The speculum is often cited as the most uncomfortable part of a gynecologist visit.^[10] It lies at the center of an important preventative health care service: the pelvic exam.^[16] The speculum is a medical instrument that has two arms that meet at a hinge – the arms look similar to a duck’s bill.^[6] The health care provider inserts the speculum into the vagina and opens the speculum to widen the vaginal walls so the provider can view the vagina and cervix more easily.^[6] For many individuals, the speculum causes pain and discomfort.^[4] This is unsurprising given that the modern speculum has remained essentially unchanged since 1870.^[15] In addition, physicians have not yet widely adopted practices that may reduce a patient’s pain and anxiety during the pelvic exam.^[7]

The speculum’s origins may inform some of the issues patients experience today. The modern speculum has a legacy of causing pain: it was invented by James Marion Sims in the 1840s when he conducted experiments on slave women – Lucy, Anarcha, and Betsey – without anesthesia even though it was available at the time.^[12] Needless to say, the speculum was not designed with the patient’s comfort in mind. Sims did not use anesthesia while developing the speculum because he held the erroneous belief that black people did not experience pain like white people did.^[12] In addition, the women were further stripped of their autonomy because Sims only required consent from their owners to conduct the experiments.^[12] Today, around 35% of women* experience pain or discomfort during pelvic exams and about 35% of women experience fear, embarrassment, or anxiety before or during the pelvic exam.^[4] 

The speculum is not specialized enough to be used for all populations who require its use.^[24] Since pain and emotional discomfort are subjective experiences, providers should utilize an individualized approach for speculum insertion and pelvic exams.^[19] As Roger Fillingim, director of the Pain Research and Intervention Center of Excellence at the University of Florida, indicates, “you treat the pain that the patient has, not the pain that you think the patient should have.”^[3] According to various studies, it appears that educating patients about pelvic exams and specula as well as encouraging patients’ personal control during the exam may decrease pain and emotional discomfort.^[8],[19] Informing patients that pain is not normal and informing them of pain management options may improve patient outcomes during pelvic exams as patients can try to mitigate the pain before it occurs.^[20] Given that the pelvic exam places people in a vulnerable position, it makes sense that bolstering the patient’s autonomy could ease the psychological discomfort surrounding the exam.^[9] For example, based on research findings, certain women indicated that they would feel more comfortable with the speculum insertion if their provider informed them of each step of the process or allowed them to look at the speculum before the exam.^[24],[9] Others indicated that they would likely feel more comfortable if the provider gave them the option to insert the speculum themselves.^[2]

While pain and emotional discomfort should be considered for updating the speculum and how it is used, such issues are trivialized when reported by women. Women’s pain is often perceived as an overreaction rather than reality in part because women are more likely to express pain.^[3] More often, physicians prescribe less pain medication for women than for men.^[11]

Providers also seem unwilling to adopt new specula into practice if they have not been rigorously tested because the current speculum is the standard.^[24] There are both economic barriers and social barriers to testing. Historically, women have been excluded from medical research. For example, the National Institute of Health did not require that scientists account for sex as a variable in medical research until 2015.^[22] It also appears that there is a gender bias against studying medical issues that primarily affect women. When analyzing funding allocation among diseases, the United States National Institutes of Health applied a disproportionate portion of its resources to diseases primarily affecting men.^[17] Issues arising from the use of the speculum or updates to the procedure have likely not been addressed or publicized to the majority of the population given that the last general overview of the speculum was published in 2008.^[24] 

In addition to the unwillingness to fund research surrounding speculum updates, doctors may not adopt new tools or updated practices due to cost. The current speculum is inexpensive, rarely needs replacing, and is easy for practitioners to use.^[7] Lack of insurance coverage and limited provider time to see patients may affect the provider’s ability to utilize pain management options or individualized solutions to pain and emotional discomfort.^[7]

By failing to address the physical and emotional harm the speculum causes, women’s health is impacted. For example, while cervical cancer is preventable through regular screenings, researchers have found that the rates of timely cervical cancer screenings for eligible adults have decreased since 2005.^[23] One of the main ways to screen for cervical cancer is through a pap smear, also known as a pap test, during the pelvic exam.^[18] Using the speculum, the health care provider checks for any irregularities and then collects cells from the cervix that are later tested for signs of cervical cancer.^[6] According to data from 2018, only about 51% of women go to the gynecologist at least once per year^[14]. Lack of access to health care remains a significant problem for marginalized groups, especially Black women.^[13] However, lack of access as a reason for being overdue for a cervical screening declined overall.^[23] By contrast, pain continues to be a significant factor in whether people continue seeking cervical cancer screenings.^[13] More specifically, some studies indicate that people refrain from seeking cervical cancer screenings because they have experienced pain during the pap smear in the past.^[13] The decline is screenings is concerning considering the American Cancer Society estimates that there will be approximately 13,820 new cases of invasive cervical cancer diagnosed in 2024.^[1]

In order to improve patient experiences and reproductive health overall, it appears more funding is required for speculum updates. Patients should also be better informed about the speculum and the pelvic exam. Lastly, providers should become zealous advocates for their patients and make their patients feel comfortable undergoing these essential diagnostic procedures. 

*This article uses “women” and “men” when the underlying source uses these categories. This article recognizes that women are not the only population that goes to the gynecologist.

References 

[1] American Cancer Society. (2024, January 17). Key Statistics for Cervical Cancer. Cervical Cancer Statistics. https://www.cancer.org/cancer/types/cervical-cancer/about/key-statistics.html. 

[2] Bergman, S. (2022, June 20). How enduring use of 150-year-old speculum puts women off smear tests. The Independent. Retrieved February 10, 2024, from 

https://www.independent.co.uk/life-style/women/speculum-use-smear-tests-pain-sexism-b21051 11.html. 

[3] Bever, L. (2023, December 13). From heart disease to iuds: how doctors dismiss women’s pain. The Washington Post. Retrieved February 10, 2024, from https://www.washingtonpost.com/wellness/interactive/2022/women-pain-gender-bias-doctors/.

[4] Bloomfield H.E., Olson A., Cantor A., et al. Screening Pelvic Examinations in Asymptomatic Average Risk Adult Women. Washington (DC): Department of Veterans Affairs (US); 2013 Sep. RESULTS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK224895/ 

[5] Chaney, P. (2020, March 18). Speculum Speculations: The Past and Future of an Iconic Gynecology Instrument. Empowered Women’s Health. https://www.volusonclub.net/empowered-womens-health/speculum-speculations-the-past-and-fut ure-of-an-iconic-gynecology-instrument/#:~:text=The%20speculum%20is%20a%20familiar,unc hanged%20for%20over%20150%20years. 

[6] Cleveland Clinic. (2022, October 3). Speculum. Speculum: Design, Purpose, Types, Exams & What to Expect. https://my.clevelandclinic.org/health/drugs/24238-speculum 

[7] Davenport, E. (2023, June 15). Let’s liberate women from the speculum. The Boston Globe. Retrieved February 10, 2024, from https://www.bostonglobe.com/2023/06/15/opinion/liberate-women-from-the-speculum/.

[8] Domar A.D., Psychological aspects of the pelvic exam: individual needs and physician involvement. Women Health. 1985-1986 Winter;10(4):75-90. doi: 10.1300/j013v10n04_07. PMID: 3832651. 

[9] George, R. (2018, April 23). How to redesign the vaginal speculum. The Guardian. Retrieved February 10, 2024, from https://www.theguardian.com/lifeandstyle/2018/apr/23/how-to-redesign-the-vaginal-speculum.

[10] Haar, E., Halitsky, V., & Stricker, G. (1977). Patientsʼ Attitudes toward Gynecologic Examination and to Gynecologists. Medical Care, 15(9), 787–795. https://doi.org/10.1097/00005650-197709000-00006.

[11] Hoffmann, D. E., & Tarzian, A. J. (2003). The Girl Who Cried Pain: A Bias Against Women in the Treatment of Pain. The Journal of Law, Medicine & Ethics, 13–27. https://doi.org/10.2139/ssrn.383803.

[12] Holland, B. (2018, December 4). The ‘Father of Modern Gynecology’ Performed Shocking Experiments on Enslaved Women. History.com. https://www.history.com/news/the-father-of-modern-gynecology-performed-shocking-experimen ts-on-slaves 

[13] Hoyo, C., Yarnall, K. S. H., Skinner, C. S., Moorman, P. G., Sellers, D., & Reid, L. (2005). Pain predicts non-adherence to pap smear screening among middle-aged African American women. Preventive Medicine, 41(2), 439–445. https://doi.org/10.1016/j.ypmed.2004.11.021 

[14] IPSOS Global Advisor. “Global Views On Healthcare.” IPSOS, 2018, www.ipsos.com/sites/default/files/ct/news/documents/2018-07/global_views_on_healthcare_201 8_-_graphic_report_0.pdf. 

[15] Kent, C. (2020, September 10). Does the vaginal speculum need a redesign?. Medical Device Network. https://www.medicaldevice-network.com/features/does-the-vaginal-speculum-need-a-redesign/?c f-view. 

[16] Mayo Clinic Staff. (2023, May 24). Pelvic exam. Mayo Clinic. https://www.mayoclinic.org/tests-procedures/pelvic-exam/about/pac-20385135.

[17] Mirin, A. A. (2021). Gender Disparity in the Funding of Diseases by the U.S. National Institutes of Health. Journal of Women’s Health, 30(7), 956–963. https://doi.org/10.1089/jwh.2020.8682

[18] National Cancer Institute. (2023, August). Cervical Cancer Screening. Cancer Trends Progress Report. https://progressreport.cancer.gov/detection/cervical_cancer.

[19] Nudson, R. (2022, June 1). Gynecology Has a Pain Problem Our discomfort is routine. what if it didn’t have to be? The Cut. Retrieved February 10, 2024, from https://www.thecut.com/2022/06/pain-in-gynecology-practice-exams.html.

[20] Oregon Health and Science University. (n.d.). Closing the Gender Pain Gap: Your Gynecologist Has Pain Control Options. Center for Women’s Health. 

https://www.ohsu.edu/womens-health/closing-gender-pain-gap-your-gynecologist-has-pain-contr ol-options. 

[21] Pardes, A. (2017, October 5). The speculum finally gets a modern redesign. Wired. Retrieved February 10, 2024, from 

https://www.wired.com/story/the-speculum-finally-gets-a-modern-redesign/#:~:text=That%20the %20speculum%20is%20old,get%20a%20good%20look%20inside. 

[22] U.S. Department of Health and Human Services. (n.d.). Not-OD-15-102: Consideration of sex as a biological variable in NIH-funded research. National Institutes of Health. https://grants.nih.gov/grants/guide/notice-files/not-od-15-102.html?itid=lk_inline_enhanced-tem plate. 

[23] Winstead, E. (2022, February 22). Why Are Many Women Overdue for Cervical Cancer Screening?. Rate of Overdue Cervical Cancer Screening Is Increasing. 

https://www.cancer.gov/news-events/cancer-currents-blog/2022/overdue-cervical-cancer-screeni ng-increasing#:~:text=Results%20on%20cervical%20screening%20from,2005%20to%2023%25 %20in%202019. 

[24] Wong, K., & Lawton, V. (2021). The Vaginal Speculum: A Review of Literature Focusing On Specula Redesigns and Improvements to the Pelvic Exam . Columbia Undergraduate Research Journal, 5(1). https://doi.org/10.52214/curj.v5i1.8084.

Whether we are talking about the people conducting and authoring research or the individuals who serve as the participants in the studies, the same fact remains true; women are disproportionately underrepresented in medical research. 

Background

This is not a new phenomenon. In fact, conditions today are much better than they used to be.  Historically, researchers have held the misguided view that females’ biology is more “variable”  than male’s due to their hormonal cycles, providing them a reason to exclude female subjects  (both humans and rats) from clinical trials.^[1] 

True Differences 

There are important differences to be noted between women and men on certain medications.  Women tend to experience higher blood drug concentrations and often take longer to eliminate a drug from their body, making it incredibly necessary to test new drugs on both men and women.^[1] In certain sectors such as cardiology, women are also found to be more likely than men to have side effects from medication at the same dose.^[2]  

The same remains true for women in the medical research workforce, with only 9% of graduates in 1970 identifying as women.³ Despite this growing to 48% in 2018, leadership positions in medicine have not reflected the same rising trend. Women remain underrepresented in full-time medical school staff, research investigators, department chairs, and deans.^[3] 

Despite progress in terms of the number of women authors of published research, the change is not reflected in positions of authority. Women are still underrepresented in senior authorship positions and significantly less likely to be named in the positions regarded as most prestigious,  first and last, when the authors are listed.^{[4, 5]} 

Harmful Exclusion  

Addressing this problem in clinical research involves first understanding the extent of harm caused by the unbalanced inclusion of participants in the scientific world. Once a study is complete,  the findings are intended to be adopted into the target population to improve outcomes.^[6] However, if the majority of male participants are included, the results will not be generalizable to the entire human population.  

This can result in major consequences for women who are recommended a regimen of medication that has only been tested on men. For clinical trials in cardiovascular disease, the leading cause of death among women, rates of female participation sit around 29%.^[2] This has huge consequences for drugs that affect the genders differently as a recent study found women obtained the optimal benefit from a heart failure drug at just 50% of the dose that men need.[2]  This isn’t just true for medications either. When it comes to implantable devices like defibrillators, women are markedly underrepresented in trials.^[2] Landmark research trials report rates as low as 14% for female participants, raising huge concerns over the efficacy of these devices in different bodies.^[2] 

Finding the Cause 

There is a range of reasons as to why women disproportionately fail to participate in trials.  Remaining beliefs surrounding the increased difficulty of studying women no doubt play a role.  Women also face unique barriers to clinical trial participation such as the logistical barriers that come with often being responsible for children in a caregiving role.^{[2, 6]} This holds true for those serving as research participants in clinical trials as well as those attempting to gain higher-ranking academic and industry positions.^[3] Women also tend to be perceived as less committed or able due to their additional life responsibilities leading to less opportunities and income.^[3] The issue of representation in research and medicine may seem benign, but in reality, it has far-reaching consequences for both women’s health and success in the workplace. Excluding women from these areas leads to medical consequences for inadequately studied pharmaceuticals as well as the perpetuation of harmful stereotypes surrounding the perception of women in medicine that only reinforces this dangerous cycle.^[7]

References

[1] Zucker, I., Prendergast, B. J., & Beery, A. K. (2022). Pervasive Neglect of Sex Differences in  Biomedical Research. Cold Spring Harbor perspectives in biology, 14(4), a039156.  https://doi.org/10.1101/cshperspect.a039156 

[2] Cho, L., Vest, A. R., O’Donoghue, M. L., Ogunniyi, M. O., Sarma, A. A., Denby, K. J., Lau,  E. S., Poole, J. E., Lindley, K. J., Mehran, R., & Cardiovascular Disease in Women Committee  Leadership Council (2021). Increasing Participation of Women in Cardiovascular Trials: JACC

Council Perspectives. Journal of the American College of Cardiology, 78(7), 737–751.  https://doi.org/10.1016/j.jacc.2021.06.022 

[3] Blumenthal, K. G., Bansal, P., Youssef, C. M., & Pappalardo, A. A. (2023). Women in  Allergy and Immunology: The Future Is Female, Let Us Soar!. The journal of allergy and  clinical immunology. In practice, 11(12), 3569–3577. https://doi.org/10.1016/j.jaip.2023.06.010 

[4] Bagga, E., Stewart, S., Gamble, G. D., Hill, J., Grey, A., & Dalbeth, N. (2021).  Representation of Women as Authors of Rheumatology Research Articles. Arthritis &  rheumatology (Hoboken, N.J.), 73(1), 162–167. https://doi.org/10.1002/art.41490 

[5] N. Pyatigorskaya & L. Di Marco. (2017). Women authorship in radiology research in France:  An analysis of the last three decades, Diagnostic and Interventional Imaging, 98(11), 769-773.  https://www.sciencedirect.com/science/article/pii/S2211568417301912 

[6] Bierer, B. E., Meloney, L. G., Ahmed, H. R., & White, S. A. (2022). Advancing the inclusion  of underrepresented women in clinical research. Cell reports. Medicine, 3(4), 100553.  https://doi.org/10.1016/j.xcrm.2022.100553 

[7] Wanted: women in research. (2010). Nature neuroscience, 13(3), 267.  https://doi.org/10.1038/nn0310-267