What to know about Cervical Cancer

January is Cervical Cancer Awareness Month. According to WHO, Cervical cancer is the 4th most frequent cancer in cis-gender women worldwide*; regular screening for it could help initiate timely treatment and save many lives. Yet, it's one of the most hated exams out there, if not the worst. Is it the lack of awareness or education, or is it something else— why do people hate getting a pap smear exam? I couldn't find a study that could correlate the lack of an exam with pelvic pain, but I wouldn't be surprised if that's one of the underlying reasons for avoiding going to see your gynecologist. One study found "pain, discomfort, anxiety, fear, embarrassment, and irritability. These negative symptoms can interfere with preventative health screening compliance, resulting in delayed or avoided care and significant health consequences." 

Is it really surprising?? The feeling of a rigid, cold metal or plastic inside you can make anyone jump from the exam table… yet we are supposed to quietly lie down on the exam table with our feet propped up in stirrups for one of the worst kinds of exam, and be prepared for the insertion of this medieval torture device without so much as a warning from the doctor. Most doctors only say, "It will pinch a little!!" as they insert this device, which, in my experience, doesn't help much. So, let's see how this exam can be made more comfortable and how we can advocate for ourselves during the exam. Let's admit that speculum exams are important; we can't and shouldn't run away from them. So, is there anything you can do? Yes! 

The USPSTF recommends screening for cervical cancer in women aged 21 to 65 years with cytology (Pap smear) every three years or, for women ages 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and HPV testing every five years.

Tips for your Pelvic Exam

1. First things first, if you are experiencing pelvic pain, it's advisable for you to consult with a Pelvic health physio.
2. Your doctor should explain the procedure and request your permission before touching you.
3. You should make your doctor aware of any pelvic pain you are experiencing & ensure that they make a note of it.
4. You should lie flat and not at 30 degrees, as lying flat keeps your pelvic and abdominal muscles relaxed. However, if you'd like to know what's happening, you could either assume a more upright position or ask for a mirror. Alternatively, you can put your hand on your doctor's to guide them slowly. You could even request to insert the speculum in yourself.
5. Practice some diaphragmatic breathing and visualization or any other relaxation practice that works for you for a few minutes before the procedure to relax the pelvic floor muscles.
6. Positioning the legs in the stirrup can further create tension in the pelvic floor, especially if your inner thigh muscles are tensing. Having a trusted friend/partner or a staff member support your legs can be extremely helpful for relaxing the muscles. Or you could insert the speculum while knees are bent and slightly touching each other and feet are still on the table before putting them up in the stirrups.
7. After explaining the process, your doctor should do a bimanual exam with lubrication (one hand on the belly and one on the vagina). This helps them determine the right shape and size of the speculum. You could always request your doctor to use a smaller speculum.
8. After this, they should insert the speculum slowly and gradually without pinching the tissue while you continue to practice breathing and relaxation of the pelvic floor muscles. Some doctors use silicone covers on top of the rigid plastic, which feels much more comfortable.
9. Please know that you are in charge, and you can always stop or ask your doctor to slow down anytime during the exam should you feel uncomfortable.
10. Please know that with menopause, the vaginal tissue elasticity reduces, making this test particularly uncomfortable. If you are experiencing dryness or a burning sensation, please speak to your GYN about it. If appropriate, they may prescribe vaginal estrogen to you, which can not only improve overall tissue health but also make future Pap tests more comfortable for you.

_{* It is important to note that cervical cancer screening is important not JUST for cis-gender women, but transgender and non-binary individuals as well. Currently, WHO has plans to eliminate cervical cancer as a global public health problem by reducing its incidence from 7.8 down to 4 per 100,0000 “females” within the lifespan of today's young girls. However, it will be unlikely for this goal to be met if the screening rates for cervical cancer remain as low as they currently are.}

_{The lack of clear screening guidelines for transgender and non-binary folks who were assigned female at birth and still have a cervix is one reason for the lower screening rate. USPSTF guidelines are specifically directed towards women, leaving a good portion of the affected population confused about whether they qualify for this screening test (pap smear) or not.}

_{Cervical cancer inequities among racial and ethnic minorities are also well documented. Black, Hispanic, and Asian individuals are more likely to be diagnosed with advanced-stage cervical cancer than non-Hispanic Whites. Sexual orientation and gender identity can further deepen these inequities. E.g. “Transgender men had 37% lower odds of being up to date with their cervical cancer screening compared to cisgender women”, according to one study.}

_{More studies are clearly required, and public health agencies need to use gender-inclusive guidelines to lower the barriers to medical screening and timely care.}

References: O'Laughlin DJ, Strelow B, Fellows N, Kelsey E, Peters S, Stevens J, Tweedy J. Addressing Anxiety and Fear during the Female Pelvic Examination. J Prim Care Community Health. 2021 Jan-Dec;12:2150132721992195. doi: 10.1177/2150132721992195. PMID: 33525968; PMCID: PMC7970676.

Lin, E., Sleboda, P., Rimel, B.J. et al. Sexual orientation and gender identity inequities in cervical cancer screening by race and ethnicity. Cancer Causes Control 35, 133–151 (2024). https://doi.org/10.1007/s10552-023-01771-2.

Peitzmeier SMM, Khullar KBS, Reisner SLSMA, Potter JMD (2014) Pap Test Use Is Lower Among Female-to-Male Patients Than Non-Transgender Women. Am J Prev Med 47(6):808–812. https://doi.org/10.1016/j.amepre.2014.07.031