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Describe at least two techniques for performing pelvic examination with a patient who has Jacki Witt, JD, MSN, WHNP-BC, SANE-A, FAANP experienced sexual assault/abuse Caroline Hewitt, DNS, RN, NP Practice at least two new pelvic examination techniques with a standardized patient Select appropriate screening and diagnostic testing for women with specific pelvic organ symptoms
Jacki Witt Watson Pharmaceuticals – Honorarium – Advisory Board Agile Pharmaceuticals – Honorarium – Advisory WHO Afaxus Pharmaceuticals – Honorarium – Advisory Committee Bayer Pharmaceuticals – Honorarium – Advisory Board WHAT WHEN Caroline Hewitt WHERE Prior to February 5, 2014 disclosures: Watson Pharmaceuticals – Honorarium-Advisory Board HOW After February 5, 2014: Nothing to disclose WHY
Identify the indications for a pelvic examination -Lithotomy common in US Describe at least two techniques for performing -Some patients pelvic examination with an obese patient find it disempowering, Describe at least two techniques for performing abusive & humiliating pelvic examination with a patient who has Haar, et al 1997 signs/symptoms of decreased estrogen stimulation -Patient’s have to vaginal tissues described metal Describe at least two techniques for performing stirrups as ‘cold’ pelvic examination with a & ‘hard’; say their use developmentally/cognitively disabled person is impersonal, sterile or degrading Olson 1981
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• 197 adult women having routine cervical cytology • Patients reported less discomfort and feelings of vulnerability if: PLASTIC : direct lamp connection, • Semi-reclining vs. supine transparency facilitates visualization, • No stirrup method used audible and sensible clicks distressing and • No significant differences in quality of cyto specimen considered not ‘green’ (but study not powered to definitively look at this outcome) • Routine in UK, Australia, N. Zealand
Seehusen et al, BMJ, 2006.
No real industry standard for size or type METAL: can be too hot or too cold, are Pedersen medium is generally 2.5 cm (1 in) considered ‘green’ and come in more sizes wide and 10 cms (4 in) long and varieties than plastic Pediatric speculae are shorter and confer an CONCUSIONS: advantage only if the cervix is < 8 cms (3 in) Choice primarily related to provider familiarity from the introitus and opinion Pedersen extra narrow is 1.5 cm (3/4 in) wide No studies comparing patient comfort and 11.5 cms (4 ¼ in) long and is useful for No analysis comparing landfill impact of plastic women with postmenopausal atrophy vs resources required to sterilize and reuse metal
Bates, et al, 2011
Longest speculum is the Graves supersize • 4 RCTs XL with an 18 cm (7 inch) bill appropriate • RCT X 2 comparing water-soluble gel to for women with long vaginal vault where water alone with conventional cytology • cervix is barely reachable by examining No difference in rate of unsatisfactory cytology in any of the studies fingers • No difference in rate of unsatisfactory cytology or in Chlamydia detection rate in one study
Griffith et al, Contraception, 2005; Amies et al, Obstet Gynecol, 2002
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If you can’t find it, perform bimanual 10, 241 Paps using ThinPrep over 1 year If deep in vault and barely reachable, need Spatula + cytobrush extra long speculum AND Significant uterine flexion will cause cervix to Broom + cytobrush be anterior Close partially retract slightly redirect anteriorly Extreme retroversion of uterus will cause ↓ cervix to be lodged behind symphysis pubis Exert more pressure on posterior fornix to manipulate it into view Statistical significance over broom alone in Pap Bates et al 2011 adequacy (endocervical component) Selvaggi et al 2000
281 HIV positive & 68 HIV negative women Abnormal anal cytology diagnosed in 26% of HIV+ & 8% of HIV- women Increased risk of anal disease as viral load increased & CD4 decreased History of anal intercourse & abnormal cervical cytology were statistically significantly associated with abnormal anal
cytology Holly, et al 2001
Recommendations from manufacturers: Dacron cotton swab on plastic stick Broom Avoid using a cotton swab on a wooden stick, ▪ Rotate in one direction for 5 rotations (do not reverse because these often break and will splinter directions) Spatula and cytobrush ▪ Rotate spatula 360 degrees ▪ Rotate brush 180 degrees in one direction (more than 180 degrees may cause bleeding and does not improve adequacy)
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Swab is rotated and slowly withdrawn from the anal canal Make sure to sample the transition zone during removal, as this area, which separates the columnar epithelium of the rectum from the keratinizing anal squamous mucosa, is the site where most anal intraepithelial neoplasms arise
Normal ovaries can range from 2-4 In women, the dorsal lithotomy position may be used cm depending on time in cycle A moistened dacron swab is inserted 5 to 6 cm without direct visualization During ovulation the ovary may be Firm lateral pressure is applied to the swab as large as 4 cm; bring patient handle back in 2 weeks to recheck if concerned or perform pelvic US
Liquid cytology preferred 84 women undergoing pelvic surgery Eliminates artifact with drying and reduces With patient consent, examined under amount of fecal material and bacteria that can anesthesia by attending, resident and obscure cellular detail medical student Pelvic exam accurate compared to surgery: 70.2% Attending 64% Residents
Beam and Chhieng, 2010 57.3% Students
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Sensitivity to detect adnexal masses much If right handed, right index and middle lower than sensitivity to assess uterine fingers are in vagina-place right foot up on size/countour. step of exam table, your knee is flexed Obesity reduced detection of adnexal masses Conclusions: Keep right elbow into your body Bimanual exam appears to be a limited screening test for upper genital tract abnormalities (even under the best possible circumstances – anesthesia) Push forward with your body, not with arm Uterine assessment appears to be more accurate muscles. than adnexal assessment
• – Ovaries can be difficult to palpate Move your fingers to side of cervix and lift • – Ovaries detected in bimanual exam fingers high on vaginal roof to form a flat performed by Ob/Gyn under anesthesia: landing pad for the ovary
• 30% in women > 55 years old Pivot your entire body toward the ovary • 51% in women < 55 years old you are palpating • 9 % in women > 200 lbs Your body, fingers, arm should be in direct alignment with the patient’s ovary
Poor evidence for distinguishing benign DROP wrist down, keep fingers flat and from malignant adnexal masses: raised Abdominal fingers sweep ovaries down Pooled sensitivity: 45% from iliac crest toward your internal fingers Pooled specificity: 90% Myers, et al 2006 Internal fingers: feel ovary slide between fingers, assess size (compare with fingers’ width), nodular?, smooth?, tender?
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First exam Trauma survivor Obese women may avoid exams due Vaginismus and vulvodynia to embarrassment or fear of clinician Postmenopausal atrophy reactions or admonitions about their Post-radiation stricture weight Women with disabilities Redundant vaginal walls Morbid obesity A sensitive approach is essential Female circumcision
PSYCHOLOGICAL TECHNICAL Will the table support her? Is table Education Exam table wide enough? Have assistant stand Consent Positioning Support Speculum choice to side of table to stabilize and Chaperone? Lubrication reassure her Advocate? Topical anesthetic Empowerment Finding the os The vulva may be hidden by the panniculus and a longer speculum is often necessary
There is a higher risk of What has she heard? diabetes; check for fungal Previous experiences with providers? infections and intertrigo What does she expect? She has CONTROL (mirror, asking permission for next step of exam) Check skin folds carefully; she An exam done WITH her¬ to her may not be able to inspect Show her PICTURES herself as well as you can
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Speculum exam: vaginal walls may have The cervix may be difficult to visualize or more relaxation and decrease visibility palpate…have her pull her knees up Use Grave’s vs Pederson speculum; may ( “cannon ball”) need more length She pulls her knees back and exposes the vaginal opening Use condom or finger cut off latex …curled up in this position may give glove to hold vaginal walls back better speculum visualization of the cervix
Have her hips over the edge of the exam table. This drops her pelvis and cervix forward and makes visualization easier
Use an instrument: ring forceps (closed) or tongue blade to gently push vaginal walls to the side to improve visibility Use larger/longer speculum as comfort dictates
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• An option in women with postmenopausal Place woman on covered floor in knee- vaginal atrophy chest position; kneeling behind her, insert two fingers into her vagina, the • How much? cervix will be easier to locate • – ½ gram QHS x 2 weeks • Reduces reactive cellular changes For cytology: place brush between your 2 fingers, insert into the vagina, • Not studied for ability to reduce pelvix exam feel for cervix and obtain the Pap discomfort, but shown to improe symptoms and findings of atrophic vaginitis
Bachman, et al, 2008
The bimanual exam is more challenging and it may be difficult to impossible to palpate Cervix small, os closed, short cervical the uterus or ovaries neck; neck may be flat against vaginal wall Place the abdominal hand UNDER the ▼rugae, pale, thin, bleeds easily from panniculus to decrease amount of adipose ▼estrogen tissue between the examiner’s hand and the Vaginal pH high >5.0 from fewer uterus lactobacilli ( ▼ estrogen levels) Polyps common Pelvic sonogram indicated if symptoms
Viscous lidocaine 2%, before exam May take longer Positioning more challenging 2-3 weeks of estrogen cream before exam Smaller speculum necessary Topical analgesic use Use smallest speculum Pain control, pain vs pressure Hypnotherapy Separate labia to see introitus, insert gently & do not twist or turn
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Stenotic os more common - to find, What is her mental, social, physical age? use OsFinder, cytobrush or lacrimal Treat her at her age of development probes (ENT tools) Previous experiences with exams? SCJ is high within the canal-use cytobrush or broom to obtain Caretakers, history of physical, sexual adequate Pap trauma? Women with developmental delays are at VERY high risk of abuse
Often small, narrow, atrophic National Study of Women with Physical Disabilities found that 94% of respondents were sexually active with sexually Assess vaginal tone: anterior – transmitted infection rates the same as cystocele and posterior- rectocele women without disabilities
Have her grip your fingers- assess pelvic musculature strength Nosek et al, 2001
By 2 years post menopause most In some women with certain types of ovaries not palpable brain damage, temperature control may be unstable If palpable consider further evaluation Keep her warm, inspect ALL areas thoroughly, she may not be aware of Ultrasound if unsure injuries ? abuse, self mutilation
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The woman guides the exam -ask how she prefers to be examined; what positions work best, what suggestions does she have for you?
Ask, ask, ask
From Table Manners: A Guide to the Pelvic Examination for Disabled Women and Health Care Providers By Ferreyra and Hughes Planned Parenthood 1991
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Screening pelvic exam started as a Method to obtain cervical specimen for CT/GC Screen for cervical cancer with cytology Screen for ovarian cancer with bimanual exam Performed annually because of “yearly Pap smear” strategy until 2003
Screen for Preferred test GC, Ct NAAT: vaginal swab or urine sample Cervical cancer Not recommended until 21 years old Cytology every 3-5 yrs afterward None, if total hysterectomy for benign disease Ovarian cancer USPSTF rec. against bimanual exam Vulvar lesions Unnecessary if asymptomatic Vaginal infxn Unnecessary if asymptomatic Myomas Unnecessary if asymptomatic
Women younger than 21 years Pelvic exam only when indicated by medical history Screen for GC, chlamydia with vaginal swab or urine Women aged 21 years or older “ACOG recommends an annual pelvic examination” ▪ No evidence supports or refutes routine exam if low risk If asymptomatic, pelvic exam should be a “shared decision” ▪ Individual risk factors, patient expectations, and medico- legal concerns may influence these decisions If TAH-BSO, decision “left to the patient” if asymptomatic
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Qaseem, et al ACP Clinical Guideline 2014
Examination Needed for ACP recommends against performing Blood pressure OC, patch, ring screening pelvic examination in Clinical breast examination None asymptomatic, nonpregnant, adult women Weight (BMI) (weight [kg]/ height [m]2 Hormonal methods
High-Value Care No evidence that routine pelvic examination in Bimanual examination, cervical inspection IUC, cap, diaphragm asymptomatic, nonpregnant, adult women provides any benefit. …we conclude that performing pelvic examination Glucose, Lipids None exposes women to unnecessary and avoidable harms with no Liver enzymes None benefit. … these examinations add unnecessary costs to the health care system. ….costs may be compounded by Thrombogenic mutations None expenses incurred by additional follow-up tests, including follow-up tests as a result of false-positive screening results, Cervical cytology (Papanicolaou smear) None increased medical visits, and costs of keeping or obtaining STD screening with laboratory tests None health insurance. HIV screening with laboratory tests None
“I find the pelvic exam to be indispensable in the assessment of the vulva, vagina, pelvic Vulvar or vaginal complaints floor, and sexual function—and it yields Pelvic or abdominal pain in a woman information I often cannot obtain in any other Exposure to STI ? way.” Pregnancy ? (known or proven)* For example, some vulvar lesions produce no symptoms but still pose a risk of cancer or represent a developing problem such as lichen sclerosis, but I cannot identify them unless I see them. The physical examination of Health maintenance (to perform cytology and tissue also prompts me to ask focused questions, frequently about things the patient is too embarrassed to bring up herself. For example, I may examine a woman and find a cystocele or urethrocele. If she hasn’t mentioned leaking urine or other difficulties, the discovery prompts me to ask more specifically about these HPV testing) symptoms. When I do, I often uncover a significant source of distress that, for whatever reason, the patient did not report herself. Other examples: On occasion, during the pelvic examination, I discover vaginismus. That finding prompts me to ask about painful sex. And sometimes a perimenopausal woman has dry vaginal tissue that is not bothersome…yet. By identifying this condition early, I can suggest interventions that prevent the dryness from becoming bothersome.
Under 21 21-29 30-65 >65 years Hyst, years old years old Years old old benign 193 females 13 – 23 years old USPSTF [D] Every 3 y Co-test: Q5 None* [D] Twenty patients (10.4%) were dx’d with PID 2012 Cytology: Q3 Lower abdominal pain reported by 90% of those Triple A None Every 3 y Co-test: Q5 None* None 2012 Cytology: Q3 dx’d with PID ACOG “Avoid” Every 3 y Co-test: Q5 None* None Lower abdominal pain reported by 56% of those 2012 Cytology: Q3 not dx’d with PID hrHPV Never Reflex Co-test or None None Lower abdominal pain and/0r dyspareunia test only reflex ▪ 100% sensitivity - 40% specificity * If adequate prior screening with negative results ▪ Positive predictive value 17% - Negative predictive Co-test: cervical cytology plus hrHPV test value 100% Cytology: cervical cytology (Pap smear) alone
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Physicians Reporting Routine Use of Pelvic Examinations for Selected Purposes, by Specialty (DocStyles Survey, 2009 )a
Retrospective analysis of 577 asymptomatic women age 17 – 25 years old NAAT positive in 68 women (11.8%) Most common physical exam findings 5.9% vaginal discharge 3.6% cervical ectopy 2.3% friability/easily induced bleeding 1.4% cervical motion tenderness Stormo, A. R. et al. Arch Intern Med 2011;171:2053-2054. 0.7% adnexal tenderness
Abnormal pelvic exam findings were infrequent (<6%) in asymptomatic young women having NAAT for chlamydia
Concerns have been voiced by some that not doing a pelvic exam may miss significant morbidity and can’t be justified
Results of this study would refute that concern Henderson JT et al Obstet Gynecol 2010 ;116:1257–64
Conclusions: Symptomatic women should have pelvic exams Finding MPC in young asymptomatic women was infrequent (9/68 or <15%) Mandatory pelvic exams in asymptomatic women is often seen as a barrier to screening Findings should increase confidence of clinicians that significant clinical disease is NOT being missed by not performing pelvic examinations choosingwisely.org
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Female Examiner Male Examiner Prefer 11% 62% Chaperone Object to 34% 9% Chaperone No preference 55% 29%
Study of 1,000 women in Scottish family planning clinic
Women < 25 and/or nulligravid more likely to dislike exam, but didn’t change preference for chaperone Fiddes, P, 2003
AAFP survey, n=5,000, 71% response rate 75% use routinely Male (84%) > Female (31%) providers More frequent use among providers who: Are younger Do fewer exams Practice in South
Rockwell et al. Ann Fam Med 2003
NO UNIVERSAL BENEFITS GUIDELINES Inform patients of availability Male providers – recommended Patient comfort AAFP no guidelines Technical ACOG addresses, Female providers – ascertain assistance but does not preference Legal protection mandate
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For some women they feel more sensation when shaved or “feel cleaner” May feel pubic hair is “ugly” Alterations in genitals: “He wants me to shave to look like a porn star.” Sex partner may prefer cunnilingus without pubic hair Shaving the vulva may make the vulva appear prepubescent (is this ok?)
NO, we clearly accept shaving underarms (a very delicate area) and the vulva is really not that different…so why does it bother us?
La Naissance de Venus, 1862. Eugene Emmanuel L’Origine du monde, 1866. Gustave Courbet. France Research data does not link vulvar Amaury Duval. France shaving to serious health sequelae.
2008 national and international literature review from 1976-2008 showed no 235 Australian undergraduate women associations between pubic shaving and 96% regularly removed leg and underarm infection. hair, most frequently by shaving Cochrane review 2006: no difference in infection rates between shaved & unshaved Femininity and attractiveness were motivators genitals British Systematic Review. J Periop Pract 2007 Mar:17(3):118-21 11 RCT’s related to clipping, depilatory vs shaving
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Options for screening 60% removed at least some pubic hair (Bimanual) Pelvic examination 48% removed all or most of it Transvaginal pelvic ultrasound (TVS) Motivators: self-enhancement and sexual Serum Tumor Marker: CA-125 attractiveness Not recommended for low risk asymptomatic Predictors: having a partner, reading fashion magazines and watching ‘Sex and the City’ and women ‘Big Brother’ Low sensitivity, specificity for early disease Authors concluded that the removal of pubic hair Low prevalence of disease furthers the belief that women’s bodies are High cost of evaluation unacceptable the way they are. Tiggeman & Hodgson, 2008
USPSTF (2012) Use a disposable razor only once in the Screening asymptomatic women with pubic area ultrasound, tumor markers, or exam is not Exfoliate before and use a moisturizing recommended [D] shaving cream or hair conditioner – never use drying bar soap Insufficient evidence to recommend for or Triple antibiotic cream (avoid vagina); against in asymptomatic women at apply scant amount a couple of minutes increased risk [I] after shaving Exfoliate daily starting 24 hours after
Don’t shave for five to seven days (if Randomized trial of 78,216 women 55-74 impossible, shave in direction of hair Annual screening with CA-125 for 6 years + growth) TVUS for 4 years (n=39,105) versus usual Moisturize! (no bar soap, try aloe vera gel) care (n=39,111) Avoid tight underwear and pants 10 US screening centers Abstain for at least 24 hours Followed a median of 12 years Black tea [brew, refrigerate and apply to Bimanual examination originally part of the area with cotton ball – soothing] screening procedures but was discontinued
JAMA. 2011;305(22):2295-2303
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Cases Blosnich, et al, 2014 Deaths Discrimination, prejudice, rejection Lack of health insurance No ‘domestic partner’ benefits Concern over documented sexual orientation Employer, loved ones, other medical providers Low perceived risk of acquiring STDs Lesbian women >30% decreased odds of having routine exams Bisexual women >2.5% times the odds of not seeking medical care due to cost JAMA. 2011;305(22):2295-2303
Surgical and path report needed? STI’s known to be transmitted female to Bilateral oophorectomy? female Taking exogenous hormones Herpes (estrogen, testosterone)? HPV If hysterectomy for cancer-continue Trichomoniasis cytology from cervical/vaginal cuff Bacterial vaginosis transmitted between and closely inspect vulva and women vagina
Mayer, et al 2008
Fethers, et al 2000, 2008 & 2013;
Prevalence of BV high in lesbian population 25 – 52 % vs 14 % in heterosexual population Groups did not differ significantly in report of Lower rates of cervical cancer screening receptive oral sex (which has been proposed as a risk for BV among Negative experiences with the healthcare lesbians) system & misinformation about disease risk & Lesbians in monogamous relationships usually preventive healthcare needs of lesbians have concordant vaginal secretions contribute to underuse of medical services in Reflects sexual transmission of BV between lesbians general & cervical cancer screening in particular BV is significantly associated with sexual contact with new and multiple male & female partners
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?Provide exam over several visits
Give her control…lift the back of the table so she can see you
ASK permission to examine
“Is it ok if we get started now?” “Could you lift the sheet so that I can start the exam?”
67 female veterans were assessed for history of sexual violence (SV), post-traumatic stress disorder (PTSD) Careful with words…rapists may say “stay and distress and pain with pelvic examination still, don’t move, relax” etc. Distress highest for women with h/o SV plus PTSD Have her assist you during the exam…hand Next highest for women with h/o SV only you cotton swabs, etc. Lowest for women with h/o neither Use mirror to guide her through the exam Higher pain ratings for women with h/o SV compared to The more empowered she is with her those without SV PTSD was not linked with more pain than was accounted for knowledge about her body the more control by SV she takes back Weitlauf, et al 2008
All women can refuse an exam
Will this exam add to her trauma? Myths, religious and cultural beliefs
How does she want you to do her exam? Africa and Middle East
What will she allow, or not allow? WHO categorizes 1 - 4
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1: Clitoridectomy (removal of clitoral hood or clitoris) Chronic urinary tract infections
2: Excision Treatment/referral (removal of clitoral hood or clitoris plus some or all of ▪ Suppressive antibiotic treatment labia minora) ▪ Deinfibulation (repair/revision of scar) 3: Infibulation (removal of all external female genitalia, leaving a small opening for blood and urine)
4: Unclassified (cutting, burning, piercing, scraping)
Recognize the type of circumcision Partial labial fusion Ensure cultural competency Complete labial fusion Provide appropriate clinical care Large sebaceous cysts (0.5 to 12 cm) Long-term complications Can obstruct introitus ▪ Urinary complications (frequent infection) Can become very painful ▪ Scarring ▪ Abscesses or large cysts require surgical excision and ▪ Pain deinfibulation ▪ Infection ▪ Infertility
Meatal obstruction and urethral strictures Obstructed vaginal environment Signs/symptoms encourages candida and bacteria growth ▪ Straining to urinate 25% of infibulated women have recurrent yeast ▪ Urinary retention infections ▪ Slow urinary stream Avoid vaginal administration of antifungal Treatment/referral Oral administration preferred ▪ Cystoscopy, urethral dilation or urethroplasty Severe dysmenorrhea and menorrhagia secondary to obstructed outflow documented as high as 65% of women Nour, 2004
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Fiddes et al. (2003) Attitudes towards pelvic examination and chaperones: a questionnaire survey of patients and providers. Contraception 67: 313-317. Flemmer, N, Doutrich, D, et al. Creating a safe and caring health care context for women who have sex with women. JNP. 2012 Jun; 8 (6): 464-69. Geisler, Chow, Schachter and McCormack. Pelvic examination findings and chlamydia trachomatis intgection in asymptomatic young womenb screened with a nucleic acid amplification test. (2007; (34): 6: 335 – 338. Gilson M et al. Does gel affect cytology or comfort in the screening Papanicolaou smear? J Am Board Fam Med 2006;19:340-4. Griffith WF et al. Vaginal speculum lubrication and its effects on cervical cytology and microbiology. Obstet Gynecol Survey 2005;60:731-2. Haar, E, Halitsky, V & Stricker, G (1997) Patients’ attitudes toward gynecologic examination and to gynecologists. Med Care 15: 787-95 Harer WB et al. Lubrication of the vaginal introitus and speculum does not affect Papanicolaou smears. Obstet Gynecol 2002;100:887-88. Hathaway JK et al. Is liquid-based Pap testing affected by water-based lubricant? Obstet Gynecol 2006;107:66-70. Holton T et al. The effect of lubricant contamination on ThinPrep® (Cytyc) cervical cytology liquid-based preparations. Cytopathol 2008;19:236-43.
Abdull Gaffar B et al. Lubricant, mucus, and other contaminant materials as a potential source Huber, J et al. “Just relax”: physicians’ experiences with women who are difficult or of interpretation errors in ThinPrep cervical cytology. J Lower Gen Tract Dis. 2010 Jan; 14(1):22- impossible to examine gynecologically. J Sex Med (2009) 6:791 – 799. 28. Levy, BS. OBG Management Is the annual pelvic exam a relic or a requisite? (2011) 23:4 Allan, G, Korownyk, C and ivers, N. Papanicolaou tests: does lubricant reduce the quality or (14 – 20) adequacy? Canad Fam Physician (2011) 57: 309) Mayer, KH, et al (2008). Sexual and gender minority health: what we know and what Amies AE et al. The effect of vaginal speculum lubrication on the rate of unsatisfactory cervical needs to be done. Am J Public Health. 98: 989-95. cytology diagnosis. Obstet Gynecol 2002;100:889-92. Myers, et al. (2006) Management of adnexal mass. Evidence Report/technology Arbyn M. et al. European guidelines for quality assurance in cervical cancer screening: Assessment 130: 1 – 145. recommendations for collecting samples for conventional and liquid-based cytology. Nour, NM. Obstetrical and Gyn Survey (2004) Female genital cutting: clinical and cultural Cytopathol 2007;18:133-9 guidelines 50 (4): 272 – 279. Atkinson BF et al. Atlas of difficult diagnoses in Cytopathology. Philadelphia: WB Saunders; Olson, BK. (1981) Patient comfort during pelvic examination: new foot supports vs metal 1998: pp 106. stirrups. JOGNN 10: 104 - 107 Bachman,G et al (2008) Efficacy of low-dose estradiol vaginal tablets in the treatment of Padilla, Radosevich & Milad. Limitations of the pelvic examination for evaluation of the atrophic vaginitis. Obset Gynecol 111:67-76 female pelvic organs. Internat’l Jour of Gyn and Ob (2005) 88:84-88. Bates, C, Carroll, N and Potter, J. The challenging pelvic examination. JGIM. (2011) 650 – 657. Qaseem, A et al. (2014) Screening pelvic examination in adult women: a clinical practice Beam, SM & Chhieng, DC (2010) Anal-rectal cytology: the other Pap test. LabMedicine, 41:168- guideline from the American college of physicians. Ann Intern Med. 2014; 161:67-72. 171.
Blake, Fletcher, Joshi and Emans. Identification of symptoms that indicate a pelvic examination Rockwell et al (2003). Chaperone Use by Family Physicians During the Collection of a Pap is necessary to exclude PID in adolescent women. Pediatric Adolescent Gynecol. (2003). 16: 25 – Smear. Ann Fam Med 2003; 1:218-220. 30. Seehusen, et al, (2006) Improving women’s experience during speculum examinations at Braddy, CM and Files, JA. Jour of Midwifery and Women’s Health (2007) Female genital routine gynaecological visits: randomised clinical trial. BMJ, 333 (7560):171-173. mutilation: cultural awareness and clinical considerations. 52 (2): 158 – 163. Selvaggi et al. (2000) Specimen adequacy and the ThinPrepPap Test: the endocervical Casselman CW et al. Use of water-soluble gel in obtaining the cervical cytologic smear. Acta component. Diag. Cytopathology. 23: 23-26 Cytol 1997;41:1861-2. Seymour, A et al. Pelvic exam is unnecessary in pregnant patients with a normal bedside Charoenkwan K et al. Effects of gel lubricant on cervical cytology. Acta Cytol 2008;52:654-8. ultrasound. Am Jour Emerg Med (2010) 28: 213-216. Close, R. Reliability of bimanual pelvic examinations performed in emergency departments. W Smith-McCune KK et al. Effect of Replens gel used with a diaphragm on test for human Jour of Medicine (2001); 175: 240-244. papillomavirus and other lower genital tract infections. J Lower Gen Tract Dis. 2006;10:213-8 Feit & Mowry. Interference potential of personal lubricants and vaginal medication on Stewart, Thistlewaite and Evans. Pelvic examination of asymptomatic women. Australian ThinPrep® Pap tests. JABFM (March-April 2011) 24:2 (181 – 186) Family Physician (2008) (37): 6: 493 – 496. Fethers, K, Marks, C, Mindel, A & Estcourt, C. (2000) Sexually transmitted infections & risk Stormo, Cooper, Hawkins and Saraiya. Physician characteristics and beliefs associated with behaviours in women who have sex with women. Sex Transm Inf 2000; 76:345-49. use of pelvic examinations in asymptomatic women. Prev Med (2012) 54: 415-421. Fethers, K et al. (2008) Sexual risk factors and bacterial vaginosis: a systematic review and meta-analysis. Clinical Infectioius Diseases 47 (11) 1426 – 1435.
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Tiggeman & Hodgson. The hairlessness norm extended: reasons for and predictors of women’s body hair removal at different body sites. Sex Roles (2008) 59: 889-897 Ventegodt, Morad and Merrick. Clinical holistic medicine: holistic pelvic examination and holistic treatment of infertility. The Scientific World Journal (2004) 4:148 – 158. Wadsworth, P and VanOrder, P. Care of the sexually assaulted woman. JNP. 2012 Jun;8 (6):433-441. Weitlauf, et al. Distress and pain during pelvic examinations. Obstetrics & Gynecology (2008): 112:6: 1343 – 1350. Westhoff, C, Jones, H and Guiaha, M. Do new guidelines and technology make the routine pelvic examination obsolete? Jour of Women’s Health (2011) 20:1 (5-10)
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