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Speculum

Let's Talk about the Dreaded Speculum

Speculum

It’s time to talk about the speculum
By the time you read this, close to 4,000,000 women will have undergone their yearly gynecologic and pelvic exams since the beginning of the year. Fast forward to the end of 2023, and close to 19,000,000 of us will have had the opportunity to visit our doctor for this critical procedure.
But our feelings about this “routine exam” are anything but routine: fear, anxiety, discomfort, humiliation, tension, and dread are just a few words that may come to mind for you. The intimate nature of the gynecologic exam creates a heightened sensitivity in almost all of us. And understandably so! Once a year, we don a paper gown and climb onto the table. Slide down, put our feet into the stirrups, and wait.
It’s about time we start talking about what is arguably the most intrusive – and annoying – component of the exam: The speculum.
The history of the speculum
If 2023 remains consistent with past years, this tool will be used on almost 60,000,000 of us by year’s end because yes, the speculum is a critical part of the gynecological exam. But its first intended use was much, much darker.
The original use of the speculum can be traced to the mid-1800s, and its roots point toward racism and misogyny. The first noted use of what we have come to know as the speculum was used by Dr. James Marion Sims, a physician living in the slave-owning South.
History tells us that he created a speculum fashioned out of a gravy spoon with a bent handle to prop open the vaginal walls of slave women he purchased for his hospital, on whom he would perform surgeries to remove vesicovaginal fistulas (without anesthesia). He would then peer inside to get a clearer picture of the reproductive system. Even in 19th-century Paris, the tool was reportedly used as a threat or torture device on sex workers who were arrested and required to undergo a physical exam. Unsurprisingly, vaginal exams were often associated with prostitution, indecency, and women obsessed with sexual activity.
But in today’s medical world, it remains a necessary evil.
Why the speculum is necessary
Designed to widen the walls of the vagina, the speculum allows access to the cervix and visualization of the part of the vagina necessary for swabs that test for STIs.
Today, there are a number of options when choosing to use a speculum with a specific patient type. Speculums come in 4 sizes, all of which have a specific purpose and intent. From smallest to largest, our physicians can choose from the following models:
Pediatric, which is used for a patient who has never had sexual intercourse or for a postmenopausal patient;
Huffman, which is used for the patient who has never had sexual intercourse;
Pedersen, which is used for the patient who has had sexual intercourse but has not given birth to a child; and
Graves, which is used for a patient who has given vaginal birth or the patient who may have a longer birth canal.

But here’s the problem: Despite having several models, the design of the speculum hasn’t really changed since the tool’s debut in the mid-1800s. And women still hate it.
The problem with the speculum
Let’s be real: the speculum is uncomfortable. Whether it’s the pressure, cold metal, tissue atrophy, or vaginismus – to name a few – the speculum makes for a miserable pelvic exam. In fact, many women are even traumatized by them.
Recent studies have found that 93% of women between the ages of 18 and 34 dread their yearly pelvic exams, and 42% of them attribute it to the discomfort caused by the speculum. That discomfort and fear of pain is enough to make 1 in 4 women between the ages of 18 and 65 skip their pelvic exams altogether. The worst part? The American College of Physicians recommended against the routine use of speculums on non-pregnant and asymptomatic females in 2014.
Despite their concerns around unnecessary discomfort for and fear expressed by patients, as of this writing, the cold, hard, and noisy tool that we have come to know remains one of the most-used medical tools today.
Why haven’t we redesigned the speculum?
It’s not that we don’t want to redesign the speculum. In fact, there have been several attempts to do exactly that.
In 2005, a San Francisco-based company designed the FemSpec, an inflatable speculum made of the same materials as condoms. Its premise was simple: a doctor could insert it like a tampon and inflate it the same way they would a tiny balloon. But it flopped because it was – get this – too new. It was removed from the market shortly thereafter.
There was also The Lotus, created by a student at the Pratt Institute. It featured a curved bill that lent itself to a more comfortable insertion, but it never made it past a student showcase due to a lack of demonstrated benefit compared to the traditional speculum.
Some experts say that the redesigns haven’t stuck their landings for two reasons: the current design works “pretty well” and, discouragingly, there’s a lack of funding available for the innovation of women’s health and reproductive health. But that doesn’t mean we’re not still trying.
The future of speculum design
Don’t give up just yet. Even with the failures we’ve seen, there are plenty of people still trying to design a speculum that allows the patient’s comfort to be put first.
The changes that are being explored today range from improved ergonomic bill design on the Sims speculum to completely redesigned methods for viewing beyond the vaginal walls. Some of the improvements under development include:
The Nella NuSpec by Ceek Women’s Health, which resembles a sleeve with a narrow bill and can be inserted by the patient;
The Orchid Spec, which was designed for silent operation, has rounded edges, and a reflective surface;
A “pocket colposcope” by Duke University Medical Center, which resembles a tampon and features a camera to make self-screening possible; and
The Yona, a modified Sims speculum covered in silicone that features 3 prongs instead of the usual 2 to allow for silent use and a smaller expansion of vaginal walls.
At Matrix Health, they believe that the “future of the speculum is not a speculum.” They have created an AI-supported pelvic assessment and diagnosis device designed for self use in a doctor’s office.

Medical advances in our lifetime have been staggering – the thought of continued use of an instrument developed nearly 200 years ago with little to no redesign improvements is hard to comprehend. The advancement of the speculum needs to be at the forefront of expert minds. Of the women who used the Nella NuSpec, 99% preferred it over the metal speculum and all patients experienced lower rates of anxiety and discomfort – even first-time or sensitive patients.
At the end of the day, the redesign of the speculum is crucial to the survival of women: 83% of cervical cancer deaths can be prevented by regular screenings. A staggering 500,000 lives could be saved if we could get them to engage with pelvic exams.
Food for thought
So what’s the end goal, you might ask? I’d suggest that there are three.
First, we need to take every availability that we have at our fingertips to remove the fear and anxiety that goes along with any gynecologic exam involving the use of a speculum.
The 2014 recommendation from the ACP (that we don’t use it on non-pregnant or asymptomatic women) is a good starting point, but we can do better.
Several physicians have questioned if the speculum truly needs a redesign at all, instead suggesting that it isn’t the tool but our approach to it that needs changing. Instead, the key is education, for both the patient and physician.
Medical Technology suggests that time-pressured clinicians are at the root of patient anxiety. When a doctor moves through their appointments at a break-neck pace, they run the risk of causing patient discomfort by accidentally pinching the patient with the speculum, which causes a sharp pain that can linger for hours. No wonder patients are less likely to come back next time.
Physicians should be taught to carry out exams in a more personalized, attentive way. They can do this by asking the patient if she’s had an exam before and offering her a quick rundown of the vagina and pelvis, even letting her hold the speculum while explaining how it works.
Secondly, we need to find a way to work with our doctors to make our experiences more comfortable. It is expected and encouraged that a healthcare provider takes the time to talk with a patient about their concerns, past experiences, and their level of discomfort. But we need to be open with them. That kind of successful dialogue will lend itself to a collaborative approach that may serve to increase understanding and empathy for something that is unfamiliar and may have frightening results for a patient.
Finally, we must incorporate human-centered design into the pelvic exam. This involves training physicians in a more patient-centric way, including increasing the patient’s involvement in the exam; using an appropriately-sized speculum; tailoring the experience to each patient; and speaking directly to the patient throughout.
There will always be aspects of total healthcare that may be uncomfortable for and will not sit well with patients. In many cases, they’re unavoidable – and this is no exception. In keeping with the advances being made every single day in this country with diagnosis, treatment regimens, and improved outcomes using technique refinement, we need to consider “workhorse tools” like the speculum as well. No matter how effective the speculum may be, there is room for improvement.
We are on the cusp of that improvement but need a powerful voice to overcome a historically apathetic perspective. It’s time that we take seriously the “little things” that aren’t so little – like the discomfort and fear of the speculum – so that we can reverse the trend of women foregoing a critically important aspect of their healthcare. If we could offer a more comfortable and less painful approach to what should be routine healthcare, the preventative levels of success we could reach would be unparalleled.
It’s time to find a way to solve the dread surrounding the pelvic exam. Just because the speculum hasn’t changed doesn’t mean that it can’t, and I truly believe that the innovations we’re already seeing in this space from companies like Matrix and Ceek Women’s Health is just the beginning.

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