By Professor Albert Singer
Would you attend a smear test after hearing this testimonial ? “….As the door opened a male doctor came in. He didn’t introduce himself just checked the paperwork facts in a cold manner and told me to get undressed. He used a cold metal speculum inserting it quite aggressively without trying to ease my stress and it was so so painful. I was in tears. I don’t think I will EVER go through this again”…
I have always felt strongly about the importance of caring about the patient’s experience. My formative gynaecological training years were in the early 1960s when hardly any emphasis was put on the women’s emotional feelings and I was appalled by the way women were treated as patients. I resolved that if I ever ran a women’s health clinic I would make one of my top priorities understanding the anxiety associated with being examined and ways to help relieve it.
In 1981 I started one of a handful of dedicated colposcopy clinics in the UK and in 1988 my colleagues and I published the first paper on the ‘Psychosexual trauma of an abnormal cervical smear‘. Since then there have been other studies that highlight the many concerns women have regarding screening and colposcopy including that it will be painful and uncomfortable with the uncertainty of what will be done during the procedure and a significant proportion fear that cancer will be diagnosed.
We have come a long way in the UK but there it is always worth reminding ourselves and all medical students of the importance of good care and recent visits abroad have shown me that women around the world are still having great problems in preserving some form of dignity during examinations.
So here is my short guide for medical professionals to help relieve the stress associated with procedures like screening and colposcopy:
1. Create a pleasant environment:
For some, simply receiving an invitation to participate in a screening programme or attending a colposcopy will induce anxiety. In fact, only 1 in 10 women have no concern or worry before attending colposcopy and the anxiety in women waiting for colposcopy is higher than for women before surgery. As Professor Marteau showed in 1990 “distress is more strongly related to anticipation of the procedure than the outcome”.
TOP TIP: A welcoming secretary and an empathetic nurse are essential. Make sure your clinic is bright, warm and welcoming. Paintings on the walls and music all create an environment that can help relieve anxiety.
Make sure the patient knows what’s going to happen:
A major cause of anxiety is a lack of knowledge on the part of the women, fearing that the procedure will somehow be a threat to their mortality, sexuality or fertility. Some women may also misinterpret an invitation to attend for cervical screening as evidence that their GP knows they have cancer (Nathoo 1988, Fylan 1998). Patients are also unaware of the risk factors including the role of smoking, HPV and its sexual context and connotations.
TOP TIP: It is essential that women receive a good explanation of what their screening or colposcopy will entail, what the results may show and what that may mean. Provide leaflets, short booklets, internet resources or even an explanatory video if possible. While these increase knowledge they may not necessarily reduce anxiety so make sure you also ask the patient if she has any questions about the procedure or the results before you begin.
Ensure your patient is comfortable:
Always remember that any form of smear test, colposcopy and even routine internal examination is an inherently invasive and threatening procedure and can be interpreted by many women as a form of abuse. More importantly, there can be both short and long term profound negative psychosexual consequences.
TOP TIP: Make sure your patient is comfortable both physically and emotionally. Introduce yourself. Ask if she has had a smear/colposcopy before and whether she was comfortable with how it went. Always warm the speculum – we used to use an electric baby bottle warmer but now you can get warm surfaced instrument trolleys or if absolutely necessary you can also run it under hot water. Warm the lubricant too and if this isn’t possible then explain that it may feel cold. Listening to music during the colposcopy and watching the video of the examination with sensitive explanations by an empathetic examiner, be it doctor or nurse colposcopist, have also been shown to reduce anxiety.
Make sure you are an empathetic and attentive doctor or nurse. Screening and colposcopy are intimate procedures and should be treated as such. If your patient is visibly distressed don’t blindly continue without trying to address the problem. Whatever age your patient is don’t assume she has ever experienced this before, is completely comfortable with the procedure or has the knowledge that you have acquired through considerable practice. Reassure the patient that the results will be expected quickly (within 14 days according to NHS guidelines), will be simple to understand and that it’s OK for them to contact the GP or clinic if they have any questions or queries.