Text reads: How to Make Paps Less Awful

In case you didn’t know, getting a pap sucks. I hate going for mine, despite being well aware of the benefits of preventing cervical cancer.


I want YOU to be able to provide this exam in a thoughtful, patient-centered way. In 2020, I wrote a LONG Tweetorial with tips and advice on paps. At the time, I just linked it here. But Twitter is frequently broken due to mis-management, so I’m posting the full content here.

Why?

My first pap experience sucked, it was done by a woman and I expected her to tell me what would happen. Instead, I was rushed back, felt scared, didn’t know what they were doing, and it HURT. I felt like she judged me for asking why it hurt. Later paps were hit and miss, sometimes being warned before the cytobrush scrape and cramp, but most times not. Even my last one, during residency by an OB attending, was done in a half-assed, rushed way. No explanation for residents who know the “drill” I guess. :\ I’ve had them done by RNs at PP, OBs in several states, and by FM docs, too. Many uncomfortable. As a physician, it’s my goal to make paps suck less for my patients. And if you’re reading this, it’s my goal to make you EXCELLENT at communication during a pap.

Let’s Get Introduced

First, I always see patients in their clothes. Sure, it saves YOU time if they’re in a gown. It also makes the patient feel exposed, cold and want to get through the talking as fast as possible so they can put their darn clothes back on, thank you very much.

During this time, I ask if they know why we do pap smears. Most people do not (thank you, terrible US sex-ed). Many still say yes, and I ask them to tell me what they know. I listen and wait for their pause, then say “Good, mostly right, but here’s my spiel!” 🙂 I then explain “the exam is done to collect cells from the cervix (may show an anatomic drawing on google, or hold up my hand to mime the cervix) to analyze in a lab and look for abnormal or cancerous cells, and for the HPV virus. Since it’s slow growing checking every 3 to 5 years lets us find cancer early enough to intervene.

(Update 2023 – These days most people schedule a pap after seeing me previously, so they come in just for pap and are already seated on table with paper drape over their lap. Often, we have discussed the pap at prior visit, but I always review just in case we didn’t!)

Get Some History

“Have you had bad experiences or pain with a pap before?” Most of the time you’re gonna get a yes and sometimes an awful story of the past. I listen. Then I acknowledge the past and apologize – “I’m sorry you had that experience, I’m going to do my best to make this one less terrible! I’ll tell you everything BEFORE I do it, and walk you through breathing so it’s not so uncomfortable.” I use this time to make sure all my pap supplies are present, that the pap vial is not expired (check expiration date!) and the light works. I also let them know “The magic word today is STOP. If you say that word, I will STOP.”

Show and Tell

“Most people cramp when we collect cells” – show them the cytobrush and broom/spatula. FYI don’t say your pap collection doesn’t hurt. You have no idea what this person will experience. Some folks feel nothing, some have intense cramps, some people get nauseated the cramps are so bad. “Everyone is different, some people have more discomfort than others. It’s normal to cramp during cell collection, and normal to spot after. We’ll talk as we go, so if something is uncomfortable you can tell me and we can stop.” And you better STOP if they say so!

The Bimanual Dilemma

You will have some attendings tell you to always perform a bimanual exam first, and others tell you only to do it if you can’t find the cervix. I find this personally uncomfortable and invasive, and that’s with a mild history of painful paps. :\ So, I discuss with the patient, using my drawing/anatomic image… “Everyone’s different, sometimes the cervix if off to the left or right, sometimes tilted toward the front or back” (don’t say ceiling or floor) “and sometimes I can’t find it immediately and have to do a manual exam. “If you’ve had difficult paps before I can do the manual exam first, but if you haven’t I can try with the speculum first.” A LOT of people know if they have a hard to find cervix and will tell you. Some don’t. But give the patient the CHOICE.

Choose Words Wisely

Quick aside – word choice matters in the exam room! It’s not a bed, it’s a TABLE. It’s not a sheet, it’s a DRAPE. They absolutely are NOT stirrups, they’re FOOT RESTS. Do not say “I’m going to touch you” instead use clinical language “I’m going to examine you now.”

Not everyone will tell you if sexual trauma in their past, so you need to use neutral, safe language ALWAYS. It’s especially important when you are doing the actual exam to say neutrally “I’m going to place the speculum, let me know if you have any discomfort.”

Time to Change

If they’re not already in paper gown or draped, now’s the time to step out to let them change. I explain “It’s easiest if you have your bottoms off entirely, including underwear, but you can keep your top on. You can keep socks and shoes on, too, I know it’s cold in here.” Because it’s always freezing in clinics. Ugh.

“This drape (sheet) is to put over your lap, but I will be moving it when I return, so please don’t tuck it under you” (last part is important because it’s cold, they’re uncomfortable, and wrapping up tight in a sheet feels better, but gets awkward when you return). When I come back I knock, crack the door and ask “Are you ready for me to return?” and WAIT for their answer.

When I walk in, I remind them I’ll explain as I go. They are seated on the table, a drape on their lap, wishing for this to be over ASAP. They may say so. But a rushed pap is not good!

Prepping to Pap

I tell them “Ok, I’m going to get the foot rests out, and have you move your bottom close to the end of the table, and put your feet in the foot rests.” I move out of the way (ie: off to the side of the table) while they do this, because sometimes you get kicked. ¯\_(ツ)_/¯

Then I sit on the stool at the foot of the table. “I’m going to adjust the drape and check your position, to make sure you’re close to the edge” – they won’t be, and I’ll say “There’s still some room at the end of the table, can you move further?” Don’t say scoot, don’t say butt. I often will say “If you feel like your bottom is about to fall off you’re in the right place,” but not if the patient seems anxious or has expressed concern about falling off already.

Regardless of age I ask “Any discomfort in your knees or hips? Do you want me to adjust the foots rests?” Pap’s already suck, no need for them to have knee, hip or back pain, too. You can adjust the table back so it’s not entirely flat, for comfort. You can offer a rolled up towel or pillow under the back, too.

Plastic Speculum?

“Today I’m using a plastic speculum, and the bad thing about it is this noise it makes” (I press the speculum so it makes the awful noise) “and I will try to keep it from making that noise. Now I’m going to move the drape again so it won’t fall on me while I do the exam”

Metal Speculum?

“You’ll hear me opening up some packages now” I say as I fight the autoclave bag to free my metal speculum from its paper and plastic prison. Otherwise, it doesn’t make a noise, unless you drop it on the floor. (In that case, get a new speculum.)

More Preparation

Now set drape back so that doesn’t happen, but attempt to keep it covering the patient as much as possible.

“First, you’ll feel the back of my gloved hand on your leg. Ok, I’m going to place the speculum now. Everyone tends to lift up off the table, so it helps to take a deep breath, breathe out on 3, and keep your bottom on the table.” (With some patients I joke that instead of trying to rise into the sky they should try to press down to the earth.) They do 2-3 deep breaths, I make sure the speculum has enough lubricant gel on it to make the placement comfortable. ProTip, yes, it’s a lot of gel, on top and bottom of the speculum, it will not ruin the pap collection. And for patients I refer to it as gel. Definitely do NOT call it “lube.”

Starting the Pap

  1. “Ok, take a deep breath, I’m going to set the speculum near you, it’ll feel cold, breathe out… ok, good job, are you ok? Great. Now is when the speculum may make that clicking noise, and there may be some discomfort while I make sure I can visualize your cervix.”
  2. Do not root around with an open speculum, that HURTS. If you see the cervix drop into the speculum, close it, readjust and open. If you try this twice without locating then you need to do a manual exam & find the cervix rather than torturing the person on the table.
  3. If the cervix is tilted posterior I will ask if they can comfortably put their fists in the small of their back, or use a rolled towel. This can help tilt the pelvis in a way that makes it easier to get the cervix into the speculum lip.
  4. “Ok, I can see the cervix, it looks normal.” Normal or healthy are good choices here. Do NOT say weird crap like “good” or “beautiful” etc. Medical terms only, avoid anything that may be sexualized or trigger past trauma.
  5. “I’m going to use the brush and broom I showed you earlier, this is the part that can cause cramping. I will count to three. Take a deep breath and out on three” – your tools are within the speculum, and on three you should place the tool at the os of the cervix & gather cells.” “Ok, now for the second one, we’re nearly done with the pap.” (My clinic now uses a single cytobrush collection method, which means only ONE pass of crampy cell collecting, which I love for my patients sakes!)
  6. I used to work without an MA, and the majority of my patients decline to have an MA as a chaperone, so I set both broom and brush into the pap vial and let them know I have to stir for 30 seconds (one spilled pap requiring re-collection cured me of the habit of leaving open pap vial with broom sitting), but when I have an MA present I may hand both to them and let them do the rest. But they may be holding the patient’s hand, in which case do the work yourself. 😉
  7. “I’ll remove the speculum” (CLOSE IT FIRST OMG; remove and set it aside). Pull drape down to give privacy to patient, then pull table extender out.
  8. Tell patient “You can put both your feet in the middle & move back on the table, & then I’ll move the footrests out of your way” (I do all that to prevent a topple from table, and to prevent them getting a gnarly bruise banging their leg into one of those foot rests moving away from the table).
  9. “Ok, I’ll let you get dressed” and step out.

Finishing the Pap

This seems like a lot of steps, and may seem like a lot of talking, but for an invasive cancer screening that happens every 3-5 years this is appropriate and should be expected. And you know what? I have had a LOT of patients tell me the pap I performed was “the least horrible version of this” and as someone who knows EXACTLY what that means it makes me feel like a great doctor to hear it. I’ve had a few patients thank me for making the exam less scary for them, and some have cried because it was such a relief to be treated properly after past shitty experiences. It’s worth the time, for them. So be awesome for them!

I’ve tried to use inclusive language in this post, but if I missed some I apologize. Also, below are some links for basic pap info, transgender pap 101, and trauma informed care. Educate yourself on all the details!

Be kind to your patients, take the time they need.

PS2: Forgot to mention if there are body jewelry or tattoos in the genital region it is NOT a topic of conversation unless you see signs of infection. Just because you can see it is not an invite to comment.

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References & Resources

Originally posted in another form 6/2020. Updated 7/5/2023