Surviving Pelvic Exams as a Survivor

By Alisha Olsthoorn, 3rd year ObGyn Resident, University of Toronto

Sexual assault. We know it’s common. According to surveys, one in three women will experience some form of sexual assault in their lifetime. A staggering 80 percent of women with disabilities will be sexually abused in their lifetime. In a Canadian study of transgender and non-binary youth aged 19-25, 1 in 4 reported having been physically forced to have sex. This means that on any given day, I’m likely to see a patient who is a survivor of sexual assault.

As a resident in obstetrics and gynecology, my patients include any individual with gynecologic organs (vulva, vagina, cervix, uterus, fallopian tubes, and ovaries), regardless of their gender identity. This could include women, transgender, non-binary, or genderqueer individuals. Based on a number of studies, we know that being a survivor of sexual assault is associated with increased rates of gynecologic issues and reduced rates of cervical cancer screening. 

A reported 94 percent of women who are sexually assaulted experience (PTSD) symptoms during the two weeks following the assault, and 30 percent will continue to experience PTSD symptoms nine months after the assault.  We know that PTSD is associated with distress and discomfort during gynecologic exams. At its most severe, these sensitive exams can trigger flashbacks and re-traumatize individuals who suffer from PTSD. These examinations involve the use of a speculum device to look at the cervix, taking swabs for screening for sexually transmitted infections (STIs) or other infections, Pap tests for cervical cancer screening, and a bimanual examination that allows the doctor to feel the uterus and ovaries. This could also include cervical exams for pregnant individuals in labour when a doctor is checking how they are progressing.

As providers, how can we do better? The responsibility is on the physician to be a provider of trauma-informed care. We’re making moves in the right direction. In 2017, the Canadian Federation of Medical Students adopted a policy paper that recognized the need for adapting medical school curricula to provide medical students with the tools to provide trauma-informed care during gynecologic examinations by focusing on the needs of the individual patient.

If you’re a survivor of sexual assault, you have your own individual experience of gynecologic care. Maybe gynecologic examinations cause a lot of anxiety and maybe you’ve had experiences with providers who were not attuned to your distress and the experience was unnecessarily painful or triggering. Maybe you’ve found a provider you trust who you’ve disclosed your history to and they are able to perform these exams in a way that makes you feel comfortable and in control of the situation. Or maybe you avoid it entirely and you’ve been putting off your long overdue Pap test or STI screening. In fact, maybe the last time you had an exam was during a cervix check in labour. At a time when you’re anticipating the delivery of your child, you’re also having examinations done that can cause significant distress.  

First off, I want to say that the way you feel during these exams or the difficulty you have proceeding with the exams, is not your fault. And as I said earlier, the responsibility is on the physician to create a safe space for you. But you and your physician can also be a team that works together to make these experiences better and improve your gynecologic care. 

“The responsibility is on the physician to create a safe space for you.”

These are by no means things you have to do or should do, but things that you can do. It is important to note that you definitely do not need to disclose your history of sexual assault to your physician, however doing so may allow them to be more attuned to this during your care and can open a line of communication. If disclosing this information risks causing you more distress or re-traumatization, you do not need to do it if you do not want to. Even if you don’t disclose, you can explain to your physician that you find gynecologic exams challenging. Addressing your concerns can help your physician individualize your care and work toward developing strategies leading up to and during the examinations that allow you to feel comfortable, safe, and in control. These conversations are best had before the exam has begun and the communication should continue throughout. 

Invasive gynecologic exams can cause anxiety and distress in survivors of sexual assault.

Some practical things you and your physician can strategize includes making sure you have someone you trust in the room with you for support. You may prefer that they talk you through the steps of the exam before you even get undressed. During the exam, allowing you to dictate the speed of the exam and having them continue to explain every step as it progresses allows some people to feel a greater sense of control and comfort. You can also ask at any time that an exam pause or stop completely. There may be other strategies that you feel would work for you. In times of distress, some people may find a specific grounding or sensory experience helpful to manage these symptoms. Your physician also likely has strategies they use with other patients so ideally, you’d feel comfortable talking about these things with a physician you trust. 

In case you’ve never felt that you had the permission to request these things from your physician – you do. If you feel like your provider would not be open to having this discussion, then there are likely gaps in their knowledge of providing trauma-informed care and they may not be the right provider for you. I acknowledge that depending on where you live, access to a different family doctor or gynecologist may be challenging. Hopefully we are moving in the direction of having all physicians across the country trained in providing you with care that allows you to feel safe, heard, comfortable, and in control. It’s what you deserve.


Fibroids – What you need to know

About one-third of Canadian womxn will develop uterine fibroids by the age of 30. The number climbs to seven out of 10 by the time womxn reach 50. These benign (non-cancerous) tumors grow in the uterus, or off of the uterus on stalks within the pelvic cavity. They can range in size from as small as a pea to as large as a grapefruit. Some womxn may never know they have them unless they are caught by a routine exam, and they may never cause adverse effects in their day-to-day life. 

However, for some womxn fibroids can have some severe symptoms, including: pelvic pain, heavy menstrual bleeding, bleeding for longer than seven days, low iron (anemia), large clots, pain in the legs or back, pain during sex, and a higher risk of infertility.   For symptomatic womxn, 20% to 50% experience a considerable social and economic impact on their lives. 

Since fibroids affect such a large number of womxn, they ought to be classified as important health concern – right? Yet, the reality is very little research has been successful in determining the cause of these tumors, or keeping track of their numbers. Medical researchers have a long way to go to better understand fibroids, and perfect less invasive procedures to remove them or lessen their effects on womxn’s reproductive health. 

Fibroids themselves are not dangerous, since they are non-cancerous in nature. However, the resulting symptoms can be extremely dangerous. Severe anemia might require multiple blood transfusions. Fibroids might prevent a womxn from becoming pregnant, or a pregnancy might be lost due to miscarriage.  Severe pelvic pain might mean missed days at work or social engagements.

As a course of action, womxn are often told that if the fibroids are not causing any discomfort or issue, they can be left alone. It is believed that fibroids may shrink a little after menopause, but can still cause problems because the tumor may calcify and harden. 

Choosing to remove fibroids might mean removing the uterus as well. One in four Canadian womxn over the age of 45 have had a hysterectomy, and at least one third of those did so because of fibroids.  Hysterectomy is rare in younger womxn, but for those experiencing extreme pain from fibroids, endometriosis, or adenomyosis, a hysterectomy can provide relief from a lifetime of future pain. 

Fibroids Affect Black Womxn Disproportionately

Black womxn are nearly guaranteed to have fibroids in their lifetime – the likelihood of a black woman having fibroids by the time she is 50 years old is a staggering 90%. They are also much more likely to have recurring fibroids or suffer from complications from them. 

We don’t know enough about why fibroids develop in the first place, why black women get them more frequently and with more severity than other races, and exactly how they affect fertility.

Fibroids affect fertility

Depending on where they are located within the uterus, fibroids can prevent implantation of an embryo, and can cause problems with the ability to become pregnant or can result in miscarriage. They can also prevent conception by obstructing the fallopian tubes, which will not allow the embryo to pass into the uterine cavity and implant on the endometrial lining.

Fibroids can also cause problems during pregnancy. These include placental abruption (detachment of the placenta, causing bleeding and loss of pregnancy, or pre-term birth), abnormal growth of the pregnancy occurring from fibroids affecting blood flow or the size of the fibroids, preventing the baby from growing properly, pre-term labor. Early labor may lead to an early delivery of the baby, and result in possible developmental problems for the child.

Active monitoring might be dangerous

Womxn are frequently told that if the fibroids are not causing any severe symptoms, they can be left alone. Womxn are left thinking that they don’t need to treat them until or unless there is a problem – by the time they become a problem, however, many doctors are only able to remove them through invasive, open procedures, frequently recommending hysterectomy over myomectomy (fibroid removal).

“Fibroids will continue to grow,” says Dr. Natalya Danilyants. “That’s a very important point. A lot of patients that come see me with very big fibroids, they have known about these fibroids for many years, but they were told ‘Just leave them; if they don’t bother you, don’t bother them,’ but that’s not the right approach. Eventually, these fibroids are going to cause symptoms. For women who are planning to have children, you don’t want to wait to get to the point where your fibroids are large. Those large fibroids can cause irreversible damage to the uterus.”

If you have a concern about fibroids, ask your doctor for an ultrasound, to get a better idea of where the fibroid is growing, how quickly, and how big it is currently. Also, be sure to tell your doctor about any symptoms you’re experiencing: fatigue, pelvic pain, pain during sex, excessive bleeding – and whether these things are new, or getting worse. A baseline is important in any health care concern – but especially so with fibroids that will keep on growing and might become problematic. 

See your doctor if you have:

  • Pelvic pain that doesn’t go away
  • Overly heavy, prolonged or painful periods
  • Spotting or bleeding between periods
  • Difficulty emptying your bladder
  • Unexplained low red blood cell count (anemia)

6 Reasons Your Vagina Hurts

Experiencing pain during intercourse is very common. Nearly three quarters of womxn have pain during intercourse – medically termed dyspareunia – at some time during their lives. For some womxn, the pain is only a temporary problem; for others, it is a long-term problem.

There are a lot of potential causes of dyspareunia. It can be related to an underlying cause that needs to be treated.

  1. An infection, like pelvic inflammatory disease or a yeast infection.
  2. Endometriosis, which can be especially worse around the time of your period, but if left untreated, can cause pain all the time.
  3. Lichen sclerosis, a skin condition treated with topical steroids.
  4. Vaginal atrophy due to lack of estrogen, which is most common in the population of women after menopause.

But sometimes after seeing multiple doctors and ruling out those common causes, you’re still left with pain during intercourse. That’s when we often end up using terms that describe the symptom, rather than the underlying cause:

5. Vulvodynia, which is chronic, otherwise unexplained pain at the
opening of the vagina, or
6. Vaginismus, the involuntary spasming of the pelvic floor muscles.

These issues, when present for a while, fall under the term chronic pelvic pain.

Acupuncture is a treatment option for vulvodynia

Treatment of vulvodynia and vaginismus requires ruling out and treating any other underlying cause, but sufferers can benefit from a multi-disciplinary approach. One approach suggests re-wiring the brain to stop interpreting normal touch as painful.

This includes cognitive behavioural therapy, mindfulness meditation, sex therapy, pelvic floor physiotherapy, along with medications to control muscle spasms, topical anasthetics, or even sometimes injections of pelvic floor muscles with Botox. It’s important to note that some of these treatments are only offered from pain specialists.

Another approach to treating vulvodynia and painful sex includes acupuncture.  According to a study published in the Journal of Integrative Medicine, more than one-third of womxn report regular pain during sex. The study aimed to discover whether targeted acupuncture could improve womxn’s pain during sex.  

The subjects were split into groups: One received generalized acupuncture two times per week for five weeks, the other received more targeted acupuncture to areas supporting the pelvic region. In the group receiving targeted acupuncture, reports of vulvar pain and dyspareunia were significantly reduced, and womxn’s self-reported scores suggested significant improvement in sexual functioning in those receiving targeted acupuncture versus those who received generalized acupuncture.

Trying different positions may help lessen the pain

Couples who are trying to overcome painful sex might try a variety of positions in order to relieve pain. If a womxn’s pain is experienced with deep penetration, any position in which the womxn is on top and better able to control the depth of penetration is likely going to feel more pleasurable for both partners. Side-lying or spooning is another less-penetrative option.  Avoiding penetration altogether and concentrating on mutual masturbation or oral sex can also be a satisfying experience.

If you’re experiencing chronic vaginal pain, you should know two important things: It’s not your fault, and there is help. See your family doctor to rule out any treatable underlying causes, and maybe ask to be referred to a pelvic floor physiotherapist.  These specialists are trained in the pelvic floor muscles and structures that support your sexual function. They can help create an individualized care plan and help you get back to feeling more like yourself.