Pap Smear Pain

February 23, 2007 8:50 PM

Pain is making it impossible for me to get a Pap smear.

After three tries, I haven't been able to successfully get a Pap smear. My gynecologist just can't get the speculum in: it hurts, a great deal. No matter how slowly or gently she tries to do it, it feels like she's trying to poke the speculum through solid flesh. She's already using the smallest speculum, but that didn't help. She can't fit her lubricated finger in there either. Since I have no known physiological abnormalities (my periods are normal, if somewhat painful, etc.), she thinks that the vaginal muscles are just becoming very tense, making it impossible to get the speculum in. However, trying to breathe and relax doesn't help, and 5mg of Valium before the most recent attempt didn't help either.

Since I've never used tampons, penetrative sex toys, or had penetrative sex, I have no other data to help me figure out whether my problems have to do with the situation (doctor's office, speculum, etc.) or whether they're the result of more general psychological or physical problems. I'm already a few years late on starting to get the Pap smear done; I'd like to get it over with.

My current gynecologist is planning to ask her colleagues for suggestions, but I'd like more advice about whether there's anything else that I can do, either before or during the exam. If you've had similar problems, what was wrong, and what helped?

posted by anonymous to health & fitness (33 answers total)

Have you ever fingered yourself?

Would it possibly be better for you if the doctor gives you instructions on how to insert the speculum, leaves the room for a while, and lets you do it yourself?

Would sensory deprivation help? Blindfold and earphones?
posted by dirtynumbangelboy at 8:59 PM on February 23, 2007

I'm wondering if your gyn is fairly new, and not sure how to deal with this. I wonder how comfortable you are with her. There is a name for this condition, she should know how to deal with it. I would think about finding a more experienced doctor.
posted by 6:1 at 9:08 PM on February 23, 2007

why doesn't she schedule an ultrasound?
posted by serena15221 at 9:14 PM on February 23, 2007

Try fingering yourself, or asking someone you care for to do it for you. Before I had penetrative sex I couldn't insert a tampon and if I had tried to get a pap smear I don't think it would have been possible; I've always been comfortable with my body (so I don't think this was psychological) but just assumed it was fairly normal that as a virgin I couldn't even fit a finger in my vagina. I think I just had an extremely tiny opening.
posted by crinklebat at 9:18 PM on February 23, 2007

If you are an intercourse-virgin, do you need pap smears? I thought (and i'm probably wrong) that cervical cancer was stimulated by the HPV which is transmitted sexually. Also, is it possible that it's your hymen which is preventing this, and can it not be surgically removed? Also, how about vaginismus?
posted by b33j at 9:18 PM on February 23, 2007

b33j, you are somewhat correct, but there are other problems besides cervical cancer that paps can uncover, which are unrelated to how sexually experienced a woman is.

I think you need to see another doctor.
posted by Brittanie at 9:39 PM on February 23, 2007

That sucks, sorry to hear you're having such a rough time of it.

I can't say where your problem might be coming from (psychological, physical, or both), but I have some suggestions that might help you prepare yourself for your next pap appointment.

There's no delicate way to put this.... Your vaginal hole is a muscle, and it sounds like you need to condition it. Use your fingers, and physically stretch the muscle walls in all directions. Just apply pressure to the muscle until you feel the familiar sensation of a muscle at its tension point (like when you're reaching for your toes and you can't go any further), and hold it there for as long as you can. Concentrate on breathing through the tension, and trying to relax as much as you can rather than fidgeting and fighting while you're stretching.

Then stretch the opposite side, then the bottom, then the top. Do this daily, or even twice daily, and you'll notice an improvement in elasticity before long, just as if you were working on making your hamstrings more limber.

Solarcaine makes a product that's basically aloe vera gel with lidocaine, a topical pain reliever. It says "for external use only", but my doctor recommends using it internally, as lube for patients with pain. It tingles like Vicks Vapo-rub, and numbs a bit. Put it on your fingers when you're stretching, and even bring it to your (eventual) pap smear appointment for the doc to use.

You might graduate to a slender sex toy or other clean, smooth object when you're ready. This will help you privately deal with any nervousness that having a foreign object inside you brings, separately from the added nervousness that a medical exam brings.

When you get past the initial hurdle of penetration, there's a second muscle deep inside that may very well also need stretching out. It's your pelvic floor muscle, and it spans your pelvis from front to back. You can (and should) begin work on this muscle even before you can touch it with your hands. Doing kegel exercises will help you learn to control the pelvic floor muscle better, will likely increase your range of motion, and will strengthen it.

I might allow a month or two of disciplined at-home conditioning before scheduling another appointment. If all else fails, the doctor you're looking for is a "pelvic pain" specialist, but you may not need one.

Good luck.
posted by nadise at 9:46 PM on February 23, 2007

b33j, you are somewhat correct, but there are other problems besides cervical cancer that paps can uncover, which are unrelated to how sexually experienced a woman is.

No, actually, there aren't. The ONLY thing a pap smear checks for is cervical cancer. Other tests (for STIs) may be run at the same time, or even from the same sample, but the only thing a pap smear is checking for is cervical (pre)cancer. If you are completely virginal (no genital contact with another person, ever) you do not need a pap smear.

If you still want to go through with it, or are having a pelvic exam for something other than cancer screening, perhaps you could try a soft inflatable speculum.
posted by Violet Hour at 10:01 PM on February 23, 2007

God, so sue me, I'm using the term pap smear in this case to also include vaginal exam.
posted by Brittanie at 10:25 PM on February 23, 2007

[please do not turn this into a "you do not need a pap" debate -- the OP is asking about OBGYN exams generally, derails can go to email or metatalk]
posted by jessamyn at 10:34 PM on February 23, 2007

Vaginismus. You want more Valium, or better yet, get drunk, if you can.

Seriously, because now the tension is feeding itself, and a gynecological exam is something you may not come to love, ever, but is definitely not that big a deal once you have experienced it once or twice. You learn to just... dissociate from your body and float far away. In the short term, intoxication will help with that.

My mom told me that she had to get liquored up to see the gyno until she was pregnant with her second child.
posted by Methylviolet at 10:47 PM on February 23, 2007

My doctor once told me that one doesn't need a pap smear if one isn't sexually active (oral or penetrative). Still, this anxiety will likely come back when you're ready for sex and who needs that added pressure?

Reading that previous link on vaginismus, it sounds like that might be a cause. When you go back to talk to your doctor, I'd definitely ask about it and see what she says.
posted by Salmonberry at 11:46 PM on February 23, 2007

There is such a thing as a "child sized speculum." It is used for children especially during sexual abuse investigations. Point is, it's a lot smaller than the adult sized one. Has she thought of/tried that?
posted by sneakin at 5:28 AM on February 24, 2007

Dear anon, I can sympathize. My pap smear was a nightmare. At least take comfort in having a doctor that's understanding. My doctor did try a pediatric speculum, but got impatient with me and just jammed it in as hard as she could. I felt like I had been stabbed in the worst possible place! And she was surprised when the swab came out, soaked in blood...

I didn't mean to scare you, just help you to take comfort in the fact that you have a doctor that's willing to listen to you and even consult other doctors to help you with your problem. I know that this whole experience is is a considerable frustration for you, and possibly even embarassing, but take heart. You're not alone.

I think one of the ways to start stretching is to try to wear really slim tampons. The first few are a pain, but it does get better. It will probably be a little more relaxed than fingering yourself at first, as tampons come with clear instructions, they are utilitarian and the process is fairly quick.

Good luck!
posted by bristolcat at 6:09 AM on February 24, 2007

Make sure the speculum is -warm- (especially if it is the metal kind). Ask if you can have a plastic one to take home and try with where you're relaxed (this is possibly very, very weird, but observing your cervical opening can be useful and interesting, in a weird way (medical photographs, nothing to get shocked over though), especially if you ever want to chart your fertility for whatever reason).

Also try practicing tightening and relaxing your muscles around something (finger, tampon).

I think it's great that your doctor is willing to be patient with you, my first attempt was a train wreck, so to speak, doctor basically gave me a look like I was cutting into her lunch break and told me to get my clothes off, get on the table, and stop asking pesky questions. I went to another doctor who had a lot more actual work to do but was still patient.
posted by anaelith at 6:40 AM on February 24, 2007

If you've never been penetrated with anything at all, is it possible you have a really, really thick hymen and it hasn't been broken yet? Perhaps the doctor will need to surgically remove part of it in order to slip the speculum in.
posted by schroedinger at 7:55 AM on February 24, 2007

Would you be more comfortable having a nurse hold your hand? If so, ask for one. It helped me relax during my first visit. And make sure to breathe (I know you said you are). I held my breath the first time and the doc said, "honey, ya gotta breathe!"
posted by IndigoRain at 8:09 AM on February 24, 2007

Your first pap attempts sound like mine. I had a large, thick hymen and the nurse couldn't fit a swab in there, let alone a speculum. I stretched it myself with my fingers at home much the way nadise outlined. It hurt and bled sometimes, but it wasn't so bad. I haven't had problems with sex or speculums since.

Good luck!
posted by christinetheslp at 8:13 AM on February 24, 2007

I understand so well.. since I have about same problem. I have penetrated myself in the past with little to no problems. But at some point, penetration turned into a nightmare. When I'm getting a pap, it's excruciating. I'm crying. I'm practically screaming. And with every visit to the gyno.. it gets worse. So I'm pretty convinced that I've developed a nasty case of vaginismus. I am a virgin, but my gyno insists I come in every year anyway. If I don't, she refuses to give me a prescription for my BC. I find it downright infuriating. I wouldn't go except that I refuse to stop taking BC.

My solution is to simply keep suffering. And when and if the day ever comes that I find a man worthy enough for me and provided he's willing.. well, I haven't figured that out. I guess I'm hoping an anxiolytic will help or some alcohol. Very terrible solutions. All these people who instruct girls like us to penetrate ourselves bother me. It's hard to penetrate yourself when you KNOW or you're convinced it's going to be extremely painful. It's all a vicious cycle/process.

Good luck.
posted by VegaValmont at 10:25 AM on February 24, 2007

In some states, you're legally required to have a pap smear before you can get birth control. I won't get started on this, but you can imagine me ranting if it makes you feel better. Anyway, point is, it may not be your doctor who's out of touch, it may be your local legislature.
posted by anaelith at 10:32 AM on February 24, 2007

Anaelith, that's not true in the US and many other countries. Neither the US Food and Drug Administration, the World Health Organization,Planned Parenthood Association, or the American College of Obstetricians and Gynecologists believe that a pelvic exam or pap smear should be required before starting hormonal birth control.

It's just up to the doctor. If your doctor won't work with you, get a new doctor! Go to Planned Parenthood (generally, they will prescibe pills without pelvic exams) or get your pills off the internet, but don't put up with being hurt for no reason.
posted by Violet Hour at 10:44 AM on February 24, 2007

You don't have to "simply keep suffering." This could turn into a huge issue when you do start having intercourse. It was a huge issue for me, basically making it impossible for me to have sex with my husband. "Simply keep suffering" wasn't an option for me, and I hope it won't be for you.

Here is another thread on painful sex which may be of interest to you.

Everything nadise said: work on stretching those muscles yourself at home. If you don't want to use your own finger, try a tampon covered by a condom and stretch out those muscles. Do you know how to do kegal exercises? Using those muscles to stop the flow of urine? Try doing a bunch of those, flexing and releasing those muscles. And these are exercises that need to be done every day over the course of a month or more.

My muscles knew how to tighten, but didn't know how to relax. So my muscles were tight All The Time and, just light tight shoulder muscles, the lack of oxygen caused them to hurt more. I finally found a doctor who knew what it was and how to fix it. She started me on lidocaine (yes, it can be used internally) and a low-dose antidepressant, and then she sent me to a vaginal physical therapist. Who just about saved my life. These exercises were KEY to my being able to have pain-free intercourse (and pelvic exams!) for the first time in my life. I'd love to talk with you more about it; my email is in my profile.
posted by rhapsodie at 10:54 AM on February 24, 2007

Goodness knows I'm no expert - I performed maybe 100 or so Pap smears in med school and internship, no more - but let's address some of the things that have been brought up here:

Your question queried whether psychological problems on your part might be to blame for this problem. The answer is no, this isn't your fault. Psychological problems cause bad adaptation to normal routine daily life. In contrast, having a large metal implement put into your most private orifice by an officious authority figure is not routine daily life. It's normal for this to be stressful and anxiety provoking, and it's perfectly all right; don't let anyone tell you otherwise.

You didn't reveal to us the reason for wanting/needing a pap smear, but why don't we just assume that there's some compelling reason you need one, since you and your doc tried 3 times to do it. Pap smears screen for cervical cancer, and while that's less important for women who haven't had sexual intercourse, it may be that you or your doc know something about your personal health history that we don't. (Maybe the original poster's mom was exposed to diethylstilboestrol during her pregnancy, for example.)

So far it sounds like the doc is proceeding in a reasonable way; 5 mg of Valium is a good start, but it may not have been enough. Valium and its related drugs have potent skeletal muscle relaxant effects. I don't agree with Methylviolet that you should use alcohol before a doctor visit. That shouldn't be necessary.

I think it's reasonable to keep on with your current doc; sounds like she's proceeding the best she knows how. And thank God for a doc who's willing to be aware of her own limitations and ask her colleagues for advice. To me, that's a sign of an ethical practitioner.

With regard to the suggestion of a vaginal ultrasound: Compared to a small speculum or a lubricated finger, a vaginal ultrasound machine is enormous - never mind the sawing away at it the operator needs to do to use it properly - and it can't do what pap smears are supposed to do, which is detect preclinical cervical cancer. By the time the ultrasound can see it, the horse is out of the barn.
posted by ikkyu2 at 11:12 AM on February 24, 2007

In some cases, sedation or even general anesthesia is an option. It sounds extreme, but it is not uncommon to anesthetize patients for MRI exams, which are certainly less invasive than pelvic exams. This sort of thing is most commonly done in young girls who need an exam for any number of reasons, but there is no reason it can't also be done in an adult, especially if it is important that the exam be done. You don't mention your age but it certainly sounds as if you might not be far removed from the pediatric age group where deep sedation or general anesthesia is routinely used for a variety of uncomfortable procedures.
posted by TedW at 12:02 PM on February 24, 2007

Follow up from the OP:

I'd like to try to make things work with my current doctor first, partly because of insurance/scheduling issues, and partly because she's been very sympathetic and willing to work with me to try to solve this, unlike previous doctors. If my problems continue, I'll definitely look for a specialist or another gynecologist.

No, I'm not currently at high risk for HPV (though everyone's supposed to start with the Pap smears at 18 or 21, and by that standard I'm already years late.) However, I also can't manage the other internal parts of the pelvic exam (which are relevant for all adult women) and that's a little worrisome, since those assess the general health of the reproductive organs. I'm also somewhat concerned that I may experience similar problems if/when I start having penetrative sex, and I assume that some of the same advice would apply to that.

Thanks for the help, everyone. I really appreciate the suggestions. I'll take more Valium next time, bring up the possibility of vaginismus or a particularly thick/complete hymen to my doctor, and try to follow nadise's advice in the meanwhile.
posted by jessamyn at 1:44 PM on February 24, 2007

One little trick from our old family doc: wiggle your toes during the procedure. It's very difficult to tense up the muscles in the vagina while wiggling one's toes.
posted by ilsa at 2:49 PM on February 24, 2007

OP: You should try to stay with your doctor. She sounds like a much better doctor than any of I've encountered.

As far as my expression that I'll keep on suffering, it's just that I've encountered a lot of shitty doctors. And I guess sometimes I feel like it's all futile. Which is a terrible attitude, I know. I don't intend to suffer forever, but for the moment it's not a pressing matter. I won't have to return to a gyno until next year and intercourse is not likely to happen any time even remotely soon.

Mostly, I'm writing another comment because I remembered something interesting. A while back I had been doing some research and I came across a study that was talking about using botox or something like it to treat vaginismus. Apparently, it worked well. Though I don't know how reliable the information was. But I thought it interesting nonetheless cause it was the first time I'd ever heard about that.
posted by VegaValmont at 3:44 PM on February 24, 2007

As a follow up to VegaValmont's comments, please keep in mind that Botox works very safely and effectively anywhere you want a muscle relaxed for four to twelve weeks. That's why it works well on forehead creases and kids with Cerebral Palsy. I've had Botox done probably a half dozen times, and recommend it for anybody trying to get rid of the number 11 between their eyebrows. There are dozens of "off label" uses for Botox too, including but not limited to jaw contouring and getting rid of migranes. But seriously? I think I'd want to do a whole lot of research and have my doctor talking to the local Allergan rep before I'd let anybody Botox my private parts!
posted by ilsa at 7:44 PM on February 24, 2007

I understand. I'm pretty dead set against botox for any purpose. That goes like triple for my nether regions. So I certainly didn't mean "go out and do it now!" But you know.. if it's safe and effective and if that were my last option, I probably would consider it.

I just mentioned it because I thought it very interesting. Clever use that probably would have never occurred to me.
posted by VegaValmont at 10:02 PM on February 24, 2007

TedW: In some cases, sedation or even general anesthesia is an option.

Wouldn't the (admittedly really small) chance of complications from anesthesia need to be outweighed by the (again, really small) chance of finding anything wrong during the exam?
posted by Violet Hour at 10:32 PM on February 24, 2007

If you've never used valium or a related drug taking 5 mgs while relaxed could put you in a very good mood or knock you out. However, 5 mgs when you're feeling tense anyway may have no effect so definately explore this option.
There's also the possibility that you have a paradoxical response to it, for some people valium has the opposite effect.
Sounds awful and I hope you both can find a solution to make the exam work.
I do feel you need to get to the root of this for a variety of future possibilities and exploration under General Anesthetic sounds far less problematic than a vaginal ultrasound.
IANA anaesthetist but I thought GA in a healthy young patient is very safe these days NO?
posted by Wilder at 4:30 AM on February 25, 2007

Wilder, Violet Hour: you both make reasonable points. Because anesthesia is not totally risk free, it is certainly more of an option if there is a compelling reason for the OP to be examined; i.e. pain, something in her history, and so forth. On the other hand, if performed by someone with proper training, anesthesia is very safe, to the point where a young, healthy patient is more likely to be injured in a car crash on the way to the hospital than to be injured by the anesthetic.
posted by TedW at 10:02 AM on February 25, 2007

I would not be afraid of GA. But that's just me. I do understand the reluctance because I used to be afraid of the idea. Maybe it's because I've begun to consider becoming an anestheisologist.

As for valium not working or having an opposite effect, that does indeed happen. I can't remember, but I've been told that as a small child I was given some sort of drug that should have relaxed me or put me out. Apparently it did nothing at all. I would assume that probably happened because I was very afraid in the situation. Fear is powerful.

As a last note, I was thinking that 5mg of valium isn't much at all. So I'm not surprised that it was ineffective.
posted by VegaValmont at 11:30 AM on February 25, 2007