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A journal club style critical review of current publications in evidence-based transgender medical care.

Wednesday, May 30, 2012

Reducing Pain Associated with Pelvic Speculum Exams

Use of gel vs. water resulted in a slight reduction in pain score on pelvic speculum exams in cisgender women without interfering with cervical cytology results. (1)

     Pelvic examinations can be uncomfortable for transgender men for a variety of reasons.  Virginal status or infrequent penetration, vaginal atrophy due to hormone therapy, and psychological factors may impair or even prevent a successful pelvic examination.  Patients may have had past experiences that were painful and may be reluctant to permit necessary pelvic screening or care.

      Cisgender women undergoing pelvic examinations also may experience discomfort.  Historically providers have been hesitant to use lubricating gel when collecting cervical cytology or chlamydia testing specimens out of concern that gels may interfere with test results, and have instead used water for speculum lubrication.  However a growing body of evidence suggests that certain lubricant products that do not contain carbomers do not interfere with such tests.  Investigators aimed to evaluate the pain associated with pelvic speculum examinations using gel lubricant as compared to water.

      This was a single-blind randomized controlled trial of 119 women assigned to either a gel (n=59) or water (n=60) group.  Pain scores were recorded on a 0-10 visual analog scale (VAS) after insertion of the speculum, but before visualization of the cervix.  Study size was determined based on a power calculation to detect a VAS difference of 0.9, which has been shown in the literature to be a threshold of clinical significance.  Menopausal women, pregnant or recently parous women as well as those with pelvic pathology were excluded.  The overwhelming majority of subjects were patients presenting for routine pelvic screening examinations.  A single physician performed all examinations.

      The gel group reported a statistically significant lower VAS score than the water group (1.41 vs. 2.15, difference 0.74).  33.9% in the gel group reported a score of 0, vs. 10% in the water group.  None of the 35 gel or 38 water patients who underwent cytology had unsatisfactory results.


     The authors identified a statistically significant reduction in VAS scores when using gel vs. water lubricant in routine pelvic examinations, with no observed cases of unsatisfactory cytology results.  The findings do not cross the threshold of clinical significance.  However these findings may have applicability in transgender men who may have baseline higher pain scores than the study group seen here; pain scores of 1-2 are remarkably low.  As one’s pain climbs on the pain scale, non-linear differences may be encountered which could cross the threshold of clinical significance.  In the very least clinicians should be reassured by this and other data that using a small amount of gel lubricant for pelvic examinations is reasonable and will not impact cytology results if the gel used does not contain carbomers.  Further study in populations more likely to experience pain on pelvic speculum examination (transgender men, menopausal women) would be useful.


1) Hill DA, Lamvu G. Effect of lubricating gel on patient comfort during vaginal speculum examination: a randomized controlled trial. Obstetrics & Gynecology. 2012;119(2, Part 1):227

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