Becca: I have no idea if there’s a better or worse time to do a pap in terms of sensitivity and comfort, although your thought regarding ovluation as being a particularly sensitive time makes a lot of sense to me. I wonder if there’s any research out there on this? I doubt it, but I guess it would be interesting to check anyway. Hopefully talking with your doctor about your discomforts will indeed reveal a different attitude, which may make a huge difference with regards to how you feel. Take care!

I love the way you, feministing and Rachel have covered it, and I am so tickled that the blog writers I subscribe to read each others’ blogs.

They didn’t actually tell me “too bad,” they just didn’t seem to have any alternative to offer and didn’t seem that concerned. Also, you’ve made me notice that I’ve been generalizing — the person I had that conversation with was the physician’s assistant, who I’ve had other concerns about as well. But she’s not my regular doctor. So one thing I can do is have a conversation with my regular doctor about this before I assume the attitude of the whole practice. Unfortunately, the PAP was equally uncomfortable when each of them did it. But at least the attitude might be better.

which is a wire instrument with a bunch of stiff plastic bristles on the end that is twirled inside the endocervical canal to collect cells from the squamocolumnar junction, and is used in conjunction with the spatula (the popscicle stick with the wide end). Or maybe you’re talking about the cervical broom or cytobroom, ,
which has a head on it that actually looks a little bit like a plastic broom with softer plastic bristles. The cytobroom is used for liquid based cytological methods, like the Thin Prep pap, rather than the older slide and fixative method, and the cervical broom has become the instrument of choice for gathering samples because it is supposed to gently swipe cells from both the endocervical canal and the ectocervix (so that you don’t need a spatula AND a cytobrush, just a broom), and is then twirled vigorously in the liquid medium to release the cells into the liquid. When the cells are eventually examined under a microscope, they’re generally much easier to see because they have essentially been “rinsed” by the liquid.

In my own experience, I have found that it’s the cytobrush that usually causes a little bit of bleeding when you twirl it inside the endocervical canal, especially in friable pregnant cervices, and is often the most uncomfortable part of the pap. The cervical broom seems gentler, because the plastic ends are softer and more forgiving than a wire brush with stiff bristles. But I do absolutely believe that women can feel their cervices, and that for some women a pap might be much more painful or sensitive than for others. If a care provider has an attitude of “too bad if you don’t like” it, though, why would you go back to that same provider?

Paps suck. While routine, they really are an uncomfortable and invasive procedure, and they do make you feel very splayed and very vulnerable, and as a provider who does paps on a regular basis, it would be good to NEVER lose sight of this!  (My own memories of speculum exams being performed on me by fellow students when we were learning how to insert speculums last year are still quite fresh, so no worries about me losing sight of this any time soon!) As a rule, paps are always the very last thing you do during a physical exam, because after the pelvic is finished, she’s ready to hop off that table, reclaim her dignity, and put her clothes on as fast as humanly possible. A few things I have begun to do routinely (recommended to me by Nazelgaving Midwife) is to give the woman a tissue before the pap even begins, so that she feels like she has some measure of control and can wipe and clean herself up immediately afterwards instead of having to remain with legs splayed waiting for someone to hand her a tissue, and the other thing I’ve been trying to routinely do is to compliment every woman’s cervix in some way, especially because that’s such a hidden, secret and sometimes embarassing or frightening part of a woman’s body, and how nice to undo some of that negativity by telling a woman she’s actually beautiful? Another trick I recently learned from one of my preceptors is to apply a very thin layer of gel to the outside of the blades of the speculum (not the tip, which actually comes in contact with the cervix and can mess up sample results) so that when you’re sliding in the speculum, it actually slides just a little bit, instead of getting stuck and tugging on sensitive tissue. We were taught in school to only use warm water on the blades so we wouldn’t interfere with the sample results, but the water has usually dripped off the blades by the time you get from the sink to the woman, and it isn’t the best lubricant in the world anyway. The preceptor who taught me this trick argued that the lubricant, if applied to the blades only, will usually collect near the entrance to the vagina (introitus) as the speculum is being slid inside, and therefore doesn’t come anywhere close to the cervix, where it can alter sample results (but does make putting in the speculum a lot easier). I’m still not sure if this is the best idea in the world, but I have tried the lubricant method once now and I do think it does make the entire procedure a little bit more comfortable for the woman.

As for ASCUS follow-up: according to the latest guidelines (ACOG Practice Bulletin No. 45, Aug, 2003), if a woman has pap results with ASCUS (atypical squamous cells of undetermined significance) but her HPV DNA capture test is negative (i.e. she is not infected with high-risk HPV strains), the recommendation is to have her return for repeat follow-up paps at 6 months and 12 months. I don’t understand why anyone would recommend coming back at 3 months, where the results would most likely be the same and no new information could be gleaned from having another pap so soon after the last one. On the other hand, if the HPV DNA capture tests are positive (i.e. the woman is infected with a high-risk strain of HPV), the recommendation is for colposcopy, just to make sure there isn’t any precancerous lesion present.

Thank you for forcing me to review all of this cervical cytology stuff, which I haven’t thought about in quite some time now! Not sure if this was helpful at all, but maybe it was, and as ever, thanks for the reminder that paps really are invasive, no-fun procedures. They are becoming very routine for me…reminders are good!

On a tangential note… yeah, PAP smears have done wonders for decreasing cervical cancer. I think they’re also more stressful for women than they need to be. It needs to be acknowledged that it’s an invasive, uncomfortable procedure and it should be done no more frequently than actually necessary. If a woman has had an ASCUS result, but the HPV genotype is found to be one that is NOT associated with cancer, the doctor still wants you to come back in 3 months, then 6 months, then 6 months again, just to make sure it didn’t turn into cancer… but at that point why is there any increased risk?

Also, the implements they use to take the sample have changed in recent years. Instead of the “popsicle stick” with the wide, curved end, there are a couple different plastic spiky devices used in sequence. Maybe I have more nerve endings on my cervix than average, but these things HURT, and it continues to hurt for a day or 2 afterward! The first time they were used on me, I didn’t see them and didn’t know to expect anything different, and I was wondering if I was crazy afterward because I felt so invaded and uncomfortable. The next time, I saw the tools laid out and realized what had happened. The doctor said, basically, that this is what they always use now, and too bad if I don’t like it.

I have always followed up with routine care, but I am really close to deciding to refuse regular PAP tests because of these concerns. It would make a really big difference if the people in the doctor’s office showed any understanding. It’s a great practice in most other ways… but like everyone else they just consider PAPs as simple and ordinary as taking someone’s temperature. It’s not that easy.

Sorry for venting on you. But I figure that you, Ms. Midwife, might actually be able to use this information in some useful way, so it might be worth sharing.