Anatomy of a GYN Appointment, By María Teresa Alzuru
Illustration by Emily Fender
Whether you are going for the first or the tenth time, a gynecologic visit can often come with some level of anxiety. The clinician is there to examine parts of your body that you can’t easily see yourself. There are extra sensitive areas you can see as well that not just anyone has regular access to. Knowing what will happen and what kind of care you can expect may help relieve some of that natural anxiety. Note: Gynecologic services can be provided by various types of healthcare providers, not just gynecologists.
Vitals
Questions
Exams
Vitals
As with almost any type of primary care visit, someone will likely take your vitals. This means they will take your weight, height, temperature, heart rate, blood pressure, and possibly your oxygen saturation (especially now in times of COVID-19). Usually these are taken by someone other than your doctor, like a nurse, assistant, or technician.
Questions
You should expect your gynecologist to ask you some questions about yourself, especially if it is your first time seeing them. At a regular check-up where nothing specific has brought you in, they may be interested in:
Personal and Family History: past surgeries, medications, chronic conditions you are aware of, allergies, and any other major family illnesses.
Menstruation: If you have a period, you should be prepared to tell them the first day of your last period and how long your period usually lasts. They will want to know if you have any pain, cramps, heavy bleeding, irregularity in your flow, or mood changes. They would want to know if any of these things are regular for you or if they are recent changes (Note: if you recently got your period for the first time, it is totally normal to experience fluctuations for the first couple of years.) If you are perimenopausal (soon to go through menopause), they can help you identify that and explain what you can expect as you go through menopause.
Sex & STIs: They should ask you for your sexual history including whether you are “sexually active,” who your partner(s) is/are and what types of sex you are having. They may also ask if you have had any issues related to sex like pain, low libido, or difficulty reaching orgasm.
Naturally, if you are having any type of sex, they may ask how you are protecting yourself from sexually transmitted infections or STIs – gonorrhea, chlamydia, trichomonas, HIV, syphilis, HPV – and whether you have had any STIs previously. The questions they asked about your sexual behavior and partners will determine what kind of STI screening they recommend. For example, gonorrhea can infect the throat, genitals and rectum, and any orifice used for sex can be swabbed for STIs.They can also offer STI testing and treatment, the HPV vaccine, and PrEP, medication you can take to prevent HIV infection.
Pregnancy and Birth Control: If you are not interested in getting pregnant but are having sex you should discuss what methods of birth control you are using and/or what methods are available to you if you would like to start or change methods. This includes being able to ask about all methods, regardless of whether or not you have had any children (there is an old misconception still floating around that IUDs are only for women who have had a child before, for example).
If you are interested in getting pregnant, this is a great place to start having conversations about how to prepare and what to expect. If you think you are pregnant, you can get a pregnancy test and discuss options with your provider, including abortion.
Irregularities: Once you’ve established all of the above, it’s important for your provider to know if anything has changed since your last visit. This is a great time to remember that emotional changes may be related to hormonal changes, so it’s completely encouraged to mention those as well.
Abuse: Ideally, your provider will create a space where you feel safe sharing whether or not you are afraid of anything at home or if you have been the victim of any violence or abuse, whether sexual or not. Depending on your history, they can alter the type of exams they conduct to make sure you are comfortable, and may also be able to perform a rape kit exam if requested.
Questions or Concerns: You should always feel like you can bring any questions or concerns to your provider during your visit. Oftentimes, you only get one visit per year to see them face to face and it’s a great opportunity for full disclosure.
Exams
A standard gynecologic visit will include two types of exams: a breast exam and a pelvic exam with a pap smear. Below is a more detailed list of what each entails. An important note is that a pelvic exam and pap smear are not recommended at every annual visit with your gynecologist. If you do not think you need one because you had one recently, it’s ok to tell your provider when your last exam was done.
Breast Exam
Purpose: Detect any lumps or irregularities that could be a sign of breast cancer.
Method: The doctor will use their fingers to feel for lumps or tenderness in your breasts, usually they use a motion as if they are using their fingers to “walk” over your breasts in circles.
Recommended frequency: Every 1-3 years for ages 25-39. Every year for ages 40 and above.
Pain involved: None.
Pelvic Exam
Purpose: Evaluate external and internal organs to see if anything looks abnormal or feels painful or tender.
Method: The doctor will insert one or two lubricated, gloved fingers into your vagina and with their other hand on the outside of your lower abdomen, they will feel around to make sure your vagina, uterus and ovaries are healthy. If medically indicated, they may also perform a recto-vaginal examination with one finger in the rectum and the other in the vagina. This is not part of every pelvic exam and is only recommended if there is a specific complaint that this could help diagnose. There is no specific age when this begins.
Recommended frequency: Guidelines on this vary and some doctors still perform these every 1-3 years. However, they are most useful if you have a complaint that an exam can help further investigate. If you feel fine, it is likely you don't need a pelvic exam.
Pain involved: This should not be painful but introducing the speculum can feel like pressure in your vagina. If you do feel pain, you should tell your doctor.
Pap Smear
Purpose: Take a sample from your cervix to test for abnormalities that may be signs of cervical cancer.
Method: The doctor will use a speculum to essentially hold the walls of your vagina open while they quickly insert a long swab to collect samples for testing. The speculum may be metal or plastic but should have warm water or a lubricant applied prior to insertion.
Recommended frequency:
Under 21: no screening
21-29 years: every 3 years
30-65 years: every 3 years OR an HPV test every 5 years, OR both every 5 years.
Above 65: no screening if a) you’ve had normal results for the last 10 years and b) you never had a “high-grade” precancerous lesion detected on previous pap smears.
Pain involved: Should not feel any pain, just the pressure of the speculum. The swab itself should not cause pain.
Gender Affirming and Inclusive Care
It’s important to keep in mind that patients who seek gynecological care can be of different gender identities and sexualities. While more and more doctors are learning strategies for practicing gender affirming care, there are a few things you as the patient can do to get the care you deserve. Ideally, your provider will initiate these conversations but you should feel empowered to do so yourself if they do not:
Let them know your preferred pronouns
Provide an organ inventory. This means letting them know if you have had any organs removed as well as what you prefer to call each organ. For example, in a typical visit, you would be given a breast exam but you may prefer your doctor refer to this differently.
Ask for an appointment first thing in the morning: if you are concerned about a waiting room full of people, explain to your doctor’s office that you would prefer to take their first appointment in the morning when the waiting room will be empty or less busy.
For providers
In addition to offering the options above and initiating these important conversations with your patients, you may also consider:
Leading by example: even displaying your pronouns on a clearly visible pin can set the tone for your patients to feel like they can advocate for care that they are comfortable with
Gender neutral bathrooms in your practice
Varied reading material in the waiting room and on the walls
Clinical forms that allow patients to indicate their sex assigned at birth as well as their gender identity separately (allow fill in the blank option for the latter)
Avoid assuming gender dysphoria for trans patients. If this is a code that is helpful to get treatment or care covered by insurance, explain that to your patient so they know why it appears on their chart. If that is not a concern, consider other accurate descriptions related to hormone imbalance that may be less problematic for a patient who does not feel any dysmorphia.
References
American College of Obstetricians and Gynecologists. (2018, August). Cervical Cancer Screening (Update). Retrieved from https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2018/08/cervical-cancer-screening-update
American College of Obstetricians and Gynecologists. (2018, October). Well-Woman Visit Committee Opinion. Retrieved from https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/10/well-woman-visit
Cervical cancer screening tests: Techniques for cervical cytology and human papillomavirus testing. (n.d.). Retrieved May 6, 2020, from https://www.uptodate.com/contents/cervical-cancer-screening-tests-techniques-for-cervical-cytology-and-human-papillomavirus-testing
Core IM. (2020, March 18). 5 Pearls on Transgender Health: Gender Affirming Care Episode 1. Retrieved from https://www.coreimpodcast.com/2020/03/18/5-pearls-on-transgender-health-gender-affirming-care-episode-1/
Mayo Clinic. (2019, July 25). Pap smear. Retrieved from https://www.mayoclinic.org/tests-procedures/pap-smear/about/pac-20394841
Mayo Clinic. (2020, May 22). HPV test. Retrieved from https://www.mayoclinic.org/tests-procedures/hpv-test/about/pac-20394355
Rainn. (n.d.). What Is a Sexual Assault Forensic Exam? Retrieved from https://www.rainn.org/articles/rape-kit
Trans Student Educational Resources. (n.d.). Gender Unicorn. Retrieved from http://transstudent.org/what-we-do/graphics/gender-unicorn/
