reason I know to ask for a pediatric speculum is because the first gyno grumbled about having to switch to one after I started screaming from the pain. And every subsequent doctor I've asked has complied, but only after looking skeptical and annoyed at not being able to use whatever their default unit is. So, yeah, I don't know how representative my experience is, but it's pleasantly shocking to hear all of you describe these thoughtful accommodations. Maybe the designers' experiences are closer to mine.
posted by Fish, fish, are you doing your duty? at 10:15 PM on October 6, 2017 [5 favorites]

Forgot to add -- I have never encountered the sock/oven mitt thing. That's thoughtful.
posted by Fish, fish, are you doing your duty? at 10:16 PM on October 6, 2017 [3 favorites]

Copy pasting another time I've talked about pap smears being a very very regional process, with my experience as an australian:

"I've never gotten fully undressed for a pap smear - last time it was knickers off, hike up my skirt and lay on the plain old exam table (hands under my bum, heels together, knees apart). And my GP made sure the speculum was not cold (no warmer, but he held it in his hands while we discussed what was about to happen)."

Usually a nurse is with me (my notes have the whole PTSD thing in there) and the only reason I have have a speculum in me is to take swabs/do a pap smear - I literally have never had anyone just have a looksie in there. A feel around as an internal exam with their fingers, yes, but no speculum to have a look at my cervix.
posted by geek anachronism at 10:35 PM on October 6, 2017 [3 favorites]

Yeah, a doctor never said that, but a couple of women of past acquaintance have...

(I always went to my wife's OBGYN appointments with her, whenever I could and I was, you know, still married to her.)
posted by Samizdata at 10:43 PM on October 6, 2017

What about a camera that has a little attachment for collecting the cells? If a phone can have 2 cameras on it I don't see why not.
posted by bleep at 11:14 PM on October 6, 2017 [1 favorite]

Copy pasting another time I've talked about pap smears being a very very regional process

Same here. No clothes off other than underwear, no stirrups in sight. I don’t think I’ve ever had any doctor, nurse or midwife use a speculum just to take a look, either - the only time anyone’s been actively just looking is when a baby’s head was involved. (Actual line: “I’m afraid you’re still only seven centimetres dilated, but your baby has lovely long black hair!”)
posted by Catseye at 12:31 AM on October 7, 2017 [2 favorites]

I never understood why it was the details that seemed to be the problem. When I picture a less invasive option that would make me vaguely okay with this, it involves robots and no other human beings in the room or, ideally, involved in the entire process. I'm not religious, it's not from some kind of trauma, it's just a complete and utter nope for me in a way that makes it deeply weird to read this kind of thing. Like, am I an actual alien, or what? This is really the thing everybody else is freaked out about? And not that there's one or more strangers literally right there while all this is happening?

I guess I shouldn't be surprised that the "modern redesign" is just some engineering and an app and not any kind of concern for the kind of deep personal violation this would represent to me, but it's still a bit disappointing that the innovations aren't, well, any more innovative than this. A guided meditation is just not going to make this happen for me.
posted by Sequence at 1:26 AM on October 7, 2017 [4 favorites]

What about a camera that has a little attachment for collecting the cells? If a phone can have 2 cameras on it I don't see why not.

If I can riff on this, this device kind of sounds like turning the speculum exam into a procedure more like a colonoscopy, where you send in a camera on a tube and yes, you can take biopsies. The challenges with using that technology in the vagina that strike me are that during a colonoscopy you have to pump a significant amount of air into the colon to be able to see the walls of the organ, and the same challenge would be faced in the vagina, which is essentially collapsed for easy storage when not in use. Because of the anatomy, any air insufflated into the vagina can theoretically pass into the abdominal cavity (the Fallopian tubes are not closed) which is extremely painful but i don’t believe necessarily dangerous. I think we are, however, rapidly moving away from the realm of it being a more comfortable option than a speculum exam, assuming the appropriate studies showed it’s as safe and you’re not going to miss pathology.

In addition, and this is perhaps more of a perspective from a country with a universal health system, its important to have a cervical screening program that relies on cheap, easily available equipment because this improves access to screening. Most people in this country would have smears done by their GP, and worldwide it’s something easily done by primary healcwre and nursing / midwifery. I don’t see much use for a tool that very few people can access in the wider scheme of things, certainly in this country it would probably end up being used by a small number of specialists only.

Further to the Australian context, the notion of a routine pelvic or speculum exam is just Not A Thing anyway, and it’s only done for a Pap or to investigate discharge or bleeding or insert an IUD. Moreover, we’re about to change our cervical cancer screening program from two-yearly Pap smears to a combination liquid-based cytology and HPV screening program which only needs five-yearly specs if all normal. The success of universal vaccination for HPV has led to such a shift in the epidemiology of cervical cancer and precancerous lesions they have been able to change the screening recommendations, which is a really great way technology has been able to reduce the number of speculum exams everyone endures!
posted by chiquitita at 2:08 AM on October 7, 2017 [21 favorites]

Another provider and recipient of spec exams weighing in. I didn't love the article, as it felt a bit like an ad or opener for a tech funding request. Yep, they do look awful and nobody likes having a pelvic. (I'd also add that procotoscopes, used for visualizing the rectum, usually for men, are just as bad). But there are already hundreds of different options in terms of size, material, shape, handle, etc., and none are perfect but they do work. If I'm placing an IUD, I need to be all up in the vag, and I need full visualization of the cervix, so a tampon/camera isn't going to work. Same for checking for ruptured membranes in labor. I also have a lot of different specula sizes/shapes--some clinicians are not so thoughtful and will just use whatever, which is awful and could even be considered negligent--and we have a heating pad in the drawer so they're not icy cold. If the heater is broken, I can hold the bills in my hand to warm them up. It's not perfect but it's not as bad as it could be. (This isn't rocket science, but does show that lots of providers, sadly, don't care about patient comfort, which won't be solved by making your speculum look like a flower or whatever). Current specula are also cheap and I can take them to the third world with me on volunteer work, and sterilize them for re-use. FWIW, I hate the plastic ones as they click, I find them more scrape-y and uncomfortable, and they can even break inside of a woman (shudder).

But beyond design, which the article seems to focus on, there's A LOT to be said for the technique of the user and the time, patience, and anticipatory guidance given to the patient as mentioned above. I know this because I've received lots of exams and I've also watched lots of colleagues do them. Some people are, unfortunately, just rough or rushing with patients. And lots don't say to patients, "If this is uncomfortable, please let me know and I'll stop." Which really should be standard of care, but sadly isn't.

That said, I'm all for innovations that help women feel more comfortable and don't discourage them from seeking necessary care. But I also worry that a camera that's designed by a tech company in Silicon Valley, available to wealthy patients who can afford the boutique care of One Medical, means that less innovation goes to my under- and uninsured patients on subsidized care. We have been pushing to move away from "routine" pelvic exams for a while, and the truth is, there are a lot of old-school clinicians who will just do a speculum and bimanual because it's what they're used to, although there's no evidence base for it. Pap guidelines have also changed so that most women with normal paps are able to go to 3-5 year recall. You may be surprised, but some women, used to the annual exam, have asked me to do a full pelvic anyway and been suspicious or displeased when I refused!

I'll also add a suggestion for people for whom spec exams are particularly unpleasant (and no, you're not alone and there's nothing wrong with you, so please feel 1000% okay with letting your provider know that): if you think it might help you, you can put the speculum in yourself. Some people find this easier and feel more in control. A speculum exam may be a bit uncomfortable, but it shouldn't hurt, and if it does, the provider is doing something wrong (except maybe if you already have an infection that is causing you pain), and you have every right to ask them to stop, start over, and/or ask for a different provider.
posted by stillmoving at 3:25 AM on October 7, 2017 [37 favorites]

Huh. The three-pronged speculum design is actually really ancient. Here are some examples from Pompeii.
posted by Mouse Army at 4:14 AM on October 7, 2017 [2 favorites]

During my very first exam in my early 20s my (female) dr actually laughed at me (not with me) when I was having trouble positioning my feet in the stirrups and scooting down the table. (What the hell?? It’s not something you practice before that first appt) I was already so nervous and she made me feel even more vulnerable and inept. She seemed vaguely entertained by the whole thing. That was 25 years ago and I still remember how I felt.
I still see female health care providers for this type of care but now I just come right out and remind them at the very start of the appt that I really hate doing this but I’ll hate it less if they tell me what they’re going to do before they do it and if they use a very small speculum. My current provider is fast and efficient and gentle and really does help me to hate it less! And she actually helps me feel empowered when the appt is over because I’ve taken responsibility to actively take care of my body.
posted by bookmammal at 4:25 AM on October 7, 2017 [11 favorites]

Because of the anatomy, any air insufflated into the vagina can theoretically pass into the abdominal cavity (the Fallopian tubes are not closed) which is extremely painful but i don’t believe necessarily dangerous.

Ehhhhh, sort of. (NSFW text, short version is that in extremely rare cases this could result in an embolism which could technically cause death.)
posted by kalimac at 7:02 AM on October 7, 2017 [1 favorite]

Totally agree with all the comments upthread about how this failed to actually consider how and why specula are used. Two more thoughts I had:

a) I was trained in medical school specifically (and repeatedly) on how to perform a speculum exam in as comfortable and respectful a manner as possible. There are some really simple techniques for this (e.g. the vector of forces on the speculum should always be pointed down, because the urethra runs along the anterior wall of the vagina and it can be really painful to put pressure there), and having been the recipient of plenty of speculum exams myself, I can tell when providers know this/think about this vs. don't know/don't care. There's a lot of room for providers to improve with the current speculum.

b) Patients are vulnerable during this exam, and patients who have emotional or physical issues that make them especially sensitive to speculum exams are especially vulnerable. Developing a new speculum that is not as effective for medical treatment -- e.g. a camera speculum that doesn't allow for collecting tissue samples, or a smaller speculum that doesn't allow full visualization of the cervix -- results in increased victimization of this vulnerable population because they become recipients of substandard medical care.

In many ways I see this as akin to the "gentle immunization" movement, where parents who are distressed by the standard vaccination schedule are offered a slower one. It's real distress engendered by what can sometimes be a gruff or insensitive presentation of the medical issues at hand, and that real distress is eased by offering... inferior medical care.
posted by telegraph at 8:24 AM on October 7, 2017 [3 favorites]

"You could create the most beautiful, most unique, most user-friendly device, but if a doctor doesn't want to learn how to use it, your patient's never going to see it"

Boy. That just about covered it huh.

I also find the whole "let's make an app!” thing to be off-putting. Some personal information is too personal. Even for Facebook (or Google).
posted by jonnay at 12:49 PM on October 7, 2017 [2 favorites]

I can only find case reports of air embolism occurring in pregnant women, attributed to air tracking around membranes to the placenta. I’d be interested in any evidence it has happened to nonpregnant women.
posted by chiquitita at 2:02 PM on October 7, 2017

As a trans man who doesn't use that hole and is pretty dysphoric about it, actually, my life was CHANGED when my OBGYN (after being incredulous that the full-sized speculum HURT) gave me the option of using a "pediatric" speculum.

The topic of speculums doesn't come up much, but I wanted to share that nugget of information for anyone else, trans or cis, who cannot deal with the "normal" speculum due to emotional or physical pain.

(OBGYN bedside manner continues to be atrocious, and among other things I like to share: transvaginal sonograms are not always necessary - you can opt for the old-fashioned kind in many cases; be a cranky ass if you are not comfortable and want to retain dignity - doctors just ASSUME things and you gotta make some noise for them to change. Prior to my top surgery, I would put my shirt back on after the breast exam and before the pelvic, because fuck you, doctor, that's why.)
posted by Wossname at 4:42 PM on October 7, 2017 [4 favorites]

A warm speculum, a warm, non-drafty room, socks, and a decent cover, a soft blanket--not that damn stiff paper cover and stupid paper "shirt" would make all the difference in the world.

Glad that's all done and finished for me. I'm sixty-four with a hyst--if I have one more OB-GYN exam in my life that's probably enough to suit me.
posted by BlueHorse at 7:21 PM on October 7, 2017 [3 favorites]

Working toward a possibly more comfortable device seems like it could only be a good thing.

This didn't use a camera, but I've read about cameras for use with smartphones being deployed in telemedicine now, in areas where regular exams and tests are not a thing. The intent is to enable remote experts to recommend early cancer intervention.
posted by zennie at 8:40 PM on October 7, 2017

I think the best thing about this project, even if it isn't medically perfect, is that it's finally introducing patient voices into the design of the tool and the experience. Because right now we don't have a voice, and even if we did, most of us wouldn't know what to ask for, or even that there could be better things to ask for. Hell, I'm not even the only person in this thread who had to find out the hard way that speculums come in different sizes, and who has to fight for the need for those different sizes to be acknowledged.

The common thread for those of us with shitty gynecological exam experiences is that humans with vaginas and uteruses and ovaries aren't people. We aren't real actual individuals with needs and traumas and bodies that feel things. We're just pieces of meat to be opened up and rummaged around in and silenced. And what these designers are saying, what this article by its existence is saying, is that we have a right to participate in what doctors say should be done to us, we have a right to make it less awful, we have a right to know there are ways to make it less awful. We have a right to demand that doctors consider our mental and physical well-being when they do things to us. People now know before their next doctor visit that they can ask for something else. Whether or not this device makes it to market, something will. Designers might not be able to force adoption, but patients can. We can demand providers explore methods actually treat us like people.

...or maybe not. But at least now we know someone is trying, and we have the right to try too.
posted by Fish, fish, are you doing your duty? at 12:51 PM on October 8, 2017 [5 favorites]

Doctor in training here, currently on my obstetrics & gynaecology placement. Been conducting speculum exams for the first time recently, and was distressed by the almost-medieval nature of the Sims-style steel speculum. I've seen plastic ones used in a paediatric context (14-16) and asked my O&G consultant why we still used these icy clanking devices. She didn't seem to want to discuss the issue. Will look forward to using something far more humane and (insofar as that's possible) comfortable.
posted by The Zeroth Law at 4:56 PM on October 9, 2017