“I didn’t feel it at all:” Pain from pap smears is often ignored. New methods help patients avoid it

When Noa Fleischacker had her first pap smear, she was struck by an unbearable, knife-like pain as soon as the speculum went in. “I literally was going to jump off the table,” Fleischacker recalled. At first, her gynecologist chalked this up to anxiety, allowing her to try again later with sedatives, but even though the drugs softened her nerves, they had no impact on her physical pain. From there, Fleischacker’s doctor sent her to a nearby hospital to get the exam under general anesthesia. 

“It was a really ridiculous situation,” Fleischacker told Salon. “I didn't know what to tell people about why I was taking the day off work … The nurses who were putting in my IV were like, ‘It says you're here for a pap smear. You don't usually get an IV for a pap smear.’”

Fleischacker was just as bewildered — but when she woke from the exam, her doctor said nothing except to come back next year. It was only years later, when Fleischacker was diagnosed with pelvic floor dysfunction, along with the vulvar pain condition vestibulodynia, that she understood why her body required such extreme measures for a routine exam.

Patients are generally told that pap smears will cause pressure or feel like a pinch, but truly intolerable pain is rarely treated as an option, except for in patients with serious sexual trauma. However, these exams can be agonizing for patients with vulvovaginal and pelvic pain conditions. According to Rashmi Pithavadian, a researcher at Western Sydney University who studies the sexual pain disorder vaginismus, such patients can have reactions as severe as passing out or throwing up during pap smears.

Pap smears are especially traumatic when providers fail to respond compassionately to patients’ pain. Bonnie Gross, who has vestibulodynia, remembers squirming on the table during her first pap smear because the speculum felt “like a hot knife digging into me” — but her doctor simply held her down and said to stay still. 

“Ever since then, I’ve been so scared of going back,” Gross said. “It’s like knowing somebody’s going to stab you and having a five-day notice.” 

Though thirteen years have passed since that initial exam, Gross still finds herself trembling with panic when she arrives for a pap smear, sometimes so much that she can’t complete the exam.

For other patients, judgmental remarks from providers aggravate the effects of physical pain by making patients feel ashamed of or even responsible for it. Kevinn Poree, who’s been diagnosed with vaginismus and vulvodynia, was 28 when she had her first pap smear, and her gynecologist was shocked to hear that she’d never been sexually active. Was Poree Catholic? she asked. Was she getting married soon? Did she hear nuns in her head, urging her not to have sex? When Poree said no to all of these, her doctor responded, “You know, it’s okay to have sex.”

Poree did know this. Unfortunately, she found sex excruciatingly painful — this was actually what brought her to the appointment in the first place. Rattled by the doctor’s comments, Poree tried to stay calm as the speculum went in, but she couldn’t help screaming at the stabbing, almost electric pain it caused. “It felt like my vagina was on fire,” she recalled.

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Like Fleischacker, Poree received no explanation for her pain. All she remembers is the attending physician laughing, asking if this was how Poree behaved during sex, before she was left sobbing alone on the exam table. “I don’t even know how long it took me to calm down enough to get dressed,” she says.

Distressing experiences like this make it hard for patients like Poree to undergo pap smears later on. For example, pre-exam anxiety can cause the pelvic floor muscles to tighten, increasing the likelihood of pain. Meanwhile, some patients may avoid future gynecology appointments altogether. 

“It made me scared to go back to the doctor,” Fleischacker said. “I didn’t feel like I was going to be treated with care and understanding.” 

This avoidance has major consequences, leaving patients at risk of undetected cervical cancer while preventing them from seeking care for their pain symptoms.  

There are adjustments clinicians can make to alleviate pain during pap smears, such as applying lube to the speculum, using a smaller one, or even allowing patients to insert the device themselves. However, clinicians tend to provide these alternatives only when patients ask, assuming that offering them up front will provoke unnecessary anxiety and prompt patients to anticipate pain — even though giving realistic expectations ahead of time can actually help to build trust between doctors and patients. 

Providers can also help by giving patients agency during exams. “A lot of this is traumatizing for people,” said Dr. Divya Goppisetty, an OB-GYN resident at Stanford University who conducts research on pain during gynecological exams. “One of the ways you can really gain trust with patients is to offer choices. Even if it's a very small choice.” 

For example, Goppisetty asks patients if they’d rather sit on the chair or the exam table while she takes their history, showing them that their preferences will be taken seriously during the appointment — including in more pressing situations later on. Choices are also essential, Goppisetty explained to Salon, because what’s best for one patient isn’t necessarily best for another. 

“You have to see your patient in front of you,” she said. “And really just meet people where they’re at.”

Still, there’s only so much providers can do when the roots of this issue extend far beyond individual clinicians. The belief that women just have low pain tolerances is widespread in medicine, causing frequent dismissal of female pain — and even more invasive gynecological procedures, like IUD insertion, still lack standardized pain management strategies.

Doctors are also constrained by a lack of training on vulvovaginal and pelvic conditions, which are not currently included in curricular guidelines for OB-GYN residency programs in the U.S., along with many other countries.

“Not all health care professionals know enough about vaginismus or painful sex to even know it's a problem,” Pithavadian said. Clinicians, unaware that their patients’ pain stems from a treatable medical condition, end up dismissing it as anxiety or ignoring it completely.

Luckily, change is slowly happening. Last year, the U.S. introduced HPV testing, where samples are swabbed from the vaginal wall rather than scraped from the cervix, as a less invasive alternative to the pap smear. Last month, the Food and Drug Administration even approved an HPV test that allows patients to collect samples at home — which can be life-changing for those with vulvovaginal and pelvic pain.

Kaitlin Bonfiglio, who avoided pap smears for over a decade due to pain from her pelvic floor dysfunction, was so astonished when her doctor offered her an at-home test that she actually cried. After years of nonstop dread about her eventual exam, Bonfiglio found that collecting a sample at home in the comfort of her bed, rather than lying across a sterile exam table, made all the difference. 

“I didn’t feel it at all,” Bonfiglio says. “It was crazy … I had such relief after finishing.”

Even so, women who test positive for HPV still need to follow up with a pap smear afterwards — which is where products like Methica CC, developed by the Netherlands-based CC Diagnostics, come in. Set to launch in the U.S. later this year, Methica CC is PCR-based, meaning it detects cancer through damage to patients’ DNA. What’s exciting about Methica CC is that labs could run it on self-collected HPV samples after they test positive, with no pap smear required. 

“It’s a very clean and hands-off process,” Ilinka Stanciu, CC Diagnostics’ quality assurance manager, told Salon.

Others, meanwhile, are working to increase physician training on female pain. For example, Fleischacker’s experiences inspired her to found the grassroots movement Tight Lipped, which campaigns for standardized OB-GYN training on vulvovaginal and pelvic pain conditions. Bonfiglio, who’s involved in Tight Lipped’s Los Angeles chapter, says the group is what made her feel comfortable seeking care in the first place. 

“It really had a material effect on my personal life,” she explained. “Just being connected with other people who have this kind of pain.” 

Plus, working directly with OB-GYN providers has “demystified the doctor’s office,” giving her an inside look at providers’ world. 

“I used to start sweating and shaking every time I went,” Bonfiglio explains. “And now I don't, because I talk to them all the time.”

Still, making pap smears trauma-free for all patients will require commitment from across the field of gynecology. 

“We need to keep pushing on [this],” Goppisetty said. “Things aren’t good right now, and our patients deserve better.”