Confessions from a Nurse Practitioner: My Turn in the Stirrups

Confessions from a Nurse Practitioner: My Turn in the Stirrups

- in Editorial, Health

a9f09de43394ece5_640_healthBy Niki Flemmer

It was my turn to be in the stirrups last month. Even though I regularly perform pelvic exams on patients in my role as a nurse practitioner in gynecologic oncology, I personally still dread being the one on the other side of the stirrups. Whenever it’s my turn, I sweat profusely, and I often am self conscious and nervous until it’s over.

I can relate to disliking the whole process and even understand why many women avoid going to gynecologic exams. I’ve noticed some women seem unbothered by it while others really struggle to make it through. Some of my patients have warned me at the beginning of the visit that these exams are really hard for them; sometimes they have a history of sexual abuse or other trauma and the exam can be very triggering for them. Sometimes they have had a bad experience or just get a lot of anxiety in general when it comes time for the exam. This is completely understandable and common.

While they are not enjoyable, pelvic exams really do save lives because Pap smears can detect cancer in the early stages while it is completely still curable, and can even detect abnormal cells before they turn into cancer. The earlier we can catch an abnormality, the quicker we can treat it, and the better your outcome will be.

Since pelvic exams are both dreaded and needed, I want to give you some ideas and suggestions to help minimize the discomfort.

It’s important for me to say here that I am not formally trained in mental health. I am not a psychologist or trained in psychiatry. I recommend whenever there is trauma that people engage in therapy or other helpful mental, emotional, and spiritual modalities. Sometimes difficulty emotionally or physically tolerating a pelvic exam can be a sign that there’s more grief to work through.  If that’s the case, I encourage you to seek, find and utilize a therapeutic modality that works for you. Healing is available to you.

That being said, I am a medical professional and I’m here to offer you some food for thought and suggestions to help you navigate the vulnerable, sometimes triggering, and often dreaded pelvic examination.

  1. Is this exam really necessary? Most likely, yes. But unless you are having symptoms or you are already overdue for a pelvic exam, it may be okay to wait for a period of time or until your next visit. Medicine is all about weighing the benefits and risks. My colleague and I recently elected not to do a gynecologic exam on a young person who had never had a pelvic exam or Pap smear before, because as we began the exam her PTSD was activated and she went into flight or fight. That is not a good time to do anything except self care. While pelvic exams and Pap smears are very important, sometimes it’s better to wait until you’ve established a trusting relationship with your health care provider before a pelvic exam is a part of your visit. Talking about this with your provider to come up with a plan or a compromise is a great way to minimize triggering events or discomfort. This dialogue can open up a discussion about your health goals, what your specific risks are, and what kind of schedule you should be on for your pelvic examinations. We trust our health care providers to be the expert in knowing the benefits and risks of tests, exams, etc. But we are the expert about ourselves. And being able to make an informed decision will do you a world of good. After a discussion with your provider about if the pelvic exam is medically necessary at this time, you will be better equipped to make an informed decision in regards to what you ultimately choose for your body.
  1. Positioning and Breathing. First of all, I know that the position of having your feet in stirrups is uncomfortable. It’s normal and natural that your legs might shake or you might sweat. As difficult as it can be sometimes, it is true that the more you are able to breath and relax your pelvis and legs, the less discomfort you will feel with the pelvic exam and the faster it will be able to be performed. So, do your best to breath and try to feel your buttocks on the table—imagine them grounded there. Feel the table supporting you. Until recently, I underestimated the power of breathing. It really, truly, is a miracle in and of itself. Becoming aware and focusing on your breath brings you to the present moment. It helps comfort you. It helps you cope. It helps slow down the adrenaline. Take deep, slow breaths. Over and over again. It’s a very important and useful self-comfort measure we can all benefit from.
  1. Why is this so triggering? For some women, pelvic exams can be very triggering of emotional pain or grief or send them back to a memory of a painful and unsafe experience. It’s important to understand what’s happening when you suddenly get transported back to the panicky feelings of past events or experience fear in your body. There is something psychologists call “your old brain” or your “lizard brain”. This part of your brain is in charge of keeping you alive – by giving you the flight, fight or freeze function. It works wonders at keeping people safe from predators and potential threats. It pumps blood to essential organs and gets your body ready to fight back or run away. The issue arises when your brain kicks into this mode when the threat of danger is no longer present. Some people develop what is called Post Traumatic Stress Disorder (PTSD). The old brain doesn’t know the difference between past, present and future. So if anything triggers your old brain into thinking it is back in that threatening situation, it will do what it needs to do to survive. And it can kick your body into full on flight/fight/freeze mode. This can mean rapid heart rate, rapid breathing, tense muscles, feelings of adrenaline, fear, and more. It’s important to understand this and to be compassionate with the part of you that is just trying to protect you from a perceived or old threat and to thank that part of you that kept you safe in the past. Understanding what is happening in your brain  and bringing compassion to it during a trigger is a big part of providing yourself comfort when you need it.
  1. Do you trust your provider? Do you feel comfortable with your health care provider? Does your health care provider ask you if you are comfortable or if you have any questions? Are they gentle with you and do everything they can to make this exam as comfortable as possible? As a health care provider, when I can sense a patient is uncomfortable before the exam, I like to stop and tell my patients that their body is THEIRS. And they are in charge. And if at any moment during the exam they need me to stop, all they have to do is tell me or to say “stop” and I will. Reminding yourself and having someone remind you that you are indeed, in control of the situation, can help alleviate some stress. I also like to find out if my patient wants me to walk them through the exam or if they want me to just be quiet. Some patients like to be told exactly what is happening. Some patients like to have a mirror handed to them so they get a chance to see their own cervix or vagina as I explain their anatomy. Others would rather me not say anything and be as efficient as possible. It’s ok to make these requests.

Finding a provider you feel comfortable with can bring you much comfort and help reduce the likelihood that stress or trauma will be triggered. Understand you have options when it comes to providers and if you don’t care for one, it’s within your right (and recommended) that you try someone else.

Most of us feel vulnerable when we are literally naked. We as health care providers try to understand and honor that. But if you are ever uncomfortable, I encourage you to honor that. You can stop the exam at any moment. It is easy to forget in doctor’s offices that you are actually hiring us, the health care providers, to help you. Ultimately you get to decide what happens to and with your body.

No one else owns you. You own you. Always. Your relationship with yourself is the most important. Secondly, having a trusting relationship with your provider can help alleviate a lot of fear and discomfort.  You and your health care provider can work together to create a partnership that serves you and your health care needs best.

Nicole Flemmer, ARNP, FNP-C is a nurse practitioner in Seattle, Washington. She developed an interdisciplinary framework for helping professionals to create effective and meaningful partnerships with their patients called Empathetic Partnership. She is also the founder of The We Belong Project, an online resource for women of sexual minority and health care providers who care for them.



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