I have a Pap smear problem.
The pelvic exam is not a thing most of us with the pertinent equipment relish. When, a few years ago, my doctor informed me that the combination of my monogamous marriedness and my lack of history of abnormal Pap results now meant I only needed to get Papped every three years or so, I was beside myself with joy.
It’s true that the Pap itself is never as bad as I expect. My problem is one of anticipation -- for whatever reason, the promise of an impending Pap is a major anxiety trigger for me.
By 18, I had already developed a loathing for the doctor’s office, mostly a result of my hated pediatrician’s relentless harping about my weight at every visit. This was, after all, the person who ordered me on my first diet at 8 years old, because I was about five pounds over the ideal weight for my age on the inane height/weight charts of the era, thus beginning the cycle of loss and gain that eventually elevated me to the lofty and majestic heights of fattery where I reside today.
When I left my pediatrician behind in my senior year of high school, my new, grownup doctor was much beloved by her patients and came highly recommended. I don’t remember much of my first Pap experience (do you?) except that as an unpenetrated young lady, it was extremely uncomfortable. Prior to this, the nurse who’d seen me first had glared at me with unrestrained annoyance and asked, “If you’re not sexually active, why are you having a pelvic exam?” The question would be repeated by my doctor. I was doing it because I thought it was the correct and responsible thing to do. But after her irritated sighing, I was not in a particularly relaxed state for it.
Later, this doctor would prescribe me birth control pills for the first time, and when my blood pressure rose a bit after having been on them a few months, she threatened to take them away. I panicked -- at that point, I WAS sexually active -- which didn’t help my blood pressure much, on that or subsequent visits.
The highly recommended doctor in question held the threat of denying me birth control pills over my head for a few years. In retrospect, I’m not sure what her point was, especially considering that hypertension runs thickly in my family, and she never actually gave me any advice on how to make my blood pressure lower. Would me being pregnant be preferred over my taking birth control and dealing with the blood pressure issue in some other way? I’ll never know. I never asked.
It wasn’t until I was in my mid-20s that I realized Pap smears didn’t have to be miserable. Although sometimes they were, like the time a Planned Parenthood doctor chose the moment when I was literally in the stirrups with the speculum in place to ask me if I’d ever considered diet and exercise. Or the time another doctor roughly fished around in my innards for several miserable minutes, demanding out loud, “Where IS your cervix?” I don’t know, ma’am, I can’t see it from here. But most of the time they were minor inconveniences.
Nevertheless, whatever the reason, I have a lot of pelvic-exam-related anxiety. So yesterday when I turned up at my doctor’s office prepared for my first Pap since 2009, my heart rate was bumping like I was raging on an elliptical trainer.
The Pap smear was devised by its namesake, Dr. George N. Papanicolaou, who first described the test in a 1941 paper published in the American Journal of Obstetrics and Gynecology. It took decades for the test to become widely known, and longer still to be accepted as useful -- which ultimately required the development of a classification system for precancerous cells, a relatively new concept at the time -- even with active boosting from the American Cancer Society.
The Pap’s ability to spot cervical cancer early on, when treatment is most likely to be effective, has resulted in the Pap smear being called “the most successful cancer screening treatment ever discovered.” This annoying little test has cut back the worldwide death rate for cervical cancer -- the fifth most common cancer in the world -- by 74% since its implementation.
Despite its effectiveness, I’ve known many women who resist going for regular Pap smears (and to be fair, new research seems to suggest we need them less often than we might think) because they hate the experience so much. Not that I can blame them. Indeed, women who are fat, poor, women of color, or any combination of all three may have lower instances of cervical cancer screenings.
Most specifically, numerous studies have shown that obesity has a markedly chilling effect on the likelihood of fat women to get regular Pap smears, with one study estimating fatties are 25% less likely to be screened on the recommended basis. And it’s not necessarily just because the fat women individually are unhappy to disrobe and literally shove their chubby snatches in a doctor’s face -- doctors themselves have reported their own reluctance to perform pelvic exams on obese women.
The best known of these studies is summed up by a 1993 paper published in the journal Women & Health:
As subjects' weight went up, negative opinions about their appearance and reluctance to obtain pelvic examinations also increased while the likelihood of having annual pelvic examinations decreased. A substantial minority (17%) and an overwhelming majority (83%) of physicians indicated they were reluctant to perform pelvic examinations on obese and reluctant patients respectively. If physicians are more reluctant to perform pelvic examinations on obese and reluctant women and obese women are more reluctant to be examined, there may be a critical delay in detecting adenocarcinomas of the female genital tract.
Having read that, I think no freaking wonder I have so much Pap anxiety! I’m nervous, the doctor’s probably nervous, and neither of us really wants to be there. Of course it’s a miserable state of affairs. As distressing as it is to hear that doctors are human and can allow their own prejudices to affect their ability to perform their jobs, it's also reassuring to know that the discomfort may not be COMPLETELY inside our heads either.
When I turned up for my cervix scraping yesterday, I was seen by a nurse practitioner whom I like a lot and feel pretty comfortable around but with whom I had not done a pelvic before, and I explained my Pap terror, even while acknowledging that it’s mostly irrational. Then I said, really as a means of changing the subject from my own neuroticness, “I also confess to feeling a little jealous that I’ve never been able to see my own cervix.”
At this, my doc produced a hand mirror seemingly from thin air, and brandishing it at me, announced, “Today you will see your cervix! We're going all 1973 in here.”
I was dubious. I knew that some people looked at their cervixes -- indeed, I know for many women, cervix-spotting is a primary means of either achieving or avoiding pregnancy. I’ve been to the Beautiful Cervix Project website (warning: that site brings new meaning to the concept of “not safe for work”); I’ve seen many pictures of cervixes belonging to strangers. I’d just never seen my own, as much as I would have liked to.
But I hate that damn speculum. I hated the old metal versions with their ominous clanking, but I think I hate the tick-tick-tick clicks of the clear Lucite speculum even more. On this particular exam, I was so tense that the first effort to insert it was unsuccessful. A few deep breaths later, round two was a go, and as the speculum snapped open I started to wonder if I’d even be able to focus on a mirror before I needed to get the despised thing out.
My doc was undeterred, and while I was thusly agape, she cheerily instructed me to sit up as much as I could while she angled the mirror to give me a line of sight up my own vag. Although I really just wanted the exam to be over, I complied because I didn’t want to back down now. And then, rising like a dimpled pinkish moon in a fleshy sky, THERE IT WAS. My cervix!
“Your os is open,” my doc narrated, “Which means you’re ovulating right now, girl.”
Suddenly the speculum didn’t even hurt anymore. I squealed and yelled, “THAT IS SO COOL.”
“It’s a beautiful cervix,” my doc announced, and it is a credit to her that she could say this out loud and not have it sound weird. “You’re awesome.”
“I AM TOTALLY AWESOME.”
The rest of the exam was no big after that, partly because conversation then turned to Our Bodies, Ourselves, a subject of which I am especially fond. Truthfully, I expect future Paps may be different from now on. I have spent most of my life fearing the speculum so much that the idea of doing anything during the exam but lying very still, very tense, my every muscle stiffened in dread, was unthinkable. Having seen it now -- the speculum and the parts of my innards actually being assessed -- the mystery has evaporated. I have faced my fear, and I’m not scared of it anymore.
After all, while going for regular cancer screening can be kind of scary and often uncomfortable, it’s also a critical part of taking good care of myself and my health. I’m there in those damn stirrups because I take my health seriously, and because I strongly believe in preventative care. And thanks to the Affordable Care Act, these days I didn’t even need to pony up a co-pay for it.
My name is Lesley, and today I have made peace with the Pap smear.