We previously published a primer on what to expect during a pap smear (which you can read aquí), which did not adequately address the pain many women experience during this procedure. In this companion piece, let’s talk about why pap smears are so painful for some women and, more importantly, what can be done to decrease pap smear pain.
By way of a refresher, pap smears are valuable because they screen for cervical cancer. They can also detect human papilloma virus (HPV) infection, which causes the vast majority of cervical cancer cases. But if women skip regular pap smears, which are recommended every 3 years for the average woman, they miss out on a key window to detect HPV infection before it progresses to precancerous and then cancerous cells. This matters especially for women on hormonal birth control, since prolonged use increases cervical cancer risk.
When pap smears hurt, women stop getting them
Unsurprisingly, a 2005 study of African American women found that painful pap smears don’t make for willing repeat customers. What fue surprising, however, was the study’s finding that the usual barriers to screening (including lower education and socioeconomic status, poor access to care, knowledge of and exposure to known risk factors of invasive cervical cancer, cancer fatalism, and perceived racism) were not enough to keep African American women away from pap smears. Instead, it was pain (especially combined with difficulty paying) that was the strongest predictor of women being unwilling to undergo future pap smears. 20 years later, the issue of payment is now a moot point, since pap smears have to be covered at 100% by insurance as preventative services–yet the pain (and fear of pain) during pap smears still abides.
Why are pap smears painful?
The reasons why pap smears are painful vary, but all are fairly intuitive. As any pelvic floor therapist will tell you, women commonly hold stress in their pelvic floor. Anything that increases stress may cause women to clench or tense up their bodies (including their pelvic floor), causing their vagina to resist the pressure of the speculum (the device used during a pap smear to open the vaginal walls, making the cervix more accessible to the provider). Unsurprisingly, this can result in feelings of pain.
Other reasons women may experience pain during a pap smear may include (but are not limited to):
- Feelings of vulnerability due to the way a woman is positioned for pap smears (which may be amplified if the provider is male);
- History of sexual trauma, which may induce flashbacks, other PTSD symptoms, or anxiety before or during a pap smear;
- Rough or clumsy technique due to an inexperienced provider;
- A standard size speculum, which may be more painful for a woman who has never had sex before.
How can we make pap smears less painful?
Include a “nonpainful step”
Some of the solutions for painful pap smears are equally intuitive. A fascinating Estudio 2023 reported that when a “nonpainful step” was added to the end of a pap smear, women were significantly menos likely to recall the pap smear as painful 5 minutes afterward, and significantly más likely to follow guidelines for repeat pap smears later on. What was the “nonpainful step?” A 15-second lag time was introduced between the rotation of the speculum (after the cervical cells specimen was collected) and its removal from the woman’s body. That one simple, brief pause made a real difference.
Use a smaller speculum
Women can also request a pediatric-size speculum be used. They can also request use of a lubricant on the speculum (though one wonders why this has to be requested, and isn’t already the norm!).
Change positions
Según un Noticias médicas de hoy artículo, trying a position other than the standard laying-on-back-with-knees-splayed-open posture may be helpful for alleviating pain during a pap smear. Dr. Zahra Ameen, a UK-based OB/GYN, told Noticias médicas de hoy, “Some people find that different positions reduce discomfort, such as putting your hands under your bottom to tilt your pelvis up and allow [your] legs to gently open and relax, allowing a more comfortable clinical examination.”
Insert the speculum yourself
Dr. Apurva Shah, a Massachusetts-based OB/GYN and member of the Mira medical board further recommended asking to insert the speculum yourself, saying “If you feel more comfortable inserting the speculum yourself, go ahead and ask to do that. You would be surprised how much easier it is for you.”
The #1 way to prevent painful pap smears
The single-most impactful way to reduce pain, Dr. Shah noted, is “Feeling in control and seeing a provider you can trust…”
“Once you are in a position of trust,” he continued, “it really impacts how your body and your pelvic floor responds to an exam.” He added, “The more relaxed and in control you feel, the less likely it is to have discomfort during the screening” since “the pelvic floor which would otherwise resist the speculum will relax and allow for a much gentler exam and an overall better experience.”
The bottom line on painful pap smears
If you have had a painful pap smear in the past, or have never had one and fear that a pap smear may be painful for you, talk to your provider about your options for easing the experience. And perhaps it goes without saying, but if your provider is completely resistant to trying any of the ways mentioned above to help alleviate pap smear pain, you might want to seek out a different provider.
Lecturas complementarias:
What you need to know before your pap smear
Birth control and cervical cancer: What’s the link?
FAM Basics: Caring for your Cervix
Referencias:
[1] Hoyo C, Yarnall KS, Skinner CS, Moorman PG, Sellers D, Reid L. Pain predicts non-adherence to pap smear screening among middle-aged African American women. Prev Med. 2005 Aug;41(2):439-45. doi: 10.1016/j.ypmed.2004.11.021. PMID: 15917039. [2] Yen HK, Cheng SY, Chiu KN, Huang CC, Yu JY, Chiang CH; NTUH Pap Study Group. Adding a nonpainful end to reduce pain recollection of Pap smear screening: a randomized controlled trial. Pain. 2023 Aug 1;164(8):1709-1717. doi: 10.1097/j.pain.0000000000002897. Epub 2023 Apr 12. PMID: 37043729.
