“Oh my god. You’re that nurse from Casualty!”, and other things that should never be said during a smear test

// 18 September 2011

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A photograph of an orange-yellow lily in close-up Most women, and some men, will be called for a smear test at some point in their life. Some of us have them as soon as we receive the letter, others – and I have to admit I am one of these – put it off as long as is humanly possible, trying to avoid the dreaded speculum. Some feminists, including Germaine Greer, advocate that we should not have smear tests at all, that they are the medicalisation of the normal functions of the human body, but nearly all the evidence suggests that smear tests are necessary and perform an important role in preventing and detecting cervical cancer. The HPV vaccine is thought to be much more helpful in prevention than smear tests, but they remain important because cervical cancer can have no symptoms, and although it is clinically difficult to analyse, reports suggest between 800 and 5000 lives are saved every year by smear tests.

So why do we hate them so much? Our logical brain might say, “It’s over in a few minutes, it’s undignified but that’s not the end of the world, it’s not that big a deal”, but they can still fill us with fear and dread. For some women this is because of a past history of sexual abuse or rape, for others because of conditions such as vulvodynia which can make any kind of vaginal penetration painful, but another reason became clear when I started discussing it with people on twitter.

This was that in all too many cases, the doctors and nurses performing the tests can be really insensitive, and even rude. @koshkajean heard the words, “Do you mind if a student nurse just has a rummage?” during a smear test, and @kinelfire described a “revolving door of other staff members who thought it was fine to interrupt! 3 of them, one by one.” @LouiseBrealey found herself in the unfortunate position of being recognised, having been an actor on TV. During her smear test, her nurse said, “Don’t I know you from somewhere? Oh my god. You’re that nurse from Casualty!… Yes, I said wanly. Yes I am.”. And @bibimcbibi explained that “As I lay spread-eagled on the table, the nurse asked me *Do you think those men on the scaffolding across the road can see us?*”.

None of those experiences are conducive to a person being able to relax, and were all misjudged by the professionals involved. While I know that the nurses know that chatting to the patient during the test will help them to relax, there are things which should always be avoided, and all of the above are prime examples.

Other things that should be avoided, and which were worryingly prevalent, were comments on people’s vaginas and cervixes. Sometimes complimentary, such as “ooh, you’ve got a LOVELY pink cervix!”, said to @londonfeminist, and others rather insulting, such as @hannahgould1 who was told, “My goodness, you’re a strange shape aren’t you?”. In my own experience, a GP was searching rather painfully for my cervix, and declared, “Oh blimey!” when she finally found it, which isn’t something you ever want to hear in those circumstances, and Jessica Reed was asked, “Did you have a baby? No? An abortion then? No? *are you sure?* Because your cervix is huge!”.

It wasn’t just cervixes being commented on, but vaginas too. Some people were told their vaginas were shallow (causing @EnstonJump to ask, “Does that mean it judges people on appearances?”), and others were deep. Some comments suggested that people’s vaginas were too large or baggy. Of all the things women are pressured to feel bad about, I had no idea that the appearance of my cervix was up for discussion.

@Jarrahpenguin, @kirstyyarr @ruwaydamustapha, @mrsnickyclark, @elmyra and @ghostlove were amongst many who felt it important to point out that they, or people they know, have had very positive pap smear experiences, and @felinefeminist describes “clinics that allow women to sit at 45 degrees for checks and insert own speculum. Really good practice!”.

Clearly, more needs to be done to ensure that women have positive smear test experiences. Tomorrow I am going to post about the official good practice guidelines, and other important areas that they do not cover, along with advice from some of the people involved in the discussions on twitter.

Because I could only mention a tiny number of the actual tweets sent in this post, I have uploaded a document where I copied and pasted a lot of the original tweets, and it is visible here. It is not complete, because I had to switch to Speech Recognition Software part way through, and selecting text is a nightmare with that.

In the meantime, some interesting reading about about cervical cancer can be found at the Jo’s Trust website, and there is some fascinating viewing (read the warning first!) at Beautiful Cervix, but if you are at all squeamish, be warned, it is a site of photos of cervixes at different stages in the menstrual cycle, pregnancy, after abortion, and after birth. Some people found it amazing, some found it disgusting.

You can read part two of this post here.

[The image is a photograph of an orange-yellow lily in close-up. It was taken by Lindsey B and is used under a Creative Commons Licence]

Comments From You

Elaine Watkins // Posted 18 September 2011 at 11:07 pm

A related topic should be the indignities women go through during breast exams. I haven’t been for a mammo in over 5 years, due to remarks such as:

-“I don’t know why you even waste our time. Your breast tissue is much too dense for us to find anything.”

-“Oh, you had a child after the age of 30? That wasn’t very smart, now was it? You just left yourself open to breast cancer.”

-“Your mom had breast cancer? Well, you’ll probably get it too, then, but with these D-cups of yours, it will be easy to even them out after the mastectomy, and your back won’t hurt as much as it probably does now. Two for the price of one!”

-“Lumps and bumps,” said the doctor to her assistant, not to me, even though I was right there in the room. “She’s full of ’em. Cysts, probably, but who can tell with all this dense tissue. We try to aspirate, she’ll just come away feeling like a pincushion.”

And finally, my primary care physician, who is herself a survivor. When I recounted to her the insults lobbed at me per the above, and the intense pain I suffered when they went at me with the ultrasound scanner, her answer was “Well, I suggest you put on your big-girl panties and get that mammogram!” I still haven’t, and plan to put it off as long as necessary. My mom didn’t even die from her breast cancer — she had heart disease. I’ve only been treated for one breast issue — a large fluid-filled cyst that I happened to find myself without the aid of radiographic technology. And then, the doctor said “That’s an odd way to find a lump. Why were you feeling yourself up that way?”

Nope, I’m not going back anytime soon.

Angela // Posted 19 September 2011 at 7:40 am

i had a bad experience too! I was obviously nervous so the nurse tried to console me with saying: I started work in the 1970s on *insert whatever it was called* ward, where every day women died of cervical cancer. It’s not that bad now. This was before the test. Afterwards she said: I can tell from looking if a woman has cervical cancer or not – you have a healthy pink cervix so I am 99% certain you are fine. I dont think she should have said any of that!

Philippa Willitts // Posted 19 September 2011 at 9:18 am

I’m sorry both of you have had these experiences. The breast examination comments were all completely insensitive and inappropriate, and Angela, what the nurse said all sounds wrong to me!

Helen // Posted 19 September 2011 at 12:37 pm

I had a really bad experience with my old GP and the gynecologist I was recommended to.

I had what I was told was loose cells which meant I was constantly spotting blood – not the best.

So went to the GP and they thought to do my smear test at the same time…the comment ooh thats a lot of blood is not the most reassuring but was fine I just wanted to get out of the room. I was called back a couple of days later because apparently the nurse’s handwriting was so bad they couldn’t read anything and had to re-do it… fine whatever.

when I got to the gynecologist the next day I was back up on the bed so he could have a “root around” and then WITHOUT TELLING ME or giving me any warning proceeded to quarterize me (burning off a layer of my insides). I was flung a pantie liner and told to go. No explanation of what he actually did to me or how long it would hurt for! I was in so much pain! Had to drive myself home (2 hours away) and I was in such a state I had to take 2 days off work

so now I can only see female doctors and I don’t know how I can bring myself to have another doctor “root around” down there again if it was needed. Traumatized doesn’t even cover it.

Philippa Willitts // Posted 19 September 2011 at 4:56 pm

Helen, that sounds awful, just horrendous! No wonder you found it traumatic.

Anonymouse // Posted 22 September 2011 at 5:32 pm

Oh my this is strangly reassuring to hear other people find smears horrible too. I thought I was just being a wimp, but I went for my first one a couple years ago I guess by now, and havent gone back though i know i should. I went to my GP, and she is lovely and professional, but the just the process of having my cervix scraped was really traumatic. I felt wobbly the rest of the day and close to tears. It felt like such a violation. It makes me wince just thinking about it. It might be because my friend, who was a trainee doctor at the time, said, before either of us had had a smear, that it looked like really brutal experience. I know I wasn’t very relaxed when i went in.

I had to stop taking the pill earlier this year and was recommended the coil as an alternative contraceptive by a number of people, but just thinking about the fitting procedure practically gave me a panic attack. I guess some people freak out about needles, blood or eyes, for me, its my cervix.

kinelfire // Posted 24 September 2011 at 10:44 am

Anonymouse – I had a Mirena coil fitted nearly three years ago. Before I went, I tried to read up about it because I figured that something going in where things are only ever expected to come out might be a bit… uncomfortable. The thing that annoys me most is that there’s a very common reaction to something being inserted into your cervix (I nearly passed out and threw up twice) but I found no mention of it anywhere online. Had I known to expect it, I might have made sure when I got to the clinic that my blood sugar wasn’t getting low (I don’t think it helped!) and allowed more time. My mum accompanied me (I wasn’t told to bring anyone, but she offered me a lift! Had I been alone it would’ve been much worse!) and was supposed to go to an appointment about an hour after mine. Needless to say, she had to cancel, what with me making all kinds of mess for the nurses to clean up.

The nurses couldn’t have been lovelier, or more patient with me, and they assured me that it happens all the time.

If I’d known what to expect, I would have prepared for it, but probably not put off. I really don’t want to be pregnant and have a terrible memory for taking pills. The hour afterwards, I felt awful, then had a couple of days of what felt like the second worst period pain ever, and it took a while for mine to settle down, but I wouldn’t *not* have got it!

When it comes to five years and this one has to be removed, I will be getting another. And I know what to expect this time!

liz // Posted 26 September 2011 at 3:56 am

Germaine Greer makes her point because she cites evidence that pap smears are not an accurate screening tool in preventing cervical cancer. She refers to Angela Raffle who is one of the world experts on pap screening.

In another article in the Guardian this author writes about pap smears: “the British Medical Journal published research that suggests that I, and millions of other women, may have been wasting our time. In order to save one life from cervical cancer, the research found, 1,000 women would need to be screened for 35 years. Worse, the researchers suggested that testing might do “more harm than good”:

After doing my research in peer reviewed medical journals, not the information put out for the lay public, which is too simplistic, I have decided that pap smears are not worth the anxiety they put me through and the cancer is too rare (always was) to worth worrying about.

http://www.guardian.co.uk/society/2003/may/22/genderissues.publichealth

Scarly // Posted 27 September 2011 at 12:07 am

Cervical cancer has always been rare, and in all my investigation into this area, I have found little evidence to suggest that cervical screening has decreased the incidence of cervical cancer, the pap smear is an eighty year old test that is not 100% percent accurate, the test only looks for cellular abnormalities in the cervix, and most of these abnormalities are normal cervical changes. A woman could get a positive result form, pregnancy (they no longer test pregnant women in the UK for this reason), hormonal changes, menopause a change in medication or diet and recent sexual activity, IMO this puts women at considerable risk for over treatment with little benefit.

What concerns me about cervical screening is that opportunistic screening of any kind often produces ‘false’ positive results which can result in over treatment and possible harm form exposure to unnecessary surgical intervention. With cervical screening these numbers are unfortunately high at least 70% of women screened for cervical cancer are referred for further investigation, as you are aware cervical cancer is rare, as such the majority of women referred do not have cervical cancer and are subjected to high amounts of stress, unnecessary treatment and sometimes surgery for no empirical benefit.

The harm caused is frightening, cervical scaring, surgical sterinosis, premature labor and hysterectomy (especially in the USA), not to mention the intrinsic violation of having your genitals examined, especially for the very young, and elderly women. What is not commonly known is that most medical practitioners get a financial incentive fin the Australian system, so the paternalistic push from our medical establishment to herd all women in for cervical screening is not just about concern for women’s health.

Informed consent is unfortunately not present when women are invited to participate in cervical screening, a doctor is obliged by law to inform their patients of the risks as well as benefits of any cancer screening and ironically this is absent where women’s health is concerned. Many women who have been diagnosed with a dysplastic cervical legion wrongly believe they have cervical cancer.

If you are interested in accessing more information on the risks of cervical screening and misinformed consent I’d suggest reading papers anything by Angela Raffle, and I’ve also listed a few papers you might like to access to give you a basic look at the peer reviewed research available.

Bush, J 2000, ‘It’s just part of being a woman: cervical screening, the body and femininity’, Social Science & Medicine, vol. 50, University of Newcastle, UK.

DeMay, RM 2000, ‘Should We Abandon Pap Smear Testing? Pathology Patterns Reviews’, American Society of Clinical Pathologists, vol. 114 S48-S51. Raffle, AE, Mackenzie, E, Alden, B, 1995, ‘Detection rates for abnormal cervical smears: what are we screening for?’ The Lancet, Vol: 345 Issue: 8963 pp: 1469 –73.

Rouse, A 2000, ‘Women, Informed Consent and Cervical screening’, British Medical Journal, viewed May 2010, http://www.bmj.com/content/320/7238/872.1/reply

Prof Michael Baum gives a very informative talk on the dangers of opportunistic breast screening, which can also be applied to the rarer form of cervical cancer.

http://www.youtube.com/watch?v=JxDnRMU-l7w

Rachel // Posted 27 September 2011 at 7:46 am

kinelfire – I’d just like to second your comments about having an IUD/IUS fitted. I had no idea what to expect, other than vague warnings from my doctor that ‘since you haven’t had children it may be uncomfortable’. I went on my own as I’m usually pretty good at coping with pain. After the coil was fitted I was given a horribly massive and bulky sanitary towel, led unceremoniously back into the waiting room, and told to sit there for a bit to make sure I felt ok… I thought that meant somebody would be coming to check on me again in half an hour or so, but no – I just sat on my own, obviously in quite a lot of pain, for about an hour. I had to call my boyfriend to come and pick me up, because there was no way I’d have been able to walk home.

Obviously this is just a really painful procedure for a lot of women, but if I’d been adequately warned in advance and encouraged to bring a friend or my boyfriend along to support me it would have been a much less distressing experience!

Anyway, on the topic of smear tests, I’ve only ever had positive experiences… A few slightly misjudged comments perhaps, but in some ways being able to laugh at the nurse trying to maintain polite conversation throughout the process just helped me get through it. But then I’ve got my next one this morning so we’ll see!

Summer // Posted 3 October 2011 at 11:16 am

What concerns me about cervical screening is that opportunistic screening of any kind often produces ‘false’ positive results which can result in over treatment and possible harm form exposure to unnecessary surgical intervention>>.

A lot of tests (even for the genetic diseases) experience ‘false positives’ which is why there’s a need for standards and controls in the area of testing, that would minimise such an event from actually happening. It’s just a shame they don’t invest in such standards for the screening, it would reduce a lot of the trauma for women who are false positive by making it clear that said positive is false.

I’ve been back 3 times for ‘abnormal cells despite making it clear that i have a weird thing whereby cells from the inside of my womb migrate out, this causes abnormality to show and (if the lab are aware) they can discount it. However the message got lost three times in translation until my fed up nurse actually called the lab and insisted it was put against my number while she was on the phone to them.

i will always go to my smear, despite being made to bleed due to a nurse ignore that i has a ’tilted womb and tendency to tear’ told by me AND on my notes. More positively, i find having a regular nurse to go to, makes these things better-more private/personal and comfortable (if she/he is good nurse).

The indignities suffered during smears however also are found at the GUM clinics-or rather SOME clinics.

I will always screen though, after watching my friend suffer through cervical cancer I personally will not take that chance despite the possibility of being called back three times for a repeat >

sohcahtoa // Posted 9 February 2012 at 8:54 pm

I know this is an old thread but I thought I’d comment anyway in case someone is able to help.

I am contemplating my first smear test with some trepidation. When researching online I have found several references to a CSA (Cervical Specific Antigen) Test, which is a simple blood test that apparently delivers results are just as accurate as a smear. It seems to have been patented in the US, but I can’t find any information about how widely it is used there, or whether it is available in Europe. I was just wondering whether anyone who works in healthcare knows if this is something that the NHS is considering (and if not, why not..).

Annuette // Posted 19 February 2012 at 2:13 pm

sohcahtoa // Posted 09 February 2012 at 20:54

Hi Sohcahtoa, I can tell you that expense will play a part in any kind of test but most importantly the NHS will be extremely leery and may well not ever use a diagnostic test that does not have WHO or CE mark status, or at the very least some other appropriate accreditation. They must adhere to strict quality systems in order to assure the public they are doing their utmost to give accurate results and use tests developed under WHO or ISO13485, ISO9001. From what it looks like this test is correctly not under WHO status and would not be under CE mark since it’s not European. This means until it has achieved a suitable status it cannot be used by a NHS diagnostic lab.

If it does received WHO status, it can then be used in diagnostics after validation, possibly by the MHRA or biological safety institute, maybe even just internal lab validation.

Smears can be horrible, sometimes they are perfectly fine. I was very nervous before mine and my first was no problem whatsoever. I’ve found the ones I’ve had issue with have been mainly due to the staff setting me on edge or being rough when doing it (making me bleed for a while after).

sohcahtoa // Posted 20 February 2012 at 9:20 am

Hi Annuette, thanks for taking the trouble to answer my question. What you say makes perfect sense – I didn’t expect the NHS to suddenly start using the test one day without extensive checks! Still, and this is complete speculation, I do wonder if there might be obstacles to getting the test certified which aren’t in women’s broader interests (though of course I admit that such a test is likely to have been developed for financial rather than purely altruistic reasons). I suppose the NHS might well argue -with some justification, to be fair – that its effective screening programme means that it doesn’t need to adopt another test.

As far as I can see there might also be other reasons, globally, not to invest in the test – in some places doctors seem to be renumerated for every smear in their practice carried out, and in the US pelvic examinations seem to be a common and accepted (by physicians, at least) part of medicine which healthcare providers are unlikely to want to change. It’s also tempting to wonder whether more research would be done into a blood test if it was for men (cf. ‘more efforts would be made to reduce the Pill’s side-effects if men had to take it’?).

I’ll probably have a smear, but when there seems to be a body of evidence that says that you shouldn’t/don’t need to (see Scarly’s post above), but on the other hand the public health message is so overwhelmingly in the other direction, it’s difficult to know what to believe. Of course, no one wants to be the unfortunate one whom a smear could have helped, but I don’t like the feeling that (most of) the medical establishment wants me to shut up and stop asking questions.

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