A genius listener asked us how to advocate for themselves during a gynecology visit - we have thoughts!
A genius listener asked us how to advocate for themselves during a gynecology visit - we have thoughts!
hello, hello.
Supraja:Oh, there it is. Sara made me a drink, encouraging me to drink earlier in the day than we'll say, And I was like do we really want to drink right now? And then we're like it's called Gyn and Tonic. We're with you guys.
Sara:We actually like to drink a lot. We're sacrificing for the audience.
Supraja:Yes, sacrifice. This is really hard for us. You're welcome, but I made it some Aperol Spritzes. That's Sara, it's like your go-to drink.
Sara:Yeah, it's like I feel like I specialize in Spritzers. I think, Sara specializes in everything.
Supraja:Sara should be a bartender. It's actually my lifelong dream, is it?
Sara:No, i want to be a travel Instagram influencer.
Supraja:I saw that you wrote that You posted it on your Instagram And I was like don't we all? I think literally anyone who has a dream and confesses to it online, it's to be a travel Instagrammer. I'm with you. I have no shame about it. I think we should all do that. Yeah, You first. You called it first You look really nice.
Sara:by the way, I know I have a date today.
Supraja:You have a date, i have a third date. I have a third date. Ooh, the third date curse about to be broken.
Sara:I don't know, i'll see. I have a third date curse.
Supraja:I can't get past the third date. That used to be my thing too. I would feel like people were super obsessed with me until the third date, And this is like I don't know.
Sara:It's because I think I lose inhibition on the third day.
Supraja:I'm like, well, let me just show you all my cards, these are all of the things I've been through. These are all of the reasons I'm problematic.
Sara:No, you're lovely.
Supraja:I think honestly. I think it's just because people realize you're the real deal On a third date. It feels like a turning point. I'm like, okay, am I really going to commit to this person and show up for them?
Sara:I feel like you hype me up so much, I'm like okay.
Supraja:Well, look at her, Stop Or listen. If you're listening, you could also watch it. Everybody get a super jet in your life.
Sara:A super jet or a Maria McKinney, because Maria McKinney thinks I walk on water.
Supraja:So yes, she should. She's like I birthed you. You have my genes.
Sara:She kills me. Anyways, yep, I have a third date?
Supraja:I'm just curious about it.
Sara:I'm starting to go into the mindset of like when I go on dates, like you're just getting to know somebody. Don't put pressure on anything, because before I'd be like, oh my God, this is date number. And now I'm like, who cares? Just like, do like this person, do not Like, just figure it out.
Supraja:Yeah, i wish that we could just be excited about the experience without being too forward thinking, like a little bit, in that you're honestly evaluating if this person is a good person. You like spending time around, but not that you have to imagine five years in the future when your kids are four and a half 100%. Not that you have to be imagining conceiving in three months.
Sara:But we're going to go to this Mexican Speak Easy that I've been really willing to go to Which one. It's called Porachito.
Supraja:Oh, I haven't even heard of that. Where is it?
Sara:Katie Clark told about it one of my other besties. It's in Seaport and I like, love Mexican food. I'm Peruvian but I wish I was Mexican. I don't know. don't tell my mother, Maria Elena is going to come for you.
Supraja:Scratch everything that you just said, but her being your high-poor wife is going to be like sada.
Sara:It's because I love Mexican food, i love Mexican culture, me too. And it's kind of funny too, because people are like oh, mckinney, have you?
Supraja:let people know this.
Sara:You should have this Mexican food and fast and like. don't ever try to tell me what's your Mexican food. You're from San Diego, I'm from. Chula Vista. Okay, i'm from Chula Vista. You can go to Mexico for my high school, so I know Mexican food. Okay, i know. I'm not Mexican, but I know.
Supraja:Mexican food. Yeah, I will say I was very pleasantly shocked when I went to San Diego by how freaking good the food there was It's so good, like nothing out here compares.
Sara:Yeah, it's true, i mean.
Supraja:Boston, boston. I'm learning to really love the food four years into living here, but it's not all the same.
Sara:You have to find the places you love Well. So, worst case scenario, I have a good Michelada Oh exciting.
Supraja:You know That's nice. Are you still going on a bike ride? Did you tell me you were doing that?
Sara:Yeah, we're going on a bike ride because I want to do something active.
Supraja:now I get tired of like sitting at a restaurant because then you're like let's do some activities And you've already had your first drink, so you kind of got to slow it down And then you kind of like, immediately get another one. Exactly, that's so fun. I love biking as a date.
Sara:I think it's fun. It's really fun. A few weeks ago I went on a hot yoga date and I was like don't ever do that again.
Supraja:Oh my God, I was like this is a bad date idea.
Sara:I was like I don't want to squat in front of this person, i don't know. I'm like bending over. I was just like no, i don't even sweat very much. I was like I feel uncomfortable.
Supraja:I feel like going to a hot yoga date is the equivalent of letting someone know you're not interested, like after that you both understand you shouldn't speak again.
Sara:We never made it to a third date. So there you go. He was such a nice guy. Yeah, that's fun, sarah.
Supraja:I'm excited that you're putting yourself out there and going on lots of dates. We'll see. Well, tell me about your wedding planning. Oh God, that's a real buzzkill. I want to know. Don't put pressure just enjoy. Okay, tell me about the thing that is so much pressure and difficult to enjoy. I wish I was one of those people who just loved the process, and maybe I will eventually get there.
Sara:It's so funny because my friends are planning and like I'll go see a venue with you, I'll go to the wedding.
Supraja:I like love, like, like all those things. Okay, do you mean it? Because literally yesterday, when we were at that party together, someone came up to me and was like why don't you ask Sarah to plan your wedding, because I care about her?
Sara:But I just told her I had checked out wedding venues in New England by myself for a month.
Supraja:Yeah, I mean, I'm down for you to help me do this, do it for me. I don't know, I feel like if I really had your interest at heart, i wouldn't make you do that, i just like love.
Sara:I love all things planning and organizing. They make me excited. So that's, why like planning, even if it's not my wedding, I think it's so excited. Yeah, that's true.
Supraja:Yeah, i think I just wanted to have a wedding that felt different, like meaningful, because it's such a big expense. I know it's meaningful for everybody, obviously, and different things are meaningful for different people. But I was like, if I'm going to justify spending so much money, i want to do it in a way that's intentional, like I want to give my money to venues that I believe in or feel really special in, like their mission etc. Etc. But it's really hard, especially when you're having an Indian wedding where you just need to have a bunch of different spaces for all these events, like, really, i just have to get married in like a really basic hotel. You're so thoughtful though.
Supraja:There's nothing wrong with hotel, which I'm also realizing. I've been to a lot of weddings at hotels that are so beautiful that I've loved, So I need to get over myself a little bit. But I'm struggling with that of just wanting it to be intentional and wanting it to feel like this money I'm spending is benefiting more than just us.
Sara:Well, my goal for you in this wedding process is to be selfish. Oh, because you're always thinking about other people. I want you to think about yourself for once.
Supraja:Super Joanne. Well, you know what's so funny My mom and my sister I was like yesterday being like I need you guys to explain to me because my sister is married and my mom is Indian Also got had a wedding too obviously but also she like knows all the details of an Indian wedding And I was like I need you guys to explain to me every single thing that happens. Like you wake up three days before what happens, what's involved? who all is there then? what happens, what?
Sara:does the ceremony mean? And they were like man.
Supraja:You were so chill that you get engaged and you're a completely different person I'm like I don't know. It's very confusing. I'm like actually I changed the second I thought I was getting engaged, where before that I was like I don't need a ring, i could just a loop whatever. And then the second I knew I was getting engaged. I was like I want a beautiful ring. I want everyone to be excited. It's kind of a mind conundrum, Like you just don't know who you are.
Sara:It's the one time you could be super selfish and do whatever you want. My goal for you is to be selfish and more think about yourself and Adam and what's important to you. unless so, what's going to make your guests happy? We're going to be happy if you're happy.
Supraja:Aw, thanks. It is really nice to have Adam because he just really wants to be part of everything, which I don't know why I'm saying it like that. Obviously it's his wedding too, but I feel like often in like hektra relationships, the person who's identified as a woman is more in charge of it, and then the stereotype is the man is just like hanging out in the background, but Adam like wants to be at all the meetings. He like wants to. He was like taking notes as my family was talking and wanted to review them with me.
Supraja:I was like it's really cute that you really want this to be 50-50. Although I was also like you're just not Indian. It's just not going to be that 50-50 because you don't know.
Sara:Well, adam's the best, so I'm not surprised He's so great.
Supraja:Okay, well, what are we talking about today?
Supraja:Well, we were going to do a question episode, which is still upcoming, but one of the questions was so good that we decided it really deserved a full episode And one of our lovely friends wrote in, which was really cute that friends wrote in, you know they were really good questions, but one of our friends wrote in and just asked how to advocate for yourself in a GYN visit and how to even know if the information you're being presented are all of your options, how to give feedback if you've had negative encounters in the past or, if that experience is negative, how to make sure that doesn't happen again, and I think that's so important.
Supraja:I feel like so many people are having an experience for the first time or have had really terrible experiences before, and, as someone doing the exam, i never want to re-traumatize someone or cause trauma, but it is really sensitive. So I love that we're going to talk about this And I also feel like we should Make it clear that I don't think it's on the person coming in for the exam to make sure that they're not traumatized. Yeah, you know, obviously that's on us, but there are some tips that help everyone just feel more in control of what's happening.
Sara:Yeah, i feel like You know I have my own goals during a visit, but I you know, so that I cover everything that's important to the patient. But when the patient is facilitating that, i think we both win. We both like at the end of the day, you're the most important person and I'm gonna be better able to take care of you if you let, if, if you're vocal about those things That you want to dress during the visit. So I always welcome that. That's literally how I start a visit. I, oh, i walk in. I'm like, hi, i'm Dr Sarah.
Supraja:McKinney.
Sara:My staff always laughs at me because I say hi. The same way every single time I go hello.
Supraja:I'm Dr And they're always like hello.
Sara:My Mickey Mouse voice and then I walk in. I'm like my understanding is this is an annual exam, but I just wanted to know if there's any questions or concerns you wanted us to address today. And most of the time people say no, nothing. I'm just here for my past year. But when somebody does have a like a list or like a few things they want to address, i love that, because then we I know exactly what you want to get out of this visit and helps me Organize the visit so we can prioritize those topics.
Supraja:Yeah and as much as I think the burden really should be more on me, i really truly believe that it's just a fact that the system is not set up for anybody to have a good experience. I love days when I have a bunch of cancellations and I can spend a good 30 40 minutes with a patient because I feel like I Really understood, they felt understood and we both left feeling like, wow, that was a good experience that changed the course of my day because you affected me and were vulnerable with me and hopefully really helped you too, But sometimes, like I have to see another patient, another patient, another patient, another patient, and I hate that.
Supraja:So I really love when people also come in with a clear idea of what they want to accomplish, so that we can Use the, the time we have together, which is just never enough, to come to some good progress, and I do. I try to ask everybody that at the beginning of a visit I try to say what are your goals for today?
Sara:What were you hoping to leave today with I love that because then I'm like Respecting your goals, your boundaries, and I want to be the best version of myself for you. Yeah, cuz you're the most important person in the room You really are yeah.
Supraja:So I think that's probably tip number one, like have an agenda, come in with things you want addressed and Know that you might not be able to go through your whole agenda, but you definitely can have multiple visits to talk about that. And it's like a business meeting. Honestly. You start up up at front saying these are the things I want to talk about. Then you come to a shared decision like okay, we'll do this and this today, we'll maybe do this in this later, or maybe we can do all of that today, or maybe we can do half of one today if with the conversation we realize it's gonna be a bigger feat. Yeah.
Sara:I'll have sometimes patients list off like five, six things and I'll say, let's pick the two to three most important things to you and then we'll figure out a time to address the rest, yeah. Or I'll say, hmm, we can spend the majority of the visit talking about all these things, but we might not have time for an actual physical exam. And oftentimes the physical exam is not what's actually important during that visit. It's actually the counseling regarding the topic They're coming in with. And great, we skip the exam. Let's spend the full 30 minutes talking about contraception, your abnormal bleeding, freezing your eggs. We can do all those topics. When we set the agenda together at the start of the visit, we're both gonna leave feeling like, okay, i did something good for this patient. The patient feels like I got all the things I had on my to-do list done and there's a plan for You know, topic five, six and seven?
Supraja:Yeah, exactly. So I think, yeah, that's a great thing. And then realizing that you don't have to have the same exam at every GYN visit. Sometimes, like you said, you don't even need an exam. Sometimes the exam is just a vulgar exam where you don't have a speculum placed on the inside And that can be affected by so many things. Like I have a patient population that has really high incidence of prior trauma. I take care of a lot of LGBTQ flow, a lot of Transpoke, a lot of gender diverse individuals, and I just think that trauma is unfortunately way more prevalent among Everyone than then we're aware of. So I always ask people have you had this exam before? How does it normally go for you? Is it particularly triggering or uncomfortable for you? Is there anything that I can do to make it easier? Do you feel comfortable having this exam today? So I try to ask all those questions up front and knowing that your answer to any of those things can be yes, no, i don't know.
Sara:Yeah, if there's certain clues about a patient like this is their first GYN exam, then I'll incorporate that into the conversation. Before we even jump to getting into the exam, you know, outfit or even getting in position for the exam, you know I'll say this is what a speculum is, this is, and then I'll say, like this is what you know, what the vagina is, what the purpose of the speculum, and I'll literally go over each step so that they can anticipate. Or, you know, if the There's a big component to trauma or poor prior experiences beforehand, we'll spend the majority of the visit just talking about that and deciding if there's even value in doing an exam today. And sometimes we'll say why don't we save the exam for another visit? And so really tailoring The exam and the, the conversation, the counseling, based on like what the patient's goals are, what their prior experiences have been like. There's so much Flexibility.
Supraja:Yeah, there's not one, one way for every patient right And I think people sometimes feel panic like I waited so long for this appointment and now I have to come back. Who knows when that will be. But one little hack is, once you're in, getting your next appointment was way easier. Especially if you and your provider have a conversation and it feels like you didn't get through everything that you and the provider decided You wanted to do, they're much more likely to figure out a place to see you sooner to finish it. So don't be afraid of that. And you can ask the question like can I see the speculum? I'm not sure if I want to do that today. Like what are our options here?
Sara:Agreed. I run a vulva clinic once a week and a lot of my patients have pain with intercourse, pain with intimacy, prior history of trauma and you know they're long visits They're 60 minutes with for a reason, because they're tough conversations and we want to be, you know, sensitive about it and there's many times when the patient you know I can tell we'll get ready for the exam and I realize, right, right now is not the money.
Sara:Yeah, that's totally fine, like I know there's no reason to rush anything. We have established a relationship like I'm and super just so right. Sometimes It takes forever to get in my specialty clinic that I run, but once I know you and we have spent a time getting to know one another, i can squeeze you in for an exam first, like because we've already done you know a lot of the The getting to know part. Yeah, and I'm so happy to accommodate patients who I really know and I know like I know exactly what I'm gonna do in this next visit.
Supraja:Yeah, easy for me to do, i agree. Okay, let's go over what exactly you should expect from a routine GYN visit. So the first is the history dressing, those specific questions and concerns. I try to do that up front and then we always ask other history, you know, to try to just understand a full picture of a person, because all of those things can relate to why You're coming in. Whatever the problem is, even if it seems irrelevant, our body is a whole system that works together, so things that might not feel that relevant can end up being relevant. So I try to be really complete in that, especially the first time I'm meeting someone, they try to really ask all the questions.
Sara:I say the same thing. I will get the agenda right when we get going and then I'll say let me just review the rest of your medical history So I can best appropriately answer this for you. Yeah, and sometimes we spend five minutes going over medical history and sometimes we spend longer because I realize actually This is gonna be quite relevant when I provide you options and counseling. Yeah, but some of the other subtopics will go into or like your obstetrical history, and sometimes that's quick. I've never been pregnant. Okay, great, that took 10 seconds.
Supraja:Yeah, and then GYN history, which is like talking about your bleeding every month, talking about pain you've had with that. Your sexual practices I try to really not make any assumptions about that, because people do all sorts of things. So I try to ask how many partners you have, how many partners your partners have? how do they identify in terms of gender, what? what do your sexual practices entail? and I kind of sometimes do give a disclaimer, like I know this is a lot of personal information For someone you just met where I'm like where do you put it? Do you put it anywhere? But that's like literally what I asked like what are you putting? is it a finger? Is it a toy? Is it a penis? Is it something else? How did that penis come to be? Was it created? Did it? like I said, i work with a lot of transgender, diverse folks, so I it has really beautifully taught me that with anyone you can't make assumptions.
Sara:I've learned some terms from our patients are like fluid, open or fluid like I don't.
Supraja:I'm like forgetting some of these terms, but yeah, you have to not just be like teach me, what does that mean?
Sara:I know okay, and do the work yourself, but I will sometimes tell people like, if I'm using the wrong term, let me know, like we're all learning and we all owe each other that you know Respect and courtesy and like some of us have not, like you know super, just always teaching me. Like I'm trying to be more mindful about using Sis. Yeah, our neutral turn. Yeah, i don't. I have not historically used those terms as frequently, but I'm realizing it is important and I am so lucky to have people in my life who do more regularly use them And I'm being mindful of it because they can make the world of a difference to.
Supraja:Yeah, i mean, i think I learned that for my patients. I feel really lucky that they've had patients with me in that growing process Not that they should have to, but I'm really grateful for it. Yeah, and I've had people tell me, like you know, my last provider just assumed because I had a partner, that's all who all I was having sex with. Yeah, just wasn't true.
Sara:So I feel really lucky to be around people who feel comfortable sharing that with me and and to be able to grow Just interacting with other human beings and I would like I will have patients giggle at me when I say like Do you have sex with you know, are you intimate with men, women or both? and then people will giggle and be like and then I'll say like, oh well, you know, that's not true of all my patients, and then people realize, huh, that's a good It's kind of nice when we're both learning in the moment or something.
Sara:You see a light bulb going somebody's head. Yeah, i try to be very like, standardized and normalize things and hopefully that page the patient realizes like I'm open to having any kind of Conversation you want to have, like I don't have any, like I just want to understand you so I can best understand your, your questions and concerns.
Supraja:Okay.
Supraja:And then I say I feel like your mic could be a little farther away, just because I can't see all of your beautiful face. So if just now I messed Sarah up and now she's way quieter, this is my way to get my voice to be loud and yours quiet. No, really, only because I noticed I couldn't see all your face and I want to, okay. But so after the a history, then it's the portion of the exam and we kind of touch on this before. But exams can be as abbreviated or as comprehensive as it makes sense for the person, the problem and getting to a solution. But just for a comprehensiveness I guess let's talk about if you were coming in for an annual, for a full exam.
Sara:So I'll generally start with like I'll feel your lymph nodes, your thigh, roi. I don't listen to people's hearts and lungs. I see neither. I did initially realize, like I don't know what I'm listening to.
Supraja:I'm a gynecologist, like that's primary care doctor.
Sara:Yeah, and I remember one time one of my chief residents did she's like I went to her for a check for a GYN visit and she didn't listen to my heart and I was a little surprised.
Sara:And then you were like I can do this too, I was like I can do this too, i don't have to listen to people's hearts because I wouldn't realize I was like, oh my God, i've been using my stethoscope in eight years. But also because, like I'm giving some, i realize I'm giving somebody false reassurance by saying everything sounds nice.
Supraja:I don't know, is that what you say? nice, what That? was music to my ears, your heart, everything sounds really nice Yeah.
Sara:Who knows, you could have like a huge, like systolic murmur and all this crazy.
Supraja:I'm not the person to pick that up.
Sara:I'm just gonna be like no, no, no, Yeah, Anyways so.
Supraja:So your gynecologist might have different levels of comfort with that. I agree, i'm not someone who does that. Occasionally I'll have a patient ask me to and I feel really tortured and I'll be like, okay, i'll do it, but just so you know, this is not my expertise, yeah. And then I just have a really low threshold to say like you should see someone where it is their expertise, yeah.
Sara:But so Some people may incorporate into their exams. Wonderful, but it's not a bad thing if they don't. It just means that's not something I'm particularly comfortable with or confident in.
Supraja:And then another part of the body that is definitely within our realm but has had a lot of changing recommendations is the breast exam. IACOG, which is American College of Obstructurists and Gynecology, says something different than some of the primary care societies, so it is definitely an evolution. how often you need that, if you need it at?
Sara:all.
Supraja:I think I still do it every one to two years and most people and Sarah follow some of the other guidelines and doesn't do it quite as systematically, unless there's a reason to, i'll bring it up with a patient and say you know, some of the evidence suggests we don't need to routinely do this anymore.
Sara:It might result in testing and biopsies that weren't necessary. And I'll ask the patient would you like me to do a breast exam? Do you have a specific concern that you wanted me to examine today? So I kind of leave it more open-ended. Now My cousin, who's a nurse practitioner in primary care, told me that she's like we don't have to do those anymore.
Supraja:I was like I know I'm like AGog. tell me I don't have to do it.
Sara:So I just bring it up to the patient and we talked about it. And then we decide and they're like, no, I have no concerns. I'm like, okay, let's skip it and let's spend more time on your public exam.
Supraja:But if you're having one done, if you have sensitivities around those things, let the person know. A lot of times a good place to advocate for yourself is before you get undressed, because you're just going to feel way more in control of what's happening, less vulnerable, so that's a good time. But you can also do it after you've gotten undressed, if you didn't do it beforehand. And the part of the exam people will look at both to assess the symmetry and assess any differences and then help it one at a time. So usually I have the patient lift one arm above their head and then kind of go up and down on the breast with two fingers, like I'm about to do it on my breast. This is why you should watch this on YouTube.
Sara:It's like the lawn mower technique.
Supraja:And there are some other techniques too, the circular technique Yeah. And the reason we have you lift your arm above your head is because we all have some breast tissue in our armpit. And then I do express the nipple too, because you want to check for nipple discharge. So why are you looking?
Sara:at me like that Am.
Supraja:I supposed to do that? Yeah, i don't know. Well, then again we also say, like it doesn't matter, maybe you don't need to do it at all, so have a conversation about that But always learning.
Sara:Always learning.
Supraja:When you express the nipple. what I do people do it differently is just take two fingers and literally like pull on the nipple to see if anything comes out, and then I do that on the other side.
Sara:I've never had somebody do that to me Really Well, I don't know.
Supraja:I mean, my fusions are like why did she just do that?
Sara:Okay, we're going to get into this when we get a direct-to-exams, because I'm literally here taking notes. Should I take notes?
Supraja:Well, sometimes people have milky discharge or other things that you have to work on.
Sara:I don't know. Can we talk about my breast after? Yeah, okay, sarah's about to take your shirt off.
Supraja:Just kidding, in private, not on this video-flash audio podcast. Wait, really, no one has ever expressed your nipple.
Sara:No, oh, interesting, except for like a partner, that's kidding Too much, oh too much, keep going, keep going.
Supraja:Well, your doctor should not express it with their mouth, Sarah. It is not like a partner. This is why I warn people that this podcast is a little spicier than you might think. Okay, so that's the breast exam, And then usually people do some kind of abdominal exam, sometimes just palpation, sometimes certain other things like percussion or listening. I feel like gynecologist. We just don't carry around a speculum We give it up Or a stethoscope, a speculum yeah, i'm gonna take the speculum, shove it in your abdomen.
Sara:I'm just kidding. I'm listening to bell sounds with my speculum.
Supraja:Yes, i'm gonna take the stethoscope. We do not often have a stethoscope in every visit, so usually I just palpate And then we move on to the pelvic portion, which is what? Woo Yes, that's how we feel about it Woo, cheers, pelvic. Okay, yeah, sarah, go off. Sarah's our bulbar specialist. So this is where I feel like you shine, sarah. Tell us all about it.
Sara:Well, it's so funny because I remember being a resident and attending physician telling me, you know, she was watching my exam during a visit. She's like Dr McKinney talks a lot But and I was like okay.
Supraja:I was like I'm a patient. feedback emailed to me like Dr Roger Gopalan was really thorough, but I didn't need all that information.
Sara:But I do tell my patients. I say I'm gonna, i'll be. I talk out loud during my exams. I'm gonna be naming your anatomy. Let me know if you have a question or if I'm talking too much. I give the caveat, but most of my patients say no. I love that you tell me what's going on.
Supraja:But if you don't, let me know I'm receptive to the feedback.
Sara:Anyways, i always start with the well. First I make sure I figure out is this the first pelvic exam my patients ever had? Because if it has, even before you place your heels into the holders, i will show you what a speculum is so you can have an idea of what to anticipate. But if you've had pelvic exams, then well, the first thing I do is just a vulva exam, and a lot of people skip the vulva exam. But I'm like a diehard vulva advocate And I, you know, like it's not a people skip the vulva exam.
Supraja:Like the vulva if you didn't hear our last episode, which you should is the outside part of that. So the vagina is the canal, the inside portion. The vulva is pretty much all of the outside, like everything else, all the all the really good stuff, like I feel like you would have to close your eyes before you put a speculum in not to do a vulva exam.
Sara:You're just like driving into the garage and you're not looking at the house. You're just like look at the house, look at the house, look at the features, the shutters, the door, the grass.
Supraja:I think Sarah's vulva exam is so beautiful. I've literally just copied her exam template and put it in all of my notes.
Sara:Well, anyways, i do tell my patients I'm going to, i'm looking at your and I'll say this because I want my patients to know their term, the term, so that they can be aware of their body, have ownership of it And so, should something come up in the future, they know how to advocate for themselves. That's like my big thing in all my visits is like I want you to know how to advocate for yourself, whether I'm your doctor in 10 years or somebody else. And I'm going to bring this up because I think you guys should follow Rachel Rubin. She's a Eurogynecologist in.
Supraja:DC. Oh, that's great job. Yes, she did an article in the New York Times. Does Rachel have a podcast? Does she want to be on ours? I know we should.
Sara:She's fabulous, She's part of the Ishwish Society And essentially it was an article in the New York Times about we should be addressing the clitoris. There's just many parts of the vulva that people kind of ignore and they can be big factors in pain and discomfort and itching And as gynecologists we should be taking ownership of it and recognizing it in our exams, because sometimes people have a condition that is only diagnosed by looking at the vulva, But we're forgetting this part of the exam. And so you look up Rachel Rubin's article in the New York Times.
Supraja:It's really good And anyways a fan girling right here, yeah, but So your vulva exam? you said you look at the outside. you look at the labia majora, the clitoris, the clitoral hood, see if it's retractable. you look at the lymph nodes, the mons.
Sara:And I look at the perineum and I'll look at the anus as well, like you know. Especially if somebody's complaining of itching or constipation, do they have hemorrhoids? Hemorrhoids yeah, exactly So. I always take a moment just to look at the vulva.
Supraja:It literally takes like 15 seconds Right, but then, for you all to know, the first part of the pelvic exam is just people. You probably will feel touch hands of spreading to see this parts on the outside, but it's not anything going inside, it's just looking and feeling the outside And I always get the patient heads up.
Sara:This is my hand on your thigh. I am now separating your labia minora so people know exactly what I'm doing. I'm not placing into anything in the vagina, i'm just looking. And so that the patient knows exactly what I'm doing and what's the purpose, i'm looking at the texture of the skin, the color. Are there any growths that look abnormal or benign? And I'll mention it. Oh, did you know? you have a mole along your perineum or in this area, like oh yeah, i didn't know that My dermatologist keeps an eye on it, or they'll say oh, i had no idea.
Supraja:I was like oh well, there's dermatologists does a Volver exam?
Sara:Some dermatologists do Impressive, so I know those are my people, But yeah so somebody and I just bring it up so that the patient knows, because sometimes they're like, oh I didn't know about that, and then I'll bring out a handheld mirror and we'll look at it together. I love the mirror.
Sara:Yeah, use a mirror a lot more Yeah because people then bring up like oh, I have these bumps, I'm really worried about them. Is this so and so? And I'm like, no, actually, let's look at it. I just love going over anatomy because I just want people to feel confident and like reassured about their bodies And if there is something that we should be worried about, then let's chat about it and address it, yeah, so that's the external portion, and then, if you're having a full exam, it's the internal portion, which is where we use the speculum.
Supraja:Now, that's the device that kind of looks like a duck bill.
Sara:Oh, that's a good.
Supraja:Yeah, looks like a duck bill. It's put inside an opened which lets you inspect the canal of the vagina, the cervix, some of the area around that. That's where swabs are collected in the vagina. If you're getting STD testing, for example, or if you have discharge, that's being tested. And then that's how we do a pap smear, which is where two swabs that are rubbed against the cervix, which is at the very top of the vagina, which is kind of the entryway of the uterus. That's where cervical cancer grows, and pap smears are testing cells on the surface to see if there is changes that could eventually become cervical cancer. The screening test. So it's telling you if you need more testing. But there are actually a lot of different ways. even that part of the exam can happen.
Sara:Yeah, so you know, one of the interesting components to the question that this friend submitted was you know how can I advocate for a speculum that's more comfortable? or are there options, or is it just one for everybody? And there are many options actually.
Supraja:Yeah.
Sara:Thinner speculums, larger speculums And oftentimes the way we decide is like has this patient had a vaginal delivery before? Is she post menopause? Is she an adolescent, a teenager, and maybe needs a smaller speculum? Does she have a history with pain with intercourse? Is she asking for a smaller speculum? There are speculums smaller than my pinky and speculums that are three, four centimeters in width.
Supraja:So there's, a variety in sizes, yeah, And I mean and just to clarify one thing that you said, which I think all that is exactly correct If you're a teenager, most likely you don't need an exam. Yeah, but sometimes if you have an issue, you do, and that should be a long conversation, not something that just automatically happens, correct? But one of the tips I would say is to ask to see it, and I try to just show people. I'm like this is the speculum, are you comfortable with?
Supraja:this And then you can say if they show it to you and you think it's too big, or whatever you can say, is there a smaller one? Can we start with something else? So hopefully people are showing you, but I know there are many times where I wish that I had taken the time to do that and you don't. So know that your provider is not going to be perfect, even though we want to be, and it's totally acceptable for you to ask to see it.
Sara:Because I think the thing that makes my heart hurt the most during a visit is when a patient we finished the exam just like, Oh, that wasn't so bad, The last one was so painful I was dreading this visit.
Supraja:And I'm like what, What, Yeah it makes my heart hurt because like the moment I try to place a speculum.
Sara:If I see the patient even wins with any discomfort right away like Oh, let's pause.
Supraja:Let me grab a cake, are you?
Sara:okay, let me grab a different speculum, let me warm it, like there's so many things we can do throughout the process to make it more comfortable. And if somebody's not doing that for you, like that's not okay, you can say stop, this is actually uncomfortable. Or can you switch this, like there's so many things that can be done beforehand And even when I'm doing my exams. This is the speculum at the opening of the vagina. I'm now going to advance it into the vagina again. I use many words. I talk too much.
Supraja:But I love it Very good mind And it was like it was great.
Sara:And even when I'm advancing, I'm trying to get her to do it again. Even when I'm advancing it into the vagina. I'm like please let me know, you know, if I need to adjust my technique, because I can.
Supraja:Yeah, I really can I try to clarify for people. This can be is uncomfortable, not even can be. It is uncomfortable. There's a lot of pressure, but it really shouldn't be painful.
Supraja:It should never be So, if you're feeling pain, tell me and I will adjust, because pain is not normal, So you don't need to just grit and bear through that. That's not what you should be feeling. Yeah, it doesn't mean people don't feel it, because people have a lot of reasons to feel pain, but it means feel comfortable speaking up and know that something can be altered. If what you're feeling is pain, yeah. And then the other thing is we use lubricant or water, you know, and some people are really sensitive to one or the other. So you can also ask, like do you use lubricant or water? I've had better experiences with this one.
Sara:Yeah, you can also warm the speculant, like my gynecologist warms my speculant for me. How with under?
Supraja:hot water. Oh, with water, or she and he or she, or they use lubricant or no, they still use lubricant.
Sara:Oh, i don't do that I should. I need all the things I should do that I don't. I don't warm it unless the patient specifically asks or if I know it's going to be uncomfortable. But also when I'm on in a different office they have drawers that warm the speculants for you?
Supraja:Oh okay, Find yourself a fancy gynecologist.
Sara:And so those are little things you can do, and giving heads up about different parts of the exam, like. so it sounds like Supergine, i do exams very similar.
Supraja:This is my hand.
Sara:I'm now doing this.
Supraja:I try to warn people about every single feeling they're going to have. When you're going to feel my hand, you're going to feel the speculum, you're going to feel more pressure, you're going to feel it open and you can ask your provider to do that Like I.
Sara:I on occasion will have a patient say I prefer if you didn't tell me what you're doing. But people are like be quiet.
Supraja:Yeah just associate And that's totally fine too. Then I'm like, okay, like I'll just tell you the big things, like something's going in, i'm not going to talk as much, i'm going to just hurry through it because that's what you're asking of me, and I love when people feel comfortable to share that with me and comfortable to tell me, like, actually, the standard way you do this is not what I want.
Sara:Yeah 100%, like it's just so easy for us to adjust and anything I can do to make you more comfortable that I want to do that. Yeah, one of the things we can do if an exam is to is not something you can do like a way, we can also do them under conscious sedation.
Supraja:Actually, some places have a facility that's done in sometimes it's done in the OR, just depending and you get medicine through an IV. You're put to sleep with medication, so you're still breathing for yourself. You don't have a tube down your throat, but you are asleep, basically. Yeah.
Sara:So yeah.
Supraja:I definitely offer that to people and people. I think more and more people are feeling empowered to ask about it, which is totally fair. You know there's no right way to do this, and someone who makes you feel like you're asking for something unreasonable by suggesting this, it's probably not the person for you to go to, because it's your body. Nothing is unreasonable to make you feel comfortable.
Sara:Yeah, So yeah, I definitely had patients say like can you actually do my pap smear in the operating room under light sedation? Absolutely. That's a fun case. For me It's so easy, it's so straightforward. Like it's more inconvenient for the patient because they probably they have to take a day and a half day off to like coordinate, be a part of the surgery.
Supraja:But, like for the provider, it's so easy and like it's more expensive generally because you have to pay for the facility fee and the anesthesia insurance covers that differently than an office procedure, which is unfortunate. So there are realities to it, but your provider should never make you feel bad about it.
Supraja:Yeah, like I love those surgery, like it's not a surgery but I love those, or cases You're like, yeah, you have time to get a drink with me, and so yeah. And then there's the rectal exam. Okay, i've had so many people tell me, like friends and things to be like my provider did a rectal exam. Is that normal? And I'm like, actually it can be, but they should have talked to you about it.
Sara:So I think this is an interesting topic because I feel like when I was a resident, a lot of my older attending physicians would say did you do a rectal exam? And I'm like no. And I'm like did you do a rectal exam? I'm like I've actually never had a rectal exam during my well, i guess a lot of things aren't happening during my G-wagging exams.
Supraja:All the surgery is sexual and contractual.
Sara:Okay, anyway, marie is not watching this episode, but okay, what are reasons? SuperJet, what is the reason you would do a rectal exam?
Supraja:I would do a rectal exam if someone had rectal specific complaints like bleeding, bleeding with their bowel movements, extreme constipation sometimes although honestly that would not that often concern for fistula, concern for rectal prolapse, endometriosis sometimes again not that common, but you can sometimes feel like the implant nodularity in the rectum. But to be honest, let's me racking my brain, yeah.
Sara:Most of the time I don't do one.
Sara:I don't routinely do them either. I do them in my vulva clinic for patients who have a history of HPV and high-grade dysplasia or abnormal cells on the cervix or somewhere else on the vulva, because then that increases your risk of having HPV or dysplasia, abnormal cells in the anus. So I, for me, personally, i have to have a specific reason to do a rectal exam. Yeah, and same reasons you just mentioned. I do know some providers routinely do them and I think that's fine, as long as you're explaining to the patient. this is part of my routine exam. These are the things I'm looking for, but somebody should be explaining to you why they're incorporating that into their exam and you can always ask, like, why are we doing this part of the exam?
Supraja:If you have any reservations like, bring them up And you can say I would prefer not to have a rectal exam. Or you can say can you tell me the components of a pelvic exam? Does it include a rectal exam And what are you hoping to learn from that? And if their answer doesn't make you feel comfortable, say I don't want that, totally fine, yeah, 100%. So, along with the rectal exam, people normally do that in combination with a bimanual exam, which I would say is more standard, and that is when you, we put two fingers into the vagina and then a hand on the abdomen And that allows us to feel the cervix, the uterus, the adnexa, which are, i mean, really what we're feeling is ovaries, although the adnexa comprises of both your tubes and your ovaries feeling for any masses, any tenderness, feeling for normal sizes of those things I feel for lymph nodes when I'm doing that too.
Sara:I'm not a. I do a bimanual exam but I also will flip my hand over and feel pelvic floor muscles for a lot of my patients, because that's the specific population that I tend to see. So you know, like an old-telepation, i'm going to be feeling your pelvic floor muscles, i'm pushing on this pelvic floor and I'll explain. But, like, don't ever hesitate to.
Supraja:Somebody should be explaining to you What's happening, why it's happening, what's?
Sara:the purpose of it. What's the benefit Like what are they interpreting from this information?
Supraja:they're gathering And then they should pause to be like do you feel comfortable with that? Yeah, um yeah. And even with the bimanual sometimes the bimanual is a lot less uncomfortable than a speculum because, at least for me, i have very small fingers, so it's a lot less just mass that's going into that space. So sometimes for people who are not comfortable with the speculum, i'll say how about a bimanual, are you comfortable with that? And then I'll say how about one finger instead of two fingers, would you be comfortable with that? And there are people where I'm like let's talk about this and you can decide if the risk to you personally, whatever this causes for you, is worth the having this exam and what we could learn from it. So, yeah, i think again. I feel like the theme is you don't have to do anything You don't want to do and you deserve to understand why certain things are being recommended to you and to make a decision Like yes, no, i don't know.
Sara:Yeah, and as a healthcare provider, we shouldn't be offended in explaining that. Like that, you know we're here to serve you and we should be able to explain, like, what's the purpose and benefit of this specific component of my history, my question, my exam.
Supraja:Yeah, and so Okay. Oh, i have a controversial question I'm interested in your take on How often do you have to see a gynecologist? Okay, are we obsolete?
Sara:I think this is a great question. No, i see my gynecologist every three years.
Supraja:You do Yeah.
Sara:Oh, wow, i see my primary care doctor every year. Oh, interesting, Because I and that varies for people, but I generally don't have many gynecological concerns or complaints. I have an IUD. I don't need to birth control prescriptions.
Supraja:And you have a very thorough primary care doctor.
Sara:I love my primary care doctor. She takes care of all the other things and you know, most medical problems like asthma, diabetes, high blood pressure, any like those things A gynecologist does not want to manage, that's, you know, like a primary care thing. And I like my primary care doctor because she tells me when I need to get screened for thyroid conditions, high cholesterol, and so I know she's going to be probably maybe more on top of that or, you know, more enthusiastic about those topics, whereas when it comes to my pap smear or talking about birth control, i want my GYN to do that. So I literally just go to my GYN for my pap smear. Some PCPs love that, are totally happy doing a pap smear, so then you might not need to see a GYN.
Supraja:But if I have a specific GYN complaint, like when I needed my IUD exchange, i went to my gynecologist to do that Yeah, whereas I think I'm the opposite, although I do not encourage my way of thinking, i was telling Sarah earlier the last primary care doctor I saw was my pediatrician. I am in my mid 30s, not good, i'm trying to get it figured out, but I will say that a lot of my gynecologists in the past have been like good friends of mine also.
Supraja:Probably not ideal but, they have been very kind to like take on some primary care responsibilities. So and I am someone with not that complicated of a medical histories So it depends on your provider, like how thorough I shouldn't even say thorough but how comfortable they are dealing with all of your health care needs versus a specific need. And that can be true for the gynecologist or the primary care. But for patients who see me, i usually say you should see me every one to two years. but it's different for different people. Like if you've had surgeries where your anatomy down there is different you don't have all the same parts that you were born with, for example maybe you don't need to be seen that often.
Supraja:Or if you're someone with an issue that we're following up on a lot, or you're on a medication that we need to adjust, maybe you need to be seen more often. But the key, i think, is to realize everybody's a little bit different and it's okay to have a conversation with your provider like how often do I need to see you? What can I expect at the next visit? Is it necessary to do it in a year? Do we want to wait two years? Do we want to only wait six months? So having comfortability to have that conversation and know that it's not a one size fits all situation is really important.
Sara:Yeah, because I'll have patients come for an annual exam and I'll ask like any questions or concerns will you want to address today? And they'll say no. And then I realized, as we go into the visit, they don't need to pass me for two or three years.
Supraja:I know I'm sometimes like you don't really need an exam. Like do you want me to do that? Yeah, like what were you hoping for? Like I don't mind the visit.
Sara:But I also, like I want you to know, like you know, you can come see me again next year, always happy to see you. It's a very straightforward visit, but like you don't have to, You don't have to, and sometimes it's more beneficial for you to see your PCP than it is for me every single year.
Sara:But, yeah, some of my patients who have like PCOS, polycystic ovarian syndrome. let me figure out the contraception protect your endometrial lining But I want you to go to your PCP to take care of, like some of the metabolic stuff or other things that I'm not as comfortable taking care of.
Supraja:So let's have a conversation about it, yeah, okay. And then, if all of us has happened and you didn't have a good experience, which, as much as we want to pretend we're perfect, i know I've gotten feedback that was not necessarily all positive and we're all human, you know we all have room to grow and do better. So I want to talk to people about, like, how they can give feedback if they want to. I think, also okay. If you don't want to spend the emotional energy on providing feedback, because that also takes effort, you just want to find a new provider, totally fine. But if it's a situation where you do want to invest in this provider you do feel like it's, or you want to, you want to stand up for yourself, for something that has happened and you want to provide feedback. There are ways to do that.
Sara:Yeah, and I've had patients write like a letter that my MA gave me before walking into the room, saying like these are things that came up at the last visit that I'd like to be addressed a little bit differently today.
Supraja:And.
Sara:I, you know, read the letter And then when I walked in I was like, oh okay, let's address this. I want to understand what your concerns are, and so I knew right away there's ways we can tweak our visits so that you're a little bit more comfortable, or things that are being addressed in a way that's that you would like to be addressed, and that was I really appreciated that. That gave me direction. It was, you know, it helped build, helped us build rapport. I could tell the patient was so grateful after. And, and you know, at the end of the day, like we can also pick up when we've done something where I'm like, why did?
Supraja:I use, I'll get it go into my office.
Sara:right then I'm like why did I use that word? Oh, i like hate myself for having said that I don't hate yourself.
Supraja:But I'm like, so I'm so hard on myself Like, like.
Sara:Sometimes I'll be like, oh, i can't wait to like visit with this patient again so I can do better, or like you know, you know.
Supraja:Yeah, or I just I feel grateful when people are vulnerable enough with me to be like Hey, can you use a different word that bothers me, like can you do this slower? Can you actually explain to me why you did that or why you want to do that? I love, i mean it, of course. Whenever anyone is telling you like I wish you had done this differently, you're like, oh God, do I? am I terrible?
Supraja:As an instinct, but I actually having two steps of thought outside of that, i'm like I'm actually so grateful that you told me that and I really want to be better And if that's not the reaction you get again, you don't have to see that doctor.
Supraja:But I would say I like what you said both in terms of you can do it in writing and you can do it to another person in the system If you don't feel comfortable saying it to your doctor to look face to face. I've definitely had people say it to me face to face too, which is great. Most, i think all, all like good clinics have an official mechanism to provide feedback, whether that's like making a patient complaint or just giving the feedback less linked to you in the complaint to you can do it both ways, and a lot of people have that on their website. Or, if you can't find it easily or it's not on the website, you could call and ask Hey, is there a hotline or an email or some form I can fill out to give feedback? and that should exist pretty much everywhere We get weekly feedback emails summarizing people's comments and usually they're like nice comments, but sometimes they're like people only tell me that I'm her.
Sara:No, but sometimes there are comments where, like I was you know the pay the provider was running 30 minutes behind and I sat in a gown or undressed in the room for 20 minutes and I didn't like that. And now, like ever since I saw those, like that's really reasonable. And now when the medical assistant asked me, like I know you're running 20 minutes behind, you want me to room the patient, I'll say room the patient, do not have her get undressed.
Supraja:Because I took that feedback.
Sara:so seriously I was like I wouldn't want to sit naked in a room for 30 minutes.
Supraja:I've had that feedback before too, like I was waiting with my clothes off for a long time.
Sara:Yeah, and so now. so I appreciated that feedback. It came. you know, it was like it was anonymous, but I was like now I'm going to treat all my patients that way And some patients will tell the medical assistant like I don't care, i'm going to get undressed right now.
Supraja:And that's great.
Sara:But I appreciate it And we do take it seriously. And if somebody's you know not receptive to your feedback, you don't need to go to them, Don't go back to them, You know, like just don't go back to them And it's probably not personal, but it's not about you and maybe there it's not about them.
Supraja:Either way They're just having a bad day or they don't understand. But you want to feel supported in your interaction, like when you go to the doctor. It should be about you. So if it's not, if it doesn't feel that way, it doesn't mean that your doctor is a terrible person, but maybe you just need a different relationship, like Sarah and Matt. Not every man is for you, but there's some good ones.
Sara:None of them have been for me. Where is he?
Supraja:damn it, sarah it's just, you're just too good. Sarah's like the cream of the crop, that's hard to live up.
Sara:I'm like Charlotte from Sex on the City. I've been dating since I was 15.
Supraja:Where is he? And she found Harry. She's so happy.
Sara:We're still together.
Supraja:Okay. So okay to summarize our tips. Tip one agenda. Have an agenda, be clear about it when you go in.
Sara:Tip two, don't be afraid to ask questions or convey what you need from the visit, because it can be tailored to however you need it to be. Whether it includes an exam, or that's reserved for another day, or you need an explanation about what's going to be included in the exam. It can be adjusted in a million ways.
Supraja:Tip three if you know things bother you or you want to have it done a certain way, bring that up in a time where you feel safe. So that could be an email beforehand to the MA. It could be before you're undressed, or if you're undressed already, it could be before you're in position.
Sara:And tip four it's okay to give feedback. It feedback can sometimes be a little painful to receive, but ideally it's constructive and it helps you become a better person, a better provider. You can give feedback. It sometimes is just about how you do it.
Supraja:And tip five final tip if you didn't like that, don't go back, get a different provider.
Sara:Go to SuperJet. There are other providers. Go to Sarah.
Supraja:There are other providers where it's going to be better, and sometimes you need a better connection with someone. Sometimes you just need a fresh start. There's no guilt involved with that. It's supposed to be about you.
Sara:I always tell my patients like you're the boss. My job is to give you the information you need to make the best decision for yourself and your family. You run the show And I really do believe that You have control. You have more control than you realize.
Supraja:And I know it can be daunting to find providers. So ask the people in your life do you see someone you like? even if they're not taking new people, sometimes they'll have. I tell everyone to go see Sarah because I trust her. I trust that she's going to be an empathetic person and that she is lovely and going to be receptive to feedback and try to cater to the person she's seeing. And I have other people I would send people to And some people I think would be a better match for someone who doesn't have a lot of trauma.
Supraja:So we all know, even if we can't accommodate someone, people in the community who would be good for different types of people. So ask your friends who they see. Ask if there is someone who specializes in a specific type of an exam. People are more of a resource to you than you might think. So don't feel so overwhelmed about like Because we know it's hard to get into the doctor, it's hard to find a provider and then you feel like you have to start over. Can be really challenging, but you're worth it. It's worth finding someone you feel comfortable with.
Sara:Yeah, so you're the boss, own it.
Supraja:Love it, celebrate it, and we're here for you. Okay, i'm going to go express Sara's nipples, because no one ever has. Oh God, bye, ciao, bye, ciao, ciao, ciao, ciao, ciao, ciao, ciao, ciao, ciao, ciao, ciao, ciao, ciao, ciao, ciao, ciao, ciao, ciao.