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 Describe at least two techniques for performing 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 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

1 8/3/2014

• 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 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 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 detection rate in one study

Griffith et al, Contraception, 2005; Amies et al, Obstet Gynecol, 2002

2 8/3/2014

 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 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)

3 8/3/2014

 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 of the rectum from the keratinizing anal squamous mucosa, is the site where most anal intraepithelial neoplasms arise

 Normal 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 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 -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  and 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 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 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

6 8/3/2014

 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

7 8/3/2014

•  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

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 to see introitus, insert gently & do not twist or turn

8 8/3/2014

 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 and posterior- women without disabilities

 Have her grip your fingers- assess pelvic musculature strength Nosek et al, 2001

 By 2 years post 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

9 8/3/2014

 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 1991

10 8/3/2014

 Screening pelvic exam started as a  Method to obtain cervical specimen for CT/GC  Screen for with cytology  Screen for 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 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 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 . 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 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%  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  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 ? female  Taking exogenous hormones  Herpes (estrogen, testosterone)?  HPV  If hysterectomy for cancer-continue  cytology from cervical/vaginal cuff  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 receptive oral sex (which has been proposed as a risk for BV among  Negative experiences with the healthcare ) system & misinformation about disease risk &  Lesbians in monogamous relationships usually 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: (removal of clitoral hood or )  Chronic urinary tract infections

2: Excision  Treatment/referral (removal of clitoral hood or clitoris plus some or all of ▪ Suppressive antibiotic treatment ) ▪ 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 ▪

 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 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 . 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 . 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 . 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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