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The American College of Obstetricians and Gynecologists recommends that all women age 18 or older need annual gynecologic examinations, including a pelvic examination, as do sexually active adolescents younger than age 18.

The American College of Obstetricians and Gynecologists recommends that all women age 18 or older need annual gynecologic examinations, including a pelvic examination, as do sexually active adolescents younger than age 18. The well-woman visit is a key part of preventive care; it includes a discussion of the patient's health history and reproductive health care needs, a physical examination, including a weight and blood pressure check, a clinical breast examination, and various tests depending on a woman's age and risk factors for disease.

Some women feel embarrassed by the exposure involved in a pelvic exam. Others view the pelvic exam as an indignity to their bodies.

Actually, these feelings, although understandable, must be overcome. Few examinations are as important to your health and well-being. Just as periodic examinations of your breasts can detect early lumps or thickening, the pelvic exam is essential for the early detection of genital cancer, infection or other abnormalities. As with breast cancer, genital cancer is best managed if found early. And early detection and treatment of other problems can often head them off before they become serious.

As a patient, the best way to approach the pelvic exam is as a routine examination that happens to take place in the gynecologic area. It should be no more embarrassing than your annual overall physical checkup, and the steps involved are no more difficult than having your blood pressure recorded.

PRE-EXAM CONSULTATION
Before beginning the pelvic exam, you and your clinician will discuss your particular requirements as a patient: Are you currently in a relationship? Are you needing birth control? Do you have a history of vaginal infection? All of these factors will be taken into consideration.

The examination usually involves two steps:

vaginal examination with a speculum
vaginal examination with the hands and fingers (digital exam). Your doctor may also want to perform a rectal checkup during the digital phase of the examination.

SPECULUM EXAMINATION
Preparation: Usually with the aid of the nurse, your body is draped with a sheet and your feet are placed in stirrups. After routinely examining the breasts, abdomen and groin, your clinician inspects the outer genitals. Because good light is important, a lamp may be used during this inspection. Generally, the examiner will place an arm or elbow on your leg or thigh before touching the outer genitals. This is to avoid startling you--in which case your genital muscles might involuntarily contract and interfere with the examination.

Inserting the Speculum: A speculum is an instrument which enlarges the vaginal opening and spreads the vaginal walls so that your clinician can "see what is going on" inside the vagina. Your clinician will carefully insert the speculum into the vaginal entrance with one hand, while using the other hand to gently spread the labia. The type or size of the speculum depends on whether the patient is sexually active, uses tampons, has had children, or is post-menopausal. To avoid discomfort, the speculum is inserted slowly and at an angle. But if you feel any distress—which is extremely rare—your clinician will adjust the speculum to make you feel more comfortable.

Inspecting the Cervix: As it is gradually rotated, the speculum can be opened to expose the cervix--the "neck" of the lower uterus that connects it with the vagina. Again, this is done with very little discomfort to the patient. By manipulating the speculum, the doctor obtains a clear view of the cervix and can examine it for cysts, tears or other abnormalities.

The Pap Smear: Named for its developer, Dr. George N. Papanicolau, the Pap test is a simple procedure which detects precancerous cells. In other words, the Pap test can warn of cancer even before clinical signs of disease are apparent.

You've probably been instructed not to use douches, vaginal creams or medications for at least 48 hours prior to your pelvic exam. This is important because these substances can distort the appearance of the cells to be studied in the Pap smear.

While the cervix is still exposed by the speculum, cells are taken from the cervix and vagina with a scraper or cotton-tipped applicator. The cells are then rinsed into a vial and sent to a laboratory for analysis.

With the speculum still in place, your physician may also take appropriate smears to determine the presence or absence of vaginal infection.

DIGITAL EXAMINATION
After gradually withdrawing the speculum, the examiner will carry out the digital examination. This is just what it sounds like: an examination with the fingers or "digits." It is also a "bimanual" examination because both hands are used--one internally and one externally on the abdomen. Wearing a glove, your clinician inserts the index and/or middle finger of one hand into the vagina. In this way, the cervix can be palpated or "felt" for consistency, shape and position. The cervix may be moved from side to side to determine if it is tender to the touch. And the upper vagina is explored for masses, tenderness, or distortion.

During the digital exam, your clinician will also examine the uterus and ovaries. While the finger (or fingers) within the vagina elevate the cervix and uterus, the other hand is gently placed on the abdomen. By "grasping" the upper portion of the uterus between the vaginal fingers and the abdominal hand, the examiner can determine its size, its mobility and the presence or absence of tenderness. The ovaries also can often be located and felt.

RECTAL CHECKUP
In order to completely rule out abnormality, your clinician may include a rectal checkup as part of the digital examination. Just stay relaxed, and you'll feel nothing more than perhaps a brief sensation of a full bowel.

The rectal examination follows naturally from the digital exam. Still wearing a glove, your clinician again inserts the index finger into the vagina. The middle finger--which has been well lubricated--is gently and slowly inserted into the anal canal. This is done to determine whether there is any mass in the anal canal or lower rectum. By reaching further into the rectal canal, the examiner can also palpate the cervix and uterus.

POST-EXAM CONSULTATION
After the pelvic exam, you'll be asked to return to the consulting room, where you and your clinician will discuss the findings of the examination. You'll be told when to expect the results of your Pap smear. If birth control is your primary concern, a contraceptive program will be tailored to your individual needs.

Your physician will also tell you when to come in for your next pelvic exam and Pap smear, generally within six months to a year. You may get a reminder in the mail--but don't wait to be reminded! Now that you know about this all-important method of detecting genital cancer and infection, you'll probably want to have a pelvic exam and Pap smear at least once every year.