Last week I was asked to do a pap on a butch lesbian in her late 30’s who has never had vaginal intercourse (including sex toys or digital penetration–I asked). Let’s just say that it was uncomfortable for both of us. Uncomfortable for her for all of the obvious reasons. And uncomfortable for me because the patient was clutching the edges of the exam table and whispering “Ow, ow, ow, ow…” This experience, plus NewFNP’s recent post on pap smear technique, got me thinking about some of my past bad paps. Like NewFNP, I pride myself on my gentle pap technique. Rather than opening the plastic speculum until it clicks several times (which is a sensation akin to having your vagina cranked open with a car jack), I hold the lever-tab-thingy down with my thumb during the whole exam and never click it open. This allows me to open the speculum only as much as necessary, and not a centimeter more. I also use a little lube on the speculum instead of water–it’s totally ok if you’re using ThinPrep instead of the old-school slide and fixative technique.
But even the gentle touch, extra lube and patience doesn’t always make a pap easy. I especially hate doing paps on women who have never been sexually active (with vaginal penetration) before. Although opinions differ on the initiation and frequency of pap smears, the U.S. Preventative Task Force recommends beginning screening at age 21, even if never sexually active. Therefore, I recommend at least a baseline pap to all of my patients over the age of 21. The problem is that I sometimes feel like a giant asshole when I implement this recommendation. My only consolation is that at least the patients are seeing me and not some of the less…how do I say?…sensitive residents in my clinic. The other consolation is that I give my most anxious patients an Ativan 30 minutes before the exam. Sometimes that helps.