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No matter how many pelvic examinations a woman has had, she’s not ever likely to feel at ease about being asked to perch her unclothed hips at the edge of the exam table and place her feet up in metal stirrups. This indelicate position — known in medical parlance as the dorsal lithotomy position — is an integral part of the pelvic exam and Pap screening, which involves widening the vagina with a speculum and obtaining cells from the cervix. The stirrups position is thought to afford the best view of the vulvovaginal area and facilitate proper placement of the speculum.
Most of us understand the value of pelvic exams and learn to live with the indignities. But for some women, the feelings of embarrassment, exposure, discomfort, and even pain during speculum exams are potential barriers to screening. The question is, couldn’t there be some acceptable, less vexing alternative? According to the findings of a study, the answer is yes. In a randomized trial of stirrups versus no stirrups for routine gynecological exams, researchers in Georgia found that the women who were allowed to keep their feet on the examining table felt significantly less vulnerable and more comfortable than those whose feet were placed in stirrups. The results were published in the July 22, 2006, British Medical Journal (BMJ).
The study demonstrates that it’s possible to perform pelvic exams and obtain cervical smears without using stirrups. It also suggests that many women might find the experience less stressful if they had the option of keeping their feet on the table.
The study
Nearly 200 women recruited from a family medical clinic at Eisenhower Army Medical Center in Fort Gordon, Ga., agreed to undergo routine speculum exams and cervical smears. Half were randomly assigned to be examined with their heels placed in metal stirrups and the other half were examined with their feet situated on the corners of an extended exam table. Clinicians involved in the study were instructed on how to position and drape the women. After the examinations, each participant completed a questionnaire evaluating her level of physical discomfort and her sense of vulnerability and loss of control. Compared to the stirrups group, women in the no-stirrups group experienced 43% less discomfort and felt 44% less vulnerable. There was no difference in their sense of control and almost no difference in the quality of the smears (two smears from the no-stirrups group were deemed inadequate).
One possible limitation of the study is that the scale that the women used to indicate their level of discomfort did not distinguish the source — for example, pain from speculum insertion, leg position, or some other problem. The authors say this could be addressed in a future study, as could concerns about smear adequacy with the no-stirrups approach. Their main conclusion is that women should have the option of being examined without stirrups. Lead author Dr. Dean Seehusen says he personally believes that the method might be so much less stressful that more women would follow up for future Pap smears, resulting in better screening rates and more cancers prevented.
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Making the pelvic exam more comfortable Being open with your clinician about your concerns is the first step toward a more relaxed experience:
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What now?
A commentary by British doctors that accompanied the BMJ article asserts that the trial results should change practice in the United States, “where many women may be unaware that there is an alternative to using stirrups in cervical screening.” It notes that in the United Kingdom, stirrups are used mainly for medical procedures such as colposcopy (a more extensive examination of the cervix following an abnormal Pap test), not for routine pelvic exams and cervical smears. According to the study, the same is true in Australia and New Zealand.
By contrast, clinicians in the United States are trained in medical school to perform pelvic exams with the woman’s feet in stirrups. The stirrups are meant to hold the legs still and in position. American physicians may want to see more evidence — for example, that smears obtained without stirrups are comparable in quality to those obtained using stirrups — before making a change. This would require larger randomized trials. According to a BMJ editorial authored by an American doctor, some clinicians worry that the no-stirrups position doesn’t allow enough room to maneuver the speculum. The study authors say that once you learn the technique, that’s not a problem.
Harvard Medical School’s Dr. Celeste Robb-Nicholson, clinician and editor-in-chief of the Harvard Women’s Health Watch, suggests that for many women, a speculum exam probably could be done without stirrups, though this would depend, in part, on individual anatomy. The chief concern is to get a good view of and access to the cervix. If you’re interested in having a pelvic exam with your feet on the table instead of in stirrups, discuss it with your clinician. A change in stirrups use is not without precedent: Stirrups were once routinely employed during childbirth, and that’s no longer the case.
It’s also important to keep in mind that many factors besides stirrups can contribute to a woman’s feelings about pelvic exams, including past gynecological experience, sexual history, and physical and emotional sensitivities. Studies suggest that good communication and positive emotional contact between a woman and her clinician can help ease many of these concerns.