Well Woman Care / Annual Exams

A gynecological exam, cultures and Papanicolau smear are a vital part of the health and well being of women everywhere.  Recommendations vary widely on the proper age at which to initiate these exams and at what point you can change from annual to every 2-3 years, but there is no debate that the GYN exam is vital to every woman’s health.  Your midwife will discuss with you your risk factors and recommend the frequency of exams, cultures and Pap smears which is best for you.  Practitioners may start seeing a young teen with painful menses or irregular cycles by the time she is 11 or 12 Years old.  These visits rarely require a physical exam and almost never a Pap smear.  The initial Pap smear and cultures are recommended within 1 year of a young woman starting sexual intercourse or by the age of 21.  Older women still need exams even if they are done having children and even if they no longer menstruate.  The frequency of these exams will also vary with the woman’s life style and medical history.

Many women think of their annual exam with the Pap smear test and shiver slightly.  No one likes to get undressed and put on one of those skimpy cover-ups even if it is not made of paper.  However, like going to the dentist or filing your taxes, it is a necessity and one we believe your midwife can help you come to look forward to doing. 

Midwives are more often women and that alone is reassuring to other women.  We often have fewer bookings of women to see on any given work day and therefore have more time for your visit.  We are less likely to be interrupted by an emergency, although they do occur and the midwifery model of care is far more holistic giving a fuller feel to your visit.  Let us look at some of the components of a Well Woman visit.

The health history

The first time any caregiver sees you that person should interview you and assess you health history.  It may seem unusual to discuss your heart health or surgical history, for example, but each of these areas and many others have a serious interaction with gynecologic and female health.  For example, a woman who has severe epilepsy may not be a good candidate for certain Oral Contraceptive Pills depending on the medications used to control her epilepsy.  A complete history will help your midwife recognize areas to be alert for and also areas to avoid.  You need to tell your midwife about all surgical procedures you have had, all medications you take, both prescription and over-the-counter as well as all supplements,  and all family or genetic problems of which you are aware.  Supplements such as St. John’s Wort or Ginko Balboa can be related to heavy bleeding, so if you are trying to be treated for this problem and fail to tell your midwife about your use of these products it makes her job and your satisfaction difficult.

During the health history bring up any problem which you want addressed.  It is a good time to ask your questions.  Sometimes it helps to write out your health history as you know it before the visit so nothing is overlooked.  Take a list of your medications and supplements, the dosages and when you take them, combinations and poor timing can negatively affect drug performance.

At each subsequent visit you will be asked a brief history update such has anything changed since the last visit.  This is your chance to tell about the gallbladder surgery you just had or say “I asked my sister what that problem our Aunt Joanne had and she said it was low thyroid”.  Health histories are very important, tell your caregiver as much as you know.  Midwives respect confidences and you need to trust them with complete histories including Sexually Transmitted Infections, pregnancy terminations or histories of sexual assault.  Having this knowledge makes your midwife your advocate.

Basic Vital Statistics

It is important to know if you are growing, or shrinking, gaining or loosing weight and if your temperature, blood pressure and pulse are normal.  The midwife uses these parameters to know if your OCP’s for example are causing you to become hypertensive.  Sometimes it seems excessive to have every health care person you see do these statistics over.  You can refuse but perhaps have your first caregiver write down the data, date and sign it then show each of the next people you see the paper and if there is no “problem” perhaps you wont need it all done again. 

For women with histories of anorexia, bulimia or other weight and eating disorders your midwife will be glad to weigh you reversed (backward), label your chart “DO NOT DISCUSS WEIGHT” or make this situation comfortable you as best she can.

Many midwives have woman centered charts which you fill out and you bring to each visit from home.  It is your record and you enter your own weight and test your own urine where appropriate.  This chart also comes to the hospital with you if you are admitted.  Some women like having responsibility for their own charts (sometimes a copy is also kept in the office) and some women like the more traditional approach.

The Exam

A midwife will commonly assess her well woman client from the top down.  She may ask to look into your mouth, feel your neck for lumps, listen to your heart and lungs and feel your abdomen for any abnormalities.  During this time she will often ask you about your Self Breast Exam (SBE) habits and technique, she may mention menopause symptoms if you are nearing that age or discuss vaccination against HPV for you or your children. 

The pelvic exam part of the visit requires that you move towards the bottom of the table and put your feet in the holders provided.  The midwife will try to keep you covered to the best of her ability.  You can bring someone to hold your hand for comfort and that person will not be able to see the procedure.  If you didn’t bring a friend most offices will gladly provide you with someone to help you through the exam, Please ask.  

During the pelvic the midwife looks at the outer structures of the perineum (your vaginal area) and checks for abnormal skin.  The midwife also examines the openings to the bladder and the rectum for any growths or abnormalities.  She may ask you to clench your muscles in this area.  A device called a speculum will help the midwife see inside the vagina for the rest of the exam.  A speculum can be metal or plastic.  They are sized for comfort and your midwife will use water or lubricant on the outside to facilitate the entry of the speculum.  The midwife may instruct you to push down a little or to cough as the speculum goes as these things make insertion easier for you.  Once the speculum is in place you may feel some pressure but not pain.  The midwife can now see your cervix and upper vagina.  Taking cultures and a Pap smear of the cervix are some of the most common techniques for women’s health.  It is usually painless as a soft plastic brush, swabs or a spatula are used to collect cells from the outside of the cervix and vagina.  An important reminder here about not douching or having sex immediately before your Pap smear is worth going over.  Douching and semen interfere to some extent with the reading of Pap smears.  In order to get the best, most accurate Pap and not to have to come in for a repeat do not Douche and abstain from sex for at least 1 day before your pap.  Do not douche if you are being seen for a possible infection for the same reason.

Many people worry that their periods will interfere with a Pap.  Heavy bleeding may disrupt the reading of the pap but if you get your period when you are due to see your midwife call and ask what they want you to do.  Some will reschedule and some will do all the rest of the visit and have you return in a few days to just get the pelvic exam and Pap.  If there is not much flow the CNM may do the Pap and pelvic as it is unlikely to interfere. 

Your midwife will also need to feel your internal organs to be sure they are not enlarged or otherwise abnormal.  In order to do this she will apply lubricant to her glove and using 1 or 2 fingers placed inside the vagina and her other hand on your abdomen she will palpate (or feel) your bladder, uterus and ovaries.  She will also feel for structures and textures in the tissue of your pelvis.  Depending on your age she will do a rectal exam and take a stool sample for blood testing.

Your midwife is aware of the hesitation many people have in undergoing these types of exams.  If your personal history includes violence towards yourself or sexual trauma she has ways to help you cope and is an expert in talking about such traumas with women who have experienced them.  Tell your midwife about problems you have had with exams in the past and she can help you overcome your fears. 

The annual exam for women is only one piece of the services open to Well Woman Care.  Midwives also do Sexually Transmitted Infection (STI) testing, pre-pregnancy counseling and evaluation, fertility counseling and family planning.  We teach about normal functions of the female cycles and hormones.  We deal with premenstrual syndrome and PMDD (Premenstrual Depressive Disorder).  Midwives are often the entry point for women into other health care because the midwife noted some problem which is not within her field of expertise and referred the woman to another care provider. 

Whether you are in to see your midwife for a routine visit or a problem visit one of the best services she will give you is education.  Midwives are well known for their teaching.  Part of the Midwifery Philosophy is that the more you know about yourself and taking care of yourself the healthier you will become.  Ask your midwife about what ever is bothering you.  While the CNM may not be able to help you directly she often has contacts with others who may be able to help.  At the very least discussing your concerns with your midwife involves her with your life and helps her to have a more well rounded knowledge of you.  A relatively new part of well woman midwifery care is vaccination.  Depending on your age or the age of your children and grandchildren the midwife may talk with you about vaccinating against Human Papilloma Virus (HPV).his vaccination has helped prevent many cases of cervical caner and now is being offered to an even wider audience to prevent rectal, oral and cervico-vaginal cancers.